REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date JW Modifier Drug Waste PY-PHARM-010 0 01-22-2022Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : 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, indust ry-standard claims editing lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. 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. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 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 ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Modifier JW Reimbursement Statement OHIO MEDICAID PY-PHARM-0100 Effective Date: 01-22-2022 2 A. Subject This policy provides guidelines for the documentation and reimbursement of discarded drug wastage from single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a gua rantee 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 proces sing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /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. This policy describes documentation requirements and reimbursement guidelines for billing of the d iscarded portion of drugs and biologicals . Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or si ngle use format. The discarded portion of single use or single dose vials must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portion s of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. C. Definitions Modifie r JW refers to the drug amount discarded (wasted) /not administered to any patient. Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial is defined as a vial of medication intended for administration by injection or i nfusion that is meant for use in a single patient for a single procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically, do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended fo r administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. Archived Modifier JW Reimbursement Statement OHIO MEDICAID PY-PHARM-0100 Effective Date: 01-22-2022 3 D. Policy Modifier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource w ill consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not adminis tered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using th e most appropriate size vial, or combination of vials, to deliver the administered dose. E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepare a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biologi cal that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. 1. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. 2. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual ArchivedModifier JW Reimbursement Statement OHIO MEDICAID PY-PHARM-0100 Effective Date: 01-22-2022 4 G. Review/Revision History DATE ACTION Date Issued Date Revised Date Effective 01-22-2022 Date Archived H. References 1. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf 2. https://www.kmap-state-k s.us/Documents/Content/Bulletins/16226%20 – %20General%20 -%20Modifier%20JW.pdf 3. https://medicaid.ohio.gov/static/Providers/Billing/Bi llingInstructions/HospitalBillingGuidelines-20210901.pdf The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
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, illne ss, 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 contr act (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 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 Overpayment Recovery-OH MCD-PY-1115 03/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Overpayment Recovery-OH MCD – PY-1115 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectOverpayment Recovery 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 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 inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified. Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond two (2) years. C. Definitions Claims Adjustment A claim that was previously paid and is being updated for one of the following reasons: o Denied as a zero payment, o a partial payment, o a reduced payment, o a penalty applied, o an additional payment or o a supplemental payment. Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource, and the other carrier is the primary insurance for the member. Credit Balance/Negative Balance Funds that are owed to CareSource because of a claim adjustment. Explanation of Payment (EOP) The EOP contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource. Overpayment Recovery-OH MCD – PY-1115 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. Improper Payment A payment that should not have been made or an overpay ment was made. Examples include, but are not limited to the following: o Payments made for an ineligible member, o Ineligible service payments, o Payments made for a service not received, and o Duplicate payments. Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB) Adjustments to the total check / remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (Beginning Segment for Payment Order/Remittance Advice (BPR), which means total payment within the EOP). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits.D. Policy I. In accordance with 42 CFR 438.608, CareSource requires providers to report any overpayment that has been received by the provider. The overpayment must be returned to CareSource within sixty (60) calendar days after the date on which the overpayment was identified and to notify CareSource in writing of the reason for the overpayment. II. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider: A. The patient's name, date of birth, and Medicaid identification number, B. The date or dates of services rendered, C. The specific claims that are subject to recovery and the amount subject to recovery, including any interest charges, which may not exceed the amount specified in Ohio law or rule, D. The specific reasons for making the recovery for each of the claims subject to recovery, E. If the recovery is a result of member disenrollment from the CareSource, the effective date of disenrollment, F. An explanation that if a written response to the notice is not received within 30 calendar days from receipt of the notice, the overpayments will be recovered from future claims, G. How the provider may submit a written response disputing the overpayment, and H. How the provider may submit a written request for an extended payment arrangem ent or settlement. Overpayment Recovery-OH MCD – PY-1115 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. II I.Overpayment RecoveriesA. Lookback period is 24 months from the claim paid date.B. Advanced notification will occur 30 days in advance of recovery.C. If the recovery occurs outside of original claim timely filing limits, the correct ed c laim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. I V.Coordination of Benefit RecoveriesA. Lookback period is 12 months from claim paid date.B. Advanced notification will occur 30 days in advance of recovery.C. If the recovery occurs outside of original claim timely filing limits, the correct ed c laim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. V. Re tro Active Eligibility RecoveriesA. Lookback period is 24 months from date CareSource is notified by Medicaid o f t he updated eligibility status.B. Advanced notification will occur 30 days in advance of recovery.C. If the recovery occurs outside of original claim timely filing limits, the correct ed c laim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. VI .Management of Claim Credit BalancesA. Regular and routine business practices, including, but not limited to, the updati ng and/ or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move apr oviders record into a negative balance in which funds would be owed toCareSource. This information will be displayed on the EOP in the PLB section.B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy.1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 w hen adj usted, instead of the $2 difference.b. The $10 negative balance is not considered to be an overpaymentsubject to the guidelines outlined in section D.I D. IV.2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D. IV. Overpayment Recovery-OH MCD – PY-1115 Effective Date: 03/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. b. The reduced payment will trigger a 30-day advanced notification with th e det ails related to the claim and overpayment.C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has bee n of fset, unless otherwise negotiated.D. Providers are notified of negative balances through (EOPs) and 835s. Providers are expected to use this information to reconcile and maintain their AccountsReceivable (AR) to account for the reconciliation of negative balances.E. Notification of negative balances and reconciliation of negative balances may not occur concurrently.1. Providers are expected to maintain their Accounts Receivable (AR) t o ac count for the reconciliation of negative balances when they occur. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CP Tcodes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules CareSource Provider ManualNational Agreement, Article V. Claims and Payments, 5.11 (d). G. Review/Revision History DATE ACTION Date Issued 04/29/2020 New policy Date Revised 07/21/2021 Revision: Added Management of Claims Balance information. 03/30/2022 Added compliance with 42 CFR 438.608 for requirement for provider to report identified overpayments. Approved at PGC. 10/26/2022 No changes. Updated references. Date Effective 03/01/2023 Date Archived 05/31/2024This 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. H.R eferences 1. Ohio Department of Medicaid. (2022, October). The Ohio Department of Medicai d O hio Medical Assistance Provider Agreement for Managed Care Plan. Retriev ed 10/ 14/2022 from www.medicaid.ohio.gov.2.O hio Revised Code. (2002, July 24). 3901.388 Payments considered final overpayment. Retrieved 10/14/2022 from www.codes.ohio.gov.
