Lipid Testing Assessing Cardiovascular Risk

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 04/04/2017 04/04/2018 1 2/01/2017 Policy Name Policy Number Lipid Testing Assessing Cardiovascular Risk PY-0 255 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.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Lipid Testing Assessing Cardiovascular Risk Ohio Medicaid PY-0255 Effective Date: 12-01-2017 2 A.SUBJECT Lipid Testing Assessing Cardiovascular Risk B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality in the United States. Vascular disease is the major contributor to CVD events. High levels of cholesterol in the blood, increase a persons risk of developing CVD . Total cholesterol levels include all the cholesterol found in various lipoproteins. Lipoproteins vary in size and density and include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and Eapoproteins. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoproteins (LDL) and high density lipoproteins (HDL), are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Lipid testing is used to indicate the chances of having cardiovascular disease (CVD) and/or of having a coronary event. C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Cholesterol-White, crystalline substance found in animal tissues and various foods that is normally synthesized by the liver and is important as a constituent of cell membrane and a precursor to steroid hormones; its level in the bloodstream can influence the pathogenesis of certain conditions, such as the development of atherosclerotic plaque and coronary artery disease. Coronary Heart Disease (CHD) – Any heart disorder caused by disease of the coronary arteries. High Density Lipoprotein (HDL) – A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol. High levels are thought to be associated with decreased risk of CHD and atherosclerosis. High-sensitivity C-reactive protein (hs-CRP) – A protein produced in the liver that is a marker of inflammation. Immunoassay-Any laboratory method for detecting a substance by using an antibody reactive with it. Lipid-Oily organic compound insoluble in water but soluble in organic solvents; essential structural component of living cells (along with proteins and carbohydrates). Low Density Lipoprotein (LDL) – A lipoprotein that transports cholesterol in the blood; composed of a moderate amount of protein and a large amount of cholesterol. High levels ar e thought to be associated with increased risk of CHD and atherosclerosis. Peripheral Arterial Disease (PAD) – A narrowing of the vessels that carry blood to the legs, arms, abdomen or kidneys; also known as peripheral vascular disease (PVD). ArchivedLipid Testing Assessing Cardiovascular Risk Ohio Medicaid PY-0255 Effective Date: 12-01-2017 3 Plaque-Deposit of fatty material on the inner lining of an arterial wall; characteristic of atherosclerosis. Triglyceride Naturally occurring ester (compound) of three fatty acids and glycerol that is the chief constituent of fats and oils. Unsaturated-Ca pable of taking up, or of uniting with, certain other elements or compounds, without the elimination of any side. D. POLICY I. CareSource members may receive lipid testing without prior authorization. Lipid testing must be medically necessary. II. Conditions in which lipid testing may be indicated include: A.Assessment of patients with atherosc lerotic cardiovascular disease. B. Evaluation of primary dyslipidemia. C. Any form of atherosclerotic disease, or any disease leading to the form ation of atherosclerotic disease.D. Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism.E. Secondary dyslipidemia, including diabetes mel litus, disorders of gastrointestinal absorption, chronic renal failure.F. Signs or symptoms of dysli pidemias, such as skin lesions. G. As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total chole sterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol,

Non-Invasive Vascular Studies

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12/01/2017 Policy Name Policy Number Non-Invasive Vascular Studies PY-0 163 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to mem ber benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guideli nes. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er pr olonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are no t provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If the re is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT ………………………….. ………………………….. ………… 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ………….. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………………… 2B. BACKGROUND ………………………….. ………………………….. ………………………….. …………….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. ……………….. 2 D. POL IC Y ………………………….. ………………………….. ………………………….. ………………………… 2 E. COND ITIONS OF COVERA GE ………………………….. ………………………….. …………………. 3 F. RELATED POL IC IES/RUL ES ………………………….. ………………………….. ……………………. 4 G. REVIEW /REV IS ION HIS TORY ………………………….. ………………………….. ………………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……………… 4 Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 2 A. SUBJECT Non-Invasive Vascular Studies B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary p olicies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Heal th care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or servi ce that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse providers, for non-invasive vascular studies to CareSource member s, as set forth in this policy. Non-invasi ve vascular studies may be used interchangeably with Duplex scan or Duplex ultrasound for the purposes of this policy. C. DEFINITIONS A duplex ultrasound is a test to see how blood moves through the arteries and veins of the body. D. POLICY I. CareSource does not require a prior authorization for a non-invasive vascular study. Note : Although a Non-Invasi ve Vascular Study does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and c omplete documentation must be presented at the time of review to validate medical necessity. II. A non-invasive vascular study may be reimbursed according to CMS/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the non-invasi ve vascular study CPT code . IV. I f the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. V. To be considered medically necessary the ordering physician must have reasonable expectation that the non-invasi ve vascular study results will potentially impact the clinical management of the patient. VI. To be considered medically necessary the following c onditions must be met: A. Significant signs/symptoms of arterial or venous disease are present B. The information is necessary for appropriate medi cal and/or surgical management C. The test is not redundant of other diagnostic procedures that must be per f ormed Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 3 VII. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/App-DD.pd f The follow ing list(s) of code s is provide d a s a re fe re nce . This list ma y not be a ll inclusive a nd is subje ct to upda te s. Ple a se re fe r to the a bove re fe re nce d source for the most curre nt coding informa tion. CPT Code s De finition 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93970 Duplex scan of extremity veins inc luding responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 93980 Duplex scan of arterial inflow and venous outflow of penile ves sels; complete study 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 93998 Unlisted noninvasive vascular diagnostic study ICD-10 De finition I 70.0 Atherosclerosis of aorta I 72.4 Aneurysm of artery of lower extremity S85.142A Laceration of anterior tibial artery, left leg, initial encounter S45.002A Unspecified injury of axillary artery, left side, initial encounter Q87.82 Arterial tortuosity syndrome S85.819A Laceration of other blood vessels at lower leg level, unspecified leg, initial encounter Archived Non-Invas ive Vas cular Studies Ohio Medicaid PY-0163 Effective Date: 12/01/2017 4 I82.419 Acute embolism and thrombosis of unspecified femoral vein S35.319S Unspecified injury of portal vein, sequela F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HIST ORY DAT EACT ION Da te Issue d 03-08-2017 Da te Re vise d 04-02-2 019 Revised the link to the CMS LCD below Da te Effe ctive 12-01-2017 H. REFERENCES 1. Appendix DD to rule 5160-1 – 60. (2017, January 1). Retrieved 2/6/2017 from http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/App-DD.pd f 2. Duplex Ultrasoun d | Society for Vascular Surgery. (2017, February 10). Retrieved 2/10/2017 from https://vascular.org/patient-reso urces/ vascular-tests/duplex-ultraso un d 3. MedlinePlus-Search Results for: ultrasound. (2017, February 10). Retrieved 2/10/2017 from https://vsearch.nlm.nih.gov/ vi visimo/cgi-bi n/qu ery-meta?v%3Aproject=medline plus& v%3Asou rces=medlin epl us-bundle&query=ultrasound& _g a=1.23 90 609 34.7 98 803 35 4.14 84 937 05 2 4. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2017, January 1). Retrieved 4/2/2019 from https://www.cms.gov/medic are-coverage-data base/d etails/lcd-details.aspx?LCDId=3404 5& ver=2 2&Date=12% 2f17%2 f201 8&DocID=L3 40 45&Se arch Typ e=Advanced&bc=KAAAABAAAAAA& The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived

Substance Use Disorder Residential Treatment

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 0 8/17/2017 0 8/17/2018 1 2/01/2017 Policy Name Policy Number Substance Use Disorder Residential Treatment PY-0 1 37 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 ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 3 H.REFERENCES ………………………………………………………………………………………… 4Archived Substance use Disorder Residential Treatment Ohio Medicaid PY-0137 Effective Date: 12-01-2017 2 A. SUBJECT Substance Use Disorder Residential Treatment B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. CareSource provides a benefit for treatment services for members with substance use disorder (SUD) in Residential Treatment Facilities (RTF). A referral is required. RTFs offer crisis intervention, counseling and psychotherapy, medications and diagnostic assessment. Most substance use disorders can be managed on an outpatient basis, including substance dependence and withdrawal. Members needing this level of care have withdrawal signs and symptoms that are sufficiently severe to require and emphasis on 24 hour structured and support rather than medical and nursing care (sometimes referred to as social detox). There may be a risk of potential harm to self or others, but there is an absence of imminent life-threatening conditions. Serious deficits in self-care or role functioning are present that cannot be managed at a lower level of care. Residential treatment may be needed when there is a marked barrier to change, or the living situation in inadequate to meet the members needs and the member lacks the ability to cope. The members treatment plan is to reduce and stabilize the current condition, p rovide supportive resources and progress to a less restrictive setting. RTFs provide continuous twenty-four hour observation, supervision and voluntary treatment services for members who do not require the intensive medical treatment of hospital based care. C. DEFINITIONS Substance use disorder (SUD) refers to the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. . Healthcare Common Procedure Coding System (HCPCS) – is an alphanumeric medical coding system used by healthcare professionals, including medical coders and billers. Current Procedural Terminology (CPT) – is a numerical medical coding system is used by healthcare professionals, including medical coders and billers. D. POLICY I. Some residential treatment services for SUD require a prior authorization. II. CareSource follows rules and guidelines set forth by the Ohio Department of Medicaid (ODM), the American Society of Addiction Medicine (ASAM) and MCG and therefore, expects all practitioners to work within their scope of practice and submit claims with the appropriate diagnosis and corresponding HCPCS/CPT codes. Archived Substance use Disorder Residential Treatment Ohio Medicaid PY-0137 Effective Date: 12-01-2017 3 III.CareSource follows the American Society of Addiction Medicine (ASAM) placement criteria as the standard of measurement for guiding treatment for individuals with SUD conditions. A. The following billing codes do not require a prior authorization: 1. H0010-Clinically managed withdrawal management (ASAM 3.2) 2. H0011 Medically monitored withdrawal management (ASAM 3.7) 3. H0012 Withdrawal management hourly residential addiction program outpatient B. The following billing codes: 1. H2034 Clinically Managed Low-Intensity Residential (ASAM 3.1) 2. H2036 2.1 Clinically-Managed Population-Specific High Intensity Residential Treatment (ASAM 3.3). Appropriate modifier is HI. 2.2 Clinically-Managed High-Intensity Residential Treatment (ASAM 3.5). No modifier is needed. 2.3 Medically-Monitored Intensive Inpatient Treatment (Adults) and Medically Monitored High-Intensity Inpatient Services (Adolescent) (ASAM 3.7). Appropriate modifier is TG. a. Do not require a prior authorization for up to the first 30 consecutive days b. This applies to first two (occurrences) up to 30 consecutive day stays c. Any stays after the first 2 stays require prior authorization 3. When billing for Residential Treatment the place of service code (POS) 55 should be used. 4. For further information please refer to: http://bh.medicaid.ohio.gov/Portals/0/Providers/20170810-FINAL-BH-Manual-V%201.1.pdf Note:Any stay under 30 consecutive days counts as a full 30 day occurrence IV. No SUD services may be billed outside of the per diem. Note:CareSource may, through post payment audit, request documentation for those services that do not require a prior authorization or those services that do not initially require a prior authorization that supports medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Providers must accurately identify and report on each claim detail line where a service took place using the most appropriate CMS place of service code. F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 0 8/17/2017 New Policy. Date Revised Date Effective 1 2/01/2017 Archived Substance use Disorder Residential Treatment Ohio Medicaid PY-0137 Effective Date: 12-01-2017 4 H.REFERENCES 1. Text Manuals and Rates. (2017, July 24). Retrieved 7/24/2017 from http://bh.medicaid.ohio.gov/manuals 2. Residential Treatment Facilities (2017, July 24). Retrieved 7/24/2017from https://www.ltc.ohio.gov/ResidentialType1.aspx 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

