REIMBURSEMENT POLICY STATEMENTINDIANA M ARKETPLACE Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Hepatitis Band C PY-087 6 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimburs ement 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 o f disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or 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 mand ate, 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 (ofte n 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), cov erage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACEPY-087 6 Effective Date: 01/01/2021 2 A. SubjectMolecular Diagnostic Testing for Hepatitis Band C B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusi on of a code in this policy does not imply any right to reimbursement or guaranteeclaims payment.Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropri atepharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis B is a liver infection caused by the Hepatiti s Bvirus (HBV). Hepatitis Bistransmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or oth er drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approxim ately 90% of infected infants become chronically infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis C is a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis ablood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-term illness but for 70% 85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons migh t not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACEPY-087 6 Effective Date: 01/01/2021 3 All facilities in the U nited States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof . CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) . Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combinatio n of the CPT anddiagnosis codes listed in the Conditions of Coverage in this policy.III. CareSource does not consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other diagnosis code and wil lnot provide reimbursement for those services.IV. Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR.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. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACEPY-087 6 Effective Date: 01/01/2021 4 87521 Infectious agent detection by nucleic acid (D NA or RNA); hepatitis C,amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed ICD-10 Code Description B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta -(super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B18.2 Chronic viral hepatitis C B18.9 Chronic viral hepatitis, unspecified B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis compli cating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium F. Related Policies/RulesN/A G. Review/Revision History DATE ACTIONDate Issued 11 /01/2019 New policyDate Revised 12/18/2019 09/30/2020 Addition of code Z20.5 Removed code Z20.5 Date Effective 01/01/2021 Date Archived H. References 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (2019, July 23). Retrieved 7/29/19 from www.cdc.gov/hepatitis. 2. License Agreement. (2019, January 15). Ret rieved 7/29/19 from www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service – Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACEPY-087 6 Effective Date: 01/01/2021 5 3. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from www.healthcare.gov/glossary/medically-necessary/. The Reimbursem ent Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Residential Treatment Services Substance Use Disorder PY-124 6 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements , 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 patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify thi s 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 limitatio ns that apply to medical conditions as covered under this policy. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Residential Treatment Services Substance Use Disorder INDIANA MARKETPLACE PY-1246 Effective Date: 01/01/20212A. Subject Residential Treatment Services Substance Use Disorder B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verif y 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 t o reimbursement or guarantee claims payment. Substance Use Disorder (SUD) services are provided on a continuum of care where the level of care varies dependent on the type and intensity of service provided. This policy address the Residential level of care. This type of care provides an intensive residential program for members with SUD. It is considered transitional with the goal of returning the member to the community with a less restrictive level of care. Treatment of substance use disorders is d ependent on a substance use disorder d iagnosis based on the Diagnostic and Statistical Manual of Mental Disorders. C. Definitions Residential Treatment A 24 hour level of care that provides a structured program for treatment of substance use disorder(s) to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing. Inpatient Services Health care ser vices relating to a patient admitted to a Hospital, Skilled Nursing Facility, or Inpatient Rehabilitation Facility. Reimbursement for the service is by a diagnosis-related group system. Health Care Services S ervices, supplies, devices, or pharmaceutica l products for the diagnosis, prevention, treatment, cure, or relief of health condition, sickness, injury, or disease.Outpatient Services Health care services other than inpatient services.Reim bursement for the service is per diem. Clinically Managed Services Per The American Society of Addiction Medicine (ASAM) , these s ervices that are directed by nonphysician addiction specialists rather than medical personnel. They are appropriate for individuals whose primary problems involve emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment and who problems i n Dimension 1 (Acute Intoxication and/or Withdraw al Potential) and Dimension 2 (Biomedical concern or complications), if any Residential Treatment Services Substance Use Disorder INDIANA MARKETPLACE PY-1246 Effective Date: 01/01/20213are minimal or can be managed through separate arrangements for medical services. Medically Monitored Services Per ASAM , these services that are provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, or other health and technical personnel under the direction of a licensed physician. Medical monitoring is provided through an appropriate mix of direct patient contact, review of records, team meetings, 24-hour coverage by a physician, 24-hour nursing, and a quality assurance program. Residential Level s of Care (LOC) per The ASAM Criteria o Clinically managed services 3.1 Clinically managed low-intensity residential program 3.5 Clinically managed residential program (high intensity for adults, medium intensity for adolescents) o Medically monitored services 3.7 Intensive for adults, high-intensity services for adolescent s D. Policy I. Prior Authorization is required. A. CareSource follows The ASAM Criteria for medical necessity . II. Billing A. Reimbursement is considered a bundled all inclusive per diem service payment and concurrent billing of individual services is not reimbursable. B. Residential treatment services are not reimbursable for non-participating facilities or providers without a mutually agreed upon need for and negotiated single case agreement. C. Residential treatment is not covered for situations in which housing arrangements are not available or are unsuitable. The inclusion of therapy services as part of Residential Treatment does not warrant coverage in this situation. D. Payments are made at the group level; not at the individual rendering provider level. 