REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Temporary Codes-OH MCD-PY-1414 05/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Cod ing methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits an d eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increa sed 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 main ly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and /or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in in terpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral he alth disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-OH MCD-PY-1414Effective Dat e: 05/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REI MBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes B. BackgroundReimbursement policies are designed to assist providers 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 estab lished 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 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/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or gua rantee claims payment.Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for emerging technologies, services, and procedures which support data collection to substantiatewidespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessary and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist. Temporary HCPCS codes may beestablished by the Centers for Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures, identify services and procedures under FDA review, or address miscellaneous services, procedures, and supplies. Durable MedicalEquipment (DME) Medicare Administrative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPCS codes may also be developed by commercial paye rs to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource considers temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code. B. A more specific code is not available to describe the service/procedure. C. The service provided is within the scope of the members benefit plan. Temporary Codes-OH MCD-PY-1414Effective Dat e: 05/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REI MBURSEMENT Policy Statement Policy and is approved.3 II. CareSource will use current industry standard procedure codes (HC PCS CPT I andCategory II codes) throughout the processing systems. HIPAA Transaction & Code Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided. III. Providers must use industry standard code sets and spec ific HCPCS CPT I andCategory II codes when available unless otherwise directed through the providers contract. IV. If specific codes are not available, unlisted codes require plan preauthorization.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 Annual review: updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived H. References1. American Academy of Professional Coders. What is HCPCS? Accessed January 2, 2024 . www.aapc.com 2. CPT Professional 2024 . American Medical Association ; 202 4. 3. HCPCS Codes – Temporary Codes for Use with Outpatient Prospective Payment System. Accessed January 2, 2024 . www.hcpcs.codes 4. Understanding the HIPAA standard transactions: the HIPAA transactions and code set rule. American Medical Association. Access ed January 2, 2024 . www.assets.ama-assn.org Approved by ODM on 1/25/2024
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict 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 ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 05/01/2024-01/31/2026 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 3 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 4 Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service B. Background Reimbursement policies are designed to assist providers 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 office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF). C. Definitions Preventive Services Exams and screenings that check for health problems with the intention to prevent any problem discovered from worsening and 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 children under the age of 18 years. D. Policy I. When any of the following pediatric and adolescent preventive exam codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse both codes at 100%. A. Preventive Health Service Codes 1. 99381-99384 2.99391-99394 B. Acute Care Visit Codes 1.99202-99205 2.99212-99215 II. When any of the following adult preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes,Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will not be reimbursed unless billed with the appropriate modifier to identify significant, separately identifiable services that were rendered by the same physician on the same date of service. A. Preventive Health Service Codes1. 99385-993872. 99395-99397B. Ac ute Care Visit Codes1. 99202-992052. 99212-99215 II I. CareSource reserves the right to request documentation to support billing bot h s ervices for all claims received. If documentation is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of th e pr eventive service. Documentation must include the following:A. Key elements supporting the additional preventive health services that wer e r endered.B. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service.C. A clear list in the assessment portion of the documentation of the acute/chronic conditions being managed at the time of the encounter. If there is a portion of th e phy sical exam that is not routinely performed at the time of a preventive service,the provider should clearly identify those exam pieces (eg, A thorough MS andneur o exam of the left hip performed as it relates to the HPI). E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approv ed H CPCS and CPT codes along with appropriate modifiers. Please refer to the OhioMedicaid fee schedule for appropriate codes. F. Related Policies/Rules Modifier 25 Reimbursement policy G. Review/Revision History DATE ACTION Date Issued 11/17/2014 Date Revised 11/17/2015 Revision includes payment policy legal language 08/06/2019 Updated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Annual review: removed reference to archived policies, 09/14/2022 updated codes, added reference to Modifier 25 policy 01/17/2024 Annual Review; Approved at Committee. Date Effective 05/01/2024 Date Archived 01/31/2026 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 H. References1. Draak K. Successfully bill a preventive service with a sick visit. American Academy Professional Coders. March 1, 2022. Accessed December 20, 2023. www.aapc.com 2. Healthcheck, O HIO ADMIN . C ODE 5160-1 -14 (2017). 