REIMBURSEMENT POLICY STATEMENTINDIANA MARKET PLACE PLANS Policy Name Policy Number Effective Da te Glycosylated Hemoglobin A1C PY-0335 02/01/2020-0 9/ 30 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………….. 1 A. Subject …………………………………………………………………………………………………………….. 2 B. Background………………………………………………………………………………………………………. 2 C. Def initions ………………………………………………………………………………………………………… 2 D. Policy ………………………………………………………………………………………………………………. 2 E. Conditions of Co v er ag e ………………………………………………………………………………………. 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 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does n ot ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tGlycosylated Hemoglobin A1C Gl y c o s y l ated Hemoglobin A1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p roc essing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. Gly c ated hemoglobin/protein testing is widely ac cepted as medically necess ary for the manag ement and control of diabetes. Glyc osylated hemoglobin A1C/protein levels are us ed to d etermine lo ng-term glucose c ontrol in d iabetes. Gly c osylated hemoglobin lev els reflect the av erag e lev el of g luc ose in the blood ov er a three-month period.C. Def initions Glycosylated Hem oglobin (A1C) a b lood test that measures your av erage blood s ugar lev els o v er the p ast 3 months. It is one of the c ommonly us ed tes ts to diagnose prediabetes and d iab etes . Glycated protein-a b lood t est that is used to ass ess g ly ce mi c c ontrol over a p eriod of 1-2 week s and lo ng-term c ontrol in d iabetic patients with abnormalities of ery throcytes. D. Polic yI. Prio r autho rization is no t required for partic ipating p roviders for glycos ylated hemoglobin (A1C)/p ro tein b lood tes ting. Note: Altho ugh CareSourc e does not r equire a p rior authorization for g lycosylated hemo g lobin (A1C)/protein blood tes ting, CareSource may req uest d ocumentation to s up p ort medic al nec essity. Appropriate and complete doc umentation must be p res ented at the time of rev iew to v alidate medical nec essity .II. CareSo urc e c ons iders sc reening for the d iagnos is of d iabetes as medic ally nec essary p rev entiv e care for t he following member g roups acc ording to the United Sta t es Prev entive Serv ic es Tas k Fo rce (US PS TF): A. As y mptomatic members age 40 to 70 y ea r s who are ov erweight or o b es eB. As y mptomatic me mbers of any ag e or weight who are in the f ollowing high-risk g roups : 1. Immed iate family his tory of diabetes 2. His t o ry of gestational diabetes or polycy stic ov arian s y ndrome 3. A f ric an Americans 4. Nat iv e Americans 5. Alas k an Natives 6. As ian Americans 3 7. His p anic s and Latinos8. Nat iv e Hawaiians 9. Nat iv e Pa c if i c Is landers Gl y c o s y l ated Hemoglobin A1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020C. As y mptomatic preg nant women who have reac hed 24 week s of gestation. III. CareSo urc e c onsiders d iagnos tic testing for the management of diabetes as medically nec es s ary for the following member g roups, with the s pecified frequencies: A. Memb ers whose diabetes is controlled, o nc e ev ery 3 monthsB. Memb ers whose diabetes is not c ontrolled may req uire testing more than four t i mes a y ea r C. Preg nant wo men, onc e per mo nt h Note: CareSo urc e may req ues t doc umentation to s upport medic al nec essity , if tes ti ng is in ex c es s of the above g uidelines.IV. Alternativ e testing, inc luding glycated protein, for ex ample, fructosamine, may be indicated f or mo nito ring the d egree of glycemic control. A. It is theref ore c onceivable that a patient wi ll hav e both a g ly cated hemoglobin and g ly c ated protein o rdered on the s ame day . B. Th i s s ho uld be limited to the initial as say of glycat ed hemoglobin, wi th s ubsequent ex c lus ive us e of glyc ated pro tein. C. Thes e tests are no t considered to be medically nec essary for the diagnosis of diabetes . V. Reimb urs ement is b ased on submitting a claim with the appropriate ICD-10 d iagnosis c ode to matc h the CPT c o de listed within this policy. If the ap propriate ICD-10 d iagnos is code is not s ub mitted with the CPT c ode, the c laim will be denied. E. Conditions of Cov erage Reimb urs ement is dependent o n, b ut not limited to, s ubmitting Centers for Medicare and Med ic aid Ser v i c e s (CM S) ap proved HCP CS and CP Tc odes and the appropriate modifiers, if ap p lic able. Pleas e refer to the CMS fee s chedule for ap propriate c odes. The follo wing l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description82985 Gly c ated p rotein 83036 Hemo g lobin; g lycosy lated (A 1C) ICD-10 Description D13.7 Benig n neo p las m of end ocrine p ancreas E08. Diab etes mellitus due to underlying c ondition wi th (A ny ICD-10 s tarting wi th E08.) E09. Drug or c hemic al induced diabetes mellitus wit h (Any ICD-10 s tarting wi th E 09 . ) E10. Ty p e 1 d iab etes mellitus wi th (A ny ICD-10 s tarting wi th E 10 . ) E11. Ty p e 2 d iab etes mellitus wi th (A ny ICD-10 s tarting wi th E 11 . ) E13. Other s p ec ified d iabetes mellitus wit h (Any ICD-10 s tarting wi th E 1 3. ) E15 No nd iabetic hy poglycemic c oma E16.0 Drug-ind uced hy pogly c emi a without c oma E16.1 Other h y p o g lyc em ia E16.2 Hypoglycemia, uns p ec ified E16.3 Inc reas ed s ec retion of g lucagon E16.8 Other sp ecified d isorders of p ancreatic internal s ecretion 4 Gl y c o s y l ated Hemoglobin A 1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020E16.9 Dis o rder of panc reatic internal s ecretion, unspecified E31.0 Auto immune polyglandular f ailure E31.1 Po ly glandular hy perfunction E31.20 Multip le end ocrine neo plas ia [ MEN] s yndrome, unspecified E31.21 Multip le end ocrine neo plas ia [ ME N] ty pe I E31.22 Multip le end ocrine neo plas ia [ ME N] ty pe IIA E31.23 Multip le end ocrine neo plas ia [ ME N] ty pe IIB E31.8 Other p o ly glandular d ysf unct ion E31.9 Po ly glandular d ysf unct ion, uns pecified E74.8 Other sp ecified d isorders of c arbohydrate metabolism E79.0 Hy p eruric emia without s igns of inflammatory art hritis and tophaceous d i s e as e E83.10 Dis o rder of iro n metabolism, unspecified E83.110 Hered itary hemochromatosis E83.111 Hemo c hro matos is due to repeated red b lood c ell transfusions E83.118 Other hemo c hromatosis E83.119 Hemo c hro mato s i s , uns p ec ified E83.19 Other d is orders of iron metabolism E88.02 Plas minogen d ef iciency E89.1 Postprocedural h y p o i ns ul i n em ia H44.2E1 Deg enerative my opia wit h o ther mac ulopathy, rig ht eye H44.2E2 Deg enerative my opia wit h o ther mac ulopathy, lef t eye H44.2E3 Deg enerative my opia wit h o ther maculopathy, b ilateral eye I21.9 Ac ute my oc ardial infarc tion, uns pec ified I21.A1 My o c ardial infarc tion t ype 2 I21.A9 Other my o c ardial infarc tion t ype K86.0 A l c o ho l-induced c hronic p ancreatitis K86.1 Other c hro nic p ancreatitis K91.2 Po s tsurgical malabsorption, not elsewhere c lassif ied L97. No n-p res s ure chronic ulcer of other part of (A ny ICD-10 starting wi th L97.) L98.415 No n-p res s ure chronic ulcer of buttock wit h mus cl e inv olv ement without evidence o f nec rosis L98.416 No n-p res s ure chronic ulcer of buttock wit h bone involvement without evidenc e of nec ro s is L98.418 No n-p res s ure c hronic ulc er of buttock wi th o t he r s p ecified s everity L98.425 No n-p res s ure chronic ulcer of bac k wi th m uscle involvement without evidence of nec ro s is L98.426 No n-p res s ure chronic ulcer of back wi th bone involvement without evidence of nec ro s is L98.428 No n-p res s ure c hronic ulc er of bac k wi th other s pecified s everity L98.495 No n-p res s ure chronic ulcer of sk in of other s i tes wit h m uscle involvement without ev id enc e of nec rosis L98.496 No n-p res s ure chronic ulcer of sk in of other s i tes wit h bone involvement without ev id enc e of nec rosis O24. Pre-ex is ting ty pe 1 diabetes mellitus, in pregnancy (A ny ICD-10 s tarting wit h O24.) O30. Trip let p reg nanc y(Any ICD-10 starting wit h O30.) O99.810 Ab no rmal g lucose c omplicating p regnancy O99.815 Ab no rmal g lucose c omplicating the p uerperium R73.01 Imp aired f asting g lucose R73.02 Imp aired g lucose to leranc e (oral) R73.03 Pred iabetes R73.09 Other ab no rmal g lucose R73.9 Hy p erg l y c emi a, uns p ec ified R78.71 Ab no rmal lead leve l in blood 5 Gl y c o s y l ated Hemoglobin A 1C INDIANA MARKET PLACE PLANS PY-0335 Effec ti v e Date: 02/01/2020R78.79 Find ing of ab normal lev el of heavy metals in blood R78.89 Find ing of other specified s ubs tances , not normally found in b lood R79.0 Ab no rmal lev el of blood mineral R79.89 Other specifi ed abnormal findings of blood c hemis try R79.9 Ab no rmal f inding of blood chemistry, unspecified T38.3X1A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentio nal), initial encounter T38.3X2A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs , intentional s e lf – harm, initial e nc ounter T38.3X3A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs, assault, i n it i a l enc o unter T38.3X4A Po is oning by insulin and oral hypoglycemic [antidiabetic] drugs, undetermined, initial enc o unter Z00.00 Enc o unter for g eneral ad ult medic al ex amination without ab normal findings Z00.01 Enc o unter for g eneral ad ult medical ex amination wit h ab normal findings Z01.812 Enc o unter for p reprocedural lab oratory ex amination Z13.1 Enc o unter for s c reening for d iabetes mellitus Z13.9 Enc o unter for s c reening, unspecified Z79.3 Lo ng t erm (c urrent) us e of hormonal c ontraceptives Z79.4 Lo ng t erm (c urrent) us e of insulin Z79.84 Lo ng t erm (c urrent ) us e of oral hy poglycemic drugs Z79.891 Lo ng t erm (c urrent) us e of opiate analgesic Z79.899 Other lo ng t erm (c urrent ) drug therapy Z86.2 Pers o nal history of diseases of the blood and blood-forming org ans and certain d is o rders inv olving the immune mechanism Z86.31 Pers o nal his tory of diabetic foot ul c e r Z86.32 Per s o nal his tory of ges tational diabetes Z86.39 Pers o nal his tory of other endoc rine, nutritional and metabolic d isease F. Related Polic ies/Rules N/ A G. Re v iew/Rev ision History DATE ACTIONDate Issued 02/01/2020Date Revised Date Effecti ve 02/01/2020 New p o licy Date Archived 09/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uid elines without a f ormal doc umented Policy. H. Ref erenc es1. Ab no rmal Blood Gluc ose and Ty p e 2 Diabetes Mellitus: Sc reening. (2015, October). Retrieved 8/29/2019 f ro m https :/ /www. uspreventiv eservicestaskforce.org /Page/Document/U pdate Summary Final/s creening-for-abnormal-blood-glucose-and-type-2 -diabetes?ds=1&s=diabetes . 