Screening and Surveillance for Colorectal Cancer

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 05/17/2016 11/01/2018 03/01/2018 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0072 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 2 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H.REFERENCES ………………………………………………………………………………………… 4 Archived Screening and Surveillance for Colorectal Cancer OHIO MEDICAID PY-0072 Effective: 03/01/20182A. SUBJECTScreening and Surveillance for Colorectal CancerB. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests for colorectal cancer as required by state requirements through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology (ACG). C. DEFINITIONS See Screening and Surveillance for Colorectal Cancer medical policy MM-0040 D. POLICY I. CareSource does not require prior authorization for screening and diagnostic colonoscopies for participating providers. II. CareSource reimburses for screening and diagnostic colonoscopies according to CareSource Medical policy MM-0040. Members must meet the criteria found in medical policy MM-0040. III. When billing for screening and surveillance colorectal services, providers should use the appropriate CPT/HCPCS codes and modifiers, if applicable. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting the state Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to state Medicaid fee schedules : http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list may not be all in clusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Code Description 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 44402 Colonoscopy through stoma; with endoscopic stent placement (including pre-and post-dilation and guide wire passage, when performed) Archived Screening and Surveillance for Colorectal Cancer OHIO MEDICAID PY-0072 Effective: 03/01/2018345330 Sigmoidoscopy, flexible; diagnostic, including collecti on of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 45333 Sigmoidoscopy, flexible; with removal of tu mor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45334 Sigmoidoscopy, flexible; with control of bleeding, any method 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, f lexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre-and post-dilation and guide wire passage, when performed) 45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection 45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, flexible; with transendoscopic balloon dilation 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when perf ormed) 45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre-and post – dilation and guide wire passage, when performed) 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dila tion and guide wire passage, when performed) 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 4539 0 Colonoscopy, flexible; with endoscopic mucosal resection Archived Screening and Surveillance for Colorectal Cancer OHIO MEDICAID PY-0072 Effective: 03/01/2018445393 Colonoscopy, flexible; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed45398 Colonoscopy, flexible; wit h band ligation(s) (e.g., hemorrhoids) 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (Cologuard) F. RELATED POLICIES/RUL ESScreening and Surveillance for Colorectal Cancer, MM-0040 G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 05/17/2016 New Policy.Date Revised 11/01/2017 Date Effective 03/01/2018 H. REFERENCES1. Ohio Department of Medicaid. (2017, October 9). Retrieved October 9, 2017, from http://medicaid.ohio.gov/FOROHIOANS/CoveredServices.aspx#669179-preventive-exams- and-screenings The Reimbursement Policy Stateme nt detai led above has r eceived due con side ration as defined in the ReimbursementPo licy Stateme nt Po licy a nd is a pprove d.Archived

Long Acting Reversible Contraceptives (LARCs)

