REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 11/29/2018 03/01/2020 03/01/2019 Policy Name Policy Number Applied Behavioral Analysis (ABA) Therapy PY-0 712 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 3D. POLICY ………………………….. ………………………….. ………………………….. ……………. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 4 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………… 5 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 5 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 5 Archived Applied Behavioral Analysis (ABA) Therapy OHIO MEDICAID PY-0 712 Effective Date: 03/01/2019 2 A. SUBJECT Applied Behavioral Analysis (ABA) Therapy 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. Reimb ursement 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 verif y 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 t o reimbursement or guarantee claims payment. Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms, depending on the developmental level and chronological age of the patient. Autism is often defined by specific impairments that affect socialization, communication, and stereotyped (repetitive) behavior, which collectively are called the Core symptoms of autism. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted, repetitive patterns of behavior, interests and activities. Individuals with a well-established diagnosis of autistic disorder, Aspergers disor der, or Pervasive Developmental Disorder NOS under previous diagnostic criteria should be given the diagnosis of ASD. There is currently no cure for ASDs, nor is there any one single treatment for the disorder. Individuals with ASDs may be managed throug h a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions. The goal of treatment for autistic patients is to minimize the severity of autism symptoms, maximize learning, facilitate social integration, and improve quality of life for both autistic individuals and their families or caregivers. Behavioral therapy programs studied to treat ASD include Intensive Behavioral Intervention (IBI), including Lovaas therapy, Early Intensive Behavioral Intervention ( EIBI), or Applied Behavior Analysis (ABA). IBI therapy involves use of operant conditioning, a behavioral modification technique using positive reinforcement to increase desired behaviors, or a neutral response to not reinforce undesired behaviors. The ope rant conditioning is delivered in a highly-structured and intensive program, with one-to-one instruction by a trained therapist. Parents are active participants in the treatment process and are taught to continue the training at home. IBI is initiated when a child is young, usually by 2 years of age. Medical research has shown improved outcomes in children that receive early behavioral and developmental/relationship-based interventions. These intensive behavioral intervention programs involve time-intensi ve, highly-structured positive reinforcement techniques by a trained behavior analyst or therapist. There is a wide variation in ABA practices from philosophy, approach, interventions and methodology, and outcome reporting. Clinical evidence from small stu dies and meta-analyses suggests that intensive behavioral therapy may have effects on intellectual functioning, language-related outcomes, acquisition of daily living skills and social functioning for some individuals. Methodological problems including sma ll sample sizes (limiting statistical analysis), lack of randomization, blind assessments, and use of prospective design limit the generalizability of the results. There is lack of definition and guidelines around characteristics of children who would bene fit from treatment, lack of evidence-based guidelines for training and credentialing, program content, measurement of success, intensity, duration and clinical criteria. CareSource fully Archived Applied Behavioral Analysis (ABA) Therapy OHIO MEDICAID PY-0 712 Effective Date: 03/01/2019 3 supports the recommendation for ongoing research, randomized control studies, standardized protocols, and longitudinal research to determine long term outcomes. The following professional societys recommendations are derived from the latest guidelines and scientific based literature available. American Academy of Pedia trics (AAP ) The AAP recommends universal screening in children aged 18 to 24 months to assist in early detection of ASD. Children that receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, adaptive behavior and social behavior. American Academy of Child and Adolescent Psychiatry (AACAP) The AACAP recommends children should routinely be tested for ASD during developmental assessments. When screening is indicative of si gnificant ASD symptoms, a thorough diagnostic evaluation should be performed. Clinicians should coordinate an appropriated multidisciplinary assessment of children with ASD and the clinician should help the family obtain appropriate, evidence-based and str uctured educational and behavioral interventions for treatment. The AACAP has practice parameters for treatment of children and adolescents with ASD. The quality of the literature is variable. None of the treatment models have emerged as superior. C. DEFINITIONS Autism Spectrum Disorder: A neurological condition, including Asperger’s syndrome and autism, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association Autism Diag nostic Interview-Revised (ADI-R): A clinical interview lasting two three hours in order to evaluate and probe for autistic symptoms or behaviors Autism Diagnostic Observation Schedule (ADOS): A standard diagnosis tool used as one facet of autism diagnost ic evaluation in conjunction with other clinical information and the health care providers clinical expertise BCaBA: Board certified assistant behavior analyst undergraduate level (Bachelors degree) BCBA: Board certified behavior analyst graduate level (Masters degree) BCBA-D: Board certified behavior analyst doctoral level (Doctoral degree) QHP: Qualified healthcare professional (BCBA, BCBA-D) RBT: Registered Behavioral Technician is a paraprofessional who practices under the close, ongoing supervision of a BCBA, BCaBA, or BCBA-DD. POLICY I. Applied Behavioral Analysis (ABA) Therapy requires a prior authorization (PA) . A. Prior Authorization (PA) is required for ABA Diagnosis and Evaluation, Initial Course of ABA Therapy and Continuation of ABA Therapy . II. CareSource reimburses for state and federal required covered services as part of a comprehensive plan of treatment for autism spectrum disorders when ordered by a licensed physician i.e. pediatrician or psychiatrist and provided by a certi fied, credentialed and /or licensed Car eSource participating therapist as outlined in the Applied Behavioral Analysis (ABA) Therapy Medical policy, MM-0028. III. ABA Therapy services may be approved for up to a six month period with subsequent interim assessment over the course of treatment. IV. CareSource will not reimburse for any e xclusions listed in the Medical policy , MM-0028. V. Duplicate services or double billing are not reimbursable. Archived Applied Behavioral Analysis (ABA) Therapy OHIO MEDICAID PY-0 712 Effective Date: 03/01/2019 4 VI. Codes listed below that state face-to-face with member means that QHP or technician must be physically present with member. A. Code 97151, Behavior identification assessment, can be billed a maximum of 24 unit s for a total of 6 hours. B. Code 97151 and 97152 can be billed for a combined total of 6 hours every 6 months after the initial assessment. VII. Codes listed in this policy below cannot be billed together for the same amount of time for the same date of service. A. BCBA or BCBA-Dcannot bill the same amount of time, for the same date of service as the BCaBA or RBT (technician). B. All services administered by a technician must be directed and supervised by the BC aBA , BCBA or BCBA-D. C. A maximum of 1 hour of QHP supervision can be billed for every 10 hours of RBT time. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting state Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual state Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclu sive and is subject to updates. CPT Code Description 97151 Behavior identification assessment , administered by a physician or other qualified healthcare professional , each 15 minutes of the physicians or other qualified healthcare professionals time face-to-face with member and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. (Attended by member and QHP) 97152 Behavior identification supporting assessment , administered by one technician under the direction of a physician or other qualified healthcare professional, face-to-face with member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one member, each 15 minutes . (Attended by member and technician (QHP may substitute for the technician)) 97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. (Attended by 2 or more me mbers and technician (QHP may substitute for technician)) 97155 Adaptive behavior treatment by protocol modification , administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes . (Attended by member and QHP; may include technician and/or caregiver) 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the member present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. (Attended caregiver and QHP) 97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the member present), face-to-face with multiple sets guardians/caregivers, each 15 minutes. Archived Applied Behavioral Analysis (ABA) Therapy OHIO MEDICAID PY-0 712 Effective Date: 03/01/2019 5 (Attended caregivers of 2 or more members and QHP) 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple members, each 15 minutes. (Attended by 2 or more members and QHP) 0362T Behavior identification supporting assessment , each 15 minutes of technicians time face-to-face with a member, requiring the following components: administered by the physician or other qualified healthcare professional who ison site;with the assistance of two or more technicians;for a patient who exhibits destructive behavior;completed in an environment that is customized, to the patients behavior.