REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 05/01/2018 05/01/2017-06/30/2021 Policy Name Policy Number Vitamin D Assay Testing PY-0226 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 3 Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 2 A. SUBJECTVitamin DAssay TestingB. 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 ac curate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Although an excess of vitamin Dis rar e it can lead to hypercalcemia. Vitamin Ddeficiency may lead to numerous disorders, the most widely known is rickets. Assessing patients vita min Dlevels is achieved by measuring the level of 25-hydroxyvitamin D. Evaluation of other metabol ites is generally not medically necessary. C. DEFINITIONS Severe deficiency: 25(OH)D: 80 ng/ml D. POLICY I. CareSource does not require a prior authorization for Vitamin Dtesting. II. CareS ource considers Vitamin Dlevels testing medically necessary for patients with the following: A. Chronic kidney disease stage III or greater B. Osteoporosis C. Osteomalacia D. Osteopenia E. Hypocalcemia F. Hypercalciura G. Hypoparath yroidism H. Malabsorption states I. Cirrhosis J. Hypervitaminosis DK. Osteosclerosis/petrosis L. Rickets M. Low exposure to sunlight N. Vitamin Ddeficiency to monitor the efficacy of replacement therapy III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the Vitamin Dtesting CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted as primary for the CPT code line, the claim will be denied. Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 3Note: Althou gh this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity.E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list ma y not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information.CPT Codes Definition 82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED ICD 10 codes DescriptionE20.0 Idiopathic hypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E21.0-E21.3 Primary hyperparathyroidism-Hyperparathyroidism, unspecified E41 Nutritional marasmus E43 Unspecified severe protein-calorie malnutrition E55.0 Rickets, active E55.9 Vitamin Ddeficiency, unspecified E67.3 Hypervitaminosis D E67.8 Other specified hyperalimentation E68 Sequelae of hyperalimentation E83.31 Familial hypophosphatemia E83.32 Hereditary vitamin D-dependent rickets (type 1) (type 2) E83.39 Other disorders of phosphorus metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E84.0 Cystic fibrosis with pulmonary manifestations E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations E89.2 Postprocedural hypoparathyroidism K50.00 Crohn's disease of small intestine without complications Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 4K50.011 Crohn's disease of small intestine with rectal bleedingK50.012 Crohn's disease of small intestine with intestinal obstruction K50.013 Crohn's disease of small intestine with fistula K50.014 Crohn's disease of small intestine with abscess K50.018 Crohn's disease of small intes tine with other complication K50.111 Crohn's disease of large intestine with rectal bleeding K50.112 Crohn's disease of large intestine with intestinal obstruction K50.113 Crohn's disease of large intestine with fistula K50.114 Crohn's disease of large intestine with abscess K50.118 Crohn's disease of large intestine with other complication K50.80 Crohn's disease of both small and large intestine without complications K50.811 Crohn's disease of both small and large intestine with rectal bleeding K50.812 Crohn's disease of both small and large intestine with intestinal obstruction K50.813 Crohn's disease of both small and large intestine with fistula K50.814 Crohn's disease of both small and large intestine with abscess K50.818 Crohn's disease of both small and large intestine with other complication K50.90 Crohn's disease, unspecified, without complications K50.911 Crohn's disease, unspecified, with rectal bleeding K50.912 Crohn's disease, unspecified, with intestinal obstruction K50.913 Crohn's disease, unspecified, with fistula K50.914 Crohn's disease, unspecified, with abscess K50.918 Crohn's disease, unspecified, with other complication K51.00 Ulcerative (chronic) pancolitis without complications K51.011 Ulcerative (chronic) pancolitis with rectal bleeding K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chronic) pancolitis with fistula K51.014 Ulcerative (chronic) pancolitis with abscess K51.018 Ulcerative (chronic) pancolitis with other complication K51.20 Ulcerative (chronic) proctitis without complications K51.211 Ulcerative (chronic) proctitis with rectal bleeding K51.212 Ulcerative (chronic) proctitis with intestinal obstruction K51.213 Ulcerative (chronic) proctitis with fistula K51.214 Ulcerative (chronic) proctitis with abscess K51.218 Ulcerative (chronic) proctitis with other complication Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 5K51.30 Ulcerative (chronic) rectosigmoiditis without complicationsK51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula K51.314 Ulcerative (chronic) rectosigmoiditis with abscess K51.318 Ulcerative (chronic) rectosigmoiditis with other complication K51.40 Inflammatory polyps of colon without complications K51.411 Inflammatory polyps of colon with rectal bleeding K51.412 Inflammatory polyps of colon with intestinal obstr uction K51.413 Inflammatory polyps of colon with fistula K51.414 Inflammatory polyps of colon with abscess K51.418 Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K51.511 Left sided colitis with rectal bleeding K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.514 Left sided colitis with abscess K51.518 Left sided colitis with other complication K52.0 Gastroenteritis and colitis due to radiation K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K74.1 Hepatic sclerosis K74.2 Hepatic fibrosis with hepatic sclerosis K76.9 Liver disease, unspecified K90.0 Celiac disease K90.1 Tropical sprue K90.2 Blind loop syndrome, not elsewhere classified K90.3 Pancreatic steatorrhea K90.41 Non-celiac gluten sensitivity K90.49 Malabsorption due to intolerance, not elsewhere classified K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.2 Postsurgical malabsorption, not elsewhere classified Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 6M80.00XA Age-related osteoporosis with current path ological fracture,unspecified site, initial encounter for fracture M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture M80.08XA Age-relat ed osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M83.0-M83.5 Puerperal osteomalacia-Other drug-induced osteomalacia in adults M83.8 Other adult osteomalacia M85.80 Other specified disorders of bone density and structure, unspecified site M85.811 Other specified disorders of bone density and structure, right shoulder M85.812 Other specified disorders of bone density and structure, left shoulder M85.821 Other specified disorders of bone density and structure, right upper arm M85.822 Other specified disorders of bone density and structure, left upper arm M85.831 Other specified disorders of bone density and structure, right forearm M85.832 Other specified disorders of bone density and structure, left forearm M85.841 Other specified disorders of bone density and structure, right hand Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 7M85.842 Other specified disorders of bone density and structure, left handM85.851 Other specified disorders of bone density and structure, right thigh M85.852 Other specified disorders of bone density and structure, left thigh M85.861 Other specified disorders of bone density and structure, right lower leg M85.862 Other specified disorders of bone density and structure, left lower leg M85.871 Other specified disorders of bone density and structure, right ankle and foot M85.872 Other specified disorders of bone density and structure, left ankle and foot M85.88 Other specified disorders of bone density and structure, other site M85.89 Other specified disorders of bone density and structure, multiple sites M89.9 Disorder of bone, unspecified M94.9 Disorder of cartilage, unspecified N18.3-N18.6 Chronic kidney disease, stage 3 (moderate) – End stage renal disease N25.81 Secondary hyperparathyroidism of renal origin Q78.2 Osteoporosis AUTHORIZATION PERIODF. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 03-08-2017Date Revised 03/19/2019 Updated code list based on revised LCD Date Effective 05/01/2017 Date Archi ved 06/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. REFERENCES1. Local Coverage Determination (LCD) Vitamin DAssay Testing (L33996). Retrieved March 19, 2019 2. Vitamin DInsufficiency. Retrieved March 2, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912737/ The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 07/01/2013 01/02/2020 02/02/2019 Policy Name Policy Number Bilateral Procedures PY-0012 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 member 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 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 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 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 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 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 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 …………………………………………………………………………………………………………… 2 B. BACKGROUND ………………………………………………………………………………………………….. 2 C. DEFINITIONS …………………………………………………………………………………………………….. 2 D. POLICY2 E. COND ITIONS OF COVERAGE ………………………………………………………………………….. 4 F. RELATED POL IC IES/RULES …………………………………………………………………………….. 4 G. REVIEW /REV IS ION HIS TORY…………………………………………………………………………… 4 H. REFERENCES …………………………………………………………………………………………………… 4 Bilateral Procedures Ohio Medicaid PY-0012 Effective Date: 02/02/2019 2 A. SUBJECT Bilateral Procedures B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. C. DEFINITIONS Bila te ra l proce dure s-are defined as surgical operations performed on both the right and left side of a patient’s body during the same operative session requiring separate sterile fields and a separate surgical incision. Modifie r-is a reporting indicator used in conjunction with a CPT code to denote that a medical service or procedure that has been performed has been altered by a specific circumstance while remaining unchanged in its definition or CPT code. D. POLICY I. CareSource will reimburse for bilateral procedures when medically necessary. II. CareSource will reimburse for bilateral procedures when providers submit their claim with appropriate CPT/HCPCS codes and modifier. A. Modifier 50 is used to report bilateral procedures (procedures described with the same CPT code) that are performed at the same operative session by the same physician on bilateral body structures (identical anatomic sites on opposite sides of the body). The use of modifier 50 is applicable only to services and/or procedures performed on identical anatomic sites or organs (e.g., eyes, ears, kidneys). B. Modifiers LT and RT may also be used to report services rendered on identical anatomic sites; however the use of these modifiers is not interchangeable with use of modifier 50. Modifiers LT and RT should only be used when the bilateral surgery rules do not apply. The bilateral surgery rules apply to procedures with a bilateral indicator of 1, as defined by the Centers for Medicare & Medicaid (CMS). When the fee schedule has a bilateral indicator of 0 or 3, as defined by CMS, use modifiers LT and RT to describe procedures performed on identical anatomic sites. 1. A bilateral procedure is reported on one line using modifier 50. Use a quantity entry of one when modifier 50 is reported. Do not submit two line items to report a bilateral procedure using modifier 50. 2. Modifier 50 should not be used to report diagnostic and radiology facility services. 3. Institutional claims received for an outpatient radiology service appended with modifier 50 will be denied. III. Surgical codes that are considered bilateral codes but are performed unilaterally on only one side of the body should be billed on one line unmodified or on one line with either the LT or the RT modifier indicating the side of the body on which the procedure was performed. Bilateral Procedures Ohio Medicaid PY-0012 Effective Date: 02/02/2019 3 A. Modifiers LT or RT are required when appropriate to identify: 1. Hospital procedures performed on identical anatomic sites on the right and left sides of the body (e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries). 2. A procedure is performed on only one side. 3. Hospital diagnostic test and radiology services performed on the right and left sides of the body. NOTE: Use of modifiers applies to services/procedures performed on the same calendar day. NOTE: CareSource will reimburse for bilateral procedures when the proper modifiers 50, LT, and RT are used. Modifier 50 is not to be utilized if the CPT code description specifies the procedure as bilateral. IV. Surgical codes that are considered bilateral codes but are performed more than once on one or each side of the body and/or body part indicated by the code definition must be billed using only the LT and RT modifiers on each line to demonstrate the procedure was performed more than once on one or each side. V. Although bilateral indicators 0 and 3 can be billed with the LT and RT modifiers, there are some differences between the two indicators; A. Some codes with an indicator of 0 may be performed more than once on a given day. However, even if performed on opposite sides of the body, these services would never be considered bilateral. B. Codes with an indicator of 0 can never be billed with modifier 50. C. Codes with an indicator of 3 can be billed with LT or RT. These services are generally radiologic and other diagnostic services. D. Codes that have an indicator of 0 that are billed using LT or RT receive reimbursement for a single code. VI. The CareSource maximum for bilateral procedures is 150% of the contracted amount allowed for the same procedures performed unilaterally when the code is billed on a single line with the 50 modifier. Bilateral Indicator Definition Submission Instructions 0 Bilateral surgery payment rules do not apply, do not use modifier 50. Do not submit these procedures with CPT modifier 50. 1 Bilateral surgery payment rules apply (150%). Use modifier 50 if bilateral. Units = 1 Submit the procedure on a single detail line with CPT modifier 50 and a quantity of 1. 2 Bilateral surgery payment rules do not apply. Already priced as bilateral. Do not use modifier 50. Units = 1 Submit the procedure with a quantity of 1. Do not submit these procedures with CPT modifier 50. 3 Bilateral surgery payment rules do not apply. Do not use modifier 50. Units = 1 or 2. Do not submit these procedures with CPT modifier 50. 9 Bilateral concept does not apply. Do not submit these procedures with CPT modifier 50. Bilateral Procedures Ohio Medicaid PY-0012 Effective Date: 02/02/2019 4 E. CONDITIONS OF COVERAGE AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DAT EACT ION Da te Issue d 07/01/2013 Da te Re vise d 01/02/2019 Revision to indicator 3 Da te Effe ctive 02/02/2019 H. REFERENCES 1. Surgical services. (2015, July 03). Retrieved August 15, 2016, from http://codes.ohio.gov/oac/5160-4-22. 