Molecular Diagnostic Testing for Hepatitis B and C

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Hepatitis Band CPY-0447 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. ……………. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Diagnostic Testing for Hepatitis Band CB. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowi ng the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronic ally infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-te rm illness but for 70% 85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) All facilities in the Unit ed States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cl eared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 3 D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy III. CareSource does not consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. I V . Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.2 Chronic viral hepatitis CB18.9 Chronic viral hepatitis, unspecified B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis complicating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium F. RELATED POLICIES/RUL ES N/A Archived Molecular Diagnostic Testing for Hepatitis Band COH IO MEDICAID PY-0447 Effective Date: 12/01/2018 4 G. REVIEW/REVISION HIST ORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Revised to reflect next review date of 12/01/2019 Date Effective H. REFERENCES 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (2015, May 31). Retri eved July 3, 2018, from www.cdc.gov /hepatitis The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived

Molecular Diagnostic Testing for Gastrointestinal Illness

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 12/01/2018 12/01/201 9 12/01/2018 Policy Name Policy Number Molecular Diagnostic Testing for Gastrointestinal Illness PY-0448 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affili ates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 2 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 3 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 4 Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 2 A. SUBJECT Molecular Testing for Gastrointestinal Illness B. BACKGROUND Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions . Molecular diagnostic testing utilizes Polymerase Chain Reaction (PC R) , a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the ta rget segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Gastrointestinal illness, as addressed in this policy, include Clostridium difficile, E. Coli, Salmonella, Shigella, Norovirus and Giardia. These infection and illnesses of the intestine can cause symptoms such as diarrhea, nausea, vomiting and abdominal cramping. There are three basic modes of transmission: in food, in water and person to person. While some of these illnesses will resolve on their own, others can spread throughout the body and require treatment to prevent a more devastating illness. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or tr eatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, co ndition, disease or its symptoms and that meet the accepted standards of medicine. D. POLICY I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for the following gastrointestinal i llnesses, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage of this policy. A. Clostridium Difficile B. Salmonella C. Shigella D. Norovirus E. Giardia III. CareSource does not consider Molecular Diagnostic Testing by PCR medically necessary for gastrointestinal illnesses when billed with any other diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as stool and saliva samples for these illnesses is viewed as low cost and given that not all cases of acute diarrhea are indicative of these illnesses, institutions should utilize these before the higher cos t Molecular Testing by PCR as the first testing option for the initial clinical presentation of acute diarrhea. Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 3 E. CONDITIONS OF COVERA GE CODE DESCRIPTION 87493 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique 87505 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, an d multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), include s multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. co li, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets A04.71 Enterocolitis due to Clostridium difficile, recurrent A04.7 2 Enterocolitis due to Clostridium difficile, not specified as recurrent A02.0 Salmonella enteritis A03.0 Shigellosis due to Shigella dysenteriae A03.1 Shigellosis due to Shigella flexneri A03.2 Shigellosis due to Shigella boydii A03.3 Shigellosis due to Shigella sonnei A03.8 Other shigellosis A03.9 Shigellosis, unspecified A04.0 Enteropathogenic Escherichia coli infection A04.1 Enterotoxigenic Escherichia coli infection A04.2 Enteroinvasive Escherichia coli infection A04.3 Enterohemorrhagic Escherichia coli infection A04.4 Other intestinal Escherichia coli infections A07.1 Giardiasis [lambliasis] A08.11 Acute gastroenteropathy due to Norwalk agent K52.9 Noninfective gastroenteritis and colitis, unspecified O99.611 Diseases of the digestive system complicating pregnancy, first trimester O99.612 Diseases of the digestive system complicating pregnancy, second trimester O99.613 Diseases of the digestive system complicating pregnancy, third trimester O99.619 Diseases of the digestive system complicating pregnancy, unspecified trimester O99.62 Diseases of the digestive system complicating childbirth O99.63 Diseases of the digestive system complicating the puerperium F. RELATED POLICIES/RUL ES N/A Archived Molecular Diagnostic Testing for Gastrointestinal Illness OH MEDICAID PY-0448 Effective Date: 12/01/2018 4 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 12/01/2018 Date Revised 11/07/2018 Updated next review date to 12/01/2019 Date Effective H. REFERENCES 1. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System Infections. (2016 , July 16). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091344/ The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived

Telemedicine Services

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 10/31/2013 07/01/2019 07/01/2018 Policy Name Policy Number Telemedicine Services PY-0084 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2 D. POLICY ………………………….. ………………………….. ………………………….. ……………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………… 5 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………. 5 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 5 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edi cal necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of func tion, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or p rovider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (i.e. , Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 Telemedicine ServicesOHIO MEDICAID PY-0084 Effective Date: 07/01/2018 A. SUBJECTTelemedicine Services B. BACKGROUNDReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office sta ff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriateCPT/HCPCS code(s) for the product or service that is being provided. The inclusi on of a code does not imply any right to reimbursement or guarantee claims payment. Telemedicine is used to support health care when the provider and patient are physically separated. Typically, the patient communicates with the provider via interactive me ans that is sufficient to establish the necessary link to the provider who is working at a different location from the patient. CareSource will reimburse participating providers, for telemedicine services, who are credentialed to deliver telemedicine services rendered to CareSource members, as set forth in this policy. C. DEFINITIONS Asynchronous store and forward technologies – is the transfer of a patients medical information, through the use of a camera or recording device, that is sent via telecommunication to another site for consultation. Distant Site (Hub) – is the location of the physician or provider rendering health care services. Electronic service delivery (electronic therapy, cyber therapy, e-therapy, etc.) – is counseling, social work or marriage and family therapy in any form offered or rendered primarily by electronic or technology-assisted means. Originating Site (Spoke) – is the location where the patient is physically located when services are provided. Place of Service Codes (POS) – are t codes that specifically indicate where a service or procedure was performed. Telemedicine – is the direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. Telemedicine vendor – is the participating provider with CareSource that renders the telemedicine services. D. POLICYI. CareSource does not require prior authorization for Telemedicine services. II. Telemedicine services may be reimbursed according to Ohio Medicaid guidelines and using appropriate CPT and/or HCPCS and modifier codes. III. Practitioners providing select behavioral health services via electronic service delivery must: A. Conduct an initial face-to-face meeting, which may be by video/audio electronically, to verify client identity. B. Obtain written, informed consent to include discussion of risks of electronic service delivery. C. Provide links to websites of certification bodies and licensure boards. 3 Telemedicine ServicesOHIO MEDICAID PY-0084 Effective Date: 07/01/2018 D. Identify appropriately training professionals to provide local assistance.E. Maintain confidentiality, including use of encryption methods. IV. Reimbursement may be made for the following health care services delivered at the distant site: A. Evaluation and management services characterized as ANY of the following: 1. Office or other outpatient services 2. Office or other outpatient consultations 3. Inpatient consultations V. The originating site is responsible for documenting the medical necessity of the health care service provided through the use of telemedicine, for securing the informed consent of the patient, and for developing and maintaining progress notes. VI. The distant site is responsible for maintaining documentation of the health care service delivered through the use of telemedicine and for sending progress notes to the originating site for incorporation into the patient’s records. Note: Although telemedicine/telehealth services do not require a prior authorizationCareSource may request documentation to support medical necessity. Appropriate and co mplete documentation must be presented at the time of review to validate medical necessity. VII. Addition information regarding behavioral health services can be found at:http://bh.medicaid.ohio.gov/Portals/0/Providers/FINAL%20BH%20Manual%20V%201.4_1204 2017.pdf E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the appropriate Ohio Medicaid fee schedules: http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf http://www.medicaid.ohio.gov/PROVIDERS/FeeScheduleandRates/SchedulesandRates.aspx#16 82653-outpatient-hospital-behavioral-health-services The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. CPT Codes Definition99201New patient Office or other outpatient visit, including problem focused history, problem focused exam, straightforward medical decision-making. 