1 PAYMENT POLICY STATEMENT : MEDICAID Original Effective Date Next Annual Review Date Last Review / Revision Date 07/26 /2016 07/26 /2017 07/26 /2016 Policy Name Policy Number Pain Management PY-0083 Policy Type Medical Administrative PaymentPayment 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 referra l, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practi ce 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 Covera ge 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 determ ination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. A.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 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. 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 those living with chronic pain. 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 as biofeedback and cognitive behavioral Archived 2 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. DEFINITIONS Medically necessary-health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. D. POLICY I. Prior Authorization (PA): CareSource requires prior authorization for all pain management injections, for all places of service. A. SOLE EXCEPTION: Trigger Point Injections (CPT codes 20552 and 20553) from a participating provider do not require a prior authorization. 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 III. Sacroiliac Procedures A. Sacroiliac joint injections (CPT code 27096, G0260, G0259) 1. CareSource 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. 2. 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. 3. Monitored anesthesia and conscious sedation will be denied as not medically necessary. 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 block 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. This policy does not address sacral conditions or injections or sacral area neurotomies. Sacral injections, 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 27279) 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 Archived 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 ) 1. 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. 2. Facet joint interventions (diagnostic and/or therapeutic) must be perf ormed under fluoroscopic or computed tomographic (CT) guidance. Facet joint interventions performed under ultrasound guidance will not be reimbursed (CPT code 76942) C.Facet Neurotomy 1. CareSource will reimburse a maximum of 2 Facet Medial Branch Neurotomies in a rolling 12 months (CPT 64633, 64634, 64635, 64636) 2. Facet Neurotomy should be performed with imaging guidance (CPT code 77003 , modifier required). Coverage for image guidance and any injection of contrast are inclusive components and are not reimbursed separately. 3. This policy does not address sacral conditions or injections or neurotomies. Sacral injections, identified on a 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. 4. For facet neurotomy, 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 Injections A. 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 i n a rolling 12 months is a total of 6, regardless of the number of levels involved. B. For epidural injections, 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 the y Archived 4 must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. C. Image guidance and any injection of contrast are inclusive components of epidural injections (CPT codes 77003, modifier required ). VI. Spinal Cord Stimulator A. A prior authorization is required both for a trial of SCS and a second prior authorization is required for implantation of a permanent SCS. B. CPT, HCPCS, and ICD-10 codes for inclusion and exclusion in coverage determinations at the claims level are listed below. VII. Implantable pain pump A. 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. 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 appropriate state Medicaid fee schedule. Injections administered by participating physicians will be reim bursed 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 medication. 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 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. Interventional Pain Injection-related Codes CPT 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 placement, 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 Archived5 guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 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 (fluoros copy 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, si ngle 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 Des truction 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 (fluoroscopy 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 thorac ic; 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), cervica l or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guida nce (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 lev el (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; thi rd and any additional level(s) (List separately in addition to code for primary procedure) 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) 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 agen t, 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 ne rves innervating that joint) with ultrasound guidance, lumbar or sacral; second level Archived 6 (List separately in addition to code for primary procedure) 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves inn ervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 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) 0 230T 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; each 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 agen t, with or without arthrography 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining of bone graft when performed, and placement of transfixing device Spinal Cord Stimulator Codes Information 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), inclu ding fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(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 Archived 7 limbs [intraoperative] 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs [intraoperative] +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 SSEP] Other CPT codes related to this policy and are covered with appropr iate 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 an d patient compliance measurements); 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 covered if selection criteria are met : A4290 Sacral nerve stimulation test lead, each C1767 Generator, neurostimulator (implantable), nonrechargeable C1778 Lead, neurostimulator (implantable) C1787 Patient programmer, neurostimulator C1816 Receiver and/or transmitter, neurostimulator (implantable) C1820 Generator, neurostimulator (implantable), non-high-frequency with rechargeable battery and charging system C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) E0745 Neuromuscular stimulator, electronic shock unit L8680 Implantable neurostimulator electrode, each L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only L8682 Implantable neurostimulator radiofreque ncy receiver L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes Archived 8 extension L8689 External recharging system for battery (internal) for use with implant able neurostimulator, replacement only L8695 External recharging system for battery (external) for use with implantable neurostimulator, replacement only 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 ischem ic 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+ ,S34.121+ – S34.129+ S34 .132+, Incomplete spinal cord lesion S34.3xx+ Injury of cauda equina ICD-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 Archived 9 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 subcu taneous 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 a nd 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 S12.000+ – S12.691+ Fracture of cervical vertebra and other parts of neck S13.100+ – S13.2 9x+ 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+ Spinal cord injury, incomplete [thoracic, lumbar, sacrum, coccyx and cauda equine ] [can be billed with/without ICD-10 code for fracture] Archived 10 S34.101+ – S34.109+ S34.121+ – S34.129+ S34.132+ – S34.139+ T66.xxx+ Radiation sickness, unspecified [radiation-induc ed 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 Pump Information 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: 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump 36576 Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36583 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access 36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral inserti on 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, alarm status, drug prescription status) 95990-95991 Refilling and maintenance of implantable pump or reservoir for drug delivery , spinal (intrathecal, epidural) or brain (intraventricular) 