REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 07/01/2017 04/04/2018 07/01/2017 Policy Name Policy Number Lipid Testing Assessing Cardiovascular Risk PY-0 255 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization mana gement guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expecte d to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternati ve, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced h erein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may u se reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Lipid Testing Assessing Cardiovascular Risk Ohio Medicaid PY-0255 Effective Date:07/01/2017 2 A.SUBJECT Lipid Testing Assessing Cardiovascular Risk B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality in the United States. Vascular disease is the major contributor to CVD events. High levels of cholesterol in the blood, increase a persons risk of developing CVD . Total cholesterol levels include all the cholesterol found in various lipoproteins. Lipoproteins vary in size and density and include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and Eapoproteins. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoproteins (LDL) and high density lipoproteins (HDL), are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Lipid testing is used to indicate the chances of having cardiovascular disease (CVD) and/or of having a coronary event. C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Cholesterol-White, crystalline substance found in animal tissues and various foods that is normally synthesized by the liver and is important as a constituent of cell membrane and a precursor to steroid hormones; its level in the bloodstream can influence the pathogenesis of certain conditions, such as the development of atherosclerotic plaque and coronary artery disease. Coronary Heart Disease (CHD) – Any heart disorder caused by disease of the coronary arteries. High Density Lipoprotein (HDL) – A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol. High levels are thought to be associated with decreased risk of CHD and atherosclerosis. High-sensitivity C-reactive protein (hs-CRP) – A protein produced in the liver that is a marker of inflammation. Immunoassay-Any laboratory method for detecting a substance by using an antibody reactive with it. Lipid-Oily organic compound insoluble in water but soluble in organic solvents; essential structural component of living cells (along with proteins and carbohydrates). Low Density Lipoprotein (LDL) – A lipoprotein that transports cholesterol in the blood; composed of a moderate amount of protein and a large amount of cholesterol. High levels ar e thought to be associated with increased risk of CHD and atherosclerosis. Peripheral Arterial Disease (PAD) – A narrowing of the vessels that carry blood to the legs, arms, abdomen or kidneys; also known as peripheral vascular disease (PVD). ArchivedLipid Testing Assessing Cardiovascular Risk Ohio Medicaid PY-0255 Effective Date:07/01/2017 3 Plaque-Deposit of fatty material on the inner lining of an arterial wall; characteristic of atherosclerosis. Triglyceride Naturally occurring ester (compound) of three fatty acids and glycerol that is the chief constituent of fats and oils. Unsaturated-Ca pable of taking up, or of uniting with, certain other elements or compounds, without the elimination of any side. D. POLICY I. CareSource members may receive lipid testing without prior authorization. Lipid testing must be medically necessary. II. Conditions in which lipid testing may be indicated include: A.Assessment of patients with atherosc lerotic cardiovascular disease. B. Evaluation of primary dyslipidemia. C. Any form of atherosclerotic disease, or any disease leading to the form ation of atherosclerotic disease.D. Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism.E. Secondary dyslipidemia, including diabetes mel litus, disorders of gastrointestinal absorption, chronic renal failure.F. Signs or symptoms of dysli pidemias, such as skin lesions. G. As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total chole sterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol,
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Effective Date Next Annual Review Effective Date 08/10/2016 05/15/2018 05/26 /2017 Policy Name Policy Number Sexually Transmitted Infections PY-00 37 Policy Type Medical Administrative Pharmacy RE IMBURSEMENT 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-st andard 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 necessi ty, 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, t hose 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, dysfunc tion 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. Me dically 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 doe s 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. , Ev idence 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 prov ided 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 ………………………………………………………………………………………….. 3 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RULES ………………………………………………………………….. 11 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………. 11 H.REFERENCES ………………………………………………………………………………………. 11Archived Sexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 2 A. SUBJECT Sexually Transmitted Infections (STI) Screening 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. Sexually transmitted infections (STIs) cause significant morbidity and mortality in the United States each year. The United States Preventive Services Task Force (USPSTF) recommends that women at increased risk of infection be screened for chlamydia, gonorrhea, human immunodeficiency virus, and syphilis. Men at increased risk should be screened for human immunodeficiency virus and syphilis. All pregnant women should be screened for hepatitis B, human immunodeficiency virus, and syphilis; pregnant women at increased risk also should be screened for chlamydia and gonorrhea. Non-pregnant women and men not at increased risk do not require routine screening for sexually transmitted infections. Engaging in high-risk sexual behavior places persons at increased risk of sexually transmitted infections. The USPSTF recommends that all sexually active women younger than 25 years be considered at increased risk of chlamydia and gonorrhea. [1] Because not all communities present equal risk of sexually transmitted infections, the USPSTF, the US Centers for Disease Control (CDC), t h e A m e r i c a n Co l l e g e o f Ob s t e t r i c i a n s a n d Gy n e c o l o g i s t s ( A CO G ) a n d o t h e r a u t h o r i t i e s encourage physicians to consider expanding or limiting the routine sexually transmitted infection screening they provide based on the community and populations they serve. [2-8] Historically, intervention efforts have focused on individual-level factors associated with STD risk. For example, It is important to educate members to practice safer sex, and for providers to screen high-risk individuals for common STIs. Investigators are now also evaluating higher-level factors (e.g., peer norms. media influences, and other social and cultural factors) which may also influence behaviors. [9] Until effective strategies involving higher-level factors emerge, matching individual factors to screening test indications is the mainstay of STI screening. Generally, a recommendation for screening is based upon the strength of evidence that acting upon results of a screening test will lead to a significantly decreased infection rate for the target population evaluated. CareSource encourages screening for Sexually Transmitted Infections consistent with the grade A and Brecommendations of the USPSTF and the Centers for Medicare & Medicaid (CMS) National Coverage Determination (NCD) Policy 210.10 for Screening for Sexually Transmitted Infections. In addition to these recommendations, CareSource encourages screening for Sexually Transmitted Infections for men at increased risk. CareSource has eliminated the annual screen limitations set forth in the NCD as well as the order of billing STI diagnosis codes. The specific rules that apply for diagnosis codes (for Medicaid members only ) are outlined in this policy. ArchivedSexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 3 C. DEFINITIONS Sexually transmitted infections (STI) – are infections that are passed from one person to another through sexual contact. Nucleic acid amplification tests (NAATs) are gene amplification laboratory tests such as polymerase chain reaction (PCR) that are cleared by the United States Food and Drug Administration (FDA) and are recommended for detection of genital tract infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae with or without symptoms. For detecting these infections of the genital tract, optimal specimen types for NAATs are vaginal swabs from women and first catch urine from men. Older nonculture tests and non-NAATs have inferior sensitivity and specificity characteristics and no longer are recommended. Since 2002, improvements in chlamydia and gonorrhea NAAT technologies have enabled significant implementation and expansion of screening programs using less invasive specimen collection. [5] High risk behaviors for acquiring a sexually transmitted disease are considered in the med ical history of a clinical evaluation. Many STIs are asymptomatic, but without detection by appropriate screening evaluation may lead to morbidity or preterm labor in pregnant women [7] 1. Early sexual activity, for example before age 18. 2. Multiple sex partners. 3. Sex with a high-risk partner (one who has multiple sex partners or other risk factors). 4. Unprotected intercourse without consistent or correct male or female condom use, except in a long-term, single-partner (monogamous) relationship. 5. Unprotected mouth-to-genital contact, except in a long-term monogamous relationship. 6. Having anal sex or a partner who does, except in a long-term, single-partner (monogamous) relationship. 7. Having sex with a partner who injects or has ever injected drugs. 8. Exchange of sex (sex work) for drugs or money. 9. Having had Chlamydia trachomatis or other sexually transmitted diseases in the past. D. POLICY I.Prior authorization is not required for any medically necessary STI screenings. NOTE: Although the drug screenings covered by this policy do not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II.Screening tests for the STIs referred to in this policy are selected laboratory tests. Materia l related to diagnostic testing in this policy is included to clarify coverage for diagnostic versus screening indications. III. Sexually Transmitted Infections (STI) Screening: Chlamydia and Gonorrhea A. CareSource considers screening for Chlamydia trachomatis (Chlamydia) and Neisseria gonorrhea (Gonorrhea) infections as medically necessary preventive care for these member groups according to the USPSTF, CDC, and NCQA: 1. All pregnant women younger than 25 years of age 2. All sexually active women younger than 25 years of age 3. Men and women with high-risk factors of any age for Chlamydia trachomatis and/or Gonorrhea infection . B. In agreement with the USPSTF, CareSource considers Chlamydia and Gonorrhea screening experimental and investigational for asymptomatic low risk men, and for women who do not meet the above criteria, because of insufficient evidence in the peer-reviewed literature for low-risk populations. Archived Sexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 4 C. Routine repeat testing of NAAT-positive genital tract specimens is not recommended because the practice does not improve the positive predictive value of the test. IV. Sexually Transmitted Infections (STI) Diagnosis: Chlamydia and Gonorrhea A. CareSource considers Chlamydia and/or Gonorrhea diagnostic testing medically necessary for members with signs or symptoms of Chlamydia and/or Gonorrhea infection. B. CareSource considers home testing for Chlamydia and/or Gonorrhea experimental and investigational because of insufficient evidence in the peer-reviewed literature. V. Sexually Transmitted I nfections (STI) Screening: Trichomoniasis/Trichomonas vaginalis A. CareSource provides coverage for screening test for Trichomoniasis in high risk men, and Trichomoniasis/trichomonas vaginalis in high risk women, pregnant women, and women under 25.[7] B. The screening of asymptomatic pregnant women for bacterial vaginosis to reduce the lik elihood of pre-term birth is considered experimental and investigational and is not covered by the American College of Obstetricians and Gynecologists. [3] C. CareSource considers screening as medically necessary for Trichomoniasis in men with high risk factors, and Trichomoniasis/Trichomonas vaginalis in women with high risk factors. D. Culture is a sensitive and highly specific commercially available method of diagnosis. Among women in whom trichomoniasis is suspected but not confirmed by microscopy, vaginal secretions should be cultured for T. vaginalis . E. An FDA-cleared PCR assay for detection of gonorrhea and chlamydial infection (Amplicor, Roche Diagnostic Corp.) has been modified for T. vaginalis detection in vaginal or endocervical swabs and in urine from women and men; sensitivity ranges from 88% 97% and specificity from 98% 99% .