1. Rendering provider is not necessary on either a UB04 or CMS1500 forms. E. For UB04 billing, revenue code 0900 should be used with identified procedure code. F. CareSource only processes CMS 1500 claims when the place of se rvice is 55 Residential Substance Abuse Treatment Facility. NOTE: The goal is to align with Medicaid billing requirements. CareSource will be transitioning to CMS1500 billing in 2022. G. Conditions of Coverage Reimbursem ent is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. Residential Treatment Services Substance Use Disorder INDIANA MARKETPLACE PY-1246 Effective Date: 01/01/20214The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. HCPCS Code ASAM LOC Description H2034 3.1 Alcohol and/or drug abuse halfway house services, per diem H0012 3.5 Alcohol and/or drug services; subacute detoxification (residential addiction program outpatient) H0013 3.7 Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) H. Related Policies/Rules Residential Treatment Center-Mental Health Evidence of Coverage And Health Insurance Contract Indiana I. Review/Revision History DATE ACTIONDate Issued 09/30/2020Date Revised Date Effective 01/01/2021 Date Archived J. References 1. Centers for Medicare & Medicaid Services. (2019, October). Place of Service Codes for Professi onal Claims. Retrieved September 8, 20 20 from www.cms.gov 2. Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller, eds. The ASAM Criteria: Treatment Criteria for Addi ctive, Substance-Related, and Co-Occurring Conditions . 3rd ed. Carson City, NV: The Change Companies; 2013. Copyright 2013 by the American Society of Addiction Medicine. 3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5thed.). https://doi.org/10.1176/appi.books.9780890425596 The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the Reimbursement Po lic y St ate m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Residential Treatment Services Mental Health PY-12 20 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing 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 patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage f or 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 Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Cov erage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Residential Treatment Services Mental Health INDIANA MARKETPLACE PY-1220 Effective Date: 01/01/20212A. Subject Residential Treatment Services Mental Health B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verif y 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 t o reimbursement or guarantee claims payment. Treatment of mental health conditions is dependent on a d iagnosis based on the Diagnostic and Statistical Manual of Mental Disorders. C. Definitions Residential Treatment A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment. Inpatient Services Health care services relating to a patient admitted to a Hospital, Skilled Nursing Facility, or Inpatient Rehabilitation Facility. Reimbursement for the service is by a diagnosis-related group system. Health Care Services S ervices, supplies, devices, or pharmaceutical products for the diagnosis, prevention, treatment, cure, or relief of health condition, sickness, injury, or disease.Outpatient Services Health care services other than inpatient services.Reim bursement for the service is per diem . D. Policy I. Prior Authorization is required. A. CareSource follows MCG Health for medical necessity . II. Billing A. Reimbursement is considered a bundled all inclusive per diem service payment and concurrent billing of individual services is not reimbursable. B. Residential treatment services are not reimbursable for non-participating facilities or providers without a mutually agreed upon need for and negotiated single case agreement.Residential Treatment Services Mental Health INDIANA MARKETPLACE PY-1220 Effective Date: 01/01/20213C. Residential treatment is not covered for situations in which home arrangements a re not available or are unsuitable. The inclusion of therapy services as part of Residential Treatment does not warrant coverage in this situation . D. Payments are made at the group level; not at the individual rendering provider level. 1. Rendering provider is not necessary on either a UB04 or CMS1500 forms. E. For UB04 billing, revenue code 0900 should be used with identified procedure code. F. CareSource only processes CMS 1500 claims when the place of se rvice is 56 Ps ychiatric Residenti al Treatment Center . NOTE: The goal is to align with Medicaid billing requirements. CareSource will be transitioning to CMS1500 billing in 2022. 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 f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. HCPCSCodeDescription H0018 Behavioral health; short-term residential (nonhospital residential treatment program ), without room and board, per diem H0019 Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days ), without room and board, per diem F. Related Policies/Rules Residential Treatment Center-Substance Use Disorder Evidence of Coverage And Health Insurance Contract Indiana G. Review/Revision History DATE ACTIONDate Issued 09/30/2020Date Revised Date Effective 01/01/2021 Date Archived H. References 1. MCG Health. (2020). Care Guidelines. Retrieved September 8, 2020 from www.mcg.com 2. Centers for Medicare & Medicaid Services. (2019, October). Place of Service Codes for Professional Claims. Retrieved September 8, 2020 from www.cms.gov Residential Treatment Services Mental Health INDIANA MARKETPLACE PY-1220 Effective Date: 01/01/20214 The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the Reimbursement Po lic y St ate m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Da te Screening f or Sexually Transmitted Inf ections PY-0205 12/01/2020-1 0/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St ate me nt ………………………………………………………………………………… 1 A. Subject …………………………………………………………………………………………………………….. 2 B. Bac k g r ou nd ………………………………………………………………………………………………………. 2 C. Def initions …………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………. 3 E. Conditions of Co v er ag e……………………………………………………………………………………….. 4 F. Related Policies/Rules ………………………………………………………………………………………… 4 G. Review/Revision His t or y ………………………………………………………………………………………. 4 H. Ref er en ce s ……………………………………………………………………………………………………….. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding and documentation guidelines. Co d ing 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd a pp lica ble re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t h ose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and with o u t wh ich the patient can be expected to suffer prolonged, increased or new morbidity, impairm ent 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 lo ca l area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or 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 Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rred 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 t his 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. 