ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Stat ement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MC Oclinical policy 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 l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for t he service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controll ing document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 6 F. Related Policies/Rules ………………………………………………………………………………………….. 6 G. Review/Revision History ……………………………………………………………………………………….. 6 H. References …………………………………………………………………………………………………………. 7 Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.2 A. Subject Medical Record Documentation Standards for Practitioners B. Background Medical record documentation is a fundamental element required to support medical necessity and is the foundation for coding and billing. Documentation relays important information such as, but not limited to, assessments completed, services provided, coordination of services, timeliness of care, plan of treatment, rationale for orders, health risk factors, member s progress, and response to treatment. C. Definitions A Valid Signature for Services Provided or Ordered-o May be handwritten or electronic : CMS permits stamped signatures if you have a physical disability and can prove to a CMS contractor you are not able to sign due to that disability , and o Is legible or can be validated by comparing to a signature log or attestation statement . Certificate of Medical Necessity (CMN) – A written statement by a practitioner attesting that a particular item or service is medically necessary for an individual . D. Policy I. Medical documentation A. General requirements 1. Each member has thei r own medical record . 2. Entries are legible . 3. Each page of the record includes the members name and date of service. 4. Entries include: a. Date of service, and b. Signature, date, and credentials of practitioner . 5. Documentation indicates that the services(s) billed we re the services provided. a. If CPT is based on a timed service, the total number of timed minutes and/or start and stop time with CPT codes/type of treatment is documented. b. If CPT is based on a group of members, the following is included: 01. Documentation to support that the member was present at each session. If member is not present for the duration of the visit, document start and stop time for the member. 02. Relationships/credentials of individuals present at each session. 03. Number of participants in group therapy/treatment . c. CPT/ modifiers /p lace o f service codes are appropriate for service and provider . d. Note reflect s the location of service. Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.3 6. Documentation reflect s medical necessity for payment of services provided and utilization of resources as it relates to the service provided and the needs/des ires of the member. 7. Documentation includes a problem list that includes significant illness or medical and behavioral conditions found in history or previous encounters. 8. When making changes in paper medical record: a. Change is clearly visible, b. White out is not utilized, and c. A single line is through an entry labeled with error, initialed, and dated. 9. When making changes in electronic medical records: a. Amendment, correction, or delayed entry is identified, and b. A reliable way to identify the original content, the modified content, and the date and person modifying the record is provided. 10. When documentation is over multiple pages: a. Additional pages from a continuation of a note are clearly identified; and b. Continuous pages contain: 01. Member name , 02. Date of service, and 03. Page number . 11. Content of documentation show s the specific needs of the member for each encounter. Duplication of another note is not acceptable. 12. Best practice standards require documentation to be written within 24 hours of the clinical or therapeutic activity and signed and dated within 14 days . B. Evaluation and management documentation 1. Per CPT guidelines, documentation support s the specific requirements based on the level of visit billed. 2. History documentation includes: a. Chief complaint , reason for the visit , b. History of present illness (HPI) , c. Medical history , d. Review of systems (ROS) to identify signs and/or symptoms; and e. Past family and social history (PFSH) . 3. Examination documentation includes: a. Constitutional includ ing vital signs and general appearance, and b. Up to 11 organ systems/body areas depending upon the level of the examination performed and coded. 4. Complexity documentation includes: a. Diagnoses and treatment options , b. Any labs , radiology or other diagnostic tests ordered/results reviewed, c. Any counseling/coordination of care, which can include time spent face to face, and d. Assessment and medical plan of care details . C. Consents 1. Are maintained in the medical record. a. Consent includes: Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.4 01. Consent to treatment, refusal to consent, or withdrawal of consent , and/or 02. Authorization for release of information, and 03. Signature and date. D. Referral Documentation 1. Supports rationale for referral that includes who and what specialty member is referred to , and 2. Demonstrates evidence of : a. Coordination of referrals to specialty practitioners , and b. Physician review of or documentation of collaboration notes . E. Laboratory Testing Documentation (i.e., labs, x-rays, biopsies) : 1. Documentation s upports rationale for test , 2. An order for the test is present , 3. How test results will guide treatment plan is evident , 4. Evidence of physician review of results , and 5. Evidence of a ppropriate timely f ollow up on test results with member . F. Preventative Care Documentation, when appropriate: 1. Records include: a. An age-appropriate immunization record, b. Evidence that preventative screenings/services are offered, c. Risk assessments are completed as appropriate ( i.e., substance use, suicide , depression) , and d. Cr isis/safety plan as appropriate . II. Durable Medical Equipment Prosthetics Orthotics and Supplies Documentation Requirements A. Detailed Written Order and Documentation includes: 1. The members name, 2. Item of DME ordered (i.e., written description, HCPCS Code, brand name, model number ), 3. Prescribing practitioners National Provider Identifier (NPI) , 4. Signature of the ordering practitioner , 5. Date of the order , 6. If order is for a supply: a. Frequency of use, b. Quantity to be dispensed. 7. Duration of use , 8. Certificate of Medical Necessity (CMN), if required. a. If a CMN is not required, a prescription with diagnoses is included, 9. Information that demonstrates that the item is m edically necessary, 10. Any changes in the members treatment plan or needs , and 11. Proof of delivery (see II. D.). B. Refill Documentation Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.5 1. Documentation of a request for refill must be either a written document received from the member or a contemporaneous written record of a phone conversation/contact between the supplier and the member. 2. The refill request must occur and be documented before shipment. 3. A retrospective attestation statement by the supplier or member is not sufficien t. 4. The refill record must include: a. Members name or authorized representative, if different from the member; b. A description of each item that is being requested; and c. Date of the refill request. d. For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the member still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date. C. Verbal Orders 1. When services are provided on the basis of a physicians verbal orders, a nurse, or other qualified practitioner responsible for furnishing or supervising the ordered services must document the orders in the patients clinical record, and sign, date, and time the orders. 2. Verbal orders must be followed up with written orders. 3. Suppliers must maintain the written physicians order to support medical necessity in the event of a post-payment review, D. Proof of Delivery 1. Proof of Delivery includes the following: a. Member s name , b. Delivery a ddress, c. Item of DME ordered (i.e., written description, HCPCS Code, brand name, model number ), d. Quantities delivered, e. Date delivered, f. Member or designee receipt signature with date; and date of s ignature, g. Relationship of anyone signing the delivery ticket as a des ignee of the patient , h. There is a specific statement for the patient to initial stating that they attest that they are satisfied with the way the orthotic or prosthesis device(s) fit and that they were trained on the proper usage and care of the device(s) , and i. Signature of the supplier and date the item was provided to the member . 2. If shipped using a third-party, shipping tracking slip or returned postage-paid delivery invoice is acceptable. 3. CareSource is able to determine from the delivery documentation that the supplier properly coded the item(s) , that the item(s) delivered are the same Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 Effective Date: 09/01/2023 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.6 item(s) submitted to for reimbursement, and that the items are intended for and received by a specific member. E . Custom item documentation includes: 1. Evidence that the item was uniquely constructed or substantially modified for a specific member , 2. Description and orders of a physician, and 3. Evidence that item is so different from another item for the same purpose that the two items cannot be grouped together for pricing purposes. III. Falsified Documentation A. Providers are reminded that deliberate falsification of medical records is a felony offense and is viewed seriously when encountered. Examples of falsifying records include: 1. Creation of new records when records are requested, 2. Back-dating entries , 3. Post-dated entries , 4. Writing over, or 5. Adding to existing documentation (except where described in amendments, late entries, or corrections). B. Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determining payment of services billed. C. Appeal of claims denied based on an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record but were not submitted on the initial review. E. Conditions of Coverage N/A F. Related Policies/Rules Behavioral Health Record Documentation Standards for Practitioners G. Review/Revision History DATES ACTIONDate Issued 03/04/2020Date Revised 04/14/2021 04/13/2022 05/25/2022 05/24/2023 Removed BH Documentation . Updated references. No changes; Updated references Per SIU added Refill Documentation and Verbal Orders to section II Added sec.I.A.12 for completion and signature. Updated references , Approved at Committee . Date Effective 09/01/2023 Medical Record Documentation Standards for Practitioners-OH-MCD-AD-0753 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.7 Date Archived H. References 1. Centers for Medicare & Medicaid Services. (1997). Documentation Guidelines for Evaluation and Management Services. Retrieved May 8, 2023 from www.cms.gov. 2. Centers for Medicare & Medicaid Services. (2020, July 15). Documentation Matters Toolkit . Retrieved May 8, 2023 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2015, December). Electronic Health Records Provider. Retrieved May 8, 2023 from www.cms.gov . 4. Centers for Medicare & Medicaid Services. (2012, December 7). Pub 10-08 Medicare Program Integrity Transmittal 442. Retrieved May 8, 2023 from www.cms.gov. 5. Centers for Medicare & Medicaid Services. (2017, August). Evaluation and Ma nagement Services. Medicare Learning Network ICN 006764. Retrieved May 8, 2023 from www.cms.gov. 6. Centers for Medicare & Medicaid Services. (2018, May). Complying with Medicare Signature Requirements Medicare Learning Network ICN 905364. Retrieved May 8, 2023 from www.cms.gov. 7. Centers for Medicare & Medicaid Services. (2020, April 6). Local Determination Article: Standard Documentation Requirement for All Claims Submitted to DME MACs (A55426). Retrieved May 8, 2023 from www.cms.gov . 8. Ohio Administrative Code. (2019, October 31). 5122-27-04 Progress notes. Retrieved May 8, 2023 from www. codes.ohio.gov. 9. United States Code of Regulations. (2019, November 8). 410.38 Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions. Retrieved May 8, 2023 from www. ecfr.gov. 10. United States Code of Regulations. (1993, June 30). 414.224 Customized items . Retrieved May 8, 2023 from www. ecfr.gov.
