Global Obstetrical Services

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 06/10/2015 03/22/2018 05/03/2017 Policy Name Policy Number Global Obstetrical Services PY-0001 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t 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 functi on, dysfunction of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 5 E.CONDITIONS OF COVERA GE ………………………………………………………………… 10 F.RELATED POLICIES/RULES ………………………………………………………………….. 11 G.REVIEW/REVISION HISTORY ………………………………………………………. ……….. 11 H.REFERENCES ………………………………………………………………………………………. 11Archived Global Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 2 A.SUBJECT Global Obstetrical Services Note: It is expected that the provider will use the appropriate Evaluation and Management (E/M) codes. Select level based upon the history, examination, and medical decision making documented in the record for that visit. CareSource will only pay services billed as Global or Partial or Split Global in accordance with state guidelines and contract requirements. B. BACKGROUND Maternity care or obstetrical services refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. Maternity care services include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e i v e i n a h o s p i t a l o r b i r t h i n g c e n t e r a s w e l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. DEFINITIONS Advanced practice nurse-The recently endorsed Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education defines four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS) and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). o Education The model calls for all APRNs to be educated in an accredited graduate-level education program in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatric , neonatal, womens health/gender-related or psych/mental health. o Certification All APRNs must pass a national certification exam that measures APRN role and population-focused competencies. APRNs will be required to maintain continued competence as evidenced by recertification in the role and population through a national certification program. Under the new APRN regulatory model all CNSs will be educated and assessed through national certification processes across the continuum from wellness through acute care. o Licensure Advanced practice registered nurses will be licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. Licensure will be required because these APRNs will be practicing in a role beyond that of the Registered Professional Nurse. 2015 American Association of Critical-Care Nurses Current Procedural Terminology (CPT) – The answer to most obstetrical billing questions can be found in the Physicians Current Procedural Terminology (CPT) manual or the CPT Assistant Archives (1990 present). Maternity Care and Delivery is a subsection of the Surgery section of the CPT book codes. An understanding of the global ArchivedGlobal Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 3 package services is needed to code Maternity Care and Delivery Services correctly. (ama-assn.org) Elective Delivery-is performed for a nonmedical reason. Some nonmedical reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in the last weeks of pregnancy. Some women request a cesarean delivery because they fear vaginal birth. (American Congress of Obstetricians and Gynecologists, 2015) Fetal death-means death prior to the complete expulsion or extraction from its mother of a product of conception, which after such expulsion or extraction, does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. “Fetal death” does not include termination of the pregnancy . (OAC 3701-7- 01 (L), Fetal death) Guidelines for perinatal care-means the sixth edition of the “Guidelines for perinatal care” issued by the American academy of pediatrics and the American congress of obstetricians and gynecologists. (OAC 3701-7-01 (M), Guidelines for perinatal care) High Risk Maternity-Maternity care complicated by a documented condition during the patients pregnancy requiring direct face-to-face practitioner care beyond the usual service. Infertility-is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to produce conception, in either case, after at least one year of trying to do so. (CareSource internal definition) Lactation consultant-means an individual who holds credentials as an “International board certified lactation consultant.” (OAC 3701-7-01 (Q), Lactation Consultant) Maternity Global-Services provided in uncomplicated maternity cases including antepartum care, delivery and postpartum care. This is a fixed payment, billable upon delivery, and must meet guidelines for payment outlined below. The date of the delivery is the date of service to be used when billing the global p renatal codes See Requirements regarding use of CPT II codes. Global services must encompass the Antepartum/Delivery/Postpartum periods as defined below. Services considered part of the global OB package will not be reimbursed separately. It may be appropriate to reimburse more than one provider for antepartum care when the patient transfers care during the antepartum period. This would disqualify the submission of a global bill. CareSource requires that all delivery charges, antepartum care, postpartum care, and any additional surgical services from the date of delivery (e.g. 58611 tubal at time of cesarean delivery) be submitted on the same claim. Only one antepartum care code may be billed per pregnancy. a. Antepartum care only, 1 to 3 visits Use the appropriate Evaluation and Management (E/M) codes. Select level based upon the history, examination, and medical decision making documented in the record for that visit. b. Antepartum care only, 4 to 6 visits Use CPT code 59425. Units = 1. c. Antepartum care only, 7 or more visits Use CPT code 59426. Units = 1. Maternity Split Global or Partial Global-services provided during the stages of maternity care outlined below and to include: Stage I: Antepartum Care, Stage II: Intrapartum Care or Delivery and Stage III: Postpartum Care, yet does not meet the criteria for maternity global services. CPT codes for antepartum care only, delivery only, delivery including postpartum care, and postpartum care only are provided for use when criteria is met for splitting the global OB package. Report the services performed using the most accurate, most ArchivedGlobal Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 4 comprehensive procedure code available. See circumstances that meet criteria for split global billing noted on page 7, section Criteria for Splitting Global OB Services. Split Global: Delivery Only OR Medicaid Antepartum d. Antepartum care only, 1 to 3 visits Use the appropriate Evaluation and Management (E/M) codes. Select level based upon the history, examination, and medical decision making documented in the record for that visit. e. Antepartum care only, 4 to 6 visits Use CPT code 59425. Units = 1. f. Antepartum care only, 7 or more visits Use CPT code 59426. Units = 1. Partial Global: Delivery and Postpartum OR Medicaid Antepartum a. Antepartum care only, 1 to 3 visits Use the appropriate Evaluation and Management (E/M) codes. Select level based upon the history, examination, and medical decision making documented in the record for that visit. b. Antepartum care only, 4 to 6 visits Use CPT code 59425. Units = 1. c. An tepartum care only, 7 or more visits Use CPT code 59426. Units = 1. Coding Guidelines-The delivery date is used as the date of service for: Any OB global code Most antepartum care codes Any delivery-only code Any delivery + postpartum code Any postpartum care only code Maternity home-means a facility for pregnant girls and women where accommodations, medical care, and social services are provided during the prenatal and postpartum periods. Maternity home does not include a private residence where obstetric or newborn services are received by a resident of the home. (OAC 3701-7-01 (W), Maternity home) Maternity Period-For billing purposes, the obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period (56 days after vaginal delivery, 60 days after C-section). Medically necessary-services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (OAC 5160-10-02) Physician-means an individual authorized under Chapter 4731 of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery. (OAC 3701-55-01 (I), Physician) Preconception care-means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. (OAC 5160-21, Reproductive Health Services.) Special delivery services-means services provided by a freestanding children’s hospital that does not offer typical obstetric services as a level I obstetric service, level II obstetric service, or level III obstetric service, but is licensed as a level III neonatal care service, and is designed and equipped to provide delivery services to pregnant women as part of a comprehensive multidisciplinary program of fetal and neonatal care when it is determined that the fetus, once delivered, will require immediate highly subspecialty neonatal intensive Archived Global Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 5 care or neonatal surgery typically provided by a level IIIB or level IIIC neonatal care service. (OAC 3701-7-01 (QQ), Special delivery services) D. POLICY I. Maternity Coverage A.Maternity services must be furnished under the supervision of a physician or certified advanced practice nurse midwife. Maternity services enable beneficiaries to voluntarily choose a provider within the CareSource network for maternity care and post-partum care .For billing purposes, the Maternity Obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period (56 days after vaginal delivery and 90 60 days after C-section). Covered services include office visits for a complete exam, pharmaceuticals (including some over the counter [OTC] products with a prescription), such as prenatal vitamins or medication related to gestational diabetes, and fetal ultrasound services are provided by or under the supervision of a medical doctor, osteopath, or eligible Maternity provider. 1. Maternity services may include the following: 1.1 Pregnancy testing/laboratory tests 1.2 Office visits 1.3 Ultrasounds 1.4 Fetal delivery 1.5 Post-Partum visits B. Maternity Global Period The CMS Physician Fee Schedule assigns maternity procedure codes a global days indicator of MMM, and does not identify the number of days for a Maternity global period. CareSource uses a Maternity Global Period of 56 days after the date of vaginal delivery and 60 days after the date of C-section delivery(date of delivery is day zero) 1. Criteria for Global Billing and Summary of Bundled Services The global obstetrical package code may only be billed when one physician, one midwif e, or the same physician group practice provides all of the patients routine obstetric care, which includes the antepartum care, delivery, and postpartum care. For this purpose, a physician group practice is defined as a clinic or an obstetric clinic with an electronic health record (EHR), or where there is no EHR, but one hard-copy patient record and each physician/nurse practitioner/nurse midwife seeing that patient has access to the same patient record and makes entries into the record as services occur. All locations of a multi-location clinic with an EHR (or one hard-copy patient record) are considered the same physician group practice. Risk Appraisal-Case Management Referral As part of the global, partial global/split requirements, providers must complete the Pregnancy Risk Assessment Form. Providers will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. Any eligible woman who meets any of the risk factors listed on the form is eligible for case management for pregnant women services and should be referred to CareSource for further screening for case management services. Maternity care and the global OB package have three (3) distinct stages: antepartum care, delivery, and postpartum care. The global OB package includes a large number of services which are considered bundled into the global OB code or the Archived Global Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 6 antepartum care, delivery, and postpartum care codes and are not eligible to be reported separately. The bundled services are summarized below: 1.1 Stage I: Antepartum Care Antepartum care begins with conception and ends with delivery. Antepartum care includes the following services which may not be billed separately: a. Initial history and physical, subsequent physical exams, and routine urinalysis. Note: Please report the initial prenatal visit with CPT code (category II code) 0500F (Initial prenatal care visit) with a date of service of the initial prenatal visit as a no-charge line item. b. Monthly visits up to 28 weeks of gestation. c. Biweekly visits to 36 weeks gestation. d. Weekly visits from 36 weeks until delivery. e. At each of these visits, the recording of weight, blood pressures, fetal heart tones, and routine chemical urinalysis (code 81000 or 81002) are included as part of the global obstetrical package. Therefore, these services are not reported separately. f. Pap smear at first prenatal visit. Note: This applies only to the Pap smear procedure. The laboratory processing is separately identifiable and payable. g. Education on breast feeding, lactation and pregnancy (HCPCS level II codes S9436 S9438, S9442 S9443) h. Exercise consultation or nutrition counseling during pregnancy (HCPCS level II codes S9449 S9452, S9470) The initial visit to establish pregnancy is allowable under the members m edical benefit. Once the pregnancy has been confirmed, the global maternity period begins. 1.2 Stage II: Intrapartum Care or Delivery Delivery begins with the passage of the fetus and the placenta from the womb into the external world. Delivery care includes the following services which may not be billed separately: a. Admission to hospital b. Admission history and physical exam c. Management of labor including fetal monitoring d. Placement of internal fetal and/or uterine monitors e. Catheterization or catheter insertion f. Preparation of the perineum with antiseptic solution g. Delivery, any method: (1) Vaginal delivery with or without forceps or vacuum extraction. (2) Cesarean delivery. h. Delivery of the placenta, any method (59414, Delivery of placenta (separate procedure)), may not be separately coded in addition to the code for the delivery service). (AMA1, 3) i. Injection of local anesthesia. j. Induction of labor with pitocin or oxytocin. This is considered an inherent part of the delivery service(s) provided. There is no separate procedure code assignment for this service. (AMA1, 6) k. Artificial rupture of membranes (AROM) before delivery. This is an inclusive component of the delivery code reported. Therefore, it would not be appropriate to report a separate code for this service. (AMA1, 9) Archived Global Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 7 1.3Stage III: Postpartum Care a. Postpartum care begins after delivery. Postpartum care includes the following services which may not be billed separately: Note : Please report the postpartum visit with CPT code (category II code) 0503F (Postpartum visit) with a date of service of the postpartum visit as a no-charge line item b. Exploration of uterus. c. Episiotomy and repair. d. Repair of cervical, vaginal or perineal lacerations. (AMA1, 4, 5) e. Placement of a hemostatic pack or agent. f. Recovery room visit. g. Hospital visits. h. Office visits or home visits (e.g. midwife care) during the Maternity Global Period. i. Education and assistance with lactation, breast and nipple care, and breast feeding. j. CareSource will reimburse: (1) One provider for delivery (2) One provider for postpartum CareSource (3) One assistant surgeon for a cesarean delivery, if documented 1.4 General Global Policy Guidelines: One physician or physician group practice must provide all of the members obstetric care in order for the global prenatal/delivery/postpartum fee to be reimbursed . For this purpose, a physician group is defined as a clinic or an obstetric clinic where there is one member record and each physician/nurse practitioner/nurse midwife seeing that member has access to the same member record and makes entries into the record as services occur. A primary care physician is responsible for overseeing patient care during the members pregnancy, delivery, and postpartum care. The clinic may elect to bill globally for all prenatal, delivery, and postpartum care services provided with the clinic, using the primary care physicians individual National Provider Identifier (NPI) as the performing provider. Global services will be reimbursed only when care includes all prenatal visits performed at medically appropriate intervals up to the date of delivery, routine urinalysis testing during the prenatal period, care for pregnancy related conditions (e.g. nausea, vomiting, cystitis, vaginitis), and the completion of the Pregnancy Risk Assessment Form (PRAF) during each trimester of care. Only one prenatal care code, 59425 (four-six visits) or 59426 (seven or more visits), may be billed per pregnancy. Billing for global services cannot be done until the date of delivery . 