2 Sc reen i n g fo r Sex ual l y Tran s mi tted In fec tions INDIANA MARKET PLACE PY-0205 Effec ti v e Date: 12/01/2020Screening for Sexually Transmitted InfectionsB. Bac k ground Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies ar e 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 their of f ice staf f are encouraged to use self-service channels to verify members eligibility.It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply an y right to reimbursement or guarantee claims paymentSexually transmitted inf ections (STIs) cause significant morbidity and mortality in the United States each year. The United States Preventive Services Task Force (USPSTF) recommends that women at increased risk of inf ection be screened f or chlamydia, gonorrhea, human immunodef iciency virus, and syphilis. Men at incr eased risk should be screened f or human immunodeficiency virus an d syphilis. All pregnant women should be screened f or hepatitis B, human immunodef iciency virus, and syphilis; pregnant women at increased risk also should be screened f or chlamydia and gonorrhea. Non-pregnant women and men not at increased risk do not require routine screening for sexually transmitted inf ections. Engaging in high-risk sexual behavior places persons at increased risk of sexually transmitted inf ections. The USPSTF recommends that all sexually active women younger than 25 years be considered at increased risk of chlamydia and gonorrhea. Because not all communities present equal risk of sexually transmitted inf ections, the USPSTF, the US Centers f or Disease Control (CDC), the American College of Obstetricians and Gynecologists (ACOG) and other authorities encourage physicians to consider expanding or limiting the routine sexually transmitted inf ection screening they provide based on the community and populations they serve.CareSource encourages screening f or Sexually Transmitted Inf ections consistent with the grade A and Brecommendations of the USPSTF and the Centers f or Medicare & Medicaid (CMS) National Coverage Determination (NCD) Policy 210.10 for Screening f or Sexually Transmitted Infections. In addition to these recommendations, CareSource encourages screening f or Sexually Transmitted Infections f or men and women at increased risk. CareSource has eliminated the annual screen limitations set f orth in the NCD as well as the order of billing STI diagnosis codes.A. Subjec t3 C. Def initionsSc reen i n g fo r Sex ual l y Tran s mi tted In fec tions INDIANA MARKET PLACE PY-0205 Effec ti v e Date: 12/01/2020Sexually Tran smit t ed Infections ( ST I ) in f ec t io ns t h at ar e passed f rom one person to another through sexual contact Nucleic Acid Amplification Tests (NAATs) gene amplif ication tests such as Polymerase Chain Reaction (PCR) t h at ar e cleared by the United States Food and Drug Administration (FDA) and are recommended f or detection of genital tract inf ections caused by Chlamydia trachomatis and Neisseria gonorrhea, with or without symptoms. High Intensity Behavioral Co uns e lin g (HIBC) to prevent ST Is ( p er the Centers f or Medicare & Medicaid Services) a program intended to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing f lexibility f or appropriate patient f ocused elements: o Education o Skills Training o Gui dance on how to change sexual behavior Screening the testing f or disease or disease precursors in seemingly well individuals so t h at e ar ly detection an d treatment c an be provided for those who test positive f or the disease High risk behaviors (related to ac q u ir ing a ST I) as outlined by the U.S. Preventive Services Task Force (USPSTF) and documented in the medical record are: o Ear ly sexual activity, f or example bef ore ag e 18. o Multiple sex partners. o Sex with a high-risk partner ( on e who h as multiple sex partners or other risk f actors). o Unprotected intercourse without consistent use of correct male or f e male condom use, except in a long-term, single partner (monogamous) relationship. o Unprotected mouth to genital contact, except in a long t e r m, single partner (monogamous) relationship. o Having an al sex or a partner who does, except in a long t e r m, single partner (monogamous) relationship. o Having sex with a partner who injects or h as ever injected drugs. o Exchange of sex (sex work) f or drugs or money. o Having h ad a sexually transmitted disease in the p as t . D. Polic y I. Prior authorization is not required f or medically necessary ST Is c r ee nin gs . A. CareSource may request the complete an d appropriate medical documentation to support and validate the medical necessity of these services. II. Sexually Transmitted Inf ections A. Chlamydia 1. CareSource considers screening f o r Chlamydia trachomatis in f e c t ions medically necessary f or these member groups: a. All pregnant women. b. All sexually active women aged 24 or younger. c. Women with high-risk behaviors of an y ag e f or Chlamydia t r ac h om at is. 2. Routine repeat testing of NAAT-positive genital tract specimens is not recommended because the practice does not improve the positive predictive value of the test.4 B. GonorrheaSc reen i n g fo r Sex ual l y Tran s mi tted In fec tions INDIANA MARKET PLACE PY-0205 Effec ti v e Date: 12/01/20201. CareSource considers screening f or Neisseria gonorrhea infections medically necessary f or these member groups: a. All pregnant women. b. All sexually active women younger t h an 25 y e ar s of age. c. Men an d women with high-risk behaviors of an y ag e f o r Neisseria gonorrhea. 2. Routine repeat testing of NAAT-p os it iv e g e nit al t r ac t specimens is not recommended because the practice does not improve the positive predictive value of the test. C. HIV 1. Everyone aged 15 to 65 should be s c r ee n ed for HIV (Human Immunodef iciency Virus) Infection. 2. People younger t h an ag e 15 an d adults older t h an 65 should be screened if they are at increased risk f or HIV inf ection. 3. All pregnant women, including women in labor who do not know their HIV status, should be screened f or HIV inf ection. D. Syphilis 1. All pregnant women should be tested f or syphilis as e ar ly as possible when they f irst present to c ar e . If a wo man h as not received prenatal c ar e p r ior to delivery, she should be tested at the time she presents f or delivery. 2. Men an d women with high risk behaviors f or syphilis infection. E. Hepatitis B 1. All pregnant women. 2. Men an d women with high-risk behaviors f or h e pat it is Binf ection.III. Documentation of High Intensity Behavioral Counseling must be present in the medical record when routine screening f or ST I related to high risk s e x ual behaviors is perf ormed.IV. Screening f or ST I for me n an d women who ar e not at increased risk, as outlined in this policy is not considered medically necessary and will not be covered or reimbursed.E. Conditions of Cov erage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Ple as e ref er to the individual f ee schedule f or appropriate codes.F. Related Polic ies/Rules N/AG. Rev iew/Rev ision HistoryDATE ACTION Date Issued 01/01/2019 New policy 5 Sc reen i n g fo r Sex ual l y Tran s mi tted In fec tions INDIANA MARKET PLACE PY-0205 Effec ti v e Date: 12/01/2020Date Revised 09/02/2020 Removed modif ier list; Updated references. Removed me n f rom chlamydia screening. Revised pregnancy testing language. Date Effective 12/01/2020 Date Archived 10/31/2022 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy . H. Ref erenc es 1. Decision Me mo f or Screening f or Sexually Transmitted Infections ( STIs) an d High-Intensity Behavioral Counseling (HIBC) to prevent STIs (CAG-00426N). 