(Attended by member and 2 or more technicians;QHP on site)0373T Adaptive behavior treatment with protocol modification each 15 minutes of t echnicians time face-to-face with patie nt , requiring the following components: administered by the physician or other qualified healthcare professional who is on site;with the assistance of two or more technicians;for a patient who exhibits destructive behavior;completed in an environment that is customized, to the patients behavior.(Attended by member and 2 or more technicians;QHP on site)Modifier Description U3 Medicaid level of care 3, as defined by state-Board Certified Behavioral Analyst (BCBA) U5 Medicaid level of care 5, as defined by state-Registered Behavior Technician (RBT) with min 1 year direct experience serving children with ASD F. RELATED POLICIES/RUL ESApplied Behavioral Analysis (ABA) Therapy MM-0028G. REVIEW/REVISION HIST ORYDATE ACTION Date Issued 11/29/2018 New Policy Date Revised Date Effective 03/01/2019 H. REFERENCES1. Behavior Analyst Certification Board. (2018, November 12). Retrieved November 12,2018 from https://www.bacb.com/ .2. Adaptive Behavior Assessment and Treatment Code Conversion Table. (2018,November 12). Retrieved from https://www.bacb.com/wp-content/uploads/CPT_Codes_Crosswalk_.pdf. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. I nd e pe n de nt med i ca l r e v iew 2/2015 Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 01/01/2019 01/01/2020 01/01/2019 Policy Name Policy Number Provider Home Visits PY-0 445 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ………………………………………………………………….. 14 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………. 14 H.REFERENCES ………………………………………………………………………………………. 14Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 2 A. SUBJECT Provider Home Visits 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. Provider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. C. DEFINITIONS Medically necessary Is defined as procedures, items, or services that meet generally accepted standards of medical practice: o To prevent, diagnose, evaluate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability and without which the person 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; o The procedures, items, or services must be the lowest cost alternative that effectively addresses and treats the medical problem, clinically appropriate in its type, frequency, extent, duration, and delivery setting; and o Be appropriate to the adverse health condition for which it is provided and is expected to produce the desired outcome. Place of Service (POS) – A two-digit code that indicates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner or a physician assistant. Home An individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. D. POLICY I. CareSource does not require a prior authorization for provider home/domicile visits. A. CareSource reimburses for home visit services per the state Medicaid fee schedule . B. Claim submission must include the appropriate CPT codes along with any applicable modifier with the appropriate place of service (POS) code. II. Place of service (POS) for provider services in the home or domicile include the following: A. POS 12 Home B. POS 13 Assisted Living Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 3 C. POS 14 Group Home D. POS 31 Skilled Nursing Facility (SNF) E. POS 32 Nursing Facility F. POS 33 Long-term Facility III. Home services for CareSource members: A. CareSource members do not need to be confined to their home to receive home services, provided by a physician. B. The CareSource members medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. C. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiarys home. Note:Although CareSource does not require a prior authorization for provider home visits, 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 state Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual state Medicaid fee schedule for appropriate codes. The following PDF list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Place of Service Description 12 Location, other than a hospital or other facility, where the patient receives care in a private residence. Code Description 99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/o r family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. 99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies ar e provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. 99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qual ified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or ArchivedProvider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 4 family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-fac e with the patient and/or family. 99344 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counsel ing and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 99345 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Me dical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs . Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family. 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coord ination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care pr ofessionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/ or family. 99350 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high comple xity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. ArchivedProvider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 5 Place of Service Description 13 Congregate residential facility with self-contained living units providing assessment of each residents needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the pr esenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided cons istent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, o ther qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent wi th the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the prese nting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehen sive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the p roblem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domi ciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counsel ing and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 6 problem(s) are self-lim ited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 993 35 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consist ent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 993 36 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of c are with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typica lly, 40 minutes are spent with the patient and/or family or caregiver. 993 37 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the proble m(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes ar e spent with the patient and/or family or caregiver. Place of Service Description 14 A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration). Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies ar e provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 7 examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other ph ysicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes a re spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decisio n making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually , the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the natu re of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision maki ng. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) a re self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provi ded consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordi nation of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high sever ity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interv al history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 8 requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Place of Service Description 31 A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. Code Description 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies a re provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of modera te severity. Typically, 35 minutes are spent at the bedside and on the pat ient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the proble m(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, fo r the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history ; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the proble m(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 9 complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nu rsing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordi nation of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided con sistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on th e patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qua lified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded p roblem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided co nsistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 10 severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, ot her qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high comple xity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit. Place of Service Description 32 A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to individuals other than those with intellectual disabilities. Code Description 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low compl exity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key component s: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with t he nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 min utes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 11 interval hi story; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) an d the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluati on and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care wi th other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a min or complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key compone nts: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Cou nseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have dev eloped a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Med ical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and /or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consi stent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient con sultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 12 problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are o f moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensiv e examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patien t’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, whic h requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies ar e provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or uni t. Place of Service Description 33 A facility which provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, oth er qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the p resenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of th e problem(s) and the patient’s and/or family’s needs. Usually, the presenting Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 13 problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or fami ly or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseli ng and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has develope d a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requi res at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, o r agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenti ng problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of thes e 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consi stent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest ho me visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and /or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 14 Modifiers Description 24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service 33 Preventive Services 57 Decision for Surgery 59 Distinct Procedural Service A1 Dressing for one wound AI Principal physician of record AM Physician, team member service AQ Physician providing a service in an unlisted health professional shortage area (HPSA) CC Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) GC This service has been performed in part by a resident under the direction of a teaching physician GV Attending physician not employed or paid under arrangement by the patient’s hospice provider GW Service not related to the hospice patient’s terminal condition HE Mental health program HO Masters degree level Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage a rea, a medically underserved area, or a rural area Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Q8 Two Class Bfindings RT Right side (used to identify procedures performed on the right side of the body) SA Nurse practitioner rendering service in collaboration with a physician UC Medica id level of care 12, as defined by each state UD Medicaid level of care 13, as defined by each state F. RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 01/01/2019 New policy Date Revised Date Effective 01/01/2019 H. REFERENCES 1. Lawriter-OAC-5160-1-01 Medicaid medical necessity: definitions and principles. (2015, March 22). Retrieved 7/1/2018 from http://codes.ohio.gov/oac/5160-1- 01. Archived Provider Home Visits OHIO MEDICAID PY-0445 Effective Date: 01/01/2019 15 2.Medicare Claims Processing Manual. (2018, June 13). Retrieved 7/1/2018 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf . 3. Place of Service Codes-Centers for Medicare & Medicaid Services. (2012, March 5). Retrieved 7/1/2018 from https://www.cms.gov/Medicare/Coding/place-of-service-codes/index.html. 4. Place of Service Code Set-Centers for Medicare & Medicaid Services. (2016, November 17). Retrieved 7/1/2018 from https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. I nd e pe nde nt medi cal rev iew 2/2015 Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Streptococcus A and BInfection PY-0452 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 2 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 4 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Mo lecular Diagnostic Testing for Streptococcus A and BInfection OH IO MEDICAID PY-0452 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Streptococcus A and BInfection B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PC R) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the ta rget segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Illnesses caused by Streptococcus A include Pharyngitis (strep throat), Scarlet Fever, Acute Rheumatic Fever and Post Streptococcal Glomerulonephritis. Illnesses caused by Streptococcus Binclude Bacteremia, Sepsis, Pneumonia, skin and soft tissue infections, bone and joint infections, meningitis (although this is a rare occurrence in adults). Screening for Streptococcus Bshould be done between 35 and 37 weeks in every pregnant women, as it is most commonly passed to newborns during the birthing process. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatmen t of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waive d tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition , disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Tes ting by PCR for Streptococcus A and Streptococcus Binfection medically necessary when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy III. CareSource does not consider Molecular Diagnostic Testing by PCR for Streptococcus A and Streptococcus Binfection to be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. IV . Conventional testing, such as the rapid strep test (throat culture) for Streptococcus A; cultures of sterile body fluids and/ or vaginal and rectal cultures in pregnant women for Streptococcus B , are viewed as effective, low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. Archived Mo lecular Diagnostic Testing for Streptococcus A and BInfection OH IO MEDICAID PY-0452 Effective Date: 12/01/2018 3 E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87651 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 87653 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique A38.0 Scarlet fever with otitis media A38.1 Scarlet fever with myocarditis A38.8 Scarlet fever with other complications A38.9 Scarlet fever, uncomplicated A40.0 Sepsis due to streptococcus, group A A40.3 Sepsis due to Streptococcus pneumoniae A40.8 Other streptococcal sepsis A40.9 Streptococcal sepsis, unspecified B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere G00.2 Streptococcal meningitis I00 Rheumatic fever without heart involvement I01.0 Acute rheumatic pericarditis I01.1 Acute rheumatic endocarditis I01.2 Acute rheumatic myocarditis I01.8 Other acute rheumatic heart disease I01.9 Acute rheumatic heart disease, unspecified J02.0 Streptococcal pharyngitis J03.00 Acute streptococcal tonsillitis, unspecified J03.01 Acute recurrent streptococcal tonsillitis J13 Pneumonia due to Streptococcus pneumoniae J15.4 Pneumonia due to other streptococci J20.2 Acute bronchitis due to streptococcus M72.6 Necrotizing fasciitis N00.9 Acute nephritic syndrome with unspecified morphologic changes A40.1 Sepsis due to streptococcus, group BB95.1 Streptococcus, group B, as the cause of diseases classified elsewhere J15.3 Pneumonia due to streptococcus, group BO99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Disea ses of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium O99.820 Streptococcus Bcarrier state complicating pregnancy O99.824 Streptococcus Bcarrier state complicating childbirth O99.825 Streptococcus Bcarrier state complicating the puerperium P23.3 Congenital pneumonia due to streptococcus, group BP36.0 Sepsis of newborn due to streptococcus, group BP36.10 Sepsis of newborn due to unspecified streptococci Archived Mo lecular Diagnostic Testing for Streptococcus A and BInfection OH IO MEDICAID PY-0452 Effective Date: 12/01/2018 4 P36.39 Sepsis of newborn due to other streptococci Z05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Z22.330 Carrier of Group Bstreptococcus F. RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/7/2018 Removed O99.5, corrected P36.319 to P36.39 Date Effective H. REFERENCES 1. Group BStrep | GBS | Home | Streptococcus | CDC. (2018, May 29). Retrieved July 23, 2018, from www.cdc.gov/groupbstrep . 