1.5 Criteria for Splitting the Global OB Services: Maternity care and delivery may be billed as a single code except when certain circumstances occur which require the package to be broken into components. a. Circumstances which require splitting the global OB package include the following: (1) The member has a change of insurer during her pregnancy (2) The member has received part of her antenatal care elsewhere, e.g. from another group practice (3) The member leaves her care with your group practice before the global OB care is complete ArchivedGlobal Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 8 (4) The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery (5) The member has an unattended, precipitous delivery (6) Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy) 1.6 Billing a Split OB Package CPT codes for antepartum care only, delivery only, delivery including postpartum care, and postpartum care only are provided for use when criteria is met for splitting the global OB package. Report the services performed using the most accurate, most comprehensive procedure code available. a. Antepartum care only, 1 to 3 visits Use the appropriate Evaluation and Management (E/M) codes. Select level based upon the history, examination, and medical decision making documented in the record for that visit. b. Antepartum care only, 4 to 6 visits Use CPT code 59425. Units = 1. c. Antepartum care only, 7 or more visits Use CPT code 59426. Units = 1. d. Postpartum care only Use CPT code 59430. Units = 1. e. Delivery only See CPT book. Code selection based on type of delivery f. Delivery, including postpartum care See CPT book. Code selection based on type of delivery. 1.7 Fee for Service to Managed Care Coverage Guidelines When obstetrical care begins as fee for service and continues with the same provider into a MCP, the provider must bill for date specific services for each plan (ODM and CS). The provider cannot submit a claim for global OB care to either program. When a member receives more than two prenatal visits in a fee for service setting and transitions into a managed care plan and changes providers, neither provider may bill for a global OB service. In this situation, both providers must bill for each date of service using the appropriate CPT code. 1.8 Delivery of Multiple Gestations Global billing for multiple gestations should include one global procedure code and a delivery only code for each subsequent delivery. The specific codes submitted will depend on the method of delivery and number of infants d elivered. When submitting claims for deliveries of more than one newborn, CareSource requires that all delivery charges, any global services, and any additional surgical services from the date of delivery be submitted on the same claim. The appropriate diagnosis code for the multiple gestations should be indicated. Multiple surgery fee reductions apply to multiple delivery services for multiple gestations. The code submitted for the second delivery and any subsequent deliveries should include a modifier 51 and a modifier 59 to indicate separate newborn. In most cases the delivery of the first newborn is considered primary and allowed at 100% and the delivery of all subsequent newborns are considered secondary and reimbursed at 50% of the contracted allowable. An exception to this rule may occur if the global OB service cannot be billed for the first newborn and the subsequent newborn is delivered by cesarean. Archived Global Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 9 1.9Limitations on Elective Obstetric Deliveries a. Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria: (1) Gestational age of the fetus must be determined to be at least thirty-nine weeks; OR (2) If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery. b.Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary are not eligible for payment. C.Claims Providers are to indicate Maternity as a diagnosis when billing any of the services listed in this policy that relate to Maternity . Providers are to complete the diagnosis code or the appropriate narrative, where applicable. In addition, providers should identify services related to the treatment of complications of Maternity. Examples: A.Surgical procedure such emergency C-Section due to fetal distress B. Atypical office visits and laboratory tests needed due to member or fetal anomalies Occasionally other services (including hospital, radiology, pharmaceutical, blood and blood derivatives) may be related to Maternity or to its complications, and should be properly identified. 1. Non-Comprehensive Maternity Visits CareSource covers maternity management services including evaluation and management (office) visits and consultations for the purpose of: 1. 1 Health of the member and developing fetus for best outcomes 2. Non-Covered Maternity Services 2.1 Home pregnancy tests 2. 2 Ultrasounds performed only for determination of sex of the fetus or to provide a keepsake picture 2.3 Three and four dimensional ultrasounds 2.4 Paternity testing 2.5 Lamaze classes 2.6 Birthing classes 2.7 Parenting classes 2.8 Home tocolytic infusion therapy D. Reimbursement Guidelines 1. Delivery Labor and delivery services are based on the need of each individual patient and can include, but not limited to, thefollowing types of services, fetal monitoring of any type of method, rupture of membranes, amnioinfusion, forceps and/or vacuum-assisted delivery, episiotomy and/or laceration repair, as well as fetal and maternal testing, and induction of labor services. 2. Vaginal Delivery Reporting Primary delivery service code: 59400 or 59610 2.1 Each additional delivery code: 59409-51 or 59612-51 2.2 If the additional service becomes a cesarean delivery, then report the primary delivery service as acesarean delivery: 59510 or 59618 3. Cesarean Delivery Reporting Primary delivery service code: 59510 or 59618 No additional procedural delivery code warranted ArchivedGlobal Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 103.1Only a single cesarean delivery service is to be reported no matter how many live births Modifier 22 should be added to support substantial additional work 4. Postpartum Care Postpartum care includes hospital and office visits following any type of delivery, and can include any number of visits (usually extends over a six-week period). It is expected that the member will have postpartum care related totheir medical needs, with the final postpartum visit at the conclusion of the postpartum period. Each of these visits can be reported with procedure code 0503F. 5. Maternity Management Services Providers must include the following information on claims for maternity management services: 5.1 A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided; AND 5.2 An appropriate ICD-9 (before 10/1/2014) or ICD-10 (after 10/1/2014) diagnosis code to indicate an encounter for maternity management 6. Maternity services are considered medically necessary f o r women in the delivery of a fetus (including, multiple gestations). Therefore, reimbursement is available for the following codes: 6.1 Obstetrical Reimbursement Codes 59409-Vaginal delivery only (with or without episiotomy and/or forceps) 59514-Cesarean delivery only 59612-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 6.2 Fetal Gestational Age Determination Delivery prior to 39 weeks of gestation Delivery at 39 weeks of gestation or later Spontaneous obstetrical deliveries occurring between 37 and 39 weeks gestation E. CONDITIONS OF COVERAGE HCPCS 58611 Ligation or transection of fallopian tube( s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps); 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59412 External cephalic version, with or without tocolysis 59414 Delivery of placenta (separate procedure) 59425 Antepartum care only; 4-6 visits 59426 A ntepartum care only; 7 or more visits 59430 Postpartum care only (separate procedure) 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59514 Cesarean delivery only; 59515 Cesarean delivery only; including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) Archived Global Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 1159610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or force ps) and postpartum care, after previous cesarean delivery 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care 0500F Initial prenatal care visit (report at first prena tal encounter with health care professional providing obstetrical care, report also date of visit and in a separate field, the last date of menstrual period LMP) 0501F Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period-LMP (Note: If reporting 0501F prenata l flow sheet, it is not necessary to report 0500F initial prenatal care visit) 0502F Subsequent prenatal care visit (excludes: patients who are seen for a condition unrelated to pregnancy or prenatal care [e.g., an upper respiratory infection; patients se en for consultation only, not for continuing care]) 0503F Postpartum care visit CPT AUTHORIZATION PERIOD Prior Authorization Members may seek maternity services from any qualified CareSource participating provider without prior authorization. F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 06/10/2015 Policy created. Date Revised 06/10/2015 Revised to include updated criteria and codes. Date Effective 05/03/2017 H. REFERENCES 1. Current Procedural Terminology. (2015, June 1). Retrieved June 11, 2015, from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page 2. Guideline Suggestions for Elective Labor Induction. (2012). Retrieved June 11, 2015, from http://www.acog.org/-/media/Districts/District-I/20120120-ElectiveIOLGuideline.pdf?dmc=1&ts=20150611T0857437601 ArchivedGlobal Obstetrical Services Ohio Medicaid PY-0001 Effective Date: 05/03/17 123. Ohio Administrative Code. (2015). Retrieved June 11, 2015, from http://codes.ohio.gov/oac/3701-40-01 4.American Association of Critical Care Nurses Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education, 2015. 5. OAC Rule 5160-1-10 Limitations on Elective Obstetric Deliveries 6. OAC Rule 5160-21 Preconception Care Services The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

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Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage document s, 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 Cove rage) 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 Original Issue Date Next Annual Review Effective Date 10/31/2013 03/12/2019 03/12/2018 Policy Name Policy Number Drug Testing PY-0020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 3 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 6 F. RELATED POLICIES/RULES …………………………………………………………………….. 8 G. REVIEW/REVISION HISTORY …………………………………………………………………… 8 H. REFERENCES ………………………………………………………………………………………… 8 2 A. SUBJECTDrug Testing B. BACKGROUNDDrug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/2018Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Pr ocessing Manual.Monitoring for controlled substances is performed to detect the use of prescription medications and illegal substances of concern for the purpose of medical treatment. Monitoring for controlled substances plays a key role particularly in the care of persons undergoing medical treatment with chronic pain therapy and substance-related disorder. Drug testing that is medically necessary for the management of members being treated with drugs that are potentially abusive or addictive such as opioids and related medications, or for members suspected of using illicit drugs solely or in combination with prescribed controlled substances, is bil lable to CareSource. Qualitative/presumptive drug testing performed as part of routine, prenatal care for pregnant members is also billable to CareSource.Providers should have a working knowledge of analytic detection including primary agents, metabolites, lab threshold concentrations, and time periods involved in detection. The combination of a patient's self-report and drug testing results serve as important tools in controlled substance monitoring, as well as a point of patient engage ment.Qualitative/presumptive testing is a routine part of care, used when immediate results are needed, knowing results may be less accurate than quantitative/confirmatory tests. Quantitative/confirmatory testing is used when results may affect changes in medication, when patients dispute qualitative/presumptive results, or in treatment transitions.Anecdotal evidence to support testing for individual patients should be balanced with the limited population evidence for added value of multiple tests for chronic pain patients or SUD patients. For example, in a 2015 evaluation of 2,551,611 de-identified patients urine drug test results over four years in the U.S., Quest Diagnostics identified that the best achieved yearly inconsistency rate (when the results of a drug screen are not consistent with the patients history and prescribed medicines) in all urine drug tests was 53% (in 2014 vs 63% in 2011).C. DEFINITIONS Qualitative analysis-The testing of a substance or mixture to determine its chemical constituents, also known as presumptive testing. Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as confirmatory testing. Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) – this benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPDST is key to ensuring that children and adolescents receive 3 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/2018appropriate preventive, dental, mental health, and developmental, and specialty services through early diagnosis and treatment. The program specifically covers comprehensive health and developmental histories, immunizations, health education, vision servic es, dental services, hearing services, and any additional health care diagnostic and treatment services for physical and mental illnesses that are coverable under the federal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered, regardless of whether the service is covered in a state's Medicaid plan. Under the EPSDT program, any Medicaid provider can find a problem, make a referral or provide treatment. This includes doctors, nurses, dentists, physical therapists, occupational therapists, speech therapists, psychologists, psychiatrists and other health care professionals. Random alcohol and drug test a lab test administered at an irregular interval which is not announced in advance to the person being tested, and which detects the presence of alcohol, drugs or substances in the individual. Independent laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSource. For further definitions, please refer to the CareSource Drug Testing Medical Policy (MM-0054), posted here: https://www.caresource.com/providers/ohio/ohio-providers/medical-policies/ .D. POLICYNOTE: CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. I. General Criteria for Coverage: Clinical guidelines, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0054. Please refer to this policy for in-depth information on medical necessity for drug testing, documentation required for claims, and CareSource monitoring and review o f drug testing claims.II. Individualized Testing : In all cases other than routine qualitative/presumptive drug testing as part of prenatal care, medical necessity for submitted charges must be individualized and documented in the members medical record and included in the treatment plan of care. CareSource does not provide coverage for drug testing for forensic, legal, employment, transportation, school purposes or other third-party requirement.III. Non-Urine Te sting: CareSource will reimburse blood testing in emergency department settings only, to evaluate acute overdose. Drug testing with blood samples performed in any other setting outside of an ER requires that medical record documentation meets criteria in t he above section D.I General Criteria for Coverage. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered unless medical record documentation meets criteria in the above section D.I General Criteria for Coverage. If covered, non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing.NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) medical record documentation meets criteria in the above section D.I General Criteria for Coverage.4 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/2018IV. Urine Testing : Urine for clinical drug testing is the specimen of choice because of its high drug concentrations and well-established testing procedures. Nevertheless, urine is one of the easiest specimens to adulterate. A. If the provider suspects such an occurrence, the provider may choose to evaluate specimen validity using validity tests. Specimen validity testing is considered to be a quality control issu e and is included in the CPT code payment. Additional codes for specimen validity testing should not be separately billed to CareSource. Tests for creatinine, specific gravity, temperature or nitrates, are not billable to and will not be reimbursed by Care Source when submitted simultaneously with a drug testing CPT code and ICD substance-related disorder code. Failure to document customized tests with medical necessity information for each individual member and for each of the drug tests ordered will result in the denial of the claim for reimbursement, audit, and/or overpayment requests, and any other program means for enforcing this policy. B. Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse. C. Orders for custom profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or to conduct additional testing as needed, are not billable to and will not be reimbursed by CareSource. D. Testing on a routine basis is neither random nor individualized. Routine or reflex testing is not billable to and will not be reimbursed by CareSource. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random. V. CareSource does not provide coverage for drug testing as a requirement to stay in a facility, for example, in sober living or residential locations. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program.VI. Provider Orders: CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms; A signed and dated provider order for the drug testing is required. The providers order must specifically match the number, level and complexity of the testing components performed.VII. Non-participating providers : Non-participating providers are not covered for drug testing laboratory services. Non-participating providers may use participating laboratories for drug testing services.VIII. Documentation Requirements : All documentation must be accurate, complete, maintaine d in the members medical record and available to CareSource upon request. The following documentation requirements apply: A. Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering provider/treating provider must indicate the medical necessity for performing a qualitative/presumptive drug test.B. Every page of the record must be legible and include appropriate member identification information (e.g., complete name, dates of service(s)). C. The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the member. D. The submitted medical record should support the use of the selected ICD-10-CM code(s) with appropriate indications for urine drug testing. E. The submitted CPT/HCPCS code should accurately describe the service performed. F. Copies of test results alone without the proper providers order for the test are not sufficient documentation of medical necessity to support a claim. G. Drug testing records and related entries in a members medical record must be provided to CareSource upon request for auditing of medical necessity. Documentation must support medical necessity and specify why each test is ordered. Documentation must 5 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/2018also support the number of analytes requested for testing, and what action the provider will take upon the findings. IX. Confirmatory and Duplicative Testing A. Routine multi-drug quantitative/confirmatory testing is not billable to and will not be reimbursed by CareSource. Quantitative/confirmatory testing must be individualized for the member and medically necessary. Routine confirmations (quantitative) of drug tests with negative results are not covered by CareSource. Quantitative/confirmatory testing is covered for a negative drug/drug class test when the negative finding is inconsistent with the members documented medical history and/or current documented chronic pain medication list, and indications substantiated in the medical recordB. Routine nonspecific or wholesale orders for drug testing (qualitative), confirmation or (quantitative) drugs of abuse testing are not billable. X. Independent Laboratories A. Drug testing conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider.B. CareSource may require documentation of FDA-approved complexity level for instrumented equipment, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab. C. Both participating providers and non-participating providers m ay potentially order laboratory tests for CareSource members D. Only participating independent laboratories can bill for quantitative/confirmatory drug tests. E. Laboratories must have the appropriate level of CLIA certification for the tests performed and be contracted (participating) with CareSource. F. Claims are not billable to CareSource if submitted by laboratories that are non-participating (not contracted) with CareSource. G. The ordering/referring provider must include the clinical indication/medical necessity in the order for the drug test as outlined above. H. The independent laboratory performing the drug testing must maintain hard copy documentation of the lab results, along with copies of the ordering/referring providers order for the drug test. I. Participating laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes s ervices ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. XI. Other Non-Billable Drug Testing A. Standing orders set up between a provider and laboratory which are prewritten and/or result in the same drugs and drug classes to be tested on a routine, repeat basis, are not billable to and will not be reimbursed by CareSource.B. Drug testing is not billable to and will not be reimbursed by CareSource if required by a third party such as: 1. Medico-legal purposes (e.g., court-ordered drug test) or 2. For employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment). 3. As a condition of: 3.1 Participation in school or community athletic activities or programs 3.2 Participation in school or community extra circular activities or programs 4. As a component of a routine physical/medical examination; e.g. (enrollment in school, enrollment in the military , etc.), EXCEPT for once yearly screening in EPSDT programs. 6 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/2018As a component of medical examination for any other administrative purposes not listed above (e.g., for purposes of marriage licensure, insurance eligibility, etc.). As a program requirement to live in sober housing or residential services. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review.E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/Fe eScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information.NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) medical record documentation meets criteria in the above section D.I General Criteria for Coverage. If covered, non-urine drug testing is reimbursed at th e lesser of coverage amounts per CPT for urine testing and non-urine testing.Codes Description80155 Drug screen quant caffeine 80159 Drug screen quant clozapine 80171 Gabapentin, drug screen quant 80173 Assay of haloperidol 80184 Phenobarbital 80299 Quantitation of drug, not elsewhere specified Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, pe r date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative/Confirmatory Tests-Description 80320 Alcohols 80321 Alcohol biomarkers; 1 or 2 80322 Alcohol biomarkers; 3 or more 80323 Alkaloids, not otherwise specified 5. 6. 7 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/201880324 Amphetamines; 1 or 280325 Amphetamines; 3 or 480326 Amphetamines; 5 or more 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 80331 Analgesics, non-opioid; 6 or more 80332 Antidepressants, serotonergic class; 1 or 2 80333 Antidepressants, serotonergic class; 3-5 80334 Antidepressants, serotonergic class; 6 or more 80335 Antidepressants, tricyclic and other cyclicals; 1 or 2 80336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepileptics, not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines 80360 Methylphenidate 80361 Opiates, 1 or more 80362 Opioids and opiate analogs; 1 or 2 80363 Opioids and opiate analogs; 3 or 4 80364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 83992 Phencyclidine (PCP) 84311 Spectrophotometry, analyte not elsewhere specified 8 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/2018Codes Description80375 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified;1-3 80376 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more 83789 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; quantitative, each specimen F. RELATED POLICIES/RULESCareSource Drug Testing Medical Policy (MM-0054) G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 01/01/2014 New Policy.Date Revised 03/08/2017 5/31/2017 added presumptive/confirmatory language clarifications defined outpatient treatment programs clarified coverage for individualized testing updated language prohibiting blanket orders, routine testing inserted language that CS may audit for medical necessity updated quantity limits of tests to 5 per type per quarter per member (regardless of provider) updated ICD-10 codes. Changes to language regarding potential Prior Authorization 10/01/2017 Changes to language regarding Prior Authorization, updatedcodes, quantity limits.11/29/2017 Updated limits, prior authorization requirements, andcovered/defunct codes.02/16/2018 Remove quantity limits and prior authorization.Date Effective 03/12/2018H. REFERENCES1. Ohio Administrative Code, Medicaid Alcohol and Drug Addiction Services. (2012, October 1). Retrieved on 8/15/2016 from http://codes.ohio.gov/oac/5160-30 2. Ohio Administrative Code, Medicaid Treatment services. (2012, July 1). Retrieved from on 8/15/2016 from http://codes.ohio.gov/oac/3793%3A2-1-08 3. Ohio Medicaid Fee Schedule Rates. (2016, August). Retrieved on 8/15/2016 from http://medicaid.ohio.gov/Portals/0/Providers/F eeScheduleRates/App-DD.pdf 4. Ohio Medicaid Fee Schedule Rates and Covered CPT Codes. (2016, January). Retrieved from on 8/15/2016 http://medicaid.ohio.gov/Port als/0/Providers/FeeScheduleRates/CPT-HCPS-2016.pdf 5. A. Barthwell, “Statement of Consensus on the Proper Utilization of Urine Testing in Identifying and Treating Substance Use Disorders,” 2015. [Online]. Available: http://farronline.org/wp-content/uploads/2015/11/Final-Report-Statement-of-Consensus-on – the-Proper-Utilization-of-Urine-Testing-in-Identifying-and-Treating-Substance-Abuse-Disorders.pdf9 Drug Testing OHIO MEDICAID PY-0020 Effective Date: 03/12/20186. A. Pesce, C. West, K. Egan City and J. Strickland, "Interpretation of urine drug testing in pain patients," Pain Medicine, vol. 13, no. 7, pp. 868-85, 2012. 7. Mayo Clinic, "Approximate detection times of drugs of abuse," Oct 2016. [Online]. Available: http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html 8. K. E. Moeller, K. C. Lee and J. C. Kissack, "Urine drug screening: Practical guide for clinicians," Mayo Clinic Proceedings, vol. 83, no. 1, pp. 66-76, Jan 2008. 9. S. Vakili, S. Currie and N. el-Guebaly, "Evaluating the utility of drug testing in an outpatient addiction program," Addictive Disorders and their Treatment, vol. 8, no. 1, pp. 22-32, 2009. 10. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye, "Review and recommendations for drug testing in substance use treatment contexts," Journal of Reward Deficiency Syndrome and Addiction Science, vol. 2, no. 1, pp. 28-45, 2016. 11. K. Dolan, D. Rouen and J. Kimber, "An overview of the use of urine, hair, sweat and saliva to detect drug use," Drug and Alcohol Review, vol. 23, no. 2, pp. 213-217, 2004. 12. A. G. Verstraete, "Detection times of drugs of abuse in blood, urine, and oral fluid," Therapeutic Drug Monitoring, vol. 26, no. 2, pp. 200-205, 2004. 13. ASAM, Principles of Addiction Medicine, 5th Edition ed., R. K. Ries, D. A. Fiellin, S. C. Miller and R. Saitz, Eds., Philadelphia, PA: Lippincott Williams & Wilkins, 2014. 14. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik, "Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study, "International Journal of Mental Health and Addiction, vol. 14, no. 1, pp. 64-80, 2016. 15. J. Dupouy, V. Macmier, H. Catala, M. Lavit, S. Oustric and M. Lapeyre-Mestre, "Does urine drug abuse screening help for managing patients? A systematic review," Drug and Alcohol Dependence, vol. 136, pp. 11-20, 2014. 16. E. Y. Hilario, M. L. Griffin, R. K. McHugh, K. A. McDermott, H. S. Connery, G. M. Fitzmaurice and R. D. Weiss, "Denial of urinalysis-confirmed opioid use in prescription opioid dependence, "Journal of Substance Abuse Treatment, vol. 48, no. 1, pp. 85-90, 2015. 17. ASAM, "Drug Testing: A White Paper of the American Society of Addiction Medicine," American Society of Addiction Medicine, Chevy Chase, MD, 2013. 18. Quest Diagnostics Health Trends Prescription Drug Monitoring Report 2015, Prescription Drug Misuse in America, Diagnostic Insights in the Continuing Drug Epidemic Battle. Accessed o n December 8, 2016. Located at https://www.questdiagnostics.com/dms/Documents/health- trends/Health_Trends_27281_MI4854_V5_LG_082715_Small.pdf 19. Ohio Administrative Code, Chapter 4723-6 Alternative Program for Chemical Dependency/Substance Use Disorder Monitoring "Random alcohol and drug screen" definition. Retrieved 3/2/2017 from http://codes.ohio.gov/oac/4723-6 . 20. Drug abuse testing services, in the United Stated Federal Code, CFR 42, Part 8 12(f)(6) Retrieved on 3/2/2017 from https://www.law.cornell.edu/cfr/text/42/8.12 21. Early and Periodic Screening, Diagnostic, and Treatment | Medicaid.gov. (n.d.). Retrieved from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html 22. Ohio Department of Medicaid-Healthchek.(n.d.). Retrieved from http://medicaid.ohio.gov/FOROHIOANS/Programs/Healthchek.aspx 23. Consensus Statement. Appropriate Use of Drug Testing in Clinical Addiction Medicine . Journal of Addiction Medicine, June 2017 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Smoking & Tobacco Cessation

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 09/20/2017 09/20/2018 0 5 /01/2018 Policy Name Policy Number Smoking & Tobacco Cessation PY-0256 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RULES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 3 H.REFERENCES ………………………………………………………………………………………… 3Archived Smoking & Tobacco Cessation OHIO MEDICAID PY-0256 Effective Date: 05/01/2018 2 A. SUBJECT Smoking & Tobacco Cessation B. BACKGROUND The use of tobacco products generally leads to tobacco/nicotine dependence 5and often results in serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases . Tobacco/nicotine dependence is a condition that often requires repeated treatments, as nicotine is strongly addictive. Because of this, quitting smoking and ending the use of tobacco use may be a difficult process requiring several, staged attempts, and may involve stress, irritability, and other withdrawal symptoms for those addicted to nicotine 10, 11, 12. However, continued tobacco use in any form is far more harmful. Tobacco smoke contains seriously harmful chemicals and carcinogens 7, 10, 13and leads to lung and other cancers, chronic lung disease, heart disease, strokes, vascular disease, and infertility. Additionally, smokeless tobacco is directly linked to cancers of the mouth, tongue, cheek, gum, esophagus, and pancreas. Counseling and medication are both effective means for ending dependency on tobacco products, and are even more effective together than either method alone 12. Counseling can be effective when delivered via individual, group, or telephone counseling, one-on-one brief help sessions with a provider, behavioral therapies, or even through mobile phone apps. Medications which have been found to be effective include prescription non-nicotine medications such as bupropion SR (Zyban ) and varenicline tartrate (Chantix ), and nicotine replacement products such as nicotine patches, inhalers or nasal sprays available by prescription, and over-the-counter nicotine patches, gums or lozenges 12, 19. The United States government recognizes the health dangers and risks associated with the use of tobacco in its citizens and has set up a free telephone support service to help people stop smoking and stop the use of tobacco, 1-800-QUIT-NOW. Callers are routed through this service to their states specific resource, and may be able to obtain free support, advice, and counseling from experienced quit-line coaches, a personalized plan to quit, practical information on how to quit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking medications, free or discounted medications (available for at least some callers in most states), referrals to other resources, and/or mailed self-help materials. CareSource encourages all of its members to refrain from the use of tobacco, and if using it in any form, to make concerted and ongoing attempts to quit its use as soon as possible. C. DEFINITIONS Tobacco products means any product containing tobacco or nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, hookahs, kreteks, e-cigarettes, vaporized and other inhaled tobacco and nicotine products, smokeless tobacco (e.g., dip, chew, snuff, snus), dissolvable tobacco (e.g., strips, sticks, orbs, lozenges), or other ingestible tobacco products, and/or chewing tobacco. D. POLICY I. Prior authorizations are required for participating (contracted) providers only when the services they are providing for tobacco cessation exceed the limits of this policy. II.Non-participating providers (not contracted with CareSource) should contact CareSource for prior authorization for these services. Archived Smoking & Tobacco Cessation OHIO MEDICAID PY-0256 Effective Date: 05/01/2018 3 III.CareSource will reimburse its participating providers for the following tobacco use intervention and cessation care methods: A. An encounter for evaluation and management of the member on the same day as counseling to prevent or cease tobacco use; and, B. One screening for tobacco use per member per calendar year if necessary; and, C. Three individual tobacco cessation counseling attempts per calendar year. 1. Each attempt may include a maximum of 4 intermediate or intensive sessions, with a total benefit of up to 12 sessions per calendar year per member. D. Nicotine replacement or non-nicotine medications prescribed and approved for use for tobacco cessation. IV. CareSource will not reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year, unless prior authorization has been obtained by the provider. V. The number of CPT, HCPCs, and diagnosis codes (ICD-10) potentially associated with the diagnosis and treatment of tobacco use and addiction is too great to list. As such, the specific tobacco cessation codes provided below are eligible to be reimbursed with any appropriate, associated co de. VI. Evaluation and Management service for the member which is provided on the same day as counseling to prevent or cease tobacco use, should be reported with modifier-25 to indicate that the E&M service is separately identifiable from the counseling. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODES DESCRIPTION 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes S9453 Smoking cessation classes, non-physician provider, per session F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 09/20/107 New Policy. Date Revised Date Effective 0 5 /01/2018 H. REFERENCES 1. Lawriter-OAC-5160-21-04 Reproductive health services: pregnancy-related services. (n.d.). Retrieved 6 September 2017 from http://codes.ohio.gov/oac/5160-21-04v1 2.Lawriter-OAC-5160-4 – 34 Preventive medicine services. (n.d.). Retrieved 6 September 2017 from http://codes.ohio.gov/oac/5160-4 -34 ArchivedSmoking & Tobacco Cessation OHIO MEDICAID PY-0256 Effective Date: 05/01/2018 4 3.Lawriter-OAC-5160-8 -05 Mental health services-other licensed professionals. (n.d.). Retrieved 6 September 2017 from http://codes.ohio.gov/oac/5160-8-05 4. CDC-Fact Sheet-Quitting Smoking-Smoking & Tobacco Use. (n.d.). Retrieved August 31, 2017, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm5.Counseling to Prevent Tobacco Use. ( Transmittal 2058, 2010, September 30 ). Centers for Medicare & Medicaid Services, Department of Health & Human Services. Retrieved September 5, 2017 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ 6. Treating Tobacco Use and Dependence. Clinical Practice Guideline. (n.d.). Fiore, Michael C (panel chair), Guideline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI)) Retrieved August 25, 2017, from http://lib.adai.washington.edu/dbtw-wpd/exec/dbtwpub.dll?AC=GET_RECORD&XC=/dbtw-wpd/exec/dbtwpub.dll&BU=http%3A%2F%2Flib.adai.washington.edu%2Febpchecksearch.ht m&TN=EBP&SN=AUTO30019&SE=457&RN=4&MR=0&TR=0&TX=1000&ES=1&CS=0&XP=&RF=Brief+Display&EF=&DF=Full+Display&RL=1&EL=1&DL=0&NP=3&ID=&MF=searchb utton.ini&MQ=&TI=0&DT=&ST=0&IR=50&NR=0&NB=0&SV=0&SS=0&BG=&FG=000000&QS=&OEX=ISO-8859-1&OEH=ISO-8859-1 7. U.S. Department of Health and Human Services. The Health Consequences of Smoking50 Years of Progress: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 8. National Institute on Drug Abuse. Research Report Series: Is Nicotine Addictive? .Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2012. 9. American Society of Addiction Medicine. Public Policy Statement on Nicotine Addiction and Tobacco .Chevy Chase (MD): American Society of Addiction Medicine, 2008. 10. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 11.U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 12. Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateClinical Practice Guidelines . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008. 13. National Toxicology Program. Report on Carcinogens, Thirteenth Edition . Research Triangle Park (NC): U.S. Department of Health and Human Sciences, National Institute of Environmental Health Sciences, National Toxicology Program, 2014. 14.U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 15. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. 16.Centers for Disease Control and Prevention. Quitting Smoking Among AdultsUnited States, 20002015 . Morbidity and Mortality Weekly Report 2017;65(52):1457-64. 17. Centers for Disease Control and Prevention. Youth Risk Behavior SurveillanceUnited States, 2015 . Morbidity and Mortality Weekly Report [serial online] 2016;66 (SS6):1 174. 18. Centers for Disease Control and Prevention. The Guide to Community Preventive Services: Reducing Tobacco Use and Secondhand Smoke Exposure . Archived Smoking & Tobacco Cessation OHIO MEDICAID PY-0256 Effective Date: 05/01/2018 5 19.U.S. Food and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation . FDA Consumer, 2006. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Breast Imaging

REIMBURSEMENT POLICY STATEMENT OH IO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 10/31/2013 1 0/04/2018 0 5/01/2018 Policy Name Policy Number Breast Imaging PY-0028 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 re ferral, 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 patien t 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 Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Breast Imaging Ohio Medicaid PY-0028 Effective Date: 05/01/2018 2 2 A.SUBJECT Breast Imaging 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. CareSource will reimburse participating providers for medically necessary and preventive screening tests for breast cancer as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and American College of Radiology (ACR). Mammography is the utilization of a low-dose x-ray imaging system for the examination of the breasts and is currently considered to be the best available method for early detection of breast cancer, particularly in the case of small or non-palpable lesions. This imaging is often employed for screening purposes in an effort to reduce morbidity and mortality of unsuspected breast cancer through earlier detection and treatment in asymptomatic patients. A Screening Mammogram typically includes two standard views of each breast (cranio-caudal and medial lateral oblique) and does not require the presence of, or monitoring by the interpreting radiologist. When abnormalities are observed a diagnostic test is required to confirm the presence of malignancy. C. DEFINITIONS Technical Component (TC) services rendered outside the scope of the physicians interpretation of the results of an examination. Professional Component (PC) physicians interpretation of the results of an examination. Global Component encompasses both the technical and professional components. See Breast Imaging Medical Policy-MM0051 for further definitions D. POLICY I. CareSource does not require prior authorization for screening and diagnostic mammograms. II. All other breast imaging, other than x-ray mammograms, require a prior authorization. II I. CareSource reimburses for screening and diagnostic mammograms according to CareSource Medical policy MM-0051. Members must meet the criteria found in medical policy MM-0051. IV. CareSource considers diagnostic mammography medically necessary for men and women with signs and symptoms of breast disease or a history of breast malignancy. V. When billing for mammography services, provider should use the appropriate CPT/HCPCS Archived Breast Imaging Ohio Medicaid PY-0028 Effective Date: 05/01/2018 3 3 codes and modifiers, if applicable. Note: Global billing is not permitted for services furnished in an outpatient facility. Critical Access Hospitals (CAHs) may not use global HCPCS codes as the TC and PC components are paid under different methodologies. 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 appropriate Ohio Medicaid fee schedule-http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. CPT Codes Mammography Code Description 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) CPT Codes Requiring Prior Authorization Code Description 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 76498 Unlisted magnetic resonance procedure (e.g., diagnostic, i nterventional) 76499 Unlisted diagnostic radiographic procedure 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited 77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 77061 Digital breast tomosynthesis; unilateral 77062 Digital breast tomosynthesis; bilateral 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) C8903 Magnetic resonance imaging with contrast, breast; unilateral Archived Breast Imaging Ohio Medicaid PY-0028 Effective Date: 05/01/2018 4 4 C8904 Magnetic resonance imaging without contrast, breast; unilateral C8905 Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral C8906 Magnetic resonance imaging with contrast, breast; bilateral C8907 Magnetic resonance imaging without contrast, breast; bilateral C8908 Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral F. RELATED POLICIES/ RULES Breast Imaging Medical Policy, MM-0051 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/31/2013 New Policy. Date Revised 10/31/2013 06/06/2016 10/04/2017 Date Effective 05 /01/2018 H.REFERENCES 1. American Cancer Society. (2017 , September). Retrieved September 25, 2017, from http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/brea st-cancer-early-detection-acs-recs 2. U.S. Preventive Services Task Force; Breast Cancer: Screening. (2016, January). Retrieved September 25, 2017, from http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=mammography 3. Laboratory and radiology services. (2014, July). Retrieved September 25, 2017, from http://codes.ohio.gov/oac/5160-4-25 The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Screening for Sexually Transmitted Infections

Screening and Surveillance for Colorectal Cancer

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 05/17/2016 11/01/2018 03/01/2018 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0072 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, i llness, or injury and without which the patien t 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 Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 2 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H.REFERENCES ………………………………………………………………………………………… 4 Archived Screening and Surveillance for Colorectal Cancer OHIO MEDICAID PY-0072 Effective: 03/01/20182A. SUBJECTScreening and Surveillance for Colorectal CancerB. 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. CareSource will reimburse participating providers for medically necessary and preventive screening tests for colorectal cancer as required by state requirements through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology (ACG). C. DEFINITIONS See Screening and Surveillance for Colorectal Cancer medical policy MM-0040 D. POLICY I. CareSource does not require prior authorization for screening and diagnostic colonoscopies for participating providers. II. CareSource reimburses for screening and diagnostic colonoscopies according to CareSource Medical policy MM-0040. Members must meet the criteria found in medical policy MM-0040. III. When billing for screening and surveillance colorectal services, providers should use the appropriate CPT/HCPCS codes and modifiers, if applicable. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting the state Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to state Medicaid fee schedules : http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list may not be all in clusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Code Description 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 44402 Colonoscopy through stoma; with endoscopic stent placement (including pre-and post-dilation and guide wire passage, when performed) Archived Screening and Surveillance for Colorectal Cancer OHIO MEDICAID PY-0072 Effective: 03/01/2018345330 Sigmoidoscopy, flexible; diagnostic, including collecti on of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 45333 Sigmoidoscopy, flexible; with removal of tu mor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45334 Sigmoidoscopy, flexible; with control of bleeding, any method 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, f lexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre-and post-dilation and guide wire passage, when performed) 45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection 45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, flexible; with transendoscopic balloon dilation 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when perf ormed) 45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre-and post – dilation and guide wire passage, when performed) 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dila tion and guide wire passage, when performed) 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 4539 0 Colonoscopy, flexible; with endoscopic mucosal resection Archived Screening and Surveillance for Colorectal Cancer OHIO MEDICAID PY-0072 Effective: 03/01/2018445393 Colonoscopy, flexible; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed45398 Colonoscopy, flexible; wit h band ligation(s) (e.g., hemorrhoids) 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (Cologuard) F. RELATED POLICIES/RUL ESScreening and Surveillance for Colorectal Cancer, MM-0040 G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 05/17/2016 New Policy.Date Revised 11/01/2017 Date Effective 03/01/2018 H. REFERENCES1. Ohio Department of Medicaid. (2017, October 9). Retrieved October 9, 2017, from http://medicaid.ohio.gov/FOROHIOANS/CoveredServices.aspx#669179-preventive-exams- and-screenings The Reimbursement Policy Stateme nt detai led above has r eceived due con side ration as defined in the ReimbursementPo licy Stateme nt Po licy a nd is a pprove d.Archived

Long Acting Reversible Contraceptives (LARCs)

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 08/23/2017 08/23/2018 0 3 /01/2018 Policy Name Policy Number Long Acting Reversible Contraceptives (LARCs) PY-03 40 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case 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 COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Long Acting Reversible Contraceptives (LARCs) Ohio Medicaid PY-0340 Effective Date: 03/01/2018 2 A. SUBJECT Long Acting Reversible Contraceptives (LARCs) B. BACKGROUND CareSource recognizes Long Acting Reversible Contraceptive methods (LARCs) to be among the most effective contraception available to our members in assisting with their reproduction and family planning decisions . While LARCs do not prevent or reduce the likelihood or danger of sexually transmitted infections or their transmission, they do allow sexually active members a greater degree of certainty with a better percentage of success, and generally, less frequent medical maintenance and intervention, than other available contraceptive methods. C. DEFINITIONS Implantable Contraceptive , or Contraceptive Implant , means a single-rod contraceptive releasing device inserted under the skin of a womans upper arm . Intrauterine Device , or IUD, means a device inserted into a womans uterus by a healthcare professional in order to prevent pregnancy. IUDs may or may not be designed to also release hormones during the period of time they are implanted in the uterus. Once placed, they should be monitored, removed, and replaced periodically. D. POLICY I. Prior authorization is not required for the long acting reversible contraceptives (LARCs) covered by this policy. NOTE: Although the LARCs covered by this policy do 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. II.Services covered under this policy include: A. Management and evaluation (office) visits and consultations for the purpose of providing LARCs; B. Health educationand counseling visits for the purpose of providing LARCs; C. Medical/surgical services/procedures provided in association with the provision of LARCs; D. Laboratory tests and procedures provided in association with the provision of LARCs; E. Drugs administered as part of LARCs; and F. Supplies provided as part of LARCs. III. Covered Settings and Timing for the insertions or removals of LARCs A. Insertion or removal of a LARC may be performed and billed in conjunction with an initial or annual comprehensive visit, a follow up comprehensive medical visit, a brief medical visit, or a supply visit by a member to a qualifying provider participant, as detailed in the corresponding CareSource Family Planning reimbursement policy. B. CareSource will also reimburse providers for LARCs inserted immediately postpartum in a hospital setting, in addition to and separately from the Diagnostic Related Group reimbursement process for the hospital. 1. In this circumstance, if the provider uses one of the following implantable devices, it must be inserted within ten minutes of birth to decrease the likelihood of expulsion of the device: 1.1 J7297-Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52m g;Archived Long Acting Reversible Contraceptives (LARCs) Ohio Medicaid PY-0340 Effective Date: 03/01/2018 3 1.2J7298-Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52mg; 1.3 J7300-Intrauterine copper contraceptive (ParaGard) ; 1.4 J7301-Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5mg; 1.5 J7307-Etonogestrel (contraceptive) implant system, including implant and supplies. IV. Implantable Contraceptive Capsules A. CareSource will reimburse the following providers for the insertion and removal of implantable contraceptive capsules, after each has been trained in accordance with the manufacturers guidelines: 1. Physicians; 2. Nurse practitioners; 3. Midwives; and, 4. Physicians assistants. B. Documentation of this training must be maintained in the providers personnel or training record. C. The insertion, management and monitoring, and removal of these capsules must be performed in compliance with all manufacturers recommendations. D. Insertions are limited to once per member within any three year period. V. Intrauterine Devices A. CareSource will reimburse the following providers for the insertion and removal of intrauterine devices, after each has been trained in accordance with the manuf acturers guidelines: 1. Physicians; 2. Nurse practitioners; 3. Midwives; and, 4. Physicians assistants. B. Documentation of this training must be maintained in the providers personnel or training record. C. The insertion, management and monitoring, and removal of these capsules must be performed in compliance with all manufacturers recommendations. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODE DESCRIPTION J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg J7300 Intrauterine copper contraceptive ( ParaGard ) J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7306 Levonorgestrel (contraceptive) (Jadelle) implant system, including implants and suppliesArchived Long Acting Reversible Contraceptives (LARCs) Ohio Medicaid PY-0340 Effective Date: 03/01/2018 4 J7307 Etonogestrel (contraceptive) implant system, including implant and supplies S4989 Contraceptive intrauterine device (e.g., Progestacert (Kyleena) IUD), including implants and supplies 11976 Removal, implantable contraceptive capsules 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, non-biodegradable drug delivery implant 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) Z30.014 Encounter for initial prescription of intrauterine contraceptive device Z30.017 Encounter for initial prescription of implantable subdermal contraceptive Z30.019 Encounter for initial prescription of contraceptives, unspecified Z30.43 Encounter for surveillance of intrauterine contraceptive device Z30.430 Encounter for insertion of intrauterine contraceptive device Z30.431 Encounter for routine checking of intrauterine contraceptive device Z30.432 Encounter for removal of intrauterine contraceptive device Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device Z30.46 Encounter for surveillance of implantable subdermal contraceptive Z30.8 Encounter for other contraceptive management (encounter for routine exam for contraceptive maintenance) Z45.89 Encounter for adjustment and management of other implanted devices Z45.9 Encounter for adjustment and management of unspecified implanted device Z97.5 Presence of (intrauterine) contraceptive device F. RELATED POLICIES/RUL ES Abortion-OH MCD PY-0 008 Family Planning-OH MCD PY-0 024 Sterilization-OH MCD PY-0 038 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 08/23/2017 New Policy. Date Revised Date Effective 0 3 /01/2018 H. REFERENCES 1. Preventive Services | HHS.gov. (n.d.). Retrieved 5/10/17 from https://www.hhs.gov/opa/title-x-family-planning/preventive-services/index.html 2. Lawriter-OAC-5160-21-02 Reproductive health services: pregnancy prevention. (n.d.). Retrieved August 8, 2017 from http://codes.ohio.gov/oac/5160-21-02 3.Long-Acting Reversible Contraception Program-ACOG. (n.d.). Retrieved August 7, 2017, from https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Cardiovascular Nuclear Medicine

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 07/01/2017 07/01/2017 07/01/2017 Policy Name Policy Number Cardiovascular Nuclear Medicine PY-0235 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case 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 COVERA GE ………………………………………………………………….. 5 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Cardiovascular Nuclear Imaging Ohio Medicaid PY-0235 Effective Date: 07/01/2017 2 A. SUBJECT Cardiovascular Nuclear Medicine B. BACKGROUND Cardiovascular nuclear imaging applies a range of radionuclide agents non-invasively through specific protocols in the evaluation of various functions including coronary artery flow, myocardial perfusion, and ventricular function. Radionuclide agents and imaging techniques are chosen for specific circumstances . The status of coronary blood flow may be evaluated through a myocardial perfusion scan. The agents selected generate images showing segmental and global myocardial blood flow through radioisotope uptake. Imaging abnormalities occur can indicate myocardial scar and ischemia in the individual, most commonly caused by coronary atherosclerosis. Ventricular function studies employ radioisotope imaging with simultaneous electrocardiography to outline the borders of the ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium. The motion of the left ventricle, synchronized with the electrocardiogram, is used to calculate wall motion and ejection fraction measurements. This information is of diagnostic and prognostic value in patients with a wide range of clinical conditions. Cardiovascular nuclear imaging tests are performed at rest, during exercise, or with pharmacologic intervention to mimic exercise in less active patients. Images acquired and evaluated may be spatially oriented in planar (single plane) or multiple planes utilizing computer integration such as single-photon emission computer tomography (SPECT). Peripartum cardiomyopathy, although not as common as other varieties, may be associated with considerable morbidity. Onset is usually shortly after delivery but may occur during the final weeks of pregnancy or be delayed until several months after delivery. The degree of impact on ventricular function does not consistently correlate with prognosis or the rate of recovery. For example, patients with a very low ejection fraction can eventually completely recover from peripartum cardiomyopathy. The U.S. Preventive Services Task Force reports no preventive care indications for cardiovascular nuclear imaging tests as screening methods for adults or children. C. DEFINITIONS Diagnostic imaging means the produ ction of images used for medical diagnosis using magnetic resonance imaging (MRI), positron emission tomography (PET), computed tomography (CT), nuclear medicine. First-pass study means a form of radionuclide angiography in which a rapid sequence of images is taken immediately after administration of a bolus of radionuclide , recording only the initial transit of the isotope through the central circulation. Metabolic Equivalent (MET) is a physiologic measurement of the functional capacity or exercise tolerance of an individual as determined from progressive exercise testing (compared stage by stage) often used to define the physical activities and intensity levels in which a person may participate safely. D. POLICY I.CareSource does not require prior authorizations for the cardiovascular nuclear medicine services covered by this policy. NOTE: Although the cardiovascular nuclear medicine covered by this policy already does not require a prior authorization, CareSource may request documentation to support medical ArchivedCardiovascular Nuclear Imaging Ohio Medicaid PY-0235 Effective Date: 07/01/2017 3 necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II. All cardiovascular nuclear tests and stress tests must be ordered by a physician or a qualified non-physician provider. III. Selection of tests should be made within the context of other tests, scheduled and previously performed, so that the anticipated information obtained is unique and not redundant. Decision-making for testing should be made based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery (if applicable) and the likelihood that the results of the cardiac testing would change the management. IV. Cardiovascular nuclear imaging is indicated and covered when performed for: A. Assessment of the functional and prognostic importance of angina; B. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy; C. Assessment of congenital anomalies of coronary arteries; D. Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years; E. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction; F. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned; G. Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures; H. Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; I.Assessment of congenital anomalies of coronary arteries; J. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in: 1. patients with poor functional capacity (less than 4 METS) and minor or intermediate clinical risk predictors, as follows: 1.1 History of ischemic heart disease; 1.2 History of compensated or prior heart failure; 1.3 History of cerebrovascular disease; 1.4 Diabetes mellitus; 1.5 Renal insufficiency. 2. patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity (less than 4 METS) undergoing high risk non-cardiac surgery, where: 2.1 High risk surgery: aortic and peripheral vascular surgery; 2.2 Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery; 2.3 Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgery. K. Evaluation of ventricular function in patients with non-ischemic myocardial disease; L. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker; M. Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin). V. First pass studies will be covered only when the information sought is immediately relevant to the management of the patients clinical condition, and has not been previously obtained or Archived Cardiovascular Nuclear Imaging Ohio Medicaid PY-0235 Effective Date: 07/01/2017 4 likely to be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification of shunts. VI. Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of myocardial infarction by EC Gor enzyme testing. Patient selection should be based on clinical grounds: A. Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making. B. Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question. VII. Special Equipment Requirements A. Given the limitations of uptake, low photon energy and redistribution, the cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. However, in light of the predictive value of exercise-induced changes in ejection fraction, an exception will be made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who bill this service must certify within their records that their laboratories are specially equipped to process such studies. B. The rapid uptake, relatively low photon energy and redistribution of thallium 201 preclude its application to studies for gated images (78478 and 78480, for dates of service prior to 01/01/2010) in most laboratories. Therefore, CPT procedure codes 78478 and 78480 (for dates of service prior to 01/01/2010) are generally not payable with HCPCS code A9505 (thallous chloride). However, an exception will be made to allow this combination for laboratories that have at least double-headed cameras and the appropriate software to facilitate the count. Such providers must certify that their laboratories are specially equipped to process such studies. C. Cardiac blood pool imaging studies are described by the codes 78472, 78473, 78481, 78483, 78494 (with add-on code 78496). Only one code from the series (with appropriate add-on) may be reported on a single date of service. D. All stress tests must be performed under the direct supervision of a physician. The nuclear test components must be performed under the general supervision of a physician. VIII. If criteria are met for selected cardiovascular nuclear imaging to evaluate left ventricular ejection fraction, CareSource covers the evaluation of peripartum cardiomyopathy. IX. Services Not Covered A. Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc . ). B. Tests that are anticipated to provide information duplicative of another test already performed. C. Tests performed when the results would not be anticipated to influence medical management decisions. D. Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan. E. Infarct avid scintigraphy if the diagnosis of myocardial infarction has already been confirmed by enzymes and/or ECG. F. Tests performed unrelated to changes in a patient’s signs or symptoms, or unrelated to an immediate pre-operative evaluation. G. Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one year following normal catheterization or non-invasive test. Archived Cardiovascular Nuclear Imaging Ohio Medicaid PY-0235 Effective Date: 07/01/2017 5 H.Tests performed for preoperative evaluation in patients undergoing low-risk surgery. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The attached list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 07/01/2017 Date Revised Date Effective 07/01/2017 H. REFERENCES 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (n.d.). Retrieved March 31, 2017, from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33960&ContrId=239&ver=11&ContrVer=1&CntrctrSelected=239*1&Cntr ctr=239&name=CGS+Administrators%2c+LLC+(15101%2c+MAC+-+Part+A)&DocType=Active&LCntrctr=239*1&bc=AgACAAQAAAAAAA%3d%3d& 2. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease, Michael J. Wolk, Steven R. Bailey, John U. Doherty, Pamela S. Douglas, Robert C. Hendel, Christopher M. Kramer, James K. Min, Manesh R. Patel, Lisa Rosenbaum, Leslee J. Shaw, Raymond F. Stainback, Joseph M. Allen, Journal of the American College of Cardiology Feb 2014, 63 (4) 380-406; DOI: 10.1016/j.jacc.2013.11.009 3. American College of Cardiology-Self Assessment Program Syllabus 4. Botnovich E, Dae M, O’Connell W, Ortendahl D, Hatner R. The scinitigraphic evaluation of the cardiovascular system. Cardiology Parmley (Ed).1994. 5. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology. J. Am Coll Cardiology (2005);46:1587-1605. 6. Committee on Exercise Testing, ACC/AHA Guidelines for Exercise Testing. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JAm Coll Cardiol. July 1997;30(1):260-311. 7. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice Cardiovascu lar Nu clear Medicin e-Codes. pdf ArchivedCardiovascular Nuclear Imaging Ohio Medicaid PY-0235 Effective Date: 07/01/2017 6 guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. JAm Coll Cardiol (2007);50:1707-1732. 8. Johnson LL, Rodney RA, Vaccarino RA, et al. Left ventricular perfusion and performance from a single radiopharmaceutical and one camera. JNucl Med 1992;33:1411-1416. 9. Klocke FJ, Baird MG, Bateman TM, et al. ACC/AHA/ASNC Guidelines for the clinical use of cardiac radionuclide imaging: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to revise the 1995 guidelines for the clinical use of radionuclide imaging). 2003: downloaded from http://www.acc.org/clinical/guidelines/radio/rni_fulltext.pdf . 10.Lee T, Cardiac Noninvasive Testing. In: Braunwald E, Goldman L. editors, Primary Cardiology. 2nd edition. Elsevier Science 2003:47-61. 11. Mariano-Goulart D, Dechaux L, Rouzet F, et al. Diagnosis of diffuse and localized arrhythmogenic right ventricular dysplasia by gated blood-pool SPECT. The Journal of Nuclear Medicine. Sept 2007;48(9):1416-1423. 12. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. NEJM 2004;351:2795-2804 13. Palmas W, Friedman JD, Diamond GA, Silber H, Kiat H, Berman D. Incremental value of simultaneous assessment of myocardial function and perfusion with technetium-99m sestamibi for prediction of extent of coronary artery disease. JACC. 1995;25(5):1024-1031. 14. Shaw LJ, Heinle SK, Borges-Neto S, Kesler K, Coleman RE, Jones RH for the Duke Noninvasive Research Working Group. Prognosis by measurements of left ventricular function during exercise. JNucl Med 1998;39:140-146. 15. St John Sutton, MG, Rutherford JD, editors. Clinical Cardiovascular Imaging: A Companion to Braunwald’s Heart Disease. Elsevier Saunders. 2004. 16. Wachers FJ, Soufer R, Zaret BL. Nuclear Cardiology. In: Heart Disease: A textbook of Cardiovascular Medicine. 6th edition. Braunwald E, Zipes Dand Libby P, editors. 2001:273-304 17. Ward RP, Mouaz HA, Grossman GB, et al. American Society of Nuclear Cardiology review of the ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). JNucl Cardiol 2007;14:e26-38. 18. Zaret BL, Beller GA. Nuclear Cardiology, State of the Art and Future Directions. Mosby 199 9. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Glycosylated Hemoglobin A1c