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 MEDIC AID Policy Name Policy Number Effective Date Readmission PY-0 724 07/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimburse ment Polic y Sta teme nt : Reimburse ment Policies prepared b y CSMG Co. a nd its a ffiliates (inc luding CareSource) a re inte nded to pro vide a genera l refere nce regardi ng billi ng, coding a nd doc ume nta tion g uidelines. Coding methodolog y, regulator y requirem e nts , ind us try-s tanda rd claims editing logic, bene fits design a nd other fac tors are co nsidered in de velopi ng Reimburse ment Po licies. In addition to this Polic y, Reimburseme nt of services is subjec t to me mber be nefits a nd eligibility o n the da te of service , medical necessity, ad here nce to pla n policies a nd procedures, claims editing logic, pro vider co ntrac tual agreeme nt, a nd app licable re ferral, authori zatio n, notification and utili zatio n manageme nt g uidelines . Medically necessary services i nclude, b ut are no t limited to , those health care services or s upplies that are proper a nd necessary fo r the diagnosis or treatme nt o f disease, illness, or i njury a nd witho ut which the patie nt can be e xpected to s uffer pro longed , i ncreased o r ne w morbidity, impairme nt o f func tion, d ys function of a body orga n or part, or sig nificant pain a nd discomfort. These services meet the sta ndards of good medical practice i n the local area, are the lo west cost alternati ve, and are not pro vided mainly for the co nvenie nce o f the me mber o r p rovider. Medically necessary se rvices also i nclude those services defi ned in any federa l or state co verage ma ndate , Evidence o f Cove rage docume nts , Medical Policy State ments, Pro vider Ma nuals , Me mber Ha ndbooks, a nd/or other policies and proced ures. This Policy does no t e ns ure a n a utho rizatio n or Reimb urseme nt of se rvices. Please refer to the pla n co ntract (often referred to as the Evidence o f Coverage) for the service(s) re fere nced herein. If there is a conflict be twee n this Polic y a nd the pla n c o ntract ( i.e. , Evidence of Co verage), the n the pla n co ntract ( i.e . , Evidence of Coverage) will be the contro lli ng document used to make the determina tion. CSMG Co. a nd its a ffiliates ma y use reasonab le discretio n in interpre ting a nd applying this Polic y to services pro vided in a particular case a nd ma y modify this Polic y a t a ny time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Backgro und ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………. 5 G. Review/Revisio n History ………………………….. ………………………….. ………………………….. ………. 5 H. References ………………………….. ………………………….. ………………………….. ………………………… 5 Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 2 A. Subject Readmission B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims of Readmissions for our Medicare Advantage members may be subject to limitatio ns and/or qualifications. Reimbursement will be established based upo n a review of the actual services provided to a member and will be determined when the claim is received for pro cessing. Health care providers and their office staff are enco uraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the prod uct or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Follo wing a hospitalizatio n, readmissio n within 30 days is often a costly preventable event and is a qua lity of care issue . It has been estimated that readmissio ns within 30 days of discharge can cost health plans more than $1 billion dollars o n an annual basis. Readmissions can result from many situatio ns but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progressio n of the disease state or due to chro nic conditions. The p urpose of this policy is to improve the quality of inpatient and transitio nal care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communicatio n between the patient, caregivers and clinicia ns, 2. provide the patient with the education needed to maintain their care at home to prevent a readmissio n, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission : a subsequent inpatient admissio n to any acute care facility which occurs within 30 days of the discharge date; excluding planned admissio ns. Planned Readmission : a no n-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Clinically-Related Readmission Chain: is a series of admissions for the same patient where the underlying reaso n for readmission is related to the care rendered during or within thirty days following a prior hospital admission. A clinically-related readmissio n may have resulted from improper or incomplete care during the initial admission or discharge planning process. The hospital where the initial admission occurred is responsible for the clinically-related readmission chain. Hospitalization Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 3 resulting from an unpreventable or unrelated event occurring after discharge and planned readmissions are not considered clinically-related. Potentially Preventable Readmission (PPR): a readmissio n within a specific time frame that is clinically related and may have been prevented had appropriate care been provided during the initial hospital stay and discharge process. A PPR is determined when, based o n CareSource guidelines, it is determined that the patient was discharged prematurely. Premature discharge evidence can be described as, but not limited to, elevated fever at the time of discharge, abnormal lab results or evidence of infection or bleeding a wound. Only admission: an admission where there was neither a prior initial admissio n nor a clinically-related readmissio n within the thirty day read missio n period Same or Similar Condition : a conditio n or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented o n the initial admissio n. Same Day : CareSource deli neat es same day as midnight to midnight of a sin gle day . D. Polic y I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observatio nal services for the following : A. Readmissions that are potentially preventable as determined by the provision of appropriate care co nsistent with the criteria outlined below: 1. A medical readmission for a continuation or recurrence of the reaso n for the initial admission due to lack of care , or for a closely related condition (e.g., a readmissio n for diabetes following an initial admission for diabetes). 2. A medical readmission for an acute decompensation of a chronic problem that was not the reaso n for the initial admissio n, bu t was plausibly related to the lack of care rendered either during or immediately after the initial admission (e.g., a readmission for diabetes in a patient whose initial admission was for an acute myocardial infarction). 3. A medical readmission for an acute medical compli c ation plausibly related to the lack of care rendered during the initial admissio n (a patient with a hernia repair and a perioperative Foley catheter readmitted for a urinary tract infection 10 days later). 4. A readmission for a surgical procedure to address a continuatio n or a recurrence of the problem causing the initial admission (a patient readmitted for an appendectomy following an initial admission for abdominal pain and fever). 5. A readmission for a surgical procedure to address a complication resulting from the lack of care rendered during the initial admission (a readmission for drainage of a post-operative wound abscess following an initial admission for a bowel resection). B. Readmission s for a condition or procedure that is clinically-related to the care provided during the prior discharge or resulting from inadequate discharge planning during the prior discharge. Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 4 C. Readmissions when t he PPR chain may co ntain o ne or more readmissions that are clinically-related to the initial admission. If the first re admission is within thirty days after the initial admissio n, the thirty day timeframe may begin again at the discharge of either the initial admission or the most recent readmission clinically-related to the initial admission . D. Readmission is to the same or to any other hospital. II. Any readm issio n that occurs within one calendar day (i.e. same day or next day) , to the same institutio n, is considered one discharge for payment purposes and will be reimbursed as one DRG payment per the OAC 5160-2 – 65. III. Readmis sions, for the purposes of determining PPRs, excludes the following circumstances: A. The original discharge was a patient initiated discharge, was against medical advice (AMA), and the circumstances of such discharge and readmission are documented in the pat ient’s medical record. B. The original discharge was for the purpose of securing treatment of a major or metastatic malignancy, major trauma, neo natal and obstetrical admission, transplant or HIV. C. Only admissions, which are defined in the definitions of this policy. Planned readmissio ns are considered "o nly admissio ns. IV. Prior authorizatio n of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim . V. Post Payment Review and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissio ns to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical reco rds for both admissions must be included with the claim submission to determine if the admission (s) is appropriate or is considered a readmissio n. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. If the incl uded documentation determines the readmission to be an inappropriate, medically unnecessary or potentially preventable admission , the hospital must be able to provide additio nal documentation to CareSource upo n request or the claim will be denied. c. If the readmissio n is determined at the time of documentatio n review to be a preventable readmissio n, the reimbursement for the read mission will be combined with the initial admission and paid as o ne claim to cover both, or all, admissions. 2. Appeals Process ArchivedReadmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 5 a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer revie w or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS f ee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT ION Date Issued 04/01/2019 Date Revised Date Effective 07/01/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803. 2. Hospital Readmission Reduction Pro gram. (2018, December 04). Ret rieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://www.cms.gov 4. Goldfield, N. I., McCullough, E. C., Hughes, J. S., Tang, A. M., Eastman, B., Rawlins, L. K., & Aver ill, R. F. (2008). Identifying potentially preventable readmissions. Retrieved from https://www.ncbi.nlm. nih.gov The Re im burseme nt Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r e cei v e d due c on si d e ra t i o n a s d e f i n e d i n the Re im burseme nt Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Streptococcus A and BInfection PY-0452 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 4 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H. REFERENCES ………………………………………………………………………………………… 4 Molecular Diagnostic Testing for Streptococcus A and BInfection OHIO MEDICAID PY-0452 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Streptococcus A and BInfection B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Illnesses caused by Streptococcus A include Pharyngitis (strep throat), Scarlet Fever, Acute Rheumatic Fever and Post Streptococcal Glomerulonephritis. Illnesses caused by Streptococcus Binclude Bacteremia, Sepsis, Pneumonia, skin and soft tissue infections, bone and joint infections, meningitis (although this is a rare occurrence in adults). Screening for Streptococcus Bshould be done between 35 and 37 weeks in every pregnant women, as it is most commonly passed to newborns during the birthing process. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy when the following criteria are met: a. Conventional testing, such as the rapid strep test (throat culture), has been performed with a negative result on the same date of service as the requested molecular diagnostic test, AND; b. The member presents with cardinal streptococcus A and/or Bsymptoms to include but not limited to: i. red, swollen tonsils ii. white or yellow coating or patches on the tonsils iii. sore throat iv. difficult or painful swallowing v. fever vi. bad breath vii. stiff neck viii. enlarged, tender glands (lymph nodes) in the neck Molecular Diagnostic Testing for Streptococcus A and BInfection OHIO MEDICAID PY-0452 Effective Date: 12/01/2018 3 II. CareSource considers Molecular Diagnostic Testing by PCR for Streptococcus A and Streptococcus Binfection appropriate as the first line of testing only when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy . IV. Conventional testing, such as the rapid strep test (throat culture) for Streptococcus A; cultures of sterile body fluids and/ or vaginal and rectal cultures in pregnant women for Streptococcus B, are viewed as effective, low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. CONDITIONS OF COVERAGE CODE DESCRIPTION 87651 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 87653 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique A38.0 Scarlet fever with otitis media A38.1 Scarlet fever with myocarditis A38.8 Scarlet fever with other complications A38.9 Scarlet fever, uncomplicated A40.0 Sepsis due to streptococcus, group A A40.3 Sepsis due to Streptococcus pneumoniae A40.8 Other streptococcal sepsis A40.9 Streptococcal sepsis, unspecified A41.9 Sepsis, unspecified organism B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere G00.2 Streptococcal meningitis I00 Rheumatic fever without heart involvement I01.0 Acute rheumatic pericarditis I01.1 Acute rheumatic endocarditis I01.2 Acute rheumatic myocarditis I01.8 Other acute rheumatic heart disease I01.9 Acute rheumatic heart disease, unspecified J02.0 Streptococcal pharyngitis J03.00 Acute streptococcal tonsillitis, unspecified J03.01 Acute recurrent streptococcal tonsillitis J13 Pneumonia due to Streptococcus pneumoniae J15.4 Pneumonia due to other streptococci J20.2 Acute bronchitis due to streptococcus M72.6 Necrotizing fasciitis N00.9 Acute nephritic syndrome with unspecified morphologic changes A40.1 Sepsis due to streptococcus, group BB95.1 Streptococcus, group B, as the cause of diseases classified elsewhere J15.3 Pneumonia due to streptococcus, group BO99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester Molecular Diagnostic Testing for Streptococcus A and BInfection OHIO MEDICAID PY-0452 Effective Date: 12/01/2018 4 O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium O99.820 Streptococcus Bcarrier state complicating pregnancy O99.824 Streptococcus Bcarrier state complicating childbirth O99.825 Streptococcus Bcarrier state complicating the puerperium P23.3 Congenital pneumonia due to streptococcus, group BP36.0 Sepsis of newborn due to streptococcus, group BZ05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Z22.330 Carrier of Group Bstreptococcus F. RELATED POLICIES/RULES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/7/2018 Removed O99.5 Date Effective H. REFERENCES 1. Group BStrep | GBS | Home | Streptococcus | CDC. (2018, May 29). Retrieved July 23, 2018, from www.cdc.gov/groupbstrep. 2. Group A Strep | Home | Group A Streptococcus | GAS | CDC. (2016, September 16). Retrieved July 23, 2018, www.cdc.gov/groupAstrep. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018-12/31/2020 Policy Name Policy Number Molecular Diagnostic Testing for Respiratory Virus PY-0451 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 ………………………….. ………………………….. ………………………….. ………………….. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. ………….. 