REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services B. BackgroundMost dental care can be provided in a traditional dental office setting with local anesthesia and , if medically necessary, a continuum of behavior al guidance strategies ranging from simple communicative techniques to nitrous oxide, enteral or parenteral sedation. Monitored anesthesia care or sedation ( minimal, moderate, or deep) may be a requirement of some members , including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations, or other special needs. As an increasing number of members of all ages and complexity seek sedation and anesthe sia for dental procedures in office-based settings, it is important to keep member safety central to the delivery of sedation and anesthesia services. Sedation and anesthesia safety in an office-based setting is dependent on patient selection, sedation and anesthesia goals, techniques, vigilant patient monitoring, as well as the skills and competencies of the patient-centered care team. A dental office setting may be a location for sedation and/or anesthesia modalities only when there are trained and licensed personnel to administer and monitor these services and office facilities are properly equipped and safe per federal and state regul atoryrequirements. Additional information on educational and clinical guidelines to deliver safe and effective sedation and anesthesia can be found in the American Dental Associations Guidelines for the Use of Sedation and General Anesthesia by Dentists (see references) . Alternatively , there are certain situations where patient s may require general anesthesiain a healthcare facility , such as an ambulatory surgical center or outpatient hospital facility. Refer to the Dental Services Rendered in a Hospital or Ambulatory Surgery Center reimbursement policy, OH MCD-PY-1244 for more information on t hese services. C. Definitions Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Office Setting An office or portion thereof utilized to provide medical and/or surgical services to the physician s or dentist s patients. Office setting does not include an office o r portion thereof licensed as an ambulatory surgical facility by the Department of Health pursuant to divi sion (E)(1) of section 3702.30 of the Ohio Revised Code (ORC) , a hospital pursuant to section 3701.07 of the ORC , or an emergency department located within such a hospital . Place of Service (POS) Codes 2-digit codes placed on health care professional claims to indicate the setting in which a service was provided. General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Sedation Continuum When patients undergo procedural sedation/analgesia, a sedation continuum is entered . Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest level, general anesthesia. o Minimal Sedation (Anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. o Moderate Sedation/Analgesia (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. o Deep Sedation/Analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may requir e assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, an d positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Note: Because sedation is a continuum, it is not always possible to predict how a patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended . Practi tioner s administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue of a patient fro m a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. D. PolicyI. Safety Attestation Questionnaire General anesthesia and monitored anesthesia care (MAC) for oral maxillofacial surgery (OMS) and dental-type services performed in the dental office setting require the dental office to complete and submit an initial Provider Questionnaire and Patient Safety Attestation for Dental Sedation/General Anesthesia for each practice location to the respective provider contracting team to ensure all Ohio regulations are followed and patient safety is prioritized. After providing to the contracting team , this General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 document should be kept on file. See Appendix A. Provider Questionnaire andPatient Safety Attestation for Dental Sedation/General Anesthesia . II. Office-Based RequirementsA. Patient Selection The treati ng dental provider should select cases based on the medical necessity criteria in section III. As noted by the American Society of Anesthesiologists (ASA): 1. The procedure to be undertaken is within the scope of practice of the health care practitioners and the capabilities of the dental office facility. 2. The procedure should be medically appropriate for a dental office and of a duration and degree of complexity that will permit the member to recover and be discharged from the facility. 3. Member s who by reason of pre-existing medical or other conditions may be at undue risk for complications should be referred to an appropriate facility for performance of the procedure and the administration of anesthesia. B. Office Facility 1. The facility must meet all state requirements. 2. Pursuant to OAC 4715-5-05 , the provider must have a properly equipped facility(s), whether fixed, mobile, or portable, for the administration of general anesthesia or deep sedation in which the permit holder has available and agrees to utilize adequate monitoring, personnel, emerge ncy equipment and drugs as recommended in the “Guidelines for the Use of Sedation and General Anesthesia by Dentists” as adopted by the October 2016 ADA House of Delegates and/or the American Association of Oral and Maxillofacial Surgeon’s Office Anesthesia Evaluation Manual , 9th edition and maintains successful completion of basic life support for healthcare providers (BLS-HCP) and advanced cardiac life support (ACLS) course(s). 3. The practitioner who uses sedation must have immediately available facilities, personnel, and equipment to manage emergency and rescue situations. A protocol for immediate access to back-up emergency services shal l be clearly outlined. For nonhospital facilities, a protocol for the immediate activation of the E mergency Medical Service (EMS) system for life-threatening complications must be established and maintained. The availability of EMS does not replace the practitioners responsibility to provide initi al rescue for life-threatening complications. 4. Pursuant to OAC 4715-5-05 in the case of a mobile or portable facility, 1 inspection of that facility by the Ohio Board shall be conducted in the office of an Ohio-licensed dentist where deep sedation or general anesthesia is administered. A written list of all monitors, emergency equipment, and other materials which the mobile anesthesia provider agrees to have available at all times while administering moderate sed ation, deep sedation, and general anesthesia in multiple locations shall be provided to the board. 5. External rescue and emergency services should be available and accessible in a timely manner should they be needed. General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 C. Genera l Monitoring and Patient SafetyEquipment used to monitor the member during sedation and anesthesia should be consistent with A merican Association of Nurse Anesthesiology (AANA) Standards for Office Based Anesthesia Practice and other nationally recognized standards and guidelines. The AAPD Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures should be followed as a guide for patient safety and any applicable state requirements. 1. An emergency cart or kit must be immediately accessible and must contain the necessary age and size-appropriate equipment (eg, oral and nasal airways, bag-valve-mask device, LMAs or other supraglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, intravenous catheters) to resuscit ate a child. 2. Monitoring devices, such as electrocardiography (ECG) machines, pulse oximeters with size-appropriate probes, end-tidal carbon dioxide monitors, and defibrillators with size-appropriate patches/paddles, must have a safety and function check on a regular ba sis as required by local or state regulation 3. Documentation prior to and during sedation shall include, but not be limited to, the following: a. health evaluation b. informed consent c. anesthesia documentation time d. treatment documentation D. Anesthesia Provider and Team 1. The practitioner providing sedation and/or anesthesia care in the dental office-based setting must have a permit in good standing issued by the state of Ohio respective licensing board. 2. There must be enough appropriately trained staff to both carry out the procedure and monitor the patient, before, during , and a fter, with a staffed recovery area in accordance with OAC 4715-5-05. 3. Pharmaceuticals must be properly stored and maintained, and th e anesthesia provider must maintain appropriate records of all controlled substances received, administered, dispensed, or used in accordance with ORC 3719.07. If the provider is function ing as a manufacturer or wholesale distributor of such su bstances, an appropriate licen se , in accordance with ORC 4729.52 , must be maintained . 4. Pre-anesthesia evaluation a. A pre-anesthesia evaluation must be completed and documented within 48 hours of an inpatient or outpatient surgery or any procedure requiring anesthesia services. This does not negate the evaluation required immediately prior to induction of anesthesia set forth by The Joint Commission. The delivery of the first dose of medication for the purpose of inducing anesthesia marks the end of the 48-hour time frame. b. In accordance with current standards of anesthesia care, some elements of the pre-anesthesia evaluation may be performed prior to the 48 hours; General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 however, these elements cannot be performed more than 30 days prior to surgery or a procedure requiring anesthesia services. Review of these elements must be conducted, and any appropriate updates documented, within the 48-hour time frame.5. Post-anesthesia evaluation a. The post-anesthesia evaluation must be performed immediately following the conclusion of services for which anesthesia was provided with documentation completed no later than 48 hours after the patient is moved into the designated recovery area. b. The accepted standards of anesthesia care indicate that the evaluation should not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation at an age-appropriate level . c. For patients unable to participate in the post-anesthesia evaluation ( eg , post-operative sedation, mechanical ventilation, age), a notation that the patient was unable to participate and why, as well as expectations for recovery time (if applicable) , should be noted. d. Patients who received long-acting regional anesthesia with acute effects last ing beyond the initial post-anesthesia evaluation time frame should have a notation that the patient is otherwise able to participate in the evaluation but full recovery from regional anesthesia has not occurred and is not expected within the stipulated time frame for the completion of the evaluation. e. Patient should not be discharged until criteria met and patient has returned to pre-anesthesia state of consciousness. A responsible adult should be present at discharge. E. Medical Necessity Criteria 1. General anesthesia and monitored anesthesia care (MAC) for oral maxillofacial surgery (OMS) and dental-type services , whether covered under the medical plan benefits or dental plan benefits , is considered medically necessary when at least 1 of the following clinical criteria are met: a. Extensive or complex oral surgical procedures , such as: 01. 