REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acupuncture Services-OH MCD-PY-0152 10/01/2022 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, 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 eli gibility 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 neces sary 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 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 betw een 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 interpr eting 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 …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Acupuncture Services-OH MCD-PY-0152 Effective Date: 10/01/2022 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.A. 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 s ervices provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitt ing 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. Acupunctur e is an ancient Chinese method of treatment 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, to 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 least a valid certificate to practice as an acupuncturist or a valid certificate to practice as an oriental medicine practitioner. Chiropractor-An individual who holds a certificate to practice acupuncture issued by s tate 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 acupuncture and oriental medicine. D. Policy I. CareSource reimburses for acupuncture services accor ding to the criteria found in Ohio Administrative Code (OAC) 5160-8 -51. II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. Acupuncture Services-OH MCD-PY-0152 Effective Date: 10/01/2022 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.III. In accordance with OAC 5160-8-51, acupuncture services are only reimbursable for the following conditions: A. Migraines B. Low back pain C. Cervical (neck) pain D. Osteoarthritis hip E. Osteoarthritis of knee F. Acute post-operative pain G. Acute nausea and vomiting (pregnancy and che motherapy-relat ed, not inpatient) . IV. 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. V. 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 additional treatment af ter an initial treatment period if any of the following occur : 1. Symptoms show no evidence of clinical improvement after an initial treatment period, or 2. Symptoms worsen over a course of treatment. NOTE: 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 mus t be presented at the time of review t o validate medical necessity. E. Conditions of Coverage Reimbursement is depen dent 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 Acupuncture Services-OH MCD-PY-0152 Effective Date: 10/01/2022 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.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) 97813 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-in sertion of needle (s) (List separately in addition for primary procedure). F. Related Policies/RulesN/A G. Review/Revision History DATE ACTIONDate Issued 10/31/2013 New PolicyDate Revised 10/31/2013, 06/06/2016 04/30/2020 05/25/2022 New Allowed Services Removed III. D. Shoulder PainDate Effective 10/01/2022Date Archived H. References1. Appendix DD to rule 5160-1- 60 (Non-Institutional Fee Schedule) (January 1, 2022).Retrieved 04/02/2020 from www.medicaid.ohio.gov . 2. Ohio Administrative Code OAC-5160-8- 51 Acupuncture services. (March 1, 2021) . Retrieved April 27, 2022 from www. codes.ohio.gov/oac . 3. Ohio Revised Code 4762.02 (2020) – License to Practice. Retrieved April 27, 2022 from www.codes.ohio.gov/orc .
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments-OH MCD-PY-1324 09/01/2022 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, 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 uti lization 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 c an 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 c ost 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 Statement s, 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 affi liates 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 …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-OH MCD-PY-1324 Effective Date: 9/01/2022 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 REIMBURSEMENTP olic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectInterest Pay ments 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 members eligibility. It is the responsibility of the submitting provider t o 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. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party. Clean claims do not include payments made to a provider of service or a third party where the timing of the payment is not directly related to submission of a completed claim by the provider of service or third party. A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. We strictly adhere to all regulatory guidelines relating to interest. We follow the guidelines outlined in Prompt Payment regulations. II. In alignment with the Ohio Administrative Code and Medicaid Provider Agreement, CareSource does not pay interest on Ohio Medicaid claims. 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. F. Related Policies/Rules NA Interest Payments-OH MCD-PY-1324 Effective Date: 9/01/2022 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.G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 01/05/2022 04/27/2022 Updated language and references per Legal. No change; did for review cycle consistency Date Effective 09/01/2022 Date Archived H. References 1. Ohio Medicaid Contract. Retrieved April 20, 2022 from www.medicaid.ohio.gov 2. Ohio Medicaid Contract, Appendix J, 4. A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party. Retrieved April 20, 2022 from www.managedcare.medicaid.ohio.gov 3. Ohio Revised Code 5164.01(C). Definitions. Retrieved April 20, 2022 from www.managedcare.medicaid.ohio.gov 4. Electronic Code of Federal Regulations (e-CFR). CFR 447.45(b). Timely claims payment. Definitions. Retrieved April 20, 2022 from www.law.cornell.edu 5. Electronic Code of Federal Regulations (e-CFR). CFR 447.45(d). Timely claims payment. Timely processing of claims. Retrieved April 20, 2022 from www.law.cornell.edu The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the ReimbursementPolicy Stateme nt Po licy a nd is a pprove d.
REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Overpayment Recovery-OH MCD-PY-1115 08/01/2022 Policy Type REIMBURSEMENT Reimbursement Pol icies 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 oth er 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, claim s 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 prope r 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 an d 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 servic es 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 ser vices. 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., Ev idence 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 ap ply to medical conditions as covered under this policy. Table 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
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 fa ctors 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, 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 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 c ontrolling 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 favora ble than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 07/01/2022-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 5 E. Conditions of Coverage ………………………………………………………………………………………….. 6 F. Related Policies/Rules …………………………………………………………………………………………… 7 G. Review/Revision History …………………………………………………………………………………………. 7 H. References …………………………………………………………………………………………………………… 7 Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterB. Background Reimbursement policies are designed to assist physicians 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 ma y be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Most dental care can be provided in a traditional dental office setting with local anesthesia and if medically necessary, a continuum of behavior guidance strategies, ranging from simple communicative techniques to nitrous oxide, enteral or parenteral sedation. Monitored anesthesia care or sedation (minimal, moderate, or deep) may be a requirement of some patients including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations or other special needs . As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia in a healthcare facility such as an ambulatory surgical center or outpatient hospital facility. C. Definitions Ambulatory Surgical Center (ASC) – Eligible ambulatory surgery centers as defined in paragraphs (A)(1) and (B) of Ohio Administrative Code (OAC) rule 5160-22-01 entitled Am bulatory Surgery Center (ASC) services: provider eligibility, coverage, and reimbursement are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective payment methodology utilized by the Ohio department of Medicaid as described in this rule. (A) Definitions, for the purposes of this rule the following meanings apply. (1) An "ambulatory surgery center (ASC)" is any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization. (2) "Enhanced ambulatory patient grouping (EAPG)" is a group of outpatient procedures, encounters, or ancillary services which reflect similar patient characteristics and resource utilization and which incorporate the use of international classification of diseases (ICD) diagnosis codes, current procedural terminology (CPT) procedural codes, and healthcare common procedure coding system (HCPCS) Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. procedure codes. (3) "EAPG grouper" is the software provided by 3M health information systems to group outpatient claims based on services performed and resource intensity. (4) "Default EAPG settings" are the default EAPG grouper options in 3M's core grouping soft ware for each EAPG grouper version. (5) "Discounting factor" is a factor applicable for multiple significant procedures or repeated ancillary services designated by default EAPG settings or both. The appropriate percentage (fifty or one hundred per cent) will be applied to the highest weighted of the multiple procedures or ancillary services payment group. (a) "Full payment" is the EAPG payment with no applicable discounting factor. (b) "Consolidation factor" is a factor of zero per cent applicable for services designated with a same procedure consolidation flag or clinical procedure consolidation flag by the EAPG grouper under default EAPG settings. (c) "Packaging factor" is a factor of zero per cent applicable for ser vices designated with a packaging flag by the EAPG grouper under default EAPG settings. (6) "ASC invoice" is a bill submitted in accordance with Chapter 5160-1 of the Administrative Code, to the department for services rendered to one eligible Medicaid beneficiary on one or more date(s) of service. For an invoice encompassing more than one date of service, each date will be processed separately as an individual c laim. (7) "ASC claim" encompasses the ASC services rendered to one eligible Medicaid beneficiary on one date of service at an ASC facility. Inpatient Hospital-A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Off Camp us-Outpatient Hospital-A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or inst itutionalization. On Campus-Outpatient Hospital-A portion of a hospitals main campus which provides diagnostic, therapeutic (both surgical and nonsur gical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. Short Procedure Unit (SPU) – A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Medical Necessity-Procedures, items or services that prevent, diagnose, evaluate or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or development al disability and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function;Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. dysfunction of a body organ or part; or significant pain and discomfort as defined by the Ohio Department of Medicaid OAC 5160-1-01. Minimal Sedation (Anxiolysis ) – A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes , and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (Conscious Sedation) – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Monitored Anesthesia Care (MAC) – Does not describe the continuum of depth of sedation; rather it describes a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Deep Sedation/Analgesia-A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia-A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Note: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/analgesia (conscious sedation) should be able to rescue patients who enter a state of de ep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescue patients who enter a state of general anesthesia. Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner prof icient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the patient to the ori ginally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. D. PolicyMost dental care and/or oral surgery is effectively provided in an office setting. However, some members may have a qualifying condition that requires the procedure be provided in a hospital setting or ambulatory surgical center under general anesthesia. The purpose of this document is to provide reimbursement and billing guidance for facility related services when dental procedures are rendered in a hospital or ambulatory surgical center (ASC) place of service (POS) under general anesthesia. Hospital inpatient or outpatient facility services and ASC facility services for the provision of dental care under general anesthesia are addressed in this policy, not dental care or oral surgery in an office setting. Professional dental services are covered only to the extent that the member has dental benefits and guidelines for dental services are provided in the DentaQuest Policy Manual. CareSource policy notes the intent of hospital, outpatient, and ASC facility requests is the medical necessity of general anesthesia services to perform dental procedures on a member. Requests with the goal of no, minimal, moderate, or deep sedation servic es, will only be considered in extenuating circumstances mandated by systemic disease for which the patient is under current medical management and which increases the probability of complications, such as respiratory illness, cardiac conditions , or bleeding disorders. Medical record and physician attested letter would be required with authorization requests. OAC 5160-2-03(A)(2)(h) states that dental services are only covered in a hospital setting when the nature of the surgery or the condition of the patient precludes performing the procedure in the dentists office or other non-hospital outpatient setting and the inpatient or outpatient service is a Medicaid covered service. As such, it would exclude any diagnostic or preventative dental serv ices delivered in a hospital setting. I. Prior authorization process A. A prior authorization is required for all dental services performed in a hospital inpatient or outpatient facility or ambulatory surgery center facility. B. Dental services authorization for a n outpatient/ASC setting 1. Requests for dental services and anesthesia are submitted to the dental vendor: DentaQuest for Ohio Medicaid. 2. Dental vendor reviews for appropriate medical necessity requirements (listed in the [DentaQuest Office Reference Manual] for general anesthesia or for IV sedation in the outpatient hospital or ASC setting. 3. Dental vendor reviews for the medical necessity of the requested procedure and will deny the procedure and anesthesia request if it does not meet medically necessary criteria for that dental procedure. The Notice of Adverse Benefit Determination (Denial Notice) is issued by dental vendor. 4. If dental procedure(s) and the general anesthesia or sedation in the outpatient hospital or ambulatory surgery center is approved, the dental vendor will send an automated fax approval letter to the requesting dentist and this can be viewed in the DentaQuest provider portal. C. Facility authorization process Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 1. Upon approval, DentaQuest participating providers are required to administer services at CareSource participating hospitals. Upon receipt of approval from DentaQuest, the provider should use the information below for facility authorization as applicable. 2. For medical Prior Authorizations, the provider (hospital or ASC facility) may submit the request on the CareSource Provider Portal at CareSource.com >Login >Provider Portal. a. The Provider may also request a Prior Authorization by calling CareSource directly at: CareSource: 800.488.0134 select option to Request an Authorization. b. The Prior Authorization should Include the facility services requested, the DentaQuest Approval Letter and authorization number. 3. The CareSource Medical Utilization Management (UM-MM) team will complete ALL the following: a. Verify that facility is in or out of network; b. Review the DentaQuest pre-determination letter (PDL) or authorization; c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted; d. Fax a Facility Approval to the hospital/ASC which can also be viewed in CareSource Provider Portal. Note: The fact that a physician, dentist or other licensed practitioner renders, prescribes, orders, certifies, recommends, approves, or submits a claim for a procedure, item, or service does not, in and of itself make the procedure, item, or service medically necessary and does not guarantee payment for it.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. Reimbursement for items assigned to a dental service EAPG type will be paid as follows: Outpatient Hospital Facility (SPU) POS (19, 22): o Use CPT code 41899 as the facility fee code. Discounting factors: payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. o Use CPT code 00170 for anesthesia for intraoral treatments, including biopsy. Time units for physician and CRNA se rvices-both personally performed and medically directed-are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (i.e. 75 minutes) 75 = 6 units (of 15 min increments). CMS Base units = 5. Maximum state allowances may be applicable. Payment for an anesthesia service is the lesser of the provider's submitted charge or the Medicaid maximum, which is determined by a formula. Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. Inpatient Hospital Facility POS (21)o All services as well as any additional Room and Board fees would have to be pr e-certified and receive medical necessity review. Services are subject t o benef it provisions.Ambulatory Surgical Center POS (24)o Use code 41899 for facility fee. Payments for dental services will be made in accordance with the discounting factors as determined by the EAPG grouper.o Use code 00170 for Anesthesia professional services. CPT 00170 is calculated inCMS Base units. The Base unit = 5 units. See under under Hospital section above.Dental/Oral Surgery Professional Services o The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. For inform ation on dental benefits, pleas e c onsult the partnered dental vendor DentaQuest Office Reference Manual for clinical guidelines, policies, and procedures. F. Related Policies/Rules NA G.Review/Revision History DATE ACTION Date Issued 09/16/2020 New Policy Date Revised 01/26/2022 Annual review. Removed dental codes, removed tables, simplified coding information Date Effective 07/01/2022 Date Archived 05/31/2024 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 follow CMS/State/NCCI guidelines without a formal documented Policy H.R eferences 1.American Academy of Pediatric Dentistry. Oral Health Policies and R ecommendations (The Reference Manual of Pediatric Dentistry). (2021-2022).Retrieved January 26, 2022 from www.aapd.org.2. C ontinuum of Depth of Sedation: Definition of General Anesthesia and Levels o f S edation/Analgesia. (2019, October 23). Retrieved January 26, 2022 from www.asahq.org.3. O hio Administrative Code. 5160-1-01. (2015, March). Medicaid medical necessity:definitions and principles. Retrieved January 27, 2022 from www. codes.ohio.gov.4. Ohio Administrative Code. (2022, January). 5160-2-02. General provisions: hospital services. Retrieved January 26, 2022 from www.codes.ohio.gov.5. O hio Administrative Code. (2015, April). 5160-2- 03. Conditions and limitations . R etrieved January 27, 2022 from www.codes.ohio.gov.6.O hio Administrative Code. (2020 January). 5160-2- 75. Outpatient hospital reimbursement . Retrieved January 26, 2022 from www.codes.ohio.gov. Dental Procedures in Hospital Outpatient Facility or Ambulatory Surgery Center OH MCD PY-1244 Effective Date: 07/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7. Ohio Administrative Code. (2017, January). 5160-4 -21. Anesthesia services. Retrieved January 26, 2022 from www.codes.ohio.gov. 8. Ohio Administrative Code. (2021, April). 5160-5 -01. Dental services . Retrieved January 26, 2022 from www.codes.ohio.gov. 9. Ohio Adm inistrative Code. (2020, September). 5160-22-01. Ambulatory surgery center (ASC) services: provider eligibility, coverage, and reimbursement . Retrieved January 27, 2022 from www.codes.ohio.gov. 10. Ohio Department of Medicaid. (2021, July). Hospital Billing Guidelines. Retrieved January 26, 2022 from www.medicaid.ohio.gov.
