Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedu res. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Reimbursement Modifiers PY-0715 09/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 10 F. Related Policies/Rules …………………………………………………………………………………………… 10 G. Review/Revision History …………………………………………………………………………………………. 10 H. References …………………………………………………………………………………………………………… 10 2 A. SubjectReimbursement Modifiers Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while othe r modifiers are used to report additional information, to the code description, of the product or service. Although CareSource accepts the use of modifiers specific to this policy, not all modifiers are included within this policy. The modifiers included w ithin this policy are those modifiers that affect the reimbursement of a service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must be made available upon CareSources request. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.C. Definitions Current Procedural Terminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT c odes. Modifier-two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. Modifier 22-Increased Procedural Services A. Modifier 22 is used to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required. The extra work may be identified by appending modifier 22 to the usual procedure code. B. Procedure codes with modifier 22 appended may be reimbursed up to 120% of the fee schedule amount. Note: This modifier is not appended to E/M services (99201-99499). Claims for 99201-99499 with modifier 22 will be denied. Medical records ARE required with the3 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019claim and must support the use of this modifier. Claims with procedures including 22 and no supporting documentation will be denied. II. Modifier 50-Bilateral Procedures A. Professional Claims Only Append modifier 50 to the appropriate unilateral code on a single claim line and indicate 1 unit in the unit field of that claim line.B. Modifier 50 applies to surgical procedures (CPT codes 10040-69990) and to radiology procedures performed bilaterally. C. Applies to any bilateral procedure performed on both sides at the same session. D. The use of modifier 50 is NOT appropriate in the following situations: 1. Using modifier 50 on a bilateral procedure performed on different areas of the right and left sides of the body. 2. Appending modifier 50 to a procedure code that is defined by CPT as primarily bilateral or a bilateral service. 3. Appending modifier 50 to a surgical CPT code, the description of which contains the words one or both. E. Do not report two line items to indicate a bilateral procedure. F. Procedure code with modifier 50 appended will reimburse 1 unit at 150% of the fee schedule amount. III. Modifier 51-Multiple Procedures A. Modifier 51 is used to report multiple procedures, other than E/M services, are performed at the same session by the same individual, the primary procedure or service is reported as listed.B. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). C. Modifier 51 should not be appended to designated "add-on" codes. D. Procedure code with modifier 51 appended will reimburse 50% of the fee listed on the Medicaid Physician Fee Schedule for the service. IV. Modifier 52-Reduced services A. Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. 1. Modifier 52 is used for reporting reduced services when the procedure was terminated after the patient was prepped and brought to the room where the service was to be performed.B. Modifier 52 may be used to report reduced radiology procedures. 1. The correct reporting is to assign the CPT code to the extent of the procedure performed. 2. This modifier is used only to report a radiology procedure that has been reduced when no other code exists to report what has been done. 3. Report the intended code with modifier 52. i. Example, if the planned procedure is a two-view chest x-ray and only one view of the chest is performed, do not report CPT code 71020-52 (for x-ray chest, two views-reduced service). Instead, report CPT code 71010 (x-ray chest, single view). ii. Example, if a barium swallow is not completed because the patient cannot handle the barium, report CPT code (74270-52). C. Modifier 52 does not provide for reimbursement of an ineligible service. D. For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. E. Procedure code with modifier 52 appended will reimburse at 50% of the fee schedule amount. 4 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. The extenuating circumstances preventing the completion of the procedure must also be documented.V. Modifier 53-Discontinued Procedure A. Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued after anesthesia is administered to the patient.2. Modifier 53 is used to ind icate that the physician terminated a surgical/diagnostic procedure due to the patients well-being. B. This modifier is not used to report an elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. C. Modifier 53 cannot be used when a laparoscopic or endoscopic procedure is converted to an open procedure. D. Modifier 53 does not provide for reimbursement of an ineligible service. E. Modifier 53 cannot be appended to E/M codes. F. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. G. Procedure code with modifier 53 appended will reimburse at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. Documentation must include a statement indicating at what point the procedure was discontinued. The extenuating cir cumstances preventing the completion of the procedure must also be documented.VI. Modifier 54-Surgical Care Only A. Modifier 54 is reported when one physician performed a surgical procedure only; another physician provides the preoperative and/or postoperative management.B. Modifier 54 must only be appended to the surgical procedure code. C. Procedure code with modifier 54 appended will reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.VII. Modifier 55-Postoperative Management Only A. Modifier 55 is reported when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by appending modifier 55 to the procedure code.B. Modifiers 55 must only be appended to the surgical procedure code. C. Procedure code with modifier 55 appended will reimburse at 15% of the fee schedule amount. 5 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. VIII. Modifier 56-Preoperative Management Only A. Modifier 56 is reported when 1 physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code.B. Modifiers 56 must only be appended to the surgical procedure code. C. Procedure code with modifier 56 appended will reimburse at 15% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.IX. Modifier 62-Two Surgeons A. Modifier 62 is reported when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure. 1. Each surgeon must report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons.2. Each surgeon must report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported without the modifier 62 added. 3. If a co-surgeon acts as an assistant in the performance of additional proc edure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or 82 added, as appropriate. B. Procedure code with modifier 62 appended will be reimbursed at 62.5% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.X. Modifier 66-Surgical Team A. Modifier 66 is reported when three or more surgeons work together during a highly complex procedure are carried out under the "surgical team" concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure code used for reporting services.B. Claims submitted by team surgeons are identified with modifier 66. C. The Centers for Medicare & Medicaid Services (CMS) established a Team Surgery Indicator (TEAM SURG) found in the CMS National Physician Fee Sche dule Relative Value File. Values are: 1. 0-Team surgeons not permitted for this procedure. 2. 1-Team surgeons may be paid; supporting documentation is required to establish medical necessity. 3. 2-Team surgeons permitted. 4. 9-Team surgeon concept does not apply. D. Codes with CMS Team Surgery Indicators of 0 and 9 should not be billed with modifier 66. E. Modifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate procedure not included in the team surgery. 6 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019F. Only one surgeon maybe be considered the primary surgeon. CareSource will not reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon. G. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. H. Procedure code with modifier 66 appended will reimburse at 150% of the established fee, divided equally between the team surgeons. I. For team surgery with three surgeons, each surgeon will be reimbursed at 50% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XI. Modifier 73-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia A. Modifier 73 is reported to a service to indicate that due to extenuating circumstances or those that threaten the well-being of the patient, a surgical or diagnostic procedure at an outpatient hospital or ambulatory surgical center (ASC) was discontinued prior to the administration of anesthesia. B. Modifier 73 is only appropriate for use by an ASC. C. Modifier 53 should not be used for any ASC service as the modifier is used exclusively on a professional claim. D. Procedure code with Modifier 73 appended will reimburse at 50% of the ASCs fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XII. Modifier 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) ProcedureAfter Administration of Anesthesia A. Modifier 74 is reported when due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia or after the procedure was started (incision made, intubation started, scope inserted.) B. Modifier 74 is not appropriate for the elective cancellation or postponement of a procedure based on the physician or patients choice. C. Modifier 74 is not appropriate when the termination of the procedure occurs prior to the beginning of the procedure or the administration of anesthesia. D. Modifier 74 is not for physician use. It is only appropriate for the ASC. E. Procedure code with modifier 74 appended will be reimbursed at 100% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier.XIII. Modifier 78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period A. Modifier 78 is reported to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure).7 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/20191. When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. 