2011. Retrieved July 22, 2020 f rom https:// www.cms.gov. 2. Centers f or Disease Control an d Prevention (CDC). 2014 Recommendations f or t h e Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae. Retrieved August 18, 2020 from www.cdc.gov 3. Centers f or Disease Control and Prevention (CDC). STD Screening Recommendations-2015 ST DTreatment Guidelines. (2016, August 22). Re t r iev ed July 22, 2020 f rom www.cdc.gov. 4. EncoderPr o, Optum 360 Access (Online Medical Coding Sof tware). ICD-10-CM Of f icial Guidelines f or Coding an d Reporting 2020. ( 2 02 0) . Retrieved July 22, 2020 f r o m www.encoderprofp.com. 5. U.S. Preventive Services Tas k Force. Screening for Chlamydia an d Gonorrhea. Retrieved July 22, 2020 f rom www.uspreventiveservicestaskf orce.org. 6. U.S. Preventive Services Tas k Force. Screening for Hu man Immunodef iciency Vir us (HIV). Retrieved July 22, 2020 f rom www.uspreventiveservicestaskforce.org.The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Screening and Surveillance for Colorectal Cancer PY-0406 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, indust ry-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 co ntractual 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 diag nosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These service s 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 condition s as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. 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 an d Surveillance for Colorectal CancerINDIANA MARKETPLACEPY-040 6 Effective Date: 01/01/2021 2 A. SubjectScreening and Surveillance for Colorectal Cancer 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 a re not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and wi ll be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most acc urate andappropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. 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 colorectal cancer declines after 75 years of age . African Americans have been shown to have higher CRC rates of incidence and it is re commended by both the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy that CRC screening begin at 45 years of age. 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 – For members who are at increase 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: 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 syndrome); 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: o Strong family history of colorectal cancer or certain types of polyps; o Personal history of colorectal cancer or certain types of polyps; Screening an d Surveillance for Colorectal CancerINDIANA MARKETPLACEPY-040 6 Effective Date: 01/01/2021 3 o Personal history of inflammatory bowel disease (i.e. ulcerative colitis or Crohns disease);o Family history of a hereditary colorectal cancer syndrome such as familial ; adenomatous polyposis (FAP) or Lynch syndrome (also known as hereditar y non-polyposis 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 providers . B. Benefit coverage is for members at least 45 years of age . C. Screening for colorectal cancer claims must be submitted with one of the following ICD-10 codes: 1. Z12.10 Encounter for sc reening for malignant neoplasm of intestinal tract, unspecified; 2. Z12.11 Encounter for screening for mal ignant neoplasm of colon; 3. Z12.12 Encounter for screening for malignant neoplasm of rectum; or 4. Z12.13 Encounter for screening for malignant neoplasm of small intestine. D. The following are reimbursed : 1. Highly sensitive fecal immunochemical test (FIT) every year 2. Highly sensitive guaiac-based fecal occult blood test (gFOBT) every year 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. Flexible sigmoidoscopy (FSIG) every 5 y ears 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 diag nostic test or other procedure. II. Colonoscopy Surveillance for Colorectal CancerA. Prior authorization is not required for par 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 malig nant 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 ca tegory codes noninfective enteritis and colitis. C. PT modifier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure. Screening an d Surveillance for Colorectal CancerINDIANA MARKETPLACEPY-040 6 Effective Date: 01/01/2021 4 E. Conditions of CoverageReimbursement is dependent on, but not limited to, submittin g 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 Coverage and Health Insurance Contract Indiana G. G. Review/Revision History DATE ACTIONDate Issued 11/ 01/2017Date Revised 04/28/2020 09/17/2020Added 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 Date Effective 01/01/2021 Date Archived H. References 1. Wolf, A., Fontham, E., Church, T., Flowers, C .Smith, Robert. (2018). Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. Retrieved August 31, 2020 from www. onlinelibrary.wiley.com 2. Rex, D., Boland, Richard, Dominitz, J., Giardiello, F ., Johnson, D., Kaltenbach, T.. Robertson, D. (2017). Colorectal cancer screening: Recommendations for physicians. GASTROINTESTINAL ENDOSCOPY , 86 (1), 18 33. doi: http://dx.doi.org/10.1016/j.gie.2017.04.003 www.asge.org 3. Wilkins, T., Mcmechan, D., Talukder, A. (2018, May 15). Colorectal Cancer Screening and Prevention. Retrieved August 31, 2020 from www.aafp.or g 4. Lieberman, D., Rex, D., Winawer, S., Giardiello, F., Johnson, D., & Levin, T. (2012, July 3). Guidelines for Colonoscopy Surveillance After Screening. American Gastroenterological Association, 143(3), 844-857. doi: https://doi.org/10.1053/j.gastro.2012.06.001 5. 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 Colleg e of Physicians. Retrieved August 31, 2020, from www.pubmed.ncbi.nlm.nih.gov 6. Doubeni, C. (20 10, March 18 ). Tests for screening for colorectal cancer. Retrieve d August 31, 2020 from www.uptodate.com 7. Centers for Medicare and Medicaid Services. (n.d.). Inform ation on Essential Health Benefits (EHB) Benchmark Plans. Retrie ved August 31, 2020 from www.cms.gov 8. United States Preventive Services Task Force (2016, June 15 ). Colorectal Cancer: Screening. Retriev ed August 31, 2020 from www.uspreventiveservicestaskforce.org 9. American College of Surgeons. (2016, May 1). Coding and reimbursement for colonoscopy. Retrieve d August 31, 2020 from www. bulletin.facs.org 10. EncoderPro. (n.d.). ICD10 CM Guidelines . Retrieved January 31, 2020 from www.encoderprofp.com Screening an d Surveillance for Colorectal CancerINDIANA MARKETPLACEPY-040 6 Effective Date: 01/01/2021 5 11. United States Code of Federal Regulations . (2015, February 27). 156.110EHB-benchmark plan standards. Retriev ed August 31, 2020 from www.govregs.com 12. Indiana General Assembly. (2019). IC 27-8-14.8 Colorectal cancer testing coverage ; exception for high deductible health plans . Retrieved September 1, 2020 from www. iga.in.gov 13. United States Code of Federal Regulations . (2015, February 27). 156.110 EHB-benchmark plan standards. Retriev ed February 5, 2020 from www.govregs.com The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Date Effective Drug Testing PY-0329 01/01/2021-12/31/2021 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………… 1 A. Subject ……………………………………………………………………………………………………………… 2 B. Bac k g r ou nd ……………………………………………………………………………………………………….. 