2. Centers f or Medicare and Medic aid Services . (2019). NCD 190.21-Glycated Hemo g lobin/Glycated Protein (190.21). 3. Ges tatio nal Diabetes Mellitus, Screening. (2014, January). Retrieved 8/29/2019 from https://www.uspreventiveservicestaskforc e.org/Page/Document/UpdateSummaryFinal/gestatio nal-d iabetes-mellitus-screeni ng?ds=1&s=diabetes.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Robotic-Assisted Surgery PY-0956 2/1/2020 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, 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 …………………………………………………………………………………. 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 …………………………………………………………………………………………………………. 3 Robotic-Assisted Surgery INDIANA MARKETPLACE PLANS PY-0956 Effective Date: 2/2/2020 2 A. Subject Robotic-Assisted Surgery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. 4Health care providers and their office 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. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invasive procedures using robotic devices designed to access surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a computer equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly through computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of robotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with the assistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services): 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased difficulty of procedures, or severity of patients condition. Robotic-Assisted Surgery INDIANA MARKETPLACE PLANS PY-0956 Effective Date: 2/2/2020 3 Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) fee schedule for appropriate codes. E. Related Policies/Rules F. Review/Revision History DATE ACTION Date Issued 2/1/2020 New Policy Date Revised Date Effective 2/1/2020 Date Archived G. References 1. Robotic surgery. MedLine Plus Web site. http://www.nlm.nih.gov/medlineplus/ency/article/007339.htm . Published May 2013. Accessed October 9, 2019 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus group. Position Papers/ Statement published on: 11/2007. Accessed October 9, 2019. Available at URL address: http://www.sages.org/publications/guidelines/consensus-document-robotic-surgery/ The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTINDIANA MARKET PLACE PLANS Policy Name Policy Number Effective Da te Preventive Ev alu at io n an d Management Services and Acute Care Visit on Same Dat e of Service PY-0905 01/01/2020-1 1/ 30 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………….. 1 A. Subject …………………………………………………………………………………………………………….. 2 B. Background………………………………………………………………………………………………………. 2 C. Def initions ………………………………………………………………………………………………………… 2 D. Policy ………………………………………………………………………………………………………………. 2 E. Conditions of Co v er ag e ………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………… 6 G. Review/Revision History ……………………………………………………………………………………… 6 H. Ref erences ………………………………………………………………………………………………………. 6 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 servic e, medical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose 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 lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tPrev en ti v e Ev al uati o n an d Man ag emen t Serv i c es and Ac ute Care Visit on Same Date of Serv i c e INDIANA MARKET PLACE PLANS PY-0905 Effec ti v e Date: 01/01/2020Preventive Evaluation and Management Services and Acute Care Vi sit on Same Date of Service B. Bac k groundReimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode d o es not imply any rig ht to reimbursement or g uarantee c laims pay ment. CareSo urc e will reimb urs e p articipating prov iders for medic ally nec ess ary and p reventive s c reening tests as required by federal s tatute through c riteria b ased on rec ommendations from the U. S . Prev entive Services Ta s k Force (US PS TF). Ap plic able c linical crit eria for the following b reas t c anc er sc reening health s ervices are d esc ribed in the c orres ponding medical policy ent itled Mammography services C. Def initions Preventive Services: are ex ams and s creenings to c heck for health problems, with the intentio n to prevent any problem d is covered f rom b ec oming worse. Prev entive serv ices m ay inc lud e, b ut are no t limited to, p hysical c heckups, hearing, v ision, and dental c hecks, nutritio nal s creenings, mental health s creenings, developmental s creenings, and v ac c inations/immunizations. Regularly s cheduled v isits to a primary c are prov ider for p rev entiv e serv ices are enc ouraged at ev ery age, but are es pecially important for c hildren und er the ag e o f 18. D. Polic yI. Prev entiv e Health Services that are b illed on the same d ate of service as an A cute Care Vi sit : a. When any o f the following p reventive health s erv ice c odes are b illed on the s ame d ate of s erv ic e as an ac ute care v isit with the appropriate ICD-10 codes , CareSource will reimb urs e o n ly the Preventive Service c ode at 100% . Th e A c ut e Care Visit Service c odes will no t b e reimburs ed unless b illed with the ap propriate modifier to identify s eparately id entifiable serv ices that were rend ered b y the s ame phy sician on the s ame date of service. i. Prev entiv e Health Service Codes 1. 99381-99387 2. 99391-99397 ii. Ac ute Care Visit Codes 1. 99201-99205 2. 99211-99215 3 Prev en ti v e Ev al uati o n an d Man ag emen t Serv i c es and Ac ute Care Visit on Same Date of Serv i c e INDIANA MARKET PLACE PLANS PY-0905 Effec ti v e Date: 01/01/2020II. CareSo urc e res erv es the right to request documentation to support billing both services f or a l l c laims rec eived. If doc umentation is req ues ted, it must c learly d elineate the p roblem-oriented his to ry , ex am, and d ecision mak ing from those of the preventiv e serv ice. Documentation mu s t inc lude the following: a. Key elements that s upport the additional p reventive health s ervices that were rend ered b. As ep arate history p aragraph desc ribing the chronic/acute c ondition that clearly supports ad d itional work need ed on the s ame date of serv ic e. c. The p ro v ider s hould c learly list in the as sessment portion of the d ocumentation the ac ute/c hronic c onditions that are b eing managed at the ti m e of the encounter. If there is a p o rtion of the phy sical exam that is no t ro utinely performed at the time of a p reventive service, the prov ider s hould c learly identify those ex am p iec es (e.g., A thorough MS and neuro ex am o f the left hip performed as it relates to the HPI). E. Conditions of Cov erageReimb urs ement is dependent o n, b ut not limited to, s ubmitting Centers for Medicare and Med ic aid Ser v i c e s (CMS) ap proved HCP CS and CP Tc odes along wit h appro priate modifiers . Pleas e ref er to the CMS fee s chedule for appropriate codes. The following l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description 99201 Office or other outpatient v is it for the ev aluation and management of a new patient, whic h req uires thes e 3 k ey c omponents : A problem foc used history; A p roblem f o c used examination; Straightforward medical dec is ion making. Co unseling and /or c o o rdination of c are with o ther p hysicians, other qualified health c are p ro f es sionals , o r agencies are p rov ided c onsistent with the nature of the p ro b lem(s ) and the patient's and/or family 's need s. Us ually , the pres enting p ro b lem(s ) are s elf-limited o r minor. Ty p ic ally, 10 minutes are s p ent face-to-fac e with the p atient and/or family. 99202 Office or other outpatient visit for the evaluation and management of a new p ati ent, whic h req uires these 3 k ey components: An ex panded p roblem focused history ; An ex p and ed problem foc used examination; Straightforward medical decision making. Co uns eling and/or c oordination of c are wit h other p hysicians, other q ualified health c are p ro fes sionals, or ag encies are p rovided c onsistent with the nature of the p ro b lem(s ) and the patient’s and/or family ‘s need s. Us ually , the pres enting p ro b lem(s ) are of low to moderate sev erity. Ty pically , 20 minutes are s pent fac e-to-f ace with the patient and/or family. 99203 Office or other outpatient v is it for the ev aluation and management of a new p ati ent, whic h req uires thes e 3 k ey c omponents : A detailed his tory; A detailed ex amination; Medic al d ecision making of lo w complex ity. Counseling and/or c o o rdination of c are with o ther p hysicians, other qualified health c are p ro f es sionals , o r agencies are p rov ided c onsistent with the nature of the problem(s ) and the patient’s and/or family ‘s need s. Us ually , the pres enting p ro b lem(s ) are of moderate s everity. Ty p ically , 30 minutes are s pent face-to-face with the p atient and/or family. 99204 Office or other o utpatient visit for t he ev aluation a nd management of a new patient, whic h req uires thes e 3 k ey c omponents: A c omprehens iv e his tory; A 4 Prev en ti v e Ev al uati o n an d Man ag emen t Serv i c es and Ac ute Care Visit on Same Date of Serv i c e INDIANA MARKET PLACE PLANS PY-0905 Effec ti v e Date: 01/01/2020c o mp rehensive examination; Medical decision making of moderate c omplexity. Co uns eling and/or coordination of care wit h other p hysicians, other qualified health c are p ro fes sionals, or ag encies are p rovided c onsistent with the nature of the p ro b lem(s ) and the patient’s and/or family ‘s need s. Us ually , the pres enting p ro b lem(s ) are of moderate to hig h s everity. Ty p ically , 45 minutes are s pent face-to-f ace with the patient and/or family.99205 Office or other outpatient v is it for the ev aluation and management of a new p atient,whic h req uires thes e 3 k ey c omponents : A c omprehensive his tory; A c o mp rehensive examination; Medical decision making of high complexity. Co uns eling and/or coordination of care wit h other p hysicians, other qualified health c are p ro fes sionals, or ag encies are p rovided c onsistent with the nature of the p ro b lem(s ) and the patient’s and/or family ‘s need s. Us ually , the pres enting p ro b lem(s ) are of moderate to hig h s everity. Ty p ically , 60 minutes are s pent face-to-f ace with the patient and/or family. 