Thyroid Testing

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12 /01 /2017 Policy Name Policy Number Thyroid Testing PY-0222 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 ………………………………………………………………….. 31 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………. 31 H.REFERENCES ………………………………………………………………………………………. 32Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 2 A.SUBJECT Thyroid Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. DEFINITIONS Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. POLICY I.CareSource does not require a prior authorization for thyroid testing. II.CareSource considers thyroid function testing medically necessary for the following: A. Members who are clinically stable up to 2 times per year B. Members who have symptoms consistent with hypothyroidism C. Members who have symptoms consistent with hyperthyroidism D. Members who are asymptomatic and 60 years of age or older, performed every 5 years E. Members who are asymptomatic but are considered high risk due to the following: 1. Family or personal history of thyroid disease, this should be limited to a one time scr eening 2. Family or personal history of Type I Diabetes or other autoimmune disorder, this should be limited to a one time screening 3. Member who is prescribed medications that may interfere with thyroid function III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. ArchivedThyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 3 E.CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference.This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Codes Definition 84436 Thyroxine: total 844 39 Thyroxine: free 84443 TSH Thyroid Stimulating Hormone 84479 Thyroid Hormone Uptake (T3 or T4) or thyroid hormone binding ration (THBR) ICD-10-CM Definition A18.81 Tuberculosis of thyroid gland C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary C73 Malignant neoplasm of thyroid gland C75.8 Malignant neoplasm with pluriglandular involvement, unspecified C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D09.3 Carcinoma in situ of thyroid and other endocrine glands D09.8 Carcinoma in situ of other specified sites D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D27.9 Benign neoplasm of unspecified ovary D34 Benign neoplasm of thyroid gland D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D44.0 Neoplasm of uncertain behavior of thyroid gland D44.2 Neoplasm of uncertain behavior of parathyroid gland D44.9 Neoplasm of uncertain behavior of unspecified endocrine gland D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 4 D53.9 Nutritional anemia, unspecified D59.0 Drug-induced autoimmune hemolytic anemia D59.1 Other autoimmune hemolytic anemias D64.9 Anemia, unspecified D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere specified E00.0 Congenital iodine-deficiency syndrome, neurological type E00.1 Congenital iodine-deficiency syndrome, myxedematous type E00.2 Congenital iodine-deficiency syndrome, mixed type E00.9 Congenital iodine-deficiency syndrome, unspecified E01.0 Iodine-deficiency related diffuse (endemic) goiter E01.1 Iodine-deficiency related multinodular (endemic) goiter E01.2 Iodine-deficiency related (endemic) goiter, unspecificied E01.8 Other iodine-deficiency related thyroid disorders and allied condition s E02 Subclinical iodine-deficiency hypothyroidism E03.0 Congenital hypothyroidism with diffuse goiter E03.1 Congenital hypothyroidism without goiter E03.2 Hypothyroidism due to medicaments and other exogenous substances E03.3 Postinfectious hypothyroidism E03.4 Atrophy of thyroid (acquired) E03.5 Myxedema coma E03.8 Other specified hypothyroidism E03.9 Hypothyroidism, unspecifide E04.0 Nontoxic diffuse goiter E04.1 Nontoxic single thyroid nodule E04.2 Nontoxic multinodular goiter E04.8 Other specified nontoxic goiter E04.9 Nontoxic goiter, unspecified E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 5 E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyroto xicosis with toxic multinodular goiter with thyrotoxic crisis or storm E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm E06.0 Acute thyroiditis E06.1 Subacute thyroiditis E06.2 Chronic thyroiditis with transient thyrotoxicosis E06.3 Autoimmune thyroiditis E06.4 Drug-induced thyroiditis E06.5 Other chronic thyroiditis E06.9 Thyroiditis, unspecified E07.0 Hypersecretion of calcitonin E07.1 Dyshornogenetic goiter E07.89 Other specified disorders of thyroid E07.9 Disorder of thyroid, unspecified 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 Diabete d 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 mephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabeted mellitus due to underlyin condition with other diabetic kidney complication E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopa thy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 6 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 nonprolifeartive diabetic retinopathy with macular edema E 08.349 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 ophth almic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified 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 wi th diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis E08.621 Diabetes mellitus due to underlying condition with foot ulcer E08.622 Diabetes mellitus due to underlying condition with other skin ulcer E08.62 8 Diabetes mellitus due to underlying condition with other skin complicatiosn E08.630 Diabetes mellitus due to underlying condition with periodontal disease E08.638 Diabetes mellitus due to underlying condition with other oral complications Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 7 E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellit us due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlying condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition with complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma 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 without macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diab etic 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 chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular ede ma 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 diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 8 E09.42 Drug or chemical induc ed 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 E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complications 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 in duced diabetes mellitus with diabetic neuropathic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic dermatitis E09.620 Drug or chemical induced diabetes mellitus with diabetic dermitis 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 periodont al disease E09.638 Drug or chemical 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 complications E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus with out 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 complications E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edems E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 9 E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic 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 E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopath y 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 polyneuropathy 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 d iabetes 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 Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 10 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 mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabete s 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 diabe tic retinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative 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 edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with pro liferative 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 po lyneuropathy 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 dia betes mellitus with diabetic neuropathic arthropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 11 E11.618 Type 2 diabetes mellitus with 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 spec ified diabetes mellitus with hyperosmolarity with coma E13.10 Other 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 diab etes 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 E13.331 Other specified diabetes mell itus 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 with proliferative diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 12 E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Othe r 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 mellitus 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 complications 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 ski n 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 with 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 E20.0 Idiopathic hypoparathyroidism E20.1 Pseudohypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E22.1 Hyperprolactinemia E22.8 Other hyperfunction of pituitary gland E22.9 Hyperfunction of pituitary gland, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 13 E23.0 Hypopituitarism E23.1 Drug-induced hypopituitarism E23.6 Other disorders of pituitary gland E25.0 Congenital adrenogenital disorders associated with enzyme deficiency E25.8 Other adrenogenital disorders E25.9 Adrenogenital disorder, unspecified E27.1 Primary adrenocortical insufficiency E27.2 Addisonian crisis E27.3 Drug-induced adrenocortical insufficiency E27.40 Unspecified adrenocortical insufficiency E27.49 Other adrenocortical insufficiency E28.310 Symptomatic premature menopause E28.319 Asymptomatic premature menopause E28.39 Other primary ovarian failure E29.1 Testicular hypofunction E31.0 Autoimmune polyglandular failure 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 E35 Disorders of endocrine glands in diseases classified elsewhere E43 Unspecified severe protein-calorie malnutrition E44.0 Moderate protein-calorie malnutrition E44.1 Mild protein-calorie malnutrition E45 Retarded development following protein-calorie malnutrition E46 Unspecified protein-calorie malnutrition E53.0 Riboflavin deficiency E64.0 Sequelae of protein-calorie malnutrition E67.1 Hypercarotinemia E78.0 Pure hypercholesterolemia E78.2 Mixed hyperlipidemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 14 E78.4 Other hyperlipidemia E78.5 Hyperlipidemia, unspecified E83.50 Unspecified disorder of calcium metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E83.59 Other disorders of calcium metabolism E83.81 Hungry bone syndrome E87.0 Hyperosmolality and hypernatremia E87.1 Hypo-osmolality and hyponatremia E89.0 Postprocedural hypothyroidism E89.2 Postprocedural hypoparathyroidism E89.3 Postprocedural hypopituitarism E89.6 Postprocedural adrenocortical ( – medullary) hypofunction F03.90 Unspecified dementia without behavioral disturbance F05 Delirium due to known physiological condition F06.0 Psychotic disorder with hallucinations due to known physiological condition F06.1 Catatonic disorder due to known physiological condition F06.2 Psychotic disorder with delusions due to known physiological condition F06.30 Mood disorder due to known physiological condition, unspecified F06.31 Mood disorder due to known physiological condition with depressive features F06.32 Mood disorder due to known physiological condition with major depressive-like episode F06.33 Mood disorder due to known physiological condition with manic features F06.34 Mood disorder due to known physiological condition with mixed features F06.4 Anxiety disorder due to known physiological condition F06.8 Other specified mental disorders due to known physiological condition F07.0 Personality change due to known physiological condition F22 Delusional disorders F23 Brief psychotic disorder F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode, severe, without psychotic symptoms Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 15 F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, cur rent episode depressed, moderate F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bipolar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31.77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in fu ll remission, most recent episode mixed F31.81 Bipolar II disorder Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 16 F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspecified F33.0 Major depressi ve disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia F41.1 Generalized anxiety disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified F53 Puerperal psychosis F63.3 Trichotillomania G25.0 Essential tremor G25.1 Drug-induced tremor G25.2 Other specified forms of tremor G25.70 Drug induced movement disorder, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 17 G25.71 Drug induced akathisia G25.79 Other drug induced movement disorders G25.89 Other specified extrapyramidal and movement disorders G25.9 Extrapyramidal and movement disorder, unspecified G26 Extrapyramidal and movement disorders in diseases classified elsewhere G30.0 Alzheimer’s disease with early onset G30.1 Alzheimer’s disease with late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified G31.01 Pick’s disease G31.09 Other frontotemporal dementia G31.1 Senile degeneration of brain, not elsewhere classified G31.84 Mild cognitive impairment, so stated G47.00 Insomnia, unspecified G47.01 Insomnia due to medical condition G47.09 Other insomnia G47.30 Sleep apnea, unspecified G47.39 Other sleep apnea G47.62 Sleep related leg cramps G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G60.9 Hereditary and idiopathic neuropathy, unspecified G71.9 Primary disorder of muscle, unspecified G72.9 Myopathy, unspecified G73.3 Myasthenic syndromes in other diseases classified elsewhere G73.7 Myopathy in diseases classified elsewhere G93.3 Postviral fatigue syndrome H02.531 Eyelid retraction right upper eyelid H02.532 Eyelid retraction right lower eyelid H02.533 Eyelid retraction right eye, unspecified eyelid Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 18 H02.534 Eyelid retraction left upper eyelid H02.535 Eyelid retraction left lower eyelid H02.536 Eyelid retraction left eye, unspecified eyelid H02.539 Eyelid retraction unspecified eye, unspecified lid H02.841 Edema of right upper eyelid H02.842 Edema of right lower eyelid H02.843 Edema of right eye, unspecified eyelid H02.844 Edema of left upper eyelid H02.845 Edema of left lower eyelid H02.846 Edema of left eye, unspecified eyelid H02.849 Edema of unspecified eye, unspecified eyelid H05.20 Unspecified exophthalmos H05.221 Edema of right orbit H05.222 Edema of left orbit H05.223 Edema of bilateral orbit H05.229 Edema of unspecified orbit H05.241 Constant exophthalmos, right eye H05.242 Constant exophthalmos, left eye H05.243 Constant exophthalmos, bilateral H05.249 Constant exophthalmos, unspecified eye H05.251 Intermittent exophthalmos, right eye H05.252 Intermittent exophthalmos, left eye H05.253 Intermittent exophthalmos, bilateral H05.259 Intermittent exophthalmos, unspecified eye H05.89 Other disorders of orbit H11.421 Conjunctival edema, right eye H11.422 Conjunctival edema, left