2 C. Def initions …………………………………………………………………………………………………………. 2 D. Policy ……………………………………………………………………………………………………………….. 3 E. Conditions of Co ve r age ……………………………………………………………………………………….. 5 F. Related Policies/Rules …………………………………………………………………………………………. 5 G. Review/Revision History ………………………………………………………………………………………. 5 H. Ref er en ce s ………………………………………………………………………………………………………… 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d 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, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or 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 Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d 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 a nd 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 th at a re le ss favorable than the limita tio n s t h at apply to me d ical conditions as covered under this policy. 2 A. Subjec tDru g Testing Drug Tes ti ng INDIANA MARKET PLACE PY-0329 Effec ti v e Date: 01/01/2021 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies ar e 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 their of f ice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service t h at is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Drug testing is a p ar t of medical c ar e during the initial assessment, ongoing monitoring, an d recovery phase f or members with substance use disorder ( SUD); for members who are at risk f or abuse/misuse of drugs; or f or other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Urine is the mo st com mo n specimen to monitor drug use. There ar e two main t y p es of urine drug testing (UDT): presumptive/qualitative and conf irmatory/quantitative. Drug testing is sometimes also ref erred to as toxicology testing.C. Def initions Presumptive/Qualitative t es t-The testing of a substance or mixt u r e to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or def initive testing.Random drug test-A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent la bo ra tory-A laboratory certif ied to p er f or m diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-pa rt icip at ing-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSource. Residential treatment services-Per the Evidence of Coverage these health c ar e services c an include individual an d group psychotherapy, f amily counseling, nursing services, and pharmacological therapy with 24 hour support.NOTE: Clinical guidelines, def initions, standards, and scenarios f or drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0130. Ple as e ref er to this policy for in-depth in f or mat io n on medical necessity f or drug testing, documentation requirements, and CareSource monitoring and review of drug testing claims.3 Drug Tes ti ng INDIANA MARKET PLACE PY-0329 Effec ti v e Date: 01/01/2021D. Polic yI. General Criteria f or Coverage A. Documentation mu st support medical necessity. B. Documentation mu st include the ICD-10 code demonstrating appropriate indication f or UDT. C. The submitted CPT/HCPCS code mu st ac c u r at e ly describe the service perf ormed. D. CareSource requires t h at the ordering providers n ame appear in the appropriate lines of the claims f orms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when t h ey ar e medically necessary to the members treatment and care 1. CareSource will cover up to 30 presumptive an d 12 definitive UDT per member per calendar year bef ore a PA is required. 2. PA is not required in an emergency r o om setting. UDT utilization will be monit ored by CareSource. 4. PA needs to mak e a c le ar case f or medical necessity f or the level of testing being requested. B. Providers and laboratories will need to ensure specimen integrity appropriate f or the stability of the drug agent being tested until the PA process is complete i.e. f reezing s pe c imen . C. Must submit appropriate clinical documentation with PA request to determ in e appropriate medical necessity. D. If needed, the licensed practitioner t h at is operating in his/her scope of practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will cover up to 30 presumptive an d 12 definitive UDT per member per calendar year bef ore a PA is required.B. Eac h CPT code is counted as one test. IV. Laboratory A. Drug testing conducted f or CareSource members by non-participating labs or f acilities is not billable to an d will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. Non-participating providers ar e not covered f or drug testing laboratory services. C. CareSource laboratories perf orming drug testing services must bill CareSource directly. CareSource does not allow pass-th rough billing of services. Any claim submitted by a provider which includes services o r de r ed by t h at provider, b ut ar e perf ormed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. V. Non-Urine Te s t ing A. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples performed in an y other setting outside of an emergency room is a non-covered benefit. C. Hair, s aliv a, or other body f luid testing f or controlled substance monitoring h as limited support in medical evidence and is not covered 4 Drug Tes ti ng INDIANA MARKET PLACE PY-0329 Effec ti v e Date: 01/01/2021VI. Conf irmatory Te s t ing A. Routine mu lt i-drug confirmatory testing is not billable an d will not be reimbursed by CareSource. B. Conf irmatory testing must be individualized f or the member and medically necessary. Routine confirmatory drug tests with negative presumptive r e s ult s ar e not covered by CareSource. C. Conf irmatory testing is billable when documentation supports 1. How the test results will guide p lan of c ar e i.e. modif ication of t r eat me n t plan, consultation with specialist and one of the f ollowing: a. Presumptive testing was negative f or prescription medications; and provider was expecting the test to be positive for prescribed medication and member reports taking medication as prescribed; b. Presumptive testing was positive f or prescription drug with abus e potential t h at was not prescribed by provider and the member disputes the presumptive testing results; c. Presumptive testing was positive f or illegal drug and the member disputes the presumptive testing results; or d. A substance or metabolite is needed to be identif ied that cannot be identif ied by presumptive testing. (e.g. se mi-synthetic an d synthetic opioids, certain benzodiazepines). VII. Non-Billable Drug Testing A. Testing t h at is not individualized such as 1. Ref lexive testing. 2. Routine orders. 3. St an d ar d orders. 4. Preprinted orders. 5. Requesting a broad spectrum of t e s ts t h at a machine is c ap ab le of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing required by third parties such as1. Testing ordered by a court or other medico-leg al purpose such as child custody. 2. Testing f or p re-employment or random testing t hat is a requirement of employment. 3. Physicians health programs (recovery f or physicians, dentists, v e t e r inar ian s , pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required f or military service. 6. Testing required by an y third p ar t y. 7. Testing in residential treatment facility, p ar t ial hospital, or sober living as a condition to remain in that community. 