REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Smoking & Tobacco Cessation PY-0256 01/01/2020-11/30 /2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statemen t ..1A. Subject ………………………….. ………………………….. ………………………….. ………………… 2B. Background ………………………….. ………………………….. ………………………….. ………….. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………. 3 D. Policy ………………………….. ………………………….. ………………………….. ………………….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………… 5 G. Review/Revision History ………………………….. ………………………….. ……………………… 5 H. Ref erences ………………………….. ………………………….. ………………………….. …………… 6 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectSmoking & Tobacco Cessation Smo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 B. BackgroundReimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are not a g uarantee of payment. Reimb ursement for claims may b e subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their o ffice staff are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a code in this p o licy does not imply any right to reimbursement o r guarant ee claims p ayment. The use o f tobacco p roducts generally leads to tobacco/nicotine dependence 3 and often results in serio us health problems. Quitting smoking greatly reduces the risk of d eveloping smoking-related d iseases . To bacco/nicotine dependence is a condition that often req uires repeated treatments, as nico tine is strongly addictive. Because of this, quitting smoking and end ing the use of tobacco use may b e a d ifficult process req uiring several, staged attempts, and may involve stress, irritability, and o ther withd rawal symptoms for those addicted to nicotine 8, 9, 10. Ho wever, continued tobacco use in any form is far more harmful. To bacco smoke contains serio usly harmful chemicals and carcinogens 5, 8, 11 and lead s to lung and o ther cancers, chro nic lung d isease, heart disease, strokes, vascular disease, and infertility. Additionally, smokeless to b acco is d irectly linked to cancers of the mouth, tongue, cheek, gum, esophagus, and p ancreas. Co unseling and m edication are b oth effective means for end ing d ependency on tobacco p ro d ucts, and are even more effective together than either method alone 10. Co unseling can be ef f ective when delivered via individual, group, or telephone counseling, o ne-on-one brief help sessions with a p rovider, behavioral therapies, or even through mobile p hone ap ps. Med ications which have b een found to be effective include prescription non-nicotine medications such as b upropion SR (Zyban ) and varenicline tartrate (Chantix ), and nicotine replacement p ro d ucts such as nicotine patches, inhalers or nasal sprays available by prescription, and over – the-co unter nicotine patches, g ums o r lozenges 10, 17. The United States government recognizes the health dangers and risks associated with the use o f tobacco in its citizens and has set up a f ree telephone support service to help people stop smo king and stop the use of tobacco, 1-800-QUIT-NOW. Callers are ro uted thro ugh this service to their state s specific resource, and may be ab le to o btain free support, advice, and counseling f ro m experienced quit-line coaches, a personalized plan to quit, practical information on how to q uit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking med ications, free o r discounted medications (available for at least some callers in most states), ref errals to other resources, and /or mailed self-help materia ls. CareSo urce encourages all of its members to refrain from the use of tobacco, and if using it in any f o rm, to make concerted and ongoing attempts to q uit its use as soon as p ossible. 3 C. Def initionsSmo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 Tobacco products means any p roduct containing tobacco o r nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, ho okahs, kreteks, e-cigarettes, vaporized and o ther inhaled tobacco and nicotine products, smokeless tobacco (e.g., d ip, chew, snuff, snus), d issolvable tobacco (e.g., strips, sticks, orbs, lozenges), or o ther ing estible tobacco p ro d ucts, and /or chewing tobacco D. PolicyI. Prio r autho rizations are req uired for participating (contracted) p roviders o nly when the services they are p roviding for tobacco cessation exceed the limits of this policy. II. No n-p articipating p roviders (no t contracted with CareSource) should contact CareSource for p rio r autho rization for these services. III. CareSo urce will reimburse its participating providers for the following tobacco use interventio n and cessation care methods: A. An enco unter for evaluation and management of the member on the same day as co unseling to prevent or cease tobacco use; and , B. Screening s for tobacco use as needed for members 20 and younger; C. One screening for tobacco use per calendar year for members 21 and older; and, D. Three ind ividual tobacco cessation counseling attempts p er calendar year. 1. Each attempt will no t exceed 12 weeks of treatment. 2. Face to face counseling sessions are req uired every 30 days during each 12 week treatment p eriod. E. Nico tine rep lacement or no n-nicotine medications p rescribed and appro ved for use for to b acco cessation. IV . CareSo urce will no t reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year, unless p rior authorization has been obtained by the p ro vider. V. The numb er of CPT, HCPCs, and d iagnosis codes (ICD-10) p otentially associated with the d iag no sis and treatment of tobacco use and addiction is too g reat to list. As such, the sp ecific tobacco cessation codes pro vided b elow are eligible to b e reimbursed with any ap p ro priate, associated code. VI. Evaluation and Management service for the member which is p rovided on the same day as co unseling to prevent or cease tobacco use, should b e rep orted with modifier 25 to indicate that the E&M service is separately identifiable from the counseling. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropr iate modifiers. Please refer to the Ohio Medicaid fee schedule. 4 Smo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Reimb ursement is dependent o n, b ut not limited t o, submitting Ohio Medicaid approved HCPCSand CPT co d es along with appropriate modifiers, if ap plicable. Please ref er to the individual Ohio Med icaid fee schedule for appro priate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description99406 Smo king and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smo king and tobacco use cessation counseling visit; intensive, greater than 10 minutes S9453 Smo king Cessation classes, non-physician p rovider, per session F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 09/20/2017 New Po licyDate Revised 08/19/2019 Annual Revision Date Effective 01/01/2020 Date Archived 11/30/2021 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal d ocumented Policy. H. Ref erencesA. Physician Services Manual, 903.19, “To bacco cessation services for Medicaid eligible memb ers.” Ib id. Appendix D, “Health check and adult p reventive visit. (2017, July 1). B. CDC – Fact Sheet – Quitting Smoking – Smoking & To bacco Use. (n.d.). C. Co unseling to Prevent To bacco Use. (Transmittal 2058, 2010, September 30). Centers for Med icare & Medicaid Services, Department of Health & Human Services. D. Treating To b acco Use and Dependence. Clinical Prac tice Guideline. (n.d .). Fiore, Michael C (p anel chair), Guid eline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI) E. U.S. Dep artment of Health and Human Services. The Health Co nsequences of Smoking 50 Years o f Progress: A Rep ort of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Co ntrol and Prevention, National Center for C hro nic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. F. Natio nal Institute o n Drug Abuse. Research Rep ort Series: Is Nicotine Addictive? Bethesda (MD): Natio nal Institutes of Health, National Institute on Drug Abuse, 2012. G. American Society of Addiction Medicine. Public Policy Statement on Nicotine Addiction and To b acco. Chevy Chase (MD): American Society of Addiction Medicine, 2008. 