2. Group A Strep | Home | Group A Streptococcus | GAS | CDC. (2016, September 16). Retrieved July 23, 2018, www.cdc.gov/groupAstrep . The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Influenza Virus Infection PY-0450 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 Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 2 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Mo lecular Diagnostic Testing for Influenza Virus Infection OH IO MEDI CAID PY-0450 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Influenza Virus Infection B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PC R) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the ta rget segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Molecular diagnostic testing for Influenza Virus can detect influenza viral RNA or nucleic acids in respiratory specimens with high sensitivity and specifici ty . The detection of influenza viral RNA or nucleic acids is not necessarily indicative of a viable or ongoing influenza viral replication . I n cases where there is known active influenza virus and the clinical picture of the patient shows signs and symptom s of the influenza virus, molecular diagnostic testi ng is not needed. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Tes ting by PCR for Influenza Virus Infection medically necessary when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy III. CareSource does not consider Molecular Diagnostic Testing by PCR for Influenza Virus Infection to be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. IV . Conventional testing, such as nasal swabs and nasopharyngeal swabs , are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. Archived Mo lecular Diagnostic Testing for Influenza Virus Infection OH IO MEDI CAID PY-0450 Effective Date: 12/01/2018 3 E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types J09.X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel in fluenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia J10.1 Influenza due to other identified influenza virus with othe r respiratory manifestations J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to other identified influenza vir us with myocarditis J10.83 Influenza due to other identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations J11.2 Influenza due to unidentified influenza virus with gastrointestina l manifestations J11.81 Influenza due to unidentified influenza virus with encephalopathy J11.82 Influenza due to unidentified influenza virus with myocarditis J11.83 Influenza due to unidentified influenza virus with otitis media J11.89 Influenza due to unidentified influenza virus with other manifestations O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99 .519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory syst em complicating the puerperium Archived Mo lecular Diagnostic Testing for Influenza Virus Infection OH IO MEDI CAID PY-0450 Effective Date: 12/01/2018 4 F. RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Corrected O00.519 to O99.519; corrected the next review date to 12/01/2019 Date Effective H. REFERENCES 1. Information on Rapid Molecular Assays, RT-PCR, and other Molecular Assays for Diagnosis of Influenza Virus Infection | Seasonal Influenza (Flu) | CDC. (2018, February 20). Retrieved July 16, 2018, from www.cdc.gov/flu/professionals/diagnosis/molecular-assays.htm . The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Herpes Simplex Virus PY-0449 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 Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. ……………. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 4 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Mo lecular Diagnostic Testing for Herpes Simplex Virus OH IO MEDICAID PY-0449 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Herpes Simplex Virus B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing t ime. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Herpes Simplex Virus (HSV) type 1 (HSV-1) or type 2 (HSV-2) causes the sexually transmitte d disease genital herpes. Individuals infected with HSV can be asymptomatic, have very mild symptoms or have symptoms that are mistaken for another skin condition. Herpes lesions typically appear as vesicles, small blisters, on or around the genitals, rect um or mouth. The first outbreak of herpes is often associated with a longer duration of herpetic lesions, increased viral shedding (making HSV transmission more likely) and systemic symptoms including fever, body aches, swollen lymph nodes, or headache. Genital herpes may cause painful genital ulcers that can be severe and persistent in persons with suppressed immune systems, such as HIV-infected persons. Both HSV-1 and HSV-2 can also cause rare but serious complications such as aseptic meningitis (inflam mation of the linings of the brain). Development of extragenital lesions (e.g. buttocks, groin, thigh, finger, or eye) may occur during the course of infection. The preferred HSV tests for patients with active genital ulcers are detection of HSV DNA by nu cleic acid amplification tests such as polymerase chain reaction (PCR), or isolation by viral culture. HSV culture requires collection of a sample from the lesion and, once viral growth is seen, specific cell staining to differentiate between HSV-1 and HSV-2. However, culture sensitivity is low, especially for recurrent lesions, and declines as lesions heal. PCR is more sensitive, allows for more rapid and accurate results, and is increasingly being used. Because viral shedding is intermittent, failure to d etect HSV by culture or PCR does not indicate an absence of HSV infection. For the symptomatic patient, testing with both virologic and serologic assays can determine whether it is a new infection or a newly-recognized old infection. A primary infection wo uld be supported by a positive virologic test and a negative serologic test, while the diagnosis of recurrent disease would be supported by positive virologic and serologic test results . All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those te sts approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health c are services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Archived Mo lecular Diagnostic Testing for Herpes Simplex Virus OH IO MEDICAID PY-0449 Effective Date: 12/01/2018 3 D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Tes ting by PCR for Herpes Simplex Virus medically necessary when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy III . CareSource does not consider Molecular Diagnostic Testing by PCR for Herpes Simplex Virus to be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. I V . Conventional testing, such as serol ogy and cultures , are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87529 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique 87530 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification 87532 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 87533 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification A60.00 Herpesviral infection of urogenital system, unspecified A60.01 Herpesviral infection of penis A60.02 Herpesviral infection of other male genital organs A60.03 Herpesviral cervicitis A60.04 Herpesviral vulvovaginitis A60.09 Anogenital herpesviral infection, unspecified A60.1 Herpesviral infection of perianal skin and rectum A60.9 Anogenital herpesviral infection, unspecified B00.0 Eczema herpeticum B00.1 Herpesviral vesicular dermatitis B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis B00.3 Herpesviral meningitis B00.4 Herpesviral encephalitis B00.50 Herpesviral ocular disease, unspecified B00.51 Herpesviral iridocyclitis B00.52 Herpesviral keratitis B00.53 Herpesviral conjunctivitis B00.59 Other herpesviral disease of eye B00.7 Disseminated herpesviral disease B00.81 Herpesviral hepatitis B00.82 Herpes simplex myelitis B00.89 Other herpesviral infection B00.9 Herpesviral infection, unspecified B08.21 Exanthema subitum [sixth disease] due to human herpesvirus 6 B10.01 Human herpesvirus 6 encephalitis B10.81 Human herpesvirus 