2. Modifier 78 should be appended when: i. The return to the operating room is unplanned. ii. The service is performed by same physician who performed the initial procedure. iii. The service is related to the initial procedure. iv. The service is performed during the postoperative period of the initial procedure (10-90 days). B. Procedure code with modifier 78 appended will be reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. XIV. Modifier 80-Assistant Surgeon A. Modifier 80 is reported to indicate surgical assistant services by a physician and is applied to the surgical procedure code(s).B. Assistant Surgeon provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated. C. Modifier 80 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 80 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XV. Modifier 81-Minimum Assistant Surgeon A. Modifier 81 is reported to indicate minimum surgical assistant services and is applied to the surgical procedure code(s).B. Minimum Assistant Surgeon is an assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon. C. Modifier 81 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 81 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XVI. Modifier 82-Assistant Surgeon (when qualified resident surgeon not available) A. Modifier 82 is reported to indicate when surgical assistance is needed, but a qualified resident was not available. B. Modifier 82 is used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable. 8 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019C. The unavailability of a qualified resident surgeon is a prerequisite for the use of this modifier. The assistant must provide documentation (certification) stating that a qualified resident was not available for this procedure and why the resident was not available. D. Procedure code with modifier 82 appended will be reimbursed at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery and why a qualified resident was not available. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XVII. Modifier AA-Anesthesia services performed personally by an anesthesiologist A. Modifier AA is used to report when the anesthesia services are personally performed by an Anesthesiologist. B. Procedure code with modifier AA appended will be reimbursed at 100% of the fee schedule amount. XVIII. Modifier AD-Anesthesia services supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. A. Modifier AD is used to report when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures.B. Procedure code with modifier AD appended will be reimbursed at 100% of the fee schedule amount. XIX. Modifier QK-Medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. A. Modifier QK is used to report when medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals.B. Procedure code with modifier QK appended will be reimbursed at 50% of the fee schedule amount. XX. Modifier QX-Anesthesia services performed by a CRNA with medical direction by an anesthesiologist. A. Modifier QX is used to report when the anesthesia services are performed by a CRNA with medical direction by an anesthesiologist.B. Procedure code with modifier QX appended will be reimbursed at 50% of the fee schedule amount. XXI. Modifier QY-Anesthesia services when an Anesthesiologist medically directs one CRNA. A. Modifier QY is used to report when an Anesthesiologist medically directs one CRNA.B. Procedure code with modifier QY appended will be reimbursed at 50% of the fee schedule amount. XXII. Modifier QZ-Anesthesia services performed personally by a CRNA without medical direction by a physician. A. Modifier QZ is used to report when the anesthesia services are personally performed by a CRNA.B. Procedure code with modifier QZ appended will be reimbursed at 100% of the fee schedule amount. XXIII. Modifier AE-Registered dietician9 A. B.Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019Modifier AE is reported to indicate when a registered dietician provides the service. Procedure code with modifier AE appended will be reimbursed at 85% of the fee schedule amount. XXIV. Modifier AS-Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) served as the assistant at surgery. A. Modifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in place of another surgeon.B. Procedure code with modifier AS appended will be reimbursed at 25% of the base code allowable schedule before multiple surgery reductions are taken. No multiple surgery reductions will be taken on codes with the AS modifier. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied.XXV. Modifier JG-Drug or biological acquired with 340B drug pricing program discount A. Providers are required to report modifier JG on the same claim line as the drug or biological HCPCS code to identif y if a drug or biological was acquired under the 340B Program. B. HCPCS code with modifier JG appended will reimburse at the average sales price (ASP) minus 22.5% for certain separately payable drugs or biologicals that are acquired through the 340B Program. XXVI. Modifier JW-Drug amount discarded (wasted)/not administered to any patient A. CareSource will consider reimbursement for: 1. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended.2. The wasted amount when billed with the amount of the drug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSource will NOT consider reimbursement for: 1. The wasted amount of a multi-dose vial drug. 2. Any drug wasted that is billed when none of the drug was administered to the patient. 3. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. XXVII. Modifier SA-Nurse practitioner (NP) rendering service in collaboration with a physician A. Modifier SA is reported to indicate when a supervising physician is billing on behalf of an ANP, or CRNFA for non-surgical services. B. Modifier SA is used when the ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier SA appended will be reimbursed at 85% of the fee schedule amount. XXVIII. Modifier TB-Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes. A. Modifier TB must be reported to identify if a drug or biological was acquired under the 340B Program.B. The use of modifier TB will not trigger a payment adjustment. Providers will receive the average sales price (ASP), plus 6% for separately payable drugs furnished. 10 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/2019XXIX. Modifier TC-Technical Component A. Technical component charges are institutional charges and not billed separately by physicians.B. A charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding Modifier TC to the usual procedure code. XXX. Modifier UD Physician Assistant (PA) rendering service in collaboration with a physician A. Modifier UD is reported to indicate when a supervising physician is billing on behalf of a PA for non-surgical services.B. Modifier UD is used when the PA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier UD appended will be reimbursed at 85% of the fee schedule amount. XXXI. Modifier 26-Professional Component A. Certain procedures are a combination of a physician component and a technical component.B. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. Note: In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2019 New policyDate Revised Date Effective 09/01/2019 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References11 Reimbursement Mo difiers OHIO MEDICAID PY-0715 Effective Date: 09/01/20191. Appendix to rule 5160-4-21. (2016, June 30). Retrieved 3/22/2019 from https://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/5160-4-21-phffnapp1-20160630-1045.pdf 2. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 3/22/2019 from https://s3.amazonaws.com/biopolicy/portal/fab42153-0f1f-4ea9-9db6-263c144aa972?response-content-disposition=inline%3B%20filename%3D%2259485-1143476.pdf%22&response-content-type=application%2Fpdf&X-Amz-Content-Sha256=e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWB6UVO57LSG6L2A%2F20190322%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190322T142429Z&X-Amz-SignedHeaders=Host&X-Amz-Expires=1800&X-Amz-Signature=689299099b6b1cc8481ca23fce721228a74bfef30ea4bc2e95a7cd5870bd298d 3. CPT overview and code approval. (2019, March 22). Retrieved from https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval 4. Medicare Claims Processing Manual Chapter 12-Physicians/Nonphys ician Practitioners. (2018, November 30). Retrieved February 18, 2019 from https ://www .cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 5. Medicare Claims Processing Manual Chapter 14-Ambulatory Surgical Centers. (2017, December 22). Retrieved February 18, 2019 from https ://www.c ms.go v/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf. 6. Modifiers Recognized by Ohio Medicaid. (2018, November 1). Retrieved from https://medic aid.ohio.gov/Portals/0/Resources/Publications/Guidance/BillingInstructions/Modif iersODM.pdf 7. Optum360 EncoderProForPayers.com-Login. (2019, February 18). Retrieved February 18, 2019 from https:// www.encoderprofp.com/epro4payers/allModifiersHandler.do?