5 Smo kin g & To bacco Cessatio nOHIO MEDICAID PY-0256 Effective Date: 1/1/2020 H. U.S. Dep artment of Health and Human Services. How To bacco Smoke Causes Disease: The . Bio logy a nd Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General.Atlanta: U.S. Department of Health and Human Services, Centers for Disease Co ntrol andPrevention, National Center for Chronic Disease Prevention and Health Promotion,Of fice on Smoking and Health, 2010I. U.S. Dep artment of Health and Human Services. Reducing To bacco Use: A Rep ort of the Surg eo n General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Co ntro l and Prevention, National Center f or Chronic Disease Prevention and Healt h Promotion, Of f ice on Smoking and Health, 2000. J. Fio re MC, Jan CR, Baker TB, et al. Treating To bacco Use and Dependence: 2008 Update Clinical Practice Guidelines. Rockville (MD): U.S. Department of Health and Human Services, Pub lic Health Service, Agency for Healthcare Research and Quality, 2008. K. Natio nal To xicology Program. Report on Carcinogens, Thirteenth Edition. Research Triang le Park (NC): U.S. Dep artment of Health and Human Sciences, National Institute of Environmental Health Science s, National Toxicology Program, 2014. L. U.S. Dep artment of Health and Human Services. The Health Co nsequences of Smoking: A Rep o rt of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers f o r Disease Co ntrol and Prevention, Nati onal Center for Chro nic Disease Prevention and Health Pro motion, Office on Smoking and Health, 2004. M. U.S. Dep artment of Health and Human Services. The Health Benefits of Smoking Cessation: A Rep o rt of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers f o r Disease Co ntrol and Prevention, Center for Chro nic Disease Prevention and Health Pro mo tion, Office on Smoking and Health, 1990. N. Centers f o r Disease Co ntrol and Prevention. Quitting Smoking Among Adults United States, 2000 2015. Mo rb idity and Mortality Weekly Report 2017:65(52):1457-64. O. Centers f o r Disease Control and Prevention. Youth Risk Behavior Surveillance United States, 2015. Mo rb idity and Mortality Weekly Report [serial online] 2016:66 (SS 6):1 174. P. Centers f o r Disease Co ntrol and Prevention. The Guid e to Community Preventive Services: Red ucing To bacco Use and Secondhand Smoke Exposure. Q. U.S. Fo od and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation. FDA Co nsumer, 2006. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Thyroid Testing PY-0222 01/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 4 Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 01/01/2020 2 A. Subject Thyroid Testing B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. Definitions Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness. Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. Policy I. CareSource does not require a prior authorization for thyroid testing. II. Thyroid function tests are used to test for thyroid function and disease. Thyroid testing may be reasonable and necessary to: A. Distinguish between primary and secondary hypothyroidism B. Confirm or rule out primary hypothyroidism C. Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer) D. Monitor drug therapy in patients with primary hypothyroidism E. Confirm or rule out primary hyperthyroidism F. Monitor therapy in patients with hyperthyroidism III. Thyroid testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyperthyroidism or hypothyroidism are noted. A. When these tests are billed at a greater frequency than the norm (two per year), the ordering physicians documentation must support the medical necessity of this frequency must be made available upon CareSources request. IV. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 01/01/2020 3 V. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS codes and the appropriate modifiers, if applicable. The appropriate ICD-10 diagnosis code must match the correct CPT and/or HCPCS code within this policy. Please refer to the Ohio Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 84436 Thyroxine; total 84439 Thyroxine; free 84443 Thyroid stimulating hormone (TSH) 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 01/01/2020 Date Revised 08/21/2019 Revision (updated diagnosis code list) Date Effective 01/01/2020 Date Archived ICD 10 Codes A18 D3A E06 E24 E43 E88 F32 G47 R06 C56 D44 E07 E25 E44 E89 F33 I48 R61 C73 D49 E08 E27 E45 F03 F34 N91 Z00 C79 D89 E09 E28 E46 F05 F39 N92 Z01 C7A E00 E10 E29 E66 F06 F41 N94 Z86 C7B E01 E11 E31 E67 F07 F53 N97 D09 E02 E13 E35 E78 F22 F63 O90 D27 E03 E20 E40 E79 F23 G25 O92 D34 E04 E22 E41 E83 F30 G30 O99 D35 E05 E23 E42 E87 F31 G31 R00 Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 01/01/2020 4 H. References 1. National Coverage Determination (NCD) for Thyroid Testing (190.22). Retrieved July 26, 2019, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved July 26, 2019, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Preventive Services and Sick Visit on Same Date of Service PY-0007 09/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 2 A. Subject Preventive Services and Sick Visit on Same Date of Service B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the respons ibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSourc e will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventi ve Services Task Force (USPSTF) . Applicable clinical criteria fo r the following breast cancer screening health services are described in the corresponding medical policy entitled Mammography services C. Definitions Preventive Services : are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional scr eenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for children under the age of 18 D. Policy I. Pediatric and Adolescent Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acu te care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. i. Preventive Health Service Codes 1. 99381-99384 2. 99391-9939 4 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 II. Adult Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the Preventive Service code at 100%. The A cute Care Visit Service codes will not be reimbursed unless billed with the appropriate modifier to Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 09/01/2019 3 identify separately identifiable services that were rendered by the same physician on the same date of service. i. Preventive Health Service Codes 1. 99385-99387 2. 99395-99397 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received . If documentatio n is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: a. Key elements that support the additional preventive health service s that were rendered b. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. c. The provider should clearly list in the assessment portion of the documentation the acute/chronic condi tions that are being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., A thorough MS and neur o exam of the left hip performed as it relates to the HPI). E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 11/17/2014 Date Revised 11/17/2015 Revision includes payment policy legal language 8/6/2019 Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Date Effective 9/1/2019 Date Archived H. References 1. Successfully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center, 20 Feb. 2013, www.aapc.com/blog/22580-successfully-bill-a – preventive-service-with-a – sick-visit/. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Da te Non-Invasive Vas c u lar Studies PY-0163 12/01/2019-0 3/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….5 G. Review/Revision History ………………………………………………………………………………………..5 H. Ref er en ce s …………………………………………………………………………………………………………5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tNon-invasive Vascular Stud ie s No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019 B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p roc essing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. No n-inv as ive v ascular s tudies utilize ultras ound to asses s irregularities in b lood flow in arterial and v eno us sy stems. Tes ting c an be p erformed in a v asc ular lab oratory , and is often the first s tep in d iagnosing vas cular disease. Res ults may display as a two dimens ional image with a s p ec tral analysis and color flow. The res ults o f these test will determine the need for more non-invasive testing or p rocedures to treat v as cular disease. CareSo urce will reimburs e providers, for no n-inv as ive v ascular s tudies to members as s et forth in this p olicy .C. Def initions Duplex scan a no n-inv as ive ev aluation of b lood flow through the arteries and v eins, by c o mb ining the use of Doppler ultrasound with t wo-dimensional struc ture and motion wit h t ime and s p ec trum analysis and /or c olor flow velocity or mapping. Non-invasive testi ng-utilizes various types of technology to evaluate f low, p erfusion, and p res s ures within the v essels at res t and with exerc is e. D. Policy I. CareSo urc e does not req uire a prior authorization for a no n-inv asive v as cular study. II. Altho ugh CareSource does not require a p rior authorization for non-inv asive vasc ular s t ud i es , CareSo urc e may request doc umentation to s upport medical nec essity as d efined in Ohio Ad ministration Co de (OAC) Rule 5160-1 Med ical Neces sity. Note: Th e us e of any Doppler d evice that produces a rec ord, but does not permit analysis of b id irec tional vas cular flow o r that d oes not prov ide a hard c opy or p rintout: is part of the physical exam of the vas cular sys tem and is not reported s ep arately. III. No n-Invasive vas cular s tudies m ust be p ers onally performed by a phy sician or technologist. A. Th e p hy s ician performing and/or interpreting the study mus t be c apable of demonstrating d o c umented training and experience and maintain any applicable documentation upon CareSo urc es request.B. Th e Tec hnic ian p erforming the study mus t be c apable of demonstrating documented training and experience and maintain any documentation upon CareSourc e request. 