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: Dry Eye Syndrome Testing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Po l i c y Effective February 1, 2014, CareSource will reimburse participating providers for dry eye syndrome testing 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) Dry Eye Syndrome , also known as keratoconjunctivitis sicca, (KCS), keratitis sicca, sicca syndrome, xerophthalmia, or simply, dry eyes, is an eye disease in which tear film evaporation is high or tear production is low, or there is an imbalance in the composition of the patients tears, or eyelid problems, medications, or environmental factors cause a lack of adequate tears, leading the patients eyes to dry out and become inflamed. (from www.mayoclinic.com)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 v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Coverage Microfluidic analysis utilizing an integrated collection and analysis device to measure tear osmolarity (one eye) is a test covered by CareSource, and using the CPT code 83861. The American Academy of Ophthalmology Preferred Practice Pattern guideline for Dry Eye Syndrome specifically recommends tear osmolarity testing for the diagnosis and management of dry eye syndrome. The tear osmolarity test is considered to be a more sensitive method of diagnosing and grading the severity of dry eye compared to corneal and conjunctival staining, tear break-up time, Schirmer test and meibomian gland grading. CareSource acknowledges that this test can only be performed at the point-of-care, as tear fluid is a fragile sample with insufficient volume to allow for collection and transfer to a reference laboratory for analysis, as stated in AMAs CPT Assistant article on the associated CPT code (83861). 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 CareSource will reimburse all participating doctors offices, including optometrists offices,performing a medically necessary tear osmolarity test , provided that the doctors office has been certified as a laboratory under the Clinical Laboratory Improvement Act (CLIA) regulations, and has a CLIA license. Re l a t e d Po l i c ies & Re f e r e n c e s St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r 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 5 Payment Policy Subject: Family Planning Po l i c y CareSource covers family planning services for members when the services are determined to be necessary for the health and well-being of the member. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. 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) Family planning services , or Pregnancy prevention/contraceptive management services , are services and supplies provided for the primary purpose of preventing or delaying pregnancy. They include services provided for the prevention of pregnancy, and related supplies. (from OAC 5160-21, Reproductive Health Services.) Infertility is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to produce conception, in either case, after at least one year of trying to do so . (CareSource internal definition) 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) Preconception care means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. (from OAC 5160-21, Reproductive Health Services.) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization Members may seek family planning services from any qualified CareSource participating provider without prior authorization. Coverage Family planning services must be furnished under the supervision of a physician or dispensed by a pharmacy for beneficiaries of childbearing age, including minors considered to be sexually active. Family planning services enable beneficiaries to voluntarily choose to prevent initial pregnancy or to limit the number of and spacing of their children. 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 5 Covered services include an office visit for a complete exam, pharmaceuticals (including some over the counter [OTC] products), supplies and devices when such services are provided by or under the supervision of a medical doctor, osteopath, or eligible family planning provider. Family planning supplies not furnished by the provider as part of the medical services must be prescribed by a physician and purchased at a pharmacy. Exceptions are condoms and similar supplies which do not require a prescription. Family planning services may include the following. Pregnancy prevention Pregnancy testing Sterilization [Separate CareSource payment policy] Hysterectomies [Separate CareSource payment policy] Infertility services [not covered] Some of these services can be easily recognized as family planning by the CPT procedure code or drug type code (for example, intrauterine device (IUD) insertion, vasectomy, contraceptive drugs and devices). Other services such as visits, laboratory tests and X-rays are not as readily identifiable as family planning services. Claims Providers are to indicate Family Planning as a diagnosis when billing any of the services listed in this policy that relate to family planning. Providers are to complete the diagnosis code or the appropriate narrative, where applicable. In addition, providers should identify services related to the treatment of complications of family planning. Examples: Surgical procedure such as incision and drainage of pelvic abscess resulting from infection with IUD Office visit and laboratory tests needed because of uterine bleeding while on oral