99211 Of f ic e or o ther o utpatient visit for the ev aluation and management of an es tab lished p atient that may not require the pres enc e of a phy sician or o ther q ualif ied health care professional. Us ually, the p resenting problem(s ) are minimal. Typ ically, 5 mi nutes are spent p erf orming or s up erv ising these s ervices. 99212 Of f ic e or o ther o utpatient visit for the ev aluation and management of an es tab lished p atient, which req uires at least 2 of these 3 k ey c omponents: A problem focused his tory ; A problem focused ex amination; Straightforward medical d ec is ion making. Co uns eling and/or c oordination of care with other phy sicians, o ther q ualified health care p rofes sionals , or ag encies are p rovided cons is tent with the nature o f the pro blem(s) and the p atient’ s and/or family’s needs. Usually, the p res enting p roblem(s) are s elf-limite d o r minor. Ty pically, 10 minutes are s p ent f ac e-to-f ace wit h the patient and /or f a mi ly . 99213 Of f ic e or o ther o utpatient visit for the ev aluation and management of an es tab lished p atient, which req uires at least 2 of these 3 k ey c omponents: An ex p and ed problem foc used history; An ex panded problem focus ed examination; Med ic al dec is ion making of low c omplexity. Co unseling and coordination of c are with o ther p hy sicians, other q ualified health c are professionals, o r agenc ies are p ro v ided c onsistent with the nature of the problem(s) and the p atient’ s and/or f amily’s needs . Usually, the pres enting problem(s ) are of low to moderate s everity . Typ ically, 15 minutes are spent f ace-to-fac e wi th the patient and /or f a mi ly. 99214 Of f ic e or o ther o utpatient visit for the ev aluation and management of an es tab lished p atient, which req uires at least 2 of these 3 k ey c omponents: A d etailed history; A d etailed examination; Medical decision making of moderate c o mp lex ity. Counseling and/or c oordination of c are with o ther p hysicians, other q ualif ied health c are professionals, o r agenc ies are p rovided consistent with the nature o f the p roblem(s) and the patient’s and /or family’ s needs. Us ually, the p res enting p roblem(s) are of moderate to high s everity . Typically, 25 minutes are s p ent f ace-to-fac e wit h the patient and/or f a mi ly. 99215 Of f ic e or o ther o utpatient visit for the ev aluation and management of an es tab lished p atient, which req uires at least 2 of these 3 k ey c omponents: A c o mp rehensive history ; A comprehens iv e examination; Medical decision making of hig h c o mplex ity. Counseling and/or c oordination of c are with other p hysicians, o ther q ualified health c are professionals, o r agenc ies are p rovided consistent with the nature o f the pro blem(s) and the p atient’ s and/or family’s needs. Usually, the p res enting p roblem(s) are of moderate to high s everity . Typically, 40 minutes are s p ent f ac e-to-face with the patient and/or family . 99381 Initial c o mprehensive preventive medicine evaluation and management of an ind iv idual inc luding an ag e and gender ap propriat e his tory, ex amination, 5 Prev en ti v e Ev al uati o n an d Man ag emen t Serv i c es and Ac ute Care Visit on Same Date of Serv i c e INDIANA MARKET PLACE PLANS PY-0905 Effec ti v e Date: 01/01/2020c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnostic procedures , new patient; infant (age younger than 1 y ear) y o ung er than 1 y ear.99382 Initial c o mprehensive p reventiv e medicine ev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnost ic procedures , new patient; early c hildhood (age 1 thro ug h 4 y ears)99383 Initial c o mprehensive p reventiv e medicine ev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnost ic procedures , new patient; late childhood (age 5 thro ug h 11 y ears ) 99384 Initial c o mprehensive p reventiv e medicine ev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnostic procedures , new patient; adolescent (age 12 thro ug h 17 y ears ) 99385 Initial c o mprehensive preventive medicine evaluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidanc e/risk factor red uction interv entions, and the o rd ering of laboratory /diagnostic procedures , new p atient; 18-39 y ears 99386 Initial c o mprehensive preventive medicine evaluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidanc e/risk factor red uction interventions, and the o rd ering of laboratory /diagnostic proce dures , new p atient; 40-64 y ears 99387 Initial c o mprehensive preventive medicine evaluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of lab oratory /diagnostic p roc edures , new p atient; 65 y ears and older 99391 Perio d ic comprehensive prev entive medicine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnostic pro cedures, es tablished p atient; infant (ag e y o ung er than 1 y ear) 99392 Perio d ic comprehensive prev entive medicine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnostic procedures, established p atient; early c hildhood (ag e 1 thro ug h 4 y e ars ) 99393 Perio d ic comprehensive prev entive medicine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory /diagnostic procedures , es tablished patient; late c hildhood (ag e 5 thro ug h 11 years) 99394 Perio d ic c omprehensive prev entive medic ine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory/diagnostic procedures, es tablished p atient; adolescent (ag e 12 thro ug h 17 y ears ) 99395 Perio d ic comprehensive prev entive medicine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory /diagnostic procedures , es tablished patient; 18-39 y ears 6 Pr even ti v e Ev al uati o n an d Man ag emen t Serv i c es and Ac ute Care Visit on Same Date of Serv i c e INDIANA MARKET PLACE PLANS PY-0905 Effec ti v e Date: 01/01/202099396 Perio d ic comprehensive prev entive medicine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory /diagnostic procedures , es tablished patient; 40-64 y ears 99397 Perio d ic comprehensive prev entive medicine reev aluation and management of an ind iv idual inc luding an ag e and gender ap propriate his tory, ex amination, c o uns eling/antic ipatory g uidance/risk factor red uction interventions, and the o rd ering of laboratory /diagnostic procedures , es tablished patient; 65 y ears and older F. Related Polic ies/RulesN/A G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 11/17/2014 Date Revised 11/17/2015 Revisio n inc ludes p ay ment policy leg al language 09/18/2019 Up d ated reimbursement rate from 50% to 100% for services that are rendered on the sam e d at e of s erviceDate Effecti ve 01/01/2020Date Archived 11/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uid elines without a f ormal doc umented Policy. H. Ref erenc es1. Successfully Bi ll a Preventiv e Serv ice wi th a Sick Visit . AAPC Knowledge Center, 20 Feb. 2013, www.aap c .com/blog/22580-succ essf ully-bill-a-preventive-service-wi th-a-sick-visit/ . 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 PLANS Policy Name Policy Number Effective Date Reimbursement Modifiers PY-0713 09/01/2019-02/28/2022 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 ………………………….. ………………………….. ………………………….. .. 10 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 10 G. Review/Revision History ………………………….. ………………………….. ………………………….. . 10 H. Ref erences ………………………….. ………………………….. ………………………….. ………………… 10 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 referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illne ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of C overage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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. SubjectReimbursement Modifiers Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 B. BackgroundReimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are not a g uarantee of payment. Reimb ursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the product or service that is b eing p rovided. The inclusion of a code in this p o licy does not imply any right to reimbursement o r guarantee claims p ayment. Mo d ifiers can b e used to further describe a product o r service rendered. Some modifiers are for inf o rmational purposes o nly, while other modifiers are used to report additional information, to the co d e d escription, of the p roduct o r servic e. Although CareSource accepts the use of modifiers sp ecific to this policy, no t all modifiers are included within this p olicy. The mo difiers included within this p olicy are tho se modifiers that affect the reimbursement of a service. Using a mo difier inap p ro priately can result in the denial of a claim or an incorrect reimbursement for a p roduct o r service. CareSource may verify the use of any modifier thro ugh post-payment audit. All inf o rmation regarding the use of these modifiers must b e made availabl e up on CareSources req uest. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. C. Def initions Current Procedural Terminology (CPT) – codes that are issued, upda ted and maintained by the American Medical Association (AMA) that provides a standard language for coding and b illing medical services and p rocedures. Healthcare Common Procedure Coding System (HCPCS) – codes that are issued, up d ated and maintained b y the American Medical Association (AMA) that p rovides a stand ard language for coding and b illing of products, supplies, and services not included in the CPT co d es. Modifier – two-character codes used along with a CPT o r HCPCS code to p rovide additional inf o rmation about the service o r supply rend ered. D. PolicyI. Modifier 22 – Increased Procedural Services A. Mo d ifier 22 is used to report services (surgical or no nsurgical) when the wo rk req uired to p ro vide a service is substantially g reater than typically req uired. The extra wo rk may be id entified by appending modifier 22 to the usual procedure code. B. Pro ced ure codes with modifier 22 ap pended may b e reimbursed up to 120% of the fee sched ule amount. Note: This mo d ifier is not ap pended to E/M services (99201-99499). Claims for 99201-99499 with mo d ifier 22 will be denied. Medical records ARE required with the 3 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 claim and must support the use of this modifier. Claims with p rocedures including 22 and no sup porting d ocumentation will be denied. II. Modifier 50 – Bilateral Pro ceduresA. Pro f essional Claims Only Append modifier 50 to the appropriate unilateral code on a sing le claim line and indicate 1 unit in the unit field of that claim line. B. Mo d ifier 50 ap plies to surgical procedures (CPT codes 10040-69990) and to rad iology p ro cedures performed bilaterally. C. Ap p lies to any b ilateral p rocedure p erformed on both sides at the same session. D. The use of modifier 50 is NOT ap propriate in the following situations: 1. Using mo difier 50 o n a bilateral p rocedure performed on different areas of the right and lef t sides of the body. 2. Ap p ending modifier 50 to a procedure code that is defined b y CPT as p rimarily b ilateral or a b ilateral service. 