Laboratory Testing in Office Setting

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Laboratory Testing in Office Setting-OH MCD-PY-1545 10/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 8 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectLaboratory Testing in Office Setting B. BackgroundDuring the course of an office visit with a physician or other qualified healthcare provider, the provider may determine that diagnostic laboratory testing is necessary to establish a diagnosis and/or determine treatment options to manage the members current health issues. W hile most laboratory tests are best performed by an independent laboratory, in some instances, results from these laboratory tests are needed immediately to manage urgent medical conditions or medical emergencies and may be performed appropriately in the p hysicians office. Due to the complexity of laboratory tests and regulations around facilities that perform these tests, only laboratory procedures on the STAT lab list may be performed in the office, while all other tests should be referred to an independ ent, contracted lab provider. C. Definitions Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Laboratory A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for th e diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories. Laboratory Procedures Defined in the Current Procedural Terminology (CPT) in the ranges 80300 through 89398 and panels 80047 through 80076 . D. PolicyI. Codes managed by a vendor (eg, Avalon) should not be affected by this policy. II. CareSource will reimburse for laboratory procedures performed in the physicians office when ALL the following apply:A. The test results are needed immediately in order to manage urgent or emergent medical situations. B. The CPT code for the test is on the short turnaround time (STAT) code list. C. The place of service (POS) 11 is used. III. All other laboratory procedures performed in the office may not be reimbursed and should be referred to an independent, contracted laboratory provider. IV. This policy does not apply to Community Mental Health C enters .Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 E. Conditions of CoverageIt is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Please refer to the individual fee schedule for appropriate codes. Place of Service (POS) CodeDescription 11 – Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examina tions, diagnosis, and treatment of illness or injury on an ambulatory basis STAT Code ListCPT / HCPCS Description 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), includes titer(s), when performed 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when pe rformed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perf ormed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry eith er with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC – MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 80324 Amphetamines; 1 or 2 80325 Amphetamines; 3 or 4 80326 Amphetamines; 5 or more 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 80331 Analgesics, non-opioid; 6 or more 80332 Antidepressants, serotonergic class; 1 or 2 80333 Antidepressants, serotonergic class; 3-5 Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 80334 Antidepressants, serotonergic class; 6 or more80335 Antidepressants, tricyclic and other cyclicals; 1 or 280336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepileptics, not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Methylphenidate 80361 Opiates, 1 or more 80362 Opioids and opiate analogs; 1 or 2 80363 Opioids and opiate analogs; 3 or 4 80364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 80375 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 80376 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81015 Urinalysis; microscopic only 81025 Urine pregnancy test, by visual color comparison methods 82043 Albumin; urine (eg, microalbumin), quantitative 82044 Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) 82247 Bilirubin; total 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82271 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82465 Cholesterol, serum or whole blood, total 82565 Creatinine; blood 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82947 Glucose; quantitative, blood (except reagent strip) 82948 Glucose; blood, reagent strip 82950 Glucose; post glucose dose (includes glucose) 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 82952 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 83036 Hemoglobin; glycosylated (A1C) 83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use 83655 Lead 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83986 pH; body fluid, not otherwise specified 83992 Phencyclidine (PCP) 84132 Potassium; serum, plasma or whole blood 84703 Gonadotropin, chorionic (hCG); qualitative 85013 Blood count; spun microhematocrit 85014 Blood count; hematocrit (Hct) 85018 Blood count; hemoglobin (Hgb) 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 85049 Blood count; platelet, automated85610 Prothrombin time;85651 Sedimentation rate, erythrocyte; non-automated 86308 Heterophile antibodies; screening 86318 Immunoassay for infectious agent antibody(ies ), qualitative or semiquantitative, single-step method (eg, reagent strip); 86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV – 2) (coronavirus disease [COVID-19]) 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); titer 86580 Skin test; tuberculosis, intradermal 86756 Antibody; respiratory syncytial virus 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 87172 Pinworm exam (eg, cellophane tape prep) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87301 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41 87400 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each 87420 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; respiratory syncytial virus 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respi ratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respi ratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87430 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus, group A87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription , when performed, and multiplex amplified probe technique, first 2 types or sub-types 87503 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcr iption, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure 87631 Infectious agent detection by nucleic acid (DNA or RNA) ; respiratory virus (eg, adenovirus, influenza virus, coronavirus, me tapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or sub-types, 3-5 targets 87634 Infectious agent detection by nucleic acid (DNA or RNA) ; respiratory syncytial virus, amplified probe technique 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique 87636 Infectious agent detection by nucleic acid (DNA or RNA) ; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique 87637 Infectious agent detection by nucleic acid (DNA or RNA) ; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique 87650 Infectious agent detection by nucleic acid (DNA or RNA) ; Streptococcus, group A, direct probe technique 87651 Infectious agent detection by nucleic acid (DNA or RNA) ; St reptococcus, group A, amplified probe technique 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B 87803 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Clostridium difficile toxin A 87804 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 87806 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 87808 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Trichomonas vaginalis Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual)observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87880 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standar ds in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/M S (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all so urces, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (an y type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes Q0111 Wet mounts, including preparations of vaginal, cervical or skin specimens Q0112 All potassium hydroxide (KOH) preparations U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel U0002 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/25/2024 New policy, approved at Committee.Date Revised 12/18/2024 Review: removed CLIA and QW modifier from policy. Approved at Committee.Laboratory Testing in Office Setting-OH MCD-PY-1545Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 05/07/2025 Review: added D.III, updated code list and references,approved at Committee. Date Effective 10/01/2025 Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed May 5 , 2025. www.ama-assn.org 2. Definitions, OHIO ADMIN CODE 3701-32-01 (2021). 3. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions, 42 U.S.C. 410.32 ( 2023 ). 4. Healthcare Common Procedure Coding System (HCPCS). Accessed May 5, 2025. www.nlm.nih.gov 5. Laboratory Requirements, 42 U.S.C. 493 ( 2023 ). 6. Laboratory Services, 42 U.S.C. 441.17 ( 2023 ). 7. Laboratory Services, OHIO ADMIN CODE 5160-11-11 (2021). 8. Managed Care: Provider Network and Contracting Requirements, OHIO ADMIN CODE 5160-26-05 (2022). 9. Other Laboratory and X-Ray Services, 42 U.S.C. 440.30 ( 2023 ). 10. Place of Service Code Set. Centers for Medicare and Medicaid Services; 202 5. Accessed April 30, 2025 . www.cms.gov ODM approved 07/10/2025