_k=101*0&_a=listRelate d&menu=4. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Emerg ency Department Electrocardiogram (EKG/ECG) Interpretation PY-0793 0 8 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource ) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbu rsement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreemen t, and applicable ref erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unctio n of a body organ or part, or signif icant pain and discomf ort. These services meet the standar ds of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage ma ndate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling d ocument used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. …….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………. 3 H. References ………………………….. ………………………….. ………………………….. …………………………. 4 Archived Em ergenc y Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICAID PY-0793 Effective Date: 0 8 /01/2019 2 A. Subject Eme rge ncy De pa rtme nt Ele ctroca rdiogra m ( EKG /ECG) Inte rpre ta tion B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a membe r and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. An electrocardiogram (EKG/ECG) is a non-invasi ve test that records the electrical activity of the heart . It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardiogram (EKG/ECG) may need t o be performed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspe cts together as one service. C. Definitions Eme rge ncy me dica l condition-is a medical condition with sudden severity and onset that in the absence of immediate medical attention could placing the patient’s health in serious jeopardy. This includes labor an d delivery, but not r outine prenatal or postpartum care, or services related to an organ transplant procedure. Ele ctroca rdiogra m (EKG/ECG) is a test that records the electrical activity of the heart . For the purpose of this policy EKG will be used to represent both EKG and ECG. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs completed in the Emergency Department (Place of service (POS) 23) . A. Regardless of POS, the modifier appended to the CPT code determines a duplicate servi ce. II. CareS ource will reimburse the first EKG claim that is received for the member of the date of service. A. If another claim for the same service EKG is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. B. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member. 1. Example: 93010 is received and is reimbursed. Another 93010 claim is received for the same date of service and is denied as duplicate service. C. If a second EKG is medically necessary, on the same date of service, to determine a cardiac change before the member is discharged, modifier 76 or modifier 77 must be appended to the s ec ond EKG for reimburs ement. Archived Em ergenc y Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICAID PY-0793 Effective Date: 0 8 /01/2019 3 1. Example: 93010 is received and r eimbursed. Another 93010 is completed and submitted for reimbursement. The second 93010 has modifier 76 or 77 (whichever is applicable) appended (93010-76 or 93010-77) to distinguish between the first and second EKG performed on the same member on the sa me date of service. III. CareSource expects providers to work with other departments, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual Ohio Medicaid fee schedule for appropriate codes. The follow ing list(s) of code s is provide d a s a re fe re nce . This list ma y not be a ll inclusive a nd is subje ct to upda te s. CPT Code Description 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation an d report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93227 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional F. Related Policies/Rules N/A G. Review/Revision History DAT EACT ION Da te Issue d 10/31/2013 Revision Da te Re vise d 3/20/2019 Updated template and code reference Da te Effe ctive 0 8 /01/2019 Archived Em ergenc y Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICAID PY-0793 Effective Date: 0 8 /01/2019 4 H. References 1. Appendix DD to rule 5160-1 – 60 (Non-Institutional Fee Schedule). (2019, January 1). Retrieved 3/12/2019 from https://medicaid.ohio.gov/Portals/0/Pro vid ers/Fe eSched ule Rates/Ap p-DD.p d f 2. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/ he alth-to pics/electrocar diog ram 3 . Lawriter-OAC-5160-2 – 21.1 Consumer co-payments for non-emergency emergency department services. (2015, April 1). Retrieved 3/12/2019 from http://codes.ohio.gov/oac/5160-2 – 2 1.1 v1 The Reimburs ement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. I nd e pe n de nt m ed i ca l r e v iew 2/2015 Archived
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Medical Drug Reimbursement Rates PY-0794 07/14/2019-12/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Stat ement ………………………….. ………………………….. ……………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherencet o plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly for the convenience of the member or provid er. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict betw eenthis Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectMedical Drug Reimbursement Rates Med ical Drug Reimbursemen t Rates OHIO MEDICAIDPY-0794 Effective Date: 07/14/2019 B. Background Reim bursem ent policies are designed to assist you when subm itting claim s to CareSource. They are routinely updated to prom ote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of paym ent. Reim bursement f or claim s m ay be subject to lim itations and/or qualif ications. Reim bursem ent will be established based upon a review of the actual services provided to a m em ber and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encourag ed to use self-service channels to verif y m em bers eligibility. It is the responsibility of the subm itting provider to subm it the m ost accurate and appropriateCPT/HCPCS code(s) f or the product or service that is being provided. The inclus ion of a code in this policy does not im ply any right to reim bursem ent or guarantee claim s paym ent. C. Def initions Average Wholesale Price (AWP) – is the m anuf acturer’s list price of the drug when sold to the wholesaler. Average Sales Price (ASP) a rate that is calculated by the m anuf acture on a quarterly basis and subm itted to Medicare. Medicare then places these rates in a f ile and uploads to the Medicare Part BDrug Average Sales Price Drug Pricing Files tab on cm s.gov. D. PolicyI. This is a reim bursem ent policy that outlines reim bursem ent rates f or drugs that are billed and adm inistered in the f ollowing places of service under the m em bers m edical benef it only when drug reim bursem ent rates are not specif ically called out in the provider contr act or the drug code is not listed on the Ohio Medicaid Fee Schedule: A. Place of Service 11 Of f ice 1. Medicares ASP (Average Sales Price) plus 6% B. Place of Service 12 Hom e 1. Manuf actures AWP (Average Wholesale Price) m inus 15% C. Place of Service 22 On Cam pus-Outpatient Hospital 1. Manuf actures AWP (Average Wholesale Price) m inus 15% E. Conditions of CoverageReim bursem ent is dependent on, but not lim ited to, subm itting Ohio Medicaid approved HCPCS and CPT codes along with appropriate m odif iers. Please ref er to the individual Ohio Medicaid f ee schedule f or appropriate codes. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 04/09/20193 Med ical Drug Reimbursemen t Rates OHIO MEDICAIDPY-0794 Effective Date: 07/14/2019 Date Revised Date Effective 07/14/2019 Date Archived 12/31/2021 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erencesThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 10/01/2019 12/01/2017-02/19/2020 Policy Name Policy Number Transthoracic Echocardiogram PY-0181 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medicalnecessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral,authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …….. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ……. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ………. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …………. 2 D. POLICY ………………………….. ………………………….. ………………………….. …………………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………….. 