96365-96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) 96522 Refilling and maintenance of implantable pump or reservoir for drug delivery, system ic (e.g., intravenous, intra-arterial) 96523 Irrigation of implanted venous access device for drug delivery systems 99601-99602 Home infusion/specialty drug administration HCPCS codes covered if selection criteria are met: A4220 Refill kit for implantable infusion pump A4300 Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc. ) external access Archived 11 A4301 Implantable access total catheter, port/reservoir (e.g., venous, arterial, epidural, subarachnoid, peritoneal, etc.) A4305 Disposable drug delivery system, flow rate of 50 ml or greater per hour [not covered for intralesional administration of narcotic analgesics and anesthetics] A4306 Disposable drug delivery system, flow rate of less than 50 ml per hour [not covered for intralesional administration of narcotic analgesics and anesthetics] C1772 Infusion pump, programmable (implantable) C1891 Infusion pump, nonprogrammable, permanent (implantable) C2626 Infusion pump, nonprogrammable, temporary (im plantable) C8957 Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump E0782 Infusion pump, implantable, nonprogrammable (includes all components, e.g., pump, catheter, connectors, etc.) E0783 Infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.) E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replace ment E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) J2270 Injection, morphine sulfate, up to 10 mg J2278 Injection, ziconotide, 1 microgram Q0081 Infusion therapy, using other than chemotherapeutic drugs, per visit S0093 Injection, morphine sulphate, 500 mg (loading dose for infusion pump) 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) G89.4 Chronic pain syndrome G95.11-G95.19 Vascular myelopathies S12.000+ – 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+ Fracture of vertebral column with spinal cord injury Archived 12 S14.151+ – S14.157+ S14.101+ – S14.139+ S14.151+ – S14.159+ Injury of nerves and spinal cord at neck level ICD-10 codes n ot 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) Archived 13 FOR SELECTED PAIN MANAGEMENT PROCEDURES, LOCALIZATION TYPES PERMITTED and EXCLUDED WITH MODIFIER RELATIONSHIPS AS PER CARESOURCE POLICY AND SELECTED AMA GUIDELINES Injection codes (IF) Imaging localization codes (THE N) Relationship YES=Covered, No=Not covered Trigger points 20552, 20553 76000 76001 77001 NO PER CARESOURCE POLICY NO IMAGING PERMITTED Trigger points 20552, 20553 77002, 77003, 76492 NO, PER CARESOURCE POLICY Epidural injections 62310 62311 64479 64480 64483 64484 0228T 0229T 0230T 0231T 76000 76001 77001 77002 NO, PER CARESOURCE POLICY NO IMAGING PERMITTED Epidural injections 62310 62311 64479 64480 64483 64484 0228T 0229T 0230T 0231T 77003 YES, but only with-59 modifier Facet injections 64490 64491 64492 64493 64494 64495 0213T 0214T 0215T 0216T 0217T 76000 76001 77001 77002 NO, PER CARESOURCE POLICY NO IMAGING PERMITTED Archived 14 Injection codes (IF) Imaging localization codes (THE N) Relationship YES=Covered, No=Not covered 0218T Facet injections 64490 64491 64492 64493 64494 64495 0213T 0214T 0215T 0216T 0217T 0218T 77003 YES, but only with-59 modifier Facet neurotomy 64633 64634 64635 64636 76000 76001 77001 77002 NO, PER CARESOURCE POLICY NO IMAGING PERMITTED Facet neurotomy 64633 64634 64635 64636 77003 YES, but only with-59 modifier Sacroiliac injections 27096 G0260 G0259 76000 76001 77001 77002 NO, PER CARESOURCE POLICY NO IMAGING PERMITTED Sacroiliac injections 27096 G0260 G0259 77003 72275 YES, but only with-59 modifier AUTHORIZATION PERIOD Archived 15 E.RELATED POLICIES/RULES See 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 HISTO RY Date Issued: 07/26//2016 Date Reviewed: 07/26/2016 Date Revised: 07/26/2016 G. REFERENCES 1. 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 The Payment Policy Stateme nt det ailed a bove has r eceived due consi deration as defined in the PaymentPoli cy Stateme nt Po li cy a nd is a pprove d. Archived
Vaccination and Immunization Services 1 PAYMENT POLICY STATEMENT : OH MEDICAIDOriginal Effective Date Next Annual Review Date Last Review / Revision Date 12/01/2013 06 /0 6 /2017 0 6 / 06 /2016 Policy Name Policy Number Va ccination and Immunization Services PY-0040 Policy Type Medical Administrative PaymentPayment 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 develop ing 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 referra l, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practi ce 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 Covera ge 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 determ ination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. A.SUBJECTVaccination and Immunization Services B.BACKGROUNDReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing.Health care providers and their office 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 appropriateCPT/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 paym ent.Vaccines must be licensed by the U.S. Food and Drug Administrations (FDA) Center forBiologics Evaluation and Research prior to use in the United States (U.S.). Before the FDAapproves a license, vaccines are tested for safety and efficacy. Vaccines approved for marketing Archived Vaccination and Immunization Services 2 may also be required to undergo additional studies to further evaluate the vaccine and often to address specific questions about the vaccine’s safety, effectiveness, or possible side effects. CareSource endorses the same recommended childhood immunization schedule that is approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). This schedule is updated annually and the most current updates can be found at www.aap.org . Health care providers may administer immunizations obtained through Ohio’s Vaccines for Children (VFC) program to CareSource members. The vaccines are available free of char ge through the Ohio Department of Health. CareSource will reimburse participating providers for immunizations/vaccines based on recommendations from the Centers for Disease Control and Prevention (CDC) and Ohio Department of Health. CareSource will reimburse providers for the administration of Medicaid approved vaccines as well as for the vaccines themselves, except in the case of immunizations provided to VFC-eligible members. In these cases, only the administration fee will be reimbursed. C. DEFINITIONS Immunization-is the process by which a person becomes protected against a disease through vaccination. This term is often used interchangeably with vaccination or inoculation. Immunity-is p rotect ion from an infectious disease. Vaccination-is t he act of introducing a vaccine into the body to produce immunity to a specific disease. Vaccine-is a product that stimulates a persons immune system to produce immunity to a specific disease, protecting the person from that disease. Vaccines are usually administered through needle injections, but can also be administered by mouth or sprayed into the nose. Vaccines for Children Program (VFC ) is a federally funded program that works to raise childhood immunization levels in the United States by supplying health care providers with free vaccines for children 18 years old and younger who might not otherwise be vaccinated because of inability to pay. CDC buys vaccines at a discount and distributes them to grantees, which in turn distribute them at no charge to those private physicians’ offices and public health clinics registered as VFC providers. To be eligible for the VFC program, a child must meet one of the following criteria: Medicaid-eligible Without health insurance Underinsured, for example, the child has health insurance that does not cover; immunizations Identified by parent or guardian as American Indian or Alaskan native D. POLICY I.Vaccines for Children Program (VFC) Providers A. To bill for VFC vaccine administration the provider must use the appropriate procedure code for the specific vaccine being administered. B. Providers are not to bill for more than the VFC vaccine administration on the date of service. Archived Vaccination and Immunization Services 3 C.If the only service provided during the encounter is vaccine administration, the provider may not bill for an office visit. D. An office visit can only be billed if a separate, identifiable service is performed during the same visit. E. When the provider gives face-to-face counseling for the patient and family during the administration of a vaccine to a patient aged 18 years or younger, code 90460 or a combination of codes 90460 and 90461 are reported, regardless of whether the vaccine is administered orally or through injection. F. The medical record documentation must support that the physician provided the vaccine counseling. G. In order to be reimbursed for the administration