contraceptives Occasionally other services (including hospital, radiology, pharmaceutical, blood and blood derivatives) may be related to family planning or to its complications, and should be properly identified. Non-Comprehensive Family Planning Visits CareSource covers pregnancy prevention/contraceptive management services including evaluation and management (office) visits and consultations for the purpose of: Pregnancy prevention/contraceptive management; Pregnancy examination and testing that includes provision of information about pregnancy prevention; Pregnancy prevention/contraceptive management, including but not limited to fertility awareness and natural family planning .Natural family planning , is the use of fertility awareness-based methods to track ovulation in order to prevent pregnancy. ArchivedThis 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 3 of 5 Pregnancy determination services when pregnancy testing yields a negative or inconclusive result and provision of information about pregnancy prevention is provided; Medical/surgical services/procedures provided for the purpose of pregnancy prevention/contraceptive management (i.e., injection, fitting, insertion, removal of contraceptive devices); Laboratory tests and procedures provided for the purpose of temporary pregnancy prevention/contraceptive management; Drugs prescribed for the purpose of pregnancy prevention/ contraceptive management; Supplies provided for the purpose of pregnancy prevention/ contraceptive management.Appropriate CPT codes should be used when billing for additional time spent discussing family planning needs with a recipient during routine, non-famil y planning office visits. Pregnancy prevention/contraceptive management services Providers must include the following information on claims for pregnancy prevention/contraceptive management services: A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided; and An appropriate ICD-9 (before 10/1/2014) or ICD-10 (after 10/1/2014) diagnosis code to indicate an encounter for contraceptive management General contraceptives Condoms are considered medically necessary for men and women in the prevention of pregnancy and to reduce the risk of sexually transmitted disease. Therefore, reimbursement is available for the following codes: Codes Description A4266 diaphragm contraceptive A4267 contraceptive supply condom male A4268 contraceptive supply condom female A4269 contraceptive supply spermicide eg foam gel J7300 Intrauterine copper contraceptive (ParaGard T 380A) J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (Mirena) IUDs require minimal, yet ongoing , oversight. When members experience active symptoms due to the IUD (e.g., excessive bleeding, cramping, or pelvic inflammatory disease) or need routine IUD surveillance, providers should report E/M codes for those visits as well as the appropriate diagnoses codes for IUD surveillance, current GYN symptoms, or current GYN disease processes. Some physicians also use ultrasound to confirm appropriate placement of an IUD at the time of insertion. When the healthcare provider performs this service, it is not bundled with the insertion codes. 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 4 of 5 Evaluation and Management CPT-4 codes, for example 99203 or 99213, may be billed when the member is counseled regarding contraception or is examined to determine the suitability of contraceptive modalities. Implantable Contraceptives: Etonogestrel Etonogestrel, 68 mg contraceptive implant (Implanon, Nexplanon) is billed with code J7307. Implanon must be FDA approved, labeled for use in the United States, and obtained from the single-source distributor. Only providers who have completed a company-sponsored training course and have been assigned a unique Training Identification Number may purchase Implanon. The certificate of training for each provider who inserts the implant must be retained by the provider and is subject to post-audit review. Implanon may be reimbursed when service is performed by on-medical practitioners (NMPs) who have completed the required training. Implanon is not reimbursable to Pharmacy providers. Providers must maintain a written log or electronic record of all Implanon implant systems, including the recipients name, medical record or CareSource number, date of surgery, and lot number of the product, for at least three years from the date of insertion. Records are subject to post-audit reviews. When billing for code J7307 [ Etonogestrel (contraceptive) implant system, including implant and supplies ], providers must attach a copy of the invoice to the claim or document the invoice number and price in the claim. Reimbursement limited to one per recipient, any provider, per 34 months . While the duration of action of Implanon is 36 months, the 34-month limit will permit early removal and insertion of a new implant . Bill in conjunction with the appropriate ICD-9 code (before 10/1/2014) or ICD-10 code (after 10/1/2014). Providers billing code J7307 more than once in 34 months must document the necessity for the repeat implant in the claim. Implantable Contraceptives: Norplant Norplant and related services are reimbursable once per member, per five years. If removal and re-implantation at the same or different incision site is performed prior to five years from the previous implantation, reimbursement is available for the removal only. When a physician inserts an implantable contraceptive, they should use