REIMBURSEMENT POLICY ST AT EMENTMarketplace Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Car e Visit on Same Dat e of Service-MP-PY-1388 IN, GA, WV, KY: 12/01/2022 OH: 01/01/2023 Policy Type REIMBURSEMENT This policy applies to the follow ing Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….3 G. Review/Revision History ………………………………………………………………………………………..3 H. Ref er en ce s …………………………………………………………………………………………………………3 I. State-Specif ic Inf o r mat ion ……………………………………………………………………………………..3 Reimbursement Po licie s prepared by CareSource a nd its a ffilia te s a re intended to provide a general reference regarding b illin 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 necessary services include, but are not limite d to, those health ca re services or supplies that a re proper and necessary for the diagnosis or treatment of disease, illn e ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 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 limita tio n s that a re le ss favorable than the limita tio n s that apply to medical conditions as covered under this policy. Prev en ti v e Ev al uati o n an d Man ag emen t Serv i c es an d Ac ute Care Visit on Same Date of Ser v i c e-MP-PY-1388 Effec ti v e Date: 12/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. A. Subjec tPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service B. Bac k groundReimbursement policies are designed to assist providers when submitting claim s to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and of f ice staf f are encouraged to use self-service channels to verif y member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service t h at is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers f or medically necessary and preventive screening tests as required by f ederal statue through criteria based on recommendations f rom the U.S. Preventive Services Task Force (USPSTF). C. Def initions Preventive Services Exams and screenings that check f or health problems with the intention to prevent any problem discovered f rom 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 c ar e provider f o r preventive services are encouraged at every age but are especially important f or children under the age of 18 years. D. Polic yI. Preventive Health Services billed on the s ame d at e of service as an Acute Car e Visit: A. When an y of the f ollowing p r ev e nt iv e health service codes ar e billed on the s ame 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 appropri at e modif ier to identif y separately identif iable services that were rendered by the same physician on the same date of service. 1. Preventive Health Service Codes a. 99381-99387 b. 99391-99397 2. Acute Car e Visit Codes a. 99202-99205 b. 99211-99215. Prev en ti v e Ev al uati o n an d Man ag emen t Serv i c es an d Ac ute Care Visit on Same Date of Ser v i c e-MP-PY-1388 Effec ti v e Date: 12/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. II. CareSource reserves the right to request documentation to support billing both services f or all claims received. If documentation is requested, it must clearly delineate the problem-orient ed history, e x am, an d decision mak in g f rom those of t he preventive service. Documentation must include the f ollowing: A. Key elements t h at support the additional preventive health services t h at were rendered B. As e p ar at e history p ar ag r ap h describing the chronic/acute condition t h at 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 t ime of the encounter. If t h er e is a portion of the physical exam that is not routinely perf ormed at the time of the preventive service, the provider should clearly identify those exam pieces (e.g., a thorough MS and neuro exam of the lef t hip perf ormed as it relates to the HPI).E. Conditions of Cov erage Reimbursement is dependent on, but not limited to, submitting Centers f or Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modif iers. Please ref er to the CMS f ee schedule f or appropriate codes. F. Related Polic ies/Rules Modif ier 25 Reimbursement policy G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 09/14/2022Date Revised Date Effective GA, IN, KY, WV: 12/01/2022 OH: 01/01/2023 Date ArchivedH. Ref erenc es1. Dr aak K. (2012 March 1). Successf ully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center. Retrieved August 9, 2022 f rom www.aapc.com. I. State-Spec if ic Inf orm ationA. Georgia 1. Ef f ective: 12/01/2022 B. Indiana 1. Ef f ective: 12/01/2022 C. Kentucky 1. Ef f ective: 12/01/2022 D. Ohio 1. Ef f ective: 01/01/2023 E. West Virginia Prev en ti v e Ev al uati o n an d Man ag emen t Serv i c es an d Ac ute Care Visit on Same Date of Ser v i c e-MP-PY-1388 Effec ti v e Date: 12/01/2022 Th e REIMBURSEMENT Policy Statemen t d etai l ed abo v e h as rec ei ved due c o ns id eratio n as defi n ed in th e REIMBURSEMENT Policy Statemen t Po l i c y an d i s approved. 1. Ef f ective: 12/01/2022
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 IN, GA, WV, KY: 11/01/2022-10/31/2023 OH: 12/01/2022-10/31/2023 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 I. State-Specific Information……………………………………………………………………………………….. 5 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 make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectModifier 59, XE, XP, XS, XU B. BackgroundReimbursement 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 f or claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are two-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modif iers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request.The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together, either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practi tioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance.The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service.Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review. A. For prepayment review, once the claim has been clinically validated, it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review.V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modi fier is available. Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty.A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 1. Are performed at different anatomic sites; and 2. Are not ordinarily performed or encountered on the same day; and 3. Cannot be described by one of the more specific anatomic NCCI Procedure to Procedure (PTP)-associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI). B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed during different patient encounters; and 2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (i.e., 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two timed procedures are performed during the same encounter but occur one after another (the first service m ust be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed at separate anatomic sites; or 2. Are performed at separate patient encounters on the same date of service. E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when: 1. The diagnostic procedure is the basis for performing the therapeutic procedure; and 2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and 3. Provides clearly the information needed to decide whether to proceed with the therapeutic procedure; and 4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.F. Modifiers XU (or 59, when applicable) may be used for a diagnostic procedure is performed after a therapeutic procedure only when: 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure; and 2. It occurs after the completion of the ther apeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires; and 3. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 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 even t of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/RulesModifier 25 ModifiersG. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date Archived GA, IN, KY, WV: 10/31/2023OH: 10/31/2023 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 H. References1. Centers for Medicare & Medicaid Services. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 24, 2022 from www.cms.gov. 2. Centers for Medicare & Medicaid Services. (2022 March). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. Rev. 11288. Retrieved June 24, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services (2022 March). MLN1783722-Proper Use of Modifiers 59 & – X{EPSU}. Retrieved July 12, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. Retrieved August 2, 2022 from www.cms.gov. 5. Centers for Medicare & Medicaid Services (2014 August). Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers for Distinct Procedural Services. Retrieved July 12, 2022 from www.cms.gov. I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effective: 11/01/2022 C. Kentucky Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Modifier 25-MP-PY-1363 IN, GA, WV, KY: 11/01/2022-10/31/2023 OH: 12/01/2022-10/31/2023 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 I. State-Specific Information ………………………………………………………………………………………. 5 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 di sease, 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 o f services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Polic y 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. Modifier 25-MP-PY-1363 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectModifier 25 B. BackgroundReimbursement 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 two-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 so me 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 Associatio n (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 significant, 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 se rvice 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. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier-57. 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 CPTModifier 25-MP-PY-1363 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the Amer ican Medical Association (AMA) that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Failure may result in prepayment and post-payment audit and unpaid claims. II. Provider claims billed with modifier-25 may be flagged for either a prepayment clinical validation or prepayment medical record coding audit and be selected for a post payment medical record review. Once the claim has been clinically validated, it is either released for payment or denied for incorrect use of the modifier.III. 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.IV. Appending modifier-25 to an E/M service is considered inappropriate in the following circumstances: 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 servi ce.Modifier 25-MP-PY-1363 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. H. The preventative E/M service is performed at the same time as a preventative care visit (e.g., 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. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, 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.F. Related Policies/RulesModifiers policy G. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2022 New PolicyDate Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date Archived GA, IN, KY, WV: 10/31/2023OH: 10/31/2023 This Policy is no longer active and has been archived. Please note that there could be oth er 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. H. References1. American College of Cardiology Foundation. (2022). Appropriate Use of Modifier 25. Retrieved June 17, 2022 from www.acc.org. 2. Centers for Medicare and Medicaid Services. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 17, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. CPT Modifier 25. Retrieved June 17, 2022 from www.palmettogba.com. 4. Centers for Medicare and Medicaid Services. (Rev. 11288, 2022, March 4). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. Modifier 25-MP-PY-1363 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5. Retrieved June 17, 2022 from www.cms.gov. 6. Felger TA, Felger M. Understanding when to use modifier-25. Fam Pract Manag. 2004;11(9):21-22. Retrieved June 17, 2022 from www.aafp.org.I. State-Specific Information A. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effective: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
REIMBURSEMENT POLICY STATEMENT Marketplace Policy Name & Number Date Effective Chiropractic Care-MP – PY-1358 IN, GA, WV: 11/01/2022-12/31/2023 OH: 12/01/2022-12/31/2023 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Ohio West Virginia Table of ContentsA. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 I. State-Specific Information……………………………………………………………………………………….. 5 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 developi ng 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 serv ices 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 make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Chiropractic Care-MP-PY-1358 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be det ermined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. DefinitionsChiropractor A Doctor of Chiropractic w ho is duly licensed and qualified to provide chiropractic services. Chiropractic Therapy Therapy that focuses on the joints of the spine and the nervous system, while osteopathic therapy includes equal emphasis on the joints and surrounding muscles, tendons and ligaments. Manipulation Therapy Osteopathic/chiropractic therapy used for treating problems associated with bones, joints and the back. Medically Necessary/Medical Necessity Health care services that a provid er would render to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (i) in accordance with generally accepted standards of medical practice; and (ii) clinically appropriate in terms of type, frequency, extent, and duration. D. PolicyI A covered chiropractic service that is legally performed will not be denied when such covered service is rendered by an in-network licensed chiropractor in the state that the covered service is performed. II. All services are subject to members share of cost (deductible, co-insurance and/or co-pays). This varies based on the members plan enrolled at the time of service.III. When manipulation services are provided in addition to an evaluation and management (E/M) office visit, modifier 25 should be appended to the E/M code. This distingui shes a significant, separately identifiable E/M office visit from the additional manipulation service.Chiropractic Care-MP-PY-1358 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. IV. Scope of practice A. Chiropractors must follow their states scope of practice. Any training or certification required by the state must be available to CareSource, upon request.V. Chiropractic patients whose diagnosis is not within the chiropractic scope of practice, shall be referred, by the chiropractor, to a medical doctor or other licensed health practitioner for treatment of that condition. VI. Manipulation therapy A. Includes chiropractic manipulation therapy used for treating problems associated with bones, joints and the back. Chiropractors would be limited to subluxations of the articulations of the human spine and its adjacent tissue. B. Annual benefit limits apply. It is the providers responsibility to validate the available remaining quantity before render ing service. Manipulations performed will be counted toward any maximum for manipulation therapy services as specified in the members Evidence of Coverage (EOC) or Schedule of Benefits regardless if: 1. Billed as the only procedure; or 2. Done in conjunction with an exam and billed as an office visit. C. The members plan does not provide benefits for manipulation therapy services provided in the home as part of Home Health Care Services. D. Modifier AT is required to be appended to any manipulation code. E. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patients neuromusculo skeletal condition.VII. All codes contained within this policy are not all inclusive but provide a general reference of covered codes based on what chiropractors are allowed to perform within their state. Codes contained within this policy that may or may not require a prior authorization should be confirmed by accessing the Provider Look-up Tool on the CareSource website (www.procedurelookup.caresource.com).VIII. The following are a list of codes that may be covered and do not require a prior authorization: A. Evaluation and management (E/M) codes (99202-99204, 99211-99214)B. 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions C. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions D. 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions E. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions F. X-rays (radiologic examination (RE)) for diagnostic purposes: 1. 72020 RE, spine, single view, specify level 2. 72040 RE, spine, cervical; 2 or 3 views 3. 72050 RE, spine, cervical; 4 or 5 views 4. 72052 RE, spine, cervical; 6 or more views 5. 72070 RE, spine; thoracic, 2 views 6. 72072 RE, spine; thoracic, 3 views 7. 