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

Cardiovascular Nuclear Medicine

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

Glycosylated Hemoglobin A1c

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

Hepatitis Panel

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

Lipid Testing Assessing Cardiovascular Risk

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date Next Annual Review Effective Date 04/04/2017 04/04/2018 1 2/01/2017 Policy Name Policy Number Lipid Testing Assessing Cardiovascular Risk PY-0 255 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization mana gement guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expecte d to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternati ve, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced h erein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may u se reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Lipid Testing Assessing Cardiovascular Risk Ohio Medicaid PY-0255 Effective Date: 12-01-2017 2 A.SUBJECT Lipid Testing Assessing Cardiovascular Risk B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality in the United States. Vascular disease is the major contributor to CVD events. High levels of cholesterol in the blood, increase a persons risk of developing CVD . Total cholesterol levels include all the cholesterol found in various lipoproteins. Lipoproteins vary in size and density and include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and Eapoproteins. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoproteins (LDL) and high density lipoproteins (HDL), are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Lipid testing is used to indicate the chances of having cardiovascular disease (CVD) and/or of having a coronary event. C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Cholesterol-White, crystalline substance found in animal tissues and various foods that is normally synthesized by the liver and is important as a constituent of cell membrane and a precursor to steroid hormones; its level in the bloodstream can influence the pathogenesis of certain conditions, such as the development of atherosclerotic plaque and coronary artery disease. Coronary Heart Disease (CHD) – Any heart disorder caused by disease of the coronary arteries. High Density Lipoprotein (HDL) – A lipoprotein that transports cholesterol in the blood; composed of a high proportion of protein and relatively little cholesterol. High levels are thought to be associated with decreased risk of CHD and atherosclerosis. High-sensitivity C-reactive protein (hs-CRP) – A protein produced in the liver that is a marker of inflammation. Immunoassay-Any laboratory method for detecting a substance by using an antibody reactive with it. Lipid-Oily organic compound insoluble in water but soluble in organic solvents; essential structural component of living cells (along with proteins and carbohydrates). Low Density Lipoprotein (LDL) – A lipoprotein that transports cholesterol in the blood; composed of a moderate amount of protein and a large amount of cholesterol. High levels ar e thought to be associated with increased risk of CHD and atherosclerosis. Peripheral Arterial Disease (PAD) – A narrowing of the vessels that carry blood to the legs, arms, abdomen or kidneys; also known as peripheral vascular disease (PVD). ArchivedLipid Testing Assessing Cardiovascular Risk Ohio Medicaid PY-0255 Effective Date: 12-01-2017 3 Plaque-Deposit of fatty material on the inner lining of an arterial wall; characteristic of atherosclerosis. Triglyceride Naturally occurring ester (compound) of three fatty acids and glycerol that is the chief constituent of fats and oils. Unsaturated-Ca pable of taking up, or of uniting with, certain other elements or compounds, without the elimination of any side. D. POLICY I. CareSource members may receive lipid testing without prior authorization. Lipid testing must be medically necessary. II. Conditions in which lipid testing may be indicated include: A.Assessment of patients with atherosc lerotic cardiovascular disease. B. Evaluation of primary dyslipidemia. C. Any form of atherosclerotic disease, or any disease leading to the form ation of atherosclerotic disease.D. Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism.E. Secondary dyslipidemia, including diabetes mel litus, disorders of gastrointestinal absorption, chronic renal failure.F. Signs or symptoms of dysli pidemias, such as skin lesions. G. As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total chole sterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol,

Non-Invasive Vascular Studies

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

Substance Use Disorder Residential Treatment

