REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-108 8 08/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. 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. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sacro iliac Jo in t Pro ced ures INDIANA MARKETPLACE PY-1088 Effective Date: 08/01/2020 2 A. Subject Sacroiliac Joint Procedures B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimb ursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verif y members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right t o reimbursement or guarantee claims payment. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be ef f ective for diagnostic purposes , but provide limited short-term relief f rom pain resulting f rom SI j oint dysf unction. C. Def initions Sacroiliac Joint Injections-corticosteroid and local anesthetic the rapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies . 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. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required f or each sacroiliac joint procedure for pain management. B. Sacroiliac Joint Injection Codes 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. C. Sacroiliac Joint I njections 1. Maximum number of benef it limits in this policy are based on medical necessity. 2. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic ef f ect, repeating no more than once every seven (7) d ays and with at least a 75% or greater reduction in pain af ter the f irst injection. 3. Once the diagnostic injections are perf ormed and the diagnosis is established, two (2) therapeutic injections per joint may be perf ormed over a 12 month period. Sacro iliac Jo in t Pro ced ures INDIANA MARKETPLACE PY-1088 Effective Date: 08/01/2020 3 4. Injections should not be repeated more frequently than every two (2) months with generally no more than a total of f our (4) injections (including both diagnostic and therapeutic) per joint in 12 months. D. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately F. Initial Radiof reque ncy Ablation of the SI Joint 1. A member can generally receive a maximum of one (1) radiof requency ablation f or SI Joint pain per side per rolling twelve (12) months when CareSource medical policy MM-0010 clinical criteria has been met. G. Repeat Radiof requency Ablation of the SI Joint 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain f or at least twelve (12) months or more f rom the initial RFA within the last thirty-six (36) months. 2. When there has not been a repeat RFA in the last thirty-six (36) months, a diagnostic injection is required. E. Conditions of Coverage 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 f or appropriate codes. The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac Joint Procedures Description 27096 Injection procedure f or sacroiliac joint, anesthetic/steroid, with image guidance (f luoroscopy or CT) including arthrography when perf ormed 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography 64625 Radiof requency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography) G0260 Injection procedure f or sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography F. Related Policies/Rules Sac roiliac Joint Procedures MM-0149 Sacro iliac Jo in t Pro ced ures INDIANA MARKETPLACE PY-1088 Effective Date: 08/01/2020 4 G. Review/Revisi on History DATE ACTION Date Issued 12/11/2019 Date Revised 05/13/2020 Revised to add coverage f or ablation of the SI Joint; added codes: 64451 64625 G0260 Date Effective 08/01/2020 Date Archived 05/31/2021 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 erences 1. CMS Physicians Fee Schedule . (n.d.). Retrieved April 24, 2020 f rom www.cms.gov The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE Policy Name Policy Number Effective Date Sacroiliac Joint Fusion PY-1155 08/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ……………….. 1A. Subject . 2B. Background ………………………….. ………………………….. ………………………….. …………… 2 C. Def initions ………………………….. ………………………….. ………………………….. …………….. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………… 3 E. Conditions of Coverage ………………………….. ………………………….. ……………………….. 4 F. Related Policies/Rules ………………………….. ………………………….. …………………………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………. 4 H. Ref erences ………………………….. ………………………….. ………………………….. ……………. 4 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. SubjectSacroiliac Joint Fusion Sacro iliac Jo in t FusionINDIANA MARKETPLACE PY-1155 Effective Date: 08/01/2020 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a me mber and will be determined when the claim is received f or processing. 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 t he most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The sacroiliac (SI) joints are f ormed by the connection of the sacrum and the right and lef t iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of f ive vertebrae that are f used together and do not move. The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of stro ng ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints. Sacroiliac Joint (SIJ) dysf unction is indicated by the abnormal movement or malalignment of the sacroiliac joint and is the main source of lower back pain in 15% to 30% of patients. The condition causes disability and pain and may be caused by prior lumbar sacral f usion, trauma, inf lammatory arthritis, sacral tumors, osteoarthriti s or pregnancy. Patients may present with low back, groin and/or gluteal pain. SI joint pain can of ten appear to be disogenic or radicular back pain. This can lead to the potential f or inaccurate diagnosis and treatment, reviews caution dif f icult diagnosis and evidence for ef f icacy. Open SIJ f usion typically involves opening the SIJ, denuding of cartilage, and bone graf ting. To stabilize the SIJ, the iliac crest bone and the sacrum are typically held together by plates or screws or an interbody f usion cage until the 2 bones f use. C. Def initions Conservative Therapy – is a multimodality plan of care. Multimodality care plans include ALL of the f ollowing: o Active Conservative Therapies – such as physical therapy, occupational therapy, a physician supervised home exercise program (HEP), or chiropractic care. 3 Sacro iliac Jo in t FusionINDIANA MARKETPLACE PY-1155 Effective Date: 08/01/2020 Home Exercise Program (HEP) – includes two components that are both required to meet CareSource policy for completion of conservative therapy: An exercise prescription and/or plan documented in the medical record. A f ollow up documented in the medical record regarding completion of a HEP (af ter suitable six (6) week period), or inability to complete a HEP due to a stated physical reason-i.e. increased pain, inability to physically perf orm exercises. (Patient inconvenience or noncompliance without explanation does not constitute inability to complete) o Passive Conser vative Therapies – such as rest, ice, heat, medical devices, TENS unit and prescription medications D. Policy I. Sacroiliac Joint Fusion A. Prior authorization is required f or minimally invasive f usion/stabilization of the sacroiliac joint (SIJ) f or the treatment of back pain when the medically necessary criteria in the Sacroiliac Joint Fusion Medical policy, MM-0838, has been met. II. ExclusionsA. Percutaneous SIJ f usion for SIJ pain is NOT indicated in the presence of : 1. Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis; 2. Generalized pain behavior (e.g. somatof orm disorder) or generalized pain disorder (e.g. fibromyalgia); 3. Inf ection, tumor, or f racture; 4. Acute, traumatic instability of the SIJ; 5. Neural compression as seen on an MRI or CT that correlates with the patients symptoms or other more likely source f or their pain. E. Conditions of CoverageReimbursement 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. 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 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graf t when performed, and placement of transf ixing device 4 F. Related Policies/RulesSacroiliac Joint Fusion MM-0842 G. Review/Revision HistorySacro iliac Jo in t FusionINDIANA MARKETPLACE PY-1155 Effective Date: 08/01/2020 DATE ACTIONDate Issued 05/13/2020 New PolicyDate Revised Date Effective 08/01/2020 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 Overpayment Recovery PY-111 4 08/0 1/2020 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, re gulatory 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 th e date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidit y, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenie nce 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 Poli cy 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 app lying this Policy to services provided in a particular case and 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 Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 08/01/2020 2 A. SubjectOverpayment Recovery 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 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 service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Retrospective review of claims paid to providers ass ist CareSource with ensuringaccuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified . Fraud, waste and abuse investigations are an exception to this policy. In these investigations, th e look back period may go beyond 2 years. C. Definitions Overpayment – A payment that exceeds amounts properly payable to a provider. These commonly are discovered during a post-payment review . Examples include but are not limited to incorrect coding, non-covered services, and billing discrepancies . Coordination of benefits (COB) – A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Retroactive eligibility – A p ayment for a member who was retroac tively terminated . Member is not eligible for benefits. Improper payment – A payment that should not have been made or an overpayment was made. Examples include but are not limited to payment made for the ineligible mem ber, ineligible service, payment made for a service not received, and duplicate payments. D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. The name a nd patient account number of the member to whom the service (s) were provided ; B. The date(s) of services provided ; Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 08/01/2020 3 C. The amount of overpayment ;D. The reason for the recoupment ; and E. That the provider has a ppeal rights . II. Overpayment R ecoveriesA. Lookback period is 24 months from the claim paid date . B. Advanced notification will occur 30 days in advance of recovery . C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits app ly to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date . B. Advanced notification will occur 30 days in advance of recovery . C. If the recovery o ccurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility RecoveriesA. Lookback period is 24 months from claim paid date . B. Advanced notification will occur 30 days in advance of recovery . C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting a pproved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Poli cies/Rules CareSource Indiana Marketplace Provider Manual National Agreement, Article V. CLAIMS AND PAYMENTS, 5.11 (d). G. Review/Revision History DATE ACTIONDate Issued 04/29/2020 New policyDate Revised Date Effective 08/01/2020 Date Archived Overpayment RecoveryINDIANA MARKETPLACEPY-111 4 Effective Date: 08/01/2020 4 H. References1. Indiana General Assembly. (n.d.). IC 27-13-36.2-8 Claim payment errors. Retrieved January 29, 2020 from www. iga.in.gov 2. Indiana General Assembly. (n.d.). IC 27-13-36.2-9 Claim overpayment adjustment. Retriev ed January 29, 2020 from www. iga.in.gov The Rei mbursement 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 Implantable Spinal Cord Stimulator PY-1135 08/01/2020-05/31/2021 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 ………………………….. ………………………….. ………………………….. ….. 3 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 require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidit y, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenien ce of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies 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. SubjectImplantable Spinal Cord Stimulator Imp lan table Sp in al Co rd Stimulato rINDIANA MARKETPLACE PY-1135 Effective Date: 08/01/2020 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual s ervices provided to a member and will be determined when the claim is received f or processing. 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 submitt ing provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lif etime. Long term outcomes are largely f avorable f or most 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 conse rvative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient 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 physicians qualif ied to deliver these health services. C. Def initions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain re lief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain . D. PolicyI. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required f or all implantable spinal cord stimulators, including short-term trial placement and permanent placement. 1. Prior authorizations f or implantable spinal cord stimulator services are not required f or the following: a. Implantable device is considered part of the procedure and does not require a separate PA. b. Analysis/study post implantation 3 c. Removal/Revision of implanted deviceImp lan table Sp in al Co rd Stimulato r INDIANA MARKETPLACE PY-1135 Effective Date: 08/01/2020 B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria f ound in the Implantable Spinal Cord Stimulator Medical policy MM-0715. E. Conditions of CoverageReimbursement 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/RulesImplantable Spinal Cord Stimulator MM-0715 G. Review/Revision HistoryDATE ACTIONDate Issued 12/11/2019Date Revised 05/13/2020 Added codes: L8679, L8681, L8682, L8683, L8689, L8695 Date Effective 08/01/2020 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. CMS Physician’s Fee Schedule. Retrieved on April 22, 2020 from www.cms.gov 2. CMS Durable Medical Equipment, Prosthetics/Orthotics and Supplies (DMEPOS) Fee Schedule. Retreived on March 4, 2020 f rom www.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 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 require ments, 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 r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfun ction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Med ically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does n ot 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 service s provided in a particular case and may modify this Policy at any time. REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE Policy Name Policy Number Effective Date Facet Joint Interventions PY-1161 08/01/2020 09/ 30/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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. Review/Revision History ………………………….. ………………………….. ………………………….. ……. 5 H. References ………………………….. ………………………….. ………………………….. ……………………… 5 Archived 2 A. Subject Facet Joint Interventions Facet Joint Interventions INDIANA MARKETPLACE PY-1161 Effective Date: 08/01/2020 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 accura te and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Interventional procedures for management of acute and chr onic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality 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 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 I njection 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. Policy I. Facet Joint Intervention s A. A prior 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. Archived 3 Facet Joint Interventions INDIANA MARKETPLACE PY-1161 Effective Date: 08/01/2020 II. Diagnostic Medial Branch Nerve Block Injections A. An initial medial branch nerve block injection in the lumbar and cervical/thoracic region is required for diagnosis. Diagnostic injections are necessary due to the high false positive rates of single injections. 1. Maximum number of benefit limits in this policy are based on medial necessity. 2. The member must meet the medic ally necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967, before a diagnostic injection is performed. III. Medial Branch Nerve Block Injections A. Once a positive diagnostic medial branch nerve block injection has been establi shed, injections are generally limited to a maximum of six (6) performed in the cervical/thoracic spine and six (6) in the lumbar spine per rolling twelve (12) month period. B. Per CPT guidelines, imaging guidance and any injection of contrast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. IV. Radiofrequency Facet Ablation A. Radiofrequency Facet Ablations are considered medically ne cessary when the member meets ALL of the medically necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967. B. A member can generally receive a maximum of two (2) radiofrequency facet ablations per rolling 12 months for each spinal region (cervical/thoracic or lumbar) involving no more than four (4) joints per session (e.g., two (2) bilateral levels or four (4) unilateral levels). 1. Repeat Radiofrequency Facet Ablation in the same spinal region and vertebral location is con sidered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy, MM-0967 has been met. V. Sedation A. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular fac et 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. Archived 4 F. Related Policies/Rules Facet Joint Interventions MM-0969 G. Review/Revision History Facet Joint Interventions INDIANA MARKETPLACE PY-1161 Effective Date: 08/01/2020 DATE ACTION Date Issued 05/13/2020 This policy replaces the Facet Medial Branch Nerve Block and Radiofrequency Facet Ablation policies. Date Revised Date Effective 08/01/2020 Date Archived 09/30/2020 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . H. 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 above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Date Effective Drug Test ing PY-0329 0 7/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, 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 neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfu nction 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 d oes 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. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 8 Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 2 A. Subject Drug Testing 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 pro cessing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the pr oduct or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for mem bers with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for 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 most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test-The testing of a substance or mixture 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 definitive testing. Random drug test-A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Residential treatment services-Per the Evidence of Coverage these health care services can include individual and group psychotherapy, family counseling, nursing services, and pharmacological therapy in a 24 hour community. NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0 066 . Please refer to this policy for in-depth i nformation on medical necessity for drug testing, d ocumentation requirements , and CareSource monitoring and review of drug testing claims.Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 3 D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the I CD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Laboratory A. Drug testing conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. Non-participating providers are not covered for drug testing laboratory services . C. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. III. Non-Urine Testing A. CareSource will reimburse blood testing in e mergency room settings . B. Drug testing with blood samples performed in any other setting outside of an e mergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered IV. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: a. Presumptive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR b. Presumptive testing was positive for prescription drug with abu se potential that was not prescribed by provider AND the member disputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines).ArchivedDrug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 4 V. Non-Billable Drug Testing A. Testing that is not individualized such as 1.1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing re quired by third parties s uch as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmaci sts, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing required by any third party. 7. Testing in residential treatment facility, partial hospital, or sober living as a condition to remain in that community. 8. Testing with another pay source that is primary such as a county, state or federal agency. 9. Testing for marriage license. 10. Forensic. 11. Testing for other admin purposes. 12. Routine physical/medical examination. C. Testing for validity of specimen It is included in the payme nt for the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subseq uent medical review audits , recovery of overpayments identified, and provider prepay review . E. CONDITIONS OF COVERAGEArchived Drug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 5 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. Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) incl udes sample validation when performed, per date of service Codes Quantitative/Confirmatory Tests-Description G0480 Drug Test definitive/Quantitative 1-7 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including met abolite(s) if performed G0481 Drug Test definitive/Quantitative 8-14 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope o r other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to contr ol for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performedArchivedDrug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 6 G0482 Drug testing definitive/Quantitative 15-21 classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative , all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed G0483 Drug testing definitive/Quantitative 22+ classes Drug test(s), definitive, utilizing (1) drug identification methods able to iden tify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), i ncluding metabolite(s) if performed G0659 Drug testing definitive/Quantitative non-specified number of drug classes Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogena se), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qu alitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80329 analgesics, non-opioid, 1 or 2 80330 analgesics, non-opioid 3-5ArchivedDrug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 7 80331 analgesics, non-opioid 6 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more 80338 antidepressants not otherwise specified 80339 antiepileptic, not otherwise specified 1-3 80340 antiepileptic, not otherwise specified 4-6 80341 antiepileptic, not otherwise specified 7 or more 80342 antipsychotics, not otherwise specified 1-3 80343 antipsychotics, not otherwise specified 4-6 80344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80367 propoxyphene 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, quali ta tive or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, quali ta tive or quantitative, not otherwise specified 4-6ArchivedDrug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 8 80377 drug, or substance definitive, quali ta tive or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0 130 CareSource Evidence of Coverage and Health Insurance Contract G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/1/2017 Date Revised 11/29/2017 0 2/16/2018 0 5/ 0 1/2019 0 8 / 0 1/2019 01 / 01/2020 03/17/2020 Updated clinical indications, quantity limits, and PA requirements Removed quantity limits and PA requirements Updated codes . Updat e I I . Date Effective 07/01/2020 H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11 /20iction Science18 from https://blumsrewarddeficiencysyndrome.com 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 results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addic tion. Retrieved on December 13, 2018 from https://www.ncbi.nlm.nih.gov 3. American Society of Addiction Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settin gs. Retrieved on December 11, 2018 from https://www.asam.org 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on December 13, 2018 from https://journals.lww.com 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendations and Reports. Retrieved on December 11, 2018 from http://dx.doi.org 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on December 11, 2018 from https://www.ecfr.gov 7. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal . Retrieved Decembe r 13, 2018 from http://www.painphysicianjournal.com ArchivedDrug Testing INDIANA MARKETPLACE PLANS PY-0 329 Effective Date: 1/1/2020 9 8. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on December 11, 2018 from https://www.va.gov 9. Washington State Interagency Guideline on Opioid Dosi ng for Chronic Non-cancer Pain. (2017) Retrieved on December 11, 2018 from https://kbml.ky.gov The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Applied Behavior Analysis for Autism Spectrum Disorder PY-0710 05/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 2 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 5 F. Related Policies/Rules …………………………………………………………………………………………….. 