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Robotic-Ass isted Surgery OH MCD PY-0957 06/01/2022 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, 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 r eferral, 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 functi on, 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 t he 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 Addi ction 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 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 …………………………………………………………………………………………………………. 3Robotic-Assisted Surgery OH MCD PY-0957 Effective Date: 06/01/2022 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 REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.A. SubjectRobotic-Assisted Surgery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invas ive procedures using robotic devices designed to access surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a computer equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly through computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of r obotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with the as sistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services): 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased Intensity, increased time, increased difficulty of procedures, or severity of patients condit ion.Robotic-Assisted Surgery OH MCD PY-0957 Effective Date: 06/01/2022 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 REIMBURSEMENTPo lic y St ate m ent Po lic y a nd is a pp rove d.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the Ohio Medicaid fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/01/2020 New PolicyDate Revised 01/19/2022 Updated references; no changes Date Effective 06/01/2022 Date Archived H. References 1. Robotic surgery. Medline Plus Web site. (May 2013) . Retrieved December 28, 2021 from www.nlm.nih.gov . 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; Retrieved December 28, 2021 from www.cms.gov. 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets . Retrieved December 28, 2021 from www.cms.gov . 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus group. Position Papers/ Statement published on 11/2007. Retrieved December 28, 2021 from www.sages.org . 5. Estes, Stephanie Jet al. Best Practices for Robotic Surgery Programs. JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 21,2 (2017): e2016.00102. Retrieved December 28, 2021 from www.nlm.nih.gov . 6. U.S. Food and Drug Administration. Computer-Assisted Surgical Systems (Aug. 20, 2021). Retrieved December 28, 2021 from www.fda.gov This guideline contains custom content th at has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC.
REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Substance Use Disorder Residential – OH MCD – PY-0137 06/01/2022-05/01/2023 Policy Type REIMBURSEMENT Table of ContentsA. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules Medical Necessity Determinations ……………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 6 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 developi ng 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 cove rage 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 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 ar e less favorable than the limitations that apply to medical conditions as covered under this policy. Substance Use Disorder Residential-OH MCD-PY-0137 Effective Date: 06/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectSubstance Use Disorder Residential B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. Policies 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, will be establis hed based upon a review of 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. Substance Use Disorder (SUD) services are provided on a continuum of care where the level of care varies dependent on the type and intensity of services provided. A residential level of care provi des an intensive, residential program for members with SUD and is considered transitional with the goal of returning the member to the community with a less restrictive level of care. It is the responsibility of the provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. Definitions0078 Medication Assisted Treatment (MAT) The use of medications, in combination with counseling and behavioral therapies , to provide a whole-patient approach to the treatment of substance use disorders. Medications used in MAT are ap proved by the Food and Drug Administration (FDA), while MAT programs are clinically driven and tailored to meet each patients needs. 00030078 Per Diem An allowance or payment made for each day of service based on the sum of the national average routine operating, ancillary and capital costs for each patient day of care. 00030078 Residential level of care Services that are co-occurring capable, co-occurring enhanced, and complexity capable in nature, while being provided by addiction treatment, mental health and general medical personnel in a twenty-four-hour treatment setting, Ohio department of Mental Health and Addiction Services (OhioMHAS) -certified and licensed, permanent facilities which are staffed twenty-four hours a day. 0003 D. Policy I. A residential program must meet all the following criteria: o Staffed 24 hours a day o Follow nationally recognized medical standards o Be certified/licensed by the Ohio Department of Mental Health and Addiction Services (OhioMHAS) to provide residential SUD treatment o Have an active provider agreement with Ohio Department of Medicaid (ODM) o Employ practitioners of SUD treatment services who meet applicable state requirements o Establish individualized treatment plans o Start discharge planning at time of admission o Schedule a follow-up visit for aftercare within seven (7) days of discharge Substance Use Disorder Residential-OH MCD-PY-0137 Effective Date: 06/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. o Provide Medication Assisted Treatment (MAT) or linkage to a prescriber for MAT o Ensure accessibility to all behavioral and physical health medication upon discharge CareSource does not consider a residential program appropriate for the following members: o A member who needs intensive medical monitoring for a severe or life threatening medical or physical condition o A member who is unable to actively participate due to severe symptoms of a co-existing mental or physical condition or severe withdrawal symptoms II. CareSource requires a prior authorization (PA) for the following: A. For the first and second admissions per calendar year, a prior authorization is only required for an admission exceeding thirty (30) consecutive days. 0078 For example, a member goes into residential treatment for the first time in a calendar year for a period of ten days. No authorization is required. The same member goes into treatment for a second admission during the same calendar year for a period of 38 days. After day 30, the facility is required to submit an authorization for days 31 through 38. B. For any stay or admission exceeding two admissions per calendar year, a prior authorization is required from the first day of admission. 