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 0 8/17/2017 0 8/17/2018 1 2/01/2017 Policy Name Policy Number Substance Use Disorder Residential Treatment PY-0 1 37 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 3 H.REFERENCES ………………………………………………………………………………………… 4Archived Substance use Disorder Residential Treatment Ohio Medicaid PY-0137 Effective Date: 12-01-2017 2 A. SUBJECT Substance Use Disorder Residential Treatment B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. CareSource provides a benefit for treatment services for members with substance use disorder (SUD) in Residential Treatment Facilities (RTF). A referral is required. RTFs offer crisis intervention, counseling and psychotherapy, medications and diagnostic assessment. Most substance use disorders can be managed on an outpatient basis, including substance dependence and withdrawal. Members needing this level of care have withdrawal signs and symptoms that are sufficiently severe to require and emphasis on 24 hour structured and support rather than medical and nursing care (sometimes referred to as social detox). There may be a risk of potential harm to self or others, but there is an absence of imminent life-threatening conditions. Serious deficits in self-care or role functioning are present that cannot be managed at a lower level of care. Residential treatment may be needed when there is a marked barrier to change, or the living situation in inadequate to meet the members needs and the member lacks the ability to cope. The members treatment plan is to reduce and stabilize the current condition, p rovide supportive resources and progress to a less restrictive setting. RTFs provide continuous twenty-four hour observation, supervision and voluntary treatment services for members who do not require the intensive medical treatment of hospital based care. C. DEFINITIONS Substance use disorder (SUD) refers to the current edition of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. . Healthcare Common Procedure Coding System (HCPCS) – is an alphanumeric medical coding system used by healthcare professionals, including medical coders and billers. Current Procedural Terminology (CPT) – is a numerical medical coding system is used by healthcare professionals, including medical coders and billers. D. POLICY I. Some residential treatment services for SUD require a prior authorization. II. CareSource follows rules and guidelines set forth by the Ohio Department of Medicaid (ODM), the American Society of Addiction Medicine (ASAM) and MCG and therefore, expects all practitioners to work within their scope of practice and submit claims with the appropriate diagnosis and corresponding HCPCS/CPT codes. Archived Substance use Disorder Residential Treatment Ohio Medicaid PY-0137 Effective Date: 12-01-2017 3 III.CareSource follows the American Society of Addiction Medicine (ASAM) placement criteria as the standard of measurement for guiding treatment for individuals with SUD conditions. A. The following billing codes do not require a prior authorization: 1. H0010-Clinically managed withdrawal management (ASAM 3.2) 2. H0011 Medically monitored withdrawal management (ASAM 3.7) 3. H0012 Withdrawal management hourly residential addiction program outpatient B. The following billing codes: 1. H2034 Clinically Managed Low-Intensity Residential (ASAM 3.1) 2. H2036 2.1 Clinically-Managed Population-Specific High Intensity Residential Treatment (ASAM 3.3). Appropriate modifier is HI. 2.2 Clinically-Managed High-Intensity Residential Treatment (ASAM 3.5). No modifier is needed. 2.3 Medically-Monitored Intensive Inpatient Treatment (Adults) and Medically Monitored High-Intensity Inpatient Services (Adolescent) (ASAM 3.7). Appropriate modifier is TG. a. Do not require a prior authorization for up to the first 30 consecutive days b. This applies to first two (occurrences) up to 30 consecutive day stays c. Any stays after the first 2 stays require prior authorization 3. When billing for Residential Treatment the place of service code (POS) 55 should be used. 4. For further information please refer to: http://bh.medicaid.ohio.gov/Portals/0/Providers/20170810-FINAL-BH-Manual-V%201.1.pdf Note:Any stay under 30 consecutive days counts as a full 30 day occurrence IV. No SUD services may be billed outside of the per diem. Note:CareSource may, through post payment audit, request documentation for those services that do not require a prior authorization or those services that do not initially require a prior authorization that supports medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Providers must accurately identify and report on each claim detail line where a service took place using the most appropriate CMS place of service code. F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 0 8/17/2017 New Policy. Date Revised Date Effective 1 2/01/2017 Archived Substance use Disorder Residential Treatment Ohio Medicaid PY-0137 Effective Date: 12-01-2017 4 H.REFERENCES 1. Text Manuals and Rates. (2017, July 24). Retrieved 7/24/2017 from http://bh.medicaid.ohio.gov/manuals 2. Residential Treatment Facilities (2017, July 24). Retrieved 7/24/2017from https://www.ltc.ohio.gov/ResidentialType1.aspx The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Thyroid Testing