8. Testing with another p ay source t h at is primary such as a county, state or f ederal agency. 9. Testing f or mar r iag e license. 10. Forensic. 5 Drug Tes ti ng INDIANA MARKET PLACE PY-0329 Effec ti v e Date: 01/01/202111. Testing f or other ad min purposes. 12. Routine physical/medical examination. C. Testing f or validity of specimen It is included in the payment f or the test an d will not be reimbursed s e par at e ly . D. Blood drug testing when completed outside of the emergency r oo m. E. Hair, s aliv a, or other body f luid testing for controlled substance mo nit or ing . F. Any type of drug testing not addressed in this policy. G. Routine nonspecif ic or wholesale orders including routine drug p an els . H. Routine use of confirmatory testing f ollowing a negative presumptive expected result. I. Custom Prof iles, standing orders, drug screen panel, custom panel, blanket orders, ref lex testing or conduct additional testing as needed orders. J. A conf irmatory test prior to discussing results of presumptive test with me mb er . NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment d at a analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Ple as e r e f er to the individual f ee schedule f or appropriate codes. F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0130 CareSource Evidence of Coverage an d Health Insurance Contract G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 10/01/2017 Date Revised 11/29/2017 02/16/201805/01/201908/01/2019 Up d ated c linical indic ations, quantity limits, and PAreq uirements01/01/2020 Remo v ed q uantity limits and PA requirements03/17/2020 Up d ated c odes. Update II.09/02/2020 Rev is ed D. II. , D. III. , and D. IV . Remo ved codesDate Effecti ve 01/01/2021 Date Archived 12/31/2021 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Please no te that there c ould be o ther Policies that may hav e s ome of the s ame rules inc orporated and CareSource res erv es the rightto f ollow CMS/State/NCCI g uidelines without a formal d o c umented Policy .6 Drug Tes ti ng INDIANA MARKET PLACE PY-0329H. REFERENCES 1. A. Jaf f e, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016, Jan u ar y ) . Review an d recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome a nd Addiction Science . 2(1): 28-45. doi: 10.17756/jrdsas.2016-02 5 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing r es u lt s in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addi ction. (14) 64-80. doi: 10.1007/s11469-015-9569-7 3. Ame r ic an Society of Addiction Med ic in e. (2017, May / Ju ne ) . Appropriate use of drug testing in clinical addiction medicine. 11(3) 163-173. doi: 10.1097/ADM.0000000000000323 4. Andersson, H. W., Wenaas, M., & Nordf jrn, T. (2019). Relapse af ter inpatient substance use treatment: A prospective cohort study among users of illicit substances. Addictive Behaviors, (90)222-228. doi:10.1016/j.addbeh.2018.11.008 5. Ame r ic an Society of Addiction Medicine (2010, October) . Public Policy St a t e ment on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings . Retrieved August 12, 2020 f rom www.asam.org. 6. Dowell, D., Haegerich, T. M., & Chou, R. (2016, March). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. Retrieved August 12, 2020 f rom www.cdc.gov 7. eCFR Code of Fe d er al Regulations. 42 Co de of Fed e ral Regulations (CFR) Par t 8. (n.d.). Retrieved August 12, 2020 f ro m www.ecfr.gov 8. Gourlay, D. L., Heit, H. H., & Cap lan , Y. H. (2015, August 31). Urine Dru g Tes t in g in Clinical Practice The Art and Science of Patient Care (Edition 6). PharmaCom Group Inc./Center f or Independent Healthcare Education 9. Jarvis, M, Williams, J, Hurf ord, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P,..Saf arian, T. (2017, April 5). Appropriate Use of Drug Testing in Clinical Addiction Medication. Journal of Addiction Medicine . Retrieved August 12, 2020 f r o m www.dca.ca.gov 10. Medicare Learning Network. (2020, May). CLIA Program an d Medicare Laboratory Services. Retrieved August 12, 2020 f rom www.cms.gov 11. National Academies of Sciences, Engineering, and Medicine. 2017. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24781. 12. Owen, G, Burton, A, Schade, C, Passik, S. (2012). Urine Drug Testing: Current Recommendations an d Best Practices. Pain Physician Journal . 15, ES119-ES133. Retrieved August 12, 2020 from www.painphysicianjournal 13. Reisf ield, MD, G. M., Webb, PhD, F. J., Bertholf, PhD, R. L., Sloan, MD, P. A., & Wilson, MD, G. R. (2007). Family physicians prof iciency in urine drug test interpretation. Journal of Opioid Management , 3 ( 6 ), 333. doi:10.5055/jom.2007.0022 14. Substance Abuse an d Mental Health Services Administration. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and Mental Health Services Ad ministration, 2012. 15. Stanos, S. P. (2017, October 10). Presidents Message. National Academies of Sciences, Engineering, an d Medicine (NASEM). Pain Medicine. 18(10). 1835-1 83 6. doi:10.1093/pm/pnx224 16. U.S. Department of Veterans Af f air s . (2017, Feb ru ar y ) . VA/DoD Clinical Practice Guideline f or Opioid Therapy for Chronic Pain. Retrieved August 12, 2020 from 7 Drug Tes ti ng INDIANA MARKET PLACE PY-0329 Effec ti v e Date: 01/01/202117. Agency Medical Directors Group. (2010). Interagency Guideline on Opioid Dosing f o r Chronic Non-cancer Pain. Retrieved August 12, 2020 f rom www.agencymeddirectors.wa.gov Th e Rei mburs emen t Policy Statemen t d etai l ed abo v e h as rec ei v ed d ue c on si derati on as d efi ned in th e Rei mburs emen t Po l i c y Statemen t Po l i c y an d i s ap p ro v ed.
This CareSource Management Group proprietary policy is not a guarantee o f payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Healthcare Acquired Conditions, Provider Preventable Conditions, and Conditions Present on AdmissionPrograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program,OH MyCare, and OH Just4Me TM Po l i c yCareSource will, as applicable, deny claims for or reduce the reimbursement amounts for claims by providers that include healthcare acquired conditions or other provider-preventable conditions , or where one of the reported conditions was not present on admission for an inpatient stay, in accordance with CMS guidelines and protocols. De f i ni t i on sHealthcare acquired condition (HAC ), means a condition occurring in any inpatient hospital setting which has a negative consequence for the member and which was not present in the member upon admission to that facility. (from Affordable Care Act of 2010, Section 2702 ) Provider preventable condition , means a condition occurring in anyhealthcare setting that is either a healthcare acquired condition or is another condition which has been found by the applicable state to be reasonably preventable by the provider through the application of procedures supported by evidence-based medical guidelines, and which has a negative consequence for the member. These types of conditions include, but are not limited to, wrong surgical or other invasive procedures, sur gical or other invasive procedures performed on the wrong body part, or surgical or other invasive procedures performed on the wrong patient. (from 42 CFR 447.26) Pr o v i d er R e i m b u r s e m e n t Gu i d e l i n es Healthcare Acquired ConditionsCareSource will not reimburse providers for healthcare acquired conditions in its members, in accordance with CMS