eye H11.423 Conjunctival edema, bilateral H11.429 Conjunctival edema, unspecified eye H11.431 Conjunctival hyperemia, right eye H11.432 Conjunctival hyperemia, left eye H11.433 Conjunctival hyperemia, bilateral H11.439 Conjunctival hyperemia, unspecified eye H49.00 Third [oculomotor] nerve palsy, unspecified eye Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 19 H49.01 Third [oculomotor] nerve palsy, right eye H49.02 Third [oculomotor] nerve palsy, left eye H49.03 Third [oculomotor] nerve palsy, bilateral H49.10 Fourth [trochlear] nerve palsy, unspecified eye H49.11 Fourth [trochlear] nerve palsy, right eye H49.12 Fourth [trochlear] nerve palsy, left eye H49.13 Fourth [trochlear] nerve palsy, bilateral H49.20 Sixth [abducent] nerve palsy, unspecified eye H49.21 Sixth [abducent] nerve palsy, right eye H49.22 Sixth [abducent] nerve palsy, left eye H49.23 Sixth [abducent] nerve palsy, bilateral H49.40 Progressive external ophthalmoplegia, unspecified eye H49.41 Progressive external ophthalmoplegia, right eye H49.42 Progressive external ophthalmoplegia, left eye H49.43 Progressive external ophthalmoplegia, bilateral H49.881 Other paralytic strabismus, right eye H49.882 Other paralytic strabismus, left eye H49.883 Other paralytic strabismus, bilateral H49.889 Other paralytic strabismus, unspecified eye H49.9 Unspecified paralytic strabismus H53.2 Diplopia I10 Essential (primary) hypertension I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal dis ease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through s tage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidn ey disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I31.3 Pericardial effusion (noninflammatory) I31.9 Disease of pericardium, unspecified I43 Cardiomyopathy in diseases classified elsewhere Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 20 I47.1 Supraventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation *I48.1 *Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation I49.2 Junctional premature depolarization I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.7 Cardiomegaly J91.8 Pleural effusion in other conditions classified elsewhere J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia K14.8 Other diseases of tongue Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 21 K52.2 Allergic and dietetic gastroenteritis and colitis K52.89 Other specified noninfective gastroenteritis and colitis K56.0 Paralytic ileus K56.7 Ileus, unspecified K59.00 Constipation, unspecified K59.01 Slow transit constipation K59.02 Outlet dysfunction constipation K59.09 Other constipation K59.3 Megacolon, not elsewhere classified L11.0 Acquired keratosis follicularis L29.9 Pruritus, unspecified L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.4 Beau’s lines L60.5 Yellow nail syndrome L60.8 Other nail disorders L62 Nail disorders in diseases classified elsewhere L63.0 Alopecia (capitis) totalis L63.1 Alopecia universalis L63.2 Ophiasis L63.8 Other alopecia areata L63.9 Alopecia areata, unspecified L64.0 Drug-induced androgenic alopecia L64.8 Other androgenic alopecia L64.9 Androgenic alopecia, unspecified L65.0 Telogen effluvium L65.1 Anagen effluvium L65.2 Alopecia mucinosa L65.8 Other specified nonscarring hair loss L65.9 Nonscarring hair loss, unspecified L66.0 Pseudopelade L66.2 Folliculitis decalvans L66.8 Other cicatricial alopecia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 22 L66.9 Cicatricial alopecia, unspecified L80 Vitiligo L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palmaris et plantaris) L86 Keratoderma in diseases classified elsewhere L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.2 Elastosis perforans serpiginosa M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lupus erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M32.19 Other organ or system involvement in systemic lupus erythematosus M32.8 Other forms of systemic lupus erythematosus M32.9 Systemic lupus erythematosus, unspecified M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyositis with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with other organ involvement M33.20 Polymyositis, organ involvement unspecified M33.21 Polymyositis with resp iratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 23 M33.99 Dermatopolymyositis, unspecified with other organ involvement M34.0 Progressive systemic sclerosis M34.1 CR(E)ST syndrome M34.2 Systemic sclerosis induced by drug and chemical M34.81 Systemic sclerosis with lung involvement M34.82 Systemic sclerosis with myopathy M34.83 Systemic sclerosis with polyneuropathy M34.89 Other systemic sclerosis M34.9 Systemic sclerosis, unspecified M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.09 Sicca syndrome with other organ involvement M35.1 Other overlap syndromes M35.5 Multifocal fibrosclerosis M35.8 Other specified systemic involvement of connective tissue M35.9 Systemic involvement of connective tissue, unspecified M36.0 Dermato(poly)myositis in neoplastic disease M36.8 Systemic disorders of connective tissue in other diseases classified elsewhere M60.80 Other myositis, unspecified site M60.811 Other myositis, right shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other myositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 24 M60.849 Other myositis, unspecified hand M60.851 Other myositis, right thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, right ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified site M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder M62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulder M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm M62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper arm M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm M62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearm M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand M62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified hand M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh M62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thigh M62.561 Muscle wasting and a trophy, not elsewhere classified, right lower leg M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 25 M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot M62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and foot M6 2.58 Muscle wasting and atrophy, not elsewhere classified, other site M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites M62.81 Muscle weakness (generalized) M62.9 Disorder of muscle, unspecified M63.80 Disorders of muscle in diseases classified elsewhere, unspecified site M63.811 Disorders of muscle in diseases classified elsewhere, right shoulder M63.812 Disorders of muscle in diseases classified elsewhere, left shoulder M63.819 Disorders of muscle in diseases classified elsewhere, unspecified shoulder M63.821 Disorders of muscle in diseases classified elsewhere, right upper arm M63.822 Disorders of muscle in diseases classified elsewhere, left upper arm M63.829 Disorders of muscle in diseases classified elsewhere, unspecified upper arm M63.831 Disorders of muscle in diseases classified elsewhere, right forearm M63.832 Disorders of muscle in diseases classified elsewhere, left forearm M63.839 Disorders of muscle in diseases classified elsewhere, unspecified forearm M63.841 Disorders of muscle in diseases classified elsewhere, right hand M63.842 Disorders of muscle in diseases classified elsewhere, left hand M63.849 Disorders of muscle in diseases classified elsewhere, unspecified hand M63.851 Disorders of muscle in diseases classified elsewhere, right thigh M63.852 Disorders of muscle in diseases classified elsewhere, left thigh M63.859 Disorders of muscle in diseases classified elsewhere, unspecified thigh M63.861 Disorders of muscle in diseases classified elsewhere, right lower leg M63.862 Disorders of muscle in diseases classified elsewhere, left lower leg M63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower leg M63.871 Disorders of muscle in diseases classified elsewhere, right ankle and foot M63.872 Disorders of muscle in diseases classified elsewhere, left ankle and foot M63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and foot M63.88 Disorders of muscle in diseases classified elsewhere, other site Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 26 M63.89 Disorders of muscle in diseases classified elsewhere, multiple sites M79.1 Myalgia M79.7 Fibromyalgia M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M86.9 Osteomyelitis, unspecified N91.0 Primary amenorrhea N91.1 Secondary amenorrhea N91.2 Amenorrhea, unspecified N91.3 Primary oligomenorrhea N91.4 Secondary oligomenorrhea N91.5 Oligomenorrhea, unspecified N92.0 Excessive and frequent menstruation with regular cycle N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified N94.4 Primary dysmenorrhea N94.5 Secondary dysmenorrhea N94.6 Dysmenorrhea, unspecified O90.5 Postpartum thyroiditis O92.29 Other disorders of breast associated with pregnancy and the puerperium O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O99.281 Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester O99.282 Endocrine, nutritional and metabolic diseases complicat ing pregnancy, second trimester O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O99.284 Endocrine, nutritional and metabolic diseases complicating childbirth O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium Q38.2 Macroglossia Q89.2 Congenital malformations of other endocrine glands R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 27 R06.09 Other forms of dyspnea R06.1 Stridor R06.83 Snoring R06.89 Other abnormalities of breathing R07.0 Pain in throat R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.14 Dysphagia, pharyngoesophageal phase R13.19 Other dysphagia R18.0 Malignant ascites R18.8 Other ascites R19.4 Change in bowel habit R19.7 Diarrhea, unspecified R19.8 Other specified symptoms and signs involving the digestive system and abdomen R20.0 Anesthesia of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation R20.9 Unspecified disturbances of skin sensation R23.4 Changes in skin texture R23.8 Other skin changes R23.9 Unspecified skin changes R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.2 Cramp and spasm R25.3 Fasciculation R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 28 R27.0 Ataxia, unspecified R27.8 Other lack of coordination R27.9 Unspecified lack of coordination R29.2 Abnormal reflex R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R40.2110 Coma scale, eyes open, never, unspecified time R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance] R40.2112 Coma scale, eyes open, never, at arrival to emergency department R40.2113 Coma scale, eyes open, never, at hospital admission R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission R40.2120 Coma scale, eyes open, to pain, unspecified time R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department R40.2123 Coma scale, eyes open, to pain, at hospital admission R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission R40.2210 Coma scale, best verbal response, none, unspecified time R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance] R40.2212 Coma scale, best verbal response, none, at arrival to emergency department R40.2213 Coma scale, best verbal response, none, at hospital admission R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department R40.2223 Coma scale, best verbal response, incomprehensibl e words, at hospital admission R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission R40.2310 Coma scale, best motor response, none, unspecified time R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance] R40.2312 Coma scale, best motor response, none, at arrival to emergency department Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 29 R40.2313 Coma scale, best motor response, none, at hospital admission R40.2314 Coma scale, bes t motor response, none, 24 hours or more after hospital admission R40.2320 Coma scale, best motor response, extension, unspecified time R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance] R40.2322 Coma scale, best motor response, extension, at arrival to emergency department R40.2323 Coma scale, best motor response, extension, at hospital admission R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance] R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission R40.4 Transient alteration of awareness R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified R41.9 Unspecified symptoms and signs involving cognitive functions and awareness R45.0 Nervousness R45.1 Restlessness and agitation R45.3 Demoralization and apathy R45.4 Irritability and anger R45.81 Low self-esteem R45.82 Worries R45.84 Anhedonia R45.86 Emotional lability R45.87 Impulsiveness R45.89 Other symptoms and signs involving emotional state R47.02 Dysphasia R47.1 Dysarthria and anarthria Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 30 R47.81 Slurred speech R47.89 Other speech disturbances R47.9 Unspecified speech disturbances R49.0 Dysphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R50.2 Drug induced fever R50.81 Fever presenting with conditions classified elsewhere R50.82 Postprocedural fever R50.83 Postvaccination fever R50.84 Febrile nonhemolytic transfusion reaction R50.9 Fever, unspecified R52 Pain, unspecified 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 R60.0 Localized edema R60.1 Generalized edema R60.9 Edema, unspecified R61 Generalized hyperhidrosis R63.0 Anorexia R63.2 Polyphagia R63.4 Abnormal weight loss R63.5 Abnormal weight gain R68.0 Hypothermia, not associated with low environmental temperature R68.81 Early satiety R68.83 Chills (without fever) R68.89 Other general symptoms and signs R90.89 Other abnormal findings on diagnostic imaging of central nervous system Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 31 R93.8 Abnormal findings on diagnostic imaging of other specified body structures R94.6 Abnormal results of thyroid function studies T66.XXXA Radiation sickness, unspecified, i nitial encounter Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z85.020 Personal history of malignant carcinoid tumor of stomach Z85.030 Personal history of malignant carcinoid tumor of large intestine Z85.040 Personal history of malignant carcinoid tumor of rectum Z85.060 Personal history of malignant carcinoid tumor of small intestine Z85.110 Personal history of malignant carcino id tumor of bronchus and lung Z85.230 Personal history of malignant carcinoid tumor of thymus Z85.520 Personal history of malignant carcinoid tumor of kidney Z85.821 Personal history of Merkel cell carcinoma Z85.850 Personal history of malignant neoplasm of thyroid Z85.858 Personal history of malignant neoplasm of other endocrine glands Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017 New policy. Date Revised Date Effective 0 12-01-2017 Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 32 H.REFERENCES 1. National Coverage Determination (NCD) for Thryoid Testing (190.22). Retrieved February 28, 2017, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved February 28, 2017, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf 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