4 or more simple and/or surgical extractions in more than 1 quadrant in 1 appointment 02. impacted wisdom teeth 03. surgical root recovery from maxillary antrum 04. surgical exposure of impacted or unerupted cuspids 05. radical excision of lesions more than 1.25 cm b. Any of the following medical conditions apply : 01. mental incapacitation (such that the members ability to cooperate with procedures is impaired), including intellectual disability, cerebral palsy, epilepsy, organic brain disease and behavioral problems associated with uncooperative but otherwise healthy children that would render the member noncompliant 02. severe physical disorders affecting the tongue or jaw movements General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 03. seizure disorders04. significant psychiatric disorders resulting in impairment of the members ability to cooperate with procedures 05. previously demonstrated idiosyncratic or severe reactions to IV sedation medication 06. medical condition(s) which require monitoring ( eg, cardiac problems, severe hypertension), a medical consultation with the members physician is recommended. 07. documented failed sedation or a condition where severe periapical infection would render local anesthesia ineffective c. Documentation that member is less than 3 years old with extensive treatment , which is provided in the members medical record . 2. Other Sedation Continuum a. Moderate/IV conscious sedation administered intravenously may be indicated for the following situations: 01. anxiety and fear when other techniques have proven inadeq uate 02. pain control when other techniques have proven inadequate 03. management of gag reflex if nitrous oxide is ineffective or not suitable 04. member medically compromised or with special needs 05. lengthy restoration procedures for pediatric members 06. allergy or sensitivity to local anesthesia b. Non-intravenous sedation may be indicated for the following situations: 01. anxiety 02. member uncooperative or unmanageable with complex dental needs c. Nitrous oxide ( anxiolysis) may be indicated for the following: 01. ineffective local anesthesia 02. anticipatory or situational anxiety 03. apprehensive/frightened child 04. member s with special needs 05. extensive and/or complex services 06. members with behavioral or uncooperative challenge s 07. management of a severe gag reflex d. Nitrous oxide and other sedation will not be considered strictly for member or provider convenience. e. Only 1 type of sedation/anesthesia is reimbursable per date of service . E. Conditions of CoverageThe following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all-inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service for all benefit categories. The member-specific benefit plan document and applicable laws that may require coverage for a specific service determine benefit coverage for health services. The inclusion of a code does not imply any rig ht to reimbursement or guarantee claim payment. See corresponding benefit grid for limitation, exclusions, and benefit categories General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 Dental Office Place of Service (POS) (11)o Use CPT code 00170 for general anesthesia or G9654 for monitored anesthesia when performing intraoral treatments. o Time units for physician and CRNA services , both personally performed and medically directed, are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as units (ie, 75 minutes ; 75 = 5 units [of 15 min increments ]. CMS base units = 5 ). Maximum state allowances may be applicable. o Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. Codes Description00170 Anesthesia for intraoral procedures, including biopsy; not otherwise specified G9654 Monitored anesthesia care (MAC) 99151 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patients level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 year s of age 99152 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the mo nitoring of the patients level of consciousness an physiological status; initial 15 minutes of intraservice time, patient age 5 years or older 99153 Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the mo nitoring of the patients level of consciousness and physiological status; each additional 15 minutes intraservice time D9222 Deep sedation/general anesthesia first 15 minutes D9223 Deep sedation/general anesthesia each subsequent 15-minute increment D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9239 Intravenous moderate (conscious) sedation/analgesia first 15 minutes D9243 Intravenous moderate (conscious) sedation/analgesia each subsequent 15 – minute increment D9248 Non-intravenous conscious se dation F. Related Policies/RulesDental Services Rendered in Hospital or Ambulatory Surgical Center G. Review/Revision HistoryDATE ACTIONDate Issued 04/09/2025 New policy. Approved at Committee.General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 Date RevisedDate Effective 11/01/2025 Date Archived H. References1. Accreditation of Office Settings, OHIO ADMIN . CODE 4731-25-07 (2018). 2. American Dental Association. Guidelines for the Use of Sedation and General Anesthesia by Dentist s. October 2016. Accessed April 9, 2025. www.ada.org 3. American Association of Oral and Maxillofacial Surgeons. Ambulatory Surgical Center Coding and Billing. Accessed April 9 , 2025. www.aaoms.org 4. ASA Committee on Economics. Distinguishing between a pre-anesthesia evaluation and a separately reportable evaluation and management service. American Society of Anesthesiologists . Updated March 2023. Accessed April 4, 2025. www.asahq.org 5. American Society of Anesthesiologists. Statement on Office-Based Anesthesia. Accessed April 8, 2025. www.asahq.org 6. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (20 24 ). 7. Conditions and Limitations, OHIO ADMIN . CODE 5160-2-03 (2022). 8. Cot, CJ, Wilson S, American Academy of Pediatric Dentistry, American Academy of Pediatrics. Guidelines for monitoring an d management of pediatric patients before, during, and after sedation f or diagnostic and therapeutic procedures. Ped Dentistry. 2019;41(4):E26-E52. Accessed April 9 , 2025. www.aapd.org 9. Definition of Terms, OHIO ADMIN . CODE 4731-25-01 (2011). 10. Dental Services, OHIO ADMIN . CODE 5160-5-01 (202 4). 11. FDA drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. US Food and Drug Administration. Updated March 8, 2018. Accessed April 9 , 2025. www.fda.gov 12. General Provisions, OHIO ADMIN . CODE 4731-25-02 (2024). 13. Licenses for Wholesale Distributors and Manufacturers of Dangerous Drugs, Outsourcing Facilities, Third-Party Logistics Providers, and Repackagers; Application; Issuance; Renewal; Fees, OHIO REV . CODE 4729.52 (2020). 14. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022). 15. Pain management in infants, adolescents and individuals with special health care needs. Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024-202 5:435-443. Accessed April 9 , 2025. www.aapd.org 16. Pediatric Anesthesia. US Food and Drug Administration. Updated April 24, 2017. Accessed February 26, 2025. www.fda.gov 17. Policy for selecting anesthesia providers for the delivery of office-based deep sedation/general anesthesia. Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024-2025:170-172. Accessed April 9 , 2025. www.aapd.org 18. Policy on care for vulnerable populations in a dental setting. Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024-2025:53-59. Accessed April 9 , 2025. www.aapd.org General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.10 19. Policy on patient safety. Reference Manual of Pediatric Dentistry. AmericanAcademy of Pediatric Dentistry; 2024-2025:27-31. Accessed April 9 , 2025. www.aapd.org 20. Policy on the ethical responsibilities in the oral health care management of infants, children, adolescents, and individuals with special health care needs . Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024 – 2025 :23-24. Accessed April 9 , 2025. www.aapd.org 21. Record of All Controlled Substances Received, Administered, Dispensed, or Used, OHIO REV . CODE 3719.07 (2019). 22. Standards for Surgery Using Anesthesia Services, OHIO ADMIN . CODE 4731-25-04 (2018). 23. Standards for Surgery Using Moderate Sedation/Analgesia, OHIO ADMIN . CODE 4731 – 25-03 (2018). 24. Standards FAQs: medication security anesthesia cart. Office Based Surgery: Medication Management MM. The Joint Commission; 2016. Accessed April 4, 2025. www.jointcommission.org 25. Standard FAQs: sedation and anesthesia rescue requirements. Office Based Surgery: Provision of Care Treatment and Services PC. The Joint Commission; 2016. Updated September 16, 2022. Accessed April 4, 2025. www.jointcommission.org 26. Standards FAQs: sedation and anesthesia understanding the assessment requirements. Office Based Surgery: Provision of Care Treatment and Services PC. The Joint Commission; 2016. Updated November 17, 2022. Accessed April 4, 2025. www.jointcommission.org 27. Use of anesthesia providers in the administration of office-based deep sedation/general anesthesia to the pediatric dental patient. Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024-2025:430-434. Accessed April 9 , 2025. www.aapd.org 28. Use of local anesthesia for pediatric dental patients. Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024-2025 :386-393. Accessed April 9 , 2025. www.aapd.org 29. Use of nitrous oxide for pediatric dental patients. Reference Manual of Pediatric Dentistry. American Academy of Pediatric Dentistry; 2024-2025 :394-401. Accessed April 9 , 2025. www.aapd.org Approved by ODM 0 8/18 /2025General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.11 Appendix AProvider Questionnaire and Safety Attestation for Dental Sedation/General Anesthesia CareSource Provider Questionnaire and Attestation for Dental Sedation/General Anesthesia Please answer the following questions and attach a full written explanation pertaining to each YES response. 1. Has any disciplinary action been taken against you by any state board or any regulatory board? ( ) YES ( ) NO 2. Have you had any patient require hospitalization or medical attention, or have you had any patient deaths in the facility or office? ( ) YES ( ) NO 3. Are there any other facts not disclosed by your answers which may have a bearing on your fitness or eligibility to practice dentistry in Ohio, in particular conscious sedation and/or general anesthesia? ( ) YES ( ) NO I, , hereby certify and attest that: (1) I have, or will contract with s omeone who does, all necessary licenses, certifications, and/or permits to the extent required by the applicable laws and regulations of the state of Ohio including, but not limited, to Ohio Admin. Code 4715-5-05, Ohio Admin. Code 4715-3-01, Ohio Admin. Co de 4715-5-06, Ohio Admin. Code 4715-5-07, Ohio Admin. Code 4715-9-01.2, Ohio Admin. Code 4715-11-02.1 Ohio Rev. Code 4715.70, Ohio Rev. Code 4715.71, Ohio Rev. Code 4715.72, and Ohio Rev. Code 4715.73 (collectively, Ohio Law) for the administration of conscious sedation and/or general anesthesia/deep sedation in a facility or private dental office setting, as appropriate; (2) I have properly equipped facility(s) or private dental office(s) for the adm inistration of conscious sedation and/or general anesthesia/deep sedation in accordance with Ohio Law and generally accepted dentistry practice standards; (3) my facility(s) or private dental office(s) is staffed with qualified de ntal providers and a supervised team of certified auxiliary personnel in accordance with Ohio Law and generally accepted dentistry practice standards; and (4) the administration of conscious sedation and/or general anesthesia/deep sedation in a facility or private dental office setting, as appropriate, wil l only be administered by qualified providers in accordance with Ohio Law. I certify and attest that all of the following equipment, drugs, and supplies are in good workingorder at each facility or private dental office for which conscious sedation or general anesthesia/deep sedation services will be performed:1. equipment capable of delivering positive pressure oxygen ventilation including ancillary airway devices 2. pulse oximeter 3. suction equipment that allows aspiration of the oral and pharyngeal cavities 4. operating table or chair that allows for patient positioning to maintain airway 