OH Med Reimbursement Policy Archived

General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services

Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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.REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 06/01/2025-10/31/2025 Policy Type REIMBURSEMENT Table of Contents A. 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 …………………………………………………………………………………………. 9 H. References …………………………………………………………………………………………………………… 9 General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services B. Background Most dental care can be provided in a traditional dental office setting with local anesthesia and, if medically necessary, a continuum of behavioral 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 anesthesia 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 regulatory requirements. 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 patients may require general anesthesia in 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 these 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 physicians patients. Office setting does not include an office or portion thereof licensed as an ambulatory surgical facility by the Department of Health pursuant to division (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 Two-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 Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the 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 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 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. Practitioners 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.D. Policy I. 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 Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 document should be kept on file. See Appendix A. Provider Questionnaire and Patient Safety Attestation for Dental Sedation/General Anesthesia. II. Office-Based Requirements A. Patient Selection The treating 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 anesthesia provider should be satisfied that 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 of a duration and degree of complexity that will permit the member to recover and be discharged from the facility. 3. Members 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. 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, emergency 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). 2. 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 shall be clearly outlined. For nonhospital facilities, a protocol for the immediate activation of the Emergency 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 initial rescue for life-threatening complications. 3. 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 sedation, deep sedation, and general anesthesia in multiple locations shall be provided to the board. 4. External rescue and emergency services should be available and accessible in a timely manner should they be needed. C. General Monitoring and Patient SafetyGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Equipment used to monitor the member during sedation and anesthesia should be consistent with American 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 resuscitate a nonbreathing and unconscious 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 basis as required by local or state regulation 3. Documentation prior to and during sedation shall include, but not be limited to, the following recommendations: 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. The practitioner should have approved formal education, whether incorporated in the core curriculum or as post-graduate education, consistent and equivalent with the level of sedation and anesthesia required for credentialing and privileging in non-office-based facilities where similar procedures are routinely performed. 2. There must be enough appropriately trained staff to both carry out the procedure and monitor the patient, before, during, and after, with a staffed recovery area in accordance with OAC 4715-5 -05. 3. Pharmaceuticals must be properly stored and maintained, and the 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 functioning as a manufacturer or wholesale distributor of such substances, an appropriate license, 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 General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 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; 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 lasting 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. 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 problemsGeneral Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 associated with uncooperative but otherwise healthy children that would render the member noncompliant 02. severe physical disorders affecting the tongue or jaw movements 03. seizure disorders 04. 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 inadequate 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 anxiety03. apprehensive/frightened child 04. members with special needs 05. extensive and/or complex services 06. members with behavioral or uncooperative challenges 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 Coverage The 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 General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 8 services. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. See corresponding benefit grid for limitation, exclusions, and benefit categories 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 years 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 monitoring 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 monitoring 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 sedation F. Related Policies/RulesDental Services Rendered in Hospital or Ambulatory Surgical Center General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 9 G. Review/Revision History DATE ACTIONDate Issued 04/09/2025 New policy. Approved at Committee. Date Revised Date Effective 06/01/2025 Date Archived 10/31/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. Accreditation of Office Settings, O HIO ADMIN . C ODE 4731-25-07 (2018). 2. American Dental Association. Guidelines for the Use of Sedation and General Anesthesia by Dentists. 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 . C ODE 5160-4- 21 (2024). 7. Conditions and Limitations, O HIO ADMIN . C ODE 5160-2- 03 (2022). 8. Cot, CJ, Wilson S, American Academy of Pediatric Dentistry, American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Ped Dentistry. 2019;41(4):E26-E52. Accessed April 9, 2025. www.aapd.org 9. Definition of Terms, O HIO ADMIN . C ODE 4731-25-01 (2011). 10. Dental Services, O HIO ADMIN . C ODE 5160-5- 01 (2024). 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, O HIO ADMIN . C ODE 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 . C ODE 4729.52 (2020). 14. M edicaid Medical Necessity: Definitions and Principles, O HIO ADMIN . C ODE 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; 2024-2025:435-443. 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 General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 10 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 19. Policy on patient safety. Reference Manual of Pediatric Dentistry. American Academy 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 . C ODE 3719.07 (2019). 22. Standards for Surgery Using Anesthesia Services, O HIO ADMIN . C ODE 4731-25-04 (2018). 23. Standards for Surgery Using Moderate Sedation/Analgesia, O HIO ADMIN . C ODE 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 04/15/2025 General Anesthesia and Monitored Anesthesia Care for Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 11 Appendix A Provider Questionnaire and Safety Attestation for Dental Sedation/General AnesthesiaCareSource 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 someone 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. Code 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 administration 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 dental providers and a supervised team of certified aux iliary 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, will 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 permanently present and in good working order 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 Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the 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 approved sponsor and have 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 Initial 1. 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 standards 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 or 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 Oral and Maxillofacial Surgery and Dental Services-OH MCD-PY-1593 Effective Date: 06/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the 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, expenses, 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):