2 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 Tran sth o racic Ech ocardiogramOHIO MEDICAID PY-0181 Effective Date: 12/01/2017 2A. SUBJECT Transthoracic Echocardiogram B. BACKGROUNDReimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy cla rification. These proprietary p o licies are no t a g uarantee of p ayment. Reimbursement for claims may b e subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accur ate and ap propriateCPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a code d o es not imply any rig ht to reimbursement or g uarantee claims payment. CareSo urce will reimburs e participating p roviders, for transthoracic echocardiograms (TTE)rend ered to CareSource members, as set forth in this policy.C. DEFINITIONS Transtho racic E chocardiogram (TTE) – is a typ e o f echo cardiogram, in which an ultrasound p ro b e (o r ultraso nic transducer) is p laced o n the chest o r ab d o men o f the p atient to o btain vario us views of the heart. D. POLICYI. CareSo urce d oes no t req uire a p rior authorization for a transthoracic echocardiogram (TTE). II. A transtho racic echocardiogram may be reimbursed according to Centers f or Medicare andMedicaid Services (CMS) LCD 34338 g uidelines using appropriate CPT and modifier codes(if ap p licable). III. A transtho racic echocardiogram may be reimbursed according to Medicaid g uidelines usingap p ro priate CPT and /or HCPCS and modifier codes (if applicable).IV. Reimb ursement is based o n submitting a claim with the appropriate ICD-10 d iagnosis codeto matc h the transthoracic echocardiogram CPT code.V. If the ap p ropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim willb e d enied .Note: Altho ug h a transthoracic echocardiogram d oes not require a p rior authorization,co mp liance with the provisions in this policy may b e monitored and addressed through post p ayment data analysis and subsequent medical review audits. E. CONDITIONS OF COVERAGEReimb ursement is dependent o n, b ut not limited to, submitting CMS ap proved HCPCS and CPT co d es alo ng with appro priate modifiers. Please refer to the Ohio Medicaid fee schedule. http ://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf Tran sth o racic Ech ocardiogramOHIO MEDICAID PY-0181 Effective Date: 12/01/2017 3F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 03-08-2017 New p o licy.Date Revised 11-14-2018 LCD L34337 has b een rescinded and rep laced with LCD L34338 . Up d ated in Section D. II. o f the p olicy 4-2-2019 Remo ved code matching tables from policy. CareSo urce f ollows LCD L34338. Updated CMS LCDlink link was b ro ken.Date Effective 12-01-2017 Date Archived 02/19/2020 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and Care Source reserves the right to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. Ap p endix DD to rule 5160-1-60. (2017, January 1). Retrieved 2/6/2017 from http ://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 2. Echo cardiogram : MedlinePlus Medical Encyclopedia. (2015, April 20). Retrieved 2/6/2017f rom https://medlineplus.gov/ency/article/003869.htm 3. Current Pro ced ural Terminology (CPT) and National Uniform Billing Co mmittee (NUBC) Licenses. Retrieved 4/2/2019 from https://www.cms.gov/medicare-coverage – d atab ase/details/lcd – d etails.aspx?LCDId=34338&ver=21&Date=12%2f17%2f2018&DocID=L34338&bc=iAAAABAAAAAA& The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12/01/2017 Policy Name Policy Number Non-Invasive Vascular Studies PY-0 163 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to mem ber benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guideli nes. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er pr olonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are no t provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If the re is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT ………………………….. ………………………….. ………… 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ………….. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………………… 2B. BACKGROUND ………………………….. ………………………….. ………………………….. …………….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. ……………….. 2 D. POL IC Y ………………………….. ………………………….. ………………………….. ………………………… 2 E. COND ITIONS OF COVERA GE ………………………….. ………………………….. …………………. 3 F. RELATED POL IC IES/RUL ES ………………………….. ………………………….. ……………………. 4 G. REVIEW /REV IS ION HIS TORY ………………………….. ………………………….. ………………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……………… 4 Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 2 A. SUBJECT Non-Invasive Vascular Studies B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary p olicies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Heal th care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or servi ce that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse providers, for non-invasive vascular studies to CareSource member s, as set forth in this policy. Non-invasi ve vascular studies may be used interchangeably with Duplex scan or Duplex ultrasound for the purposes of this policy. C. DEFINITIONS A duplex ultrasound is a test to see how blood moves through the arteries and veins of the body. D. POLICY I. CareSource does not require a prior authorization for a non-invasive vascular study. Note : Although a Non-Invasi ve Vascular Study does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and c omplete documentation must be presented at the time of review to validate medical necessity. II. A non-invasive vascular study may be reimbursed according to CMS/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the non-invasi ve vascular study CPT code . IV. I f the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. V. To be considered medically necessary the ordering physician must have reasonable expectation that the non-invasi ve vascular study results will potentially impact the clinical management of the patient. VI. To be considered medically necessary the following c onditions must be met: A. Significant signs/symptoms of arterial or venous disease are present B. The information is necessary for appropriate medi cal and/or surgical management C. The test is not redundant of other diagnostic procedures that must be per f ormed Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 3 VII. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/App-DD.pd f The follow ing list(s) of code s is provide d a s a re fe re nce . This list ma y not be a ll inclusive a nd is subje ct to upda te s. Ple a se re fe r to the a bove re fe re nce d source for the most curre nt coding informa tion. CPT Code s De finition 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93970 Duplex scan of extremity veins inc luding responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 93980 Duplex scan of arterial inflow and venous outflow of penile ves sels; complete study 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 93998 Unlisted noninvasive vascular diagnostic study ICD-10 De finition I 70.0 Atherosclerosis of aorta I 72.4 Aneurysm of artery of lower extremity S85.142A Laceration of anterior tibial artery, left leg, initial encounter S45.002A Unspecified injury of axillary artery, left side, initial encounter Q87.82 Arterial tortuosity syndrome S85.819A Laceration of other blood vessels at lower leg level, unspecified leg, initial encounter Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 4 I82.419 Acute embolism and thrombosis of unspecified femoral vein S35.319S Unspecified injury of portal vein, sequela F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HIST ORY DAT EACT ION Da te Issue d 03-08-2017 Da te Re vise d 04-02-2 019 Revised the link to the CMS LCD below Da te Effe ctive 12-01-2017 H. REFERENCES 1. Appendix DD to rule 5160-1 – 60. (2017, January 1). Retrieved 2/6/2017 from http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/App-DD.pd f 2. Duplex Ultrasoun d | Society for Vascular Surgery. (2017, February 10). Retrieved 2/10/2017 from https://vascular.org/patient-reso urces/ vascular-tests/duplex-ultraso un d 3. MedlinePlus-Search Results for: ultrasound. (2017, February 10). Retrieved 2/10/2017 from https://vsearch.nlm.nih.gov/ vi visimo/cgi-bi n/qu ery-meta?v%3Aproject=medline plus& v%3Asou rces=medlin epl us-bundle&query=ultrasound& _g a=1.23 90 609 34.7 98 803 35 4.14 84 937 05 2 4. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2017, January 1). Retrieved 4/2/2019 from https://www.cms.gov/medic are-coverage-data base/d etails/lcd-details.aspx?LCDId=3404 5& ver=2 2&Date=12% 2f17%2 f201 8&DocID=L3 40 45&Se arch Typ e=Advanced&bc=KAAAABAAAAAA& The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 05/01/2018 05/01/2017-06/30/2021 Policy Name Policy Number Vitamin D Assay Testing PY-0226 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 3 Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 2 A. SUBJECTVitamin DAssay TestingB. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most ac curate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Although an excess of vitamin Dis rar e it can lead to hypercalcemia. Vitamin Ddeficiency may lead to numerous disorders, the most widely known is rickets. Assessing patients vita min Dlevels is achieved by measuring the level of 25-hydroxyvitamin D. Evaluation of other metabol ites is generally not medically necessary. C. DEFINITIONS Severe deficiency: 25(OH)D: 80 ng/ml D. POLICY I. CareSource does not require a prior authorization for Vitamin Dtesting. II. CareS ource considers Vitamin Dlevels testing medically necessary for patients with the following: A. Chronic kidney disease stage III or greater B. Osteoporosis C. Osteomalacia D. Osteopenia E. Hypocalcemia F. Hypercalciura G. Hypoparath yroidism H. Malabsorption states I. Cirrhosis J. Hypervitaminosis DK. Osteosclerosis/petrosis L. Rickets M. Low exposure to sunlight N. Vitamin Ddeficiency to monitor the efficacy of replacement therapy III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the Vitamin Dtesting CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted as primary for the CPT code line, the claim will be denied. Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 3Note: Althou gh this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity.E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list ma y not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information.CPT Codes Definition 82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED ICD 10 codes DescriptionE20.0 Idiopathic hypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E21.0-E21.3 Primary hyperparathyroidism-Hyperparathyroidism, unspecified E41 Nutritional marasmus E43 Unspecified severe protein-calorie malnutrition E55.0 Rickets, active E55.9 Vitamin Ddeficiency, unspecified E67.3 Hypervitaminosis D E67.8 Other specified hyperalimentation E68 Sequelae of hyperalimentation E83.31 Familial hypophosphatemia E83.32 Hereditary vitamin D-dependent rickets (type 1) (type 2) E83.39 Other disorders of phosphorus metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E84.0 Cystic fibrosis with pulmonary manifestations E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations E89.2 Postprocedural hypoparathyroidism K50.00 Crohn's disease of small intestine without complications Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 4K50.011 Crohn's disease of small intestine with rectal bleedingK50.012 Crohn's disease of small intestine with intestinal obstruction K50.013 Crohn's disease of small intestine with fistula K50.014 Crohn's disease of small intestine with abscess K50.018 Crohn's disease of small intes tine with other complication K50.111 Crohn's disease of large intestine with rectal bleeding K50.112 Crohn's disease of large intestine with intestinal obstruction K50.113 Crohn's disease of large intestine with fistula K50.114 Crohn's disease of large intestine with abscess K50.118 Crohn's disease of large intestine with other complication K50.80 Crohn's disease of both small and large intestine without complications K50.811 Crohn's disease of both small and large intestine with rectal bleeding K50.812 Crohn's disease of both small and large intestine with intestinal obstruction K50.813 Crohn's disease of both small and large intestine with fistula K50.814 Crohn's disease of both small and large intestine with abscess K50.818 Crohn's disease of both small and large intestine with other complication K50.90 Crohn's disease, unspecified, without complications K50.911 Crohn's disease, unspecified, with rectal bleeding K50.912 Crohn's disease, unspecified, with intestinal obstruction K50.913 Crohn's disease, unspecified, with fistula K50.914 Crohn's disease, unspecified, with abscess K50.918 Crohn's disease, unspecified, with other complication K51.00 Ulcerative (chronic) pancolitis without complications K51.011 Ulcerative (chronic) pancolitis with rectal bleeding K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chronic) pancolitis with fistula K51.014 Ulcerative (chronic) pancolitis with abscess K51.018 Ulcerative (chronic) pancolitis with other complication K51.20 Ulcerative (chronic) proctitis without complications K51.211 Ulcerative (chronic) proctitis with rectal bleeding K51.212 Ulcerative (chronic) proctitis with intestinal obstruction K51.213 Ulcerative (chronic) proctitis with fistula K51.214 Ulcerative (chronic) proctitis with abscess K51.218 Ulcerative (chronic) proctitis with other complication Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 5K51.30 Ulcerative (chronic) rectosigmoiditis without complicationsK51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula K51.314 Ulcerative (chronic) rectosigmoiditis with abscess K51.318 Ulcerative (chronic) rectosigmoiditis with other complication K51.40 Inflammatory polyps of colon without complications K51.411 Inflammatory polyps of colon with rectal bleeding K51.412 Inflammatory polyps of colon with intestinal obstr uction K51.413 Inflammatory polyps of colon with fistula K51.414 Inflammatory polyps of colon with abscess K51.418 Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K51.511 Left sided colitis with rectal bleeding K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.514 Left sided colitis with abscess K51.518 Left sided colitis with other complication K52.0 Gastroenteritis and colitis due to radiation K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K74.1 Hepatic sclerosis K74.2 Hepatic fibrosis with hepatic sclerosis K76.9 Liver disease, unspecified K90.0 Celiac disease K90.1 Tropical sprue K90.2 Blind loop syndrome, not elsewhere classified K90.3 Pancreatic steatorrhea K90.41 Non-celiac gluten sensitivity K90.49 Malabsorption due to intolerance, not elsewhere classified K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.2 Postsurgical malabsorption, not elsewhere classified Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 6M80.00XA Age-related osteoporosis with current path ological fracture,unspecified site, initial encounter for fracture M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture M80.08XA Age-relat ed osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M83.0-M83.5 Puerperal osteomalacia-Other drug-induced osteomalacia in adults M83.8 Other adult osteomalacia M85.80 Other specified disorders of bone density and structure, unspecified site M85.811 Other specified disorders of bone density and structure, right shoulder M85.812 Other specified disorders of bone density and structure, left shoulder M85.821 Other specified disorders of bone density and structure, right upper arm M85.822 Other specified disorders of bone density and structure, left upper arm M85.831 Other specified disorders of bone density and structure, right forearm M85.832 Other specified disorders of bone density and structure, left forearm M85.841 Other specified disorders of bone density and structure, right hand Vitamin DAssay Testing OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 7M85.842 Other specified disorders of bone density and structure, left handM85.851 Other specified disorders of bone density and structure, right thigh M85.852 Other specified disorders of bone density and structure, left thigh M85.861 Other specified disorders of bone density and structure, right lower leg M85.862 Other specified disorders of bone density and structure, left lower leg M85.871 Other specified disorders of bone density and structure, right ankle and foot M85.872 Other specified disorders of bone density and structure, left ankle and foot M85.88 Other specified disorders of bone density and structure, other site M85.89 Other specified disorders of bone density and structure, multiple sites M89.9 Disorder of bone, unspecified M94.9 Disorder of cartilage, unspecified N18.3-N18.6 Chronic kidney disease, stage 3 (moderate) – End stage renal disease N25.81 Secondary hyperparathyroidism of renal origin Q78.2 Osteoporosis AUTHORIZATION PERIODF. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 03-08-2017Date Revised 03/19/2019 Updated code list based on revised LCD Date Effective 05/01/2017 Date Archi ved 06/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. REFERENCES1. Local Coverage Determination (LCD) Vitamin DAssay Testing (L33996). Retrieved March 19, 2019 2. Vitamin DInsufficiency. Retrieved March 2, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912737/ The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 07/01/2013 01/02/2020 02/02/2019 Policy Name Policy Number Bilateral Procedures PY-0012 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable ref erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT …………………………………………………………………. 1 TABLE OF CONTENTS ……………………………………………………………………………………………….. 1 A. SUBJECT …………………………………………………………………………………………………………… 2 B. BACKGROUND ………………………………………………………………………………………………….. 2 C. DEFINITIONS …………………………………………………………………………………………………….. 2 D. POLICY2 E. COND ITIONS OF COVERAGE ………………………………………………………………………….. 4 F. RELATED POL IC IES/RULES …………………………………………………………………………….. 4 G. REVIEW /REV IS ION HIS TORY…………………………………………………………………………… 4 H. REFERENCES …………………………………………………………………………………………………… 4 Bilateral Procedures Ohio Medicaid PY-0012 Effective Date: 02/02/2019 2 A. SUBJECT Bilateral Procedures B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. C. DEFINITIONS Bila te ra l proce dure s-are defined as surgical operations performed on both the right and left side of a patient’s body during the same operative session requiring separate sterile fields and a separate surgical incision. Modifie r-is a reporting indicator used in conjunction with a CPT code to denote that a medical service or procedure that has been performed has been altered by a specific circumstance while remaining unchanged in its definition or CPT code. D. POLICY I. CareSource will reimburse for bilateral procedures when medically necessary. II. CareSource will reimburse for bilateral procedures when providers submit their claim with appropriate CPT/HCPCS codes and modifier. A. Modifier 50 is used to report bilateral procedures (procedures described with the same CPT code) that are performed at the same operative session by the same physician on bilateral body structures (identical anatomic sites on opposite sides of the body). The use of modifier 50 is applicable only to services and/or procedures performed on identical anatomic sites or organs (e.g., eyes, ears, kidneys). B. Modifiers LT and RT may also be used to report services rendered on identical anatomic sites; however the use of these modifiers is not interchangeable with use of modifier 50. Modifiers LT and RT should only be used when the bilateral surgery rules do not apply. The bilateral surgery rules apply to procedures with a bilateral indicator of 1, as defined by the Centers for Medicare & Medicaid (CMS). When the fee schedule has a bilateral indicator of 0 or 3, as defined by CMS, use modifiers LT and RT to describe procedures performed on identical anatomic sites. 