fee, the corresponding vaccine must be billed on the same claim/date. Similarly, the vaccine should not be billed without the administration code. II.Non-Vaccines for Children Program (VFC) Providers A. The codes 90633, 90634, 90645, 90646, 90647, 90648, 90656, 90658, 90660, 90707, 90710, 90714, 90715, 90716, 90718, 90732, 90733, and 90734 for individuals eighteen years or younger will be covered under the VFC program. B. For adults over 18 years of age, these codes will be reimbursed at the lesser of the providers billed charge or the Medicaid maximum. C. Immunizations are reimbursable as a physician or clinic service only if the immunization was provided in a nonhospital setting. D. Immunizations administered in a hospital setting are reimbursable only to a hospital billing on an institutional claim form/transaction. E. When the physician or qualified health care professional does not perform the vaccine counseling to the patient or family, or when vaccines are administered to patients older than 18 years, codes 90471 90474 are reported instead of codes 90460 90461. Codes 90471 90474 are reported as appropriate based on their current guidelines (i.e., either 90471 or 90473 is reported for the first vaccine administered to a patient on a calendar date, and codes 90472 and 90474 are reported for each additional vaccine given on the same date based on its route of administration). III. Children 18 and under: A. Immunizations are covered through the Vaccines for Children (VFC) program. Some vaccines administered through this program include : 1. Diphtheria 2. Haemophilus influenzae type b 3. Hepatitis A 4. Hepatitis B 5. Influenza (Flu shot) 6. Tuberculosis(TB) 7. Rotavirus 8. Rubella 9. Tetanus 10. Varicella (chickenpox) 11. Human Papillomavirus (HPV) 12. Poliomyelitis 13. Pneumococcal 14. Measles 15. Mumps ArchivedVaccination and Immunization Services 4 16. Meningococcal 17. Pertussis (whooping cough) Note:HPV vaccines coverage is for members ages 9-26; male & female. IV. Adults age 19 and older: A. Immunizations for Adults CareSource Medicaid include: 1. Influenza (Flu shots are covered at a participating pharmacy) 2. Tetanus, diphtheria, pertussis (Td/Tdap) 3. Va ricella 4. Human Papillomavirus (HPV) 5. Tuberculosis(TB) 6. Measles, mumps, rubella (MMR) 7. Pneumococcal (polysaccharide) 8. Meningococcal 9. Hepatitis A 10. Hepatitis BNote: HPV vaccines coverage is only for members ages 9-26; male & female. V. Vaccines for travel outside of the United States are not covered. 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 appropriate state Medicaid fee schedule. 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 referenced sources for the most current coding information. CPT Codes Code Description 90460 Immunization administration through 18 years of age via any route of administration, with face to face counseling by physician or other qualified health care professional; first or only component of vaccine/toxoid. 90461 Immunization administration through 18 years of age via any route of administration, with face to face counseling by physician or other qualified health care professional; each additional vaccine/toxoid component . 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) 90474 Immunization administration by intranasal or or al route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Archived Vaccination and Immunization Services 5 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for intra muscular use 90621 Meningococcal recombinant lipoprotein vaccine, Serogroup B (MenB), 3 dose schedule, for intramuscular use 90632 Hepatitis A vaccine (HepA), adult dosage, for intramuscular use 90633 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for intramuscular use 90634 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular use 90636 Hepatitis A and hepatitis Bvaccine (HepA-HepB), adult dosage, for intramuscular use 90644 Meningoco ccal conjugate vaccine, serogroups C & Yand Haemophilus influenzae type Bvaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-18 months of age, for intramuscular use 90647 Haemophilus influenza type b vaccine (Hib), PRP-OMP conjugate 3 dose schedule, for intramuscular use 90648 Haemophilus influenza b vaccine (Hib), PRP-Tconjugate, 4 dose schedule, for intramuscular use 90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use 90681 Rotavirus vaccine, human, att enuated (RV1), 2 dose schedule, live, for oral use 90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type B, and inactivated poliovirus vaccine (DTap-IPV/Hib), for intramuscular use 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) when administered t o individuals younger than 7 years, for intramuscular use 90702 Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for intramuscular use 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subc utaneous use 90710 Measles, mumps, rubella and varicella vaccine (MMRV), live, for subcutaneous use 90712 Poliovirus vaccine, (any type[s]), (OPV), live, for oral use (Code deleted 12/31/2015) 90713 Poliovirus vaccine, inactivated (IPV), for subcutaneou s or intramuscular use 90714 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use 90716 Varicella virus vaccine (VAR), live, for subcutaneous use 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use 90733 Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135,quadrivalent (MPSV4), for subcutaneous use 90734 Meningococcal conjugate vaccine, serogroups A, C, Yand W-135, quadrivalent (MenACW Y), for intra muscular use 90740 Hepatitis Bvaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use 90743 Hepatitis Bvaccine (HepB), adolescent, 2 dose schedule, for intramuscular use 90744 Hepatitis Bvaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use 90746 Hepatitis Bvaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use ArchivedVaccination and Immunization Services 6 90747 Hepatitis Bvaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use 90748 Hepatitis Band Haemophilus influenza type b vaccine (Hib-HepB), for intramuscular use HCPCS Description G0010 Administration of hepatitis Bvaccine J3530 Nasal vaccine inhalation AUTHORIZATION PERIOD If applicable, reimbursement is dependent upon products and services frequency, duration and timeframe set forth by Medicaid. E. RELATED POLICIES/RULES Further information can be found at:http://codes.ohio. gov/oac/5160-4-12 https://www.caresource.com/members/ohio/ohio-medicaid/benefits-and-services/healthchek-program/ F. REVIEW/REVISION HISTORY Date Issued: 12/01/2013 Date Reviewed: 12/01/2013, 06/ 06/2016 Date Revised: 06/06/2016 G. REFERENCES 1. Immunization Program. (2014, December). Retrieved May 23, 2016, from http://www.odh.ohio.gov/odhprograms/bid/immunization/immindex1.aspx 2. Vaccines and Immunizations. (2016, May). Retrieved May 23, 2016, from http://www.cdc.gov/vaccines/ The Payment Policy Stateme nt det ailed a bove has r eceived due consi deration as defined in the PaymentPoli cy Stateme nt Po li cy a nd is a pprove d. Archived
1 PAYMENT POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 10/31/2013 03/09/2017 03/09/2016 Policy Name Policy Number Advanced Diagnostic Imaging Services PY-0041 Policy Type Medical Administrativ e Payment 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 limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practi ce 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 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 services provided in a particular case and may modify this Pol icy at any time. A.SUBJECTAdvanced diagnostic imaging ServicesB. B ACKGROUNDCareSource will cover medically necessary imaging services including diagnostic radiology,mammography, bone densitometry, nuclear medicine, magnetic resonance imaging/magnetic resonance angiography (MRI/MRA), computerized tomography/ computerized tomographic angiography (CT/CTA), positron emission tomography (PET scan) and ultrasound procedures.C. D EFINITIONSAdvanced d iagnostic Imaging (ADI) refers to the applications of high energy modalities and other technologies to allow the visualization and examination of body tissues including but not limited to computed tomography (CT), magnetic resonance imaging (MRI),magnetic resonance angiography (MRA) , and positron emission tomography (PET).Technical Component represents the non-physician work (including facility, equipment,personnel and administrative costs ) related to the procedure.Professional Component refers to the physician work related to performing and interpreting the results of a procedure . Archived 2D. POLICY I. Prior Authorization A. Diagnostic imaging services performed in the emergency room, observation, and inpatient settings do not require prior authorization. B. CareSource requires providers to obtain authorization prior to requesting ADI services in an outpatient setting, including: 1. CT/CTA 2. MRI/MRA 3. PET Scan 4. Nuclear Cardiology C. MRI/MRA, CT/CTA and PET procedures must be performed in a participating designated free-standing imaging center or a participating hospital. D. If the rendering provider identifies a need to extend the examination to a contiguous body area or identifies a need to perform a different examination than what was originally authorized, the radiologist or facility should notify NIA of the extended study or additional service within the same day. 1. NIA will either update the authorization record to include the extended examination or issue a new authorization number for the additional service. II. Global Payment and Component Services A. CareSource covers the professional component for physicians in any setting. 