Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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, 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, 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 make the determination. CSMG Co. 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.REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled Cost PY-0004 08/01/2020-11/30/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 8 F. Related Policies/Rules ……………………………………………………………………………………………. 9 G. Review/Revision History …………………………………………………………………………………………. 9 H. References …………………………………………………………………………………………………………… 9 2 Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020A. Subject Obstetrical Care Unbundled Cost B. BackgroundObstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include 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 all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. Following Ohio Department of Medicaids direction, unbundled codes are to be used by practitioners except for Freestanding Birthing Centers. Freestanding Birthing Centers must using 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 . 1 Prenatal profile-Initial laboratory services. Initial and prenatal visit-Practitioner visit to determine member is pregnant Unbundled obstetrical care-The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care-Is for basic care (including taking and subsequent updating of medical history, physical examination, recording of vital signs, and routine chemical urinalysis) provided monthly up to 28 weeks gestation, biweekly therefore up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery-Includes admission to facility, medical history during admission, physical examinations, management of labor (either vaginal delivery or by cesarean section) 2. o Postpartum care-The period that, begins on the last day of pregnancy and extends through the end of the month in which the 60 day period following 1 http://codes.ohio.gov/orc/3702.141 2 http://codes.ohio.gov/oac/5160-21-04v1Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 3 termination of pregnancy ends 3. The American College of Obstetricians and Gynecologists (ACOG) recommends contact within the first 3 weeks postpartum. High risk delivery-Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth-Delivery before 39 weeks of pregnancy. 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. D. Policy I. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum 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 a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Please use 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. C. Unbundled Obstetric Care-Report the services performed using the most accurate, most comprehensive procedure code available based on what services the practitioner performed. The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 1. Unbundled obstetric care should be billed when any of the following occur: a. The member has a change of insurer during pregnancy; b. The member has received part of the antenatal care elsewhere, e.g. from another group practice; c. The member leaves your group practice before the global obstetrical care is complete; d. The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery; e. The member has an unattended precipitous delivery; and f. Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy). 3 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=fabf1d19393c9f6586501c8e23999687&ty=HTML&h=L&mc=true&n=pt42.4.440&r =PARTObstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 4 2. Antepartum care only Antepartum care only does not include delivery or postpartum care: a. Use the appropriate CPT and trimester code(s):CPT Code Description59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits E/M For antepartum care for 1-3 visits b. Use the appropriate modifier (This list may not be all inclusive):Modifier Description24 Unrelated evaluation and management service by the same physician or other qualified health care professional during the postoperative period c. E/M codes for antepartum care are limited to 3. d. Only one code, either 59425 or 59426 can be billed per pregnancy. e. Antepartum care only code includes the following (This list may not be all inclusive): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly from 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent history 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery 09. Routine chemical urinalysis 10. Termination of pregnancy by abortion 11. Referral to another physician for delivery 3. 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): 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) Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 5 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive) Services included that may NOTbe 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 section Previous cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean delivery Cesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial 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 Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 6 E/M services provided within 24hours of delivery d. Modifiers 01. Use the appropriate modifier (This list may not be all inclusive):CPT Code Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 80 Assistant surgeon – may be used for delivery only if no antepartum or postpartum care was performed 4. Delivery and postpartum care only If only delivery and postpartum care were provided a. Use the appropriate CPT and trimester code: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 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 forceps7 Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/202009. Caesarean delivery 10. Classic cesarean section 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery 13. Previous cesarean delivery who present with the expectation of a vaginal delivery 14. Caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery 5. Postpartum care only-If postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one 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 hospital 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 are not allowed to be billed separately (This list may not be all inclusive) the following: 01. Hospital, office, and outpatient visits following cesarean section or vaginal delivery; or 02. Qualified health care professional providing all or 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 i.e. respiratory tract infection; or 02. Treatment and management of complications during the postpartum period that require additional services.II. Member eligibility A. 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 gestations.A. 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.Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 8 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 deliveries 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 Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Codes Description 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits E/M For antepartum care for 1-3 visits 59409 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 59410 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 59430 Postpartum care only. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 9 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during the postoperative period 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct procedure/service 80 Assistant surgeon – may be used for delivery only if no antepartum or postpartum care was performed F. Related Policies/RulesObstetrical Care Hospital Admissions MM-0897 Obstetrical Care Total Cost PY-0939 G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 04/01/2020 Updated codes, template Date Effective 08/01/2020 New title was Preferred Obstetrical Services; policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Date Archived 11/30/2020 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. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved June 27, 2019, from https://www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved June 14, 2019 from https://www.aapc.com 5. American Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on August 1, 2019 from https:// www.aapc.com 6. EncoderPro.com for Payers Professional. (2019) Retrieved June 27, 2019, from https://www.encoderprofp.com 7. The American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved June 27, 2019, from Obstetrical Care Unbundled Cost OHIO MEDICAID PY-0004 Effective Date: 08/01/2020 10 https://www.acog.org 8. The American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modifier 22. Retrieved June 27, 2019, from https://www.acog.org 9. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Induction of Labor. Retrieved July 31, 2019, from https://www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved July 31, 2019 from https://www.acog.org 11. American College of Obstetricians and Gynecologists. (2019), April Correct Coding Initiative Version 25.1. Retrieved June 14, 2019 from https://www.acog.org 12. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved August 1, 2019, from https://www.acog.org 13. American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth. Retrieved August 1, 2019 from https://www.acog.org 14. Ohio Administrative Code. (2017). 3701-4-01 Definitions. Retrieved August 1, 2019, from http://codes.ohio.gov 15. Department of Ohio Medicaid. (2019, June). Modifiers Recognized by Ohio Medicaid. Retrieved August 1, 2019 from https:// www.medicaid.ohio.gov 16. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved August 1, 2019 from http://codes.ohio.gov 17. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrieved August 1, 2019 from http://codes.ohio.gov 18. Ohio Administrative Code. (2019). 5160-26 Managed health care programs; definitions. Retrieved August 1, 2019 from http://codes.ohio.gov 19. Ohio Revised Code. (2012). 3702.141 Rules may apply to existing health care facility. Retrieved August 1, 2019 from http://codes.ohio.gov 20. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health services; pregnancy-related services. Retrieved August 1, 2019 from http://codes.ohio.gov 21. Ohio Revised Code (2017). 4723.43 Scope of specialized nursing services. Retrieved August 1, 2019 from http://codes.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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, dysfun ction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to service s provided in a particular case and may modify this Policy at any time. REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Nutritional Supplements PY-0779 08/01/2020-12/31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules …………………………………………………………………………………………… 6 G. Review/Revision History …………………………………………………………………………………………. 6 H. References ………………………………………………………………………………………………………….. 62 A. Subject Nutritional Supplements Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 08/01/2020B. BackgroundReimbursement policies are designed to assist you 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/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. Nutrition may be delivered through a tube into the stomach or small intestine. Enteral Nutrition may be medically necessary for dietary management to provide sufficient caloric and nutrition needs as a result of limited or impaired ability to ingest, diges t, absorb or metabolize nutrients; or for a special medically determined nutrient requirement. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enter al nutrition may be either for total enteral nutrition or for supplemental enteral nutrition. Parenteral nutrition is nutrition provided through an intravenous line. Home Infusion Therapy is NOT covered in this policy. This policy includes nutrition that is for medical purposes only. C. Definitions Enteral Nutrition Nutrition delivered through an enteral access device into the gastrointestinal tract bypassing the oral cavity. Medical Food Food specially formulated and processed to be consumed or administered by oral intake or enteral access device. The intent is to meet distinctive nutritional requirements of a disease or condition when dietary management cannot be met by modifying a normal diet. Enteral Access Device A tube or stoma is placed directly into the gastrointestinal tract for the delivery of nutrients. Inborn Errors Of Metabolism (IEM) Inheri ted biochemical disorders resulting in enzyme defects that interfere with normal metabolism of protein, fat, or carbohydrate. Therapeutic oral non-medical nutrition: o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens. i.e. diabetes mellitus, celiac disease Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 08/01/2020 3 o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional food Food that is fortified to produce specific beneficial health effects. o Texture Modified Food and Thickened Fluids Liquidized/thin puree, thick puree, finely minced or modified normal. o Modified Normal Eating normal foods, but avoiding particulate foods that are a choking hazard. Medical Nutrition Therapy Per Ohio Administrative Code is defined as the use of specific nutrition services to treat an illness, injury, or condition. Medical nutrition therapy services include nutrition assessment, intervention, and counseling1 Unit 100 calories = 1 unit. D. Policy I. Prior Authorization A. Prior authorization is NOT required for 1. HCPCS code B4162 or B4157. 2. Medical Nutrition Therapy. B. Prior authorization is required for 1. Oral nutrition (except for HCPCS code B4162 and B4157). 2. Enteral nutrition (except for HCPCS code B4162 and B4157). 3. Food supplements, nutritional supplements and infant formula when a. Requesting greater than 72 units per month OR b. Member is under the age of five and does not meet criteria for any other local, state, or federal program. 4. Donor human milk. C. Prior authorization is required for non-participating providers. II. Quantity Limits A. Nutritional counseling is limited to one visit per calendar year for diagnosis of obesity. B. C areSource provides enteral nutrition through participating durable medical equipment (DME) providers allowing home delivery of medically necessary enteral nutrition. III. Enteral Nutrition A. CareSource pays for the dispensing and shipping/delivery of enteral nutrition B. CareSource does NOT reimburse for the following 1. Based on the Ohio Administrative Code 2 a. Ordinary prepared food; b. Commercial products that serve as ordinary food (e.g., shakes, smoothies, energy bars, vitamin or mineral supplements, baby food); c. Food products to be eaten as part of a diet related to diabetes, obesity, gastric bypass, or bariatric surgery; 1 http://codes.ohio.gov/oac/5160-8-41v1 2 http://ohrules.elaws.us/oac/5160-10-26Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 08/01/2020 4 d. Food products for which a provider receives Medicaid per diem payment; and e. Standard infant formula (not used to treat errors of metabolism) for which payment may be made through a program other than Medicaid. 2. Quantities that exceed a one months supply 3. Supplies dispensed greater than one week before scheduled date 4. Enteral nutrition for members with advanced dementia 5. When use of product is for convenience or preference of member/caregiver. 