0078 The same member above admits for residential treatment for a third time during the same calendar year. A prior authorization for this admission is required, starting day one (1). C. Changes in level of care: When a step-up or step-down occurs between two SUD residential level of care codes within the same residential provider agency and there is consecutive billing, the step-up or step-down is counted as a single event. When step-up or step-down occurs between two SUD residential level of care codes and billing is not consecutive, the events will be considered separate events. PAs may be required, depending on the members utilization in that calenda r year. a. If the step-up or step-down occurs during the first thirty (30) days of the first or second of the two (2) allowed SUD residential events, no PA is required for the step-up or step-down. b. If the step-up or step-down occurs after a PA has been authorized, either because the length of stay (LOS) has exceeded thirty (30) days or this is the third or more event in a calendar year, then the step-up or step-down doesrequire a new/updated PA.D. SU DResidential Facility Transfers: 0078 Prior Authorization is required for a same level-of-care admission or transfer between two SUD residential facilities (national provider identifiers (NPI) and/or tax identification numbers (TIN)) when the total number of days at that level-of-care exceeds 30 calendar days, and there is not a break in stay that is greater than 24-hours between admissions indicating two separate events. If the admission has already required prior authorization for any reason, the t ransition admission will require that prior authorization be obtained by the receiving facility from the date of admission.Substance Use Disorder Residential-OH MCD-PY-0137 Effective Date: 06/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 0078 Same level-of-care admissions or transfers between two SUD residential facilities (NPIs and/or TINs) without a break in stay of greater than 24 hours is not considered a separate event and will not accumulate as a separate event. 0078 If there is a break in stay that is greater than 24 hours between a same level-of-care admission or transfer between two SUD residential facilities (NPIs and/or TINs), the admission to the receiving facility is considered a separate event and is subject to prior authorization from the date of admission, beginning with the thir d admission in a calendar year and will accumulate as separate events.It is the responsibility of the facility to check the annual service usage to avoid a claim denial for no prior authorization. III. Documentation A. At least one documented face-to-face interaction must be provided by a clinical/treatment team member with the member at the substance use residential site in order to bill per diem. B. Member medical records must show evidence of medical necessity of services and follow Ohio Administrative Code guidelines. C. The residential program has a written Affiliation Agreement, so members are connected and ensured access to outpatient care in a timely manner upon discharge. The residential program has policies and procedures in place to monitor its affiliations.IV. Medical Necessity Criteria CareSource follows The American Society of Addiction Medicine (ASAM) Criteria as required by the Ohio Department of Medicaid. V. Billing A. Residential level of care admission: 1. One admission is considered one length of stay (LOS). 2. Any stay under 30 consecutive days counts as a full 30-day admission. 3. Service gaps in excess of 24 hours are considered a termination of one admission. 4. Leaving the SUD residential treatment facility associated with significant changes in health status, such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in level of care, and/or incarceration are considered a termination of one admission.5. Brief leave of absences (24 hours or less, except in rare instances), when supported by members individualized treatment plan, should be documented in the members treatment plan, and the provider should continue to bill for treatment services during these times. Brief leave of absences include but are not limited to the following: 0078 Family visits 0078 Religious services 0078 Same day health services 0078 Social support group attendance B. The benefit follows the member, not the providers tax identification number.Substance Use Disorder Residential-OH MCD-PY-0137 Effective Date: 06/01/2022 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. C. CareSource only processes claims from the following: 1. Provider type 95 OhioMHAS certified/licensed treatment program; 2. Provider specialty 954 OhioMHAS certified/licensed SUD residential facility; and 3. Plac e of service code 55 Residential Substance Abuse Treatment Facility.D. Claims billed out of sequence from date of service may cause claims to deny inappropriately for no prior authorization. E. Claims are paid as they are received. If a member receives services from more than one provider, claims are paid to providers who submit first, regardless of date of service.F. SUD residential is paid per diem. Per diem does not include room and board costs and/or payments.G. CareSource does not reimburse separately for services provided by the residential treatment service, including: 1. Ongoing assessments and diagnostic evaluations 2. Crisis intervention 3. Individual, group, family psychotherapy and counseling 4. Case management 5. Substance use disorder peer recovery services 6. Urine drug screens 7. Medical services 8. Medication administration H. A member can only receive services through one level of care at a time. 1. CareSource considers the following services non-billable when a member is in residential level of care: a. Therapeutic behavioral services. b. Psychosocial rehabilitation. c. Community psychiatric supportive treatment.d. Mental health day treatment. e. Assertive community treatment. f. Intensive home-based treatment. 2. CareSource does consider select behavioral health services provided to a member from practitioners not affiliated (based on billing group TIN) with the residential treatment program as billable concurrent to the SUD residential admission when the service i s medically necessary, and the treatment is outside of the scope of the residential treatment program. Examples include medication assisted treatment (MAT) and psychiatry. 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 Behavioral Health Ohio fee schedule for appropriate codes.