3. Preventive Services, O HIO ADMIN . C ODE 5160-1-16 (2017). Approved by ODM on 01/25/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acupuncture Services-OH MCD-PY-0152 05/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of func tion, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Thi s Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to s ervices provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/R ules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2024 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Acupuncture Services B. Background Reimbursement policies are designed to assist providers 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 wi ll be determined when the claim is received for processing. Health care providers and 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 /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Acupuncture is an ancient Chinese method of treatmen t based on the theory that stimulation of specific key points on or near the skin by the insertion of needles or by other methods improves vital energy flow . The term acupuncture describes a variety of methods and styles to stimulate specific anatomic points in the body. Acupuncture is used to relieve pain, induce surgical anesthesia, or for therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatment . C. Definitions Acupuncturist-A n individual who holds , at a minimum, a valid certificate to practice as an acupuncturist or as an oriental medicine practitioner. Chiropractor-An individual who holds a certificate to practice acupuncture issued by a state chiropractic board. Other Individual Medicaid Provider-A physician assistant or an advanced registered nurse practitioner who has a valid certificate as an acupuncturist . Physician-An individual who has completed medical training in acupuncture with a current and active designation or an equivalent designation from the National Certification Commission for A cupuncture and Oriental Medicine. D. Policy I. CareSource reimburses for acupuncture services according to the criteria found in Ohio Administrative Code (OAC) 5160-8 -51 for the following conditions: A. m igraines B. low back pain C. cervical (neck) pain D. osteoarthritis hip E. osteoarthritis of knee F. acute post-operative pain Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2024 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3G. a cute nausea and vomiting (pregnancy and chemotherapy-related, not inpatient ) II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. Although CareSource does not require a prior authorization for the first 30 visits for acupuncture services, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. III. Participating providers must be one of the following: A. A physician who has completed medical training in acupuncture with a current and active designation, or an equivalent designation from the National Certification Commission for Acupuncture and Oriental Medicine. B. A chiropractor with a valid certificate to practice acupuncture. C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant , with a valid certificate as an acupuncturist. IV. Limitations: A. No separate reimbursement will be made for both an evaluation and management service and an acupuncture service performed by the same provider to the same individual on the same day. B. No separate reimbursement will be made for services that are an incidental part of a visit , such as but not limited to, providing instruction on breathing techniques, diet , or exercise. C. No reimbursement will be made for an additional treatment after an initial treatment period if any of the following occur : 1. symptoms show no evidence of clinical improvement after an initial treatment period 2. symptoms worsen ov er a course of treatment . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one on one contact with the patient 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2024 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.497813 Acupuncture, 1 or more needles with electrical stimulation, initial 15 minutes of personal one on one contact with patient 97814 Acupuncture, 1 or more needles with electrical stimulation, each addition 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition for primary procedure) F. Related Policies/Rules N/AG. Review/Revision History DATE ACTIONDate Issued 10/31/2013 New Policy Date Revised 10/31/2013 06/06/2016 04/30/2020 05/25/2022 05/24/2023 01/17/2024 New Allowed Services Removed III. D. Shoulder Pain Updated references. No changes. Approved at committee. Updated references. No changes. Approved at CommitteeDate Effective 05/01/2024Date Archived H. References1. Acupuncture Services , O HIO ADMIN . CODE 5160-8-51 (2021). 2. License to Practice, O HIO REV . CODE 4762.02 (2023) . 3. Non-Institutional Fee Schedule, Appendix DD, O HIO ADMIN . CODE 5160-1- 60 (2024 ). Approved by ODM on 1/25/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -OH MCD-PY-0039 03/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSou rce and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical 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 no t limited to, those health care services or supplies that are proper and necessary for the d iagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These serv ices meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to t he 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. CareSource 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. According t o the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Transcutaneous Electrical Nerve Stimulators (TENS) -OH MCD-PY-0039Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulat ors (TENS) B. BackgroundReimbursement policies are designed to assist providers 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 office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guaranteeclaims payment.Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin.C. Definitions Accessories – A collective term that encompasses but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches , and covers. Supplies – A collective term that encompasses but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries , and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) – The application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. D. PolicyI. CareSource requires a prior authorization (PA) for a TENS unit. CareSource follows the Ohio Administrative Code for clinical criteria for the following devices: A. E0720 Two-lead unit B. E0730 Four-lead unit II. Supplies (A4595) do not require a prior authorization.A. Supplies are not reimbursable during the trial period. B. Supplies ar e not reimbursable during the rental period. Transcutaneous Electrical Nerve Stimulators (TENS) -OH MCD-PY-0039Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Once the members TENS unit has converted to a purchase due to the necessity of continued treatment, the following apply:1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed . 2. CareSource covers 1 unit of supplies (A4595) per month for a 2-lead TENS unit (E0720) and 2 units per month for a 4-lead TENS unit (E0730). 3. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 4. Separate payment is not provided for individual supply items. D. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim may deny. E. Conditions of Cove rageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusiveand is subject to updates.HCPCS Code Description E0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers DescriptionNU Purchase of new equipment RR Rental (use the ‘RR’ modifier when DME is to be rented) F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09/16/2020 07/15/2022 12/13/2023Updated policy to align with OAC updatesUpdated prior authorization requirement. PGC approved via electronic vote. Revised background information. No change to section D. Updated references. Annual review: rearranged criteria, updated references. Approved at Committee. Date Effective 03/01/2024 Transcutaneous Electrical Nerve Stimulators (TENS) -OH MCD-PY-0039Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Date ArchivedH. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS) , OHIO ADMIN . CODE 5160-10-01 app. (2021) . 2. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN . CODE 5160-10-01 (2021). 3. DMEPOS: Transcutaneous Electrical Nerve Stimulation (TENS) Units , OHIO ADMIN . CODE 5160-10-15 ( 2018 ). 4. Gibson W, Wand BM, Meads C , Catley MJ, OConnell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane Reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 5. Johnson MI, Paley CA, Wittkopf PG, Mulvey MR, Jones G. Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina (Kaunas) . 2022;58(6):803. doi:10.33 90/medicina58060803 6. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina . 2022;58(10):1332. doi:10.3390/medicina58101332 ODM Approved 01/11/202 4
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 26 and TC: Professional and Technical Component – OH MCD-PY-1474 03/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guideline s. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medi cally necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the 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 provide d 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 Handbook s, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co nflict 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 ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavio ral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 26 and TC: Professional and Technical Component B. BackgroundReimbursement policies are designed to a ssist providers 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 office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guaran teeclaims payment.According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specificcircumstance but not changed in its definition or code. It may also provide more information about a service such as it was performed more than once, unusual events occurred, or it was performed by more than one physician and/or in more than one location. The Current Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used fo r administrative management purposes such as claimsprocessing and developing guidelines for medical care review. Some p rocedure coding,described by a single CPT code, is comprised of two distinct portions: a professional component (26) and a technical co mponent (TC) . When the professional component of one such procedure is performed separately, the specific service performed by the physician may be identified by adding CPT modifier 26 . In this scenario, the facility provides the technical component of a s ervice/procedure , bill ing the same procedure code with modifier TC. In this way the components of the service can be separately billed by the provider and facility. C. Definitions Global Procedure /Service – Represents both the professional and technical component as a complete procedure or service. Identified by reporting the procedure without modifier 26 or TC. Modifier 26 ( Professional Component) – Used to indicate when a physician or other qualified healt h care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Modifier TC (Technical Component) Used to indicate the technical personnel,equipment, supplies and institutional ch arges of a service or procedure . D. PolicyI. CareSource expects providers and facilities to adhere to national coding guidelines and standards when utilizing modifiers . II. Modifier 26A. The professional component is outlined as a physicians service, which may include technician supervision, interpretation of re sults, and a written and signed report. B. To claim only the professional portion of a service, CPT instructs professionals (or providers) to append modifier 26 to the appropriate CPT code. C. Modifier 26 is also be used t o bill for the professional component p ortion of a test when the provider utilizes equipment owned by a hospital/facility . III. Modifier TCA. The technical component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the procedure.B. The payment for the technical component portion also includes the practice expense and the malpractice expense. C. To claim only the technical portion of a service, append modifier TC to the appropriate CPT code. D. Fees for the technical component are generally r eimbursed to the facility or practice that provides or pays for the supplies, equipment, and/or clinical staff (technicians). E. Hospitals are typically exempt from appending modifier TC , because it is assumed that the hospital is billing for the technical co mponent portion of any onsite service. IV. Global Procedure /ServiceA. The global procedure is when the same physician or other qualified health care professional performed both the professional component and technical component of that service. This may be the case if an X-ray of a broken bone is taken in the orthopedic surgeons office. B. A global service is identified by reporting the eligible code without modifier 26 or TC. In such cases, the provider is reimbursed for the equipment, supplies, and technical su pport, as well as the interpretation of the results and the report. C. When reporting a global service, no modifiers are necessary to receive payment for both components of the service. V. ExclusionsA. Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (eg, 93010 Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only).B. Do not append modifier TC if there is a dedicated code to describe the technical component, for example, 93005 electrocardiogram: tracing only, without interpretation and report. C. CareSource does not allow reimbursement for use of modifier 26 or modifier TC when 1. It is reported with an Evaluation and Management (E&M) code. 2. There is a separate standalone code that describes the professional component only, technical component only , or global test only of a selected diagnostic test. VI. Duplicate billingA. W hen o ne provider reports a global procedure and a different provider reports the same procedure with a professional (26) or technical (TC) component modifier for the same patient on the same date of service, the first charge approved by CareSource will be eligi ble for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. B. W hen one provider reports a procedure with a professional (26) and a different provider reports a global p rocedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement . C. When one provider reports a procedure with a technical (TC) component modifier and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimburse ment and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. VII. CareSource may request documentation for post-payment review of claims submitted with modifier 26 or modifier TC. If documenta tion is not provided, CareSource may recoup previously paid claim. E. Conditions of CoverageNA F. Related Policies/RulesElectrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation G. Review/Revision HistoryDATE ACTIONDate Issued 11/29/2023 New policy. Approved at Committee.Date Revised Modifier 26 and TC: Professional and Technical Component-OH MCD-PY-1474Effective Da te: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Date Effective 03/01/2024Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed November 6, 2023. www.ama-assn.org 2. Medical and Surgical Services, OHIO ADMIN . CODE 5160-4-01 to 33 (2022). 3. Medicare Claims Processing Manual Chapter 23 – Fee Schedule Administration an d Coding Requirements . Centers for Medicare and Medicaid Services. Revised June 2, 2023. Accessed November 6, 2023. www.cms.gov 4. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2022. Accessed November 6, 2023. www.medicaid.ohio.gov ODM Approved 01/11/2024
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 03/0 1/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guideli nes. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member ben efits 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. Me dically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the 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 provi ded 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 Handbo oks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discreti on in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behav ioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medic al conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………… 2 B. Background ………………………….. ………………………….. ………………………….. ………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………. 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 7 H. References ………………………….. ………………………….. ………………………….. …………………… 8 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care-Unbundled Cost B. BackgroundReimbursement policies are designed to assist providers 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 office staff are encouraged to use self-service channels to verif y a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology ( CPT )/Healthcare Common ProcedureCoding System ( HCPCS )/International Classification of Disease-10( ICD-10 ) code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply a right to reimbursement or guarantee claims payment. Obstetrical care refers to the health care treatment given in relation to pregnan cy anddelivery of a newborn child. This include s care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members r e c e iv e in a h o s p it a l o r b ir t h in g c e n t e r a s we l l as all associated outpatient services . The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using CPT codes, HCPCS codes and/or revenue codes. The codes denote services and/or procedure s performed. The billed codes must be fully supported in the medical record. Unless otherwise noted, this policy applies only to participating providers and facilities. This policy is for practitioners who meet either of the following: obstetrical practitioners not part of a free standing birthing center obstetrical practitioners part of a Free Standing Birthing Center when any of the following occur: o It is the preferred method of billing o The member has a change of insurer during pregnancy o The member has received part of the antenatal care elsewhere (eg , from another group practice ) o The member leaves the practitioners group practice before the global obstetrical care is complete o The member must be referred to a provider from another group p ractice or a different licensure (eg , midwife to medical doctor) for a cesarean delivery o The member has an unattended precipitous delivery Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 o Termination of pregnancy without delivery (eg , miscarriage, ectopic pregnancy)C. Definitions Initial and Prenatal Visit – A p ractitioner visit to determine whether a member is pregnant. Freestanding Birthing Center (FBC) – Birth centers are freestanding facilities that are not considered hospitals , provid ing peripartum care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth . High Risk Delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. Premature Birth – Delivery before 3 7 weeks of pregnancy is completed . Prenatal Profile – Initial laboratory servi ces. Unbundled Obstetrical Care – The practitioner bil ls delivery, antepartum care, and postpartum care independently. o Antepartum Care – Defines basic care (including obtaining and updating subsequent medical history, physical examination, recording of vital signs, and routine chemical urinalysis) provided monthly up to 28 weeks gestation, biweekly there after up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery – Includes admission to a facility, medical history during ad mission, physical examinations, and management of labor (either by vaginal delivery or by cesarean section). o Postpartum Care – The time period that begins on the last day of pregnancy and extends through the end of the month in which the 60 day period following termination of pregnancy ends. The American College of Obstetricians and Gynecologists (ACOG) recommends contact within the first 3 weeks post partum. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile – Evaluation and management (E/M) codes are utilized for t he initial visit , prenatal profile , and antepartum care. B. Risk Appraisal – Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Additional PRAF submi ssions may be considered on a case by case basis due to special cases where new or changed risk factors are identified and merit additional PRAF submissions. Those cases will be reviewed for medical necessity and appropriate reimbursement may occur. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 2. Any eligible woman who meets any of the risk factors listed on the PregnancyRisk Assessment Form (PRAF) is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. C. Unbundled Obstetric Care – The practitioner w ill bill antepartum care, delivery, and postpartum care independently of one another. 1. Antepart um care only – do es not include delivery or postpartum care: a. Use the appropriate E/M code and trimester code(s) . b. Use the appropriate modifier , if applicable . 2. Delivery only – Use if only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code(s): c. Services (This list may not be all inclusive):Services included that may NO Tbe billed separately Services excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Inducing labor using pitocin or oxytocinInjecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as deliveryDelivery of placenta unless it occurs at a separate encounter from the delivery Minor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of delivery3. Delivery and postpartum care only – If only delivery and postpartum care were provided . a. Use the appropriate CPT and trimester code: b. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately ( this list may not be all inclusive): 01. admission history 02. admission to hospital 03. artificial rupture of membranes 04. care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. hospital/office visits following cesarean section or vaginal delivery 06. management of uncomp licated labor 07. physical exam 08. vaginal delivery with or without episiotomy or forceps 09. caesarean delivery 10. classic cesarean section 11. low cesarean section 12. successful vaginal delivery after previous cesarean delivery 13. previous cesarean delivery member who present s with the expectation of a vaginal delivery CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 14. caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery4. Postpartum care only , if postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one code 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code. This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include and therefore is not allowed to be billed separately for the following (not an all inclusive list ): 01. office and outpatient visits following cesarean section or vaginal delivery 02. qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. con ditions unrelated to pregnancy (eg , respiratory tract infection ) 02. treatment and management of complications during the postpartum period that require additional services II. Member EligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner must use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical , or normal hospital evaluation and management services are not reimbursa ble. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services , including laboratory services , are reimbursable. III. Multiple GestationsA. Include diagnosis code for multiple gestations. B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed. C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. IV. High Risk DeliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 supervision of high-risk pregnancy. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 B. Modifier 22 should be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual fee schedule for appropriate codes . The following list of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CPT Code DescriptionE/M For antepartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59430 Postpartum care only. 59514 Cesarean delivery only 59515 Cesarean delivery only; including postpartum care 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care F. Related Policies/RulesObstetrical Care-Hospital Admissions Obstetrical Care-Total Cost G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/202110/10/202210/11 /2023 Updated codes, template New title was Preferred Obstetrical Services; policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Clarified who can bill unbundled charges. Revised antepartum language for clarity. Remov ed modifiers. Updated references. Approved at PGC. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 Annual review. Updated references. Approved at Committee.Date Effective 03/01/2024 Date Archived H. References1. 2023 OB/GYN Coding Manual: Components of Correct Coding . American College of Obstetricians and Gynecologists; 2023. Accessed September 20, 2023. www.acog.org 2. ACOG committee opinion 736: presidential task force on redefining the postpartum visit. Obstet Gynecol . 2018;131(5):e140-e150. Reaffirmed 2021. Accessed September 19, 2023. www.acog.org 3. Code obstetrical care with confidence. American Academy of Professional Coders. December 1, 2011. Accessed September 20, 2023. www.aapc.com 4. Definitions, OHIO ADMIN . CODE 4723-8-01 (2021). 5. Freestanding Birth Center Services, OHIO ADMIN . CODE 5160-18-01 (2023). 6. From antepartum to postpartum, get the CPT OB basics. American Academy of Professional Coders. August 1, 2013. Accessed September 20, 2023. www.aapc.com 7. Limitations on Elective Obstetric Deliveries, OHIO ADMIN . CODE 5160-1-10 (2015). 8. Billing for care after the initial outpatient postpartum visit: the fourth trimester. American College of Obstetricians and Gynecologists. Accessed September 20, 202 3. www.acog.org 9. Managem ent of Late-Term and Postterm Pregnancies . American College of Obstetricians and Gynecologists; 2014. Practice Bulletin No. 146. Accessed September 20, 202 3. www.acog.org 10. Cesarean Delivery on Maternal Request . American College of Obstetricians and Gynecolo gists; 2019. Committee Opinion No. 761. www.acog.org 11. Medically Indicated Late-Preterm and Early-Term Deliveries . American College of Obstetricians and Gynecologists; 2021. Committee Opinion No. 831. www.acog.org 12. Safe Prevention of the Primary Cesarean Deli very . American College of Obstetricians and Gynecologists; 2014. Obstetroc Care Consensus No. 1. www.acog.org 13. Managed Care: Definitions, Ohio Admin. Code 5160-26-01 (2022). 14. Modifiers Recognized by Ohio Medicaid. Ohio Dept of Medicaid. November 28, 2011. Revised January 28, 2022. Accessed September 20, 2023. www.medicaid.ohio.gov 15. Preterm labor and birth: frequently asked questions. American College of Obstetricians and Gynecologists. Updated April 2023. Accessed September 20, 2023. www.acog.org 16. Repr oductive Health Services: Pregnancy-Related Services, Ohio Admin. Code 5160-21-04 (2022). 17. Scope of Specialized Nursing Services, Ohio Rev. Code 4723.43 (2020). Approved ODM 11/16/2023