6. B4104 enteral formula additive. Enteral formula codes include all nutrient components. IV. Human Donor Milk A. CareSource only provides payment if the provider is a member in good standing with the human milk banking association of North America B. CareSource reimburses for the processing and delivery/shipping C. CareSource does NOT reimburse for 1. Payments to a provider for supplying the donor human milk 2. Payments for the milk itselfE. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting OH Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual OH Medicaid 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. CPT Code Description B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE, PER DAY B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED (PER DAY, INCLUDES BAGS/CONTAINERS) B4081 NASOGASTRIC TUBING WITH STYLET B4082 NASOGASTRIC TUBING WITHOUT STYLET B4083 STOMACH TUBE, LEVINE TYPE B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE B4100 FOOD THICKENER, ORAL, PER OUNCE B4105 IN-LINE CARTTRIDGE CONTAINING DIGESTIVE ENZYM(S) FOR ENERAL FEEDING, EACH B4149 ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4150 ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 08/01/2020 5 AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH ANENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITB4152 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATER THAN 1.5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS,CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALO RIES = 1 UNIT B4153 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS ANDPEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1UNIT B4154 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS,FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDI NG TUBE, 100 CALORIES = 1 UNIT B4155 ENTERAL FORMULA, NUTRITIONALLY INCOMPLETE/MODULAR NUTRIENTS, INCLUDES SPECIFIC NUTRIENTS, CARBOHYDRATES (E.G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E.G. GLUTAMINE, ARGININE), FAT (E.G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4157 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4158 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4159 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE SOY BASED WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4160 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE CALORICALLY DENSE (EQUAL TO OR GREATER THAN 0.7 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDIN GTUBE, 100 CALORIES = 1 UNIT B4161 ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMINO ACIDS AND PEPTIDE CHAIN PROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4162 ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B9002 ENTERAL NUTRITION INFUSION PUMP – WITH ALARM B9998 ENTERAL SUPPLIES, NOT OTHERWISE SPECIFIED 97802 MEDICAL NUTRITION INDIV IN Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 08/01/2020 6 97803 MED NUTRITION INDIV SUBSEQ97804 MEDICAL NUTRITION GROUP S9470 NUTRITIONAL COUNSELING, DIET T2101 BREAST MILK PROC/STORE/DIST, PER OZ Modifiers Description U1 USED TO DIFFERENTIATE B4100 AS A CONCENTRATED FORMULA BO ADMINISTRATION BY MOUTH RATHER THAN BY FEEDING TUBE F. Related Policies/RulesNutritional Supplements MM-0024G. Review/Revision History DATE ACTIONDate Issued 09/09/2019Date Revised 04/01/2020 Added Relizorb as covered Date Effective 08/01/2020 Date Archived 12/31/2020 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. Medicaid. Early and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on December 11, 2018 from https:/ /www.medicaid.gov 2. Lawriter-OAC-5160-8- 41 Medical nutrition therapy services. (n.d.). Retrieved on February 25, 2019 from http://codes.ohio.gov 3. Lawriter-OAC-5160-10-26 DMEPOS: nutrition products. (n.d.). Retrieved on February 21, 2019 from http://codes.ohio.govThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Applied Behavior Analysis for Autism Spectrum Disorder PY-0712 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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 make the determination. CSMG Co. 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. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 5 F. Related Policies/Rules …………………………………………………………………………………………….. 6 G. Review/Revision History ………………………………………………………………………………………….. 6 H. References ……………………………………………………………………………………………………………. 6 Applied Behavior Analysis Therapy for Autism Spectrum Disorder OHIO MEDICAID PY-0712 Effective Date: 06/01/2020 2 A. Subject Applied Behavior Analysis Therapy for Autism Spectrum Disorder B. Background Reimbursement policies are designed to assist you 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/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. Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms, depending on the developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereotyped (repetitive) behavior. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted, repetitive patterns of behavior, interests and activities. There is currently no cure for ASD, nor is there any one single treatment for the disorder. Individuals with ASD may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions. The goal of treatment for members with ASD is to minimize the severity of ASD symptoms, maximize learning, facilitate social integration, and improve quality of life for both the members and their families/caregivers. C. Definitions Autism Spectrum Disorder-A neurological condition, including Asperger’s syndrome and autism, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. BCaBA-Behavioral Analyst Certification Board (BACB) certified assistant behavior analyst undergraduate level. BCBA-BACB certified behavior analyst graduate level. BCBA-D – BACB certified behavior analyst doctoral level. RBT-BACB Registered Behavioral Technician. Practice of applied behavioral analysis-Designs, implements, and evaluates instructional and environmental modifications to produce socially significant improvements in human behavior. Qualified RBT supervisor-BCBA/BCBA-D, BCaBA, or an individual licensed in another behavioral health profession who is competent in ABA and it is within their scope of practice. Applied Behavior Analysis Therapy for Autism Spectrum Disorder OHIO MEDICAID PY-0712 Effective Date: 06/01/2020 3 RBT supervision-Ongoing supervision must be at a minimum of 5% of the hours spent providing behavior-analytic services per month1. This includes a minimum of 2 face-to-face contacts per month. Face-to-Face-QHP or technician must be physically present with member. On-site-QHP is immediately available and can be interrupted to assist and give direction. QHP-Qualified Healthcare Professional: Licensed Behavior Analyst, Board Certified Behavior Analyst-Doctoral, Board Certified Behavior Analyst, Psychologist, or other credentialed professional whose scope of practice, training, and competence includes applied behavior analysis. Assistant-An assistant behavior analyst or trained technician who delivers services under the direction of the QHP. Customized environment-Environment that is configured to safely conduct a functional analysis of destructive behavior or treatment for that behavior. D. Policy I. Prior Authorization (PA) is required for all of the following: A. Initial Treatment Plan for ABA therapy; B. Continuation of ABA therapy; and C. Transitioning ABA therapy to school environment. II. An ASD diagnosis must be primary in order for services to be reviewed for approval. III. Reimbursement A. Duplicate services or double billing are not reimbursable (except as noted in IV. F. below). 