Laboratory Testing in Office Setting

Obstetrical Care – Unbundled Cost

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 03/01/2025 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 contract (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 ………………………….. ………………………….. ………………………….. ….. 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 7 H. References ………………………….. ………………………….. ………………………….. …………………… 8 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care-Unbundled Cost B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verif y a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology ( CPT )/Healthcare Common ProcedureCoding System ( HCPCS )/International Classification of Disease-10( ICD-10 ) code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply a right to reimbursement or guarantee claims payment. Obstetrical care refers to the health care treatment given in relation to pregnancy anddelivery of a newborn child. This include s care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members r e c e iv e in a h o s p it a l o r b ir t h in g c e n t e r a s we l l 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 CPT codes, HCPCS codes and/or revenue codes. The codes denote servic es and/or procedure s performed. The billed codes must be fully supported in the medical record. Unless otherwise noted, this policy applies only to participating providers and facilities. This policy is for practitioners who meet either of the following: Obstetrical practitioners not part of a free standing birthing center Obstetrical practitioners part of a Free Standing Birthing Center when any of the following occur: o It is the preferred method of billing . o The member has a change of insurer during pregnancy . o The member has received part of the antenatal care elsewhere (eg , from another group practice ). o The member leaves the practitioners group practice before the global obstetrical care is complete . o The member must be referred to a provider from another group practice or a different licensure (eg , midwife to medical doctor) for a cesarean delivery . o The member has an unattended precipitous delivery . Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 o Termination of pregnancy without delivery (eg , miscarriage, ectopic pregnancy) .C. Definitions Initial and Prenatal Visit A practitioner visit to determine whether a member is pregnant. Freestanding Birthing Center (FBC) Birth centers are freestanding facilities that are not considered hospitals , provid ing peripartum care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth . High Risk Delivery Labor management and delivery for an unstable or critically ill pregnant patient. 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. Premature Birth Delivery before 37 weeks of pregnancy is completed. Prenatal Profile Initial laboratory services. Unbundled Obstetrical Care The practitioner bil ls delivery, antepartum care, and postpartum care independently. o Antepartum Care Defines basic care (including obtaining and updating subsequent medical history, physical examination, recording of vital signs, and routine chemical urinalysis) provided monthly up to 28 weeks gestation, biweekly there after up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery Includes admission to a facility, medical history during admission, physical examinations, and management of labor (either by vaginal delivery or by cesarean section). o Postpartum Care The time period that begins on the last day of pregnancy and extends through the end of the month in which the 60 day period following termination of pregnancy ends. The American College of Obstetricians and Gynecologists (ACOG) recommends contact within the first 3 weeks post partum. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile – Evaluation and management (E/M) codes are utilized for t he initial visit , prenatal profile , and antepartum care. B. Risk Appraisal – Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Additional PRAF submissions may be considered on a case by case basis due to special cases where new or changed risk factors are identified and merit additional PRAF submissions. Those cases will be reviewed for medical necessity and appropriate reimbursem ent may occur. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 2. Any eligible woman who meets any of the risk factors listed on the PregnancyRisk Assessment Form (PRAF) is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. C. Unbundled Obstetric Care – The practitioner w ill bill antepartum care, delivery, and postpartum care independently of one another. 1. Antepartum care only – do es not include delivery or postpartum care: a. Use the appropriate E/M code and trimester code(s) . b. Use the appropriate modifier , if applicable . 2. Delivery only – Use if only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code(s): c. Services (This list may not be all inclusive):Services included that may NO Tbe billed separately Services excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Inducing labor using pitocin or oxytocinInjecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as deliveryDelivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of delivery3. Delivery and postpartum care only – If only delivery and postpartum care were provided . a. Use the appropriate CPT and trimester code: b. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately ( this list may not be all inclusive): 01. admission history 02. admission to hospital 03. artificial rupture of membranes 04. care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. hospital/office visits following cesarean section or vaginal delivery 06. management of uncomplicated labor 07. physical exam 08. vaginal delivery with or without episiotomy or forceps 09. caesarean delivery 10. classic cesarean section 11. low cesarean section 12. successful vaginal delivery after previous cesarean delivery 13. previous cesarean delivery member who present s with the expectation of a vaginal delivery CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 14. caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery4. Postpartum care only , if postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one code 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code. This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include and therefore is not allowed to be billed separately for the following (not an all inclusive list ): 01. office and outpatient visits following cesarean section or vaginal delivery 02. qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. conditions unrelated to pregnancy (eg , respiratory tract infection ) 02. treatment and management of complications during the postpartum period that require additional services II. Member EligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner must use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical , or normal hospital evaluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services , including laboratory services , are reimbursable. III. Multiple GestationsA. Include diagnosis code for multiple gestations. B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed. C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. IV. High Risk DeliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 supervision of high-risk pregnancy. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 B. Modifier 22 should be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided.E. Conditions of CoverageReimbursement 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 of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CPT Code DescriptionE/M For antepartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59430 Postpartum care only. 59514 Cesarean delivery only 59515 Cesarean delivery only; including postpartum care 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care F. Related Policies/RulesObstetrical Care-Hospital Admissions Obstetrical Care-Total Cost G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/202110/10/202210/11 /2023 Updated codes, template New title was Preferred Obstetrical Services; policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Clarified who can bill unbundled charges. Revised antepartum language for clarity. Remov ed modifiers. Updated references. Approved at Committee. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 11/20/2024 Annual review. Updated references. Approved at Committee.Date Effective 03/01/2025 Date Archived H. References1. 2024 OB/GYN Coding Manual: Components of Correct Coding . American College of Obstetricians and Gynecologists; 2024. Accessed November 11, 2024. www.acog.org 2. American Academy of Professional Coders. Code obstetrical care with confidence. December 1, 2011. Accessed October 14, 2024. www.aapc.com 2. American College of Obstetricians and Gynecologists. Billing for care after the initial outpatient postpartum visit: the fourth trimester. Accessed October 14, 2024. www.acog.org 3. American College of Obstetricians and Gynecologists. Optimizing postpartum care. Obstet Gynecol . ACOG Committee Opinion No. 736. 2018;131(5):e140-e150. Accessed October 14, 2024. www.acog.org 4. American College of Obstetricians and Gynecologists. Preterm labor and birth. Updated April 2023. Accessed October 14, 2024. www.acog.org 8. Cesarean Delivery on Maternal Request . American College of Obstetricians and Gynecologists; 2019. Committee Opinion No. 761. Reaffirmed 2024. Accessed November 1, 2024. www.acog.org 5. Definitions, OHIO ADMIN . CODE 4723-8-01 (2021). 6. Freestanding Birth Center Services, OHIO ADMIN . CODE 5160-18-01 (2023). 7. Limitations on Elective Obstetric Deliveries, OHIO ADMIN . CODE 5160-1-10 (2015). 8. Management of Late-Term and Postterm Pregnancies . American College of Obstetricians and Gynecologists; 2014. Practice Bulletin No. 146. Accessed November 11, 2024. www.acog.org 9. Medically Indicated Late-Preterm and Early-Term Deliveries . American College of Obstetricians and Gynecologists; 2021. Committee Opinion No. 831. Accessed November 1, 2024. www.acog.org 10. Managed Care: Definitions, OHIO ADMIN . CODE 5160-26-01 (2022). 11. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2011. Revised January 28, 2022. Accessed September 20, 2023. www.medicaid.ohio.gov 12. Reproductive Health Services: Pregnancy-Related Services, OHIO ADMIN . CODE 5160-21-04 (2022). 13. Scope of Specialized Nursing Services, Ohio Rev. Code 4723.43 (2020). Approved by ODM 1 2/12/202 4