3 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019IV. All no n-inv asive v ascular diagnostic studies m ust be performed under at least one of the f o llowing settings: A. Perf o rmed by a physician who is c ompetent in diagnostic v ascular s tudies or und er the g eneral s up erv is ion of p hysicians who have d emonstrated minimum entry lev el c o mp etency b y being c redentialed in v ascular technology B. Perf o rmed by a tec hnician who is certified in v ascular technology C. Perf o rmed in f acilities wit h laboratories accredited in v as c ular tec hnology V. No n-inv as ive v as cular s tudy inc ludes: A. Pro v iding p atient c are during the s tudyB. Sup erv is ion of the procedure C. Interp retatio n of s tudy results wit h hard c opy output or d igital s torage of imaging is ac c ep table. Note: Altho ugh CareSourc e does not require a p rior authorization for no n-invasive v as c ular s tudies, CareSourc e may req uest documentation to support medical nec es s ity, including the non-invas iv e vas cular s tudy hard c opy or d igital c opy res ults . VI. Dup lex s canning and phys iologic s tudies may b e reimburs ed during the same encounter if the p hy s iologic studies are ab normal and/or to evaluate v asc ular trauma, thromboembolic ev ents or aneury smal disease, if the phys ic ian/provider c an document medical neces si ty in the p atients medical rec ord.E. Conditions of Cov erage Reimb urs ement is dependent o n, b ut not limited to, s ubmitting Ohio Medicaid approved CPT and /o r HCPCS codes and the appropriate modifiers , if applicable. The ap p ro priate ICD-10 diagnosis code m ust m atc h the c orrect CPT and /or HCPCS code within this policy Please refer to the Ohio Med icaid fee sc hedule for appro priate c odes . The following l i st(s) of codes is provided as a reference. This list may not be all-inclusive and is subject to updates. CPT Code Description 93880 Dup lex s can of ex trac ranial arteries ; c omplete b ilateral s tudy 93882 Dup lex s can of extrac ranial arteries; unilateral or limited s tudy 93886 Trans c ranial Do ppler s tudy of the intrac ranial arteries; complete s t ud y 93888 Trans c ranial Do p pler s tudy of the intracranial arteries ; limited s tudy 93890 Trans c ranial Do ppler s tudy of the intrac ranial arteries; v asoreactiv ity s tudy 93892 Trans c ranial Do ppler s tudy of the intracranial arteries ; emboli detection witho ut intrav enous mic robubble injection 93893 Trans c ranial Do ppler s tudy of the intracranial arteries ; emboli detection with intrav eno us microbubble injection 93922 Limited bilateral noninvasive phys iologic s tudies of upper or lower ex tremity arteries , (eg , for lower ex tremity : ank le/brachial indices at d is tal posterior tib ial and anterior tibial/dors alis pedis arteries p lus bidirec tional, Doppler wav ef o rm rec ording and analys is at 1-2 lev els , or ank le/brac hial indices at d is tal p osterior tibial and anterior tibial/dors alis p edis arteries plus v olume p lethy s mography at 1-2 lev els, or ank le/brachial indices at distal posterior tib ial and anterior tibial/dors alis p ed i s arteries wit h, trans cutaneous oxygen tens io n measurement at 1-2 lev els) 93923 Co mp lete b ilateral noninvasive p hysiologic studies of upper or lo wer ex tremity arteries, 3 or more levels (eg, for lower ext remit y: ank le/brachial ind ic es at d ist al p osterior tibial and anterior tib ial/dorsa l is pedis arteries 4 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019p lus s eg mental b lood p ressure measurements with b idirectional Doppler wav ef o rm rec ording and analys is , at 3 o r more lev els, or ank le/brac hial ind ic es at distal p osterior tibial and anterior tibial/dors alis pedis arteries p lus s eg mental v olume plethy smography at 3 o r more lev els, o r ank le/b rac hial indices at d istal pos terior tibial and anterior tibial/dors alis p ed is arteries plus s egmental transcutaneous oxygen tension meas urements at 3 or more levels), or single level study wit h provocativ e f unc tional maneuvers (eg, meas urements wi th postural p ro vocative t est s, o r meas urements with reac tive hy peremia)93924 No ninv as ive p hy siologic s tudies of lo wer extremity arteries, at res t and f o llowing treadmill s tress testing, (ie, bidirectional Doppler wav eform or v o lume p lethysmography rec ording and analysis at res t with ank le/brachial ind ic es immediately after and at t imed interv als following performanc e of a s tand ard ized protocol on a motorized treadmill p lus rec ording of time of o ns et of c laudication or other s ymptoms , maximal walking t i me, and ti m e to rec o v ery ) c omplete b ilateral study93925 Dup lex sc an of lower ex tremity arteries or arterial b ypass grafts ; c omplete b ilateral s tudy 93926 Dup lex sc an of lower ex tremity arteries or arterial b ypass grafts ; unilateral o r limited study 93930 Dup lex sc an of upper ex tremity arteries or arterial bypass grafts; complete b ilateral s tudy 93931 Dup lex sc an of upper ex tremity arteries or arterial bypass grafts ; unilateral o r limited study 93970 Dup lex sc an of extremity v eins including responses to compression and o ther maneuv ers ; c omplete b ilateral study 93971 Dup lex sc an of extremity v eins including responses to compression and o ther maneuv ers ; unilateral o r limited study 93975 Dup lex sc an of arterial inflow and v enous outflow of abdominal, pelvic, s c ro tal contents and/or retro peritoneal organs; complete s tudy 93976 Dup lex sc an of arterial inflow and v enous outflow of abdominal, pelvic, s c ro tal contents and/or retro peritoneal organs; limited s tudy 93978 Dup lex sc an of aorta, inferior vena cav a, iliac vas culature, or bypass grafts; c o mp lete study 93979 Dup lex sc an of aorta, inferior vena cav a, iliac vas culature, or bypass grafts; unilateral o r limited s tudy 93980 Dup lex sc an of arterial inflow and v enous outflow of penile ves sels ; c o mp lete study 93981 Dup lex sc an of arterial inflow and venous outflow of penile vess els ; follow – up o r limited s tudy 93990 Dup lex sc an of hemodialysis ac cess (inc luding arterial inflow, body of ac c es s and v enous outflow) 93998 Unlis ted no ninvasive v ascular d iagnos tic s tudy I CD 10 CodesA48 G97 I79-I83 N18 R42 S65 Z95 5 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019D 57 H34-H35 I85-I87 N28 R47 S75 Z98-Z99 D 68 H47 I96-I97 N50-N52 R55 S85 D 75 H53 J 96 O22 R60 S95 E 08-E11 H81 K55 O8 6-O87 S06 T3 8 E13 H93 K 74-K76 Q2 7-Q28 S09 T4 5 F52 I10 L53-L54 R04 S15 T7 9-T8 2 G04 I12-I13 L76 R06-R07 S25 T8 7 G4 5-G46 I16 L97 R09-R10 S35 Z01 G54 I25-I27 M30-M31 R22 S38 Z09 G8 1-G83 I60-I63 M79 R26-R27 S45 Z48 G93 I65-I77 M96 R29 S55 Z86 F. Related Polic ies/RulesN/A G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 03/08/2017 Date Revised 08/07/2019 Up d ated c odes and reimb ursement c rit e ria Date Effecti ve 12/01/2019 Date Archived 03/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed . Please no te that there c ould be o ther Po lic ies that may hav e s ome of the s ame rules inc o rp orated and Care Source res erves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Polic y H. Ref erenc es1. Leers , S. A. (2019, Ju ly 3). Duplex Ultrasound. Retrieved from https://v ascular.org/patient-res o urc es/vascular-tests/duplex-ultrasound 2. Lawriter-OAC-5160-1- 01 Med ic aid m ed i c al nec essity : definitions and principles.(2015, Marc h 22). Retriev ed from http://c odes.ohio.gov/oac /5160-1-01 6 No n-i nv as ive Vas c ul ar Stud i es OHIO MEDICAID PY-0163 Effec ti v e Date: 12/01/2019 3. No n-inv as ive Tes ting for Vascular Diseas e. (2019, January 7). Retrieved from http s://my.clevelandclinic.org/health/diagnostics/17545-vascular-disease-no n-invas ive-t es ti ng4. Ohio Med icaid Non-Ins titutional Fee Schedule. (2019, January 1). Retrieved from https://www.medicaid.ohio.gov/Portals /0/Providers/FeeSc heduleRates/App-DD. p dfThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Preventive Services and Sick Visit on Same Date of Service PY-0007 09/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 0 9 / 0 1 / 2 0 1 9 2 A. Subject Preventive Services and Sick Visit on Same Date of Service B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care pr oviders and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventi ve Services Task Force (USPSTF) . Applicable clinical criteria for the following breast cancer screening health services are described in the corresponding medical policy entitled Mammography services C. Definitions Preventive Services : are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing , vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are espe cially important for children under the age of 18 D. Policy I. Pediatric and Adolescent Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. i. Preventive Health Service Codes 1. 99381-99384 2. 99391-9939 4 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 II. Adult Preventive Health Services that are billed on the same date of service as an Acute Care Visit: a. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the Acute Care Visit code at 100%. The Preventive Service codes will not be reimbursed unless billed with the appropriate modifier to identify Archived Preventive Services and Sick Visit on Same Date of Service OHIO MEDICAID PY-0007 Effective Date: 0 9 / 0 1 / 2 0 1 9 3 separately identifiable services that were rendered by the same physician on the same date of service. i. Preventive Health Service Codes 1. 99385-99387 2. 99395-99397 ii. Acute Care Visit Codes 1. 