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12 /01 /2017 Policy Name Policy Number Thyroid Testing PY-0222 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ………………………………………………………………….. 31 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………. 31 H.REFERENCES ………………………………………………………………………………………. 32Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 2 A.SUBJECT Thyroid Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. DEFINITIONS Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. POLICY I.CareSource does not require a prior authorization for thyroid testing. II.CareSource considers thyroid function testing medically necessary for the following: A. Members who are clinically stable up to 2 times per year B. Members who have symptoms consistent with hypothyroidism C. Members who have symptoms consistent with hyperthyroidism D. Members who are asymptomatic and 60 years of age or older, performed every 5 years E. Members who are asymptomatic but are considered high risk due to the following: 1. Family or personal history of thyroid disease, this should be limited to a one time scr eening 2. Family or personal history of Type I Diabetes or other autoimmune disorder, this should be limited to a one time screening 3. Member who is prescribed medications that may interfere with thyroid function III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. ArchivedThyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 3 E.CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference.This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Codes Definition 84436 Thyroxine: total 844 39 Thyroxine: free 84443 TSH Thyroid Stimulating Hormone 84479 Thyroid Hormone Uptake (T3 or T4) or thyroid hormone binding ration (THBR) ICD-10-CM Definition A18.81 Tuberculosis of thyroid gland C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary C73 Malignant neoplasm of thyroid gland C75.8 Malignant neoplasm with pluriglandular involvement, unspecified C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D09.3 Carcinoma in situ of thyroid and other endocrine glands D09.8 Carcinoma in situ of other specified sites D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D27.9 Benign neoplasm of unspecified ovary D34 Benign neoplasm of thyroid gland D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D44.0 Neoplasm of uncertain behavior of thyroid gland D44.2 Neoplasm of uncertain behavior of parathyroid gland D44.9 Neoplasm of uncertain behavior of unspecified endocrine gland D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 4 D53.9 Nutritional anemia, unspecified D59.0 Drug-induced autoimmune hemolytic anemia D59.1 Other autoimmune hemolytic anemias D64.9 Anemia, unspecified D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere specified E00.0 Congenital iodine-deficiency syndrome, neurological type E00.1 Congenital iodine-deficiency syndrome, myxedematous type E00.2 Congenital iodine-deficiency syndrome, mixed type E00.9 Congenital iodine-deficiency syndrome, unspecified E01.0 Iodine-deficiency related diffuse (endemic) goiter E01.1 Iodine-deficiency related multinodular (endemic) goiter E01.2 Iodine-deficiency related (endemic) goiter, unspecificied E01.8 Other iodine-deficiency related thyroid disorders and allied condition s E02 Subclinical iodine-deficiency hypothyroidism E03.0 Congenital hypothyroidism with diffuse goiter E03.1 Congenital hypothyroidism without goiter E03.2 Hypothyroidism due to medicaments and other exogenous substances E03.3 Postinfectious hypothyroidism E03.4 Atrophy of thyroid (acquired) E03.5 Myxedema coma E03.8 Other specified hypothyroidism E03.9 Hypothyroidism, unspecifide E04.0 Nontoxic diffuse goiter E04.1 Nontoxic single thyroid nodule E04.2 Nontoxic multinodular goiter E04.8 Other specified nontoxic goiter E04.9 Nontoxic goiter, unspecified E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 5 E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyroto xicosis with toxic multinodular goiter with thyrotoxic crisis or storm E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm E06.0 Acute thyroiditis E06.1 Subacute thyroiditis E06.2 Chronic thyroiditis with transient thyrotoxicosis E06.3 Autoimmune thyroiditis E06.4 Drug-induced thyroiditis E06.5 Other chronic thyroiditis E06.9 Thyroiditis, unspecified E07.0 Hypersecretion of calcitonin E07.1 Dyshornogenetic goiter E07.89 Other specified disorders of thyroid E07.9 Disorder of thyroid, unspecified E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabete d mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic mephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabeted mellitus due to underlyin condition with other diabetic kidney complication E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopa thy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 6 E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema E08.341 Diabetes mellitus due to underlying condition with severe nonprolifeartive diabetic retinopathy with macular edema E 08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.39 Diabetes mellitus due to underlying condition with other diabetic ophth almic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition wi th diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis E08.621 Diabetes mellitus due to underlying condition with foot ulcer E08.622 Diabetes mellitus due to underlying condition with other skin ulcer E08.62 8 Diabetes mellitus due to underlying condition with other skin complicatiosn E08.630 Diabetes mellitus due to underlying condition with periodontal disease E08.638 Diabetes mellitus due to underlying condition with other oral complications Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 7 E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellit us due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlying condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition with complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diab etic retinopathy without macular edema E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular ede ma