Obstetrical Care – Total Cost for Freestanding Birthing Centers

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care – Total Cost for Freestanding Birthing Centers – OH MCD PY-0939 03/01/2025 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 Obstetrical Care – Total Cost for Freestanding Birthing Centers-OH MCD PY-0939 Effective Dat e: 03/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care-Total Cost for Free standing Birthing Centers B. BackgroundObstetrical 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 ofthe 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. Allother 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 revised code as a level one, two, or three 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. PolicyI. 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 Dat e: 03/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 care.B. Risk Appraisal-Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form and will be paid for the completion of the form once during the pregnancy. Use HCPCS code H1000 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 case management 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 (this list may not be all inclusive): a. admission history b. admission to hospital c. artificial 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. fetal heart tones i. hospital/office visits following vaginal delivery j. initial/subsequent history k. management of uncomplicated labor l. physical exams m. recording of weight/blood pressures n. routine chemical urinalysis o. routine prenatal visits p. successful vaginal delivery after previous cesarean delivery q. vaginal delivery with or without episiotomy or forceps . E. Conditions of CoverageReimbursement 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. Obstetrical Care – Total Cost for Freestanding Birthing Centers-OH MCD PY-0939 Effective Dat e: 03/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 CODES DESCRIPTION59400 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 HistoryDATE ACTIONDate Issued 7/22/2020Date Revised 10/26/2022 10/11/202311/06/2024Annual review with e ditorial changes. References updated. Annual review. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Date Effective 03/01/2025 Date Archived H. References1. 202 4 OB/GYN Coding Manual: Components of Correct Coding . American College of Obstetricians and Gynecologists; 202 4. Accessed October 7, 2024 . 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 October 7, 2024. www.acog.org 3. Cesarean Delivery on Maternal Request . American College of Obstetricians and Gynecologists; Reaffirmed 2021 . Committee Opinion No. 761. www.acog.org 4. Definitions, OHIO ADMIN . CODE 4723-8-01 (202 1). 5. Freestanding Birth Center Services, OHIO ADMIN . CODE 5160-18-01 (2023). 6. Limitations on Elective Obstetric Deliveries, OHIO ADMIN . CODE 5160-1-10 (2015). 7. Managed Care: Definitions, OHIO 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 September 20, 2022. 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 October 14, 2024. www.acog.org 10. Mind these modifier 22 dos and donts. American Academy of Professional Coders. April 10, 2006. Accessed October 14, 2024. www.aapc.com 11. Reproductive Health Services: Pregnancy-Related Services, OHIO ADMIN . CODE 5160-21-04 (2022). 12. Caughey AB, et al; American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol . 2014;210(3):179-193. doi:10.1016/j.ajog.2014.01.026 Obstetrical Care – Total Cost for Freestanding Birthing Centers-OH MCD PY-0939 Effective Dat e: 03/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 13. Scope of Specialized Nursing Services, OHIO REV . CODE 4723.43 (2020).Approved by ODM 1 1/21/202 4

