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 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 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 Pain Pump PY-1070 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 ………………………………………………………………………………………………………….. 4Implantable Pain Pump OHIO MEDICAID PY-1070 Effective Date: 04/01/2020 2 A. SubjectImplantable Pain Pump 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 Implantable Pain Pump: Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for continuous or variable rates of infusion D. Policy I. Implantable Pain Pump A. Prior authorization (PA) is required for all implantable pain pumps, including trial administration, permanent placement and single shot intrathecal injections for the treatment of severe chronic intractable pain of malignant or non-malignant origin. 1. Prior authorizations for implantable pain pump services are not required for the following: a. Implantable device is considered part of the procedure and does not require a separate PA. b. Analysis post implantation c. Refilling and maintenance of the implanted device d. Removal/Revision of implanted device Implantable Pain Pump OHIO MEDICAID PY-1070 Effective Date: 04/01/2020 3 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. B.Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump medical policy MM-0077.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 individual Ohio Medicaid fee Implantable Pain Pump Description 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62355 Removal of previously implanted intrathecal or epidural catheter 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming 62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care professional) 95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; 95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional C1772 Infusion pump, programmable (implantable Implantable Pain Pump OHIO MEDICAID PY-1070 Effective Date: 04/01/2020 4 E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) F. Related Policies/RulesImplantable Pain Pump MM-0077G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 09/08/2016 Date Effective 04/01/2020 Date Archived 10/31/2020 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 OHI OMEDICAID Policy Name Policy Number Effective Date Facet Medial Branch Nerve Blocks PY-1063 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 ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Facet Medial Branch Nerve Blocks OHIO MEDICAID PY-1063 Effective Date: 04/01/2020 2 A. Subject Facet Medial Branch Nerve Blocks 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 conserva tive 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 fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Facet Medial Branch Nerve Blocks : Injection of a local anesthetic with or without a corticosteroid into the vicinity of the medial branch nerves of the dorsal rami. D. Policy I. Facet Medial Branch Nerve Blocks A. A prior authorization (PA) is required for each facet medial branch nerve block injection for pain management. Documentat ion, including dates of service, for conservative therapies are not required for PA but must be available upon request. 1. Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably h igh false positive rate of single MBB injections. a. A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant relief of primary (index) pain 50%. 2. A maximum of six (6) facet injection sessions inclusive of medial branch blocks, intraarticular injections, and facet cyst rupture and facet medial branch neur otomies may be performed per rolling 12 months in the cervical/thoracic spine and six (6) in the lumbar spine. 3. Neither conscious sedation nor Monitored Anesthesia Care (M AC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. Archived Facet Medial Branch Nerve Blocks OHIO MEDICAID PY-1063 Effective Date: 04/01/2020 3 4. Per CPT guidelines, imaging guidance and any injection of contrast are inclusive components of all facet medial branch nerve blocks and are not reimb ursed separately. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along wit h appropriate modifiers. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Facet Medial Branch Nerve Blocks Description 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 Inje ction(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to c ode for primary procedure) F. Related Policies/Rules Facet Medial Branch Nerve Blocks MM-0008 G. Review/Revision History DATE ACTION Date Issued 07/26/2016 Date Revised 09/08/2016 Date Effective 04/01/2020 Date Archived Archived Facet Medial Branch Nerve Blocks OHIO MEDICAID PY-1063 Effective Date: 04/01/2020 4 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, 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 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 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 services provided in a particular case and may modify this Policy at any time. REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Epidural Steroid Injections PY-1055 04/01/2020-09/30/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………………………………………………………………….. 1A. 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 …………………………………………………………………………………………………………….. 5 2 A. Subject Epidural Steroid Injections Epidural Steroid Injections OHIO MEDICAID PY-1055 Effective Date: 04/01/2020B. 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 Epidural Steroid Injections: for persistent or chronic radicular pain involve injection of corticosteroid, local anesthetic, opioid, or combination medication into the epidural space, requiring fluoroscopic imaging and injection of an appropriate agent to achieve a selective reproducible blockage of a specific nerve root. Anatomic locations for epidural injections may involve the interlaminar space at the midline between vertebral bodies, caudal epidural injections, or transforaminal epidural injections. Epidural injections may be diagnostic for localizing and determining the cause of radiating pain and providing short term pain relief. D. Policy I.Epidural Steroid Injections A. A prior authorization (PA) is required for each epidural injection for pain management and each spine region excluding labor and delivery in childbirth and for post-surgical pain. Documentation, including dates of service for conservative therapies, are not required for PA, but must be available upon request. B. Interlaminar or Caudal Epidural Injections 1. More than 1 epidural injection per treatment date will not be authorized. 2. Bilateral injections and modifiers will not be recognized and coverage will be denied. 3. Prior authorization will be required for each epidural injection by the same or any physician. 4. Repeat injections sooner than 3 weeks may not reach pharmacodynamic effect of the corticosteroid and will not be covered. 3 Epidural Steroid Injections OHIO MEDICAID PY-1055 Effective Date: 04/01/2020 5. Requests for repeat injections beyond 3 weeks without documentation of suitable pain score reduction and functional improvements, or other documented rationale as described in Policy section will not be covered. C. For Transforaminal Epidurals or Selective Nerve Root Blocks (SNRBs) 1. Transforaminal Epidurals provided to more than 2 vertebral levels per treatment date, whether unilateral or bilateral, will not be authorized and will not be covered. 2. Repeat injections sooner than 3 weeks may not reach pharmacodynamic effect of the corticosteroid and will not be covered. 3. Requests for repeat injections beyond 3 weeks without documentation of suitable pain score reduction and functional improvements, or other documented rationale as described in Policy section will not be covered. D. The maximum epidurals of all types of epidural injections a member can receive in a rolling 12 months is a total of 6, regardless of the number of levels involved. E. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not compensated for separately, or unbundled, for coverage. F. Ultrasound guidance for epidural injections is inappropriate. G. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. 1. Coverage for monitored anesthesia will not be provided as not medically necessary. 2. When anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. 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. Epidural Description62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) 4 Epidural Steroid Injections OHIO MEDICAID PY-1055 Effective Date: 04/01/2020 62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) F. Related Policies/Rules Epidural Steroid Injections OH MCD MM-0007G. Review/Revision History DATE ACTION Date Issued 07/26/2016 Date Revised 09/08/2016 Date Effective 04/01/2020 Date Archived 09/30/2020 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. 5 H. References Epidural Steroid Injections OHIO MEDICAID PY-1055 Effective Date: 04/01/2020 1. 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 PolicyStatement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policyand is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Positive Airway Pressure Devices for Pulmonary Disorders PY-0313 04/01/2020-04/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement 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 requirem ents, 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 lowes t 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 Statem ents, 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 ……………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules …………………………………………………………………………………………….. 