E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 8 E09.42 Drug or chemical induc ed diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complications E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E09.610 Drug or chemical in duced diabetes mellitus with diabetic neuropathic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic dermatitis E09.620 Drug or chemical induced diabetes mellitus with diabetic dermitis E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer E09.628 Drug or chemical induced diabetes mellitus with other skin complications E09.630 Drug or chemical induced diabetes mellitus with periodont al disease E09.638 Drug or chemical induced diabetes mellitus with other oral complications E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complications E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus with out complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complications E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edems E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 9 E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopath y with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 d iabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10..628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 10 E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabete s mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabe tic retinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with pro liferative diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic po lyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 dia betes mellitus with diabetic neuropathic arthropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 11 E11.618 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other spec ified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E13.311 Other specified diab etes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.331 Other specified diabetes mell itus with moderate nonproliferative diabetic retinopathy with macular edema E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 12 E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Othe r specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy E13.620 Other specified diabetes mellitus with diabetic dermatitis E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other ski n complications E13.630 Other specified diabetes mellitus with periodontal disease E13.638 Other specified diabetes mellitus with other oral complications E13.641 Other specified diabetes mellitus with hypoglycemia with coma E13.649 Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications E20.0 Idiopathic hypoparathyroidism E20.1 Pseudohypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E22.1 Hyperprolactinemia E22.8 Other hyperfunction of pituitary gland E22.9 Hyperfunction of pituitary gland, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 13 E23.0 Hypopituitarism E23.1 Drug-induced hypopituitarism E23.6 Other disorders of pituitary gland E25.0 Congenital adrenogenital disorders associated with enzyme deficiency E25.8 Other adrenogenital disorders E25.9 Adrenogenital disorder, unspecified E27.1 Primary adrenocortical insufficiency E27.2 Addisonian crisis E27.3 Drug-induced adrenocortical insufficiency E27.40 Unspecified adrenocortical insufficiency E27.49 Other adrenocortical insufficiency E28.310 Symptomatic premature menopause E28.319 Asymptomatic premature menopause E28.39 Other primary ovarian failure E29.1 Testicular hypofunction E31.0 Autoimmune polyglandular failure E31.1 Polyglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E31.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E35 Disorders of endocrine glands in diseases classified elsewhere E43 Unspecified severe protein-calorie malnutrition E44.0 Moderate protein-calorie malnutrition E44.1 Mild protein-calorie malnutrition E45 Retarded development following protein-calorie malnutrition E46 Unspecified protein-calorie malnutrition E53.0 Riboflavin deficiency E64.0 Sequelae of protein-calorie malnutrition E67.1 Hypercarotinemia E78.0 Pure hypercholesterolemia E78.2 Mixed hyperlipidemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 14 E78.4 Other hyperlipidemia E78.5 Hyperlipidemia, unspecified E83.50 Unspecified disorder of calcium metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E83.59 Other disorders of calcium metabolism E83.81 Hungry bone syndrome E87.0 Hyperosmolality and hypernatremia E87.1 Hypo-osmolality and hyponatremia E89.0 Postprocedural hypothyroidism E89.2 Postprocedural hypoparathyroidism E89.3 Postprocedural hypopituitarism E89.6 Postprocedural adrenocortical ( – medullary) hypofunction F03.90 Unspecified dementia without behavioral disturbance F05 Delirium due to known physiological condition F06.0 Psychotic disorder with hallucinations due to known physiological condition F06.1 Catatonic disorder due to known physiological condition F06.2 Psychotic disorder with delusions due to known physiological condition F06.30 Mood disorder due to known physiological condition, unspecified F06.31 Mood disorder due to known physiological condition with depressive features F06.32 Mood disorder due to known physiological condition with major depressive-like episode F06.33 Mood disorder due to known physiological condition with manic features F06.34 Mood disorder due to known physiological condition with mixed features F06.4 Anxiety disorder due to known physiological condition F06.8 Other specified mental disorders due to known physiological condition F07.0 Personality change due to known physiological condition F22 Delusional disorders F23 Brief psychotic disorder F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode, severe, without psychotic symptoms Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 15 F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, cur rent episode depressed, moderate F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bipolar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31.77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in fu ll remission, most recent