Emergency Department Electrocardiogram (EKG/ECG) and Imaging Interpretation

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Emerg ency Department Electrocardiogram (EKG/ECG) Interpretation PY-0793 0 8 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource ) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbu rsement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreemen t, and applicable ref erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unctio n of a body organ or part, or signif icant pain and discomf ort. These services meet the standar ds of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage ma ndate, 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 ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling d ocument used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y 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 Em ergenc y Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICAID PY-0793 Effective Date: 0 8 /01/2019 2 A. Subject Eme rge ncy De pa rtme nt Ele ctroca rdiogra m ( EKG /ECG) Inte rpre ta tion 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 membe r 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. An electrocardiogram (EKG/ECG) is a non-invasi ve test that records the electrical activity of the heart . It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardiogram (EKG/ECG) may need t o be performed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspe cts together as one service. C. Definitions Eme rge ncy me dica l condition-is a medical condition with sudden severity and onset that in the absence of immediate medical attention could placing the patient’s health in serious jeopardy. This includes labor an d delivery, but not r outine prenatal or postpartum care, or services related to an organ transplant procedure. Ele ctroca rdiogra m (EKG/ECG) is a test that records the electrical activity of the heart . For the purpose of this policy EKG will be used to represent both EKG and ECG. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs completed in the Emergency Department (Place of service (POS) 23) . A. Regardless of POS, the modifier appended to the CPT code determines a duplicate servi ce. II. CareS ource will reimburse the first EKG claim that is received for the member of the date of service. A. If another claim for the same service EKG is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. B. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member. 1. Example: 93010 is received and is reimbursed. Another 93010 claim is received for the same date of service and is denied as duplicate service. C. If a second EKG is medically necessary, on the same date of service, to determine a cardiac change before the member is discharged, modifier 76 or modifier 77 must be appended to the s ec ond EKG for reimburs ement. Archived Em ergenc y Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICAID PY-0793 Effective Date: 0 8 /01/2019 3 1. Example: 93010 is received and r eimbursed. Another 93010 is completed and submitted for reimbursement. The second 93010 has modifier 76 or 77 (whichever is applicable) appended (93010-76 or 93010-77) to distinguish between the first and second EKG performed on the same member on the sa me date of service. III. CareSource expects providers to work with other departments, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. 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 individual Ohio Medicaid fee schedule for appropriate codes. The follow ing list(s) of code s is provide d a s a re fe re nce . This list ma y not be a ll inclusive a nd is subje ct to upda te s. CPT Code Description 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation an d report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93227 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional F. Related Policies/Rules N/A G. Review/Revision History DAT EACT ION Da te Issue d 10/31/2013 Revision Da te Re vise d 3/20/2019 Updated template and code reference Da te Effe ctive 0 8 /01/2019 Archived Em ergenc y Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICAID PY-0793 Effective Date: 0 8 /01/2019 4 H. References 1. Appendix DD to rule 5160-1 – 60 (Non-Institutional Fee Schedule). (2019, January 1). Retrieved 3/12/2019 from https://medicaid.ohio.gov/Portals/0/Pro vid ers/Fe eSched ule Rates/Ap p-DD.p d f 2. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/ he alth-to pics/electrocar diog ram 3 . Lawriter-OAC-5160-2 – 21.1 Consumer co-payments for non-emergency emergency department services. (2015, April 1). Retrieved 3/12/2019 from http://codes.ohio.gov/oac/5160-2 – 2 1.1 v1 The Reimburs ement 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. I nd e pe n de nt m ed i ca l r e v iew 2/2015 Archived

Vitamin D Assay Testing

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 05/01/2018 05/01/2017 Policy Name Policy Number Vitamin DAssay Testing PY-0226 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 3 Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 2 A. SUBJECT Vitamin DAssay 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 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 does not imply any right to reimbursement or guarantee claims payment. Although an excess of vitamin Dis rare it can lead to hypercalcemia. Vitamin Ddeficiency may lead to numerous disorders, the most widely known is rickets. Assessing patients vitamin Dlevels is achieved by measuring the level of 25-hydroxyvitamin D. Evaluation of other metabolites is generally not medically necessary. C. DEFINITIONS Severe deficiency: 25(OH)D: 80 ng/ml D. POLICY I. CareSource does not require a prior authorization for Vitamin Dtesting. II. CareSource considers Vitamin Dlevels testing medically necessary for patients with the following: A. Chronic kidney disease stage III or greater B. Osteoporosis C. Osteomalacia D. Osteopenia E. Hypocalcemia F. Hypercalciura G. Hypoparathyroidism H. Malabsorption states I. Cirrhosis J. Hypervitaminosis DK. Osteosclerosis/petrosis L. Rickets M. Low exposure to sunlight N. Vitamin Ddeficiency to monitor the efficacy of replacement therapy III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the Vitamin Dtesting CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted as primary for the CPT code line, the claim will be denied. Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 3 Note: Although this service 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 Reimbursement 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/LabServicesPayment.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 82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED ICD 10 codes Description E20.0 Idiopathic hypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E21.0-E21.3 Primary hyperparathyroidism-Hyperparathyroidism, unspecified E41 Nutritional marasmus E43 Unspecified severe protein-calorie malnutrition E55.0 Rickets, active E55.9 Vitamin Ddeficiency, unspecified E67.3 Hypervitaminosis DE67.8 Other specified hyperalimentation E68 Sequelae of hyperalimentation E83.31 Familial hypophosphatemia E83.32 Hereditary vitamin D-dependent rickets (type 1) (type 2) E83.39 Other disorders of phosphorus metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E84.0 Cystic fibrosis with pulmonary manifestations E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations E89.2 Postprocedural hypoparathyroidism K50.00 Crohn’s disease of small intestine without complications Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 4 K50.011 Crohn’s disease of small intestine with rectal bleeding K50.012 Crohn’s disease of small intestine with intestinal obstruction K50.013 Crohn’s disease of small intestine with fistula K50.014 Crohn’s disease of small intestine with abscess K50.018 Crohn’s disease of small intestine with other complication K50.111 Crohn’s disease of large intestine with rectal bleeding K50.112 Crohn’s disease of large intestine with intestinal obstruction K50.113 Crohn’s disease of large intestine with fistula K50.114 Crohn’s disease of large intestine with abscess K50.118 Crohn’s disease of large intestine with other complication K50.80 Crohn’s disease of both small and large intestine without complications K50.811 Crohn’s disease of both small and large intestine with rectal bleeding K50.812 Crohn’s