72074 RE, spine; thoracic, minimum of 4 views 8. 72080 RE, spine; thoracolumbar junction, minimum of 2 views Chiropractic Care-MP-PY-1358 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 9. 72081 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); one view 10. 72082 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views 11. 72083 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 4 or 5 views 12. 72084 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); minimum of 6 views 13. 72100 RE, spine, lumbosacral; 2 or 3 views 14. 72110 RE, spine, lumbosacral; minimum of 4 views 15. 72114 RE, spine, lumbosacral; complete, including bending views, minimum of 6 views 16. 72120 RE, spine, lumbosacral; bending views only, 2 or 3 views 17. 72170 RE, pelvis; 1 or 2 views 18. 72190 RE, pelvis; complete, minimum of 3 views 19. 72200 RE, sacroiliac joints; less than 3 views 20. 72202 RE, sacroiliac joints; 3 or more views 21. 72220 RE, sacrum and coccyx, minimum of 2 views 22. 73000 RE; clavicle, complete 23. 73010 RE; scapula, complete 24. 73020 RE, shoulder; 1 view 25. 73030 RE, shoulder; complete, minimum of 2 views 26. 73050 RE; acromioclavicular joints, bilateral, with or without weighted distraction 27. 73501 RE, hip, unilateral, with pelvis when performed; 1 view 28. 73502 RE, hip, unilateral, with pelvis when performed; 2-3 views 29. 73503 RE, hip, unilateral, with pelvis when performed; minimum of 4 views 30. 73521 RE, hips, bilateral, with pelvis when performed; 2 views 31. 73522 RE, hips, bilateral, with pelvis when performed; 3-4 views 32. 73523 RE, hips, bilateral, with pelvis when performed; minimum of 5 views 33. 73551 RE, femur; 1 view 34. 73552 RE, femur; minimum 2 viewsIX. Codes that may be covered but require a prior authorization: A. 97010 hot or cold packs B. 97012 traction C. 97014 electrical stimulation D. 97035 ultrasound E. 97139 unlisted therapeutic procedure F. 97140 manual therapy techniqueChiropractic Care-MP-PY-1358 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. X. Exclusions/services not covered for Chiropractors: A. 20560 needle insertion(s) without injection(s); 1 or 2 muscle(s) -dry needling B. 20561 needle insertion(s) without injection(s); 3 or more muscles-dry needling 1. CareSource follows the Center for Medicare and Medicaid (CMS) analysis stating that acupuncture includes dry needling. 2. Acupuncture is not a covered benefit.E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 Reimbursement policy G. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022 New policy. Replaces individual marketplace policies. Date Revised Date Effective GA, IN, WV: 11/01/2022 OH: 12/01/2022 Date Archived GA, IN, WV: 12/31/2023OH: 12/31/2023 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 Pol icy. H. References1. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Use of the AT modifier for Chiropractic Billing (May 7, 2019). Retrieved 07/25/2022 from www.cms.gov. 2. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Local Coverage Determination (LCD L37254). Chiropractic Services (February 3,2022). Retri eved 07/25/2022 from www.cms.gov. 3. National Coverage Analysis for Acupuncture for Chronic Low Back Pain CAG-00452N. January 21, 2020. Retrieved 07/25/2022 from www.cms.gov. 4. The Association of Chiropractic Colleges. (n.d.). Chiropractic Paradigm/Scope & Practice. Retrieved 07/25/2022 from www.chirocolleges.org. I. State-Specific Information A. Georgia 1. Effective: 11/01/2022 2. References a. 2020 Georgia Code. Title 43-Professions and Businesses. Chapter 9 Chiropractors. 43-9 -1. Definitions. Retrieved 07/25/2022 from www.law.justia.com. Chiropractic Care-MP-PY-1358 Effective Date: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. b. 2020 Georgia Code. Title 43-Professions and Businesses. Chapter 9 Chiropractors. 43-9 -16. Scope of Practice; Injury From Want of Reasonable Degree of Care Is a Tort. Retrieved 07/25/2022 from www.law.justia.com. c. MARKETPLACE PLAN Georgia Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-ga-basic-eoc. B. Indiana 1. Effective: 11/01/2022 2. References a. 2020 Indiana Code. Title 25 ARTICLE 10. Chapter 1. Regulation of Chiropractors IC 25-10-1-1. Definitions. Retrieved 07/25/2022 from www.iga.in.gov. b. 2020 Indiana Code. Title 25 ARTICLE 10. Chapter 1. Regulation of Chiropractors IC 25-10-1-17. Authority to diagnose and treat injuries, conditions, and disorders. Retrieved 07/25/2022 from www.iga.in.gov. c. MARKETPLACE PLAN Indiana Evidence of Coverage 2022. C. Ohio 1. Effective: 12/01/2022 2. References a. Ohio Revised Code/Title 47 Occupations-Professions/Chapter 4734 Chiropractors. Section 4734.01 | Practice of chiropractic defined. Retrieved 07/25/2022 from www.codes.ohio.gov. b. Ohio Revised Code/Title 47 Occupations-Professions/Chapter 4734 Chiropractors. Section 4734.15 | Scope of practice of chiropractic . Retrieved 07/25/2022 from www.codes.ohio.gov. c. MARKETPLACE PLAN Ohio Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-oh-basic-eoc. D. West Virginia 1. Effective: 11/01/2022 2. References a. WEST VIRGINIA CODE CHAPTER 30. PROFESSIONS AND OCCUPATIONS. ARTICLE 16. CHIROPRACTORS. 30-16-18. Scope of practice; chiropractic assistants; expert testimony. Retrieved 07/25/2022 from www.code.wvlegislature.gov. b. WEST VIRGINIA CODE CHAPTER 30. PROFESSIONS AND OCCUPATIONS. ARTICLE 16. CHIROPRACTORS. 30-16-20. Use of physiotherapeutic devices; electrodiagnostic devices; specialty practice. Retrieved 07/25/2022 from www.code.wvlegislature.gov. c. MARKETPLACE PLAN West Virginia Evidence of Coverage 2022. www.caresource.com/documents/marketplace-2022-wv-basic-eoc/
Reimbursement Policy Statement: 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 – stan dard 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, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfun ction 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. Med ically 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., Eviden ce 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 (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitat ions that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Standard Medical Billing Guidance PY-PHARM-0128-IN – MP 07-22-2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. . 2 B. Background ………………………….. ………………………….. ………………………….. …………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……………….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ……. 4 H. References ………………………….. ………………………….. ………………………….. ……………………… 5 2 A. SubjectStandard Medical Billing Guidance Standard Billing Reimbursement Statement INDIANA MARKETPLACE PY-PHARM-0128-IN-MP Effective Date: 07-22-2022 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submit ting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 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. This reimbu rsement policy applies to all health care services reported using theCMS1500 Health Insurance Professional Claim Form (a/k/a HCFA), the CMS 1450 Health Insurance Institutional Claim Form (a/k/a UB04) or its electronic equivalent or any successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Additionally, this policy applies to drugs and biologicals being used for FDA-approved indications or labels. Drugs and biologicals used for indications other than those in the approved labeling may be covered if it is determined that the u se is medically accepted, taking into consideration the major drug compendia, authoritative medical literatures and/or accepted standards of medical practice. C. Definitions Indication is defined as a diagnosis, illness, injury, syndrome, condition, or other clinical parameter for which a drug may be given. is defined as birth before 37 weeks of gestation. FDA approved Indication/Label is the official description of a drug product which includes indication (what the drug is used for); who should take it; adve rse events (side effects); instructions for uses in pregnancy, children, and other populations; and safety information for the patient. Labels are often found inside drug product packaging. Off-label/Unlabeled use of a drug is defined as a use for a non-FDA approved indication, that is, one that is not listed on the drugs official label/prescribing information. Off-label use is further defined as giving the drug in a way that deviates significantly from the labeled prescribing information for a particular indication. This includes but is not necessarily limited to, dosage, route of administration, duration and frequency of administration, and population to whom the drug would be administered. 