REIMBUR SEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care – Total Cost f or Freestanding Birthing Centers-OH MCD PY-0939 03/01/2023 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Obstetrical Care – To tal Co st fo r Freestan d in g Birth in g Cen ters-OH MCD PY-0939 Effective Dat e: 03/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectObstetrical Care Total Cost for Free standing Birthing Centers B. BackgroundObstetrical care ref ers to the 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 r e c e i ve in a h o s p i tal or b i r thi ng c e nte r as w e l l all associated outpatient services. The services provided must be appropriate to the specif ic medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims f or reimbursement will serve as the providers certif ication of the medical necessity f or these services. Proper billing and submission guidelines must be f ollowed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The co des denote services and/or the procedure performed. The billed codes are required to be f ully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and f acilities. The total obstetrical care code is only to be used by Freestanding Birthing Centers. Allother practitioners must not bill and will not be reimbursed f or total care obstetrical codes.C. Def initions Freestanding Birthing Center (FBC) – Any f acility in which deliveries routinely occur, regardless of whether the f acility is located on the campus of another health care f acility, 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 . Prenatal Profile – Initial laboratory services. Initial and Prenatal Visit – Practitioner visit to determine member is pregnant. Total Obstetrical Care – Includes antepartum care, delivery, and postpartum care. Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was conf irmed and extends f or 280 days or 40 weeks. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Prof ile 1. The initial visit and prenatal prof ile are reimbursed separately f rom other obstetrical care. These are to be billed immediately af ter f irst contact. 2. Evaluation and management (E/M) codes ar e utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care. B. Risk Appraisal-Case Management Ref erral 1. Providers may complete th e Pregnancy Risk Assessment Form and will be paid f or the completion of the f orm once during the pregnancy . Use HCPCS code H1000 on the associated claim to indicate that an Obstetrical Care – To tal Co st fo r Freestan d in g Birth in g Cen ters-OH MCD PY-0939 Effective Dat e: 03/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.assessment f orm was submitted .2. Any eligible woman who meets any of the risk f actors listed on the f orm is qualif ied f or case management services for pregnant women and should be ref erred to CareSource fo r f urther screening f or those case management services. 3. Total obstetrical care code: a. Total obstetrical care code is CP T 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or f orceps) and postpartum care b. A corresponding obstetrical diagnosis with appropriate trimester must be listed on the claim. An ICD-10 code f rom category Z34 should be listed as the f irst diagnosis f or routine obstetric care. 4. Services included that are not to be billed separa tely (this list may not be all inclusive): a. Admission history b. Admission to hospital c. Artif icial rupture of membranes d. Care provided f or an uncomplicated pregnancy including delivery as well as antepartum and postpartum e. Visits each month up to 28 weeks gestation f. Visits every other week f rom 29-36 weeks gestation g. Visits weekly f rom 36 weeks until delivery h. Fetal heart tones i. Hospital/of f ice visits f ollowing vaginal delivery j. Initial/subsequent history k. Management of uncomplicated labor l. Physical exams m. Recording of weight/blood pressures n. Routine chemical urinalysis o. Routine prenatal visits p. Successf ul vaginal delivery af ter previous cesarean delivery q. Vaginal delivery with or without episiotomy or f orceps . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule f or appropriate codes . The following list(s) of codes is provided as a reference. This l ist may not beall inclusive and is subject to updates.CODES DESCRIPTION 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or f orceps) and postpartum care H1000 Pre natal care , at risk assessment Obstetrical Care – To tal Co st fo r Freestan d in g Birth in g Cen ters-OH MCD PY-0939 Effective Dat e: 03/01/2023 The REIMBURSEMENT Policy Statement detailed abo ve has recei ved due con sideration as defined inth e REIMBURSEMENT Policy Statement Policy and is approved.F. Related Policies/RulesObstetrical Care Unbundled Services G. Review/Revision HistoryDATE ACTIONDate Issued 7/22/2020Date Revised 10/26/2022 Annual review with e ditorial changes. Ref erences updated. Date Effective 03/01/2023 Date Archived H. Ref erences 1. Text American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modif ier 22. Retrieved October 20, 2022 f rom www.acog.org 2. American College of Obstetricians and Gynecologists. (2011, December). Patient Saf ety Checklist: Scheduling Induction of Labor. Retrieved October 20, 2022 f rom www.acog.org 3. American College of Obstetricians and Gynecologists. (2011, December). Patient Saf ety Checklist: Scheduling Planned Cesarean Delivery. Retrieved October 20, 2022 f rom www.acog.org 4. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved October 20, 2022 f rom www.acog.org 5. American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved October 19, 2022 f rom www.acog.org 6. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved October 20, 2022 from www.codes.ohio.gov 7. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrieved October 20, 2022 f rom www.codes.ohio.gov Ohio Administrative Code. (2019). 5160-26 Managed health care programs; def initions. Retrieved October 20, 2022 f rom www.codes.ohio.gov 8. Ohio Administrative Cod e. (2019). 5160-26 Managed health care programs; def initions. Retrieved October 20, 2022 f rom www.codes.ohio.gov 9. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health services; pregnancy-related services. Retrieved October 20, 2022 from www.codes.ohio.gov 10. Ohio Revised Code (2017). 4723.43 Scope of specialized nursing services. Retrieved October 20, 2022 f rom www.codes.ohio.gov
REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 02/01/2023-02/29/2024 Policy Type REIMBURSEMENT Table of Contents A.Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 3 D. Policy ………………………………………………………………………………………………………………… 3 E. Conditions of Coverage ………………………………………………………………………………………… 6 F. Related Policies/Rules ………………………………………………………………………………………….. 7 G. Review/Revision History ……………………………………………………………………………………….. 7 H. References …………………………………………………………………………………………………………. 8 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 Reimbur sement 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, b ut 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 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 pla n 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 sub ject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 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 es tablished 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 a members eligibility.It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding 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 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 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. Submissi on 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 procedures 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; or 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 (e.g., 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 practice or a different licensure (e.g., midwife to MD) for a cesarean delivery; or o The member has an unattended precipitous delivery; and o Termination of pregnancy without delivery (e.g., miscarriage, ectopic pregnancy). Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. C. DefinitionsFreestanding Birthing Center (FBC) – Birth centers are freestanding facilities that are not considered hospitals, providing peripartum care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth. Prenatal Profile-Initial laboratory services. Initial and Prenatal Visit-A practitioner visit to determine whether member is pregnant. Unbundled Obstetrical Care-The practitioner bills 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 thereafter up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery-Includes admission to facility, medical history during admission, 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 postpartum. High Risk Delivery-Labor management and delivery for a n 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 37 weeks of pregnancy is completed. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile. Evaluation and management (E/M) codes are utilized for the 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. Please use 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 Pregnancy Risk Assessment Form (PR AF) 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 will bill antepartum care, delivery, and postpartum care independently of one another. 1. Antepartum care only-does not include delivery or postpartum care: a. Use the appropriate E/M code and trimester code(s) b. Use the appropriate modifier, if applicable. Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 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): CPT Code Description 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive): Services included that may N OT be 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 section Previous cesarean delivery who present with expectation of vaginal delivery Successful vaginal delivery after previous cesarean delivery Cesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Cesarean delivery Classic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as delivery Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. Delivery of placenta unless it occurs at a separate encounter from the delivery Minor laceration repairs Inpatient management after delivery/discharge services E/M services provided within 24 hours of delivery 3.Delivery and postpartum care only-If only delivery and postpartum care wer e pr ovided.a. Use the appropriate CPT and trimester code: CPT Code Description 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59515 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 b. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately (This list may not b e a ll inclusive):01. Admission history02. Admission to hospital03. Artificial rupture of membranes04. Care provided for uncomplicated pregnancy including delivery,antepartum, and postpartum care05. Hospital/office visits following cesarean section or vaginal delivery06. Management of uncomplicated labor07. Physical exam08. Vaginal delivery with or without episiotomy or forceps09. Caesarean delivery10. Classic cesarean section11. Low cesarean section12. Successful vaginal delivery after previous cesarean delivery13. Previous cesarean delivery member who presents with t he ex pectation of a vaginal delivery14. Caesarean delivery following unsuccessful vaginal delivery attemp t af ter previous cesarean delivery 4. P ostpartum 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/Mpregnancy related visits provided for postpartum care. Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined i n the REIMBURSEMENT Policy Statement Policy and is approved. c.There is no specified number of visits included in the postpartum code.This includes hospital and office visits following vaginal or cesar ean s ection 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; or02. 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. Conditions unrelated to pregnancy (e.g. respiratory tract infection); or02. Treatment and management of complications during the postpartum period that require additional services. II. M ember EligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, t he pr actitioner must use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical, o r nor mal hospital evaluation and management services are not reimbursable.B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services, including laboratory services, are reimbursable. III. Multiple Gestations A. 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 singl e c esarean delivery code is to be reported regardless of how many cesarea n bi rths. D. Modifier 22 should be added to support substanti al additional work.Documentation must be submitted with the claim demonstrating the reason and t he additional work provided. I V.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.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 Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. The following list of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description E/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/Rules Obstetrical Care Hospital Admissions MM-0897Obstetrical Care Total Cost PY-0939 G. Review/Revision History DATE ACTION Date Issued 06/10/2015 Date 10/18/2017 Updated codes, template Revised 07/22/2020 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. 09/15/2021 Revised antepartum language for clarity. Removed modifiers. Updated references. Approved at PGC. 10/10/2022 Editorial changes and reference updates only. Date Effective 02/01/2023 Date Archived 02/29/2024 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 fo llow CMS/State/NCCI guidelines without a formal documented Policy. Obstetrical Care Unbundled Cost-OH MCD-PY-0004 Effective Date:02/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. H.References 1. The American College of Obstetricians and Gynecologist. (2018, May). PresidentialTask Force on Redefining the Postpartum Visit. Retrieved October 4, 2022 from www.acog.org2. A merican Medical Association. (1997, April). Global OB Codes: Reporting and Use.CPT Assistant .3. American Medical Association (2015, January). Maternity Care and Delivery. CPTAssistant.4. American Academy of Professional Coders. (2013, August 1). From Antepartum t o P ostpartum, Get the CPT OB Basics. Retrieved October 4, 2022 from www.aapc.com5. A merican Academy of Professional Coders. (2011, December). Code ObstetricalCare with Confidence. Retrieved on October 4, 2022 from www.aapc.com6. The A merican College of Obstetricians and Gynecologists. (n.d.). Coding forPostpartum Services (The 4 th Trimester). Retrieved October 4, 2022 from www.acog.org 7. A merican College of Obstetricians and Gynecologists. (2011, December). PatientSafety Checklist: Scheduling Induction of Labor. Retrieved October 4, 2022 from www.acog.org 8. A merican College of Obstetricians and Gynecologists. (2011, December). PatientSafety Checklist: Scheduling Planned Cesarean Delivery. Retrieved October 4, 2022 f rom www.acog.org 9. A merican College of Obstetricians and Gynecologists. (2018, May, reaffirmed 2021).Optimizing Postpartum Care. Retrieved October 4, 2022 from www.acog.org 10. A merican College of Obstetricians and Gynecologists. (2019, January). Preter m Labor and Birth. Retrieved October 4, 2022 from www.acog.org11.Department of Ohio Medicaid. (2022, January). Modifiers Recognized by Ohi o M edicaid. Retrieved October 4, 2022 from www.medic aid.ohio.gov 12.O hio Administrative Code. (2018). 4723-8- 01 Definitions. Retrieved October 4, 2022from www.codes.ohio.gov 13. O hio Administrative Code. (2018). 5160-18-01 | Freestanding birth center services.Retrieved October 4, 2022 from www.codes.ohio.gov 14. O hio Administrative Code. (2015). 5160-1-10 Limitations on Elective ObstetricDeliveries. Retrieved October 4, 2022 from www.codes.ohio.gov 15. O hio Administrative Code. (2022 ). 5160-26-01 Managed health care programs;definitions. Retrieved October 4, 2022 from www.codes.ohio.gov 16. O hio Administrative Code. (2022). 5160-21-04 Reproductive health services;pregnancy-related services. Retrieved October 4, 2022 from www.codes.ohio.gov 17. O hio Revised Code (2021) . 4723.43 Scope of specialized nursing services.Retrieved October 4, 2022 from www.codes.ohio.gov