Dental Services Rendered In A Hospital Or Ambulatory Surgery Center

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Dental Services Rendered in a Hospital or Ambulatory Surgery Center – OH MCD-PY-1244 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource, and its affiliates are intended to provide a general reference regarding billi ng, coding, and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, bene fits design and other factors are considered in developing Reimbursement Policies. These policies are designed to assist providers and facilities submitting claims to CareSource. The policies are routinely updated to promote accurate coding and clarificati on. These proprietary policies are not a guarantee of payment. This Policy does not ensure an authorization or reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service( s) referenced herein . If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and any applicable referral, authorizatio n, notification, and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and wit hout which the patient can be expected to s uffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services must meet the standards of good clinical practice in the l ocal area, are the lowest cost alternati ve, and are not provided for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Prior authorization is required for certain services. If authorization is not obtained prior to performing the service, CareSource may not reimburse for the procedure. Health care providers and their office staff are encouraged to use the self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology/Healthcare Common Procedure Codin g System (CPT/HCPCS) code(s) for the medical product or service being provided and the appropriate Current Dental Terminology (CDT) code(s) for the dental product or service. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee for a submitted claim payment. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered und er this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 4 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDental Services Rendered in a Hospital or Ambulatory Surgery Center B. BackgroundThe decision to perform dental care in a particular place of service is based on a wide variety of factors, including the age and special health care needs (physical, intellectual, and developmental disabilities or long-term medical conditions) of the individual, in addition to the type, number , and complexity of procedure s planned. These factors also determine the type of anesthesia used during the procedure. Most dental care can be provided in a dental office setting with local anesthesia or local anesthesia supplemented with non-pharmacological behavior guidance (basic toadvanced techniques) and/or pharmacological options. Basic non-pharmacological behavior guidance includes communication guidance, positive pre-visit imagery, direct observation, tell-show-do, ask-tell-ask, voice control, non-verbal communication, posit ive reinforcement and descriptive praise, distraction, and desensitization. Pharmacological options may include nitrous oxide, oral conscious sedation and intravenous (IV) sedation (mild, moderate, or deep) , or monitored general anesthesia by trained certi fied individuals in each level of sedation dentistry. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require the use of gener al anesthesia as medically necessary in a healthcare facility, such as an ambulatory surgical center , hospital operating room , or short procedure unit (SPU). C. Definitions Ambulatory Surgical Center (ASC) Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization that meets all criteria of Ohio Administrative Code (OAC) 5160-22-01. Enhanced Ambulatory Patient Groups (EAPGs ) A patient classification system designed to explain the amount and type of resources used during an ambulatory visit. Each EAPG have similar clinical characteristics, resource use , and cost. Inpatient Hospital A nonpsychiatric facility which primarily p rovides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Medical Necessity Procedures, items, or services which prev ent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease, or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without its use the person can be expected to suffer prolonged, increased, or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort as defined by OAC 5160-1-01. Monitored Anesthesia Care (MAC) A specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Outpatient Hospital A facility which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilit ation services to sick or injured persons who do not require admission or an overnight stay . Place of Service (POS) Codes Two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. Sedation Continuum When patients undergo procedural