[10] APTIMA T. vaginalis Analyte Specific Reagents (ASR, Gen-Probe, Inc.) also can detect T. vaginalis RNA by transcription-mediated amplification using the same instrumentation platforms available for the FDA-cleared APTIMA Combo2 assay for diagnosis of gonorrhea and chlamydial infection; published validation studies of T. vaginalis ASR found sensitivity ranging from 74% 98% and specificity of 87% 98%.[11] E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information.I.Coverage-General A. CareSource will cover screening for these USPSTF-indicated STIs with the appropriate Food and Drug Adm inistration (FDA)-approved/cleared laboratory tests when ordered and performed by an eligible provider for these services, and when used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulat ions. B. High-Intensity Behavioral Counseling (HIBC) to prevent STIs may be provided on the same date of services as an annual wellness visit, evaluation and management (E&M) service, or during the global billing period for obstetrical care, but only one HIBC may be provided on any one date of service. Archived Sexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 5 II.Covered Screening Tests for Asymptomatic Members A. If policy criteria are met, CareSource will reimburse for the following CPT codes once per calendar year for screening when medically necessary to test f or sexually transmitted infections (STIs) in asymptomatic men and women if accompanied by one or more of the following gender-appropriate ICD-10 codes: B. If policy criteria are met, CareSource will reimburse for the above CPT codes when medically necessary to test for sexually transmitted infections (STIs) in asymptomatic men and women if accompanied by one or more of the following gender-appropriate ICD-10 codes: Z00.01 Encounter for general adul t medical examination with abnormal findings Z20 Contact with and (suspected) exposure to communicable diseases Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission Z20.8 Contact with and (suspec ted) exposure to other communicable diseases Z20.818 Contact with and (suspected) exposure to other bacterial communicable diseases Z20.89 Contact with and (suspected) exposure to other communicable diseases Z20.9 Contact with and (suspected) expos ure to unspecified communicable disease Z22.4 Carrier of infections with a predominantly sexual mode of transmission Z72.51-Z72.53 High-risk sexual behavior Codes Description 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis , amplified probe technique 87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 87661 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique Z 00 Encounter for general examination without complaint, suspected or reported diagnosis Z00.0 Encounter for general adult medical examination Z00.3 Encounter for examination for adolescent development state Z00.8 Encounter for other general examinat ion Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.8 Encounter for screening for other infectious and pa rasitic diseases [chlamydia] Z34 Encounter for supervision of normal pregnancy Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified Codes Description ArchivedSexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 6 O09 O09.A3 Supervision of high-risk pregnancy III.Covered Screening Tests for Symptomatic Members A. Chlamydia. If policy criteria are met, CareSource will reimburse for the following CPT codes for diagnosis when medically necessary to test for sexually transmitted infections (STIs) if accompanied by one or more of the following gender-appropri ate ICD-10 codes: Codes Description 86631 Antibody; Chlamydia 86632 Antibody; Chlamydia,Igm 87110 Culture, Chlamydia 87270 Chlamydia trachomatis antigen detection by DFA 87320 Chlamydia trachomatis antigen detection by EIA 87490 Chlamydia trachomat is detect by DNA, dir. probe 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87810 Chlamydia trachomatis detect by immunoassay 87800 Detect agent mult i , DNA , direct A55 Chlamydial lymphog ranuloma (venereum) A56 Other sexually transmitted chlamydial diseases A56.0 Chlamydial infection of lower genitourinary tract A56.00 Chlamydial infection of lower genitourinary tract, unspecified A56.01 Chlamydial cystitis and urethritis A56. 02 Chlamydial vulvovaginitis A56.09 Other chlamydial infection of lower genitourinary tract A56.1 Chlamydial infection of pelviperitoneum and other genitourinary organs A56.11 Chlamydial female pelvic inflammatory disease A56.19 Other chlamydia l genitourinary infection A56.2 Chlamydial infection of genitourinary tract, unspecified A56.3 Chlamydial infection of anus and rectum A56.4 Chlamydial infection of pharynx A56.8 Sexually transmitted chlamydial infection of other sites A74 Other diseases caused by chlamydiae A74.0 Chlamydial conjunctivitis A74.8 Other chlamydial diseases A74.81 Chlamydial peritonitis A74.89 Other chlamydial diseases A74.9 Chlamydial infection, unspecified N71.0 Acute inflammatory disease of u terus N71.1 Chronic inflammatory disease of uterus N71.9 Inflammatory disease of uterus, unspecified N72 Inflammatory disease of cervix uteri N73 Other female pelvic inflammatory diseases N73.0 Acute parametritis and pelvic cellulitis N73.1 Chronic parametritis and pelvic cellulitis N73.2 Unspecified parametritis and pelvic cellulitis N73.3 Female acute pelvic peritonitis N73.4 Female chronic pelvic peritonitis N73.5 Female pelvic peritonitis, unspecified ArchivedSexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 7 N73.6 Female pelvic peritoneal adh esions (post infective) N73.8 Other specified female pelvic inflammatory diseases N73.9 Female pelvic inflammatory disease, unspecified N74 Female pelvic inflammatory disorders in diseases classified elsewhere N76 Other inflammation of vagina and vulva N76.0 Acute Vaginitis N76.1 Subacute and chronic vaginitis N76.2 Acute vulvitis N76.3 Subacute and chronic vulvitis N76.4 Abscess of vulva N76.5 Ulceration of vagina N76.6 Ulceration of vulva N76.8 Other specified inflammation of vagina and vulva N76.81 Mucositis (ulcerative) of vagina and vulva N76.89 Other specified inflammation of vagina and vulva N34 Urethritis N34.0 Urethral abscess N34.1 Nonspecific urethritis N34.2 Other urethritis N34.3 Urethral syndrome, unspecified O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium B. Gonorrhea .If policy criteria are met, CareSource will reimburse for the following CPT codes for diagnosis when medically necessary to test for sexually transmitted infections (STIs) if accompanied by one or more of the following gender-appropriate ICD-10 codes: Code Description 87590 N. gonorrhoeae by DNA, direct probe 87591 Infectious agent detection by nucleic acid (DNA or RNA) ; Neisseria gonorrhoeae, amplified probe technique 87850 N. gonorrhoeae detection by immunoassay 87800 Detect agent mult i , DNA , direct A54 Gonococcal infection A54.0 Gonococcal infection of lower genitourinary tract without periurethral or accessory g land abscess A54.00 Gonococcal infection of lower genitourinary tract, unspecified A54.01 Gonococcal cystitis and urethritis, unspecified A54.02 Gonococcal vulvovaginitis, unspecified A54.03 Gonococcal cervicitis, unspecified A54.09 Other gonoc occal infection of lower genitourinary tract A54.1 Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess A54.2 Gonococcal pelviperitonitis and other gonococcal genitourinary infection A54.21 Gonococcal inf ection of kidney and ureter A54.22 Gonococcal prostatitis A54.23 Gonococcal infection of other male genital organs A54.24 Gonococcal female pelvic inflammatory disease ArchivedSexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 8 A54.29 Other gonococcal genitourinary infections A54.3 Gonococcal infectio n of eye A54.30 Gonococcal infection of eye, unspecified A54.31 Gonococcal conjunctivitis A54.32 Gonococcal iridocyclitis A54.33 Gonococcal keratitis A54.39 Other gonococcal eye infection A54.4 Gonococcal infection of musculoskeletal system A54.40 Gonococcal infection of musculoskeletal system, unspecified A54.41 Gonococcal spondylopathy A54.42 Gonococcal arthritis A54.43 Gonococcal osteomyelitis A54.49 Gonococcal infection of other musculoskeletal tissue A54.5 Gonococcal ph aryngitis A54.6 Gonococcal infection of anus and rectum A54.8 Other gonococcal infections A54.81 Gonococcal meningitis A54.82 Gonococcal brain abscess A54.83 Gonococcal heart infection A54.84 Gonococcal pneumonia A54.85 Gonococcal perit onitis A54.86 Gonococcal sepsis A54.89 Other gonococcal infections A54.9 Gonococcal infection, unspecified N71.0 Acute inflammatory disease of uterus N71.1 Chronic inflammatory disease of uterus N71.9 Inflammatory disease of uterus, unspecified N72 Inflammatory disease of cervix uteri N73 Other female pelvic inflammatory diseases N73.0 Acute parametritis and pelvic cellulitis N73.1 Chronic parametritis and pelvic cellulitis N73.2 Unspecified parametritis and pelvic cellulitis N73.3 Fema le acute pelvic peritonitis N73.4 Female chronic pelvic peritonitis N73.5 Female pelvic peritonitis, unspecified N73.6 Female pelvic peritoneal adhesions (post infective) N73.8 Other specified female pelvic inflammatory diseases N73.9 Fem ale pelvic inflammatory disease, unspecified N74 Female pelvic inflammatory disorders in diseases classified elsewhere N76 Other inflammation of vagina and vulva N76.0 Acute Vaginitis N76.1 Subacute and chronic vaginitis N76.2 Acute vulvitis N76.3 Subacute and chronic vulvitis N76.4 Abscess of vulva N76.5 Ulceration of vagina N76.6 Ulceration of vulva N76.8 Other specified inflammation of vagina and vulva N76.81 Mucositis (ulcerative) of vagina and vulva N76.89 Other specified inflammation of vagina and vulva N34 Urethritis N34.0 Urethral abscess Archived Sexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 9 N34.1 Nonspecific urethritis N34.2 Other urethritis N34.3 Urethral syndrome, unspecified O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, chil dbirth and the puerperium C. Trichomoniasis/Trichomonas vaginalis .If policy criteria are met, CareSource will reimburse for the following CPT codes for diagnosis when medically necessary to test for sexually transmitted infections (STIs) if accompanied by one or more of the following gender-appropriate ICD-10 codes: Codes Description 87661 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique A59 Trichomoniasis A59.9 Trichomoniasis, unspecified A59 .00 Urogenital trichomoniasis, unspecified A59.01 Trichomonal vulvovaginitis A59.02 Trichomonal prostatitis A59.03 Trichomonal cystitis and urethritis A59.09 Other urogenital trichomoniasis A59.8 Trichomoniasis of other sites A59.9 Trichomoniasis, un specified N71 Acute inflammatory disease of uterus N71.1 Chronic inflammatory disease of uterus N71.9 Inflammatory disease of uterus, unspecified N72 Inflammatory disease of cervix uteri N73 Other female pelvic inflammatory diseases N73.0 Acute param etritis and pelvic cellulitis N73.1 Chronic parametritis and pelvic cellulitis N73.2 Unspecified parametritis and pelvic cellulitis N73.3 Female acute pelvic peritonitis N73.4 Female chronic pelvic peritonitis N73.5 Female pelvic peritonitis, u nspecified N73.6 Female pelvic peritoneal adhesions (post infective) N73.8 Other specified female pelvic inflammatory diseases N73.9 Female pelvic inflammatory disease, unspecified N74 Female pelvic inflammatory disorders in diseases classified e lsewhere N76 Other inflammation of vagina and vulva N76.0 Acute Vaginitis N76.1 Subacute and chronic vaginitis N76.2 Acute vulvitis N76.3 Subacute and chronic vulvitis N76.4 Abscess of vulva N76.5 Ulceration of vagina N76.6 Ulceration of vulva N7 6.8 Other specified inflammation of vagina and vulva N76.81 Mucositis (ulcerative) of vagina and vulva N76.89 Other specified inflammation of vagina and vulva N34 Urethritis ArchivedSexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 10N34.0 Urethral abscess N34.1 Nonspecific urethritis N34.2 Other urethritis N34.3 Urethral syndrome, unspecified O98 Maternal infectious and parasitic diseases classifiable elsewhere but complicating pregnancy, childbirth and the puerperium D. Syphilis .If policy criteria are met, CareSource will reimburse for the following CPT codes for diagnosis when medically necessary to test for sexually transmitted infections (STIs) if accompanied by one or more of the following ICD-10 codes: Codes Description 86592 Syphilis test non-Trep Qual 86593 Syphilis test non-Trep Quant 86780 Treponema pallidum A50 A 50.9 Congenital syphilis A51 A51.9 Early syphilis A52 A52.9 Late syphilis A53 A53.9 Other and unspecified syphilis A65 Nonvenereal syphilis E.Hepatitis B .If policy criteria are met, CareSource will reimburse for the following CPT codes for diagnosis when medically necessary to test for sexually transmitted infections (STIs) in women if accompanied by one or more of the following ICD-10 codes: Codes Description 87340 Hepatitis Bsurface antigen detection by EIA 87341 Hepatitis Bsurface, ag, EIA B16 B16.9 Acute hepatitis BB17 B17.9 Other acute viral hepatitis B18 B18.9 Chronic viral hepatitis B19 B19.9 Unspecified viral hepatitis IV. Non-Covered Services A. The US CDC notes that current guidelines do not support PCR testing for bacterial vaginosis or vaginal discharge. t orkowski et al state that “PCR also has been used in research settings for the detection of a variety of organisms associated with BV, but evaluation of its clinical utility is uncertain.”