4 G. Review/Revision History ………………………………………………………………………………………….. 4 H. References ……………………………………………………………………………………………………………. 4 Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICAID PY-0313 Effective Date: 04/01/20202A. Subject Positive Airway Pressure Devices for Pulmonary Disorders 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 submit ting 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. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to treat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bilevel or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulmonary disease ( COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome. C. Definitions Adherence is the use of the device regularly as prescribed by the ordering physician. Medical necessity-is defined as the following: o procedures, items, or services that prevent, diagnose, evaluate, correct, or treat an adverse health condition such as an illnes s, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability; o generally accepted standards of medical practice; o clinically appropriate in its type, frequency, extent, duration, and delivery setting; o appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome; o the lowest cost alternative that effectively addresses and treats the medical problem. D. Policy I. CareSource does not require a prior authorization for participating providers for the first 3 month rental on a PAP machine (CPAP/BiPAP). A. CPAP (E0601) and BiPAP (E0470) machines are a 10 month rent to purchase. B. Prior authorization must be obtain ed through CareSource starting after the 3rd month rental (months 4-10). C. Documentation that confirms adherence must be submitted along with the prior authorization request. Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICAID PY-0313 Effective Date: 04/01/20203D . BiPAP machines E0471 and E0472 are a continuous rental and never cap out as a purchase. II. Providers that dispense the PAP machine must ensure and document the members adherence with its use. A. CareSource considers adherence with the use of PAP as the following: 1. A dherenc e is the use of the device regularly as prescribed by the ordering physician. 2. If there is a discontinuation of use at any time, the PAP supplier is expected to ascertain adherence and stop billing for the equipment, related accessories and supplies. III. When lack of adherence of a PAP machine is confirmed, further rental and providers claims will be denied. A. Any reimbursement , for the PAP machine, that was dispensed during the time of non-adherence will be recouped by CareSource. B. Any reimbursement, for the supplies, that were dispensed during the time of non-adherence will be recouped by CareSource. IV. Non-participating providers require a prior authorization for the entire rental period. Note: Although CareSource does not require a prior authorization during the first 3 months of use, CareSource may request documentation to support medical necessity that shows adherence to the ordered use of the PAP machine. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the 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. CPT Code Description A4604 Tubing with integrated heating element for use with positive airway pressure device A7030 Full face mask used with positive airway pressure device, each A7031 Face mask interface, replacement for full face mask, each A7032 Cushion for use on nasal mask interface, replacement only, each A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Headgear used with positive airway pressure device A7035 Headgear used with positive airway pressure device A7036 Chinstrap used with p ositive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, nondisposable, used with positive airway pressure device Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICAID PY-0313 Effective Date: 04/01/20204E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) E0561 Humidifier, non-heated, used with positive airway pressure device E0562 Humidif ier, heated, used with positive airway pressure device E0601 Continuous positive airway pressure (CPAP) device Modifiers Description RR Rental (use the RR ‘ modifier when DME is to be rented) NU New equipment (use the NU modifier when DME is purchase d) F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 11/01/2017Date Revised 12/11 /2019 Updated references , modifiers and adherence definition Date Effective 04/01/2020 Date Archived 04/30/2021 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. References 1. CPAP-NHLBI, NIH. (2019, July 29). Retrieved 7/29/19 from https://www.nhlbi.nih.gov/health-topics/cpap. 2. Lawriter-OAC-5160-1-01 Medicaid medical necessity: definitions and principles. (2015, March 22). Retrieved 7/29/19 from http://codes.ohio.gov/oac/5160-1-01. 3. Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) (2019, January 1). Retrieved 7/29/19 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33718& ver=16&SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Both&s=42&KeyWord=Positive+Airway+Pressure+(PAP)+Devices+for+the+Treatment+of+Obstructiv e+Sleep+Apnea&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=tru e&bc=IAAAACAAAAAA&. 4 . Schedules and Rates. (2019, January 1). Retrieved 7/29/19 from https://medicaid.ohio.gov/Provider/FeeScheduleandRates/SchedulesandRates#1682570-durable-medical-equipment-prostheses-orthoses-and-supplies-dmepos. Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICAID PY-0313 Effective Date: 04/01/20205 The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Readmission PY-0724 07/01/2019-12/31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 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 Reimbursemen t 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, 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 Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure 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 prov ided in a particular case and may modify this Policy at any time. 2 Read missionOHIO MEDICAID PY-0724 Effective Date: 07/01/2019 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims of R eadmissions f or our Medicare Advantage members may be subject to limitations and/or qualif ications. 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 f or proc essing. Health care providers and their of fice staf f are encouraged to use self-service channels to verify members eligibility. Following a hospitalization, readmission within 30 days is of ten a costly preventable event and is a quality of care issue. It has been estimated that readmissions within 30 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result f rom many situations but most of ten are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, f amily and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progression of the disease state or due to chronic conditions. The purpose of this policy is to improve the quality of inpatient and transitional care that is being rendered to the members of CareSource. This includes but is not limited to the f ollowing: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perf orm pre discharge assessment to ensu re patient is ready to be discharged, and 4. provide ef fective post discharge coordination of care. C. Def initions Readmission : a subsequent inpatient admission to an acute care f acility which occurs within 30 days of the discharge date; excluding planned admissions. Planned Readmission : a non-acute admission f or a scheduled procedure f or limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Clinically-Related Readmission Chain: is a series of admissions f or the same patient where the underlying reason for readmission is related to the care rendered during or within thirty days f ollowing a prior hospital admission. A clinically-related readmission may have resulted f rom improper or incomplete care during the initial admission or discharge planning process. The hospital where the initial admission occurred is responsible f or the clinically-related readmission chain. Hospitalization resulting f rom an unpreventable or unrelated event o ccurring af ter discharge and planned readmissions are not considered clinically-related. Potentially Preventable Readmission (PPR): a readmission within a specif ic time f rame that is clinically related and may have been prevented had appropriate care been provided during the initial hospital stay and discharge process. A PPR is A. Subject3 Read missionOHIO MEDICAID PY-0724 Effective Date: 07/01/2019 determined when, based on CareSource guidelines, it is determined that the patient was discharged prematurely. Premature discharge evidence can be described as, but not limited to, elevated f ever at the time of discharge, abnormal lab results or evidence of inf ection or bleeding a wound. Only admission: an admission where there was neither a prior initial admission nor a clinically-related readmission within the thirty day readmission period Same or Similar Condition : a condition or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented on the initial admission. Same Day : CareSource delineates same day as midnight to midnight of a single day. D. PolicyI. This is a reimbursement policy that def ines the payment rules for hospitals and acute care f acilities that are reimbursed f or inpatient or observational services f or the f ollowing: A. Readmissions that are potentially preventable as determined by the provisi on of appropriate care consistent with the criteria outlined below: 1. A medical readmission f or a continuation or recurrence of the reason for the initial admission due to lack of care, or f or a closely related condition (e.g., a readmission f or diabetes f ollowing an initial admission f or diabetes). 