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Diabetes Self-Management Training-OH MCD-AD-1109 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limita tions that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditio ns of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Diabetes Self-Management Training-OH MCD-AD-1109Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectDiabetes Self-Management Training B. Background37.3 million people or 11.3% of the population in the United States have diabetes (DM). This does not include the estimated 8.5 million adults aged 18 years or older who are considered undiagnosed. Approximately 5 %-10% of individuals with diabetes have Type 1, while Type 2 accounts for the remaining 90 %-95% of cases. According to the Centers for Disease Controls (CDCs) National Diabetes Statistic Report , both Type 1 and Type 2 diabetes in children and adolescents has significa ntly increased . Patients with diabetes require close medical monitor ing . When blood glucose levels arepoorly controlled, patients are at risk of complications, including heart disease, stroke, peripheral vascular disease, retinal damage, kidney disease, impotence, and nerve damage.The American Diabetes Association (ADA) r ecommends that all individuals with diabetesreceive di abetes self-management training . The program should include individualized instruction on healthy eating habits , physical activity, optimizing metabolic control , and preventing complications. Recent cl inical trials have shown a small , but statistically significant reduction in patients A1C levels when receiving dia betes self-management training. C. Definitions Diabetes An abnormal glucose metabolism condition diagnosed using the following criteria: o A fasting blood sugar greater than or equal to 126 mg/dL on two different occasions , o A 2 hour post-glucose challenge greater than or equal to 200 mg/dL on two different occasions , or o A random glucose test over 200 mg/dL for a person with symptom atic hyperglycemia . Diabetes Self-Management Training (DSMT) A multidisciplinary educational program led by qualified provider s with the goal of achieving greater self – management of the disease process , including the self-administration of injectable medication . Medical Nutrition Therapy Nutritional, diagnostic, therapeutic , and counseling services on diabetic or renal disease management provided by a registered dietitian or nutrition al professional for the purpose of managing diabetes or renal disease. National Diabetes Prevention Program (NDPP) A partnership of public and private organizations bringing evidence-based lifestyle support program s to ass ist at – risk individuals from developing type 2 diabetes. Diabetes Self-Management Training-OH MCD-AD-1109Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 D. PolicyI. Diabetes Self-Management Training (DSM T) is considered medical ly necessary and covered based on the following criteria : A. An individual must 1. have a current diabetes diagnosis 2. not previously received DSMT 3. receive t raining in a setting other than an inpatient hospital or an emergency department B. Program components include the following core content : 1. diabetes pathophysiology and treatment options 2. healthy eating 3. physical activity 4. medication usage 5. monitoring and using patient health data 6. preventing, detecting, and treating acute and chronic complications 7. health y coping with psychosocial issues and concerns 8. problem solving C. A physician signed attestation is required in the members plan of care . The attest ation must include the specific medical condition(s) supporting DSMT and confi rmation of physician-management and training of the diabetic condition . D. Any of the following providers may render or supervise a DSMT service: physician, physician assistant, advanced practice registered nurse, registered nurse , registered dietitian nutritionist, or pharmacist. E. Training is furnished within a continuous 12-month period and consists of initial training and follow-up training. 1. Training is delivered in half-hour increments. 2. Members may receive up to 10 hours /20 un its of initial training in a group setting of 2 to 20 individuals. a. One hour of individual training may be given to assess the members training needs. b. Individualized t raining may occur when there is no group sess ion available within 2 months of the training being ordered, or the physician determines that the member has special needs , which would hinder effective participation in group training . 3. Follow-up training may occur after completi ng 10 hours of initial training over 12 months . a. Follow-up sessions are limited to two hours of any combination of individual or group training . b. The physician must document in the members medical re cord the specific medical condition addressed by follow-up training . II. National Diabetes Prevention Program (NDPP) is medically necessary and covered under the following criteria : A. A member is 1. At least 18 years of age Diabetes Self-Management Training-OH MCD-AD-1109Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 2. Overweight3. Not currently pregnant 4. Not diagnosed with type 1 or type 2 diabetes 5. At least one of the following is met : Is diagnosed with prediabetes Has a history of gestational diabetes Had a high-risk result on a prediabetes test B. Any of the following providers may render or supervise a NDPP service: physician, physician assistant , or advanced practice registered nurse. III. Medical Nutrition Therapy (MNT) is a covered service and medically necessary with the following criteria : A. Therapy program is designed with 1. In-depth individualized nutrition assessment 2. Extensive follow-up to provide repeated reinforcement to facilitate behavior al change 3. Establishes goals, a care plan, and interventions 4. Multiple follow-up visits to promote individualized behavioral and lifestyle changes relat ed to nutrition deficiencies, and medical condition or disease 5. Service is provided by a registered dietitian or a nutritional professional B. Length of MNT 1. Initial year: up to 3 hours of MNT may be reimbursed 2. Subsequent years: up to 2 hours of MNT may be reimbursed E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 04/28/2021 New policyDate Revised 02/09/2022 06/07 /2023Annual review. Updated references, statistics ,added MNT and NDPP criteria Annual review: Updated references & revised language ; Approved at Committee. Date Effective 09/01/2023 Date Archived H. References1. Definitions , 42 C.F.R. 410.130 (2021). 2. Diabetes Prevention and Self-Management Training, OHIO ADMIN . CODE 5160-8-53 (2022). Diabetes Self-Management Training-OH MCD-AD-1109Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.5 3. Diabetes Outpatient Self-Management Training . Centers for Medicare and MedicaidServices; 2001. NCD publication 100-3(40.1). Accessed May 3, 2023. www.cms.gov 4. Holt RIG, DeVries JH, Hess-Fischl A, et al. The management of type 1 diabetes in adults: a consensus report by the American Diabetes Associ ation (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia . 2021;64:2609-2652. doi: 10.1007/s00125-021-05568-3 5. Levitsky LL, Madhusmita M. Overview of the management of type 1 diabetes mellitus in children and adolescents. UpToDate . Updated January 5, 2023. Accessed May 3, 2023. www.uptodate.com 6. National Diabetes S tatistics Report . Centers for Disease Control and Prevention ; 2022 . Accessed May 3, 2023. www.cdc.gov 7. Outpatient Diabetes Self-Management Training and Diabe tes Outcome Measurements, 42 C.F.R. 410.140 -.46 (2021) . 8. Services Provide d By a Dietitian, OHIO ADMIN . CODE 5160-8-41 (202 1). 9. Weinstock RS. Management of blood glucose in adults with type 1 diabetes mellitus. UpToDate . Updated January 10, 2023. Accessed May 3, 2023. www.uptodate.com 10. Wexler DJ. Initial managemen t of hyperglycemia in adults with type 2 diabetes mellitus. UpToDate . Upda ted October 31, 2022. Accessed May 3, 2023. www.uptodate.com