3 Standard Billing Reimbursement StatementINDIANA MARKETPLACE PY-PHARM-0128-IN-MP Effective Date: 07-22-2022 Unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is indicated on the official label. Drug compendia , defined as summaries of drug information that are compiled by experts who have reviewed clinical data on drugs. CMS (Center for Medicare and Medicaid Services) recognizes the following compendia: American Medical Association Drug Evaluations (AMA-DE), United States Pharmacopoeia-Drug Information (USP-DI) or its successor publication and American Hospital Formulary Service-Drug Information (AHFS-DI) as authoritative sources for use in the determination of a “medically-accepted indication” of drugs and biologicals used off – label in an anticancer chemotherapeutic regimen. The USP DI is a database of drug information developed by the U.S. Pharmacopoeia but maintained by Micromedex, which contains medically accepted uses for generic and brand name drug products D. PolicyCareSource requires t hat the use of a drug or biological must be safe and effective and otherwise reasonable and necessary. Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this requirement when used for indications specified on the labeling. Therefore, reimbursement may be provided for the use of an FDA approved drug or biological, if: It was administered on or after the date of the FDAs approval; It is reasonable and necessary for the individual patient; and All other applicable coverage requirements are met. An unlabeled use of a drug is a use that is not included as an indication on the drug’s label as approved by the FDA. FDA approved drugs used for indications other than what is ind icated on the official label may be covered if it is determined that the use is medically necessary, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. The following guideline s identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice. Not for Particular Illness Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered (except for certain immunizations.) Route of Administration Not Indicated Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. Excessive Medications Medications administered for treatment of a disease which exceed the frequency or duration of dosing indicated by accepted standards of medical pra ctice are not covered. Effective January 1, 1994, off-label, medically accepted indications of Food and Drug Administration -(FDA) approved drugs and biologicals used in an anti-neoplastic chemotherapeutic regimen are identified under the indications descri bed below. A 4 Standard Billing Reimbursement StatementINDIANA MARKETPLACE PY-PHARM-0128-IN-MP Effective Date: 07-22-2022 regimen is a combination of anti-neoplastic agents clinically recognized for the treatment of a specific type of cancer. Off-label, medically accepted indications are supported in either one or more of the compendia or in peer-reviewed medical literature. E. Conditions of CoverageA medically accepted indication is one of the following: An FDA approved, labeled indicat ion or a use supported in the American Hospital Formulary Service Drug Information (AHFS-DI), NCCN Drugs and Biologics Compendium, Truven Health Analytics Micromedex Drug Dex , Elsevier/Gold Standard Clinical Pharmacology and Wolters Kluwer Lexi – Drugs as the acceptable compendia based on CMS’ Change Request 6191 (Compendia as Authoritative Sources for Use in the Determination of a “Medically Accepted Indication” of Drugs and Biologicals Used Off-Label in an Anti-Cancer Chemotherapeutic Regimen); or Articles of Local Coverage Determinations (LCDs) published by CMS. In general, a use is identified by a compendium as medically accepted if the: Indication is a Category 1 or 2A in NCCN, or Class I, Class IIa, or Class IIb in DrugDex; or, Narrative text in AHFS-DI or Clinical Pharmacology is supportive, or Indication is listed in Lexi-Drugs as Use: Off-Label and rated as Evidence Level A A use is not medically accepted by a compendium if the: Indication is a Category 3 in NCCN or a Class III in DrugDex; or, Narrative text in AHFS or Clinical Pharmacology is not supportive, or Indication is listed in Lexi-Drugs as Use: Unsupported If a use is identified as not indicated by CMS or the FDA, or if a use is specifically identified as not indicated in one or more of the compendia listed, or if it is determined, based on peer-reviewed medical literature, that a particular use of a drug is not safe and effective, the off-label use is not supported and the drug will not be co vered. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate IssuedDate Revised Date Effective 07-22-2022 Date Archived 5 Standard Billing Reimbursement StatementINDIANA MARKETPLACE PY-PHARM-0128-IN-MP Effective Date: 07-22-2022 1. Drugs@FDA Glossary of Terms https://www.fda.gov/drugs/drug-approvals-and-databases/drugsfda-glossary-terms 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals 3. United States Federal Food, Drug and Cosmetic Act https:/ /www.f da.gov/regulatory-information/laws – enforced-fda/federal-food-drug-and-cosmetic-act-fdc-act The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. H. References
REIMBURSEMENT POLICY STATEMENT Indiana Marketplace Policy Name & Number Date Effective Interest Payments-IN MP-PY-1318 08/01/2022-06/30/2023 Policy Type REIMBURSEMENT 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 …………………………………………………………………………………………………………… 3 Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illne ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan cont ract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this 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. Interest Payments – IN MP-PY-1318 Effective Date: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectInterest Payments B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify 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 provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. DefinitionsAdjusted 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 regulat ion defining timeliness and interest requirements. D. Policy 1. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. (IC 12.15.21.3, IC 27.13.36.2.4 ) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims starts on the date the provider disputes the original payment with CareSource. IV. 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 allottedInterest Payments – IN MP-PY-1318 Effective Date: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. V. CareSource only pays interest on claim payment that is occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI. CareSource performs regular reviews of paid claims to correct claim payment. A. Reviews can include items, such as retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Reviews 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. 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. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/31/2021 New Policy Date Revised 04/27/2022 No changes; Updated references Date Effective 08/01/2022 Date Archived 06/30/2023 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 P olicy. H. References1. Bureau of the Fiscal Service. (2013, January-2021, June). Interest Rates. Retrieved April 6, 2022 from www.fiscal.treasury.gov. 2. Centers for Medicare & Medicaid Services. (2019, January). Notice of New Interest Rate for Medicare Overpayments and Underpayments-2nd Qtr. Retrieved April 6, 2022 from www.cms.gov. 3. Federal Register. Prompt Payment Interest Rate; Contract Disputes Act. Retrieved April 6, 2022 from www.fiscal.treasury.gov. 4. Indiana General Assembly. (2021). IC 27-13-36.2-4. Retrieved April 6, 2022 from www.iga.in.gov. 5. Justia US Law. (2021). 2018 Indiana Code Title 12. Human Services Article 15. Medicaid Chapter 21. Rules 12-15-21-3. Required rules.Retrieved April 6,Interest Payments – IN MP-PY-1318 Effective Date: 08/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2022 from www.justia.com/codes/indiana. 6. Legal Information Institute. 42 CFR 422.520-Prompt payment by MA organization. Retrieved April 6, 2022 from www.law.cornell.edu. 7. Social Security Association. Sec 1816(c)(2)(B. Retrieved April 6, 2022 from www.ssa.gov. 8. Social Security Association. Sec 1842(c)(2)(B). Retrieved April 6, 2022 from www.ssa.gov. 9. United States Government Publishing Office. Title 31, Section 3902. Retrieved April 6, 2022 from www.govinfo.gov. 10. United States Government Publishing Office. Title 42, Section 7109. Retrieved April 6, 2022 from www.govinfo.gov.The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY ST AT EMENT Indiana Marketplace Policy Name & Number Date Effective Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center IN MP PY-1305 06/01/2022-02 /2 8/ 2023Policy TypeREIMBURSEMENT Table of ContentsA. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..4 E. Conditions of Co v er ag e ………………………………………………………………………………………..6 F. Related Policies/Rules ………………………………………………………………………………………….6 G. Review/Revision His t or y ……………………………………………………………………………………….6 H. Ref er en ce s …………………………………………………………………………………………………………7 Reimbursement Po licie s prepared by CareSource and its a ffilia te s a re intended to provide a general reference regarding b illin 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 su bject to member benefits a n d e lig ib ility 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 limite d to, those health c are services or supplies that are proper and necessary for the diagnosis or treatment of disease, i lln e ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and disco mf o rt . These services meet the standards of good me dica l practice in the local area, are the lowest cost alternative , and are not provided mainly for the convenience of the member o r provider. Me d ica 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. Th is 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 Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its a ffilia te s ma y use reasonable discretion in interpreting and applyi ng th is 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 t reatment of a behavioral health disorder will not be subject to any limita tio n s that are less favorable than the limita tio n s that apply to medical conditions as covered under this policy. Den tal Pro c ed ures in Hospital Outpatient Fac ili ty or Ambul atory Surgery Center IN MP PY-1305 Effec ti v e Date: 06/01/2022 Th e REIMBURSEMENT Po l i c y Statement d etail ed abo v e h as rec eiv ed d ue c o nsi deration as d efined in th e REIMBURSEMENT Po l i c y Statemen t Policy and is ap prov ed. A. Subjec tDental Procedures in a Hospital, Ou t pa tie nt Facility or Amb u lat ory Su rg ery Center B. Bac k groundReimbursement policies are designed to assist physicians submitting claims to CareSource. They ar e routinely updated to promote ac c u r at e coding an d policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f o r claims ma y be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their office s t af f ar e 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) f or 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. Most dental care can be provided in a traditional dental of f ice setting with local anesthesia and if medically necessary, a continuum of behavior guidance strategies, ranging f rom simple communicative techniques to nitrous oxide, enteral or parenteral seda tion. Monitored anesthesia c ar e or sedation (minimal, moderate, or deep) may be a requirement of some patients including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations or other special needs. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia in a healthcare f ac ility such as an ambulatory surgical center or outpatient hospital f acility.C. Def initionsAmbulatory Surgical Center (ASC) – A health care f acility that specializes in providing surgery, pain management and certain diagnostic (e.g., colonoscopy) services i n an outpatient setting. In simple terms ambulatory surger y center procedures are more intensive than those done in the average doctors office but not so intensive as to require a hospital stay. o Sec. 14. (a) Def inition "Ambulatory outpatient surgical center", f or p u r poses of IC 16-21, IC 16-32-5, and IC 16-38-2, means a public or private institution that meets the conditions listed in Indiana Code IC 16-18-2-14. o Any f acility that meets the def inition of an ambulatory outpatient surgical center f ound in Indiana Code IC 16-18-2-14 "Ambulatory outpatient surgical center" mu st be licensed by the Indiana State Department of Health (ISDH) on an annual basis. Hospital-A health care f acility that generally is an institution, a p lac e , a building, or an agency that holds out to the general public t h at it is operated f or hospital purposes and that it provides care, accommodations, f acilities, and equipment, in connection with the services of a physician, to individuals who may need medical or surgical services. Any f acility that meets the def inition of Den tal Pro c ed ures in Hospital Outpatient Fac ili ty or Ambul atory Surgery Center IN MP PY-1305 Effec ti v e Date: 06/01/2022 Th e REIMBURSEMENT Po l i c y Statement d etail ed abo v e h as rec eiv ed d ue c o nsi deration as d efined in th e REIMBURSEMENT Po l i c y Statemen t Policy and is ap prov ed. a hospital f ound in Indiana Code 16-18-2-17 9 mu st be licensed by the Indiana State Department of Health (ISDH). o Inpatient Hospital-A f acility, other than psychiatric, which primarily provides diagnostic, therapeutic ( b ot h s u r gic al an d nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted f or a variety of medical conditions. o Off Campus Outpatient Ho s p it a l-A portion of an of f-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. o On Campus Outpatient Hospital-A portion of a hospitals main campus which provides diagnostic, therapeutic ( b ot h s u r gic al an d nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. o Short Procedure Un it (SPU ) – A unit of a hospital organized f or the delivery of ambulatory surgical, diagnostic or medical services. Medically Necessary-The health insurance exchange defines medically necessary services as health care services or supplies that are needed to diagnose or t r e at an illness, injury, condition, d is eas e , or its symptoms and that meet accepted standards of medicine. As outlined by the Centers for Medicare & Medicaid Services (CMS), medically necessary services or supplies: o Are proper an d needed for the diagnosis or treatment of a medical condition. o Are provided f or the diagnosis, d ir ec t c ar e , an d treatment of a medical condition. o Meet the standards of good medical practice in the lo c al ar e a and are not mainly f or the convenience of the patient or the physician. Minimal Sedation (Anxiolysis ) – A drug-induced state during which patients respond normally to verbal commands. Although cognitive f unction and physical coordination may b e impaired, air way ref lexes an d ventilatory an d cardiovascular f unctions are unaf fected. Moderate Sedation (Analgesia) (Conscious Sedation) – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions ar e required to main t ain a patent air way and spontaneous ventilation is adequate. Cardiovascular f unction is usually maintained. Ref lex withdrawal f rom a painf ul stimulus is NOT considered a purposeful response. Monitored Anesthesia Care (MAC) – Does not describe the continuum of depth of sedation; rather it describes a specif ic anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.Deep Sedation (Analgesia) – A dr ug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully f ollowing repeated or painf ul stimulation. The ability to independently maintain ventilatory f unction may be impaired. Patients may require assis tance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular f unction is usually maintained. Den tal Pro c ed ures in Hospital Outpatient Fac ili ty or Ambul atory Surgery Center IN MP PY-1305 Effec ti v e Date: 06/01/2022 Th e REIMBURSEMENT Po l i c y Statement d etail ed abo v e h as rec eiv ed d ue c o nsi deration as d efined in th e REIMBURSEMENT Po l i c y Statemen t Policy and is ap prov ed. General Anesthesia-A drug-induced loss of consciousness during which patients are not arousable, even by painf ul stimulation. The ability to independently main t ain ventilatory f unction is of ten impaired. Patients of ten require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilat ion or drug-induced depression of neuromuscular f unction. Cardiovascular f unction may be impaired.NOT E: Because sedation is a continuum, it is not alway s possible to predict how an individual patient will respond. Practitioners intending to produce a giv en level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescue patients who enter a state of deep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescue patients who enter a state of general anesthesia.D. Polic yRescue of a patient f rom a deeper level of sedation t h an intended is an intervention by a practitioner proficient