2. A medical readmission f or an acute decompensation of a chronic problem that was not the reason f or the initial admission, but was potentially related to the lack of care rendered either during or immediately af ter the initial admission (e.g., a readmission f or diabetes in a patient whose initial admission was f or an acute myocardial inf arction). 3. A medical readmission f or an acute medical complication potentially related to the lack of care rendered during the initial admission (a patient with a hernia repair and a perioperative Foley catheter readmitted for a urinary tract inf ection 10 days later). 4. A readmission f or a surgical procedure to address a continuation or a recurrence of the problem causing the initial admission (a patient readmitted f or an appendectomy f ollowing an initial admission f or abdominal pain and f ever). 5. A readmission f or a surgic al procedure to address a complication resulting f rom the lack of care rendered during the initial admission (a readmission f or drainage of a post-operative wound abscess following an initial admission for a bowel resection). B. Readmissions f or a condition o r procedure that is clinically-related to the care provided during the prior discharge or resulting f rom inadequate discharge planning during the prior discharge. C. Readmissions when the PPR chain may contain one or more readmissions that are clinically-rela ted to the initial admission. If the f irst readmission is within thirty days af ter the initial admission, the thirty day timef rame may begin again at the discharge of either the initial admission or the most recent readmission clinically – related to the in itial admission. D. Readmission is to the same hospital. 4 Read missionOHIO MEDICAID PY-0724 Effective Date: 07/01/2019 II. Any readmission that occurs within one calendar day (i.e. same day or next day), to the same institution, is considered one discharge f or payment purposes and will be reimbursed as one DRG payment per the OAC 5160-2-65. III. Readmissions, f or the purposes of d etermining PPRs, excludes the f ollowing circumstances: A. The original discharge was a patient initiated discharge, was against medical advice (AMA), and the circumstances of such discharge and readmission are documented in the patient’s medical record. B. The o riginal discharge was f or the purpose of securing treatment of a major or metastatic malignancy, major trauma, neonatal and obstetrical admission, transplant or HIV. C. Only admissions, which are def ined in the definitions of this policy. Planned readmissions are considered “only admissions. IV. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review f or medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will au tomatically deny which will result in a denial of the claim. V. Post Payment Review and Appeals Process:1. CareSource reserves the right to monitor and review claim submissions to minimize the need f or post-payment claim adjustments as well as review payments retrospectively. a. Medical records f or both admissions must be included with the claim submission to determine if the admission(s) is appropriate or is considered a readmission. 01. Failure f rom the acute care f acility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. Medical records f or both admissions must be submitted with the claim if both admissions originated f rom the same f acility or Tax Identif ication Number (TIN). 01. Failure f rom the acute care f acility or inpatient hospital to provide complete medical records will result in an automatic denial of the cla im c. If the included documentati on determines the readmission to be an inappropriate, medically unnecessary or potentially preventable admission, the hospital must be able to provide additional documentation to CareSource upon request or the claim will be denied. d. If the readmission is determined at the time of documentation review to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admission and paid as one claim to cover both, or all, admissions. 2. Appeals Process 5 Read missionOHIO MEDICAID PY-0724 Effective Date: 07/01/2019 a. All acute care f acilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer review or formal appeal. E. Conditions of CoverageReimb ursement is dependent on, but no t limited to, submitting claims based on National Correct Co d ing Guidelines. F. Related Policies/RulesG. Re view/Revision HistoryDATE ACTIONDate Issued 04/01/2019Date Revised Date Effective 07/01/2019 Date Archived 12/31/2020 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erences1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Ho spital readmissions red uction p ro g ram. Circulation , 131 (20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Ho sp ital readmissions red uction program. Circulation , 131 (20), 1796-803. 2. Ho sp ital Read mission Reduction Pro gram. (2018, December 04). Retrieved from http s:// www.cms.gov 3. Med icare Claims Processing Manual. (2018, No vember 9). Retrieved January 23, 2019, from http s:// www.cms.gov 4. Go ld field, N. I., McCullough, E. C., Hughes, J. S., Tang , A. M., Eastman, B., Rawlins, L. K., & Averill, R. F. (2008). Id entifying potentially p reventable read missions. Retrieved from http s:// www.ncbi.nlm.nih.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 Glycosylated Hemoglobin A1C PY-0157 03/01/2020 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 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 …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Glycosylated Hemoglobin A1C OHIO MEDICAID PY-0157 Effective Date: 03/01/2020 2 A. Subject Glycosylated Hemoglobin A1C 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. Glycated hemoglobin/protein testing is widely accepted as medically necessary for the management and control of diabetes. Glycosylated hemoglobin A1C/protein levels are used to determine long-term glucose control in diabetes. Glycosylated hemoglobin levels reflect the average level of glucose in the blood over a three-month period. C. Definitions Glycosylated Hemoglobin (A1C) a blood test that measures your average blood sugar levels over the past 3 months. It is one of the commonly used tests to diagnose prediabetes and diabetes. Glycated protein-a blood test that is used to assess glycemic control over a period of 1-2 weeks and long-term control in diabetic patients with abnormalities of erythrocytes. D. Policy I. Prior authorization is not required for glycosylated hemoglobin (A1C)/protein blood testing. Note: Although CareSource does not require a prior authorization for glycosylated hemoglobin (A1C)/protein blood testing, 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. CareSource considers screening for the diagnosis of diabetes as medically necessary preventive care for the following member groups according to the United States Preventive Services Task Force (USPSTF): A. Asymptomatic members age 40 to 70 years who are overweight or obese B. Asymptomatic members of any age or weight who are in the following high-risk groups: 1. Immediate family history of diabetes 2. History of gestational diabetes or polycystic ovarian syndrome 3. African Americans 4. Native Americans 5. Alaskan Natives 6. Asian Americans 7. Hispanics and Latinos Glycosylated Hemoglobin A1C OHIO MEDICAID PY-0157 Effective Date: 03/01/2020 3 8. Native Hawaiians 9. Native Pacific Islanders C. Asymptomatic pregnant women who have reached 24 weeks of gestation. III. CareSource considers diagnostic testing for the management of diabetes as medically necessary for the following member groups, with the specified frequencies: A. Members whose diabetes is controlled, once every 3 months B. Members whose diabetes is not controlled may require testing more than four times a year C. Pregnant women, once per month Note: CareSource may request documentation to support medical necessity, if testing is in excess of the above guidelines. IV. Alternative testing, including glycated protein, for example, fructosamine, may be indicated for monitoring the degree of glycemic control. A. It is therefore conceivable that a patient will have both a glycated hemoglobin and glycated protein ordered on the same day. B. This should be limited to the initial assay of glycated hemoglobin, with subsequent exclusive use of glycated protein. C. These tests are not considered to be medically necessary for the diagnosis of diabetes. V. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the CPT code listed within this policy. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the 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. CPT Code Description 82985 Glycated protein 83036 Hemoglobin; glycosylated (A1C) ICD-10 Description D13.7 Benign neoplasm of endocrine pancreas E08. Diabetes mellitus due to underlying condition with (Any ICD-10 starting with E08.) E09. Drug or chemical induced diabetes mellitus with (Any ICD-10 starting with E09.) E10. Type 1 diabetes mellitus with (Any ICD-10 starting with E10.) E11. Type 2 diabetes mellitus with (Any ICD-10 starting with E11.) E13. Other specified diabetes mellitus with (Any ICD-10 starting with E13.) E15 Nondiabetic hypoglycemic coma E16.0 Drug-induced hypoglycemia without coma E16.1 Other hypoglycemia E16.2 Hypoglycemia, unspecified E16.3 Increased secretion of glucagon E16.8 Other specified disorders of pancreatic internal secretion Glycosylated Hemoglobin A1C OHIO MEDICAID PY-0157 Effective Date: 03/01/2020 4 E16.9 Disorder of pancreatic internal secretion, unspecified E31.0 Autoimmune polyglandular failure E31.1 Polyglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E31.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E74.8 Other specified disorders of carbohydrate metabolism E79.0 Hyperuricemia without signs of inflammatory arthritis and tophaceous disease E83.10 Disorder of iron metabolism, unspecified E83.110 Hereditary hemochromatosis E83.111 Hemochromatosis due to repeated red blood cell transfusions E83.118 Other hemochromatosis E83.119 Hemochromatosis, unspecified E83.19 Other disorders of iron metabolism E88.02 Plasminogen deficiency E89.1 Postprocedural hypoinsulinemia H44.2E1 Degenerative myopia with other maculopathy, right eye H44.2E2 Degenerative myopia with other maculopathy, left eye H44.2E3 Degenerative myopia with other maculopathy, bilateral eye I21.9 Acute myocardial infarction, unspecified I21.A1 Myocardial infarction type 2 I21.A9 Other myocardial infarction type K86.0 Alcohol-induced chronic pancreatitis K86.1 Other chronic pancreatitis K91.2 Postsurgical malabsorption, not elsewhere classified L97. Non-pressure chronic ulcer of other part of (Any ICD-10 starting with L97.) L98.415 Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis L98.416 Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis L98.418 Non-pressure chronic ulcer of buttock with other specified severity L98.425 Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis L98.426 Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis L98.428 Non-pressure chronic ulcer of back with other specified severity L98.495 Non-pressure chronic ulcer of skin of other sites with muscle involvement without evidence of necrosis L98.496 Non-pressure chronic ulcer of skin of other sites with bone involvement without evidence of necrosis O24. Pre-existing type 1 diabetes mellitus, in pregnancy (Any ICD-10 starting with O24.) O30. Pregnancy(Any ICD-10 starting with O30.) O99.810 Abnormal glucose complicating pregnancy O99.815 Abnormal glucose complicating the puerperium R73.01 Impaired fasting glucose R73.02 Impaired glucose tolerance (oral) R73.03 Prediabetes R73.09 Other abnormal glucose R73.9 Hyperglycemia, unspecified R78.71 Abnormal lead level in blood Glycosylated Hemoglobin A1C OHIO MEDICAID PY-0157 Effective Date: 03/01/2020 5 R78.79 Finding of abnormal level of heavy metals in blood R78.89 Finding of other specified substances, not normally found in blood R79.0 Abnormal level of blood mineral R79.89 Other specified abnormal findings of blood chemistry R79.9 Abnormal finding of blood chemistry, unspecified T38.3X1A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter T38.3X2A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, intentional self-harm, initial encounter T38.3X3A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, assault, initial encounter T38.3X4A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, undetermined, initial encounter Z00.00 Encounter for general adult medical examination without abnormal findings Z00.01 Encounter for general adult medical examination with abnormal findings Z01.812 Encounter for preprocedural laboratory examination Z13.1 Encounter for screening for diabetes mellitus Z13.9 Encounter for screening, unspecified Z79.3 Long term (current) use of hormonal contraceptives Z79.4 Long term (current) use of insulin Z79.84 Long term (current) use of oral hypoglycemic drugs Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.31 Personal history of diabetic foot ulcer Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 12/01/2017 Date Revised 10/16/2019 Updated references and diagnosis code list Date Effective 03/01/2020 Date Archived H. References 1. Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. (2015, October). Retrieved 8/29/2019 from https://www.uspreventiveservicestaskforce.org/Page/Document/Update SummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=diabetes. 2. Centers for Medicare and Medicaid Services. (2019). NCD 190.21-Glycated Hemoglobin/Glycated Protein (190.21). 3. Gestational Diabetes Mellitus, Screening. (2014, January). Retrieved 8/29/2019 from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestational-diabetes-mellitus-screening?ds=1&s=diabetes 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 PLANS Policy Name Policy Number Effective Date Robotic-Assisted Surgery PY-0957 03/01/2020-05/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 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, regulato ry requir ements, 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, dysfuncti on 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. 2 A. SubjectRobotic-Assisted Surgery Ro bo tic-Assisted Surg eryOHIO MEDICAID PLANS PY-0957 Effective Date: 3/1/2020 B. Background Reimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are no t a g uarantee of p ayment. Reimbursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be determined when the claim is received for p rocessing. Health care p ro viders and their office staf f are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a code in this p o licy does no t imply any right to reimbursement or guarantee claims p ayment. Ro b o t-assisted surgery involves the use of a robot and computer technology under the direction and g uid ance of a surgeon. These surg eries are minimally invasive p rocedures using robotic d evices d esigned to access surgical locations through smaller incisions or ports. There surg eries are g enerally p erformed using a wo rkstation console containing remote controls for the surg ical instruments as well as a computer equipped with a three-dimensional magnified video moni tor of the surg ical site through use of miniature cameras. The p rimary d ifference between ro botic and co nventional laparoscopic procedures is that the surgical instruments are manipulated indirectly thro ug h computer controls rather than manually by the sur geon. The ro b otic contro ls allow the surg ical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar f ashion as would be done in an o pen p rocedure. Examples of robotic surgical systems includ e the d a Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Ro botic Surgical System (Computer Motion, Inc.) C. Def initions Robotic Assisted Surgery – is def ined as the perf ormance of operative procedures with the assistance of robotic technology. D. PolicyI. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modif ier 22 (increased procedural services):1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased dif ficulty of procedures, or severity of patients conditi on. 3 Conditions of CoverageRo bo tic-Assisted Surg eryOHIO MEDICAID PLANS PY-0957 Effective Date: 03/01/2020 Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the Ohio Medicaid f ee schedule f or appropriate codes. E. Related Policies/RulesF. Review/Revision HistoryDATE ACTIONDate Issued 03/01/2020 New Po licyDate Revised Date Effective 03/01/202 0 Date Archived 05/31/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy G. Ref erences1. Ro b o tic surgery. MedLine Plus Web site. http ://www.nlm.nih.gov/medlineplus/ency/article/007339.htm . Published May 2013. Accessed Octo ber 9, 2019. 2. Centers f o r Medicare and Medicaid Services, CMS Manual System and other CMS p ub lications and services; http ://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#To pOfPage 3. Ohio Dep artment of Medicaid http://jfs.ohio.gov/ 4. Centers f o r Medicare and Medicaid Services, Healthcare Co mmon Procedure Coding System, HCPCS Release and Code Sets http ://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#To pOfPage 5. Daniel M. Herro n, MD. A consensus Document o n Robotic Surgery. Prepared by the SAGES – MIRA Ro b o tic S urgery Co nsensus g roup. Position Papers/ Statement p ublished o n: 11/2007. Accessed October 9, 2019. Available at URL ad dress: http ://www.sages.org/publicati ons/guidelines/consensus-document-robotic-surgery/ 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 Date Reimbursement Modifiers PY-0715 09/01/2019-08/31/2023 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 ………………………………………………………………………………………….. 10 F. Related Policies/Rules …………………………………………………………………………………………… 10 G. Review/Revis ion History …………………………………………………………………………………………. 