1. The technical component is covered only when that service is provided in an appropriate non-facility setting. B. The global service (which is inclusive of the professional component) is covered by CareSource in non-facility settings. 1. When a physician reports a global procedure, the physician is responsible for the overall performance and quality of the test. 2. The physician must either personally perform the test or it must be performed under the physicians supervision and direction. 3. The physician must personally interpret the results and complete the written report. 4. While some radiology procedures and diagnostic tests may not require the presence of the supervising physician on the premises, other procedures dictate that the physician be present and and/or directly involved in the performance of the procedure. C. Interpretation of radiology services are covered for any physician trained in the interpretation of the study. 1. The provider who interprets the study must be the one who prepares and signs the written report for the medical record. D. Review of results and explanation to the beneficiary are part of the attending physicians E/M service and are not considered as interpretation of the study. E. Incidental and ancillary services (e.g. contrast, drugs, related supplies etc) utilized in advanced diagnostic i maging studies will be reimbursed within the global payment and will not be reimbursed separately. 1. This includes (but is not limited to) submissions involving A codes, Jcodes, Qcodes). III. Multiple Services on Same day A. CareSource covers bilateral x-rays when medically necessary. 1. Bilateral services are studies done on the same body area, once on the right side and once on the left side. Comparison films obtained for routine purposes are not Archived 3covered. 2. Providers should use a bilateral code when available. B. CareSource also covers multiple studies of both areas if reported with the appropriate modifier. 1. Examples would include bilateral wrist studies done before and after fracture care on both wrists the same day for the same patient or doing films to assess a patients response to medical care, such as multiple chest films to monitor the cardiopulmonary status of a critically ill patient . IV. Billing Information A. CareSource recognizes a professional component and a technical component for each radiological procedure. 1. When both components are performed by one provider, they are recognized as the total (radiological) procedure. B. X-rays and documentation of all results of radiological procedures must be maintained on file for a period of six years. 1. In addition, x-rays must be of sufficient quality to ensure ease of diagnosis and must be marked with the patients name and dated for ready identification. C. When submitting a claim for radiology services, providers must use the appropriate modifiers. 1. CareSource will directly reimburse a radiologist the professional component when the radiologist performs the initial interpretation of a radiological examination. 2. CareSource will directly reimburse a radiologist or cardiologist for the professional component when the radiologist or cardiologist interprets a radiological procedure that has already been interpreted by another physician. 3. In th is case, the radiologists or cardiologists interpretation is deemed a specialists evaluation (of the interpretation of the treating physician) whose findings could affect the course of treatment initiated or cause a new course of treatment to begin. D. Rei mbursement is not allowed for an interpretation of a radiologic procedure performed by the attending, treating, or emergency room physician after a radiologists or cardiologists interpretation. 1. Such a service would be considered a part of the physicians overall workup or treatment of the patient and reimbursed as part of the visit. 2. Physician providing radiological services in an inpatient hospital, an outpatient hospital, or an emergency room setting may bill CareSource only for the professional compo nent. E. CareSource will reimburse a physician/provider for only the technical component if: 1. The physician personally performed the service or the service was performed by an employee of the physician/provider 2. The professional component was performed by another physician/provider 3. The service was performed in a setting other than an inpatient hospital, an outpatient hospital or an emergency room. F. CareSource will reimburse a physician for the total procedure when the radiologist or treating physician performs the professional and technical components of a radiological procedure in a setting other than an inpatient hospital, an outpatient hospital, or an emergency room. G. CareSource will reimburse any other non-hospital provider for the total procedure when: 1. The physician who performed the professional component has an employment or contractual arrangement for the provider to bill for the professional services 2. The technical component was performed in a setting other than an inpatient Archived 4hospital, an outpatient hospital, or an emergency room. V. Diagnostic and Radiology Services A. In accordance with AMA Principles of CPT Coding CareSource will not compensate a diagnostic test or radiology service billed with modifier 26 (professional component) and modifier TC (technical component) if the technical and professional components of the service are performed by the same provider billed on the same or different claim on the same date of service. CONDITIONS OF COVERAGE HCPCS CPT AUTHORIZATION PERIOD E. RELATED POLICIES/RULES CareSource Payment Policy: Emergency Department EKG and Imaging Interpretation CareSource Payment Policy: Bilateral Procedures OHIO: https://www.caresource.com/providers/ohio/ohio-providers/payment-policies/ KENTUCKY: https://www.caresource.com/providers/kentucky/medicaid/payment-policies/F. REVIEW/REVISION HISTORY Date Issued: 10/31/2013 Date Reviewed: 10/31/2013, 03/09/2016 Date Revised: 03/09/2016-CareSource requires providers to obtain authorization prior to requesting ADI services in an office or outpatient setting . G. REFERENCES 1. OAC 5160-4- 25, Physician Services, Laboratory and Radiology services. 2. 907 KAR 3:005. Physicians’ Services, Section 5. Prior Authorization Requirements The Payment Policy Stateme nt detailed a bove has r eceived due con side ration as defined in the PaymentPo licy Stateme nt Policy and is a pprove d.Archived
PAYMENT POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 11/17/2014 11/17/2016 11/17/2015 Policy Name Policy Number Preventive Services and Sick Visit on Same Date of Service PY-0007 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. I n 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 limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practi ce 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 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 services provided in a particular case and may modify this Policy at any time. A.SUBJECTPreventive Services and Sick Visit on Same Date of ServiceB. BACKGROUND CareSource will reimburse participating providers as outlined in this policy when a preventiv e s ervices visit or exam and a sick visit are performed on the same date of service for aCareSource member.C.D EFINITIONSCurrent Procedural Terminology (CPT) codes are numbers assigned to every task,medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American MedicalA ssociationPrev entive Services are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing, vision, and dental checks,nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for childre n under the age of 21ArchivedD. POLICY Preventive medicine exam codes 99381-99387 and 99391-99397 should be billed with the appropriate ICD-9 diagnosis codes (if before 10/1/2015) or ICD-10 diagnosis codes (after 10/1/2015). When a provider conducts a preventive medicine service or exam at the time of an acute care visit, Evaluation & Management CPT codes 99201-99205 or 99212-99215 may be submitted along with the appropriate ICD-9 or ICD-10 code, indicating the reason for t he acute care visit, as a secondary diagnosis. CareSource will reimburse the provider for the preventive medicine CPT code at 100% of the allowed amount, and will reimburse the provider for the acute care CPT code at 50% of the allowed amount. Please see the examples provided below. Correct Billing Example (this examp le is pre-10/1/2015, using ICD-9) Date of Service Procedure Diagnosis Code Billed Amount Allowed Amount01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 462 $100.00 $20.19 (50%) Incorrect Billing Example (this example is pre-10/1/2015, using ICD-9) Date of Service ProcedureDiagnosis Code Billed Amount Allowed Amount 01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 V20.0 $100.00 $0.00 For Medicare Plan members, reference the Applicable National Coverage Descriptions (NCD) and Local Coverage Descriptions (LCD).CONDITIONS OF COVERAGE HCPCS CPT A UTHORIZATION PERIOD E. RELATED POLICIES/RULES F. REVIEW/REVISION HISTORY Date Issued: 11/17/2014 Date Reviewed: 11/17/2014, 11/17/2015 Date Revised: 11/17/2015 Revision includes payment policy legal language. G. REFERENCES The Payment Policy Stateme nt detailed a bove has r eceived due con side ration as defined in the PaymentPo licy Stateme nt Policy and is a pprove d. Archived