in airway management and advanced lif e support. The qualif ied practitioner corrects adverse physiologic consequences of the deeper-t han-intended level of sedation (such as hypoventilation, hypoxia, and hypotensi on) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. Most dental care and/or oral surgery is ef fectively provided in an of fice setting. However, some members may have a qualif ying condition that requires the procedure be provided in a hospital setting or ambulatory surgical center under general anesthesia. The purpose of this document is to provide reimbursement and billing guida nce f or f acility related services when dental procedures are rendered in a hospital or ambulatory surgery center (ASC) place of service (POS) under general anesthesia. Hospital inpatient or outpatient f acility services and ASC f acility services f or the provision of dental care under general anesthesia ar e addressed in this policy, not dental c ar e or o r al surgery in an of f ice setting. Professional dental services are covered only to the extent t h at the member has dental benef its and guidelines for dental services are provided in the CareSource Dental Of f ice Reference and Policy Manual. CareSource policy notes the intent of hospital, outpatient, and ASC f acility requests is the medical necessity of general anesthesia services to perform dental procedures on a member. Requests with the goal of no, minimal, moderate or deep sedation services, will only be considered in extenuating circumst ances mandated by systemic disease f or which the patient is under current medical management and which increases the probability of complications, such as respiratory illness, cardiac conditions, or bleeding disorders. Medical record and physician attested letter would be required with authorization requests.Den tal Pro c ed ures in Hospital Outpatient Fac ili ty or Ambul atory Surgery Center IN MP PY-1305 Effec ti v e Date: 06/01/2022 Th e REIMBURSEMENT Po l i c y Statement d etail ed abo v e h as rec eiv ed d ue c o nsi deration as d efined in th e REIMBURSEMENT Po l i c y Statemen t Policy and is ap prov ed. Dental services ar e only covered in a hospital setting when the nature of the surgery o r the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting and the inpatient or outpatient service is a Health Insurance Marketplace covered service. As such, it would exclude any diagnostic or preventive dental services delivered in a hospital setting, if these services ca nnot be perf ormed in office. I. Dental Prior Authorization Process A. A prior authorization is required f o r all dental services performed in a hospital inpatient or outpatient f acility, or an ambulatory surgery center facility. B. Dental services authorization f or an outpatient/ASC setting: 1. Requests f or dental services under general anesthesia are submitted to DentaQuest Dental Utilization Review. 2. DentaQuest reviews f or appropriate medical necessity requirements (listed in the DentaQuest Dental Of f ice Reference Manual) f or general anesthesia or f or IV sedation in the outpatient h o s pit al or ASC setting. 3. If service request does not meet medical necessity criteria, the Notice of Adverse Benef it Determination (Denial Notice) is issued by DentaQuest. 4. If dental procedure(s) and the general anesthesia/sedation in the outpatient hospital or ambulatory surgery center are approved, DentaQuest will send an automated approval letter to the requesting dentist and this can be v iewed in the DentaQuest provider portal. C. Facility Authorization Process 1. Upon approval, DentaQuest participating providers ar e required to administer services at CareSource participating hospitals/f acilities. Upon receipt of approval f rom DentaQuest, the pr ovider should use the inf ormation below for f acility authorization as applicable. 2. For f acility administrative pre-certification, the ( h o s pit al or ASC f acility) may : a. Submit the request on the CareSource Provider Po r t al at CareSource.com >Login >Provider Portal; or b. Request a Facility Certif ication by calling CareSource directly at: CareSource: 800.488.0134 and select option to Request an Authorization (if immediate precertification needs). NOTE: The request should Include the facility services requested, the Dental Authorization Approval Letter and the dental authorization number. 3. CareSource Medical Utilization Management t e am will complete ALL of the f ollowing: a. Verif y t h at the f acility is in network; b. Review the dental pre-determination letter (PDL) or au t h or iz at ion ;c. Determine medical necessity f or any other f acility-r elat e d CPT/HCPCS codes submitted that require PA; d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider portal. Den tal Pro c ed ures in Hospital Outpatient Fac ili ty or Ambul atory Surgery Center IN MP PY-1305 Effec ti v e Date: 06/01/2022 Th e REIMBURSEMENT Po l i c y Statement d etail ed abo v e h as rec eiv ed d ue c o nsi deration as d efined in th e REIMBURSEMENT Po l i c y Statemen t Policy and is ap prov ed. NOTE: The f act that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim f o r a procedure, item or service does not, in an d of itself make the procedure, item, or service medically necessary and does not guarantee payment f or it.E. Conditions of Cov erageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule f or appropriate codes. The f ollowing information is provided as a ref erence. This list may not be all inclusive and is subject to updat e s : Outpatient Hospital Facility (SPU) POS (19, 22); Ambulatory Surgical Center POS (24) o Use CPT code 41899 as facility fee c o de. Will be paid according to CareSource c o nt r ac t an d the Me dic ar e Physician Fee Schedule (PF S). Dental-related f acility charges mu st be billed on an institutional claim (UB-04 claim f orm, Portal institutional claim, 837I transaction). o Use CPT 00170 for anesthesia for in t raoral treatments, including b i o psy. Will be paid according to CareSource c o nt r ac t an d the Me dic ar e Physician Fee Schedule (PF S). All associated prof essional services, such as radiology an d anesthesia, as well as an c illar y services related to the dental services, must be billed on a prof essional claim (CMS-1500 claim f orm or electronic equivalent). Inpatient Hospital Facility POS (21) o All services as well as any additional room and board f ees would h av e to be pre-certif ied and receive medical necessity review. Services are subject to benefit provisions and criteria f or dental hospital admissions f or both adult and pediatric members is in accordance with CareSource and Dental Benef its Administrator clinical guidelines. Dental/Oral Su rg ery Professional Services o The scope of this policy is limited to medical plan coverage of the f acility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. The professional dental procedure codes listed are f or ref erence only and do not imply coverage of dental procedures. Inf ormation on dental benefits, please consult the DentaQuest Of fice Reference Manual f or clinical guidelines, policies, and procedures.F. Related Polic ies/RulesNAG. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 01/20/2021 New PolicyDen tal Pro c ed ures in Hospital Outpatient Fac ili ty or Ambul atory Surgery Center IN MP PY-1305 Effec ti v e Date: 06/01/2022 Th e REIMBURSEMENT Po l i c y Statement d etail ed abo v e h as rec eiv ed d ue c o nsi deration as d efined in th e REIMBURSEMENT Po l i c y Statemen t Policy and is ap prov ed. Date Revised 01/28/2022 Annual review. Removed tables, removed d en tal codes, simplif ied coding information Date Effective 06/01/2022 Date Archived 02/28/2023 This Policy is no longer active an d h as been archived. Please note t h at there could be other Policies t h at may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f o r mal documented Policy. H. Ref erenc es1. American Academy of Pediatric Dentistry. Oral Health Policies and Recommendations (The Ref erence Manual of Pediatric Dentistry). (2021-2022). Retrieved January 28, 2022 f rom www.aapd.org. 2. Continuum of Depth of Sedation: Definition of General Anesthesia an d Levels of Sedation/Analgesia. (2019, October 23). Retrieved January 28, 2022 f rom www.asahq.or g. 3. Indiana Department of Health. Ambulatory Outpatient Surgical Centers (ASC) Licensing and Certif ication Program. Retrieved January 28, 2022 f rom www.in.gov . 4. Indiana General Assembly. Indiana Code. Updated November 9, 2021. Retrieved January 28, 2022 f rom www.iga.in.gov .