Speech-Language Pathology

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 11/01/2017 11/01/2018 11/01/2017 Policy Name Policy Number Speech-Language Pathology PY-0 175 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 mem ber 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 guideli nes. 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 pr olonged, 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 no t provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If the re 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 Speech-Language Pathology Ohio Medicaid PY-0175 Effective Date: 11/01/2017 2 A.SUBJECT Speech-Language Pathology B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Speech-language pathology services include the diagnosis and treatment of speech and language disorders. These services are provided by speech-language pathologists (SLP) within the scope of their practice. Speech-language pathologists diagnose and treat swallowing disorders (dysphagia) and communication disabilities. Speech, language, and swallowing disorders can be a result of a variety of causes, such as a hearing loss, autism, developmental delay, Parkinsons disease, a cleft palate, stroke or brain injury. C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Speech-language pathology-is a field in which a clinician specializes in the eval uation and treatment of disorders, cognition , swallowing, voice, and communication disorders. Clinicians are known as speech-language pathologists (SLP), speech and language therapists , or speech therapist. D. POLICY I. CareSource members may receive up to 30 visits per calendar year (January1 December 31 st) without prior authorization. Additional visits require a prior authorization. Speech-language pathology services must be medical ly necessary. Note:If the CareSource member is under 21 years of age, AND the provider is a participating provider with CareSource, there is no limit to the amount of visits for Speech-language pathology services when medically necessary. Prior authorization is required for all non-participating providers for therapy services. II. Reimbursement is based off of Ohio Administrative code 5160-8-33 skilled therapy: documentation of services. For further information please refer to: http://codes.ohio.gov/oac/5160-8-33 III.Speech-language pathology services: A. Must be medically necessary and, under accepted standards of medical practice, be considered specific and effective treatment for the patient’s condition. B. There must be an expectation that the patient’s condition: 1. Will improve significantly within sixty days after the evaluation. 2. Or the services must be necessary for the establishment of a safe and effective maintenance program if the member is not expected to attain full functionality orArchivedSpeech-Language Pathology Ohio Medicaid PY-0175 Effective Date: 11/01/2017 3 make significant progress toward expected developmental milestones within twelve months. C. In cases that are of a progressively degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function. D. The order or referral for the evaluation and any specific testing in areas of concern should be designated by the referring physician in consultation with an SLP. E.The documentation of the screening, evaluation or re-evaluation, by the SLP, should demonstrate that an actual hands-on assessment occurred to support the medical necessity for reimbursement of the evaluation or re-evaluation and should differentiate between evaluation, re-evaluation and screening. F. Documentation is expected to support the ability of the member to learn and retain instruction. Denial of services may result from lack of such documentation. In cases where the member has questionable cognitive skills, a brief assessment should be performed and documented in order to establish the patient’s learning ability. IV. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the speech-language pathology service CPT code. V. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. VI. Non-Covered Services A. Regular routine reassessments of patients and the following screening assessments are not covered: 1. V5008 2. V5010 3. V5362 4. V5363 5. V5364 B. Evaluations, in the absence of signs and symptoms, are not covered. C. Reevaluation may be covered, if necessary, because of a change in the members condition, new clinical findings or failure to respond to the therapeutic interventions outlined in the plan of care. Note: Although speech-language therapy services for members 21 and over do not require a prior authorization for the first 30 visits, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF 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/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.ArchivedSpeech-Language Pathology Ohio Medicaid PY-0175 Effective Date: 11/01/2017 4 F.RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/01/2017 New Policy. Date Revised Date Effective 11/01/2017 H. REFERENCES 1. Appendix DD to rule 5160-1-60. (2017, January 1). Retrieved 3/23/2017 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 2. Medically Necessary-HealthCare.gov Glossary | HealthCare.gov. (2017, March 14). Retrieved 3/14/17 from https://www.healthcare.gov/glossary/medically-necessary/ 3. Speech-Language Pathologists: Occupational Outlook Handbook: U.S. Bureau of Labor Statistics. (2017, March 23). Retrieved 3/23/2017 from https://stats.bls.gov/ooh/Healthcare/Speech-language-pathologists.htm 4. Lawriter-OAC-5160-8-33 Skilled therapy: documentation of services. (2014, January 1). Retrieved 3/27/17 from http://codes.ohio.gov/oac/5160-8-33 5. Ohio Department of Medicaid-Covered Services. (2017, March 27). Retrieved 3/27/17 from http://medicaid.ohio.gov/FOROHIOANS/CoveredServices.aspx#652245-speechlanguage-pathology-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

Positive Airway Pressure Devices for Pulmonary Disorders

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 1 1/01/2017 1 1/01/2018 1 1/01/2017 Policy Name Policy Number Positive Airway Pressure Devices for Pulmonary Disorders PY-0313 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 COVERAGE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Positive Airway Pressure Devices for Pulmonary Disorders Ohio Medicaid PY-0313 Effective Date: 11/01/2017 2 A. SUBJECT Positive Airway Pressure Devices for Pulmonary Disorders B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to treat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bilevel or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulmonary disease (COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Adherence is the use of the device regularly as prescribed by the ordering physician. Deviation is the altered or lack of use of the device as prescribed by the ordering physician. D. POLICY I. CareSource does not require a prior authorization for the first 3 month rental on a PAP machines (CPAP/BiPAP) . A. CPAP (E0601) machines and BiPAP (E0470) are a 10 month rent to purchase. B. Prior authorization must be obtain through CareSource starting after the 3 rdmonth rental (months 4-10). C. BiPAP machines (E0471) are a continuous rental and are never cap out as a purchase II.Providers that dispense the PAP machine must ensure and document the members compliance with its use. A. CareSource considers adherence with the use of PAP as the following: 1. The member uses the device regularly as prescribed by the ordering physician. 2. If there is a discontinuation of use at any time, the PAP supplier is expected to ascertain adherence and stop billing for the equipment, related accessories and supplies. Archived Positive Airway Pressure Devices for Pulmonary Disorders Ohio Medicaid PY-0313 Effective Date: 11/01/2017 3 3. The member has follow-up appointments with the ordering physician to determine effectiveness and that documentation is keep on file with the supplier and will be made available upon request by CareSource if needed. III. When lack of adherence or deviation from the ordered use of a PAP machine is confirmed, the PAP machine, further rental and providers claims will be denied. A. Any reimbursement that was dispersed during the time of deviation will be recouped by CareSource. B. Any supplies that were dispensed during the time of deviation will be recouped by CareSource. Note:Although CareSource does not require a prior authorization during the first 3 months of use, CareSource may request documentation to support medical necessity that shows adherence to the ordered use of the PAP machine. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E.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://codes.ohio.gov/pdf/oh/admin/2016/5160-10-03_ph_ff_a_app2_20160321_1242.pdf The following PDF 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 A4604 Tubing with integrated heating element for use with positive airway pressure device A7030 Full face mask used with positive airway pressure device A7031 Face mask interface, replacement for full face mask A7032 Cushion for use on nasal mask interface, r eplacement only A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap A7035 Headgear used with positive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, non-disposable, used with positive airway pressure device E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interfa ce E0601 Continuous positive airway pressure (CPAP) device F. RELATED POLICIES/RUL ES MCG Ambulatory Care 21st Edition ACG: A-0337 CPAP Titration, Home (APAP) MCG Ambulatory Care 21st Edition ACG: A-0338 CPAP Titration, Sleep Center MCG Ambulatory Care 21st Edition ACG: A-0431 Noninvasive Positive Pressure Ventilation (CPAP, BiPAP) ArchivedPositive Airway Pressure Devices for Pulmonary Disorders Ohio Medicaid PY-0313 Effective Date: 11/01/2017 4 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 1 1/01/2017 New Policy. Date Revised Date Effective 1 1/01/2017 H. REFERENCES 1. CPAP-NHLBI, NIH. (2016, December 9). Retrieved 5/8/2017 from https://www.nhlbi.nih.gov/health/health-topics/topics/cpap/ 2. CPAP vs BiPAP-American Sleep Association. (2017). Retrieved 5/21/2017 from https://www.sleepassociation.org/cpap-vs-bipap/ 3. Lawriter-OAC-5160-10-22 Volume ventilators, positive and negative pressure ventilators, continuous positive airway pressure (CPAP), alternating positive airway pressure (APAP), and intermittent positive pressure ventilation (IPPV). (2013, January 1). Retrieved 5/8/2017 from http://codes.ohio.gov/oac/5160-10-22 4. Milliman Guidelines (MCG). 2017. 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