3/4 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 Mo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 A. SUBJECTMolecular Diagnostic Testing for Respiratory Virus B. BACKGROUND Mo lecular testing, following a d iagnosis or suspected diagnosis can help guide appropriate therap y b y id entifying specific therapeutic targ ets and appropriate p harmaceutical interventions. Mo lecular d iagnostic testing utilizes Polymerase Chain Reaction (PC R), a g enetic amplification techniq ue that only requires small q uantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory p rocessing time. Knowing the gene seq uence, or at minimum the b orders of the ta rget segment of DNA to b e amplified, is a p rereq uisite to a successful PCR amplification of DNA. Mo lecular Diagnostic testing for the respiratory viruses known as Adenovirus, Influenza Virus,Co ro navirus, Metapneumovirus, Parainfluenza Virus, Respiratory Syncytial Virus (RSV) and Rhino virus can be utilized in the p resence of symptoms such as cough, fever, headache, fatigue, rhino rrhea, p haryngitis and a g eneral unwell feeling, that wo uld create a clinical picture of a resp irato ry virus. Molecular Diagnosti c testing for respiratory viruses is no t indicated for every p atient that presents with these signs and symptoms, as treatment is generally the same for all of the viruses and resolve with little to no p harmacological treatment, except in immuno compromised p atients. All f acilities in the United States that perform laboratory testing on human specimens for health assessment or the d iagnosis, prevention, o r treatm ent of disease are reg ulated under the Clinical Lab o ratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared b y the FDA for ho me use and those tests ap proved for waiver und er the CLIA criteria. Although CLIA req uires that wai ved tests must be simple and have a lo w risk for erro neous results, this d o es not mean that waived tests are completely erro r-proof. CareSource may p eriodically req uire review of a providers office testing p olicies and p rocedures when p erforming CLIA-waiv ed tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a g enetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services o r supplies needed to d iagnosis o r treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of med icine. D. POLICYI. No Prio r Authorization is req uired for the Molecular Diagnostic Testing by PCR addressed in this p o licy. II. CareSo urce considers Molecular Diagnostic Testing by PCR for Respiratory Virus medically necessary when submitted with any combination of the CPT and diagnosis codes listed in the Co nd itions of Coverage in this policy III. CareSo urce d oes no t consider Molecular Diagnostic Testing by PCR for Respiratory Virus to b e med ically necessary when b illed with any o ther d iagnosis code and will no t p rovide reimb ursement for those services. IV . Co nventional testing, such as rap id antigen di rect tests, d irect fluorescent antibody testing and cultures, are viewed as low cost and should b e utilized b efore the higher cost Molecular Diag no stic Testing by PCR. 3 E. CON DITIONS OF COVERAGEMo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 CODE DESCRIPTION 87631 Inf ectious agent d etection b y nucleic acid (DNA or RNA); respiratory virus (eg , adenovirus, influenza virus, coronavirus, metapneumovirus, p arainf luenza virus, respiratory syncytial virus, rhinovirus), includes multip lex reverse transcription, when p erformed, and multiplex amp lified probe technique, multiple types or subtypes, 3-5 targ ets 87632 Inf ectious agent d etection b y nucleic acid (DNA or RNA); respiratory virus (eg , adenovirus, influenza virus, coronavirus, metapneumovirus, p arainf luenza virus, respiratory syncytial virus, rhinovirus), includes multip lex reverse transcription, when performed, and multiplex amp lified probe technique, mu ltiple types or subtypes, 6-11 targ ets 87633 Inf ectious agent d etection b y nucleic acid (DNA or RNA); respiratory virus (eg , adenovirus, influenza virus, coronavirus, metapneumovirus, p arainf luenza virus, respiratory syncytial virus, rhinovirus), includes multip lex reverse transcription, when performed, and multiplex amp lified probe technique, multiple types or subtypes, 12-25 targets B30.2 Viral p haryng oconjunctivitis B34.0 Ad eno virus infection, unspecified B34.2 Co ro navirus infection, unspecified B97.0 Ad eno virus as the cause of d iseases classified elsewhere B97.21 SARS-associated coro navirus as the cause of d iseases classified elsewhere B97.29 Other co ro navirus as the cause of diseases classified elsewhere B97.4 Resp iratory syncytial virus as the cause of d iseases classified elsewhere B97.81 Human metap neumovirus as the cause of d iseases classified elsewhere B97.89 Other viral ag ents as the cause of diseases classified elsewhere J00 Acute nasopharyngitis [common cold] J05.0 Acute o bstructive laryngitis [cro up] J06.9 Acute up per respiratory infection, unspecified J09.X1 Inf luenza d ue to identified novel influenza A virus with p neumonia J09.X2 Inf luenza d ue to identified novel influenza A virus with other respiratory manif estations J09.X3 Inf luenza d ue to identified novel influenza A virus with g astrointestinal manif estations J09.X9 Inf luenza d ue to identified novel influenza A virus with o ther manif estations J10.00 Inf luenza d ue to other id entified influenza virus with unspecified type of p neumo nia J10.01 Inf luenza d ue to other id entified influenza virus with the same o ther id entified influenza virus p neumonia J10.08 Inf luenza d ue to other id entified influenza virus with other specified p neumo nia J10.1 Inf luenza d ue to other id entified influenza virus with other respiratory manif estations J10.2 Inf luenza d ue to other id entified influenza virus with gastro intestinal manif estations J10.81 Inf luenza d ue to other id entified influenza virus with encephalopathy J10.82 Inf luenza d ue to unidentified influenza virus with myocarditis 4 Mo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 J10.83 Inf luenza d ue to other id entified influenza virus with otitis media J10.89 Inf luenza d ue to other id entified influenza virus with other manif estations J11.00 Inf luenza d ue to unidentified influenza virus with unspecified type of p neumo nia J11.08 Inf luenza d ue to unidentified influenza virus with specified pneumonia J11.1 Inf luenza d ue to unidentified influenza virus with other respiratory manif estations J11.2 Inf luenza d ue to unidentified influenza virus with g astrointestinal manif estations J11.81 Inf luenza d ue to unidentified influenza virus with encephalopathy J11.82 Inf luenza d ue to unidentified influenza virus with myocarditis J11.83 Inf luenza d ue to unidentified influenza virus with otitis media J11.89 Inf luenza d ue to unidentified influenza virus with other manifestations J12.0 Ad eno viral pneumonia J12.1 Resp iratory syncytial virus p neumonia J12.2 Parainf luenza virus pneumonia J12.3 Human metap neumovirus pneumonia J12.81 Pneumo nia due to SARS-associated coronavirus J12.9 Viral p neumonia, unspecified J20.4 Acute b ronchitis due to parainfluenza virus J20.5 Acute b ronchitis due to respiratory syncytial virus J20.6 Acute b ronchitis due to rhinovirus J21.0 Acute b ronchiolitis d ue to respiratory syncytial virus J21.9 Acute b ronchiolitis, unspecified O98.511 Other viral d iseases complicating pregnancy, first trimester O98.512 Other viral d iseases complicating pregnancy, second trimester O98.513 Other viral d iseases complicating pregnancy, third trimester O98.519 Other viral d iseases complicating pregnancy, unspecified trimester O98.52 Other viral d iseases complicating childbirth O98.53 Other viral d iseases complicating the puerperium O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unsp ecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium F. RELATED POLICIES/RULESN/A 5 G. REVIEW/REVISION HISTORYMo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 DATE ACTIONDate Issued 12/01/2018Date Revised 11/07/2018 Up d ated the next review d ate to 12/01/2019 Date Effective 12/01/2018 Date Archived 12/31/2020 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. NREVSS | Home | National Respiratory and Enteric Virus Surv System | CDC. (2018, August 14). Retrieved August 16, 2018, from https:// www.cdc.gov/surveillance/nrevss/index.html. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018 Policy Name Policy NumberMolecular Diagnostic Testing for Influenza Virus Infection PY-0450Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan 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 ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Mo lecular Diagnostic Testing for Influenza Virus InfectionOH IO MEDI CAIDPY-0450 Effective Date: 12/01/2018 2 A. SUBJECTMolecular Diagnostic Testing for Influenza Virus Infection B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain R eaction (PCR) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the border s of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Molecular diagnostic testing for Influenza Virus can detect influenza viral RNA or nucleic acids in respiratory specimens with high sensitivity an d specificity . The detection of influenza viral RNA ornucleic acids is not necessarily indicative of a viable or ongoing influenza viral replication . In cases where there is known active influenza virus and the clinical picture of the patient shows signs and symptoms of the influenza virus, molecular diagnostic testi ng is not needed. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of dise ase are regulated under the ClinicalLaboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests m ust be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, diseas e or its symptoms and that meet the accepted standards of medicine. D. POLICYI. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy when the following criteria are met: a. Conventional testing, such as a nasal swab has been performed with a negative result on the same date of service as the requested molecular diagnostic test, AND; b. The member presents with cardinal influenza virus infection symptoms to include but not limited to: i. Fever over 100.4 F ii. Aching muscles iii. Chills and sweats iv. Headache v. Dry, persistent cough vi. Fatigue and weakness vii. Nasal congestion viii. Sore throat Mo lecular Diagnostic Testing for Influenza Virus InfectionOH IO MEDI CAIDPY-0450 Effective Date: 12/01/2018 3 II. CareSource considers Molecular Diagnostic Tes ting by PCR for Influenza Virus Infection appropriate as the first line testing only when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy IV. Conventional testing, such as nasal swabs and nasopharyngeal swabs , are viewed as lowcost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR.E. CONDITIONS OF COVERA GECODE DESCRIPTION 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types J09. X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia J10.08 Influenza due to other identified influenza virus with other specified pneumonia J10.1 Influenza due to other identified influenza virus with other respiratory manifestations J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to other identified influenza virus with myocarditis J10.83 Influenza due to o ther identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations J11.81 Influenza due to unidentified influenza virus with encephalopathy J11.82 Influenza due to unidentified influenza virus with myocarditis J11.83 Influenza due to unidentified influenza virus with otitis media J11.89 Influenza due to unidentified influenza virus with other manifestations O99.511 Diseases of the respiratory system complicating pregnancy, first trimester Mo lecular Diagnostic Testing for Influenza Virus InfectionOH IO MEDI CAIDPY-0450 Effective Date: 12/01/2018 4 O99.512 Diseases of the respiratory system complicating pregnancy, second trimesterO99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium F. RELATED POLICIES/RUL ESN/A G. REVIEW/REVISION HIST ORY DATE ACTIONDate Issued 12/01/2018Date Revised 11/07/2018 Corrected O00.519 to O99.519; corrected the next review date to 12/01/2019 Date Effective 12 /01 /2018 Archive Date 02/02 /2021 H. REFERENCES1. Information on Rapid Molecular Assays, RT-PCR, and other Molecular Assays for Diagnosis of Influenza Virus Infection | Seasonal Influenza (Flu) | CDC. (2018, February 20). Retrieved July 16, 2018, from www.cdc.gov/flu/professionals/diagnosis/molecular – assays.htm . 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 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Gastrointestinal Illness PY-0448 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affili ates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 2 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Testing for Gastrointestinal Illness B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PC R) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the ta rget segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Gastrointestinal illness, as addressed in this policy, include Clostridium difficile, E. Coli, Salmonella, Shigella, Norovirus and Giardia. These infection and illnesses of the intestine can cause symptoms such as diarrhea, nausea, vomiting and abdominal cramping. There are three basic modes of transmission: in food, in water and person to person. While some of these illnesses will resolve on their own, others can spread throughout the body and require treatment to prevent a more devastating illness. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or tr eatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, co ndition, disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for the following gastrointestinal i llnesses, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage of this policy. A. Clostridium Difficile B. Salmonella C. Shigella D. Norovirus E. Giardia III. CareSource does not consider Molecular Diagnostic Testing by PCR medically necessary for gastrointestinal illnesses when billed with any other diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as stool and saliva samples for these illnesses is viewed as low cost and given that not all cases of acute diarrhea are indicative of these illnesses, institutions should utilize these before the higher cos t Molecular Testing by PCR as the first testing option for the initial clinical presentation of acute diarrhea. Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 3 E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87493 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique 87505 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, an d multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), include s multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. co li, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets A04.71 Enterocolitis due to Clostridium difficile, recurrent A04.7 2 Enterocolitis due to Clostridium difficile, not specified as recurrent A02.0 Salmonella enteritis A03.0 Shigellosis due to Shigella dysenteriae A03.1 Shigellosis due to Shigella flexneri A03.2 Shigellosis due to Shigella boydii A03.3 Shigellosis due to Shigella sonnei A03.8 Other shigellosis A03.9 Shigellosis, unspecified A04.0 Enteropathogenic Escherichia coli infection A04.1 Enterotoxigenic Escherichia coli infection A04.2 Enteroinvasive Escherichia coli infection A04.3 Enterohemorrhagic Escherichia coli infection A04.4 Other intestinal Escherichia coli infections A07.1 Giardiasis [lambliasis] A08.11 Acute gastroenteropathy due to Norwalk agent K52.9 Noninfective gastroenteritis and colitis, unspecified O99.611 Diseases of the digestive system complicating pregnancy, first trimester O99.612 Diseases of the digestive system complicating pregnancy, second trimester O99.613 Diseases of the digestive system complicating pregnancy, third trimester O99.619 Diseases of the digestive system complicating pregnancy, unspecified trimester O99.62 Diseases of the digestive system complicating childbirth O99.63 Diseases of the digestive system complicating the puerperium F. RELATED POLICIES/RUL ES N/A Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 4 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Updated next review date to 12/01/2019 Date Effective H. REFERENCES 1. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System Infections. (2016 , July 16). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091344/ The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Transcutaneous Electrical Nerve Stimulation (TENS) PY-0039 0 5 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case 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 ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 2 A. Subject Transcutaneous Electrical Nerve Stimulation (TENS) B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the respons ibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims paymen t. Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied t o the members skin. CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day (1 month) trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. C. Definitions Transcutaneous electrical nerve stimulation (TENS) – is the application of mild electrical stimulation , to skin electrodes placed over a painful are a that causes interference with transmission of painful stimuli. Accessories-includes but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches and covers. Supplies-includes but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries and battery charger for rechargeable batteries. D. Policy I. CareSource does not req uire a p rior a uthorization (PA) for a TENS unit or supplies for participating providers . A. Non-participating providers DO require a prior authorization for a TENS unit (E0720 or E0730). B. Non-participating providers DO NOT require a prior authorization for supplies (A4595). II. CareSource reimburses for TENS units and supplies according to the Ohio Administrative Code 5160-10-15. III. TENS units are reimburse d on a 4 month rent to purchase basis after a successful 1 month non-reimbursable trial period. IV. Reimbursement is limited to the maximum amount for a two-lead unit (E0720) , unless the provider obtains and maintains documentation in the members file attesting the medical necessity of a four-lead unit (E0730) . Archived Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 3 V. After a TENS unit has been purchased, no separate payment is allowed for accessories. VI . Documentation A. The provider of the TENS unit must complete the Certificate of Medical Necessity: Transcutaneous Electrical Nerve Stimulation (TENS) Units , ODM form 03402 , attesting to the medical necessity of the device, which must be available for review upon CareSources request. B. Per the Ohio A dministrative Code 5160-10-15, a diagnosis of “chronic intractable pain” is not in itself sufficient to warrant coverage of a TENS unit. C. For neurogenic p ain, a n attestation that the individual is experiencing intractable, nerve-related p ain that has laste d at least 6 months must be available for review upon CareSources request. D. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than thirty days is needed for acute pain following surgery and includes the date of surgery. E. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain and, if applicable, enabled a significant reduction in medication (e.g., muscle relaxants, narcotics, analgesics) must be completed and available for review upon CareSources request . F. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request, before reimbursement is made for supplies or repair. G. The provider must also provide the member with a physical face to face fitting and instruction on the use of the TENS unit. H. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record. VI I. Rental of a TENS unit to treat post-operative pain is limited to a single thirty-day period and may not be extended. Modifier RR should be used in this case. VIII. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units ( after the successful 1 month non-reimbursable trial period ). VIII . Supplies A. Supplies are not reimbursable during the trial period . B. Supplies ar e not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase (after 1 month trial period and 4 month rental period) CareSource covers only 1 unit of supplies (A4595) per month for a TENS unit (E0720 or E0730). D . Claims for 2 units or more per month of supplies (A4595) will not be reimbursed. E. After a TENS unit has been purchased for an individual, regardless of payment source : 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed , at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for i ndividual supply items. F. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim will be denied. ArchivedTranscutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 4 E. Conditions of Coverage Reimbursement 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 schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. HCPCS Code Description E0720 TENS unit , 2-lead , localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and batter y pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Only 1 unit per member per month will be reimbursed. No separate payment is made for TENS supplies during any month in which a TENS unit is rented. Modifiers Description LL Lease/rental (use the ‘ll’ modifier when dme equipment rental is to be applied against the purchase price) NR New when rented (use the ‘nr’ modifier when dme which was new at the time of rental is subsequently purchased) NU Purchase of new equipment RR Rental (use the ‘rr’ modifier when dme is to be rented) F. Related Policies/Rules Ohio Administrative Code 5160-10-15 G. Review/Revision History DATE ACTION Date Issued 08/23/2004 Date Revised 02/06/2019 Updated policy to align with OAC updates Date Effective 05 /01/2019 H. References 1. Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) Appendix to rule 5160-10-01. (2019, January 1). Retrieved 1/20/2019 from http://codes.ohio.gov/pdf/oh/admin/2018/5160-10-01_ph_rv_a_app1_20181119_1356.pdf . 2. Lawriter-OAC-5160-10-15 DMEPOS: transcutaneous electrical nerve stimulation (TENS) units. (2018, July 16). Retrieved 1/20/2019 from http://codes.ohio.gov/oac/5160-10-15. 