guidelines.Provider Preventable ConditionsCareSource will not reimburse providers for provider preventable conditions in its members. If CareSource can reasonably identify and isolate the portion of the claim which is directly related to the treatment of the provider preventable condition, then Ca reSource will reduce the reimbursement of the claim by that specific amount related to the provider preventable condition. CareSource will not, however, impose a reduction in reimbursement on any claim when a provider preventable condition is found in a CareSource member to have been This CareSource Management Group proprietary policy is not a guarantee o f payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 present and in existence prior to the providers treatment of that member. This CareSource Management Group proprietary policy is not a guarantee o f payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 2 CareSource will take all necessary actions in order for any state to comply with and implement applicable federal and state laws, regulations, policy guidance and any state policies and procedures relating to the identification, reporting, andnon-paymen t of claims with provider preventable conditions. CareSource requires providers to comply with all federal, state, and CareSource-issued reporting requirements around provider preventable conditions as a condition of claims reimbursement. Conditions Pr esent on AdmissionHospitals will not receive additional payment for inpatient claims in which one of the conditions reported on the claim was not present when the CareSource member was admitted to the facility. Any such claim will be paid as though the se condary diagnosis were not present.In accordance with CMS guidelines, CareSource requires facilities to promptly report present on admission information for both primary and secondary diagnoses when submitting claims NOTE : Regardless of how CareSource reimburses, reduces reimbursement for,or denies any claims under this policy, providers may not deny access to healthcare services to any CareSource member based on a healthcare acquired condition or provider preventable co ndition contracted by that member. R e l a t e d Po l i c i e s & R e f e r e n c e sDeficit Reduction Act of 2005, Section 5001(c), Hospital quality improvement.Affordable Care Act of 2010, Section 2702, Payment adjustment for healthcare acquired conditions. 42 USC 1396b-1, Payment adjustment for healthcare acquired conditions. 42 CFR 447.26, Prohibition on payment for provider-preventable conditions. 907 KAR 14:005, Healthcare acquired conditions and other provider preventable conditions. OH Department of Medicaid Hospital Handbook, HHTL 3352-13-05, Inpatient Hospital Reimbursement on or after July 1, 2013. St a t e Exc ep t i o n sNONE Do c um e n t Hi s t or y
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Facet Joint Interventions PY-0061 11 /01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Pari ty 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 Contents Reimbursement 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. Revie w/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Facet Joint InterventionsINDIANA MARKETPLACEPY-0061 Effective Date: 11 /01/2020 2 A. SubjectFacet Joint Interventions 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 a re 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 actu al 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 sub mitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Interventiona l procedures for management of acute and chronic pain are part of acomprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and ai m to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Zygapophyseal (aka facet) Joint Level – refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint. Diagnostic Medial Branch Nerve Block Injection – refers to the diagnosis of facet – mediated pain requiring the establishment of pain relief following medial branch blocks (MBB) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish t he facet joint as the pain source. Radiofrequency Facet Ablation (RFA) – is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves . D. PolicyI. Facet Joint Interventions A. A p rior authorization (PA) is required for each facet joint intervention for pain management. Documentation, including dates of service, for conservative therapies are not required for PA, but must be available upon request. Facet Joint InterventionsINDIANA MARKETPLACEPY-0061 Effective Date: 11 /01/2020 3 II. Medial Branch Nerve Block InjectionsA. Up to two medial branch nerve block injections in the cervical/thoracic or lumbar regions are considered medically necessary. 1. Only three (3) spinal levels (unilateral or bilateral) may be treated at the same time (maximum amount of six injections per rolling 12 months); 2. A response of at least 50% pain relief must be achieved before the second injection is performed; and 3. Injectio ns should be at least two (2) weeks apart. 4. Maximum number of benefit limits in this policy are based on medial necessity. 5. The member must meet the medically necessary criteria in the corresponding Facet Join t Interventions medical policy, before a diagno stic injection is performed. III. Per CPT guidelines, imaging guidance and any injec tion of contrast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. IV. Radiofrequency Facet AblationA. Radiofrequency Facet Ablations are considered medically necessary when the member meets ALL of the medically necessary criteria in the corresponding Facet Joint Interventions medical policy . B. A maximum of four (4 ) radiofrequency facet ablation s per rolling twelve (12) months (two left and two right per spinal region: cervical, thoracic or lumbar). C. Repeat Radiofrequency Facet Ablation in the same spin al region and side is considered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy has been met. V. Sedation A. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. 1. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. 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. The following list(s) of co des is provided as a reference. This list may not be all inclusive and is subject to updates. Facet Joint InterventionsINDIANA MARKETPLACEPY-0061 Effective Date: 11 /01/2020 4 F. Related Policies/RulesFacet Joint Interventions Medical Policy G. Review/Revision History DATE ACTIONDate Issued 05/13/2020 This policy replaces the Facet Medial BranchNerve Block and Radiofrequency Facet Ablation policies. Date Revised 07/22/2020 11/11/2020Revisions: Medial Branch Nerve Block injection clinical criteria; requirement of one successful RFA session.Revision: RFA language revised around benefitlimit for clarity. (This revision does not require a network notification or a change of the Effective Date). Date Effective 11/01/2020 Date Archived H. References 1. Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule. Retrieved on April 15, 2020 from cms.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Epidural Steroid Injections PY-1052 09/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard 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 func tion, 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 p rovider. 