3. Ap p ending modifier 50 to a surgical CPT code, the d escription of which contains the wo rd s o ne or b oth. E. Do no t report two line items to ind icate a b ilateral p rocedure. F. Pro ced ure code with modifier 50 ap pended will reimburse 1 unit at 150% of the fee sched ule amount. III . Modifier 51 – Multiple Pro ceduresA. Mo d ifier 51 is used to report multiple procedures, other than E/M services, are p erformed at the same session b y the same ind ividual, the p rimary p rocedure o r service is reported as listed . B. The ad d itional procedure(s) or service(s) may b e identified b y appending modifier 51 to the ad d itional p rocedure or service code(s). C. Mo d ifier 51 should not be appended to designated “add-on” codes. D. Pro ced ure code with modifier 51 ap pended will reimburse 50% of the fee listed on the Med icaid Physician Fee Schedule for the service. IV . Modifier 52 – Red uced servicesA. Und er certain circumstances a service or pro cedure is partially reduced or eliminated at the d iscretion of the p hysician or other qualified health care p rofessional. 1. Mo d ifier 52 is used for reporting reduced services when the procedure was terminated after the p atient was p repped and brought to the ro om where the service was to be p erformed. B. Mo d ifier 52 may be used to report reduced radiology procedures. 1. The co rrect reporting is to assign the CPT code to the extent of the p rocedure p erf ormed. 2. This mo d ifier is used o nly to rep ort a rad iology procedure that has been red uced when no o ther co de exists to report what has been done. 3. Rep o rt the intended code with modifier 52. i. Examp le, if the planned p rocedure is a two-view chest x-ray and only one view of the chest is p erformed, d o not rep ort CPT co de 71020-52 (for x-ray chest, two views-red uced service). Instead, rep ort CPT code 71010 (x-ray chest, single view). ii. Examp le, if a barium swallow is not completed because the patient cannot handle the b arium, rep ort CPT co de (74270-52). C. Mo d ifier 52 d oes no t provide for reimbursement of an ineligible service. D. Fo r ho spital o utpatient reporting of a p reviously scheduled pro cedure/service that is p artially red uced or cancelled as a result of extenuating circumstances o r those that threaten the well-b eing of the patient prior to or after ad ministration of anesthesi a, see mo d ifiers 73 and 74. E. Pro ced ure code with modifier 52 ap pended will reimburse at 50% of the fee schedule amo unt. 4 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 Note: Med ical records are no t required with the claim, but must be available up on CareSo urces request. Clinical information d ocumented in the patient’s records must support to use of this modifier. The extenuating circumstances preventing the co mpletion of the procedure must also b e documented V. Modifier 53 – Disco ntinued ProcedureA. Und er certain circumstances, the p hysician or o ther qualified health care professional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances o r those that threaten the well-b eing of the patient, it may b e necessary to indicate that a surgical or d iagnostic p rocedure was started b ut d iscontinued after anesthesia is administered to the p atient. 2. Mo d ifier 53 is used to ind icate that the physician terminated a surgical/diagnostic p ro cedure d ue to the p atients well-b eing. B. This mo d ifier is not used to rep ort an elective cancellation of a p rocedure p rior to the p atient’s anesthesia induction and/or surgical preparation in the operating suite. C. Mo d ifier 53 cannot b e used when a lap aroscopic or end oscopic pro cedure is converted to an o p en procedure. D. Mo d ifier 53 does not pro vide for reimbursement of an ineligible service. E. Mo d ifier 53 cannot be ap pended to E/M codes. F. Fo r o utp atient ho spital/ambulatory surgery center (ASC) reporting of a previously sched uled pro cedure/service that is partially red uced or cancelled as a result of extenuating circumstances or those that threaten the well-b eing of the patient prior to or af ter ad ministration of anesthesia, see modifiers 73 and 74. G. Pro ced ure code with modifier 53 ap pended will reimburse at 25% of the fee schedule amo unt. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical inf ormation documented in the patient’s records must sup port to use of this modifier. Documentation must include a statement ind icating at what point the pro cedure was d iscontinued. The extenuating circumstances preventing the completion of the p rocedure must also be d o cumented. VI. Modifier 54 – Surgical Care OnlyA. Mo d ifier 54 is reported when o ne physician p erformed a surgical pro cedure only; ano ther p hysician provides the preoperative and/or postoperative management. B. Mo d ifier 54 must o nly be appended to the surgical procedure code. C. Pro ced ure code with modifier 54 ap pended will reimbursed at 70% of the fee schedule amo unt. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. VII . Modifier 55 – Po stoperative Management OnlyA. Mo d ifier 55 is rep orted when 1 p hysician or o ther q ualified health care professional p erf ormed the postoperative management and another performed the surgical p ro cedure, the postoperative component may be id entified by appending modifier 55 to the p ro cedure code. B. Mo d ifiers 55 must only be appended to the surgical procedure code. C. Pro ced ure code with modifier 55 ap pended will reimburse at 15% of the fee schedule amo unt. 5 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 Note: Med ical records are no t required with the claim, but must be available up on CareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. VII I. Modifier 56 – Preo p erative Management OnlyA. Mo d ifier 56 is rep orted when 1 p hysician performed the preoperative care and evaluatio n and another physician p erformed the surgical procedure. Modifier 56 is ap p end ed to the surgical code. B. Mo d ifiers 56 must only be appended to the surgical procedure code. C. Pro ced ure code with modifier 56 ap pended will reimburse at 15% of the fee schedule amo unt. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. IX . Modifier 62 – Two Surg eonsA. Mo d ifier 62 is rep orted when 2 surg eons work together as primary surgeons performing d istinct part(s) of a p rocedure. 1. Each surg eon must rep ort his/her distinct o perative wo rk by adding the modifier 62 to the p ro cedure code and any associated add-on codes(s ) for that p rocedure as long as b o th surgeons continue to work together as primary surgeons. 2. Each surg eon must rep ort the co-surg ery once using the same procedure code. If ad d itional procedure(s), including add-o n procedures(s) are p erformed d uring the same surg ical session, separate code(s) may also b e reported without the modifier 62 ad d ed . 3. If a co-surg eon acts as an assistant in the p erformance of ad ditional p rocedure(s) d uring the same surgical session, those services may be reported using separate p ro cedure code(s) with the modifier 80 or 82 ad ded, as ap propriate. B. Pro ced ure code with modifier 62 ap pended will b e reimbursed at 62.5% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. X. Modifier 66 – Surg ical TeamA. Mo d ifier 66 is rep orted when three o r more surgeons wo rk together d uring a highly co mp lex procedure are carried out und er the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of mo d ifier 66 to the b asic procedure code used for rep orting services. B. Claims sub mitted by team surgeons are id entified with modifier 66. C. The Centers f o r Medicare & Medicaid Services (CMS) established a Team Surgery Ind icato r (TEAM SURG) found in the CMS National Physician Fee Schedule Relative Value File. Values are: 1. 0-Team surg eo ns not permitted for this procedure. 2. 1-Team surg eo ns may be paid; supporting documentation is req uired to establish med ical necessity. 3. 2-Team surg eo ns permitted. 4. 9-Team surg eo n concept does not apply. D. Co d es with CMS Team Surgery Ind icators of 0 and 9 should not be billed with modifier 66. E. Mo d ifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate p ro cedure no t included in the team surgery. 6 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 F. Only o ne surg eon maybe be considered the primary surgeon. CareSource will not reimb urse p rocedures when two surgeons each bill o ne side of bilateral surgery as the p rimary surgeon. G. Each p hysician participating in the surgical team must bill the ap plicable procedure co d e(s) for their ind ividual services with Modifier 66. H. Pro ced ure code with modifier 66 ap pended will reimburse at 150% of the established fee, d ivid ed equally between the team surgeons. I. Fo r team surg ery with three surg eons, each surgeon will be reimbursed at 50% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. XI. Modifier 73 – Discontinued Outpatient Ho spital/Ambulatory Surg ery Center (ASC) ProcedurePrior to the Administration of Anesthesia A. Mo d ifier 73 is rep orted to a service to indicate that due to extenuating circumstances o r tho se that threaten the well-being of the patient, a surgical or d iagnost ic p rocedure at an o utp atient hospital o r ambulatory surgical center (ASC) was d iscontinued prior to the ad ministration of anesthesia. B. Mo d ifier 73 is o nly appropriate for use by an ASC. C. Mo d ifier 53 should not be used for any ASC service as the modifier is used exclusively on a p ro fessional claim. D. Pro ced ure code with Modifier 73 ap pended will reimburse at 50% of the ASCs fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. XII . Modifier 74 – Discontinued Outpatient Ho spital/Ambulatory Surgery Center (ASC) ProcedureAfter Ad ministration of Anesthesia A. Mo d ifier 74 is rep orted when d ue to extenuating circumstances or those that threaten the well-b eing of the p atient, the physician may terminate a surgical or d iagnostic procedure after the ad ministration of anesthesia or after the p rocedure was started (incision made, intub ation started, scope inserted.) B. Mo d ifier 74 is not ap propriate for the elective cancellation or p ostponement of a p ro cedure based on the p hysician or patients choice. C. Mo d ifier 74 is not ap propriate when the termination of the procedure occurs prior to the b eg inning of the procedure or the administration of anesthesia. D. Mo d ifier 74 is no t for physician use. It is only appropriate for the ASC. E. Pro ced ure code with modifier 74 ap pended will b e reimbursed at 100% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. XII I. Modifier 78 – Unp lanned Return to the Op erating/Procedure Ro om by the Same Physician orOther Qualif ied Health Care Professional Following Initial Procedure for a Related Pro cedure During the Postoperative Period A. Mo d ifier 78 is reported to indicate that another pro cedure was p erformed during the p o stoperative period of the initial pro cedure (unplanned procedure following initial p ro cedure). 