disease of both small and large intestine with intestinal obstruction K50.813 Crohn’s disease of both small and large intestine with fistula K50.814 Crohn’s disease of both small and large intestine with abscess K50.818 Crohn’s disease of both small and large intestine with other complication K50.90 Crohn’s disease, unspecified, without complications K50.911 Crohn’s disease, unspecified, with rectal bleeding K50.912 Crohn’s disease, unspecified, with intestinal obstruction K50.913 Crohn’s disease, unspecified, with fistula K50.914 Crohn’s disease, unspecified, with abscess K50.918 Crohn’s disease, unspecified, with other complication K51.00 Ulcerative (chronic) pancolitis without complications K51.011 Ulcerative (chronic) pancolitis with rectal bleeding K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chronic) pancolitis with fistula K51.014 Ulcerative (chronic) pancolitis with abscess K51.018 Ulcerative (chronic) pancolitis with other complication K51.20 Ulcerative (chronic) proctitis without complications K51.211 Ulcerative (chronic) proctitis with rectal bleeding K51.212 Ulcerative (chronic) proctitis with intestinal obstruction K51.213 Ulcerative (chronic) proctitis with fistula K51.214 Ulcerative (chronic) proctitis with abscess K51.218 Ulcerative (chronic) proctitis with other complication Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 5 K51.30 Ulcerative (chronic) rectosigmoiditis without complications K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula K51.314 Ulcerative (chronic) rectosigmoiditis with abscess K51.318 Ulcerative (chronic) rectosigmoiditis with other complication K51.40 Inflammatory polyps of colon without complications K51.411 Inflammatory polyps of colon with rectal bleeding K51.412 Inflammatory polyps of colon with intestinal obstruction K51.413 Inflammatory polyps of colon with fistula K51.414 Inflammatory polyps of colon with abscess K51.418 Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K51.511 Left sided colitis with rectal bleeding K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.514 Left sided colitis with abscess K51.518 Left sided colitis with other complication K52.0 Gastroenteritis and colitis due to radiation K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K74.1 Hepatic sclerosis K74.2 Hepatic fibrosis with hepatic sclerosis K76.9 Liver disease, unspecified K90.0 Celiac disease K90.1 Tropical sprue K90.2 Blind loop syndrome, not elsewhere classified K90.3 Pancreatic steatorrhea K90.41 Non-celiac gluten sensitivity K90.49 Malabsorption due to intolerance, not elsewhere classified K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.2 Postsurgical malabsorption, not elsewhere classified Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 6 M80.00XA Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M83.0-M83.5 Puerperal osteomalacia-Other drug-induced osteomalacia in adults M83.8 Other adult osteomalacia M85.80 Other specified disorders of bone density and structure, unspecified site M85.811 Other specified disorders of bone density and structure, right shoulder M85.812 Other specified disorders of bone density and structure, left shoulder M85.821 Other specified disorders of bone density and structure, right upper arm M85.822 Other specified disorders of bone density and structure, left upper arm M85.831 Other specified disorders of bone density and structure, right forearm M85.832 Other specified disorders of bone density and structure, left forearm M85.841 Other specified disorders of bone density and structure, right hand Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 7 M85.842 Other specified disorders of bone density and structure, left hand M85.851 Other specified disorders of bone density and structure, right thigh M85.852 Other specified disorders of bone density and structure, left thigh M85.861 Other specified disorders of bone density and structure, right lower leg M85.862 Other specified disorders of bone density and structure, left lower leg M85.871 Other specified disorders of bone density and structure, right ankle and foot M85.872 Other specified disorders of bone density and structure, left ankle and foot M85.88 Other specified disorders of bone density and structure, other site M85.89 Other specified disorders of bone density and structure, multiple sites M89.9 Disorder of bone, unspecified M94.9 Disorder of cartilage, unspecified N18.3-N18.6 Chronic kidney disease, stage 3 (moderate) – End stage renal disease N25.81 Secondary hyperparathyroidism of renal origin Q78.2 Osteoporosis AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017 Date Revised 03/19/2019 Updated code list based on revised LCD Date Effective 05/01/2017 H. REFERENCES 1. Local Coverage Determination (LCD) Vitamin DAssay Testing (L33996). Retrieved March 19, 2019 2. Vitamin DInsufficiency. Retrieved March 2, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912737/ The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service PY-0007 09/01/2019 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 ………………………………………………………………………………………….. 6 G. Review/Revision History ……………………………………………………………………………………….. 6 H. References …………………………………………………………………………………………………………. 6 Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 2 A. Subject Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service 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 does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF). Applicable clinical criteria for the following breast cancer screening health services are described in the corresponding medical policy entitled Mammography services C. Definitions Preventive Services: are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for children under the age of 18. D. Policy I. Pediatric and Adolescent Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. i. Preventive Health Service Codes 1. 99381-99384 2. 99391-99394 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 II. Adult Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 3 reimburse only the Preventive Service code at 100%. The Acute Care Visit Service codes will not be reimbursed unless billed with the appropriate modifier to identify separately identifiable services that were rendered by the same physician on the same date of service. i. Preventive Health Service Codes 1. 99385-99387 2. 99395-99397 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received. If documentation is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: a. Key elements that support the additional preventive health services that were rendered b. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. c. The provider should clearly list in the assessment portion of the documentation the acute/chronic conditions that are being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., A thorough MS and neuro exam of the left hip performed as it relates to the HPI). E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule 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 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 4 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 5 presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) younger than 1 year. 99382 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) 99383 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) 99384 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) 99392 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) 99393 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) 99394 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) 99385 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 6 99386 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years 99387 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older 99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years 99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years 99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 11/17/2014 Date Revised 11/17/2015 Revision includes payment policy legal language 8/6/2019 Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Date Effective 9/1/2019 Date Archived H. References 1. Successfully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center, 20 Feb. 2013, www.aapc.com/blog/22580-successfully-bill-a-preventive-service-with-a-sick-visit/. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Readmission

