REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Da te Vaccinations an d Immunizations PY-0040 10/01/2019-0 3/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….5 G. Review/Revision History ………………………………………………………………………………………..5 H. Ref er en ce s …………………………………………………………………………………………………………5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable r e f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tVaccinations and I mmun iza tio ns Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/2019B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. CareSo urc e c overs and reimburs es for immunizations/vacc ines b ased on the recommendations f ro m the Centers for Dis ease Control and Prevention (CD C) and the Advisory Committee o n Immunizatio n Prac tices (ACIP). Th e Vac c ines for Children (V FC) p rogram is a federally funded program that provides v accines at no c o s t to c hildren who might not otherwise be v accinated b ecause of inability to pay . The Centers f o r Diseas e Co ntrol and Prev ention (CDC) p urchas es v ac cines at a d is count and d is tributes them to s tate health d epartments whic h in turn distribute them at no charge to those p riv ate p hy sicians offic es and public health clinics reg istered as VFC p roviders. The Vac c ines for Children (VFC) p rogram helps pro vide v acc ines to c hildren whose p arents o r g uard ians may not be ab le to afford them. The VFC p rogram helps ens ure that c hildren hav e a b etter c hanc e of getting their rec ommended v ac cinations on s chedule. Vacc ines available thro ug h the VF Cpro gram are those rec ommended by the A dvisory Committee on Immunization Prac t ic es (A CIP ).C. Def initions Immunization-is an ino c ulation ag ainst a v accine preventable disease. Vaccination-the ac t of introducing a vacc ine into the body to produce immunity to a spec if ic d is ease. Vaccine-a p ro d uct that s timulates a pers ons immune sy stem to produce immunity to a specific disease, p rotecting the p er s o n from that disease. Vacc ines are usually ad ministered thro ug h need le injec tions, b ut c an also b e administered by mouth or s prayed into the nose. Vaccines for Children Program (VF C) – the program for distribution of pediatric v accines ad minis tered by the Department for Public Health. D. Polic yI. Vac c inations and Immunizations f or CareSourc e members 18 y ears old or younger: A. CareSo urc e d oes not differentiate between providers that participate or do not participate in the Vac c ines for Children program. 1. All claims for v accines administered to children 18 years of ag e or younger wi ll be reimb urs ed for the ad ministration only. 3 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/20192. All c laims must b e submitted with appropriate CPT and ICD-10 code to ens ure that the p ro v ider is properly reimb ursed f or the administration o nly of the correc t v accine. II. Vac c inations and Immunizations for CareSourc e members 19 years old or older: A. CareSo urc e may reimb urse f or v acc inations that are administered in accordanc e wi th the CD Cad ult v ac cination/immunization s chedule: 1. All c laims must b e submitted with the appropriate CPT and ICD-10 c ode to ens ure that the p ro vider is properly reimbursed for the administration and the toxoid that w as ad ministered. 2. CareSo urc e d oes not cover v accines or immunizations for travel outside of the United States . III. Hep atitis A vaccine: A. CareSo urc e members who may be at high risk f or Hep ati ti s A infec tion are eligible to rec eiv e the Hep atitis A v accine regard les s of age. 1. Pro v ider may s ubmit cl a im s f or Hepatitis A tox oid and v accination administration i. Fo r c hild ren ages b irt h thro ugh 18: procedure c odes 90633 and 90634. ii. Fo r ad ults age 19 and older: proc edure codes 90632 and 90636. E. Conditions of Cov erageReimb urs ement is dependent o n, b ut not limited to, s ubmitting Ohio Medicaid approved HCPCS and CP Tcodes along with ap propriate modifiers, if applicable. Pleas e refer to the individual Ohio Med ic aid fee s chedule for ap propriate c odes. The following l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description90460 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, with c ounseling b y phy sician o r other qualified health care p ro f es sional; f irs t or o n ly c omponent of each v accine or toxoid administered 90461 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, wit h counseling by p hysician or o ther qualified health care p ro f es sional; eac h ad ditional v acc ine o r toxoid component adminis tered (Lis t s ep arately in addition to code for p rimary p rocedure) 90471 Immunizatio n ad ministration (inc ludes perc utaneous, intradermal, s ub c utaneous, o r intramusc ular injec tions); 1 v accine (s ingle o r c o mb ination v acc ine/toxoid) 90472 Immunizatio n ad ministration (includes p erc utaneous, intrad ermal, s ub c utaneous, or intramusc ular injec tions ); eac h additional vacc ine (s ingle or c o mbination vacc ine/toxoid) (Lis t separately in addition to c ode for p rimary p rocedure) 90473 Immunizatio n adminis tration by intranasal or oral r o ut e ; 1 v accine (single or c o mb ination v acc ine/toxoid) 90474 Immunizatio n ad ministration by intranasal or o ral route; eac h additional vaccine (s ingle or c ombination v accine/toxoid) (List s eparately in addition to c o d e for p rimary p rocedure) 90620 Mening o cocc al rec o mbinant p rotein and outer membrane vesicle v acc ine, s ero g roup B (MenB-4C), 2 d ose s chedule, for intramus cular use 90621 Mening o cocc al rec o mbinant lipoprotein vacc ine, s erogroup B (MenB – FHb p ), 2 o r 3 d ose s chedule, for intramus cular use 90633 Hep atitis A vac cine (HepA), pediatric/adolesc ent dosage-2 dose s chedule, f o r intramuscular us e 90634 Hep atitis A vac cine (HepA), pediatric/adolesc ent dosage-3 dose s chedule, f o r intramuscular us e 4 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/201990636 Hep atitis A and hepatitis Bv accine (HepA-HepB), adult dosage, for intramus c ular us e 90644 Mening o cocc al c onjugate v ac cine, s ero groups C & Yand Haemophilus inf luenzae ty pe b vacc ine (Hib-MenCY), 4 d ose s chedule, when ad minis tered to c hildren 6 week s-18 months of age, for intramuscular use 90647 Haemo p hilus influenzae t ype b vac cine (Hib), PRP-O MP conjugate, 3 dose s c hed ule, for intramuscular us e 90648 Haemo p hilus influenzae t ype b vacc ine (Hib), PRP-T c onjugate, 4 dose s c hed ule, for intramuscular us e 90649 Human Pap illomavirus vacc ine, types 6, 11, 16, 18, quadrivalent (4v HPV), 3 d o s e s c hedule, for intramuscular us e 90650 Human Pap illomavirus vacc ine, types 16, 18, bivalent (2vHP V), 3 dose s c hed ule, for intramuscular us e 90651 Human Pap illomav irus vacc ine types 6, 11, 16, 18, 31, 33, 45, 52, 58, no nav alent (9v HPV), 2 o r 3 d ose s chedule, for intramuscular us e 90653 Inf luenza v ac c ine, inac tivated (IIV ), s ubunit, adjuvanted, f or intramus cular us e 90655 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, preserv ative free, 0.25 mL d o s age, for intramuscular us e 90656 Inf luenza v irus v accine, trivalent (IIV 3), split v irus , p reservative free, 0.5 mL d o s age, for intramuscular us e 90657 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.25 mL dosage, f or intramus c ular us e 90658 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.5 mL dosage, for intramus c ular us e 90660 Inf luenza v irus vaccine, triv alent, live (LA IV 3), for intranas al us e 90662 Inf luenza v irus v acc ine (IIV ), split virus, preserv ative free, enhanc ed immuno genicity via increas ed antigen c ontent, for intramuscular use 90664 Inf luenza v irus v accine, live (LA IV ), pandemic formulation, for intranasal us e 90666 Inf luenza v irus v accine (IIV ), p andemic formulation, s p li t virus, preservative f ree, f or intramusc ular us e 90667 Inf luenza v irus v accine (IIV ), p andemic formulation, s p li t virus, adjuv anted, f o r intramuscular us e 90668 Inf luenza v irus v accine (IIV ), pandemic formulation, sp l it virus, for intramus c ular us e 90670 Pneumo c occal c onjugate v accine, 13 v alent (P CV13), for intramusc ular us e 90672 Inf luenza v irus v ac c ine, q uadrivalent, live (LA IV 4), for intranas al use 90673 Inf luenza v irus v accine, trivalent (RIV 3), d erived f rom recombinant DNA, hemag g lutinin (HA) pro tein only, preserv ative and antibiotic free, for intramus c ular us e 90674 Inf luenza v irus v ac c ine, q uadrivalent (c c IIV 4), d erived f rom c ell c ultures, s ub unit, preserv ative and antibiotic free, 0.5 mL dosage, for intramuscular us e 90680 Ro tav irus vacc ine, p entavalent (RV 5), 3 d os e s chedule, live, f or o ral us e 90681 Ro tav irus vac cine, human, attenuated (RV 1), 2 d ose schedule, live, for oral us e 90685 Inf luenza v irus v ac c ine, quadriv alent (IIV 4), split virus, p reserv ative free, 0.25 mL, f or intramuscular us e 90686 Inf luenza v irus v accine, quadrivalent (IIV 4), sp l it virus , preserv ative free, 0.5 mL d o s age, for intramuscular us e 90688 Inf luenza v irus v accine, q uadriv alent (IIV 4), split v irus, 0.5 mL dos age, f or intramus c ular us e 5 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/201990696 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine and inac tivated p o liov irus vac cine (D Ta P-IP V), when administered to c hildren 4 through 6 y ears o f ag e, for intramus cular use 90698 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine, Haemophil us inf luenzae ty pe b, and inactivated poliovirus v accine, (D Ta P-IP V/Hi b), for intramus cular us e 90700 Dip