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Three-Day Window Payment-OH MCD-AD-1001 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the E vidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Cove rage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limita tions that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. 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 Three-Day Window Payment-OH MCD-AD-1001Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.2 A. SubjectThree-day Window Payment B. BackgroundThe Ohio Administrative Code 5160-2-02( G) states that outpatient services provided within three calendar days prior to the date of admission in hospitals will be covered as inpatient services. This includes emergency room and observation services. C. Definitions Behavioral Health (BH) Services Include m ent al health and substance use disorder services. Hospitals that provide outpatient BH services must meet the Medicare conditions of participation, have accreditation by a national accrediting body, and have accreditation for the BH services that they provide . Inpatient Member who is admitted to a hospital based upon the written orders of a practitioner of physician services and whose inpatient stay continues beyond midnight of the day of admission. Inpatient Services Services which are ordinarily furnished in a hospital for the care and treatment of patients, including all covered services provided to members during the course of their inpatient hospital stay except for direct-care services provided by a practitioner o f physician services . Emergency room (ER) services are covered as an inpatient service when member is admitted from the ER. Outpatient Services Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the directi on of a practitioner of physician services which are furnished to an outpatient by a hospital. Outpatient services do not include direct-care services provided by a practitioner of physician services . Practitioner of Physician Services Include physician s, podiatrists, dentists, clinical nurse specialists, certified nurse-midwives, certified nurse practitioners, or physician assistants. D. PolicyI. Three-Day Payment Rule A. Claims submitted for outpatient services (including emergency room and observation services) that were provided within the three calendar days prior to the inpatient admission for the same member for the same hospital or wholly owned hospital system may be denied if the services are not combined into one claim. 1. The outpatient services and inpatient admission must be submitted on one inpatient claim. 2. The dates of the claims should begin with the outpatient service through the inpatient discharge. B. If the hosp ital submits the outpatient claim separately before the inpatient claim, the inpatient claim may be deemed as a duplicate claim and may be denied payment. The inpatient hospital will need to work with the outpatient hospital to pay the outpatient visit and to have the outpatient hospital void its paid claim for Three-Day Window Payment-OH MCD-AD-1001Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.3 the outpatient service. The inpatient hospital should then resubmit the claim so that it includes inpatient and outpatient services.C. If both the inpatient and outpatient services are initia lly paid for the same hospital or wholly owned hospital system, retroactive recovery may be initiated for the outpatient services inclusive by the three-day window. D. Physician practices and entities should use modifier PD (diagnostic or related non-diagnos tic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within three days or one day) to identify services subject to the payment window. E. ICD-10 diagnosis code Z01.81X should be used to indicate an enc ounter for preprocedural examinations to flag the outpatient claim as related to an inpatient service/procedure. F. To avoid duplication for nursing facility residents: 1. The outpatient service claim should note the entire inpatient stay along with the dates o f the outpatient services; and 2. The nursing facility claim should note the room and board days with the hospital leave days. II. The following exceptions apply:A. When a members Medicaid coverage changes payer sources (fee-for-service or managed care) on t he date of the inpatient admission, all outpatient services provided within three calendar days prior to the inpatient admission will be submitted to the payer source responsible for those dates of service. The inpatient claim will be submitted to the paye r source in effect on the date of admission. B. When a member is admitted under the inpatient hospital service program benefit plan, all outpatient services provided by either the same hospital or different hospital, prior to the inpatient admission will not be included on the inpatient claim, with the exception of any outpatient services provided on the date of admission which will be included on the inpatient hospital claim if provided at the same facility as the inpatient admission. C. Outpatient hospital beha vioral health services provided in the outpatient hospital setting w ithin three calendar days prior to the inpatient admission are exempt from the three-day window policy . E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATES ACTIONDate Issued 10/30/2019 Changed from PY. Added to the same hospital in I.A.Three-Day Window Payment-OH MCD-AD-1001Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.4 Date Revised 02/04/202205/10/2023 Annual review. Editorial changes Annual review: added I.C, updated references, definitions. Approved at Committee. Date Effective 09/01/2023 Date Archived H. References1. Ohio Department of Medicaid. Office of Policy: Hospital Billing Guidelines . Revised July 26, 2021. Accessed April 20, 2023. www. medicaid.ohio.gov. 2. General Provisions: Hospital Services, OHIO ADMIN. CODE 5160-2-02 (2022).
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Provider Home Visits-OH MCD-AD-1165 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clini cal 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 limited to, those health ca re 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, 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 necessar y services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do 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 in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Pro vid er Ho me V isits-OH MCD-AD-1165Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.A. SubjectProvider Home Visits B. BackgroundProvider home visits are medical care visits rendered in the home setting to an individual f or the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is def ined as the individual’s place of residence, including private residence/domicile, assisted living f acility, group home, custodial care f acility, long-term care f acility, or skilled nursing f acility. C. Def initions Home An individual’s place of residence, including private residence/domicile, assisted living f acility, group homes, custodial care f acility, long-term care f acility, or skilled nursing f acility. Participating Provider A provider that is contracted with CareSource to service members. Place of Service ( POS) A two-digit code that indicates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner, or a physician assistant. Non-Participating Provider A provider that is not contracted with C areSource to service members. Services Services that occur in the members place of residence that normally would be perf ormed in an of fice/outpatient setting, such as evaluation and management (E&M) visits, wound care, podiatry care, eye care, etc. D. PolicyI. CareSource reimburses participati ng or non-participating providers f or services perf ormed in a members place of residence that usually can be perf ormed at an of f ice visit. A. CareSource will reimburse providers according to the Medicaid f ee schedule. B. Durable medical equipment (DME) services in the place of residence are subject to medical necessity review and should be provided by in network (participating) provider . C. Ancillary services such as labs and x-ray services in the place of residence are subject to medical necessity rev iew and should be provided by in network (participating) provider. II. Claim submission must include the appropriate Current Procedural Terminology (CPT) codes along with any applicable modif ier with the appropriate place of service (POS) code.A. Place of s ervice (POS) f or provider services in the members place of residence should include one of the f ollowing: 1. POS 12 Home 2. POS 13 Assisted Living 3. POS 14 Group Home Pro vid er Ho me V isits-OH MCD-AD-1165Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.4. POS 31 Skilled Nursing Facility (SNF)5. POS 32 Long-term Facility 6. POS 33 Custodial Care/Rest Home III. CareSource reimburses f or services that occur in the members place of residence that normally would be perf ormed in an of f ice/outpatien t setting, such as E&M visits,wound care, podiatry care, eye care, etc. A. CareSource members do not need to be conf ined to a place of residence to receive services provided by a provider. B. The CareSource members medical record must document the me dical necessity of the visit made in place of residence. C. A visit cannot be billed by a provider unless the provider was actually present in the members place of residence. IV. Services perf ormed in the members place of residence may be subject to r eview.CareSource may request documentation of services performed. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. If medical necessity is not conf irmed based on the documentation submitted, rec oupment may occur. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 01/01/2019 New policyDate Revised 02/16/2022 05/10/2023Converted f rom PY-0444 to AD-1165. Change d physician to provider to more inclusive. Approved at PGC. Annual review. Update ref erence. Approved at Committee. Date Effective 09/01/2023 Date Archived H. Ref erences1. Places of service codes f or professional claims. Centers f or Medicare & Medicaid Services. September 2021. Accessed March 27, 2023. www.cms.gov .