sedation/analgesia, they enter a sedation continuum. Several levels have been formally defined along this continuum: minimal sedation/anxiolysis, moderate sedation, deep sedation, and at the deepest lev el, general anesthesia. o Minimal Sedation (Anxiolysis ) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascul ar functions are unaffected. o Moderate Sedation/Analgesia (Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No intervent ions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. o Deep Sedation/Analgesia A drug-induc ed depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. o General Anesthesia A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depre ssion of neuromuscular function. Cardiovascular function may be impaired. NOTE : Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation sh ould be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation should be able to rescue patients who enter a state of deep sedation, while those administering deep sedation should be able to rescue patients who enter a state of general anesthesia. Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced cardiac life support. The qualified pra ctitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue th e procedure at an unintended Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 level of sedation. Short Procedure Unit (SPU ) A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic, or medical services. D. PolicyThis policy is intended to provide guidance on the process for obtaining authorization and reimbursement for dental services performed in a place of service (ASC or hospital OR/SPU) and reimbursement for related facility charges (eg, operating room, anesthesia, medical consults). CareSource Dental Benefit s for Ohio Medicaid are administered through our partnereddelegated vendor DentaQuest. Coverage for professional services performed by the dentist/oral surgeon in the POS (ASC or OR/SPU) and reimbursement for these services may be provided through the den tal benefit once approved via the DentaQuest process of dental utilization review for medical necessity of services and requested place of service. Medical necessity criteria and clinical policies are in the respective Dental Office Reference Manual ( DentaQuest ). OAC 5160-2-03(A)(2)(h) states that dental services are only covered in a hospital settin g when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non – hospital outpatient setting and the inpatient or outpatient service is a Medicaid covered service. As such, it would exclude any diagnostic or preventative dental services that could be performed effectively and safely in an ambulatory state, unless patient characteristics and cooperation do not allow it. . CareSource Medical Benefits for Ohio Medicaid are administered directly throughCareSource. Coverage and reimbursement for f acility charges (eg, operating room,anesthesia) related to dental services performed in POS (ASC or OR/SPU), are eligible for coverage and reimbursement under the member’s medical benefit when t he dental services have been approved via the DentaQuest Utilization Management process. The two-step process for dental services and facility services should be followed forobtaining authorization prior to submitting claims for reimbursement:A. Step 1-Dental authorization for services to be performed in a (OR/SPU or ASC) 1. Requests for dental services in POS (19, 21, 22, 24) are submitted by the treating dental provider to the CareSource Ohio Medicaid dental vendor, DentaQues t. The p rovider must incl ude POS on dental claim and add in authorization notes request is for hospital or ASC setting. 2. The dental vendor reviews for appropriate medical necessity requirements [listed in the DentaQuest Office Reference Manual Section 14.05 Criteria for Authorization of Operating Room (OR) Cases] . 3. If the dental authorization is approved, the dental vendor wil l send an automated fax approval letter to the requesting dentist which can additionally be viewed in the DentaQuest provider portal. Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 4. If the dental authorization request is not approved, a Notice of Adverse Benefit Determination (Denial Notice) will be iss ued by the dental vendor to the submitting provider. B. Step 2 – Facility precertification process Once dental procedure approval has been obtained, providers are required to administer services at CareSource participating hospitals and must obtain facility precertification. 1. For facility precertification , the facility provider (hospital or ASC) may submit the request on the CareSource Provider Portal at CareSource.com . 2. The Provider may also request a facility precertification by calling CareSource directly at 800.488.0134 and select the option to request an authorization. 