OH Med Reimbursement Policy Archived | Page 23

Post Stabilization Care Services

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 PolicySubject: Post Stabilization Care Services Po l i c y CareSource will be responsible for medically-necessary post-stabilization care provided by any participating or non-participating emergency ro om for eligible members. Prior authorization is not required for any emergency department services or for services by a participating provider in an observation setting. De f i n i t i o n sEmergency medical condition ,” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expe ct the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily fun ctions; or serious dysfunction of any bodily organ or part. (from OAC 5101:3-26-01 (W, X)) “Post-stabilization care services are covered services related to an emergency medical condition that a treating physician views as medically necessary and that are provided to the patient after an emergency medical condition has been stabilized. Post Stabilization Care Services are rendered to maintain, or under certain circumstances to improve or resolve the members stabilized condition. (from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals.pdf) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sThe purpose of this policy is to explain CareSource coverage for Post-Stabilization Care Services when provided in an emergency department. Prior AuthorizationPrior authorization is not required for coverage of Post-Stabilization Services when these services are provided in any emergency department or for services by a participating provider in an observation setting. To requ est prior authorization for observation services as a non-participating provider or to request authorization for an inpatient admission please call 1-800 – 488-0134. When calling, follow the prompt for Post Stabilization. During regular business hours, the call will be answered by the CareSource Medical Management Department. If calling after regular business hours, the call will be answered by the CareSource Nurse Triage Line. 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 If there is mutual agreement about a non-participating facility providingobservation services, the non-participating facility must sign a negotiated rate form to attest that they will accept Medicaid reimbursement. Refer to the CareSource Medical Manage ment Out of Network Referrals and Negotiations policy for additional information. CoveragePost-stabilization care services are covered services that are:Related to an emergency medical condition; Provided after a CareSource member is stabili zed; and Provided to maintain the stabilized condition, or under certain circumstances, to improve or resolve the members condition. CareSources financial responsibility for post-stabilization care services ends when: A non-participating emerge ncy room at the treating hospital assumes responsibility for the members care; A non-participating hospital assumes responsibility for the members care through transfer; A CareSource representative and the non-participating treating physician reach an agreement concerning the members care; or The member is discharged. Re l a t e d Po l i c i e s & Re f e r e n c e sOAC Chapter 5160-26-3, Managed Care Plan, Managed health care programs, Covered services. CMS Medicare Managed Care Manual – Chapter 4 – Benefits and Beneficiary Protections; 20.5 Post-Stabilization Care Services CareSou rce Emergency Department Services Policy St a t e Ex c e p t i o n sNONE Do c u m e n t Hi s t o r y10/31/2013 OAC Rule renumbered from 5101:3-26-3, per Legislative Service Commission Guidelines.

Mammography Services

Unlisted Surgical Procedures for Outpatient Claims

Transcutaneous Electrical Nerve Stimulators (“TENS”)