[7] The CDC does not indicate any role for PCR tests in the assessment of vaginal discharge without suspicion for C. trachomatis or N. gonorrhoeae based on history of sexual activity and presence of mucopurulent cervicitis. Otherwise, the cause of vaginal infection can be evaluated and diagnosed by pH and microscopic examination of the discharge. B37.0-B37.9 Candidiasis N76.0-N76.3 Acute, subacute, chronic vaginitis and vulvitis [bacterial vaginosis associated bacteria 2 (BVAB2), megasphaera type 2] Codes Description ArchivedSexually Transmitted Infections OHIO Medicaid PY-0037 Effective Date: 05/26/17 11N77.1 Vaginitis, vulvitis and vulvovaginitis in diseases cla ssified elsewhere [bacterial vaginosis associated bacteria 2 (BVAB2), megasphaera type 2] AUTHORIZATION PERIOD F. RELATED POLICIES/RUL ES 1. Centers for Medicare & Medicaid Services Manual Pub. 100-3 National Coverage Determination / 210.10 Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs 2. United States Preventive Services Task Force Recommendations G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 08/10/2016 Date Revised 0 5/26/2017 Date Effectiv e 05/26 /2017 H. REFERENCES 1. H. D. Nelson, B. Zakher, A. Cantor, M. Deagas, and M. Pappas, “Screening for Gonorrhea and Chlamydia: Systematic Review to Update the U.S. Preventive Services Task Force Recommendations. Evidence Synthesis No. 115. AHRQ Publication No. 13-05184-EF-1,” Rockville, MD, 2014. 2. J. A. Conry and H. Brown, “Well-Woman Task Force: Components of the Well-Woman Visit,” Obstet Gynecol, vol. 126, pp. 697-701, Oct 2015. 3. ACOG, “ACOG Practice Bulletin No. 31: Assessment of Risk Factors for Preterm Birth,” Obstetrics & Gynecology, vol. 98, pp. 709-716, 2001. 4. ACOG, “ACOG Committee Opinion no. 598: Committee on Adolescent Health Care: The initial reproductive health visit,” Obstet Gynecol, vol. 123, pp. 1143-7, May 2014. 5. CDC, “Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae –2014,” MMWR Recomm Rep, vol. 63, pp. 1-19, Mar 14 2014. 6. H. Weinstock, S. Berman, and W. Cates, Jr., “Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000,” Perspect Sex Reprod Health, vol. 36, pp. 6-10, Jan-Feb 2004. 7. K. A. Workowski, S. Berman, C. Centers for Disease, and Prevention, “Sexually transmitted diseases treatment guidelines, 2010,” MMWR Recomm Rep, vol. 59, pp. 1-110, Dec 17 2010. 8. CDC. (2011), (Retrieved July 24, 2016). STDs Adolescents and Young Adults. . Available: at http://www.cdc.gov/std/stats11/adol.htm 9. D. M. Upchurch, W. M. Mason, Y. Kusunoki, and M. J. Kriechbaum, “Social and behavioral determinants of self-reported STD among adolescents,” Perspect Sex Reprod Health, vol. 36, pp. 276-87, Nov-Dec 2004. 1 0. B. Van Der Pol, C. S. Kraft, and J. A. Williams, “Use of an adaptation of a commercially available PCR assay aimed at diagnosis of chlamydia and gonorrhea to detect Trichomonas vaginalis in urogenital specimens,” JClin Microbiol, vol. 44, pp. 366-73, Feb 2006. 11. M. B. Nye, J. R. Schwebke, and B. A. Body, “Comparison of APTIMA Trichomonas vaginalis transcription-mediated amplification to wet mount microscopy, culture, and polymerase chain reaction for diagnosis of trichomoniasis in men and women,” Am JObstet Gynecol, vol. 200, pp. 188 e1-7, Feb 2009. 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
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 06/01/2017 05/15 /2018 06/01/2017 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0072 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Screening and Surveillance for Colorectal Cancer Ohio Medicaid PY-0072 Last Revised 06/01/17 2 A. SUBJECT Screening and Surveillance for Colorectal Cancer 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 colorectal cancer as required by state requirements through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology (ACG). Applicable clinical criteria for the following colorectal cancer screening health services are described i n the corresponding medical policy entitled Screening and Surveillance for Colorectal Cancer : Air Contrast Barium Enema (ACBE) every 5 years; Flexible sigmoidoscopy every 5 years in combination with fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT) every 3 years. Multi-targeted stool DNA test (Cologuard) every 3 years when clinical criteria are met; (see the Screening and Surveillance for Colorectal Cancer policy ) Screening Colonoscopy every 10 years in average risk patients. Screening Colonoscopy every 24 months in high risk patients FOBT or FIT annually C. DEFINITIONS See corresponding CareSource medical policy titled, Screening and Surveillance for Colorectal Cancer: https://www.caresource.com/documents/medicaid-screening-and-surveillance-for-colorectal-cancer/ D. POLICY CareSource will reimburse providers for Screening and Surveillance for Colorectal Cancer utilized through Medicaid when approved by CareSource. I. Medicaid screening and surveillance for colorectal cancer are reimbursed based on the Medicaid fee schedule. II.If required, providers must submit their prior authorization number their claim form, as well as appropriate HCPCS and/or CPT codes along with appropriate modifiers in accordance with CMS. Archived Screening and Surveillance for Colorectal Cancer Ohio Medicaid PY-0072 Last Revised 06/01/17 3 E.CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers. Please refer to : http://jfs.ohio.gov/ 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 Code Description 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of t umor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, flexible; with transendoscopic balloon dilation 45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre-and post-dilation and guide wire passage, when performed) 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45390 Colonoscopy, flexible; with endoscopic mucosal resection 45393 Colonoscopy, flexible; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed 45398 Colonoscopy, flexible; with band ligation(s) (e.g., hemorrhoids) 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm repo rted as a positive or negative result (Cologuard) Archived Screening and Surveillance for Colorectal Cancer Ohio Medicaid PY-0072 Last Revised 06/01/17 4 AUTHORIZATION PERIOD If applicable, reimbursement is dependent upon products and services frequency, duration and timeframe set forth by Medicaid. F. RELATED POLICIES/RUL ES Screening and Surveillance for Colorectal Cancer, MM-0040 (Medicaid) G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 06/01/2017 Date Revised Date Effective 06/01/2017 H. REFERENCES 1. Ohio Department of Medicaid. (2016, May 16). Retrieved May 16, 2016, from http://medicaid.ohio.gov/FOROHIOANS/CoveredServices.aspx#669179-preventive-exams-and-screenings 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
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Effective Date Next Annual Review Effective Date 05/15/2017 05/01/2018 05/15 /2017 Policy Name Policy Number Hepatitis Panel PY-0 206 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and 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. Medical ly 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, inc reased 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 m ainly 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 conf lict 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 i n 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 ………………………………………………………………………………………….. 4 D.POLICY …………………………………………………………………………………………………. 4 E.CONDITIONS OF COVERAGE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 7 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 8 H.REFERENCES ………………………………………………………………………………………… 8Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 2 A.SUBJECT Hepatitis Panel B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other causes. Viral hepatitis can be due to one of at least five viruses, discussed here. Most cases of viral hepatitis are caused by Hepatitis A virus (HAV), Hepatitis Bvirus (HBV), or Hepatitis Cvirus (HCV), although viral hepatitis can also be caused by the less-prevalent viruses Hepatitis Dand E. HBV is spread exclusively by the members exposure to infected blood or bodily fluids. In the United States, sexual transmission accounts for thirty to sixty percent of new cases of HBV infection. Despite the overall decline in HCV infection rates in the United States over the past several decades, HCV infection rates among young adults may be increasing [2]. In a study of CDC surveillance data, the incidence of cases of acute HCV infection reported among individuals younger than 30 years old rose from 2006 to 2012 by 13 percent annually in nonurban counties and by 5 percent annually in urban counties [ 3]. Due to a rise in injection drug use among younger individuals, the large majority of infected individuals are white, with men and women evenly represented. The actual incidence of acute HCV infection is likely greater than these estimates, given the difficulty in diagnosis of acute HCV infection, incomplete case reporting (including expanding infection rates among the homeless and incarcerated individuals, which is a significant population), and narrow national case definitions. The prevalence of chronic HCV infection in the United States is currently the highest among individuals born between 1945 and 1965. In children and adolescents in the United States, HAV is the most common cause of hepatitis. Prior exposure is indicated by a positive blood test known as Immunoglobulin Ganti-HAV (IgG anti-HAV) for the Hepatitis A virus. Acute HAV is specifically diagnosed by IgM anti-HAV, which typically results within four weeks of exposure, and which disappears within three months of the first positive blood test. IgG anti-HAV is similar in the timing of its appearance but does not subside, app earing indefinitely. Its detection in blood testing indicates the members prior effective immunization to, or recovery from infection. Although HAV is spread most commonly by the oral consumption or transmission of fecal matter from an infected individual, other methods of infection are is possible during the acute viral stage of the disease. After exposure, standard immune globulin may be effective as prophylactic care. Chronic HCV infection is indicated with a reactive HCV antibody test and a positive molecular test indicating the presence of HCV RNA, confirming the diagnosis of HCV infection. If HCV RNA is not detected, then the reactive antibody test likely indicates either a past HCV infection that has since cleared or false positive [4 ]. ArchivedHepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 3 HBV producesseparate surface, core, and e (envelope) antigens when it infects the liver; only the surface antigen for hepatitis Bsurface (HBsAg) is included as part of the standard panel. After being exposed to the hepatitis virus(es), the immune system typically re sponds by producing antibodies to each antigen. Hepatitis Bsurface antibody (HBsAb) – IgM antibody is part of the standard panel. However, HBsAg is the earlier marker, appearing four to eight weeks after exposure, and normally disappearing within six months after its appearance. If HBsAg remains detectable for a period of time exceeding six months, it is an indication of chronic HBV infection in the member. HBcAb, in the form of both IgG and IgM antibodies, are sequentially the next to appear in serum, typically becoming detectable two to three months following exposure . The detectable presence of the IgM antibody gradually declines or disappears entirely from one to two years following exposure, but the IgG usually remains detectable for the lifetime of th e member. Because HBsAg is present for a relatively short period of time and normally at a very low concentration, a negative result from the blood test does not necessarily exclude an HBV diagnosis. By contrast, HBcAb appears in a much higher concentratio n and the antibodies typically remain at that higher level for a longer period of time. That said, it follows that a positive result is not necessarily diagnostic of acute disease, since the elevated antibodies may still be the result of a previous infecti on. In the usual course of the disease, the last marker to appear is HBsAb, which can be found in serum four to six months following exposure and remains positive indefinitely signifying immunity to the patient. The diagnosis of acute HBV infection is best established by documentation of a positive result for the IgM antibody against the core antigen (HBcAb-IgM), and by identifying a positive result for the hepatitis Bsurface antigen (HBsAg). The diagnosis of chr onic HBV infection is established primarily by identifying a positive hepatitis Bsurface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core