Modifier 59, XE, XP, XS, XU

Modifier 25

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 25-OH MCD-PY-1360 11/01/ 2024 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 edit ing 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 p lan 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 s ervices or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body org an 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 aut horization 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 particula r 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 favo rable 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: 11/01/2024The 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. Reimbursemen t 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 some specific circumstance. Modifier 25 is used to report an Evaluation andManage ment (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 signi ficant, 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 service. There must be documentation that substantiates the use of modifier 25 pro vided 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 procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by do cumentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condi tion 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. Thi s modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57 for a surgical 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 do not affect the reimbursement rate. CareSource may verify the use of any modifier through pre payment and post-payment edit or audit. Using a modifierinappropriately 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 CareSource s request. CareSource uses published guidelines fromModifier 25-OH MCD-PY-1360Effective Dat e: 11/01/2024The 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 physicia ns and medical students that maintains the Current Procedural 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 servi ces and procedures. Evaluation and Management (E/M) A medical 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 provides 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 pr ovide 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 flag ged for either a prepayment clinical validation or prepayment 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 claim s. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submi ssion, 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 manageme nt 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: 11/01/2024The 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 th e 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-operativ e 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 the 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 minor procedure since reimbursement for the procedur e 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 same time as a preventative care visit (eg, a prevent ative 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 c linical documentation. 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 standards, 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 providers 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 PolicyDate Revised 08/02/2023 Annual Review: updated references. Approved at Committee Modifier 25-OH MCD-PY-1360Effective Dat e: 11/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 07/17 /2024 Review: updated references, approved at CommitteeDate Effective 11/01/2024 Date Archived H. References1. Appropriate use of Modifier 25. American College of Cardiology. Accessed July 8, 2024 . www.acc.org 2. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed July 8, 2024 . www.aapc.com 3. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . Centers for Medicare and Medicaid Services; 202 4. Accessed July 8, 2024 . www.cms.gov 4. CPT Modifier 25. Palmetto GBA. Accessed July 24, 2023. www.palmettogba.com 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag . 2004;11(9):21-22. Accessed July 8, 2024. www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 2024 . Accessed July 8, 2024 . www.cms.go v Approved ODM 0 7/25/2024