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 5 Payment Policy Subject: Transcutaneous Electrical Nerve Stimulators ( TENS) Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Po l i c y Effective February 1, 2014, CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. De f i n i t i o n s Transcutaneous electrical nerve stimulation (TENS ) is the application of mild electrical stimulation to skin electrodes placed over a painful area. It causes interference with transmission of painful stimuli. (from Tabers Cyclopedic Medical Dictionary, 18thEdition) 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 v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Prior Authorization Prior authorization is not required when TENS units are prescribed within the limits of this policy. The pain must have been present for at least 6 months and other appropriate treatment modalities must have been tried and failed. Coverage CareSource considers only the following conditions as being eligible for the use of a TENS unit after other appropriate treatment modalities have been tried and have failed: Herpes zoster with other nervous system complications;Reflex sympathetic dystrophy;Other nerve root and plexus disorders;Mononeuritis of upper limb and mononeuritis multiplex;Mononeuritis of lower limb and unspecified site;Osteoarthrosis and allied disorders, if arthroplasty is not indicated, the patient has disabling knee pain or stiffness or the patient has inadequate response to 6 or more weeks of treatment with medication;Spondylosis of unspecified site;Intervertebral disc disorders;Brachial neuritis or radiculitis, not otherwise specified; 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 5 Spinal stenosis, other than cervical; Lumbago; Sciatica; Dysmenorrhea, if secondary causes have been ruled-out Myalgia and myositis, unspecifi ed; Neuralgia, neuritis, and radiculitis, unspecified; or Other postsurgical status when used for acute post-operative pain for 30 days from the day of surgery where conventional pain control techniques fail to adequately reduce pain and/or medication-related adverse events are unacceptable and/or Opioid dosage reduction is needed. Use of a TENS unit and related services for conditions not listed above are not eligible for reimbursement because the medical effectiveness of such therapy has not been established. Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive): Headache Visceral abdominal pain Pelvic pain Temporomandibular joint (TMJ) pain Acute pain (e.g.; angina, back pain, fractures, musculoskeletal) Cancer or cancer treatment-related pain Chronic low back pain Fibromyalgia Multiple Sclerosis Neuropathy The conditions listed in this policy may not be associated with members treated with acupuncture, nor may they be associated with any variation of acupuncture techniques, as acupuncture is not a covered service . Documentation The provider of the TENS unit must complete a Certificate of Medical necessity attesting to the medical necessity of the services, which may be reviewed by CareSource. The provider must also assure that the member using the device is properly instructed in how to use the device in support of his or her ordered treatment plan and is aware of and understands any emergency procedures regarding the use of the TENS unit. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical re cord. The following documentation to be kept in the providers records: The Certificate of Medical Necessity. A face-to-face examination of the patient should be documented in the medical records. This record should clearly support and document the medical necessity of the TENS Unit as part of an overall treatment plan. ArchivedThis 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 3 of 5 Specific documentation as to what medical diagnosis the TENS unit is prescribed. The diagnosis must be complete. Chronic intractable pain in itself is not a sufficient diagnosis to warrant coverage. Attestation by the prescriber that a non-reimbursable trial period of at least 30 days resulted in substantial relief from pain (except for postoperative members). An estimated length of use for the unit must be in the medical records When a TENS unit is used specifically for acute post-operative pain, the medical necessity of the TENS unit is limited and will be reimbursed by CareSource only for 30 days from the day of surgery. No further reimbursement for this reason will be authoriz ed. Rental When used for the treatment of chronic, intractable pain, the TENS unit must be used by the member on a trial basis for a minimum of one month (30 days). This period is not reimbursable by CareSource to the provider. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. CareSource will reimburse the provider for an additional, trial period of 1 month (30 days). A rental period of 90 days may be submitted to CareSource if the documentation in the providers records indicates pain control benefits such as a specific reduction in medications, e.g., muscle relaxants, narcotics, analgesics directly resulting from the use of the TENS unit. Payment for rental units includes all necessary accessories and supplies, and includes fitting and instructions/education in the proper use of the TENS unit. The provider must have a physical location available to the member for the initial face-to-face fitting and instruction/education efforts.CareSource will not consider reimbursement for any other HCPCS codes for supplies and accessories during the rental period. Supplies are included in the rental amount. Purchase TENS units are covered as rental only for a maximum of 4 months. For usage beyond 4 months, a ll prior rental payments made by CareSource for the use of a TENS unit by a member are applied to the subsequent purchase of the TENS unit. For coverage of a purchase, the physician must determine that the member is likely to derive significant therapeutic benefit from continuous use of the unit over a long er period of time. Upon receiving a claim for the purchase of a TENS unit, CareSource will reimburse the provider for the purchase price of the TENS unit, less any monthly rental payments already made for that unit. Purchase will only be considered after 3 months rental and when there is clear documentation in the medical record demonstrating that: 1. The use of the TENS Unit was successful in reducing pain; 2. You have assessed the patients condition and have determined that ongoing treatment with the TENS unit is medically necessary. 3. You submit a statement with the claim submission that attests to the requirements in 1. and 2. above. 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 4 of 5 TENS units provided to members must have two or four leads with more than one modality and must be covered by a warranty of 2 years or more when purchased on behalf of the CareSource member. CareSource will not authorize the purchase or rental of a used TENS unit unless the specific unit was used previously by the member . CareSource does not allow for the sharing of TENS units. If a TENS unit is ordered for use with four leads, the medical record must document why two leads are insufficient to meet the members needs. In the event that a member has already been renting a TENS unit before enrolling in CareSource and is eligible to purchase that unit, then the claim for the purchase must include appropriate documentation showing the full period of the rental. Supplies CareSource covers 1 unit of supplies for a two-lead TENS unit and 2 units of supplies for a four-lead TENS unit. For supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For products that are supplied as refills to the original order, suppliers must contact the member prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the member . This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the patient regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, th e supplier must deliver the product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. Industry standards state the TENS supply code A4595 includes the following: Electrodes (any type) Conductive paste or gel (if needed, depending on the type of electrode) Tape or other adhesive (if needed, depending on the type of electrode) Adhesive remover Skin preparation materials. Batteries (9 volt or AA, single use or rechargeable) Battery charger (if rechargeable batteries are used) Replacement lead wires (if more often than every 12 months per medical necessity)Supplies for a TENS unit owned by a patient must be dispensed and billed on a monthly basis in quantities no greater than actually needed by the patient as no automatic shipments or stockpiling of these supplies are permitted. No supplies may be billed before they have been provided to the patient. Reimbursement for supplies must be made under a single all-inclusive code [A4595]. CareSource will reimburse one (1) unit for a two-lead TENS Unit supplies and two (2) units for four-lead TENS unit. 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 5 of 5 Billing Modifiers Rental Modifiers accepted by CareSource are as follows: RR Rental LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price) Purchase Modifiers accepted by CareSource are as follows: NU New equipment CPT codes E0720 or E0730 must be submitted with the modifier NU to indicate the purchase of the TENS unit. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim will be denied. Any such denials may be appealed by the provider via the CareSource Medical Management department. Re l a t e d Po l i c i es & Re f e r e n c e s CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-8, Chapter 5, Section 5.2.6: Medical Supplies (DME) / Transcutaneous electrical nerve stimulators (TENS) CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 10.2, 160.7.1, 160.13, 160.27, 280.13. Ohio Administrative Code 4761:1-3- 02 Ohio Administrative Code 5160-10-15, Transcutaneous electrical nerve stimulators (TENS). Ohio Administrative Code 4752:02(B)(1) 201 Kentucky Administrative Regulations 2:350 , Home medical equipment service providers. Milliman Care Guidelines St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 04/30/2014Certificate of Medical Necessity required; Reimbursable rental period clarified; Reimbursement for purchase will subtract any rental payments; Documentation of rental required for new members; Appeals addressed; correct modifiers required. 10/31/2013 OAC Rule renumbered from 5101:3-10-15, per Legislative Service Commission Guidelines. Archived