REIMBURSEMENT POLICY STATEMENT OHIO MEDIC AID Policy Name Policy Number Effective Date Readmission PY-0 724 07/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimburse ment Polic y Sta teme nt : Reimburse ment Policies prepared b y CSMG Co. a nd its a ffiliates (inc luding CareSource) a re inte nded to pro vide a genera l refere nce regardi ng billi ng, coding a nd doc ume nta tion g uidelines. Coding methodolog y, regulator y requirem e nts , ind us try-s tanda rd claims editing logic, bene fits design a nd other fac tors are co nsidered in de velopi ng Reimburse ment Po licies. In addition to this Polic y, Reimburseme nt of services is subjec t to me mber be nefits a nd eligibility o n the da te of service , medical necessity, ad here nce to pla n policies a nd procedures, claims editing logic, pro vider co ntrac tual agreeme nt, a nd app licable re ferral, authori zatio n, notification and utili zatio n manageme nt g uidelines . Medically necessary services i nclude, b ut are no t limited to , those health care services or s upplies that are proper a nd necessary fo r the diagnosis or treatme nt o f disease, illness, or i njury a nd witho ut which the patie nt can be e xpected to s uffer pro longed , i ncreased o r ne w morbidity, impairme nt o f func tion, d ys function of a body orga n or part, or sig nificant pain a nd discomfort. These services meet the sta ndards of good medical practice i n the local area, are the lo west cost alternati ve, and are not pro vided mainly for the co nvenie nce o f the me mber o r p rovider. Medically necessary se rvices also i nclude those services defi ned in any federa l or state co verage ma ndate , Evidence o f Cove rage docume nts , Medical Policy State ments, Pro vider Ma nuals , Me mber Ha ndbooks, a nd/or other policies and proced ures. This Policy does no t e ns ure a n a utho rizatio n or Reimb urseme nt of se rvices. Please refer to the pla n co ntract (often referred to as the Evidence o f Coverage) for the service(s) re fere nced herein. If there is a conflict be twee n this Polic y a nd the pla n c o ntract ( i.e. , Evidence of Co verage), the n the pla n co ntract ( i.e . , Evidence of Coverage) will be the contro lli ng document used to make the determina tion. CSMG Co. a nd its a ffiliates ma y use reasonab le discretio n in interpre ting a nd applying this Polic y to services pro vided in a particular case a nd ma y modify this Polic y a t a ny time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Backgro und ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………. 5 G. Review/Revisio n History ………………………….. ………………………….. ………………………….. ………. 5 H. References ………………………….. ………………………….. ………………………….. ………………………… 5 Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 2 A. Subject Readmission 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 of Readmissions for our Medicare Advantage members may be subject to limitatio ns and/or qualifications. Reimbursement will be established based upo n a review of the actual services provided to a member and will be determined when the claim is received for pro cessing. Health care providers and their office staff are enco uraged 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 prod uct or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Follo wing a hospitalizatio n, readmissio n within 30 days is often a costly preventable event and is a qua lity of care issue . It has been estimated that readmissio ns within 30 days of discharge can cost health plans more than $1 billion dollars o n an annual basis. Readmissions can result from many situatio ns but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progressio n of the disease state or due to chro nic conditions. The p urpose of this policy is to improve the quality of inpatient and transitio nal care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communicatio n between the patient, caregivers and clinicia ns, 2. provide the patient with the education needed to maintain their care at home to prevent a readmissio n, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission : a subsequent inpatient admissio n to any acute care facility which occurs within 30 days of the discharge date; excluding planned admissio ns. Planned Readmission : a no n-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Clinically-Related Readmission Chain: is a series of admissions for the same patient where the underlying reaso n for readmission is related to the care rendered during or within thirty days following a prior hospital admission. A clinically-related readmissio n may have resulted from improper or incomplete care during the initial admission or discharge planning process. The hospital where the initial admission occurred is responsible for the clinically-related readmission chain. Hospitalization Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 3 resulting from an unpreventable or unrelated event occurring after discharge and planned readmissions are not considered clinically-related. Potentially Preventable Readmission (PPR): a readmissio n within a specific time frame 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 determined when, based o n CareSource guidelines, it is determined that the patient was discharged prematurely. Premature discharge evidence can be described as, but not limited to, elevated fever at the time of discharge, abnormal lab results or evidence of infection or bleeding a wound. Only admission: an admission where there was neither a prior initial admissio n nor a clinically-related readmissio n within the thirty day read missio n period Same or Similar Condition : a conditio n or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented o n the initial admissio n. Same Day : CareSource deli neat es same day as midnight to midnight of a sin gle day . D. Polic y I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observatio nal services for the following : A. Readmissions that are potentially preventable as determined by the provision of appropriate care co nsistent with the criteria outlined below: 1. A medical readmission for a continuation or recurrence of the reaso n for the initial admission due to lack of care , or for a closely related condition (e.g., a readmissio n for diabetes following an initial admission for diabetes). 2. A medical readmission for an acute decompensation of a chronic problem that was not the reaso n for the initial admissio n, bu t was plausibly related to the lack of care rendered either during or immediately after the initial admission (e.g., a readmission for diabetes in a patient whose initial admission was for an acute myocardial infarction). 3. A medical readmission for an acute medical compli c ation plausibly related to the lack of care rendered during the initial admissio n (a patient with a hernia repair and a perioperative Foley catheter readmitted for a urinary tract infection 10 days later). 4. A readmission for a surgical procedure to address a continuatio n or a recurrence of the problem causing the initial admission (a patient readmitted for an appendectomy following an initial admission for abdominal pain and fever). 5. A readmission for a surgical procedure to address a complication resulting from the lack of care rendered during the initial admission (a readmission for drainage of a post-operative wound abscess following an initial admission for a bowel resection). B. Readmission s for a condition or procedure that is clinically-related to the care provided during the prior discharge or resulting from inadequate discharge planning during the prior discharge. Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 4 C. Readmissions when t he PPR chain may co ntain o ne or more readmissions that are clinically-related to the initial admission. If the first re admission is within thirty days after the initial admissio n, the thirty day timeframe may begin again at the discharge of either the initial admission or the most recent readmission clinically-related to the initial admission . D. Readmission is to the same or to any other hospital. II. Any readm issio n that occurs within one calendar day (i.e. same day or next day) , to the same institutio n, is considered one discharge for payment purposes and will be reimbursed as one DRG payment per the OAC 5160-2 – 65. III. Readmis sions, for the purposes of determining PPRs, excludes the following 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 pat ient’s medical record. B. The original discharge was for the purpose of securing treatment of a major or metastatic malignancy, major trauma, neo natal and obstetrical admission, transplant or HIV. C. Only admissions, which are defined in the definitions of this policy. Planned readmissio ns are considered "o nly admissio ns. IV. Prior authorizatio n 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 for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically 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 submissio ns to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical reco rds for both admissions must be included with the claim submission to determine if the admission (s) is appropriate or is considered a readmissio n. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. If the incl uded documentation determines the readmission to be an inappropriate, medically unnecessary or potentially preventable admission , the hospital must be able to provide additio nal documentation to CareSource upo n request or the claim will be denied. c. If the readmissio n is determined at the time of documentatio n review to be a preventable readmissio n, the reimbursement for the read mission will be combined with the initial admission and paid as o ne claim to cover both, or all, admissions. 2. Appeals Process ArchivedReadmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 5 a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer revie w or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS f ee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT ION Date Issued 04/01/2019 Date Revised Date Effective 07/01/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803. 2. Hospital Readmission Reduction Pro gram. (2018, December 04). Ret rieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://www.cms.gov 4. Goldfield, N. I., McCullough, E. C., Hughes, J. S., Tang, A. M., Eastman, B., Rawlins, L. K., & Aver ill, R. F. (2008). Identifying potentially preventable readmissions. Retrieved from https://www.ncbi.nlm. nih.gov The Re im burseme nt 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 e cei 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 Re im burseme nt 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

Nutritional Supplements

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Nutritional Supplements PY-0779 1/1/2020-07/ 31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules …………………………………………………………………………………………… 6 G. Review/Revision History ………………………………………………………………………………………… 6 H. References ………………………………………………………………………………………………………….. 6 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 pol icies 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 a nd applying this Policy to services provided in a particular case and may modify this Policy at any time.2 A. SubjectNutritional SupplementsNutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 1/1/2020B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. Nutrition may be delivered through a tube into the stomach or small intestine. Enteral Nutrition may be medically necessary for dietary management to provide sufficient caloric and nutrition needs as a result of limited or impaired abil ity to ingest, digest, absorb or metabolize nutrients; or for a special medically determined nutrient requirement. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enteral nutrition may be either for total enteral nutrition or for supplemental enteral nutrition. Parenteral nutrition is nutrition provided through an intravenous line. Home Infusion Therapy is NOT covered in this policy. This policy includes nutrition that is for medical purposes only. C. Definitions Enteral Nutrition Nutrition delivered through an enteral access device into the gastrointestinal tract bypassing the oral cavity. Medical Food Food specially formulated and processed to be consumed or administered by oral intake or enteral access device. The intent is to meet distinctive nutritional requirements of a disease or condition when dietary management cannot be met by modifying a normal diet. Enteral Access Device A tube or stoma is placed directly into the gastrointestinal tract for the delivery of nutrients. Inborn Errors Of Metabolism (IEM) Inherited biochemical disorders resulting in enzyme defects that interfere with normal metabolism of protein, fat, or carbohydrate. Therapeutic oral non-medical nutrition: o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens. i.e. diabetes mellitus, celiac disease Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 1/1/2020 3 o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional food Food that is fortified to produce specific beneficial health effects. o Texture Modified Food and Thickened Fluids-Liquidized/thin puree, thick puree, finely minced or modified normal. o Modified Normal Eating normal foods, but avoiding particulate foods t hat are a choking hazard. Medical Nutrition Therapy Per Ohio Administrative Code is defined as the use of specific nutrition services to treat an illness, injury, or condition. Medical nutrition therapy services include nutrition assessment, intervention, and counseling1 D. Policy I. Prior Authorization A. Prior authorization is NOT required for 1. HCPCS code B4162 or B4157. 2. Medical Nutrition Therapy. B. Prior authorization is required for 1. Oral nutrition (except for HCPCS code B4162 and B4157). 2. Enteral nutrition (except for HCPCS code B4162 and B4157). 3. Food supplements, nutritional supplements and infant formula when a. Requesting greater than 72 units per month OR b. Member is under the age of five and does not meet criteria for any other local, state, or federal program. 4. Donor human milk. C. Prior authorization is required for non-participating providers. II. Quantity Limits A. Nutritional counseling is limited to one visit per calendar year for diagnosis of obesity. B. CareSource provides enteral nutrition through participating durable medical equipment (DME) providers allowing home delivery of medically necessary enteral nutrition. III. Enteral Nutrition A. CareSource pays for the dispensing and shipping/delivery of enteral nutrition B. CareSource does NOT reimburse for the following 1. Based on the Ohio Administrative Code 2 a. Ordinary prepared food; b. Commercial products that serve as ordinary food (e.g., shakes, smoothies, energy bars, vitamin or mineral supplements, baby food); c. Food products to be eaten as part of a diet related to diabetes, obesity, gastric bypass, or bariatric surgery; 1 http://codes.ohio.gov/oac/5160-8-41v1 2 http://ohrules.elaws.us/oac/5160-10-26Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 1/1/2020 4 d. Food products for which a provider receives Medicaid per diem payment; and e. Standard infant formula (not used to treat errors of metabolism) for which payment may be made through a program other than Medicaid. 2. Quantities that exceed a one months supply 3. Supplies dispensed greater than one week before scheduled date 4. Relizorb (insufficient evidence) 5. Enteral nutrition for members with advanced dementia 6. When use of product is for convenience or preference of member/caregiver. 7. B4104 enteral formula additive. Enteral formula codes include all nutrient components. IV. Human Donor Milk A. CareSource only provides payment if the provider is a member in good standing with the human milk banking association of North America B. CareSource reimburses for the processing and delivery/shipping C. CareSource does NOT reimburse for 1. Payments to a provider for supplying the donor human milk 2. Payments for the milk itselfE. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting OH Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual OH Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE, PER DAY B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED (PER DAY, INCLUDES BAGS/CONTAINERS) B4081 NASOGASTRIC TUBING WITH STYLET B4082 NASOGASTRIC TUBING WITHOUT STYLET B4083 STOMACH TUBE, LEVINE TYPE B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE B4100 FOOD THICKENER, ORAL, PER OUNCE B4149 ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4150 ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 1/1/2020 5 AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH ANENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4152 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATER THAN 1.5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS,CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALO RIES = 1 UNIT B4153 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS ANDPEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1UNIT B4154 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS,FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDI NG TUBE, 100 CALORIES = 1 UNIT B4155 ENTERAL FORMULA, NUTRITIONALLY INCOMPLETE/MODULAR NUTRIENTS, INCLUDES SPECIFIC NUTRIENTS, CARBOHYDRATES (E.G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E.G. GLUTAMINE, ARGININE), FAT (E.G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4157 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4158 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4159 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE SOY BASED WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4160 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE CALORICALLY DENSE (EQUAL TO OR GREATER THAN 0.7 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4161 ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMINO ACIDS AND PEPTIDE CHAIN PROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4162 ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B9002 ENTERAL NUTRITION INFUSION PUMP – WITH ALARM B9998 ENTERAL SUPPLIES, NOT OTHERWISE SPECIFIED 97802 MEDICAL NUTRITION INDIV IN Nutritional Supplements OHIO MEDICAID PY-0779 Effective Date: 1/1/2020 6 97803 MED NUTRITION INDIV SUBSEQ97804 MEDICAL NUTRITION GROUP S9470 NUTRITIONAL COUNSELING, DIET T2101 BREAST MILK PROC/STORE/DIST, PER OZ Modifiers Description U1 USED TO DIFFERENTIATE B4100 AS A CONCENTRATED FORMULA BO ADMINISTRATION BY MOUTH RATHER THAN BY FEEDING TUBE F. Related Policies/RulesNutritional Supplements MM-0024G. Review/Revision History DATE ACTIONDate Issued 09/09/2019Date Revised Date Effective 01/01/2020 New policy Date Archived 07/ 31/2020 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy . H. References1. Medicaid. Early and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https:// www.medicaid.gov/medicaid/benefits/epsdt/index.html 2. Lawriter-OAC-5160-8- 41 Medical nutrition therapy services. (n.d.). Retrieved on 2/25/2019 from http://codes.ohio.gov/oac/5160-8-41v1 3. Lawriter-OAC-5160-10-26 DMEPOS: nutrition products. (n.d.). Retrieved on 2//21/2019 from http://codes.ohio.gov/oac/5160-10-26The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Smoking & Tobacco Cessation

REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Smoking & Tobacco Cessation PY-0256 01/01/2020-11/30 /2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statemen t ..1A. Subject ………………………….. ………………………….. ………………………….. ………………… 2B. Background ………………………….. ………………………….. ………………………….. ………….. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………. 3 D. Policy ………………………….. ………………………….. ………………………….. ………………….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………… 5 G. Review/Revision History ………………………….. ………………………….. ……………………… 5 H. Ref erences ………………………….. ………………………….. ………………………….. …………… 6 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 provided in a particular case and may modify this Policy at any time. 2 A. SubjectSmoking & Tobacco Cessation Smo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 B. BackgroundReimb 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 not a g uarantee of payment. Reimb ursement for claims may b e 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 d etermined when the claim is received for p rocessing. Health care p ro viders and their o ffice staff 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 not imply any right to reimbursement o r guarant ee claims p ayment. The use o f tobacco p roducts generally leads to tobacco/nicotine dependence 3 and often results in serio us health problems. Quitting smoking greatly reduces the risk of d eveloping smoking-related d iseases . To bacco/nicotine dependence is a condition that often req uires repeated treatments, as nico tine is strongly addictive. Because of this, quitting smoking and end ing the use of tobacco use may b e a d ifficult process req uiring several, staged attempts, and may involve stress, irritability, and o ther withd rawal symptoms for those addicted to nicotine 8, 9, 10. Ho wever, continued tobacco use in any form is far more harmful. To bacco smoke contains serio usly harmful chemicals and carcinogens 5, 8, 11 and lead s to lung and o ther cancers, chro nic lung d isease, heart disease, strokes, vascular disease, and infertility. Additionally, smokeless to b acco is d irectly linked to cancers of the mouth, tongue, cheek, gum, esophagus, and p ancreas. Co unseling and m edication are b oth effective means for end ing d ependency on tobacco p ro d ucts, and are even more effective together than either method alone 10. Co unseling can be ef f ective when delivered via individual, group, or telephone counseling, o ne-on-one brief help sessions with a p rovider, behavioral therapies, or even through mobile p hone ap ps. Med ications which have b een found to be effective include prescription non-nicotine medications such as b upropion SR (Zyban ) and varenicline tartrate (Chantix ), and nicotine replacement p ro d ucts such as nicotine patches, inhalers or nasal sprays available by prescription, and over – the-co unter nicotine patches, g ums o r lozenges 10, 17. The United States government recognizes the health dangers and risks associated with the use o f tobacco in its citizens and has set up a f ree telephone support service to help people stop smo king and stop the use of tobacco, 1-800-QUIT-NOW. Callers are ro uted thro ugh this service to their state s specific resource, and may be ab le to o btain free support, advice, and counseling f ro m experienced quit-line coaches, a personalized plan to quit, practical information on how to q uit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking med ications, free o r discounted medications (available for at least some callers in most states), ref errals to other resources, and /or mailed self-help materia ls. CareSo urce encourages all of its members to refrain from the use of tobacco, and if using it in any f o rm, to make concerted and ongoing attempts to q uit its use as soon as p ossible. 3 C. Def initionsSmo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 Tobacco products means any p roduct containing tobacco o r nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, ho okahs, kreteks, e-cigarettes, vaporized and o ther inhaled tobacco and nicotine products, smokeless tobacco (e.g., d ip, chew, snuff, snus), d issolvable tobacco (e.g., strips, sticks, orbs, lozenges), or o ther ing estible tobacco p ro d ucts, and /or chewing tobacco D. PolicyI. Prio r autho rizations are req uired for participating (contracted) p roviders o nly when the services they are p roviding for tobacco cessation exceed the limits of this policy. II. No n-p articipating p roviders (no t contracted with CareSource) should contact CareSource for p rio r autho rization for these services. III. CareSo urce will reimburse its participating providers for the following tobacco use interventio n and cessation care methods: A. An enco unter for evaluation and management of the member on the same day as co unseling to prevent or cease tobacco use; and , B. Screening s for tobacco use as needed for members 20 and younger; C. One screening for tobacco use per calendar year for members 21 and older; and, D. Three ind ividual tobacco cessation counseling attempts p er calendar year. 1. Each attempt will no t exceed 12 weeks of treatment. 2. Face to face counseling sessions are req uired every 30 days during each 12 week treatment p eriod. E. Nico tine rep lacement or no n-nicotine medications p rescribed and appro ved for use for to b acco cessation. IV . CareSo urce will no t reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year, unless p rior authorization has been obtained by the p ro vider. V. The numb er of CPT, HCPCs, and d iagnosis codes (ICD-10) p otentially associated with the d iag no sis and treatment of tobacco use and addiction is too g reat to list. As such, the sp ecific tobacco cessation codes pro vided b elow are eligible to b e reimbursed with any ap p ro priate, associated code. VI. Evaluation and Management service for the member which is p rovided on the same day as co unseling to prevent or cease tobacco use, should b e rep orted with modifier 25 to indicate that the E&M service is separately identifiable from the counseling. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropr iate modifiers. Please refer to the Ohio Medicaid fee schedule. 4 Smo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 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. Reimb ursement is dependent o n, b ut not limited t o, submitting Ohio Medicaid approved HCPCSand CPT co d es along with appropriate modifiers, if ap plicable. Please ref er to the individual Ohio Med icaid fee schedule for appro priate 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 Description99406 Smo king and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smo king and tobacco use cessation counseling visit; intensive, greater than 10 minutes S9453 Smo king Cessation classes, non-physician p rovider, per session F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 09/20/2017 New Po licyDate Revised 08/19/2019 Annual Revision Date Effective 01/01/2020 Date Archived 11/30/2021 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 d ocumented Policy. H. Ref erencesA. Physician Services Manual, 903.19, “To bacco cessation services for Medicaid eligible memb ers.” Ib id. Appendix D, “Health check and adult p reventive visit. (2017, July 1). B. CDC – Fact Sheet – Quitting Smoking – Smoking & To bacco Use. (n.d.). C. Co unseling to Prevent To bacco Use. (Transmittal 2058, 2010, September 30). Centers for Med icare & Medicaid Services, Department of Health & Human Services. D. Treating To b acco Use and Dependence. Clinical Prac tice Guideline. (n.d .). Fiore, Michael C (p anel chair), Guid eline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI) E. U.S. Dep artment of Health and Human Services. The Health Co nsequences of Smoking 50 Years o f Progress: A Rep ort of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Co ntrol and Prevention, National Center for C hro nic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. F. Natio nal Institute o n Drug Abuse. Research Rep ort Series: Is Nicotine Addictive? Bethesda (MD): Natio nal Institutes of Health, National Institute on Drug Abuse, 2012. G. American Society of Addiction Medicine. Public Policy Statement on Nicotine Addiction and To b acco. Chevy Chase (MD): American Society of Addiction Medicine, 2008. 5 Smo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 H. U.S. Dep artment of Health and Human Services. How To bacco Smoke Causes Disease: The . Bio logy a nd Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General.Atlanta: U.S. Department of Health and Human Services, Centers for Disease Co ntrol andPrevention, National Center for Chronic Disease Prevention and Health Promotion,Of fice on Smoking and Health, 2010I. U.S. Dep artment of Health and Human Services. Reducing To bacco Use: A Rep ort of the Surg eo n General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Co ntro l and Prevention, National Center f or Chronic Disease Prevention and Healt h Promotion, Of f ice on Smoking and Health, 2000. J. Fio re MC, Jan CR, Baker TB, et al. Treating To bacco Use and Dependence: 2008 Update Clinical Practice Guidelines. Rockville (MD): U.S. Department of Health and Human Services, Pub lic Health Service, Agency for Healthcare Research and Quality, 2008. K. Natio nal To xicology Program. Report on Carcinogens, Thirteenth Edition. Research Triang le Park (NC): U.S. Dep artment of Health and Human Sciences, National Institute of Environmental Health Science s, National Toxicology Program, 2014. L. U.S. Dep artment of Health and Human Services. The Health Co nsequences of Smoking: A Rep o rt of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers f o r Disease Co ntrol and Prevention, Nati onal Center for Chro nic Disease Prevention and Health Pro motion, Office on Smoking and Health, 2004. M. U.S. Dep artment of Health and Human Services. The Health Benefits of Smoking Cessation: A Rep o rt of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers f o r Disease Co ntrol and Prevention, Center for Chro nic Disease Prevention and Health Pro mo tion, Office on Smoking and Health, 1990. N. Centers f o r Disease Co ntrol and Prevention. Quitting Smoking Among Adults United States, 2000 2015. Mo rb idity and Mortality Weekly Report 2017:65(52):1457-64. O. Centers f o r Disease Control and Prevention. Youth Risk Behavior Surveillance United States, 2015. Mo rb idity and Mortality Weekly Report [serial online] 2016:66 (SS 6):1 174. P. Centers f o r Disease Co ntrol and Prevention. The Guid e to Community Preventive Services: Red ucing To bacco Use and Secondhand Smoke Exposure. Q. U.S. Fo od and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation. FDA Co nsumer, 2006. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Thyroid Testing

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Thyroid Testing PY-0222 01/01/2020 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 ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 4 Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 01/01/2020 2 A. Subject Thyroid 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 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. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. Definitions Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness. Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. Policy I. CareSource does not require a prior authorization for thyroid testing. II. Thyroid function tests are used to test for thyroid function and disease. Thyroid testing may be reasonable and necessary to: A. Distinguish between primary and secondary hypothyroidism B. Confirm or rule out primary hypothyroidism C. Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer) D. Monitor drug therapy in patients with primary hypothyroidism E. Confirm or rule out primary hyperthyroidism F. Monitor therapy in patients with hyperthyroidism III. Thyroid testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyperthyroidism or hypothyroidism are noted. A. When these tests are billed at a greater frequency than the norm (two per year), the ordering physicians documentation must support the medical necessity of this frequency must be made available upon CareSources request. IV. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 01/01/2020 3 V. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service 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 Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS codes and the appropriate modifiers, if applicable. The appropriate ICD-10 diagnosis code must match the correct CPT and/or HCPCS code within this policy. 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 84436 Thyroxine; total 84439 Thyroxine; free 84443 Thyroid stimulating hormone (TSH) 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 01/01/2020 Date Revised 08/21/2019 Revision (updated diagnosis code list) Date Effective 01/01/2020 Date Archived ICD 10 Codes A18 D3A E06 E24 E43 E88 F32 G47 R06 C56 D44 E07 E25 E44 E89 F33 I48 R61 C73 D49 E08 E27 E45 F03 F34 N91 Z00 C79 D89 E09 E28 E46 F05 F39 N92 Z01 C7A E00 E10 E29 E66 F06 F41 N94 Z86 C7B E01 E11 E31 E67 F07 F53 N97 D09 E02 E13 E35 E78 F22 F63 O90 D27 E03 E20 E40 E79 F23 G25 O92 D34 E04 E22 E41 E83 F30 G30 O99 D35 E05 E23 E42 E87 F31 G31 R00 Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 01/01/2020 4 H. References 1. National Coverage Determination (NCD) for Thyroid Testing (190.22). Retrieved July 26, 2019, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved July 26, 2019, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Preventive Services and Sick Visit on Same Date of Service