1. A bilateral procedure is reported on one line using modifier 50. Use a quantity entry of one when modifier 50 is reported. Do not submit two line items to report a bilateral procedure using modifier 50. 2. Modifier 50 should not be used to report diagnostic and radiology facility services. 3. Institutional claims received for an outpatient radiology service appended with modifier 50 will be denied. III. Surgical codes that are considered bilateral codes but are performed unilaterally on only one side of the body should be billed on one line unmodified or on one line with either the LT or the RT modifier indicating the side of the body on which the procedure was performed. Bilateral Procedures Ohio Medicaid PY-0012 Effective Date: 02/02/2019 3 A. Modifiers LT or RT are required when appropriate to identify: 1. Hospital procedures performed on identical anatomic sites on the right and left sides of the body (e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries). 2. A procedure is performed on only one side. 3. Hospital diagnostic test and radiology services performed on the right and left sides of the body. NOTE: Use of modifiers applies to services/procedures performed on the same calendar day. NOTE: CareSource will reimburse for bilateral procedures when the proper modifiers 50, LT, and RT are used. Modifier 50 is not to be utilized if the CPT code description specifies the procedure as bilateral. IV. Surgical codes that are considered bilateral codes but are performed more than once on one or each side of the body and/or body part indicated by the code definition must be billed using only the LT and RT modifiers on each line to demonstrate the procedure was performed more than once on one or each side. V. Although bilateral indicators 0 and 3 can be billed with the LT and RT modifiers, there are some differences between the two indicators; A. Some codes with an indicator of 0 may be performed more than once on a given day. However, even if performed on opposite sides of the body, these services would never be considered bilateral. B. Codes with an indicator of 0 can never be billed with modifier 50. C. Codes with an indicator of 3 can be billed with LT or RT. These services are generally radiologic and other diagnostic services. D. Codes that have an indicator of 0 that are billed using LT or RT receive reimbursement for a single code. VI. The CareSource maximum for bilateral procedures is 150% of the contracted amount allowed for the same procedures performed unilaterally when the code is billed on a single line with the 50 modifier. Bilateral Indicator Definition Submission Instructions 0 Bilateral surgery payment rules do not apply, do not use modifier 50. Do not submit these procedures with CPT modifier 50. 1 Bilateral surgery payment rules apply (150%). Use modifier 50 if bilateral. Units = 1 Submit the procedure on a single detail line with CPT modifier 50 and a quantity of 1. 2 Bilateral surgery payment rules do not apply. Already priced as bilateral. Do not use modifier 50. Units = 1 Submit the procedure with a quantity of 1. Do not submit these procedures with CPT modifier 50. 3 Bilateral surgery payment rules do not apply. Do not use modifier 50. Units = 1 or 2. Do not submit these procedures with CPT modifier 50. 9 Bilateral concept does not apply. Do not submit these procedures with CPT modifier 50. Bilateral Procedures Ohio Medicaid PY-0012 Effective Date: 02/02/2019 4 E. CONDITIONS OF COVERAGE AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DAT EACT ION Da te Issue d 07/01/2013 Da te Re vise d 01/02/2019 Revision to indicator 3 Da te Effe ctive 02/02/2019 H. REFERENCES 1. Surgical services. (2015, July 03). Retrieved August 15, 2016, from http://codes.ohio.gov/oac/5160-4-22. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDIC AID Policy Name Policy Number Effective Date Readmission PY-0 724 07/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimburse ment Polic y Sta teme nt : Reimburse ment Policies prepared b y CSMG Co. a nd its a ffiliates (inc luding CareSource) a re inte nded to pro vide a genera l refere nce regardi ng billi ng, coding a nd doc ume nta tion g uidelines. Coding methodolog y, regulator y requirem e nts , ind us try-s tanda rd claims editing logic, bene fits design a nd other fac tors are co nsidered in de velopi ng Reimburse ment Po licies. In addition to this Polic y, Reimburseme nt of services is subjec t to me mber be nefits a nd eligibility o n the da te of service , medical necessity, ad here nce to pla n policies a nd procedures, claims editing logic, pro vider co ntrac tual agreeme nt, a nd app licable re ferral, authori zatio n, notification and utili zatio n manageme nt g uidelines . Medically necessary services i nclude, b ut are no t limited to , those health care services or s upplies that are proper a nd necessary fo r the diagnosis or treatme nt o f disease, illness, or i njury a nd witho ut which the patie nt can be e xpected to s uffer pro longed , i ncreased o r ne w morbidity, impairme nt o f func tion, d ys function of a body orga n or part, or sig nificant pain a nd discomfort. These services meet the sta ndards of good medical practice i n the local area, are the lo west cost alternati ve, and are not pro vided mainly for the co nvenie nce o f the me mber o r p rovider. Medically necessary se rvices also i nclude those services defi ned in any federa l or state co verage ma ndate , Evidence o f Cove rage docume nts , Medical Policy State ments, Pro vider Ma nuals , Me mber Ha ndbooks, a nd/or other policies and proced ures. This Policy does no t e ns ure a n a utho rizatio n or Reimb urseme nt of se rvices. Please refer to the pla n co ntract (often referred to as the Evidence o f Coverage) for the service(s) re fere nced herein. If there is a conflict be twee n this Polic y a nd the pla n c o ntract ( i.e. , Evidence of Co verage), the n the pla n co ntract ( i.e . , Evidence of Coverage) will be the contro lli ng document used to make the determina tion. CSMG Co. a nd its a ffiliates ma y use reasonab le discretio n in interpre ting a nd applying this Polic y to services pro vided in a particular case a nd ma y modify this Polic y a t a ny time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Backgro und ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………. 5 G. Review/Revisio n History ………………………….. ………………………….. ………………………….. ………. 5 H. References ………………………….. ………………………….. ………………………….. ………………………… 5 Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 2 A. Subject Readmission B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims of Readmissions for our Medicare Advantage members may be subject to limitatio ns and/or qualifications. Reimbursement will be established based upo n a review of the actual services provided to a member and will be determined when the claim is received for pro cessing. Health care providers and their office staff are enco uraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the prod uct or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Follo wing a hospitalizatio n, readmissio n within 30 days is often a costly preventable event and is a qua lity of care issue . It has been estimated that readmissio ns within 30 days of discharge can cost health plans more than $1 billion dollars o n an annual basis. Readmissions can result from many situatio ns but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progressio n of the disease state or due to chro nic conditions. The p urpose of this policy is to improve the quality of inpatient and transitio nal care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communicatio n between the patient, caregivers and clinicia ns, 2. provide the patient with the education needed to maintain their care at home to prevent a readmissio n, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission : a subsequent inpatient admissio n to any acute care facility which occurs within 30 days of the discharge date; excluding planned admissio ns. Planned Readmission : a no n-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Clinically-Related Readmission Chain: is a series of admissions for the same patient where the underlying reaso n for readmission is related to the care rendered during or within thirty days following a prior hospital admission. A clinically-related readmissio n may have resulted from improper or incomplete care during the initial admission or discharge planning process. The hospital where the initial admission occurred is responsible for the clinically-related readmission chain. Hospitalization Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 3 resulting from an unpreventable or unrelated event occurring after discharge and planned readmissions are not considered clinically-related. Potentially Preventable Readmission (PPR): a readmissio n within a specific time frame that is clinically related and may have been prevented had appropriate care been provided during the initial hospital stay and discharge process. A PPR is determined when, based o n CareSource guidelines, it is determined that the patient was discharged prematurely. Premature discharge evidence can be described as, but not limited to, elevated fever at the time of discharge, abnormal lab results or evidence of infection or bleeding a wound. Only admission: an admission where there was neither a prior initial admissio n nor a clinically-related readmissio n within the thirty day read missio n period Same or Similar Condition : a conditio n or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented o n the initial admissio n. Same Day : CareSource deli neat es same day as midnight to midnight of a sin gle day . D. Polic y I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observatio nal services for the following : A. Readmissions that are potentially preventable as determined by the provision of appropriate care co nsistent with the criteria outlined below: 1. A medical readmission for a continuation or recurrence of the reaso n for the initial admission due to lack of care , or for a closely related condition (e.g., a readmissio n for diabetes following an initial admission for diabetes). 