episode mixed F31.81 Bipolar II disorder Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 16 F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspecified F33.0 Major depressi ve disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia F41.1 Generalized anxiety disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified F53 Puerperal psychosis F63.3 Trichotillomania G25.0 Essential tremor G25.1 Drug-induced tremor G25.2 Other specified forms of tremor G25.70 Drug induced movement disorder, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 17 G25.71 Drug induced akathisia G25.79 Other drug induced movement disorders G25.89 Other specified extrapyramidal and movement disorders G25.9 Extrapyramidal and movement disorder, unspecified G26 Extrapyramidal and movement disorders in diseases classified elsewhere G30.0 Alzheimer’s disease with early onset G30.1 Alzheimer’s disease with late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified G31.01 Pick’s disease G31.09 Other frontotemporal dementia G31.1 Senile degeneration of brain, not elsewhere classified G31.84 Mild cognitive impairment, so stated G47.00 Insomnia, unspecified G47.01 Insomnia due to medical condition G47.09 Other insomnia G47.30 Sleep apnea, unspecified G47.39 Other sleep apnea G47.62 Sleep related leg cramps G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G60.9 Hereditary and idiopathic neuropathy, unspecified G71.9 Primary disorder of muscle, unspecified G72.9 Myopathy, unspecified G73.3 Myasthenic syndromes in other diseases classified elsewhere G73.7 Myopathy in diseases classified elsewhere G93.3 Postviral fatigue syndrome H02.531 Eyelid retraction right upper eyelid H02.532 Eyelid retraction right lower eyelid H02.533 Eyelid retraction right eye, unspecified eyelid Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 18 H02.534 Eyelid retraction left upper eyelid H02.535 Eyelid retraction left lower eyelid H02.536 Eyelid retraction left eye, unspecified eyelid H02.539 Eyelid retraction unspecified eye, unspecified lid H02.841 Edema of right upper eyelid H02.842 Edema of right lower eyelid H02.843 Edema of right eye, unspecified eyelid H02.844 Edema of left upper eyelid H02.845 Edema of left lower eyelid H02.846 Edema of left eye, unspecified eyelid H02.849 Edema of unspecified eye, unspecified eyelid H05.20 Unspecified exophthalmos H05.221 Edema of right orbit H05.222 Edema of left orbit H05.223 Edema of bilateral orbit H05.229 Edema of unspecified orbit H05.241 Constant exophthalmos, right eye H05.242 Constant exophthalmos, left eye H05.243 Constant exophthalmos, bilateral H05.249 Constant exophthalmos, unspecified eye H05.251 Intermittent exophthalmos, right eye H05.252 Intermittent exophthalmos, left eye H05.253 Intermittent exophthalmos, bilateral H05.259 Intermittent exophthalmos, unspecified eye H05.89 Other disorders of orbit H11.421 Conjunctival edema, right eye H11.422 Conjunctival edema, left eye H11.423 Conjunctival edema, bilateral H11.429 Conjunctival edema, unspecified eye H11.431 Conjunctival hyperemia, right eye H11.432 Conjunctival hyperemia, left eye H11.433 Conjunctival hyperemia, bilateral H11.439 Conjunctival hyperemia, unspecified eye H49.00 Third [oculomotor] nerve palsy, unspecified eye Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 19 H49.01 Third [oculomotor] nerve palsy, right eye H49.02 Third [oculomotor] nerve palsy, left eye H49.03 Third [oculomotor] nerve palsy, bilateral H49.10 Fourth [trochlear] nerve palsy, unspecified eye H49.11 Fourth [trochlear] nerve palsy, right eye H49.12 Fourth [trochlear] nerve palsy, left eye H49.13 Fourth [trochlear] nerve palsy, bilateral H49.20 Sixth [abducent] nerve palsy, unspecified eye H49.21 Sixth [abducent] nerve palsy, right eye H49.22 Sixth [abducent] nerve palsy, left eye H49.23 Sixth [abducent] nerve palsy, bilateral H49.40 Progressive external ophthalmoplegia, unspecified eye H49.41 Progressive external ophthalmoplegia, right eye H49.42 Progressive external ophthalmoplegia, left eye H49.43 Progressive external ophthalmoplegia, bilateral H49.881 Other paralytic strabismus, right eye H49.882 Other paralytic strabismus, left eye H49.883 Other paralytic strabismus, bilateral H49.889 Other paralytic strabismus, unspecified eye H49.9 Unspecified paralytic strabismus H53.2 Diplopia I10 Essential (primary) hypertension I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal dis ease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through s tage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidn ey disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I31.3 Pericardial effusion (noninflammatory) I31.9 Disease of pericardium, unspecified I43 Cardiomyopathy in diseases classified elsewhere Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 20 I47.1 Supraventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation *I48.1 *Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation I49.2 Junctional premature depolarization I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.7 Cardiomegaly J91.8 Pleural effusion in other conditions classified elsewhere J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia K14.8 Other diseases of tongue Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 21 K52.2 Allergic and dietetic gastroenteritis and colitis K52.89 Other specified noninfective gastroenteritis and colitis K56.0 Paralytic ileus K56.7 Ileus, unspecified K59.00 Constipation, unspecified K59.01 Slow transit constipation K59.02 Outlet dysfunction constipation K59.09 Other constipation K59.3 Megacolon, not elsewhere classified L11.0 Acquired keratosis follicularis L29.9 Pruritus, unspecified L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.4 Beau’s lines L60.5 Yellow nail syndrome L60.8 Other nail disorders L62 Nail disorders in diseases classified elsewhere L63.0 Alopecia (capitis) totalis L63.1 Alopecia universalis L63.2 Ophiasis L63.8 Other alopecia areata L63.9 Alopecia areata, unspecified L64.0 Drug-induced androgenic alopecia L64.8 Other androgenic alopecia L64.9 Androgenic alopecia, unspecified L65.0 Telogen effluvium