7 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 1. When this p ro cedure is related to the first, and requires the use of an o p erating/procedure room, it may be reported by adding modifier 78 to the related p ro cedure. 2. Mo d ifier 78 should be appended when: i. The return to the o perating room is unplanned. ii. The service is performed by same physician who p erformed the initial p ro cedure. iii. The service is related to the initial procedure. i v . The service is p erformed during the postoperative p eriod of the initial pro cedure (10-90 d ays) B. Pro ced ure code with modifier 78 ap pe nded will be reimbursed at 70% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up on CareSo urces request. Clinical information documented in the p atient’s records must sup port to use of this modifier. XIV . Modifier 80 – Assistant SurgeonA. Mo d ifier 80 is reported to indicate surgical assistant services by a physician and is ap p lied to the surgical pro cedure code(s). B. Assistant Surgeon provides f ull assistance to the p rimary surgeon and is capable of taking o ver the surgery should the primary surgeon become incapacitated. C. Mo d ifier 80 will no t be accepted from non-physicians. Modifier AS should be used. D. Pro ced ure code with modifier 80 ap pended will be reimbursed at 16% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this modifier and operative notes must contain suffic ient inf o rmation to support the medical necessity of an assistant at surgery. If there is no accounting b y the surgeon for what was p erformed by the assistant the claim wo uld be denied. XV. Modifier 81 – Minimum Assistant SurgeonA. Mo d ifier 81 is reported to indicate minimum surgical assistant services and is applied to the surg ical procedure code(s). B. Minimum Assistant Surgeon is an assistant who d oes not p articipate in the entire p ro cedure but provides minimal assistance to the primary surgeon. C. Mo d ifier 81 will no t be accepted from non-p hysicians. Modifier AS should be used. D. Pro ced ure code with modifier 81 appended will be reimbursed at 16% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be a vailable up onCareSo urces request. Clinical information documented in the patient’s records must sup port to use of this modifier and operative notes must contain sufficient inf o rmation to support the medical necessity of an assistant at surgery. If there is no accounting b y the surgeon for what was p erformed by the assistant the claim wo uld be denied. XV I. Modifier 82 – Assistant Surg eon (when q ualified resident surgeon no t avail able)A. Mo d ifier 82 is rep orted to ind icate when surg ical assistance is needed, b ut a q ualified resid ent was not available. B. Mo d ifier 82 is used p rimarily in teaching hospitals to ind icate that a q ualified resident surg eo n is unavailable. 8 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 C. The unavailab ility of a q ualified resident surgeon is a p rerequisite for the use of this mo d ifier. The assistant must p rovide d ocumentation (certification) stating that a q ualified resid ent was not available for this procedure and why the resident was not available. D. Pro ced ure code with modifier 82 ap pended will be reimbursed at 16% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information documented in the patient’s records must sup port the use of this modifier and operative notes must contain suf ficient information to supp ort the medical necessity of an assistant at surg ery and why a q ualified resident was not available. If there is no acco unting b y the surgeon for what was p erformed by the assistant the claim wo uld be denied. XV II . Modifier AA – Anesthesia services performed p ersonally by an anesthesiologistA. Mo d ifier AA is used to report when the anesthesia services are p ersonally p erformed by an Anesthesiologist. B. Pro ced ure code with modifier AA appended will be reimbursed at 100% of the fee sched ule amount. XV II I. Modifier AD – Anesthesia services supervised by an anesthesiologist: more than 4co ncurrent anesthesia procedures. A. Mo d ifier AD is used to rep ort when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia pro cedures. B. Pro ced ure code with modifier AD ap pended will be reimbursed at 100% of the fee sched ule amount. XIX . Modifier QK – Med ical direction of 2, 3 or 4 co ncurrent anesthesia services involving q ualif ied individuals. A. Mo d ifier QK is used to rep ort when med ical d irection of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. B. Pro ced ure code with modifier QK appended will be reimbursed at 50% of the fee sched ule amount. XX. Modifier QX – Anesthesia services p erformed by a CRNA with med ical direction by an anesthesiologist. A. Mo d ifier QX is used to rep ort when the anesthesia services are performed by a CRNA with med ical d irection by an anesthesiologist. B. Pro ced ure code with modifier QX appended will be reimbursed at 50% of the fee sched ule amount. XX I. Modifier QY – Anesthesia services when an Anesthesiologist medically d irects one CRNA.A. Mo d ifier QY is used to rep ort when an Anesthesiologist medically directs o ne CRNA. B. Pro ced ure code with modifier QY ap pended will be reimbursed at 50% of the fee sched ule amount. XX II . Modifier QZ – Anesthesia services performed p ersonally by a CRNA witho ut medical d irection by a physician. A. Mo d ifier QZ is used to rep ort when the anesthesia services are p erso nally p erformed by a CRNA. B. Pro ced ure code with modifier QZ appended will be reimbursed at 100% of the fee sched ule amount. XX II I. Modifier AE – Registered dieticianA. Mo d ifier AE is rep orted to indicate when a reg istered dietician provides the service. 9 Reimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 B. Pro ced ure code with modifier AE appended will b e reimbursed at 85% of the fee sched ule amount. XX IV . Modifier AS – Physician Assistant (PA), Nurse Practitioner (NP) or Certified NurseSp ecialist (CNS) served as the assistant at surgery. A. Mo d ifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in p lace of another surgeon. B. Pro ced ure code with modifier AS appended will be reimbursed at 16% of the base code allo wab le fee schedule before multiple surgery red uctions are taken. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical inf ormation documented in the p atient’s reco rd s must support the use of this modifier and o perative no tes must co ntain sufficient information to support the medical necessity of an assistant at surg ery. If there is no accounting b y the surg eon for what was performed by the assistant the claim wo uld be d enied. XXV. Modifier JW – Drug amount d iscard ed (wasted)/not admini stered to any p atientA. CareSo urce will consider reimbursement for: 1. A sing le-dose or single-use vial d rug that is wasted, when Modifier JW is appended. 2. The wasted amount when b illed with the amount of the d rug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSo urce will NOT co nsider reimbursement for: 1. The wasted amount of a multi-dose vial drug . 2. Any d rug wasted that is b illed when no ne of the drug was administered to the p atient. 3. Any d rug wasted that is b illed without using the most ap propriate size vial, or co mb ination of vials, to deliver the administered d ose. XX VI . Modifier SA – Nurse p ractitioner (NP) rend ering service in collaboration with a p hysician A. Mo d ifier SA is reported to indicate when a supervising physician is billing on behalf of an ANP, o r CRNFA for no n-surgical services. B. Mo d ifier SA is used when the ANP, or CRNFA is assisting with any other p rocedure that DOES NOT include surgery. C. Pro ced ure code with modifier SA appended will be reimbursed at 85% of the fee sched ule amount. XX VI I. Modifier TC – Technical Co mponentA. Technical co mponent charges are institutional charges and no t b illed separately by p hysicians. B. A charg e may b e made for the technical component alone. Under those circumstances the technical component charge is identified by ad ding Modifier TC to the usual p ro cedure code. XX VI II . Modifier 26 – Pro fessional Co mponentA. Certain p ro cedures are a co mbination of a p hysician component and a technical co mp onent. B. When the p hysician component is reported separately, the service may be identified by ad d ing the modifier 26 to the usual procedure number. 