5. firm platform for cardiopulmonary resuscitation (CPR) 6. fail-safe inhalation system if nitrous oxide/oxygen is used 7. equipment necessary to establish intravascular access 8. equipment to continuously monitor blood pressure, heart rate, and rhythm 9. EKG monitor (required for general anesthesia/deep sedation only) General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.12 10. manual or automatic external defibrillator11. appropriate emergency drugs per advanced cardiovascular life support (ACLS), including reversal agents for narcotics and/or benzodiazepines depending on which is actually utilized, or pediatric advanced life support (PALS) protocol 12. recovery area with available oxygen and suction 13. continual monitoring of end tidal CO2 (expired carbon dioxide), unless invalidated by the nature of the patient, procedure or equipment (required for general anesthesia/deep sedation only) I certify and attest all of the aforementioned equipment, drugs, and supplies will at all times remain in good working order and shall be subject to random on-site inspection by CareSource or its delegated benefits administrator . I further certify and attest that all rendering providers of conscious sedation or general anesthesia/deep sedation services and all support personnel are certified in CPR at the basic life support healthcare provider level from a Ohio Board of Dentistry a pproved sponsor andhave the appropriate education and training required under Ohio Law. In addition, I certify and attest all rendering providers of conscious sedation or general anesthesia/deep sedation services have: (1) (A) a current certification in a dvanced cardiovascular life support (ACLS) for adult patients, or (B) a pediatric advanced life support (PALS) for pediatric patients, or (2) an appropriate dental sedation/anesthesia emergency management course approved by Ohio Board of Dentistry. I certify and attest all of the aforementioned certifications will be maintained in accordance with Ohio Law and copies of such certification shall be provided to CareSource upon request.Please initial each paragraph Initial1. I understand I am responsible for maintaining full compliance at all times with Ohio Law when conscious sedation and/or general anesthesia/deep sedation services will be performed at the facility(s) or private dental office(s) listed on this questionnaire and attestation. 2. I understand and agree that CareSource has the full authority to conduct on-site visits at each facility or private dental office listed on this questionnaire and attestation to ensure I am following Ohio Law and generally accepted dentistry practice stand ards when administering conscious sedation or general anesthesia/deep sedation. 3. I understand and agree that I must notify CareSource immediately of any change that may affect the ability of the facility(s) or private dental office(s) listed on this questionnaire and attestation to safely and effectively administer conscious sedation o r general anesthesia/deep sedation services. 4. I understand and agree that I must notify CareSource and fill out additional questionnaire(s) and attestation(s) if I wish to add any additional facilities or private dental offices that are not currently listed on this questionnaire and attestation that will administer conscious sedation or general anesthesia/deep sedation services. General Anesthesia and Monitored Anesthesia Care for Oraland Maxillofacial Surgery and Dental Services-OH MCD-PY-1593Effective Dat e: 11/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.13 5. I understand and agree that if I choose to utilize the services of an anesthesiologist who is duly licensed to practice medicine in Ohio pursuant to Chapter 4731 of the Revised Code and who is a member of the anesthesiology staff of an institution classified as a hospital and issued a permit under Ohio Admin. Code 5160-2-01 and for administering conscious sedation or general anesthesia in a dental office setting, that such anesthesiologist must remain on the premises of the facility or private dental office until any patient given conscious sedation or general anesthesia/deep sedation by the anesthesiologist is stabilized and has regained consciousness. 6. I understand and agree that in order to administer conscious sedation or general anesthesia/deep sedation services on CareSource members, all services may be subject to post payment review and all records must be timely available upon request. 7. I understand and agree that maintaining full compliance with Ohio Law for the administration of conscious sedation or general anesthesia/ deep sedation services is material to CareSources review and decision process when considering prior authorization requests. 8. I acknowledge, understand and agree to defend, indemnify and hold harmless CareSource and its directors, officers, employees, agents and affiliates against any and all allegations, actions, suits, demands, liabilities, obligations, losses, settlements, expen ses, damages, costs,judgements, claims or other liabilities, including reasonable attorney fees resulting from any and all acts or omissions arising out of or in connection with administration of conscious sedition or general anesthesia. I, the undersigned, do hereby affirm that all statements made and information contained in this questionnaire and attestation are true, accurate, and correct to the best of my knowledge and belief. Provider Signature: Date:Ohio Medicaid ID#:Facility/Office Name(s):Facility/Office Address(es):
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Monitored Anesthesia Care-OH MCD-PY-1685 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Monitored Anesthesia Care-OH MCD-PY-1685Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectMonitored Anesthesia Care B. BackgroundICD-10 guidelines are a set of rules regarding the classification of diagnoses and reasons for health care visits in all settings based on the statistical classification of disease published by the World Health Organization. The guidelines are approved by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics (NCHS). Under the Health Insurance Portability and Accountability Act (HIPAA), adherence to these guidelines is mandatory. Code assignment is based on the providers documentation outlining the relationship between the condition and the care or procedure, unless otherwise instructed by theclassification. There must be a cause-and-effect relationship between the care provided and the condition. In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. Current Procedural Terminology (CPT) codes are the official code set for compliancemandated by HIPPA for healthcare procedures and services and are developed and maintained by the American Medical Association (AMA). CPT includes the use of modifiers to clarify the service reported and increase reimbursement accuracy and coding consistency. In billing, medical necessity is demonstrated by the diagnosis code assigned and whether the documented elements are consistent with the problems addressed (CPT). The Medicaid National Correct Coding Initiative (NCCI) aims to reduce improper payments in the Medicaid program and includes edits for Procedure-to-Procedure (PTP),Medically Unlikely Edits (MUE), and Add-on Code (AOC). Claims denied by NCCI edits are based on a determination of inappropriate coding and not on the basis of medical necessity. Clinical judgment is not nee ded to deny a claim based on correct coding. Certain surgical procedures may include anesthesia services as part of a global fee. In such cases, procedure-to-procedure edits may prevent separate billing for monitoredanesthesia care (M AC ) when it is not allowed. These edits help ensure that claims for anesthesia services are consistent with clinical guidelines and that services billed together are appropriate. CareSource follows guidance from the Ohio Dept of Medicaid (ODM) for payment of MAC. C. Definitions Anesthesia Services The administration of any drug or combination of drugs to create deep sedation/analgesia, regional anesthesia or general anesthesia but does not include topical or local anesthesia or moderate sedation/analgesia. Monitored Anesthesia Care-OH MCD-PY-1685Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Claim A bill from a provider for health care services assigned a unique identifier ,including a bill for services , a line item of services and/or all services for one member within a bill . Edit Adjusting 1 or more procedure codes billed by a participating provider on a claim for payment or a practice that results in o Payment for some but not all of the procedure code originally billed . o Payment for a different procedure code than the procedure code originally billed. o A reduced payment as a result of services claimed under more than 1 procedure code on the same service date. Office Se tting An office or portion thereof utilized to provide medical and/or surgical services to the physician’s own patients but not includ ing an office or portion thereof licensed as an ambulatory surgical facility pursuant to ORC 3702.30, a registered hospital pursuant to ORC 3701.07 or an emergency department located within such a hospital . Procedure Codes The AMAs CPT code, the American Dental Associations Current Dental Terminology , and CMSs Health Care Common Procedure Coding Syste m (HCPCS) . Provider A physician or any qualified healthcare practitioner who is legally accountable for establishing a members diagnosis. D. PolicyI. General Reimbursement Guidelines A. All claims for MAC are to be submitted in accordance with established guidelines managed by the Ohio Administrative and Revised Codes (OAC and ORC, respectively), particularly as related to OAC 5160-4-21 . B. In accordance with the ODM, claims are to be submitted pursuant to the NCCI and coding standards set forth in the following guides: 1. Healthcare Common Procedure Coding System 2. Current Procedural Terminology Codebook 3. Current Dental Terminology Codebook 4. Internal Classification of Diseases Handbook C. When adjudicating claims, CareSource utilizes code editing software to evaluate the accuracy of diagnos es and procedure codes to ensure that claims are processed consistently, accurately, and efficiently. The software evaluate s accuracy of the procedure code only, not medical necessity for the procedure. The edits utilized include 1. Medicaid NCCI 2. ICD-10 guidelines 3. CPT guidelines 4. HCPCS guidelines 5. CMS published materials, as applicable 6. state published reimbursement guidelines 7. state and federal statutes and regulations Monitored Anesthesia Care-OH MCD-PY-1685Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 D. Per correct coding, the ICD-10 diagnosis and the CPT/HCPCS code demonstrate the cause-and-effect relationship of the condition and care provided. Claims may be denied due to an improper grouping of codes. E. It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. The provider must also use ap plicable modifiers, as necessary , including those that indicate whether a procedure was personally performed, medically directed or medically supervised. II. MACA. MAC should be provided by qualified anesthesia personnel continuously present to monitor the member and provide care in accordance with state licensure requirements. B. During MAC, the attending anesthetist should assess the member s oxygenation, ventilation, circulation, and temperature using the most appropriate methods available , including advanced non-invasive monitoring techniques . Close observation is essential to foresee the need for administering general anesthesia or addressing adverse physiological reactions. The potential for the procedure to become more complex or lead to unexpected complications necessitates thorough monitoring and possible anesthetic interven tion. C. Certain anesthesia procedures are typically performed by the attending surgeon and are included in the global fee, no t billed separately. However, in specific cases, MAC