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Pharmacogenomics-CYP Gene Testing-OH MCD-AD-1342 08/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization a nd technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessa ry 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 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 a ny Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do 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 in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. 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 ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Pharmacogenomics-CYP Gene Testing-OH MCD-AD-1342 Effective Dat e: 08/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectPharmacogenomic s CYP Gene Testing B. BackgroundPharmacogenomics is an area of precision medicine that provides information about an individua ls genes, influencing therapeutic strategies and assessing the likelihood of benefit or toxicity to a given drug. This form of medication management has been eva luated in a variety of clinical scenarios . As pharmacogenomics expands and laboratories offering testing proliferate, the value of a given test in terms of patient benefit may be obscured by multiple contributing factors , including exaggerated public marke ting claims, inconsistencies in test standardization, continued patient variation in response to prescribed medication, incomplete knowledge of drug metabolism, and limitations in regulatory oversight. To manage these challenges, the clinical validity and clinical utility of a specific gene or biomarker with a specific drug target should demonstrate improvement in patient outcomes . C. Definitions Clinical Utility – The likelihood that a test will, by prompting an intervention, result in an improved health out come . Clinical Validity – The predictive value of a test for a given clinical outcome . Unbundling – HCPCS/CPT codes should be reported only if all services described by the code are performed. Multiple codes should not be reported if a single code exists that describes the services performed. The codes include all services usually performed as part of the procedure as a standard of medical/ surgical practice and should not be separately report ed s imply because codes exist for the se rvices. D. PolicyI. General Guidelines A. Biomarker testing with uncertain clinical significance in MCG will be considered experimental and investigational. B. Unbundling of codes in a panel is an incorrect billing practice and will result in payment recovery. C. Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, injury, illness, or other health condition which CareSource determines in its sole discretion to be experimental or investigational is not covered by CareSource. II. Based on review of existing evidence, there are currently no clinical indications for the high-volume tests below , and t he current role remains uncertain. Therefore,CareSource considers these requests experimental and investigational. This is not an all-inclusive list. CPT Codes Testing Examples 81225 – CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) Genecept Assay, GeneSight, Pharmacogenomics-CYP Gene Testing-OH MCD-AD-1342 Effective Dat e: 08/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.81226 – CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g.,drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) OneOme RightMed, PGxOnePlus, CQuentia, IDGenetix, PROOVE, GARSPREDX, SureGene, PharmacoDx 81227 – CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) 81230 – CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (e.g., drug metabolism), gene analysis, common variant(s) (e.g., *2, *22) 81291 – MTHFR (5, 10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C) 0345U Psychiatry (e.g., depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 III. CareSource applies coding edits to medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. Proper billing and submission guidelines must be followed, including the following: A. Use of industry standard, compliant co des on all claims submissions, including CPT codes and/or HCPCS codes. B. Services considered to be mutually exclusive, incidental to or integral to the primary service rendered are not allowed additional payment. C. Propri etary panel testing requires evidence-based documentation of medical necessity. D. Submission of the most accurate and appropriate CPT/HCPCS code(s) for the product or service being provided, including coding to the highest level of specificity. IV . CareSo urce consider s the followin g not medically necessary (not an all-inclusive list) :A. Pharmacogen omic testing or screening in the general population. B. A non-covered test billed by using unlisted procedure codes. C. The use of multi-gene panels for genetic polym orphisms, including, but not limited to, pain management, cardiovascular drugs, anthracyclines, or polypharmacy for evaluating drug-metabolizer status (i.e., GeneSight ADHD, SureGene Test, PharmacoDx). D. Tests considered screening in the absence of clinical signs /symptoms of disease. E. Tests that do not confirm new data for decision making but confirm a known diagnosis or information. F. Tests to determine risk for developing a disease or condition. G. Tests without diagnosis-specific indications. H. Tests performed to ensure a tissue specimen matches an individual. E. Conditions of CoverageCodes referenced in this policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. F. Related Policies/RulesOverpayment Recovery Experimental and Investigational Items and Services Pharmacogenomics-CYP Gene Testing-OH MCD-AD-1342 Effective Dat e: 08/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.G. Review/Revision HistoryDATE ACTIONDate Issued 04/26/20 23 Approved at Committee.Date Revised Date Effective 08/01/2023 Date Archived H. References1. American Academy of Child & Adolescent Psychiatry. Pharmacogenetic Testing. (2019, December). Retrieved February 14, 2023 from www.aacap.org . 2. American Health Information Management Association. Documenting Pharmacogenomic Testing with CPT Codes. Retrieved February 23, 2023 from www.ahima.org . 3. Centers for Disease Control and Prevention (CDC). Clinical Laboratory Improvement Amendments (CLIA). (2022, November 14). Retrieved February 27, 2023 from www.cdc.gov . 4. Centers for Medicaid and Medicare Services. National Correct Coding Initiative Policy Manual For Medicaid Services . (2021, January 1). Retrieved February 23, 2023 from www.medicaid.gov. 5. Food and Drug Administration (FDA). List of Cleared or Approved Companion Diagnostic Devices (In Vitro and Imagin g Tools). (2023, February 14). Retrieved February 23, 2023 from www.fda.gov. 6. Hayes Clinical Utility Evaluation: APOE Genetic Testing for Alzheimer Disease. (2022, March 18). Retrieved March 16, 2023 from www.hayesinc.com. 7. Hayes Clinical Utility Evaluation : MTHRF Genetic Testing for Severe MTHFR Enzyme Deficiency. (2021, May 23). Retrieved March 16, 2023 from www.hayesinc.com. 8. Hayes Clinical Utility Evaluation: MTHRF Genetic Testing in Common Clinical Conditions. (2021, May 23). Retrieved March 16, 2023 fro m www.hayesinc.com . 9. Hayes Clinical Utility Evaluation: MTHRF Pharmacogenetic Genotyping for Altering Drug Treatment. ( 2021, May 23). Retrieved March 16, 2023 from www.hayesinc.com. 10. Hayes Clinical Utility Evaluation: Pharmacogenetic and Pharmacogenomic Test ing for Opioid Treatment for Pain in Adults. (2022, October 26). Retrieved March 16, 2023 from www.hayesinc.com . 11. Hayes Clinical Utility Evaluation: Pharmacogenetic and Pharmacogenomic Testing to Improve Outcomes Related to Opioid Use Disorder. (2022, Janu ary 27). Retrieved March 16, 2023 from www.hayesinc.com. 12. Hayes Clinical Utility Evaluation: Pharmacogenomic Testing for Attention – Deficit/Hyperactivity Disorder. (2022, January 12). Retrieved March 16, 2023 from www.hayesinc.com. 13. Hayes Clinical Utility Eva luation: Pharmacogenomic Testing of Selected Mental Health Conditions. (2021, December 6). Retrieved March 16, 2023 from www.hayesinc.com . Pharmacogenomics-CYP Gene Testing-OH MCD-AD-1342 Effective Dat e: 08/01/2023 The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.14. Hayes Molecular Test Assessment: GeneSight Psychotropic (Assurex Health Inc./Myriad Neuros cience). ( 2021, September 10). Retrieved March 16, 2023 from www.hayesinc.com. 15. Hayes Precision Medicine Research Brief: Genecept Assay (Genomind). (2016, April 7). Retrieved March 16, 2023 from www.hayesinc.com. 16. Hayes Precision Medicine Research Brief: PGxOne Plus (Admera Health). (2017, March 23). Retrieved March 16, 2023 from www.hayesinc.com. 17. Hayes Precision Medicine Research Brief: Proove Opioid Risk Test (Proove Biosciences). (2016, July 28). Retrieved March 16, 2023 from www.hayesinc.com . 18. Hicks J, et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline for CYP2D6 and CYP2C19 gen otypes and dosing of selective serotonin reuptake inhibitors. Clin Pharmacol Ther . 2015; 98:127. 19. Kohlmann W, Slavotinek A. Genetic Testing. (2023, February). Retrieved March 16, 2023 from www.uptodate.com. 20. MCG. 27 th Edition. Pharmacogenetics . Retrieved Mar ch 16, 2023 from www.careweb.careguidelines.com. 21. National Human Genome Research Institute. Deoxyribonucleic Acid (DNA) Fact Sheet. (2020, August 24). Retrieved February 14, 2023 from www.genome.gov . 22. National Institutes of Health, Library of Medicine. Phar macogenetic Tests. ( 2021, July 7). Retrieved February 14, 2023 from www.medlineplus.gov. 23. National Institute of Health. National Cancer Institute (NCI). NCI Dictionary of Genetics Terms. Retrieved February 20, 2023 from www.cancer.gov . 24. Ohio Administrative Code. Rule 5160-11-11. Laboratory services . Retrieved February 23, 2023 from w ww.codes.ohi o.gov . 25. Ohio Administrative Code. Rule 5160-26-05. Managed care: Provider network and contracting requirements . Retrieved February 23, 2023 from www.codes.ohio.gov. 26. Raby B. Personalized Medicine. (2023, February). Retrieved March 16, 2023 from www.uptodate.com. 27. Tantisira K, Weiss S. Overview of Pharmacogenomics. (2023, February). Retrieved March 16, 2023 from www.uptodate.com .