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Preventive Services and Sick Visit on Same Date of Service PY-0007 09/01/2019 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, 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 polic ies 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 o r 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 par t, 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 authorizati on 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 t he 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 a nd may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 2 A. Subject Preventive Services and Sick Visit on Same Date of Service 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 respons ibility 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. CareSourc e will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventi ve Services Task Force (USPSTF) . Applicable clinical criteria fo r the following breast cancer screening health services are described in the corresponding medical policy entitled Mammography services C. Definitions Preventive Services : are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional scr eenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for children under the age of 18 D. Policy I. Pediatric and Adolescent Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acu te care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. i. Preventive Health Service Codes 1. 99381-99384 2. 99391-9939 4 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 II. Adult Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the Preventive Service code at 100%. The A cute Care Visit Service codes will not be reimbursed unless billed with the appropriate modifier to Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 3 identify separately identifiable services that were rendered by the same physician on the same date of service. i. Preventive Health Service Codes 1. 99385-99387 2. 99395-99397 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received . If documentatio n is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: a. Key elements that support the additional preventive health service s that were rendered b. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. c. The provider should clearly list in the assessment portion of the documentation the acute/chronic condi tions that are being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., A thorough MS and neur o exam of the left hip performed as it relates to the HPI). 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. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 11/17/2014 Date Revised 11/17/2015 Revision includes payment policy legal language 8/6/2019 Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Date Effective 9/1/2019 Date Archived H. References 1. Successfully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center, 20 Feb. 2013, www.aapc.com/blog/22580-successfully-bill-a – preventive-service-with-a – sick-visit/. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. 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

Non-Invasive Vascular Studies

REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Da te Non-Invasive Vas c u lar Studies PY-0163 12/01/2019-0 3/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….5 G. Review/Revision History ………………………………………………………………………………………..5 H. Ref er en ce s …………………………………………………………………………………………………………5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tNon-invasive Vascular Stud ie s No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019 B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p roc essing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. No n-inv as ive v ascular s tudies utilize ultras ound to asses s irregularities in b lood flow in arterial and v eno us sy stems. Tes ting c an be p erformed in a v asc ular lab oratory , and is often the first s tep in d iagnosing vas cular disease. Res ults may display as a two dimens ional image with a s p ec tral analysis and color flow. The res ults o f these test will determine the need for more non-invasive testing or p rocedures to treat v as cular disease. CareSo urce will reimburs e providers, for no n-inv as ive v ascular s tudies to members as s et forth in this p olicy .C. Def initions Duplex scan a no n-inv as ive ev aluation of b lood flow through the arteries and v eins, by c o mb ining the use of Doppler ultrasound with t wo-dimensional struc ture and motion wit h t ime and s p ec trum analysis and /or c olor flow velocity or mapping. Non-invasive testi ng-utilizes various types of technology to evaluate f low, p erfusion, and p res s ures within the v essels at res t and with exerc is e. D. Policy I. CareSo urc e does not req uire a prior authorization for a no n-inv asive v as cular study. II. Altho ugh CareSource does not require a p rior authorization for non-inv asive vasc ular s t ud i es , CareSo urc e may request doc umentation to s upport medical nec essity as d efined in Ohio Ad ministration Co de (OAC) Rule 5160-1 Med ical Neces sity. Note: Th e us e of any Doppler d evice that produces a rec ord, but does not permit analysis of b id irec tional vas cular flow o r that d oes not prov ide a hard c opy or p rintout: is part of the physical exam of the vas cular sys tem and is not reported s ep arately. III. No n-Invasive vas cular s tudies m ust be p ers onally performed by a phy sician or technologist. A. Th e p hy s ician performing and/or interpreting the study mus t be c apable of demonstrating d o c umented training and experience and maintain any applicable documentation upon CareSo urc es request.B. Th e Tec hnic ian p erforming the study mus t be c apable of demonstrating documented training and experience and maintain any documentation upon CareSourc e request. 3 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019IV. All no n-inv asive v ascular diagnostic studies m ust be performed under at least one of the f o llowing settings: A. Perf o rmed by a physician who is c ompetent in diagnostic v ascular s tudies or und er the g eneral s up erv is ion of p hysicians who have d emonstrated minimum entry lev el c o mp etency b y being c redentialed in v ascular technology B. Perf o rmed by a tec hnician who is certified in v ascular technology C. Perf o rmed in f acilities wit h laboratories accredited in v as c ular tec hnology V. No n-inv as ive v as cular s tudy inc ludes: A. Pro v iding p atient c are during the s tudyB. Sup erv is ion of the procedure C. Interp retatio n of s tudy results wit h hard c opy output or d igital s torage of imaging is ac c ep table. Note: Altho ugh CareSourc e does not require a p rior authorization for no n-invasive v as c ular s tudies, CareSourc e may req uest documentation to support medical nec es s ity, including the non-invas iv e vas cular s tudy hard c opy or d igital c opy res ults . VI. Dup lex s canning and phys iologic s tudies may b e reimburs ed during the same encounter if the p hy s iologic studies are ab normal and/or to evaluate v asc ular trauma, thromboembolic ev ents or aneury smal disease, if the phys ic ian/provider c an document medical neces si ty in the p atients medical rec ord.E. Conditions of Cov erage Reimb urs ement is dependent o n, b ut not limited to, s ubmitting Ohio Medicaid approved CPT and /o r HCPCS codes and the appropriate modifiers , if applicable. The ap p ro priate ICD-10 diagnosis code m ust m atc h the c orrect CPT and /or HCPCS code within this policy Please refer to the Ohio Med icaid fee sc hedule for appro priate c odes . The following l i st(s) of codes is provided as a reference. This list may not be all-inclusive and is subject to updates. CPT Code Description 93880 Dup lex s can of ex trac ranial arteries ; c omplete b ilateral s tudy 93882 Dup lex s can of extrac ranial arteries; unilateral or limited s tudy 93886 Trans c ranial Do ppler s tudy of the intrac ranial arteries; complete s t ud y 93888 Trans c ranial Do p pler s tudy of the intracranial arteries ; limited s tudy 93890 Trans c ranial Do ppler s tudy of the intrac ranial arteries; v asoreactiv ity s tudy 93892 Trans c ranial Do ppler s tudy of the intracranial arteries ; emboli detection witho ut intrav enous mic robubble injection 93893 Trans c ranial Do ppler s tudy of the intracranial arteries ; emboli detection with intrav eno us microbubble injection 93922 Limited bilateral noninvasive phys iologic s tudies of upper or lower ex tremity arteries , (eg , for lower ex tremity : ank le/brachial indices at d is tal posterior tib ial and anterior tibial/dors alis pedis arteries p lus bidirec tional, Doppler wav ef o rm rec