2. A medical readmission for an acute decompensation of a chronic problem that was not the reaso n for the initial admissio n, bu t was plausibly related to the lack of care rendered either during or immediately after the initial admission (e.g., a readmission for diabetes in a patient whose initial admission was for an acute myocardial infarction). 3. A medical readmission for an acute medical compli c ation plausibly related to the lack of care rendered during the initial admissio n (a patient with a hernia repair and a perioperative Foley catheter readmitted for a urinary tract infection 10 days later). 4. A readmission for a surgical procedure to address a continuatio n or a recurrence of the problem causing the initial admission (a patient readmitted for an appendectomy following an initial admission for abdominal pain and fever). 5. A readmission for a surgical procedure to address a complication resulting from the lack of care rendered during the initial admission (a readmission for drainage of a post-operative wound abscess following an initial admission for a bowel resection). B. Readmission s for a condition or procedure that is clinically-related to the care provided during the prior discharge or resulting from inadequate discharge planning during the prior discharge. Archived Readmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 4 C. Readmissions when t he PPR chain may co ntain o ne or more readmissions that are clinically-related to the initial admission. If the first re admission is within thirty days after the initial admissio n, the thirty day timeframe may begin again at the discharge of either the initial admission or the most recent readmission clinically-related to the initial admission . D. Readmission is to the same or to any other hospital. II. Any readm issio n that occurs within one calendar day (i.e. same day or next day) , to the same institutio n, is considered one discharge for payment purposes and will be reimbursed as one DRG payment per the OAC 5160-2 – 65. III. Readmis sions, for the purposes of determining PPRs, excludes the following circumstances: A. The original discharge was a patient initiated discharge, was against medical advice (AMA), and the circumstances of such discharge and readmission are documented in the pat ient’s medical record. B. The original discharge was for the purpose of securing treatment of a major or metastatic malignancy, major trauma, neo natal and obstetrical admission, transplant or HIV. C. Only admissions, which are defined in the definitions of this policy. Planned readmissio ns are considered "o nly admissio ns. IV. Prior authorizatio n of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim . V. Post Payment Review and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissio ns to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical reco rds for both admissions must be included with the claim submission to determine if the admission (s) is appropriate or is considered a readmissio n. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. If the incl uded documentation determines the readmission to be an inappropriate, medically unnecessary or potentially preventable admission , the hospital must be able to provide additio nal documentation to CareSource upo n request or the claim will be denied. c. If the readmissio n is determined at the time of documentatio n review to be a preventable readmissio n, the reimbursement for the read mission will be combined with the initial admission and paid as o ne claim to cover both, or all, admissions. 2. Appeals Process ArchivedReadmission OHIO MED IC AID PY-0724 Effective Date: 07/01/2019 5 a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer revie w or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS f ee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT ION Date Issued 04/01/2019 Date Revised Date Effective 07/01/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803. 2. Hospital Readmission Reduction Pro gram. (2018, December 04). Ret rieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://www.cms.gov 4. Goldfield, N. I., McCullough, E. C., Hughes, J. S., Tang, A. M., Eastman, B., Rawlins, L. K., & Aver ill, R. F. (2008). Identifying potentially preventable readmissions. Retrieved from https://www.ncbi.nlm. nih.gov The Re im burseme nt Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r e cei v e d due c on si d e ra t i o n a s d e f i n e d i n the Re im burseme nt Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Streptococcus A and BInfection PY-0452 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 4 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H. REFERENCES ………………………………………………………………………………………… 4 Molecular Diagnostic Testing for Streptococcus A and BInfection OHIO MEDICAID PY-0452 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Streptococcus A and BInfection B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Illnesses caused by Streptococcus A include Pharyngitis (strep throat), Scarlet Fever, Acute Rheumatic Fever and Post Streptococcal Glomerulonephritis. Illnesses caused by Streptococcus Binclude Bacteremia, Sepsis, Pneumonia, skin and soft tissue infections, bone and joint infections, meningitis (although this is a rare occurrence in adults). Screening for Streptococcus Bshould be done between 35 and 37 weeks in every pregnant women, as it is most commonly passed to newborns during the birthing process. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy when the following criteria are met: a. Conventional testing, such as the rapid strep test (throat culture), has been performed with a negative result on the same date of service as the requested molecular diagnostic test, AND; b. The member presents with cardinal streptococcus A and/or Bsymptoms to include but not limited to: i. red, swollen tonsils ii. white or yellow coating or patches on the tonsils iii. sore throat iv. difficult or painful swallowing v. fever vi. bad breath vii. stiff neck viii. enlarged, tender glands (lymph nodes) in the neck Molecular Diagnostic Testing for Streptococcus A and BInfection OHIO MEDICAID PY-0452 Effective Date: 12/01/2018 3 II. CareSource considers Molecular Diagnostic Testing by PCR for Streptococcus A and Streptococcus Binfection appropriate as the first line of testing only when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy . IV. Conventional testing, such as the rapid strep test (throat culture) for Streptococcus A; cultures of sterile body fluids and/ or vaginal and rectal cultures in pregnant women for Streptococcus B, are viewed as effective, low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. CONDITIONS OF COVERAGE CODE DESCRIPTION 87651 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 87653 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique A38.0 Scarlet fever with otitis media A38.1 Scarlet fever with myocarditis A38.8 Scarlet fever with other complications A38.9 Scarlet fever, uncomplicated A40.0 Sepsis due to streptococcus, group A A40.3 Sepsis due to Streptococcus pneumoniae A40.8 Other streptococcal sepsis A40.9 Streptococcal sepsis, unspecified A41.9 Sepsis, unspecified organism B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere G00.2 Streptococcal meningitis I00 Rheumatic fever without heart involvement I01.0 Acute rheumatic pericarditis I01.1 Acute rheumatic endocarditis I01.2 Acute rheumatic myocarditis I01.8 Other acute rheumatic heart disease I01.9 Acute rheumatic heart disease, unspecified J02.0 Streptococcal pharyngitis J03.00 Acute streptococcal tonsillitis, unspecified J03.01 Acute recurrent streptococcal tonsillitis J13 Pneumonia due to Streptococcus pneumoniae J15.4 Pneumonia due to other streptococci J20.2 Acute bronchitis due to streptococcus M72.6 Necrotizing fasciitis N00.9 Acute nephritic syndrome with unspecified morphologic changes A40.1 Sepsis due to streptococcus, group BB95.1 Streptococcus, group B, as the cause of diseases classified elsewhere J15.3 Pneumonia due to streptococcus, group BO99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester Molecular Diagnostic Testing for Streptococcus A and BInfection OHIO MEDICAID PY-0452 Effective Date: 12/01/2018 4 O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium O99.820 Streptococcus Bcarrier state complicating pregnancy O99.824 Streptococcus Bcarrier state complicating childbirth O99.825 Streptococcus Bcarrier state complicating the puerperium P23.3 Congenital pneumonia due to streptococcus, group BP36.0 Sepsis of newborn due to streptococcus, group BZ05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Z22.330 Carrier of Group Bstreptococcus F. RELATED POLICIES/RULES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/7/2018 Removed O99.5 Date Effective H. REFERENCES 1. Group BStrep | GBS | Home | Streptococcus | CDC. (2018, May 29). Retrieved July 23, 2018, from www.cdc.gov/groupbstrep. 