antigen (HBcAb-IgG). Additional tests such as Hepatitis Be-antigen (HBeAg) and Hepa titis Be-antibody (HBeAb), which are the envelope antigen and antibody for Hepatitis B, are not included in the standard Hepatitis Panel. However, they can be a marker of replication and infectivity associated with an increased risk of transmission. After an HBV vaccination series is completed, HBsAb can be followed to verify an appropriate antibody response.Once a diagnosis is established, specific tests can be used to monitor the course of the disease. If hepatitis appears in a patient after transfusion, HCV is the most common cause. HCV is responsible for 15% to 20% of all cases of acute hepatitis overall, and is the most common cause of chronic liver disease. The test most commonly used to identify HCV is one that measures HCV antibodies, which nor mally appear in the patients blood between two to four months after infection. False positive HCV results can occur. For this reason, positive results are usually verified by a more specific technique. Like HBV, HCV is spread exclusively through exposure to infected blood or body fluids. This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the timeframe of the initial infection or exposure, and/or the stage of the disease is unknown, a patient with continued symptoms of liver disease despite a completely negative Hepatitis Panel may need another panel performed approximately two weeks to two months later in order to exclude the possibility of hepatitis. The specific rules that apply for diagnosis codes (for Medicaid members only) are outlined in this policy. ArchivedHepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 4 C. DEFINITIONS Medically necessary means health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. D. POLICY I.Prior authorization is not required for any medically necessary hepatitis panel screenings. NOTE: Although the hepatitis testing covered by this policy do es not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II.Tests for the Hepatitis panel referred to in this policy are selected laboratory tests. Material related to diagnostic testing in this policy is included to clarify coverage for diagnostic versus screening indications. III. CareSource will reimburse providers for the medically necessary screening, diagnoses, and subsequent treatments for, and management of hepatitis as documented in the medical record in the following circumstances: A. To detect viral hepatitis infection when there are abnormal liver function test results, with or without signs or symptoms of hepatitis; and B. Prior to and subsequent to liver transplantation. IV. Coverage A. CareSource will cover screening for hepatitis with the appropriate laboratory tests when ordered and performed by a provider for these services, and when used in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but 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. I.Covered Services A. If policy criteria are met, CareSource will reimburse for an acute hepatitis panel once per calendar year for screening when medically necessary to test for hepatitis in asymptomatic men and women if accompanied by one or more of the appropriate ICD-10 codes.CareSource will reimburse for a repeat panel approximately two weeks to two months after the initial one to exclude the possibility of hepatitis in a patient with continued symptoms of liver disease despite a completely negative first Hepatitis Panel. Codes Description 80074 Acute Hepatitis Panel Codes Description B15.0 Hepatitis A with hepatic coma B15.9 Hepatitis A without hepatic coma B16.0 Acute hepatitis Bwith delta-agent with hepatic coma Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 5 B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute he patitis Cwith hepatic coma B17.2 Acute hepatitis EB17.8 Other specified acute viral hepatitis B17.9 Acute viral hepatitis, unspecified B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B18.2 Chronic viral hepatitis CB18.8 Other chronic viral hepatitis B18.9 Chronic viral hepatitis, unspecified B19.0 Unspecified viral hepatitis with hepatic coma B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma B19.9 Unspecified viral hepatitis without hepatic coma G93.3 Post-viral fatigue syn drome I85.00 Esophageal varices without bleeding I85.01 Esophageal varices with bleeding I85.10 Secondary esophageal varices without bleeding I85.11 Secondary esophageal varices with bleeding K70.41 Alcoholic hepatic failure with coma K71.0 Toxic liver disease with cholestasis K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.2 Toxic liver disease with acute hepatitis K71.3 Toxic liver disease with chronic persistent hepatitis K71.4 Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 Toxic liver disease with hepatitis, not elsewhere classified K71.7 Toxic liver disease with fibrosis and cirrhosis of liver K71.8 Toxic liver disease with other disorders of liver K71.9 Toxic liver disease, unspecified K72.00 Acute and subacute hepatic failure without coma K72.01 Acute and subacute hepatic failure with coma K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K74.0 Hepatic fibrosis K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.0 Abscess of liver K75.1 Phlebitis of portal vein K75.2 Nonspecific reactive hepatitis K75.3 Granulomatous hepatitis, not elsewhere classified Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 6 K75.81 Nonalcoholic steatohepatitis (NASH) K75.89 Other specified inflammatory liver diseases K75.9 Inflammatory liver disease, unspecified K76.2 Central hemorrhagic necrosis of liver K76.4 Peliosis hepatis K76.6 Portal hypertension K76.7 Hepatorenal syndrome K76.81 Hepatopulmonary syndrome R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.2 Pelvic and perineal pain R10.30 Lower abdominal pain, unspecified R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain R10.811 Right upper quadrant abdominal tenderness R10.821 Right upper quadrant rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 7 R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight Code Description R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight II.Non-Covered Services A. Once a diagnosis of hepatitis has been made, CareSource will cover appropriate and medically necessary, individual hepatitis testing for its members, but does not cover ongoing hepatitis panel testing. AUTHORIZATION PERIOD F. RELATED POLICIES/RUL ES ArchivedHepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 8 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 05/15/2017 Date Revised Date Effective 05/15/2017 H. REFERENCES 1. R. K. Ockner, Approaches to the diagnosis of jaundice, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W.B. Saunders, pp. 817-818. 2. R. K. Ockner, Acute viral hepatitis, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W .B. Saunders, pp. 818-826. 3. R. K. Ockner, Chronic hepatitis, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W .B. Saunders, pp. 830-834. 4. D. A. Arvan, Acute viral hepatitis, in Panzer, R.J., Black, E.R., & Griner, P.F. (eds.), Diagnostic Strategies for Common Medical Problems, 1991, American College of Physicians, pp. 141-151. 5. D. M. Goldberg, Diagnostic Enzymology, in Gornall, A.G. (ed.), Applied Biochemistry of Clinical Disorders (2nd ed.), 1986, J.B. Lippincott, pp. 33-51. 6. M. R. Pincus and J. A. Scha ffner, Assessment of liver function, in Henry J.B.(ed.), Clinical Diagnosis & Management by Laboratory Methods (19th ed.), 1996, W.B. Saunders, pp 253-267. 7. Tietz, N.W. (ed.), Clinical Guide to Laboratory Tests (3rd ed.), 1995, pp. 320-327. 8. D. Zakim, D. and T.D. Boyer, Hepatology (2nd ed.), 1990, W.B. Saunders. 9. Harrisons Principles of Internal Medicine (14th ed.), 1998, McGraw Hill. 10. J. Wallach, Interpretation of Diagnostic Tests, 1996, Little Brown and Co. 11. Illustrated Guide to Diagnostic Tests (2nd ed.), 1997, Springhouse Corporation. 12. Sleisenger and Fordtranss Gastrointestinal and Liver Disease (6th ed.), 1997, W.B. Saunders. 13. CDC. (2017), (Retrieved February 20, 2017). HCV Facts for Health Professionals . Available at https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm 1. Epidemiology and transmission of hepatitis Cvirus infection, Basics | Diabetes | CDC. (n.d.).Retrieved 02-14-2017 from https://www.cdc.gov/diabetes/basics/diabetes.html. 14. Hepatitis Cvirus infection amo ng adolescents and young adults: Massachusetts, 2002-2009, Basics | Diabetes | CDC. (n.d.).Retrieved 02-14-2017 from https://www.uptodate.com/contents/epidemiology-and-transmission-of-hepatitis-c-virus-infection/abstract/5-7. 15. Emerging epidemic of hep atitis Cvirus infections among young nonurban persons who inject drugs in the United States, 2006-2012, Basics | Diabetes | CDC. (n.d.).Retrieved 02-20-2017 from https://www.uptodate.com/contents/epidemiology-and-transmission-of-hepatitis-c-virus-infection?source=search_result&search=hepatitis%20c%20epidemiology&selectedTitle=1~150. 16. Recommendations for Testing, Managing, and Treating Hepatitis C, Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. Retrieved 08-01-2016 from http://www.hcvguidelines.org/. The Reimbursement 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
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date: Next Annual Review Effective Date 01/01/2016 0 5/03/2018 01/01/2016 Policy Name Policy Number Three-Day Payment Window PY-0128 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 ………………………………………………………………….. 3 F.RELATED POLICIES/RULES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 3 H.REFERENCES ………………………………………………………………………………………… 4Archived Three-Day Payment Window Ohio Medicaid PY-0128 Effective Date: 01/01/2016 2 A.SUBJECT Three-Day Payment Window B. BACKGROUND I. Medicare Background : Section 102 of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, Pub. L. 111-192, signed into law on June 25, 2010, sets forth, in part, the Medicare three-day payment window, which is Medicare’s policy for payment of outpatient services provided on either the date of a beneficiary’s admission or during the three calendar days immediately preceding the date of a beneficiary’s inpatient admission to a subsection (d) hospital subject to the inpatient prospective payment system (IPPS). Under the Medicare three-day payment window policy, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the claim for a beneficiary’s inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient nondiagnostic services that are furnished to the beneficiary during the 3-day payment window. Under the three-day payment window policy, all outpatient diagnostic services furnish ed to a Medicare beneficiary by a hospital (or an entity wholly owned or operated by the hospital), on the date of a beneficiary’s admission or during the 3 days immediately preceding the date of a beneficiary’s inpatient hospital admission, must be included on the Part A bill for the beneficiary’s inpatient stay at the hospital. According to CMS, this law makes the policy pertaining to admission-related outpatient nondiagnostic services more consistent with common hospital billing practices. II.Ohio Medicaid Background: The Ohio Department of Medicaid amended the Ohio Administrative Code 5160-2- 02 to adopt a similar three-day payment window for outpatient services rendered prior to an inpatient admission occurring on and after January 1, 2016. Specifically, the amended section 5160-2-02(B)(2) states: Effective for inpatient admissions that begin on or after January 1, 2016, outpatient services, as described in paragraph (B)(4) of this rule, provided within three calendar days prior to the date of admission in hospitals described in rule 5160-2-01 of the Administrative Code will be covered as inpatient services. This includes emergency room and observation services. The OAC three-day payment window policy differs from the Medicare policy in that it requires that all outpatient diagnostic and non-diagnostic services rendered within the payment window be bundled with the inpatient claim, regardless of whether or not the services are clinically related to the admission. C. DEFINITIONS For purposes of this policy, Hospital is defined as hospitals described in rule 5160-2-01 of the Ohio Administrative Code, and Outpatient services” are defined at OAC Section 5160-2-02(B)(4) as follows: Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital as defined in rule 5160-2-01 of the Administrative Code. Outpatient services do not include direct-care services provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5160-4-01 of the Administrative Code. Wholly owned is defined as follows: An entity is wholly owned by the hospital if th e hospital is the sole owner of the entity. (See 42 CFR 412.2) Wholly operated is defined as follows: An entity is wholly operated by a hospital if the hospital has exclusive responsibility for conducting and overseeing the entitys routine operations, regardless of whether the hospital also has policymaking authority over the entity. (See 42 CFR 412.2) Archived Three-Day Payment Window Ohio Medicaid PY-0128 Effective Date: 01/01/2016 3 D.POLICY I. General. As an Ohio Medicaid Managed Care Entity, it is the CareSource policy that effective for inpatient admissions that begin on or after January 1, 2016, outpatient services, as described in paragraph (B) (4) of OAC 5160-2-02(B) (2), provided within three calendar days prior to the date of admission in hospitals described in rule 5160-2-01 of the Ohio Administrative Code, will be covered as inpatient services. This includes emergency room and observation services. This rule applies to all outpatient services provided by the admitting hospital, as well as hospitals wholly owned or operated by the admitting hospital. Therefore, hospitals must bundle on the inpatient claim all outpatient services rendered by the admitting hospital or a hospital wholly owned or operated by the hospital within three (3) calendar days prior to the date of admission. II.Compliance with Three-Day Payment Rule. A. Outpatient claim s submitted by a Hospital and rendered on or after January 1, 2016 are subject to this rule and will be denied if rendered within three calendar days prior to an inpatient admission of the same patient receiving the outpatient services . 