3. The facility approval request should include the facility services (ie, operating room charges, anesthesia) requested, the DentaQuest Authorization Approval Letter, and authorization number. 4. The CareSource Medical Utilization Management (UM-MM) team will complete ALL the following: a. Verify that the facility is in network. b. Review the DentaQuest pre-determination letter (PDL) or approved dental authorization and complete adm inistrative approval for facility fee and anesthesia. c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted. d. Fax a Facility Approval to the hospital/ASC which can also be viewed in the CareSource Provider Portal. E. Conditions of CoverageFacility reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate code modifiers, if applicable to CareSource. Please refer to the individual fee schedule for appropriate codes. Reimbursement for items assign ed to a dental service EAPG type will be paid as follows: Outpatient Hospital Facility (SPU) POS (19, 22) o Use CPT code 41899 as the facility fee code. Discounting factors – payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. o Use CPT code 00170 for anesthesia when performing intraoral treatments, including biopsy. Time units for physician and CRNA services – both personally performed and medically directed, are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time u nit is rounded to one decimal place. Total minutes are listed as the units (ie, 75 minutes) 75 = 5 units (of 15 min increments). CMS Base units = 5. Maximum state allowances ma y be applicable. Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. Inpatient Hospital Facility POS (21) Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 o All services as well as any additional room and board fees need to be pre-certified and receive medical necessity review. Services are subject to benefit provisions. Ambulatory Surgical Center POS (24) o Use code 41899 for facility fee. Payments for dental s ervices will be made in accordance with the discounting factors as determined by the EAPG grouper. o Use code 00170 for Anesthesia professional services. CPT 00170 is calculated in CMS base units. The base unit = 5 units. See under Hospital section above. Dental/Oral Surgery Professional ServicesThe scope of this policy is limited to medical plan coverage reimbursement codes for facility and/or general anesthesia services provided in conjunction with dental treatment, and not the actual dental or oral surg ery services provided. For information on dental benefits and coding, please consult the partnered dental vendor DentaQuest Office R eference Manual for clinical guidelines, policies, and procedures. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/16/2020 New PolicyDate Revised 01/26/2022 02/14/202406/04 /2025Annual review. Removed dental codes , removed tables, simplified coding information Annual review: adjusted title, updated definitions, policy language, and references, corrected base unit typo. Approved at Committee. Review: updated references, appro ved at Committee. Date Effective 09/01/2025 Date Archived H. References1. Ambulatory Surgery Center (ASC) Services: Provider Eligibility, Coverage, and Reimbursement OHIO ADMIN . CODE 5160-22-01 (202 4). 2. Anesthesia Services, OHIO ADMIN . CODE 5160-4-21 (20 24 ). 3. Committee on Quality Management and Departmental Administration. Cont inuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. American Society of Anesthesiologists. Updated October 23, 20 24 . Accessed May 1, 2025 . www.asahq.org 4. Conditions and Limitations, OHIO ADMIN . CODE 5160-2-03 (2022). 5. Dental Services, OHIO ADMIN . CODE 5160-5-01 (202 4). 6. General Provisions: Hospital Services, OHIO ADMIN . CODE 5160-2-02 (202 4). 7. Hospital Billing Guidelines . Ohio Dept of Medicaid ; 2021. Accessed May 1, 2 025 . www.medicaid.ohio.gov Dental Services Rendered in a Hospital orAmbulatory Surgery Center-OH MCD-PY-1244Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 8. Management of dental patients with special health care needs. Reference Manual ofPediatr ic Dent istry . American Academy of Pediatric Dentistry ; 202 4-2025:343-350 . Accessed May 1, 2025 . www.aapd.org 9. Medicaid Medical Necessity: Definitions and Principles, OHIO ADMIN . CODE 5160-1- 01 (2022). 10. Outpatient Hospital Reimbursement, OHIO ADMIN . CODE 5160-2-75 (202 4). 11. Policy on hospitalization and operating room access for oral care of infants, chi ldren, adolescents, and individuals with special health care needs. Reference Manual of Pediatr ic Dent istry . American Academy of Pediatric Dentistry ; 2024-2025:173-175 . Accessed May 1, 2025 . www.aapd.org 12. Policy on third-party reimbursement for management of patients with special health care needs. Reference Manual of Pediatr ic Dent istry . American Academy of Pediatric Dentistry ; 2024-2025:186-189 . Accessed May 1, 2025 . www.aapd. org Approved ODM 0 6/1 0/2025