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Payment to Out of Network Providers-IN MP-PY – 1341 05/01/2022 Policy Type REIMBURSEMENT 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 add ition 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 referra l, 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 practi ce in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Covera ge 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 Evi dence 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 d etermination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Payment to Out of Network Providers-IN MP-PY-1341 Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectPayment to Out of Network Providers 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 verif y a 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 beingprovided. The inclusion of a code in this policy does not imply an y right to reimbursement or guarantee claims payment. This policy is intended to define the reimbursement rate for claims received fromproviders who are not contracted (out of network) providers with CareSource.C. Definitions Emergency Services Emergency health care services are used to treat an emergency medical condition. Emergency Medical Condition A medical condition that manifests itself by signs and symptoms of sufficient severity or acuity, including severe pain, su ch that a prudent layperson would reasonably have cause to believe constitutes a condition that the absence of immediate medical attention could reasonably be expected to result in: o Placing the health of the individual or, with respect to a pregnant woman , the health of the woman or her unborn child, in serious jeopardy; o Serious impairment to bodily functions; or o Serious dysfunction of any bodily organ or part. Unanticipated Out-of-Network Care Health care services, including clinical laboratory servi ces, that are covered under a health benefit plan and that are provided by an out-of-network provider when either of the following conditions applies: o The covered person did not have the ability to request such services from an in – network provider. o The s ervices provided were emergency services. Payment to Out of Network Providers-IN MP-PY-1341 Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.D. PolicyServices provided by out-of-network providers are not covered under Marketplace Plans, however, exceptions exist. For those situations where CareSource is required to provide out-of-network coverage and the reimbursement methodology is not defined, CareSources standard reimbursement will be as follows: I. Preauthorized, medically n ecessary services rendered to CareSource members by out-of-network providers will be reimbursed a s follows : A. Rates established via Medicare pricing . B. If a service or procedure is covered by CareSource and not priced by Medicare or Medicaid, CareSource will use the Indiana Custom Fee Schedule for Indiana Marketplace payment determinations. C. If the code is not on the Medicare fee schedule, or the custom fee schedule, it will be reimbursed at 135 % of the Indiana Medicaid fee schedule. D. If a service o r procedure is not priced by Medicare or Medicaid, then it will be reimbursed to the provider at 35% of billed charges. II. In the event of emergency services and unanticipated out of network care,CareSource will adhere to the Federal No Surprises Act , January 1, 2022 . A. No prior authorization is required for emergency services. B. Reimbursement rates for out of network services will be paid per the I ndiana House Bill 1004 at the usual and customary established rate. III. In the event of any conflict between this policy and a providers agreement with CareSource, the providers agreement will be the governing document.IV. Exclusions:A. Provider types whose reimbursement methodology is mandated by state/federalregulati on/statute or rule or directive. B. Emergency health care services will be reimbursed based on state regulations. E. 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. F. Related Policies/Rules Evidence of Coverage and Health Insurance Contract Indiana G. Review/Revision History DATE ACTIONDate Issued 01/19/2022 New policyDate Revised Date Effective 05/01/2022 Date Archived Payment to Out of Network Providers-IN MP-PY-1341 Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. References1. B. Fuchs, J. Hoadley. January 19, 2021. Summary of the No Surprises Act. January 1, 2021. Retrieved 1 2/16/2021 from www.commonwealthfund.org. 2. IN Code 27-1-45-8 (2020) . Out of Network Practitioner Providing Services at in Network Facility; Reimbursement; Notice; Explanation of Costs if Exceeds Estimate; Emergency Rules . Retrieved on 12/16/2021 from www.law.justia.com . 3. IN Code 12-15-12 (2020). Managed Care . Retrieved on 12/16/2021 from www.law.justia.com. 4. IN Code 25-1-9-23 (2020) . In Network Practitioner Charges; Good Faith Estimates; Requirements; Reimbursement of Out of Network Practitioners; Notice; Explanation of Costs Exceeding Estimate; Exemption; Rules . Ret rieved on 12/16/2021 from www.law.justia.com . 5. Indiana General Assembly 2020 Session. House Bill 1004. Retrieved on 12/16/2021 from www.iga.in.gov. 6. No Surprises Act of the 2021 Consolidated Appropriations Act. Pub. L. No. 116-260, 134 Stat. 1182, Division BB, 109. Retrieved 1 2/16/2021 from www.congress.gov .
