Hepatitis Panel

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Effective Date Next Annual Review Effective Date 05/15/2017 05/01/2018 05/15 /2017 Policy Name Policy Number Hepatitis Panel PY-0 206 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medical ly necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, inc reased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided m ainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conf lict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion i n interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 4 D.POLICY …………………………………………………………………………………………………. 4 E.CONDITIONS OF COVERAGE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 7 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 8 H.REFERENCES ………………………………………………………………………………………… 8Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 2 A.SUBJECT Hepatitis Panel B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other causes. Viral hepatitis can be due to one of at least five viruses, discussed here. Most cases of viral hepatitis are caused by Hepatitis A virus (HAV), Hepatitis Bvirus (HBV), or Hepatitis Cvirus (HCV), although viral hepatitis can also be caused by the less-prevalent viruses Hepatitis Dand E. HBV is spread exclusively by the members exposure to infected blood or bodily fluids. In the United States, sexual transmission accounts for thirty to sixty percent of new cases of HBV infection. Despite the overall decline in HCV infection rates in the United States over the past several decades, HCV infection rates among young adults may be increasing [2]. In a study of CDC surveillance data, the incidence of cases of acute HCV infection reported among individuals younger than 30 years old rose from 2006 to 2012 by 13 percent annually in nonurban counties and by 5 percent annually in urban counties [ 3]. Due to a rise in injection drug use among younger individuals, the large majority of infected individuals are white, with men and women evenly represented. The actual incidence of acute HCV infection is likely greater than these estimates, given the difficulty in diagnosis of acute HCV infection, incomplete case reporting (including expanding infection rates among the homeless and incarcerated individuals, which is a significant population), and narrow national case definitions. The prevalence of chronic HCV infection in the United States is currently the highest among individuals born between 1945 and 1965. In children and adolescents in the United States, HAV is the most common cause of hepatitis. Prior exposure is indicated by a positive blood test known as Immunoglobulin Ganti-HAV (IgG anti-HAV) for the Hepatitis A virus. Acute HAV is specifically diagnosed by IgM anti-HAV, which typically results within four weeks of exposure, and which disappears within three months of the first positive blood test. IgG anti-HAV is similar in the timing of its appearance but does not subside, app earing indefinitely. Its detection in blood testing indicates the members prior effective immunization to, or recovery from infection. Although HAV is spread most commonly by the oral consumption or transmission of fecal matter from an infected individual, other methods of infection are is possible during the acute viral stage of the disease. After exposure, standard immune globulin may be effective as prophylactic care. Chronic HCV infection is indicated with a reactive HCV antibody test and a positive molecular test indicating the presence of HCV RNA, confirming the diagnosis of HCV infection. If HCV RNA is not detected, then the reactive antibody test likely indicates either a past HCV infection that has since cleared or false positive [4 ]. ArchivedHepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 3 HBV producesseparate surface, core, and e (envelope) antigens when it infects the liver; only the surface antigen for hepatitis Bsurface (HBsAg) is included as part of the standard panel. After being exposed to the hepatitis virus(es), the immune system typically re sponds by producing antibodies to each antigen. Hepatitis Bsurface antibody (HBsAb) – IgM antibody is part of the standard panel. However, HBsAg is the earlier marker, appearing four to eight weeks after exposure, and normally disappearing within six months after its appearance. If HBsAg remains detectable for a period of time exceeding six months, it is an indication of chronic HBV infection in the member. HBcAb, in the form of both IgG and IgM antibodies, are sequentially the next to appear in serum, typically becoming detectable two to three months following exposure . The detectable presence of the IgM antibody gradually declines or disappears entirely from one to two years following exposure, but the IgG usually remains detectable for the lifetime of th e member. Because HBsAg is present for a relatively short period of time and normally at a very low concentration, a negative result from the blood test does not necessarily exclude an HBV diagnosis. By contrast, HBcAb appears in a much higher concentratio n and the antibodies typically remain at that higher level for a longer period of time. That said, it follows that a positive result is not necessarily diagnostic of acute disease, since the elevated antibodies may still be the result of a previous infecti on. In the usual course of the disease, the last marker to appear is HBsAb, which can be found in serum four to six months following exposure and remains positive indefinitely signifying immunity to the patient. The diagnosis of acute HBV infection is best established by documentation of a positive result for the IgM antibody against the core antigen (HBcAb-IgM), and by identifying a positive result for the hepatitis Bsurface antigen (HBsAg). The diagnosis of chr onic HBV infection is established primarily by identifying a positive hepatitis Bsurface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core antigen (HBcAb-IgG). Additional tests such as Hepatitis Be-antigen (HBeAg) and Hepa titis Be-antibody (HBeAb), which are the envelope antigen and antibody for Hepatitis B, are not included in the standard Hepatitis Panel. However, they can be a marker of replication and infectivity associated with an increased risk of transmission. After an HBV vaccination series is completed, HBsAb can be followed to verify an appropriate antibody response.Once a diagnosis is established, specific tests can be used to monitor the course of the disease. If hepatitis appears in a patient after transfusion, HCV is the most common cause. HCV is responsible for 15% to 20% of all cases of acute hepatitis overall, and is the most common cause of chronic liver disease. The test most commonly used to identify HCV is one that measures HCV antibodies, which nor mally appear in the patients blood between two to four months after infection. False positive HCV results can occur. For this reason, positive results are usually verified by a more specific technique. Like HBV, HCV is spread exclusively through exposure to infected blood or body fluids. This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the timeframe of the initial infection or exposure, and/or the stage of the disease is unknown, a patient with continued symptoms of liver disease despite a completely negative Hepatitis Panel may need another panel performed approximately two weeks to two months later in order to exclude the possibility of hepatitis. The specific rules that apply for diagnosis codes (for Medicaid members only) are outlined in this policy. ArchivedHepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 4 C. DEFINITIONS Medically necessary means health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. D. POLICY I.Prior authorization is not required for any medically necessary hepatitis panel screenings. NOTE: Although the hepatitis testing covered by this policy do es not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II.Tests for the Hepatitis panel referred to in this policy are selected laboratory tests. Material related to diagnostic testing in this policy is included to clarify coverage for diagnostic versus screening indications. III. CareSource will reimburse providers for the medically necessary screening, diagnoses, and subsequent treatments for, and management of hepatitis as documented in the medical record in the following circumstances: A. To detect viral hepatitis infection when there are abnormal liver function test results, with or without signs or symptoms of hepatitis; and B. Prior to and subsequent to liver transplantation. IV. Coverage A. CareSource will cover screening for hepatitis with the appropriate laboratory tests when ordered and performed by a provider for these services, and when used in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. I.Covered Services A. If policy criteria are met, CareSource will reimburse for an acute hepatitis panel once per calendar year for screening when medically necessary to test for hepatitis in asymptomatic men and women if accompanied by one or more of the appropriate ICD-10 codes.CareSource will reimburse for a repeat panel approximately two weeks to two months after the initial one to exclude the possibility of hepatitis in a patient with continued symptoms of liver disease despite a completely negative first Hepatitis Panel. Codes Description 80074 Acute Hepatitis Panel Codes Description B15.0 Hepatitis A with hepatic coma B15.9 Hepatitis A without hepatic coma B16.0 Acute hepatitis Bwith delta-agent with hepatic coma Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 5 B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute he patitis Cwith hepatic coma B17.2 Acute hepatitis EB17.8 Other specified acute viral hepatitis B17.9 Acute viral hepatitis, unspecified B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B18.2 Chronic viral hepatitis CB18.8 Other chronic viral hepatitis B18.9 Chronic viral hepatitis, unspecified B19.0 Unspecified viral hepatitis with hepatic coma B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma B19.9 Unspecified viral hepatitis without hepatic coma G93.3 Post-viral fatigue syn drome I85.00 Esophageal varices without bleeding I85.01 Esophageal varices with bleeding I85.10 Secondary esophageal varices without bleeding I85.11 Secondary esophageal varices with bleeding K70.41 Alcoholic hepatic failure with coma K71.0 Toxic liver disease with cholestasis K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.2 Toxic liver disease with acute hepatitis K71.3 Toxic liver disease with chronic persistent hepatitis K71.4 Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 Toxic liver disease with hepatitis, not elsewhere classified K71.7 Toxic liver disease with fibrosis and cirrhosis of liver K71.8 Toxic liver disease with other disorders of liver K71.9 Toxic liver disease, unspecified K72.00 Acute and subacute hepatic failure without coma K72.01 Acute and subacute hepatic failure with coma K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K74.0 Hepatic fibrosis K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.0 Abscess of liver K75.1 Phlebitis of portal vein K75.2 Nonspecific reactive hepatitis K75.3 Granulomatous hepatitis, not elsewhere classified Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 6 K75.81 Nonalcoholic steatohepatitis (NASH) K75.89 Other specified inflammatory liver diseases K75.9 Inflammatory liver disease, unspecified K76.2 Central hemorrhagic necrosis of liver K76.4 Peliosis hepatis K76.6 Portal hypertension K76.7 Hepatorenal syndrome K76.81 Hepatopulmonary syndrome R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.2 Pelvic and perineal pain R10.30 Lower abdominal pain, unspecified R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain R10.811 Right upper quadrant abdominal tenderness R10.821 Right upper quadrant rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia Archived Hepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 7 R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight Code Description R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight II.Non-Covered Services A. Once a diagnosis of hepatitis has been made, CareSource will cover appropriate and medically necessary, individual hepatitis testing for its members, but does not cover ongoing hepatitis panel testing. AUTHORIZATION PERIOD F. RELATED POLICIES/RUL ES ArchivedHepatitis Panel Ohio Medicaid PY-0206 Effective Date 05/15/17 8 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 05/15/2017 Date Revised Date Effective 05/15/2017 H. REFERENCES 1. R. K. Ockner, Approaches to the diagnosis of jaundice, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W.B. Saunders, pp. 817-818. 2. R. K. Ockner, Acute viral hepatitis, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W .B. Saunders, pp. 818-826. 3. R. K. Ockner, Chronic hepatitis, in Wyngaarden, J.B., and Smith, L.H. (eds.), Cecil Textbook of Medicine (18th ed.), 1988, W .B. Saunders, pp. 830-834. 4. D. A. Arvan, Acute viral hepatitis, in Panzer, R.J., Black, E.R., & Griner, P.F. (eds.), Diagnostic Strategies for Common Medical Problems, 1991, American College of Physicians, pp. 141-151. 5. D. M. Goldberg, Diagnostic Enzymology, in Gornall, A.G. (ed.), Applied Biochemistry of Clinical Disorders (2nd ed.), 1986, J.B. Lippincott, pp. 33-51. 6. M. R. Pincus and J. A. Scha ffner, Assessment of liver function, in Henry J.B.(ed.), Clinical Diagnosis & Management by Laboratory Methods (19th ed.), 1996, W.B. Saunders, pp 253-267. 7. Tietz, N.W. (ed.), Clinical Guide to Laboratory Tests (3rd ed.), 1995, pp. 320-327. 8. D. Zakim, D. and T.D. Boyer, Hepatology (2nd ed.), 1990, W.B. Saunders. 9. Harrisons Principles of Internal Medicine (14th ed.), 1998, McGraw Hill. 10. J. Wallach, Interpretation of Diagnostic Tests, 1996, Little Brown and Co. 11. Illustrated Guide to Diagnostic Tests (2nd ed.), 1997, Springhouse Corporation. 12. Sleisenger and Fordtranss Gastrointestinal and Liver Disease (6th ed.), 1997, W.B. Saunders. 13. CDC. (2017), (Retrieved February 20, 2017). HCV Facts for Health Professionals . Available at https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm 1. Epidemiology and transmission of hepatitis Cvirus infection, Basics | Diabetes | CDC. (n.d.).Retrieved 02-14-2017 from https://www.cdc.gov/diabetes/basics/diabetes.html. 14. Hepatitis Cvirus infection amo ng adolescents and young adults: Massachusetts, 2002-2009, Basics | Diabetes | CDC. (n.d.).Retrieved 02-14-2017 from https://www.uptodate.com/contents/epidemiology-and-transmission-of-hepatitis-c-virus-infection/abstract/5-7. 15. Emerging epidemic of hep atitis Cvirus infections among young nonurban persons who inject drugs in the United States, 2006-2012, Basics | Diabetes | CDC. (n.d.).Retrieved 02-20-2017 from https://www.uptodate.com/contents/epidemiology-and-transmission-of-hepatitis-c-virus-infection?source=search_result&search=hepatitis%20c%20epidemiology&selectedTitle=1~150. 16. Recommendations for Testing, Managing, and Treating Hepatitis C, Joint panel from the American Association of the Study of Liver Diseases and the Infectious Diseases Society of America. Retrieved 08-01-2016 from http://www.hcvguidelines.org/. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Three-Day Payment Window