Neonatal Intensive Care Unit (NICU) Level of Care

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 07/01/2024 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 no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude 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 Rei mbursement 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 c ontract (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 mo dify 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 li mitations 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 ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimburseme nt based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitaliz ation will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review proce ss. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities ra ngefrom a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newbornbabies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of ca re that a newborn with specifieddiagnoses and symptoms requires. All four levels of care are represented by a unique revenue code . Any inpatient revenue codes not billed as levels II-IV will be recognized as a level I. Level I = 0171 Level II = 0172 Le vel III = 0173 Level IV = 0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy is not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of care (IOC) Care based on the complexity of care that a ne wborn with specified diagnoses and symptoms requires. Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well baby care services A basic level of care to neona tes who are low risk. D. PolicyI. As per federal mandate, newborn members are covered at an inpatient facility for a 2-day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , preauthori zation is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to provide documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. Wh en a newborn require s a NICU admission or a higher IOC service, a priorauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, a prior authorizati on should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to newborn nursery or pediatric level of care,NICU level of care will not be assigned regardless of interventions completed during transitional time. VI. Clinical review will determine appropriate IOC utilizing MCG standards. CareSourcewill adjust IOC reimbursement if clinical documentation does not support the IOCbilled. VII. Inpatient admissions may be reviewed to ensure that all services are of anappropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued auth orization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria as well as CareSource policy. VIII. In order to avoid reimbursement delay or adjustments, providers are encour aged to reference MCG guidelines as well as the clarifications and specific details below. Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 NICU LevelRevenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 – Routine Care (LOC-010) Level 1 – Neonatal care may be indicated for a newborn or neonate with any of the following: Physiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) who is in need of care consisting of one or more of the following: o Routine newborn care o Evaluation and care of neonates with conditions that require inpatient services available at Level I o Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues, (eg: Sustained weight gain, poor PO feeding ) or e stablishment of safe discharge destination and plan o Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks o Absence of parenteral medications o Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level II Intensity of Care Criteria 2 – Continuing Care (LOC-011)Level 2 – Neonatal care may be indicated for one or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen, ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation (less than 50% of total nutrition) o IV heparin lock medications o IV medications in a physiologically/clinically stable infant o IV treatment of hypoglycemia at a rate less than or equal to 5 mg/kg/min or hypoglycemia that is responsive to one IV dextrose bolus (2 ml/kg or 200mg/kg) Weaning from nasogastric (NG) or naso-jejunal (NJ) tube feedings while attempting to increase oral intake Apnea, bradycardia, or desaturation, but with episodes requiring stimulation, or only self – limited episodes; OR o apnea countdown OR o events requirin g caffeine Services for neonatal abstinence syndrome (NAS) requiring medication (weaning) when the Finnegan score is 8 or less or Eat Sleep Console (ESC) scores are improving Monitor of jaundice during phototherapy requiring frequent lab draws due to high risk etiology Temperature control system, eg, incubator, radiant warmer, in otherwise stable infant Evaluation for sepsis NOT toxic appearing but on antibiotics Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Clinically stable infections completing course of IV medications Continued inpatient care du ring convalescence from condition(s) treated in Level Ill care W ithdrawal of Life support; end of life care; palliative care Level 3 0173: Newborn Level III Intensity of Care Criteria 3 – Intermediate Care (LOC-012)Level 3 – Neonatal care includes Level 2 requirements and one or more of the following: Respiratory support using one of the following: o HFNC with > 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), Nasal intermittent positive pressure ventil ation (NIPPV) o Conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o High-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring Positive pressure ventilation (PPV ) Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring greater than 5 mg/kg/min or hypoglycemia not responsive to one IV dex trose bolus 200 mg/kg or 2 ml/kg of D10W Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) greater than 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia wi th evidence of hemolysis requiring intravenous immunoglobulin (IV IG ) or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermi a Surgica l conditions requiring general anesthesia up to 2 days post-op if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring intravenous fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 – Intensive Care (LOC-013)Level 4 – Neonatal care includes Level 3 requirements and one or more of the following clinical interventions: Perioperative care following surgical repair of severe neonatal conditions, for example: o Bowel resection for necrotizing enterocolitis (NEC) o Tracheoesophageal fistula or esophageal atresia repair o Cardiac surgery excluding PDA ligation o Myelomeningocele closure (up to 48 hours post-op) Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 o Organ transplant Medically necessary inhaled nitric oxide (iNO) Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange tran sfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing intravenous fluid/medication support o Dialysis o IV sedati on that includes paralysis o Prostaglandin infusion Cardiopulmonary resuscitation (CPR ) in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation ( eg , hemolytic anem ia, disseminated intravascular coagulation, hemorrhage) E. Conditions of Coverage I. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align preauthorized levels of care and/ or clinically validate diagnoses, procedures and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care Issue a base DRG payment Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping Request for complete medical records and/or itemized statements to support the services on the claim may be made II. In the event of any conflict between this policy and any written agreement betweenthe provider and CareSource, that written agreement will be the governing document.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/13/2023 New policy . Approved at Committee.Date Revised Date Effective 07/01/2024 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 Date ArchivedH. References1. About preterm labor and birth. National Institutes of Health. Reviewed May 9, 2023. Accessed February 19, 2024. www.nichd.nih.gov 2. Admission to NICU. Specification Manual for Joint Commission National Quality Measures . The Joint Commission; 2022. Version 2023A . Accessed February 19, 2024. www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care: LOC-010 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www .careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care: LOC-011 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care: LOC-012 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care: LOC-013 (ISC GRG). MCG Health. 28th ed. Accessed February 19, 2024. www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Sta ndards for levels of neonatal care: II, III, and IV. Pediatr . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 ODM Approved 03/28/2024