99202New patient Office or other outpatient visit, including expanded problem focused history, expanded problem focused exam, straightforward medical decision-making. 99203New patient Office or other outpatient visit for the evaluation and management of the member, including a detailed history, a detailed examination and medical decision making of low complexity. 99204 New patient Office or other outpatient visit for the evaluation and management of the member, including a comprehensive history, a 4 Telemedicine ServicesOHIO MEDICAID PY-0084 Effective Date: 07/01/2018 comprehensive examination and medical decision making of moderate complexity. 99205Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 99211Established patient Office or other outpatient visit for the evaluation and management of the member that may not require the presence of physician or other qualified health care professional. 99212Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: problem focused history, problem focused exam, straightforward medical decision-making. 99213Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: an expanded problem focused history, an expanded problem focused exam and medical decision making of low complexity. 99214Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: a detailed history, a detailed examination and medical decision making of moderate complexity. 99215Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 99354 Prolonged evaluation and management or psychotherapy service(s); first hour 99355Prolonged evaluation and management or psychotherapy service(s) each additional 30 minutes 90791 Psychiatric Diagnostic Evaluation w/o Medical 90792 Psychiatric Diagnostic Evaluation w/ Medical 90832 Individual Psychotherapy – 30 minutes 90834 Individual Psychotherapy 45 minutes 90837 Individual Psychotherapy 60+ minutes 90833 Individual Psychotherapy w/ E/M Service 90836 Individual Psychotherapy w/ E/M Service 90838 Individual Psychotherapy w/ E/M Service 90846 Family Psychotherapy w/o patient 50 minutes 90847 Family psychotherapy (conjoint, w/ patient present) 50 minutes 90849 Multiple-family group psychotherapy 90853 Group Psychotherapy (not multi-family group) 90863 Pharmacologic management 96101 Psychological Testing 96111 Developmental Testing 5 F. RELATED POLICIES/RULESN/A G. REVIEW/REVISION HISTORYTelemedicine Services OHIO MEDICAID PY-0084 Effective Date: 07/01/2018 DATE ACTIONDate Issued 10/31/2013Date Revised 11/29/2016 02/22/2018 Added additional information regarding behavioral healthpractitioners responsibilities, 1 modifier and 21 behavioral health codes. Date Effective 07/01/2018 Archive Date 03 /05 /2021 H. REFERENCES1. Telemedicine | Medicaid.gov. (2017, December 1). Retrieved December 1, 2017 from https://www.medicaid.gov/medicaid/benefits/telemed/index.html 3. OAC – 5160-1-18 Telemedicine. (2015, January 2). Retrieved December 1, 2017 from http://codes.ohio.gov/oac/5160-1-18 4. Fee Schedule Rates-App endix DD to rule 5160-1-60. (2017, January 1). Retrieved December 1, 2017 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 5. OAC – 4757-5-13 Standards of practice and professional conduct: electronic service delivery (internet, email, teleconference, etc.). (2016, July 1). Retrieved December 1, 2017 from http://codes.ohio.go v/oac/4757-5-13 6. Chapter 5160-27 Community Mental Health Agency Services. (2017, January 1). Retrieved December 1, 2017 from http://codes.ohio.gov/oac/5160-27 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. 96116 Neurobehavioral Status Exam 96118 Neuropsychological Testing H0036 Community Psychiatric Supportive Treatment Individual or Group H0001 SUD Assessment H0004 SUD Individual Counseling H0005 SUD Group Counseling H0006 SUD Case Management Q3014 Telehealth originating site facility fee Modifier Description GT Via interactive audio and video telecommunication systems 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