may be deemed reasonable and necessary for procedures usually handled by the attending surgeon, provided certain conditions exist. In these scenarios, MAC may be essential to address serious accompanying conditions and ensure a smooth anesthesia process (a nd surgery) by preventing adverse physiological complications. It is important that any special conditions or criteria are documented in the medical record. D. High-quality MAC is essential and demands the same level of expertise and effort as administering general anesthesia. If the necessary criteria are not met or if the procedures are deemed unnecessary, full payment may be denied. E. For procedures that typically do not necessitate anesthesia services, MAC may be covered if the member s condition warrants qualified anesthesia personnel to provide monitoring alongside the physician performing the procedure . This must be documented in the medical record. F. The presence of an underlying condition may not be adequate justification for the necessity of MAC. The medical condition must be substantial enough to require MAC (eg, member being on medication , member exhibiting symptoms ). Simply having a stable, managed condition is not, by itself, sufficient. G. No additional payment will be made on account of physical status, age, body temperature (hypothermia or hyperthermia), emergency conditions or time of day. Monitored Anesthesia Care-OH MCD-PY-1685Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 E. Conditions of CoverageI. Anesthesia services must be submitted with at least 1 CPT anesthesia code. These codes are reimbursed based on time units using the standard anesthesia formula. II. All documentation must be maintained in the medical record and made available upon request, including the following:A. legible pages with appropriate member identification information (eg, complete name, dates of service[s]) B. legible signature of the physician or non-physician practitioner responsible for and providing care C. support for medical necessity of the services and selected ICD-10 code(s) and CPT/HCPCS codes performed /used D. the reason for MAC E. a pre-anesthesia evaluation, including a history and physical exam F. evidence of continuous monitoring of member oxygenation, ventilation, circulation , and temperature G. a post-anesthesia evaluation, including any unusual events or complications H. member status on discharge III. Required anesthesia modifiers may include the following, which are provided as a courtesy only: Modifier Provider Type AA Anesthesiologist physician, personally performed AD Anesthesiologist physician, supervising over 4 qualified non-physician anesthetists performing concurrent anesthesia procedures QK Anesthesiologist physician, supervising 2-4 qualified non-physician anesthetists performing concurrent anesthesia procedures QS Monitored anesthesia care reported with an anesthesia procedure code QX CRNA or AA directed by anesthesiologist physician QY Anesthesiologist physician, supervising 1 qualified non-physician anesthetist QZ CRNA, personally performed F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/16/2025 New policy. Approved at Committee.Date Revised Date Effective 11/01/2025 Date Archived H. References1. 2025 ICD-10-CM Official Guidelines for Coding and Reporting . AAPC; 2025. Monitored Anesthesia Care-OH MCD-PY-1685Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 2. American Medical Association CPT Editorial Panel . cpt 2025 Professional Edition .American Medical Association; 2024. 3. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (2024). 4. CPT codes. American Medical Association. Accessed June 5, 2025. www.ama – assn.org 5. Health Care Contracts Definitions, OHIO REV . CODE 3963.01 (2024). 6. Medicaid NCCI Coding Policy Manual . Centers for Medicare and Medicaid Services; 2025. 7. Office Based Surgery , OHIO ADMIN . CODE Chapter 4731-25 (2024). 8. Ohio Medicaid Provider Agreement for Managed Care Organization. The Ohio Dept of Medicaid. Revised January 2025. 9. Provider Manual Ohio Medicaid . CareSource; 2024. Accessed June 16, 2025. www.caresource.com 10. Submission of Medicaid Claims, OHIO ADMIN . C ODE 5160-1-19 (2023). Approved by Ohio Department of Medicaid 08/05/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 59 , XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are 2-character code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a mo difier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situ ations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date o f service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established 4 HCPCS modifiersto define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review.A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59.VI. Modifier X {EPSU} (or 59 , when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. performed at separate anatomic sites 2. performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure . 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires . 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure . 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.) Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised 08/02/2023 07/17/2024 07/16 /2025 Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee. Review: updated references, approved at Committee. Date Effective 11/01/2025 Date Archived H. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 202 5. Accessed June 27, 2025 . www.cms.gov 2. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2024) 3. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioner s. US Centers for Medicare and Medicaid Services; 202 4. Accessed June 27, 2025 . www.cms.gov 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated April 11, 2025 . Accessed June 27, 2025 . www.cms.gov 5. MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare & Medicaid Services; 202 4. Accessed June 27, 2025 . www.cms.gov 6. Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed June 27, 2025 . www.cms.gov Approved ODM 08/05/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Coding Guidelines-OH MCD-PY-1677 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Coding Guidelines-OH MCD-PY-1677Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectCoding Guidelines B. BackgroundCode assignment for claims is based upon the providers (ie, physician or other qualified healthcare practitioner legally accountable for establishing the patients diagnosis) documentation outlining the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. There must be a cause-and – effect relationship between the care provided and the condition. ICD-10 guidelines are a set of rules regarding the classification of diagnoses andreasons for health care visits in all settings based on the statistical classification of disease published by the World Health Organization. These guidelines are approved by the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), the Centers for Medicare and Medicaid Services ( CMS), and the National Center for Health Statistics (NCHS). Under the Health Insurance Portability and Accountability Act (HIPAA), adherence to these guidelines is mandatory. In addition to general coding guidelines outlined by the ICD-10 manual , additionalguidelines are provided within for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. The Current Procedural Terminology (CPT) is the official code set for compliancemandated by HIPPA for healthcare procedures and services. These codes are developed and maintained by the American Medical Association (AMA). These codes and their guidelines are designed to communicate as a statistical classification of clinically recognized and generally accepted services provided by healthcare professionals. The use of these codes and guidelines simplifies the reporting and processing of services for advance d analytics of these procedures. CPT includes the use of modifiers to clarify the service that is being reported. Using modifiers increases reimbursement accuracy and coding consistency. In billing, medical necessity is demonstrated by the diagnosis code assigned ( ie, ICD-10) and whether thedocumented elements are consistent with the problems addressed ( ie, CPT).The Medicaid National Correct Coding Initiative (NCCI) aims to reduce improper payments in the Medicaid program. It includes edits for Procedure-to-Procedure (PTP),Medically Unlikely Edits (MUE), and Add-on Code (AOC). Claims denied by NCCI edits are based upon a determination of inappropriate coding and not on the basis of medical necessity. Clinical judgment is not needed to deny a claim based on correct coding. Coding Guidelines-OH MCD-PY-1677Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Claim A bill from a provider for health care services assigned a unique identifier. A claim can include any of the following: (1) a bill for services (2) a line item of services (3) all services for one member within a bill Edit Adjusting one or more procedure codes billed by a participating provider on a claim for payment or a practice that results in any of the following: (1) Payment for some, but not all of the procedure code originally billed by a participating provider. (2) Payment for a different procedure code than the procedure code originally billed by a participating provider. (3) A reduced payment as a result of services provided to an enrollee that are claimed under more than one procedure code on the same service date. Procedure Codes Includes the American Medical Associations current procedural terminology code, the American Dental Associations current dental terminology, and the Centers for Medicare and Medicaid Services health care common procedure coding system. Provider A physician or any qualified healthcare practitioner who is legally accountable for establishing the patients diagnosis. D. PolicyI. In accordance with the Ohio Department of Medicaid (ODM), claims are to be submitted pursuant to the national correct coding initiative and according to the coding standards set forth in the following guides: A. the healthcare common procedure coding system B. the current procedural terminology codebook C. the current dental terminology codebook D. the internal classification of diseases handbook II. When adjudicating claims, CareSource utilizes code editing software to help evaluate the accuracy of diagnosis and procedure codes on submitted claims to ensure claims are processed consistently, accurately, and efficiently. The software helps evaluate the accuracy of the procedure code only, not the medical necessity of the procedure.The edits utilized include A. Medicaid NCCI Policy Manual B. ICD-10 guidelines C. CPT guidelines D. HCPCS guidelines E. CMS published materials, as applicable F. state published reimbursement guidelines G. state and federal statutes and regulations Coding Guidelines-OH MCD-PY-1677Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 III. Per ICD-10 guidelines , there must be a cause-and-effect relationship between the care provided and the condition. As such, the ICD-10 diagnosis and the CPT/HCPCS code demonstrate th is through analytics in coding software . Claims may be denied due to an improper grouping of codes. E. Conditions of CoverageN/A F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 07/30/2025 Approved at Committee.Date Revised Date Effective 11/01/2025 Date Archived H. References1. 2025 ICD-10-CM Official Guidelines for Coding and Reporting . AAPC; 2025. 2. CPT Codes. American Medical Association. Accessed July 30, 2025. www.ama – assn.org 3. Current Procedural Coding Expert . A merican Medical Association ; 2024. 4. Health Care Contracts Definitions, OHIO REV . CODE 3963.01 (2024). 5. Medicaid NCCI Coding Policy Manual . Centers for Medicare and Medicaid Services; 2025. 6. Ohio Medicaid Provider Agreement for Managed Care Organization. The Ohio Dept of Medicaid. Revised January 2025. 7. Provider Manual Ohio Medicaid . CareSource; 2024. 