Residential Treatment Services – Substance Use Disorder

REIMBURSEMENT POLICY STATEMENTOhio Medi caid Policy Name & Number Date Effective Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137 07/01/2024 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. Codi ng methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically n ecessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increas ed or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainl y 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 int erpreting 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 hea lth 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 ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectResidential Treatment Services – Substance Use Disorder (SUD) B. BackgroundSubstance Use Disorder (SUD) treatment is dependent on the needs of the member with the type, length, and intensity of treatment determined by the severity of the SUD, 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 int ensive inpatient levels of care, are considered transitional with the goal of returning the member to the community with a less restrictive level of care. Level 3 services include residential and/or inpatient services that are clinically managed or medical ly monitored. Level 4 services include medically managed, intensive inpatient services. Providers use the ASAM level of care criteria as a basis for the provision of SUD benefits to deliver services for the full continuum of care, which also ensures that care isdelivered consistently with industry-standard criteria. ASAM also provides key benchmarks from nationally adopted standards of care and guidelines involving evidence-based treatment measures that guide services. Treatment of substance use disorder s is dependent on an SUD diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) . C. Definitions American Society of Addiction Medicine (ASAM) A professional medical society dedicated to increasing access and improving the quality of addiction treatment, educating p rofessionals and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of pati ents with addiction. 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 rather than medical personn el appropriate for members whose primary problems involve emotional, behavioral, cognitive, readiness to change, relapse, or recovery environment concerns. Intoxication, withdrawal, and biomedical concerns, if present, are safely manageable in a clinically managed service, 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 Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.setting on a 24-hour basis under the direct care of a physician, including psychiatric hospitalization, inpatient detoxification, and emergency evaluation and stabilization. Medically Managed Services Services involving 24-hour nursing and daily medical care by a n appropriately trained and licensed physician providing diagnostic and treatment services directly, managing the provision of those services, or both, particularly under Level 4 medically managed intensive inpatient 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, team 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 or payment made for each day of service based on the sum of the national average routine operating, a ncillary , and capital costs for each patient day of care. Residential Level of Care Services for BH that can include individual, family and group therapy, nursing services, medication assisted treatment, detoxification (ambulatory or subacute) , and phar macological therapy in a congregate living community with 24-hour support. D. PolicyI. A residential program is staffed 24 hours a day and follows nationally recognized medical standards. Programs must meet criteria established in the Ohio Admin istrative Code (OAC) 5122-29-09, including the following (not all-inclusive, see OAC) : A. maintains written policies and pr ocedures ensur ing appropriate referral to other levels of care, including discharge planning and follow-up communications with member and provider(s) documented in the medical record B. employ s practitioners and supervisors of service s who meet OAC 5122-29-30 C. capab le of admitting, initiating, and referring members receiving MAT and facilitating continuity of pharmacotherapy through care transitions D. deliver all component practitioner services in accordance with Chapter 5122-29 of the OAC E. provide developmentally appropr iate services that address education needs and promote family or significant other involvement if serving members under the age of 18 II. A prior authorization (P A) is require d for the following:A. For the 1st and 2nd admissions per calendar year, a PA is only required for an admission exceeding 30 consecutive days. For example, a member goes into residential treatment for the 1st time in a calendar year for a period of 10 days. No PA is required. The same member goes into treatment for a 2nd admissio n during the same calendar year for a Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.period of 38 days. After day 30, the facility is required to obtain a PA for days31 through 38. B. For any stay or admission exceeding 2 admissions per calendar year, a prior authorization is required from the 1st day o f admission. The same member above admits for residential treatment for a 3rd time during the same calendar year. A PA for this admission is required , starting day 1. C. Changes in level of care 1. When step-up or step-down occur s between two SUD r esidenti al level of care 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 two SUD residential level of care codes and billing i s not consecutive, the events will be considered separate events . PAs 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. 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 ste p-up or step-down does require a new/updated PA. D. SUD residential facility transfers 1. Prior authorization is required for a same level of care admission or transfer between 2 SUD residentia l facilities ( national provider identifiers (NPI) and/or tax ide ntification numbers [TIN ]) when the total number of days at that level of care exceeds 30 calendar days and there is not a break in stay that is greater than 24-hours between admissions indicating two separate events . If the admission has already required a PA for any reason, the transition admission will require that a PA be obtained by the receiving facility from the date of admission. 2. Same level of care 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 level of care admission or transfer between 2 SUD residenti al facilities (NPIs and/or TINs) , the admission to the receiving facility is considered a separate event and is subject to a PA 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 to the member at the site in order to bill per diem . B. Medical record s must show evidence of medical necessity of services and follow OAC gui delines . C. Program s must have written Affiliation Agreement s monitored by program Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.policies and procedures to ensure member access to outpatient care in a timely manner upon discharge . IV. B illingA. Residential level of care 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 SUD residential treatment facility associated with signific ant changes in health status, such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in level of care, 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 tax identification number . C. CareSource processes claims from the following: 1. provider type 95 OhioMHAS certified/licensed treatment program 2. 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 seq uence from date of service may cause inappropriate den ials for no prior authorization . 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 re sidential is paid per diem , which do es not include room and board costs and/or p ayments . G. CareSource does not reimburse separately for services provided by the residential treatment service , including 1. ongoing assessments and diagnostic evaluations 2. crisis in tervention 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 level of care at a time. 1. CareSource considers the following services non-billable when a member is in residential level of care : a. therapeutic behavioral services b. psychosocial rehabilitation c. community psychiatric supportive treatment d. mental health day treatment e. assertive community t reatment f. intensive home-based treatment Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2. Select BH 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 Behavioral Health 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 level of care criteria can be found in the OAC , including programs for individuals under age 18, SUD case management, and crisis services. F. Related Polic ies/RulesI. CareSource Policies A. Medical Necessity Determinations B. Behavioral Health Documentation Standards II. Regulations A. Behavioral Health Nursing Services, OHIO ADMIN . CODE 5160-27-11 (2023). B. Behavioral Health Services-Other Licensed Professionals, OHIO ADMIN . CODE 5160-8-05 (2021). C. Certifying Community Mental Health Services or Addiction Services Providers, OHIO REV . CODE 5119.36 (2023). G. Review/Revision HistoryH. 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. DATE ACTIONDate Issued 08/17/2017Date Revised 05/15/2019 09/16/202012/28/202011/30/202101/18/ 202 301/31/2024 Updated definition s, medical necessary criteria, and billing . Updated definition s. A dded 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. Date Effective 07/01/2024 Date Archived Residential Treatment Services – Substance Use Disorder-OH MCD-PY-0137Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.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. Inpatient psychiatric facility PPS . Centers for Medicare and Medicaid Services. Updated September 6, 2023. Accessed December 2 7, 202 3. www.cms.gov 6. Medicaid Behavioral Health State Plan Services Provider Req uirements and Reimbursement Manual . Ohio Dept of Medicaid; 2023. Accessed December 27, 2023. www.medicaid.ohio.gov 7. Residential and Withdrawal Management Substance Use Disorder Services, OHIO ADMIN . CODE 5122-29-09 (2023). 8. Statutes, regulations, and guidelines. Substance Abuse and Mental Health Services Administration. Updated September 28, 2023. Accessed December 27, 2 023. www.samhsa.gov 9. Substance-Related Disorders, Residential Behavioral Health Level of Care, Adult: B-903-RES. 27 th ed., MCG Health. Updated September 21, 2023. Accessed December 27, 2023. www.careweb.careguidelines.com 10. Substance-Related Disorders, Residential Behavioral Health Level of Care, Child or Adolescent: B-907-RES. 27 th ed., MCG Health. Updated September 21, 20 23. Accessed December 27, 2023. www.careweb.careguidelines.com 11. Substance-Related Disorders, Residential Care: B-015-RES. 27 th ed., MCG Health. Updated September 21, 2023. Accessed December 27, 2023. www.careweb.careguidelines.com 12. Substance Use Disorder Qua lified Residential Treatment Program (QRTP) for Youth, OHIO ADMIN . CODE 5122-29-09.1 (2022). 13. Substance Use Disorder Treatment Services, OHIO ADMIN . CODE 5160-27-09 (2021). 14. Withdrawal Management, Adult, Residential Care: B-031-RES. 27 th ed., MCG Health. Updated September 21, 2023. Accessed December 27, 2023. www.careweb.careguidelines.com Approved by Oh io Dep t of Medicaid 03/28/2024