(footnotes added here) MEDICAID POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 10/ 18/2013 10/18 /2016 10/20/2015 Policy Name Policy Number Allergy Testing and Allergen Immunotherapy PY-0006 Policy Type Medical Administrativ e Payment Medicaid Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) apply to Medicaid health benefit pl ans administered by CSMG and its affiliates and are derived from literature based on and supported by applicable federal or state c overage mandates, clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not lim ited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or pro vider. 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. M edic aid Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan benefit document (i.e., Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there i s a conflict between the Medicaid Policy Statement and the plan benefit document, t hen the plan benefit document will be the controlling document used to make the determination. In the absence of any applicable controlling fe deral or state coverage mandate, benefits are ultimately determined by the applicable plan benefit document. A.SUBJECTAllergy Testing and Allergen ImmunotherapyB. BACKGROUNDC. D EFINITIONSAllergen immunotherapy: (Desensitization, Hypo-sensitization) is parenteral administratio n of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scaleto a dosage maintained as maintenance therapy.Allergy: Refers to an acquired potential for developing adverse reactions that are medi at ed b y the immune system (via IgE antibodies). Allergic disease represents the clinical manifestations of these adverse immune responses.Allergy testing: Identifying the offending antigen(s) for a patient by in-vivo testin g per cutaneous, intradermal, and less commonly, patch and photo patch tests.Dose: A 1cc aliquot of medicine or serum taken from a single, multi-dose vial. Ten doses are typically obtained from such a vial. In accordance with CMS guidelines, diluted doses will not be reimbursed; instead, if the medication or serum is diluted, only those doses designated from the maintenance vial (a maximum of ten) will be reimbursed.D. PO LICYI. Allergy testingCareSource will reimburse providers of physician services for the performance an d ev aluation of allergy sensitivity tests when the following conditions are met: Archivevd (footnotes added here)A. A complete medical and allergic/immunologic history and physical examination must be done prior to performing diagnostic testing and be made available to CareSource upon request B. Th e testing must be performed based on the medical and allergic/immunologic history and physical examination that documents that the antigen being used for the testing exists within a reasonable probability of exposure in the patients environment and be documented in the patients medical record C. Based on the information in the medical record, the testing must be limited to the minimal number of necessary tests to reach a diagnosis 1. Percutaneous tests, intra-cutaneous/intradermal tests, photo patch test s, and patch tests, photo tests, or application tests are reimbursed on a per test basis. When submitting claims, the provider must specify the number of tests performed. 2. Quantitative or semi-quantitative in-vitro allergen specific IgE tests (formerly referred to a RAST tests) are covered if skin testing is not possible or not reliable and they are performed by providers certified under the Clinical Laboratory Improvement Amendment of 1988 (CLIA 88) to perform the tests. 3. Ophthalmic mucous membrane tests and direct nasal mucous membrane tests are allowed only when skin testing cannot test allergens. 4. If an ingestion challenge test is completed in less than 61 minutes, according to CPT/RUC rules, an E/M code should be used instead of 95076, if appropriate. 5. The add-on code [95079] is intended to be used for challenges lasting beyond the two hour base code. CPT rules require that an add-on must last at least for 1 min. more than 50% of the total duration of the code, which means ph ysicians should not use 95079 until the additional time equaled at least 31 minutes beyond the firs t two hour oral food challenge. D. Allergen immunotherapy 1. Providers may be reimbursed for the professional services necessary for allergen immunotherapy. 2. An office visit may be reimbursed in addition to the allergen immunotherapy codes (95115, 95117, 95144-95180) only if other identifiable services are provided at that time. If an office visit code is submitted with an allergen immunotherapy service, the modifier 25 must be used. 3. Allergen immunotherapy will not be covered for the following antigens: newsprint, tobacco smoke, dandelion, orris root, phenol, formalin, alcohol, sugar, yeast, grain mill dust, goldenrod, pyrethrum, marigold, soyb ean dust, honeysuckle, wool, fiberglass, green tea, or chalk since they are not considered medically necessary. 4. CareSource recognizes two components of allergen immunotherapy, one being the administration (injection) of the antigen, which includes all professional services associated with the administration of the antigen, and the other being the antigen itself. These two components must be separate on the claim, regardless of whether or not the provider who prescribes and provides the antigen is the same as the provider who administers the antigen. E. Injections 1. For reimbursement for the administration (injection) of allergenic extract or stinging insect venom, the provider must use CPT code 95115 or 95117. The allergenic extract may be administered by the physician or by a properly instructed employee under the general supervision of the physician in an office setting. These codes may not be used with CPT code 95144 [Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vials]. Archivevd (footnotes added here)F. Antigens (excluding stinging insect venoms) 1. When the provider prescribes and provides single or multiple antigens for allergen immunotherapy in multiple-dose vials (i.e., vials containing two or more doses of antigens), the provider must use CPT code 95165 [Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; single or multiple antigens] in the procedure/service code block and the number of doses contained in the vial in the unit(s) block on the invoice. If the provider dispenses two or more multiple-dose vials of antigen, for each vial dispensed CPT code 95165 must be listed on a separate line along with the corresponding number of doses. 2. For example, if a patient cannot be treated with immunotherapy by placing all antigens in one vial and two multi-dose vials containing ten doses each must be dispensed, the CPT code 95165 must be listed on two separate lines and a 10 (for ten doses) must be entered for the corresponding units. 3. CPT code 95144, the single dose vial antigen preparation code, must not be used as one of the components of a complete service performed by a provider. The code must be used only if the provider providing the antigen is providing it to be injected by some other entity. The number of vials prepared must be indicated. 4. CareSource does not recognize CPT codes 95120 through 95134 because they represent complete services, i.e., services that include the injection service as well as the antigen and its preparation. Only component billing will be allowed. Providers providing both components of the service must do component billing. The provider must, as appropriate, use one of the injection CPT codes (95115 or 95117) and one of the antigen/antigen preparation CPT codes (95145 through 95149, 95165, or 95170). The number of doses must be specified. G. Insect venoms in single dose vials or preparations 1. If the provider administers the venom(s), CPT code 95115 or 95117 must be used for the injection(s) of the antigen(s). 