10 E. Conditions of CoverageReimbursemen t Mo d ifiersINDIANA MARKETPLACEPLANS PY-0713 Effective Date: 09/01/2019 Reimb ursement is dependent o n, b ut not limited to, submitting Centers for Medicare and Med icaid Services (CMS) ap proved CPT/HCPCS codes along with appropriate modifiers, if ap p licable. Please ref er to the individual CMS fee schedule for ap propriate codes. Pro viders must follow p roper billing, industry standard s, and state compliant codes on all claim sub missions. The use o f modifiers must be fully supported in the medical record and /or office no tes. Unless otherwise noted within the polic y, our p olicies ap ply to both p articipating and no np articipating p roviders and facilities. Note: In the event o f any conflict between this p olicy and a p roviders contract with CareSource, the p ro viders contract will be the governing document. F. Related Po licies/Rules N/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2019 New p o licyDate Revised Date Effective 09/01/2019 Da te Archived 02/28/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and Care Source reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erences1. Billing 340B Mo difiers und er the Ho spital Outpatient Pro spective Payment System (OPPS). (2018, Ap ril 2). Retrieved 3/22/2019 f rom https:// www.cms.gov/Medicare/Medicare-Fee-for – Serv i c e-P ay men t /Ho s p i tal Ou tp ati e ntP PS / Do w nl o ad s /B i l l i ng-34 0B-Mo d i f i ers-u nd e r-Ho s p i tal – OPPS.pdf 2. CPT o verview and code approval. (2019, March 22). Retrieved from https://www.ama – assn.o rg/practice-management/cpt/cpt-overview-and-code-appro val. 3. Med icare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, No vember 30). Retrieved February 18, 2019 from https ://www .cm s.gov/Regulations – and-Guid ance/Guidance/Manuals/Downloads/clm104c12.pdf. 4. Med icare Claims Processing Manual Chapter 14 – Ambulatory Surgical Center s. (2017, Decemb er 22). Retrieved February 18, 2019 from https ://www.c ms .go v/Regulations-and- Guid ance/Guidance/Manuals/Downloads/clm104c14.pdf. 5. Op tum360 EncoderProForPayers.com – Lo gin. (2019, February 18). Retrieved February 18, 2019 f ro m http s :// www.enc o d erp ro f p .c o m/ep ro 4p ay e rs /al l Mo d i f i ers Ha nd l er.d o ?_k = 1 0 1 * 0& _ a= l i s tR el at e d &menu=4. 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 Emergency Department Electrocardiogram (EKG/ECG) Interpretation PY-07 88 0 7 /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 ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Emergency Department Electrocardiogram (EKG/ECG) Interpretation INDIANA MARKETPLACE PLANS PY-07 88 Effective Date: 0 7 /01/2019 2 A. Subject Emergency Department Electrocardiogram (EKG/ECG) Interpretation 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 membe r 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. An electrocardiogram (EKG/ECG) is a non-inv asive test that records the electrical activity of the heart. It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardiogram (EKG/ECG) may need to be perform ed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. C. Definitions Emergency medical condition-is a medical condition with sudden severity and onset that in the absence of immediate medical attention could placing the patient’s health in serious jeopardy. This includes labor and delivery, but not routine prenatal or postpartum care, or services related to an organ transplant procedure. Electrocardiogram (EKG/ECG) is a test that records the electrical activity of the heart. For the purpose of this policy EKG will be used to represent both EKG and ECG. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs completed in the Emergency Department (Place of service (POS) 23). A. Regardless of POS, the modifier appended to the CPT code determines a duplicate service. II. CareSource will reimburse the first EKG claim that is received for the member of the date of service. A. If another claim for the same service EKG is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same da te of service. B. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member. 1. Example: 93010 is received and is reimbursed. Another 93010 claim is received for the same date of service and is denied as duplicate service. C. If a second EKG is medically necessary, on the same date of service, to determine a cardiac change before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG for reimbursement. Archived Emergency Department Electrocardiogram (EKG/ECG) Interpretation INDIANA MARKETPLACE PLANS PY-07 88 Effective Date: 0 7 /01/2019 3 1. Example: 93010 is received and reimbursed. Another 93010 is completed and submitted for reimbursement. The second 93010 has modifier 76 or 77 (whichever is applicable) appended (93010-76 or 93010-77) to distinguish between the first and second EKG p erformed on the same member on the same date of service. III. CareSource expects providers to work with other departmen ts, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. E. Conditions o f Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual CMS fee schedule for app ropriate 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 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93227 External electrocardiographic recording up to 48 hours by continuous rhythm record ing and storage; review and interpretation by a physician or other qualified health care professional Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 0 7 /01/2019 New policy Date Revised Date Effective 0 7 /01/2019 Archived Emergency Department Electrocardiogram (EKG/ECG) Interpretation INDIANA MARKETPLACE PLANS PY-07 88 Effective Date: 0 7 /01/2019 4 H. References 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2018, October 1). Retrieved 3/12/2019 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37283&ver=9&DocType=2&Cntrctr=238&Cntrctr Selected=238*2&s=42&bc=AAIAAAAAAAAA& . 2. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/health-topics/electrocardiogram 3. Physician Fee Schedule Search. (2019). Retrieved 3/12/2019 from https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=3&H1=93010&M=5 . 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. I nd e pe n de nt med i ca l r e v iew 2/2015 Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Readmission PY-0725 06/01/2019 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, 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 …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 5 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Readmission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 06/01/2019 2 A. Subject Readmission 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 of Readmissions for our Medicare Advantage members 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. Following a hospitalization, readmission within 30 days is often a costly preventable event and is a quality of care issue. It has been estimated that readmissions within 30 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result from many situations but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progression of the disease state or due to chronic conditions. The purpose of this policy is to improve the quality of inpatient and transitional care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission: a subsequent inpatient admission to any acute care facility which occurs within 30 days of the discharge date; excluding planned admissions. Planned Readmission: a non-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Same or Similar Condition: a condition or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented on the initial admission. Same Day: CareSource delineates same day as midnight to midnight of a single day. Readmission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 06/01/2019 3 D. Policy I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observational services for the following categories: A. Same day readmission or observational stay for a related condition B. Same day readmission or observational stay for an unrelated condition C. Planned Readmissions and/or leave of absence D. Unplanned admissions to an acute, general, short-term hospital occurring within 30 calendar days from the date of discharge from the same or another acute, general, short-term hospital II. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim. III. An administrative review of all readmissions will take place based on the following Medicare readmission review criteria: A. Same day readmission or observational stay for a related condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed based on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital combine the two admissions on one claim. 2. If the member is readmitted during the same day as the initial admission for the same or a related condition and both the initial and the subsequent admission are billed separately, CareSource will deny the claim as separate DRGs. The facility must submit the initial admission and the subsequent admission on one claim to receive reimbursement. B. Same day readmission or observational stay for an unrelated condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed based on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital to bill the claims separately but the claim that contains an admission date that is the same as the discharge date must include condition code B4 as indicated in the Medicare billing guidelines. C. Planned readmission and/or leave of absence criteria: 1. When a readmission to the same acute care facility or inpatient hospital is expected and the member does not require a hospital level of care during the timeframe between the two admissions, the member may be placed on leave of absence by the provider. a. CareSource follows the Medicare Inpatient Hospital Services billing guidelines found in the Medicare Claims Processing Manual, Chapter 3 for leave of absence billing guidelines which requires that the facility Readmission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 06/01/2019 4 submit one claim and receive one combined DRG payment for both admissions both are for the treatment of the same episode of illness. b. Examples of a planned readmission include, but are not limited to, situations where surgery could not be scheduled immediately due to scheduling availability, a specific surgical team that is needed for the procedure is not available, bilateral staged surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin at the time of initial admission. c. CareSource reserves the right to request medical records to determine if the claim was properly billed. d. Leave of absence does not apply to cancer chemotherapy or similar repetitive treatments. D. Determination of Unplanned Readmissions criteria: 1. CareSource will review the clinical documentation on all potential readmissions to determine if the admission was a potentially preventable readmission (PPR) based on the following Medicare guidelines: a. Premature discharge of patient that resulted in subsequent readmission of patient to same hospital. Premature discharge includes when a patient is discharged even though he/she should have remained in the hospital for further testing or treatment or was not medically stable at the time of discharge. A patient is not medically stable when, in CareSource judgement, the patient’s condition is such that it is medically unsound to discharge