Sterilization

This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may b e subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2Payment Policy Subject: Sterilization Po l i c yCareSource provides coverage for sterilization when it meets the criteria for those services as outlined in this policy. The physician is responsible for obtaining the state-appropriate signed informed consent form from the member. De f i n i t i o n sSterilization , means any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing. (From 42 CFR 441.251) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization CareSource requires prior authorization for inpatient voluntary sterilization of eligible members . Covered sterilization services include: Management and evaluation (office) visits and consultations for the purpose of providing sterilization services;Health education and counseling visits for the purpose of providing sterilization services;Medical/surgical services/procedures provided in association with the provision of sterilization services;Laboratory tests and procedures provided in association with the provision of sterilization services;Drugs administered in accordance with sterilization services; andSupplies provided in accordance with the provision of sterilization services. Bill ing Providers are responsible for using the appropriate CPT codes on their invoices . Rei mbursement CareSource will reimburse Medicaid providers for sterilization services only if all the following requirements are met: The Member is at least 21 years of age at the time of the informed consent. The Member is mentally competent and not institutionalized. Archived This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may b e subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Sterilization is the result of a voluntary request for services by a Member legally capable of consenting to such a procedure. The Member is given a thorough explanation of the procedure. In instances where the individual is blind, deaf or otherwise handicapped or unable to understand the language of the consent, an interpreter must be provided for interpretation. Informed consent is obtained on the state-appropriate forms, which are located on the CareSource website under the Provider section and in the Supplements/ Forms section of the CareSource manual, with appropriate, legible signature(s) and submitted to our health plan with the claim. Informed consent is not obtained while the individual to be sterilized is in labor or childbirth seeking to obtain or obtaining an abortion, or under the influence of alcohol or other substances that affect the individuals state of awareness. The procedure is scheduled at least 30 days, but not more than 180 days, after the consent is signed. These requirements are applicable to all sterilizations when the primary intent of the sterilizing procedure is fertility control. Re l a t e d Po l i c ies & Re f e r e n c e s OAC 5160-21, Medicaid covered reproductive health services, preconception care services . 907 KAR 1:054. Primary care center and federally-qualified health center services KAR 3:005 Section 4-10 Physician Services St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-21, per Legislative Service Commission Guidelines. Archived