1. Any previously paid outpatient claims, if subject to this rule, will be denied. 2. Claims where a Hospital has been paid for an inpatient claim and subsequently submits a claim for an outpatient service that was rendered within three calendar days prior to the inpatient admission of that patient will be denied. B. Examples: 1. Patient A received an outpatient service from Hospital A on January 1, 2016. Hospital A submitted the claim as an outpatient claim. On January 4, 2016, Patient A is admitted to Hospital A as an inpatient. The outpatient service rendered to Patient A on January 1, 2016 will be denied and is subject to recoupment because it was rendered within three calendar days of Patient As inpatient admission to Hospital A. 2. Patient Breceived an outpatient service from Hospital Bon January 1, 2016. On January 5, 2016, Patient Bis admitted to Hospital Bas an inpatient. The outpatient service rendered to Patient Bon January 1, 2016 will be approved (provided that it otherwise meets any applicable service and reimbursement requirements) because it was rendered outside of the three-day payment window. E. CONDITIONS OF COVER AGE F. RELATED POLICIES/RUL ES https://www.caresource.com/documents/observation-care/ G.REVIEW/REVISION HISTORY DATE ACTION Date Issued 01/01/2016 Date Revised Date Effective 01/01/2016 ArchivedThree-Day Payment Window Ohio Medicaid PY-0128 Effective Date: 01/01/2016 4 H. REFERENCES 1. 42 CFR 412.2(c)(5) 2. Medicare Claims Processing Manual (Pub. 100-4), Chapter 3, section 40.3, Outpatient Services Treated as Inpatient Services. 3. OAC 5160-2-02(B)(2) 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
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 05/01/2018 05/01/2017 Policy Name Policy Number Vitamin DAssay Testing PY-0226 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patien t can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low es t cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service (s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT ………………………….. ………………………….. ………… 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ………….. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………………… 2B. BACKGROUND ………………………….. ………………………….. ………………………….. …………….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. ……………….. 2 D. POL IC Y ………………………….. ………………………….. ………………………….. ………………………… 2 E. COND ITIONS OF COVERA GE ………………………….. ………………………….. …………………. 3 F. RELATED POL IC IES/RUL ES ………………………….. ………………………….. ……………………. 3 G. REVIEW /REV IS ION HIS TORY ………………………….. ………………………….. ………………….. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. ……………… 3 Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 2 A. SUBJECT Vitamin DAssay Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care pr oviders and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Although an excess of vitamin Dis rar e it can lead to hypercalcemia. Vitamin Ddef iciency may lead to numerous disorders, the most widely k nown is rickets. Assessing patients vita min Dlevels is achieved by measuring the level of 25-hydroxyvita min D. Evaluation of other metabol ites is generally not medically nec essary. C. DEFINITIONS Severe deficiency: 25(OH)D: 80 ng/ml D. POLICY I. CareSource does not require a prior autho rization for Vitamin Dtesting. II. CareS ource considers Vitamin Dlevels testing medically necessary for patients with the following: A. Chronic kidney disease stage III or greater B. Osteoporosis C. Osteomalacia D. Osteopenia E. Hypocalcemia F. Hypercalciura G. Hypopa rath y roidism H. Malabsorption states I. Cirrhosis J. Hypervitaminosis DK. Osteosclerosis/petrosis L. Rickets M. Low exposu re to sunlight N. Vitamin Ddeficiency to monitor the efficacy of replacement therapy III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the Vitamin Dtesting CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 3 Note : Althou gh this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimburs ement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/LabS er vicesPayme nt.pdf The following list(s) of code s is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Code s De finition 8 23 06 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED ICD 10 code s De scription E20.0 Idiopathic hypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E21.0-E21.3 Primary hyperparathyroidism-Hyperparathyroidism, unspecified E41 Nutritional marasmus E43 Unspecified severe protein-calorie malnutrition E55.0 Rickets, active E55.9 Vitamin Ddeficiency, unspecified E67.3 Hypervitaminosis DE67.8 Other specified hyperalimentation E68 Sequelae of hyperalimentation E83.31 Familial hypophosphatemia E83.32 Hereditary vitamin D-dependent ric k ets (ty pe 1) (ty pe 2) E83.39 Other disorders of phosphorus metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E84.0 Cystic fibrosis with pulmonary manifestations E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations E89.2 Postprocedural hypoparathyroidism K50.00 Crohn’s disease of small intestine without complications Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 4 K50.011 Crohn’s disease of small intestine with rectal bleeding K50.012 Crohn’s disease of small intestine with intestinal obstruction K50.013 Crohn’s disease of small intestine with fistula K50.014 Crohn’s disease of small intestine with abscess K50.018 Crohn’s disease of small intestine with other complication K50.111 Crohn’s disease of large intestine with rectal bleeding K50.112 Crohn’s disease of large intestine with intestinal obstruction K50.113 Crohn’s disease of large intestine with fistula K50.114 Crohn’s disease of large intestine with abscess K50.118 Crohn’s disease of large intestine with other complication K50.80 Crohn’s disease of both small and large intestine without complications K50.811 Crohn’s disease of both small and large intestine with rectal bleeding K50.812 Crohn’s disease of both small and large intestine with intestinal obstruction K50.813 Crohn’s disease of both small and large intestine with fistula K50.814 Crohn’s disease of both small and large intestine with abscess K50.818 Crohn’s disease of both small and large intestine with other complication K50.90 Crohn’s disease, unspecified, without complications K50.911 Crohn’s disease, unspecified, with rectal bleeding K50.912 Crohn’s disease, unspecified, with intestinal obstruction K50.913 Crohn’s disease, unspecified, with fistula K50.914 Crohn’s disease, unspecified, with abscess K50.918 Crohn’s disease, unspecified, with other complication K51.00 Ulcerative (chronic) pancolitis without complications K51.011 Ulcerative (chronic) pancolitis with rectal bleeding K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chron ic) pancolitis with fistula K51.014 Ulcerative (chronic) pancolitis with abscess K51.018 Ulcerative (chronic) pancolitis with other complication K51.20 Ulcerative (chronic) proctitis without complications K51.211 Ulcerative (chronic) proctitis with rectal bleeding K51.212 Ulcerative (chronic) proctitis with intestinal obstruction K51.213 Ulcerative (chronic) proctitis with fistula K51.214 Ulcerative (chronic) proctitis with abscess K51.218 Ulcerative (chronic) proctitis with other complication Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 5 K51.30 Ulcerative (chronic) rectosigmoiditis without complications K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula K51.314 Ulcerative (chronic) rectosigmoiditis with abscess K51.318 Ulcerative (chronic) rectosigmoiditis with other complication K51.40 Inflammatory polyps of colon without complications K51.411 Inflammatory polyps of colon with rectal bl eeding K51.412 Inflammatory polyps of colon with intestinal obstruction K51.413 Inflammatory polyps of colon with fistula K51.414 Inflammatory polyps of colon with abscess K51.418 Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K51.511 Left sided colitis with rectal bleeding K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.514 Left sided colitis with abscess K51.518 Left sided colitis with other complication K52.0 Gastroenteritis and colitis due to radiation K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K74.1 Hepatic sclerosis K74.2 Hepatic fibrosis with hepatic sclerosis K76.9 Liver disease, unspecified K90.0 Celiac disease K90.1 Tropical sprue K90.2 Blind loop syndrome, not elsewhere classified K90.3 Pancreatic steatorrhea K90.41 Non-celiac gluten sensitivity K90.49 Malabsorption due to intolerance, not elsewhere classified K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.2 Postsurgical malabsorption, not elsewhere classified Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 6 M80.00XA Age-related osteoporosis with current path ological fracture, unspecified site, initial encounter for fracture M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M80.061A Age-related osteoporosis with current p athological fracture, right lower leg, initial encounter for fracture M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M83.0-M83.5 Puerperal osteomalacia-Other drug-induced osteomalacia in adults M83.8 Other adult osteomalacia M85.80 Other specified disorders of bone density and structure, unspecified site M85.811 Other specified disorders of bone density and structure, right shoulder M85.812 Other specified disorders of bone density and structure, left shoulder M85.821 Other specified disorders of bone density and structure, right upper arm M85.822 Other specified disorders of bone density and structure, left upper arm M85.831 Other specified disorders of bone density and structure, right forearm M85.832 Other specified disorders of bone density and structure, left forearm M85.841 Other specified disorders of bone density and structure, right hand Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 7 M85.842 Other specified disorders of bone density and structure, left hand M85.851 Other specified disorders of bone density and structure, right thigh M85.852 Other specified disorders of bone density and structure, left thigh M85.861 Other specified disorders of bone densit y and structure, right lower leg M85.862 Other specified disorders of bone density and structure, left lower leg M85.871 Other specified disorders of bone density and structure, right ankle and foot M85.872 Other specified disorders of bone density and structure, left ankle and foot M85.88 Other specified disorders of bone density and structure, other site M85.89 Other specified disorders of bone density and structure, multiple sites M89.9 Disorder of bone, unspecified M94.9 Disorder of cartilage, unspecified N18.3-N18.6 Chronic kidney disease, stage 3 (moderate) – End stage renal disease N25.81 Secondary hyperparathyroidism of renal origin Q78.2 Osteoporosis A UTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DAT EACT ION Da te Issue d 03-08-2017 Da te Re vise d 03/19/2019 Updated code list based on revised LCD Da te Effe ctive 05/01/2017 H. REFERENCES 1. Local Coverage Determination (LCD) Vitamin DAssay Testing (L33996). Retrieved March 19, 2019 2. Vitamin DInsufficiency. Retrieved March 2, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC29 127 37/ The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 05/01 /2017 Policy Name Policy Number Thyroid Testing PY-0222 Policy Typ e 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 servic es 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 morbi dity, 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 conve nience 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 polici es and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ………………………………………………………………….. 31 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………. 31 H.REFERENCES ………………………………………………………………………………………. 32Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 2 A.SUBJECT Thyroid Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify membe rs eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. DEFINITIONS Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. POLICY I. CareSource does not require a prior authorization for thyroid testing. II.CareSource considers thyroid function testing medically necessary for the following: A. Members who are clinically stable up to 2 times per year B. Members who have symptoms consistent with hypothyroidism C. Members who have symptoms consistent with hyperthyroidism D. Members who are asymptomatic and 60 years of age or older, performed every 5 years E. Members who are asymptomatic but are considered high risk due to the following: 1. Family or personal history of thyroid disease, this should be limited to a one time screening 2. Family or personal history of Type I Diabetes or other autoimmune disorder, this should be limited to a one time screening 3. Member who is prescribed medications that may interfere with thyroid function III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 3 E.CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Codes Definition 84436 Thyroxine: total 84339 Thyroxine: free 84443 TSH Thyroid Stimulating Hormone 84479 Thyroid Hormone Uptake (T3 or T4) or thyroid hormone binding ration (THBR) ICD-10-CM Definition A18.81 Tuberculosis of thyroid gland C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary C73 Malignant neoplasm of thyroid gland C75.8 Malignant neoplasm with pluriglandular involvement, unspecified C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D09.3 Carcinoma in situ of thyroid and other endocrine glands D09.8 Carcinoma in situ of other specified sites D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D27.9 Benign neoplasm of unspecified ovary D34 Benign neoplasm of thyroid gland D35.2 Benig n neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D44.0 Neoplasm of uncertain behavior of thyroid gland D44.2 Neoplasm of uncertain behavior of parathyroid gland D44.9 Neoplasm of uncertain behavior of unspecified endocrine g land D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency ArchivedThyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 4 D53.9 Nutritional anemia, unspecified D59.0 Drug-induced autoimmune hemolytic anemi a D59.1 Other autoimmune hemolytic anemias D64.9 Anemia, unspecified D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere specified E00.0 Congenital iodine-deficiency synd rome, neurological type E00.1 Congenital iodine-deficiency syndrome, myxedematous type E00.2 Congenital iodine-deficiency syndrome, mixed type E00.9 Congenital iodine-deficiency syndrome, unspecified E01.0 Iodine-deficiency related diffuse (endemic) go iter E01.1 Iodine-deficiency related multinodular (endemic) goiter E01.2 Iodine-deficiency related (endemic) goiter, unspecificied E01.8 Other iodine-deficiency related thyroid disorders and allied conditions E02 Subclinical iodine-deficiency hypothyro idism E03.0 Congenital hypothyroidism with diffuse goiter E03.1 Congenital hypothyroidism without goiter E03.2 Hypothyroidism due to medicaments and other exogenous substances E03.3 Postinfectious hypothyroidism E03.4 Atrophy of thyroid (acquired) E0 3.5 Myxedema coma E03.8 Other specified hypothyroidism E03.9 Hypothyroidism, unspecifide E04.0 Nontoxic diffuse goiter E04.1 Nontoxic single thyroid nodule E04.2 Nontoxic multinodular goiter E04.8 Other specified nontoxic goiter E04.9 Nontoxic goit er, unspecified E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 5 E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic cri sis or storm E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm E05 .41 Thyrotoxicosis factitia with thyrotoxic crisis or storm E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm E06.0 Acute thyroiditis E06.1 Subacute thyroiditis E06.2 Chronic thyroiditis with transient thyrotoxicosis E06.3 Autoimmune thyroiditis E06.4 Drug-induced thyroiditis E06.5 Other chr onic thyroiditis E06.9 Thyroiditis, unspecified E07.0 Hypersecretion of calcitonin E07.1 Dyshornogenetic goiter E07.89 Other specified disorders of thyroid E07.9 Disorder of thyroid, unspecified E08.00 Diabetes mellitus due to underlying condition w ith hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabeted mellitus due to underlying condition with ketoacidosis without coma E08.1 1 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic mephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabeted mellitus due to underlyin condition with other diabetic kidney complication E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 6 E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema E08.329 Diabetes mellitus due to underlying condition with mild nonproliferati ve diabetic retinopathy without macular edema E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferativ e diabetic retinopathy without macular edema E08.341 Diabetes mellitus due to underlying condition with severe nonprolifeartive diabetic retinopathy with macular edema E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative dia betic retinopathy without macular edema E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabeti c neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diab etic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with diabetic neurological complication E08.51 Diabetes mellitus due to underlying condit ion with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08 .610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis E08.621 Diabetes mellitus due to underlying condition with foot ulcer E08.622 Diabetes mellitus due to underlying condition with other skin ulcer E08.628 Diabetes mellitus due to underlying condition with other skin complicatiosn E08.630 Diabetes melli tus due to underlying condition with periodontal disease E08.638 Diabetes mellitus due to underlying condition with other oral complications Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 7 E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellitus due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlyi ng condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition with complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemic al induced diabetes mellitus with diabetic nephropathy E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E09.311 Drug or chemi cal induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E09.331 Drug or chemical induced diabetes mellitus with moderate nonpro liferative diabetic retinopathy without macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.341 Drug or chemical induced diabetes mellitus with severe nonprolifera tive diabetic retinopathy with macular edema E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinop athy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.39 Drug or chemical induced diabetes me llitus with other diabetic ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 8 E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)ne uropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complications E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with oth er circulatory complications E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic dermatitis E09.620 Drug or chemical induced diabetes mellitus wi th diabetic dermitis E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer E09.628 Drug or chemical induced diabetes mellitus with other skin complications E09.630 Dr ug or chemical induced diabetes mellitus with periodontal disease E09.638 Drug or chemical induced diabetes mellitus with other oral complications E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma E09.649 Drug or chemical in duced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complications E09.8 Drug or chemical induced diabetes mell itus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus with out complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complications E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edems E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 9 E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild no nproliferative diabetic retinopathy without macular edema E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.351 Type 1 diabetes mellitu s with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mel litus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy wit hout gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 d iabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10..628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 Type 1 diabetes mellitus with h ypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 10 E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without c omplications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic re tinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.3 41 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with prolifera tive diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellit us with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 11 E11.61 8 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabete s mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabet es mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspe cified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy w ithout macular edema E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specifie d diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 12 E13.36 Other specified diabetes mellitus with diabetic cataract E 13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus w ith other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other spec ified diabetes mellitus with other circulatory complications E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy E13.620 Other specified diabetes mellitus with diabetic dermatitis E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other skin complications E13.630 Other sp ecified diabetes mellitus with periodontal disease E13.638 Other specified diabetes mellitus with other oral complications E13.641 Other specified diabetes mellitus with hypoglycemia with coma E13.649 Other specified diabetes mellitus with hypogly cemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specifi ed diabetes mellitus without complications E20.0 Idiopathic hypoparathyroidism E20.1 Pseudohypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E22.1 Hyperprolactinemia E22.8 Other hyperfunction of pitui tary gland E22.9 Hyperfunction of pituitary gland, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 13 E23.0 Hypopituitarism E23.1 Drug-induced hypopituitarism E23.6 Other disorders of pituitary gland E25.0 Congenital adrenogenital disorders associated with enzyme deficiency E25 .8 Other adrenogenital disorders E25.9 Adrenogenital disorder, unspecified E27.1 Primary adrenocortical insufficiency E27.2 Addisonian crisis E27.3 Drug-induced adrenocortical insufficiency E27.40 Unspecified adrenocortical insufficiency E27.49 Other adrenocortical insufficiency E28.310 Symptomatic premature menopause E28.319 Asymptomatic premature menopause E28.39 Other primary ovarian failure E29.1 Testicular hypofunction E31.0 Autoimmune polyglandular failure E31.1 Pol yglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E3 1.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E35 Disorders of endocrine glands in diseases classified elsewhere E43 Unspecified severe protein-calorie malnutrition E44.0 Moderate protein-calorie malnutrition E44.1 Mild protein-calorie malnutrition E45 Retarded development following protein-calorie malnutrition E46 Unspecified protein-calorie malnutrition E53.0 Riboflavin deficiency E64.0 Sequelae of protein-calorie malnutrition E67.1 Hyperca rotinemia E78.0 Pure hypercholesterolemia E78.2 Mixed hyperlipidemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 14 E78.4 Other hyperlipidemia E78.5 Hyperlipidemia, unspecified E83.50 Unspecified disorder of calcium metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E83.59 Othe r disorders of calcium metabolism E83.81 Hungry bone syndrome E87.0 Hyperosmolality and hypernatremia E87.1 Hypo-osmolality and hyponatremia E89.0 Postprocedural hypothyroidism E89.2 Postprocedural hypoparathyroidism E89.3 Postprocedural h ypopituitarism E89.6 Postprocedural adrenocortical ( – medullary) hypofunction F03.90 Unspecified dementia without behavioral disturbance F05 Delirium due to known physiological condition F06.0 Psychotic disorder with hallucinations due to known physiological condition F06.1 Catatonic disorder due to known physiological condition F06.2 Psychotic disorder with delusions due to known physiological condition F06.30 Mood disorder due to known physiological condition, unspecified F06.31 Moo d disorder due to known physiological condition with depressive features F06.32 Mood disorder due to known physiological condition with major depressive-like episode F06.33 Mood disorder due to known physiological condition with manic features F06. 