2. When a provider prescribes and/or provides stinging insect venom antigens in single dose vials or preparations, CPT codes 95145 to 95149 must be used. 2.1 For each single dose vial or preparation provided, a unit of service of 1 must be reported. 2.2 If the provider also administers the venom, CPT code 95115 or 95117 must be used for the injection(s). H. Insect venoms in multiple dose vials or preparations 1. When a provider prescribes and provides single or multiple stinging insect venom(s) in multiple dose vials, CPT codes 95145 to 95149 must be used. The number reported as the unit of service must represent the total number of doses contained in the vial. 2. Regardless of the number of doses, the date of service reported should be: 2.1 The date the vial is dispensed to the patient, if the patient takes the vial home to be administered at a different office OR 2.2 The date that the first dose is administered to the patient, if the vial is kept in the physicians office. 3. If the provider also administers the venom, CPT code 95115 or 95117 must be used for the single or multiple injection(s). The correct quantity is one for either code. Archivevd (footnotes added here) CONDITIONS OF COVERAGE CareSource will reimburse a participating provider of physician services for allergy testing and injections administered by a properly instructed person in an office setting in accordance with the physicians prescribed plan of treatment. C areSource does not cover: Allergen immunotherapy that is considered experimental, investigational, or u nproven; A llergen therapy administered by the member at home, from vials of serum prepared by t he pr ovider.HCP CS CPT AUT HORIZATION PERIOD/PRIOR AUTHORIZATION Authorization is not required for immunotherapy services administered by a participating provider within the limitations outlined. E. R ELATED POLICIES/RULESCareSource Policy-Antigen Leukocyte Cellular Antibody Testing (ALCAT) F . REVIEW/REVISION HISTORYDate Issued: 10/18/2013 Date Reviewed: 10/18/2013, 02/01/2015, 10/20/2015 Date Revised: 02/01/2015 Definition of dose; non-covered services; updated OAC reference G. R EFERENCES1. Federal Register 65 FR 653762. OAC Chapter 5160-4- 19 Physician Services / Allergy services.3. (from BlueCross BlueShield Online Medical Dictionary, www.bcbsms.com) ) 4.(from www.tuftshealthplan.com)Th e med ical Policy Stateme nt detailed a bove has r eceived due con side ration as defined in the Medic al Policy Stateme nt Policy and is a pprove d.Archivevd
1 Medical Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical manag ement industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited t o, 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 pract ice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessa ry services also include those services defined in any Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization or payment of services. Please refer to the plan c ontract (often referred to as the Evidence of Coverage) for the service(s) referencedin the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evi dence ofCoverage), then the plan contract (i .e., Evidence of Coverage) will be the controlling document used to make the determination. For Medicare plans please reference the below link to search for Applicable National Coverage Descriptions (NCD) and Local Coverage Descriptions (LCD):OHIO ONLY: MEDICAL POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 10/06/2015 10/06/2016 10/06/2015 Policy Name Policy Number Observation Care Services PY-0003 A. SUBJECTObservation Care Services B. BACKGROUND Patients presenting to the Emergency Department: Determinations for ongoing treatment of members presenting to an emergency department (ED) may depend on several factors. These include, but are not limited to, the specific condition in question, the members medical history, the severity of the presenti ng signs and symptoms, the predictability of adverse events and/or the availability and anticipated intensity of necessary service(s) following initial evaluation and management. Members, whether as a result of an uncertain diagnosis, unacceptable cli nical risk, indeterminatecourse, unexpected complication(s) and/or other factors, may require a period of time for observing and monitoring, further evaluation and/or treatment. This may relate to a known condition or to establish a diagnosis in order to facilitate discharge from an ED, or conversely, to determine that further acute care in the hospital is necessary. Such situations are frequently amenable to the use of outpatient or observation care. Patients undergoing Outpatient Procedures: Observati on Level of Care should not be used forroutine diagnostic services, outpatient surgeries or ambulatory procedures under normal circumstances. Further, the usual preparation and the routine or expected recovery monitoring and care following such procedures are not considered Observation Services.Determinations for short term monitoring, evaluation and/or stabilizing care of members following invasive diagnostic testing or outpatient surgery who have sustained an unexpected delay in recovery and/or com plication may be amenable to the use of observation care prior to dischargeor as a means of determining that further Inpatient Care is necessary.2 Observation Care: In these and other appropriate clinical settings, Observation Care has been described as a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, an d reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation Care is considered to be medically necessary when the patient’s current conditionrequires outpatient hospital services, or when there is a significant risk of deterioration in the immediate future such that continued observation in a non-hospital environment is inadvisable.Any determination for Inpati ent Care or Observation Care for a member is covered only whenprovided by the order of a physician or another healthcare professional authorized by State licensure law and hospital staff bylaws to admit patients to the hospital based on the providers pro fessional expectation of the care that will be needed for that member.In general, if the treating physician or healthcare professional is uncertain if an inpatient admission is appropriate, or if the presenting complaint is symptom oriented (i.e. abd ominal pain,chest pain, and shortness of breath) consideration should be given to admitting the patient for observation.The generally accepted rule is that the physician “should order an inpatient admission for patients who are expected to need hospi tal care for 24 hours or longer and treat other patients on anoutpatient basis. Modifications have been provided by CMS through final rule [CMS-1599-F] for the purpose of determining how inpatient admissions are reviewed for reimbursement, This rule state s, In addition to services designated as inpatient-only, surgical procedures, diagnostic tests and other treatments are generally appropriate for inpatient hospital admission and payment under Medicare Part A when the physician (1) expects the beneficiary to require a stay that crosses at least two midnights and (2) admits the beneficiary to the hospital based upon that expectation. The timeframe used for determining the expected stay begins when the individual begins receiving services in the hospital and includes Observation Services as well as services provided in the emergency department, outpatient and other areas.An inpatien t admission is not covered when the care can be provided in a less intensive settingwithout significantly and indirectly threatening the patient's safety or health.Decisions for the appropriate Level of Care should be made in a timely manner. In most cases, the decision whether to discharge a patient from the hospital (following resolution of the clinical situations that have led to the observation care) or to admit the patient as an inpatient can bemade in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases does reasonable and necessary outpatient Observation Services span more than 48 hours.C. DEFINITIONSInpatient Care: Acute, m edically complex management and care furnished to a patient while resident in a hospital. This includes, but is not limited to, room and board, diagnostic services; nursing, social and therapeutic services; medical and surgical services and associated anc illary care. Level of Care: The intensity and complexity of clinical (medical-surgical) services provided under the supervision of a physician, or other appropriate health care provider, within the health care facility appropriate for those services. 