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Effective Date Next Annual Review Effective Date 05/03/2017 05/03/2018 1 2/01/2017 Policy Name Policy Number Glycosylated Hemoglobin A1c PY-0 157 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 re ferral, authorization, notification and utilization mana gement 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 expecte d 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 alternati ve, 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 h erein. 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 u se 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. POLICY …………………………………………………………………………………………………. 4 D. CONDITIONS OF COVERAGE ………………………………………………………………….. 4 E. RELATED POLICIES/RULES ………………………………………………………………….. 19 F. REVIEW/REVISION HISTORY ………………………………………………………………… 20 G. REFERENCES ………………………………………………………………………………………. 20 Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 2 A.SUBJECT Glycosylated Hemoglobin-A1c 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. Diabetes is a disease in which the afflicted patient has blood glucose levels above normal. This is caused by the bodys inability to make enough insulin in the pancrea s, or cannot efficiently use the insulin it does produce. This causes glucose levels to elevate. Over time, elevated glucose levels can lead to very serious medical complications for the patient, including kidney failure, circulatory and nerve problems, heart disease, or blindness. The management of diabetes requires regular measurements of blood glucose levels. Glycosylated hemoglobin A1c/protein levels are used to determine long-term glucose control in diabetes. Alternative names for these tests include glycated or glycosylated hemoglobin or Hgb, hemoglobin glycated or glycosylated protein, and fructosamine. Glycated hemoglobin (equivalent to hemoglobin A1) refers to total glycosylated hemoglobin present in erythrocytes, usually determined by affinity or ion-exchange chromatographic methodology. Hemoglobin A1c refers to the major component of hemoglobin A1, usually determined by ion-exchange affinity chromatography, immunoassay or agar gel electrophoresis. Fructosamine or glycated protein refers to glycosylated protein present in a serum or plasma sample. Glycated protein refers to measurement of the component of the specific protein that is glycated usually by colorimetric method or affinity chromatography. The management of diabetes mellitus requires regular determinations of blood glucose levels. Glycosylated hemoglobin A1c/protein levels are used to assess long-term glucose control in diabetes. Alternative names for these tests include glycated or glycosylated hemoglobin or Hgb, hemoglobin glycated or glycosylated protein, and fructosamine. Glycated hemoglobin in whole blood measures glycemic control over a period of 4 to 8 weeks and is generally considered to be the appropriate monitoring test for patients who are capable of maintaining long-term, stable control of their disease . This testing may be medically necessary every 3 months to establish whether or not their glycemic control has been on average within the target range. More frequent testing, every 1 to 2 months, may be necessary in a patient whose diabetes regimen has undergone changes to improve control, or in whom the provider suspects or has evidence that some other disease or condition may have altered a previously satisfactory level of control (example: post-surgery, or as a result of glucocorticoid therapy). Glycated protein in serum/plasma assesses glycemic control over a period of 1 to 2 weeks. Research indicates that it may be reasonable and necessary to monitor glycated protein monthly in pregnant diabetic women. Glycated hemoglobin/protein test results may be low, indicating significant, persistentArchived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 3 hypoglycemia, in nesidioblastosis or insulinoma, conditions which are accompanied by inappropriate hyperinsulinemia. A below normal test value is helpful in establishing the patient’s hypoglycemic state in those conditions. 1.Indications 1.1 Glycated hemoglobin/protein testing is widely accepted as medically necessary for the management and control of diabetes. It is also valuable to assess hyperglycemia, a history of hyperglycemia or dangerous hypoglycemia. Glycated protein testing may be used in place of glycated hemoglobin in the management of diabetic patients, and is particularly useful in patients who have abnormalities of erythrocytes such as hemolytic anemia or hemoglobinopathie s. 1.2 The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. This recommendation applies to adults aged 40 to 70 years who are seen in primary care settings and do not have obvious symptoms of diabetes. Persons who have a family history of diabetes, have a history of gestational diabetes or polycystic ovarian syndrome, or are members of certain racial/ethnic groups (that is, African Americans, American Indians or Alaskan Natives, Asian Americans, Hispanics or Latinos, or Native Hawaiians or Pacific Islanders) may be at increased risk for diabetes at a younger age or at a lower body mass index. Clinicians should consider screening earlier in persons with 1 or more of these characteristics. 1.3 The USPSTF recommends screening for gestational diabetes mellitus (GDM) in asymptomatic pregnant women after 24 weeks of gestation, with an evidence grade of Bfrom the literature to support this recommendation. 2. Limitations 2.1 On a controlled diabetic patient, tests for glycated hemoglobin should be administered no more often than every three months to determine whether the patient’s metabolic control has been on average within the target range. For diabetic pregnant women, tests should generally be performed no more often than once a month. Testing for uncontrolled type one or two diabetes mellitus may require testing more than four times a year for situations outlined above, and medical necessity documentation must be made available to support such testing. 2.2 Many methods for the analysis of glycated hemoglobin show significant interference from elevated levels of fetal hemoglobin or by variant hemoglobin molecules. When the glycated hemoglobin assay is initially performed in these patients, the laboratory may inform the ordering physician of a possible analytical interference. Alternative testing, including glycated protein, for example, fructosamine, may be indicated for the monitoring of the degree of glycemic control in this situation. It is therefore conceivable that a patient will have both a glycated hemoglobin and glycated protein ordered on the same day. This should be limited to the initial assay of glycated hemoglobin, with subsequent exclusive use of glycated protein. These tests are not considered to be medically necessary for the diagnosis of diabetes. 2.3 The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for GDM in asymptomatic pregnant women before 24 weeks of gestation.Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 4 C.POLICY I. Prior authorization is not required for participating providers for any medically necessary blood glucose testing. NOTE: Although the drug screenings covered by this policy do 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. II.Diagnostic tests for blood glucose levels as referred to in this policy are selected laboratory tests. Material related to diagnostic testing in this policy is included to clarify coverage for diagnostic versus screening indications. III. CareSource considers screening for diagnosis of diabetes as medically necessary preventive care for these member groups according to the United States Preventive Services Task Force (USPSTF): A. Members aged 40 to 70 years who are asymptomatic, and overweight or obese; B. Members of any age or weight who are asymptomatic, in the following high-risk groups: 1. Immediate family history of diabetes; 2. History of gestational diabetes or polycystic ovarian syndrome. C. Members of any age and weight who are asymptomatic, in the following high-risk groups: 1. African Americans 2. American Indians 3. Alaskan Natives 4. Asian Americans 5. Hispanics and Latinos 6. Native Hawaiians 7. Native Pacific Islanders D. Pregnant women who have reached 24 weeks of gestation. IV. CareSource considers regular, ongoing testing for the management of diabetes as medically necessary for the following member groups who have previously been diagnosed with diabetes, with the specified frequencies: A. Members whose diabetes is controlled, once every 3 months B. Members whose diabetes is not controlled, as medically necessary C. Pregnant women, once per month D. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid 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 may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information.ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 5 I. Coverage: A. If policy criteria are met, CareSource will reimburse its participating providers for the following CPT codes for diagnosis when medically necessary to test for diabetes, if accompanied by one or more of the following ICD-10 codes: Codes Description 82985 Glycated protein 83036 Hemoglobin; glycated ICD-10-CM Codes Description D13.7 Benign neoplasm of endocrine pancreas E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic nephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabetes mellitus due to underlying condition with other diabetic kidney complicati on E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema E08.341 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy with macular edema E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 6 ICD-10-CM Codes Description E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with other diabetic neurological c omplication E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E09.351 Drug or chemic al induced diabetes mellitus with proliferative diabetic retinopathy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabe tic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 7 ICD-10-CM Codes Desc ription E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complication E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropa thic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic arthropathy E09.620 Drug or chemical induced diabetes mellitus with diabetic dermatitis E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer E09.628 Drug or chemical induced diabetes mellitus with other skin complications E09.630 Drug or chemical induced diabetes mellitus with periodontal disease E09.638 Drug or chemi cal induced diabetes mellitus with other oral complications E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complication E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical i nduced diabetes mellitus without complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild nonproliferative diabeti c retinopathy without macular edema E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 8 ICD-10-CM Codes Description E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic poly neuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10.628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellit us with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonprolife rative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular ed ema Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 9 ICD-10-CM Codes Description E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy E11.618 Type 2 diabetes mellitus wi th other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Oth er specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 10ICD-10-CM Codes Description E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.359 Other specified diabetes mellitus wit h proliferative diabetic retinopathy without macular edema E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellit us with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complicati ons E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy E13.620 Other specified diabetes mellitus with diabetic dermatitis E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other skin complications E13.630 Other specified diabetes mellitus with periodontal disease E13.638 Other specified diabetes mellitus with other oral complications E13.641 Other specified diabetes mellitus with hypoglycemia with coma E13.649 Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus wi th hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications E15 Nondiabetic hypoglycemic coma E16.0 Drug-induced hypoglycemia without coma E16.1 Other hypoglycemia E16.2 Hypoglycemia, unspecified E16.3 Increased secretion of glucagon E16.8 Other specified disorders of pancreatic internal secretion E16.9 Disorder of pancreatic internal secretion, unspecified E31.0 Autoimmune polyglandular failure ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 11ICD-10-CM Codes Description E31.1 Polyglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E31.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E74.8 Other specified disorders of carbohydrate metabolism E79.0 Hyperuricemia without signs of inflammatory arthritis and tophaceous disease E83.10 Disorder of iron metabolism, unspecified E83.110 Hereditary hemochromatosis E83.111 Hemochromatosis due to repeated red blood cell transfusions E83.118 Other hemochromatosis E83.119 Hemochromatosis, unspecified E83.19 Other disorders of iron metabolism K86.0 Alcohol-induced chronic pancreatitis K86.1 Other chronic pancreatitis K91.2 Postsurgical malabsorption, not elsewhere classified O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester O24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester O24.119 Pre-existing di abetes mellitus, type 2, in pregnancy, unspecified trimester O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium O24.311 Unspecified pre-existing diabetes mellitus in pregnancy, first trimester O24.312 Unspecified pre-existing diabetes mellitus in pregnancy, second trimester O24.313 Unspecified pre-existing diabetes mellitus in pregnancy, third trimester O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester O24.33 Unspecified pre-existing diabetes mellitus in the puerperium O24.410 Gestational diabetes mellitus in pregnancy, diet controlled O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled O24.419 Gestational diabetes mellitus in pregnancy, unspecified control O24.430 Gestational diabetes mellitus in the puerperium, diet controlled O24.434 Gestational diabetes mellitus in the puerperium, insulin controlled O24.439 Gestational diabetes mellitus in the puerperium, unspecified control O24.811 Other pre-existing diabetes mellitus in pregnancy, first trimester O24.812 Other pre-existing diabetes mellitus in pregnancy, second trimester O24.813 Other pre-existing dia betes mellitus in pregnancy, third trimester O24.819 Other pre-existing diabetes mellitus in pregnancy, unspecified trimester O24.83 Other pre-existing diabetes mellitus in the puerperium O24.911 Unspecified diabetes mellitus in pregnancy, first trimester ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 12ICD-10-CM Codes Description O24.912 Unspecified diabetes mellitus in pregnancy, second trimester O24.913 Unspecified diabetes mellitus in pregnancy, third trimester O24.919 Unspecified diabetes mellitus in pregnancy, unspecified trimester O24.93 Unspecified diabetes mellitus in the puerperium O99.810 Abnormal glucose complicating pregnancy O99.815 Abnormal glucose complicating the puerperium R73.01 Impaired fasting gl ucose R73.02 Impaired glucose tolerance (oral) R73.09 Other abnormal glucose R73.9 Hyperglycemia, unspecified R78.71 Abnormal lead level in blood R78.79 Finding of abnormal level of heavy metals in blood R78.89 Finding of other specified substances, not normally found in blood R79.0 Abnormal level of blood mineral R79.89 Other specified abnormal findings of blood chemistry R79.9 Abnormal finding of blood chemistry, unspecified T38.3X1A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter T38.3X2A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, intentional self-harm, initial encounter T38.3X3A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, assault, initial encounter T38.3X4A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, undetermined, initial encounter Z79.3 Long term (current) use of hormonal contraceptiv es Z79.4 Long term (current) use of insulin Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.31 Personal history of diabetic foot ulcer Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other en docrine, nutritional and metabolic disease Related to: Hypertension Diagnoses ICD-10-CM Codes Description I10 Essential (primary) hypertension I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I15.0 Renovasc ular hypertension I15.1 Hypertension secondary to other renal disorders I15.2 Hypertension secondary to endocrine disorders I15.8 Other secondary hypertension I15.9 Secondary hypertension, unspecified N26.2 Page kidney ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 13ICD-10-CM Codes Description O10.011 Pre-existing essential hypertension complicating pregnancy, first trimester O10.012 Pre-existing essential hypertension complicating pregnancy, second trimester O10.013 Pre-existing essential hypertension complicating pregnancy, third trimester O10.019 Pre-existing essential hypertension complicating pregnancy, unspecified trimester O10.02 Primary tuberculous complex, bacteriological or histological examination unknown (at present) O10.03 Primary tuberculous complex, tubercle bacilli found (in sputum) by microscopy O10.111 Pre-existing hypertensive heart disease complicating pregnancy, first trimester O10.112 Pre-existing hypertensive heart disease complicating pregnancy, second trimester O10.113 Pre-existing hypertensive heart disease complicating pregnancy, third trimester O10.119 Pre-existing hypertensive heart disease complicating pregnancy, unspecified trimester O10.12 Pre-existing hypertensive heart disease complicating childbirth O10.13 Pre-existing hypertensive heart disease complicating the puerperium O10.211 Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester O10.212 Pre-existing hypertensive chronic kidney disease complicating pregnancy, second trimester O10.213 Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester O10.219 Pre-existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester O10.22 Pre-existing hypertensive