L65.1 Anagen effluvium L65.2 Alopecia mucinosa L65.8 Other specified nonscarring hair loss L65.9 Nonscarring hair loss, unspecified L66.0 Pseudopelade L66.2 Folliculitis decalvans L66.8 Other cicatricial alopecia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 22 L66.9 Cicatricial alopecia, unspecified L80 Vitiligo L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palmaris et plantaris) L86 Keratoderma in diseases classified elsewhere L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.2 Elastosis perforans serpiginosa M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lupus erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M32.19 Other organ or system involvement in systemic lupus erythematosus M32.8 Other forms of systemic lupus erythematosus M32.9 Systemic lupus erythematosus, unspecified M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyositis with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with other organ involvement M33.20 Polymyositis, organ involvement unspecified M33.21 Polymyositis with resp iratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 23 M33.99 Dermatopolymyositis, unspecified with other organ involvement M34.0 Progressive systemic sclerosis M34.1 CR(E)ST syndrome M34.2 Systemic sclerosis induced by drug and chemical M34.81 Systemic sclerosis with lung involvement M34.82 Systemic sclerosis with myopathy M34.83 Systemic sclerosis with polyneuropathy M34.89 Other systemic sclerosis M34.9 Systemic sclerosis, unspecified M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.09 Sicca syndrome with other organ involvement M35.1 Other overlap syndromes M35.5 Multifocal fibrosclerosis M35.8 Other specified systemic involvement of connective tissue M35.9 Systemic involvement of connective tissue, unspecified M36.0 Dermato(poly)myositis in neoplastic disease M36.8 Systemic disorders of connective tissue in other diseases classified elsewhere M60.80 Other myositis, unspecified site M60.811 Other myositis, right shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other myositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 24 M60.849 Other myositis, unspecified hand M60.851 Other myositis, right thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, right ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified site M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder M62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulder M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm M62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper arm M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm M62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearm M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand M62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified hand M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh M62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thigh M62.561 Muscle wasting and a trophy, not elsewhere classified, right lower leg M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 25 M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot M62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and foot M6 2.58 Muscle wasting and atrophy, not elsewhere classified, other site M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites M62.81 Muscle weakness (generalized) M62.9 Disorder of muscle, unspecified M63.80 Disorders of muscle in diseases classified elsewhere, unspecified site M63.811 Disorders of muscle in diseases classified elsewhere, right shoulder M63.812 Disorders of muscle in diseases classified elsewhere, left shoulder M63.819 Disorders of muscle in diseases classified elsewhere, unspecified shoulder M63.821 Disorders of muscle in diseases classified elsewhere, right upper arm M63.822 Disorders of muscle in diseases classified elsewhere, left upper arm M63.829 Disorders of muscle in diseases classified elsewhere, unspecified upper arm M63.831 Disorders of muscle in diseases classified elsewhere, right forearm M63.832 Disorders of muscle in diseases classified elsewhere, left forearm M63.839 Disorders of muscle in diseases classified elsewhere, unspecified forearm M63.841 Disorders of muscle in diseases classified elsewhere, right hand M63.842 Disorders of muscle in diseases classified elsewhere, left hand M63.849 Disorders of muscle in diseases classified elsewhere, unspecified hand M63.851 Disorders of muscle in diseases classified elsewhere, right thigh M63.852 Disorders of muscle in diseases classified elsewhere, left thigh M63.859 Disorders of muscle in diseases classified elsewhere, unspecified thigh M63.861 Disorders of muscle in diseases classified elsewhere, right lower leg M63.862 Disorders of muscle in diseases classified elsewhere, left lower leg M63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower leg M63.871 Disorders of muscle in diseases classified elsewhere, right ankle and foot M63.872 Disorders of muscle in diseases classified elsewhere, left ankle and foot M63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and foot M63.88 Disorders of muscle in diseases classified elsewhere, other site Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 26 M63.89 Disorders of muscle in diseases classified elsewhere, multiple sites M79.1 Myalgia M79.7 Fibromyalgia M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M86.9 Osteomyelitis, unspecified N91.0 Primary amenorrhea N91.1 Secondary amenorrhea N91.2 Amenorrhea, unspecified N91.3 Primary oligomenorrhea N91.4 Secondary oligomenorrhea N91.5 Oligomenorrhea, unspecified N92.0 Excessive and frequent menstruation with regular cycle N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified N94.4 Primary dysmenorrhea N94.5 Secondary dysmenorrhea N94.6 Dysmenorrhea, unspecified O90.5 Postpartum thyroiditis O92.29 Other disorders of breast associated with pregnancy and the puerperium O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O99.281 Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester O99.282 Endocrine, nutritional and metabolic diseases complicat ing pregnancy, second trimester