Occupational and Physical Therapy

REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Original Issue Date Next Annual Review Effective Date 11/01/2017 11/01/2018 11/01/2017-10/22/2020 Policy Name Policy Number Occupational and Physical Therapy PY-0030 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …….. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ……. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ………. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …………. 2 D. POLICY ………………………….. ………………………….. ………………………….. …………………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………….. 4 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to mem ber benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be exp ected 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 altern ative, 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) refer enced 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. A. SUBJECTOccupational and Physical Therapy Occup ational and Physical Therap y Ohio Med icaid PY-0030 Ef fective Date: 11/01/2017 B. BACKGROUND Reimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are not a g uarantee of payment. Reimb ursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submit ting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a code in this p o licy does not imply any right to reimbursement o r guarantee claims p ayment. Occup ational and P hysical therapy services help improve the lives of patients through co mp rehensive evaluations, recommendations for adaptive equipment and training in its use, and g uid ance and ed ucation for family members and caregivers. Occup ational therapy (OT) focuses on ad apting the environment of the member to fit their need s.This includ es helping people regain skills after an injury, supporting older ad ults that have exp erienced a p hysical o r mental change and teaching children with d isabilities ho w to incre ase p articipation in school and social activities. Physical therapy (PT) focuses on increasing the members physical ability to participate in their enviro nment. This includ es helping people regain physical strength, f unction and independence and to red uce p ain after an injury or mental change. PT teaches members how to manage their p hysical condition, prevent further injury and achieve long-term health benefits. C. DEFINITIONS Medically necessary health products, supplies o r services that are necessary for the d iag no sis or treatment of d isease, illness, or injury and meet accepted g uidelines of med ical p ractice. Place OH MCD definition Physical Therapy – is a health p rofession that helps patients reduce pain and improve or resto re mo bility to achieve independence in their activities of d aily living. Occupational therapy – is a health profession that helps patients develop skills in o rder to achieve ind ependence in their activities of d aily living. D. POLICYI. CareSo urce members o ver 21 years of ag e may receive up to 30 visits for o utpatient physical therap y services per calendar year (January1 December 31 st) witho ut p rior authorization, if the p ro vider is a p articipating pro vider with CareSource. Ad d itional visits b eyond 30 require a p rio r autho rization. II. CareSo urce members o ver 21 years of ag e may receive up to 30 visits for o utpatient o ccupational therapy services per calendar year (January1 December 31 st) without prior autho rizatio n, if the provider is a p articipating pro vider with CareSource. Additional visits b eyo nd 30 req uire a p rior authorization. III. If the CareSo urce member is under 21 years of age, AND the pro vider is a p articipating p ro vider with CareSource, there is no prior authorization req uired an d there is no limit to the amo unt of visits for OT/PT services when medically necessary. Occup ational and Physical Therap yOhio Med icaid PY-0030 Ef fective Date: 11/01/2017 IV . Memb ers receiving therapy in the home (place of service 12) from a p articipating p rovider do no t req uire a p rior authorization and do not have a limit to the number of visits. V. Prio r autho rization is required for all non-participating p roviders for therapy services VI. Reimb ursement is based off of Ohio Administrative Co de 5160-8-33 skilled therapy:d o cumentation of services and Ohio Administrative Co de 5160-8-32 skilled therapy: co verage. For further information p lease refer to: http://codes.ohi o.gov/oac/5160-8-33 and http ://codes.ohio.gov/oac/5160-8-32 VII. Physical and Occupational therapy services: A. Includ es aq uatic and massage therapy B. Must be medically necessary and, und er accepted standards of medical practice, be co nsidered specific and effective treatment for the p atient’s condition. C. A clinical evaluation and assessment of the members need for OT/PT therap y services must include the following elements: 1. An ap p ropriate diagnosis of the disorder or a description of the p hysical or sensory f unctionality deficit. 2. A current review of the individual’s p hysical, aud itory, visual, motor, and cognitive status. 3. A case history, including the individual’s d evelopment and capacity to participate in therap y and if ap propriate, their familys perspectives 4. The o utco mes of standardized tests, no n-standardized tests o r other test results and interp retation that use age-appropriate developmental criteria. 5. An evaluatio n justifying the need for OT/PT therapy services, which may be exp ressed as o ne of two p rognoses of the p atient’s rehabilitative o r developmental p o tential: 5. 1 The p atient’s functionality is expected to improve within sixty (60) d ays after the evaluatio n because of the initiation of therapy services o r the patient’s f unctionality is expected to improve within six months after the evaluation due to OT/PT therap y services, and the patient is expected to attain full functionality or make sig nificant p rogress toward expected g oals within twelve months; or 5. 2 The p atient is not expected to attain full functionality or make significant progress to ward the expected goals within twelve months, b ut a safe and effective maintenance p rogram may be established; and 6. Any reco mmendations for further ap praisal, follow-up, or referral. VIII . Op hthalmologists may bill for code 97110 and 97530 for vision therapy, howeverOp to metrists reimbursement is based o n the providers specific contract and codes 97110 and 97530 may no t be rei mbursable. To confirm whether your contract reimburses for these co des, please contact your Health Partner rep resentative. IX . Reimb ursement is b ased on submitting a claim with the appropriate ICD-10 diagnosis code to match the OT/PT therap y service CPT code. See attached PDF. X. If the ap p ropriate ICD-10 diagnosis code is no t submitted with the CPT code, the claim will be d enied . XI. No n-Co vered ServicesA. Evaluations, in the absence of signs and symptoms, are not covered. B. Reevaluatio n may b e co vered, if necessary, b ecause of a chang e in the memb ers co nd ition, new clinical f indings o r f ailure to resp ond to the therap eutic interventions o utlined in the plan of care. Occup ational and Physical Therap yOhio Med icaid PY-0030 Ef fective Date: 11/01/2017 Note: Altho ug h occupational and physical therapy services do no t req uire a p rior autho rizatio n for the first 30 visits and has no limit for CareSource members under 21 years o f ag e, CareSource may request documentation to suppor t medical necessity. Ap p ropriate and complete d ocumentation must b e presented at the time of review to valid ate medical necessity. XII. CareSo urce f ollows the federal, state and contract g uidelines related to the p rovision of EPSDT Preventive Services & EPSDT Sp ecial Services (other necessary health services d eemed medically necessary/ d iagnostic services/ treatment services) E. CONDITIONS OF COVERAGE Reimb ursement is dependent o n, b ut not limited to, submitting Ohio Medicaid approved HCPCS and CPT co d es alo ng with appropriate modifiers. Please ref er to the Ohio Medicaid fee schedule http ://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following PDF list(s) of codes is provided as a reference. This list may not be all inc lusive and is subject to updates. Please refer to the above referenced source for the most current coding information. F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 11/01/2017 New Po licy. Date Revised Date Effective 11/01/2017 Date Archived 10/22/2020 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES 1. Ap p endix DD to rule 5160-1-60. (2017, January 1). Retrieved 3/23/2017 from http ://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 2. Med ically Necessary – HealthCare.gov Glossary | HealthCare.gov. (2017, March 14). Retrieved 3/14/17 from https://www.healthcare.gov/glossary/medically-necessary/ 3. Ab o ut Occupational Therap y. (2017). Retrieved 4/5/2017 from http ://www.aota.org/About-Occupational-Therap y.aspx 4. Who Are Physical Therap ists? (2017). Retrieved 4/5/2017 from http ://www.apta.org/AboutPTs/ 5. Lawriter – OAC – 5160-8-33 Skilled therapy: documentation of services. (2014, January 1). Retrieved 3/27/17 fro m http://codes.ohio.gov/oac/5160-8-33 6. Lawriter – OAC – 5160-8-32 Skilled therapy: coverage. (2014, January 1). Retrieved 3/27/17 f ro m http://codes.ohio.gov/oac/5160-8-32 7. Ohio Dep artment of Medicaid – Co vered Services. (2017, March 27). Retrieved 3/27/17 f ro m http://medicaid.ohio.gov/FOROHIOANS/CoveredServices.aspx#652244 – o ccupational-therapy 8. Ohio Dep artment of Medicaid – Co vered Services. (2017, March 27). Retrieved 3/27/17 f ro m http ://med i c ai d .o hi o .g o v /FOROHI OA NS / Co v e red Se rv i c es .as p x #6 52 2 43-p hy s i c a l – therap y The Payment Policy Statement detailed above has received due consideration as defined in the Payment Policy Statement Policy and is approved.