Occupational, Physical & Speech Therapy

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: Occupational, Physical, & Speech Therapy Po l i c yCareSource will reimburse physicians or skilled therapists for occupational, physical, and speech therapy within the limits of this policy. De f i n i t i o n sOccupational therapy is the evaluation and treatment of patients whose function is impaired by developmental deficiencies, physical injury or illness. The treatment approach used depends on the disorder or impairment, and may include therapy based on engagement in meaningful activities of daily life (as self-care skills, education, work, or social interaction) especially to enable or encourage participation in such activities despite impairments or limitations in physical or mental functioning. (from Merriam-Webster.com Medical Dictionary) Physical therapy is the evaluation and treatment of patients using therapeutic exercise, physical modalities, assistive devices, and patient education and training for the preservation, enhancement, or restoration of movement and physical function impaired or threatened by disability, injury, or disease. (from Merriam-Webster.com Medical Dictionary) Speech therapy is the treatment of speech and communication disorders. The treatment approach used depends on the disorder and may include physical exercises to strengthen the muscles used in speech (oral-motor work), speech drills to improve clarity, or sound production practice to improve articulation. Speech therapy is aimed to help a person with a speech or language disorder or problem to restore basic speech skills. (from MedicineNet.com) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization Prior authorization is required when the dates of service exceed the limits outlined in this policy. Coverage Limits Skilled therapy services are allowable for reimbursement only if an authorized prescriber prescribes therapies for a reasonable amount and frequency. Please refer to the CareSource Benefit Grid for the allowable services and number of covered visits for therapy services. Additional therapy services may be requested; prior authorization is required for those. 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 Modifiers The following modifiers must be used when submitting claims for therapy services. Appropriate supporting documentation is also required. GN : Services delivered under an outpatient speech language pathology plan of care; GO : Services delivered under an outpatient occupational therapy plan of care GP: Services delivered under an outpatient physical therapy plan of care Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-34, Skilled Therapies in Non-Institutional Settings , Speech Therapy 907 KAR 3.005 Section 6.3 Physicians services / Therapy Limits St a t e Ex c e p t i o n s NONE Do c u m e n t Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:3-34, per Legislative Service Commission Guidelines. Archived