34 Mood disorder due to known physiological condition with mixed features F06.4 Anxiety disorder due to known physiological condition F06.8 Other specified mental disorders due to known physiological condition F07.0 Personality change due to know n physiological condition F22 Delusional disorders F23 Brief psychotic disorder F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptom s, moderate F30.13 Manic episode, severe, without psychotic symptoms Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 15 F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bip olar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, current episode depressed, moderate F31.4 Bipolar disorder, current episode depresse d, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bip olar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31 .77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in full remission, most recent episode mixed F31.81 Bipolar II disorder Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 16 F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.3 Major depressive disorder, single episode, severe wit h psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspec ified F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psy chotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depres sive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F41.0 Panic disorder [ episodic paroxysmal anxiety] without agoraphobia F41.1 Generalized anxiety disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified F53 Puerperal psychosis F63.3 Trichotillom ania G25.0 Essential tremor G25.1 Drug-induced tremor G25.2 Other specified forms of tremor G25.70 Drug induced movement disorder, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 17 G25.71 Drug induced akathisia G25.79 Other drug induced movement disorders G25.89 Other spec ified extrapyramidal and movement disorders G25.9 Extrapyramidal and movement disorder, unspecified G26 Extrapyramidal and movement disorders in diseases classified elsewhere G30.0 Alzheimer’s disease with early onset G30.1 Alzheimer’s disease w ith late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified G31.01 Pick’s disease G31.09 Other frontotemporal dementia G31.1 Senile degeneration of brain, not elsewhere classified G31.84 Mild cognitive impairment , so stated G47.00 Insomnia, unspecified G47.01 Insomnia due to medical condition G47.09 Other insomnia G47.30 Sleep apnea, unspecified G47.39 Other sleep apnea G47.62 Sleep related leg cramps G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G60.9 Hereditary and idiopathic neuropathy, unspecified G71.9 Primary disorder of muscle, unspecified G72.9 Myopathy, unspecified G73.3 Myasthenic syndromes in other diseases classified elsewhere G73.7 Myopathy in diseases classified elsewhere G93.3 Postviral fatigue syndrome H02.531 Eyelid retraction right u pper eyelid H02.532 Eyelid retraction right lower eyelid H02.533 Eyelid retraction right eye, unspecified eyelid Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 18 H02.534 Eyelid retraction left upper eyelid H02.535 Eyelid retraction left lower eyelid H02.536 Eyelid retraction left eye, unspe cified eyelid H02.539 Eyelid retraction unspecified eye, unspecified lid H02.841 Edema of right upper eyelid H02.842 Edema of right lower eyelid H02.843 Edema of right eye, unspecified eyelid H02.844 Edema of left upper eyelid H02.845 Ede ma of left lower eyelid H02.846 Edema of left eye, unspecified eyelid H02.849 Edema of unspecified eye, unspecified eyelid H05.20 Unspecified exophthalmos H05.221 Edema of right orbit H05.222 Edema of left orbit H05.223 Edema of bilateral orbit H05.229 Edema of unspecified orbit H05.241 Constant exophthalmos, right eye H05.242 Constant exophthalmos, left eye H05.243 Constant exophthalmos, bilateral H05.249 Constant exophthalmos, unspecified eye H05.251 Intermittent exopht halmos, right eye H05.252 Intermittent exophthalmos, left eye H05.253 Intermittent exophthalmos, bilateral H05.259 Intermittent exophthalmos, unspecified eye H05.89 Other disorders of orbit H11.421 Conjunctival edema, right eye H11.422 Co njunctival edema, left eye H11.423 Conjunctival edema, bilateral H11.429 Conjunctival edema, unspecified eye H11.431 Conjunctival hyperemia, right eye H11.432 Conjunctival hyperemia, left eye H11.433 Conjunctival hyperemia, bilateral H11.43 9 Conjunctival hyperemia, unspecified eye H49.00 Third [oculomotor] nerve palsy, unspecified eye Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 19 H49.01 Third [oculomotor] nerve palsy, right eye H49.02 Third [oculomotor] nerve palsy, left eye H49.03 Third [oculomotor] nerve palsy, bilateral H49.10 Fourth [trochlear] nerve palsy, unspecified eye H49.11 Fourth [trochlear] nerve palsy, right eye H49.12 Fourth [trochlear] nerve palsy, left eye H49.13 Fourth [trochlear] nerve palsy, bilateral H49.20 Sixth [abducent] nerve palsy, uns pecified eye H49.21 Sixth [abducent] nerve palsy, right eye H49.22 Sixth [abducent] nerve palsy, left eye H49.23 Sixth [abducent] nerve palsy, bilateral H49.40 Progressive external ophthalmoplegia, unspecified eye H49.41 Progressive external ophthalmoplegia, right eye H49.42 Progressive external ophthalmoplegia, left eye H49.43 Progressive external ophthalmoplegia, bilateral H49.881 Other paralytic strabismus, right eye H49.882 Other paralytic strabismus, left eye H49.883 Other paralytic strabismus, bilateral H49.889 Other paralytic strabismus, unspecified eye H49.9 Unspecified paralytic strabismus H53.2 Diplopia I10 Essential (primary) hypertension I12.0 Hypertensive chronic kidney disease with stage 5 chronic ki dney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and sta ge 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I 13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, o r end stage renal disease I31.3 Pericardial effusion (noninflammatory) I31.9 Disease of pericardium, unspecified I43 Cardiomyopathy in diseases classified elsewhere Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 20 I47.1 Supraventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation *I48.1 *Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation I49.2 Junctional premature depolarization I49.8 Other specified cardiac arrhythmias I4 9.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on ch ronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestiv e) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and dias tolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.7 Cardiomegaly J91.8 Pleural effusion in other conditions classified elsewhere J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia K14.8 Other diseases of tongue Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 21 K52.2 Allergic and dietetic gastroenteritis and colitis K52.89 Other specifie d noninfective gastroenteritis and colitis K56.0 Paralytic ileus K56.7 Ileus, unspecified K59.00 Constipation, unspecified K59.01 Slow transit constipation K59.02 Outlet dysfunction constipation K59.09 Other constipation K59.3 Megacolo n, not elsewhere classified L11.0 Acquired keratosis follicularis L29.9 Pruritus, unspecified L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.4 Beau’s lines L60.5 Yellow nail syndrome L60.8 Other nail disorders L6 2 Nail disorders in diseases classified elsewhere L63.0 Alopecia (capitis) totalis L63.1 Alopecia universalis L63.2 Ophiasis L63.8 Other alopecia areata L63.9 Alopecia areata, unspecified L64.0 Drug-induced androgenic alopecia L64.8 Ot her androgenic alopecia L64.9 Androgenic alopecia, unspecified L65.0 Telogen effluvium L65.1 Anagen effluvium L65.2 Alopecia mucinosa L65.8 Other specified nonscarring hair loss L65.9 Nonscarring hair loss, unspecified L66.0 Pseudopela de L66.2 Folliculitis decalvans L66.8 Other cicatricial alopecia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 22 L66.9 Cicatricial alopecia, unspecified L80 Vitiligo L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palm aris et plantaris) L86 Keratoderma in diseases classified elsewhere L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.2 Elastosis perforans serpiginosa M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lup us erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M32.19 Other organ or system involvement in systemic lupus erythematosus M32.8 Other forms of systemic lupus erythematosus M32.9 Systemic lupu s erythematosus, unspecified M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyosit is with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with o ther organ involvement M33.20 Polymyositis, organ involvement unspecified M33.21 Polymyositis with respiratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M33.90 Dermatopolymyositis, unspeci fied, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 23 M33.99 Dermatopolymyositis, unspecified with other organ involvement M34.0 Progressiv e systemic sclerosis M34.1 CR(E)ST syndrome M34.2 Systemic sclerosis induced by drug and chemical M34.81 Systemic sclerosis with lung involvement M34.82 Systemic sclerosis with myopathy M34.83 Systemic sclerosis with polyneuropathy M34.89 Other systemic sclerosis M34.9 Systemic sclerosis, unspecified M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.09 Sicca syndrome with other organ involvement M35.1 Other overlap syndromes M35.5 Multifocal fibrosclerosis M35.8 Other specified systemic involvement of connective tissue M35.9 Systemic in volvement of connective tissue, unspecified M36.0 Dermato(poly)myositis in neoplastic disease M36.8 Systemic disorders of connective tissue in other diseases classified elsewhere M60.80 Other myositis, unspecified site M60.811 Other myositis, r ight shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other my ositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 24 M60.849 Other myositis, unspecified hand M60.851 Other myositis, r ight thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, r ight ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M62.50 Muscle wasting an d atrophy, not elsewhere classified, unspecified site M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder M62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulder M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm M62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper arm M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm M62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearm M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand M62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified hand M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh M62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thigh M62.561 Muscle wast ing and atrophy, not elsewhere classified, right lower leg M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 25 M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot M62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and foot M62.58 Muscle wastin g and atrophy, not elsewhere classified, other site M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites M62.81 Muscle weakness (generalized) M62.9 Disorder of muscle, unspecified M63.80 Disorders of muscle in diseases cla ssified elsewhere, unspecified site M63.811 Disorders of muscle in diseases classified elsewhere, right shoulder M63.812 Disorders of muscle in diseases classified elsewhere, left shoulder M63.819 Disorders of muscle in diseases classified elsewhe re, unspecified shoulder M63.821 Disorders of muscle in diseases classified elsewhere, right upper arm M63.822 Disorders of muscle in diseases classified elsewhere, left upper arm M63.829 Disorders of muscle in diseases classified elsewhere, unspe cified upper arm M63.831 Disorders of muscle in diseases classified elsewhere, right forearm M63.832 Disorders of muscle in diseases classified elsewhere, left forearm M63.839 Disorders of muscle in diseases classified elsewhere, unspecified forea rm M63.841 Disorders of muscle in diseases classified elsewhere, right hand M63.842 Disorders of muscle in diseases classified elsewhere, left hand M63.849 Disorders of muscle in diseases classified elsewhere, unspecified hand M63.851 Disorders of muscle in diseases classified elsewhere, right thigh M63.852 Disorders of muscle in diseases classified elsewhere, left thigh M63.859 Disorders of muscle in diseases classified elsewhere, unspecified thigh M63.861 Disorders of muscle in diseas es classified elsewhere, right lower leg M63.862 Disorders of muscle in diseases classified elsewhere, left lower leg M63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower leg M63.871 Disorders of muscle in diseases class ified elsewhere, right ankle and foot M63.872 Disorders of muscle in diseases classified elsewhere, left ankle and foot M63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and foot M63.88 Disorders of muscle in diseases classified elsewhere, other site Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 26 M63.89 Disorders of muscle in diseases classified elsewhere, multiple sites M79.1 Myalgia M79.7 Fibromyalgia M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological frac ture M86.9 Osteomyelitis, unspecified N91.0 Primary amenorrhea N91.1 Secondary amenorrhea N91.2 Amenorrhea, unspecified N91.3 Primary oligomenorrhea N91.4 Secondary oligomenorrhea N91.5 Oligomenorrhea, unspecified N92.0 Excessive and frequent menstruation with regular cycle N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified N94.4 Primary dysmenorrhea N94.5 Secondary dysmenorrhea N94.6 Dysmenorrhea, unspecified O90.5 Postpartum thyr oiditis O92.29 Other disorders of breast associated with pregnancy and the puerperium O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O99.281 