Genetic Testing – Polymerase Chain Reaction

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 08/08/2016 08/18/201 8 09/27/2017 Policy Name Policy Number Genetic Testing-Polymerase Chain Reaction PY-0101 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 se rvices 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 utiliz ation management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) ref erenced 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 affiliat es 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 ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Genetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 2 A.SUBJECT Genetic Testing-Polymerase Chain Reaction B. BACKGROUND Polymerase Chain Reaction (PCR) is a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time period. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. PCR plays a diagnostic role when selected pathogens pose difficulties for specimen collection or culture characteristics (time, environment, or substrate constraints). For example, evaluating viral load by PCR technique for HIV helps gauge response to therapies. However, the technique is also so sensitive that amplified contaminant DNA is problematic to achieving valid test results. False positive results may also occur if DNA from one specimen contaminates another. The technique cannot distinguish DNA from colonizing organisms, or even DNA from dead microbes in a specimen, from those causing clinically significant infections. In fact, for many types of microbes the test sensitivities, specificities, and predictive values of PCR gene testing are not reported for large patient groups. Repeated cycles of synthesizing complementary strands of DNA are performed in a stepwise manner up to 30 times to achieve adequate gene amplification for diagnosis. Cycles involve 1) denaturing DNA with heat to create single strands, 2) annealing PCR primers of oligonucleotides (short pieces of DNA of 20-30 base pairs each) to the DNA to be amplified, and 3) enzymatic synthesis of complementary DNA with Taq polymerase or Pfu polymerase. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. Errors can occur anywhere in the testing process, particularly when the manufacturer’s instructions are not followed and when testing personnel are not familiar with all aspects of the test system. Some waived tests have potential for serious health impacts and unintended consequences if performed incorrectly. To decrease the risk of erroneous results, the test needs to be performed correctly, by trained personnel and in an environment where good laboratory practices are followed. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. CareSource will cover influenza testing with the CPT 87502 only when a CLIA-waived manufacturer testing system performs gene amplification by polymerase chain reaction (PCR) or nucleic acid amplification technology (NAT) testing. Appropriate indications must be documented in the members medical record and available for review by CareSource upon request. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) D. POLICY I. A Prior Authorization is not required for selected PCR testing. Archived Genetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 3 II. CareSource considers nucleic acid amplification testing (NAAT) by polymerase chain reaction (PCR) to be medically necessary for the following indications in oncology and heritable conditions: A. Chronic Lymphocytic Leukemia (CLL) [1] B. BCR-ABL testing for Chronic Myelogenous Leukemia (CML) [2] [3] [4] C. Mucosa-Associated Lymphoid Tissue (MALT) [5] D. Lynch syndrome [6] [7] E. BRAF mutation which is seen in colorectal carcinoma, gliomas, hepatobiliary carcinomas, melanoma, papillary thyroid carcinoma, ovarian teratomas and serous tumors, and hairy-cell leukemia (HCL). [8,9] F. The use of PCR gene testing for persons who meet criteria has been demonstrated in a variety of heritable conditions and is supported by published literature or endorsed by consensus professional societies. These conditions include certain primary thrombophilias[10], Tay-Sachs and Canavan diseases[11], Fabry disease[12], Gaucher disease[13], Niemann-pick disease[14], Hemochromatosis[15], Rett syndrome[16], Huntington’s disease[17], Celiac disease[18], Ankylosing spondylitis[19], Prader-Willi or Angelman syndrome, and other short-stature syndromes[20], Fragile Xsyndrome[21], and sickle-cell disease[22]. Applications of selected PCR techniques are also part of the workup and management for candidates donating organs and tissues. [23, 24] The first-line screening test for Tay-Sachs remains an enzyme activity test rather than genotyping. Genotyping is used for preimplantation diagnosis and confirmatory testing. In contrast, DNA-based testing is used for Canavan screening and diagnosis. G. Methylenetetrahydrofolate reductase (MTHFR) polymorphism testing has little clinical utility and does not meet medical necessity criteria as meta-analyses have disproven an association between elevated homocysteine and risk for coronary artery disease and between MTHFR polymorphisms and risk for venous thromboembolism.[25] III. CareSource considers NAAT by PCR to be medically necessary for the following indications in infectious disease management: A. Shiga toxin –producing Escherichia coli (STEC) [26] B. C. difficile enterocolitis [27-29] C. Entamoeba species [30,31] D. Tuberculosis[32] E. Staphylococcus aureus[33] F. Actinomyces species may be identified in tissue specimens with a 16s rRNA sequencing and PCR assay.[34, 35] G. Dengue is a mosquito-borne febrile illness and diagnosis requires laboratory confirmation by culture, NAAT or testing for dengue specific antibodies.[37] For other mosquito-borne illnesses such as West Nile virus and Zika, PCR also has diagnostic utility, including in saliva tests.[38] Ebola may be diagnosed by PCR techniques on plasma.[39] IV. CareSource considers viral PCR testing in conjunction with a Clinical Laboratory Improvement Amendments (CLIA)-approved reference lab as medically necessary for indications endorsed in a primary or supplemental diagnostic approach as described by the Infectious Diseases Society of America (IDSA). [40] Many molecular diagnostic tests for viral pathogens include PCR techniques, offered by CLIA-certified reference laboratories. Viral syndrome testing is considered based on the patient’s age, history, immune status, and other variables. According to the IDSA, diagnostic samples are obtained and tested for the most likely agents.[40] Samples are commonly held frozen in the microbiology laboratory for additional testing if necessary, given that it is not cost-effective to test initial samples broadly for multiple viruses.[40] These viral pathogens include: A. Herpes virus infections [41, 42], Varicella and Zoster[43], Measles[44], Mumps[45], Cytomegalovirus [40], Adenovirus [40], Enterovirus [42], and Parvovirus [40]. Archived Genetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 4 B.For persons with positive HIV, antigen/antibody combination immunoassays and either HIV-1 negative or indeterminate HIV-2 differentiation immunoassay, PCR testing is indicated.[40, 46, 47] C. The diagnosis of hepatitis B (HBV) or C (HCV) typically begins with an antibody test for screening or in the presence of acute hepatitis. For hepatitis B, PCR viral genetic assays may be applied to determine viral genotype, detecting genotypic drug resistance mutations, and identifying core promoter/ precore mutations.[48] For hepatitis C, persons with positive screening test results should undergo confirmatory or supplemental testing for HCV RNA by molecular test methods. V. PCR techniques have been developed for a variety of respiratory pathogens and may be included in diagnostic algorithms for affected persons in the pediatric and adult populations. The Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) consensus guidelines on the management of community-acquired pneumonia in adults report that testing is optional for persons who are not hospitalized [49]. However, patients who require hospitalization should have pretreatment blood cultures, culture and Gram stain of good-quality samples of expectorated sputum and, if disease is severe, urinary antigen tests for S. pneumoniae and Legionella pneumophila, when available. [49] Evaluation of bronchoscopically obtained samples and/or thoracentesis-obtained samples of pleural fluid may be necessary for diagnosis in hospitalized persons unable to produce a sputum sample. PCR testing may be applied in selected cases where microorganisms are suspected based upon age, history, immune status, and other variables. PCR testing is available for Mycoplasma. [49] VI. CareSource considers PCR testing for pathogens of other types or in other anatomic sites medically necessary as described by the IDSA and the American Society for Microbiology (ASM) in A Guide to Utilization of the Microbiology Laboratory for Diagnos is of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM).[40] Guidelines were developed by both laboratory and clinical experts and provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions.[40] VII. For many pathogens, while a PCR test is available, the clinical utility is not clearly defined by available evidence, evidence is insufficient or inconclusive, or there is no support for quantification PCR testing. For Bartonella henselae and quintona species, immunofluorescent antibody assay serology is sensitive and specific, and there is no inconclusive evidence of an indication for quantification. [50, 51]. For many pathogens, such as Chlamydia pneumoniae, Hepatitis G, herpes simplex virus (HSV), Herpes virus-6, Legionella pneumophilia, Mycobacteria avium-intracellulare, Mycoplasma pneumoniae, Neisseria gonorrhoeae, and Streptococcus, group A guidelines from the IDSA do not have a recommendation for quantification.[40] VIII. For sexually transmitted infections including Chlamydia, Gonorrhea, Syphilis, and other pathogens, refer to the CareSource Sexually Transmitted Infection (STI) policy. E. CONDITIONS OF COVERA GE HCPCS CPT AUTHORIZATION PERIOD Archived Genetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 5 F.RELATED POLICIES/RUL ES 1. Genetic Testing, Genetic Screening and Genetic Counseling (MM-0003) 2. Sexually Transmitted Infections (PY-0037) G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 8/16/2016 Date Revised 8/ 16/2016, 9/26/2016, 11/15/2016 09/26/2016 Removed Cystic Fibrosis criteria and reference. 