2. Group A Strep | Home | Group A Streptococcus | GAS | CDC. (2016, September 16). Retrieved July 23, 2018, www.cdc.gov/groupAstrep. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/2019 12/01/2018-12/31/2020 Policy Name Policy Number Molecular Diagnostic Testing for Respiratory Virus PY-0451 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …….. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ……. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ………. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …………. 2 D. POLICY ………………………….. ………………………….. ………………………….. ………………….. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. ………….. 3/4 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 Mo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 A. SUBJECTMolecular Diagnostic Testing for Respiratory Virus B. BACKGROUND Mo lecular testing, following a d iagnosis or suspected diagnosis can help guide appropriate therap y b y id entifying specific therapeutic targ ets and appropriate p harmaceutical interventions. Mo lecular d iagnostic testing utilizes Polymerase Chain Reaction (PC R), a g enetic amplification techniq ue that only requires small q uantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory p rocessing time. Knowing the gene seq uence, or at minimum the b orders of the ta rget segment of DNA to b e amplified, is a p rereq uisite to a successful PCR amplification of DNA. Mo lecular Diagnostic testing for the respiratory viruses known as Adenovirus, Influenza Virus,Co ro navirus, Metapneumovirus, Parainfluenza Virus, Respiratory Syncytial Virus (RSV) and Rhino virus can be utilized in the p resence of symptoms such as cough, fever, headache, fatigue, rhino rrhea, p haryngitis and a g eneral unwell feeling, that wo uld create a clinical picture of a resp irato ry virus. Molecular Diagnosti c testing for respiratory viruses is no t indicated for every p atient that presents with these signs and symptoms, as treatment is generally the same for all of the viruses and resolve with little to no p harmacological treatment, except in immuno compromised p atients. All f acilities in the United States that perform laboratory testing on human specimens for health assessment or the d iagnosis, prevention, o r treatm ent of disease are reg ulated under the Clinical Lab o ratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared b y the FDA for ho me use and those tests ap proved for waiver und er the CLIA criteria. Although CLIA req uires that wai ved tests must be simple and have a lo w risk for erro neous results, this d o es not mean that waived tests are completely erro r-proof. CareSource may p eriodically req uire review of a providers office testing p olicies and p rocedures when p erforming CLIA-waiv ed tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a g enetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services o r supplies needed to d iagnosis o r treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of med icine. D. POLICYI. No Prio r Authorization is req uired for the Molecular Diagnostic Testing by PCR addressed in this p o licy. II. CareSo urce considers Molecular Diagnostic Testing by PCR for Respiratory Virus medically necessary when submitted with any combination of the CPT and diagnosis codes listed in the Co nd itions of Coverage in this policy III. CareSo urce d oes no t consider Molecular Diagnostic Testing by PCR for Respiratory Virus to b e med ically necessary when b illed with any o ther d iagnosis code and will no t p rovide reimb ursement for those services. IV . Co nventional testing, such as rap id antigen di rect tests, d irect fluorescent antibody testing and cultures, are viewed as low cost and should b e utilized b efore the higher cost Molecular Diag no stic Testing by PCR. 3 E. CON DITIONS OF COVERAGEMo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 CODE DESCRIPTION 87631 Inf ectious agent d etection b y nucleic acid (DNA or RNA); respiratory virus (eg , adenovirus, influenza virus, coronavirus, metapneumovirus, p arainf luenza virus, respiratory syncytial virus, rhinovirus), includes multip lex reverse transcription, when p erformed, and multiplex amp lified probe technique, multiple types or subtypes, 3-5 targ ets 87632 Inf ectious agent d etection b y nucleic acid (DNA or RNA); respiratory virus (eg , adenovirus, influenza virus, coronavirus, metapneumovirus, p arainf luenza virus, respiratory syncytial virus, rhinovirus), includes multip lex reverse transcription, when performed, and multiplex amp lified probe technique, mu ltiple types or subtypes, 6-11 targ ets 87633 Inf ectious agent d etection b y nucleic acid (DNA or RNA); respiratory virus (eg , adenovirus, influenza virus, coronavirus, metapneumovirus, p arainf luenza virus, respiratory syncytial virus, rhinovirus), includes multip lex reverse transcription, when performed, and multiplex amp lified probe technique, multiple types or subtypes, 12-25 targets B30.2 Viral p haryng oconjunctivitis B34.0 Ad eno virus infection, unspecified B34.2 Co ro navirus infection, unspecified B97.0 Ad eno virus as the cause of d iseases classified elsewhere B97.21 SARS-associated coro navirus as the cause of d iseases classified elsewhere B97.29 Other co ro navirus as the cause of diseases classified elsewhere B97.4 Resp iratory syncytial virus as the cause of d iseases classified elsewhere B97.81 Human metap neumovirus as the cause of d iseases classified elsewhere B97.89 Other viral ag ents as the cause of diseases classified elsewhere J00 Acute nasopharyngitis [common cold] J05.0 Acute o bstructive laryngitis [cro up] J06.9 Acute up per respiratory infection, unspecified J09.X1 Inf luenza d ue to identified novel influenza A virus with p neumonia J09.X2 Inf luenza d ue to identified novel influenza A virus with other respiratory manif estations J09.X3 Inf luenza d ue to identified novel influenza A virus with g astrointestinal manif estations J09.X9 Inf luenza d ue to identified novel influenza A virus with o ther manif estations J10.00 Inf luenza d ue to other id entified influenza virus with unspecified type of p neumo nia J10.01 Inf luenza d ue to other id entified influenza virus with the same o ther id entified influenza virus p neumonia J10.08 Inf luenza d ue to other id entified influenza virus with other specified p neumo nia J10.1 Inf luenza d ue to other id entified influenza virus with other respiratory manif estations J10.2 Inf luenza d ue to other id entified influenza virus with gastro intestinal manif estations J10.81 Inf luenza d ue to other id entified influenza virus with encephalopathy J10.82 Inf luenza d ue to unidentified influenza virus with myocarditis 4 Mo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 J10.83 Inf luenza d ue to other id entified influenza virus with otitis media J10.89 Inf luenza d ue to other id entified influenza virus with other manif estations J11.00 Inf luenza d ue to unidentified influenza virus with unspecified type of p neumo nia J11.08 Inf luenza d ue to unidentified influenza virus with specified pneumonia J11.1 Inf luenza d ue to unidentified influenza virus with other respiratory manif estations J11.2 Inf luenza d ue to unidentified influenza virus with g astrointestinal manif estations J11.81 Inf luenza d ue to unidentified influenza virus with encephalopathy J11.82 Inf luenza d ue to unidentified influenza virus with myocarditis J11.83 Inf luenza d ue to unidentified influenza virus with otitis media J11.89 Inf luenza d ue to unidentified influenza virus with other manifestations J12.0 Ad eno viral pneumonia J12.1 Resp iratory syncytial virus p neumonia J12.2 Parainf luenza virus pneumonia J12.3 Human metap neumovirus pneumonia J12.81 Pneumo nia due to SARS-associated coronavirus J12.9 Viral p neumonia, unspecified J20.4 Acute b ronchitis due to parainfluenza virus J20.5 Acute b ronchitis due to respiratory syncytial virus J20.6 Acute b ronchitis due to rhinovirus J21.0 Acute b ronchiolitis d ue to respiratory syncytial virus J21.9 Acute b ronchiolitis, unspecified O98.511 Other viral d iseases complicating pregnancy, first trimester O98.512 Other viral d iseases complicating pregnancy, second trimester O98.513 Other viral d iseases complicating pregnancy, third trimester O98.519 Other viral d iseases complicating pregnancy, unspecified trimester O98.52 Other viral d iseases complicating childbirth O98.53 Other viral d iseases complicating the puerperium O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unsp ecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium F. RELATED POLICIES/RULESN/A 5 G. REVIEW/REVISION HISTORYMo lecular Diag n o stic Testin g fo r Resp iratory VirusOHIO MEDICAID PY-0451 Effective Date: 12/01/2018 DATE ACTIONDate Issued 12/01/2018Date Revised 11/07/2018 Up d ated the next review d ate to 12/01/2019 Date Effective 12/01/2018 Date Archived 12/31/2020 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. NREVSS | Home | National Respiratory and Enteric Virus Surv System | CDC. (2018, August 14). Retrieved August 16, 2018, from https:// www.cdc.gov/surveillance/nrevss/index.html. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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