Acupuncture Services

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 10/31/2013 07/01/2019 01/01/2018 Policy Name Policy Number Acupuncture Services PY-0152 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 4 Acupuncture Services OHIO MEDICAID PY-0152 Effective Date: 01/01/2018 2 A. SUBJECT Acupuncture Services B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Acupuncture is an ancient Chinese method of treatment based on the theory that stimulation of specific key points on or near the skin by the insertion of needles or by other methods improves vital energy flow. The term acupuncture describes a variety of methods and styles to stimulate specific anatomic points in the body. Acupuncture is used to relieve pain, to induce surgical anesthesia, or for therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatment. C. DEFINITIONS Acupuncturist-is an individual who holds at least a valid certificate to practice as an acupuncturist or a valid certificate to practice as an oriental medicine practitioner. Chiropractor-is a chiropractor who holds a certificate to practice acupuncture issued by the state chiropractic board. Other individual medicaid provider-is a physician assistant or an advanced registered nurse practitioner that has a valid certificate as an acupuncturist. Physician-is a physician that has completed medical training in acupuncture with a current and active designation, or an equivalent designation, as a diplomate in acupuncture from the national certification commission for acupuncture and oriental medicine. D. POLICY I. CareSource reimburses for acupuncture services according to the criteria found in the Ohio Administrative Code (OAC) 5160-8-51. II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. III. In accordance with OAC 5160-8-51, acupuncture services are only reimbursable for the following conditions: A. Migraines. B. Low back pain. IV. Participating providers must be one of the following: A. A physician that has completed medical training in acupuncture with a current and active designation, or an equivalent designation, as a diplomate in acupuncture from the national certification commission for acupuncture and oriental medicine. B. A chiropractor with a valid certificate to practice acupuncture. Acupuncture Services OHIO MEDICAID PY-0152 Effective Date: 01/01/2018 3 C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant with a valid certificate as an acupuncturist. V. Limitations: A. No separate reimbursement will be made for both an evaluation and management service and an acupuncture service performed by the same provider to the same individual on the same day. B. No separate reimbursement will be made for services that are an incidental part of a visit (providing instruction on breathing techniques, diet, or exercise). C. No reimbursement will be made for additional treatment in either of the following circumstances: 1. Symptoms show no evidence of clinical improvement after an initial treatment period; or 2. Symptoms worsen over a course of treatment. Note: Although CareSource does not require a prior authorization for the first 30 visits for acupuncture services, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio state Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) F. RELATED POLICIES/RULES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/31/2013 New Policy. Date Revised 10/31/2013 06/06/2016 02/08/2018 New allowed service. Date Effective 01/01/2018 Acupuncture Services OHIO MEDICAID PY-0152 Effective Date: 01/01/2018 4 H. REFERENCES 1. Appendix DD to rule 5160-1-60. (2018, January 1). Retrieved 1/22/2018 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 2. Lawriter-OAC-5160-8-51 Acupuncture services. (2018, January 1). Retrieved 1/22/2018 from http://codes.ohio.gov/oac/5160-8-51v1 3. Lawriter-ORC. (2013, March 22). Retrieved 1/22/2018 from http://codes.ohio.gov/orc/4762 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Preferred Obstetrical Services