Endocrine, nutritional and metabolic diseases complic ating pregnancy, first trimester O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O99.284 Endocrine, nutrit ional and metabolic diseases complicating childbirth O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium Q38.2 Macroglossia Q89.2 Congenital malformations of other endocrine glands R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 27 R06.09 Other forms of dyspnea R06.1 Stridor R06.83 Snoring R06.89 Other abnormalities of breathing R07.0 Pain in throat R09.89 Other specified symptoms an d signs involving the circulatory and respiratory systems R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.14 Dysphagia, pharyngoesophage al phase R13.19 Other dysphagia R18.0 Malignant ascites R18.8 Other ascites R19.4 Change in bowel habit R19.7 Diarrhea, unspecified R19.8 Other specified symptoms and signs involving the digestive system and abdomen R20.0 Anesthesia of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation R20.9 Unspecified disturbances of skin sensation R23.4 Changes in skin texture R23.8 Other skin changes R23.9 Unspecified skin changes R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.2 Cramp and spasm R25.3 Fasciculation R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 28 R27.0 Ataxia, unspec ified R27.8 Other lack of coordination R27.9 Unspecified lack of coordination R29.2 Abnormal reflex R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R40.2110 Coma scale, eyes open, never, unspecified time R40.2111 Coma scale, ey es open, never, in the field [EMT or ambulance] R40.2112 Coma scale, eyes open, never, at arrival to emergency department R40.2113 Coma scale, eyes open, never, at hospital admission R40.2114 Coma scale, eyes open, never, 24 hours or more after ho spital admission R40.2120 Coma scale, eyes open, to pain, unspecified time R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department R40.2123 Coma scale, eyes open, to pain, at hospital admission R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission R40.2210 Coma scale, best verbal response, none, unspecified time R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance] R40.2212 Coma scale, best verbal response, none, at arrival to emergency department R40.2213 Coma scale, best verbal response, none, at hospital admission R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] R40.2222 Coma scale, best verbal respon se, incomprehensible words, at arrival to emergency department R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission R40.2310 Coma scale, best motor response, none, unspecified time R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance] R40.2312 Coma scale, best motor response, none, at arrival to emergency department Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 29 R40.231 3 Coma scale, best motor response, none, at hospital admission R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission R40.2320 Coma scale, best motor response, extension, unspecified time R40.2321 Coma scale, be st motor response, extension, in the field [EMT or ambulance] R40.2322 Coma scale, best motor response, extension, at arrival to emergency department R40.2323 Coma scale, best motor response, extension, at hospital admission R40.2324 Coma scale, b est motor response, extension, 24 hours or more after hospital admission R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance] R4 0.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission R40.4 Transient alteration of awareness R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified R41.9 Unspecif ied symptoms and signs involving cognitive functions and awareness R45.0 Nervousness R45.1 Restlessness and agitation R45.3 Demoralization and apathy R45.4 Irritability and anger R45.81 Low self-esteem R45.82 Worries R45.84 Anhedonia R45.86 Emotional lability R45.87 Impulsiveness R45.89 Other symptoms and signs involving emotional state R47.02 Dysphasia R47.1 Dysarthria and anarthria Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 30 R47.81 Slurred speech R47.89 Other speech disturbances R47.9 Unspecified speech d isturbances R49.0 Dysphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R50.2 Drug induced fever R50.81 Fever presenting with conditions classified elsewhere R50.82 Postprocedural fever R50.83 Postvaccination fever R50.84 Febrile nonhemolytic transfusion reaction R50.9 Fever, unspecified R52 Pain, unspecified R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53. 82 Chronic fatigue, unspecified R53.83 Other fatigue R60.0 Localized edema R60.1 Generalized edema R60.9 Edema, unspecified R61 Generalized hyperhidrosis R63.0 Anorexia R63.2 Polyphagia R63.4 Abnormal weight loss R63.5 Abnormal weight gain R68.0 Hypothermia, not associated with low environmental temperature R68.81 Early satiety R68.83 Chills (without fever) R68.89 Other general symptoms and signs R90.89 Other abnormal findings on diagnostic imaging of central nervou s system Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 31 R93.8 Abnormal findings on diagnostic imaging of other specified body structures R94.6 Abnormal results of thyroid function studies T66.XXXA Radiation sickness, unspecified, initial encounter Z08 Encounter for follow-up examination aft er completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use o f opiate analgesic Z79.899 Other long term (current) drug therapy Z85.020 Personal history of malignant carcinoid tumor of stomach Z85.030 Personal history of malignant carcinoid tumor of large intestine Z85.040 Personal history of malignant ca rcinoid tumor of rectum Z85.060 Personal history of malignant carcinoid tumor of small intestine Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung Z85.230 Personal history of malignant carcinoid tumor of thymus Z85.520 Personal history of malignant carcinoid tumor of kidney Z85.821 Personal history of Merkel cell carcinoma Z85.850 Personal history of malignant neoplasm of thyroid Z85.858 Personal history of malignant neoplasm of other endocrine glands Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017 Date Revised Date Effective 05-01-2017 Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 32 H.REFERENCES1. National Coverage Determination (NCD) for Thryoid Testing (190.22). Retrieved February 28,2017, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D&2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and ChangeReport ICD-10-CM. Retrieved February 28, 2017, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. OH-P-1298Archived
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 0 5/01/2017 Policy Name Policy Number Sleep Studies PY-0169 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 COVERAGE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Sleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 2 A.SUBJECT Sleep Studies B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary 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. Sleep Studies and Polysomnography (PSG) refers to the test performed for people who suffer from insomnia, excessive daytime sleepiness, obstructive sleep apnea, breathing difficulties during sleep, or beh avior disturbances during sleep. It is the continuous monitoring and recording, of a patients body functions, during sleep. It may include eye movement, brain waves, blood pressure, oxygen saturation, muscle activity and heart rhythm. For the purpose o f this policy, the terms sleep study and Polysomnography may be used interchangeably. However, when submitting a claim for reimbursement, providers should use the most appropriate CPT code with the appropriate associated definition. CareSource will re imburse providers, for sleep studies to CareSource members, as set forth in this policy. C. DEFINITIONS Narcolepsy-is a syndrome that is characterized by abnormal sleep tendencies. Obstructive Sleep Apnea (OSA) – is the obstruction of airflow, during sleep, due to the collapse of the oropharyngeal walls. Parasomnias-are a group of conditions that may occur during sleep that can often lead to injury to the patient or others and damage to the surroundings. These conditions may include sleepwal king, sleep terrors, and rapid eye movement (REM) sleep behavior disorders. Polysomnography (PSG) – is a sleep study that records certain body functions during sleep and is used to diagnose sleep disorders. Sleep Apnea-is the interruption of airflow for at least 10 seconds. D. POLICY I. CareSource does not require a prior authorization for a sleep studies. II. A sleep study/polysomnography (PSG) may be reimbursed according to CMS/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the sleep study/polysomnography (PSG) CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. V. Sleep study/PSG is considered medically necessary and covered: A. Only if the patient has the symptoms or complaints of one of the conditions listed below. 1. Narcolepsy ArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 3 2. Parasomnias 3. Sleep Apnea B. The patients must be referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physicians orders. C. The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests. D. The test is not redundant of other diagnostic procedures that must be performed. VI. Polysomnography (PSG) includes the stages of sleep, which requires items a through c below. Polysomnography is defined to minimally include, but is not limited to, the following A. A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp. B. Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye. C. A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, and/or masseter regions. D. Rhythm electrocardiogram (ECG). E. Nasal and/or oral airflow via both thermistor and nasal pressure sensor. F. Respiratory indication by chest-wall and abdominal movement measured using respiratory inductive plethysmography, endoesophageal pressure or by intercostal EMG. G. Gas exchange (oxygen saturation) by oximetry or transcutaneous monitoring H. Bilateral anterior tibialis muscle activity, motor activity-movement using EMG. I.Body positions by directly applied sensors or by direct observation. VII. Home sleep testing is NOT covered by CareSource for Ohio Medicaid members. Included are: A. 95800, 95801, 95803, 95806 VI II. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. Note: Although a Sleep Study does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/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 fo r the most current coding information. CPT Codes Definition 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist ArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 4 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analys is and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist 95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist 95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes 95813 Electroencephalogram (EEG) extended monitoring; greater than 1 hour 95816 Electroencephalogram (EEG); including recording awake and drowsy 95819 Electroencephalogram (EEG); including recording awake and asleep 95822 Electroencephalogram (EEG); recording in coma or sleep only 95824 Electroencephalogram (EEG); cerebral death evaluation only 95827 Electroencephalogram (EEG); all night recording 95829 Electrocorticogram at surgery (separate procedure) 95830 Insertion by physician or other qualified health care professional of sphenoidal electrodes for electroencephalographic (EEG) recording 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 95832 Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) 95852 Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side 95857 Cholinesterase inhibitor challenge test for myasthenia gravis 95860 Needle electromyography; 1 extremity with or without related paraspinal areas 95861 Needle electromyography; 2 extremities with or without rela ted paraspinal areas 95863 Needle electromyography; 3 extremities with or without related paraspinal areas 95864 Needle electromyography; 4 extremities with or without related paraspinal areas 95865 Needle electromyography; larynx Archived Sleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 5 ICD-10 Definition G47.10 Hypersomnia, unspecified G47.3 Sleep apnea G47.33 Obstructive sleep apnea (adult) (pediatric) G47.41 Narcolepsy G47.5 Parasomnia F.RELATED POLICIES/RULES G.REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017Date Revised Date Effective H.REFERENCES1.Appendix DD to rule 5160-1 -60. (2017, January 1). Retrieved 2/6/2017 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates /App-DD.pdf2. Lawriter-OAC. (2016, September 1). Retrieved 3/6/2017 from http://codes.ohio.gov/oac/5160-10 3. Local Coverage Determination (LCD): POLYSOMNOGRAPHY and Other Sleep Studies(L36839). (2017, February 16). Retrieved 3/6/2017 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36839&ver=3&CoverageSelection=Both&ArticleType=All&PolicyType=Fi nal&s=North+Carolina&KeyWord=polysomnography&KeyW ordLookUp=Title&KeyWordSearc hType=And&bc=gAAAACAAAAAAAA%3d%3d&The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. OH-P-1299Archived
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