99201-99205 2. 99212-99215 III. CareSource reserves the right to request documentation to support billing both services for all claims received . If documentatio n is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: a. Key elements that support the additional preventive health service s that were rendered b. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. c. The provider should clearly list in the assessment portion of the documentation the acute/chronic condi tions that are being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., A thorough MS and neur o exam of the left hip performed as it relates to the HPI). E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 11/17/2014 Date Revised 11/17/2015 Revision includes payment policy legal language 8/6/2019 Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Date Effective 9 /1/2019 Date Archived H. References 1. Successfully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center, 20 Feb. 2013, www.aapc.com/blog/22580-successfully-bill-a – preventive-service-with-a – sick-visit/. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Da te Vaccinations an d Immunizations PY-0040 10/01/2019-0 3/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….5 G. Review/Revision History ………………………………………………………………………………………..5 H. Ref er en ce s …………………………………………………………………………………………………………5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable r e f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tVaccinations and I mmun iza tio ns Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/2019B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. CareSo urc e c overs and reimburs es for immunizations/vacc ines b ased on the recommendations f ro m the Centers for Dis ease Control and Prevention (CD C) and the Advisory Committee o n Immunizatio n Prac tices (ACIP). Th e Vac c ines for Children (V FC) p rogram is a federally funded program that provides v accines at no c o s t to c hildren who might not otherwise be v accinated b ecause of inability to pay . The Centers f o r Diseas e Co ntrol and Prev ention (CDC) p urchas es v ac cines at a d is count and d is tributes them to s tate health d epartments whic h in turn distribute them at no charge to those p riv ate p hy sicians offic es and public health clinics reg istered as VFC p roviders. The Vac c ines for Children (VFC) p rogram helps pro vide v acc ines to c hildren whose p arents o r g uard ians may not be ab le to afford them. The VFC p rogram helps ens ure that c hildren hav e a b etter c hanc e of getting their rec ommended v ac cinations on s chedule. Vacc ines available thro ug h the VF Cpro gram are those rec ommended by the A dvisory Committee on Immunization Prac t ic es (A CIP ).C. Def initions Immunization-is an ino c ulation ag ainst a v accine preventable disease. Vaccination-the ac t of introducing a vacc ine into the body to produce immunity to a spec if ic d is ease. Vaccine-a p ro d uct that s timulates a pers ons immune sy stem to produce immunity to a specific disease, p rotecting the p er s o n from that disease. Vacc ines are usually ad ministered thro ug h need le injec tions, b ut c an also b e administered by mouth or s prayed into the nose. Vaccines for Children Program (VF C) – the program for distribution of pediatric v accines ad minis tered by the Department for Public Health. D. Polic yI. Vac c inations and Immunizations f or CareSourc e members 18 y ears old or younger: A. CareSo urc e d oes not differentiate between providers that participate or do not participate in the Vac c ines for Children program. 1. All claims for v accines administered to children 18 years of ag e or younger wi ll be reimb urs ed for the ad ministration only. 3 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/20192. All c laims must b e submitted with appropriate CPT and ICD-10 code to ens ure that the p ro v ider is properly reimb ursed f or the administration o nly of the correc t v accine. II. Vac c inations and Immunizations for CareSourc e members 19 years old or older: A. CareSo urc e may reimb urse f or v acc inations that are administered in accordanc e wi th the CD Cad ult v ac cination/immunization s chedule: 1. All c laims must b e submitted with the appropriate CPT and ICD-10 c ode to ens ure that the p ro vider is properly reimbursed for the administration and the toxoid that w as ad ministered. 2. CareSo urc e d oes not cover v accines or immunizations for travel outside of the United States . III. Hep atitis A vaccine: A. CareSo urc e members who may be at high risk f or Hep ati ti s A infec tion are eligible to rec eiv e the Hep atitis A v accine regard les s of age. 1. Pro v ider may s ubmit cl a im s f or Hepatitis A tox oid and v accination administration i. Fo r c hild ren ages b irt h thro ugh 18: procedure c odes 90633 and 90634. ii. Fo r ad ults age 19 and older: proc edure codes 90632 and 90636. E. Conditions of Cov erageReimb urs ement is dependent o n, b ut not limited to, s ubmitting Ohio Medicaid approved HCPCS and CP Tcodes along with ap propriate modifiers, if applicable. Pleas e refer to the individual Ohio Med ic aid fee s chedule for ap propriate c odes. The following l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description90460 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, with c ounseling b y phy sician o r other qualified health care p ro f es sional; f irs t or o n ly c omponent of each v accine or toxoid administered 90461 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, wit h counseling by p hysician or o ther qualified health care p ro f es sional; eac h ad ditional v acc ine o r toxoid component adminis tered (Lis t s ep arately in addition to code for p rimary p rocedure) 90471 Immunizatio n ad ministration (inc ludes perc utaneous, intradermal, s ub c utaneous, o r intramusc ular injec tions); 1 v accine (s ingle o r c o mb ination v acc ine/toxoid) 90472 Immunizatio n ad ministration (includes p erc utaneous, intrad ermal, s ub c utaneous, or intramusc ular injec tions ); eac h additional vacc ine (s ingle or c o mbination vacc ine/toxoid) (Lis t separately in addition to c ode for p rimary p rocedure) 90473 Immunizatio n adminis tration by intranasal or oral r o ut e ; 1 v accine (single or c o mb ination v acc ine/toxoid) 90474 Immunizatio n ad ministration by intranasal or o ral route; eac h additional vaccine (s ingle or c ombination v accine/toxoid) (List s eparately in addition to c o d e for p rimary p rocedure) 90620 Mening o cocc al rec o mbinant p rotein and outer membrane vesicle v acc ine, s ero g roup B (MenB-4C), 2 d ose s chedule, for intramus cular use 90621 Mening o cocc al rec o mbinant lipoprotein vacc ine, s erogroup B (MenB – FHb p ), 2 o r 3 d ose s chedule, for intramus cular use 90633 Hep atitis A vac cine (HepA), pediatric/adolesc ent dosage-2 dose s chedule, f o r intramuscular us e 90634 Hep atitis A vac cine (HepA), pediatric/adolesc ent dosage-3 dose s chedule, f o r intramuscular us e 4 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/201990636 Hep atitis A and hepatitis Bv accine (HepA-HepB), adult dosage, for intramus c ular us e 90644 Mening o cocc al c onjugate v ac cine, s ero groups C & Yand Haemophilus inf luenzae ty pe b vacc ine (Hib-MenCY), 4 d ose s chedule, when ad minis tered to c hildren 6 week s-18 months of age, for intramuscular use 90647 Haemo p hilus influenzae t ype b vac cine (Hib), PRP-O MP conjugate, 3 dose s c hed ule, for intramuscular us e 90648 Haemo p hilus influenzae t ype b vacc ine (Hib), PRP-T c onjugate, 4 dose s c hed ule, for intramuscular us e 90649 Human Pap illomavirus vacc ine, types 6, 11, 16, 18, quadrivalent (4v HPV), 3 d o s e s c hedule, for intramuscular us e 90650 Human Pap illomavirus vacc ine, types 16, 18, bivalent (2vHP V), 3 dose s c hed ule, for intramuscular us e 90651 Human Pap illomav irus vacc ine types 6, 11, 16, 18, 31, 33, 45, 52, 58, no nav alent (9v HPV), 2 o r 3 d ose s chedule, for intramuscular us e 90653 Inf luenza v ac c ine, inac tivated (IIV ), s ubunit, adjuvanted, f or intramus cular us e 90655 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, preserv ative free, 0.25 mL d o s age, for intramuscular us e 90656 Inf luenza v irus v accine, trivalent (IIV 3), split v irus , p reservative free, 0.5 mL d o s age, for intramuscular us e 90657 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.25 mL dosage, f or intramus c ular us e 90658 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.5 mL dosage, for intramus c ular us e 90660 Inf luenza v irus vaccine, triv alent, live (LA IV 3), for intranas al us e 90662 Inf luenza v irus v acc ine (IIV ), split virus, preserv ative free, enhanc ed immuno genicity via increas ed antigen c ontent, for intramuscular use 90664 Inf luenza v irus v accine, live (LA IV ), pandemic formulation, for intranasal us e 90666 Inf luenza v irus v accine (IIV ), p andemic formulation, s p li t virus, preservative f ree, f or intramusc ular us e 90667 Inf luenza v irus v accine (IIV ), p andemic formulation, s p li t virus, adjuv anted, f o r intramuscular us e 90668 Inf luenza v irus v accine (IIV ), pandemic formulation, sp l it virus, for intramus c ular us e 90670 Pneumo c occal c onjugate v accine, 13 v alent (P CV13), for