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406 05/01/2022 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 methodolo gy, 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 ser vices 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 mo rbidity, 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 co nvenience 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 pol icies 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 an d applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectScreening and Surveillance for Colorectal Cancer 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 a re 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. The evidence is convincing that appropriate screening reduces colorectal cancer mortality in adults 50-75 years of age. The benefit of early detection of and intervention for color ectal cancer declines after 75 years of age . African Americans have been shown to have higher colorectal cancer rates of incidence , and it is recommended by both the American College of Gastroenterology and the American Society for Gastrointestinal Endosco py that screening begin at 45 years of age. 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 guarant ee claims payment. C. Definitions Colorectal Cancer Screening – Detects early stage colorectal cancer and precancerous lesions in asymptomatic members with an average risk of colorectal cancer. Surveillance for Colorectal Cancer Close observation f or mem bers who are at increase d or high risk for colorectal cancer. Average risk – Per American Cancer Society Guidelines, members who are at average risk for colorectal cancer do not have the following : o Personal history of colorectal cancer or certain types of polyps; o Family history of colorectal cancer; o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease); o A confirmed or suspected hereditary colorectal cancer syndrome (i.e. familial adenomatous polyposis or Lynch syndrom e); or o Personal history of getting radiation to abdomen or pelvic area to treat prior cancer. Increased or high risk – Per American Cancer Society Guidelines, members who are at increased or high risk for colorectal cancer include the following : o Strong family history of colorectal cancer or certain types of polyps; o Personal history of colorectal cancer or certain types of polyps; o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease); Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.o Family history of a hereditary colorectal cancer syndrome such as familial; adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditary non-pol yposis colon cancer or HNPCC); or o Personal history of radiation to the abdomen or pelvic area to treat a prior cancer. D. Policy I. 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 forty-five years of age if a t risk for colorectal cancer , according to most recent published guidelines of American Cancer Society . 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, unspe cified 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 D. The following are reimbursed : 1. Highly sensit ive fecal immunochemical test (FIT) annually 2. Highly sensitive guaiac-based fecal occult blood test (gFOBT) annually 3. Multi-targeted stool DNA test (mt-sDNA) every 3 years 4. Colonoscopy every 10 years 5. CT colonography (virtual colonoscopy) every 5 years 6. Flexibl e sigmoidoscopy (FSIG) every 5 years E. A follow-up colonoscopy is reimbursed as part of the screening process when a noncolonoscopy test is positive. F. Screening with plasma or serum markers is NOT covered. G. PT modifier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure. II. Colonoscopy Surveillance for Colorectal CancerA. Prior authorization is not required for par ticipating 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 disease; 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 Person al history of colonic polyps; or 8. Z92.3 Personal history of irradiation or radiation therapy; or 9. K50 through K52 category codes noninfective enteritis and colitis. Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.C. PT modifier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure. E. Condition s of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes alo ng with appropriate modifiers. Please refer to the individual CMS fee schedule for appropriate codes. F. Related Policies/Rules Evidence of Coverag e and Health Insurance Contract Indiana G. Review/Revision History DATE ACTIONDate Issued 11/ 01/2017Date Revised 04/28/2020 09/17/202001/12/2022Added 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. Date Effective 05/01/202 2 Date Archived H. References 1. Centers for Medicare and Medicaid Services. (2021, January 19). Billing and Coding: Colorectal Cancer Screening – Medical Policy Article. Retrieved December 16, 2021 from www.cms.gov. 2. Centers for Medicare and Medicaid Services. (2020, April 20). Informati on on Essential Health Benefits (EHB) Benchmark Plans. Retrieved December 16, 2021 from www.cms.gov. 3. Doubeni, C. (2021, December 07). Tests for screening for colorectal cancer. Retrieved December 16, 2021 from www.u ptodate.com . 4. EncoderPro. (n.d.). ICD10 CM Guidelines. Retrieved January 12, 2022 from www.encoderprofp.com. 5. Indiana General Assembly. (2021, November 09). IC 27-8-14-8.3 Colorectal cancer testing coverage, exception for high deductible health plans. Retrie ved December 16, 2021 from www.iga.in.gov. 6. Qaseem, A., Crandall, C. J., Mustafa, R. A., Hicks, L. A., & Wilt, T. J. (2019, November 5). Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement from the American College of P hysicians. Retrieved December 16, 2021 from www.annals.org. 7. Rex, D., et. al . (2017). Colorectal cancer screening: Recommendations for physicians. Gastrointestinal Endoscopy, 86(1), 18 33. Retrieved December 16, 2021 from www.asge.org/. 8. Samir, G, et.al. (20 20). Recommendations for follow-up after colonoscopy and polypectomy: A concensus update by the United States Multi-Society Task Force Screening andSurveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 05/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.on Colorectal Cancer (American Society for Gastrointestinal Endoscopy, AGA Institute and The American College of Gastroen terology). Retrieved January 12,2022 from www.giejounal.org. 9. Wilkins, T., Mcmechan, D., Talukder, A. (2018, May 15). Colorectal Cancer Screening and Prevention. Retrieved December 16, 2021 from https://www.aafp.org. 10. Wolf, A., et. al. (2018). Colorectal c ancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. Retrieved December 16, 2021 from www.onlinelibrary.wiley.com. 11. United States Code of Federal Regulations. (2021, September 27). 156.110 EHB-benchmark plan sta ndards. Retrieved December 16, 2021 from www.govregs.com . 12. United States Preventive Services Task Force (2016, June 15). Colorectal Cancer: Screening. Retrieved December 16 , 202 1 from www.uspreventiveservicestaskforce.org .
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Robotic-Assisted Surgery IN MP PY-0956 05/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, 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 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.Table of Contents A. 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 …………………………………………………………………………………………………………. 3Robotic-Assisted Surgery IN MP PY-0956 Effective Date: 05/01/2022 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 REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectRobotic-Assisted Surgery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. 4Health care providers and their office sta ff 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. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invasive procedures using robotic devices designed to access surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a compute r equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly t hrough computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of robotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with t he assistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services): 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased difficulty of procedures, or severity of patients condition.Robotic-Assisted Surgery IN MP PY-0956 Effective Date: 05/01/2022 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 REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 02/01/2020 New PolicyDate Revised 01/19/2022 No changes; updated references Date Effective 05/01/2022 Date Archived H. References 1. Robotic surgery. Medline Plus Web site. (May 2013) . Retrieved December 28, 2021 from www.nlm.nih.gov . 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; Retrieved December 28, 2021 from www.cms.gov. 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets . Retrieved December 28, 2021 from www.cms.gov . 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus group. Position Papers/ Statement published on 11/2007. Retrieved December 28, 2021 from www.sages.org . 5. Estes, Stephanie Jet al. Best Practices for Robotic Surgery Programs. JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 21,2 (2017): e2016.00102. Retrieved December 28, 2021 from www.nlm.nih.gov . 6. U.S. Food and Drug Administration. Computer-Assisted Surgical Systems (Aug. 20, 2021). Retrieved December 28, 2021 from www.fda.govThis guideline contains custom content that has been modifi ed from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC.
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