10 H. References …………………………………………………………………………………………………………… 10 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, 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 procedu res. 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. 2 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019A. Subject Reimbursement Modifiers 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.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Although CareSource accepts the use of modifiers specific to this policy, not all modifiers are included within this policy. The modifiers included within this policy are those modifiers that affect the reimbursement of a service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must be made available upon CareSources request. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.C. Definitions Current Procedural Terminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier-two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. Modifier 22-Increased Procedural Services A. Modifier 22 is used to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required. The extra work may be identified by appending modifier 22 to the usual procedure code. B. Procedure codes with modifier 22 appended may be reimbursed up to 120% of the fee schedule amount. Note: This modifier is not appended to E/M services (99201-99499). Claims for 99201-99499 with modifier 22 will be denied. Medical records ARE required with the3 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019claim and must support the use of this modifier. Claims with procedures including 22 and no supporting documentation will be denied. II. Modifier 50-Bilateral Procedures A. Professional Claims Only Append modifier 50 to the appropriate unilateral code on a single claim line and indicate 1 unit in the unit field of that claim line.B. Modifier 50 applies to surgical procedures (CPT codes 10040-69990) and to radiology procedures performed bilaterally. C. Applies to any bilateral procedure performed on both sides at the same session. D. The use of modifier 50 is NOT appropriate in the following situations: 1. Using modifier 50 on a bilateral procedure performed on different areas of the right and left sides of the body. 2. Appending modifier 50 to a procedure code that is defined by CPT as primarily bilateral or a bilateral service. 3. Appending modifier 50 to a surgical CPT code, the description of which contains the words one or both. E. Do not report two line items to indicate a bilateral procedure. F. Procedure code with modifier 50 appended will reimburse 1 unit at 150% of the fee schedule amount. III. Modifier 51-Multiple Procedures A. Modifier 51 is used to report multiple procedures, other than E/M services, are performed at the same session by the same individual, the primary procedure or service is reported as listed.B. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). C. Modifier 51 should not be appended to designated "add-on" codes. D. Procedure code with modifier 51 appended will reimburse 50% of the fee listed on the Medicaid Physician Fee Schedule for the service. IV. Modifier 52-Reduced services A. Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. 1. Modifier 52 is used for reporting reduced services when the procedure was terminated after the patient was prepped and brought to the room where the service was to be performed.B. Modifier 52 may be used to report reduced radiology procedures. 1. The correct reporting is to assign the CPT code to the extent of the procedure performed. 2. This modifier is used only to report a radiology procedure that has been reduced when no other code exists to report what has been done. 3. Report the intended code with modifier 52. i. Example, if the planned procedure is a two-view chest x-ray and only one view of the chest is performed, do not report CPT code 71020-52 (for x-ray chest, two views-reduced service). Instead, report CPT code 71010 (x-ray chest, single view). ii. Example, if a barium swallow is not completed because the patient cannot handle the barium, report CPT code (74270-52). C. Modifier 52 does not provide for reimbursement of an ineligible service. D. For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. E. Procedure code with modifier 52 appended will reimburse at 50% of the fee schedule amount. 4 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. The extenuating circumstances preventing the completion of the procedure must also be documented.V. Modifier 53-Discontinued Procedure A. Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued after anesthesia is administered to the patient. 2. Modifier 53 is used to indicate that the physician terminated a surgical/diagnostic procedure due to the patients well-being. B. This modifier is not used to report an elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. C. Modifier 53 cannot be used when a laparoscopic or endoscopic procedure is converted to an open procedure. D. Modifier 53 does not provide for reimbursement of an ineligible service. E. Modifier 53 cannot be appended to E/M codes. F. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or a fter administration of anesthesia, see modifiers 73 and 74. G. Procedure code with modifier 53 appended will reimburse at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. Documentation must include a statement indicating at what point the procedure was discontinued. The extenuating cir cumstances preventing the completion of the procedure must also be documented.VI. Modifier 54-Surgical Care Only A. Modifier 54 is reported when one physician performed a surgical procedure only; another physician provides the preoperative and/or postoperative management.B. Modifier 54 must only be appended to the surgical procedure code. C. Procedure code with modifier 54 appended will reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.VII. Modifier 55-Postoperative Management Only A. Modifier 55 is reported when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by appending modifier 55 to the procedure code.B. Modifiers 55 must only be appended to the surgical procedure code. C. Procedure code with modifier 55 appended will reimburse at 15% of the fee schedule amount. 5 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. VIII. Modifier 56-Preoperative Management Only A. Modifier 56 is reported when 1 physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code.B. Modifiers 56 must only be appended to the surgical procedure code. C. Procedure code with modifier 56 appended will reimburse at 15% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.IX. Modifier 62-Two Surgeons A. Modifier 62 is reported when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure. 1. Each surgeon must report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons.2. Each surgeon must report the co-surgery once using the same procedure code. If additi onal procedure(s), including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported without the modifier 62 added. 3. If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or 82 added, as appropriate. B. Procedure code with modifier 62 appended will be reimbursed at 62.5% of the fee schedule amount . Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.X. Modifier 66-Surgical Team A. Modifier 66 is reported when three or more surgeons work together during a highly complex procedure are carried out under the "surgical team" concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic proc edure code used for reporting services.B. Claims submitted by team surgeons are identified with modifier 66. C. The Centers for Medicare & Medicaid Services (CMS) established a Team Surgery Indicator (TEAM SURG) found in the CMS National Physician Fee Schedule Relative Value File. Values are: 1. 0-Team surgeons not permitted for this procedure. 2. 1-Team surgeons may be paid; supporting documentation is required to establish medical necessity. 3. 2-Team surgeons permitted. 4. 9-Team surgeon concept does not apply. D. Codes with CMS Team Surgery Indicators of 0 and 9 should not be billed with modifier 66. E. Modifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate procedure not included in the team surgery. 6 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019F. Only one surgeon maybe be considered the primary surgeon. CareSource will not reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon. G. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. H. Procedure code with modifier 66 appended will reimburse at 150% of the established fee, divided equally between the team surgeons. I. For team surgery with three surgeons, each surgeon will be reimbursed at 50% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XI. Modifier 73-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) ProcedurePrior to the Administration of Anesthesia A. Modifier 73 is reported to a service to indicate that due to extenuating circumstances or those that threaten the well-being of the patient, a surgical or diagnostic procedure at an outpatient hospital or ambulatory surgical center (ASC) was discontinued prior to the administration of anesthesia. B. Modifier 73 is only appropriate for use by an ASC. C. Modifier 53 should not be used for any ASC service as the modifier is used exclusively on a professional claim. D. Procedure code with Modifier 73 appended will reimburse at 50% of the ASCs fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XII. Modifier 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) ProcedureAfter Administration of Anesthesia A. Modifier 74 is reported when due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia or after the procedure was started (incision made, intubation started, scope inserted.) B. Modifier 74 is not appropriate for the elective cancellation or postponement of a procedure based on the physician or patients choice. C. Modifier 74 is not appropriate when the termination of the procedure occurs prior to the beginning of the procedure or the administration of anesthesia. D. Modifier 74 is not for physician use. It is only appropriate for the ASC. E. Procedure code with modifier 74 appended will be reimbursed at 100% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XIII. Modifier 78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period A. Modifier 78 is reported to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure).7 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/20191. When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. 2. Modifier 78 should be appended when: i. The return to the operating room is unplanned. ii. The service is performed by same physician who performed the initial procedure. iii. The service is related to the initial procedure. iv. The service is performed during the postoperative period of the initial procedure (10-90 days). B. Procedure code with modifier 78 appended will be reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. XIV. Modifier 80-Assistant Surgeon A. Modifier 80 is reported to indicate surgical assistant services by a physician and is applied to the surgical procedure code(s). B. Assistant Surgeon provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated. C. Modifier 80 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 80 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XV. Modifier 81-Minimum Assistant Surgeon A. Modifier 81 is reported to indicate minimum surgical assistant services and is applied to the surgical procedure code(s).B. Minimum Assistant Surgeon is an assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon. C. Modifier 81 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 81 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XVI. Modifier 82-Assistant Surgeon (when qualified resident surgeon not available) A. Modifier 82 is reported to indicate when surgical assistance is needed, but a qualified resident was not available. B. Modifier 82 is used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable. 8 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019C. The unavailability of a qualified resident surgeon is a prerequisite for the use of this modifier. The assistant must provide documentation (certification) stating that a qualified resident was not available for this procedure and why the resident was not available. D. Procedure code with modifier 82 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery and why a qualified resident was not available. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XVII. Modifier AA-Anesthesia services performed personally by an anesthesiologist A. Modifier AA is used to report when the anesthesia services are personally performed by an Anesthesiologist. B. Procedure code with modifier AA appended will be reimbursed at 100% of the fee schedule amount. XVIII. Modifier AD-Anesthesia services supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. A. Modifier AD is used to report when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures.B. Procedure code with modifier AD appended will be reimbursed at 100% of the fee schedule amount. XIX. Modifier QK-Medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. A. Modifier QK is used to report when medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals.B. Procedure code with modifier QK appended will be reimbursed at 50% of the fee schedule amount. XX. Modifier QX-Anesthesia services performed by a CRNA with medical direction by an anesthesiologist. A. Modifier QX is used to report when the anesthesia services are performed by a CRNA with medical direction by an anesthesiologist.B. Procedure code with modifier QX appended will be reimbursed at 50% of the fee schedule amount. XXI. Modifier QY-Anesthesia services when an Anesthesiologist medically directs one CRNA. A. Modifier QY is used to report when an Anesthesiologist medically directs one CRNA.B. Procedure code with modifier QY appended will be reimbursed at 50% of the fee schedule amount. XXII. Modifier QZ-Anesthesia services performed personally by a CRNA without medical direction by a physician. A. Modifier QZ is used to report when the anesthesia services are personally performed by a CRNA.B. Procedure code with modifier QZ appended will be reimbursed at 100% of the fee schedule amount. XXIII. Modifier AE-Registered dietician A. Modifier AE is reported to indicate when a registered dietician provides the service.9 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019B. Procedure code with modifier AE appended will be reimbursed at 85% of the fee schedule amount. XXIV. Modifier AS-Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) served as the assistant at surgery. A. Modifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in place of another surgeon.B. Procedure code with modifier AS appended will be reimbursed at 25% of the base code allowable fee schedule before multiple surgery reductions are taken. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XXV. Modifier JW-Drug amount discarded (wasted)/not administered to any patient A. CareSource will consider reimbursement for: 1. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended.2. The wasted amount when billed with the amount of the drug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSource will NOT consider reimbursement for: 1. The wasted amount of a multi-dose vial drug. 2. Any drug wasted that is billed when none of the drug was administered to the patient. 3. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. XXVI. Modifier SA-Nurse practitioner (NP) rendering service in collaboration with a physician A. Procedure code with modifier SA appended will be reimbursed at 100% of the fee schedule when billed with Place of Service (POS) other than 21, 22 or 23. B. Procedure code with modifier SA appended will be reimbursed at 85% of the fee schedule amount when billed with Place of Service (POS) 21, 22 or 23. XXVII. Modifier SE-Drug acquired through the 340B drug pricing program. State and/or federally-funded programs/services.XXVIII. Modifier TC-Technical Component A. Technical component charges are institutional charges and not billed separately by physicians.B. A charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding Modifier TC to the usual procedure code. XXIX. Modifier UD Physician Assistant (PA) rendering service in collaboration with a physician A. Modifier UD is reported to indicate when a supervising physician is billing on behalf of a PA for non-surgical services.B. Modifier UD is used when the PA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier UD appended will be reimbursed at 85% of the fee schedule amount. 10 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019 XXX. Modifier 26-Professional Component A. Certain procedures are a combination of a physician component and a technical component. B. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. Note: In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2019 New policyDate Revised Date Effective 09/01/2019 Archive Dare 08/31/2023 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. Appendix to rule 5160-4- 21. (2016, June 30). Retrieved 3/22/2019 from https://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/5160-4- 21-phffnapp1-20160630-1045.pdf 2. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 3/22/2019 from https://s3.amazonaws.com/biopolicy/portal/fab42153-0f1f-4ea9-9db6-263c144aa972?response-content-disposition=inline%3B%20filename%3D%2259485-1143476.pdf%22&response-content-type=application%2Fpdf&X-Amz-Content-Sha256=e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWB6UVO57LSG6L2A%2F20190322%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190322T142429Z&X-Amz-SignedHeaders=Host& X-Amz-Expires=1800&X-Amz-Signature=689299099b6b1cc8481ca23fce721228a74bfef30ea4bc2e95a7cd5870bd298d 3. CPT overview and code approval. (2019, March 22). Retrieved from https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval Medicare Claims 11 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019 Processing Manual Chapter 12-Physicians/Nonphysician Practitioners (2018, November 30). Retrieved February 18, 2019 from https ://www .cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 4. Medicare Claims Processing Manual Chapter 14-Ambulatory Surgical Centers. (2017, Dece mber 22). Retrieved February 18, 2019 from https ://www.c ms.go v/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf. 5. Modifiers Recognized by Ohio Medicaid. (2018, November 1). Retrieved from https://medicaid.ohio.gov/Portals/0/Resources/Publications/Guidance/BillingInstructions/Modif iersODM.pdf 6. Optum360 EncoderProForPayers.com-Login. (20 19, February 18). Retrieved February 18, 2019 from https:// www.encoderprofp.com/epro4payers/allModifiersHandler.do?