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments OH MCD-PY-1324 05/01/2022 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, 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 ser vice, 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 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 me mber 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 Pol icy 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 subjec t 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 ………………………………………………………………………………………… 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments OH MCD-PY-1324 Effective Date: 5/01/2022 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.A. Subject Interest Pay ments 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 ch annels 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. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim is a claim that can be processed without obtaining additional information from the p rovider of a service or from a third party. Clean claims do not include payments made to a provider of service or a third party where the timing of the payment is not directly related to submission of a completed claim by the provider of service or third party. A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. We strictly adhere to all regulatory guidelines relating to interest. We follow the guidelines outlined in Prompt Payment regulations. II. In ali gnment with the Ohio Administrative Code and Medicaid Provider Agreement, CareSource does not pay interest on Ohio Medicaid claims. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along wi th appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Related Policies/Rules NA Interest Payments OH MCD-PY-1324 Effective Date: 5/01/2022 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.G. Review/Revision HistoryDATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 01/05/2022 Updated language and references per Legal. Date Effective 05/01/2022 Date Archived H. References 1. Ohio Medicaid Contract. Retrieved December 18, 2021 from www.medicaid.ohio.gov 2. Ohio Medicaid Contract, Appendix J, 4. A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party. Retrieved December 21, 2021 from www.managedcare.medicaid.ohio.gov 3. Ohio Revised Code 5164.01(C). Definitions. Retrieved December 21, 2021 from www.managedcare.medicaid.ohio.gov 4. Electronic Code of Federal Regulations (e-CFR). CFR 447.45(b). Timely claims payment. Definitions. Retrieved December 21, 2021 from www.law.cornell.edu 5. Electronic Code of Federal Regulations (e-CFR). CFR 447.45(d). Timely claims payment. Timely processing of claims. Retrieved December 21, 2021 from www.law.cornell.edu The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the ReimbursementPolic y St ate m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Orthotics – OH MCD – PY-1151 03/01/2022Policy TypeREIMBURSEMENTReimbursement 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 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 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 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 Orthotics-OH MCD-PY-1 151Effective Date: 03/01/2022 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the REIMBURSEMENTPo licy Stateme nt Po licy a nd is a pprove d.A. SubjectOrthotics 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. Thes e pr oprietary policies are not a guarantee of payment. Reimbursement for claims may bes ubject to limitations and/or qualifications. Reimbursement will be established base d upon a r eview 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 us e s elf-service channels to verify members eligibility.It i s the responsibility of the submitting provider to submit the most accurate and appropri ate C PT/HCPCS code(s) for the product or service that is being provided. The inclusion o f a c ode in this policy does not imply any right to reimbursement or guarantee claims paym ent. The pur pose of this policy is to reinforce CareSources ability to audit post payment claims and to ensure that reimbursement was justified by reviewing providers documentati on to c onfirm medical necessity. C. Definitions Certificate of medical necessity (CMN) – is a written statement by a practitioner attesting that a particular item or service is medically necessary for an individual.Orthotics-means the evaluation, measurement, design, fabrication, assembly, fitting,adjusting, servicing, or training in the use of an orthotic device, or the repair,replacement, adjustment, or service of an existing orthotic device.O rthotic device-means a custom fabricated or fitted medical device used to suppor t, c orrect, or alleviate neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity. The device is dispensed to an eligible CareSource member by an appropri ate pr ovider, and can be considered for: back, spinal (lumbar, cervical, and/or thoracic), foot,ankle, and knee indications. D. Policy I. CareSource may request documentation from the ordering physician and the dispensi ng D urable Medical Equipment ( DME) provider to confirm medical necessity of the orthotic device.A. The orthotic device must be a covered orthotic device and ordered and furnished by an eligible provider to an eligible CareSource member . Eligible Medicaid providers ofthe fol lowing types having prescriptive authority under Ohio law may certify them edical necessity of an Orthotic device:1. A physician;2. A podiatrist;3. An advanced practice registered nurse with a relevant specialty (e.g., clinical nurse specialist, certified nurse practitioner); or Orthotics-OH MCD-PY-1 151 Effective Date: 03/01/2022 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the REIMBURSEMENTPo licy Stateme nt Po licy a nd is a pprove d.4. A physician assistan t.B.C areSource may request the CMN after the claim has been submitted.C. An illegible CMN will not be accepted. II.The fol lowing criteria for reimbursement must be inclu ded: A. The provider must be enrolled as a DME supplier for Medicaid.B.The orthotic device must have a prescription.C. The practitioner must conduct a face-to-face encounter.D. The date of a prescription cannot precede the date of the face-to-face encounter nor can it be more than 180 days afterwar d. E.The date of a prescription must be no more than 60 days before the date the orthotic device is dispensed to the member . F. The m edical practitioner acting as prescriber must be actively involved in managi ng the r ecipient's medical care. The department may disallow a prescription written by a pr actitioner who has no professional relationship with the recipi ent. G. The pr escribed DME device must be directly related to a medical condition of ther ecipient that the practitioner evaluates, assesses, or actively treats durin g the enc ounter . H. N o additional face-to-face encounter