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 06/10/2015 0 6 /01/2019 0 6 /01/2018 Policy Name Policy Number Preferred Obstetrical Services PY-0004 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 7 F.RELATED POLICIES/RULES ……………………………………………………………………. 7 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 8 H.REFERENCES ………………………………………………………………………………………… 8Archived Preferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 2 A.SUBJECT Obstetrical Services Ohio Medicaid does not currently reimburse for global obstetrical services coding and/or billing. Because of this, CareSource also does not reimburse for global obstetrical services coding and/or billing unless the providers contract has been specifically negotiated to include those codes and rates. This policy addresses reimbursement for obstetrical services for those providers whose CareSource contracts do not include negotiated global obstetrical services codes and rates. B. BACKGROUND Maternity care or obstetrical services refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. Maternity care services include care during the prenatal period, labor, birthing, and the postpartum period. CareSource reimburses for obstetrical services members r e c e i v e i n a h o s p i t a l o r b i r t h i n g c e n t e r a s w e l l as all as sociated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedur al Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. DEFINITIONS Advanced practice nurse-The recently endorsed Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education defines four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS) and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). Current Procedural Terminology (CPT) – The answer to most obstetrical billing questions can be found in the Physicians Current Procedural Terminology (CPT) manual or the CPT Assistant Archives (1990 present). Maternity Care and Delivery is a subsection of the Surgery section of the CPT book codes. A n understanding of the global package services is needed to code Maternity Care and Delivery Services correctly. Elective Delivery-is performed for a nonmedical reason. Some nonmedical reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in the last weeks of pregnancy, or are past their due date and not naturally in labor yet. Some women request a cesarean delivery because they fear vaginal birth. (American Congress of Obstetricians and Gynecologists, 2015) Fetal death-means death prior to the complete expulsion or extraction from its mother of a product of conception, which after such expulsion or extraction, does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. “Fetal death” does not include termination of the pregnancy. (OAC 3701-7- 01 (L), Fetal death ) High Risk Maternity-Maternity care complicated by a documented condition during the patients pregnancy requiring direct face-to-face practitioner care beyond the usual service. Infertility-is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 3 produce conception, in either case, after at least one year of trying to do so. (CareSource internal definition) Lactation consultant-means an individual who holds credentials as an “International board certified lactation consultant.” (OAC 3701-7-01 (Q), Lactation consultant ) Maternity home-means a facility for pregnant girls and women where accommodations, medical care, and social services are provided during the prenatal and postpartum periods. Maternity home does not include a private residence where obstetric or newborn services are received by a resident of the home. (OAC 3701-7-01 (W), Maternity home) Maternity Period-For billing purposes, the obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period ( 56 days after vaginal delivery, 60 days after C-section ). Medically necessary-services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (OAC 5160-10-02) Non-Obstetric E/M service: Visit(s) occurring outside the regularly scheduled antepartum period during which the same physician or physician group and/or other health care professional providing maternity care, also provides services for a non-obstetric condition such as bronchitis, flu, or upper respiratory infection. Physician-means an individual authorized under Chapter 4731 of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery . (OAC 3701-55-01 (I), Physician) Physician group, Physician group practice means a clinic or an obstetric clinic either with an electronic health record ( EHR), or where there is no EHR, but one member record and each physician/nurse practitioner/nurse midwife seeing that member has access to the same member record and makes entries into the record as services occur. All locations of a multi-location clinic with an EHR (or one patient record) are considered the same physician group practice. Preconception care-means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. D. POLICY I. Prior Authorization Prior authorization is not required for the preferred obstetrical and maternity services covered under this policy. NOTE : Although the preferred obstetrical and maternity services covered by this policy do not require prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II.Maternity Coverage-General A. Maternity services must be furnished under the supervision of a physician or certified advanced practice nurse midwife. Maternity services enable beneficiaries to voluntarily choose a provider within the CareSource network for maternity care and postpartum care . For billing purposes, the Maternity Obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period ( 56 days after vaginal delivery and 60 days after C-section ). 