1. If member is receiving other treatment (i.e. speech therapy), ABA therapy cannot be billed at the same time on the same date of service. B. Exclusions listed in the Medical policy, MM-0028 are not reimbursable. C. Face-to-face verses non face-to-face time 1. 97151 includes face-to-face time with the member/caregiver to conduct assessments as well as non face-to-face time (such as reviewing records, scoring and interpreting assessment, and writing the treatment plan or progress report). This code is intended for reporting initial assessment and treatment plan development and reassessment and progress reported by the QHP. 2. Only face-to-face time is reported with 97153-97158 and 0373T as the day to day assessment and treatment planning by the QHP is included in these codes. IV. Limitations A. Initial and continuation authorizations are required every 6 months. B. Transitioning ABA therapy to school environment authorization is generally limited to a maximum of 4 months for services provided in the school. C. A Medically Unlikely Edit for a CPT code is the maximum units of service that a provider can report for one member on one date of service. 1. Maximum units allowed per CPT*: 1 https://www.bacb.com Applied Behavior Analysis Therapy for Autism Spectrum Disorder OHIO MEDICAID PY-0712 Effective Date: 06/01/2020 4 CPT Max unit allowed 97151 32 97152 8 97153 32 97154 12 97155 24 97156 16 97157 16 97158 16 0362T 8 0373T 32 *If the state updates the MUE list, the update will take precedence over the MUEs in this policy. D. Each RBT must obtain ongoing supervision for 5-10% of the hours spent providing behavior-analytic services per month. E. The treatment codes are based on daily total units of service in 15 minute increments. A unit of time is attained when the mid-point is passed. 1. Time interval examples: Units Number of minutes 1 unit >8 minutes through 22 minutes 2 units >23 minutes through 37 minutes 3 units >38 minutes through 52 minutes 4 units >53 minutes through 67 minutes 5 units >68 minutes through 82 minutes 6 units >83 minutes through 97 minutes 7 units >98 minutes through 112 minutes 8 units >113 minutes through 127 minutes F. Concurrent billing 1. 97154 and 97158 may not be reported concurrently as 97158 is intended for a QHP-led group session. 2. The following chart summarizes when 97155 can be billed concurrently with codes for direct treatment of the member. Direct Treatment Codes Direction of Technician Code (May be billed concurrently with direct treatment code) 97153 Individual treatment by technician or QHP 97155 By QHP 97154 97155 Applied Behavior Analysis Therapy for Autism Spectrum Disorder OHIO MEDICAID PY-0712 Effective Date: 06/01/2020 5 Group treatment by technician or QHP By QHP 0373T Individual treatment by 2 or more technicians or 2 or more QHPs None this is bundled into 0373T E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 97151 Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physicians or other qualified healthcare professionals time face-to-face with member and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. (Attended by member and QHP) 97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. (Attended by 2 or more members and technician (QHP may substitute for technician)) 97155 Adaptive behavior treatment by protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. (Attended by member and QHP; may include technician and/or caregiver) 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the member present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. (Attended caregiver and QHP)Applied Behavior Analysis Therapy for Autism Spectrum Disorder OHIO MEDICAID PY-0712 Effective Date: 06/01/2020 6 97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the member present), face-to-face with multiple sets guardians/caregivers, each 15 minutes. (Attended caregivers of 2 or more members and QHP) 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple members, each 15 minutes. (Attended by 2 or more members and QHP) 0362T Behavior identification supporting assessment, each 15 minutes of technicians time face-to-face with a member, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patients behavior. (Attended by member and 2 or more technicians; QHP on site) 0373T Adaptive behavior treatment with protocol modification each 15 minutes of technicians time face-to-face with patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patients behavior. (Attended by member and 2 or more technicians; QHP on site) F. Related Policies/Rules Applied Behavioral Analysis (ABA) Therapy MM-0028 G. Review/Revision History DATE ACTION Date Issued 11/29/2018 New Policy Date Revised 04/12/2019 01/27/2020 Removed U3 & U5 modifiers Revised definitions, clarified PA requirements, added ASD diagnosis as primary, added specificity to reimbursement, updated limitations, added MUE, added time intervals, added specificity to concurrent billing. Date Effective 06/01/2020 H. References 1. Behavior Analyst Certification Board. (2018, November 12). Retrieved November 12, 2018 from https://www.bacb.com Applied Behavior Analysis Therapy for Autism Spectrum Disorder OHIO MEDICAID PY-0712 Effective Date: 06/01/2020 7 2. Behavior Analyst Certification Board. (2018, October 18). Adaptive Behavior Assessment and Treatment Code Conversion Table. Retrieved January 5, 2020 from https://www.bacb.com 3. American Medical Association. (2018). Coding Update: Reporting Adaptive Behavior Assessment and Treatment Services in 2019. CPT Assistant, 28(11). 4. Behavior Analyst Certification Board. (2014). Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved December 3, 2019 from https://www.bacb.com 5. Centers for Medicare & Medicare Services. (2019, 4th quarter). Practitioner Services Medically Unlikely Edits Table. Retrieved December 3, 2019 from http://www.cms.gov 6. Centers for Medicare & Medicaid Services. (2018, March). Medicare Claims Processing Manual Chapter 5 Part BOutpatient Rehabilitation and CORF/OPT Services. Retrieved December 3, 2019 from https://www.cms.gov 7. ABA International. (2019, January). Supplemental Guidance on Interpreting and Applying the 2019 CPT codes for Adaptive Behavior Services. Retrieved December 3, 2019 from https://www.abainternational.org 8. Ohio Revised Code. (2017). 39.23.84 Coverage for autism spectrum disorder. Retrieved November 22, 2019 from http://codes.ohio.gov 9. Ohio Revised Code. (n.d.). 4783 Behavior Analysts. Retrieved November 22, 2019 from http://codes.ohio.gov 10. Ohio Revised Code. (2017). 1751.84 Coverage for autism spectrum disorder. Retrieved December 3, 2019 from http://codes.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Da te Vaccinations an d Immunizations PY-0040 10/01/2019-0 3/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….5 G. Review/Revision History ………………………………………………………………………………………..5 H. Ref er en ce s …………………………………………………………………………………………………………5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable r e f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose 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, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly 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. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy 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. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tVaccinations and I mmun iza tio ns Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/2019B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. CareSo urc e c overs and reimburs es for immunizations/vacc ines b ased on the recommendations f ro m the Centers for Dis ease Control and Prevention (CD C) and the Advisory Committee o n Immunizatio n Prac tices (ACIP). Th e Vac c ines for Children (V FC) p rogram is a federally funded program that provides v accines at no c o s t to c hildren who might not otherwise be v accinated b ecause of inability to pay . The Centers f o r Diseas e Co ntrol and Prev ention (CDC) p urchas es v ac cines at a d is count and d is tributes them to s tate health d epartments whic h in turn distribute them at no charge to those p riv ate p hy sicians offic es and public health clinics reg istered as VFC p roviders. The Vac c ines for Children (VFC) p rogram helps pro vide v acc ines to c hildren whose p arents o r g uard ians may not be ab le to afford them. The VFC p rogram helps ens ure that c hildren hav e a b etter c hanc e of getting their rec ommended v ac cinations on s chedule. Vacc ines available thro ug h the VF Cpro gram are those rec ommended by the A dvisory Committee on Immunization Prac t ic es (A CIP ).C. Def initions Immunization-is an ino c ulation ag ainst a v accine preventable disease. Vaccination-the ac t of introducing a vacc ine into the body to produce immunity to a spec if ic d is ease. Vaccine-a p ro d uct that s timulates a pers ons immune sy stem to produce immunity to a specific disease, p rotecting the p er s o n from that disease. Vacc ines are usually ad ministered thro ug h need le injec tions, b ut c an also b e administered by mouth or s prayed into the nose. Vaccines for Children Program (VF C) – the program for distribution of pediatric v accines ad minis tered by the Department for Public Health. D. Polic yI. Vac c inations and Immunizations f or CareSourc e members 18 y ears old or younger: A. CareSo urc e d oes not differentiate between providers that participate or do not participate in the Vac c ines for Children program. 1. All claims for v accines administered to children 18 years of ag e or younger wi ll be reimb urs ed for the ad ministration only. 3 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/20192. All c laims must b e submitted with appropriate CPT and ICD-10 code to ens ure that the p ro v ider is properly reimb ursed f or the administration o nly of the correc t v accine. II. Vac c inations and Immunizations for CareSourc e members 19 years old or older: A. CareSo urc e may reimb urse f or v acc inations that are administered in accordanc e wi th the CD Cad ult v ac cination/immunization s chedule: 1. All c laims must b e submitted with the appropriate CPT and ICD-10 c ode to ens ure that the p ro vider is properly reimbursed for the administration and the toxoid that w as ad ministered. 2. CareSo urc e d oes not cover v accines or immunizations for travel outside of the United States . III. Hep atitis A vaccine: A. CareSo urc e members who may be at high risk f or Hep ati ti s A infec tion are eligible to rec eiv e the Hep atitis A v accine regard les s of age. 1. Pro v ider may s ubmit cl a im s f or Hepatitis A tox oid and v accination administration i. Fo r c hild ren ages b irt h thro ugh 18: procedure c odes 90633 and 90634. ii. Fo r ad ults age 19 and older: proc edure codes 90632 and 90636. E. Conditions of Cov erageReimb urs ement is dependent o n, b ut not limited to, s ubmitting Ohio Medicaid approved HCPCS and CP Tcodes along with ap propriate modifiers, if applicable. Pleas e refer to the individual Ohio Med ic aid fee s chedule for ap propriate c odes. The following l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description90460 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, with c ounseling b y phy sician o r other qualified health care p ro f es sional; f irs t or o n ly c omponent of each v accine or toxoid administered 90461 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, wit h counseling by p hysician or o ther qualified health care p ro f es sional; eac h ad ditional v acc ine o r toxoid component adminis tered (Lis t s ep arately in addition to code for p rimary p rocedure) 90471 Immunizatio n ad ministration (inc ludes perc utaneous, intradermal, s ub c utaneous, o r intramusc ular injec tions); 1 v accine (s ingle o r c o mb ination v acc ine/toxoid) 90472 Immunizatio n ad ministration (includes p erc utaneous, intrad ermal, s ub c utaneous, or intramusc ular injec tions ); eac h additional vacc ine (s ingle or c o mbination vacc ine/toxoid) (Lis t separately in addition to c ode for p rimary p rocedure) 90473 Immunizatio n adminis tration by intranasal or oral r o ut e ; 1 v accine (single or c o mb ination v acc ine/toxoid) 90474 Immunizatio n ad ministration by intranasal or o ral route; eac h additional vaccine (s ingle or c ombination v accine/toxoid) (List s eparately in addition to c o d e for p rimary p rocedure) 90620 Mening o cocc al rec o mbinant p rotein and outer membrane vesicle v acc ine, s ero g roup B (MenB-4C), 2 d ose s chedule, for intramus cular use 90621 Mening o cocc al rec o mbinant lipoprotein vacc ine, s erogroup B (MenB – FHb p ), 2 o r 3 d ose s chedule, for intramus cular use 90633 Hep atitis A vac cine (HepA), pediatric/adolesc ent dosage-2 dose s chedule, f o r intramuscular us e 90634 Hep atitis A vac cine (HepA), pediatric/adolesc ent dosage-3 dose s chedule, f o r intramuscular us e 4 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/201990636 Hep atitis A and hepatitis Bv accine (HepA-HepB), adult dosage, for intramus c ular us e 90644 Mening o cocc al c onjugate v ac cine, s ero groups C & Yand Haemophilus inf luenzae ty pe b vacc ine (Hib-MenCY), 4 d ose s chedule, when ad minis tered to c hildren 6 week s-18 months of age, for intramuscular use 90647 Haemo p hilus influenzae t ype b vac cine (Hib), PRP-O MP conjugate, 3 dose s c hed ule, for intramuscular us e 90648 Haemo p hilus influenzae t ype b vacc ine (Hib), PRP-T c onjugate, 4 dose s c hed ule, for intramuscular us e 90649 Human Pap illomavirus vacc ine, types 6, 11, 16, 18, quadrivalent (4v HPV), 3 d o s e s c hedule, for intramuscular us e 90650 Human Pap illomavirus vacc ine, types 16, 18, bivalent (2vHP V), 3 dose s c hed ule, for intramuscular us e 90651 Human Pap illomav irus vacc ine types 6, 11, 16, 18, 31, 33, 45, 52, 58, no nav alent (9v HPV), 2 o r 3 d ose s chedule, for intramuscular us e 90653 Inf luenza v ac c ine, inac tivated (IIV ), s ubunit, adjuvanted, f or intramus cular us e 90655 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, preserv ative free, 0.25 mL d o s age, for intramuscular us e 90656 Inf luenza v irus v accine, trivalent (IIV 3), split v irus , p reservative free, 0.5 mL d o s age, for intramuscular us e 90657 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.25 mL dosage, f or intramus c ular us e 90658 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.5 mL dosage, for intramus c ular us e 90660 Inf luenza v irus vaccine, triv alent, live (LA IV 3), for intranas al us e 90662 Inf luenza v irus v acc ine (IIV ), split virus, preserv ative free, enhanc ed immuno genicity via increas ed antigen c ontent, for intramuscular use 90664 Inf luenza v irus v accine, live (LA IV ), pandemic formulation, for intranasal us e 90666 Inf luenza v irus v accine (IIV ), p andemic formulation, s p li t virus, preservative f ree, f or intramusc ular us e 90667 Inf luenza v irus v accine (IIV ), p andemic formulation, s p li t virus, adjuv anted, f o r intramuscular us e 90668 Inf luenza v irus v accine (IIV ), pandemic formulation, sp l it virus, for intramus c ular us e 90670 Pneumo c occal c onjugate v accine, 13 v alent (P CV13), for intramusc ular us e 90672 Inf luenza v irus v ac c ine, q uadrivalent, live (LA IV 4), for intranas al use 90673 Inf luenza v irus v accine, trivalent (RIV 3), d erived f rom recombinant DNA, hemag g lutinin (HA) pro tein only, preserv ative and antibiotic free, for intramus c ular us e 90674 Inf luenza v irus v ac c ine, q uadrivalent (c c IIV 