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):

Neonatal Intensive Care Unit (NICU) Level of Care

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 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD – PY-1430 07/01/2025-01/31/2026 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 6 F. Related Policies/Rules ……………………………………………………………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 7 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of CareB. Background This 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 reimbursement 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 hospitalization 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 process. 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 range from 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 newborn babies 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 care that a newborn with specified diagnoses and symptoms require. All four levels of care are represented by a unique revenue code. Any inpatient revenue codes not billed as levels 2-4 will be recognized as level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=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 are not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms requires. Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Newborn Care Services 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 neonates who are low risk.D. PolicyI. 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 revenue codes 0170/0171 and 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), authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to submit documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn requires a NICU admission or a higher IOC service, an authorization is required. IV. If a complication develops with the mother or baby that necessitates additional hospital days, NICU admission, or non-well-baby service, an authorization 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. CareSource will adjust IOC reimbursement if clinical documentation does not support the IOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate 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 authorization 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 encouraged 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 Date: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 NICU Level Revenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care (LOC-010) Neonatal care may be indicated for the physiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn careEvaluation and care of neonates with conditions that require inpatient services availabl e at Level I 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 POfeeding), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medicationsEvaluation and management of glucose levels without IV fluids, diagnostic 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) Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen ( 2L/min), with other co-morbidities stableAdministration of intravenous (IV) medicationsIV Therapy; peripheral or PICCo IV fluids inclusive of hyperalimentation ( 2 L/minute of blended oxygen, continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation (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 PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min of IV treatment or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG 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 hypothermia Surgical 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 IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013) Includes Level 3 requirements and 1 or more of the following: 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) o organ transplant Medically necessary inhaled nitric oxide (iNO) Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 E.Conditions of Coverage I. Reimbursement is independent of the location of care and corresponds to t he m edical treatment provided and level of service the neonate requires. To ensur e ac curate reimbursement, submitted claims will be reviewed to align with authoriz ed l evels 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 careIssue a base DRG paymentAdjust claim diagnoses/procedures that are not substantiated in the medica l i nformation provided and apply DRG regrouping,A request for complete medical records and/or itemized statements to support the services on the claim may be madeII. In the event of any conflict between this policy and any written agreement betw een t he provider and CareSource, that written agreement will be the governi ng doc ument. F.Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 03/13/2023 New policy. Approved at Committee. Date Revised 03/12/2025 Periodic review. Updated definitions, section D. and references. Approved at Committee. Date Effective 07/01/2025 Date Archived 01/31/2026 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. Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week)Therapeutic coolingExchange transfusion (day of procedure)Uncontrolled active seizures despite medicationsOngoing cardiovascular support (inotropes, chronotropes, antiarrhythmics)Severe hemodynamic instability requiring ongoing IV fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusionCPR 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 anemia, disseminated intravascular coagulation, hemorrhage) Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Date: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 H.R eferences 1. About preterm labor and birth. National Institutes of Health (NIH). Reviewed May 9,2023. Accessed January 30, 2025. www.nichd.nih.gov2. A dmission to NICU. Specification Manual for Joint Commission National QualityMeasures . The Joint Commission; 2024. Version 2024B1. www.manual.jointcommission.org3. I ntensity of Care Criteria 1-Routine Care. LOC-010 (ISC GRG). MCG Health. 28t h ed. Accessed January 30, 2025. www.careweb.careguidelines.com4. Intensity of Care Criteria 2-Continuing Care. LOC-011 (ISC GRG). MCG Health.28th ed. Accessed January 30, 2025. www.careweb.careguidelines.com5. I ntensity of Care Criteria 3-Intermediate Care. LOC-012 (ISC GRG). MCG Health.28th ed. Accessed January 30, 2025. www.careweb.careguidelines.com6. I ntensity of Care Criteria 4-Intensive Care. LOC-013 (ISC GRG). MCG Health. 28t h ed. Accessed January 30, 2025. www.careweb.careguidelines.com7.St ark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III,and IV. Pediatrics . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 Approved ODM 03/20/2025

