REIMBURSEMENT POLICY STATEMENT KENTUCKY MEDICAID Original Issue Date Next Annual Review Effective Date 08/29/2017 11/01/2019 11/01/2018 Policy Name Policy Number Long Acting Reversible Contraceptives (LARCs) PY-0343 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 4 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H. REFERENCES ………………………………………………………………………………………… 4 Long Acting Reversible Contraceptives (LARCs) Kentucky Medicaid PY-0343 Effective Date: 11/01/2018 2 A. SUBJECT Long Acting Reversible Contraceptives (LARCs) B. BACKGROUND Humana-CareSource recognizes Long Acting Reversible Contraceptive methods (LARCs) to be among the most effective contraception available to our members in assisting with their reproduction and family planning decisions. While LARCs do not prevent or reduce the likelihood or danger of sexually transmitted infections or their transmission, they do allow sexually active members a greater degree of certainty with a better percentage of success, and generally, less frequent medical maintenance and intervention, than other available contraceptive methods. C. DEFINITIONS Implantable Contraceptive, or Contraceptive Implant, means a single-rod contraceptive releasing device inserted under the skin of a womans upper arm. Intrauterine Device, or IUD, means a device inserted into a womans uterus by a healthcare professional in order to prevent pregnancy. IUDs may or may not be designed to also release hormones during the period of time they are implanted in the uterus. Once placed, they should be monitored, removed, and replaced periodically. D. POLICY I. Prior authorization is not required for the long acting reversible contraceptives (LARCs) covered by this policy. NOTE: Although the LARCs covered by this policy do not require a prior authorization, Humana-CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II. Services covered under this policy include: A. Management and evaluation (office) visits and consultations for the purpose of providing LARCs; B. Health education and counseling visits for the purpose of providing LARCs; C. Medical/surgical services/procedures provided in association with the provision of LARCs; D. Laboratory tests and procedures provided in association with the provision of LARCs; E. Drugs administered as part of LARCs; and F. Supplies provided as part of LARCs. III. Covered Settings and Timing for the insertions or removals of LARCs A. Insertion or removal of a LARC may be performed and billed in conjunction with an initial or annual comprehensive visit, a follow up comprehensive medical visit, a brief medical visit, or a supply visit by a member to a qualifying provider participant, as detailed in the corresponding Humana-CareSource Family Planning reimbursement policy. B. Humana-CareSource will also reimburse providers for LARCs inserted immediately postpartum in a hospital setting, in addition to and separately from the Diagnostic Related Group reimbursement process for the hospital. 1. In this circumstance, if the provider uses one of the following implantable devices, it must be inserted within ten minutes of birth to decrease the likelihood of expulsion of the device: 1.1 J7297-Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52mg; Long Acting Reversible Contraceptives (LARCs) Kentucky Medicaid PY-0343 Effective Date: 11/01/2018 3 1.2 J7298-Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52mg; 1.3 J7300-Intrauterine copper contraceptive (ParaGard); or, 1.4 J7301-Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5mg; 1.5 J7307-Etonogestrel (contraceptive) implant system, including implant and supplies. IV. Implantable Contraceptive Capsules A. Humana-CareSource will reimburse the following providers for the insertion and removal of implantable contraceptive capsules, after each has been trained in accordance with the manufacturers guidelines: 1. Physicians; 2. Nurse practitioners; 3. Midwives; and, 4. Physicians assistants. B. Documentation of this training must be maintained in the providers personnel or training record. C. The insertion, management and monitoring, and removal of these capsules must be performed in compliance with all manufacturers recommendations. D. Insertions are limited to once per member within any three year period. V. Intrauterine Devices A. Humana-CareSource will reimburse the following providers for the insertion and removal of intrauterine devices, after each has been trained in accordance with the manufacturers guidelines: 1. Physicians; 2. Nurse practitioners; 3. Midwives; and, 4. Physicians assistants. B. Documentation of this training must be maintained in the providers personnel or training record. C. The insertion, management and monitoring, and removal of these capsules must be performed in compliance with all manufacturers recommendations. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Kentucky Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Kentucky Medicaid fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODE DESCRIPTION J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg J7300 Intrauterine copper contraceptive (ParaGard) J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7306 Levonorgestrel (contraceptive) (Jadelle) implant system, including implants and supplies Long Acting Reversible Contraceptives (LARCs) Kentucky Medicaid PY-0343 Effective Date: 11/01/2018 4 J7307 Etonogestrel (contraceptive) implant system, including implant and supplies S4989 Contraceptive intrauterine device (e.g., Progestacert (Kyleena) IUD), including implants and supplies 11976 Removal, implantable contraceptive capsules 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, non-biodegradable drug delivery implant 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) Z30.014 Encounter for initial prescription of intrauterine contraceptive device Z30.017 Encounter for initial prescription of implantable subdermal contraceptive Z30.019 Encounter for initial prescription of contraceptives, unspecified Z30.43 Encounter for surveillance of intrauterine contraceptive device Z30.430 Encounter for insertion of intrauterine contraceptive device Z30.431 Encounter for routine checking of intrauterine contraceptive device Z30.432 Encounter for removal of intrauterine contraceptive device Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device Z30.46 Encounter for surveillance of implantable subdermal contraceptive Z30.8 Encounter for other contraceptive management (encounter for routine exam for contraceptive maintenance) Z45.89 Encounter for adjustment and management of other implanted devices Z45.9 Encounter for adjustment and management of unspecified implanted device Z97.5 Presence of (intrauterine) contraceptive device F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 08/29/2017 New Policy. Date Revised Date Effective 11/01/2018 H. REFERENCES 1. Preventive Services | HHS.gov. (n.d.). 2. 907 KAR 1:048. Family planning services. (n.d.). 3. 907 KAR 1:049. Payments for family planning services. (n.d.). 4. 2017, from Long-Acting Reversible Contraception Program-ACOG. (n.d.). The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT KENTUCKY MEDICAID Original Issue Date Next Annual Review Effective Date 04/05/2017 06/01/2019 06/01/2018 Policy Name Policy Number Debridement Services PY-0251 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including Humana CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 3 Debridement Services KENTUCKY MEDICAID PY-0251 Effective Date: 06/01/2018 2 A. SUBJECT Debridement Services B. BACKGROUND Debridement Services are indicated in select cases to assist in promoting wound healing where removal of deep seated foreign material or nonviable tissue at the level of the skin, subcutaneous tissue, fascia, muscle or bone is required. The intent of debridement is to reduce infection and bacterial contaminates, cleaning the wound and removing any mechanical impediments in order to provide a favorable environment for wound healing or surgical intervention as necessary. Prior to initiating debridement blunt probes may be used to evaluate the extent of the wound and assess for abscesses or sinus tracts. Co-morbid conditions that would impede normal wound healing, along with identifying the etiology of the wound and educating the patient on compliance should be addressed prior to beginning treatment. In the instance that debridement services are indicated, it is expected that they will be performed within reason and at appropriate treatment intervals. The expected outcome of wound debridement, with appropriate care and barring extenuating medical or surgical obstacles, is decreased wound size and volume. Should appropriate healing not occur, it is expected and reasonable for the plan of care for the wound to be modified. C. DEFINITIONS Debridement is the removal of infected, contaminated, damaged, devitalized, necrotic, or foreign tissue from a wound. D. POLICY I. No Prior Authorization NOTE: Although the debridement covered by this policy do not require a prior authorization, Humana CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity II. Covered Areas of Debridement A. CPT codes 11000 and 11001 describe removal of extensive eczematous or infected skin. 1. CPT codes 11000 and 11001 are not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. 2. CPT code 11001 is limited to those practitioners who are licensed to perform surgery above the ankle, since the amount of skin required by the code is more than that contained on both feet. B. CPT codes 11042-11047 should be used for debridement of relatively localized areas depending upon the involvement of contiguous underlying structures. III. Osteomyelitis A. Debridement for osteomyelitis is covered for chronic osteomyelitis and osteomyelitis associated with an open wound. IV. Chronic Foot Ulcer Management A. Debridement of diabetic foot ulcers more frequently than once every seven (7) days, for longer than three (3) consecutive calendar months, is not indicative of an effective plan of treatment. Should a patient require more debridement services per wound than noted above, the medical record must include careful documentation reflecting neuropathic, vascular, metabolic, or other co-morbid conditions. B. Removing a collar of callus (hyperkeratotic tissue) around an ulcer is not considered debridement of skin or necrotic tissue and should be billed under CPT code 11055 or 11056. Debridement Services KENTUCKY MEDICAID PY-0251 Effective Date: 06/01/2018 3 V. Limitations of Coverage A. Debridement services are not covered in the absence of necrotic, devitalized, fibrotic, or other tissue or foreign matter present that would interfere with the normal wound healing process and must be documented in the medical record. B. Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care and is not addressed in this policy. C. The Debridement Services policy does not apply to CPT codes 97597, 97598 and 97602, as these services are provided by physical and occupational therapist. D. Anesthesia services are not separately reimbursable for these services. E. In the outpatient treatment setting, services beyond the fifth surgical debridement, billed with CPT code 11043, 11046 and/ or 11044, 11047; per patient, per year, per wound will require a medical review of records to determine medical necessity E. CONDITIONS OF COVERAGE HCPCS CPT F. RELATED POLICIES/RULES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 04/05/2017 New Policy. Date Revised Date Effective 06/01/2018 H. REFERENCES 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2016, September 1). Retrieved March 31, 2017, from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34032&ContrId=240&ver=16&ContrVer=1&CntrctrSelected=240*1&Cntr ctr=240&name=CGS+Administrators%2c+LLC+(15201%2c+MAC+-+Part+A)&DocType=Active&LCntrctr=240*1&bc=AgACAAQAAAAAAA%3d%3d& 2. Lawriter-OAC-5160-1-01 Medicaid medical necessity: definitions and principles. (2015, March 22). Retrieved March 31, 2017, from http://codes.ohio.gov/oac/5160-1-01 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
1 PAYMENT POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 10/31/2013 03/09/2017 03/09/2016 Policy Name Policy Number Advanced Diagnostic Imaging Services PY-0041 Policy Type Medical Administrativ e Payment Payment 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 Payment Policies. In addition to this Policy, payment 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 practi ce in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or payment 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 Pol icy at any time. A.SUBJECTAdvanced diagnostic imaging ServicesB. B ACKGROUNDCareSource will cover medically necessary imaging services including diagnostic radiology,mammography, bone densitometry, nuclear medicine, magnetic resonance imaging/magnetic resonance angiography (MRI/MRA), computerized tomography/ computerized tomographic angiography (CT/CTA), positron emission tomography (PET scan) and ultrasound procedures.C. D EFINITIONSAdvanced d iagnostic Imaging (ADI) refers to the applications of high energy modalities and other technologies to allow the visualization and examination of body tissues including but not limited to computed tomography (CT), magnetic resonance imaging (MRI),magnetic resonance angiography (MRA) , and positron emission tomography (PET).Technical Component represents the non-physician work (including facility, equipment,personnel and administrative costs ) related to the procedure.Professional Component refers to the physician work related to performing and interpreting the results of a procedure . Archived 2D. POLICY I. Prior Authorization A. Diagnostic imaging services performed in the emergency room, observation, and inpatient settings do not require prior authorization. B. CareSource requires providers to obtain authorization prior to requesting ADI services in an outpatient setting, including: 1. CT/CTA 2. MRI/MRA 3. PET Scan 4. Nuclear Cardiology C. MRI/MRA, CT/CTA and PET procedures must be performed in a participating designated free-standing imaging center or a participating hospital. D. If the rendering provider identifies a need to extend the examination to a contiguous body area or identifies a need to perform a different examination than what was originally authorized, the radiologist or facility should notify NIA of the extended study or additional service within the same day. 1. NIA will either update the authorization record to include the extended examination or issue a new authorization number for the additional service. II. Global Payment and Component Services A. CareSource covers the professional component for physicians in any setting. 1. The technical component is covered only when that service is provided in an appropriate non-facility setting. B. The global service (which is inclusive of the professional component) is covered by CareSource in non-facility settings. 1. When a physician reports a global procedure, the physician is responsible for the overall performance and quality of the test. 2. The physician must either personally perform the test or it must be performed under the physicians supervision and direction. 3. The physician must personally interpret the results and complete the written report. 4. While some radiology procedures and diagnostic tests may not require the presence of the supervising physician on the premises, other procedures dictate that the physician be present and and/or directly involved in the performance of the procedure. C. Interpretation of radiology services are covered for any physician trained in the interpretation of the study. 1. The provider who interprets the study must be the one who prepares and signs the written report for the medical record. D. Review of results and explanation to the beneficiary are part of the attending physicians E/M service and are not considered as interpretation of the study. E. Incidental and ancillary services (e.g. contrast, drugs, related supplies etc) utilized in advanced diagnostic i maging studies will be reimbursed within the global payment and will not be reimbursed separately. 1. This includes (but is not limited to) submissions involving A codes, Jcodes, Qcodes). III. Multiple Services on Same day A. CareSource covers bilateral x-rays when medically necessary. 