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Issue Date: Next Annual Review Effective Date 01/01/2016 0 5/03/2018 01/01/2016 Policy Name Policy Number Three-Day Payment Window PY-0128 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RULES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 3 H.REFERENCES ………………………………………………………………………………………… 4Archived Three-Day Payment Window Ohio Medicaid PY-0128 Effective Date: 01/01/2016 2 A.SUBJECT Three-Day Payment Window B. BACKGROUND I. Medicare Background : Section 102 of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, Pub. L. 111-192, signed into law on June 25, 2010, sets forth, in part, the Medicare three-day payment window, which is Medicare’s policy for payment of outpatient services provided on either the date of a beneficiary’s admission or during the three calendar days immediately preceding the date of a beneficiary’s inpatient admission to a subsection (d) hospital subject to the inpatient prospective payment system (IPPS). Under the Medicare three-day payment window policy, a hospital (or an entity that is wholly owned or wholly operated by the hospital) must include on the claim for a beneficiary’s inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient nondiagnostic services that are furnished to the beneficiary during the 3-day payment window. Under the three-day payment window policy, all outpatient diagnostic services furnish ed to a Medicare beneficiary by a hospital (or an entity wholly owned or operated by the hospital), on the date of a beneficiary’s admission or during the 3 days immediately preceding the date of a beneficiary’s inpatient hospital admission, must be included on the Part A bill for the beneficiary’s inpatient stay at the hospital. According to CMS, this law makes the policy pertaining to admission-related outpatient nondiagnostic services more consistent with common hospital billing practices. II.Ohio Medicaid Background: The Ohio Department of Medicaid amended the Ohio Administrative Code 5160-2- 02 to adopt a similar three-day payment window for outpatient services rendered prior to an inpatient admission occurring on and after January 1, 2016. Specifically, the amended section 5160-2-02(B)(2) states: Effective for inpatient admissions that begin on or after January 1, 2016, outpatient services, as described in paragraph (B)(4) of this rule, provided within three calendar days prior to the date of admission in hospitals described in rule 5160-2-01 of the Administrative Code will be covered as inpatient services. This includes emergency room and observation services. The OAC three-day payment window policy differs from the Medicare policy in that it requires that all outpatient diagnostic and non-diagnostic services rendered within the payment window be bundled with the inpatient claim, regardless of whether or not the services are clinically related to the admission. C. DEFINITIONS For purposes of this policy, Hospital is defined as hospitals described in rule 5160-2-01 of the Ohio Administrative Code, and Outpatient services” are defined at OAC Section 5160-2-02(B)(4) as follows: Diagnostic, therapeutic, rehabilitative, or palliative treatment or services furnished by or under the direction of a physician or dentist which are furnished to an outpatient by a hospital as defined in rule 5160-2-01 of the Administrative Code. Outpatient services do not include direct-care services provided by physicians, podiatrists and dentists. Outpatient services exclude direct-care physician services except as provided in rule 5160-4-01 of the Administrative Code. Wholly owned is defined as follows: An entity is wholly owned by the hospital if th e hospital is the sole owner of the entity. (See 42 CFR 412.2) Wholly operated is defined as follows: An entity is wholly operated by a hospital if the hospital has exclusive responsibility for conducting and overseeing the entitys routine operations, regardless of whether the hospital also has policymaking authority over the entity. (See 42 CFR 412.2) Archived Three-Day Payment Window Ohio Medicaid PY-0128 Effective Date: 01/01/2016 3 D.POLICY I. General. As an Ohio Medicaid Managed Care Entity, it is the CareSource policy that effective for inpatient admissions that begin on or after January 1, 2016, outpatient services, as described in paragraph (B) (4) of OAC 5160-2-02(B) (2), provided within three calendar days prior to the date of admission in hospitals described in rule 5160-2-01 of the Ohio Administrative Code, will be covered as inpatient services. This includes emergency room and observation services. This rule applies to all outpatient services provided by the admitting hospital, as well as hospitals wholly owned or operated by the admitting hospital. Therefore, hospitals must bundle on the inpatient claim all outpatient services rendered by the admitting hospital or a hospital wholly owned or operated by the hospital within three (3) calendar days prior to the date of admission. II.Compliance with Three-Day Payment Rule. A. Outpatient claim s submitted by a Hospital and rendered on or after January 1, 2016 are subject to this rule and will be denied if rendered within three calendar days prior to an inpatient admission of the same patient receiving the outpatient services . 1. Any previously paid outpatient claims, if subject to this rule, will be denied. 2. Claims where a Hospital has been paid for an inpatient claim and subsequently submits a claim for an outpatient service that was rendered within three calendar days prior to the inpatient admission of that patient will be denied. B. Examples: 1. Patient A received an outpatient service from Hospital A on January 1, 2016. Hospital A submitted the claim as an outpatient claim. On January 4, 2016, Patient A is admitted to Hospital A as an inpatient. The outpatient service rendered to Patient A on January 1, 2016 will be denied and is subject to recoupment because it was rendered within three calendar days of Patient As inpatient admission to Hospital A. 2. Patient Breceived an outpatient service from Hospital Bon January 1, 2016. On January 5, 2016, Patient Bis admitted to Hospital Bas an inpatient. The outpatient service rendered to Patient Bon January 1, 2016 will be approved (provided that it otherwise meets any applicable service and reimbursement requirements) because it was rendered outside of the three-day payment window. E. CONDITIONS OF COVER AGE F. RELATED POLICIES/RUL ES https://www.caresource.com/documents/observation-care/ G.REVIEW/REVISION HISTORY DATE ACTION Date Issued 01/01/2016 Date Revised Date Effective 01/01/2016 ArchivedThree-Day Payment Window Ohio Medicaid PY-0128 Effective Date: 01/01/2016 4 H. REFERENCES 1. 42 CFR 412.2(c)(5) 2. Medicare Claims Processing Manual (Pub. 100-4), Chapter 3, section 40.3, Outpatient Services Treated as Inpatient Services. 3. OAC 5160-2-02(B)(2) The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived

Vitamin D Assay Testing

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 05/01/2018 05/01/2017 Policy Name Policy Number Vitamin DAssay Testing PY-0226 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patien t can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low es t cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service (s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT ………………………….. ………………………….. ………… 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ………….. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………………… 2B. BACKGROUND ………………………….. ………………………….. ………………………….. …………….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. ……………….. 2 D. POL IC Y ………………………….. ………………………….. ………………………….. ………………………… 2 E. COND ITIONS OF COVERA GE ………………………….. ………………………….. …………………. 3 F. RELATED POL IC IES/RUL ES ………………………….. ………………………….. ……………………. 3 G. REVIEW /REV IS ION HIS TORY ………………………….. ………………………….. ………………….. 3 H. REFERENCES ………………………….. ………………………….. ………………………….. ……………… 3 Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 2 A. SUBJECT Vitamin DAssay Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care pr oviders and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Although an excess of vitamin Dis rar e it can lead to hypercalcemia. Vitamin Ddef iciency may lead to numerous disorders, the most widely k nown is rickets. Assessing patients vita min Dlevels is achieved by measuring the level of 25-hydroxyvita min D. Evaluation of other metabol ites is generally not medically nec essary. C. DEFINITIONS Severe deficiency: 25(OH)D: 80 ng/ml D. POLICY I. CareSource does not require a prior autho rization for Vitamin Dtesting. II. CareS ource considers Vitamin Dlevels testing medically necessary for patients with the following: A. Chronic kidney disease stage III or greater B. Osteoporosis C. Osteomalacia D. Osteopenia E. Hypocalcemia F. Hypercalciura G. Hypopa rath y roidism H. Malabsorption states I. Cirrhosis J. Hypervitaminosis DK. Osteosclerosis/petrosis L. Rickets M. Low exposu re to sunlight N. Vitamin Ddeficiency to monitor the efficacy of replacement therapy III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the Vitamin Dtesting CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 3 Note : Althou gh this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimburs ement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Pro vi de rs/FeeSche dul eRates/LabS er vicesPayme nt.pdf The following list(s) of code s is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Code s De finition 8 23 06 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED ICD 10 code s De scription E20.0 Idiopathic hypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E21.0-E21.3 Primary hyperparathyroidism-Hyperparathyroidism, unspecified E41 Nutritional marasmus E43 Unspecified severe protein-calorie malnutrition E55.0 Rickets, active E55.9 Vitamin Ddeficiency, unspecified E67.3 Hypervitaminosis DE67.8 Other specified hyperalimentation E68 Sequelae of hyperalimentation E83.31 Familial hypophosphatemia E83.32 Hereditary vitamin D-dependent ric k ets (ty pe 1) (ty pe 2) E83.39 Other disorders of phosphorus metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E84.0 Cystic fibrosis with pulmonary manifestations E84.11 Meconium ileus in cystic fibrosis E84.19 Cystic fibrosis with other intestinal manifestations E84.8 Cystic fibrosis with other manifestations E89.2 Postprocedural hypoparathyroidism K50.00 Crohn’s disease of small intestine without complications Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 4 K50.011 Crohn’s disease of small intestine with rectal bleeding K50.012 Crohn’s disease of small intestine with intestinal obstruction K50.013 Crohn’s disease of small intestine with fistula K50.014 Crohn’s disease of small intestine with abscess K50.018 Crohn’s disease of small intestine with other complication K50.111 Crohn’s disease of large intestine with rectal bleeding K50.112 Crohn’s disease of large intestine with intestinal obstruction K50.113 Crohn’s disease of large intestine with fistula K50.114 Crohn’s disease of large intestine with abscess K50.118 Crohn’s disease of large intestine with other complication K50.80 Crohn’s disease of both small and large intestine without complications K50.811 Crohn’s disease of both small and large intestine with rectal bleeding K50.812 Crohn’s disease of both small and large intestine with intestinal obstruction K50.813 Crohn’s disease of both small and large intestine with fistula K50.814 Crohn’s disease of both small and large intestine with abscess K50.818 Crohn’s disease of both small and large intestine with other complication K50.90 Crohn’s disease, unspecified, without complications K50.911 Crohn’s disease, unspecified, with rectal bleeding K50.912 Crohn’s disease, unspecified, with intestinal obstruction K50.913 Crohn’s disease, unspecified, with fistula K50.914 Crohn’s disease, unspecified, with abscess K50.918 Crohn’s disease, unspecified, with other complication K51.00 Ulcerative (chronic) pancolitis without complications K51.011 Ulcerative (chronic) pancolitis with rectal bleeding K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction K51.013 Ulcerative (chron ic) pancolitis with fistula K51.014 Ulcerative (chronic) pancolitis with abscess K51.018 Ulcerative (chronic) pancolitis with other complication K51.20 Ulcerative (chronic) proctitis without complications K51.211 Ulcerative (chronic) proctitis with rectal bleeding K51.212 Ulcerative (chronic) proctitis with intestinal obstruction K51.213 Ulcerative (chronic) proctitis with fistula K51.214 Ulcerative (chronic) proctitis with abscess K51.218 Ulcerative (chronic) proctitis with other complication Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 5 K51.30 Ulcerative (chronic) rectosigmoiditis without complications K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction K51.313 Ulcerative (chronic) rectosigmoiditis with fistula K51.314 Ulcerative (chronic) rectosigmoiditis with abscess K51.318 Ulcerative (chronic) rectosigmoiditis with other complication K51.40 Inflammatory polyps of colon without complications K51.411 Inflammatory polyps of colon with rectal bl eeding K51.412 Inflammatory polyps of colon with intestinal obstruction K51.413 Inflammatory polyps of colon with fistula K51.414 Inflammatory polyps of colon with abscess K51.418 Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K51.511 Left sided colitis with rectal bleeding K51.512 Left sided colitis with intestinal obstruction K51.513 Left sided colitis with fistula K51.514 Left sided colitis with abscess K51.518 Left sided colitis with other complication K52.0 Gastroenteritis and colitis due to radiation K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K74.1 Hepatic sclerosis K74.2 Hepatic fibrosis with hepatic sclerosis K76.9 Liver disease, unspecified K90.0 Celiac disease K90.1 Tropical sprue K90.2 Blind loop syndrome, not elsewhere classified K90.3 Pancreatic steatorrhea K90.41 Non-celiac gluten sensitivity K90.49 Malabsorption due to intolerance, not elsewhere classified K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.2 Postsurgical malabsorption, not elsewhere classified Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 6 M80.00XA Age-related osteoporosis with current path ological fracture, unspecified site, initial encounter for fracture M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture M80.061A Age-related osteoporosis with current p athological fracture, right lower leg, initial encounter for fracture M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M81.0 Age-related osteoporosis without current pathological fracture M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M83.0-M83.5 Puerperal osteomalacia-Other drug-induced osteomalacia in adults M83.8 Other adult osteomalacia M85.80 Other specified disorders of bone density and structure, unspecified site M85.811 Other specified disorders of bone density and structure, right shoulder M85.812 Other specified disorders of bone density and structure, left shoulder M85.821 Other specified disorders of bone density and structure, right upper arm M85.822 Other specified disorders of bone density and structure, left upper arm M85.831 Other specified disorders of bone density and structure, right forearm M85.832 Other specified disorders of bone density and structure, left forearm M85.841 Other specified disorders of bone density and structure, right hand Archived Vitam in DAs s ay Tes ting OHIO MEDICAID PY-0226 Effective Date: 05/01/2017 7 M85.842 Other specified disorders of bone density and structure, left hand M85.851 Other specified disorders of bone density and structure, right thigh M85.852 Other specified disorders of bone density and structure, left thigh M85.861 Other specified disorders of bone densit y and structure, right lower leg M85.862 Other specified disorders of bone density and structure, left lower leg M85.871 Other specified disorders of bone density and structure, right ankle and foot M85.872 Other specified disorders of bone density and structure, left ankle and foot M85.88 Other specified disorders of bone density and structure, other site M85.89 Other specified disorders of bone density and structure, multiple sites M89.9 Disorder of bone, unspecified M94.9 Disorder of cartilage, unspecified N18.3-N18.6 Chronic kidney disease, stage 3 (moderate) – End stage renal disease N25.81 Secondary hyperparathyroidism of renal origin Q78.2 Osteoporosis A UTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DAT EACT ION Da te Issue d 03-08-2017 Da te Re vise d 03/19/2019 Updated code list based on revised LCD Da te Effe ctive 05/01/2017 H. REFERENCES 1. Local Coverage Determination (LCD) Vitamin DAssay Testing (L33996). Retrieved March 19, 2019 2. Vitamin DInsufficiency. Retrieved March 2, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC29 127 37/ The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived

Thyroid Testing

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 05/01 /2017 Policy Name Policy Number Thyroid Testing PY-0222 Policy Typ e Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary servic es include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbi dity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the conve nience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other polici es and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ………………………………………………………………….. 31 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………. 31 H.REFERENCES ………………………………………………………………………………………. 32Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 2 A.SUBJECT Thyroid Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify membe rs eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. DEFINITIONS Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. POLICY I. CareSource does not require a prior authorization for thyroid testing. II.CareSource considers thyroid function testing medically necessary for the following: A. Members who are clinically stable up to 2 times per year B. Members who have symptoms consistent with hypothyroidism C. Members who have symptoms consistent with hyperthyroidism D. Members who are asymptomatic and 60 years of age or older, performed every 5 years E. Members who are asymptomatic but are considered high risk due to the following: 1. Family or personal history of thyroid disease, this should be limited to a one time screening 2. Family or personal history of Type I Diabetes or other autoimmune disorder, this should be limited to a one time screening 3. Member who is prescribed medications that may interfere with thyroid function III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 3 E.CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/LabServicesPayment.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CPT Codes Definition 84436 Thyroxine: total 84339 Thyroxine: free 84443 TSH Thyroid Stimulating Hormone 84479 Thyroid Hormone Uptake (T3 or T4) or thyroid hormone binding ration (THBR) ICD-10-CM Definition A18.81 Tuberculosis of thyroid gland C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary C73 Malignant neoplasm of thyroid gland C75.8 Malignant neoplasm with pluriglandular involvement, unspecified C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D09.3 Carcinoma in situ of thyroid and other endocrine glands D09.8 Carcinoma in situ of other specified sites D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D27.9 Benign neoplasm of unspecified ovary D34 Benign neoplasm of thyroid gland D35.2 Benig n neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D44.0 Neoplasm of uncertain behavior of thyroid gland D44.2 Neoplasm of uncertain behavior of parathyroid gland D44.9 Neoplasm of uncertain behavior of unspecified endocrine g land D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency ArchivedThyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 4 D53.9 Nutritional anemia, unspecified D59.0 Drug-induced autoimmune hemolytic anemi a D59.1 Other autoimmune hemolytic anemias D64.9 Anemia, unspecified D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere specified E00.0 Congenital iodine-deficiency synd rome, neurological type E00.1 Congenital iodine-deficiency syndrome, myxedematous type E00.2 Congenital iodine-deficiency syndrome, mixed type E00.9 Congenital iodine-deficiency syndrome, unspecified E01.0 Iodine-deficiency related diffuse (endemic) go iter E01.1 Iodine-deficiency related multinodular (endemic) goiter E01.2 Iodine-deficiency related (endemic) goiter, unspecificied E01.8 Other iodine-deficiency related thyroid disorders and allied conditions E02 Subclinical iodine-deficiency hypothyro idism E03.0 Congenital hypothyroidism with diffuse goiter E03.1 Congenital hypothyroidism without goiter E03.2 Hypothyroidism due to medicaments and other exogenous substances E03.3 Postinfectious hypothyroidism E03.4 Atrophy of thyroid (acquired) E0 3.5 Myxedema coma E03.8 Other specified hypothyroidism E03.9 Hypothyroidism, unspecifide E04.0 Nontoxic diffuse goiter E04.1 Nontoxic single thyroid nodule E04.2 Nontoxic multinodular goiter E04.8 Other specified nontoxic goiter E04.9 Nontoxic goit er, unspecified E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 5 E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic cri sis or storm E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm E05 .41 Thyrotoxicosis factitia with thyrotoxic crisis or storm E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm E06.0 Acute thyroiditis E06.1 Subacute thyroiditis E06.2 Chronic thyroiditis with transient thyrotoxicosis E06.3 Autoimmune thyroiditis E06.4 Drug-induced thyroiditis E06.5 Other chr onic thyroiditis E06.9 Thyroiditis, unspecified E07.0 Hypersecretion of calcitonin E07.1 Dyshornogenetic goiter E07.89 Other specified disorders of thyroid E07.9 Disorder of thyroid, unspecified E08.00 Diabetes mellitus due to underlying condition w ith hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabeted mellitus due to underlying condition with ketoacidosis without coma E08.1 1 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic mephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabeted mellitus due to underlyin condition with other diabetic kidney complication E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 6 E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema E08.329 Diabetes mellitus due to underlying condition with mild nonproliferati ve diabetic retinopathy without macular edema E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferativ e diabetic retinopathy without macular edema E08.341 Diabetes mellitus due to underlying condition with severe nonprolifeartive diabetic retinopathy with macular edema E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative dia betic retinopathy without macular edema E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabeti c neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diab etic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with diabetic neurological complication E08.51 Diabetes mellitus due to underlying condit ion with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08 .610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis E08.621 Diabetes mellitus due to underlying condition with foot ulcer E08.622 Diabetes mellitus due to underlying condition with other skin ulcer E08.628 Diabetes mellitus due to underlying condition with other skin complicatiosn E08.630 Diabetes melli tus due to underlying condition with periodontal disease E08.638 Diabetes mellitus due to underlying condition with other oral complications Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 7 E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellitus due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlyi ng condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition with complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemic al induced diabetes mellitus with diabetic nephropathy E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E09.311 Drug or chemi cal induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E09.331 Drug or chemical induced diabetes mellitus with moderate nonpro liferative diabetic retinopathy without macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.341 Drug or chemical induced diabetes mellitus with severe nonprolifera tive diabetic retinopathy with macular edema E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinop athy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.39 Drug or chemical induced diabetes me llitus with other diabetic ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 8 E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)ne uropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complications E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with oth er circulatory complications E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic dermatitis E09.620 Drug or chemical induced diabetes mellitus wi th diabetic dermitis E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer E09.628 Drug or chemical induced diabetes mellitus with other skin complications E09.630 Dr ug or chemical induced diabetes mellitus with periodontal disease E09.638 Drug or chemical induced diabetes mellitus with other oral complications E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma E09.649 Drug or chemical in duced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complications E09.8 Drug or chemical induced diabetes mell itus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus with out complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complications E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edems E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 9 E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild no nproliferative diabetic retinopathy without macular edema E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.351 Type 1 diabetes mellitu s with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mel litus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy wit hout gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 d iabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10..628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 Type 1 diabetes mellitus with h ypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 10 E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without c omplications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic re tinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.3 41 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with prolifera tive diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellit us with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 11 E11.61 8 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabete s mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabet es mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspe cified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy w ithout macular edema E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specifie d diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 12 E13.36 Other specified diabetes mellitus with diabetic cataract E 13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus w ith other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other spec ified diabetes mellitus with other circulatory complications E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy E13.620 Other specified diabetes mellitus with diabetic dermatitis E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other skin complications E13.630 Other sp ecified diabetes mellitus with periodontal disease E13.638 Other specified diabetes mellitus with other oral complications E13.641 Other specified diabetes mellitus with hypoglycemia with coma E13.649 Other specified diabetes mellitus with hypogly cemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specifi ed diabetes mellitus without complications E20.0 Idiopathic hypoparathyroidism E20.1 Pseudohypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E22.1 Hyperprolactinemia E22.8 Other hyperfunction of pitui tary gland E22.9 Hyperfunction of pituitary gland, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 13 E23.0 Hypopituitarism E23.1 Drug-induced hypopituitarism E23.6 Other disorders of pituitary gland E25.0 Congenital adrenogenital disorders associated with enzyme deficiency E25 .8 Other adrenogenital disorders E25.9 Adrenogenital disorder, unspecified E27.1 Primary adrenocortical insufficiency E27.2 Addisonian crisis E27.3 Drug-induced adrenocortical insufficiency E27.40 Unspecified adrenocortical insufficiency E27.49 Other adrenocortical insufficiency E28.310 Symptomatic premature menopause E28.319 Asymptomatic premature menopause E28.39 Other primary ovarian failure E29.1 Testicular hypofunction E31.0 Autoimmune polyglandular failure E31.1 Pol yglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E3 1.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E35 Disorders of endocrine glands in diseases classified elsewhere E43 Unspecified severe protein-calorie malnutrition E44.0 Moderate protein-calorie malnutrition E44.1 Mild protein-calorie malnutrition E45 Retarded development following protein-calorie malnutrition E46 Unspecified protein-calorie malnutrition E53.0 Riboflavin deficiency E64.0 Sequelae of protein-calorie malnutrition E67.1 Hyperca rotinemia E78.0 Pure hypercholesterolemia E78.2 Mixed hyperlipidemia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 14 E78.4 Other hyperlipidemia E78.5 Hyperlipidemia, unspecified E83.50 Unspecified disorder of calcium metabolism E83.51 Hypocalcemia E83.52 Hypercalcemia E83.59 Othe r disorders of calcium metabolism E83.81 Hungry bone syndrome E87.0 Hyperosmolality and hypernatremia E87.1 Hypo-osmolality and hyponatremia E89.0 Postprocedural hypothyroidism E89.2 Postprocedural hypoparathyroidism E89.3 Postprocedural h ypopituitarism E89.6 Postprocedural adrenocortical ( – medullary) hypofunction F03.90 Unspecified dementia without behavioral disturbance F05 Delirium due to known physiological condition F06.0 Psychotic disorder with hallucinations due to known physiological condition F06.1 Catatonic disorder due to known physiological condition F06.2 Psychotic disorder with delusions due to known physiological condition F06.30 Mood disorder due to known physiological condition, unspecified F06.31 Moo d disorder due to known physiological condition with depressive features F06.32 Mood disorder due to known physiological condition with major depressive-like episode F06.33 Mood disorder due to known physiological condition with manic features F06. 34 Mood disorder due to known physiological condition with mixed features F06.4 Anxiety disorder due to known physiological condition F06.8 Other specified mental disorders due to known physiological condition F07.0 Personality change due to know n physiological condition F22 Delusional disorders F23 Brief psychotic disorder F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptom s, moderate F30.13 Manic episode, severe, without psychotic symptoms Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 15 F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bip olar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, current episode depressed, moderate F31.4 Bipolar disorder, current episode depresse d, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bip olar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31 .77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in full remission, most recent episode mixed F31.81 Bipolar II disorder Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 16 F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features F32.3 Major depressive disorder, single episode, severe wit h psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspec ified F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psy chotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depres sive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F41.0 Panic disorder [ episodic paroxysmal anxiety] without agoraphobia F41.1 Generalized anxiety disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified F53 Puerperal psychosis F63.3 Trichotillom ania G25.0 Essential tremor G25.1 Drug-induced tremor G25.2 Other specified forms of tremor G25.70 Drug induced movement disorder, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 17 G25.71 Drug induced akathisia G25.79 Other drug induced movement disorders G25.89 Other spec ified extrapyramidal and movement disorders G25.9 Extrapyramidal and movement disorder, unspecified G26 Extrapyramidal and movement disorders in diseases classified elsewhere G30.0 Alzheimer’s disease with early onset G30.1 Alzheimer’s disease w ith late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified G31.01 Pick’s disease G31.09 Other frontotemporal dementia G31.1 Senile degeneration of brain, not elsewhere classified G31.84 Mild cognitive impairment , so stated G47.00 Insomnia, unspecified G47.01 Insomnia due to medical condition G47.09 Other insomnia G47.30 Sleep apnea, unspecified G47.39 Other sleep apnea G47.62 Sleep related leg cramps G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G60.9 Hereditary and idiopathic neuropathy, unspecified G71.9 Primary disorder of muscle, unspecified G72.9 Myopathy, unspecified G73.3 Myasthenic syndromes in other diseases classified elsewhere G73.7 Myopathy in diseases classified elsewhere G93.3 Postviral fatigue syndrome H02.531 Eyelid retraction right u pper eyelid H02.532 Eyelid retraction right lower eyelid H02.533 Eyelid retraction right eye, unspecified eyelid Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 18 H02.534 Eyelid retraction left upper eyelid H02.535 Eyelid retraction left lower eyelid H02.536 Eyelid retraction left eye, unspe cified eyelid H02.539 Eyelid retraction unspecified eye, unspecified lid H02.841 Edema