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Molecular Diagnostic Testing-OH MCD-AD-1049 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 l ocal 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prep ared by CareSource and its affiliates do 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 in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. According to the rules of Ment al Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under t his policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Mo lecular Diag n o stic Testing-OH MCD-AD-1049Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.2 A. SubjectMolecular Diagnostics Testing B. BackgroundMolecular diagnostic testing (MDT), f ollowing a diagnosis or suspected diagnosis, can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. MDT utilizes a genetic amplif ication technique, polymerase chain reaction (PCR ), that uses 0.1 mg of DNA f rom a single cell to achieve shorter laboratory processing times f or results. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplif ied, is a prerequisite to a successf ul PCR amplif ication of DNA. All f acilities in the United States that perf orm laboratory testing on human specimens f or health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived testsinclude test systems that are cleared by the U.S. Food and Drug Administration (FDA) f or home use and those tests approved f or waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have low risk f or errone ous 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 perf orming CLIA-waived tests. C. Def initions Polymerase Chain Reaction (PCR) – A laboratory method used to look f or certain changes in a gene or chromosome, which may help f ind and diagnose a genetic condition or a disease. It may also be used to look at pieces of the DNA f rom certain bacteria, viruses, or other microorganisms to h elp diagnose an inf ection. D. PolicyI. CareSource considers conventional testing, such as rapid antigen direct tests, direct f luorescent antibody testing, and cultures as lower cost and should be utilized bef ore the higher cost molecular diagnostic testing (MDT) by PCR. II. Providers should utilize conventional testing first.A. If conventional testing is:1. Positive no f urther testing is medically necessary. 2. Negative if the members presenting symptoms support the diagnosis, then MDT by PCR testing is medically necessary to conf irm diagnosis. Examples of relevant diagnoses are, but not limited to, gastroenteritis, streptococcal pharyngitis, acute hepatitis, Shigellosis. B. Diseases complicating pregnancy are an exception to the above. III. Ca reSource may request documentation to support medical necessity.Mo lecular Diag n o stic Testing-OH MCD-AD-1049Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.3 E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/25/2022 New policyDate Revised 05/10/2023 Annual review. No changes. Approved at Committee. Date Effective 09/01/2023 Date Archived H. Ref erences1. National Cancer Institute at the National Institutes of Health. Polymerase chain reaction. Accessed May 01, 2023 f rom www.cancer.gov.
ADMINISTRATI VE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Claims Editing and Review-OH MCD-AD-1175 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and t echnology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or 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 part, or significant pain and discomfort. The se 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 E vidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do 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 in the Adminis trative Policy Statement. If there is a conflict between the Administrative Policy Statement 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 determina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Claims Ed itin g an d Review-OH MCD-AD-1175Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.2 A. SubjectClaims Editing and Review B. BackgroundAll health care providers are expected to utilize the same standard coding sets and rules to codif y the services provided during encounters with patients. This codification is used to bill insurance carriers f or reimbursement, known as a claim. In the codif ication process, there are rules that must be f ollowed to appropriately codify the encounter into a claim, which is then sent to the insurance carrier f or reimbursement. All claims submitted to CareSource f or reimbursement consideration are subject to claims editing. This ensures that appropriate coding sets are used and, rules are appliedin billing by the provider. This also ensures that appropriate reimbursement is made to the provider f or services rendered. This policy aims to outline the source of edits and rules CareSource ut ilizes f or claims editing and review.C. Def initionsNA D. PolicyI. To ensure appropriate and timely reimbursement f or services rendered to enrollees, CareSource utilizes automated claims editing to enf orce appropriate coding and billing practices by providers when submitting claims. A. Appropriate coding and billing of c laims allows f or the accurate adjudication and reimbursement f or services rendered to a CareSource enrollee. B. All claims submitted to CareSource are subject to this editing. II. CareSource models edits and rules onA. Industry standard coding rules, manuals, guidelines, directives, and relevant state and f ederal regulations f or claims editing B. Resources used to source these coding and billing standards include, but are not limited to, the f ollowing list: 1. X12 or ASC X12 – The Accredited Standards Committee (ASC) X12 – claim submission rules and edits applied to inbound electronic claims – www.x12.org 2. WEDI SNIP or SNIP – Workgroups f or Electronic Data Interchange Strategic National Implementation Process claim submission rules and edits applied to inbound electronic claims related to HIPAA compliant f ile exchanges 3. Current Procedural Terminology (CPT) Manual f rom AMA (American Medical Association) 4. HCPCS – Healthcare Common procedure Coding System Level II coding guidelines 5. UB Editor – Manual f rom the American Hospital Association (AHA) Coding directives Claims Ed itin g an d Review-OH MCD-AD-1175Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.3 6. ICD-10-CM manual7. Center f or Medicare and Medica id (CMS) rules and notif ications a. CMS Billing rules and instructions (www.cms.gov) b. Medicar e NCCI Instructions/ Manual c. Medicaid NCCI Instructions/ Manual d. NCD & LCD Bulletins e. National Physician Fee Schedule (NPFS) instructions 8. Food and Drug Administration (FDA) guidelines (www.fda.gov) 9. Center of Disease Control (CDC) guidelines (ww w.cdc.gov) 10. U.S. Preventive Services Task Force (www.uspreventiveservicestaskf orce.org) 11. State Agencies (as appropriate f or enrollees coverage) a. Arkansas Department of Human Services (humanservices.arkansas.gov) b. Georgia Department of Community Health (dch.georgia.gov) c. Georgia Of f ice of Insurance and Saf ety (oci.georgia.gov) d. Indiana Department of Insurance (in.gov/idoi) e. Iowa Insurance Division (iid.iowa.gov) f. Kentucky Department of Insurance (insurance.ky.gov) g. North Carolina Department of Insurance (ncdoi.gov ) h. Ohio Department of Medicaid (medicaid.ohio.gov) i. Ohi o Department of Insurance (insurance.ohio.gov) j. West Virginia Of f ices of the Insurance Commissioner (wvinsurance.gov) 12. State and National recognized Medical Association and Specialt y Experts including, but not limited to: a. American College of Radiology b. American Academy of Pediatrics c. Ohio State Chiropractic Association d. American College of Obstetricians and Gynecologists 13. CareSources Website (www.caresource.com) a. Polic ies b. Provider Manuals c. Provider Notif ications III. CareSource strives to keep our editing current with all changes as they occur; as such, edits may be added, modif ied, or removed based on changes, clarif ications ,and new directives received from these resources and any other resources that may become applicable. IV. CareSource sends providers the outcomes of the edits through the standard Explanation of Payment (EOP) process. Providers EOPs indicate the f ailures by the use of industry standard CARC and RARC coding system. The provider can obtainadditional inf ormation by reviewing CareSource’s Provider Portal and/or the CareSource Provider Manual (www.CareSource.com).Claims Ed itin g an d Review-OH MCD-AD-1175Effective Dat e: 09/01/2023The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.4 V. Providers may f ile a dispute and provide additional inf ormation to support the providers position for reconsideration of reimbursement. Instruction to f ile a dispute related to a denial or rejection of a claim can be f ound at our website(www.CareSource.c om) ; please refer to the Provider Manual, under Claim Dispute Process. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 04/27/2022 Approved at PGC.Date Revised 05/10/2023 Annual review. Updated II. B. 11. Approved at Committee. Date Effective 09/01/2023 Date Archived H. Ref erencesNA