08/31/2017 8/31/2017-removed expansive clinical explanations, added 87511, 87481, 87507, 87530 and 87541 as covered CPT codes; updated diagnosis codes and added PDF with CPT codes and ICD-10. Date Effective 09/27/2017 H. REFERENCES [1] D. Kienle, A. Benner, C. Laufle, D. Winkler, C. Schneider, A. Buhler , et al., “Gene expression factors as predictors of genetic risk and survival in chronic lymphocytic leukemia,” Haematologica, vol. 95, pp. 102-9, Jan 2010. [2] F. Notta, C. G. Mullighan, J. C. Wang, A. Poeppl, S. Doulatov, L. A. Phillips , et al., “Evolution of human BCR-ABL1 lymphoblastic leukaemia-initiating cells,” Nature, vol. 469, pp. 362-367, 2011. [3] A. A. Darji and P. D. Bharadia, “CHRONIC MYELOGENOUS LEUKEMIA: A REVIEW AND UPDATE OF CURRENT AND FUTURE THERAPY,” International Journal of Pharmacy and Pharmaceutical Sciences, vol. 8, 2016. [4] M. W. Deininger, “Molecular monitoring in CML and the prospects for treatment-free remissions,” Hematology Am Soc Hematol Educ Program, vol. 2015, pp. 257-63, 2015. [5] A. D. Zelenetz, J. S. Abramson, R. H. Advani, C. B. Andreadis, J. C. Byrd, M. S. Czuczman , et al. , “NCCN Clinical Practice Guidelines in Oncology: non-Hodgkin’s lymphomas,” JNatl Compr Canc Netw, vol. 8, pp. 288-334, Mar 2010. [6] H. Hampel, “NCCN increases the emphasis on genetic/familial high-risk assessment in [7] K. M. Chin, B. Wessler, P. Chew, and J. Lau, “Genetic Tests for Cancer,” in Genetic Tests for Cancer , ed Rockville (MD), 2006. [8] P. G. Febbo, M. Ladanyi, K. D. Aldape, A. M. De Marzo, M. E. Hammond, D. F. Hayes , et al., “NCCN Task Force report: Evaluating the clinical utility of tumor markers in oncology,” Journal of the National Comprehensive Cancer Network, vol. 9, pp. S-1-S-32, 2011. [9] S. Pakneshan, A. Salajegheh, R. A. Smith, and A. K. Lam, “Clinicopathological relevance of BRAF mutations in human cancer,” Pathology, vol. 45, pp. 346-56, Jun 2013. [10] S. Moll, “W ho should be tested for thrombophilia?,” Genet Med, vol. 13, pp. 19-20, 01//print 2011. [11] A. Colaianni, S. Chandrasekharan, and R. Cook-Deegan, “Impact of gene patents and licensing practices on access to genetic testing and carrier screening for Tay-Sachs and Canavan disease,” Genet Med, vol. 12, pp. S5-S14, 04//print 2010. [12] R. Schiffmann, M. Fuller, L. A. Clarke, and J. M. F. G. Aerts, “Is it Fabry disease?,” Genet Med, 05/19/online 2016. [13] C. R. Scott, G. Pastores, H. Andersson, J. Charrow, P. Kaplan, E. Kolodny , et al., “The clinical expression of Gaucher disease correlates with genotype: Data from 570 patients,” Genet Med, vol. 2, pp. 65-65, 01//print 2000. [14] R. Y. Wang, O. A. Bodamer, M. S. Watson, and W. R. Wilcox, “Lysosomal storage diseases: Diagnostic confirmation and management of presymptomatic individuals,” Genet Med, vol. 13, pp. 457-484, 05//print 2011. Archived Genetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 6 [15] C. Mura, O. Raguenes, V. Scotet, S. Jacolot, A.-Y. Mercier, and C. Ferec, “A 6-year survey of HFE gene test for hemochromatosis diagnosis,” Genet Med, vol. 7, pp. 68-73, 01//print 2005. [16] T. Bienvenu and J. Chelly, “Molecular genetics of Rett syndrome: when DNA methylation goes unrecognized,” Nat Rev Genet, vol. 7, pp. 415-426, 06//print 2006. [17] W. H. Rogowski, S. D. Grosse, and M. J. Khoury, “Challenges of translating genetic tests into clinical and public health practice,” Nat Rev Genet, vol. 10, pp. 489-495, 07//print 2009. [18] G. J. Tack, W. H. M. Verbeek, M. W. J. Schreurs, and C. J. J. Mulder, “The spectrum of celiac disease: epidemiology, clinical aspects and treatment,” Nat Rev Gastroenterol Hepatol, vol. 7, pp. 204-213, 04//print 2010. [19] L.-S. Tam, J. Gu, and D. Yu, “Pathogenesis of ankylosing spondylitis,” Nat Rev Rheumatol, vol. 6, pp. 399-405, 07//print 2010. [20] S. B. Cassidy, S. Schwartz, J. L. Miller, and D. J. Driscoll, “Prader-Willi syndrome,” Genet Med, vol. 14, pp. 10-26, 01//print 2012. [21] D. C. Crawford, J. M. Acuna, and S. L. Sherman, “FMR1 and the fragile Xsyndrome: Human genome epidemiology review,” Genet Med, vol. 3, pp. 359-371, 09//print 2001. [22] M. Bender and G. D. Seibel, “Sickle cell disease,” 2014. [23] N. Kamani, S. Spellman, C. K. Hurley, J. N. Barker, F. O. Smith, M. Oudshoorn , et al., “State of the art review: HLA matching and outcome of unrelated donor umbilical cord blood transplants,” Biol Blood Marrow Transplant, vol. 14, pp. 1-6, Jan 2008. [24] L. D’Orsogna, S. Fidler, A. Irish, B. Saker, H. Moody, and F. T. Christiansen, “HLA donor-specific antibody detected by solid phase assay identifies high-risk transplantation pairs irrespective of CDC crossmatch results: case reports and literature review,” Clin Transpl, pp. 497-501, 2006. [25] S. E. Hickey, C. J. Curry, and H. V. Toriello, “ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing,” Genet Med, vol. 15, pp. 153-6, Feb 2013. [26] L. H. Gould, C. Bopp, N. Strockbine, R. Atkinson, V. Baselski, B. Body , et al., “Recommendations for diagnosis of shiga toxin –producing Escherichia coli infections by clinical laboratories,” MMWR Recomm Rep, vol. 58, pp. 1-14, Oct 16 2009. [27] S. H. Cohen, D. N. Gerding, S. Johnson, C. P. Kelly, V. G. Loo, L. C. McDonald , et al., “Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA),” Infect Control Hosp Epidemiol, vol. 31, pp. 431-55, May 2010. [28] S. B. Selvaraju, M. Gripka, K. Estes, A. Nguyen, M. A. Jackson, and R. Selvarangan, “Detection of toxigenic Clostridium difficile in pediatric stool samples: an evaluation of Quik Check Complete Antigen assay, BD GeneOhm Cdiff PCR, and ProGastro Cd PCR assays,” Diagnostic Microbiology and Infectious Disease, vol. 71, pp. 224-229, 11// 2011. [29] M. H. Wilcox, T. Planche, F. C. Fang, and P. Gilligan, “What is the current role of algorithmic approaches for diagnosis of Clostridium difficile infection?,” JClin Microbiol, vol. 48, pp. 4347-53, Dec 2010. [30] S. Roy, M. Kabir, D. Mondal, I. K. M. Ali, W. A. Petri, and R. Haque, “Real-time-PCR assay for diagnosis of Entamoeba histolytica infection,” Journal of clinical microbiology, vol. 43, pp. 2168-2172, 2005. [31] S. Solaymani-Mohammadi, C. M. Coyle, S. M. Factor, and W. A. Petri Jr, “Amebic colitis in an antigenically and serologically negative patient: usefulness of a small-subunit ribosomal RNA gene-based polymerase chain reaction in diagnosis,” Diagnostic Microbiology and Infectious Disease, vol. 62, pp. 333-335, 11// 2008. [32] P. Nahid, S. E. Dorman, N. Alipanah, P. M. Barry, J. L. Brozek, A. Cattamanchi , et al., “Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis,” Clinical Infectious Diseases, p. ciw376, 2016. [33] D. L. Stevens, A. L. Bisno, H. F. Chambers, E. P. Dellinger, E. J. Goldstein, S. L. Gorbach , et al. , “Practice guidelines for the diagnosis and management of skin and soft tissue ArchivedGenetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 7 infections: 2014 update by the Infectious Diseases Society of America,” Clinical Infectious Diseases, vol. 59, pp. e10-e52, 2014. [34] M. J. Belmont, P. M. Behar, and M. K. Wax, “Atypical presentations of actinomycosis,” Head & neck, vol. 21, pp. 264-268, 1999. [35] T. Hansen, M. Kunkel, E. Springer, C. Walter, A. Weber, E. Siegel , et al., “Actinomycosis of the jaws –histopathological study of 45 patients shows significant involvement in bisphosphonate-associated osteonecrosis and infected osteoradionecrosis,” Virchows Arch, vol. 451, pp. 1009-17, Dec 2007. [36] C. L. Schroeder, H. P. Narra, M. Rojas, A. Sahni, J. Patel, K. Khanipov , et al., “Bacterial small RNAs in the Genus Rickettsia,” BMC Genomics, vol. 16, p. 1075, 2015. [37] M. G. Teixeira and M. L. Barreto, “Diagnosis and management of dengue,” BMJ, vol. 339, 2009. [38] D. Musso, C. Roche, T. X. Nhan, E. Robin, A. Teissier, and V. M. Cao-Lormeau, “Detection of Zika virus in saliva,” JClin Virol, vol. 68, pp. 53-5, Jul 2015. [39] J. R. Spengler, A. K. McElroy, J. R. Harmon, U. Stroher, S. T. Nichol, and C. F. Spiropoulou, “Relationship Between Ebola Virus Real-Time Quantitative Polymerase Chain Reaction-Based Threshold Cycle Value and Virus Isolation From Human Plasma,” JInfect Dis, vol. 212 Suppl 2, pp. S346-9, Oct 1 2015. [40] E. J. Baron, J. M. Miller, M. P. Weinstein, S. S. Richter, P. H. Gilligan, R. B. Thomson , et al., “A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM) a,” Clinical Infectious Diseases, vol. 57, pp. e22-e121, August 15, 2013 2013. [41] D. W . Kimberlin, “Diagnosis of herpes simplex virus in the era of polymerase chain reaction,” The Pediatric infectious disease journal, vol. 25, pp. 841-842, 2006. [42] R. L. DeBiasi and K. L. Tyler, “Molecular methods for diagnosis of viral encephalitis,” Clinical microbiology reviews, vol. 17, pp. 903-925, 2004. [43] P. A. Thomas and P. Geraldine, “Infectious keratitis,” Current opinion in infectious diseases, vol. 20, pp. 129-141, 2007. [44] R. S. van Binnendijk, S. van den Hof, H. van den Kerkhof, R. H. G. Kohl, F. Woonink, G. A. M. Berbers , et al., “Evaluation of Serological and Virological Tests in the Diagnosis of Clinical and Subclinical Measles Virus Infections during an Outbreak of Measles in The Netherlands,” Journal of Infectious Diseases, vol. 188, pp. 898-903, September 15, 2003 2003. [45] C. H. Krause, K. Eastick, and M. M. Ogilvie, “Real-time PCR for mumps diagnosis on clinical specimens comparison with results of conventional methods of virus detection and nested PCR,” Journal of clinical virology, vol. 37, pp. 184-189, 2006. [46] CDC. (2014, Quick reference guide-Laboratory testing for the diagnosis of HIV infection : updated recommendations. CDC Stacks. Available: https://stacks.cdc.gov/view/cdc/23446 [47] G. Murphy and C. Aitken, “HIV testing the perspective from across the pond,” Journal of Clinical Virology, vol. 52, pp. S71-S76, 2011. [48] A. Valsamakis, “Molecular testing in the diagnosis and management of chronic hepatitis B,” Clinical microbiology reviews, vol. 20, pp. 426-439, 2007. [49] L. A. Mandell, R. G. Wunderink, A. Anzueto, J. G. Bartlett, G. D. Campbell, N. C. Dean , et al. , “Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults,” Clinical Infectious Diseases, vol. 44, pp. S27-S72, March 1, 2007 2007. [50] P. E. Fournier, J. L. Mainardi, and D. Raoult, “Value of microimmunofluorescence for diagnosis and follow-up of Bartonella endocarditis,” Clin Diagn Lab Immunol, vol. 9, pp. 795-801, Jul 2002. [51] L. M. Mofenson, M. T. Brady, S. P. Danner, K. L. Dominguez, R. Hazra, E. Handelsman , et al., “Guidelines for the Prevention and Treatment of Opportunistic Infections among HIVexposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the ArchivedGenetic Testing-Polymerase Chain Reaction Ohio Medicaid PY-0101 Effective Date:09/27/2017 8 Pediatric Infectious Diseases Society, and the American Academy of Pediatrics,” MMWR Recomm Rep, vol. 58, pp. 1-166, Sep 4 2009. [52] K. A. Workowski, S. Berman, C. Centers for Disease, and Prevention, “Sexually transmitted diseases treatment guidelines, 2010,” MMWR Recomm Rep, vol. 59, pp. 1-110, Dec 17 2010. [53] ACOG, “ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis,” Obstet Gynecol, vol. 107, pp. 1195-1206, May 2006. The Reimbursement Policy Stateme nt det ailed a bove has r eceived due consi deration as defined in the ReimbursementPo li cy Stateme nt Po li cy a nd is a pprove d. Archived