intramusc ular us e 90672 Inf luenza v irus v ac c ine, q uadrivalent, live (LA IV 4), for intranas al use 90673 Inf luenza v irus v accine, trivalent (RIV 3), d erived f rom recombinant DNA, hemag g lutinin (HA) pro tein only, preserv ative and antibiotic free, for intramus c ular us e 90674 Inf luenza v irus v ac c ine, q uadrivalent (c c IIV 4), d erived f rom c ell c ultures, s ub unit, preserv ative and antibiotic free, 0.5 mL dosage, for intramuscular us e 90680 Ro tav irus vacc ine, p entavalent (RV 5), 3 d os e s chedule, live, f or o ral us e 90681 Ro tav irus vac cine, human, attenuated (RV 1), 2 d ose schedule, live, for oral us e 90685 Inf luenza v irus v ac c ine, quadriv alent (IIV 4), split virus, p reserv ative free, 0.25 mL, f or intramuscular us e 90686 Inf luenza v irus v accine, quadrivalent (IIV 4), sp l it virus , preserv ative free, 0.5 mL d o s age, for intramuscular us e 90688 Inf luenza v irus v accine, q uadriv alent (IIV 4), split v irus, 0.5 mL dos age, f or intramus c ular us e 5 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/201990696 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine and inac tivated p o liov irus vac cine (D Ta P-IP V), when administered to c hildren 4 through 6 y ears o f ag e, for intramus cular use 90698 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine, Haemophil us inf luenzae ty pe b, and inactivated poliovirus v accine, (D Ta P-IP V/Hi b), for intramus cular us e 90700 Dip htheria, tetanus toxoids, and acellular p ertuss is vaccine (D TaP ), when ad minis tered to ind iv iduals y ounger than 7 y ears, for intramuscular us e 90702 Dip htheria and tetanus toxoids adsorbed (DT) when ad ministered to ind iv iduals y ounger than 7 y ears, for intramuscular us e 90707 Meas les , mumps and rubella virus v accine (MMR), l iv e, for subcutaneous us e 90710 Meas les , mumps, rubella, and varicella vacc ine (MMRV ), live, for s ub c utaneous us e 90713 Po lio virus v acc ine, inac tivated (IP V ), for s ub cutaneous or intramuscular use 90714 Tetanus and d iphtheria toxoids adsorbed (Td ), pres ervativ e free, when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cular us e 90715 Tetanus , d iphtheria toxoids and ac ellular pertussis vac cine (Td ap), when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cul ar u s e 90716 Varicella v irus vac cine (V AR), live, f or s ubcutaneous us e 90723 Dip htheria, tetanus toxoids, acellular pertussis v accine, hepatitis B, and inac tiv ated poliovirus v accine (D TaP-Hep B-IPV), for intramusc ular us e 90732 Pneumo c occal polys accharide v accine, 23-v alent (PPSV23), adult o r immuno s uppressed p atient dosage, when administered to individuals 2 y ears o r o lder, for s ubcutaneous o r intramusc ular us e 90733 Mening o cocc al polys accharide vacc ine, serogroups A, C, Y, W-135, q uad riv alent (MPSV4), for s ubc utaneous us e 90734 Mening o cocc al c onjugate vacc ine, serogroups A, C, Yand W-135, q uad riv alent (MCV4 o r MenACWY), for intramusc ular us e 90743 Hep atitis Bv acc ine, ad oles cent (2 dose s c hedule) f or intramuscular u s e; 90744 Hep atitis Bvac cine (HepB), pediatric/adolesc ent dosage, 3 d ose schedule, f o r intramuscular us e 90756 Inf luenza v irus v ac cine, quadrivalent (c cIIV 4), d erived fro m cell c ultures , s ub unit, antibiotic free, 0.5mL d osage, for intramus cular use F. Related Polic ies/Rules G. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 12/01/2013Date Revised 06/12/2019 Up d ated policy to align wit h CDC and VFC program 01/18/2020 Rev is io n remov ed lang uage to allow for toxoidreimb urs ement and p rovided additional c larification f o r Hep atitis A vacc ine ad ministration and reimb urs ementDate Effecti ve 10/01/2019 Date Archived 03/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . 6 Vaccinations an d Immun i zati o ns OHIO MEDICAID PY-0040 Effec ti v e Date: 10/01/2019H. Ref erenc es 1. Ad ult Immunization Schedule by Va c c i ne and Age Group | CD C. (2019, February 5). Retriev ed May 13, 2019, from https : // www.cdc.go v 2. Birt h-18 Years Immunization Schedule | CDC. (2019, February 5). Retrieved May 13, 2019, f ro m https :/ /www. cdc.go v3. FOR OHIOA NS . (2019, May 13). Retrieved May 13, 2019, f rom https://medicaid.ohio.gov 4. Free Vac c ines. (2014, No vember). Retrieved May 15, 2019 f rom https ://odh.ohio.gov 5. Lis t of CP Tand HCPCS codes c overed for Enhanc ed Ambulatory Patient Groups (E AP G)] . (2019, Feb ruary 1). Retriev ed May 15, 2019 from https://medicaid.ohio.gov 6. Med ic aid A dvisory Letter (MA L) No. 632. (2019, May 14). Retrieved May 15, 2019, from http s://medicaid.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Substance Use Disorder Residential PY-0137 7/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 2 A. Subject Substance Use Disorder Residential B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Substance Use Disorder (SUD) services are provided on a continuum of care where the level of care varies dependent on the type and intensity of service provided. This policy address the Residential level of care. This type of care provides an intensive residential program for members with SUD. It is considered transitional with the goal of returning the member to the community with a less restrictive level of care. C. Definitions Residential level of care for substance use disorder-According to the Ohio Administrative Code, residential services provide addiction treatment and mental health (MH) services; and is staffed 24 hours a day. This includes withdrawal management. Treatment services include assessments, diagnostic evaluations, crisis intervention, psychotherapy, counseling, case management, peer recovery services, urine drug screens, medication assisted treatment and medical services. A residential program must meet all of the following: o Follow nationally recognized medical standards o Be an Ohio Department of Mental Health and Addiction Services (OMHAS) certified/licensed facility to provide residential SUD treatment o Have an active provider agreement with ODM o All practitioners of the SUD treatment service must meet applicable state requirements o Establish individualized treatment plans o Start discharge planning at time of admission o Schedule a follow-up visit within 7 days of discharge for aftercare o Provide Medication Assisted Treatment o Ensure accessibility to medication upon discharge CareSource does NOT consider a residential program appropriate for: o Intensive medical monitoring needed for severe or life threatening medical or physical condition o A member who is unable to actively participate due to Severe symptoms of co-existing mental or physical condition Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 3 Severe withdrawal symptoms D. Policy I. CareSource requires a prior authorization for the following: A. For the first and second admission per calendar year, a prior authorization is only required for an admission exceeding 30 consecutive days. B. For admissions exceeding the two admissions per calendar year, a prior authorization is required from the first day of admission. NOTE: One admission is considered one CPT code. II. Documentation A. At least one documented face-to-face service must be provided by a clinical/treatment team member with the member at the SU residential site in order to bill per diem, except for situations described below in IV. A. B. Members medical record must show evidence of medical necessity of services. C. The residential program has a written Affiliation Agreement so that members are connected/ensured access to outpatient care in timely manner upon discharge. The residential program has policies and procedures in place to monitor its affiliations. III. Medical Necessity Criteria CareSource follows The ASAM Criteria as required by the Ohio Department of Medicaid. IV. Billing A. Residential level of care admission one admission is considered one length of stay 1. Any stay under 30 consecutive days count as a full 30 day occurrence. 2. Service gaps in excess of 24 hours are considered a termination of one admission. 3. Leaving the SUD residential treatment facility associated with significant changes in health status such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in level of care, and/or incarceration are considered a termination of one admission 4. Brief leave of absences (24 hours or less, except in rare instances) when supported by members individualized treatment plan should be documented in the members treatment plan, and the provider should continue to bill for treatment services during these times. a. Brief leave of absences include but are not limited to the following: 01. Family visits, 02. Religious services 03. Same day health services 04. Social support group attendance B. CareSource only processes claims from 1. Provider type of 95 OhioMHAS certified/licensed treatment program AND Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 4 2. Provider specialty 954 OhioMHAS certified/licensed SUD residential facility AND 3. Place of service code 55-Residential Substance Abuse Treatment Facility C. Claims billed out of sequence from date of service may cause claims to deny inappropriately for no prior authorization D. Claims are paid as they are received. If member receives services from more than one provider, claims are paid to providers that submit first regardless of date of service. E. SUD residential is paid per diem. Per Diem does NOT include room and board costs/payments. F. CareSource does not reimburse separately for services provided by the residential treatment service including: 1. Ongoing assessments and diagnostic evaluations. 