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectEpidural Steroid Injections Ep id ural Stero id In jectionsINDIANA MARKETPLACE PY-1052 Effective Date: 09/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guara ntee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processin g. Health care providers and their of f ice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product o r service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lif etime. Long term outcomes are largely f avorable f or m ost patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is def ined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures f or management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting pa tient self – management and aim to reduce the impact of pain on a patient’s daily lif e, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by ph ysicians qualif ied to deliver these health services. C. Def initions Epidural Steroid Injections – f or persistent or chronic radicular pain involve injection of corticosteroid, local anesthetic, opioid, or combination medication into the epidural space, requiring f luoroscopic imaging and injection of an appropriate agent to achieve a selective reproducible blockage of a specif ic nerve root. Anatomic locations f or epidural injections may involve the interlaminar space at the midline between vertebral bodies, caudal epidural injections or transf oraminal epidural injections. Epidural injections may be diagnostic f or localizing and determining the cause of radiating pain and providing short term pain relief . D. Policy I. Epidural Steroid Injections A. A prior authorization (PA) is required f or each epidural injection f or pain management by the same or any physician, excluding labor and delivery in 3 Ep id ural Stero id In jectionsINDIANA MARKETPLACE PY-1052 Effective Date: 09/01/2020 childbirth and f or post surgical pain. Documentation, including dates of service, f or conservative therapies are not required f or PA, but must be available upon request. 1. Maximum number of benef it limits in this policy are based on medical necessity. B. The ma ximum epidurals of all types of epidural injections a member can receive in a rolling twelve (12) months is generally a total of six (6), regardless of the number of levels involved. 1. Repeat injections sooner than three (3) weeks may not reach pharmacodynamic ef f ect of the corticosteroid and will not be covered. 2. Requests f or repeat injections beyond three (3) weeks without documentation of suitable pain score reduction and f unctional improvements, or other documented rationale as described in this policy will not be covered. C. For Interlaminar or Caudal Epidural Injections 1. More than one (1) epidural injection per treatment date will not be authorized. 2. Bilateral injections and modif iers will not be recognized and coverage will be denied. D. For Transf oraminal Epidurals or Selective Nerve Root Blocks (SNRBs) 1. Transf oraminal Epidurals provided to more than two (2) vertebral levels per treatment date, whether unilateral or bilateral, will not be authorized and will not be covered. 2. Prior authorization is required f or treatment sessions per each spine region. E. Repeat Therapeutic Injections 1. Epidural injections may be repeated only when considered medically necessary and the f ollowing criteria is met: a. There must be at least 21 days between injections; b. No more than three (3) procedures in a twelve (12) -week period of time per region; c. Prior injection had a positive response by significantly decreasing pain; d. The patient continues to have ongoing pain or documented functional disability ( 6 on a scale of 0 to 10); and e. The patient is actively engaged in other f orms of conservative non – operative treatment. (1) Unless pain prevents the patient f rom participating in conservative therapy, which must be documented in the contemporaneous medical record. F. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not compensated f or separately or unbundled f or coverage. G. Ultrasound guidance f or epidural injections is inappropriate. H. Conscious sedation, if required f or co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible f or additional reimbursement if administered by a second provid er. 1. Coverage f or monitored anesthesia will not be provided as not medically necessary. 2. When anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. 4 E. Conditions of CoverageEp id ural Stero id In jectionsINDIANA MARKETPLACE PY-1052 Effective Date: 09/01/2020 Reimbursement 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 for appropriate codes. F. Related Policies/RulesEpidural Steroid Injections MM-0161 G. Review/Revision HistoryACTIONDate Issued 12/11/2019Date Revised 06/10/2020 Annual Update: Updated language regarding market benef it limit requirements. Date Effective 09/01/2020 Date Archived 05/31/2021 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy H. Ref erences1. Centers f or Medicare and Medicaid Services (CMS) Physician Fee Schedule. Retrieved on April 15, 2020 f rom cms.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Trigger Point Injections PY-1097 09/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time.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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Trigger Point InjectionsINDIANA MARKETPLACEPY-1097 Effective Date: 09/01/2020 2 A. SubjectTrigger Point Injections B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes arelargely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain t hat persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a m ultimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services.C. Definitions Trigger Point Injections – A trigger point is a hyper excitable area of the body, where the application of a stimulus w ill provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substance s (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. D. Policy I. Trigger Point Injections A. A prior authorization (PA) is required for each trigger point injection for pain management. B. Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. Trigger Point InjectionsINDIANA MARKETPLACEPY-1097 Effective Date: 09/01/2020 3 C. For trigger-point injections of a local anesthetic or a steroid, generally no more than eig ht dates of service will be covered per calendar year per patient D. Injections may be repeated only with documented positive results to prior trigger point injection s of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning and activity tolerance. E. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. F. Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for s ervice rendered to a particular patient on a particular date. G. A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. 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. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Trigger Point InjectionsDescription 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles F. Related Policies/Rules Trigger Point Injections MM-0183 G. Review/Revision History DATE ACTIONDate Issued 12/11/2019Date Revised 06/10/2020 Annual Update: No changes Date Effective 09/01/2020 Date Archived Trigger Point InjectionsINDIANA MARKETPLACEPY-1097 Effective Date: 09/01/2020 4 H. References1. Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule. Retrieved on April 15, 2020 from cms.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
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