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifiers-OH MCD-PY-1345 02/01/2023 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, regula tory 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 da te 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 incl ude, 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, i mpairment 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 an d 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.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 Modifiers-OH MCD-PY-1345 Effective Date: 02/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEM ENT Policy Statement Policy and is approved.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. Modi fiers can be found in the appendices of bothCPT and HCPCS manuals. Use of a modifier 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 fo r 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 complication of the initial procedure. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reim bursement 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 services and procedures. Healthcare Common Procedure Coding System (HCPCS) – Codes that are issued, updated, 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-1345 Effective Date: 02/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEM ENT Policy Statement Policy and is approved.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); Diagn osis Related Group (DRG) guidelines; and CCI table edits . The inclusion 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 10/12/2022Added Place of Service 19 to Modifier SARemoved modifiers, changed background and policy sections to simplify language No changes. Updated references. Date Effective 02/01/2023 Date Archived Modifiers-OH MCD-PY-1345 Effective Date: 02/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEM ENT Policy Statement Policy and is approved.H. REFERENCES1. Appendix to rule 5160-4-21. (2016, June 30). Retrieved 09/30/2022 from www.codes.ohio.gov 2. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 09/30/2022 from www.cms.gov 3. CPT overview and code approval. (202 2, September 30 ). Retrieved 09/30/2022 from www.ama-assn.org 4. Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (20 22 , March 4). Retrieved 09/ 30 /202 2 from www.cms.gov 5. Medicare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved 09/ 30 /202 2 from www.cms.gov 6. Modifiers Recognized by Ohio Medicaid. (20 22 , J anuary 28 ). Retrieved 09/ 30 /202 2 from www. medicaid.ohio.gov 7. Optum360 EncoderProForPayers.com – Login. (202 2, September 30 ) Retrieved 09/ 30 /202 2 from www.encoderprofp.com 8. Ohio Administrative Code Rule 5160-4-21. Anesthesia Services. (2017, January 1). Retrieved 09/ 30 /202 2 from www .codes.ohio.gov
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 01/01/2023 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, re gulatory 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 th e 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, increased or new morbidit y, 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 convenie nce 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 Polic y 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 appl ying 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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME)Modifiers-OH MCD-PY-0022Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectDurable Medical Equipment (DME) Modifiers B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office 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 pro duct or service that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informat ional 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 se rvice.The purpose of this policy is to simplify and standardize the use of modifiers, when billing 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 mod ifierRR 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 addressed in this policy ( e.g., 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 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 supply rendered. D. Policy I. This polic y 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-0022Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.NOTE: This policy addresses modifiers associated with billing, not specific DME equipment coverage. Some DME equipment may have individual policies whi ch 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 within this pol icy. 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 auth orizations are based on: a. A calendar month authorization period, through the month in which the member becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in th e 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 purchas e 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 RR was left off the claim in error, CareSource will review the claim during a post-payment audit and p roper 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 C. RB – Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are considered new equipment) Durable Medical Equipment (DME)Modifiers-OH MCD-PY-0022Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.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 Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 05/13/2020 New policyDate Revised 09/ 14/2022 No changes. Updated references. Date Effective 01/01/2023 Date Archived H. References 1. 5160-10-01 Durable medical equipment, prostheses, orthoses, and supplies general provisions. (0 7/01/20 21). Retrieved on 09/06/ 202 2 from www.codes.ohio.gov.