1. Bilateral services are studies done on the same body area, once on the right side and once on the left side. Comparison films obtained for routine purposes are not Archived 3covered. 2. Providers should use a bilateral code when available. B. CareSource also covers multiple studies of both areas if reported with the appropriate modifier. 1. Examples would include bilateral wrist studies done before and after fracture care on both wrists the same day for the same patient or doing films to assess a patients response to medical care, such as multiple chest films to monitor the cardiopulmonary status of a critically ill patient . IV. Billing Information A. CareSource recognizes a professional component and a technical component for each radiological procedure. 1. When both components are performed by one provider, they are recognized as the total (radiological) procedure. B. X-rays and documentation of all results of radiological procedures must be maintained on file for a period of six years. 1. In addition, x-rays must be of sufficient quality to ensure ease of diagnosis and must be marked with the patients name and dated for ready identification. C. When submitting a claim for radiology services, providers must use the appropriate modifiers. 1. CareSource will directly reimburse a radiologist the professional component when the radiologist performs the initial interpretation of a radiological examination. 2. CareSource will directly reimburse a radiologist or cardiologist for the professional component when the radiologist or cardiologist interprets a radiological procedure that has already been interpreted by another physician. 3. In th is case, the radiologists or cardiologists interpretation is deemed a specialists evaluation (of the interpretation of the treating physician) whose findings could affect the course of treatment initiated or cause a new course of treatment to begin. D. Rei mbursement is not allowed for an interpretation of a radiologic procedure performed by the attending, treating, or emergency room physician after a radiologists or cardiologists interpretation. 1. Such a service would be considered a part of the physicians overall workup or treatment of the patient and reimbursed as part of the visit. 2. Physician providing radiological services in an inpatient hospital, an outpatient hospital, or an emergency room setting may bill CareSource only for the professional compo nent. E. CareSource will reimburse a physician/provider for only the technical component if: 1. The physician personally performed the service or the service was performed by an employee of the physician/provider 2. The professional component was performed by another physician/provider 3. The service was performed in a setting other than an inpatient hospital, an outpatient hospital or an emergency room. F. CareSource will reimburse a physician for the total procedure when the radiologist or treating physician performs the professional and technical components of a radiological procedure in a setting other than an inpatient hospital, an outpatient hospital, or an emergency room. G. CareSource will reimburse any other non-hospital provider for the total procedure when: 1. The physician who performed the professional component has an employment or contractual arrangement for the provider to bill for the professional services 2. The technical component was performed in a setting other than an inpatient Archived 4hospital, an outpatient hospital, or an emergency room. V. Diagnostic and Radiology Services A. In accordance with AMA Principles of CPT Coding CareSource will not compensate a diagnostic test or radiology service billed with modifier 26 (professional component) and modifier TC (technical component) if the technical and professional components of the service are performed by the same provider billed on the same or different claim on the same date of service. CONDITIONS OF COVERAGE HCPCS CPT AUTHORIZATION PERIOD E. RELATED POLICIES/RULES CareSource Payment Policy: Emergency Department EKG and Imaging Interpretation CareSource Payment Policy: Bilateral Procedures OHIO: https://www.caresource.com/providers/ohio/ohio-providers/payment-policies/ KENTUCKY: https://www.caresource.com/providers/kentucky/medicaid/payment-policies/F. REVIEW/REVISION HISTORY Date Issued: 10/31/2013 Date Reviewed: 10/31/2013, 03/09/2016 Date Revised: 03/09/2016-CareSource requires providers to obtain authorization prior to requesting ADI services in an office or outpatient setting . G. REFERENCES 1. OAC 5160-4- 25, Physician Services, Laboratory and Radiology services. 2. 907 KAR 3:005. Physicians’ Services, Section 5. Prior Authorization Requirements The Payment Policy Stateme nt detailed a bove has r eceived due con side ration as defined in the PaymentPo licy Stateme nt Policy and is a pprove d.Archived