chronic kidney disease complicating childb irth O10.23 Pre-existing hypertensive chronic kidney disease complicating the puerperium O10.311 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester O10.312 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester O10.313 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester O10.319 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester O10.32 Pre-existing hypertensive heart and chronic kidney disease complicating childbirth O10.33 Pre-existing hypertensive heart and chronic kidney disease complicating the puerperium O10.411 Pre-existing secondary hypertension complicating pregnancy, first trimester O10.412 Pre-existing secondary hypertension complicating pregnancy, second trimester ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 14ICD-10-CM Codes Description O10.413 Pre-existing secondary hypertension complicating pregnancy, third trimester O10.419 Pre-existing secondary hypertension complicating pregnancy, unspecified trimester O10.42 Pre-existing secondary hypertension complicating childbirth O10.43 Pre-existing secondary hypertension complicating the puerperium O10.911 Unspecified pre-existing hypertension complicating pregnancy, first trimester O10.912 Unspecified pre-existing hypertension complicating pregnancy, second trimester O10.913 Unspecified pre-existing hypertension complicating pregnancy, third trimester O10.919 Unspecified pre-existing hypertension complicating pregnancy, unspecified trimester O10.92 Unspecified pre-existing hypertension complicating childbirth O10.93 Unspecified pre-existing hypertension complicating the puerperium O11.1 Pre-existing hypertension with pr e-eclampsia, first trimester O11.2 Pre-existing hypertension with pre-eclampsia, second trimester O11.3 Pre-existing hypertension with pre-eclampsia, third trimester O11.9 Pre-existing hypertension with pre-eclampsia, unspecified trimester O13.1 Gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester O13.2 Gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester O13.3 Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester O13.9 Gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified trimester O16.1 Unspecified maternal hypertension, first trimester O16.2 Unspecified maternal hypertension, second trimester O16.3 Unspecified maternal hypertension, third trimester O16.9 Unspecified maternal hypertension, unspecified trimester Related to: Pregnancy Diagnoses Codes Description Z33.1 Pregnant state, incidental Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester Z34.01 Encounter for supervision of normal first pregnancy, first trimester Z34.02 Encounter for supervision of normal first pregnancy, second trimester Z.34.03 Encounter for supervision of normal first preg nancy, third trimester Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester Z34.81 Encounter for supervision of other normal pregnancy, first trimester Z34.82 Encounter for supervision of other normal pregnancy, second trimester Z34.83 Encounter for supervision of other normal pregnancy, third trimester Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trime ster ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 15ICD-10-CM Codes Description Z.34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester Z36 Encounter for antenatal screening of mother O09.00 Supervision of pregnancy with history of infertility, unspecified trimester O09.01 Supervision of pregnancy with history of infertility, first trimester O09.02 Supervision of pregnancy with history of infertility, second trimester O09.03 Supervision of pregnancy with history of infertility, third trimester O09.10 Supervision of pregnancy with history of ectopic pregnancy, unspecified trimester O09.11 Supervision of pregnancy with history of ectopic pregnancy, first trimester O09.12 Supe rvision of pregnancy with history of ectopic pregnancy, second trimester O09.13 Supervision of pregnancy with history of ectopic pregnancy, third trimester O09.211 Supervision of pregnancy with history of pre-term labor, first trimester O09.212 Supervision of pregnancy with history of pre-term labor, second trimester O09.213 Supervision of pregnancy with history of pre-term labor, third trimester O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester O09.291 Sup ervision of pregnancy with other poor reproductive or obstetric history, first trimester O09.292 Supervision of pregnancy with other poor reproductive or obstetric history, second trimester O09.293 Supervision of pregnancy with other poor reproductive or obstetric history, third trimester O09.299 Supervision of pregnancy with other poor reproductive or obstetric history, unspecified trimester O09.30 Supervision of pregnancy with insufficient antenatal care, unspecified trimester O09.31 Supervision of pregnancy with insufficient antenatal care, first trimester O09.32 Supervision of pregnancy with insufficient antenatal care, second trimester O09.33 Supervision of pregnancy with insufficient antenatal care, third trimester O09.40 Supervision of pregnancy with grand multiparity, unspecified trimester O09.41 Supervision of pregnancy with grand multiparity, first trimester O09.42 Supervision of pregnancy with grand multiparity, second trimester O09.43 Supervision of pregnancy with grand multipari ty, third trimester O09.511 Supervision of elderly primigravida, first trimester O09.512 Supervision of elderly primigravida, second trimester O09.513 Supervision of elderly primigravida, third trimester O09.519 Supervision of elderly primigravida, unspecified trimester O09.521 Supervision of elderly multigravida, first trimester O09.522 Supervision of elderly multigravida, second trimester O09.523 Supervision of elderly multigravida, third trimester O09.529 Supervision of elderly multigravida, unspecified trimester O09.611 Supervision of young primigravida, first trimester ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 16ICD-10-CM Codes Description O09.612 Supervision of young primigravida, second trimester O09.613 Supervision of young primigravida, third trimester O09.619 Supervision of young primigravida, unspecified trimester O09.621 Supervision of young multigravida, first trimester O09.622 Supervision of young multigravida, second trimester O09.623 Supervision of young multigravida, third trimester O09.629 Supervision of young multigravida, unspecified trimester O09.70 Supervision of high risk pregnancy due to social problems, unspecified trimester O09.71 Supervision of high risk pregnancy due to social problems, first trimester O09.72 Supervision of high risk pregnancy due t o social problems, second trimester O09.73 Supervision of high risk pregnancy due to social problems, third trimester O09.811 Supervision of pregnancy resulting from assisted reproductive technology, first trimester O09.812 Supervision of pregnancy resulting from assisted reproductive technology, second trimester O09.813 Supervision of pregnancy resulting from assisted reproductive technology, third trimester O09.819 Supervision of pregnancy resulting from assisted reproductive technology, unspecif ied trimester O09.821 Supervision of pregnancy with history of in utero procedure during previous pregnancy, first trimester O09.822 Supervision of pregnancy with history of in utero procedure during previous pregnancy, second trimester O09.823 Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester O09.829 Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester O09.891 Supervision of other high risk pregnancies, first trimester O09.892 Supervision of other high risk pregnancies, second trimester O09.893 Supervision of other high risk pregnancies, third trimester O09.899 Supervision of other high risk pregnancies, unspecified trimester O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester O09.91 Supervision of high risk pregnancy, unspecified, first trimester O09.92 Supervision of high risk pregnancy, unspecified, second trimester O09.93 Supervision of high risk pregnancy, unspecified, third trimester O36.80X0 Pregnancy with inconclusive fetal viability, not applicable or unspecified O36.80X1 Pregnancy with inconclusive fetal viability, fetus 1 O36.80X2 Pregnancy with inconclusive fetal viability, fetus 2 O36.80X3 Pregnancy with inconclusive fetal viability, fetus 3 O36.80X4 Pregnancy with inconclusive fetal viability, fetus 4 O36.80X5 Pregnancy with inconclusive fetal viability, fetus 5 O36.80X9 Pregnancy with inconclusive fetal viability, other fetus O30.001 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester O30.002 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 17ICD-10-CM Codes Description O30.003 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.009 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.011 Twin pregnancy, monochorionic/monoamniotic, first trimester O30.012 Twin pregnancy, monochorionic/monoamniotic, second trimester O30.013 Twin pregnancy, monochorionic/monoamniotic, third trimester O30.019 Twin pregnancy, monochorionic/monoamniotic, unspecifi ed trimester O30.021 Conjoined twin pregnancy, first trimester O30.022 Conjoined twin pregnancy, second trimester O30.023 Conjoined twin pregnancy, third trimester O30.031 Twin pregnancy, monochorionic/diamniotic, first trimester O30.032 Twin pregnancy, monochorionic/diamniotic, second trimester O30.033 Twin pregnancy, monochorionic/diamniotic, third trimester O30.039 Twin pregnancy, monochorionic/diamniotic, unspecified trimester O30.041 Twin pregnancy, dichorionic/diamniotic, first trimester O30.042 Twin pregnancy, dichorionic/diamniotic, second trimester O30.043 Twin pregnancy, dichorionic/diamniotic, third trimester O30.049 Twin pregnancy, dichorionic/diamniotic, unspecified trimester O30.091 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimester O30.092 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester O30.093 Twin pregnancy, unable to determine number of placenta and number of amn iotic sacs, third trimester O30.099 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.101 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimest er O30.102 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester O30.103 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.109 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.111 Triplet pregnancy with two or more monochorionic fetuses, first trimester O30.112 Triplet pregnancy with two or more monochorionic fetuses, second trimester O30.113 Triplet pregnancy with two or more monochorionic fetuses, third trimester O30.119 Triplet pregnancy with two or more monochorionic fetuses, unspecified trimester O30.121 Triplet pregnancy with two or more monoamniotic fetuses, f irst trimester O30.122 Triplet pregnancy with two or more monoamniotic fetuses, second trimester O30.123 Triplet pregnancy with two or more monoamniotic fetuses, third trimester O30.129 Triplet pregnancy with two or more monoamniotic fetuses, unspecified trimester ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 18ICD-10-CM Codes Description O30.191 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimester O30.192 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester O30.193 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester O30.199 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.201 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester O30.202 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester O30.203 Quadruple t pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.209 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.211 Quadruplet pregnancy with two or more monochorionic fetuses, first trimester O30.212 Quadruplet pregnancy with two or more monochorionic fetuses, second trimester O30.213 Quadruplet pregnancy with two or more monochorionic fetuses, third trimester O30.219 Quadruplet pregnan cy with two or more monochorionic fetuses, unspecified trimester O30.221 Quadruplet pregnancy with two or more monoamniotic fetuses, first trimester O30.222 Quadruplet pregnancy with two or more monoamniotic fetuses, second trimester O30.223 Quadruplet pregnancy with two or more monoamniotic fetuses, third trimester O30.229 Quadruplet pregnancy with two or more monoamniotic fetuses, unspecified trimester O30.291 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, f irst trimester O30.292 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester O30.293 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester O30.299 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.801 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, first trimester O30.802 Ot her specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, second trimester O30.803 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.809 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.811 Other specified multiple gestation with two or more monochorionic fetuses, first trimester ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 19ICD-10-CM Codes Description O30.812 Other specified multiple gestation with two or more monochorionic fetuses, second trimester O30.813 Other specified multiple gestation with two or more monochorionic fetuses, third trimester O30.819 Other specified multiple gestation with two or more monochorionic fetuses, unspecified trimester O30.821 Other specified multiple gestation with two or more monoamniotic fetuses, first trimester O30.822 Other specified multiple gestation with two or more monoamniotic fetuses, second trimester O30.823 Other specified multiple gestation with two or more monoamniotic fetuses, third trimester O30.829 Other specified multiple gestation with two or more monoamniotic fetuses, unspecified trimester O30.891 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, first trimester O30.892 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, second trimester O30.893 Other specified multip le gestation, unable to determine number of placenta and number of amniotic sacs, third trimester O30.899 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.90 Multiple gestat ion, unspecified, unspecified trimester O30.91 Multiple gestation, unspecified, first trimester O30.92 Multiple gestation, unspecified, second trimester O30.93 Multiple gestation, unspecified, third trimester Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. AUTHORIZATION PERIOD E. RELATED POLICIES/RUL ES 1. CMS Medicare National Coverage Determinations Coding Policy Manual and Change Report October 2016 Changes Accessed online 1/3/2017 at https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201610_ICD10.pdf 2. U.S. Preventive Services Task Force, Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening, 2015, located at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=diabetes 3. U.S. Preventive Services Task Force, Gestational Diabetes Mellitus, Screening Adolescent & Adult Published 2014 located at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestational-diabetes-mellitus-screening?ds=1&s=diabetes ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 12/01/2017 20F. REVIEW/REVISION HISTORY DATE ACTION Date Issued 05/03/2017 Date Revised Date Effective 12/01/2017 G. REFERENCES 1. Basics | Diabetes | CDC. (n.d.). Retrieved from https://www.cdc.gov/diabetes/basics/diabetes.html 2. CMS Medicare National Coverage Determinations Coding Policy Manual and Change Report October 2016 Changes Accessed online 1/3/2017 at https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201610_ICD10.pdf 3. U.S. Preventive Services Task Force, Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening, 2015, located at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screen ing-for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=diabetes 4. U.S. Preventive Services Task Force, Gestational Diabetes Mellitus, Screening Adolescent & Adult Published 2014 located at https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestational-diabetes-mellitus-screening?ds=1&s=diabetes 5. Bower, Bruce F. and Robert Moore, Endocrine Function and Carbohydrates. Clinical Laboratory Medicine, Kenneth D. McClatchy, editor. Baltimore/Williams & Wilkins, 1994. pp. 321-323. 6. Tests of Glycemia in Diabetes. Diabetes Care. 1/98, 21:Supp. 1:S69-S71.American Association of Clinical Endocrinologists Guidelines for Management of Diabetes Mellitus 7. Dons, Robert F, Endocrine & Metabolic Testing Manual, 3rd Edition. Expert Committee on Glycated Hgb. Diabetes Care, 11/84, 7:6:602-606. Evaluation of Glycated Hgb in Diabetes, Diabetes. 7/91 30:613-617. 8. Foster, Daniel W., Diabetes Mellitus, Harrisons Principles of Internal Medicine. 13th ed., Kurt J. Isselbacher et al. Editors, New York/McGraw-Hill, 1994, pg. 1990. 9. Management of Diabetes in Older Patients. Practical Therapeutics. 1991, Drugs 41:4:548-565.. 10. Koch, D. D, Fructosamine: How Useful Is It? Laboratory Medicine, V. 21, N. 8, August 1990, pp. 497-503. 11 Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, Diabetes Care, Volume 20, Number 7, July 1997, pp. 1183 et seq. 12 Sacks, David B., Carbohydrates. In Tietz Textbook of Clinical Chemistry, 2nd Ed., Carl A. Burtis and Edward R. Ashwood, editors. Philadelphia, W.B. Saunders Co., 1994. pp. 980-988. 13 Tests of Glycemia in Diabetes. Diabetes Care. 1/98, 21:Supp. 1:S69-S71, pp. 518-520. American Association of Clinical Endocrinologists Guidelines for Management of Diabetes Mellitus The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Hepatitis Panel