8. Submission of Medicaid Claims, OHIO ADMIN . CODE 5160-1-19 (2023). Approved by ODM 08/14/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Laboratory Testing in Office Setting-OH MCD-PY-1545 10/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectLaboratory Testing in Office Setting B. BackgroundDuring the course of an office visit with a physician or other qualified healthcare provider, the provider may determine that diagnostic laboratory testing is necessary to establish a diagnosis and/or determine treatment options to manage the members current health issues. W hile most laboratory tests are best performed by an independent laboratory, in some instances, results from these laboratory tests are needed immediately to manage urgent medical conditions or medical emergencies and may be performed appropriately in the p hysicians office. Due to the complexity of laboratory tests and regulations around facilities that perform these tests, only laboratory procedures on the STAT lab list may be performed in the office, while all other tests should be referred to an independ ent, contracted lab provider. C. Definitions Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Laboratory A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for th e diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories. Laboratory Procedures Defined in the Current Procedural Terminology (CPT) in the ranges 80300 through 89398 and panels 80047 through 80076 . D. PolicyI. Codes managed by a vendor (eg, Avalon) should not be affected by this policy. II. CareSource will reimburse for laboratory procedures performed in the physicians office when ALL the following apply:A. The test results are needed immediately in order to manage urgent or emergent medical situations. B. The CPT code for the test is on the short turnaround time (STAT) code list. C. The place of service (POS) 11 is used. III. All other laboratory procedures performed in the office may not be reimbursed and should be referred to an independent, contracted laboratory provider. IV. This policy does not apply to Community Mental Health C enters .Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 E. Conditions of CoverageIt is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Please refer to the individual fee schedule for appropriate codes. Place of Service (POS) CodeDescription 11 – Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examina tions, diagnosis, and treatment of illness or injury on an ambulatory basis STAT Code ListCPT / HCPCS Description 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), includes titer(s), when performed 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when pe rformed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perf ormed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry eith er with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC – MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 80324 Amphetamines; 1 or 2 80325 Amphetamines; 3 or 4 80326 Amphetamines; 5 or more 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 80331 Analgesics, non-opioid; 6 or more 80332 Antidepressants, serotonergic class; 1 or 2 80333 Antidepressants, serotonergic class; 3-5 Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 80334 Antidepressants, serotonergic class; 6 or more80335 Antidepressants, tricyclic and other cyclicals; 1 or 280336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepileptics, not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Methylphenidate 80361 Opiates, 1 or more 80362 Opioids and opiate analogs; 1 or 2 80363 Opioids and opiate analogs; 3 or 4 80364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 80375 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 80376 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81015 Urinalysis; microscopic only 81025 Urine pregnancy test, by visual color comparison methods 82043 Albumin; urine (eg, microalbumin), quantitative 82044 Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) 82247 Bilirubin; total 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82271 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82465 Cholesterol, serum or whole blood, total 82565 Creatinine; blood 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82947 Glucose; quantitative, blood (except reagent strip) 82948 Glucose; blood, reagent strip 82950 Glucose; post glucose dose (includes glucose) 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 82952 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 83036 Hemoglobin; glycosylated (A1C) 83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use 83655 Lead 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83986 pH; body fluid, not otherwise specified 83992 Phencyclidine (PCP) 84132 Potassium; serum, plasma or whole blood 84703 Gonadotropin, chorionic (hCG); qualitative 85013 Blood count; spun microhematocrit 85014 Blood count; hematocrit (Hct) 85018 Blood count; hemoglobin (Hgb) 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 85049 Blood count; platelet, automated85610 Prothrombin time;85651 Sedimentation rate, erythrocyte; non-automated 86308 Heterophile antibodies; screening 86318 Immunoassay for infectious agent antibody(ies ), qualitative or semiquantitative, single-step method (eg, reagent strip); 86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV – 2) (coronavirus disease [COVID-19]) 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); titer 86580 Skin test; tuberculosis, intradermal 86756 Antibody; respiratory syncytial virus 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 87172 Pinworm exam (eg, cellophane tape prep) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87301 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41 87400 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each 87420 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; respiratory syncytial virus 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respi ratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respi ratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87430 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus, group A87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription , when performed, and multiplex amplified probe technique, first 2 types or sub-types 87503 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcr iption, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure 87631 Infectious agent detection by nucleic acid (DNA or RNA) ; respiratory virus (eg, adenovirus, influenza virus, coronavirus, me tapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or sub-types, 3-5 targets 87634 Infectious agent detection by nucleic acid (DNA or RNA) ; respiratory syncytial virus, amplified probe technique 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique 87636 Infectious agent detection by nucleic acid (DNA or RNA) ; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique 87637 Infectious agent detection by nucleic acid (DNA or RNA) ; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique 87650 Infectious agent detection by nucleic acid (DNA or RNA) ; Streptococcus, group A, direct probe technique 87651 Infectious agent detection by nucleic acid (DNA or RNA) ; St reptococcus, group A, amplified probe technique 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B 87803 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Clostridium difficile toxin A 87804 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 87806 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 87808 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Trichomonas vaginalis Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual)observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87880 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standar ds in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/M S (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all so urces, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (an y type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes Q0111 Wet mounts, including preparations of vaginal, cervical or skin specimens Q0112 All potassium hydroxide (KOH) preparations U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel U0002 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/25/2024 New policy, approved at Committee.Date Revised 12/18/2024 Review: removed CLIA and QW modifier from policy. Approved at Committee.Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 05/07/2025 Review: added D.III, updated code list and references,approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed May 5 , 2025. www.ama-assn.org 2. Definitions, OHIO ADMIN CODE 3701-32-01 (2021). 3. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions, 42 U.S.C. 410.32 ( 2023 ). 4. Healthcare Common Procedure Coding System (HCPCS). Accessed May 5, 2025. www.nlm.nih.gov 5. Laboratory Requirements, 42 U.S.C. 493 ( 2023 ). 6. Laboratory Services, 42 U.S.C. 441.17 ( 2023 ). 7. Laboratory Services, OHIO ADMIN CODE 5160-11-11 (2021). 8. Managed Care: Provider Network and Contracting Requirements, OHIO ADMIN CODE 5160-26-05 (2022). 9. Other Laboratory and X-Ray Services, 42 U.S.C. 440.30 ( 2023 ). 10. Place of Service Code Set. Centers for Medicare and Medicaid Services; 202 5. Accessed April 30, 2025 . www.cms.gov ODM approved 07/10/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a b ody organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectResidential Treatment Services – Substance Use Disorder (SUD) B. BackgroundSubstance Use Disorder (SUD) treatment is dependent on member needs with the type, length and intensity of treatment determined by the severity of the diagnosis , types of substances used, support systems available, prior life experiences, and behavioral, physical, gender, cultural, cognitive and/or social factors. Additional factors include the availability of treatment in the community and coverage for the cost of care. The American Society of Addiction Medicines (ASAM) levels 3 and 4, or residential and intensive inpatient levels of care (LOC) , are considered transitional with the goal of returning the member to the community with a less restrictive LOC . Level 3 services include residential and/or inpatient services that are clinically managed or medically monitored. Level 4 services include medically managed, intensive inpatient services. Providers use the ASAM criteria as the basis to deliver services for the full continuum of care,ensur ing that care is delivered consistently with industry-standard criteria. ASAM also provides key benchmarks from nationally adopted standards of care and guidelines involving evidence-based treatment measures t o guide services. Treatment of substance use disorders is dependent on a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM) . CareSource follows the Ohio Dep t of Medicaids (ODM) policies and procedures and the OhioRevised and Administrative Codes (ORC and OAC, respectively).C. Definitions ASAMs Residential Levels of Care (LOC): o 3.1 Clinically managed, low-intensity residential program o 3.3 Clinically managed, high-intensity, population specific o 3.5 Clinically managed, high-intensity residential program for adults and/or medium intensity for adolescents o 3.7 Medical ly monitored, intensive inpatient for adults and/or high-intensity for adolescents Clinically Managed Services Services directed by nonphysician addiction specialists appropriate for members with emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment concerns. Intoxication, withdrawal, and biomedical concerns, if present, are safely manageable, particularly under Level 3.1 , 3.3, and 3.5 residential programs. Inpatient Services Behavioral health (BH) services provided during an inpatient admission or confinement for acute inpatient services in a hospital or treatment setting on a 24-hour basis under the direct care of a physician, including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.3 Medically Managed Services Services involving 24-hour nursing and daily medical care by an appropriately