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 09/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by Ca reSource and its affiliates are derived from literature based on and supported by 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 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 suff er 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 l ocal area, are the lowest cost alternative, and ar e not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policie s and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do 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 in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitat ions that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 9 F. Related Policies/Rules ………………………………………………………………………………………….. 9 G. Review/Revision History ……………………………………………………………………………………….. 9 H. References …………………………………………………………………………………………………………. 9 Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.2A. Subject Behavioral Health Service Documentation StandardsB. BackgroundMedical record documentation is a fundamental element required to support medical necessity and is the foundation for coding and billing. Documentation relays important information such as , but not limited to , assessments completed, services provided, coordination of services, timeliness of care, plan of care/ treatment, rationale for orders, health risk factors, member s progress towards goals of the treatment plan, and response to treatment. C. Definitions Behavioral Health-Behavioral Health is used as an umbrella term that includes mental health & substance use disorder conditions and developmental disabilities/delays, such as Autism. General Supervision The supervisor must be available by telephone to provide assistance and direction if needed. Direct Supervision The supervisor must be immediately available and interruptible to provide assistance and direction throughout the performance of the procedure; however, he or she does not need to be present in the room when the procedure is performed. A Valid Signature for Services Provided or Ordered o May be handwritten or electronic; CMS permits stamped signatures if you have a physical disability and can prove to a CMS contractor that you are not able to sign due to that disability; and o Is legible or can be validated by comparing to a signature log or attestation statement. D. Policy I. General Service Documentation Standards A. General requirements 1. Each member must have thei r own medical record. 2. Documentation must be legible. 3. Each page of the record must include the members name , and date of service . 4. Multiple pages must be numbered. 5. Documentation must include: a. Diagnosis b. Signature, date, and credentials of practitioner . 6. Documentation must indicate that the services(s) billed we re the services provided. Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.3a. If service is based on a timed service, the total number of timed minutes and/or start and stop time with service codes/type of treatment is documented. b. If service is based on a group of members, the following is included: 01. Documentation to support that the member was present at each session. If member is not present for the duration of the session , document start and stop time for the member. 02. Relationships/ name/credentials of other professionals present at each session . 03. Number of participants in group therapy/treatment . c. Service Code/Modifiers codes are appropriate for service and provider . d. Documentation must reflect the location of service using the appropriate Place of Service Code and/or, if rendered via tele-health, the location of the member and the location of the provider, as well as the modality of tele-health used to render the servi ce. 7. Content of documentation must indicate the specific needs, intervention, and progress toward the goals of the treatment plan for each service rendered. Duplication of notes is not acceptable documentation practice. 8. Documentation must reflect medical necessity for payment of services provided and the specific needs/desires of the member that are reflected in the treatment plan . 9. Changes to documentation: a. Electronic Medical Record changes: 01. Amendment, correction, or delayed entry is identified; and 02. A reliable way to identify the original content, the modified content, and the date and person modifying the record is provided. b. Paper Medical Record changes: 01. Change is clearly visible; 02. White out is not utilized; and 03. A single line is through an entry labeled with error, initialed, and dated. B. Consents 1. Are maintained in the medical record. a. Consent includes: 01. Consent to treatment, refusal to consent, or withdrawal of consent ; and/or 02. Authorization for release of information; and 03. Signature and date. C. Referral Docum entation 1. Supports rationale for referral that includes who and what specialty member is referred to ; and 2. Demonstrates evidence of : a. Coordination of referrals to specialty practitioners ; and b. Physician review of or documentation of collaboration notes . D. Laboratory Testing Documentation: Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.41. Documentation s upports rationale for test ; 2. An order for the test is present ; 3. How test results will guide treatment plan is evident; 4. Evidence of physician review of results ; and 5. Evidence of a ppropriate timely f ollow up on test results with member . E. Preventive Care Documentation include the following when appropriate: 1. Evidence that preventive screenings/services were discussed, or referr al placed; 2. Risk assessments are completed (i.e. , substance use, suicide, depression); and 3. Cr isis/safety plan . II. Service Specific Documentation Expectations A. Diagnostic assessment documentation must include the following: 1. Presenting problem and/or History of Present Illness a. Current symptoms ; b. Changes in functional impairment or symptoms ; c. Onset of symptoms ; d. Circumstances leading to evaluation; 2. Evaluation of comorbid physical health concerns/needs; 3. Strengths-based assessment of member , where applicable; 4. Identification of natural, community, and professional supports , where applicable; 5. Evaluation of social determinant of health concerns/needs, where applicable; 6. Substance Use History; 7. Past psychiatric /behavioral health treatment , including past psychiatric medications ; 8. Medical history; 9. Past family and social history (PFSH); 10. Review of organ systems/body areas depending upon the level of the examination performed and coded, where applicable; 11. Current physical and behavioral health medications, including changes and prn medication utilization; 12. Allergies; 13. Standar dized assessment tools/diagnostic testing, results, and interpretation (i.e. , Clinical Institute Withdrawal Assessment f or Alcohol (CIWA), Clinical Opioid Withdrawal Scale (COWS), Autism Diagnostic Observation Schedule (ADOS), Patient Health Questionnaire (PHQ), Columbia Suicide Severity Rating Scale (CSSRS) or Vanderbilt Diagnostic Rating Scales), if pertinent ; 14. Psychiatric assessment and mental status exam that includes , but is not limited to, the following: a. Description of patients judgment and insight; b. Assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (i.e. , depression, anxiety, agitation) ; Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.5c. Constitutional including vital signs and general appearance; d. Attitudes and behavior described; e. Estimated intellectual and memory functioning and orientation; and 15. Summary, diagnosis, and plan. NOTE: Significant or abnormal findings need to be described in a narrative format. B. Treatment plan documentation must include all of the following: 1. Type, amount, frequency, and duration of any and all needed/known treatment services; 2. Provider of any and all needed/known treatment services; 3. Goals for any and all needed/known treatment services. Goals m ust be: a. Mutually agreed upon; b. Age-appropriate; c. Quantifiable with target dates; d. Measurable with criteria for continued stay; e. Directly related to the admission reason if applicable; and f. Relevant to the diagnostic assessment, testing, and/or screening; 4. Inte rventions to be used ; 5. Frequency of review of the treatment plan. Frequency of review must be appropriate for the identified needs of the member and progress towards the associated goals; 6. Documentation that the treatment plan has been reviewed with the patient and, as appropriate, with family members, parents, legal guardians, custodians, or significant others. NOTE: If the member is unable or refuses to participate in the treatment planning or services, document reason given. 7. Estimated length of stay and/or course of treatment for any and/all treatments ; 8. Criteria for discharge from treatment and completion of the treatment plan;9. Applied Behavior Analysis (ABA) treatment plans must : a. Show a clear connection between the results of the behavioral assessment to the member specific goals. The goals must focus on identified areas of specific behaviors or targeted deficits. The goals must include baseline data, measurement, and mastery criteria to address the core deficits of Autism Spectrum Disorder (ASD); and b. Be based on members other daily activities. C. Inpatient/Outpatient psychiatric progress note includes the following as applicable: 1. Per service code guidelines, documentation supports the specific requirements based on the level of service billed. 