Obstetrical Care – Unbundled Cost

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 05/01/2025 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: 05/01/2025The 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 and delivery 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 services 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: 05/01/2025The 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 . Providers are encouraged to submit a PRAF any time there is a change in condition during the pregnancy. Please use code H1000 and append modifier 33 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the Pregnancy Risk 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. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Note: CareSource follows the Ohio Department of Medicaid (ODM) guidance regarding PRAF and can be submitted during any pregnancy stage according to ODM . Beginning 4/1/2025 ODM will allow PRAF submissions for Postpartum care . 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 deliveryCPT 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: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Classic cesarean sectionLow cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as delivery Delivery 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 delivery 3. 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 CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 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: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 13. previous cesarean delivery member who present s with the expectation of a vaginal delivery 14. caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery 4. 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 DeliveriesObstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 A. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 supervision of high-risk pregnancy.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 09/15/2021Updated codes, templateNew 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. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 10/10/202210/11 /2023 11/20/2024 01/15/2025 Revised antepartum language for clarity. Remov ed modifiers. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Updated D.I.B.1. Approved at Committee. Date Effective 05/01/2025 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). ODM Approved on 01/23/2025

Transcutaneous Electrical Nerve Stimulators (TENS)

REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -OH MCD-PY-0039 04/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to p rovide 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, 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 t he 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 Addi ction 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 ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Transcutaneous Electrical Nerve Stimulat ors (TENS) -OH MCD-PY-0039Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulat ors (TENS) B. BackgroundTranscutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin. C. Definitions Accessories A collective term that encompasses but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches , and covers. Supplies A collective term that encompasses but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries , and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. D. PolicyI. CareSource may require medical necessity r eview for a TENS unit. CareSource follows the Ohio Administrative Code for clinical criteria for the following devices: A. E0720 Two-lead unit B. E0730 Four-lead unit II. SuppliesA. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase due to the necessity of continued treatment, the following apply: 1. Separate payment may be made for necessary supplies, which must be dispensed only when needed . 2. CareSource covers 1 unit of su pplies (A4595) per month for a 2-lead TENS unit (E0720) and 2 units per month for a 4-lead TENS unit (E0730). 3. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 4. Separat e payment is not provided for individual supply items. D. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and Transcutaneous Electrical Nerve Stimulat ors (TENS) -OH MCD-PY-0039Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 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.HCPCS Code DescriptionE0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers DescriptionNU Purchase of new equipmentRR Rental (use the ‘RR’ modifier when DME is to be rented) F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09/16/2020 07/15/2022 12/13/202312/18 /2024Updated policy to align with OAC updates . Updated prior authorization requirement. PGC approved via electronic vote. Revised background information. Updated references. Annual review: rearranged criteria, updated references. Approved at Committee. Review: removed PA language, updated references, approved at Committee . Date Effective 04/01/2025 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS) , OHIO ADMIN . CODE 5160-10-01 (202 4). 2. DMEPOS: Transcutaneous Electrical Nerve Stimulation (TENS) Units , OHIO ADMIN . CODE 5160-10-15 ( 20 24 ). 3. Gibson W, Wand BM, Meads C, et al . Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane Reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 4. Johnson MI, Pal ey CA, Wittkopf PG, et al . Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: Transcutaneous Electrical Nerve Stimulat ors (TENS) -OH MCD-PY-0039Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 a secondary analysis of the meta-TENS study to improve future research. Medicina(Kaunas) . 2022;58(6):803. doi:10.3390/medicina58060803 5. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina . 2022;58(10):1332. doi:10.3390/medicina58101332 ODM Approved 01/ 09/2025