is necessary for a separate DME device if an enc ounter conducted within the preceding twelve months addresses the medical condition for which the DME device is being prescri bed. III. A ny request for an orthotic device must originate with an eligible CareSource member , the m embers authorized representative, or a medical practitioner acting as prescriber and must be made with the members full knowledge and cons ent. I V. When instruction must be given in the safe and appropriate use of an orthotic device, i t i s the responsibility of the provider to ensure that the member or someone authorized t o as sist the member has received such instruction . V. For each claim submitted for payment, a provider must keep supporting documentson fi l e:A. R efer to CareSource Administrative policy Medical Record Documentation Standards for Practiti oners-AD-0753. VI.Payment is not available for an orthotic device that is a duplicate or conflicts wit h another device currently in the members possession, regardless of payment or supply source. Providers are responsible for ascertaining whether duplication or conflict exists . E. Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee s chedule for appropriate codes . F. Related Policies/Rules Medical Record Documentation Standards for Practitioners-AD-0753 Orthotics-OH MCD-PY-1 151 Effective Date: 03/01/2022T he REIMBURSEMENTPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the REIMBURSEMENTPo licy Stateme nt Po licy a nd is a pprove d.G. Review/Revision HistoryDATE ACTION Date Issued 06/10/2020 Date Revised 11/10/2021 Revised Policy language. Approved at PGC. Date Effective 03/01/2022 Date Archived H.References 1. Ohio Administrative Code. (2021, October 21). Chapter 4755: Ohio OccupationalTherapy, Physical Therapy, and Athletic Trainers Board. Retrieved October 21, 2021from www.codes.ohio.gov.2. Ohio Administrative Code. (2021, July 1). 5160-10-01 Durable medical equipm ent, pr ostheses, orthoses, and supplies (DMEPOS): general provisions. Retrieved October21, 2021 from www.codes.ohio.gov . 3.O hio Administrative Code. (2018, July 16). 5160-10-31 DMEPOS: footwear and foot orthoses. Retrieved October 21, 2021 from www.codes.ohio.gov.
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifiers OH MCD-PY-1345 03/01/2022 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 m ethodology, 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 eli gibility 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 neces sary 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 o r 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 fo r 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 o ther 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 betw een 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 interpr eting 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 Dat e: 03/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe RE IMBURSEMENT Policy Statement Policy and is approved.A. SUBJECTReimbursement Modifiers B. BACKGROUNDReimbursement policies are designed to assist you 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 cla ims 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 off ice staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure ha s been altered by some specific circumstance. Modifiers can be found in the appendices of both CPT 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 sur geon, 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 provid er; 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 reimburs ement. 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 c laim 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 mai ntained 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 Me dical 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 Dat e: 03/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe RE IMBURSEMENT 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 t he 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 Hospita l 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; 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 mo difiers, 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 follow proper billing, industry standards, and state compliant codes on all claim 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 app ly to bothparticipating and nonparticipating providers and facilities.Note: In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. RELATED POLICIES/RULESNA G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 09/01/2019 New policyDate Revised 04/15/2020 10/13/2021 Added Place of Service 19 to Modifier SA Removed modifiers, changed background and policy sections to simplify language Date Effective 03/01/2022 Date Archived H. REFERENCES1. Appendix to rule 5160-4-21. (2016, June 30). Retrieved 10/6/2021 from www. codes.ohio.gov Modifiers OH MCD-PY-1345 Effective Dat e: 03/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe RE IMBURSEMENT Policy Statement Policy and is approved.2. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 10/6/2021 from www. codes.ohio.gov3. CPT overview and code approval. (2021, October 6). Retrieved from www.ama – assn.org 4. Medicare Claims Proc essing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved October 6, 2021 from www.cms.gov 5. Medicare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved October 6, 2021 fro m www.cms.gov 6. Modifiers Recognized by Ohio Medicaid. (2019, June 1). Retrieved October 6, 2021 from www. medicaid.ohio.gov 7. Optum360 EncoderProForPayers.com – Login. (2021, October 6) Retrieved October 6, 2021 from www.encoderprofp.com 8. Ohio Administrative C ode Rule 5160-4-21. Anesthesia Services. (2017, January 1). Retrieved October 6, 2021 from www. codes.ohio.gov
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled Cost PY-0004 01 /01 /2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement 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 P olicy 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 ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. 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 CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 2 A. SubjectObstetrical Care Unbundled Cost 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 esta blished based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibilit y. 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 reimbursemen t or guarantee claims payment.Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource cove rs obstetrical services members r e c e iv ein 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 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 Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. This policy is for practitioners that meet either of the following: Obstetrical practitioners who are not part of a Free Standing Birthing Center;or Obstetrical practitioners who are part of a Free Standing Birthing Center when any of the following occur: o It is their preferred method of billing; o The member has a change of insurer during pregnancy ; o The member has received part of the antenatal care else where, e.g. from another group practice ; o The member leaves your 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 cesarea n 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 CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 3 C. Definitions Freestanding 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 . Prenatal profile – Initi al laboratory services. Initial and prenatal visit – Practitioner visit to determine member is pregnant Unbundled obstetrical care – The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care – Is for 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 therefore up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery – Includes admission to facility, medical history during admission, physical examinations, management of labor (either vaginal delivery or by cesarean section). o Postpartum care – The period that, b egins 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. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 weeks of pregnancy. 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 40 weeks. D. Policy I. Obstetrical Care A. Initial Visit and Prenatal Profile 1. Evaluation and management (E/M) code s 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. 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 (PRAF) is q ualified 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 would bill antepartum care , delivery, and postpartum care independently of one another. 1. Antepartum 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 Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 4 2. Delivery only Use if only a delive ry 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 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 c. Services (This list may not be all inclusive) :Services included that may NOTbe billed separatelyServices 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 Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as deliveryObstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 5 Delivery of placenta unless it occurs at a separate encounter from the deliveryMinor 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: CPT Code Description59410 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 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 uncomplicated 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 who present with the expectation of a vaginal delivery 14. Caesarean delivery following unsucce ssful vaginal delivery attempt after previous cesarean delivery 4. Postpartum care only – If postpartum care only was provided:a. Use code 59430 postpartum care only. Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 6 b. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy rela ted 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 (This list may not be all inclusive) : 01. Office and outpatient visits following cesarean section or vaginal delivery; or 02. Qualified health care professional providing all or 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 i.e. respiratory tract infection ; or 02. Treatment and management of co mplications 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 postpartu m code to be reimbursed. Charges for hospital admission, history and physical or normal 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 laborat ory 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 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. 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 . Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 7 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(s) 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-0897 Obstetrical Care Total Cost PY-0939 G. Review/Revision History DATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/2021Updated codes, templateNew 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. Date Effective 01/01/202 2 Date Archived Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 8 H. References1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved September 13, 2021 , from www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved September 13, 2021 from www.aapc.com 5. Amer ican Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on September 13, 2021 from www.aapc.com 6. EncoderPro.com for Payers Professional. (2019) Retrieved September 13, 2021 , from www.encoderprofp.com 7. The Amer ican College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved September 13, 2021 , from www.acog.org 8. The American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modifier 22. Retrieved September 13, 2021 , from www.acog.org 9. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Schedu ling Induction of Labor. Retrieved September 13, 2021 , www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved September 13, 2021 from www.acog.org 11. Americ an College of Obstetricians and Gynecologists . (2019 ), April Correct Coding Initiative Version 25.1. Retrieved September 13, 2021 from www.acog.org 12. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved Sept ember 13, 2021 , from www.acog.org 13. American College of Obstetricians and Gynecologists. (2019, January). Prete rm Labor and Birth. Retrieved A ugust 1, 2019 from www.acog.org 14. Ohio Administrative Code. (2017). 3701-4-01 Definitions . Retrieved September 13, 2021 , from www.codes.ohio.gov 15. Ohio Administrative Code. (2018). 5160-18-01 | Freestanding birth center services. Retrieved September 13, 2021 from www.codes.ohio.gov 16. Department of Ohio Medicaid. (2019, June). Modifiers Recognized by Ohio Medicaid. Retrie ved September 13, 2021 from www.medicaid.ohio.gov 17. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved September 13, 2021 from www. codes.ohio.gov 18. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrie ved September 13, 2021 from www. codes.ohio.gov 19. Ohio Administrative Code. (2019). 5160-26 Managed health care programs; definitions. Retrieved September 13, 2021 from www. codes.ohio.gov 20. Ohio Revised Code. (2012). 3702.141 Rules may apply to existing health care facility. Retrieved September 13, 2021 from www. codes.ohio.gov 21. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health service s; pregnancy-related services. Retrieved September 13, 2021 from www. codes.ohio.gov Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 01/01/2022 9 22. Ohio Revised Code (2017). 4723.4 3 Scope of specialized nursing services.Retrieved September 13, 2021 from www. codes.ohio.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
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