of right upper eyelid H02.842 Edema of right lower eyelid H02.843 Edema of right eye, unspecified eyelid H02.844 Edema of left upper eyelid H02.845 Ede ma of left lower eyelid H02.846 Edema of left eye, unspecified eyelid H02.849 Edema of unspecified eye, unspecified eyelid H05.20 Unspecified exophthalmos H05.221 Edema of right orbit H05.222 Edema of left orbit H05.223 Edema of bilateral orbit H05.229 Edema of unspecified orbit H05.241 Constant exophthalmos, right eye H05.242 Constant exophthalmos, left eye H05.243 Constant exophthalmos, bilateral H05.249 Constant exophthalmos, unspecified eye H05.251 Intermittent exopht halmos, right eye H05.252 Intermittent exophthalmos, left eye H05.253 Intermittent exophthalmos, bilateral H05.259 Intermittent exophthalmos, unspecified eye H05.89 Other disorders of orbit H11.421 Conjunctival edema, right eye H11.422 Co njunctival edema, left eye H11.423 Conjunctival edema, bilateral H11.429 Conjunctival edema, unspecified eye H11.431 Conjunctival hyperemia, right eye H11.432 Conjunctival hyperemia, left eye H11.433 Conjunctival hyperemia, bilateral H11.43 9 Conjunctival hyperemia, unspecified eye H49.00 Third [oculomotor] nerve palsy, unspecified eye Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 19 H49.01 Third [oculomotor] nerve palsy, right eye H49.02 Third [oculomotor] nerve palsy, left eye H49.03 Third [oculomotor] nerve palsy, bilateral H49.10 Fourth [trochlear] nerve palsy, unspecified eye H49.11 Fourth [trochlear] nerve palsy, right eye H49.12 Fourth [trochlear] nerve palsy, left eye H49.13 Fourth [trochlear] nerve palsy, bilateral H49.20 Sixth [abducent] nerve palsy, uns pecified eye H49.21 Sixth [abducent] nerve palsy, right eye H49.22 Sixth [abducent] nerve palsy, left eye H49.23 Sixth [abducent] nerve palsy, bilateral H49.40 Progressive external ophthalmoplegia, unspecified eye H49.41 Progressive external ophthalmoplegia, right eye H49.42 Progressive external ophthalmoplegia, left eye H49.43 Progressive external ophthalmoplegia, bilateral H49.881 Other paralytic strabismus, right eye H49.882 Other paralytic strabismus, left eye H49.883 Other paralytic strabismus, bilateral H49.889 Other paralytic strabismus, unspecified eye H49.9 Unspecified paralytic strabismus H53.2 Diplopia I10 Essential (primary) hypertension I12.0 Hypertensive chronic kidney disease with stage 5 chronic ki dney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and sta ge 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I 13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, o r end stage renal disease I31.3 Pericardial effusion (noninflammatory) I31.9 Disease of pericardium, unspecified I43 Cardiomyopathy in diseases classified elsewhere Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 20 I47.1 Supraventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation *I48.1 *Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation I49.2 Junctional premature depolarization I49.8 Other specified cardiac arrhythmias I4 9.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on ch ronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestiv e) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and dias tolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.7 Cardiomegaly J91.8 Pleural effusion in other conditions classified elsewhere J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia K14.8 Other diseases of tongue Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 21 K52.2 Allergic and dietetic gastroenteritis and colitis K52.89 Other specifie d noninfective gastroenteritis and colitis K56.0 Paralytic ileus K56.7 Ileus, unspecified K59.00 Constipation, unspecified K59.01 Slow transit constipation K59.02 Outlet dysfunction constipation K59.09 Other constipation K59.3 Megacolo n, not elsewhere classified L11.0 Acquired keratosis follicularis L29.9 Pruritus, unspecified L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.4 Beau’s lines L60.5 Yellow nail syndrome L60.8 Other nail disorders L6 2 Nail disorders in diseases classified elsewhere L63.0 Alopecia (capitis) totalis L63.1 Alopecia universalis L63.2 Ophiasis L63.8 Other alopecia areata L63.9 Alopecia areata, unspecified L64.0 Drug-induced androgenic alopecia L64.8 Ot her androgenic alopecia L64.9 Androgenic alopecia, unspecified L65.0 Telogen effluvium L65.1 Anagen effluvium L65.2 Alopecia mucinosa L65.8 Other specified nonscarring hair loss L65.9 Nonscarring hair loss, unspecified L66.0 Pseudopela de L66.2 Folliculitis decalvans L66.8 Other cicatricial alopecia Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 22 L66.9 Cicatricial alopecia, unspecified L80 Vitiligo L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palm aris et plantaris) L86 Keratoderma in diseases classified elsewhere L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.2 Elastosis perforans serpiginosa M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lup us erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M32.19 Other organ or system involvement in systemic lupus erythematosus M32.8 Other forms of systemic lupus erythematosus M32.9 Systemic lupu s erythematosus, unspecified M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyosit is with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with o ther organ involvement M33.20 Polymyositis, organ involvement unspecified M33.21 Polymyositis with respiratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M33.90 Dermatopolymyositis, unspeci fied, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 23 M33.99 Dermatopolymyositis, unspecified with other organ involvement M34.0 Progressiv e systemic sclerosis M34.1 CR(E)ST syndrome M34.2 Systemic sclerosis induced by drug and chemical M34.81 Systemic sclerosis with lung involvement M34.82 Systemic sclerosis with myopathy M34.83 Systemic sclerosis with polyneuropathy M34.89 Other systemic sclerosis M34.9 Systemic sclerosis, unspecified M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.09 Sicca syndrome with other organ involvement M35.1 Other overlap syndromes M35.5 Multifocal fibrosclerosis M35.8 Other specified systemic involvement of connective tissue M35.9 Systemic in volvement of connective tissue, unspecified M36.0 Dermato(poly)myositis in neoplastic disease M36.8 Systemic disorders of connective tissue in other diseases classified elsewhere M60.80 Other myositis, unspecified site M60.811 Other myositis, r ight shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other my ositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 24 M60.849 Other myositis, unspecified hand M60.851 Other myositis, r ight thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, r ight ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M62.50 Muscle wasting an d atrophy, not elsewhere classified, unspecified site M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder M62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulder M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm M62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper arm M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm M62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearm M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand M62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified hand M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh M62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thigh M62.561 Muscle wast ing and atrophy, not elsewhere classified, right lower leg M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 25 M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot M62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and foot M62.58 Muscle wastin g and atrophy, not elsewhere classified, other site M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites M62.81 Muscle weakness (generalized) M62.9 Disorder of muscle, unspecified M63.80 Disorders of muscle in diseases cla ssified elsewhere, unspecified site M63.811 Disorders of muscle in diseases classified elsewhere, right shoulder M63.812 Disorders of muscle in diseases classified elsewhere, left shoulder M63.819 Disorders of muscle in diseases classified elsewhe re, unspecified shoulder M63.821 Disorders of muscle in diseases classified elsewhere, right upper arm M63.822 Disorders of muscle in diseases classified elsewhere, left upper arm M63.829 Disorders of muscle in diseases classified elsewhere, unspe cified upper arm M63.831 Disorders of muscle in diseases classified elsewhere, right forearm M63.832 Disorders of muscle in diseases classified elsewhere, left forearm M63.839 Disorders of muscle in diseases classified elsewhere, unspecified forea rm M63.841 Disorders of muscle in diseases classified elsewhere, right hand M63.842 Disorders of muscle in diseases classified elsewhere, left hand M63.849 Disorders of muscle in diseases classified elsewhere, unspecified hand M63.851 Disorders of muscle in diseases classified elsewhere, right thigh M63.852 Disorders of muscle in diseases classified elsewhere, left thigh M63.859 Disorders of muscle in diseases classified elsewhere, unspecified thigh M63.861 Disorders of muscle in diseas es classified elsewhere, right lower leg M63.862 Disorders of muscle in diseases classified elsewhere, left lower leg M63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower leg M63.871 Disorders of muscle in diseases class ified elsewhere, right ankle and foot M63.872 Disorders of muscle in diseases classified elsewhere, left ankle and foot M63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and foot M63.88 Disorders of muscle in diseases classified elsewhere, other site Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 26 M63.89 Disorders of muscle in diseases classified elsewhere, multiple sites M79.1 Myalgia M79.7 Fibromyalgia M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological frac ture M86.9 Osteomyelitis, unspecified N91.0 Primary amenorrhea N91.1 Secondary amenorrhea N91.2 Amenorrhea, unspecified N91.3 Primary oligomenorrhea N91.4 Secondary oligomenorrhea N91.5 Oligomenorrhea, unspecified N92.0 Excessive and frequent menstruation with regular cycle N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified N94.4 Primary dysmenorrhea N94.5 Secondary dysmenorrhea N94.6 Dysmenorrhea, unspecified O90.5 Postpartum thyr oiditis O92.29 Other disorders of breast associated with pregnancy and the puerperium O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O99.281 Endocrine, nutritional and metabolic diseases complic ating pregnancy, first trimester O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O99.284 Endocrine, nutrit ional and metabolic diseases complicating childbirth O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium Q38.2 Macroglossia Q89.2 Congenital malformations of other endocrine glands R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 27 R06.09 Other forms of dyspnea R06.1 Stridor R06.83 Snoring R06.89 Other abnormalities of breathing R07.0 Pain in throat R09.89 Other specified symptoms an d signs involving the circulatory and respiratory systems R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.14 Dysphagia, pharyngoesophage al phase R13.19 Other dysphagia R18.0 Malignant ascites R18.8 Other ascites R19.4 Change in bowel habit R19.7 Diarrhea, unspecified R19.8 Other specified symptoms and signs involving the digestive system and abdomen R20.0 Anesthesia of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation R20.9 Unspecified disturbances of skin sensation R23.4 Changes in skin texture R23.8 Other skin changes R23.9 Unspecified skin changes R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.2 Cramp and spasm R25.3 Fasciculation R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 28 R27.0 Ataxia, unspec ified R27.8 Other lack of coordination R27.9 Unspecified lack of coordination R29.2 Abnormal reflex R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R40.2110 Coma scale, eyes open, never, unspecified time R40.2111 Coma scale, ey es open, never, in the field [EMT or ambulance] R40.2112 Coma scale, eyes open, never, at arrival to emergency department R40.2113 Coma scale, eyes open, never, at hospital admission R40.2114 Coma scale, eyes open, never, 24 hours or more after ho spital admission R40.2120 Coma scale, eyes open, to pain, unspecified time R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department R40.2123 Coma scale, eyes open, to pain, at hospital admission R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission R40.2210 Coma scale, best verbal response, none, unspecified time R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance] R40.2212 Coma scale, best verbal response, none, at arrival to emergency department R40.2213 Coma scale, best verbal response, none, at hospital admission R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] R40.2222 Coma scale, best verbal respon se, incomprehensible words, at arrival to emergency department R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission R40.2310 Coma scale, best motor response, none, unspecified time R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance] R40.2312 Coma scale, best motor response, none, at arrival to emergency department Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 29 R40.231 3 Coma scale, best motor response, none, at hospital admission R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission R40.2320 Coma scale, best motor response, extension, unspecified time R40.2321 Coma scale, be st motor response, extension, in the field [EMT or ambulance] R40.2322 Coma scale, best motor response, extension, at arrival to emergency department R40.2323 Coma scale, best motor response, extension, at hospital admission R40.2324 Coma scale, b est motor response, extension, 24 hours or more after hospital admission R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance] R4 0.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission R40.4 Transient alteration of awareness R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified R41.9 Unspecif ied symptoms and signs involving cognitive functions and awareness R45.0 Nervousness R45.1 Restlessness and agitation R45.3 Demoralization and apathy R45.4 Irritability and anger R45.81 Low self-esteem R45.82 Worries R45.84 Anhedonia R45.86 Emotional lability R45.87 Impulsiveness R45.89 Other symptoms and signs involving emotional state R47.02 Dysphasia R47.1 Dysarthria and anarthria Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 30 R47.81 Slurred speech R47.89 Other speech disturbances R47.9 Unspecified speech d isturbances R49.0 Dysphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R50.2 Drug induced fever R50.81 Fever presenting with conditions classified elsewhere R50.82 Postprocedural fever R50.83 Postvaccination fever R50.84 Febrile nonhemolytic transfusion reaction R50.9 Fever, unspecified R52 Pain, unspecified R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53. 82 Chronic fatigue, unspecified R53.83 Other fatigue R60.0 Localized edema R60.1 Generalized edema R60.9 Edema, unspecified R61 Generalized hyperhidrosis R63.0 Anorexia R63.2 Polyphagia R63.4 Abnormal weight loss R63.5 Abnormal weight gain R68.0 Hypothermia, not associated with low environmental temperature R68.81 Early satiety R68.83 Chills (without fever) R68.89 Other general symptoms and signs R90.89 Other abnormal findings on diagnostic imaging of central nervou s system Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 31 R93.8 Abnormal findings on diagnostic imaging of other specified body structures R94.6 Abnormal results of thyroid function studies T66.XXXA Radiation sickness, unspecified, initial encounter Z08 Encounter for follow-up examination aft er completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use o f opiate analgesic Z79.899 Other long term (current) drug therapy Z85.020 Personal history of malignant carcinoid tumor of stomach Z85.030 Personal history of malignant carcinoid tumor of large intestine Z85.040 Personal history of malignant ca rcinoid tumor of rectum Z85.060 Personal history of malignant carcinoid tumor of small intestine Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung Z85.230 Personal history of malignant carcinoid tumor of thymus Z85.520 Personal history of malignant carcinoid tumor of kidney Z85.821 Personal history of Merkel cell carcinoma Z85.850 Personal history of malignant neoplasm of thyroid Z85.858 Personal history of malignant neoplasm of other endocrine glands Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017 Date Revised Date Effective 05-01-2017 Archived Thyroid Testing OHIO MEDICAID PY-0222 Effective Date: 05-01-2017 32 H.REFERENCES1. National Coverage Determination (NCD) for Thryoid Testing (190.22). Retrieved February 28,2017, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D&2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and ChangeReport ICD-10-CM. Retrieved February 28, 2017, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. OH-P-1298Archived