Laboratory Testing in Office Setting

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 Laboratory Testing in Office Setting-OH MCD-PY-1545 04/01/2025-09/30/2025 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 2 F. Related Policies/Rules ……………………………………………………………………………………………. 8 G. Review/Revision History …………………………………………………………………………………………. 8 H. References …………………………………………………………………………………………………………… 8 Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectLaboratory Testing in Office SettingB. Background During the course of an office visit with a physician or other qualified healthcare provider, the provider may determine that diagnostic laboratory testing is necessary to establish a diagnosis and/or determine treatment options to manage the members current health issues. While most laboratory tests are best performed by an independent laboratory, in some instances, results from these laboratory tests are needed immediately to manage urgent medical conditions or medical emergencies and may be performed appropriately in the physicians office. Due to the complexity of laboratory tests and regulations around facilities that perform these tests, only laboratory procedures on the STAT lab list may be performed in the office, while all other tests should be referred to an independent, contracted lab provider. C. Definitions Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Laboratory A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories. Laboratory Procedures Defined in the Current Procedural Terminology (CPT) in the ranges 80300 through 89398 and panels 80047 through 80076. D. Policy I. CareSource will reimburse for laboratory procedures performed in the physicians office when ALL the following apply: A. The test results are needed immediately in order to manage urgent or emergent medical situations. B. The CPT code for the test is on the short turnaround time (STAT) code list. C. The place of service (POS) 11 is used. II. All other laboratory procedures performed in the office may not be reimbursed and should be referred to an independent, contracted laboratory provider. E. Conditions of Coverage It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Please refer to the individual fee schedule for appropriate codes. Place of Service Description(POS) Code11 – Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis STAT Code List CPT / HCPCSDescription0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0223U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), includes titer(s), when performed 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 80324 Amphetamines; 1 or 2 80325 Amphetamines; 3 or 4 80326 Amphetamines; 5 or more 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 80331 Analgesics, non-opioid; 6 or more80332 Antidepressants, serotonergic class; 1 or 280333 Antidepressants, serotonergic class; 3-5 80334 Antidepressants, serotonergic class; 6 or more 80335 Antidepressants, tricyclic and other cyclicals; 1 or 2 80336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepileptics, not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Methylphenidate 80361 Opiates, 1 or more 80362 Opioids and opiate analogs; 1 or 2 80363 Opioids and opiate analogs; 3 or 4 80364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 80375 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 80376 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6 Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 ormore83992 Phencyclidine (PCP) 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81015 Urinalysis; microscopic only 81025 Urine pregnancy test, by visual color comparison methods 82043 Albumin; urine (eg, microalbumin), quantitative 82044 Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) 82247 Bilirubin; total 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82271 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82465 Cholesterol, serum or whole blood, total 82565 Creatinine; blood 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82947 Glucose; quantitative, blood (except reagent strip) 82948 Glucose; blood, reagent strip 82950 Glucose; post glucose dose (includes glucose) 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 82952 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 83036 Hemoglobin; glycosylated (A1C) 83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use 83655 Lead 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83986 pH; body fluid, not otherwise specified 84132 Potassium; serum, plasma or whole blood 84703 Gonadotropin, chorionic (hCG); qualitative 85013 Blood count; spun microhematocrit 85014 Blood count; hematocrit (Hct) 85018 Blood count; hemoglobin (Hgb) Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) andautomated differential WBC count85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) 85049 Blood count; platelet, automated 85610 Prothrombin time; 85651 Sedimentation rate, erythrocyte; non-automated 86308 Heterophile antibodies; screening 86318 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); 