6 infection Archived Mo lecular Diagnostic Testing for Herpes Simplex Virus OH IO MEDICAID PY-0449 Effective Date: 12/01/2018 4 O98.311 Other infections with a predominantly sexual mode of transmission complicating pregnancy, first trimester O98.312 Other infections with a predominantly sexual mode of transmission complicating pregnancy, second trimester O98.313 Other infections with a predominantly sexual mode of transmission complicating pregnancy, third trimester O98.319 Other infections with a predominantly sexual mode of transmission complicating pregnancy, unspecified trimester O98.32 Other infections with a predominantly sexual mode of transmission complicating childbirth O98.33 Other infections with a predominantly sexual mode of transmission complicating the puerperium O98.511 Other viral diseases complicating pregnancy, first trimester O98.512 Other viral diseases complicating pregnancy, second trimester O98.513 Other viral diseases complicating pregnancy, third trimester O98.519 Other viral diseases complicating pregnancy, unspecified trimester O98.52 Other viral diseases complicating childbirth O98.53 Other viral diseases complicating the puerperium F. RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/7/2018 A dded ICD-10 098.519 in code table , corrected next review date to reflect 12/01/2019 Date Effective H. REFERENCES 1. STD Facts-Genital Herpes (Detailed version). (2017, February 9). Retrieved July 10, 2018, from www.cdc.gov/std/herpes/stdfact-herpes-detailed.htm . The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Hepatitis Band CPY-0447 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 Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. ……………. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Hepatitis Band CB. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowi ng the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronic ally infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-te rm illness but for 70% 85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) All facilities in the Unit ed States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cl eared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 3 D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy III. CareSource does not consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. I V . Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.2 Chronic viral hepatitis CB18.9 Chronic viral hepatitis, unspecified B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis complicating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium F. RELATED POLICIES/RUL ES N/A Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 4 G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Revised to reflect next review date of 12/01/2019 Date Effective H. REFERENCES 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (2015, May 31). Retri eved July 3, 2018, from www.cdc.gov /hepatitis The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Gastrointestinal Illness PY-0448 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affili ates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 2 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Testing for Gastrointestinal Illness B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PC R) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the ta rget segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Gastrointestinal illness, as addressed in this policy, include Clostridium difficile, E. Coli, Salmonella, Shigella, Norovirus and Giardia. These infection and illnesses of the intestine can cause symptoms such as diarrhea, nausea, vomiting and abdominal cramping. There are three basic modes of transmission: in food, in water and person to person. While some of these illnesses will resolve on their own, others can spread throughout the body and require treatment to prevent a more devastating illness. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or tr eatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, co ndition, disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for the following gastrointestinal i llnesses, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage of this policy. A. Clostridium Difficile B. Salmonella C. Shigella D. Norovirus E. Giardia III. CareSource does not consider Molecular Diagnostic Testing by PCR medically necessary for gastrointestinal illnesses when billed with any other diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as stool and saliva samples for these illnesses is viewed as low cost and given that not all cases of acute diarrhea are indicative of these illnesses, institutions should utilize these before the higher cos t Molecular Testing by PCR as the first testing option for the initial clinical presentation of acute diarrhea. Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 3 E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87493 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique 87505 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, an d multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), include s multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. co li, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets A04.71 Enterocolitis due to Clostridium difficile, recurrent A04.7 2 Enterocolitis due to Clostridium difficile, not specified as recurrent A02.0 Salmonella enteritis A03.0 Shigellosis due to Shigella dysenteriae A03.1 Shigellosis due to Shigella flexneri A03.2 Shigellosis due to Shigella boydii A03.3 Shigellosis due to Shigella sonnei A03.8 Other shigellosis A03.9 Shigellosis, unspecified A04.0 Enteropathogenic Escherichia coli infection A04.1 Enterotoxigenic Escherichia coli infection A04.2 Enteroinvasive Escherichia coli infection A04.3 Enterohemorrhagic Escherichia coli infection A04.4 Other intestinal Escherichia coli infections A07.1 Giardiasis [lambliasis] A08.11 Acute gastroenteropathy due to Norwalk agent K52.9 Noninfective gastroenteritis and colitis, unspecified O99.611 Diseases of the digestive system complicating pregnancy, first trimester O99.612 Diseases of the digestive system complicating pregnancy, second trimester O99.613 Diseases of the digestive system complicating pregnancy, third trimester O99.619 Diseases of the digestive system complicating pregnancy, unspecified trimester O99.62 Diseases of the digestive system complicating childbirth O99.63 Diseases of the digestive system complicating the puerperium F. RELATED POLICIES/RUL ES N/A Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 4 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Updated next review date to 12/01/2019 Date Effective H. REFERENCES 1. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System Infections. (2016 , July 16). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091344/ The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 10/31/2013 07/01/2019 07/01/2018 Policy Name Policy Number Telemedicine Services PY-0084 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2 D. POLICY ………………………….. ………………………….. ………………………….. ……………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………… 5 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………. 5 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 5 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 edi cal 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 func tion, 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 p rovider. 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 contr act (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 Telemedicine ServicesOHIO MEDICAID PY-0084 Effective Date: 07/01/2018 A. SUBJECTTelemedicine Services B. BACKGROUNDReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office 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 appropriateCPT/HCPCS code(s) for the product or service that is being provided. The inclusi on of a code does not imply any right to reimbursement or guarantee claims payment. Telemedicine is used to support health care when the provider and patient are physically separated. Typically, the patient communicates with the provider via interactive me ans that is sufficient to establish the necessary link to the provider who is working at a different location from the patient. CareSource will reimburse participating providers, for telemedicine services, who are credentialed to deliver telemedicine services rendered to CareSource members, as set forth in this policy. C. DEFINITIONS Asynchronous store and forward technologies – is the transfer of a patients medical information, through the use of a camera or recording device, that is sent via telecommunication to another site for consultation. Distant Site (Hub) – is the location of the physician or provider rendering health care services. Electronic service delivery (electronic therapy, cyber therapy, e-therapy, etc.) – is counseling, social work or marriage and family therapy in any form offered or rendered primarily by electronic or technology-assisted means. Originating Site (Spoke) – is the location where the patient is physically located when services are provided. Place of Service Codes (POS) – are t codes that specifically indicate where a service or procedure was performed. Telemedicine – is the direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. Telemedicine vendor – is the participating provider with CareSource that renders the telemedicine services. D. POLICYI. CareSource does not require prior authorization for Telemedicine services. II. Telemedicine services may be reimbursed according to Ohio Medicaid guidelines and using appropriate CPT and/or HCPCS and modifier codes. III. Practitioners providing select behavioral health services via electronic service delivery must: A. Conduct an initial face-to-face meeting, which may be by video/audio electronically, to verify client identity. B. Obtain written, informed consent to include discussion of risks of electronic service delivery. C. Provide links to websites of certification bodies and licensure boards. 