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12 /01 /1 7 Policy Name Policy Number Hepatitis Panel PY-0 206 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 el igibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically nece ssary 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 f or 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 be tween this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 4D. POLICY ………………………….. ………………………….. ………………………….. ……………. 4 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 4 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 8 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 8 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 8 Archived Hepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 2 A. SUBJECT Hepatitis Panel B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care pr oviders and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other causes. Viral hepatitis can be due to one of at least five viruses, discussed here. Most cases of viral hepatitis are caused by Hepatitis A virus (HAV), Hepatitis Bvirus (HBV), or Hepatitis Cvirus (HCV), although viral hepatitis can also be caused by the less-prevalent viruses Hepatitis Dand E. HBV is spread exclusively by the members exposure to infected blood or bodily fluids. In the United States, sexual transmission accounts for thirty to sixty percent of new cases of HBV infection. Despite the overall decline in HCV infection rates in the United States over the past several decades , HCV infection rates among young adults may be increasing [ 2 ]. In a study of CDC surveillance data, the incidence of cases of acute HCV infection reported among individuals younger than 30 years old rose from 2006 to 2012 by 13 percent annually in nonurban counties and by 5 percent annually in urban counties [ 3 ]. Due to a rise in i njection drug use among younger individuals, the large majority of infected individuals are white, with men and women evenly represented. The actual incidence of acute HCV infection is likely greater than these estimates, given the difficulty in diagnosis of acute HCV infection, incomplete case reporting (including expanding infection rates among the homeless and incarcerated individuals, which is a significant population) , and narrow national case definitions. The prevalence of chronic HCV infection in the United States is currently the highest among individuals born between 1945 and 1965. In children and adolescents in the United States, HAV is the most common cause of hepatitis. Prior exposure is indicated by a positive blood test known as Immunoglobulin Ganti-HAV (IgG anti-HAV) for the Hepatitis A virus. Acute HAV is specifically diagnosed by IgM anti-HAV, which typically results within four weeks of exposure, and which disappears within three months of the first positive blood test. IgG anti-HAV is sim ilar in the timing of its appearance but does not subside, appearing indefinitely. Its detection in blood testing indicates the members prior effective immunization to, or recovery from infection. Although HAV is spread most commonly by the oral consumpti on or transmission of fecal matter from an infected individual, other methods of infection are is possible during the acute viral stage of the disease. After exposure, standard immune globulin may be effective as prophylactic care. Chronic HCV infection i s indicated with a reactive HCV antibody test and a positive molecular test indicating the presence of HCV RNA, confirming the diagnosis of HCV infection. If HCV RNA is not detected, then the reactive antibody test likely indicates either a past HCV infect ion that has s ince cleared or false positive [ 4 ]. Archived Hepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 3 HBV produces separate surface, core, and e (envelope) antigens when it infects the liver; only the surface antigen for hepatitis Bsurface (HBsAg ) is included as part of the standard panel. After being exposed to the hepatitis virus(es), the immune system typically responds by producing antibodies to each antigen . Hepatitis Bsurface antibody (HBsAb) – IgM antibody is part of the standard panel. Howe ver, HBsAg is the earlier marker, appearing four to eight weeks after exposure, and normally disappearing within six months after its appearance. If HBsAg remains detectable for a period of time exceeding six months, it is an indication of chronic HBV infe ction in the member. HBcAb, in the form of both IgG and IgM antibodies, are sequentially the next to appear in serum, typically becoming detectable two to three months following exposure . The detectable presence of the IgM antibody gradually declines or disappears entirely from one to two years following exposure, but the IgG usually remains detectable for the lifetime of the member. Because HBsAg is present for a relatively short period of time and normally at a very low concentration, a negative result from the blood test does not necessarily exclude an HBV diagnosis. By contrast, HBcAb appears in a much higher concentration and the antibodies typically remain at that higher level for a longer period of time. That said, it follows that a positive result is not necessarily diagnostic of acute disease, since the elevated antibodies may still be the result of a previous infection. In the usual course of the disease, the last marker to appear is HBsAb, which can be found in serum four to six months followin g exposure and remains positive indefinitely signifying immunity to the patient. The diagnosis of acute HBV infection is best established by documentation of a positive result for the IgM antibody against the core antigen (HBcAb-IgM), and by identifying a positive result for the hepatitis Bsurface antigen (HBsAg). The diagnosis of chronic HBV infection is established primarily by identifying a positive hepatitis Bsurface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core a ntigen (HBcAb-IgG). Additional tests such as Hepatitis Be-antigen (HBeAg) and Hepatitis Be-antibody (HBeAb), which are the envelope antigen and antibody for Hepatitis B, are not included in the standard Hepatitis Panel. However, they can be a marker of r eplication and infectivity associated with an increased risk of transmission. After an HBV vaccination series is completed, HBsAb can be followed to verify an appropriate antibody response. Once a diagnosis is established, specific tests can be used to monitor the course of the disease. If hepatitis appears in a patient after transfusion, HCV is the most common cause. HCV is responsible for 15% to 20% of all cases of acute hepatitis overall, and is the most common cause of chronic liver disease. The tes t most commonly used to identify HCV is one that measures HCV antibodies, which normally appear in the patients blood between two to four months after infection. False positive HCV results can occur . For this reason, positive results are usually verified by a more specific technique. Like HBV, HCV is spread exclusively through exposure to infected blood or body fluids. This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the timeframe of the ini tial infection or exposure, and/or the stage of the disease is unknown, a patient with continued symptoms of liver disease despite a completely negative Hepatitis Panel may need another panel performed approximately two weeks to two months later in order t o exclude the possibility of hepatitis. The specific rules that apply for diagnosis codes (for Medicaid members only ) are outlined in this policy. Archived Hepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 4 C. DEFINITIONS Medically necessary means health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice . D. POLICY I. Prior authorization is not required for any medically necessary h epatitis p anel screenings. NOTE: Although the hepatitis testing covered by this policy do es not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete doc umentation must be presented at the time of review to validat e medical necessity. II. Tests for the Hepatitis panel referred to in this policy are selected laboratory tests. Material related to diagnostic testing in this policy is included to clarify coverage for diagnostic versus screening indications. III. CareSource wil l reimburse providers for the medically necessary screening, diagnoses, and subsequent treatments for , and management of hepatitis as documented in the medical record in the following circumstances: A. To detect viral hepatitis infection when there are abnormal liver function test results, with or without signs or symptoms of hepatitis; and B. Prior to and subsequent to liver transplantation. IV. Coverage A. CareSource will cover screening for hepatitis with the appropriate laboratory tests when ordered and performed by a provider for these services, and when used in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but no t limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. https://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the m ost current coding information. I. Covered Services A. If policy criteria are met, CareSource will reimburse for an acute hepatitis panel once per calendar year for screening when medically necessary to test for hepatitis in asymptomatic men and women if accompanied by one or more of the appropriate ICD-10 codes. CareSource will reimburse for a repeat panel approximately two weeks to two months after the initial one to exclude the possibility of hepatitis in a patient with continued symptoms of liver d isease despite a completely negative first Hepatitis Panel. Codes Description 80074 Acute Hepatitis Panel Codes Description B15.0 Hepatitis A with hepatic coma B15.9 Hepatitis A without hepatic coma B16.0 Acute hepatitis Bwith delta-agent with hepatic coma ArchivedHepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 5 B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B17.2 Acute hepatitis EB17.8 Other specified acute viral hepatitis B17.9 Acute viral hepatitis, unspecified B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B18.2 Chronic viral hepatitis CB18.8 Other chronic viral hepatitis B18.9 Chronic viral hepatitis, unspecified B19.0 Unspecified viral hepatitis with hepatic coma B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma B19.9 Unspecified viral hepatitis without hepatic coma G93.3 Post-viral fatigue syndrome I85.00 Esophageal varices without bleeding I85.01 Esophageal varices with bleeding I85.10 Secondary esophageal varices without bleeding I85.11 Secondary esophageal varices with bleeding K70.41 Alcoholic hepatic failure with coma K71.0 Toxic liver disease with cholestasis K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.2 Toxic liver disease with acute hepatitis K71.3 Toxic liver disease with chroni c persistent hepatitis K71.4 Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 Toxic liver disease with hepatitis, not elsewhere classified K71.7 Toxic liver disease with fibrosis and cirrhosis of liver K71.8 Toxic liver disease with other disorders of liver K71.9 Toxic liver disease, unspecified K72.00 Acute and subacute hepatic failure without coma K72.01 Acute and subacute hepatic failure with coma K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K74.0 Hepatic fibrosis K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.0 Abscess of liver K75.1 Phlebitis of portal vein K75.2 Nonspecific reactive hepatitis K75.3 Granulomatous hepatitis, not elsewhere classified Archived Hepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 6 K75.81 Nonalcoholic steatohepatitis (NASH) K75.89 Other specified inflammatory liver diseases K75.9 Inflammatory liver disease, unspecified K76.2 Central hemorrhagic necrosis of liver K76.4 Peliosis hepatis K76.6 Portal hypertension K76.7 Hepatorenal syndrome K76.81 Hepatopulmonary syndrome R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.2 Pelvic and perineal pain R10.30 Lower abdominal pain, unspecified R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain R10.811 Right upper quadrant abdominal tenderness R10.821 Right upper quadrant rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia Archived Hepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 7 R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight R74.0 Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH] R94.5 Abnormal results of liver function studies T86.40 Unspecified c omplication of liver transplant T86.41 Liver transplant rejection T86.42 Liver transplant failure T86.43 Liver transplant infection T86.49 Other complications of liver transplant Z01.89 Encounter for other specified special examinations Z05.0 Observation and evaluation of newborn for suspected cardiac condition ruled out Z05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Z05.2 Observation and evaluation of newborn for suspected neurological condition ruled out Z05.3 Observation and evaluation of newborn for suspected respiratory condition ruled out Z05.41 Observation and evaluation of newborn for suspected genetic condition ruled out Z05.42 Observation and evaluation of newborn for suspected metabolic condition ruled out Z05.43 Observation and evaluation of newborn for suspected immunologic condition ruled out Z05.5 Observation and evaluation of newborn for suspected gastrointestinal condition ruled out Z05.6 Observation and evaluation of newborn for suspected ge nitourinary condition ruled out Z05.71 Observation and evaluation of newborn for suspected skin and subcutaneous tissue condition ruled out Z05.72 Observation and evaluation of newborn for suspected musculoskeletal condition ruled out Z05.73 Observation and evaluation of newborn for suspected connective tissue condition ruled out Z05.8 Observation and evaluation of newborn for other specified suspected condition ruled out Z05.9 Observation and evaluation of newborn for unspecified suspected condition ruled out Z19.1 Hormone sensitive malignancy status Z19.2 Hormone resistant malignancy status Z29.11 Encounter for prophylactic immunotherapy for respiratory syncytial virus (RSV) Z84.82 Family history of sudden infant death syndrome II. Non-Covered Services A. Once a diagnosis of hepatitis has been made , CareSource will cover appropriate and medically necessary, individual hepatitis test ing for its members, but does not cover ongoing hepatitis panel testing . Archived Hepatitis Panel Ohio Me dicaid PY-0206 Effective Date 12 /01/17 8 F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 03-08-2017 New policy. Date Revised 11/14/2018 Updated link from Appendix DD to the OH MCD Lab Codes link and updated the codes. Date Effective 12-01-2017 H. REFERENCES 1 . R. K. Ockner, Approaches to the diagnosis of jaundice, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W.B. Saunders, pp. 817-818. 2. R. K. Ockner, Acute viral hepatitis, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W .B. Saunders, pp. 818-826. 3 . R. K. Ockner, Chronic hepatitis, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W .B. Saunders, pp. 830-834. 4 . D. A. Arvan, Acute viral hepatitis, in Panzer, R.J., Black, E.R., & Griner, P.F. (eds.), Diagnostic Stra tegies for Common Medical Problems, 1991, American College of Physicians, pp. 141-151. 5 . D. M. Goldberg, Diagnostic Enzymology, in Gornall, A.G. (ed.), Applied Biochemistry of Clinical Disorders (2nd ed.), 1986, J.B. Lippincott, pp. 33-51. 6 . M. R. Pinc us and J. A. Schaffner, Assessment of liver function, in Henry J.B.(ed.), Clinical Diagnosis & Management by Laboratory Methods (19th ed.), 1996, W.B. Saunders, pp 253-267. 7. Tietz, N.W. (ed.), Clinical Guide to Laboratory Tests (3rd ed.), 1995, pp. 320-327. 8. D. Zakim, D. and T.D. Boyer, Hepatology (2nd ed.), 1990, W.B. Saunders. 9. Harrisons Principles of Internal Medicine (14th ed.), 1998, McGraw Hill. 10. J. Wallach, Interpretation of Diagnostic Tests, 1996, Little Brown and Co. 11. Illustrated Guide to Diagnostic Tests (2nd ed.), 1997, Springhouse Corporation. 12. Sleisenger and Fordtranss Gastrointestinal and Liver Disease (6th ed.), 1997, W.B. Saunders. 13 . CDC. (2017), (Retrieved February 20, 2017 ). HCV Facts for Health Professionals . Availa ble at https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm 1. Epidemiology and transmission of hepatitis Cvirus infection, Basics | Diabetes | CDC. (n.d.).Retrieved 02-14-2017 from https://www.cdc.gov/diab etes/basics/diabetes.html. 14. Hepatitis Cvirus infect ion among adolescents and young adults: Massachusetts, 2002-2009, Basics | Diabetes | CDC. (n.d.).Retrieved 02-14-2017 from https://www.uptodate.com/contents/epidemiology-and-transmission-of-hepatitis-c – virus-infection/abstract/5-7. 15. Emerging epidemic of hepatitis Cvirus infections among young nonurban persons who inject drugs in the United States, 2006-2012, Basics | Diabetes | CDC. (n.d.).Retrieved 02-20-2017 from https://www.uptodate.com/contents/epidemiology-and-transmission-of-hepatitis-c – virus-infection?source=search_result&search=hepatitis%20c%20ep idemiology&selectedTitle=1~150. 16. Recommendations for Testing, Managing, and Treating Hepatitis C, Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. Retrieved 08-01-2016 from http://www.hcvguidelines.org/. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived

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