Sleep Studies

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 0 5/01/2017 Policy Name Policy Number Sleep Studies PY-0169 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Sleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 2 A.SUBJECT Sleep Studies B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Sleep Studies and Polysomnography (PSG) refers to the test performed for people who suffer from insomnia, excessive daytime sleepiness, obstructive sleep apnea, breathing difficulties during sleep, or beh avior disturbances during sleep. It is the continuous monitoring and recording, of a patients body functions, during sleep. It may include eye movement, brain waves, blood pressure, oxygen saturation, muscle activity and heart rhythm. For the purpose o f this policy, the terms sleep study and Polysomnography may be used interchangeably. However, when submitting a claim for reimbursement, providers should use the most appropriate CPT code with the appropriate associated definition. CareSource will re imburse providers, for sleep studies to CareSource members, as set forth in this policy. C. DEFINITIONS Narcolepsy-is a syndrome that is characterized by abnormal sleep tendencies. Obstructive Sleep Apnea (OSA) – is the obstruction of airflow, during sleep, due to the collapse of the oropharyngeal walls. Parasomnias-are a group of conditions that may occur during sleep that can often lead to injury to the patient or others and damage to the surroundings. These conditions may include sleepwal king, sleep terrors, and rapid eye movement (REM) sleep behavior disorders. Polysomnography (PSG) – is a sleep study that records certain body functions during sleep and is used to diagnose sleep disorders. Sleep Apnea-is the interruption of airflow for at least 10 seconds. D. POLICY I. CareSource does not require a prior authorization for a sleep studies. II. A sleep study/polysomnography (PSG) may be reimbursed according to CMS/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the sleep study/polysomnography (PSG) CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. V. Sleep study/PSG is considered medically necessary and covered: A. Only if the patient has the symptoms or complaints of one of the conditions listed below. 1. Narcolepsy ArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 3 2. Parasomnias 3. Sleep Apnea B. The patients must be referred to the sleep disorder clinic by their attending physicians, and the clinic maintains a record of the attending physicians orders. C. The need for diagnostic testing is confirmed by medical evidence, e.g., physician examinations and laboratory tests. D. The test is not redundant of other diagnostic procedures that must be performed. VI. Polysomnography (PSG) includes the stages of sleep, which requires items a through c below. Polysomnography is defined to minimally include, but is not limited to, the following A. A 1-4 lead electroencephalogram (EEG) to measure global neural encephalographic activity using electrodes placed on the scalp. B. Electrooculogram (EOG) to measure eye movements using electrodes placed near the outer canthus of each eye. C. A submental electromyogram (EMG) to measure submental electromyographic activity using electrodes placed over the mentalis, submentalis muscle, and/or masseter regions. D. Rhythm electrocardiogram (ECG). E. Nasal and/or oral airflow via both thermistor and nasal pressure sensor. F. Respiratory indication by chest-wall and abdominal movement measured using respiratory inductive plethysmography, endoesophageal pressure or by intercostal EMG. G. Gas exchange (oxygen saturation) by oximetry or transcutaneous monitoring H. Bilateral anterior tibialis muscle activity, motor activity-movement using EMG. I.Body positions by directly applied sensors or by direct observation. VII. Home sleep testing is NOT covered by CareSource for Ohio Medicaid members. Included are: A. 95800, 95801, 95803, 95806 VI II. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. Note: Although a Sleep Study does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source fo r the most current coding information. CPT Codes Definition 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist ArchivedSleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 4 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analys is and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist 95808 Polysomnography; any age, sleep staging with 1-3 additional parameters of sleep, attended by a technologist 95810 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95811 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes 95813 Electroencephalogram (EEG) extended monitoring; greater than 1 hour 95816 Electroencephalogram (EEG); including recording awake and drowsy 95819 Electroencephalogram (EEG); including recording awake and asleep 95822 Electroencephalogram (EEG); recording in coma or sleep only 95824 Electroencephalogram (EEG); cerebral death evaluation only 95827 Electroencephalogram (EEG); all night recording 95829 Electrocorticogram at surgery (separate procedure) 95830 Insertion by physician or other qualified health care professional of sphenoidal electrodes for electroencephalographic (EEG) recording 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 95832 Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) 95852 Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side 95857 Cholinesterase inhibitor challenge test for myasthenia gravis 95860 Needle electromyography; 1 extremity with or without related paraspinal areas 95861 Needle electromyography; 2 extremities with or without rela ted paraspinal areas 95863 Needle electromyography; 3 extremities with or without related paraspinal areas 95864 Needle electromyography; 4 extremities with or without related paraspinal areas 95865 Needle electromyography; larynx Archived Sleep Studies OHIO MEDICAID PY-0169 Effective Date: 05-01-2017 5 ICD-10 Definition G47.10 Hypersomnia, unspecified G47.3 Sleep apnea G47.33 Obstructive sleep apnea (adult) (pediatric) G47.41 Narcolepsy G47.5 Parasomnia F.RELATED POLICIES/RULES G.REVIEW/REVISION HISTORY DATE ACTION Date Issued 03-08-2017Date Revised Date Effective H.REFERENCES1.Appendix DD to rule 5160-1 -60. (2017, January 1). Retrieved 2/6/2017 from http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates /App-DD.pdf2. Lawriter-OAC. (2016, September 1). Retrieved 3/6/2017 from http://codes.ohio.gov/oac/5160-10 3. Local Coverage Determination (LCD): POLYSOMNOGRAPHY and Other Sleep Studies(L36839). (2017, February 16). Retrieved 3/6/2017 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36839&ver=3&CoverageSelection=Both&ArticleType=All&PolicyType=Fi nal&s=North+Carolina&KeyWord=polysomnography&KeyW ordLookUp=Title&KeyWordSearc hType=And&bc=gAAAACAAAAAAAA%3d%3d&The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. OH-P-1299Archived

Glycosylated Hemoglobin A1c

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Effective Date Next Annual Review Effective Date 05/03/2017 05/03/2018 05/03/2017 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: 05-03-2017 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, persistent ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 05-03-2017 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. ArchivedGlycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 05-03-2017 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/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. Archived Glycosylated Hemoglobin A1c Ohio Medicaid PY-0157 Effective: 05-03-2017 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 Diabete s 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 Diabet es 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: 05-03-2017 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 complication 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: 05-03-2017 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: 05-03-2017 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: 05-03-2017 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: 05-03-2017 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: 05-03-2017 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 mell itus, 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: 05-03-2017 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: 05-03-2017 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 hypertens ive 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 childbirth 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, unspeci fied 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: 05-03-2017 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 pregnancy, 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: 05-03-2017 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 Supervision 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 o f 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: 05-03-2017 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 to 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 pregn ancy, 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: 05-03-2017 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, unspecified trimeste r 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 amniotic 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 trimester 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, uns pecified 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, first tr imester 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: 05-03-2017 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 Quadruplet pregna ncy, 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 pregnancy 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: 05-03-2017 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, se cond 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: 05-03-2017 20F. REVIEW/REVISION HISTORY DATE ACTION Date Issued 05/03/2017 Date Revised Date Effective 05/03/2017 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

Telemedicine Services

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Original Effective Date Next Annual Review Effective Date 10/31/2013 05/03/2017 05/03 /17 Policy Name Policy Number Telemedicine Services PY-0084 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 benefit s 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. Medica lly necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, in creased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a con flict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Telemedicine Services OHIO Medicaid PY-0084 Effective Date: 05/03/2017 2 A.SUBJECT Telemedicine Services B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use se lf-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 telemedicine services, who are credentialed to deliver telemedicine services rendered to CareSource members, as set forth in this policy. Telemedicine is used to support health care when the provider and patient are physically separated. Typically, the patient communicates with the provider via interactive means that is sufficient to establish the necessary link to the provider who is working at a different location from the patient. C. DEFINITIONS Asynchronous store and forward technologies-means the transmission of a patients medical information from an originating site to the physician or practitioner at the distant site. Distant Site-is the location of the physician or provider rendering health care services. o The distant site is responsible for maintaining documentation of the health care service delivered through the use of telemedicine and for sending progress notes to the originating site for incorporation into the patient’s records. Electronic service delivery (electronic therapy, cyber therapy, e-therapy, etc.) – is counseling, social work or marriage and family therapy in any form offered or rendered primarily by electronic or technology-assisted means. Originating Site-is the location where the patient is physically located when services are provided. o The originating site is responsible for documenting the medical necessity of the health care service provided through the use of telemedicine, for securing the informed consent of the patient, and for developing and maintaining progress notes. Place of Service Codes (POS) – These codes specifically indicate where a service or procedure was performed. Telemedicine-is the direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. Telemedicine vendor-is the participating provider with CareSource that renders the telemedicine services. D. POLICY I. CareSource does not require prior authorization for Telemedicine services. II. Telemedicine services may be reimbursed according to Ohio Medicaid guidelines using appropriate CPT and/or HCPCS and modifier codes. ArchivedTelemedicine Services OHIO Medicaid PY-0084 Effective Date: 05/03/2017 3 III. Practi tioners providing counseling, social work and marriage & family therapy via electronic service delivery must: A. Conduct an initial face-to-face meeting, which may be by video/audio electronically, to verify client identity. B. Obtain written, informed consent to include discussion of risks of electronic service delivery. C. Provide links to websites of certification bodies and licensure boards. D. Identify appropriately training professionals to provide local assistance. E. Maintain confidentiality, including use of encryption methods. IV . Reimbursement may be made for the following health care services delivered at the distant site: A. Evaluation and management services characterized as ANY of the following: 1. Office or other outpatient services 2. Office or other outpatient consultations 3. Inpatient consultations E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the appropriate Ohio Medicaid fee schedule http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. CareSource will reimburse participating providers for the following CPT/HCPCS codes when evaluating CareSource members via Telemedicine vendor locations: CPT Codes Definition 99201 New patient Office or other outpatient visit, including problem focused history, problem focused exam, straightforward medical decision-making. 99202 New patient Office or other outpatient visit, including expanded problem focused history, expanded problem focused exam, straightforward medical decision-making. 99203 New patient Office or other outpatient visit for the evaluation and management of the member, including a detailed history, a detailed examination and medical decision making of low complexity. 99204 New patient Office or other outpatient visit for the evaluation and management of the member, including a comprehensive history, a comprehensive examination and medical decision making of moderate complexity. 99211 Established patient Office or other outp atient visit for the evaluation and management of the member that may not require the presence of physician or other qualified health care professional. 99212 Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: problem focused history, problem focused exam, straightforward medical decision-making. Archived Telemedicine Services OHIO Medicaid PY-0084 Effective Date: 05/03/2017 4 99213 Established patient Office or other outpatient visit for the evaluation and management of the memb er, including at least two of the following components: an expanded problem focused history, an expanded problem focused exam and medical decision making of low complexity. 99214 Established patient Office or other outpatient visit for the evaluation and management of the member, including at least two of the following components: a detailed history, a detailed examination and medical decision making of moderate complexity. Q3014 Telehealth originating site facility fee Modifier Description GT Via interactive audio and video telecommunication systems AUTHORIZATION PERIOD F.RELATED POLICIES/RUL ESG. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/31/2013 Date Revised 11/29/2016 Date Effective 05/03/2017 H.REFERENCES1. Telemedicine | Medicaid.gov. (2016, June 24). Retrieved June 24 , 2016, fromhttps://www.medicaid.gov/medicaid-chip-program-information/by-topics/delive ry-systems/telemedicine.html2. Telehealth Services. (2016, June 30). Retrieved June 24, 2016 from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf3. OAC-5160-1-18 Telemedicine. (2015, January 2). Retrieved June 24, 2016 from http://codes.ohio.gov/oac/5160-1-18 4. Fee Schedule Rates-Appendix DD to rule 5160-1-60. (2016, August). Retrieved August 23,2016 from http://medicaid.ohio.gov/Port als/0/Providers/FeeScheduleRates/App-DD.pdf5. OAC-4757-5-13 Standards of practice and professional conduct: electronic service delivery(internet, email, teleconference, etc.). (2016, July 1). Retrieved August 23, 2016 from http://codes.ohio.gov/oac/4757-5-13 6. Chapter 5160-27 Community Mental Health Agency Services . (2015, October 1). RetrievedAugust 23, 2016 from http://codes.ohio.gov/oac/5160-27 7. OAC-5122-29-03 Behavioral health counseling and therapy service. (2014, July 1).Retrieved August 23, 2016 from http://codes.ohio.gov/oac/5122-29-03 The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. OH-P-1288Archived