3 Telemedicine ServicesOHIO MEDICAID PY-0084 Effective Date: 07/01/2018 D. Identify appropriately training professionals to provide local assistance.E. Maintain confidentiality, including use of encryption methods. IV. Reimbursement may be made for the following health care services delivered at the distant site: A. Evaluation and management services characterized as ANY of the following: 1. Office or other outpatient services 2. Office or other outpatient consultations 3. Inpatient consultations V. The originating site is responsible for documenting the medical necessity of the health care service provided through the use of telemedicine, for securing the informed consent of the patient, and for developing and maintaining progress notes. VI. The distant site is responsible for maintaining documentation of the health care service delivered through the use of telemedicine and for sending progress notes to the originating site for incorporation into the patient’s records. Note: Although telemedicine/telehealth services do not require a prior authorizationCareSource may request documentation to support medical necessity. Appropriate and co mplete documentation must be presented at the time of review to validate medical necessity. VII. Addition information regarding behavioral health services can be found at:http://bh.medicaid.ohio.gov/Portals/0/Providers/FINAL%20BH%20Manual%20V%201.4_1204 2017.pdf E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the appropriate Ohio Medicaid fee schedules: http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf http://www.medicaid.ohio.gov/PROVIDERS/FeeScheduleandRates/SchedulesandRates.aspx#16 82653-outpatient-hospital-behavioral-health-services 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 sources for the most current coding information. CPT Codes Definition99201New patient Office or other outpatient visit, including problem focused history, problem focused exam, straightforward medical decision-making. 99202New patient Office or other outpatient visit, including expanded problem focused history, expanded problem focused exam, straightforward medical decision-making. 99203New patient Office or other outpatient visit for the evaluation and management of the member, including a detailed history, a detailed examination and medical decision making of low complexity. 99204 New patient Office or other outpatient visit for the evaluation and management of the member, including a comprehensive history, a 4 Telemedicine ServicesOHIO MEDICAID PY-0084 Effective Date: 07/01/2018 comprehensive examination and medical decision making of moderate complexity. 99205Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 99211Established patient Office or other outpatient visit for the evaluation and management of the member that may not require the presence of physician or other qualified health care professional. 99212Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: problem focused history, problem focused exam, straightforward medical decision-making. 99213Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: an expanded problem focused history, an expanded problem focused exam and medical decision making of low complexity. 99214Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: a detailed history, a detailed examination and medical decision making of moderate complexity. 99215Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 99354 Prolonged evaluation and management or psychotherapy service(s); first hour 99355Prolonged evaluation and management or psychotherapy service(s) each additional 30 minutes 90791 Psychiatric Diagnostic Evaluation w/o Medical 90792 Psychiatric Diagnostic Evaluation w/ Medical 90832 Individual Psychotherapy – 30 minutes 90834 Individual Psychotherapy 45 minutes 90837 Individual Psychotherapy 60+ minutes 90833 Individual Psychotherapy w/ E/M Service 90836 Individual Psychotherapy w/ E/M Service 90838 Individual Psychotherapy w/ E/M Service 90846 Family Psychotherapy w/o patient 50 minutes 90847 Family psychotherapy (conjoint, w/ patient present) 50 minutes 90849 Multiple-family group psychotherapy 90853 Group Psychotherapy (not multi-family group) 90863 Pharmacologic management 96101 Psychological Testing 96111 Developmental Testing 5 F. RELATED POLICIES/RULESN/A G. REVIEW/REVISION HISTORYTelemedicine Services OHIO MEDICAID PY-0084 Effective Date: 07/01/2018 DATE ACTIONDate Issued 10/31/2013Date Revised 11/29/2016 02/22/2018 Added additional information regarding behavioral healthpractitioners responsibilities, 1 modifier and 21 behavioral health codes. Date Effective 07/01/2018 Archive Date 03 /05 /2021 H. REFERENCES1. Telemedicine | Medicaid.gov. (2017, December 1). Retrieved December 1, 2017 from https://www.medicaid.gov/medicaid/benefits/telemed/index.html 3. OAC – 5160-1-18 Telemedicine. (2015, January 2). Retrieved December 1, 2017 from http://codes.ohio.gov/oac/5160-1-18 4. Fee Schedule Rates-App endix DD to rule 5160-1-60. (2017, January 1). Retrieved December 1, 2017 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 5. OAC – 4757-5-13 Standards of practice and professional conduct: electronic service delivery (internet, email, teleconference, etc.). (2016, July 1). Retrieved December 1, 2017 from http://codes.ohio.go v/oac/4757-5-13 6. Chapter 5160-27 Community Mental Health Agency Services. (2017, January 1). Retrieved December 1, 2017 from http://codes.ohio.gov/oac/5160-27 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. 96116 Neurobehavioral Status Exam 96118 Neuropsychological Testing H0036 Community Psychiatric Supportive Treatment Individual or Group H0001 SUD Assessment H0004 SUD Individual Counseling H0005 SUD Group Counseling H0006 SUD Case Management Q3014 Telehealth originating site facility fee Modifier Description GT Via interactive audio and video telecommunication systems 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 10/31/2013 07/01/2019 01/01/2018 Policy Name Policy Number Acupuncture Services PY-0152 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 4 Acupuncture Services OHIO MEDICAID PY-0152 Effective Date: 01/01/2018 2 A. SUBJECT Acupuncture Services B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Acupuncture is an ancient Chinese method of treatment based on the theory that stimulation of specific key points on or near the skin by the insertion of needles or by other methods improves vital energy flow. The term acupuncture describes a variety of methods and styles to stimulate specific anatomic points in the body. Acupuncture is used to relieve pain, to induce surgical anesthesia, or for therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatment. C. DEFINITIONS Acupuncturist-is an individual who holds at least a valid certificate to practice as an acupuncturist or a valid certificate to practice as an oriental medicine practitioner. Chiropractor-is a chiropractor who holds a certificate to practice acupuncture issued by the state chiropractic board. Other individual medicaid provider-is a physician assistant or an advanced registered nurse practitioner that has a valid certificate as an acupuncturist. Physician-is a physician that has completed medical training in acupuncture with a current and active designation, or an equivalent designation, as a diplomate in acupuncture from the national certification commission for acupuncture and oriental medicine. D. POLICY I. CareSource reimburses for acupuncture services according to the criteria found in the Ohio Administrative Code (OAC) 5160-8-51. II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. III. In accordance with OAC 5160-8-51, acupuncture services are only reimbursable for the following conditions: A. Migraines. B. Low back pain. IV. Participating providers must be one of the following: A. A physician that has completed medical training in acupuncture with a current and active designation, or an equivalent designation, as a diplomate in acupuncture from the national certification commission for acupuncture and oriental medicine. B. A chiropractor with a valid certificate to practice acupuncture. Acupuncture Services OHIO MEDICAID PY-0152 Effective Date: 01/01/2018 3 C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant with a valid certificate as an acupuncturist. V. Limitations: A. No