htheria, tetanus toxoids, and acellular p ertuss is vaccine (D TaP ), when ad minis tered to ind iv iduals y ounger than 7 y ears, for intramuscular us e 90702 Dip htheria and tetanus toxoids adsorbed (DT) when ad ministered to ind iv iduals y ounger than 7 y ears, for intramuscular us e 90707 Meas les , mumps and rubella virus v accine (MMR), l iv e, for subcutaneous us e 90710 Meas les , mumps, rubella, and varicella vacc ine (MMRV ), live, for s ub c utaneous us e 90713 Po lio virus v acc ine, inac tivated (IP V ), for s ub cutaneous or intramuscular use 90714 Tetanus and d iphtheria toxoids adsorbed (Td ), pres ervativ e free, when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cular us e 90715 Tetanus , d iphtheria toxoids and ac ellular pertussis vac cine (Td ap), when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cul ar u s e 90716 Varicella v irus vac cine (V AR), live, f or s ubcutaneous us e 90723 Dip htheria, tetanus toxoids, acellular pertussis v accine, hepatitis B, and inac tiv ated poliovirus v accine (D TaP-Hep B-IPV), for intramusc ular us e 90732 Pneumo c occal polys accharide v accine, 23-v alent (PPSV23), adult o r immuno s uppressed p atient dosage, when administered to individuals 2 y ears o r o lder, for s ubcutaneous o r intramusc ular us e 90733 Mening o cocc al polys accharide vacc ine, serogroups A, C, Y, W-135, q uad riv alent (MPSV4), for s ubc utaneous us e 90734 Mening o cocc al c onjugate vacc ine, serogroups A, C, Yand W-135, q uad riv alent (MCV4 o r MenACWY), for intramusc ular us e 90743 Hep atitis Bv acc ine, ad oles cent (2 dose s c hedule) f or intramuscular u s e; 90744 Hep atitis Bvac cine (HepB), pediatric/adolesc ent dosage, 3 d ose schedule, f o r intramuscular us e 90756 Inf luenza v irus v ac cine, quadrivalent (c cIIV 4), d erived fro m cell c ultures , s ub unit, antibiotic free, 0.5mL d osage, for intramus cular use F. Related Polic ies/Rules G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 12/01/2013Date Revised 06/12/2019 Up d ated policy to align wit h CDC and VFC program 01/18/2020 Rev is io n remov ed lang uage to allow for toxoidreimb urs ement and p rovided additional c larification f o r Hep atitis A vacc ine ad ministration and reimb urs ementDate Effecti ve 10/01/2019 Date Archived 03/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . 6 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/2019H. Ref erenc es 1. Ad ult Immunization Schedule by Va c c i ne and Age Group | CD C. (2019, February 5). Retriev ed May 13, 2019, from https : // www.cdc.go v 2. Birt h-18 Years Immunization Schedule | CDC. (2019, February 5). Retrieved May 13, 2019, f ro m https :/ /www. cdc.go v3. FOR OHIOA NS . (2019, May 13). Retrieved May 13, 2019, f rom https://medicaid.ohio.gov 4. Free Vac c ines. (2014, No vember). Retrieved May 15, 2019 f rom https ://odh.ohio.gov 5. Lis t of CP Tand HCPCS codes c overed for Enhanc ed Ambulatory Patient Groups (E AP G)] . (2019, Feb ruary 1). Retriev ed May 15, 2019 from https://medicaid.ohio.gov 6. Med ic aid A dvisory Letter (MA L) No. 632. (2019, May 14). Retrieved May 15, 2019, from http s://medicaid.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Substance Use Disorder Residential PY-0137 7/1/2019 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 …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 2 A. Subject Substance Use Disorder Residential 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. Substance Use Disorder (SUD) services are provided on a continuum of care where the level of care varies dependent on the type and intensity of service provided. This policy address the Residential level of care. This type of care provides an intensive residential program for members with SUD. It is considered transitional with the goal of returning the member to the community with a less restrictive level of care. C. Definitions Residential level of care for substance use disorder-According to the Ohio Administrative Code, residential services provide addiction treatment and mental health (MH) services; and is staffed 24 hours a day. This includes withdrawal management. Treatment services include assessments, diagnostic evaluations, crisis intervention, psychotherapy, counseling, case management, peer recovery services, urine drug screens, medication assisted treatment and medical services. A residential program must meet all of the following: o Follow nationally recognized medical standards o Be an Ohio Department of Mental Health and Addiction Services (OMHAS) certified/licensed facility to provide residential SUD treatment o Have an active provider agreement with ODM o All practitioners of the SUD treatment service must meet applicable state requirements o Establish individualized treatment plans o Start discharge planning at time of admission o Schedule a follow-up visit within 7 days of discharge for aftercare o Provide Medication Assisted Treatment o Ensure accessibility to medication upon discharge CareSource does NOT consider a residential program appropriate for: o Intensive medical monitoring needed for severe or life threatening medical or physical condition o A member who is unable to actively participate due to Severe symptoms of co-existing mental or physical condition Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 3 Severe withdrawal symptoms D. Policy I. CareSource requires a prior authorization for the following: A. For the first and second admission per calendar year, a prior authorization is only required for an admission exceeding 30 consecutive days. B. For admissions exceeding the two admissions per calendar year, a prior authorization is required from the first day of admission. NOTE: One admission is considered one CPT code. II. Documentation A. At least one documented face-to-face service must be provided by a clinical/treatment team member with the member at the SU residential site in order to bill per diem, except for situations described below in IV. A. B. Members medical record must show evidence of medical necessity of services. C. The residential program has a written Affiliation Agreement so that members are connected/ensured access to outpatient care in timely manner upon discharge. The residential program has policies and procedures in place to monitor its affiliations. III. Medical Necessity Criteria CareSource follows The ASAM Criteria as required by the Ohio Department of Medicaid. IV. Billing A. Residential level of care admission one admission is considered one length of stay 1. Any stay under 30 consecutive days count as a full 30 day occurrence. 2. Service gaps in excess of 24 hours are considered a termination of one admission. 3. Leaving the SUD residential treatment facility associated with significant changes in health status such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in level of care, and/or incarceration are considered a termination of one admission 4. Brief leave of absences (24 hours or less, except in rare instances) when supported by members individualized treatment plan should be documented in the members treatment plan, and the provider should continue to bill for treatment services during these times. a. Brief leave of absences include but are not limited to the following: 01. Family visits, 02. Religious services 03. Same day health services 04. Social support group attendance B. CareSource only processes claims from 1. Provider type of 95 OhioMHAS certified/licensed treatment program AND Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 4 2. Provider specialty 954 OhioMHAS certified/licensed SUD residential facility AND 3. Place of service code 55-Residential Substance Abuse Treatment Facility C. Claims billed out of sequence from date of service may cause claims to deny inappropriately for no prior authorization D. Claims are paid as they are received. If member receives services from more than one provider, claims are paid to providers that submit first regardless of date of service. E. SUD residential is paid per diem. Per Diem does NOT include room and board costs/payments. F. CareSource does not reimburse separately for services provided by the residential treatment service including: 1. Ongoing assessments and diagnostic evaluations. 2. Crisis intervention. 3. Individual, group, family psychotherapy and counseling. 4. Case management. 5. Substance use disorder peer recovery services. 6. Urine drug screens. 7. Medical services. 8. Medication administration G. A member can only receive services through one level of care at a time. 1. CareSource considers the following services non-billable when member is in a. Residential level of care b. Therapeutic behavioral services. c. Psychosocial rehabilitation. d. Community psychiatric supportive treatment. e. Mental health day treatment. f. Assertive community treatment. g. Intensive home based treatment. 2. CareSource does consider services provided to a member from practitioners not affiliated (based on billing group TIN) with the residential treatment program as billable when the service is medically necessary and the treatment is outside of the scope of residential level of care. Examples include medication assisted treatment (MAT) and psychiatry. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description H2034 Clinically Managed Low-Intensity Residential Treatment ASAM 3.1 H2036 Clinically Managed High Intensity Residential Treatment ASAM 3.5 Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 5 Procedure Modifier Description HI Clinically Managed Population-Specific High Intensity Residential Treatment ASAM 3.3 (Adults) May be used with H2036. TG Medically Monitored Intensive Inpatient Treatment (Adults) and Medically Monitored High-Intensity Inpatient Services (Adolescent) ASAM 3.7 May be used with H2036. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 08/17/2017 Date Revised 5/15/2019 Date Effective 7/1/2019 Updated definition, medical necessary criteria, billing H. References 1. Lawriter-OAC-5160-27-01 Eligible provider for behavioral health services. (n.d.). Retrieved on 5/8/2019 from http://codes.ohio.gov/oac/5160-27-01 2. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved on 5/8/2019 from http://codes.ohio.gov/oac/5160-27-09v1 3. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved on 5/8/2019 from http://codes.ohio.gov/oac/5160-27-09v1 4. Lawriter OAC 5122-29-09 Residential, withdrawal management, and inpatient substance use disorder services. (n.d.) Retrieved on 5/15/2019 from http://codes.ohio.gov/oac/5122-29-09v1 5. Ohio Department of Medicaid. (2019, March 4). Medicaid Behavioral health State Plan Services Provider Requirements and Reimbursement Manual. Retrieved on 5/8/2019 from https://bh.medicaid.ohio.gov/Portals/0/Providers/BH%20Manual%20V%201.6_as%20of%203.4.19.pdf?ver=2019-04-23-140505-050 6. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Billing Guidelines for Determination of Refractive State PY-0808 10 /01/2019-04/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirem ents, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the 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 ……………………………………………………………………………………………………………. 3 Billing Guidelines for Determination of Refractive State OHIO MEDICAID PY-0 808 Effective Date: 10/01/2019 2 A. Subject Billing Guidance for Determination of Refractive State 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 sta ff 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 inclus ion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Refraction services determines ocular refraction in an eye exam. A phoropter that contains wheels with different lenses having different strengths determ ines which combination provides the sharpest vision. This combination determines the prescription needed for glasses or contacts to correct the error. C. Definitions Comprehensive Eye Exam An evaluation of the visual system including, but not limited to; acuity, prescription for corrective lenses, pupils, side vision, eye movement, eye pressure, front part of eye, retina, and optic nerve. Refractive State Determination-The act or technique of determining ocular refraction and identi fying abnormalities as a basis for the prescription of corrective lenses . D. Policy I. CareSource does not require a prior authorization (PA) for the following eye exams: A. 92002-Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient; B. 92004-Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, comprehensive, new patient, one or more visits; C. 92012-Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, intermediate, established patient D. 92014-Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, one or more visits . I I. Determination of refractive state (92015) performed by an optometrist or ophthalmologist is covered on ce every (12) months. A. Any additional need for determination of refractive state must include documentation for medical necessity along with claim . Note: Although prior authorization is not required for determination of refractive state , CareSource will review documentation to support medical necessity. CareSource may request additional documentation if the information submitted with the claim does not confirm medical necessity. Billing Guidelines for Determination of Refractive State OHIO MEDICAID PY-0 808 Effective Date: 10/01/2019 3 III. CareSource allows separate reimbursement for d etermination of refractive s tate (92015) when included in an eye exam.E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS codes along with appropriate modifiers , if applicable. Please refer to the Ohio Medicaid fee sched ule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be a ll-inclusive and is subject to updates. CPT Code Description 92 002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient 92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, comprehensive, new patient, one or more visits 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, intermediate, established patient 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, one or more visits 92015 Determination of refractive state F. Related Policies/RulesN/AG. Review/Revision HistoryDATE ACTIONDate Issued 10 /01/2019 New policyDate Revised Date Effective 10 /01/2019 Date Ar chived 04/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Polic y. H. References1. Eye Exam and Vision Testing Basics. (2019, February 5). Retrieved from https://www.aao.org/eye-health/tips-prevention/eye-exams-101 2. Lawriter-OAC 5160-6 Vision Care Services. (2019, April 19). Retrieved from http://codes.ohio.gov/oac/5160-6 3. Ohio Department of Medicaid Fee Schedules and Rates. (2019, April 22). Retrieved from https://medicaid.ohio.gov/Provider/FeeScheduleandRates/SchedulesandRates#1682654-eye-care-services Billing Guidelines for Determination of Refractive State OHIO MEDICAID PY-0 808 Effective Date: 10/01/2019 4 4. Refraction assessment. (2019, February 21). Retrieved from https://www.mayoclinic.org/tests-procedures/eye-exam/multimedia/refraction-assessment/img-20006171 The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
2 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Date Effective Drug Testing PY-0020 7/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 3 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 6 F. RELATED POLICIES/RULES …………………………………………………………………….. 7 G. REVIEW/REVISION HISTORY …………………………………………………………………… 7 H. REFERENCES ………………………………………………………………………………………… 8 I. APPENDIX A …………………………………………………………………………………………… 9 3 A. SubjectDrug Testing Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019B. 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 does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual.Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members wit h substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of conce rn.Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualitative and confirmatory/quantitative. Drug testing is sometimes also referred to as toxicology testing.C. Definitions Presumptive/Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing.Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) -This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test-A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Qualified Labor atories: When an out-of-network qualified laboratory provides toxicology test results to the referring health care provider within two business days of receipt of the test specimen, the MCP shall pay that laboratory at least sixty percent of the Medicaid laboratory services fee schedule. For the purposes of this 4 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019requirement, a qualified laboratory is a laboratory that is enrolled with Medicaid as an independent laboratory, and that meets all of the following conditions : 1. Is accredited by the College of American Pathologists; and 2. Is approved by the New York Clinical Laboratory Evaluation Program; and 3. Indicates to the MCP that it is providing services and billing as a qualified laboratory Residential services-Ohio Administrative code defines residential services as These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. 1 NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0054. Please refer to this policy for in-depth information on medical necessity for drug testing, documentation requirements, and CareSource monitoring and review of drug testing claims.D. PolicyI. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. CareSource will require a PA for UDT tests >30 presumptive and/or > 12 confirmatory UDT per member per calendar year 2. PA is required for any non-participating provider with CareSource for non-emergency room setting. 3. PA is required for any non-participating, non-qualified lab/facility with CareSource for non-emergency room setting. 4. PA is required for any non-participating, qualified lab/facility with CareSource for non-emergency room setting. 5. PA is not required in an emergency room setting. UDT utilization will be monitored by CareSourc e. 6. PA needs to make a clear case for medical necessity for the level of testing being requested. 1 http://codes.ohio.gov/oac/5160-27-09v15 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will cover up to 30 presumptive and 12 definitive UDT per member per calendar year. 1. CareSource will cover up to 30 presumptive UDT per member per calendar year. 2. CareSource will cover up to 12 definitive UDT per member per calendar year. B. For presumptive tests, each CPT code is counted as one test. C. For confirmatory tests, all CPT tests performed on the same date of service count as one test. IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource.V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care service for children under age 21. VI. Non-Urine Testing A. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples performed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not coveredVII. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billab le and will not be reimbursed by CareSource. B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following:a. Presump tive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR 6 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member disputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing. (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testi ng that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing required by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Forensic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately.D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prio r to discussing results of presumptive test with member. 