4), d erived f rom c ell c ultures, s ub unit, preserv ative and antibiotic free, 0.5 mL dosage, for intramuscular us e 90680 Ro tav irus vacc ine, p entavalent (RV 5), 3 d os e s chedule, live, f or o ral us e 90681 Ro tav irus vac cine, human, attenuated (RV 1), 2 d ose schedule, live, for oral us e 90685 Inf luenza v irus v ac c ine, quadriv alent (IIV 4), split virus, p reserv ative free, 0.25 mL, f or intramuscular us e 90686 Inf luenza v irus v accine, quadrivalent (IIV 4), sp l it virus , preserv ative free, 0.5 mL d o s age, for intramuscular us e 90688 Inf luenza v irus v accine, q uadriv alent (IIV 4), split v irus, 0.5 mL dos age, f or intramus c ular us e 5 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/201990696 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine and inac tivated p o liov irus vac cine (D Ta P-IP V), when administered to c hildren 4 through 6 y ears o f ag e, for intramus cular use 90698 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine, Haemophil us inf luenzae ty pe b, and inactivated poliovirus v accine, (D Ta P-IP V/Hi b), for intramus cular us e 90700 Dip htheria, tetanus toxoids, and acellular p ertuss is vaccine (D TaP ), when ad minis tered to ind iv iduals y ounger than 7 y ears, for intramuscular us e 90702 Dip htheria and tetanus toxoids adsorbed (DT) when ad ministered to ind iv iduals y ounger than 7 y ears, for intramuscular us e 90707 Meas les , mumps and rubella virus v accine (MMR), l iv e, for subcutaneous us e 90710 Meas les , mumps, rubella, and varicella vacc ine (MMRV ), live, for s ub c utaneous us e 90713 Po lio virus v acc ine, inac tivated (IP V ), for s ub cutaneous or intramuscular use 90714 Tetanus and d iphtheria toxoids adsorbed (Td ), pres ervativ e free, when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cular us e 90715 Tetanus , d iphtheria toxoids and ac ellular pertussis vac cine (Td ap), when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cul ar u s e 90716 Varicella v irus vac cine (V AR), live, f or s ubcutaneous us e 90723 Dip htheria, tetanus toxoids, acellular pertussis v accine, hepatitis B, and inac tiv ated poliovirus v accine (D TaP-Hep B-IPV), for intramusc ular us e 90732 Pneumo c occal polys accharide v accine, 23-v alent (PPSV23), adult o r immuno s uppressed p atient dosage, when administered to individuals 2 y ears o r o lder, for s ubcutaneous o r intramusc ular us e 90733 Mening o cocc al polys accharide vacc ine, serogroups A, C, Y, W-135, q uad riv alent (MPSV4), for s ubc utaneous us e 90734 Mening o cocc al c onjugate vacc ine, serogroups A, C, Yand W-135, q uad riv alent (MCV4 o r MenACWY), for intramusc ular us e 90743 Hep atitis Bv acc ine, ad oles cent (2 dose s c hedule) f or intramuscular u s e; 90744 Hep atitis Bvac cine (HepB), pediatric/adolesc ent dosage, 3 d ose schedule, f o r intramuscular us e 90756 Inf luenza v irus v ac cine, quadrivalent (c cIIV 4), d erived fro m cell c ultures , s ub unit, antibiotic free, 0.5mL d osage, for intramus cular use F. Related Polic ies/Rules G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 12/01/2013Date Revised 06/12/2019 Up d ated policy to align wit h CDC and VFC program 01/18/2020 Rev is io n remov ed lang uage to allow for toxoidreimb urs ement and p rovided additional c larification f o r Hep atitis A vacc ine ad ministration and reimb urs ementDate Effecti ve 10/01/2019 Date Archived 03/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . 6 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/2019H. Ref erenc es 1. Ad ult Immunization Schedule by Va c c i ne and Age Group | CD C. (2019, February 5). Retriev ed May 13, 2019, from https : // www.cdc.go v 2. Birt h-18 Years Immunization Schedule | CDC. (2019, February 5). Retrieved May 13, 2019, f ro m https :/ /www. cdc.go v3. FOR OHIOA NS . (2019, May 13). Retrieved May 13, 2019, f rom https://medicaid.ohio.gov 4. Free Vac c ines. (2014, No vember). Retrieved May 15, 2019 f rom https ://odh.ohio.gov 5. Lis t of CP Tand HCPCS codes c overed for Enhanc ed Ambulatory Patient Groups (E AP G)] . (2019, Feb ruary 1). Retriev ed May 15, 2019 from https://medicaid.ohio.gov 6. Med ic aid A dvisory Letter (MA L) No. 632. (2019, May 14). Retrieved May 15, 2019, from http s://medicaid.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, 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, illne ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of C overage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. 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.REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Inpatient Services Less Than 24 Hours PY-0960 03/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimburs ement Policy Statement ………………………….. ………………………….. …………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 3 H. References ………………………….. ………………………….. ………………………….. …………………….. 3 2 A. SubjectInpatient Services Less Than 24 Hours Inpatient Services Less Than 24 HoursOHIO MEDICAID PY-0960 Effective Date: 03/01/2020 B. BackgroundReimbursement policies are designed to assist you 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 their office staf f are encouraged to use self-service channels to verify members eligibility. C. Definitions Inpatient : Defined by OAC A patient who is admitted to a hospital based upon the written orders of a physician or dentist and whose inpatient stay continues beyon d midnight of the day of admission. Outpatient services: Defined by OAC Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital. Outpatient services do not include direct-care s ervices provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5160-4-01 of the Administrative Code. Inpatient services: Defined by OAC Services which are ordinarily furnish ed in a hospital for the care and treatment of inpatients. Inpatient services include all covered services provided to patients during the course of their inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct – care services provided by physicians, podiatrists, and dentists. Inpatient hospital services exclude direct-care physician services except as provided in rule 5160-4-01 of the Administrative Code. Emergency room services are covered as an inpatient service when a patient is admitted from the emergency room. Transfer – A patient is said to be “transferred” when he or she: o Is moved from one eligible hospital’s inpatient or outpatient department, as described in rule 5160-2-01 of the Administrative Code, to ano ther eligible hospital’s inpatient or outpatient department, including state psychiatric facilities. o Is moved from an eligible hospital to the same hospital’s distinct part psychiatric unit. o Is moved to an eligible hospital from the same hospital’s distinct part psychiatric unit. D. PolicyI. For all inpatient services billed to CareSource that do not meet the definition of an inpatient service as defined in this policy will be denied, with the exc eption of the 3 Inpatient Services Less Than 24 HoursOHIO MEDICAID PY-0960 Effective Date: 03/01/2020 exclusions outlined below. Hospitals may resubmit denied claims for the services provided to the patient on the date of admission as an outpatient claim. II. Inpatient services are defined as: A. All covered services provided to patients during the course of thei r inpatient stay, whether furnished directly by the hospital or under arrangement, except for direct-care services provided by physicians, podiatrists, and dentists. B. Emergency room services are covered as an inpatient service when a patient is admitted fro m the emergency room. C. Observation services rendered to the member 3 days preceding an inpatient stay should be included in the inpatient stay. D. Exclusions to inpatient services that will be paid as a DRG are: 1. The member dies, 2. The member is transferred to another inpatient unit within the hospital, 3. The member is transferred to another hospital, or 4. The member is transferred to a state psychiatric facility. E. If member leaves Against Medical Advice (AMA) AND the member does not stay beyond midnight of the day of admission, the inpatient claim will be denied. The claim may be resubmitted as an outpatient. E. Conditions of CoverageReimbursement is dependent on, but not limited to, billing based on correct coding guidelines. Prior authorization of the inpatient services is not a guarantee of payment. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate IssuedDate Revised Date Effective 03/01/2020 Date Archived 02 /02 /2021 H. References1. Hospital Billing Guidelines – medicaid.ohio.gov. (2018, July 1). Retrieved October 3, 2019, from https://medicaid.ohio.gov 2. Ohio Administration Code Chapter 5160-2 Hospital Services. (n.d.). Retrieved October 3, 2019, from http://codes.ohio.gov 3. Ohio Administration Code Chapter 5160-2 Hospital Services. (n.d.). Retrieved October 3, 2019, from http://codes.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Hepatitis Panel for Acute Viral Hepatitis PY-0206 5/1/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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 make the determination. CSMG Co. 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 4 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H. REFERENCES ………………………………………………………………………………………… 4 Hepatitis Panel for Acute Viral Hepatitis OHIO MEDICAID PY-0206 Effective Date: 5/1/2020 2 A. SUBJECT Hepatitis Panel for Acute Viral Hepatitis B. BACKGROUND Reimbursement policies are designed to assist you 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/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. Acute viral hepatitis (AVH) is a systemic infection that mostly affects the liver. It can be caused by a virus, a toxin, or could be the beginning of chronic liver disease. The viruses that most often cause AVH are hepatitis A, B, C, D, and E. The typical symptoms are shown in all forms of AHV including jaundice, fatigue, abdominal pain, loss of appetite, nausea, diarrhea, fever, and dark urine. C. DEFINITIONS Hepatitis panel: consists of the following tests: o Hepatitis A antibody (HAAb), IgM Antibody o Hepatitis Bcore antibody (HBcAb), IgM Antibody o Hepatitis Bsurface antigen (HBsAg) o Hepatitis Cantibody D. POLICY I. Prior authorization is not required for hepatitis panel tests that are medically necessary. Note: Although a Hepatitis panel does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II. Hepatitis panel is considered medically necessary when used for a differential diagnosis in members with ANY of the following: A. Symptoms of hepatitis infection OR B. Abnormal liver function tests OR C. Before and after a liver transplantation. III. Hepatitis panel must be ordered and performed by a provider for these services, and when used in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. Hepatitis Panel for Acute Viral Hepatitis OHIO MEDICAID PY-0206 Effective Date: 5/1/2020 3 IV. Non-Covered Services A. Once a diagnosis of hepatitis has been made, CareSource will not cover ongoing hepatitis panel testing. CareSource will cover, appropriate and medically necessary, individual hepatitis testing for its members. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Codes Description 80074 Acute Hepatitis Panel Diagnosis Codes Description M25.50 Pain in unspecified joint M79.10 Myalgia, unspecified site R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.33 Periumbilical pain R10.811 Right upper quadrant abdominal tenderness R10.821 Right upper quadrant rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R17 Unspecified jaundice R19.5 Other fecal abnormalities (abnormal stool color) R50.9 Fever, Unspecified R53.1 Weakness R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue Hepatitis Panel for Acute Viral Hepatitis OHIO MEDICAID PY-0206 Effective Date: 5/1/2020 4 R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) Failure to thrive (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight R74.0 Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH] R74.8 Abnormal levels of other serum enzymes R74.9 Abnormal serum enzyme level, unspecified R82.998 Other abnormal findings in urine R94.5 Abnormal results of liver function studies T86.40 Unspecified complication of liver transplant T86.41 Liver transplant rejection T86.42 Liver transplant failure T86.43 Liver transplant infection T86.49 Other complications of liver transplant Z76.82 Awaiting organ transplant status Z94.4 Liver transplant status F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03/22/2017 Date Revised 05/01/2017 1/8/2020 Removed ICD-10 and references to asymptomatic members. Added ICD-10 for panel. Title changed was hepatitis panel. Date Effective 5/1/2020 Date Archived H. REFERENCES 1. National Coverage Determination (NCD) for Hepatitis Panel/Acute Hepatitis Panel (190.33). (2003, January 1). Retrieved November 21, 2019 from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=166&ncdver=1&CoverageSelection=Both&ArticleType=All&Hepatitis Panel for Acute Viral Hepatitis OHIO MEDICAID PY-0206 Effective Date: 5/1/2020 5 PolicyType=Final&s=Ohio&KeyWord=hepatitis+panel&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA& 2. Centers for Medicare and Medicaid Services. Lab NCDs-ICD-10. (n.d.). Retrieved November 21, 2019, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDsICD10 3. World Gastroenterology Organisation Practice Guidelines: (2003, December). Retrieved November 21, 2019, from https://www.worldgastroenterology.org/UserFiles/file/guidelines/management-of-acute-viral-hepatitis-english-2003.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Hepatitis Band CPY-0447 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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 Polici es. 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 applica ble 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 llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 t o 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 t o make the determination. CSMG Co. 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. ……………. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Hepatitis Band CB. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowi ng the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronic ally infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-te rm illness but for 70% 85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) All facilities in the Unit ed States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cl eared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 3 D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy III. CareSource does not consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. I V . Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.2 Chronic viral hepatitis CB18.9 Chronic viral hepatitis, unspecified B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis complicating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium F. RELATED POLICIES/RUL ES N/A Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 4 G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Revised to reflect next review date of 12/01/2019 Date Effective H. REFERENCES 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (2015, May 31). Retri eved July 3, 2018, from www.cdc.gov /hepatitis The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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, 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, 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 make the determination. CSMG Co. 