separate reimbursement will be made for both an evaluation and management service and an acupuncture service performed by the same provider to the same individual on the same day. B. No separate reimbursement will be made for services that are an incidental part of a visit (providing instruction on breathing techniques, diet, or exercise). C. No reimbursement will be made for additional treatment in either of the following circumstances: 1. Symptoms show no evidence of clinical improvement after an initial treatment period; or 2. Symptoms worsen over a course of treatment. Note: Although CareSource does not require a prior authorization for the first 30 visits for acupuncture services, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio state Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) F. RELATED POLICIES/RULES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/31/2013 New Policy. Date Revised 10/31/2013 06/06/2016 02/08/2018 New allowed service. Date Effective 01/01/2018 Acupuncture Services OHIO MEDICAID PY-0152 Effective Date: 01/01/2018 4 H. REFERENCES 1. Appendix DD to rule 5160-1-60. (2018, January 1). Retrieved 1/22/2018 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 2. Lawriter-OAC-5160-8-51 Acupuncture services. (2018, January 1). Retrieved 1/22/2018 from http://codes.ohio.gov/oac/5160-8-51v1 3. Lawriter-ORC. (2013, March 22). Retrieved 1/22/2018 from http://codes.ohio.gov/orc/4762 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 MEDICAIDOriginal Issue Date Next Annual Review Effective Date 06/10/2015 0 6 /01/2019 0 6 /01/2018 Policy Name Policy Number Preferred Obstetrical Services PY-0004 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 7 F.RELATED POLICIES/RULES ……………………………………………………………………. 7 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 8 H.REFERENCES ………………………………………………………………………………………… 8Archived Preferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 2 A.SUBJECT Obstetrical Services Ohio Medicaid does not currently reimburse for global obstetrical services coding and/or billing. Because of this, CareSource also does not reimburse for global obstetrical services coding and/or billing unless the providers contract has been specifically negotiated to include those codes and rates. This policy addresses reimbursement for obstetrical services for those providers whose CareSource contracts do not include negotiated global obstetrical services codes and rates. B. BACKGROUND Maternity care or obstetrical services refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. Maternity care services include care during the prenatal period, labor, birthing, and the postpartum period. CareSource reimburses for obstetrical services members r e c e i v e i n a h o s p i t a l o r b i r t h i n g c e n t e r a s w e l l as all as sociated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedur al Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. DEFINITIONS Advanced practice nurse-The recently endorsed Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education defines four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS) and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). Current Procedural Terminology (CPT) – The answer to most obstetrical billing questions can be found in the Physicians Current Procedural Terminology (CPT) manual or the CPT Assistant Archives (1990 present). Maternity Care and Delivery is a subsection of the Surgery section of the CPT book codes. A n understanding of the global package services is needed to code Maternity Care and Delivery Services correctly. Elective Delivery-is performed for a nonmedical reason. Some nonmedical reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in the last weeks of pregnancy, or are past their due date and not naturally in labor yet. Some women request a cesarean delivery because they fear vaginal birth. (American Congress of Obstetricians and Gynecologists, 2015) Fetal death-means death prior to the complete expulsion or extraction from its mother of a product of conception, which after such expulsion or extraction, does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. “Fetal death” does not include termination of the pregnancy. (OAC 3701-7- 01 (L), Fetal death ) High Risk Maternity-Maternity care complicated by a documented condition during the patients pregnancy requiring direct face-to-face practitioner care beyond the usual service. Infertility-is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 3 produce conception, in either case, after at least one year of trying to do so. (CareSource internal definition) Lactation consultant-means an individual who holds credentials as an “International board certified lactation consultant.” (OAC 3701-7-01 (Q), Lactation consultant ) Maternity home-means a facility for pregnant girls and women where accommodations, medical care, and social services are provided during the prenatal and postpartum periods. Maternity home does not include a private residence where obstetric or newborn services are received by a resident of the home. (OAC 3701-7-01 (W), Maternity home) Maternity Period-For billing purposes, the obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period ( 56 days after vaginal delivery, 60 days after C-section ). Medically necessary-services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (OAC 5160-10-02) Non-Obstetric E/M service: Visit(s) occurring outside the regularly scheduled antepartum period during which the same physician or physician group and/or other health care professional providing maternity care, also provides services for a non-obstetric condition such as bronchitis, flu, or upper respiratory infection. Physician-means an individual authorized under Chapter 4731 of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery . (OAC 3701-55-01 (I), Physician) Physician group, Physician group practice means a clinic or an obstetric clinic either with an electronic health record ( EHR), or where there is no EHR, but one member record and each physician/nurse practitioner/nurse midwife seeing that member has access to the same member record and makes entries into the record as services occur. All locations of a multi-location clinic with an EHR (or one patient record) are considered the same physician group practice. Preconception care-means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. D. POLICY I. Prior Authorization Prior authorization is not required for the preferred obstetrical and maternity services covered under this policy. NOTE : Although the preferred obstetrical and maternity services covered by this policy do not require 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. II.Maternity Coverage-General A. Maternity services must be furnished under the supervision of a physician or certified advanced practice nurse midwife. Maternity services enable beneficiaries to voluntarily choose a provider within the CareSource network for maternity care and postpartum care . For billing purposes, the Maternity Obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period ( 56 days after vaginal delivery and 60 days after C-section ). 1. Covered services include office visits for a complete exam, pharmaceuticals (including some over the counter [OTC] products with a prescription), such as prenatal vitamins or medication related to gestational diabetes, and fetal ultrasound services are provided by or under the supervision of a medical doctor, osteopath, or eligible maternity provider. 2. Maternity services may include the following: 2.1 Pregnancy testing/laboratory tests. 2.2 Office visits. ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 4 2.3Ultrasounds 2.4 Fetal delivery. 2.5 Postpartum visits. III. Criteria for Itemized Billing A. Antepartum Care Only 1. The CPT Editorial Board created codes 59425 (Antepartum care only; 4-6 visits) and 59426 (Antepartum care only; 7 or more visits) to account for the following situations when all of the routine antepartum care is not provided by the same physician, physician group, and/or other health care professional: 1.1 The member has a change of insurer during her pregnancy. 1.2 The member has received part of her antenatal care elsewhere e.g. from another physician or physician group practice. 1.3 The member leaves her care with your group practice before the global obstetrical care is complete. 1.4 The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery. 1.5 The member has an unattended, precipitous delivery . Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy). 2. CareSource will reimburse for the antepartum care only CPT codes 59425 or 59426 when reported by same group physician and/or other health care professional as follows: 2.1 A single claim submission of CPT code 59425 or 59426 for the antepartum care only (one unit). 2.2 The initial, office visit in which the pregnancy is confirmed may be reported and separately reimbursed when the antepartum record has not been initiated. 