trained and licensed physician providing diagnostic and treatment services directly, managing the provision of those services, or both, particularly under Level 4 programs. Medically Monitored Services Services provided by an interdisciplinary staff of nurses, counselors, social workers, addiction specialists, or other health and technical personnel under the direction of a licensed physician through a mix of direct patient contact, review of records, te am meetings, 24-hour coverage by a physician and nursing staff and a quality assurance program, particularly under Level 3.7 inpatient programs. Medication Assisted Treatment (MAT) The use of Food and Drug Administration (FDA) -approved medications in combination with counseling and behavioral therapies to provide a whole-patient approach to the treatment of SUD. Per Diem An allowance /payment made for each day of service based on the sum of the national average routine operating, ancillary , and capital costs for each patient day of care. Residential LOC Services for BH that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) , and pharmacological therapy in a congregate living community with 24-hour support. D. PolicyI. A residential program is staffed 24 hours a day and follows ASAMs LOC criteria and OA C 5122-29-09 . II. A review of medical necessity is require d for the following:A. For the 1st and 2nd admissions per calendar year, a review is only required for admission exceeding 30 consecutive days. For example, a member goes into treatment the 1st time in a calendar year for 10 days. No review is required. The same member goes into treatment for a 2nd admission during the same calendar year for 38 days. After day 30, the facility is required to obtain an authorization for days 31 through 38. B. For any stay or admission exceeding 2 admissions per calendar year, a review is required from the 1st day of admission. The same member above admits for treatment for a 3rd time during the same calendar year. A review for this admission is required , starting day 1. C. Changes in LOC 1. When step-up or step-down occur s between 2 SUD r esidential LOC codes within the same residential provider agency and there is consecutive billing, the step-up or step-down is counted as a single event. 2. When step-up or step-down occurs between 2 SUD residential LOC codes and billing is not consecutive, the events will be considered separate events . Reviews of medical necessity may be required , depending on the members utilization in that calendar year . a. If step-up or step-down occurs during the 1st 30 days of the 1st or 2nd of the 2 allowed SUD residential events, no PA is required for the step-up or step-down. Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.4 b. If the step-up or step-down occurs after a PA has been authorized, either because the length of stay (LOS) exceeded 30 days or this is the 3rd or more event in a calendar year, then the step-up or step-down does require a new/updated PA. D. SUD residential facility transfers 1. A review of medical necessity is required for a same LOC admission or transfer between 2 SUD residentia l facilities ( national provider identifiers (NPI) and/or tax identification numbers [TIN ]) when the total number of days at that LOC exceeds 30 calendar days and there is not a break in stay that is greater than 24-hours between admissions indicating 2 separate events . If the admission already required a review or authorization for any reason, the transition admission will require that a review be obtained by the receiving facility from the date of admission. 2. Same LOC admissions or transfers between 2 SUD residential facilities (NPIs and/or TINs) without a break in stay of greater than 24 hours is not considered a separate event and will not accumulate as a separate event. 3. If there is a break in stay that is greater than 24 hours between a same LOC admission or transfer between 2 SUD residential facilities (NPIs and/or TINs), the admission to the receiving facility is considered a separate event and is subject to a review from the date of admission, beginning with the 3rd admission in a calendar year and will accumulate as separate events. III. DocumentationA. At least 1 documented face-to-face interaction must be performed by a clinical treatment team provider at the site in order to bill per diem . B. Medical record s must substantiate the medical necessity of services and follow OAC guidelines for documentation in OAC 5160-1-27 and 5160-8-05 . C. Program s must have written Affiliation Agreement s monitored by program policies and procedures to ensure member access to outpatient care in a timely manner upon discharge . IV. B illingA. Residential LOC admission 1. One admission is considered 1 length of stay (LOS). 2. Any stay under 30 consecutive days counts as a full 30-day admission. 3. Service gaps in excess of 24 hours are considered a termination of 1 admission. 4. Leaving the facility associated with significant changes in health status, such as leaving against medical advice, step-ups ( including acute medical admissions) or step-downs in LOC , and/or incarceration are considered a termination of 1 admission . 5. Brief leave of absences (24 hours or less except in rare instances ), when supported by the members individualized treatment plan , should be documented in the members treatment plan . B. The benefit follows the member not the providers TIN . C. CareSource processes claims from the following: Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined in theREIMBURSEMENT Policy Statement Policy and is approved.5 1. provider type 95 OhioMHAS certified/licensed treatment program2. provider specialty 954 OhioMHAS certified/licensed SUD residential facility 3. place of service code 55 residential substance abuse treatment facility D. Claims billed out of sequence from date of service may cause inappropriate den ials for no prior authorization or review of medical necessity . E. Claims are paid as received. If a member receives services from more than 1 provider, claims are paid to providers who submit 1st , regardless of date of service. F. SUD residential is paid per diem , which do es not include room and board costs and/or payments . G. CareSource does not reimburse separately for services provided by the residential treatment service, including 1. ongoing assessments and diagnostic evaluations 2. crisis intervention 3. individual, group, family psychotherapy and counseling 4. case management 5. substance use disorder peer recovery services 6. urine drug screens 7. medical services H. A member can only receive services through 1 LOC at a time. 1. CareSource considers the following services non-billable when a member is in residential LOC : a. therapeutic behavioral services b. psychosocial rehabilitation c. community psychiatric supportive treatment d. mental health day treatment e. assertive community treatment f. intensive home-based treatment 2. Select services , including MAT and psychiatry for example, provided to a member by practitioners not affiliated with the residential treatment program (based on billing group TIN) are considered by CareSource as billable concurrent to the SUD residential admission when the service is medically necessary , and the treatment is outside of the scope of the residential treatment program . E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers. Refer to the BH Ohio fee schedule for codes. Code inclusion in this policy does not imply any right to reimbursement or guarantee claim (s) payment. Additional provisions for services compliant with ASAM s LOC criteria can be found in the OAC , including programs for individuals under age 18, SUD case management, and crisis services. F. Related Policies/RulesMedical Necessity Determinations Behavioral Health Documentation Standards Residential Treatment Services-Substance Use Disorder-OH MCD-PY-0137 Effective Date: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 G. Review/Revision History DATE ACTION Date Issued 08/17/2017 Date Revised 05/15/2019 09/16/2020 12/28/2020 11/30/2021 01/18/2023 01/31/2024 06/04/2025 Updated definitions, medical necessary criteria, and billing. Updated definitions. Added note under D.I. Added D.I.C.;D.1.IV. A.5, IV.B. Added related policy. Revised D.IV.H.2 & I.C.D. & E. Provided clarification per ODM D. 1. C, D, and E; and D. IV. A. Removed codes from policy, updated definitions. Annual review. Updated background. Added definitions. Annual review. Updated D.I.A. Deleted Sections D.II and V., 8 on VI.G. Updated Fand H. Approved at Committee. Annual review. Updated reference list. Approved at Committee. Date Effective 09/01/2025 Date Archived H.References1. American Society of Addiction Medicine. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 4th Ed. Hazelton Betty Ford Foundation; 2023.2. Coverage and Limitations of Behavioral Health Services, OHIO ADMIN. CODE 5160-27-02(2022).3. Eligible Provider for Behavioral Health Services, OHIO ADMIN. CODE 5160-27-01 (2023).4. Eligible Providers and Supervisors, OHIO ADMIN. CODE 5122-29-30 (2022).5. Medicaid Behavioral Health State Plan Services Provider Requirements and Reimbursement Manual. Ohio Dept of Medicaid; 2023. Accessed May 8, 2025. www.medicaid.ohio.gov6. Residential and Withdrawal Management Substance Use Disorder Services, OHIO ADMIN. CODE 5122-29-09 (2023).7. Statutes, regulations, and guidelines. Substance Abuse and Mental Health Services Administration. Accessed May 8, 2025. www.samhsa.gov8. Substance Use Disorder Qualified Residential Treatment Program (QRTP) for Youth, OHIO ADMIN. CODE 5122-29-09.1 (2022).9. Substance Use Disorder Treatment Services, OHIO ADMIN. CODE 5160-27-09 (2021).Approved by Ohio Dept of Medicaid 06/10/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care-Total Cost for Freestanding Birthing Centers – OH MCD-PY-0939 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 Contents A. Subject ………………………………………………………………………………………………………………………………. 2 B. Background ……………………………………………………………………………………………………………………….. 2 C. Definitions ………………………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ……………………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………………………. 4 G. Review/Revision History ……………………………………………………………………………………………………. 4 H. References ………………………………………………………………………………………………………………………… 4Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 09/01/2025 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.2 A. Subject Obstetrical Care-Total Cost for Frees tanding Birthing Centers B. Background Obstetrical care refers to health care treatment given in relation to pregnancy and delivery of a newborn child. This includes care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center, as well as all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. The total obstetrical care code is only to be used by Freestanding Birthing Centers. All other practitioners must not bill and will not be reimbursed for total care obstetrical codes. C. Definitions Freestanding Birthing Center (FBC) Any facility in which deliveries routinely occur, regardless of whether the facility is located on the campus of another health care facility, and which is not licensed under Chapter 3711 of the Ohio Revised Code as a level 1, 2 or 3 maternity unit or a limited maternity unit . Initial and Prenatal Visit Practitioner visit to determine if a member is pregnant. Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 weeks. Prenatal Profile Initial laboratory services. Total Obstetrical Care Antepartum care, delivery, and postpartum care. D. Policy I. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 09/01/2025 The REIMBURSEMENT Policy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3 care. B. Risk Appraisal-Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) any time there is a change in condition during the pregnancy. Use code H1000 and append modifier 33 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those services. 