Obstetrical Services – Preferred

REIMBURSEMENT POLICY STATEMENT OHIO MEDICAIDOriginal Issue Date Next Annual Review Effective Date 06/10/2015 03/22/2018 05/03/17 Policy Name Policy Number Preferred Obstetrical Services PY-0004 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 4 E.CONDITIONS OF COVERA GE ………………………………………………………………… 10 F.RELATED POLICIES/RULES ………………………………………………………………….. 11 G.REVIEW/REVISION HISTORY ………………………………………………………. ……….. 11 H.REFERENCES ………………………………………………………………………………………. 11Archived Preferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 2 A. SUBJECT Obstetrical Services Note: It is expected that the provider will use the appropriate Evaluation and Management (E/M) codes. Select level based upon the history, examination, and medical decision making documented in the record for that visit. B. BACKGROUND Maternity care or obstetrical services refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. Maternity care services include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e i v e i n a h o s p i t a l o r b i r t h i n g c e n t e r a s w e l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for payment will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. DEFINITIONS Advanced practice nurse-The recently endorsed Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education defines four APRN roles: certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS) and certified nurse practitioner (CNP). These four roles are given the title of advanced practice registered nurse (APRN). o Education The model calls for all APRNs to be educated in an accredited gradua te-level education program in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatric , neonatal, womens health/gender-related or psych/mental health. o Certification All APRNs must pass a national certification exam that measures APRN role and population-focused competencies. APRNs will be required to maintain continued competence as evidenced by recertification in the role and population through a national certification program. Under the new APRN regulatory model all CNSs will be educated and assessed through national certification processes across the continuum from wellness through acute care. o Licensure Advanced practice registered nurses will be licensed independent practitioners who are expected to practice within standards established or recognized by a licensing body. Licensure will be required because these APRNs will be practicing in a role beyond that of the Registered Professional Nurse. 2015 American Association of Critical-Care Nurses Current Procedural Terminology (CPT) – The answer to most obstetrical billing questions can be found in the Physicians Current Procedural Terminology (CPT) manual or the CPT Assistant Archives (1990 present). Maternity Care and Delivery is a subsection of the Surgery section of the CPT book codes. A n understanding of the global package services is needed to code Maternity Care and Delivery Services correctly. (ama-assn.org) ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 3 Elective Delivery-is performed for a nonmedical reason. Some nonmedical reasons include wanting to schedule the birth of the baby on a specific date or living far away from the hospital. Some women request delivery because they are uncomfortable in the last weeks of pregnancy. Some women request a cesarean delivery because they fear vaginal birth. (American Congress of Obstetricians and Gynecologists, 2015) Fetal death-means death prior to the complete expulsion or extraction from its mother of a product of conception, which after such expulsion or extraction, does not breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. “Fetal death” does not include termination of the pregnancy. Guidelines for perinatal care-means the sixth edition of the “Guidelines for perinatal care” issued by the American academy of pediatrics and the American congress of obstetricians and gynecologists. High Risk Maternity-Maternity care complicated by a documented condition during the patients pregnancy requiring direct face-to-face practitioner care beyond the usual service. Infertility-is defined as the condition of (i) a presumably healthy woman of childbearing age who has been unable to conceive or (ii) a presumably healthy man who has been unable to produce conception, in either case, after at least one year of trying to do so. (CareSource internal definition) Lactation consultant-means an individual who holds credentials as an “International board certified lactation consultant.” Coding Guidelines-The delivery date is used as the date of service for: o Any OB global code o Most antepartum care codes o Any delivery-only code o Any delivery + postpartum code o Any postpartum care only code Maternity home-means a facility for pregnant girls and women where accommodations, medical care, and social services are provided during the prenatal and postpartum periods. Maternity home does not include a private residence where obstetric or newborn services are received by a resident of the home. (OAC 3701-7-01 (W), Maternity home) Maternity Period-For billing purposes, the obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period (56 days after vaginal delivery, 60 days after C-section ). Medically necessary-services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (OAC 5160-10-02) Modifier 22: Increased Procedural Services: When the work required providing a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physician and mental effort required). Note: This modifier should not be appended to an E/M service. Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 4 reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. Modifier 59: Distinct Procedural Servi ce: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25. Non-Obstetric (OB) E/M service: Visit(s) occurring outside the regularly scheduled antepartum period whereby the Same Group Physician and/or Other Health Care Professional providing maternity care provides services for a condition such as bronchitis, flu, or upper respiratory infection. Obstetric (OB) Related E/M service : Additional visit(s) provided in addition to routine antepartum care for a high-risk or complicated pregnancy. Physician-means an individual authorized under Chapter 4731 of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery. Preconception care-means Medicaid-covered preventive medicine services provided prior to a pregnancy for the purpose of achieving optimal outcome of future pregnancies. Special delivery services-means services provided by a freestanding children’s hospital that does not offer typical obstetric services as a level I obstetric service, level II obstetric service, or level III obstetric service, but is licensed as a level III neonatal care service, and is designed and equipped to provide delivery services to pregnant women as part of a comprehensive multidisciplinary program of fetal and neonatal care when it is determined that the fetus, once delivered, will require immediate highly subspecialty neonatal intensive care or neonatal surgery typically provided by a level IIIB or level IIIC neonatal care service. D. POLICY I. Maternity Coverage A. Maternity services must be furnished under the supervision of a physician or certified advanced practice nurse midwife. Maternity services enable beneficiaries to voluntarily choose a provider within the CareSource network for maternity care and post-partum care .For billing purposes, the Maternity Obstetrical period begins on the date of the initial visit in which pregnancy was confirmed and extends through the end of the postpartum period (56 days after vaginal delivery and 60 days after C-section). Covered services include office visits for a complete exam, pharmaceuticals (including some over the counter [OTC] products with a prescription), such as prenatal vitamins or medication related to gestational diabetes, and fetal ultrasound services are provided by or under the supervision of a medical doctor, osteopath, or eligible Maternity provider. 1. Maternity services may include the following: 1.1 Pregnancy testing/laboratory tests 1.2 Office visits 1.3 Ultrasounds Archived Preferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 5 1.4Fetal delivery 1.5 Post-Partum visits B. Maternity Global Period The CMS Physician Fee Schedule assigns maternity procedure codes a global days indicator of MMM, and does not identify the number of days for a Maternity global period. CareSource uses a Maternity Global Period of 56 days after the date of vaginal delivery and 60 days after the date of C-section delivery(date of delivery is day zero) Criteria for Itemized Billing 1. Antepartum Care Only 1.1 The CPT Editorial Board created codes 59425 (Antepartum care only; 4-6 visits) and 59426 (Antepartum care only; 7 or more visits) to accommodate for situations such as termination of a pregnancy, relocation of a patient or change to another physician. In these situations, all the routine antepartum care (usually 13 visits) or global (OB) care may not be provided by Same Group Physician and/or Other /Health Care Professional. 1.2 The antepartum care only CPT codes 59425 or 59426 should be reported by Same Group Physician and/or Other Health Care Professionals when: 1.3 As described by ACOG and the AMA, the antepartum care only codes 59425 and 59426 should be reported as described below: a. A single claim submission of CPT code 59425 or 59426 for the antepartum care only, excluding the confirmatory visit that may be reported and separately reimbursed when the antepartum record has not been initiated. b. The units reported should be one. c. The dates reported should be the range of time covered. For example, if the patient had a total of 4-6 antepartum visits then the physician and/or other health care professional should report CPT code 59425 with the “from and to” dates for which the services occurred. 2. Delivery Services Only 2.1 Per the CPT book, “Delivery services include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery.” 2.2 The following are the CPT defined delivery only codes: a. 59409-Vaginal delivery only (with or without episiotomy and/or forceps b. 59514-Cesarean delivery only c. 59612-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) d. 59620-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 3. Items Included in the Delivery Services 3.1 According to CPT and ACOG coding guidelines, the following services are included in the delivery services codes and should not be reported separately: a. Admission to the hospital b. The admission history and physical examination c. Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician d. Intravenous (IV) induction of labor via oxytocin (CPT codes 96365-96367) e. Delivery of the placenta; any method f. Repair of first or second degree lacerations 3.2 CareSource will not separately reimburse for these services when one of the delivery codes is reported. ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 6 3.3CareSource considers insertion of cervical dilator (CPT 59200) to be included if performed on the same date of delivery. 3.4 Per ACOG coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB (59400, 59610) or delivery only (59409, 59410, 59612 and 59614) codes. Claims submitted with modifier 22 must include medical record documentation which supports the use of the modifier; please refer to the Increased Procedural Services section of this policy and CareSources Increased Procedural Services policy. 4. Postpartum Care Only 4.1 The following is the CPT defined postpartum care only code: a. 59430-Postpartum care only (separate procedure) 4.2 CareSource follows ACOG guidelines and considers the postpartum period to be six weeks following the date of the cesarean or vaginal delivery. 4.3 The following services are included in postpartum care and are not separately reimbursable services: a. Uncomplicated outpatient visits related to the pregnancy b. Discussion of contraception c. The following services are not included in postpartum care and are separately reimbursable services, when reported subsequent to CPT code 59430: (1) Evaluation and management of problems or complications related to the pregnancy Note: The postpartum care only code should be reported by the Same Group Physician and/or Other Health Care Professional that provides the patient with services of postpartum care only. If a physician provides any component of antepartum along with postpartum care, but does not perform the delivery, then the services should be itemized by using the appropriate antepartum care code (see Antepartum Care Only section of policy) and postpartum care code (CPT code 59430). 5. Delivery Only including Postpartum Care Sometimes a physician performs the delivery and postpartum care with minimal or no antepartum care. In these instances, the CPT book has codes for vaginal and cesarean section deliveries that encompass both of these services. 