2.3 The dates should document the range of time covered by the visits. For example, if the patient had a total of 4-6 antepartum visits then the physician and/or other health care professional should report CPT code 59425 with the “from and to” dates for which the services occurred. B. Delivery Services Only 1. Delivery begins with the passage of the fetus and the placenta from the womb into the external world. 1.1 Delivery only codes are: a. 59409-Vaginal delivery only (with or without episiotomy and/or forceps. b. 59514-Cesarean delivery only. c. 59612-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps). d. 59620-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery. 2. Items Included in the Delivery Services 2.1 Labor and delivery services are based on the need of each individual patient and can include, but are not limited to the types of services listed in this section. 2.2 The following services are included in the delivery services codes and will not be reimbursed separately: a. Admission to the hospital. b. The admission history and physical examination. c. Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician. d. Intravenous (IV) induction of labor via oxytocin (CPT codes 96365-96367). e. Delivery of the placenta; any method. f. Repair of first or second degree lacerations. ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 5 2.3Insertion of cervical dilator (CPT 59200) is included in the delivery services and will not be separately reimbursed if performed on the same date of delivery. 2.4 Third and fourth degree lacerations should be identified by appending modifier 22 to the delivery codes. Claims submitted with modifier 22 must include medical record documentation which supports the use of the modifier; please refer to the Increased Procedural Services section of this policy, Section III-I. C. Postpartum Care Only 1. The postpartum care only code should be reported by the physician, physician group, or other health care professional who provides the patient with services of postpartum care only. If a physician provides any component of antepartum along with postpartum care, but does not perform the delivery, then the services should be itemized by using the appropriate antepartum care code (see Antepartum Care Only Section III-A) and postpartum care code 59430. 2. The CPT code for postpartum care only is 59430-Postpartum care only (separate procedure). 3. CareSource follows ACOG guidelines and considers the postpartum period to be six weeks following the date of the cesarean or vaginal delivery. Postpartum care includes hospital and office visits following any type of delivery, and can include any number of visits. Each of these visits can be reported with procedure code 0503F. 4. The following services are included in postpartum care and are not separately reimbursable services: 4.1 Uncomplicated outpatient visits related to the pregnancy. 4.2 Discussion of contraception. 5. Evaluation and management of problems or complications related to the pregnancy are services not included in postpartum care and will be reimbursed separately, in addition to code 59430. D. Delivery including Postpartum Care 1. Sometimes a physician performs the delivery and postpartum care with minimal or no antepartum care. In these instances, claims should include codes for vaginal and cesarean section deliveries that encompass both of these services. 2. Delivery plus postpartum care codes are: 2.1 59410-Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care. 2.2 59515-Cesarean delivery only; including postpartum care. 2.3 59614-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care. 2.4 59622-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care. 3. The delivery only including postpartum care codes should be reported by the same physician, physician group, or other health care professional for a single gestation when: 3.1 The delivery and postpartum care services are the only services provided 3.2 The delivery and postpartum care services are provided in addition to a limited amount of antepartum care (e.g., CPT code 59425) 4. The following services are included in delivery only including postpartum care code and are not separately reimbursable services: 4.1 Hospital visits related to the delivery during the delivery confinement. 4.2 Uncomplicated outpatient visits related to the pregnancy. 4.3 Discussion of contraception. E. Non-Obstetric Care When a member is seen for a condition unrelated to pregnancy (e.g., bronchitis, flu), these E/M visits are considered Non-Obstetric E/M services and can be reported as they occur. The diagnosis code used in conjunction with the E/M service should support the non-obstetric condition being treated and/or evaluated. CareSource will reimburse non-ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 6 obstetric care and related office E/M services during the entirety of the pregnancy and maternal care; use appropriate diagnosis codes identifying the condition is not related to pregnancy care, and the appropriate modifiers (generally, modifier 24). F. Risk Appraisal-Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. G. Delivery of Multiple Gestations CareSource follows ACOG coding guidelines for vaginal, cesarean section, or a combination of vaginal and cesarean section deliveries of multiple births (twins, triplets, etc.) . Use appropriate codes and modifiers regarding the delivery of and work associated with multiple births. H. Fetal Non-Stress Test CareSource will reimburse for fetal non-stress testing, including for multiple non-stress tests on a single fetus on the same day, or on multiple gestations, as medically necessary. I. Increased Procedural Services 1. When the work required providing a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. The determination of reimbursement for obstetrical services submitted with modifier 22 is based on individual review of clinical documentation that supports use of the modifier identifying an increased procedural service per CPT modifier guidelines. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physician and mental effort required). 2. For information regarding additional payment of E/M services that go beyond the typical number encountered in an average pregnancy, please refer to the High Risk/Complications section of this policy. J. Limitations on Elective Obstetric Deliveries 1. Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria: 1.1 Gestational age of the fetus must be determined to be at least thirty-nine weeks; or, 1.2 If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery. NOTE: Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary, will not be reimbursed. K. Non-Comprehensive Maternity Visits CareSource reimburses providers for maternity management services including E/M (office) visits and consultations for the purpose of health of the member and developing fetus for best outcomes. L. Maternity Services Not Reimbursed 1. Home pregnancy tests; 2. Ultrasounds performed only for determination of sex of the fetus or to provide a keepsake picture; 3. Three and four dimensional ultrasounds; 4. Paternity testing; Archived Preferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 7 5.Lamaze classes; 6. Birthing classes; 7. Parenting classes; and, 8. Home tocolytic infusion therapy. E. CONDITIONS OF COVERAGE CODE DESCRIPTION 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps); 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59412 External cephalic version, with or without tocolysis 59414 Delivery of placenta (separate procedure) 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59430 Postpartum care only (separate procedure) 59514 Cesarean delivery only; 59515 Cesarean delivery only; including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care 0500F Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care, report also date of visit and in a separate field, the last date of menstrual period LMP) 0501F Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period-LMP (Not e: If reporting 0501F prenatal flow sheet, it is not necessary to report 0500F initial prenatal care visit) 0502F Subsequent prenatal care visit (excludes: patients who are seen for a condition unrelated to pregnancy or prenatal care [e.g., an upper respi ratory infection; patients seen for consultation only, not for continuing care]) 0503F Postpartum care visit F. RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 6/10/2015 ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 8 Date Revised 10/18/2017 Updated codes, template. Date Effective 0 6 /01/2018 H. REFERENCES 1. Current Procedural Terminology. (2015, June 1). Retrieved June 11, 2015, from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page 2. Guideline Suggestions for Elective Labor Induction. (2012). Retrieved June 11, 2015, from http://www.acog.org/-/media/Districts/District-I/20120120-ElectiveIOLGuideline.pdf?dmc=1&ts=20150611T0857437601 3. Ohio Administrative Code. (2015). Retrieved June 11, 2015, from http://codes.ohio.gov/oac/3701-40-01 4.American Association of Critical Care Nurses Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education, 2015. 5. OAC Rule 5160-1-10 Limitations on Elective Obstetric Deliveries. 6. OAC Rule 5160-21 Preconception Care Services. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
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