1. Covered services include office visits for a complete exam, pharmaceuticals (including some over the counter [OTC] products with a prescription), such as prenatal vitamins or medication related to gestational diabetes, and fetal ultrasound services are provided by or under the supervision of a medical doctor, osteopath, or eligible maternity provider. 2. Maternity services may include the following: 2.1 Pregnancy testing/laboratory tests. 2.2 Office visits. ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 4 2.3Ultrasounds 2.4 Fetal delivery. 2.5 Postpartum visits. III. Criteria for Itemized Billing A. Antepartum Care Only 1. The CPT Editorial Board created codes 59425 (Antepartum care only; 4-6 visits) and 59426 (Antepartum care only; 7 or more visits) to account for the following situations when all of the routine antepartum care is not provided by the same physician, physician group, and/or other health care professional: 1.1 The member has a change of insurer during her pregnancy. 1.2 The member has received part of her antenatal care elsewhere e.g. from another physician or physician group practice. 1.3 The member leaves her care with your group practice before the global obstetrical care is complete. 1.4 The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery. 1.5 The member has an unattended, precipitous delivery . Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy). 2. CareSource will reimburse for the antepartum care only CPT codes 59425 or 59426 when reported by same group physician and/or other health care professional as follows: 2.1 A single claim submission of CPT code 59425 or 59426 for the antepartum care only (one unit). 2.2 The initial, office visit in which the pregnancy is confirmed may be reported and separately reimbursed when the antepartum record has not been initiated. 2.3 The dates should document the range of time covered by the visits. For example, if the patient had a total of 4-6 antepartum visits then the physician and/or other health care professional should report CPT code 59425 with the “from and to” dates for which the services occurred. B. Delivery Services Only 1. Delivery begins with the passage of the fetus and the placenta from the womb into the external world. 1.1 Delivery only codes are: a. 59409-Vaginal delivery only (with or without episiotomy and/or forceps. b. 59514-Cesarean delivery only. c. 59612-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps). d. 59620-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery. 2. Items Included in the Delivery Services 2.1 Labor and delivery services are based on the need of each individual patient and can include, but are not limited to the types of services listed in this section. 2.2 The following services are included in the delivery services codes and will not be reimbursed separately: a. Admission to the hospital. b. The admission history and physical examination. c. Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician. d. Intravenous (IV) induction of labor via oxytocin (CPT codes 96365-96367). e. Delivery of the placenta; any method. f. Repair of first or second degree lacerations. ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 5 2.3Insertion of cervical dilator (CPT 59200) is included in the delivery services and will not be separately reimbursed if performed on the same date of delivery. 2.4 Third and fourth degree lacerations should be identified by appending modifier 22 to the delivery codes. Claims submitted with modifier 22 must include medical record documentation which supports the use of the modifier; please refer to the Increased Procedural Services section of this policy, Section III-I. C. Postpartum Care Only 1. The postpartum care only code should be reported by the physician, physician group, or other health care professional who provides the patient with services of postpartum care only. If a physician provides any component of antepartum along with postpartum care, but does not perform the delivery, then the services should be itemized by using the appropriate antepartum care code (see Antepartum Care Only Section III-A) and postpartum care code 59430. 2. The CPT code for postpartum care only is 59430-Postpartum care only (separate procedure). 3. CareSource follows ACOG guidelines and considers the postpartum period to be six weeks following the date of the cesarean or vaginal delivery. Postpartum care includes hospital and office visits following any type of delivery, and can include any number of visits. Each of these visits can be reported with procedure code 0503F. 4. The following services are included in postpartum care and are not separately reimbursable services: 4.1 Uncomplicated outpatient visits related to the pregnancy. 4.2 Discussion of contraception. 5. Evaluation and management of problems or complications related to the pregnancy are services not included in postpartum care and will be reimbursed separately, in addition to code 59430. D. Delivery including Postpartum Care 1. Sometimes a physician performs the delivery and postpartum care with minimal or no antepartum care. In these instances, claims should include codes for vaginal and cesarean section deliveries that encompass both of these services. 