2. Daily psychiatric inpatient progress note includes the following as applicable: Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.6a. Summary of what has occurred since previous day and current symptoms; b. Review of response to medications/side effects and prn utilization c. Mental Status Exam, includes, but is not limited to: 01. Description of patients judgment and insight ; 02. Assessment of mental status including orientation to time, place, and person; recent and remote memory; and mood and affect (i.e. , depression, anxiety, agitation); 03. Constitutional including vital signs and general appearance; 04. Attitudes and behavior described; 05. Estimated intellectual and memory functioning and orientation; d. Rationale for changes in medications or other interventions is clearly documented ; and e. Reason for continued stay . 3. Outpatient psychiatric progress note includes: a. Symptoms since last visit and current symptoms ; b. Changes in f amily, social or medical history ; c. Mental Status Exam, include, but is not limited to: 01. Description of patients judgment and insight; 02. Assessment of mental status including orientation to time, place, and person; recen t and remote memory; and mood and affect (i.e. , depression, anxiety, agitation); 03. Constitutional including vital signs and general appearance; 04. Attitudes and behavior described; 05. Estimated intellectual and memory functioning and orientation; d. Rationale for changes in medications or other interventions is clearly documented. 4. Best practice standards require progress notes to be written within 24 hours of the clinical or therapeutic activity and signed and dated within 14 days. 5. Interactive Complexity documentation must include: a. Evidence of communication factors that complicate the delivery of a behavioral health service during the delivery of the service. This may include: 01. The need to manage maladaptive communication (related to, e.g., high anx iety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care; 02. Caregiver emotions or behaviors that interfere with implementation of the treatment plan; 03. Evidence or disclosure of a sentinel event and mandated report to a third party (e.g., abuse or neglect with report to state agency) with initiation of discussion of the sentinel event and/or report with patient and other visit participants; 04. Use of play equipment, physical devices, interp reter, or translator to overcome barriers to diagnostic or therapeutic interaction with a patient who is not fluent in the same language or who has not Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.7developed or lost expressive or receptive language skills to use or understand typical language. This does not include billing solely for the purpose of translation or interpretation services. b. Evidence of interactions with others or interventions to overcome communication factors that complicate the delivery of a behavioral service during the delivery of the services. This may include: 01. Interactions with individuals legally responsible for the care of a member, such as minors or adults with guardians; 02. Interactions with others involved with the care of a member during the service, such as adults accompanied by one or more participating family members or interpreter or language translator. This does not include billing solely for the purpose of translation or interpretation services; 03. Interactions other third parties, such as child welfare agencies, parole or probation officers, or schools. D. Discharge plan documentation must include the following: 1. A discharge planning evaluation including, but not limited to , assessment of the following: a. Treatment regimen was established; services including addressing rehabilitation needs; b. Connections were made with appropriate outpatient behavioral health resources, including community behavioral health resources; c. Scheduled follow-up appointments within 7 calendar days of discharge, and/or coordinating transportation to follow-up appointments ; d. Medication reconciliation occurred and prescriptions related to treatment regimen were available at discharge and /or e. Two weeks worth of medication was provided to the member at the time of discharge and/or f. Transportation to the pharmacy was scheduled; g. Availability of appropriate services , which would include services such as medical, meals, and household services; h. Need for and feasibility of specialized medical equipment, or permanent physical modifications to the home; i. Capacity for self-care, or alternatively to be cared for by others ; j. Criticality of the appropriate services; k. Readmission risk score or severity score; and l. Members access to appropriate services. 2. A provider should review social determinants of health (SDoH) when determining if a member is ready for discharge including, but not limited to: a. Cognitive status; b. Activity level and functional status; c. Current home and suitability for members condition (i.e. , drug free environment); d. Availability of appropriate family or community support; e. Ability to obtain medications and services; Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.8f. Ability to meet nutritional needs ; g. Potential barriers to care, such as homelessness and telephone availability; h. Availability of transportation for follow-up care; and i. Availability of community services. 3. Documentation should support the following discharge standards: a. A discharge plan that includes the provider(s) responsible for follow up care ( the discharge planning evaluation should be used as a guide in the development of the discharge plan); b. All necessary medical and behavioral health information pertinent to illness and treatment, post-discharge goals of care was provided to the appropriate post-acute care service providers at the time of discharge ; c. Coordination and/or referrals with the CareSource case manager, community agencies, and providers responsible for follow up care; d. Completion of medication reconciliation/management; e. Needed DME and supplies are in place prior to discharge; f. Scheduled appointments are listed with dates, times, names, telephone numbers and addresses ( m ental health practitioner follow-up is recommended within 7 days of discharge for members with a mental illness) ; g. Crisis plan and notation that copy was provided to caregiver; and h. Member/guardian and family engagement as needed. III. Supervision Documentation Expectations A. General supervision documentation must include: 1. Dates of supervision; 2. Start and end times; 3. Member identifying information; 4. Purpose of supervision; 5. Outcome of supervision, including any modification to treatment interventions and/or treatment plan; 6. Name/credentials of the supervisor and, if documenting for billing purposes, the National Provider Identifier number of the supervisor; 7. Type of supervision: general or direct; 8. Validation that supervision was rendered within the scope of the license/certification of the supervisor/supervisee 9. Date and signature of supervisor/supervisee, including credentials B. ABA Supervision documentation must include: 1. Dates of supervision visit; 2. Start and end times of visit; 3. Names of individuals present at each session. If individual is not present for the duration of the visit, document start and stop time for that individual; 4. Relationships/credentials of individuals present at each session; 5. Review of services provided (number and type); 6. Review of data that will form the basis of a continued treatment plan; Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.97. Review of progress; 8. Results of monitoring tools to note progress; 9. Changes to treatment plan; 10. Collaboration of care among providers; and 11. Date, signature, and credentials of treating provider. IV. Falsified Documentation A. Providers are reminded that deliberate falsification of medical records is a felony offense and is viewed seriously when encountered. Examples of falsifying records include: 1. Creation of new records when records are requested; 2. Back-dating entries; 3. Post-dated entries; 4. Writing over, or 5. Adding to existing documentation (except where described in amendments, late entries, or corrections). B. Corrections to the medical record legally amended prior to claims submission and/or medical review will be considered in determining the validity of services billed. If these changes appear in the record following payment determination based on medical review, only the original record will be reviewed in determini ng payment of services billed. C. Appeal of claims denied on the basis of an incomplete record may result in a reversal of the original denial if the information supplied includes pages or components that were part of the original medical record but were not submitted on the initial review . E. Conditions of Coverage NA F. Related Policies/Rules Medical Record Documentation Standards for Practitioners G. Review/Revision History DATES ACTIONDate Issued O4/28/2021 New PolicyDate Revised 04/27/2022 05/10/2023 Removed date of birth on every page Added sec. II.C.4 on signed and dated progress notes; updated references. Approved at Committee. Date Effective 09/01/2023 Date Archived H. References 1. Alper E, OMalley T, Greenwald J. (2020, July 16). Hospital discharge and readmission. Retrieved April 1 7, 2023 from www.uptodate.com .Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.102. American Psychiatric Association. Clinical Documentation. Retrieved April 17, 2023 from www.psychiatry.org. 3. Bajorek S , McElroy V. (2020, March 25). Patient Safety Primer. Discharge Planning and Transitions of Care. Retrieved April 1 7, 2023 from www.psnet.ahrq.gov. 4. The Behavior Analyst Certification Board. (2020, November). RBT Supervision and Supervisor Requirements . Registered Behavior Technician Handbook. Retrieved April 17, 2023 from www.bacb.com . 5. Behavioral health services-other licensed professionals , O HIO ADMIN CODE 5160-8-05 ( 2021 ), www.codes.ohio.gov 6. Centers for Medicare & Medicaid Services. (1997). Documentation Guidelines for Evaluation and Management Services. Retrieved April 17, 2023 from www.cms.gov. 7. Centers for Medicare & Medicaid Services. (2015, December). Electronic Health Records Provider. Retrieved April 17, 2023 from www.cms.gov . 8. Centers for Medicare & Medicaid Services. (2012, December 7). Pub 10-08 Medicare Program Integrity Transmittal 442. Retrieved April 17, 2023 from www.cms.gov. 9. Centers for Medicare & Medicaid Services. (2017, August). Evaluation and Management Services. Medicare Learning Network ICN 006764. Retrieved April 17, 2023 from www.cms.gov. 10. Centers for Medicare & Medicaid Services. (2018, May). Complying with Medicare Signature Requirements Medicare Learning Network ICN 905364. Retrieved April 1 7, 2023 from www.cms.gov. 11. Centers for Medicare & Medicaid Services. (2020, April 6). Local Determination Article: Standard Documentation Requirement for All Claims Submitted to DME MACs (A55426). Retrieved April 17, 2023 from www.cms.gov . 12. Centers for Medicare & Medicaid Services. (2020 June 15). Medicaid Documentation for Behavioral Health Practitioners . Retrieved April 17, 2023 from www.cms.gov . 13. Centers for Medicare & Medicaid Services. (2020, January). Medical Mental Health. Retrieved April 1 7, 2023 from www.cms.gov . 14. Center for Medicare & Medicaid Services. MLN Matters Number: MM3389. (2004, July 30). Retrieved April 1 7, 2023 from www.cms.gov . 15. Centers or Medicare & Medicaid Services. (2013, May 17). Revision to State Operations Manual (SOM), Hospital Appendix A Int erpretive Guidelines for 42 CFR 482.43, Discharge Planning. Retrieved April 1 7, 2023 from www.cms.gov 16. Condition of participation: Discharge planning, 42 C.F.R. 482.43 ( 2021), www.govregs.com. 17. The Council of Autism Service Providers. (2020). Applied Behav ior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved April 17, 2023 from www.casproviders.org . 18. Customized items, 42 C.F.R. 414.224 ( 2021), www.ecfr.io. 19. Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions, 42 C.F.R. 410.38 (2021 ), www.ecfr.io. 20. Medicaid. (n.d.) Follow-Up After Hospitalization for Mental Illness: Ages 18 and Older. Retrieved April 1 7, 2023 from www.medicaid.gov . Behavioral Health Service Record Documentation Standards OH MCD-AD-1066 Effective Date: 09/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.1121. National Quality Forum. (2010 update). Safe Practices for Better Healthcare 2010 update Consensus Report. Retrieved April 1 7, 2023 from www.qualityforum.org. 22. National Transitions of Care Coalition. (n.d.). The NTOCC 7-Essential Elements. Retrieved Apri l 1 7, 2023 from www.ntocc.org . 23. Patient Safety Network. (2019, September 7). Patient Safety Primer. Readmissions and Adverse Events After Discharge. Retrieved April 17, 2023 from www.psnet.ahrq.gov . 24. Progress notes , O HIO ADMIN CODE 5122-27-04 (2019), www. codes.ohio.gov.
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Experimental and Investigational Item or Service-OH MCD-AD-0006 07/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by 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 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do 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 in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. 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
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Against Medical Advice (AMA) -OH MCD-AD-0788 08/01/2023 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy 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 o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically n ec-essary services also include those services defined in any Evidence of Coverage documents, Medical Policy Statements, Pro-vider M anuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of ser-vices. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Ad-minis trative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evi-dence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the det er-mina tion. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2B. Background ………………………….. ………………………….. ………………………….. …………………… 2C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 2 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Against Medical Advice (AMA) -OH MCD-AD-0788Effective Dat e: 08/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.A. SubjectAgainst Medical Advice (AMA) B. BackgroundStudies show that patients discharged against medical advice (AMA) are at higher risk for inadequately treated medical conditions, readmissions, and /or negative health outcomes when compared to planned discharges. Documented reasons for leaving AMA may include a lack of satisfaction with the treatment team , treatment team members or facility, a general mistrust of medical systems, underutilization of social support, and/or a lack of health insurance or low socio-economic status. Additionally, research also indicates that previous medical diagn oses substantially impact rates of discharge AMA with psychiatric, substance abuse and human immunodeficiency virus patients exhibiting the most significant risk. C. Definitions Against Medical Advice (AMA) – A patient chooses to leave the hospital or acu te care setting before a practitioner writes the order for discharge. D. PolicyI. CareSource will only pay for services, procedures, and supplies rendered. II. The discharge status code on the submitted claim must indicate that the member left against medical advice.III. If a member leaves against medical advice from the emergency department and the facility has submitted a medical necessity review for inpatient ser vices, only services rendered as part of the emergency department visit will be considered for payment. IV. Claims are subject to retrospective review , and CareSource reserves the right to adjust reimbursement in accordance with the policies above . E. Condition s of CoverageMember must be eligible at the time the service, procedure or supply was provided, and the service, procedure, or supply must be a covered benefit. Reimbursement is depen dent on, but not limited to, submitting approved HCPCS and CPT codes alo ng with appropriate modifiers, if applicable. All services, procedures, and supplies are subject to review for medical necessity, which does not guarantee reimbursement. F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistoryDATES ACTIONDate Issued 02/05/2020Date Revised 12/16/2020 02/07/2022 Annual review. Against Medical Advice (AMA) -OH MCD-AD-0788Effective Dat e: 08/01/2023The ADMINISTRATIVE Policy Statement detailed above has recei ved due consideration as defined in theADMINISTRATIVE Policy Statement Policy and is approved.04/12/2023 Annual review. Approved at Committee.Date Effective 08/01/2023 Date Archived H. References1. Albayati A, et al. Why do patients leave against medical advice? Reasons, conse- quences, prevention, and interventions. Healthcare (Basel) . 2021;9(2):111. doi:10.3390/healthcare9020111 . 2. Alper E, OMalley T, & Greenwald J. (2023, February 3). Hospital discharge and re-admission . Retrieved March 21, 2023 from www.uptodate.com . 3. Centers for Medicare and Medicaid. Patient discharge status codes and hospital transfer policies. Retrieved March 21, 2023 from www.hhs.gov. 4. Hasan O, et al. Leaving against medical advice from in-patient departments rate, reasons and predicting risk factors for re-visiting hospital retrospective cohort from a tertiary care h ospital. Int JHealth Policy Man . 2019;8(8):474-479 doi:10.15/2019.26 . 5. Khalili M, et al. Discharge against medical advice in paediatric patients. JTaibah Univ Med Sci . 2019;14(3):262-267. doi:10.1016/j.jtumed. 2019.03.001 . 6. Levenson J. Psychological factor s affecting other medical conditions: Management. (2022, September 19). Retrieved March 21, 2023 from www.uptodate.com . 7. Ohio Administrative Code (OAC). 5160-2-02. General provisions: Hospital services. (2022, January 1). Retrieved March 21, 2023 from www.c odes.ohio.gov . 8. Ohio Administrative Code (OAC). 5160-2-14. Potentially preventable readmissions. (2022, January 1). Retrieved March 21, 2023 from www.codes.ohio.gov . 9. Ohio Department of Medicaid. Office of Policy. Hospital Billing Guidelines (after September 1, 2021). (2021, July 26). Retrieved March 21, 2023 from www.medicaid.ohio.gov.
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