Bilateral Procedures

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 07/01/2013 01/02/2020 01/02/2019 Policy Name Policy Number Bilateral Procedures PY-0012 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 ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY 2E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 4 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 4 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Bilateral Procedures Ohio Med icaid PY-0012 Effective Date: 02 /0 2 /201 9 2 A. SUBJECT Bilateral Procedures B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and w ill be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most ac curate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. C. DEFINITIONS Bilateral procedures-are defined as surgical operations performed on both the right and left side of a patient’s body during the same operative session requiring separate sterile fields and a separate surgical incision. Modifier-is a reporting indicator used in conjunction with a CPT code to denote that a medical service or procedure that has been performed has been altered by a specific circumstance while remaining unchanged in its definition or CPT code. D. POLICY I. CareSource will reimburse for bilateral procedures when medically necessary. II. CareSource will reimburse for bilateral procedures when providers submit their claim with appropriate CPT/HCPCS codes and modifier. A. Modifier 50 is used to report bilateral procedures (procedures described with the same CPT code) that are performed at the same operative session by the same physician on bilateral body structures (identical anatomic sites on opposite sides of the body). The use of modifier 50 is applicable only to services and/or procedures performed on identical anatomic sites or organs (e.g., eyes, ears, kidneys). B. Modifiers LT and RT may also be used to report services rendered on identical anatomic sites; however the use of these modifiers is not interchangeable with use of modifier 50. Modifiers LT and RT should only be used when the bilateral surgery rules do not apply. The bilateral surgery rules apply to procedures with a bilateral indicator of 1 , as defined by the Centers for Medicare & Medicaid (CMS). When the fee schedule has a bilateral indicator of 0 or 3 , as defined by CMS, use modifiers LT and RT to describe procedures performed on identical anatomic sites. 1. A bilateral procedure is reported on one line using modifier 50. Use a quantity entry of one when modifier 50 is reported. Do not submit two line items to report a bilateral procedure using modifier 50. 2. Modifier 50 should not be used to report diagnostic and radiology facility services. 3. Institutional claims received for an outpatient radiology service appended with modifier 50 will be denied. III. Surgical codes that are considered bilateral codes but are performed unilaterally on only one side of the body should be billed on one line unmodified or on one line with either the LT or the RT modifier indicating the side of the body on which the procedure was performed. Archived Bilateral Procedures Ohio Med icaid PY-0012 Effective Date: 02 /0 2 /201 9 3 A. Modifiers LT or RT are required when appropriate to identify: 1. Hospital procedures performed on identical anatomic sites on the right and left sides of the body (e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries). 2. A procedure is performed on only one side. 3. Hospital diagnostic test and radiology services performed on the right and left sides of the body. NOTE: Use of modifiers applies to services/procedures performed on the same calendar day. NOTE: CareSource will reimburse for bilateral procedures when the proper modifiers 50, LT, and RT are used. Modifier 50 is not to be utilized if the CPT code description specifies the procedure as bilateral. IV. Surgical codes that are considered bilateral codes but are performed more than once on one or each side of the body and/or body part indicated by the code definition must be billed using only the LT and RT modifiers on each line to demonstrate the procedure was performed more than once on one or each side. V. Although bilateral indicators 0 and 3 can be billed with the LT and RT modifiers, there are some differences between the two indicators; A. Some codes with an indicator of 0 may be performed more than once on a given day. However, even if performed on opposite sides of the body, these services would never be considered bilateral. B. Codes with an i ndicator of 0 can never be billed with modifier 50. C. Codes with an indicator of 3 can be billed with LT or RT. These services are generally radiologic and other diagnostic services. D. Codes that have an indicator of 0 that are billed using LT or RT receive reimbursement for a single code. VI. The CareSource maximum for bilateral procedures is 150% of the contracted amount allowed for the same procedures performed unilaterally when the code is billed on a single line with the 50 modifier. Bilateral Indicator Definition Submission Instructions 0 Bilateral surgery payment rules do not apply, do not use modifier 50. Do not submit these procedures with CPT modifier 50. 1 Bilateral surgery payment rules apply (150%). Use modifier 50 if bilateral. Units = 1 Submit the procedure on a single detail line with CPT modifier 50 and a quantity of 1. 2 Bilateral surgery payment rules do not apply. Already priced as bilateral. Do not use modifier 50. Units = 1 Submit the procedure with a quantity of 1. Do not submit these procedures with CPT modifier 50. 3 Bilateral surgery payment rules do not apply. Do not use modifier 50. Units = 1 or 2. Do not submit these procedures with CPT modifier 50. 9 Bilateral concept does not apply. Do not submit these procedures with CPT modifier 50. Archived Bilateral Procedures Ohio Med icaid PY-0012 Effective Date: 02 /0 2 /201 9 4 E. CONDITIONS OF COVERA GE A UTHORIZATION PERIOD F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 07/01/2013 Date Revised 01 / 02/2019 Revision Date Effective 02/02/2019 H. REFERENCES 1. Surgical services. (2015, July 03). Retrieved August 15, 2016, from http://codes.ohio.gov/oac/5160-4 – 22 . The Reimbursement 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

Positive Airway Pressure Devices for Pulmonary Disorders

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 0 9/01/2017 0 9/01/2018 09/01/2017 Policy Name Policy Number Positive Airway Pressure Devices for Pulmonary Disorders PY-0313 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 ………………………………………….. Error! Bookmark not defined. A.SUBJECT …………………………………………………….. Error! Bookmark not defined. B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………. Error! Bookmark not defined. E.CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES …………………………. Error! Bookmark not defined. G.REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H.REFERENCES ………………………………………………………………………………………… 4 Archived Positive Airway Pressure Devices for Pulmonary Disorders Ohio Medicaid PY-0313 Effective Date: 09/01/2017 2 A. SUBJECT Positive Airway Pressure Devices for Pulmonary Disorders B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to treat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bilevel or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulmonary disease (COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Adherence is the use of the device regularly as prescribed by the ordering physician. Deviation is the altered or lack of use of the device as prescribed by the ordering physician. D. POLICY I. CareSource does not require a prior authorization for the first 3 month rental on a PAP machines (CPAP/BiPAP) . A. CPAP (E0601) machines and BiPAP (E0470) are a 10 month rent to purchase. B. Prior authorization must be obtain through CareSource starting after the 3 rdmonth rental (months 4-10). C. BiPAP machines (E0471) are a continuous rental and are never cap out as a purchase II.Providers that dispense the PAP machine must ensure and document the members compliance with its use. A. CareSource considers adherence with the use of PAP as the following: 1. The member uses the device regularly as prescribed by the ordering physician. 2. If there is a discontinuation of use at any time, the PAP supplier is expected to ascertain adherence and stop billing for the equipment, related accessories and supplies. Archived Positive Airway Pressure Devices for Pulmonary Disorders Ohio Medicaid PY-0313 Effective Date: 09/01/2017 3 3. The member has follow-up appointments with the ordering physician to determine effectiveness and that documentation is keep on file with the supplier and will be made available upon request by CareSource if needed. III. When lack of adherence or deviation from the ordered use of a PAP machine is confirmed, the PAP machine, further rental and providers claims will be denied. A. Any reimbursement that was dispersed during the time of deviation will be recouped by CareSource. B. Any supplies that were dispensed during the time of deviation will be recouped by CareSource. Note:Although CareSource does not require a prior authorization during the first 3 months of use, CareSource may request documentation to support medical necessity that shows adherence to the ordered use of the PAP machine. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E.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://codes.ohio.gov/pdf/oh/admin/2016/5160-10-03_ph_ff_a_app2_20160321_1242.pdf The following PDF 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 A4604 Tubing with integrated heating element for use with positive airway pressure device A7030 Full face mask used with positive airway pressure device A7031 Face mask interface, replacement for full face mask A7032 Cushion for use on nasal mask interface, r eplacement only A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap A7035 Headgear used with positive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, non-disposable, used with positive airway pressure device E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interfa ce E0601 Continuous positive airway pressure (CPAP) device F. RELATED POLICIES/RUL ES MCG Ambulatory Care 20 thEdition ACG: A-0337 CPAP Titration, Home (APAP) MCG Ambulatory Care 20 thEdition ACG: A-0338 CPAP Titration, Sleep Center MCG Ambulatory Care 20th Edition ACG: A-0431 Noninvasive Positive Pressure Ventilation (CPAP, BiPAP) ArchivedPositive Airway Pressure Devices for Pulmonary Disorders Ohio Medicaid PY-0313 Effective Date: 09/01/2017 4 G.REVIEW/REVISION HISTORY DATE ACTION Date Issued 0 9/01/2017 Date Revised Date Effective 09/01/2017 H.REFERENCES1. CPAP-NHLBI, NIH. (2016, December 9). Retrieved 5/8/2017 from https://www.nhlbi.nih.gov/health/health-topics/topics/cpap/ 2. CPAP vs BiPAP-American Sleep Association. (2017). Retrieved 5/21/2017 from https://www.sleepassociation.org/cpap-vs-bipap/ 3. Lawriter-OAC-5160-10-22 Volume ventilators, positive and negative pressure ventilators,continuous positive airway pressure (CPAP), alternating positive airway pressure (APAP),and intermittent positive pressure ventilation (IPPV). (2013, January 1). Retrieved 5/8/2017from http://codes.ohio.gov/oac/5160-10-22 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. OH-P-1343Archived

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