6 G. Review/Revision History ………………………………………………………………………………………….. 6 H. References ……………………………………………………………………………………………………………. 7 Applied Behavior Analysis Therapy for Autism Spectrum Disorder INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 05/01/2020 2 A. Subject Applied Behavior Analysis Therapy for Autism Spectrum 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 verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms, depending on the developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereotyped (repetitive) behavior. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted, repetitive patterns of behavior, interests and activities. There is currently no cure for ASD, nor is there any one single treatment for the disorder. Individuals with ASD may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions. The goal of treatment for members with ASD is to minimize the severity of ASD symptoms, maximize learning, facilitate social integration, and improve quality of life for both the members and their families/caregivers. C. Definitions Autism Spectrum Disorder-A neurological condition, including Asperger’s syndrome and autism, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. BCaBA-Behavioral Analyst Certification Board (BACB) certified assistant behavior analyst undergraduate level. BCBA-BACB certified behavior analyst graduate level. BCBA-D – BACB certified behavior analyst doctoral level. RBT-BACB Registered Behavioral Technician. Practice of applied behavioral analysis-Designs, implements, and evaluates instructional and environmental modifications to produce socially significant improvements in human behavior. Applied Behavior Analysis Therapy for Autism Spectrum Disorder INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 05/01/2020 3 Qualified RBT supervisor-BCBA/BCBA-D, BCaBA, or an individual licensed in another behavioral health profession who is competent in ABA and it is within their scope of practice. RBT supervision-Ongoing supervision must be at a minimum of 5% of the hours spent providing behavior-analytic services per month1. This includes a minimum of 2 face-to-face contacts per month. Face-to-Face-QHP or technician must be physically present with member. On-site-QHP is immediately available and can be interrupted to assist and give direction. QHP-Qualified Healthcare Professional: Licensed Behavior Analyst, Board Certified Behavior Analyst-Doctoral, Board Certified Behavior Analyst, Psychologist, Health services provider in psychology (HSPP), or other credentialed professional whose scope of practice, training, and competence includes applied behavior analysis. Assistant-An assistant behavior analyst or trained technician who delivers services under the direction of the QHP. Customized environment-Environment that is configured to safely conduct a functional analysis of destructive behavior or treatment for that behavior. D. Policy I. Prior Authorization (PA) is required for all of the following: A. Initial Treatment Plan for ABA therapy; B. Continuation of ABA therapy; and C. Transitioning ABA therapy to school environment. II. An ASD diagnosis must be primary in order for services to be reviewed for approval. III. Reimbursement A. Duplicate services or double billing are not reimbursable (except as noted in IV. F. below). 1. If member is receiving other treatment (i.e. speech therapy), ABA therapy cannot be billed at the same time on the same date of service. B. Exclusions listed in the Medical policy, MM-0259 are not reimbursable. C. Face-to-face verses non face-to-face time 1. 97151 includes face-to-face time with the member/caregiver to conduct assessments as well as non face-to-face time (such as reviewing records, scoring and interpreting assessment, and writing the treatment plan or progress report). This code is intended for reporting initial assessment and treatment plan development and reassessment and progress reported by the QHP. 2. Only face-to-face time is reported with 97153-97158 and 0373T as the day to day assessment and treatment planning by the QHP is included in these codes. IV. Limitations A. Initial and continuation authorizations are required every 6 months. 1 https://www.bacb.com Applied Behavior Analysis Therapy for Autism Spectrum Disorder INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 05/01/2020 4 B. Transitioning ABA therapy to school environment authorization is generally limited to a maximum of 4 months for services provided in the school. C. A Medically Unlikely Edit for a CPT code is the maximum units of service that a provider can report for one member on one date of service. 1. Maximum units allowed per CPT*: CPT Max unit allowed 97151 32 97152 8 97153 32 97154 12 97155 24 97156 16 97157 16 97158 16 0362T 8 0373T 32 *If CMS updates the MUE list, the update will take precedence over the MUEs in this policy. D. Each RBT must obtain ongoing supervision for 5-10% of the hours spent providing behavior-analytic services per month. E. The treatment codes are based on daily total units of service in 15 minute increments. A unit of time is attained when the mid-point is passed. 1. Time interval examples: Units Number of minutes 1 unit >8 minutes through 22 minutes 2 units >23 minutes through 37 minutes 3 units >38 minutes through 52 minutes 4 units >53 minutes through 67 minutes 5 units >68 minutes through 82 minutes 6 units >83 minutes through 97 minutes 7 units >98 minutes through 112 minutes 8 units >113 minutes through 127 minutes F. Concurrent billing 1. 97154 and 97158 may not be reported concurrently as 97158 is intended for a QHP-led group session. 