5.1 The following are CPT defined delivery plus postpartum care codes: a. 59410-Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care b. 59515-Cesarean delivery only; including postpartum care c. 59614-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care d. 59622-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care 5.2 The delivery only including postpartum care codes should be reported by the Same Group Physicians and/or Other Health Care Professional for a single gestation when: a. The delivery and postpartum care services are the only services provided b. The delivery and postpartum care services are provided in addition to a limited amount of antepartum care (e.g., CPT code 59425) 5.3 The following services are included in delivery only including postpartum care code and are not separately reimbursable services: a. Hospital visits related to the delivery during the delivery confinement b. Uncomplicated outpatient visits related to the pregnancy c. Discussion of contraception 6. Non-Obstetric Care During Antepartum Stage ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 7 Per ACOG guidelines, when a patient is seen for a condition unrelated to pregnancy (e.g., bronchitis, flu), these E/M visits are considered Non-Obstetric (OB) E/M services and can be reported as they occur. The diagnosis code used in conjunction with the E/M service should support the non-OB condition being treated and/or evaluated. CareSource will reimburse non-OB related E/M services rendered during the antepartum stage of care only when the appropriate diagnosis code being used clearly identifies the condition is not related to pregnancy care. 7. Non-Obstetric Care During the Postpartum Stage CareSource will reimburse non-OB related office E/M services rendered during the postpartum care when submitted with modifier 24. 8. Risk Appraisal-Case Management Referral Providers may complete the Pregnancy Risk Assessment Form and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. Any eligible woman who meets any of the risk factors listed on the form is eligible for case management for pregnant women services and should be referred to CareSource for further screening for case management services. C. Delivery of Multiple Gestations CareSource’s reimbursement for twin deliveries follows ACOG’s coding guidelines for vaginal, cesarean section, or a combination of vaginal and cesarean section deliveries. See table below for appropriate code submission regarding delivery of twin births. Vaginal Baby A Baby B 59400 59409-59 VBAC* Baby A Baby B 59610 59612-59 Cesarean Delivery Baby A & Baby B 59510 Repeat Cesarean Delivery Baby A & Baby B 59518 Vaginal Delivery + Cesarean Delivery Baby BBaby A 59510 59409-51 VBAC + Repeat Cesarean Delivery Baby BBaby A 59618 59612-51 *VBAC=vaginal birth after cesarean If there is increased physician work involvement for delivery of the second baby, modifier 22 is added to the global cesarean code (CPT codes 59510 or 59618). Claims submitted with modifier 22 must include medical record documentation which supports the use of the modifier. D. Fetal Non-Stress Test Per coding guidelines multiple non-stress tests performed on a single fetus on the same day should be reported with CPT code 59025 for the initial test. Code 59025 should be reported subsequently with modifier 76, to identify the repeated procedure(s) by the same physician; or with modifier 77 appended, to identify that the repeated procedure(s) was performed by another physicia n. 1. Multiple non-stress tests performed on twin gestations should be reported in the following manner: ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 8 1.1The initial test for the first fetus is reported using CPT code 59025; if subsequent testing is performed on the same fetus. CPT code 59025 is then reported a second time with modifier 76, to identify the repeated procedure by the same physician; or with modifier 77, to identify that the non-stress test was repeated by another physician. 1.2 The initial test for the second fetus is reported using CPT code 59025 with modifier 59 appended, to identify that a separate fetus is being evaluated. If subsequent testing is performed on the second fetus, CPT code 59025 with modifier 59 is reported a second time with modifier 76, to identify the repeated procedure by the same physician; or modifier 77, to identify that the non-stress test was repeated by another physician. E. Increased Procedural Services The determination to allow additional reimbursement for OB services submitted with modifier 22 is based on individual review of clinical documentation that supports use of the modifier identifying an increased procedural service per CPT modifier guidelines. Accordingly, physicians and other health care professionals should submit supporting medical records whenever modifier 22 is utilized . 1. The following identifies some common OB situations that involve modifier 22; please note this is NOT an all-inclusive list: 1.1 Per ACOG coding guidelines, modifier 22 can be used for increased services associated with delivery of twins; for further information, please refer to the Multiple Gestation section of this policy. 1.2 Per ACOG coding guidelines, it is not appropriate to append modifier 22 to the global OB code when additional E/M services result in greater than the typical 13 routine antepartum visits. For information regarding additional payment of E/M services that go beyond the typical number encountered in an average pregnancy, please refer to the High Risk/Complications section of this policy. F. Assistant Surgeon and Cesarean Sections Only a non-global cesarean section delivery code (CPT codes 59514 or 59620) is a reimbursable. G. Limitations on Elective Obstetric Deliveries 1. Payment for any cesarean section, labor induction, or any delivery following labor induction is subject to the following criteria: 1.1 Gestational age of the fetus must be determined to be at least thirty-nine weeks; OR 1.2 If a delivery occurs prior to thirty-nine weeks gestation, maternal and/or fetal conditions must indicate medical necessity for the delivery. NOTE: Cesarean sections, labor inductions, or any deliveries following labor induction that occur PRIOR to thirty-nine weeks gestation that are not considered MEDICALLY NECESSARY are not eligible for payment. H. Claims Providers are to indicate Maternity as a diagnosis when billing any of the services listed in this policy that relate to Maternity .Providers are to complete the diagnosis code or the appropriate narrative, where applicable. In addition, providers should identify services related to the treatment of complications of Maternity. Examples: Archived Preferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 9 1.Surgical procedure such emergency C-Section due to fetal distress 2. Atypical office visits and laboratory tests needed due to member or fetal anomalies Occasionally other services (including hospital, radiology, pharmaceutical, blood and blood derivatives) may be related to Maternity or to its complications, and should be properly identified. I.Non-Comprehensive Maternity Visits CareSource covers maternity management services including evaluation and management (office) visits and consultations for the purpose of health of the member and developing fetus for best outcomes. J. Non-Covered Maternity Services 1. Home pregnancy tests 2. Ultrasounds performed only for determination of sex of the fetus or to provide a keepsake picture 3. Three and four dimensional ultrasounds 4. Paternity testing 5. Lamaze classes 6. Birthing classes 7. Parenting classes 8. Home tocolytic infusion therapy K. Reimbursement Guidelines 1. Delivery Labor and delivery services are based on the need of each individual patient and can include, but not limited to, thefollowing types of services, fetal monitoring of any type of method, rupture of membranes, amnioinfusion, forceps and/or vacuum-assisted delivery, episiotomy and/or laceration repair, as well as fetal and maternal testing, andinduction of labor services. 2. Vaginal Delivery Reporting 2.1 Primary delivery service code: 59400 or 59610 2.2 Each additional delivery code: 59409-51 or 59612-51 2.3 If the additional service becomes a cesarean delivery, then report the primary delivery service as a cesarean delivery: 59510 or 59618 3. Cesarean Delivery Reporting 3.1 Primary delivery service code: 59510 or 59618 3.2 No additional procedural delivery code warranted 3.3 Only a single cesarean delivery service is to be reported no matter how many live births a. Modifier 22 should be added to support substantial additional work 4. Postpartum Care Postpartum care includes hospital and office visits following any type of delivery, and can include any number ofvisits (usually extends over a six-week period). It is expected that the member will have postpartum care related to their medical needs, with the final postpartum visit at the conclusion of the postpartum period. Each of these visitscan be reported with procedure code 0503F. 5. Maternity Management Services Providers must include the following information on claims for maternity management services: 5.1 A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided AND ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 10 5.2An appropriate ICD-10 diagnosis code to indicate an encounter for maternity management 6. Maternity services are considered medically necessary for women in the delivery of a fetus (including, multiple gestations). Therefore, reimbursement is available for the following codes: 6.1 Obstetrical Reimbursement Codes a. 59409-Vaginal delivery only (with or without episiotomy and/or forceps) b. 59514-Cesarean delivery only c. 259612-Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) d. 59620-Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 6.2 Fetal Gestational Age Determination a. Delivery prior to 39 weeks of gestation b. Delivery at 39 weeks of gestation or later c. Spontaneous obstetrical deliveries occurring between 37 and 39 weeks gestation E. CONDITIONS OF COVERA GE HCPCS Code Description 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) 59400 Routine obstetric care including antepartum ca re, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps); 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59412 External cephalic version, with or without tocolysis 59414 Delivery of placenta (separate procedure) 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59430 Postpartum care only (separate procedure) 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59514 Cesarean delivery only; 59515 Cesarean delivery only; including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure) 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum ca re, after previous cesarean deliver y 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery 59620 Cesarean delivery only, following attempted vaginal delivery after previous ArchivedPreferred Obstetrical Services OHIO Medicaid PY-0004 Effective Date: 05/03/2017 11 cesarean delivery; 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care 0500F Initial prenatal care visit (report at first prenatal en counter with health care professional providing obstetrical care, report also date of visit and in a separate field, the last date of menstrual period LMP) 0501F Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period-LMP (Note: If reporting 0501F prenatal flow sheet, it is not necessary to report 0500F initial prenatal care visit) 0502F Subsequent prenatal care visit (excludes: patients who are seen for a condition unrelated to pregnancy or prenatal care [e.g., an upper respiratory infection; patients s een for consultation only, not for continuing care]) 0503F Postpartum care visit CPT AUTHORIZATION PERIOD Prior Authorization Members may seek maternity services from any qualified CareSource participating provider without prior authorization. F. RELATED POLICIES/RUL ES 1. American Association of Critical Care Nurses Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education, 2015. 2. OAC Rule 5160-1-10 Limitations on Elective Obstetric Deliveries 3. OAC Rule 5160-21 Preconception Care Services G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 6/10/2015 Date Revised 6/10/2016 Date Effective 05/03/2017 H. REFERENCES 1. Current Procedural Terminology. (2015, June 1). Retrieved June 11, 2015, from http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page 2. Guideline Suggestions for Elective Labor Induction. (2012). Retrieved June 11, 2015, from http://www.acog.org/-/media/Districts/District-I/20120120-ElectiveIOLGuideline.pdf?dmc=1&ts=20150611T0857437601 3. Ohio Administrative Code. (2015). Retrieved June 11, 2015, from http://codes.ohio.gov/oac/3701-40-01 The Reimbursement Policy Statement 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