(footnotes added here) MEDICAID POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 10/ 18/2013 10/18 /2016 10/20/2015 Policy Name Policy Number Allergy Testing and Allergen Immunotherapy PY-0006 Policy Type Medical Administrativ e Payment Medicaid Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) apply to Medicaid health benefit pl ans administered by CSMG and its affiliates and are derived from literature based on and supported by applicable federal or state c overage mandates, clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not lim ited 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 pro vider. 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. M edic aid Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan benefit document (i.e., Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there i s a conflict between the Medicaid Policy Statement and the plan benefit document, t hen the plan benefit document will be the controlling document used to make the determination. In the absence of any applicable controlling fe deral or state coverage mandate, benefits are ultimately determined by the applicable plan benefit document. A.SUBJECTAllergy Testing and Allergen ImmunotherapyB. BACKGROUNDC. D EFINITIONSAllergen immunotherapy: (Desensitization, Hypo-sensitization) is parenteral administratio n of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scaleto a dosage maintained as maintenance therapy.Allergy: Refers to an acquired potential for developing adverse reactions that are medi at ed b y the immune system (via IgE antibodies). Allergic disease represents the clinical manifestations of these adverse immune responses.Allergy testing: Identifying the offending antigen(s) for a patient by in-vivo testin g per cutaneous, intradermal, and less commonly, patch and photo patch tests.Dose: A 1cc aliquot of medicine or serum taken from a single, multi-dose vial. Ten doses are typically obtained from such a vial. In accordance with CMS guidelines, diluted doses will not be reimbursed; instead, if the medication or serum is diluted, only those doses designated from the maintenance vial (a maximum of ten) will be reimbursed.D. PO LICYI. Allergy testingCareSource will reimburse providers of physician services for the performance an d ev aluation of allergy sensitivity tests when the following conditions are met: Archivevd (footnotes added here)A. A complete medical and allergic/immunologic history and physical examination must be done prior to performing diagnostic testing and be made available to CareSource upon request B. Th e testing must be performed based on the medical and allergic/immunologic history and physical examination that documents that the antigen being used for the testing exists within a reasonable probability of exposure in the patients environment and be documented in the patients medical record C. Based on the information in the medical record, the testing must be limited to the minimal number of necessary tests to reach a diagnosis 1. Percutaneous tests, intra-cutaneous/intradermal tests, photo patch test s, and patch tests, photo tests, or application tests are reimbursed on a per test basis. When submitting claims, the provider must specify the number of tests performed. 2. Quantitative or semi-quantitative in-vitro allergen specific IgE tests (formerly referred to a RAST tests) are covered if skin testing is not possible or not reliable and they are performed by providers certified under the Clinical Laboratory Improvement Amendment of 1988 (CLIA 88) to perform the tests. 3. Ophthalmic mucous membrane tests and direct nasal mucous membrane tests are allowed only when skin testing cannot test allergens. 4. If an ingestion challenge test is completed in less than 61 minutes, according to CPT/RUC rules, an E/M code should be used instead of 95076, if appropriate. 5. The add-on code [95079] is intended to be used for challenges lasting beyond the two hour base code. CPT rules require that an add-on must last at least for 1 min. more than 50% of the total duration of the code, which means ph ysicians should not use 95079 until the additional time equaled at least 31 minutes beyond the firs t two hour oral food challenge. D. Allergen immunotherapy 1. Providers may be reimbursed for the professional services necessary for allergen immunotherapy. 2. An office visit may be reimbursed in addition to the allergen immunotherapy codes (95115, 95117, 95144-95180) only if other identifiable services are provided at that time. If an office visit code is submitted with an allergen immunotherapy service, the modifier 25 must be used. 3. Allergen immunotherapy will not be covered for the following antigens: newsprint, tobacco smoke, dandelion, orris root, phenol, formalin, alcohol, sugar, yeast, grain mill dust, goldenrod, pyrethrum, marigold, soyb ean dust, honeysuckle, wool, fiberglass, green tea, or chalk since they are not considered medically necessary. 4. CareSource recognizes two components of allergen immunotherapy, one being the administration (injection) of the antigen, which includes all professional services associated with the administration of the antigen, and the other being the antigen itself. These two components must be separate on the claim, regardless of whether or not the provider who prescribes and provides the antigen is the same as the provider who administers the antigen. E. Injections 1. For reimbursement for the administration (injection) of allergenic extract or stinging insect venom, the provider must use CPT code 95115 or 95117. The allergenic extract may be administered by the physician or by a properly instructed employee under the general supervision of the physician in an office setting. These codes may not be used with CPT code 95144 [Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vials]. Archivevd (footnotes added here)F. Antigens (excluding stinging insect venoms) 1. When the provider prescribes and provides single or multiple antigens for allergen immunotherapy in multiple-dose vials (i.e., vials containing two or more doses of antigens), the provider must use CPT code 95165 [Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; single or multiple antigens] in the procedure/service code block and the number of doses contained in the vial in the unit(s) block on the invoice. If the provider dispenses two or more multiple-dose vials of antigen, for each vial dispensed CPT code 95165 must be listed on a separate line along with the corresponding number of doses. 