or transfer the patient. Evidence such as elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a patient may have been prematurely discharged from the hospital; b. When a patient is readmitted to a hospital for care that, pursuant to professionally recognized standards of health care, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during the first admission. c. The readmission is the result of a lack of documentation and/or coordination of care between the inpatient and outpatient team in regards to post discharge care and coordination with a CareSource Care Manager for the member. E. The following readmission criteria listed below are excluded from this readmission policy when the diagnosis for the exclusion is in the admitting or the primary diagnosis position of the claim: a. If the member is being transferred from an out-of-network to an in-network facility or if the member is being transferred to a facility that provides care that was not available at the initial facility; b. Transfers to distinct psychiatric units within the same facility. When transferring within the same facility, documentation must show that the diagnosis necessitating the transfer was psychiatric in nature and that the patient received active psychiatric treatment. c. If the readmission is part of planned repetitive treatments or staged treatments, such as chemotherapy or staged surgical procedures;Readmission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 06/01/2019 5 d. Readmissions where the discharge status of the first discharge was left against medical advice (AMA); e. Obstetrical readmissions. IV. Post Payment Review and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissions to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical records for both admissions may be requested to determine if the admission(s) is appropriate or is considered a readmission. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records when requested will result in an automatic denial of the claim. b. Medical records for both admissions must be submitted with the claim if both admissions originated from the same facility or Tax Identification Number (TIN). 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim c. If the readmission is determined at the time of documentation review to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admission and paid as one claim to cover both, or all, admissions. 2. Appeals Process a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer review or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 04/01/2019 Date Revised 09/17/2019 Added Section IV., 1., a & b Date Effective 06/01/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-803. Readmission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 06/01/2019 6 2. Hospital Readmission Reduction Program. (2018, December 04). Retrieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://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 INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Thyroid Testing PY-0861 12/01/2019 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, 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 …………………………………………………………………………………. 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 Thyroid Testing INDIANA MARKETPLACE PLANS PY-0861 Effective Date: 12/01/2019 2 A. Subject Thyroid 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 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. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. Definitions Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. Policy I. CareSource does not require a prior authorization for thyroid testing. II. Thyroid function tests are used to test for thyroid function and disease. Thyroid testing may be reasonable and necessary to: A. Distinguish between primary and secondary hypothyroidism B. Confirm or rule out primary hypothyroidism C. Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer) D. Monitor drug therapy in patients with primary hypothyroidism E. Confirm or rule out primary hyperthyroidism F. Monitor therapy in patients with hyperthyroidism III. Thyroid testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyperthyroidism or hypothyroidism are noted. A. When these tests are billed at a greater frequency than the norm (two per year), the ordering physicians documentation must support the medical necessity of this frequency must be made available upon CareSources request. Thyroid Testing INDIANA MARKETPLACE PLANS PY-0861 Effective Date: 12/01/2019 3 IV. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. V. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service 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. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes and the appropriate modifiers, if applicable. The appropriate ICD-10 diagnosis code must match the correct CPT and/or HCPCS code within this policy. Please refer to the individual 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 84436 Thyroxine; total 84439 Thyroxine; free 84443 Thyroid stimulating hormone (TSH) 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 12/01/2019 New Policy Date Revised Date Effective 12/01/2019 Date Archived ICD 10 Codes A18 D3A E06 E24 E43 E88 F32 G47 R06 C56 D44 E07 E25 E44 E89 F33 I48 R61 C73 D49 E08 E27 E45 F03 F34 N91 Z00 C79 D89 E09 E28 E46 F05 F39 N92 Z01 C7A E00 E10 E29 E66 F06 F41 N94 Z86 C7B E01 E11 E31 E67 F07 F53 N97 D09 E02 E13 E35 E78 F22 F63 O90 D27 E03 E20 E40 E79 F23 G25 O92 D34 E04 E22 E41 E83 F30 G30 O99 D35 E05 E23 E42 E87 F31 G31 R00 Thyroid Testing INDIANA MARKETPLACE PLANS PY-0861 Effective Date: 12/01/2019 4 H. References 1. National Coverage Determination (NCD) for Thyroid Testing (190.22). Retrieved July 26, 2019, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved July 26, 2019, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf 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 PLANS Policy Name Policy Number Effective Date Non-Invasive Vascular Studies PY-0841 11/01/2019-02/28/2021 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, 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 dis ease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of go od 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, Ev idence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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. SubjectNon-invasive Vascular Studies No n-In vasive Vascular Stud iesINDIANA MARKETPLACE PLANS PY-0841 Effective Date: 11/01/2019 B. Background Reimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are not a g uarantee of payment. Reimb ursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use self-service channels to verify 0050 eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the product or service that is b eing p rovided. The inclusion of a code in this p o licy does not imply any right to reimbursement o r guarant ee claims p ayment. No n-invasive vascular studies utilize ultrasound to assess irregularities in b lood flow in arterial and veno us systems. Testing can b e p erformed in a vascular lab oratory, and is often the first step in d iagnosing vascular disease. Resul ts may d isplay as a two dimensional image with a sp ectral analysis and color flow. The results of these test will d etermine the need for more no n – invasive testing or p rocedures to treat vascular d isease. CareSo urce will reimburse p roviders, for no n-invasive vascular studies to members as set forth in this policy. C. Def initions0078 Duplex scan 00B1 a no n-invasive evaluation of b lood flow through the arteries and veins, by co mb ining the use of Doppler ultrasound with two-dimensional structure and motion wi th time and sp ectrum analysis and /or color flow velocity or mapping. 0078 Non-invasive testing-utilizes various types of technology to evaluate flow, perfusion, and p ressures within the vessels at rest and with exercise. D. PolicyI. CareSo urce d oes not require a p rior authorization for a no n-invasive vascular study. II. Altho ugh CareSource does not req uire a p rior authorization for non-invasive vascular studies,CareSo urce may request d ocumentation to support medical necessity A. Med ical necessity is d efined as health products, supplies or services that are necessary for the d iag nosis or treatment of d isease, illness, o r injury and meet accepted guidelines of med ical practice. Note: The use of any Doppler device that p roduces a record, but d oes not permit analysis o f b idirectional vascular flow or that does no t p rovide a hard copy or p rintout: 0078 is part of the physical exam of the vascular system and is not rep orted sep arately. III. No n-Invasive vascular studies must be personally performed by a physician or technologistA. The p hysician performing and/or interp reting the study must be capable of demonstrating d o cumented training and experience and maintain any applicable documentation upon 0026 request. B. The technici an p erforming the study must b e capable of demonstrating d ocumented training and experience and maintain any documentation upon CareSource req uest. 3 No n-In vasive Vascular Stud iesINDIANA MARKETPLACE PLANS PY-0841 Effective Date: 11/01/2019 IV . All no n-invasive vascular d iagnostic studies must be performed under at least one of the f o llowing settings: A. Perf o rmed by a physician who is competent in no n-invasive vascular studies or under the g eneral sup ervision of p hysicians who have d emonstrated minimum entry level co mp etency by being credentialed in vascular technology B. Perf o rmed by a technician who is certified in vascular technology C. Perf o rmed in facilities with laboratories accredited in va scular technology. V. No n-invasive vascular study includes:A. Pro viding patient care d uring the study B. Sup ervision of the procedure C. Interp retatio n of study results with hard copy output or d igital storage of imaging is accep table. Note: Altho ugh CareSource does not require a p rior authorization for no n-invasive vascular stud ies, CareSource may req uest documentation to support medical necessity, includ ing the non-invasive vascular study hard copy or d igital copy results. VI. Dup lex scanning and physiologic studies may be reimbursed during the same encounter if the p hysiologic studies are ab normal and/or to evaluate vascular trauma, thro mboembolic events or aneurysmal disease, if the p hysician/provider can d ocument medical necessity in the 0053 medical record. E. Conditions of CoverageReimb ursement is dependent o n, b ut not limited to, submitting Centers for Medicare and Med icaid Services (CMS) approved HCPCS and CPT codes and the appropriate modifiers, if ap p licable. The ap propriate ICD-10 d iagnosis code must match the correct CPT and /or HCPCS co d e within this p olicy. Please refer to the ind ividual CMS fee schedule for appropriate codes. 