2. Crisis intervention. 3. Individual, group, family psychotherapy and counseling. 4. Case management. 5. Substance use disorder peer recovery services. 6. Urine drug screens. 7. Medical services. 8. Medication administration G. A member can only receive services through one level of care at a time. 1. CareSource considers the following services non-billable when member is in a. Residential level of care b. Therapeutic behavioral services. c. Psychosocial rehabilitation. d. Community psychiatric supportive treatment. e. Mental health day treatment. f. Assertive community treatment. g. Intensive home based treatment. 2. CareSource does consider services provided to a member from practitioners not affiliated (based on billing group TIN) with the residential treatment program as billable when the service is medically necessary and the treatment is outside of the scope of residential level of care. Examples include medication assisted treatment (MAT) and psychiatry. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description H2034 Clinically Managed Low-Intensity Residential Treatment ASAM 3.1 H2036 Clinically Managed High Intensity Residential Treatment ASAM 3.5 Substance Use Disorder Residential OHIO MEDICAID PY-0137 Effective Date: 7/1/2019 5 Procedure Modifier Description HI Clinically Managed Population-Specific High Intensity Residential Treatment ASAM 3.3 (Adults) May be used with H2036. TG Medically Monitored Intensive Inpatient Treatment (Adults) and Medically Monitored High-Intensity Inpatient Services (Adolescent) ASAM 3.7 May be used with H2036. F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 08/17/2017 Date Revised 5/15/2019 Date Effective 7/1/2019 Updated definition, medical necessary criteria, billing H. References 1. Lawriter-OAC-5160-27-01 Eligible provider for behavioral health services. (n.d.). Retrieved on 5/8/2019 from http://codes.ohio.gov/oac/5160-27-01 2. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved on 5/8/2019 from http://codes.ohio.gov/oac/5160-27-09v1 3. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved on 5/8/2019 from http://codes.ohio.gov/oac/5160-27-09v1 4. Lawriter OAC 5122-29-09 Residential, withdrawal management, and inpatient substance use disorder services. (n.d.) Retrieved on 5/15/2019 from http://codes.ohio.gov/oac/5122-29-09v1 5. Ohio Department of Medicaid. (2019, March 4). Medicaid Behavioral health State Plan Services Provider Requirements and Reimbursement Manual. Retrieved on 5/8/2019 from https://bh.medicaid.ohio.gov/Portals/0/Providers/BH%20Manual%20V%201.6_as%20of%203.4.19.pdf?ver=2019-04-23-140505-050 6. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Billing Guidelines for Determination of Refractive State PY-0808 10 /01/2019-04/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirem ents, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules …………………………………………………………………………………………….. 3 G. Review/Revision History ………………………………………………………………………………………….. 3 H. References ……………………………………………………………………………………………………………. 3 Billing Guidelines for Determination of Refractive State OHIO MEDICAID PY-0 808 Effective Date: 10/01/2019 2 A. Subject Billing Guidance for Determination of Refractive State B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office sta ff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclus ion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Refraction services determines ocular refraction in an eye exam. A phoropter that contains wheels with different lenses having different strengths determ ines which combination provides the sharpest vision. This combination determines the prescription needed for glasses or contacts to correct the error. C. Definitions Comprehensive Eye Exam An evaluation of the visual system including, but not limited to; acuity, prescription for corrective lenses, pupils, side vision, eye movement, eye pressure, front part of eye, retina, and optic nerve. Refractive State Determination-The act or technique of determining ocular refraction and identi fying abnormalities as a basis for the prescription of corrective lenses . D. Policy I. CareSource does not require a prior authorization (PA) for the following eye exams: A. 92002-Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient; B. 92004-Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, comprehensive, new patient, one or more visits; C. 92012-Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, intermediate, established patient D. 92014-Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, one or more visits . I I. Determination of refractive state (92015) performed by an optometrist or ophthalmologist is covered on ce every (12) months. A. Any additional need for determination of refractive state must include documentation for medical necessity along with claim . Note: Although prior authorization is not required for determination of refractive state , CareSource will review documentation to support medical necessity. CareSource may request additional documentation if the information submitted with the claim does not confirm medical necessity. Billing Guidelines for Determination of Refractive State OHIO MEDICAID PY-0 808 Effective Date: 10/01/2019 3 III. CareSource allows separate reimbursement for d etermination of refractive s tate (92015) when included in an eye exam.E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS codes along with appropriate modifiers , if applicable. Please refer to the Ohio Medicaid fee sched ule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be a ll-inclusive and is subject to updates. CPT Code Description 92 002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, intermediate, new patient 92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program, comprehensive, new patient, one or more visits 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, intermediate, established patient 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program, comprehensive, established patient, one or more visits 92015 Determination of refractive state F. Related Policies/RulesN/AG. Review/Revision HistoryDATE ACTIONDate Issued 10 /01/2019 New policyDate Revised Date Effective 10 /01/2019 Date Ar chived 04/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Polic y. H. References1. Eye Exam and Vision Testing Basics. (2019, February 5). Retrieved from https://www.aao.org/eye-health/tips-prevention/eye-exams-101 2. Lawriter-OAC 5160-6 Vision Care Services. (2019, April 19). Retrieved from http://codes.ohio.gov/oac/5160-6 3. Ohio Department of Medicaid Fee Schedules and Rates. (2019, April 22). Retrieved from https://medicaid.ohio.gov/Provider/FeeScheduleandRates/SchedulesandRates#1682654-eye-care-services Billing Guidelines for Determination of Refractive State OHIO MEDICAID PY-0 808 Effective Date: 10/01/2019 4 4. Refraction assessment. (2019, February 21). Retrieved from https://www.mayoclinic.org/tests-procedures/eye-exam/multimedia/refraction-assessment/img-20006171 The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
2 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Date Effective Drug Testing PY-0020 7/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 3 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 6 F. RELATED POLICIES/RULES …………………………………………………………………….. 7 G. REVIEW/REVISION HISTORY …………………………………………………………………… 7 H. REFERENCES ………………………………………………………………………………………… 8 I. APPENDIX A …………………………………………………………………………………………… 9 3 A. SubjectDrug Testing Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual.Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members wit h substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of conce rn.Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualitative and confirmatory/quantitative. Drug testing is sometimes also referred to as toxicology testing.C. Definitions Presumptive/Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing.Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) -This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test-A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Qualified Labor atories: When an out-of-network qualified laboratory provides toxicology test results to the referring health care provider within two business days of receipt of the test specimen, the MCP shall pay that laboratory at least sixty percent of the Medicaid laboratory services fee schedule. For the purposes of this 4 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019requirement, a qualified laboratory is a laboratory that is enrolled with Medicaid as an independent laboratory, and that meets all of the following conditions : 1. Is accredited by the College of American Pathologists; and 2. Is approved by the New York Clinical Laboratory Evaluation Program; and 3. Indicates to the MCP that it is providing services and billing as a qualified laboratory Residential services-Ohio Administrative code defines residential services as These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. 