7 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the Ohio Medicaid fee schedule. The following list(s) of 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.Codes Qualitative/Presumptive Tests-Description80305Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when pe rformed, per date of service80306Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perf ormed, per date of service80307Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of serviceCodes Quantitative/Confirmatory Tests-Description 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80329 analgesics, non-opioid, 1 or 2 80330 analgesics, non-opioid 3-5 80331 analgesics, non-opioid 6 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more 80338 antidepressants not otherwise specified 80339 antiepileptics, not otherwise specified 1-3 80340 antiepileptics, not otherwise specified 4-6 80341 antiepileptics, not otherwise specified 7 or more 8 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/201980342 antipsychotics, not otherwise specified 1-380343 antipsychotics, not otherwise specified 4-680344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80367 propoxphene 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, qualitative or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, qualitative or quantitative, not otherwise specified 4-6 80377 drug, or substance definitive, qualitative or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0054 G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 11/29/2017Date Revised 3/8/2017 5/31/2017 10/1/2017 11/29/2017 2/16/2018 5/13/2019 9 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/20197/1/20197/8/2019 9/6/2019Updated clinical indications, quantity limits, and PArequirements Updated qualified laboratories per ODM guidance Added OH PA form Date Effective 7/1/2019 H. REFERENCES1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science. Retrieved on 12/11/20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 3. American Society of Addiction Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https ://www.asam.org/doc s/default-source/public-policy-statements/1drug-testing—clinical-10-10.pdf?sfvrsn=1b11ac97_0#search="urine drug test ing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine. Retrieved on 12/13/2018 from https://journals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_ Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendations and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https:// www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42 .1.8&r=PART#se42.1.8_12 7. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved from http://codes.ohio.gov/oac/5160-27-09v1 8. Medicaid. Ea rly and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https ://www.medicaid.gov/medicaid/benefits/epsdt/index.html 9. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 10. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https:// www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf11. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%2 0on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20Drug%20Testing%20Guidance.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.10 APPENDIX ADrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORMThe Clinical Advisory Group of the Ohio Department of Mental Health and Addiction Services established broad guidelines to appropriate clinical use of urine drug screening for patients with a substance use disorder. These guidelines took into account ease of access for patients by eliminating barriers to care, as well as account for patient safety, acuity, risk of relapse/overdose, level of care, and sustained abstinence. Date of Request: Patient Information Last Name: First Name: DOB: Member ID: Patient phone # Provider Information 1. Ordering Provider Name: Tax ID: NPI: Phone Fax: 2. Service Provider (Laboratory/Facility) Name: Tax ID: NPI: Phone Fax: Supporting Documentation-Supporting documents must be attached (including current medication list including current MAT, OTC meds, supplements that may interfere with testing; patients drug(s) of choice; ICD-10 Diagnosis code(s); drug testing history with results) Reason for request: (Check all that apply): Addiction Treatment Chronic pain management Other Patients current phase of care: Induction Stabilization Maintenance Long term maintenance Relapse 2 Patients current ASAM Level of Care: ; not yet determined List date of testing if different than the date of this PA request: 1. Presumptive (select one): 80305 80306 80307 2. Confirmatory include type of test (s): For Patients with Chronic Pain on Opioid Therapy-Provide results of most recent screening. Additional Clinical InformationIs patient currently pregnant? Yes No If suspected diversion, list risk factors: Has patient been adherent to MAT over past 3 months: Yes NoIf no, All of time Most of time Erratic Poor Unknown Has medication administration been observed: Yes No Provide any additional information that is needed to be considered with this completed form. Form completed by: Phone number:2 OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM T0977 2 Definition of Relapse: (ASAM National Practice Guideline (2015) A process in which an individual who has established abstinence or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pursuit of reward and/or relief through the use of substances and other behaviors. OH P-1677
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Date Effective Drug Test ing PY-0020 7/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfu nction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy d oes not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 6 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 7 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 8I . APPENDIX A ………………………….. ………………………….. ………………………….. ……… 9 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 2 A. Subject Drug Testing B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; an d all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for me mbers with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs ar e of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory /Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Early and Periodic Screening, Diagnostic and Treatment ( EPSDT ) – This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test-A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Qualified Laboratories : When an out-of-network qualified laboratory provides toxicology test results to the referring health care provider within two business days of receipt of the test specimen, the MCP shall pay that laboratory at least sixty percent of the Medicaid laborato ry services fee schedule. For the purposes of this Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 3 requirement, a qualified laboratory is a laboratory that is enrolled with Medicaid as an independent laboratory, and that meets all of the following conditions : 1. Is accredited by the College of American Pathologists; and 2. Is approved by the New York Clinical Laboratory Evaluation Program; and 3. Indicates to the MCP that it is providing services and billing as a qualified laboratory Residential services-Ohio Administrative code defines residential services as These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. 1NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0054 . Please refer to this policy for in-depth information on medical necessity for drug testing, d ocumentation requirements , and CareSource monitoring and review of drug testing claims. D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the I CD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. The Ohio Department of Health Standard UDT PA Form must be provided along with the appropriate supporting documentation when requesting a PA. 2. CareSource will require a PA for UDT te sts >30 presumptive and/or > 12 confirmatory UDT per member per calendar year 3. PA is required for any non-participating provider with CareSource for non-emergency room setting. 4. PA is required for any non-participating, non-qualified lab/facility with CareS ource for non-emergency room setting. 5. PA is required for any non-participating, qualified lab/facility with CareSource for non-emergency room setting. 6. PA is not required in an emergency room setting . UDT utilization will be monitored by CareSource . 1http://codes.ohio.gov/oac/5160-27-09v1 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 4 7. PA needs to make a clear case for medical necessity for the level of testing being requested . B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will cover up to 30 presumptive and 12 definitive UDT per member per calendar year. 1. CareSource will cover up to 30 presumptive UDT per member per calendar year. 2. CareSource will cover up to 12 definitive UDT per member per calendar year. B. For presumptive tests, each CPT code is counted as one test . C. For confirmatory tests, all CPT tests performed on the same date of service count as one test. IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other t han that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care s ervice for children under age 21 . VI. Non-Urine Testing A. CareSource will reimburse blood testing in e mergency room settings . B. Drug testing with blood samples performed in any other setting outside of an e mergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VII. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 5 a. Presumptive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member d isputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testing that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing re quired by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Foren sic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed o utside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 6 I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits , recovery of overpayments identified, and provider prepay review . E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes . Please refer to the Ohio Medicaid fee schedule . The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perform ed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative /Confirmatory Tests-Description 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80329 analgesics, non-opioid, 1 or 2 80330 analgesics, non-opioid 3-5 80331 analgesics, non-opioid 6 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more ArchivedDrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 7 80338 antidepressants not otherwise specified 80339 antiepileptics, not otherwise specified 1-3 80340 antiepileptics, not otherwise specified 4-6 80341 antiepileptics, not otherwise specified 7 or more 80342 antipsychotics, not otherwise specified 1-3 80343 antipsychotics, not otherwise specified 4-6 80344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80367 propoxphene 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, qualitative or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, qualitative or quantitative, not otherwise specified 4-6 80377 drug, or substance definitive, qualitative or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0054 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/29/2017 Date Revised 3/8/2017 5/31/2017 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 8 10/1/2017 11/29/2017 2/16/2018 5/13/2019 7/1/2019 7/8/2019 9/ 24 /2019 Updated clinical indications, quantity limits, and PA requirements Updated qualified laboratories per ODM guidance Added ODM PA form Date Effective 7/1/2019 H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11 /20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 3. American Society of Addict ion Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https://www.asam.org/docs/default-source/public-policy-statemen ts/1drug-testing — clinical-10-10.pdf?sfvrsn=1b11ac97_0#search=”urine drug testing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on 12/13/2018 from https://jo urnals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendati ons and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42.1.8&r=PART#se42.1.8_12 7. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved from http://codes.ohio.gov/oac/5160-27-09 v1 8. Medicaid. Ea rly and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html 9. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendat ions and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 10. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf 11. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky .gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%20on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20Drug%20Testing%20Guidance.pdf Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 9 The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. APPENDIX A OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM The Clinical Advisory Group of the Ohio Department of Mental Health and Addiction Services established broad guidelines to appropriate clinical use of urine drug screening for patients with a substance use disorder. These guidelines took into account ease of access for patients by eliminating barriers to care, as well as account for patient safety, acuity, risk of relapse/overdose, level of care, and sustained abstinence. Date of Request: _____________________ Patient Information Last Name: ________________________________First Name: ________________________________ DOB: ___________ Member ID: ______________________ Patient phone # ______________ Provider Information 1. Ordering Provider Name: ___________________________________________________ _________ Tax ID: ________________NPI: ___________________Phone _________________ Fax:__________________ 2. Service Provider (Laboratory/Facility) Name: _____________________________________________ Tax ID: ________________NPI: ___________________Phone ______ ___________ Fax:__________________ Supporting Documentation-Supporting documents must be attached (including current medication list including current MAT, OTC meds, supplements that may interfere with testing; patients drug(s) of choice; ICD-10 Diagno sis code(s); drug testing history with results) Reason for request: (Check all that apply): Addiction Treatment Chronic pain management Other ____________________ Patients current phase of care: Induction Stabilization Maintenance Long term maintenance Relapse 2Patients current ASAM Level of Care: ________________________; not yet determined List date of testing if different than the date of this PA request: ________________________ 1. Presumptive (select one): 80305 80306 80307 2. Confirmatory include type of test (s): ______________________________________ For Patients with Chronic Pain on Opioid Therapy-Provide results of most recent screening. Additional Clinical Information Is patient curr ently pregnant? Yes No If suspected diversion, list risk factors: __________________________________________________ Has patient been adherent to MAT over past 3 months: Yes No If no, All of time Most of time Erratic Poor Un known Has medication administration been observed: Yes No 2OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM T0977 2Definition of Relapse: (ASAM National Practice Guideline (2015) A process in which an individual who has established abstinen ce or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pu rsuit of reward and/or relief through the use of substances and other behaviors. OH P-1677 ArchivedDrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 10 Provide any additional information that is needed to be considered with this completed form. Form completed by: _____________________________ Phone number:_____________________ Archived
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 procedu res. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Reimbursement Modifiers PY-0715 09/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 10 F. Related Policies/Rules …………………………………………………………………………………………… 10 G. Review/Revision History …………………………………………………………………………………………. 10 H. References …………………………………………………………………………………………………………… 10 2 A. SubjectReimbursement Modifiers Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while othe r modifiers are used to report additional information, to the code description, of the product or service. Although CareSource accepts the use of modifiers specific to this policy, not all modifiers are included within this policy. The modifiers included w ithin this policy are those modifiers that affect the reimbursement of a service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must be made available upon CareSources request. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.C. Definitions Current Procedural Terminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT c odes. Modifier-two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. Modifier 22-Increased Procedural Services A. Modifier 22 is used to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required. The extra work may be identified by appending modifier 22 to the usual procedure code. B. Procedure codes with modifier 22 appended may be reimbursed up to 120% of the fee schedule amount. Note: This modifier is not appended to E/M services (99201-99499). Claims for 99201-99499 with modifier 22 will be denied. Medical records ARE required with the3 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019claim and must support the use of this modifier. Claims with procedures including 22 and no supporting documentation will be denied. II. Modifier 50-Bilateral Procedures A. Professional Claims Only Append modifier 50 to the appropriate unilateral code on a single claim line and indicate 1 unit in the unit field of that claim line.B. Modifier 50 applies to surgical procedures (CPT codes 10040-69990) and to radiology procedures performed bilaterally. C. Applies to any bilateral procedure performed on both sides at the same session. D. The use of modifier 50 is NOT appropriate in the following situations: 1. Using modifier 50 on a bilateral procedure performed on different areas of the right and left sides of the body. 2. Appending modifier 50 to a procedure code that is defined by CPT as primarily bilateral or a bilateral service. 3. Appending modifier 50 to a surgical CPT code, the description of which contains the words one or both. E. Do not report two line items to indicate a bilateral procedure. F. Procedure code with modifier 50 appended will reimburse 1 unit at 150% of the fee schedule amount. III. Modifier 51-Multiple Procedures A. Modifier 51 is used to report multiple procedures, other than E/M services, are performed at the same session by the same individual, the primary procedure or service is reported as listed.B. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). C. Modifier 51 should not be appended to designated "add-on" codes. D. Procedure code with modifier 51 appended will reimburse 50% of the fee listed on the Medicaid Physician Fee Schedule for the service. IV. Modifier 52-Reduced services A. Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. 1. Modifier 52 is used for reporting reduced services when the procedure was terminated after the patient was prepped and brought to the room where the service was to be performed.B. Modifier 52 may be used to report reduced radiology procedures. 1. The correct reporting is to assign the CPT code to the extent of the procedure performed. 2. This modifier is used only to report a radiology procedure that has been reduced when no other code exists to report what has been done. 3. Report the intended code with modifier 52. i. Example, if the planned procedure is a two-view chest x-ray and only one view of the chest is performed, do not report CPT code 71020-52 (for x-ray chest, two views-reduced service). Instead, report CPT code 71010 (x-ray chest, single view). ii. Example, if a barium swallow is not completed because the patient cannot handle the barium, report CPT code (74270-52). C. Modifier 52 does not provide for reimbursement of an ineligible service. D. For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. E. Procedure code with modifier 52 appended will reimburse at 50% of the fee schedule amount. 4 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. The extenuating circumstances preventing the completion of the procedure must also be documented.V. Modifier 53-Discontinued Procedure A. Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued after anesthesia is administered to the patient.2. Modifier 53 is used to ind icate that the physician terminated a surgical/diagnostic procedure due to the patients well-being. B. This modifier is not used to report an elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. C. Modifier 53 cannot be used when a laparoscopic or endoscopic procedure is converted to an open procedure. D. Modifier 53 does not provide for reimbursement of an ineligible service. E. Modifier 53 cannot be appended to E/M codes. F. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. G. Procedure code with modifier 53 appended will reimburse at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. Documentation must include a statement indicating at what point the procedure was discontinued. The extenuating cir cumstances preventing the completion of the procedure must also be documented.VI. Modifier 54-Surgical Care Only A. Modifier 54 is reported when one physician performed a surgical procedure only; another physician provides the preoperative and/or postoperative management.B. Modifier 54 must only be appended to the surgical procedure code. C. Procedure code with modifier 54 appended will reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.VII. Modifier 55-Postoperative Management Only A. Modifier 55 is reported when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by appending modifier 55 to the procedure code.B. Modifiers 55 must only be appended to the surgical procedure code. C. Procedure code with modifier 55 appended will reimburse at 15% of the fee schedule amount. 5 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. VIII. Modifier 56-Preoperative Management Only A. Modifier 56 is reported when 1 physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code.B. Modifiers 56 must only be appended to the surgical procedure code. C. Procedure code with modifier 56 appended will reimburse at 15% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.IX. Modifier 62-Two Surgeons A. Modifier 62 is reported when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure. 1. Each surgeon must report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons.2. Each surgeon must report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported without the modifier 62 added. 3. If a co-surgeon acts as an assistant in the performance of additional proc edure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or 82 added, as appropriate. B. Procedure code with modifier 62 appended will be reimbursed at 62.5% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.X. Modifier 66-Surgical Team A. Modifier 66 is reported when three or more surgeons work together during a highly complex procedure are carried out under the "surgical team" concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure code used for reporting services.B. Claims submitted by team surgeons are identified with modifier 66. C. The Centers for Medicare & Medicaid Services (CMS) established a Team Surgery Indicator (TEAM SURG) found in the CMS National Physician Fee Sche dule Relative Value File. Values are: 1. 0-Team surgeons not permitted for this procedure. 2. 1-Team surgeons may be paid; supporting documentation is required to establish medical necessity. 3. 2-Team surgeons permitted. 4. 9-Team surgeon concept does not apply. D. Codes with CMS Team Surgery Indicators of 0 and 9 should not be billed with modifier 66. E. Modifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate procedure not included in the team surgery. 6 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019F. Only one surgeon maybe be considered the primary surgeon. CareSource will not reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon. G. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. H. Procedure code with modifier 66 appended will reimburse at 150% of the established fee, divided equally between the team surgeons. I. For team surgery with three surgeons, each surgeon will be reimbursed at 50% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XI. Modifier 73-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia A. Modifier 73 is reported to a service to indicate that due to extenuating circumstances or those that threaten the well-being of the patient, a surgical or diagnostic procedure at an outpatient hospital or ambulatory surgical center (ASC) was discontinued prior to the administration of anesthesia. B. Modifier 73 is only appropriate for use by an ASC. C. Modifier 53 should not be used for any ASC service as the modifier is used exclusively on a professional claim. D. Procedure code with Modifier 73 appended will reimburse at 50% of the ASCs fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XII. Modifier 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) ProcedureAfter Administration of Anesthesia A. Modifier 74 is reported when due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia or after the procedure was started (incision made, intubation started, scope inserted.) B. Modifier 74 is not appropriate for the elective cancellation or postponement of a procedure based on the physician or patients choice. C. Modifier 74 is not appropriate when the termination of the procedure occurs prior to the beginning of the procedure or the administration of anesthesia. D. Modifier 74 is not for physician use. It is only appropriate for the ASC. E. Procedure code with modifier 74 appended will be reimbursed at 100% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XIII. Modifier 78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period A. Modifier 78 is reported to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure).7 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/20191. When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. 2. Modifier 78 should be appended when: i. The return to the operating room is unplanned. ii. The service is performed by same physician who performed the initial procedure. iii. The service is related to the initial procedure. iv. The service is performed during the postoperative period of the initial procedure (10-90 days). B. Procedure code with modifier 78 appended will be reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. XIV. Modifier 80-Assistant Surgeon A. Modifier 80 is reported to indicate surgical assistant services by a physician and is applied to the surgical procedure code(s).B. Assistant Surgeon provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated. C. Modifier 80 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 80 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XV. Modifier 81-Minimum Assistant Surgeon A. Modifier 81 is reported to indicate minimum surgical assistant services and is applied to the surgical procedure code(s).B. Minimum Assistant Surgeon is an assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon. C. Modifier 81 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 81 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XVI. Modifier 82-Assistant Surgeon (when qualified resident surgeon not available) A. Modifier 82 is reported to indicate when surgical assistance is needed, but a qualified resident was not available. B. Modifier 82 is used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable. 8 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019C. The unavailability of a qualified resident surgeon is a prerequisite for the use of this modifier. The assistant must provide documentation (certification) stating that a qualified resident was not available for this procedure and why the resident was not available. D. Procedure code with modifier 82 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery and why a qualified resident was not available. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XVII. Modifier AA-Anesthesia services performed personally by an anesthesiologist A. Modifier AA is used to report when the anesthesia services are personally performed by an Anesthesiologist. B. Procedure code with modifier AA appended will be reimbursed at 100% of the fee schedule amount. XVIII. Modifier AD-Anesthesia services supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. A. Modifier AD is used to report when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures.B. Procedure code with modifier AD appended will be reimbursed at 100% of the fee schedule amount. XIX. Modifier QK-Medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. A. Modifier QK is used to report when medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals.B. Procedure code with modifier QK appended will be reimbursed at 50% of the fee schedule amount. XX. Modifier QX-Anesthesia services performed by a CRNA with medical direction by an anesthesiologist. A. Modifier QX is used to report when the anesthesia services are performed by a CRNA with medical direction by an anesthesiologist.B. Procedure code with modifier QX appended will be reimbursed at 50% of the fee schedule amount. XXI. Modifier QY-Anesthesia services when an Anesthesiologist medically directs one CRNA. A. Modifier QY is used to report when an Anesthesiologist medically directs one CRNA.B. Procedure code with modifier QY appended will be reimbursed at 50% of the fee schedule amount. XXII. Modifier QZ-Anesthesia services performed personally by a CRNA without medical direction by a physician. A. Modifier QZ is used to report when the anesthesia services are personally performed by a CRNA.B. Procedure code with modifier QZ appended will be reimbursed at 100% of the fee schedule amount. XXIII. Modifier AE-Registered dietician9 A. B.Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Modifier AE is reported to indicate when a registered dietician provides the service. Procedure code with modifier AE appended will be reimbursed at 85% of the fee schedule amount. XXIV. Modifier AS-Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) served as the assistant at surgery. A. Modifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in place of another surgeon.B. Procedure code with modifier AS appended will be reimbursed at 25% of the base code allowable schedule before multiple surgery reductions are taken. No multiple surgery reductions will be taken on codes with the AS modifier. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XXV. Modifier JG-Drug or biological acquired with 340B drug pricing program discount A. Providers are required to report modifier JG on the same claim line as the drug or biological HCPCS code to identif y if a drug or biological was acquired under the 340B Program. B. HCPCS code with modifier JG appended will reimburse at the average sales price (ASP) minus 22.5% for certain separately payable drugs or biologicals that are acquired through the 340B Program. XXVI. Modifier JW-Drug amount discarded (wasted)/not administered to any patient A. CareSource will consider reimbursement for: 1. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended.2. The wasted amount when billed with the amount of the drug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSource will NOT consider reimbursement for: 1. The wasted amount of a multi-dose vial drug. 2. Any drug wasted that is billed when none of the drug was administered to the patient. 3. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. XXVII. Modifier SA-Nurse practitioner (NP) rendering service in collaboration with a physician A. Modifier SA is reported to indicate when a supervising physician is billing on behalf of an ANP, or CRNFA for non-surgical services. B. Modifier SA is used when the ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier SA appended will be reimbursed at 85% of the fee schedule amount. XXVIII. Modifier TB-Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes. A. Modifier TB must be reported to identify if a drug or biological was acquired under the 340B Program.B. The use of modifier TB will not trigger a payment adjustment. Providers will receive the average sales price (ASP), plus 6% for separately payable drugs furnished. 10 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019XXIX. Modifier TC-Technical Component A. Technical component charges are institutional charges and not billed separately by physicians.B. A charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding Modifier TC to the usual procedure code. XXX. Modifier UD Physician Assistant (PA) rendering service in collaboration with a physician A. Modifier UD is reported to indicate when a supervising physician is billing on behalf of a PA for non-surgical services.B. Modifier UD is used when the PA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier UD appended will be reimbursed at 85% of the fee schedule amount. XXXI. Modifier 26-Professional Component A. Certain procedures are a combination of a physician component and a technical component.B. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. Note: In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2019 New policyDate Revised Date Effective 09/01/2019 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. References11 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/20191. Appendix to rule 5160-4-21. (2016, June 30). Retrieved 3/22/2019 from https://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/5160-4-21-phffnapp1-20160630-1045.pdf 2. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 3/22/2019 from https://s3.amazonaws.com/biopolicy/portal/fab42153-0f1f-4ea9-9db6-263c144aa972?response-content-disposition=inline%3B%20filename%3D%2259485-1143476.pdf%22&response-content-type=application%2Fpdf&X-Amz-Content-Sha256=e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWB6UVO57LSG6L2A%2F20190322%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190322T142429Z&X-Amz-SignedHeaders=Host&X-Amz-Expires=1800&X-Amz-Signature=689299099b6b1cc8481ca23fce721228a74bfef30ea4bc2e95a7cd5870bd298d 3. CPT overview and code approval. (2019, March 22). Retrieved from https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval 4. Medicare Claims Processing Manual Chapter 12-Physicians/Nonphys ician Practitioners. (2018, November 30). Retrieved February 18, 2019 from https ://www .cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 5. Medicare Claims Processing Manual Chapter 14-Ambulatory Surgical Centers. (2017, December 22). Retrieved February 18, 2019 from https ://www.c ms.go v/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf. 6. Modifiers Recognized by Ohio Medicaid. (2018, November 1). Retrieved from https://medic aid.ohio.gov/Portals/0/Resources/Publications/Guidance/BillingInstructions/Modif iersODM.pdf 7. Optum360 EncoderProForPayers.com-Login. (2019, February 18). Retrieved February 18, 2019 from https:// www.encoderprofp.com/epro4payers/allModifiersHandler.do?_k=101*0&_a=listRelate d&menu=4. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Medical Drug Reimbursement Rates PY-0794 07/14/2019-12/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Stat ement ………………………….. ………………………….. ……………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, 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, adherencet o 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 w ithout w hich 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 low est cost alternative, and are not provided mainly for the convenience of the member or provid er. 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 betw eenthis Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill 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. SubjectMedical Drug Reimbursement Rates Med ical Drug Reimbursemen t Rates OHIO MEDICAIDPY-0794 Effective Date: 07/14/2019 B. Background Reim bursem ent policies are designed to assist you when subm itting claim s to CareSource. They are routinely updated to prom ote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of paym ent. Reim bursement f or claim s m ay be subject to lim itations and/or qualif ications. Reim bursem ent will be established based upon a review of the actual services provided to a m em ber and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encourag ed to use self-service channels to verif y m em bers eligibility. It is the responsibility of the subm itting provider to subm it the m ost accurate and appropriateCPT/HCPCS code(s) f or the product or service that is being provided. The inclus ion of a code in this policy does not im ply any right to reim bursem ent or guarantee claim s paym ent. C. Def initions Average Wholesale Price (AWP) – is the m anuf acturer’s list price of the drug when sold to the wholesaler. Average Sales Price (ASP) a rate that is calculated by the m anuf acture on a quarterly basis and subm itted to Medicare. Medicare then places these rates in a f ile and uploads to the Medicare Part BDrug Average Sales Price Drug Pricing Files tab on cm s.gov. D. PolicyI. This is a reim bursem ent policy that outlines reim bursem ent rates f or drugs that are billed and adm inistered in the f ollowing places of service under the m em bers m edical benef it only when drug reim bursem ent rates are not specif ically called out in the provider contr act or the drug code is not listed on the Ohio Medicaid Fee Schedule: A. Place of Service 11 Of f ice 1. Medicares ASP (Average Sales Price) plus 6% B. Place of Service 12 Hom e 1. Manuf actures AWP (Average Wholesale Price) m inus 15% C. Place of Service 22 On Cam pus-Outpatient Hospital 1. Manuf actures AWP (Average Wholesale Price) m inus 15% E. Conditions of CoverageReim bursem ent is dependent on, but not lim ited to, subm itting Ohio Medicaid approved HCPCS and CPT codes along with appropriate m odif iers. Please ref er to the individual Ohio Medicaid f ee schedule f or appropriate codes. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 04/09/20193 Med ical Drug Reimbursemen t Rates OHIO MEDICAIDPY-0794 Effective Date: 07/14/2019 Date Revised Date Effective 07/14/2019 Date Archived 12/31/2021 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 documented Policy H. Ref erencesThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 10/01/2019 12/01/2017-02/19/2020 Policy Name Policy Number Transthoracic Echocardiogram PY-0181 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, medicalnecessity, 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 and may modify this Policy at any time.Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …….. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ……. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ………. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …………. 2 D. POLICY ………………………….. ………………………….. ………………………….. …………………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………….. 2 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 Tran sth o racic Ech ocardiogramOHIO MEDICAID PY-0181 Effective Date: 12/01/2017 2A. SUBJECT Transthoracic Echocardiogram 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 cla rification. These proprietary p o licies are no t a g uarantee of p ayment. Reimbursement 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 office 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 accur ate and ap propriateCPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a code d o es not imply any rig ht to reimbursement or g uarantee claims payment. CareSo urce will reimburs e participating p roviders, for transthoracic echocardiograms (TTE)rend ered to CareSource members, as set forth in this policy.C. DEFINITIONS Transtho racic E chocardiogram (TTE) – is a typ e o f echo cardiogram, in which an ultrasound p ro b e (o r ultraso nic transducer) is p laced o n the chest o r ab d o men o f the p atient to o btain vario us views of the heart. D. POLICYI. CareSo urce d oes no t req uire a p rior authorization for a transthoracic echocardiogram (TTE). II. A transtho racic echocardiogram may be reimbursed according to Centers f or Medicare andMedicaid Services (CMS) LCD 34338 g uidelines using appropriate CPT and modifier codes(if ap p licable). III. A transtho racic echocardiogram may be reimbursed according to Medicaid g uidelines usingap p ro priate CPT and /or HCPCS and modifier codes (if applicable).IV. Reimb ursement is based o n submitting a claim with the appropriate ICD-10 d iagnosis codeto matc h the transthoracic echocardiogram CPT code.V. If the ap p ropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim willb e d enied .Note: Altho ug h a transthoracic echocardiogram d oes not require a p rior authorization,co mp liance with the provisions in this policy may b e monitored and addressed through post p ayment data analysis and subsequent medical review audits. E. CONDITIONS OF COVERAGEReimb ursement is dependent o n, b ut not limited to, submitting CMS ap proved HCPCS and CPT co d es alo ng with appro priate modifiers. Please refer to the Ohio Medicaid fee schedule. http ://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf Tran sth o racic Ech ocardiogramOHIO MEDICAID PY-0181 Effective Date: 12/01/2017 3F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 03-08-2017 New p o licy.Date Revised 11-14-2018 LCD L34337 has b een rescinded and rep laced with LCD L34338 . Up d ated in Section D. II. o f the p olicy 4-2-2019 Remo ved code matching tables from policy. CareSo urce f ollows LCD L34338. Updated CMS LCDlink link was b ro ken.Date Effective 12-01-2017 Date Archived 02/19/2020 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and Care Source reserves the right to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. Ap p endix DD to rule 5160-1-60. (2017, January 1). Retrieved 2/6/2017 from http ://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 2. Echo cardiogram : MedlinePlus Medical Encyclopedia. (2015, April 20). Retrieved 2/6/2017f rom https://medlineplus.gov/ency/article/003869.htm 3. Current Pro ced ural Terminology (CPT) and National Uniform Billing Co mmittee (NUBC) Licenses. Retrieved 4/2/2019 from https://www.cms.gov/medicare-coverage – d atab ase/details/lcd – d etails.aspx?LCDId=34338&ver=21&Date=12%2f17%2f2018&DocID=L34338&bc=iAAAABAAAAAA& The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12/01/2017 Policy Name Policy Number Non-Invasive Vascular Studies PY-0 163 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to mem ber benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guideli nes. 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 pr olonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are no t 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 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 ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If the re 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 document 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. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT ………………………….. ………………………….. ………… 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ………….. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………………… 2B. BACKGROUND ………………………….. ………………………….. ………………………….. …………….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. ……………….. 2 D. POL IC Y ………………………….. ………………………….. ………………………….. ………………………… 2 E. COND ITIONS OF COVERA GE ………………………….. ………………………….. …………………. 3 F. RELATED POL IC IES/RUL ES ………………………….. ………………………….. ……………………. 4 G. REVIEW /REV IS ION HIS TORY ………………………….. ………………………….. ………………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……………… 4 Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 2 A. SUBJECT Non-Invasive Vascular Studies B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary p olicies 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. Heal th 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 servi ce that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse providers, for non-invasive vascular studies to CareSource member s, as set forth in this policy. Non-invasi ve vascular studies may be used interchangeably with Duplex scan or Duplex ultrasound for the purposes of this policy. C. DEFINITIONS A duplex ultrasound is a test to see how blood moves through the arteries and veins of the body. D. POLICY I. CareSource does not require a prior authorization for a non-invasive vascular study. Note : Although a Non-Invasi ve Vascular Study does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and c omplete documentation must be presented at the time of review to validate medical necessity. II. A non-invasive vascular study may be reimbursed according to CMS/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the non-invasi ve vascular study CPT code . IV. I f the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. V. To be considered medically necessary the ordering physician must have reasonable expectation that the non-invasi ve vascular study results will potentially impact the clinical management of the patient. VI. To be considered medically necessary the following c onditions must be met: A. Significant signs/symptoms of arterial or venous disease are present B. The information is necessary for appropriate medi cal and/or surgical management C. The test is not redundant of other diagnostic procedures that must be per f ormed Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 3 VII. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. E. CONDITIONS OF COVERA GE 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/Pro vi de rs/FeeSche dul eRates/App-DD.pd f 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. Ple a se re fe r to the a bove re fe re nce d source for the most curre nt coding informa tion. CPT Code s De finition 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93970 Duplex scan of extremity veins inc luding responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 93980 Duplex scan of arterial inflow and venous outflow of penile ves sels; complete study 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 93998 Unlisted noninvasive vascular diagnostic study ICD-10 De finition I 70.0 Atherosclerosis of aorta I 72.4 Aneurysm of artery of lower extremity S85.142A Laceration of anterior tibial artery, left leg, initial encounter S45.002A Unspecified injury of axillary artery, left side, initial encounter Q87.82 Arterial tortuosity syndrome S85.819A Laceration of other blood vessels at lower leg level, unspecified leg, initial encounter Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 4 I82.419 Acute embolism and thrombosis of unspecified femoral vein S35.319S Unspecified injury of portal vein, sequela F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HIST ORY DAT EACT ION Da te Issue d 03-08-2017 Da te Re vise d 04-02-2 019 Revised the link to the CMS LCD below Da te Effe ctive 12-01-2017 H. REFERENCES 1. Appendix DD to rule 5160-1 – 60. (2017, January 1). Retrieved 2/6/2017 from http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/App-DD.pd f 2. Duplex Ultrasoun d | Society for Vascular Surgery. (2017, February 10). Retrieved 2/10/2017 from https://vascular.org/patient-reso urces/ vascular-tests/duplex-ultraso un d 3. MedlinePlus-Search Results for: ultrasound. (2017, February 10). Retrieved 2/10/2017 from https://vsearch.nlm.nih.gov/ vi visimo/cgi-bi n/qu ery-meta?v%3Aproject=medline plus& v%3Asou rces=medlin epl us-bundle&query=ultrasound& _g a=1.23 90 609 34.7 98 803 35 4.14 84 937 05 2 4. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2017, January 1). Retrieved 4/2/2019 from https://www.cms.gov/medic are-coverage-data base/d etails/lcd-details.aspx?LCDId=3404 5& ver=2 2&Date=12% 2f17%2 f201 8&DocID=L3 40 45&Se arch Typ e=Advanced&bc=KAAAABAAAAAA& 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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