ording and analys is at 1-2 lev els , or ank le/brac hial indices at d is tal p osterior tibial and anterior tibial/dors alis p edis arteries plus v olume p lethy s mography at 1-2 lev els, or ank le/brachial indices at distal posterior tib ial and anterior tibial/dors alis p ed i s arteries wit h, trans cutaneous oxygen tens io n measurement at 1-2 lev els) 93923 Co mp lete b ilateral noninvasive p hysiologic studies of upper or lo wer ex tremity arteries, 3 or more levels (eg, for lower ext remit y: ank le/brachial ind ic es at d ist al p osterior tibial and anterior tib ial/dorsa l is pedis arteries 4 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019p lus s eg mental b lood p ressure measurements with b idirectional Doppler wav ef o rm rec ording and analys is , at 3 o r more lev els, or ank le/brac hial ind ic es at distal p osterior tibial and anterior tibial/dors alis pedis arteries p lus s eg mental v olume plethy smography at 3 o r more lev els, o r ank le/b rac hial indices at d istal pos terior tibial and anterior tibial/dors alis p ed is arteries plus s egmental transcutaneous oxygen tension meas urements at 3 or more levels), or single level study wit h provocativ e f unc tional maneuvers (eg, meas urements wi th postural p ro vocative t est s, o r meas urements with reac tive hy peremia)93924 No ninv as ive p hy siologic s tudies of lo wer extremity arteries, at res t and f o llowing treadmill s tress testing, (ie, bidirectional Doppler wav eform or v o lume p lethysmography rec ording and analysis at res t with ank le/brachial ind ic es immediately after and at t imed interv als following performanc e of a s tand ard ized protocol on a motorized treadmill p lus rec ording of time of o ns et of c laudication or other s ymptoms , maximal walking t i me, and ti m e to rec o v ery ) c omplete b ilateral study93925 Dup lex sc an of lower ex tremity arteries or arterial b ypass grafts ; c omplete b ilateral s tudy 93926 Dup lex sc an of lower ex tremity arteries or arterial b ypass grafts ; unilateral o r limited study 93930 Dup lex sc an of upper ex tremity arteries or arterial bypass grafts; complete b ilateral s tudy 93931 Dup lex sc an of upper ex tremity arteries or arterial bypass grafts ; unilateral o r limited study 93970 Dup lex sc an of extremity v eins including responses to compression and o ther maneuv ers ; c omplete b ilateral study 93971 Dup lex sc an of extremity v eins including responses to compression and o ther maneuv ers ; unilateral o r limited study 93975 Dup lex sc an of arterial inflow and v enous outflow of abdominal, pelvic, s c ro tal contents and/or retro peritoneal organs; complete s tudy 93976 Dup lex sc an of arterial inflow and v enous outflow of abdominal, pelvic, s c ro tal contents and/or retro peritoneal organs; limited s tudy 93978 Dup lex sc an of aorta, inferior vena cav a, iliac vas culature, or bypass grafts; c o mp lete study 93979 Dup lex sc an of aorta, inferior vena cav a, iliac vas culature, or bypass grafts; unilateral o r limited s tudy 93980 Dup lex sc an of arterial inflow and v enous outflow of penile ves sels ; c o mp lete study 93981 Dup lex sc an of arterial inflow and venous outflow of penile vess els ; follow – up o r limited s tudy 93990 Dup lex sc an of hemodialysis ac cess (inc luding arterial inflow, body of ac c es s and v enous outflow) 93998 Unlis ted no ninvasive v ascular d iagnos tic s tudy I CD 10 CodesA48 G97 I79-I83 N18 R42 S65 Z95 5 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019D 57 H34-H35 I85-I87 N28 R47 S75 Z98-Z99 D 68 H47 I96-I97 N50-N52 R55 S85 D 75 H53 J 96 O22 R60 S95 E 08-E11 H81 K55 O8 6-O87 S06 T3 8 E13 H93 K 74-K76 Q2 7-Q28 S09 T4 5 F52 I10 L53-L54 R04 S15 T7 9-T8 2 G04 I12-I13 L76 R06-R07 S25 T8 7 G4 5-G46 I16 L97 R09-R10 S35 Z01 G54 I25-I27 M30-M31 R22 S38 Z09 G8 1-G83 I60-I63 M79 R26-R27 S45 Z48 G93 I65-I77 M96 R29 S55 Z86 F. Related Polic ies/RulesN/A G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 03/08/2017 Date Revised 08/07/2019 Up d ated c odes and reimb ursement c rit e ria Date Effecti ve 12/01/2019 Date Archived 03/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed . Please no te that there c ould be o ther Po lic ies that may hav e s ome of the s ame rules inc o rp orated and Care Source res erves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Polic y H. Ref erenc es1. Leers , S. A. (2019, Ju ly 3). Duplex Ultrasound. Retrieved from https://v ascular.org/patient-res o urc es/vascular-tests/duplex-ultrasound 2. Lawriter-OAC-5160-1- 01 Med ic aid m ed i c al nec essity : definitions and principles.(2015, Marc h 22). Retriev ed from http://c odes.ohio.gov/oac /5160-1-01 6 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019 3. No n-inv as ive Tes ting for Vascular Diseas e. (2019, January 7). Retrieved from http s://my.clevelandclinic.org/health/diagnostics/17545-vascular-disease-no n-invas ive-t es ti ng4. Ohio Med icaid Non-Ins titutional Fee Schedule. (2019, January 1). Retrieved from https://www.medicaid.ohio.gov/Portals /0/Providers/FeeSc heduleRates/App-DD. p dfThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Preventive Services and Sick Visit on Same Date of Service

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Preventive Services and Sick Visit on Same Date of Service PY-0007 09/01/2019 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, 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 polic ies 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 o r 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 par t, 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 authorizati on 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 t he 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 a nd may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 0 9 / 0 1 / 2 0 1 9 2 A. Subject Preventive Services and Sick Visit on Same Date of Service 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 pr oviders 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. CareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventi ve Services Task Force (USPSTF) . Applicable clinical criteria for the following breast cancer screening health services are described in the corresponding medical policy entitled Mammography services C. Definitions Preventive Services : are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing , vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are espe cially important for children under the age of 18 D. Policy I. Pediatric and Adolescent Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. i. Preventive Health Service Codes 1. 99381-99384 2. 99391-9939 4 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 II. Adult Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the Acute Care Visit code at 100%. The Preventive Service codes will not be reimbursed unless billed with the appropriate modifier to identify Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 0 9 / 0 1 / 2 0 1 9 3 separately identifiable services that were rendered by the same physician on the same date of service. i. Preventive Health Service Codes 1. 99385-99387 2. 99395-99397 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received . If documentatio n is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: a. Key elements that support the additional preventive health service s that were rendered b. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. c. The provider should clearly list in the assessment portion of the documentation the acute/chronic condi tions that are being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., A thorough MS and neur o exam of the left hip performed as it relates to the HPI). 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. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 11/17/2014 Date Revised 11/17/2015 Revision includes payment policy legal language 8/6/2019 Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Date Effective 9 /1/2019 Date Archived H. References 1. Successfully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center, 20 Feb. 2013, www.aapc.com/blog/22580-successfully-bill-a – preventive-service-with-a – sick-visit/. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. 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

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