86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); titer 86580 Skin test; tuberculosis, intradermal 86756 Antibody; respiratory syncytial virus 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 87172 Pinworm exam (eg, cellophane tape prep) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87301 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41 87400 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87430 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus,group A87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B 87803 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Clostridium difficile toxin A 87804 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 87806 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 87808 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Trichomonas vaginalis 87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87880 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), any specimen source G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 8 mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes G2023 Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source Q0111 Wet mounts, including preparations of vaginal, cervical or skin specimens Q0112 All potassium hydroxide (KOH) preparations U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel U0002 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R U0004 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R F.Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 09/25/2024 New policy, approved at Committee. Date Revised 12/18/2024 Review: removed CLIA and QW modifier from policy. Approved at Committee. Date Effective 04/01/2025 Date Archived 09/30/2025 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.CPT Code Detail. Optum Encoder Pro; 2024. Accessed December 18, 2024. www.encoderprofp.com2. De finitions, O HIO ADMIN CODE 3701-32-01 (2021).3. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests : C onditions, 42 U.S.C. 410.32 (2023).4. HCPCS Code Detail. Optum Encoder Pro; 2024. Accessed December 18, 2024. Laboratory Testing in Office Setting-OH MCD-PY-1545 Effective Date: 04/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 9 www.encoderprofp.com5. Laboratory Requirements, 42 U.S.C. 493 (2023). 6. Laboratory Services, 42 U.S.C. 441.17 (2023). 7. Laboratory Services, O HIO ADMIN CODE 5160-11-11 (2021). 8. Managed Care: Provider Network and Contracting Requirements, O HIO ADMIN CODE 5160-26-05 (2022). 9. Other Laboratory and X-Ray Services, 42 U.S.C. 440.30 (2023). 10. Place of Service Code Set. Centers for Medicare and Medicaid Services; 2024. Accessed December 18, 2024. www.cms.gov ODM approved 01/09/2025

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

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 Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 11/01/2024-10/31/2025 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XUB. Background Reimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are 2-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established 4 HCPCS modifiers to define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59.C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review. A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. performed at separate anatomic sites 2. performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure.2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires. 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure. 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.)Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 E.C onditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of stat e s pecific instructions, the CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.P roviders must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to bot h par ticipating and nonparticipating providers and facilities.In t he event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document. F. Related Policies/Rules Modifier 2 5 M odifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised 08/02/2023 07/17/2024 Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee. Date Effective 11/01/2024 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.R eferences 1.General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 2024. Accessed July 1, 2024. www.cms.gov2.M edicare Claims Processing Manual Chapter 12 Physicians/Nonphysici an P ractitioners . US Centers for Medicare and Medicaid Services; 2024. Accessed Jul y 1, 2024. www.cms.gov3.Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicar e and M edicaid Services. Updated September 6, 2023. Accessed July 1, 2024. www.cms.gov4. M LN1783722-Proper Use of Modifiers 59 & – X{EPSU}. US Centers for Medicare & M edicaid Services; 2024. Accessed July 1, 2024. www.cms.gov5.Tr ansmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers forDistinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed July 1, 2024. www.cms.gov Approved ODM 07/25/2024

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