3. Using TENS for pain control: the state of the evidence. (2015, March 1). Retrieved 1/20/2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186747/ . Archived Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 5 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. I nd e pe n de nt med i ca l r e v iew 2/2015 Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Avastin for use in Ophthalmology Billing Guideline PY-0706 05/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Avastin for use in Ophthalmology Billing Guideline OHIO MEDICAID PY-0706 Effective Date: 05/01/2019 2 A. Subject Avastin for use in Ophthalmology Billing Guideline 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. Avastin is a drug used in the treatment of wet age-related macular degeneration, diabetic eye disease and other problems of the retina. Avastin is injected into the eye and helps to slow down disease related vision loss. The use of Avastin to treat eye disease is considered off-label, which is allowed by the FDA when doctors are well informed regarding the drug and there are studies that prove its an effective treatment option. There is no cure for macular degeneration, treatment is aimed at slowing down the progression of the disease and preventing vision loss. C. Definitions Macular Degeneration a progressive vision impairment resulting from deterioration of the central part of the retina, known as macula. D. Policy I. CareSource does not require a Prior Authorization for the use of Avastin in Ophthalmology, when billed with the following codes: A. J3490 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. B. J3590 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. E. CONDITIONS OF COVERAGE HCPCS J3490, J3590 NDC 50242-0061-01 or 50242-0060-01 F. RELATED POLICIES/RULES N/A Avastin for use in Ophthalmology Billing Guideline OHIO MEDICAID PY-0706 Effective Date: 05/01/2019 3 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 05/01/2019 New policy Date Revised Date Effective 05/01/2019 H. REFERENCES 1. Boyd, K. (2018, May 22). What Is Avastin? Retrieved October 29, 2018, from https://www.aao.org/eye-health/drugs/avastin 2. “Off-Label” and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices-Information Sheet. (2018, July 12). Retrieved October 29, 2018, from https://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm 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 Transcutaneous Electrical Nerve Stimulation (TENS) PY-0039 0 5 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case 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 ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 2 A. Subject Transcutaneous Electrical Nerve Stimulation (TENS) B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the respons ibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims paymen t. Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied t o the members skin. CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day (1 month) trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. C. Definitions Transcutaneous electrical nerve stimulation (TENS) – is the application of mild electrical stimulation , to skin electrodes placed over a painful are a that causes interference with transmission of painful stimuli. Accessories-includes but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches and covers. Supplies-includes but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries and battery charger for rechargeable batteries. D. Policy I. CareSource does not req uire a p rior a uthorization (PA) for a TENS unit or supplies for participating providers . A. Non-participating providers DO require a prior authorization for a TENS unit (E0720 or E0730). B. Non-participating providers DO NOT require a prior authorization for supplies (A4595). II. CareSource reimburses for TENS units and supplies according to the Ohio Administrative Code 5160-10-15. III. TENS units are reimburse d on a 4 month rent to purchase basis after a successful 1 month non-reimbursable trial period. IV. Reimbursement is limited to the maximum amount for a two-lead unit (E0720) , unless the provider obtains and maintains documentation in the members file attesting the medical necessity of a four-lead unit (E0730) . Archived Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 3 V. After a TENS unit has been purchased, no separate payment is allowed for accessories. VI . Documentation A. The provider of the TENS unit must complete the Certificate of Medical Necessity: Transcutaneous Electrical Nerve Stimulation (TENS) Units , ODM form 03402 , attesting to the medical necessity of the device, which must be available for review upon CareSources request. B. Per the Ohio A dministrative Code 5160-10-15, a diagnosis of “chronic intractable pain” is not in itself sufficient to warrant coverage of a TENS unit. C. For neurogenic p ain, a n attestation that the individual is experiencing intractable, nerve-related p ain that has laste d at least 6 months must be available for review upon CareSources request. D. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than thirty days is needed for acute pain following surgery and includes the date of surgery. E. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain and, if applicable, enabled a significant reduction in medication (e.g., muscle relaxants, narcotics, analgesics) must be completed and available for review upon CareSources request . F. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request, before reimbursement is made for supplies or repair. G. The provider must also provide the member with a physical face to face fitting and instruction on the use of the TENS unit. H. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record. VI I. Rental of a TENS unit to treat post-operative pain is limited to a single thirty-day period and may not be extended. Modifier RR should be used in this case. VIII. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units ( after the successful 1 month non-reimbursable trial period ). VIII . Supplies A. Supplies are not reimbursable during the trial period . B. Supplies ar e not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase (after 1 month trial period and 4 month rental period) CareSource covers only 1 unit of supplies (A4595) per month for a TENS unit (E0720 or E0730). D . Claims for 2 units or more per month of supplies (A4595) will not be reimbursed. E. After a TENS unit has been purchased for an individual, regardless of payment source : 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed , at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for i ndividual supply items. F. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim will be denied. ArchivedTranscutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 4 E. Conditions of Coverage Reimbursement 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 schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. HCPCS Code Description E0720 TENS unit , 2-lead , localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and batter y pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Only 1 unit per member per month will be reimbursed. No separate payment is made for TENS supplies during any month in which a TENS unit is rented. Modifiers Description LL Lease/rental (use the ‘ll’ modifier when dme equipment rental is to be applied against the purchase price) NR New when rented (use the ‘nr’ modifier when dme which was new at the time of rental is subsequently purchased) NU Purchase of new equipment RR Rental (use the ‘rr’ modifier when dme is to be rented) F. Related Policies/Rules Ohio Administrative Code 5160-10-15 G. Review/Revision History DATE ACTION Date Issued 08/23/2004 Date Revised 02/06/2019 Updated policy to align with OAC updates Date Effective 05 /01/2019 H. References 1. Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) Appendix to rule 5160-10-01. (2019, January 1). Retrieved 1/20/2019 from http://codes.ohio.gov/pdf/oh/admin/2018/5160-10-01_ph_rv_a_app1_20181119_1356.pdf . 2. Lawriter-OAC-5160-10-15 DMEPOS: transcutaneous electrical nerve stimulation (TENS) units. (2018, July 16). Retrieved 1/20/2019 from http://codes.ohio.gov/oac/5160-10-15. 3. Using TENS for pain control: the state of the evidence. (2015, March 1). Retrieved 1/20/2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186747/ . Archived Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICAID PY-0039 Effective Date: 0 5 /01/2019 5 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. I nd e pe n de nt med i ca l r e v iew 2/2015 Archived
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