0078 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 93880 Dup lex scan of extracranial arteries; complete bilateral study 93882 Dup lex scan of extracranial arteries; unilateral or limited study 93886 Transcranial Do ppler study of the intracranial arteries; complete study 93888 Transcranial Do ppler study of the intracranial arteries; limited study 93890 Transcranial Do ppler study of the intracranial arteries; vasoreactivity study 93892 Transcranial Do ppler study of the intracranial arteries; emboli d etection without intraveno us micro bubble injection 93893 Transcranial Do ppler study of the intracranial arteries; emboli detection with intraveno us micro bubble injection 93922 Limited b ilateral noninvasive physiologic studies of up per or lo wer extremity arteries, (eg , for lower extremity: ankle/brachial indices at d istal posterior tibial and anterio r tibial /dorsalis p edis arteries plus b idirectional, Doppler waveform reco rd ing and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tib ial and anterior tibial/dorsalis pedis arteries p lus volume plethysmography at 1-2 levels, or ankle/brachia l indices at distal posterior tibial and anterior 4 No n-In vasive Vascular Stud iesINDIANA MARKETPLACE PLANS PY-0841 Effective Date: 11/01/2019 tib ial/dorsalis pedis arteries with, transcutaneous o xygen tension measurementat 1-2 levels)93923 Co mp lete b ilateral no ninvasive physiologic studies of upper or lo wer extremity arteries, 3 o r mo re levels (eg, for lo wer extremity: ankle/brachial indices at d istal p osterior tibial and anterior tibial/dorsalis p edis arteries plus segmental b lo o d pressure measurements with bidirectional Doppler waveform record ing and analysis, at 3 o r more levels, or ankle/brachial indices at d istal posterior tib ial and anterio r tibial/dorsalis pedis arteries p lus segmental volume p lethysmography at 3 o r more levels, or ankle/brachial indices at d istal p o sterior tibial and anterior tibial/dorsalis pedis arteries p lus segmental transcutaneous o xygen tension measurements at 3 o r m ore levels), o r single level stud y with p rovocative functional maneuvers (eg, measurements with p o stural p rovocative tests, or measurements with reactive hyperemia) 93924 No ninvasive p hysiologic studies of lo wer extremity arteries, at rest and f o llowing treadmill stress testing, (ie, bidirectional Doppler waveform or volume p lethysmography recording and analysis at rest with ankle/brachial indices immed iately after and at t imed intervals following performance of a stand ard ized protocol on a motorized treadmill p lus recording of time of o nset of claudication or o ther symptoms, maximal walking time, and time to recovery) co mp lete bilateral study 93925 Dup lex scan of lo wer extremity arteries o r arterial bypass g rafts; complete b ilateral study 93926 Dup lex scan of lo wer extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Dup lex scan of up per extremity arteries or arterial bypass grafts; complete b ilateral study 93931 Dup lex scan of up per extremity arteries o r arterial bypass grafts; unilateral or limited study 93970 Dup lex scan of extremity veins including responses to compression and other maneuvers; complete b ilateral study 93971 Dup lex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Dup lex scan of arterial inflow and venous outflow of abdominal, p elvic, scrotal co ntents and /or retroperitoneal o rgans; complete study 93976 Dup lex scan of arterial inflow and venous outflow of abdominal, p elvic, scrotal co ntents and /or retroperitoneal o rgans; limited study 93978 Dup lex scan of ao rta, inferior vena cava, iliac vasculature, or bypass grafts; co mp lete study 93979 Dup lex scan of ao rta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral o r limited study 93980 Dup lex scan of arterial inflow and venous outflow of penile vessels; complete stud y 93981 Dup lex scan of arterial inflow and venous o utflow of penile vessels; follow-up or limited study 93990 Dup lex scan of hemodialysis access (including arterial inflow, b ody of access and veno us outflow) 93998 Unlisted noninvasive vascular diagnostic study
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Gastrointestinal Illness PY-0860 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, 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 …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Molecular Diagnostic Testing for Gastrointestinal Illness INDIANA MARKETPLACE PLANS PY-0860 Effective Date: 11/01/2019 2 A. Subject Molecular Diagnostic Testing for Gastrointestinal Illness 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. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Gastrointestinal illness, as addressed in this policy, include Clostridium difficile, E. Coli, Salmonella, Shigella, Norovirus and Giardia. These infection and illnesses of the intestine can cause symptoms such as diarrhea, nausea, vomiting and abdominal cramping. There are three basic modes of transmission: in food, in water and person to person. While some of these illnesses will resolve on their own, others can spread throughout the body and require treatment to prevent a more devastating illness. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Molecular Diagnostic Testing for Gastrointestinal Illness INDIANA MARKETPLACE PLANS PY-0860 Effective Date: 11/01/2019 3 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 the following gastrointestinal illnesses, when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage of this policy. A. Clostridium Difficile B. Salmonella C. Shigella D. Norovirus E. Giardia F. E. coli III. CareSource does not consider Molecular Diagnostic Testing by PCR medically necessary for gastrointestinal illnesses when billed with any other ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as stool and saliva samples for these illnesses is viewed as low cost and given that not all cases of acute diarrhea are indicative of these illnesses, institutions should utilize these before the higher cost Molecular Testing by PCR as the first testing option for the initial clinical presentation of acute diarrhea. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. 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 87493 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique-Not on physician look up 87505 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targetsMolecular Diagnostic Testing for Gastrointestinal Illness INDIANA MARKETPLACE PLANS PY-0860 Effective Date: 11/01/2019 4 ICD-10 Code Description A04.71 Enterocolitis due to Clostridium difficile, recurrent A04.72 Enterocolitis due to Clostridium difficile, not specified as recurrent A02.0 Salmonella enteritis A03.0 Shigellosis due to Shigella dysenteriae A03.1 Shigellosis due to Shigella flexneri A03.2 Shigellosis due to Shigella boydii A03.3 Shigellosis due to Shigella sonnei A03.8 Other shigellosis A03.9 Shigellosis, unspecified A04.0 Enteropathogenic Escherichia coli infection A04.1 Enterotoxigenic Escherichia coli infection A04.2 Enteroinvasive Escherichia coli infection A04.3 Enterohemorrhagic Escherichia coli infection A04.4 Other intestinal Escherichia coli infections A07.1 Giardiasis [lambliasis] A08.11 Acute gastroenteropathy due to Norwalk agent A09 Infectious Gastroenteritis and colitis, unspecified O99.611 Diseases of the digestive system complicating pregnancy, first trimester O99.612 Diseases of the digestive system complicating pregnancy, second trimester O99.613 Diseases of the digestive system complicating pregnancy, third trimester O99.619 Diseases of the digestive system complicating pregnancy, unspecified trimester O99.62 Diseases of the digestive system complicating childbirth O99.63 Diseases of the digestive system complicating the puerperium F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 11/01/2019 New Policy Date Revised Date Effective 11/01/2019 Date Archived H. References 1. 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. 2. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. 3. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System Infections. (2016, July 16). Retrieved 7/29/19 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091344/ext. 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 1 1/ 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 Archived Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACE PLANS PY-08 7 6 Effective Date: 1 1 / 0 1 / 2 0 1 9 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 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 recei ved 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. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for examp le, 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 transmitted 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. Ris k 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 equi pment 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 hea lth problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the dise ase, especially injecting drugs. (1) All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvemen t Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, t his does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. Archived Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACE PLANS PY-08 7 6 Effective Date: 1 1 / 0 1 / 2 0 1 9 3 C. Definitions Polymerase Chain Reaction (PCR) – a genetic am plification 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. Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) appro ved 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 pr ovided 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 Archived Molecular Diagnostic Testing for Hepatitis Band CINDIANA MARKETPLACE PLANS PY-08 7 6 Effective Date: 1 1 / 0 1 / 2 0 1 9 4 B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwithout 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 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 1 1/0 1/2019 New Policy Date Revised Date Effective 1 1/01/201 9 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. Archived
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