Interest Payments

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments-OH MCD-PY-1324 06/01/2024 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 suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude 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 Rei mbursement 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 c ontract (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 (MHP AEA), 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 ………………………………………………………………………………………… 2 F. Related Policies/R ules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-OH MCD-PY-1324 Effective Date: 06/01/2024 The REIMBURSEMENTPolic 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 REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/H CPCS/ICD-10 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. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party and do not include payments made to a provider of service or a third party where the timing of the payment is not directly related to submission of a completed claim by the provider of service or third party. A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. II. In alignment with the Ohio Administrative Code and the Medicaid Provider Agreement, CareSource does not pay interest on Ohio Medicaid claims. 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 f ee schedule for appropriate codes. Interest Payments-OH MCD-PY-1324 Effective Date: 06/01/2024 The REIMBURSEMENTPolicy 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.3F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 01/05/2022 04/27/2022 04/ 12/2023 01/31/2024Updated language and references per Legal. No change; did for review cycle consistency No change; updated references. Approved at Committee. No change; updated references. Approved at Committee.Date Effective 06/01/2024 Date Archived H. References1. Definitions, O HIO REV . CODE 5164.01(C) (2023 ). 2. Ohio Medicaid Contract, Appendix J, 4. Accessed January 2, 2024. www.managedcare.medicaid.ohio.gov 3. Timely Claims Payment, 42 C.F.R. 447.45(b) (2022). Approved by ODM 2/29/2024