2. Delivery plus postpartum care codes are: 2.1 59410-Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care. 2.2 59515-Cesarean delivery only; including postpartum care. 2.3 59614-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care. 2.4 59622-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care. 3. The delivery only including postpartum care codes should be reported by the same physician, physician group, or other health care professional for a single gestation when: 3.1 The delivery and postpartum care services are the only services provided 3.2 The delivery and postpartum care services are provided in addition to a limited amount of antepartum care (e.g., CPT code 59425) 4. The following services are included in delivery only including postpartum care code and are not separately reimbursable services: 4.1 Hospital visits related to the delivery during the delivery confinement. 4.2 Uncomplicated outpatient visits related to the pregnancy. 4.3 Discussion of contraception. E. Non-Obstetric Care When a member is seen for a condition unrelated to pregnancy (e.g., bronchitis, flu), these E/M visits are considered Non-Obstetric E/M services and can be reported as they occur. The diagnosis code used in conjunction with the E/M service should support the non-obstetric condition being treated and/or evaluated. CareSource will reimburse non-ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 6 obstetric care and related office E/M services during the entirety of the pregnancy and maternal care; use appropriate diagnosis codes identifying the condition is not related to pregnancy care, and the appropriate modifiers (generally, modifier 24). F. Risk Appraisal-Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. G. Delivery of Multiple Gestations CareSource follows ACOG coding guidelines for vaginal, cesarean section, or a combination of vaginal and cesarean section deliveries of multiple births (twins, triplets, etc.) . Use appropriate codes and modifiers regarding the delivery of and work associated with multiple births. H. Fetal Non-Stress Test CareSource will reimburse for fetal non-stress testing, including for multiple non-stress tests on a single fetus on the same day, or on multiple gestations, as medically necessary. I. Increased Procedural Services 1. When the work required providing a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. The determination of reimbursement for obstetrical services submitted with modifier 22 is based on individual review of clinical documentation that supports use of the modifier identifying an increased procedural service per CPT modifier guidelines. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physician and mental effort required). 2. For information regarding additional payment of E/M services that go beyond the typical number encountered in an average pregnancy, please refer to the High Risk/Complications section of this policy. J. Limitations on Elective Obstetric Deliveries 1. Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria: 1.1 Gestational age of the fetus must be determined to be at least thirty-nine weeks; or, 1.2 If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery. NOTE: Cesarean sections, labor inductions, or any deliveries following labor induction that occur prior to thirty-nine weeks gestation that are not considered medically necessary, will not be reimbursed. K. Non-Comprehensive Maternity Visits CareSource reimburses providers for maternity management services including E/M (office) visits and consultations for the purpose of health of the member and developing fetus for best outcomes. L. Maternity Services Not Reimbursed 1. Home pregnancy tests; 2. Ultrasounds performed only for determination of sex of the fetus or to provide a keepsake picture; 3. Three and four dimensional ultrasounds; 4. Paternity testing; Archived Preferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 7 5.Lamaze classes; 6. Birthing classes; 7. Parenting classes; and, 8. Home tocolytic infusion therapy. E. CONDITIONS OF COVERAGE CODE DESCRIPTION 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps); 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59412 External cephalic version, with or without tocolysis 59414 Delivery of placenta (separate procedure) 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59430 Postpartum care only (separate procedure) 59514 Cesarean delivery only; 59515 Cesarean delivery only; including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care 0500F Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care, report also date of visit and in a separate field, the last date of menstrual period LMP) 0501F Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period-LMP (Not e: If reporting 0501F prenatal flow sheet, it is not necessary to report 0500F initial prenatal care visit) 0502F Subsequent prenatal care visit (excludes: patients who are seen for a condition unrelated to pregnancy or prenatal care [e.g., an upper respi ratory infection; patients seen for consultation only, not for continuing care]) 0503F Postpartum care visit F. RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 6/10/2015 ArchivedPreferred Obstetrical Services OHIO MEDICAID PY-0004 Effective Date: 06/01/2018 8 Date Revised 10/18/2017 Updated codes, template. Date Effective 0 6 /01/2018 H. REFERENCES 1. Current Procedural Terminology. (2015, June 1). Retrieved June 11, 2015, from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page 2. Guideline Suggestions for Elective Labor Induction. (2012). Retrieved June 11, 2015, from http://www.acog.org/-/media/Districts/District-I/20120120-ElectiveIOLGuideline.pdf?dmc=1&ts=20150611T0857437601 3. Ohio Administrative Code. (2015). Retrieved June 11, 2015, from http://codes.ohio.gov/oac/3701-40-01 4.American Association of Critical Care Nurses Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education, 2015. 5. OAC Rule 5160-1-10 Limitations on Elective Obstetric Deliveries. 6. OAC Rule 5160-21 Preconception Care Services. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Global Obstetrical Services