3. Total obstetrical care code: a. Total obstetrical care code is CPT 59400-Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care. b. A corresponding obstetrical diagnosis with appropriate trimester must be listed on the claim. An ICD-10 code from category Z34 should be listed as the first diagnosis for routine obstetric care. 4. Services included that are not to be billed separately (not all inclusive): a. a dmission history b. a dmission to hospital c. a rtificial rupture of membranes d. care provided for an uncomplicated pregnancy, including delivery , as well as antepartum and postpartum e. visits each month up to 28 weeks gestation f. visits every other week from 29-36 weeks gestation g. visits weekly from 36 weeks until delivery h. f etal heart tones i. h ospital/office visits following vaginal delivery j. i nitial/subsequent history k. m anagement of uncomplicated labor l. physical exams m. recording of weight/blood pressures n. r outine chemical urinalysis o. r outine prenatal visits p. successful vaginal delivery after previous cesarean delivery q. vaginal delivery with or without episiotomy or forceps .E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CODES DESCRIPTION Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 09/01/2025 The REIMBURSEMENT Policy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.4 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care H1000 Pre natal care, at risk assessment F. Related Policies/RulesObstetrical Care-Unbundled Services G. Review/Revision History DATE ACTIONDate Issued 7/22/2020Date Revised 10/26/2022 10/11/2023 11/06/2024 04/23/2025 Annual review with e ditorial changes. References updated. Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Periodic review. Updated D.1.B.1.PRAF submission clarification and added modifier. Date Effective 09/01/2025 Date Archived H. References1. 2025 OB/GYN Coding Manual: Components of Correct Coding. American College of Obstetricians and Gynecologists; 2025 . Accessed April 14, 2025 . www.acog.org 2. ACOG committee opinion 736: presidential task force on redefining the postpartum visit. Obstet Gynecol . 2018;131(5):e140-e150. Reaffirmed 2021. Accessed April 14, 2025. www.acog.org 3. Cesarean Delivery on Maternal Request . American College of Obstetricians and Gynecologists; Committee Opinion No. 761. Reaffirmed 2021 . Committee Opinion No. 761. Accessed April 14, 2025. www.acog.org 4. Definitions, O HIO ADMIN . CODE 4723-8- 01 (2021). 5. Freestanding Birth Center Services, O HIO ADMIN . CODE 5160-18-01 (2023). 6. Limitations on Elective Obstetric Deliveries, O HIO ADMIN . CODE 5160-1- 10 (2015). 7. Managed Care: Definitions, O HIO ADMIN . CODE 5160-26-01 (2022). 8. Management of Late-Term and Postterm Pregnancies . American College of Obstetricians and Gynecologists ; 2014. Practice Bulletin No. 146. Accessed April 14, 2025. www.acog.org 9. Medically Indicated Late-Preterm and Early-Term Deliveries . American College of Obstetricians and Gynecologists; 2021. Committee Opinion No. 831. Updated February 2024. Accessed April 14, 2025. www.acog.org 10. How-to Modifier 22. American Academy of Professional Coders. 2025. Accessed April 14, 2025 . www.aapc.com 11. Reproductive Health Services: Pregnancy-Related Services, O HIO ADMIN . CODE 5160-21-04 (2025 ). 12. Caughey AB, et al; American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am JObstet Gynecol . 2014;210(3):179-193. doi:10.1016/j.ajog.2014.01.026 13. Scope of Specialized Nursing Services, O HIO REV . CODE 4723.43 (2020). Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 09/01/2025 The REIMBURSEMENT Polic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.5 Approved by ODM 05/13/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center – OH MCD-PY-1244 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource, and its affiliates are intended to provide a general reference regarding billi ng, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, bene fits design and other factors are considered in developing Reimbursement Policies. These policies are designed to assist providers and facilities submitting claims to CareSource. The policies are routinely updated to promote accurate coding and clarificati on. These proprietary policies are not a guarantee of payment. This Policy does not ensure an authorization or reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service( s) referenced herein . If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and any applicable referral, authorizatio n, notification, and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and wit hout which the patient can be expected to s uffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services must meet the standards of good clinical practice in the l ocal area, are the lowest cost alternati ve, and are not provided for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Prior authorization is required for certain services. If authorization is not obtained prior to performing the service, CareSource may not reimburse for the procedure. Health care providers and their office staff are encouraged to use the self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology/Healthcare Common Procedure Codin g System (CPT/HCPCS) code(s) for the medical product or service being provided and the appropriate Current Dental Terminology (CDT) code(s) for the dental product or service. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee for a submitted claim payment. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 und er this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or long-term medical conditions) of the individual, in addition to the type, number , and complexity of procedure s planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic toadvanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, posit ive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep) , or monitored general anesthesia by trained certi fied individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of gener al anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgical center , hospital operating room , or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization that meets all criteria of Ohio Administrative Code (OAC) 5160-22-01. Enhanced Ambulatory Patient Groups (EAPGs ) A patient classification system designed to explain the amount and type of resources used during an ambulatory visit. Each EAPG have similar clinical characteristics, resource use , and cost. Inpatient Hospital A nonpsychiatric facility which primarily p rovides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Medical Necessity Procedures, items, or services which prev ent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease, or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without its use the person 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 as defined by OAC 5160-1-01. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilit ation services to sick or injured persons who do not require admission or an overnight stay . Place of Service (POS) Codes Two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Sedation Continuum When patients undergo procedural sedation/analgesia, they enter a sedation continuum. Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest lev el, general anesthesia. o Minimal Sedation (Anxiolysis ) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascul ar functions are unaffected. o Moderate Sedation/Analgesia (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No intervent ions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. o Deep Sedation/Analgesia A drug-induc ed depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depre ssion of neuromuscular function. Cardiovascular function may be impaired. NOTE : Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation sh ould be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. The qualified pra ctitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue th e procedure at an unintended Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesthesia, medical consults). CareSource Dental Benefit s for Ohio Medicaid are administered through our partnereddelegated vendor DentaQuest. Coverage for professional services performed by the dentist/oral surgeon in the POS (ASC or OR/SPU) and reimbursement for these services may be provided through the den tal benefit once approved via the DentaQuest process of dental utilization review for medical necessity of services and requested place of service. Medical necessity criteria and clinical policies are in the respective Dental Office Reference Manual ( DentaQuest ). OAC 5160-2-03(A)(2)(h) states that dental services are only covered in a hospital settin g when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non – hospital outpatient setting and the inpatient or outpatient service is a Medicaid covered service. As such, it would exclude any diagnostic or preventative dental services that could be performed effectively and safely in an ambulatory state, unless patient characteristics and cooperation do not allow it. . CareSource Medical Benefits for Ohio Medicaid are administered directly throughCareSource. Coverage and reimbursement for f acility charges (eg, operating room,anesthesia) related to dental services performed in POS (ASC or OR/SPU), are eligible for coverage and reimbursement under the member’s medical benefit when t he dental services have been approved via the DentaQuest Utilization Management process. The two-step process for dental services and facility services should be followed forobtaining authorization prior to submitting claims for reimbursement:A. Step 1-Dental authorization for services to be performed in a (OR/SPU or ASC) 1. Requests for dental services in POS (19, 21, 22, 24) are submitted by the treating dental provider to the CareSource Ohio Medicaid dental vendor, DentaQues t. The p rovider must incl ude POS on dental claim and add in authorization notes request is for hospital or ASC setting. 2. The dental vendor reviews for appropriate medical necessity requirements [listed in the DentaQuest Office Reference Manual Section 14.05 Criteria for Authorization of Operating Room (OR) Cases] . 3. If the dental authorization is approved, the dental vendor wil l send an automated fax approval letter to the requesting dentist which can additionally be viewed in the DentaQuest provider portal. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 4. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination (Denial Notice) will be iss ued by the dental vendor to the submitting provider. B. Step 2 – Facility precertification process Once dental procedure approval has been obtained, providers are required to administer services at CareSource participating hospitals and must obtain facility precertification. 1. For facility precertification , the facility provider (hospital or ASC) may submit the request on the CareSource Provider Portal at CareSource.com . 2. The Provider may also request a facility precertification by calling CareSource directly at 800.488.0134 and select the option to request an authorization. 3. The facility approval request should include the facility services (ie, operating room charges, anesthesia) requested, the DentaQuest Authorization Approval Letter, and authorization number. 4. The CareSource Medical Utilization Management (UM-MM) team will complete ALL the following: a. Verify that the facility is in network. b. Review the DentaQuest pre-determination letter (PDL) or approved dental authorization and complete adm inistrative approval for facility fee and anesthesia. c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted. d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal. E. Conditions of CoverageFacility reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate code modifiers, if applicable to CareSource. Please refer to the individual fee schedule for appropriate codes. Reimbursement for items assign ed to a dental service EAPG type will be paid as follows: Outpatient Hospital Facility (SPU) POS (19, 22) o Use CPT code 41899 as the facility fee code. Discounting factors – payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. o Use CPT code 00170 for anesthesia when performing intraoral treatments, including biopsy. Time units for physician and CRNA services – both personally performed and medically directed, are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time u nit is rounded to one decimal place. Total minutes are listed as the units (ie, 75 minutes) 75 = 5 units (of 15 min increments). CMS Base units = 5. Maximum state allowances ma y be applicable. Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. Inpatient Hospital Facility POS (21) Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 o All services as well as any additional room and board fees need to be pre-certified and receive medical necessity review. Services are subject to benefit provisions. Ambulatory Surgical Center POS (24) o Use code 41899 for facility fee. Payments for dental s ervices will be made in accordance with the discounting factors as determined by the EAPG grouper. o Use code 00170 for Anesthesia professional services. CPT 00170 is calculated in CMS base units. The base unit = 5 units. See under Hospital section above. Dental/Oral Surgery Professional ServicesThe scope of this policy is limited to medical plan coverage reimbursement codes for facility and/or general anesthesia services provided in conjunction with dental treatment, and not the actual dental or oral surg ery services provided. For information on dental benefits and coding, please consult the partnered dental vendor DentaQuest Office R eference Manual for clinical guidelines, policies, and procedures. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/16/2020 New PolicyDate Revised 01/26/2022 02/14/202406/04 /2025Annual review. Removed dental codes , removed tables, simplified coding information Annual review: adjusted title, updated definitions, policy language, and references, corrected base unit typo. Approved at Committee. Review: updated references, appro ved at Committee. Date Effective 09/01/2025 Date Archived H. References1. Ambulatory Surgery Center (ASC) Services: Provider Eligibility, Coverage, and Reimbursement OHIO ADMIN . CODE 5160-22-01 (202 4). 2. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (20 24 ). 3. Committee on Quality Management and Departmental Administration. Cont inuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. American Society of Anesthesiologists. Updated October 23, 20 24 . Accessed May 1, 2025 . www.asahq.org 4. Conditions and Limitations, OHIO ADMIN . CODE 5160-2-03 (2022). 5. Dental Services, OHIO ADMIN . CODE 5160-5-01 (202 4). 6. General Provisions: Hospital Services, OHIO ADMIN . CODE 5160-2-02 (202 4). 7. Hospital Billing Guidelines . Ohio Dept of Medicaid ; 2021. Accessed May 1, 2 025 . www.medicaid.ohio.gov Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 8. Management of dental patients with special health care needs. Reference Manual ofPediatr ic Dent istry . American Academy of Pediatric Dentistry ; 202 4-2025:343-350 . Accessed May 1, 2025 . www.aapd.org 9. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022). 10. Outpatient Hospital Reimbursement, OHIO ADMIN . CODE 5160-2-75 (202 4). 11. Policy on hospitalization and operating room access for oral care of infants, chi ldren, adolescents, and individuals with special health care needs. Reference Manual of Pediatr ic Dent istry . American Academy of Pediatric Dentistry ; 2024-2025:173-175 . Accessed May 1, 2025 . www.aapd.org 12. Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr ic Dent istry . American Academy of Pediatric Dentistry ; 2024-2025:186-189 . Accessed May 1, 2025 . www.aapd. org Approved ODM 0 6/1 0/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 25-OH MCD-PY-1360 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirement s, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of fun ction, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to s ervices provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-OH MCD-PY-1360Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-digit code that provide a way for physicians and otherqualified health care professionals to indicate that a service or procedure has been altered by som e specific circumstance. Modifier 25 is used to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CPT ) book defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other ser vice. There must be documentation that substantiates the use of modifier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedu re that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Manage ment Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57 for a sur gical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others d o not affect the reimbursement rate. CareSource may verify the use of anymodifier through prepayment and post-payment edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or servic e. All information regarding the use of these modifiers must be made available upon CareSources request. CareSource uses published guidelines from Modifier 25-OH MCD-PY-1360Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedu ral Terminology coding system. Current Procedural Terminology (CPT ) Codes that are issue d, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Evaluation and Management (E/M) A me dical coding process established by Congress that supports medical billing and determines the type and severity of patient conditions. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provid es a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment clinical validation or prepaymen t medical record coding review .A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSo urce will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of claim s. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. Modifier 25-OH MCD-PY-1360Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 VI. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances: A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than t he procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the m inor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the sa me time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with Modifier 25. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry sta ndards, and state compliant codes on allclaims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating pr oviders and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022 New PolicyModifier 25-OH MCD-PY-1360Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Date Revised 08/02/202307/17/2024 06/04/ 2025 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Review: added 99211 statement, updated references, approved at Committee. Date Effective 09/01/2025 Date Archived H. References1. American Medical Association. Reporting CPT modifier 5. CPT Assistant (Online). 2023;33 (11):1-12. Accessed May 13, 2025. www.ama.assn.org 2. Appropriate use of Modifier 25. American College of Cardiology. Accessed May 13, 2025 . www.acc.org 3. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed May 13, 2025 . www.aapc.com 4. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Ma nual for Medicare Services . Centers for Medicare and Medicaid Services; 202 5. Accessed May 13, 2025 . www.cms.gov 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed May 13, 2025 . www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 202 5. Accessed May 13, 2025 . www.cms.gov Approved ODM 06/ 13/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Unlisted and Miscellaneous Codes-OH MCD-PY-1456 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 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 ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Unlisted and Miscellaneous Codes-OH MCD-PY-1456 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectUnlisted and Miscellaneous Codes B. BackgroundCurrent Procedure Terminology (CPT) codes are used to describe medical procedures and physician services. The American Medical Association (AMA) maintains and distributes CPT codes. Health Care Common Procedure Coding System (HCPCS) code set represents items, supplies , and non-physician services not addressed by the CPT codes. The Centers for Medicare and Medicaid Services (CMS) establishes and maintains the HCPCS codes. These code sets w ere established so providers can use the most specific and appropriate code when submitting claims for reimbursement of services rendered to members. Occasionally, a CPT/ HCPCS code may not be available for a procedure or service ifrarely used, unusual , or new. Only then would p roviders use an unlisted, unclassified,not otherwise specified (NOS) , not otherwise classified (NOC) , miscellaneous , or generic code for any such procedure , service , item, suppl y, or non-physician service . C. Definitions Durable Medical Equipment (DME) A collective term for equipment and supplies ordered by a health care provider for everyday or extended use. Miscellaneous ( Unlisted, Unclassified, Not Otherwise Specified (NOS ,) or Not Otherwise Classified [NOC ]) Codes Submitted by a supplier for an item or service for which there is no existing code that adequately describes the item or service being billed. Unlisted Code A code represent ing an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code . D. PolicyI. All unlisted or miscellaneous codes require a medical necessity review prior to the service . II. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.III. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.IV. Medical necessity review submitted for unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration : A. a complete description of the item ( eg, the manufacturer, model or style, size , as applicable ), a list of all bundled components, and an itemization of all charges B. statement that no other code exists that would be more appropriate C. any other information requested by CareSource Unlisted and Miscellaneous Codes-OH MCD-PY-1456 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 V. Unlisted/non-specific codes used for procedures deemed to be experimental and investigational will be reviewed for medical necessity . VI. CareSource may request warranty information regarding the DME item or supply when an unlisted or miscellaneous code is used . If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization. VII. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are commonly used incorrectly. Code DescriptionA4335 Incontinence supply; miscellaneous A4421 Ostomy supply; miscellaneous A9999 Miscellaneous DME supply or accessory, not otherwise specified B9998 Not otherwise classified ( NOC) for enteral supplies E1399 Durable medical equipment, miscellaneous K0108 Wheelchair component or accessory, not otherwise specified Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based on a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guaran teeclaims payment.All unlisted or miscellaneous codes defined within this policy are subject to medicalnecessity review and prior authorization. Prior authorization is not a guarantee of payment. CareSource may verify the use of any code through post-payment audit. If a moreappropriate code is discovered, CareSource may request recoupment.Unlisted and Miscellaneous Codes-OH MCD-PY-1456 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/11/2023 New policy. Approved at Committee.Date Revised 04/09/2025 Periodic review. Updated references. Approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed March 31, 2025 . www.ama-assn.org 2. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN . CODE 5160-10-01 (2024). 3. Healthcare Common Procedure Coding System (HCPCS). American Medical Association. Accessed March 31, 2025 . www.ama-assn.org 4. Medicaid Medical Necessity: Definitions and Principles, O HIO ADMIN . C ODE 5160-1- 01 (2022). Approved ODM 04 /14/202 5
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