1 NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0054. Please refer to this policy for in-depth information on medical necessity for drug testing, documentation requirements, and CareSource monitoring and review of drug testing claims.D. PolicyI. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. CareSource will require a PA for UDT tests >30 presumptive and/or > 12 confirmatory UDT per member per calendar year 2. PA is required for any non-participating provider with CareSource for non-emergency room setting. 3. PA is required for any non-participating, non-qualified lab/facility with CareSource for non-emergency room setting. 4. PA is required for any non-participating, qualified lab/facility with CareSource for non-emergency room setting. 5. PA is not required in an emergency room setting. UDT utilization will be monitored by CareSourc e. 6. PA needs to make a clear case for medical necessity for the level of testing being requested. 1 http://codes.ohio.gov/oac/5160-27-09v15 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will cover up to 30 presumptive and 12 definitive UDT per member per calendar year. 1. CareSource will cover up to 30 presumptive UDT per member per calendar year. 2. CareSource will cover up to 12 definitive UDT per member per calendar year. B. For presumptive tests, each CPT code is counted as one test. C. For confirmatory tests, all CPT tests performed on the same date of service count as one test. IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource.V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care service for children under age 21. VI. Non-Urine Testing A. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples performed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not coveredVII. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billab le and will not be reimbursed by CareSource. B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following:a. Presump tive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR 6 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member disputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing. (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testi ng that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing required by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Forensic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately.D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prio r to discussing results of presumptive test with member. 7 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the Ohio Medicaid fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information.Codes Qualitative/Presumptive Tests-Description80305Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when pe rformed, per date of service80306Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perf ormed, per date of service80307Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of serviceCodes Quantitative/Confirmatory Tests-Description 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80329 analgesics, non-opioid, 1 or 2 80330 analgesics, non-opioid 3-5 80331 analgesics, non-opioid 6 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more 80338 antidepressants not otherwise specified 80339 antiepileptics, not otherwise specified 1-3 80340 antiepileptics, not otherwise specified 4-6 80341 antiepileptics, not otherwise specified 7 or more 8 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/201980342 antipsychotics, not otherwise specified 1-380343 antipsychotics, not otherwise specified 4-680344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80367 propoxphene 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, qualitative or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, qualitative or quantitative, not otherwise specified 4-6 80377 drug, or substance definitive, qualitative or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0054 G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 11/29/2017Date Revised 3/8/2017 5/31/2017 10/1/2017 11/29/2017 2/16/2018 5/13/2019 9 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/20197/1/20197/8/2019 9/6/2019Updated clinical indications, quantity limits, and PArequirements Updated qualified laboratories per ODM guidance Added OH PA form Date Effective 7/1/2019 H. REFERENCES1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science. Retrieved on 12/11/20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 3. American Society of Addiction Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https ://www.asam.org/doc s/default-source/public-policy-statements/1drug-testing—clinical-10-10.pdf?sfvrsn=1b11ac97_0#search="urine drug test ing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine. Retrieved on 12/13/2018 from https://journals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_ Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendations and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https:// www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42 .1.8&r=PART#se42.1.8_12 7. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved from http://codes.ohio.gov/oac/5160-27-09v1 8. Medicaid. Ea rly and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https ://www.medicaid.gov/medicaid/benefits/epsdt/index.html 9. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 10. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https:// www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf11. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%2 0on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20Drug%20Testing%20Guidance.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.10 APPENDIX ADrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORMThe Clinical Advisory Group of the Ohio Department of Mental Health and Addiction Services established broad guidelines to appropriate clinical use of urine drug screening for patients with a substance use disorder. These guidelines took into account ease of access for patients by eliminating barriers to care, as well as account for patient safety, acuity, risk of relapse/overdose, level of care, and sustained abstinence. Date of Request: Patient Information Last Name: First Name: DOB: Member ID: Patient phone # Provider Information 1. Ordering Provider Name: Tax ID: NPI: Phone Fax: 2. Service Provider (Laboratory/Facility) Name: Tax ID: NPI: Phone Fax: Supporting Documentation-Supporting documents must be attached (including current medication list including current MAT, OTC meds, supplements that may interfere with testing; patients drug(s) of choice; ICD-10 Diagnosis code(s); drug testing history with results) Reason for request: (Check all that apply): Addiction Treatment Chronic pain management Other Patients current phase of care: Induction Stabilization Maintenance Long term maintenance Relapse 2 Patients current ASAM Level of Care: ; not yet determined List date of testing if different than the date of this PA request: 1. Presumptive (select one): 80305 80306 80307 2. Confirmatory include type of test (s): For Patients with Chronic Pain on Opioid Therapy-Provide results of most recent screening. Additional Clinical InformationIs patient currently pregnant? Yes No If suspected diversion, list risk factors: Has patient been adherent to MAT over past 3 months: Yes NoIf no, All of time Most of time Erratic Poor Unknown Has medication administration been observed: Yes No Provide any additional information that is needed to be considered with this completed form. Form completed by: Phone number:2 OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM T0977 2 Definition of Relapse: (ASAM National Practice Guideline (2015) A process in which an individual who has established abstinence or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pursuit of reward and/or relief through the use of substances and other behaviors. OH P-1677