3 Observation Services: Patient specific services furnished by a hospital on its premises,including the use of a bed, periodic monitoring by nursing and other staff, and any other services that are reasonable and necessary to evaluate a pat ients condition or to determine the need for a possible (inpatient) admission to the hospital. Outpatient Procedures: Diagnostic and/or therapeutic clinical services rendered at a clinic, hospital or other medical facility which by virtue of their expected intensity do not necessitate that the patient be admitted to a hospital for an extended stay. D. POLICYAlthough th e reimbursement may vary, the quality of the care and services rendered whether Inpatient or under Observation should be equivalent. For the purposes of billing codes, Observation Care is divided into Initial (CPT 99218-99220) and Subsequent phases and Admission and Discharge services. Reimbursement for Initial Observation Care is covered only when billed by a physician or other qualified health care provider who ordered the hospital outpatient Observation Services and was responsible for the member during their episode of Observation Care.Initial Care is also inclusive of all care rendered by the ordering physician on the date the patients Observation Services began. All other physicians who furnish consultations or additional evalua tions or services while the patient is receiving hospital outpatient ObservationServices must bill the appropriate outpatient service codes. For a physician or qualified health care provider to bill Initial Observation Care codes, a medical obser vation record, which is independent of any record developed as a result of care delivered ineither an emergency department or outpatient facility, must be developed. This record should include the dated and timed physicians orders regarding the Observat ion Services the patient is to receive, nursing notes, and progress notes. In those circumstances in which a member is held in observation status for more than two calendar dates, or when physicians other than the supervising physician provide healt h servicesbilling should utilize Subsequent observation codes TCPT 99224 – 99226).Evaluation and management services incorporated into subsequent observation care include reviewing and updating the medical record, integrating the results of diagno stic studies anddocumenting changes in the patients status in response to management since the last assessment by the physician, in addition to the interval history, exam and medical decision making.Payment policy for medical services rendered to Ca reSource members is based on the principleof medical necessity. CareSource will utilize established industry guidelines when reviewing for reimbursement of medically necessary services provided as a result of inpatient admission. Observation Services are not subject to medical necessity review.For Medicare Plan members, reference the Applicable National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). Compliance with NCDs and LCDs is required where applicable.Note: The following list of codes may not be all inclusive and codes that have been deleted or that are not effective at the time of health services are provided may not be eligible for payment. CPT codes 99217-99220 are utilized for Initial observation care for (E/M) services provided to new or established patients admitted to “observation status” for care in a hospital. 4 CPT codes 99224-99226 apply to subsequent observation care evaluation and management services in a hospital setting. CPT codes 99234-99236 are used to report E/M services provided to patients admitted and discharged on the same date of service. HCPCS CPTAUTHORIZATION PERIODE. RELATED POLICIES/RULES1. OAC 5160-30 Alcohol and Drug Addiction Services 2. 42 CFR, Section 410.32 3. 907 KAR 3:110. Community mental health center substance abuse services 4. http://www.healthnetworklabs.com/Pages/MedicareCoveragePolicy/GuidetoMedicaresFreque ntlyUsedCoveragePolicies.pdf F. REVIEW/REVISION HISTORYDate Issued: 10/06/2015 Date Reviewed: 10/06/2015 Date Revised: G. REFERENCES1. CMS Manual. Department of Health & Human Services (DHHS), August 26, 2011. https://www.cms.gov/Regulations-and – Guidance/Guidance/Transmittals/downloads/R2282CP.pdf 2. Centers for Medicare & Medicaid Services (CMS). Baltimore, MD, 2015. http://www.cms.gov/medicare-coverage-database/details/lcd – details.aspx?LCDId=27548&ContrId=314&ver=69&ContrVer=1&Date=03%2f11%2f2013&Do cID=L27548&bc=AAAAAAgAAAAAAA%3d%3d& 3. Centers for Medicare & Medicaid Services (CMS). Baltimore, MD, 2015. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06.pdf 4. Centers for Medicare & Medicaid Services (CMS). Baltimore, MD, 2015. https://www.cms.gov/Regulations-and – Guida nce/Guidance/Transmittals/downloads/R2282CP.pdf This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC.The medical Policy Statement detailed above has received due consideration as defined in the Medical Policy Statement Policy and is approved.
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Colonoscopies Programs Covered: OH Medicaid, KY Medicaid, OH MyCare, and Just4Me TM (all states) Po lic y Effective February 1, 2014, CareSource will reimburse participating providers for medically necessary and preventive screening colonoscopies as set forth in this policy. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) 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. (from OAC 5160-10-02) Pr o vi d er Rei m b u r se m e n t Gu i d e lin e s CareSource Just4Me & Medicaid CareSource will reimburse participating providers for the cost of medically necessary and preventive screening colonoscopies for any member aged 50 or older, and for high-risk members, with no limit on frequency. For high risk patients under the age of 50, CareSource requires the provider submit documentation of family history. No prior authorization is required for participating providers. See the qualifying high-risk factors in the section below. CareSource MyCare-For its MyCare members, CareSource will reimburse participating providers for the cost of screening colonoscopies once every 10 years, when no risk factors are present. ( G0121 with dx V76.51 Special screening for malignant neoplasm of the colon ). For high-risk MyCare members, CareSource will reimburse participating providers for the cost of a screening colonoscopy every 2 years ( G0105 plus appropriate diagnosis code ). High risk factors include: oA close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.o A family history of familial adenomatous polyposis. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 o A family history of hereditary nonpolyposis colorectal cancer. o A personal history of adenomatous polyps. o A personal history of colorectal cancer. o Inflammatory bowel disease, including Crohns disease and ulcerative colitis. Re l a t e d Po l i c i es & Re f e r e n c e sOAC 5160-4-34, Preventive medicine services. St a t e Exc ep t i o n s NONE Do c u m e n t Rev i si o n Hi s t or y Archived
Payment Policy S ubject: CPT Codes Not Covered in an Emergency Room Setting P rograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and Just4Me (all states) TM Policy CareSource will not reimburse claims for CPT Codes 93308, 93971, or 95992 when submitted with a Place of Service code 23 (Emergency Room-Hospital) , as set forth in this policy . This policy is not new and therefore has no specific effective date; rather, its purpose is to clarify any misunderstandings among our providers around these procedure codes. Definitions Current Procedural Terminology (CPT) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Healthcare Common Procedure Coding System (HCPCS ) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT) . HCPCS currently includes two levels of codes: Level I consists of the American Medical Association’s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I) . (from www.wikipedia.org) 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. ( from OAC 5160-10-02) Place of Service Codes, (POS) means codes which are regularly published by the Centers for Medicare & Medicaid Services, and which are used on reimbursement claims submitted for professional services rendered by healthcare providers. These codes specifically indicate where a service or procedure was performed. (from www.cms.gov )This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2Archived Provider Reimbursement Guidelines CPT Codes Addressed 93308: Follow-up or limited transthoracic echo (no Doppler or colorflow). 93971: Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. 