O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O99.284 Endocrine, nutritional and metabolic diseases complicating childbirth O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium Q38.2 Macroglossia Q89.2 Congenital malformations of other endocrine glands R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 27 R06.09 Other forms of dyspnea R06.1 Stridor R06.83 Snoring R06.89 Other abnormalities of breathing R07.0 Pain in throat R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.14 Dysphagia, pharyngoesophageal phase R13.19 Other dysphagia R18.0 Malignant ascites R18.8 Other ascites R19.4 Change in bowel habit R19.7 Diarrhea, unspecified R19.8 Other specified symptoms and signs involving the digestive system and abdomen R20.0 Anesthesia of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation R20.9 Unspecified disturbances of skin sensation R23.4 Changes in skin texture R23.8 Other skin changes R23.9 Unspecified skin changes R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.2 Cramp and spasm R25.3 Fasciculation R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 28 R27.0 Ataxia, unspecified R27.8 Other lack of coordination R27.9 Unspecified lack of coordination R29.2 Abnormal reflex R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R40.2110 Coma scale, eyes open, never, unspecified time R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance] R40.2112 Coma scale, eyes open, never, at arrival to emergency department R40.2113 Coma scale, eyes open, never, at hospital admission R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission R40.2120 Coma scale, eyes open, to pain, unspecified time R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department R40.2123 Coma scale, eyes open, to pain, at hospital admission R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission R40.2210 Coma scale, best verbal response, none, unspecified time R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance] R40.2212 Coma scale, best verbal response, none, at arrival to emergency department R40.2213 Coma scale, best verbal response, none, at hospital admission R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department R40.2223 Coma scale, best verbal response, incomprehensibl e words, at hospital admission R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission R40.2310 Coma scale, best motor response, none, unspecified time R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance] R40.2312 Coma scale, best motor response, none, at arrival to emergency department Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 29 R40.2313 Coma scale, best motor response, none, at hospital admission R40.2314 Coma scale, bes t motor response, none, 24 hours or more after hospital admission R40.2320 Coma scale, best motor response, extension, unspecified time R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance] R40.2322 Coma scale, best motor response, extension, at arrival to emergency department R40.2323 Coma scale, best motor response, extension, at hospital admission R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance] R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission R40.4 Transient alteration of awareness R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified R41.9 Unspecified symptoms and signs involving cognitive functions and awareness R45.0 Nervousness R45.1 Restlessness and agitation R45.3 Demoralization and apathy R45.4 Irritability and anger R45.81 Low self-esteem R45.82 Worries R45.84 Anhedonia R45.86 Emotional lability R45.87 Impulsiveness R45.89 Other symptoms and signs involving emotional state R47.02 Dysphasia R47.1 Dysarthria and anarthria Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 30 R47.81 Slurred speech R47.89 Other speech disturbances R47.9 Unspecified speech disturbances R49.0 Dysphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R50.2 Drug induced fever R50.81 Fever presenting with conditions classified elsewhere R50.82 Postprocedural fever R50.83 Postvaccination fever R50.84 Febrile nonhemolytic transfusion reaction R50.9 Fever, unspecified R52 Pain, unspecified R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R60.0 Localized edema R60.1 Generalized edema R60.9 Edema, unspecified R61 Generalized hyperhidrosis R63.0 Anorexia R63.2 Polyphagia R63.4 Abnormal weight loss R63.5 Abnormal weight gain R68.0 Hypothermia, not associated with low environmental temperature R68.81 Early satiety R68.83 Chills (without fever) R68.89 Other general symptoms and signs R90.89 Other abnormal findings on diagnostic imaging of central nervous system Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 31 R93.8 Abnormal findings on diagnostic imaging of other specified body structures R94.6 Abnormal results of thyroid function studies T66.XXXA Radiation sickness, unspecified, i nitial encounter Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z85.020 Personal history of malignant carcinoid tumor of stomach Z85.030 Personal history of malignant carcinoid tumor of large intestine Z85.040 Personal history of malignant carcinoid tumor of rectum Z85.060 Personal history of malignant carcinoid tumor of small intestine Z85.110 Personal history of malignant carcino id tumor of bronchus and lung Z85.230 Personal history of malignant carcinoid tumor of thymus Z85.520 Personal history of malignant carcinoid tumor of kidney Z85.821 Personal history of Merkel cell carcinoma Z85.850 Personal history of malignant neoplasm of thyroid Z85.858 Personal history of malignant neoplasm of other endocrine glands Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017 New policy. Date Revised Date Effective 0 12-01-2017 Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 12-01-2017 32 H.REFERENCES 1. National Coverage Determination (NCD) for Thryoid Testing (190.22). Retrieved February 28, 2017, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved February 28, 2017, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Speech-Language Pathology

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

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