Nursery and Psychiatric Hospital Levels

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: Nursery and Psych iatric Hospital Levels OHIO ONLY Policy CareSource places sole reliance on the Ohio Department of Health for information relating to the assignment of a hospitals nursery and psychiatric hospital levels . Definitions Level I nursery is a nursery unit within a hospital which is registered with and recognized by the Ohio Department of Health as a level I nursery. Le vel II nursery is a nursery unit within a hospital which is registered with and recognized by the Ohio Department of Health as a level II nursery. L evel III nursery is a nursery unit within a hospital that is registered with and recognized by the Ohio Department of Health as a level III nursery. (All, from OAC 5101:3-2- 02) Provider Reimbursement Guidelines Background Hospitals must be registered and must report certain information to the Ohio Department of Health ( ODH) annually in accordance with section 3701.07 of the Ohio Revised Code. The ODH uses this information to establish the appropriate level of nursery care and the appropriate level of psychiatric care for each hospital. Survey information and other data are found for each hospital in Ohio at http://publicapps.odh.ohio.gov/eid/default.aspx . Levels There are three different levels of nurseries. Level I is also called a newborn or well-baby nursery. Level II is a neonatal intensive care unit (NICU) that can provide care for a baby who is moderately sick but expected to improve quickly.Level III nursery offers the most intensive care possible for the sickest and smallest of babies.There are two different Psychiatric levels, 0 and 1. 0 [zero] indicates the hospital has no psychiatric beds.1 indicates the hospital has psychiatric beds/ward. 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 CareSource uses the nursery and hospital psychiatric levels assigned by the Ohio Department of Health when setting up individual hospital provider agreements in their claims processing systems. These levels established within the CareSource claims processing system may impact how individual Medicaid patient claims are processed and paid in Ohio. Hospitals that have concerns regarding the appropriateness of the nursery and psych iatric levels assigned to them should direct their questions to the Ohio Department of Health. Related Polic ies & References Ohio Department of Health Hospital Registration Information-h ttp://publicapps.odh.ohio.gov/eid/default.aspx State Exceptions This payment policy applies to Ohio only. Document Revision History Archived

Imaging Services

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 3 Payment PolicySubject: Imaging ServicesP o l i c yCareSource will cover medically necessary imaging services including diagnostic radiology, mammography, bone densitometry, nuclear medicine, magnetic resonance imaging/magnetic resonance angiography (MRI/MRA), computer ized tomography/ computerized tomographic angiography (CT/CTA), positron emission tomography (PET scan) and ultrasound procedures. De f i n i t i o n sDiagnostic imaging , means the u se of high energy modalities and other technologies to allow the visualization and examination of body tissues. Diagnostic imaging includes, but is not limited to, x-rays, ultrasound, magnetic resonance imaging (MRI), positron emission tomography (PET) , and computed tomography (CT). (From NIM/NIH MedLine Plus ) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior AuthorizationDiagnostic imaging services performed in the emergency room, observation, and inpatient settings do not require prior authorization. CareSource requires providers to obtain authorization prior to requesting imaging services in an outpatient setting, including: CT/CTA MRI/MRA PET Scan Nuclear Cardiology MRI/MRA, CT/CTA and PET procedures must be performed in a participa ting designated free-standing imaging center or a participating hospital. 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 au thorized, the radiologist or facility should notify NIA of the extended study or additional service within the same day. NIA will either update the authorization record to include the extended examination or issue a new authorization number for the additio nal service. Global / Component ServicesCareSource covers global services for physicians in non-facility settings, and the professional component is covered for physicians in any setting. The technical component is only covered when the service is provi ded in an appropriate non – facility setting. The global service and its professional component service cannot both be covered for the same service since the professional component is 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 3 included in the global service. 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 3 of 3 When a physician reports a global procedure, the physician is responsible for the overall performance and quali ty of the test. The physician must either personallyperform the test or it must be performed under the physicians supervision and direction. The physician must personally interpret the results and complete the written report. While some radiology procedu res 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. Interpretation of radiology servic es are covered for any physician trained in the interpretation of the study. The provider who interprets the study must be the one who evaluates the study and prepares and signs the written report for the medical record. Review of results and explanati on to the beneficiary are part of the attending physicians E/M service and are not considered as interpretation of the study. Multiple Services on Same dayCareSource covers bilateral x-rays when medically necessary. 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 covered. Providers should use a bilateral code when available. CareSource also covers multiple studies of both areas if reported with the appropriate modifier. 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. Billing InformationCareSource recognizes a professional component and a technical component for each radiological procedure. When both components are performed by one provider, they ar e recognized as the total (radiological) procedure.X-rays and documentation of all results of radiological procedures must be maintained on file for a period of six years. 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. When submitting a claim for radiology services, providers must use the appropriate modifiers. CareSource will directly reimburse a radiologist the professional component when the radiologist performs the initial interpretation of a radiological examination. 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. In this case, the radiologists or cardiologists interpretation is a specialists evaluation (of th e interpretation of the treating physician) whose findings could affect the course of treatment initiated or cause a new course of treatment to begin. Reimbursement 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. 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. A physician provid ing radiological services in an 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 4 of 3 inpatient hospital, an outpatient hospital, or an emergency room setting may bill CareSource only for the professional component.CareSource will reimburse a physician/provider for only the technical componen t if: The physician personally performed the service or the service was performed by an employee of the physician/provider; The professional component was performed by another physician/provider; and The service was performed in a setting other than an inpatient hospital, an outpatient hospital or an emergency room. CareSource will reimburse a physician for the total procedure when the radiologist or treating physician performs the professional and technical components of a radiological procedu re in a setting other than an inpatient hospital, an outpatient hospital, or an emergency room. CareSource will reimburse any other non hospital provider for the total procedure when: The physician who performed the professional component has an employ ment or contractual arrangement for the provider to bill for the professional services; and The technical component was performed in a setting other than an inpatient hospital, an outpatient hospital, or an emergency room. Diagnostic and Radiology Services 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. According to the AMA Principles of CPT Coding, it is not appropriate to report the components of the professional and technical service separately. Re l a t e d Po l i c i es & Re f e r e n c e sOAC 5160-4-25, Physician Services, Laboratory and Radiology services.907 KAR 3:005. Physicians’ Services, Section 5. Prior Authorization Requirements CareSource Payment Policy: Emergency Department EKG and Imaging Interpretation CareSource Payment Policy: Bilateral Procedures St a t e Ex c e p t i o n sKY (product sp ecific) Do c u m e n t Re v i s i o n Hi s t o r y10/31/2013 OAC Rule renumbered from 5101:3-4-25, per Legislative ServiceCommission Guidelines.