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-OH MCD-PY-0007 01/01/2023 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 nece ssity, 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, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysf unction 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 d oes not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services pr ovided 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 limitatio ns 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 Preventive Evaluation and Management Services andAcute Care Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service 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 claim s 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 staf f 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. Theinclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary andpreventive screening tests as required by federal statute through criteria based on recommenda tions from the U.S. Preventive Services Task Force (USPSTF).C. Definitions Preventive Services – Exams and screenings t hat 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 encourage d at every age but are especially important for children under the age of 18 years . D. PolicyI. Pediatric and adolescent preventive health services bil led on the same date of service as an acute care visit: A. 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 bot h codes at 100%. 1. Preventive Health Service Codes a. 99381-99384 b. 99391-99394 2. Acute Care Visit Codes a. 9920 2-99205 b. 99212-99215 . II. Adult preventive health services billed on the same date of service as an acute care visit: Preventive Evaluation and Management Services andAcute Care Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. 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, CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will not be reimbursed u nless billed with the appropriate modifier to identify significant, separately identifiable services that were rendered by the same physician on the same date of service. 1. Preventive Health Service Codes a. 99385-99387 b. 99395-99397 2. Acute Care Visit Codes a. 992 02-99205 b. 99212-99215 . III. CareSource reserves the right to request documentation to support billing both services for all claims received. If documentation is requeste d, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: A. Key elements support ing the additional preventive health services that were rendered . B. A se parate 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 the physical exam that is not routinely performed at the time of a preventive service, the provider should clearly identify those exam pieces (e.g., A thorough MS and neuro exam of the left hip performed as it r elates to the HPI). E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with ap propriate modifiers. Please refer to the Ohio Medicaid fee schedule for appropriate codes. F. Related Policies/RulesModifier 25 Reimbursement policy G. Review/Revision HistoryDATE ACTIONDate Issued 11/17/2014Date Revised 11/17/2015 08/06/2019 09/14/2022Revision includes payment policy legal languageUpdated reimbursement rate from 50% to 100% for services that are rendered on the same date of service Annual review : removed reference to archived policies , updated codes, added reference to Modi fier 25 policy Date Effective 01/01/2023 Date Archived Preventive Evaluation and Management Services andAcute Care Visit on Same Date of Service-OH MCD-PY-0007Effective Dat e: 01/01/2023 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. References 1. Draak K. (2012 March 1). Successfully Bill a Preventive Service with a Sick Visit. AAPC Knowledge Center . Retrieved August 9, 2022 from www.aapc.com .
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulation (TENS) -OH MCD-PY-0039 11/01/2022 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 TranscutaneousElectrical Nerve Stimulation (TENS) -OH MCD-PY-0039Effective Dat e: 11/01/ 2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectTranscutaneous Electrical Nerve Stimulation (TENS) 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 inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmissio n of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin. C. Definitions Transcutaneous electrical nerve stimulation (TENS) – is the application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. Accessories – includes but is not necessarily limited to adapters, clips, additional connect ing cable for lead wires, carrying pouches and covers. Supplies – includes 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. D. Policy I. CareSource requires a prior authorization (PA) for a TENS unit. 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 are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers onl y 1 unit of supplies (A4595) per month for a 2-Lead TENS unit (E0720) or 2 units per month for a 4-Lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: TranscutaneousElectrical Nerve Stimulation (TENS) -OH MCD-PY-0039Effective Dat e: 11/01/ 2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.1. Separate payment may be made for nece ssary supplies, which must be dispensed only when they are needed, at a frequency not to exceed once per month. 2. 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. 3. No separate payment is allowed for individual supply items. E. If a submitted claim does not include a modifier , or includes an incorrect or inappropriate modifier, the claim may deny. E. Conditions of Coverage Reimbursement is dependent on, but not lim ited 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 inclusive and is subject to updates.HCPCS Code DescriptionE0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must inclu de 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 Description NU Purchase of new equipment RR Rental (use the ‘RR’ modifier when DME is to be rented) F. Related Policies/RulesNA G. Review/Revision History DATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09/16/2020 07/1 5/202 2 Updated policy to align with OAC updates Updated prior authorization requirement. PGC approved via electronic vote. Revised background information. No change to section D. Updated references. Date Effective 11/01/2022 Date Archived TranscutaneousElectrical Nerve Stimulation (TENS) -OH MCD-PY-0039Effective Dat e: 11/01/ 2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. References1. Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) Appendix to rule 5160-10-01. (2019, January 1). Retrieved 07 /12/20 22 from www.codes.ohio.gov. 2. Lawriter – OAC – 5160-10-15 DMEPOS: transcutaneous electrical nerve stimulation (TENS) units. (2018, July 16). Retrieved 07 /12 /20 22 from www.codes.ohio.gov. 3. Using TENS for pain control: the state of the evidence. (2015, March 1). Retrieved 07 /12/20 22 from www.ncbi.nlm.nih.gov. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC
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