95992 : Standard canalith repositioning procedures (e.g., Epley maneuver, Sermont maneuver), per day. ( Note: audiologists cannot bill Medicare for this procedure, as canalith repositioning procedures are not di agnostic tests) Prior Authorization No prior authorization from CareSource is required before providing these services to its members. Reimbursement It is CareSource policy to reimburse providers for the procedures defined by these CPT codes, unless these procedures are performed in the setting of an Emergency Room or freestanding emergency room (POS 23). When performed in an ER setting, the results of these procedures are generally referred to and read by the appropriate on-call specialist (a cardiologist, is one likely example) and the code is billed by that specialist. If the code is also billed by the emergency room unit, that means that CareSource is processing two separate claims for the same procedure, when only one procedure was rendered to the CareSource member. CareSource does not reimburse multiple providers for a single procedure, and on that basis, CareSource will deny claims for these procedures when performed in an ER setting . Related Policies & References State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 PaymentPolicySubject: Pass-Through Billing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4MeTM Po lic yEffective November 1, 2014, CareSource prohibits pass-through billing as set forth in this policy. Any claim submitted by a provider which includes services ordered by that provider, but which were performed by a person or entity other than that provider or a direct employee of that provider will not be reimbursed. De f i ni t i on sCLIA, means the Clinical Laboratory Improvement Amendments of 1988, which are federal regulatory standards that apply to all clinical laboratory testing performed on hum ans in the United States except clinical trials and basic research. (from http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA & Intern al CareSource definition) Direct Employee, means an employee of a provider who is under direct supervision of the ordering provider and the services is billed by the ordering provider. An employee is person that receives a W-2 (as opposed to a 1099) from the participating provider and does not have their own provider or NPI number. (CareSource internal definition) Pr o vi d er Rei m b u r se m e n t Gu i d el i n es CareSource prohibits pass-through billing. Pass-through billing occurs when an ordering provider requests and bills for services that are not performed by the ordering provider or by a direct employee of that provider. With respect to laboratory services, CareSource will reimburse for the services which the provider itself is certified through CLIA to perform. Claims may not be submitted to CareSource for any laboratory services for which a provider lacks the applicable CLIA certification. Additionally, CareSource members cannot be billed for any such services. CareSource considers any claim for services related to pass-through billing not eligible for reimbursement. Providers must bill CareSource only for those services which they or their direct employees perform. Providers will not bill, charge, seek payment for or submit any claims to CareSource, nor will they have any recourse against CareSource or any of its members for amounts related to the provision of pass-through billing. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Rel at ed Po l i c i e s & Ref e r en ce s42 CFR 493, Standards and certification: Laboratory Requirements. St a t e Exc ep t i o n s NONE Doc u m e nt Hi s t o r y
Payment Policy S ubject: Medication Assisted Therapy Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCarePolicy CareSource will reimburse its providers as outlined in this policy for their administration and management of medication-assisted therapies aimed at helping CareSource members withdraw completely from dependencies on short and long acting opioids . Definitions Current Procedural Terminology (CPT) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained/ updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Healthcare Common Procedure Coding System (HCPCS ) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT). HCPCS currently includes two levels of codes: Level I consists of the American Medical Association’s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I). (from www.wikipedia.org) Provider Reimbursement Guidelines Prior Authorization CareSource will manage the use of Buprenorphine Naloxone (Suboxone) / Buprenorphine (Subutex) and Zubsolv by its members through a prior authorization program that assures appropriate indication for and utilization of the drug (s). Buprenorphine Naloxone (Suboxone) / Buprenorphine (Subutex) and Zubsolv treatment should be accompanied by ongoing counseling an d psychosocial programs, combined with periodic urine screening to assure compliance with management protocols. C overage Buprenorphine Naloxone (Suboxone) / Buprenorphine (Subutex) and Zubsolv are CIII controlled medications used to treat opioid dependency and addiction. Clinical studies have demonstrated success in withdrawing patients completely from short and long acting opioids. It has also been demonstrated that Buprenorphine Naloxone (Suboxone) is commonly abused by combined usage with opioids and other commonly abused drugs , and by diversion to unintended users and for unintended purposes. This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 3 Archived The recommended clinical guidelines for the use of Buprenorphine in the treatment of opioid addiction suggest that physicians must periodically and regularly screen all patients for substance use and substance related problems. Complete assessment may require several office visits, but initial treatment should not be delayed during this period. Further recommendations include initial and ongoing drug screening to detect or confirm the recent use of drugs (e.g., alcohol, benzodiazepines, barbiturates), which could complicate the management of the members health. Urine screening is the most commonly us ed and generally most cost-effective testing method. Please refer to the CareSource Provider Payment Policy, Drug Screening, for more information. Documentation & Requirements CareSource providers who prescribe Buprenorphine Naloxone (Suboxone) / Buprenorphine (Subutex) to CareSource members, must follow these guidelines: The provider will monitor the states reporting system for members being treated (e.g. Ohio OARRS). Member s will be seen by the provider monthly at a minimum for the first 3 m onths , and no less frequently than every 2 months thereafter . All member s receiving Bupr enorphine Naloxone (Suboxone) / Buprenorphine (Subutex) should be actively engaged in therapeutic counseling either by treating physician or by an appropriately skilled consultant . Urine drug screening should be obtained as indicated using qualitative urine screening only, or other tests only if specifically indicated. Buprenorphine Naloxone (Suboxone)/Buprenorphine (Subutex) management is a Medicaid-covered service, and claims should be submitted to CareSource with the standard office E & MCPT codes, pharmacologic management, or individual psychotherapy with E & M . Claims for a ssociated counseling should be submitted using standard individual management counseling codes , depending on time spent with the member. If individual counseling codes are submitted in a claim , CareSource will not reimburse for the E & MCPT code(s) or pharmacologic management code. If counseling is referred outside the office, only E & Mor pharmacologic management CPT codes should be submitted to CareSource as part of the claim. This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 3 Archived Because Buprenorphine Naloxone (Suboxone)/Buprenorphine (Subutex) management is a covered service for CareSource members, the provider may not bill , or balance bill the member for provided services and may not request a signed waiver committing the member to payment arrangements other than the standard reimbursement provided by CareSource as outlined above . The combination medication Buprenorphine/ Naloxone (Suboxone)/ Buprenorphine (Subutex) is the only medication approved for use under these guidelines. No “off-label” or experimental use of buprenorphine/naloxone is permitted, nor will it be reimbursed under this policy. Additionally, Buprenorphine/Naloxone (Suboxone)/ Buprenorphine (Subutex) must be used as an adjunctive treatment within an individualized treatment plan for opioid addiction. It is not appropriate as a stand-alone treatment procedure. Related Polic ies & References CareSource Provider Payment Policy: Drug Screening Ohio Administrative Code 5160-30-02, Coverage and limitation policies for alcohol and other drug treatment services. Ohio Administrative Code 5160-30-03, Billable services. Ohio Administrative Code 5160-30-04, Reimbursement for community Medicaid alcohol and other drug treatment services. Ohio Administrative Code 3793: 2-1- 08 Alcohol and drug addiction programs/Treatment programs. State Exceptions NONE Document Revision History . This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 3 Archived
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