_k=101*0&_a=listRelate d&menu=4. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved12 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019 13 Reimbursement Modifiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12/01/2017 Policy Name Policy Number Sleep Studies PY-0169 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 re ferral, 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 patien t 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 lowes t 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 Statem ents, 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 ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. ……………. 2 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 3 Archived Sleep Studies OHIO MEDICAID PY-0169 Effective Date: 12-01-2017 2 A. SUBJECT Sleep Studies 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 f or 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 the ir 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 does not imply any right to reimbursement or guarantee claims payment. Sleep Studies and Polysomnography (PSG) refers to the test performed for people who suffer from insomnia, excessive daytime sleepiness, obstructive sleep a pnea, breathing difficulties during sleep, or behavior disturbances during sleep. It is the continuous monitoring and recording, of a patients body functions, during sleep. It may include eye movement, brain waves, blood pressure, oxygen saturation, mus cle activity and heart rhythm. For the purpose of this policy, the terms sleep study and Polysomnography may be used interchangeably. However, when submitting a claim for reimbursement, providers should use the most appropriate CPT code with the appr opriate associated definition. CareSource will reimburse providers, for sleep studies to CareSource members, as set forth in this policy. C. DEFINITIONS Narcolepsy-is a syndrome that is characterized by abnormal sleep tendencies. Obstructive Sleep Apnea (OSA) – is the obstruction of airflow, during sleep, due to the collapse of the oropharyngeal walls. Parasomnias-are a group of conditions that may occur during sleep that can often lead to injury to the patient or others and damage to the s urroundings. These conditions may include sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorders. Polysomnography (PSG) – is a sleep study that records certain body functions during sleep and is used to diagnose sleep disorder s. Sleep Apnea-is the interruption of airflow for at least 10 seconds. D. POLICY I. CareSource does not require a prior authorization for a sleep studies. II. A sleep study/polysomnography (PSG) may be reimbursed according to CMS/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the sleep study/polysomnography (PSG) CPT code. IV. If the appropriate ICD-1 0 diagnosis code is not submitted with the CPT code, the claim will be denied. V. Sleep study/PSG is considered medically necessary and covered: A. Only if the patient has the symptoms or complaints of one of the conditions listed below. 1. NarcolepsyArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 12-01-2017 3 2. Parasomnias 3. Sleep Apnea B. The patients must be referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physicians orders. C. The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests. D. The test is not redundant of other diagnostic procedures that must be performed. VI. Polysomnography (PSG) includes the stages of sleep, which requires items a through c below. Poly somnography is defined to minimally include, but i s not limited to, the following A. A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp. B. Electrooculogram (EOG) to measure eye mov ements using electrodes placed near the outer canthus of each eye. C. A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, and/or masseter regions. D. Rhythm electrocardiogram (ECG). E. Nasal and/or oral airflow via both thermistor and nasal pressure sensor. F. Respiratory indication by chest-wall and abdominal movement measured using respiratory inductive plethysmography, endoesophageal pressure or by intercos t al EMG. G. Gas exchange (oxygen saturation) by oximet ry or transcutaneous monitoring H. Bilateral anterior tibialis muscle activity, motor activity-movement using EMG. I. Body positions by directly applied sensors or by direct observation. VII. Home slee p testing is NOT covered by CareSource for Ohio Medicaid members. Included are: A. 95800, 95801, 95803, 95806 VI II. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. Note: Although a Sleep Study 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. E. CONDITIONS OF COVERAGE Reimburs ement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 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 Definition 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologistArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 12-01-2017 4 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist 95808 Pol ysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist 95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95811 Polysomnog raphy; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes 95813 Electroencephalogram (EEG) extended monitoring; greater than 1 hour 95816 Electroencephalogram (EEG); including recording awake and drowsy 95819 Electroencephalogram (EEG); including recording awake and asleep 95822 Elec troencephalogram (EEG); recording in coma or sleep only 95824 Electroencephalogram (EEG); cerebral death evaluation only 95827 Electroencephalogram (EEG); all night recording 95829 Electrocorticogram at surgery (separate procedure) 95830 Insertion by physician or other qualified health care professional of sphenoidal electrodes for electroencephalographic (EEG) recording 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 95832 Muscle testing, manual (se parate procedure) with report; hand, with or without comparison with normal side 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) 95852 Range of motion measurements and report (separate procedure); hand, with or witho ut comparison with normal side 95857 Cholinesterase inhibitor challenge test for myasthenia gravis 95860 Needle electromyography; 1 extremity with or without related paraspinal areas 95861 Needle electromyography; 2 extremities with or without related paraspinal areas 95863 Needle electromyography; 3 extremities with or without related paraspinal areas 95864 Needle electromyography; 4 extremities with or without related paraspinal areas 95865 Needle electromyography; larynxArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 12-01-2017 5 ICD-10 Definition G47.10 Hypersomnia, unspecified G47.3 Sleep apnea G47.33 Obstructive sleep apnea (adult) (pediatric) G47.41 Narcolepsy G47.5 Parasomnia G47.9 Sleep Disorder, Unspecified F. RELATED POLICIES/RULESG. REVIEW/REVISION HISTORYDATE ACTION Date Issued 03-08-2017 New policy. Date Revised Date Effective 12-01-2017H. REFERENCES1. Appendix DD to rule 5160-1 – 60. (2017, January 1). Retrieved 2/6/2017 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf2. Lawriter-OAC. (2016, September 1). Retrieved 3/6/2017 from http://codes.ohio.gov/oac/5160-103. Local Coverage Determination (LCD): POLYSOMNOGRAPHY and Other Sleep Studies(L36839). (2017, February 16). Retrieved 3/6/2017 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36839&ver=3&CoverageSelection=Bot h&ArticleType=All&PolicyType=Fi nal&s=North+Carolina&KeyWord=polysomnography&KeyW ordLookUp=Title&KeyWordSearc hType=And&bc=gAAAACAAAAAAAA%3d%3d& 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 OHIO MEDICAID Policy Name Policy Number Date Effective Drug Test ing PY-0020 7/1/2019 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, m edical neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, 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, dysfu nction 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 d oes 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 ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 6 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 7 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 8I . APPENDIX A ………………………….. ………………………….. ………………………….. ……… 9 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 2 A. Subject Drug Testing 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 w ill 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 does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; an d all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for me mbers with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs ar e of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory /Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Early and Periodic Screening, Diagnostic and Treatment ( EPSDT ) – This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test-A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Qualified Laboratories : When an out-of-network qualified laboratory provides toxicology test results to the referring health care provider within two business days of receipt of the test specimen, the MCP shall pay that laboratory at least sixty percent of the Medicaid laborato ry services fee schedule. For the purposes of this Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 3 requirement, a qualified laboratory is a laboratory that is enrolled with Medicaid as an independent laboratory, and that meets all of the following conditions : 1. Is accredited by the College of American Pathologists; and 2. Is approved by the New York Clinical Laboratory Evaluation Program; and 3. Indicates to the MCP that it is providing services and billing as a qualified laboratory Residential services-Ohio Administrative code defines residential services as These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. 1NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0054 . Please refer to this policy for in-depth information on medical necessity for drug testing, d ocumentation requirements , and CareSource monitoring and review of drug testing claims. D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the I CD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. The Ohio Department of Health Standard UDT PA Form must be provided along with the appropriate supporting documentation when requesting a PA. 2. CareSource will require a PA for UDT te sts >30 presumptive and/or > 12 confirmatory UDT per member per calendar year 3. PA is required for any non-participating provider with CareSource for non-emergency room setting. 4. PA is required for any non-participating, non-qualified lab/facility with CareS ource for non-emergency room setting. 5. PA is required for any non-participating, qualified lab/facility with CareSource for non-emergency room setting. 6. PA is not required in an emergency room setting . UDT utilization will be monitored by CareSource . 1http://codes.ohio.gov/oac/5160-27-09v1 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 4 7. PA needs to make a clear case for medical necessity for the level of testing being requested . B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will cover up to 30 presumptive and 12 definitive UDT per member per calendar year. 1. CareSource will cover up to 30 presumptive UDT per member per calendar year. 2. CareSource will cover up to 12 definitive UDT per member per calendar year. B. For presumptive tests, each CPT code is counted as one test . C. For confirmatory tests, all CPT tests performed on the same date of service count as one test. IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other t han that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care s ervice for children under age 21 . VI. Non-Urine Testing A. CareSource will reimburse blood testing in e mergency room settings . B. Drug testing with blood samples performed in any other setting outside of an e mergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VII. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 5 a. Presumptive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member d isputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testing that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing re quired by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Foren sic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed o utside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 6 I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits , recovery of overpayments identified, and provider prepay review . E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes . Please refer to the Ohio Medicaid fee schedule . The following list(s) of cod es 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. Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perform ed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative /Confirmatory Tests-Description 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80329 analgesics, non-opioid, 1 or 2 80330 analgesics, non-opioid 3-5 80331 analgesics, non-opioid 6 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more ArchivedDrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 7 80338 antidepressants not otherwise specified 80339 antiepileptics, not otherwise specified 1-3 80340 antiepileptics, not otherwise specified 4-6 80341 antiepileptics, not otherwise specified 7 or more 80342 antipsychotics, not otherwise specified 1-3 80343 antipsychotics, not otherwise specified 4-6 80344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80367 propoxphene 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, qualitative or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, qualitative or quantitative, not otherwise specified 4-6 80377 drug, or substance definitive, qualitative or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0054 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/29/2017 Date Revised 3/8/2017 5/31/2017 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 8 10/1/2017 11/29/2017 2/16/2018 5/13/2019 7/1/2019 7/8/2019 9/ 24 /2019 Updated clinical indications, quantity limits, and PA requirements Updated qualified laboratories per ODM guidance Added ODM PA form Date Effective 7/1/2019 H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11 /20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 3. American Society of Addict ion Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https://www.asam.org/docs/default-source/public-policy-statemen ts/1drug-testing — clinical-10-10.pdf?sfvrsn=1b11ac97_0#search=”urine drug testing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on 12/13/2018 from https://jo urnals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendati ons and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42.1.8&r=PART#se42.1.8_12 7. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved from http://codes.ohio.gov/oac/5160-27-09 v1 8. Medicaid. Ea rly and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html 9. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendat ions and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 10. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf 11. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky .gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%20on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20Drug%20Testing%20Guidance.pdf Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 9 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. APPENDIX A OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM The Clinical Advisory Group of the Ohio Department of Mental Health and Addiction Services established broad guidelines to appropriate clinical use of urine drug screening for patients with a substance use disorder. These guidelines took into account ease of access for patients by eliminating barriers to care, as well as account for patient safety, acuity, risk of relapse/overdose, level of care, and sustained abstinence. Date of Request: _____________________ Patient Information Last Name: ________________________________First Name: ________________________________ DOB: ___________ Member ID: ______________________ Patient phone # ______________ Provider Information 1. Ordering Provider Name: ___________________________________________________ _________ Tax ID: ________________NPI: ___________________Phone _________________ Fax:__________________ 2. Service Provider (Laboratory/Facility) Name: _____________________________________________ Tax ID: ________________NPI: ___________________Phone ______ ___________ Fax:__________________ Supporting Documentation-Supporting documents must be attached (including current medication list including current MAT, OTC meds, supplements that may interfere with testing; patients drug(s) of choice; ICD-10 Diagno sis code(s); drug testing history with results) Reason for request: (Check all that apply): Addiction Treatment Chronic pain management Other ____________________ Patients current phase of care: Induction Stabilization Maintenance Long term maintenance Relapse 2Patients current ASAM Level of Care: ________________________; not yet determined List date of testing if different than the date of this PA request: ________________________ 1. Presumptive (select one): 80305 80306 80307 2. Confirmatory include type of test (s): ______________________________________ For Patients with Chronic Pain on Opioid Therapy-Provide results of most recent screening. Additional Clinical Information Is patient curr ently pregnant? Yes No If suspected diversion, list risk factors: __________________________________________________ Has patient been adherent to MAT over past 3 months: Yes No If no, All of time Most of time Erratic Poor Un known Has medication administration been observed: Yes No 2OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM T0977 2Definition of Relapse: (ASAM National Practice Guideline (2015) A process in which an individual who has established abstinen ce or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pu rsuit of reward and/or relief through the use of substances and other behaviors. OH P-1677 ArchivedDrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 10 Provide any additional information that is needed to be considered with this completed form. Form completed by: _____________________________ Phone number:_____________________ Archived
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