Obstetrical Services – Global

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

Pain Management

1 Payment 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 Payment Policies. In addition to this Policy, payment 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 limite d 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 l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provide r. 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 payment 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 serv ices provided in a particular case and may modify this Policy at any time.PAYMENT POLICY STATEMENT: OH MEDICAID Original Effective Date Next Annual Review Date Last Review / Revision Date 07/26/2016 07/26/2017 09/08/2016 Policy Name Policy Number Pain Management PY-0083 Policy Type Medical Administrative Payment A. SUBJECTPain Management B. BACKGROUNDReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f 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 inclusi on of a code does not imply any right to reimbursement or guarantee claims payment. Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the physical function and quality of life of tho se living with chronicpain. Treatment approaches to chronic pain include, but are not limited to, pharmacological measures, interventional procedures, physical therapy, physical exercise, application of ice and/or heat, and psychological measures, such a s biofeedback and cognitive behavioral2 therapy. Pain management, regarding this policy, is the utilization of different types of injections, stimulator or infusion pump for the relief of chronic pain. C. DEFINITIONSMedically necessary – health services that are necessary for the diagnosis or tr eatment of disease, illness, or injury and meet accepted standards of medical practice. D. POLICYI. Prior Authorization (PA): CareSource requires prior authorization for selected pain management injections as described below, for all places of service. II. Trigger Point Injections (CPT codes 20552 and 20553)A. CareSource will reimburse up to a maximum of no more than eight dates of service per calendar year per patient, regardless of location, duration of symptoms, rendering provider, or interval between injections. B. CareSource will not reimburse for localization by any technique for trigger point injections. C. No prior authorization is required for par providers. III. Sacroiliac ProceduresA. Sacroiliac joint injections (CPT code 27096, G0260, G0259) A. Care Source will reimburse injections for diagnosis or treatment that are given no less than 14 calendar days apart, with no more than four injections total, 2 per side, in a rolling 12 months. B. Image guidance and/or injection of contrast for sacroiliac joint injections for pain will be denied for coverage as not medically necessary. If neural blockade is applied for different regions, or different sides, injections are performed at least one week apart and timelines are monitored in the PA process. C. Monitored anesthesia and conscious sedation will be denied as not medically necessary. D. Prior authorization is required for providers. B. Sacroiliac neurotomy 1. Thermal or pulsed, cooled neurotomy by Radio-Frequency Ablation (RFA) or other techniques for sacroiliac pain are not covered due to insufficient, limited, or inconclusive published data. Also, sacroiliac neurotomy billed as a facet medial branch nerve blo ck are not allowed coverage. Studies provide limited evidence regarding the efficacy and safety of thermal radiofrequency ablation (TRA), for individuals with SI joint pain, and contain insufficient data that allows for definitive conclusions. 2. Sacral inj ections, identified on the claim by the ICD-10 codes M43.27, M43.28, M46.1, M53.2X7, M53.2X8, M53.3, M53.87, M53.88, are not covered when submitted with a claim for facet medial branch nerve block. C. Sacroiliac Joint Fusion, or Arthrodesis (CPT code 2727 9) 1. Sacroiliac joint fusion procedures are not covered due to limited data, mixed outcomes, and inconclusive evidence. IV. Facet medial branch nerve procedures.A. A maximum of five (5) facet injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and facet medial branch neurotomies may be performed per rolling 12 months in the cervical/thoracic spine and five (5) in the lumbar spine. A session is defined as all injections/blocks/RF procedures performed on one 3 day and includes medial branch blocks (MBNB), intraarticular injections (IA), facet cyst ruptures, and radiofrequency (RF) ablations. B. Facet medial branch nerve blocks (CPT codes 64490, 64491, 64492, 64493, 64494,64495, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T ) A. CareSource will prior authorize and reimburse Facet medial branch nerve blocks up to the targeted joint itself, one joint above and one joint below on the same side, or bilaterally per treatment session if medical necessity criteria are substantiated in the medical record. B. Facet joint interventions (diagnostic and/or therapeutic) must be performed under fluoroscopic or computed tomog raphic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be reimbursed (CPT code 76942) C. Facet Neurotomy1. CareSource will prior authorize and reimburse a maximum of 2 Facet Medial Branch Neurotomies in a rolling 12 months, if medically necessary (CPT 64633, 64634, 64635, 64636) 2. Facet Neurotomy should be performed with imaging guidance (. Coverage for image guidance and any injection of contrast are inclusive components and are not reimbursed separately. 3. For conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. Coverage for monitored anesthesia care (MAC) is not medically necessary. If anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs V. Epidural Steroid InjectionsA. Includes: Interlaminar, Transforaminal, or Caudal Epidural Injections (For CPT codes 62310, 62311, 0228T, 0229T, 0230T, 0231T). 1. Only 1 Interlaminar or Caudal Epidural Injection will be authorized per treatment date. 2. Bilateral injections and modifiers will not be reimbursed (For CPT codes 62310, 62311). 3. Greater than 3 interlaminar epidural injections within a rolling 12 months will not be reimbursed. (For CPT codes 62310, 62311). 4. Transforaminal Epidurals (CPT codes 64479,64480,64483,64484 ) provided to more than 2 vertebral levels per treatment date, whether unilateral or bilateral will not be reimbursed. 5. Greater than 3 transforaminal epidural injections within a rolling 12 months will not be reimbursed. (CPT codes 64479,64480,64483,64484 ) 6. Repeat injections sooner than 3 weeks will not be reimbursed. 7. The maximum epidurals of all types of epidural injections a member can receive in a rolling 12 months is a total of 6, regardless of the number of levels involved. 8. Prior authorization is required for all epidural steroid injections. B. For conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. Coverage for monitored anesthesia care (MAC) will not be provided as not medically necessary. If anesthesia services are provided they must be delivered by CareSource c redentialed providers, including anesthesiologists and/or CRNAs. C. Image guidance and any injection of contrast are inclusive components of epidural injections. 4 VI. Spinal Cord Stimulator A. A prior authorization is required both for a trial o f SCS and a second prior authorization is required for implantation of a permanent SCS. (CPT codes 63650, 63655, 63865) B. CPT, HCPCS, and ICD-10 codes for inclusion and exclusion in coverage determinations at the claims level are listed below. VII. Implantable pain pumpA. A prior authorization is required for each proposed preliminary trial injection and for each proposed placement of an Implantable Infusion Pain Pump for pain management. (CPT codes 62350-62351 and 62360-62362) CONDITIONS OF C OVERAGEReimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the appropriate state Medicaid fee schedule.Injections administered by participating physicians will be reimbursed for the bundled CPT code which includes both the injection administration and the pain medication. CareSource will not reimburse any claim which shows the separate (unbundled) cost for (a) the administration of the injection and (b) the me dication. Additionally, CareSource will not reimburse a non-participating provider or pain management clinic or anesthesia group (or other such non – participating provider) for either the administration of these injections or the pain medications injected, without prior authorization from CareSource. Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.The following list(s) of codes is provided as a refere nce. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Interventional Pain Injection-related CodesCPT Code Description 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed 62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter place ment, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 5 64483 Injection(s ), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoro scopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to cod e for primary procedure) 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code fo r primary procedure) 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary proc edure) 6 0228T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level 0229T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) 0230T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level 0231T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; ea ch additional level (List separately in addition to code for primary procedure) G0259 Injection procedure for sacroiliac joint; arthrography G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography CareSource does not provide coverage for the below CPT code:27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining of bone graft when performed, and placement of transfixing deviceSpinal Cord Stimulator CodesInformation in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by “+” : CPT codes covered if selection criteria are met : 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/padd le(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver CPT codes not covered for indications listed in the policy : 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs [intraoperative] 95926 in lower limbs [intraoperative] 95927 in the trunk or head [intraoperative] 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs [intraoperative] 95929 lower limbs [intraoperative] 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs [intraoperative] 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs [intraoperative] 7 +95940 Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) [MEP and SSEP] +95941 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure) [MEP and SSE P] Other CPT codes related to this policy and are covered with appropriate selection criteria : 95970 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurement s); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming 95971 simple spinal cord, or peripheral (i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming 95972 complex spinal cord, or peripheral (i.e., peripheral nerve, sacral nerve, neuromuscular) (except cranial nerve) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming HCPCS codes not covered for indications listed in this policy : G0453 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) [MEP and SSEP] CD-10 codes covered if selection criteria are met : A52.11 Tabes dorsalis B02.21 – B02.29 Zoster [herpes zoster] with other nervous system involvement F10.182, F10.282, F10.982 Alcohol abuse/dependence/use with alcohol-induced sleep disorder F51.01 – F51.9 Sleep disorders not due to a substance or known physiological condition G03.9 Meningitis, unspecified [lumbar arachnoiditis] G11.0 – G11.9 Hereditary ataxia G47.00 – G47.9 Sleep disorders G54.6 – G54.7 Phantom limb syndrome G90.50 – G90.59 Complex regional pain syndrome I I20.0 – I20.9 Angina pectoris [intractable angina in members who are not surgical candidates and whose pain is unresponsive to all standard therapies] I49.01 Ventricular fibrillation I73.00 – I73.9 Other peripheral vascular diseases [with chronic ischemic limb pain] M96.1 Postlaminectomy syndrome, not elsewhere classified [failed back surgery syndrome] R26.0 – R27.9 Abnormalities of gait and mobility and other lack of coordination S22.000+ – S22.089+ S32.000+ – S32.2xx+ Fracture of thoracic and lumbar vertebra, sacrum and coccyx [must be billed an incompleted spinal cord injury code] S23.100+ – S23.171+ S33.100+ – S33.39x+ Subluxation and dislocation of thoracic and lumbar vertebra, sacrum and coccyx S24.151+ – S24.159+ Incomplete spinal cord lesion 8 ,S34.121+ – S34.129+ S34.132+, S34.3xx+ Injury of cauda equinaICD-10 codes not covered for indications listed in this policy : C00.0 – C96.9 Malignant neoplasms D00.0 – D09.9 Carcinoma in situ D43.0 – D43.2 Neoplasm of uncertain behavior of brain [glioma] E08.40, E08.42, E09.40, E09.42, E10.40, E10.42, E11.40, E11.42, E13.40, E13.42 Diabetes mellitus with diabetic polyneuropathy G20 Parkinson’s disease G43.001 – G43.919 Migraine G44.1 Vascular headache, not elsewhere classified G50.0 Trigeminal neuralgia G54.8 Other nerve root and plexus disorders [intercostal neuralgia] G56.00 – G58.9 Mononeuropathies of upper and lower limbs G89.21 – G89.4 Chronic pain, not elsewhere classified I47.0 – I47.9 Paroxysmal tachycardia I69 .093, I69.193, I69.293, I69.393, I69.893, I69.993 Ataxia following cerebrovascular disease K58.0 – K58.9 Irritable bowel syndrome K83.8 Other specified diseases of biliary tract [Sphincter of Oddi dysfunction] L59.9 Other disorders of skin and subcutaneous tissue related to radiation [radiation-induced brain injury or stroke] M50.00 – M50.93 Cervical disc disorders M51.04 – M51.07 Thoracic, thoracolumbar, and lumbosacral intervertebral disk disorders with myelopathy M51.24 – M51.27, M51.9 Other and unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc displacement M53.82 Other specified dorsopathies, cervical region M54.2 Cervicalgia M54.11-M54.13 Radiculopathy [cervical region] M62.40 – M62.49 Contracture of muscle [spasticity of muscle] M62.830 Muscle spasm of back M96.1 Postlaminectomy syndrome, not elsewhere classified [failed cervical spine surgery syndrome] N94.0 – N94.9 Pain and other conditions associated with female genital organs and menstrual cycle [inguinal pain – female] [chronic pelvic pain] R10.0 – R10.9 Abdominal and pelvic pain [inguinal pain – male] [chronic visceral] [chronic pelvic pain] R25.0 – R25.9 Abnormal involuntary movements [spasticity] R40.0 – R40.4 Somnolence, stupor and coma R51 Headache S06.0x0+ – S06.9×9+ Intracranial injury [radiation-induced brain injury] S10.0xx+ – S10.97x+ Superficial injury of neck 9 S12.000+ – S12.691+ Fracture of cervical vertebra and other parts of neck S13.100+ – S13.29x+ Subluxation and dislocation of cervical vertebra S14.0xx+ – S14.9xx+ Injury of nerves and spinal cord at neck level S22.000+ – S22.089+ S32.000+ – S32.2xx+ Fracture of thoracic and lumbar, sacrum and coccyx S24.101+ – S24.109+ S24.151+ – S24.159+ S34.101+ – S34.109+ S34.121+ – S34.129+ S34.132+ – S34.139+ Spinal cord injury, incomplete [thoracic, lumbar, sacrum, coccyx and cauda equine ] [can be billed with/without ICD-10 code for fracture] T66.xxx+ Radiation sickness, unspecified [radiation-induced brain injury or stroke] ICD-10 codes contraindicated for this policy : F45.0-F45.9 Somatoform disorders I01.0 – I15.9 I21.01 – I72.9 I74.0 – I99.9 Diseases of the circulatory system Implantable Pain PumpInformation in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by “+”: CPT codes covered if selection criteria are met: 62350 – 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump 62355 Removal of previously implanted intrathecal or epidural catheter 62360 – 62362 Implantation or replacement of device for intrathecal or epidural drug infusion 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 62367 – 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, al arm status, drug prescription status) 95990 – 95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular) 96522 Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (e.g., intravenous, intra-arterial) ICD-10 codes covered if selection criteria are met (not all inclusive): G89.0 Central pain syndrome G89.21 – G89.29 Chronic pain, not elsewhere classified G89.3 Neoplasm related pain (acute) (chronic) 10 G89.4 Chronic pain syndrome G95.11 – G95.19 Vascular myelopathies S12.000+ – Fracture of vertebral column with spinal cord injury S12.001+ S12.100+ – S12.101+ S12.200+ – S12.201+ S12.300+ – S12.301+ S12.400+ – S12.401+ S12.500+ – S12.501+ S12.600+ – S12.601+ S14.101+ – S14.107+ S14.111+ – S14.117+ S14.121+ – S14.127+ S14.131+ – S14.137+ S14.151+ – S14.157+ S14.101+ – Injury of nerves and spinal cord at neck level S14.139+ S14.151+ – S14.159+ ICD-10 codes not covered for indications listed in this policy: K31.84 Gastroparesis M54.10 – M54.18 Radiculopathy M79.2 Neuralgia and neuritis, unspecified ICD-10 codes covered if selection criteria are met (not all-inclusive): G89.3 Neoplasm related pain (acute) (chronic) AUTHORIZATION PERIODE. RELATED POLICIES/RULESSee Medical policy Epidural Steroid Injections See Medical policy Facet medial branch nerve blocks See Medical policy Facet Neurotomy See Medical policy Trigger Point Injections See Medical policy Sacroiliac Joint Injections F. REVIEW/REVISION HISTORYDate Issued: 07/26//2016 Date Reviewed: 07/26/2016, 09/08/2016 Date Revised: 07/26/2016, 11 09/08/2016 Revisions to CPT/HCPCS codes, modify criteria language for prior authorizations, medical necessity, codes, and Ohio Departm ent of Medicaid rules. G. REFERENCES1. Lawriter – OAC – 5160-4-12(D) (4) Immunizations, injections and infusions (including trigger – point injections), and provider-administered pharmaceuticals. (2015, November 1). Retrieved June 22, 2016, from http://codes.ohio.gov/oac/5160-4-12 2. Lawriter – OAC – 5160-10-02 Coverage and limitations for medical supplier services. (2012, November 1). Retrieved June 22, 2016, from http://codes.ohio.gov/oac/5160-10-02 3. CareSource Medical Policies located at https://www.caresource.com/providers/policies/ The Pay ment Policy Statement detailed above has received due consideration as defined in the Payment Policy Statement Policy and is approved.

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