code 11981 [ Insertion, non-biodegradable drug delivery implant ]. Code 11976 [ Removal, implantable contraceptive capsules ] is for use with those members that have the older Norplant capsule systems that need to be removed. For a member who comes to the office to have an implant removed and has a contraceptive rod inserted at the same visit, codes 11976 and 11981 are appropriate; submit the claim as 11976, 11981-51 (Multiple procedures). Note: providers should report the appropriate diagnostic codes for this combination service. When a memberhas a contraceptive rod removed, report 11982 [ Removal of a non-biodegradable drug delivery implant ] or 11983 [Removal with reinsertion of a non-biodegradable drug delivery implant] . [Source: http://www.obgmanagement.com/article_pages.asp?aid=10149 .] ArchivedThis 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 5 of 5 Pregnancy testing CareSource covers pregnancy testing in the physic ians office. Code Description 81025 Pregnancy Test Kits Urine, Qualitative 84703QW Pregnancy Test Urine Instrument Infertility Services (Assisted Reproductive Technology) CareSource does not cover infertility services. Under no circumstances are the following procedures covered: Drugs prescribed in accordance with Chapter 51 60-9 (Pharmacy Services) of the Ohio Administrative Code and/or drugs administered in accordance with Chapter 51 60-4 (Physician Services) of the Ohio Administrative Code; Assisted reproductive technologies (ART); In vitro fertilization; Intrauterine insemination/artificial insemination; and Surgery, including procedures for the reversal of voluntary sterilization. Re l a t e d Po l i c i es & Re f e r e n c e s OAC Rule 5160-21 Preconception Care Services 907 KAR 1:048. Family planning services CareSource Sterilization & Hysterectomy policies St a t e Ex c e p t i o n s NONE Do c u m e n t Hi s t o r 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 Payment Policy Subject: Mammography Services Po l i c yCareSource will reimburse physicians for mammography services for women thirty-five years of age and over. In addition, CareSource will reimburse physicians for mammography services for women under thirty-five years, if a woman is at high risk of developing breast cancer. De f i n i t i o n s”Mammogram ” means an x-ray examination of the breast using equipment d edicated specifically for mammography, including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, with two (2) views of each breast and with an average radiation exposure at the current recommended level as set forth in guidelines of the American College of Radiology. (from KAR 304.17-316) Screening Mammogram means a mammogram (as defined above) examination performed to detect unsuspected breast cancer in asymptomatic women. Standard views are obtained, and thus the interpreting physician does not need to be present at the facility to monitor the examination when the patient is imaged. (from ACR Practice Guideline for the performance of Screening and Diagnostic Mammography, www.acr.org/~/media ) Dia gnostic Mammogram means a mammogram performed to evaluate patients who have signs and/or symptoms of breast disease, imaging findings of concern, or prior imaging findings requiring specific follow-up. Diagnostic mammography requires direct supervision. (from ACR Practice Guideline for the performance of Screening and Diagnostic Mammography, www.acr.org/~/media) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization CareSource does not require prior authorization for screening and diagnostic mammograms. Coverage No payment will be made for a s creening mammogram provided to a member under thirty-five years, unless a woman is at high risk of developing breast cancer and medical necessity is provided . The patients medical records must clearly document the patients immediate risk of developing breast cancer at an age less than thirty-five. 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 One screening mammogram may be paid for a member over the age of thirty-four and under the age of forty. One screening mammogram every twelve months may be paid for a memberwho is over the age of thirty-nine. Diagnostic mammograms are covered reg ardless of the recipients age. Providers must use the Healthcare Common Procedure Coding System/ Current Procedural Terminology (HCPCS/CPT) codes. Mammography services may be reimbursed in one of the following three ways: Technical Component (TC) services rendered outside the scope of the physicians interpretation of the results of an examination. Professional Component (PC) physicians interpretation of the results of an examination. Global Component encompasses both the technical and professional components. Global billing is not permitted for services furnished in an outpatient facility. Critical Access Hospitals (CAHs) may not use global HCPCS codes as the TC and PC components are paid under different methodologies. Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-4- 25(B)(10) , Physician Services , Laboratory and radiology services Kentucky Revised Code 304.17-316 Coverage for mammograms. St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-4-25(B)(10),per Legislative Service Commission Guidelines. 