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

Drug Testing

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

Smoking & Tobacco Cessation

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

Breast Imaging

REIMBURSEMENT POLICY STATEMENT OH IO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 10/31/2013 1 0/04/2018 0 5/01/2018 Policy Name Policy Number Breast Imaging PY-0028 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Breast Imaging Ohio Medicaid PY-0028 Effective Date: 05/01/2018 2 2 A.SUBJECT Breast Imaging B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests for breast cancer as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and American College of Radiology (ACR). Mammography is the utilization of a low-dose x-ray imaging system for the examination of the breasts and is currently considered to be the best available method for early detection of breast cancer, particularly in the case of small or non-palpable lesions. This imaging is often employed for screening purposes in an effort to reduce morbidity and mortality of unsuspected breast cancer through earlier detection and treatment in asymptomatic patients. A Screening Mammogram typically includes two standard views of each breast (cranio-caudal and medial lateral oblique) and does not require the presence of, or monitoring by the interpreting radiologist. When abnormalities are observed a diagnostic test is required to confirm the presence of malignancy. C. DEFINITIONS Technical Component (TC) services rendered outside the scope of the physicians interpretation of the results of an examination. Professional Component (PC) physicians interpretation of the results of an examination. Global Component encompasses both the technical and professional components. See Breast Imaging Medical Policy-MM0051 for further definitions D. POLICY I. CareSource does not require prior authorization for screening and diagnostic mammograms. II. All other breast imaging, other than x-ray mammograms, require a prior authorization. II I. CareSource reimburses for screening and diagnostic mammograms according to CareSource Medical policy MM-0051. Members must meet the criteria found in medical policy MM-0051. IV. CareSource considers diagnostic mammography medically necessary for men and women with signs and symptoms of breast disease or a history of breast malignancy. V. When billing for mammography services, provider should use the appropriate CPT/HCPCS Archived Breast Imaging Ohio Medicaid PY-0028 Effective Date: 05/01/2018 3 3 codes and modifiers, if applicable. Note: Global billing is not permitted for services furnished in an outpatient facility. Critical Access Hospitals (CAHs) may not use global HCPCS codes as the TC and PC components are paid under different methodologies. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the appropriate Ohio Medicaid fee schedule-http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. CPT Codes Mammography Code Description 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) CPT Codes Requiring Prior Authorization Code Description 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 76498 Unlisted magnetic resonance procedure (e.g., diagnostic, i nterventional) 76499 Unlisted diagnostic radiographic procedure 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited 77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 77061 Digital breast tomosynthesis; unilateral 77062 Digital breast tomosynthesis; bilateral 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) C8903 Magnetic resonance imaging with contrast, breast; unilateral Archived Breast Imaging Ohio Medicaid PY-0028 Effective Date: 05/01/2018 4 4 C8904 Magnetic resonance imaging without contrast, breast; unilateral C8905 Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral C8906 Magnetic resonance imaging with contrast, breast; bilateral C8907 Magnetic resonance imaging without contrast, breast; bilateral C8908 Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral F. RELATED POLICIES/ RULES Breast Imaging Medical Policy, MM-0051 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/31/2013 New Policy. Date Revised 10/31/2013 06/06/2016 10/04/2017 Date Effective 05 /01/2018 H.REFERENCES 1. American Cancer Society. (2017 , September). Retrieved September 25, 2017, from http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/brea st-cancer-early-detection-acs-recs 2. U.S. Preventive Services Task Force; Breast Cancer: Screening. (2016, January). Retrieved September 25, 2017, from http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=mammography 3. Laboratory and radiology services. (2014, July). Retrieved September 25, 2017, from http://codes.ohio.gov/oac/5160-4-25 The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Screening for Sexually Transmitted Infections

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