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Date Effective Drug Test ing PY-0020 7/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfu nction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy d oes not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 6 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 7 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 8I . APPENDIX A ………………………….. ………………………….. ………………………….. ……… 9 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 2 A. Subject Drug Testing B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; an d all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for me mbers with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs ar e of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory /Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Early and Periodic Screening, Diagnostic and Treatment ( EPSDT ) – This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test-A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Qualified Laboratories : When an out-of-network qualified laboratory provides toxicology test results to the referring health care provider within two business days of receipt of the test specimen, the MCP shall pay that laboratory at least sixty percent of the Medicaid laborato ry services fee schedule. For the purposes of this Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 3 requirement, a qualified laboratory is a laboratory that is enrolled with Medicaid as an independent laboratory, and that meets all of the following conditions : 1. Is accredited by the College of American Pathologists; and 2. Is approved by the New York Clinical Laboratory Evaluation Program; and 3. Indicates to the MCP that it is providing services and billing as a qualified laboratory Residential services-Ohio Administrative code defines residential services as These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. 1NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0054 . Please refer to this policy for in-depth information on medical necessity for drug testing, d ocumentation requirements , and CareSource monitoring and review of drug testing claims. D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the I CD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. The Ohio Department of Health Standard UDT PA Form must be provided along with the appropriate supporting documentation when requesting a PA. 2. CareSource will require a PA for UDT te sts >30 presumptive and/or > 12 confirmatory UDT per member per calendar year 3. PA is required for any non-participating provider with CareSource for non-emergency room setting. 4. PA is required for any non-participating, non-qualified lab/facility with CareS ource for non-emergency room setting. 5. PA is required for any non-participating, qualified lab/facility with CareSource for non-emergency room setting. 6. PA is not required in an emergency room setting . UDT utilization will be monitored by CareSource . 1http://codes.ohio.gov/oac/5160-27-09v1 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 4 7. PA needs to make a clear case for medical necessity for the level of testing being requested . B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will cover up to 30 presumptive and 12 definitive UDT per member per calendar year. 1. CareSource will cover up to 30 presumptive UDT per member per calendar year. 2. CareSource will cover up to 12 definitive UDT per member per calendar year. B. For presumptive tests, each CPT code is counted as one test . C. For confirmatory tests, all CPT tests performed on the same date of service count as one test. IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other t han that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care s ervice for children under age 21 . VI. Non-Urine Testing A. CareSource will reimburse blood testing in e mergency room settings . B. Drug testing with blood samples performed in any other setting outside of an e mergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VII. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 5 a. Presumptive testing was negative for prescription medications AND provider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member d isputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testing that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing re quired by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Foren sic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed o utside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 6 I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits , recovery of overpayments identified, and provider prepay review . E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes . Please refer to the Ohio Medicaid fee schedule . The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when perform ed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative /Confirmatory Tests-Description 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80329 analgesics, non-opioid, 1 or 2 80330 analgesics, non-opioid 3-5 80331 analgesics, non-opioid 6 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more ArchivedDrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 7 80338 antidepressants not otherwise specified 80339 antiepileptics, not otherwise specified 1-3 80340 antiepileptics, not otherwise specified 4-6 80341 antiepileptics, not otherwise specified 7 or more 80342 antipsychotics, not otherwise specified 1-3 80343 antipsychotics, not otherwise specified 4-6 80344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone 80366 pregabalin 80367 propoxphene 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, qualitative or quantitative, not otherwise specified 1-3 80376 drug, or substance definitive, qualitative or quantitative, not otherwise specified 4-6 80377 drug, or substance definitive, qualitative or quantitative, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0054 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/29/2017 Date Revised 3/8/2017 5/31/2017 Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 8 10/1/2017 11/29/2017 2/16/2018 5/13/2019 7/1/2019 7/8/2019 9/ 24 /2019 Updated clinical indications, quantity limits, and PA requirements Updated qualified laboratories per ODM guidance Added ODM PA form Date Effective 7/1/2019 H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11 /20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 3. American Society of Addict ion Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https://www.asam.org/docs/default-source/public-policy-statemen ts/1drug-testing — clinical-10-10.pdf?sfvrsn=1b11ac97_0#search=”urine drug testing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on 12/13/2018 from https://jo urnals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendati ons and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42.1.8&r=PART#se42.1.8_12 7. Lawriter-OAC-5160-27-09 Substance use disorder treatment services. (n.d.). Retrieved from http://codes.ohio.gov/oac/5160-27-09 v1 8. Medicaid. Ea rly and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html 9. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendat ions and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 10. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf 11. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky .gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%20on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20Drug%20Testing%20Guidance.pdf Archived Drug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 9 The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. APPENDIX A OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM The Clinical Advisory Group of the Ohio Department of Mental Health and Addiction Services established broad guidelines to appropriate clinical use of urine drug screening for patients with a substance use disorder. These guidelines took into account ease of access for patients by eliminating barriers to care, as well as account for patient safety, acuity, risk of relapse/overdose, level of care, and sustained abstinence. Date of Request: _____________________ Patient Information Last Name: ________________________________First Name: ________________________________ DOB: ___________ Member ID: ______________________ Patient phone # ______________ Provider Information 1. Ordering Provider Name: ___________________________________________________ _________ Tax ID: ________________NPI: ___________________Phone _________________ Fax:__________________ 2. Service Provider (Laboratory/Facility) Name: _____________________________________________ Tax ID: ________________NPI: ___________________Phone ______ ___________ Fax:__________________ Supporting Documentation-Supporting documents must be attached (including current medication list including current MAT, OTC meds, supplements that may interfere with testing; patients drug(s) of choice; ICD-10 Diagno sis code(s); drug testing history with results) Reason for request: (Check all that apply): Addiction Treatment Chronic pain management Other ____________________ Patients current phase of care: Induction Stabilization Maintenance Long term maintenance Relapse 2Patients current ASAM Level of Care: ________________________; not yet determined List date of testing if different than the date of this PA request: ________________________ 1. Presumptive (select one): 80305 80306 80307 2. Confirmatory include type of test (s): ______________________________________ For Patients with Chronic Pain on Opioid Therapy-Provide results of most recent screening. Additional Clinical Information Is patient curr ently pregnant? Yes No If suspected diversion, list risk factors: __________________________________________________ Has patient been adherent to MAT over past 3 months: Yes No If no, All of time Most of time Erratic Poor Un known Has medication administration been observed: Yes No 2OHIO URINE DRUG SCREEN PRIOR AUTHORIZATION (PA) REQUEST FORM T0977 2Definition of Relapse: (ASAM National Practice Guideline (2015) A process in which an individual who has established abstinen ce or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pu rsuit of reward and/or relief through the use of substances and other behaviors. OH P-1677 ArchivedDrug Testing OHIO MEDICAID PY-0020 Effective Date: 7/1/2019 10 Provide any additional information that is needed to be considered with this completed form. Form completed by: _____________________________ Phone number:_____________________ Archived
© Copyright CareSource 2026. All rights reserved.
System Details