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 5 Payment Policy Subject: Transcutaneous Electrical Nerve Stimulators ( TENS) Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Po l i c y Effective February 1, 2014, CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. De f i n i t i o n s Transcutaneous electrical nerve stimulation (TENS ) is the application of mild electrical stimulation to skin electrodes placed over a painful area. It causes interference with transmission of painful stimuli. (from Tabers Cyclopedic Medical Dictionary, 18thEdition) 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 v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization Prior authorization is not required when TENS units are prescribed within the limits of this policy. The pain must have been present for at least 6 months and other appropriate treatment modalities must have been tried and failed. Coverage CareSource considers only the following conditions as being eligible for the use of a TENS unit after other appropriate treatment modalities have been tried and have failed: Herpes zoster with other nervous system complications;Reflex sympathetic dystrophy;Other nerve root and plexus disorders;Mononeuritis of upper limb and mononeuritis multiplex;Mononeuritis of lower limb and unspecified site;Osteoarthrosis and allied disorders, if arthroplasty is not indicated, the patient has disabling knee pain or stiffness or the patient has inadequate response to 6 or more weeks of treatment with medication;Spondylosis of unspecified site;Intervertebral disc disorders;Brachial neuritis or radiculitis, not otherwise specified; 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 5 Spinal stenosis, other than cervical; Lumbago; Sciatica; Dysmenorrhea, if secondary causes have been ruled-out Myalgia and myositis, unspecifi ed; Neuralgia, neuritis, and radiculitis, unspecified; or Other postsurgical status when used for acute post-operative pain for 30 days from the day of surgery where conventional pain control techniques fail to adequately reduce pain and/or medication-related adverse events are unacceptable and/or Opioid dosage reduction is needed. Use of a TENS unit and related services for conditions not listed above are not eligible for reimbursement because the medical effectiveness of such therapy has not been established. Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive): Headache Visceral abdominal pain Pelvic pain Temporomandibular joint (TMJ) pain Acute pain (e.g.; angina, back pain, fractures, musculoskeletal) Cancer or cancer treatment-related pain Chronic low back pain Fibromyalgia Multiple Sclerosis Neuropathy The conditions listed in this policy may not be associated with members treated with acupuncture, nor may they be associated with any variation of acupuncture techniques, as acupuncture is not a covered service . Documentation The provider of the TENS unit must complete a Certificate of Medical necessity attesting to the medical necessity of the services, which may be reviewed by CareSource. The provider must also assure that the member using the device is properly instructed in how to use the device in support of his or her ordered treatment plan and is aware of and understands any emergency procedures regarding the use of the TENS unit. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical re cord. The following documentation to be kept in the providers records: The Certificate of Medical Necessity. A face-to-face examination of the patient should be documented in the medical records. This record should clearly support and document the medical necessity of the TENS Unit as part of an overall treatment plan. ArchivedThis 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 3 of 5 Specific documentation as to what medical diagnosis the TENS unit is prescribed. The diagnosis must be complete. Chronic intractable pain in itself is not a sufficient diagnosis to warrant coverage. Attestation by the prescriber that a non-reimbursable trial period of at least 30 days resulted in substantial relief from pain (except for postoperative members). An estimated length of use for the unit must be in the medical records When a TENS unit is used specifically for acute post-operative pain, the medical necessity of the TENS unit is limited and will be reimbursed by CareSource only for 30 days from the day of surgery. No further reimbursement for this reason will be authoriz ed. Rental When used for the treatment of chronic, intractable pain, the TENS unit must be used by the member on a trial basis for a minimum of one month (30 days). This period is not reimbursable by CareSource to the provider. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. CareSource will reimburse the provider for an additional, trial period of 1 month (30 days). A rental period of 90 days may be submitted to CareSource if the documentation in the providers records indicates pain control benefits such as a specific reduction in medications, e.g., muscle relaxants, narcotics, analgesics directly resulting from the use of the TENS unit. Payment for rental units includes all necessary accessories and supplies, and includes fitting and instructions/education in the proper use of the TENS unit. The provider must have a physical location available to the member for the initial face-to-face fitting and instruction/education efforts.CareSource will not consider reimbursement for any other HCPCS codes for supplies and accessories during the rental period. Supplies are included in the rental amount. Purchase TENS units are covered as rental only for a maximum of 4 months. For usage beyond 4 months, a ll prior rental payments made by CareSource for the use of a TENS unit by a member are applied to the subsequent purchase of the TENS unit. For coverage of a purchase, the physician must determine that the member is likely to derive significant therapeutic benefit from continuous use of the unit over a long er period of time. Upon receiving a claim for the purchase of a TENS unit, CareSource will reimburse the provider for the purchase price of the TENS unit, less any monthly rental payments already made for that unit. Purchase will only be considered after 3 months rental and when there is clear documentation in the medical record demonstrating that: 1. The use of the TENS Unit was successful in reducing pain; 2. You have assessed the patients condition and have determined that ongoing treatment with the TENS unit is medically necessary. 