Dental Services Rendered in a Hospital or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 06/01/2024-08/31/2025 Policy Type REIMBURSEMENT Rei mbursement Policies prepared by CareSource, and its affiliates are intended to provide a general reference regarding billing, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. These policies are designed to assist providers and facilities submitting claims to CareSource. The policies are routinely updated to promote accurate coding and clarification. 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 pl an contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Rei mbursement 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, authorization, notification, and utilization management guidelines. Medically necessary services include, but are not limited to, those heal th 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 suffer 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 local area, are the lowest cost alternative, and are not provided for the convenience of the member or provider. Medically necessar y 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. Heal th 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 Coding 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 under this policy. Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 4 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6H. References …………………………………………………………………………………………………………… 6Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. Background The 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 procedures 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 to advanced 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, positive 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 certified 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 general 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 provides 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 prevent, 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 or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation 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 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. oModerate 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.oDeep 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 require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.oGeneral 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 depression 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 should 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 practitioner 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 the procedure at an unintended level of sedation.Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 Short Procedure Unit (SPU) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services.D. Policy This 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 Benefits for Ohio Medicaid are administered through our partnered delegated 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 dental 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 setting 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 through CareSource. Coverage and reimbursement for facility 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 the dental services have been approved via the DentaQuest Utilization Management process. The two-step process for dental services and facility services should be followed for obtaining 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, DentaQuest. The provider must include 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 forAuthorization of Operating Room (OR) Cases].3. If the dental authorization is approved, the dental vendor will send an automated fax approval letter to the requesting dentist which can additionally be viewed in the DentaQuest provider portal. 4. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination (Denial Notice) will be issued by the dental vendor to the submitting provider. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 B. Step 2-Facility precertification processOnce 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 administrative 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 Coverage Facility 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 assigned 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 unit 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 may be applicable. P ayment 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) 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. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 Ambulatory Surgical Center POS (24)o Use code 41899 for facility fee. Payments for dental services 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 i n C MS base units. The base unit = 5 units. See under Hospital section above.D ental/Oral Surgery Professional Services The 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 surgery services provided. For information on dental benefits and coding, please consult the partnered dental vendor DentaQuest Office Reference Manual for clinical guidelines, policies, and procedures. F.Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 09/16/2020 New Policy Date Revised 01/26/2022 02/14/2024 Annual 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. Date Effective 06/01 /2024 Date Archived 08/31/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1. Ambulatory Surgery Center (ASC) Services: Provider Eligibility, Coverage, and R eimbursement O HIO ADMIN . C ODE 5160-22-01 (2020).2. Anesthesia Services, O HIO ADMIN . C ODE 5160-4- 21 (2017).3. Committee on Quality Management and Departmental Administration. Continuum ofDepth of Sedation: Definition of General Anesthesia and Levels ofSedation/Analgesia. American Society of Anesthesiologists. Updated October 23,2019. Accessed February 7, 2024. www.asahq.org 4. C onditions and Limitations, O HIO ADMIN . C ODE 5160-2- 03 (2022).5. Dental Services, O HIO ADMIN . C ODE 5160-5- 01 (2022).6. General Provisions: Hospital Services, O HIO ADMIN . C ODE 5160-2- 02 (2022).7. Hospital Billing Guidelines . Ohio Dept of Medicaid; 2021. Accessed January 31,2024. www.medicaid.ohio.gov 8. M anagement of dental patients with special health care needs. Reference Manual ofPediatric Dentistry . American Academy of Pediatric Dentistry; 2023:337-344. Dental Services Rendered in a Hospital or Ambulatory Surgery Center-OH MCD-PY-1244 Effective Date: 06/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 Accessed February 13, 2024. www.aapd.org 9. Medicaid Medical Necessity: Definitions and Principles, O HIO ADMIN . C ODE 5160-1-01 (2022).10. Outpatient Hospital Reimbursement, O HIO ADMIN . C ODE 5160-2- 75 (2020).11. Policy on hospitalization and operating room access for oral care of infants, children,adolescents, and individuals with special health care needs. Reference Manual ofPediatric Dentistry . American Academy of Pediatric Dentistry; 2023:169-170. Accessed February 13, 2024. www.aapd.org 1 2. Policy on third-party reimbursement for management of patients with special healt h c are needs. Reference Manual of Pediatric Dentistry . American Academy ofPediatric Dentistry; 2023:181-184. Accessed February 13, 2024. www.aapd.org Approved ODM 03/07/2024

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