REIMBURSEMENT POLICY STATEMENTOhio Medica id Policy Name & Number Date Effective Unlisted and Miscellaneous Procedure Codes-OH MCD-PY-1456 03/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary servic es include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbi dity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the conve nience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other polici es and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Po licy 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and a pplying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder wi ll not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Unlisted and Miscellaneous Procedure Codes-OH MCD-PY-1456 Effective Dat e: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectUnlisted and Miscellaneous Codes 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 w ill 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 ac curate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Current Procedure Terminology (CPT) codes are used to describe medical proceduresand physician services. The American Medical Association (AMA) maintains and distributes CPT codes. Health Care Common Procedure Coding System (HCPCS) code set represents items, supplies , and non-physician services not addre ssed by the CPTcodes. The Centers for Medicare and Medicaid Services (CMS) establishes and maintains the HCPCS codes. These code sets w ere established so providers can use the most specific and appropriate code when submitting claims for reimbursement of services rendered to members. Occasionally, a CPT/ HCPCS code may not be available for a procedure or service if it israrely used, unusual , or new. Only then would p roviders use an unlisted, unclassified,not otherwise specified (NOS) , not otherwise classified (NOC) , unlisted , miscellaneous , or generic code for any such procedure , service , item, suppl y, or non-physician service . C. Definitions Durable Medical Equipment (DME) – Equipment and supplies ordered by a health care provider for everyday or extended use. Miscellaneous ( Unlisted, Unclassified, Not Otherwise Specified (NOS ,) or Not Otherwise Classified [NOC ]) Codes – Submitted by a supplier for an item or service for which there is no existing code that adequately describes the item or service being billed. Unlisted Code – A code represent ing an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code . D. PolicyI. All unlisted or miscellaneous codes require a prior authorization and medical necessity review. Unlisted and Miscellaneous Procedure Codes-OH MCD-PY-1456 Effective Dat e: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.III. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.IV. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review: A. a complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges B. statement that no other code exists that would be more appropriate C. any other information requested by CareSource V. Unlisted/non-specific codes used for procedures deemed to be experimental and investigational will be reviewed for medical necessity . VI. WarrantyCareSource may request warranty information regarding the DME item or supply when an unlisted or miscellaneous code is used . If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the pri or authorization. VII. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly. Code DescriptionA4335 Incontinence supply; miscellaneous A4421 Ostomy supply; miscellaneous A9999 Miscellaneous DME supply or accessory, not otherwise specified B9998 Not otherwise classified ( NOC) for enteral supplies E1399 Durable medical equipment, miscellaneous K0108 Wheelchair component or accessory, not otherwise specified Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device E. Conditions of CoverageAll unlisted or miscellaneous codes defined within this policy are subject to medical necessity review and prior authorization. Prior authorization is not a guarantee of payment. Unlisted and Miscellaneous Procedure Codes-OH MCD-PY-1456 Effective Dat e: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 CareSource may verify the use of any code through post-payment audit. If a more appropriate code is discovered, CareSource may request recoupment. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/11/2023 New policy. Approved at Committee.Date Revised Date Effective 03/01/2024 Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed October 2, 2023. www.ama-assn.org 2. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN . CODE 5160-10-01 (2021). 3. Durable Medical Equipment (DME). Accessed October 2, 2023. www.healthcare.gov 4. Healthcare Common Procedure Coding System (H CPCS) . American Medical Association. Accessed October 2, 2023. www.ama-assn.org 5. Medicaid Medical Necessity: Definitions and Principles, O HIO ADMIN . C ODE 5160-1- 01 (2022). Approved ODM 11/16/2023
REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 02/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates 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 cons idered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, pr ovider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services 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 functi on, dysfunction of a body organ or part, or significant pain and discomfort. Thes e services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refe r 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. CareSource 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. Accor ding to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical cond itions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 3 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …………………. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 4 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 4 Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 02/01/2024 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectObstetrical Care-Total Cost for Free s tanding Birthing CentersB. BackgroundObstetrical care refers to health care treatment given in relation to pregnancy and delivery of a newborn child. This includes care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center as well all associated outpatient services. The services provided must be appropriate to the specific medic al needs of the member.Determination of medical necessity is the responsibility of the physician.Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT)codes, Healthcare Common Procedure Coding System (HCPCS) code s and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities.The to tal obstetrical care code is only to be used by Freestanding Birthing Centers. All other practitioners must not bill and will not be reimbursed for total care obstetrical codes.C. DefinitionsFreestanding Birthing Center (FBC) – Any facility in which deliveries routinely occur, regardless of whether the facility is located on the campus of another health care facility, and which is not licensed under Chapter 3711 of the revised code as a level one, two, or three maternity unit or a limited maternity unit .Initial and Prenatal Visit-Practitioner visit to determine member is pregnant.Pregnancy-For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40weeks.Prenatal Profile-Initial laboratory services.Total Obstetrical Care-Includes antepartum care, delivery, and postpartum care.D. PolicyI. Obstetrical CareA. Initial Visit and Prenatal Profile1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact.2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care.B. Risk Appraisal-Case Management Referral Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 02/01/2024 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 1. Providers may complete the Pregnancy Risk Assessment Form and will be paid for the completion of the form once during the pregnancy.Use HCPCS code H1000 on the associated claim to indicate that an assessment form was submitted .2. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services.3. Total obstetrical care code:a. Total obstetrical care code is CPT 59400-Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care b. A corresponding obstetrical diagnosis with appropriate trimester must be listed on the claim. A n ICD-10 code from category Z34 should be listed as the first diagnosis for routine obstetric care.4. Services included that are not to be billed separately (this list may not be all inclusive):a. a dmission history b. a dmission to hospital c. a rtificial rupture of membranes d. c are provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum e. v isits each month up to 28 weeks gestation f. v isits every other week from 29-36 weeks gestation g. v isits weekly from 36 weeks until delivery h. f etal heart tones i. h ospital/office visits following vaginal delivery j. i nitial/subsequent history k. m anagement of uncomplicated labor l. p hysical exams m. r ecording of weight/blood pressures n. r outine chemical urinalysis o. r outine prenatal visits p. s uccessful vaginal delivery after previous cesarean delivery q. v aginal delivery with or without episiotomy or forceps .E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes .The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CODES DESCRIPTION 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care Obstetrical Care-Total Cost for Freestanding Birthing Centers-OH MCD-PY-0939 Effective Date: 02/01/2024 The REIMBURSEMENT Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the REIMBURSEMENT Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. H1000 Pre natal care, at risk assessment F. Related Policies/RulesObstetrical Care-Unbundled ServicesG. Review/Revision HistoryDATE ACTION Date Issued 7/22/2020 Date Revised 10/26/2022 10/11/2023 Annual review with e ditorial changes. References updated. Annual review. Updated references. Approved at Committee. Date Effective 02/01/2024 Date Archived H. References1. 2023 OB/GYN Coding Manual: Components of Correct Coding . American College ofObstetricians and Gynecologists; 2023. Accessed September 20, 2023. www.acog.org2. ACOG committee opinion 736: presidential task force on redefining the postpartum visit. Obstet Gynecol . 2018;131(5):e 140-e150. Reaffirmed 2021. AccessedSeptember 19, 2023. www.acog.org3. Cesarean Delivery on Maternal Request . American College of Obstetricians andGynecologists; 2019. Committee Opinion No. 761. www.acog.org4. Definitions, OHIO A DMIN . CODE 4723-8 – 01 (2021).5. Freestanding birth center services, OHIO A DMIN . CODE 5160-18-01 (2023).6. Limitations on Elective Obstetric Deliveries, OHIO A DMIN . CODE 5160-1 – 10 (2015).7. Managed Care: Definitions, OHIO A DMIN . CODE 5160-26-01 (2022).8. Management of Late-Term and Postterm Pr egnancies . American College ofObstetricians and Gynecologists ; 2014. Practice Bulletin No. 146 . AccessedSeptember 20, 202 3 . www.acog.org9. Medically Indicated Late-Preterm and Early-Term Deliveries . American College ofObstetricians and Gynecologists; 2021 . Committee Opinion No. 831. www.acog.org10. Mind these modifier 22 dos and donts. American Academy of Professional Coders.April 10, 2006. Accessed September 20, 2023. www.aapc.com11. Reproductive Health Services: Pregnancy-Related Services, OHIO A DMIN . CODE5160-21-04 (2022).12. Safe Prevention of the Primary Cesarean Delivery . American College ofObstetricians and Gynecologists; 2014. Obstetric Care Consensus No. 1. www.acog.org13. Scope of Specialized Nursing Services, OHIO REV . CODE 4723.43 (2020).Approved by ODM 10/26/2023
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 02/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical 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 no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medica l practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a 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 ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Ad diction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 02/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusi on of a code in this policy does not imply any right to reimbursement or guaranteeclaims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additionalinformation, to the code description, of the product or service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service.The purpose of this policy is to simplify and standardize the use of modifiers, whenbilling for rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU. CareSource expects providers to use the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers add ressed in this policy ( eg, LT, RT, etc.). C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated , and maintained by the American Medical Association (AMA) that provide a standard lang uage for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. This policy outlines the use of Durable Medical Equipment (DME ) modifiers for the rental and/or purchase of DME. Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 02/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 NOTE: This policy addresses modifiers associated with billing, not specific DME equipment coverage. Some DME equipment may have individual po licies which can be referenced for detailed information. The modifiers addressed in this policy is not an all-inclusive list and providers should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed withi n this policy. II. DME items can be:A. purchased B. rented or C. rented on a short-term basis and then purchased at the end of the rental period III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable:A. Purchase Modifier – NU: 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier – RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. 2. All rental authorizations are based on: a. A calendar month authorization period, through the month in which the membe r becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in the OAC 5160-10-01, the initial rental period must not exceed six months. a. After the initial six-month rental period, additional rental months may be authorized if medically necessary. 4. The combined total reimbursement for rental and subsequent purchase of a DME item, cannot exceed the Medicaid maximum fee. 5. At the end of the rent to purchase period, the DME becomes the property of the member. IV. Disposable supplies do not require a modifier.A. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier R Rwas left off the claim in error, CareSource will review the claim during a post-payment audit and proper reimbursement adjustment will occur. V. Modifiers that are not to be used for claims submission for DME equipment:A. LL – Lease/rental B. NR – New when rented Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 02/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 C. RB – Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement par ts are considered new equipment) VI. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB.NOTE: CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must made available upon CareSources request. E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020 New policyDate Revised 09/14/2022 10/1 1/2023 No changes. Updated references. Annual review. Updated references. Approved at Committee. Date Effective 02/01/2024 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, O HIO ADMIN CODE 5160-10-01 (2021). 2. Durable Medical Equipment (DME). Accessed October 2, 2023. www.healthcare.gov 3. HCPCS (HCPCS – Healthcare Common Procedure Coding System). Accessed October 2, 2023. www.nlm.nih.gov 4. What are medical coding modifiers? 2023. American Academy of Professional Coders. Accessed October 2, 2023. www.aapc.com Approved by ODM 10/26/2023
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifiers-OH MCD-PY-1345 02/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical 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 no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude 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 Rei mbursement 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 c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mo dify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the li mitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 3 E. Conditions of coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related policies/rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/revision history ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ………………….. 4 Modifiers-OH MCD-PY-1345Effective Dat e: 02/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualific ations. 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 chan nels to verify a members eligibility. Reimbursement modifiers are two-digit code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both CPT and HCPCS manuals. Use of a modifi er does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure . To indicate that a procedure was performed on the left side, right side, or bilaterally . To report multiple procedures performed during the same session by the same health care provider . To indicate multiple health care professionals participated in the procedure . To indicate a subsequent procedure is due to a compl ication of the initial procedure. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) – Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical serv ices and procedures. Healthcare Common Procedure Coding System (HCPCS) – Codes that are issued, upda ted, and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier – Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. Modifiers-OH MCD-PY-1345Effective Dat e: 02/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT /HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive) : National Correct Coding Initiative (NCCI) editing guidelines American Medical Association (AMA) guidelines American Hospital Association (AHA) billing rules Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) ICD-10 CM and PCS National Drug Codes (NDC) Diagnosis Related Group (DRG) guidelines CCI table edits . The in clusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of coverageReimbursement is dependent up on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of State specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follo w proper billing, industry standards, and state compliant codes on allclaim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participa ting and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related policies/rules NA G. Review/revision historyDATE ACTIONDate Issued 09/01/2019 New policyDate Revised 04/15/2020 10/13/2021 10/12/202209/27/2023Added Place of Service 19 to Modifier SA Removed modifiers, changed background and policy sections to simplify language No changes. Updated references. Updated references. Approved at Committee. Date Effective 02/01/2024 Date Archived Modifiers-OH MCD-PY-1345Effective Dat e: 02/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS) . US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed September 11, 2023. www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed September 11, 2023. www.ama-assn.org 3. Medicare Claims Processing Manual, XII: Ph ysicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 2003. Revised February 9, 2023. Accessed September 11, 2023. www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers . US Centers for Medicare and Me dicaid Services; 2003. Revised March 24, 2023. Accessed September 11, 2023. www.cms.gov 5. Optum Encoder Pro. 2023. Accessed September 11, 2023. www.encoderprofp.com Approved by ODM 10/26/2023
© Copyright CareSource 2026. All rights reserved.
System Details