3. You submit a statement with the claim submission that attests to the requirements in 1. and 2. above. 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 4 of 5 TENS units provided to members must have two or four leads with more than one modality and must be covered by a warranty of 2 years or more when purchased on behalf of the CareSource member. CareSource will not authorize the purchase or rental of a used TENS unit unless the specific unit was used previously by the member . CareSource does not allow for the sharing of TENS units. If a TENS unit is ordered for use with four leads, the medical record must document why two leads are insufficient to meet the members needs. In the event that a member has already been renting a TENS unit before enrolling in CareSource and is eligible to purchase that unit, then the claim for the purchase must include appropriate documentation showing the full period of the rental. Supplies CareSource covers 1 unit of supplies for a two-lead TENS unit and 2 units of supplies for a four-lead TENS unit. For supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For products that are supplied as refills to the original order, suppliers must contact the member prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the member . This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the patient regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, th e supplier must deliver the product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. Industry standards state the TENS supply code A4595 includes the following: Electrodes (any type) Conductive paste or gel (if needed, depending on the type of electrode) Tape or other adhesive (if needed, depending on the type of electrode) Adhesive remover Skin preparation materials. Batteries (9 volt or AA, single use or rechargeable) Battery charger (if rechargeable batteries are used) Replacement lead wires (if more often than every 12 months per medical necessity)Supplies for a TENS unit owned by a patient must be dispensed and billed on a monthly basis in quantities no greater than actually needed by the patient as no automatic shipments or stockpiling of these supplies are permitted. No supplies may be billed before they have been provided to the patient. Reimbursement for supplies must be made under a single all-inclusive code [A4595]. CareSource will reimburse one (1) unit for a two-lead TENS Unit supplies and two (2) units for four-lead TENS unit. 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 5 of 5 Billing Modifiers Rental Modifiers accepted by CareSource are as follows: RR Rental LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price) Purchase Modifiers accepted by CareSource are as follows: NU New equipment CPT codes E0720 or E0730 must be submitted with the modifier NU to indicate the purchase of the TENS unit. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim will be denied. Any such denials may be appealed by the provider via the CareSource Medical Management department. Re l a t e d Po l i c i es & Re f e r e n c e s CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-8, Chapter 5, Section 5.2.6: Medical Supplies (DME) / Transcutaneous electrical nerve stimulators (TENS) CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 10.2, 160.7.1, 160.13, 160.27, 280.13. Ohio Administrative Code 4761:1-3- 02 Ohio Administrative Code 5160-10-15, Transcutaneous electrical nerve stimulators (TENS). Ohio Administrative Code 4752:02(B)(1) 201 Kentucky Administrative Regulations 2:350 , Home medical equipment service providers. Milliman Care Guidelines St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 04/30/2014Certificate of Medical Necessity required; Reimbursable rental period clarified; Reimbursement for purchase will subtract any rental payments; Documentation of rental required for new members; Appeals addressed; correct modifiers required. 10/31/2013 OAC Rule renumbered from 5101:3-10-15, per Legislative Service Commission Guidelines. Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may b e subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2Payment Policy Subject: Sterilization Po l i c yCareSource provides coverage for sterilization when it meets the criteria for those services as outlined in this policy. The physician is responsible for obtaining the state-appropriate signed informed consent form from the member. De f i n i t i o n sSterilization , means any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing. (From 42 CFR 441.251) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization CareSource requires prior authorization for inpatient voluntary sterilization of eligible members . Covered sterilization services include: Management and evaluation (office) visits and consultations for the purpose of providing sterilization services;Health education and counseling visits for the purpose of providing sterilization services;Medical/surgical services/procedures provided in association with the provision of sterilization services;Laboratory tests and procedures provided in association with the provision of sterilization services;Drugs administered in accordance with sterilization services; andSupplies provided in accordance with the provision of sterilization services. Bill ing Providers are responsible for using the appropriate CPT codes on their invoices . Rei mbursement CareSource will reimburse Medicaid providers for sterilization services only if all the following requirements are met: The Member is at least 21 years of age at the time of the informed consent. The Member is mentally competent and not institutionalized. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may b e subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Sterilization is the result of a voluntary request for services by a Member legally capable of consenting to such a procedure. The Member is given a thorough explanation of the procedure. In instances where the individual is blind, deaf or otherwise handicapped or unable to understand the language of the consent, an interpreter must be provided for interpretation. Informed consent is obtained on the state-appropriate forms, which are located on the CareSource website under the Provider section and in the Supplements/ Forms section of the CareSource manual, with appropriate, legible signature(s) and submitted to our health plan with the claim. Informed consent is not obtained while the individual to be sterilized is in labor or childbirth seeking to obtain or obtaining an abortion, or under the influence of alcohol or other substances that affect the individuals state of awareness. The procedure is scheduled at least 30 days, but not more than 180 days, after the consent is signed. These requirements are applicable to all sterilizations when the primary intent of the sterilizing procedure is fertility control. Re l a t e d Po l i c ies & Re f e r e n c e s OAC 5160-21, Medicaid covered reproductive health services, preconception care services . 907 KAR 1:054. Primary care center and federally-qualified health center services KAR 3:005 Section 4-10 Physician Services St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-21, per Legislative Service Commission Guidelines. 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 Payment Policy Subject: Occupational, Physical, & Speech Therapy Po l i c yCareSource will reimburse physicians or skilled therapists for occupational, physical, and speech therapy within the limits of this policy. De f i n i t i o n sOccupational therapy is the evaluation and treatment of patients whose function is impaired by developmental deficiencies, physical injury or illness. The treatment approach used depends on the disorder or impairment, and may include therapy based on engagement in meaningful activities of daily life (as self-care skills, education, work, or social interaction) especially to enable or encourage participation in such activities despite impairments or limitations in physical or mental functioning. (from Merriam-Webster.com Medical Dictionary) Physical therapy is the evaluation and treatment of patients using therapeutic exercise, physical modalities, assistive devices, and patient education and training for the preservation, enhancement, or restoration of movement and physical function impaired or threatened by disability, injury, or disease. (from Merriam-Webster.com Medical Dictionary) Speech therapy is the treatment of speech and communication disorders. The treatment approach used depends on the disorder and may include physical exercises to strengthen the muscles used in speech (oral-motor work), speech drills to improve clarity, or sound production practice to improve articulation. Speech therapy is aimed to help a person with a speech or language disorder or problem to restore basic speech skills. (from MedicineNet.com) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization Prior authorization is required when the dates of service exceed the limits outlined in this policy. Coverage Limits Skilled therapy services are allowable for reimbursement only if an authorized prescriber prescribes therapies for a reasonable amount and frequency. Please refer to the CareSource Benefit Grid for the allowable services and number of covered visits for therapy services. Additional therapy services may be requested; prior authorization is required for those. 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 Modifiers The following modifiers must be used when submitting claims for therapy services. Appropriate supporting documentation is also required. GN : Services delivered under an outpatient speech language pathology plan of care; GO : Services delivered under an outpatient occupational therapy plan of care GP: Services delivered under an outpatient physical therapy plan of care Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-34, Skilled Therapies in Non-Institutional Settings , Speech Therapy 907 KAR 3.005 Section 6.3 Physicians services / Therapy Limits St a t e Ex c e p t i o n s NONE Do c u m e n t Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-34, per Legislative Service Commission Guidelines. Archived
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