2. The following chart summarizes when 97155 can be billed concurrently with codes for direct treatment of the member. Applied Behavior Analysis Therapy for Autism Spectrum Disorder INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 05/01/2020 5 Direct Treatment Codes Direction of Technician Code (May be billed concurrently with direct treatment code) 97153 Individual treatment by technician or QHP 97155 By QHP 97154 Group treatment by technician or QHP 97155 By QHP 0373T Individual treatment by 2 or more technicians or 2 or more QHPs None this is bundled into 0373T 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 97151 Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physicians or other qualified healthcare professionals time face-to-face with member and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. (Attended by member and QHP) 97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. (Attended by 2 or more members and technician (QHP may substitute for technician)) 97155 Adaptive behavior treatment by protocol modification, administered by physician or other qualified healthcare professional, which may includeApplied Behavior Analysis Therapy for Autism Spectrum Disorder INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 05/01/2020 6 simultaneous direction of technician, face-to-face with one patient, each 15 minutes. (Attended by member and QHP; may include technician and/or caregiver) 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the member present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. (Attended caregiver and QHP) 97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the member present), face-to-face with multiple sets guardians/caregivers, each 15 minutes. (Attended caregivers of 2 or more members and QHP) 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple members, each 15 minutes. (Attended by 2 or more members and QHP) 0362T Behavior identification supporting assessment, each 15 minutes of technicians time face-to-face with a member, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patients behavior. (Attended by member and 2 or more technicians; QHP on site) 0373T Adaptive behavior treatment with protocol modification each 15 minutes of technicians time face-to-face with patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patients behavior. (Attended by member and 2 or more technicians; QHP on site) F. Related Policies/Rules Applied Behavioral Analysis (ABA) Therapy MM-0259 Evidence of Coverage and Health Insurance Contract Indiana G. Review/Revision History DATE ACTION Date Issued 11/29/2018 New Policy Date Revised 04/12/2019 01/22/2020 Removed Modifiers Revised definitions, clarified PA requirements, added ASD diagnosis as primary, added specificity to reimbursement, updated limitations, added MUE, Applied Behavior Analysis Therapy for Autism Spectrum Disorder INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 05/01/2020 7 added time intervals, added specificity to concurrent billing. Date Effective 05/01/2020 H. References 1. Behavior Analyst Certification Board. (2018, November 12). Retrieved November 12, 2018 from https://www.bacb.com 2. Behavior Analyst Certification Board. (2018, October 18). Adaptive Behavior Assessment and Treatment Code Conversion Table. Retrieved January 5, 2020 from https://www.bacb.com 3. American Medical Association. (2018). Coding Update: Reporting Adaptive Behavior Assessment and Treatment Services in 2019. CPT Assistant, 28(11). 4. Behavior Analyst Certification Board. (2014). Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved on December 3, 2019 from https://www.bacb.com 5. Centers for Medicare & Medicare Services. (2019, 4th quarter). Practitioner Services Medically Unlikely Edits Table. Retrieved December 3, 2019 from http://www.cms.gov 6. Centers for Medicare & Medicaid Services. (2018, March). Medicare Claims Processing Manual Chapter 5 Part BOutpatient Rehabilitation and CORF/OPT Services. Retrieved on December 3, 2019 from https://www.cms.gov 7. ABA International. (2019, January). Supplemental Guidance on Interpreting and Applying the 2019 CPT codes for Adaptive Behavior Services. Retrieved on 12/3/2019 from https://www.abainternational.org 8. Indiana Department of Insurance. (2015, June 17). Payment of Undisputed ABA Treatment During Appeals Process. Bulletin 216. Retrieved January 15, 2020 from https://www.in.gov 9. Indiana Department of Insurance. (2006, March 30). Insurance Coverage for Pervasive Development Disorders Bulletin 136. Retrieved January 15, 2020 from https://www.in.gov 10. Indiana Department of Insurance. (2010, April 27). Pervasive Developmental Disorders Coverage Clarification Bulletin 179. Retrieved January 15, 2020 from https://www.in.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE Policy Name Policy Number Effective Date Hepatitis Panel for Acute Viral Hepatitis PY-0211 4/1/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 4 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H. REFERENCES ………………………………………………………………………………………… 4 Hepatitis Panel for Acute Viral Hepatitis INDIANA MARKETPLACE PY-0211 Effective Date: 4/1/2020 2 SUBJECT Hepatitis Panel for Acute Viral Hepatitis A. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Acute viral hepatitis (AVH) is a systemic infection that mostly affects the liver. It can be caused by a virus, a toxin, or could be the beginning of chronic liver disease. The viruses that most often cause AVH are hepatitis A, B, C, D, and E. The typical symptoms are shown in all forms of AHV including jaundice, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, fever, and dark urine. B. DEFINITIONS Hepatitis panel: consists of the following tests: o Hepatitis A antibody (HAAb), IgM Antibody o Hepatitis Bcore antibody (HBcAb), IgM Antibody o Hepatitis Bsurface antigen (HBsAg) o Hepatitis Cantibody C. POLICY I. Prior authorization is not required for hepatitis panel tests that are medically necessary. Note: Although a Hepatitis panel does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II. Hepatitis panel is considered medically necessary when used for a differential diagnosis in members with ANY of the following: A. Symptoms of hepatitis infection OR B. Abnormal liver function tests OR C. Before and after a liver transplantation. III. Hepatitis panel must be ordered and performed by a provider for these services, Hepatitis Panel for Acute Viral Hepatitis INDIANA MARKETPLACE PY-0211 Effective Date: 4/1/2020 3 and when used in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. IV. Non-Covered Services A. Once a diagnosis of hepatitis has been made, CareSource will not cover ongoing hepatitis panel testing. CareSource will cover, appropriate and medically necessary, individual hepatitis testing for its members. D. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Codes Description 80074 Acute Hepatitis Panel Diagnosis Codes Description M25.50 Pain in unspecified joint M79.10 Myalgia, unspecified site R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.33 Periumbilical pain R10.811 Right upper quadrant abdominal tenderness R10.821 Right upper quadrant rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R17 Unspecified jaundice R19.5 Other fecal abnormalities (abnormal stool color) R50.9 Fever, Unspecified R53.1 Weakness R53.81 Other malaise Hepatitis Panel for Acute Viral Hepatitis INDIANA MARKETPLACE PY-0211 Effective Date: 4/1/2020 4 R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) Failure to thrive (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight R74.0 Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH] R74.8 Abnormal levels of other serum enzymes R74.9 Abnormal serum enzyme level, unspecified R82.998 Other abnormal findings in urine R94.5 Abnormal results of liver function studies T86.40 Unspecified complication of liver transplant T86.41 Liver transplant rejection T86.42 Liver transplant failure T86.43 Liver transplant infection T86.49 Other complications of liver transplant Z76.82 Awaiting organ transplant status Z94.4 Liver transplant status E. RELATED POLICIES/RULES F. REVIEW/REVISION HISTORY DATE ACTION Date Issued 5/15/2017 Date Revised 1/8/2020 Removed ICD-10 and references to asymptomatic members. Title changed was hepatitis panel. Date Effective 4/1/2020 Removed ICD-10 and references to asymptomatic members. Title changed was hepatitis panel. G. REFERENCES 1. National Coverage Determination (NCD) for Hepatitis Panel/Acute Hepatitis Panel (190.33). (2003, January 1). Retrieved November 21, 2019 from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=166&ncdver=1&CoverageSelection=Both&ArticleType=All&Hepatitis Panel for Acute Viral Hepatitis INDIANA MARKETPLACE PY-0211 Effective Date: 4/1/2020 5 PolicyType=Final&s=Ohio&KeyWord=hepatitis+panel&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA& 2. Centers for Medicare and Medicaid Services. Lab NCDs-ICD-10. (n.d.). Retrieved November 21, 2019, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10 3. World Gastroenterology Organisation Practice Guidelines: (2003, December). Retrieved November 21, 2019, from https://www.worldgastroenterology.org/UserFiles/file/guidelines/management-of-acute-viral-hepatitis-english-2003.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Hepatitis Band CPY-08 76 11/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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-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 and may modify this Policy at any time. Table of Contents Reimbursement 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 MARKETPLACE PLANS PY-08 7 6 Effective Date: 11/01/2019 2 A. Subject Molecular Diagnostic Testing for Hepatitis Band CB. 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 quali fications. 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 c hannels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not i mply any right to reimbursement or guarantee claims payment. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Mol ecular 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 Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis trans mitted 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 other 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: approximately 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 Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-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 might not be aware of their infection beca use 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) All facilities in the United States that perform laboratory te sting 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 th ose 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 r eview of a providers office testing policies and procedures when performing CLIA-waived tests. Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACE PLANS PY-08 7 6 Effective Date: 11/01/2019 3 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 combination of the CPT and ICD-10 diagnosis codes listed in the Condit ions 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 ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventio nal 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 Centers for Medicar e & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) 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 87521 Infectious agent detection by nucleic acid (DNA 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 B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACE PLANS PY-08 7 6 Effective Date: 11/01/2019 4 B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwit hout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.2 Chronic viral hepatitis CB18.9 Chronic viral hepatitis, unspecified 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 complicating 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 Z20.5 Contact with and (suspected) exposure to viral hepatitis F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 11/01/2019 New Policy Date Revised 1 2/18/2019 A ddition of code Z20.5 Date Effective 11/01/2019 Date Archived H. References 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (201 9 , July 2 3 ). Retrieved 7/29/19 from www.cdc.gov/hepatitis. 2. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 3. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https ://www.healthcare.gov/glossary/medically-necessary/. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d.
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, 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, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfun ction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Med ically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does n ot 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. REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Date Effective Drug Testing PY-0329 1/1/2020 06/ 30/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 4 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………. 7 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. ………….. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 7 Archived 2 A. Subject Drug Testing Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 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 accura te and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Drug testing is a part of medical care during the initial assessment, on going monitoring, and recovery phase for members with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when pr escription medications or illegal drugs are of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualitative and confirmatory/quantitative. Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive/Qualitative test-The testing of a substance or mixture 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 definitive testing. Random drug test-A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Residential treatment services-Per the Evidence of Coverage these health care services can include individual and group psychotherapy, family counseling, nursing services, and pharmacological therapy in a 24 hour community. NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0066. Please refer to this policy for in-depth information on medical necessity for drug testing, do cumentation requirements, and CareSource monitoring and review of drug testing claims. Archived 3 Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the app ropriate lines of the claims forms. II. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. III. Non-Urine Testing A. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples performed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered IV. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource. B. Confirmatory testing must be individualized for the member and medically neces sary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: a. Presumptive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR b. Pr esumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member disputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing. (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). V. Non-Billable Drug Testing A. Testi ng that is not individualized such as 1. Reflexive testing. Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 4 Routine orders. Standard orders. Preprinted orders. Requesting a broad spectrum of tests that a machine is capable 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 as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing required by any third party. 7. Testing in residential treatment facility, partial hospital, or sober living as a condition to remain in that community. 8. Testing with another pay source that is primary such as a county, state or feder al agency. 9. Testing for marriage license. 10. Forensic. 11. Testing for other admin purposes. 12. Routine physical/medical examination. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Indiana Marketplace approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the CMS fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sou rce for the most current coding information. 2. 3. 4. 5. Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 5 Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instr ument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometr y either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative/Confirmatory Tests-Description G0480 Drug Test definitive/Quantitative 1-7 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC /MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug Test definitive/Quantitative 8-14 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or q uantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0482 Drug testing definitive/Quantitative 15-21 classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or q uantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 6 G0483 Drug testing definitive/Quantitative 22+ classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/M S (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all so urces, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed G0659 Drug testing definitive/Quantitative non-specified number of drug classes Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (an y type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more 80338 antidepressants not otherwise specified 80339 antiepileptic, not otherwise specified 1-3 80340 antiepileptic, not otherwise specified 4-6 80341 antiepileptic, not otherwise specified 7 or more 80342 antipsychotics, not otherwise specified 1-3 80343 antipsychotics, not otherwise specified 4-6 80344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 7 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, qualitative or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, qualitative or quantitative, not otherwise specified 4-6 80377 drug, or substance definitive, qualitative or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0130 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/1/2017 Date Revised 11/29/2017 2/16/2018 5/1/2019 8/1/2019 Updated clinical indications, quantity limits, and PA requirements Date Effective 1/1/2020 Removed quantity limits and PA requirements. Date Archive 06/30/2020 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11/20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 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 results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 1/1/2020 8 3. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 4. American Society of Addiction Medicine (Revised 2010). Public Policy Statement on Dr ug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https ://www.asam.org/docs/default-source/public-policy-statements/1drug-testing — clinical-10-10.pdf?sfvrsn=1b11ac97_0#search=”urine drug testing 5. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on 12/13/2018 from https://journals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_ Drug_Testing_in_Clinical.1.aspx 6. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendations and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 7. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https:// www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42 .1.8&r=PART#se42.1.8_12 8. CareSource Evidence of Coverage and Health Insurance Contract (2019). Retrieved on 3/27/2019 from https ://www.caresource.com/documents/2019-oh-mp-enhanced-eoc/ 9. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Bes t Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 10. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https:// www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf 11. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%2 0on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pai n%20Urine%20Drug%20Testing%20Guidance.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Archived
© Copyright CareSource 2026. All rights reserved.
System Details