2. For example, if a patient cannot be treated with immunotherapy by placing all antigens in one vial and two multi-dose vials containing ten doses each must be dispensed, the CPT code 95165 must be listed on two separate lines and a 10 (for ten doses) must be entered for the corresponding units. 3. CPT code 95144, the single dose vial antigen preparation code, must not be used as one of the components of a complete service performed by a provider. The code must be used only if the provider providing the antigen is providing it to be injected by some other entity. The number of vials prepared must be indicated. 4. CareSource does not recognize CPT codes 95120 through 95134 because they represent complete services, i.e., services that include the injection service as well as the antigen and its preparation. Only component billing will be allowed. Providers providing both components of the service must do component billing. The provider must, as appropriate, use one of the injection CPT codes (95115 or 95117) and one of the antigen/antigen preparation CPT codes (95145 through 95149, 95165, or 95170). The number of doses must be specified. G. Insect venoms in single dose vials or preparations 1. If the provider administers the venom(s), CPT code 95115 or 95117 must be used for the injection(s) of the antigen(s). 2. When a provider prescribes and/or provides stinging insect venom antigens in single dose vials or preparations, CPT codes 95145 to 95149 must be used. 2.1 For each single dose vial or preparation provided, a unit of service of 1 must be reported. 2.2 If the provider also administers the venom, CPT code 95115 or 95117 must be used for the injection(s). H. Insect venoms in multiple dose vials or preparations 1. When a provider prescribes and provides single or multiple stinging insect venom(s) in multiple dose vials, CPT codes 95145 to 95149 must be used. The number reported as the unit of service must represent the total number of doses contained in the vial. 2. Regardless of the number of doses, the date of service reported should be: 2.1 The date the vial is dispensed to the patient, if the patient takes the vial home to be administered at a different office OR 2.2 The date that the first dose is administered to the patient, if the vial is kept in the physicians office. 3. If the provider also administers the venom, CPT code 95115 or 95117 must be used for the single or multiple injection(s). The correct quantity is one for either code. Archivevd (footnotes added here) CONDITIONS OF COVERAGE CareSource will reimburse a participating provider of physician services for allergy testing and injections administered by a properly instructed person in an office setting in accordance with the physicians prescribed plan of treatment. C areSource does not cover: Allergen immunotherapy that is considered experimental, investigational, or u nproven; A llergen therapy administered by the member at home, from vials of serum prepared by t he pr ovider.HCP CS CPT AUT HORIZATION PERIOD/PRIOR AUTHORIZATION Authorization is not required for immunotherapy services administered by a participating provider within the limitations outlined. E. R ELATED POLICIES/RULESCareSource Policy-Antigen Leukocyte Cellular Antibody Testing (ALCAT) F . REVIEW/REVISION HISTORYDate Issued: 10/18/2013 Date Reviewed: 10/18/2013, 02/01/2015, 10/20/2015 Date Revised: 02/01/2015 Definition of dose; non-covered services; updated OAC reference G. R EFERENCES1. Federal Register 65 FR 653762. OAC Chapter 5160-4- 19 Physician Services / Allergy services.3. (from BlueCross BlueShield Online Medical Dictionary, www.bcbsms.com) ) 4.(from www.tuftshealthplan.com)Th e med ical Policy Stateme nt detailed a bove has r eceived due con side ration as defined in the Medic al Policy Stateme nt Policy and is a pprove d.Archivevd
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Colonoscopies Programs Covered: OH Medicaid, KY Medicaid, OH MyCare, and Just4Me TM (all states) Po lic y Effective February 1, 2014, CareSource will reimburse participating providers for medically necessary and preventive screening colonoscopies as set forth in this policy. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o vi d er Rei m b u r se m e n t Gu i d e lin e s CareSource Just4Me & Medicaid CareSource will reimburse participating providers for the cost of medically necessary and preventive screening colonoscopies for any member aged 50 or older, and for high-risk members, with no limit on frequency. For high risk patients under the age of 50, CareSource requires the provider submit documentation of family history. No prior authorization is required for participating providers. See the qualifying high-risk factors in the section below. CareSource MyCare-For its MyCare members, CareSource will reimburse participating providers for the cost of screening colonoscopies once every 10 years, when no risk factors are present. ( G0121 with dx V76.51 Special screening for malignant neoplasm of the colon ). For high-risk MyCare members, CareSource will reimburse participating providers for the cost of a screening colonoscopy every 2 years ( G0105 plus appropriate diagnosis code ). High risk factors include: oA close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.o A family history of familial adenomatous polyposis. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 o A family history of hereditary nonpolyposis colorectal cancer. o A personal history of adenomatous polyps. o A personal history of colorectal cancer. o Inflammatory bowel disease, including Crohns disease and ulcerative colitis. Re l a t e d Po l i c i es & Re f e r e n c e sOAC 5160-4-34, Preventive medicine services. St a t e Exc ep t i o n s NONE Do c u m e n t Rev i si o n Hi s t or y Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 PaymentPolicySubject: Pass-Through Billing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4MeTM Po lic yEffective November 1, 2014, CareSource prohibits pass-through billing as set forth in this policy. Any claim submitted by a provider which includes services ordered by that provider, but which were performed by a person or entity other than that provider or a direct employee of that provider will not be reimbursed. De f i ni t i on sCLIA, means the Clinical Laboratory Improvement Amendments of 1988, which are federal regulatory standards that apply to all clinical laboratory testing performed on hum ans in the United States except clinical trials and basic research. (from http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA & Intern al CareSource definition) Direct Employee, means an employee of a provider who is under direct supervision of the ordering provider and the services is billed by the ordering provider. An employee is person that receives a W-2 (as opposed to a 1099) from the participating provider and does not have their own provider or NPI number. (CareSource internal definition) Pr o vi d er Rei m b u r se m e n t Gu i d el i n es CareSource prohibits pass-through billing. Pass-through billing occurs when an ordering provider requests and bills for services that are not performed by the ordering provider or by a direct employee of that provider. With respect to laboratory services, CareSource will reimburse for the services which the provider itself is certified through CLIA to perform. Claims may not be submitted to CareSource for any laboratory services for which a provider lacks the applicable CLIA certification. Additionally, CareSource members cannot be billed for any such services. CareSource considers any claim for services related to pass-through billing not eligible for reimbursement. Providers must bill CareSource only for those services which they or their direct employees perform. Providers will not bill, charge, seek payment for or submit any claims to CareSource, nor will they have any recourse against CareSource or any of its members for amounts related to the provision of pass-through billing. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Rel at ed Po l i c i e s & Ref e r en ce s42 CFR 493, Standards and certification: Laboratory Requirements. St a t e Exc ep t i o n s NONE Doc u m e nt Hi s t o r y
Payment Policy S ubject: Psychiatric Day Programs P rograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Policy CareSource will reimburse participating providers for psychiatric day programs at negotiated per diem rate for the mental health and wellness services provided as part of the day program , as described herein . Definitions None required Provider Reimbursement Guidelines The purpose of this policy is to explain the r eimbursement for providers of psychiatric day facility programs and their component treatments and services as offered to CareSource members . CareSource typically enters into specific negotiated contract s with its providers which establish a defined per diem rate for psychiatric day services. Prior Authorization Prior authorization is required for reimbursement of psychiatric day facility programs. To request prior authorization for these services, please call 1-800-488-0134. During regular business hours, the call will be answered by the CareSource Medical Management Department. If calling after regular business hours, the call will be answered by the CareSource Nurse Triage Line. C overage Psychiatric facility services offered as day (outpatient) programs vary from facility to facility in the scope and content of their services. CareSource considers that all such services a re included in the established per diem rate negotiated with each participating fa cility. However, CareSource will separately reimburse a f acility for the following outpatient hospital and professional services : Speech therapy;Physical therapy;Laboratory ;Radiology ; and,Psychiatrist services.This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Archived These services are not considered to be included in the per diem rate and instead will be reimbursed to the facility in accordance with the fee schedule established at the time of the agreement negotiated and entered into by CareSource and that facility. Related Policies & References OAC Chapter 5160-8- 05, Psychology services provided by licensed psychologists . OAC Chapter 5160-29, Outpatient health facility services. 907 KAR 1:044, Coverage provisions and requirements regarding community mental health center services. State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Archived
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