Emergency Department EKG and Imaging Interpretation

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: Emergency Department EKG and Imaging Interpretation Po l i c yCareSource reimburses for emergency department services provided to CareSource enrolled members, including reimbursement for the complete and definitive interpretation of EKGs and imaging studies provided for evaluation and management of the emergency care. De f i n i t i o n sEmergency medical condition ,” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. (From OAC 5101:3-26-01 (W, X)) “Emergency services ,” means covered inpatient services, outpatient services, or medical transportation that are provided by a qualified provider and are needed to evaluate, treat, or stabilize an emergency medical condition. As used in this policy, providers of emergency ser vices also include physicians or other health care professionals or health care facilities not under employment or under contractual arrangement with an MCP.(From OAC 5101:3-26-01 (W, X)) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization Emergency services (as defined above) do not require prior authorization.Only those services that are medically necessary for the evaluation and management of the patient in the ED setting will be reimbursed. Complete and Definitive Interpretation of EKGs and Imaging Studies refers to the interpretation that is provided by a physician with documented specialized education and training appropriate to the service provided and which is reported separately, documenting all findings typically reported for the particular exam and which is considered final and the report of record for the medical chart and which is separately retrievable. EKG and Imaging interpretations billed by ED physicians and other specialists in the ED setting will not be reimbursed separately if they do not conform with the above definition as they are considered to be an integral part of the evaluation and management services reimbursed to the physician. 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 Hospital emergency department services billed by the facility are usually accompanied by global charges for any EKG and Imaging services provided. Interpretations for these services are usually considered the complete and definitive interpretations that are provided by specialists contracted on behalf of the hospital and which are reimbursed as part of the global reimbursement paid to the facility. Duplicate charges for interpretation of EKG or imaging services rendered by ED or other specialty physicians will not be reimbursed. Ultrasound diagnostic procedures provided in the ED will be reimbursed when medically necessary, consistent with CPT definition, if accompanied by a separate report and not billed also by the hospital or a radiologist providing an over-read. Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-2-21(H), Policies for outpatient hospital services, Emergency room visit claims. CareSource-Post Stabilization Care Policy St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013OAC Rule renumbered from 5101:32-21(H), per Legislative Service Commission Guidelines. Archived