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.REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1092 04/01/2020-08 /31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules …………………………………………………………………………………………… 3 G. Review/Revision History ………………………………………………………………………………………… 3 H. References ………………………………………………………………………………………………………….. 32 A. SubjectSacroiliac Joint ProceduresSacroiliac Joint Procedures OHIO MEDICAID PY-1092 Effective Date: 04/01/2020 B. BackgroundReimbursement policies are designed to assist you 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient's daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services.C. Definitions Sacroiliac Joint Procedures: corticosteroid and local anesthetic therapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required for each sacroiliac joint injection for pain management. Documentation, including dates of service, for conservative therapies are not required for PA, but must be available upon request. B. Sacroiliac joint injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic effect, repeating no more than once every seven (7) days and with at least a 75% or greater reduction in pain after the first injection. 2. Once the diagnostic injections are performed and the diagnosis is established, two (2) therapeutic injections per joint may be performed over a 12 month period. 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of four (4) injections (including both diagnostic and therapeutic) per joint in 12 months. 3 Sacroiliac Joint Procedures OHIO MEDICAID PY-1092 Effective Date: 04/01/2020C. Radiofrequency Facet Ablation for Sacroiliac Pain 1. Thermal or pulsed, cooled neurotomy by Radiofrequency Facet Ablation (RFA) or other techniques for sacroiliac pain are NOT covered.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Ohio Medicaid 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. Sacroiliac JointProcedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed F. Related Policies/RulesSacroiliac Joint Procedures MM-0010 G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 09/08/2016 Date Effective 04/01/2020 Date Archived 08 /31/2020 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. Ohio Department of Medicaid Fee Schedules . (n.d.). Retrieved November 15, 2019, from https://medicaid.ohio.gov/Provider/FeeScheduleandRates/SchedulesandRates#1682579-outpatient-hospital-services.The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Radiofrequency Facet Ablation PY-1083 04/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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 Polici es. 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 applica ble 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 llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 t o 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 t o make the determination. CSMG Co. 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. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Radiofrequency Facet Ablation OHIO MEDICAID PY-1083 Effective Date: 04/01/2020 2 A. Subject Radiofrequency Facet Ablation B. Background Reimbursement policies are designed to assist you 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 act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting 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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Stud y of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. I nterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Radiofrequency Facet Ablation: is performed using percutaneous introdu ction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. Policy I. Radiofrequency Facet Ablation A. A prior authorization (PA) is required for each radiofrequency facet joint denervation/ablation for pain management . Documentation, including dates of service, for conservative th erapies are not required for PA but must be available upon request B. For each spinal region (cervical/thoracic or lumbar) two (2) radiofrequency facet ablations per rolling 1 2 months, involving no more than four (4) joints per session, e.g., two (2) bilateral level s or four (4) unilateral levels . C. A repeat RFA in the same spine region requires documented pain relief of at least 50% for a minimum of 6 months after the initial RFA . D. Repeat RFA cannot be performed for at least six (6) months following the initial RFA . E. Radiofrequency facet ablation should be performed with imaging guidance . 1. Coverage for image guidance and any injection of contrast are inclusive components and are not reimbursed separately. Archived Radiofrequency Facet Ablation OHIO MEDICAID PY-1083 Effective Date: 04/01/2020 3 E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes al ong with appropriate modifiers. Please refer to the individual Ohio Medicaid Fee Schedule for app ropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Radiofrequency Facet Ablation Description 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64635 Destruction by neurolytic agent, paravertebral face t joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) F. Related Policies/Rules Radiofrequency Facet Ablation MM-0101 G. Review/Revision History DATE ACTION Date Issued 07/26/2016 Date Revised 09/08/2016 Date Effective 04/01/2020 Date Archived H. References 1. Ohio Depa rt ment of Medicaid Fee Schedules . (n.d.). Retrieved November 15, 2019, from https://medicaid.ohio.gov/Provider/FeeScheduleandRates/SchedulesandRates#1682579-outpatient-hospital-services . The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) 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, 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, 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 make the determination. CSMG Co. 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. REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1076 04/01/2020-10/31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules …………………………………………………………………………………………… 4 G. Review/Revision History ………………………………………………………………………………………… 4 H. References ………………………………………………………………………………………………………….. 5Implantable Spinal Cord Stimulator OHIO MEDICAID PY-1076 Effective Date: 04/01/2020 2 A. SubjectImplantable Spinal Cord Stimulator B. Background Reimbursement policies are designed to assist you 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 their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient's daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions 0078 Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain. D. Policy I. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required for all implantable spinal cord stimulators, including short-term trial placement and permanent placement. 1. Prior authorizations for implantable spinal cord stimulator services are not required for the following: a. Implantable device and device components are considered part of the procedure and does not require a separate PA. b. Removal/revision of implanted device c. Electronic analysis/studies post implantation B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria found in the Implantable Spinal Cord Stimulator Medical policy MM-0076. Implantable Spinal Cord Stimulator OHIO MEDICAID PY-1076 Effective Date: 04/01/2020 3 E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule for appropriate codes. 0078 The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.Implantable SpinalCord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or
© Copyright CareSource 2025. All rights reserved.
System Details