Durable Medical Equipment and Modifiers

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 3 Payment Policy Subject: Durable Medical Equipment and Modifiers Po l i c yCareSource will reimburse medically necessary DME services in accordance with state guidelines and requires the use of standard HIPAA compliance modifiers as appropriate. De f i n i t i o n sDurable medical equipment ( DME ) is equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, is not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Examples are: hospital beds, wheelchairs, and ventilators. (from OAC 5101:3-10-02 (A)(3)) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization Prior authorization for the following DME/other items is required regardless of the cost: All items equaling $750 or aboveAll powered or customized wheelchairsManual wheelchair rentals over 3 monthsHearing AidsContact LensesAll miscellaneous codes (example E1399) Rental only Appropriate HIPAA modifier: RR Rental (use the RR modifier when DME is to be rented)Certain durable medical equipment requiring servicing to ensure the health and safety of recipients will be designated as rental only. The rental payment may be specified in your s tates guidelines . Unless otherwise specified, no modifier code is used in billing rental only items. Use the modifier code RR when billing short-term rental. Routinely purchased items, lump sum purchase Appropriate HIPAA modifier: NU New equipmentMost items on the Medicaid Supply List are categorized as routinely purchased items and would ordinarily be purchased and become the property of the consumer. 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 3 Short term rental and rent to purchaseAppropriate HIPAA modifier: LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price) NR New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased.) Payment for short term rental of equipment will be made at ten per cent per month of the maximum amount allowable for a specific item. The combined total reimbursement for rental and subsequent (within ninety days of the end of the rental service) purchase of a DME item, cannot exceed the Medicaid maximum fee. For items authorized for rental on a monthly basis, payment will be made through the month in which the consumer becomes ineligible, the item is no longer medically necessary or the maximum amount allowable is reached. For items authorized for rental on a daily basis, only those days when the consumer is eligible and the item is medically necessary are billable to the department. When Durable Medical Equipment and Services are not covered DME Add-ons or Upgrades are not covered : When the DME add-ons or upgrades are intended primarily for convenience or upgrades beyond what is necessary to meet the members legitimate medical needs. Examples include: decorative items, unique materials (e.g. magnesium wheelchairs wheels, lights, extra batteries, etc.); or When it does not provide a therapeutic benefit to a patient in need because of certain medical conditions or illnesses; or When the DME has not been prescribed by a physician; or When the DME serves primarily as a comfort or convenience item. Trays, back packs, wheelchair racing equipment are examples of non-covered or convenience items; or When the equipment is used in a facility that is expected to provide such items to the patient; or For DME add-ons or upgrades that are intended primarily for member/caregiver convenience, or that do not significantly enhance DME functionality; or, When the devices and equipment are used to enhance the environmental setting (for example; air conditioners, humidifiers, air filters, portable Jacuzzi pumps, or chair lifts used to go up and down the stairs). These are not primarily medical in nature and will not be eligible for coverage; or, For DME add-ons or upgrades that are intended primarily for member/caregiver convenience, or that do not significantly enhance DME functionality; or, Equipment delivery services and set-up, education and training for patient and family, and associated nursing visits are not eligible for separate reimbursement regardless of agreement to rent or purchase. ArchivedThis 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 3 of 3 Home DME may be subject to medical necessity review. DME requires a prescription to rent or purchase before it is eligible for coverage. Payment of eligible fees will begin on the day the device is delivered, set-up, and ready for use by our member at the location needed. DME rental rates and maintenance fees should be calculated for payment on a prorated basis, based on provider contracted rates, when a full 30 days are not utilized by the member. Documentation Requirements for DME: The supplier is responsible for obtaining a signed, dated, written agreement from the member for the additional charges prior to delivery of the non-covered items. To review DME for medical necessity the following information is required: Physicians plan of treatment, including anticipated time frame that the equipment will be needed. Physicians involvement in supervising the use of the prescribed item. Detailed description of the members clinical and functional status so that a determination of medical necessity can be made. Medical records may be requested to determine medical necessity. Re l a t e d Po l i c i es & Re f e r e n c e s Chapter 5160-10 Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers 907 KAR 1:479. Durable medical equipment covered benefits and reimbursement See also: CareSource Payment Policy, Durable Medical Equipment and Modifiers KENTUCKY ONLY St a t e Ex c e p t i o n s KY Do c u m e n t Re v i s i o n Hi s t o r y 10/31/2013 OAC Rule renumbered from 5101:3-10, per Legislative Service Commission Guidelines. Archived