REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Hepatitis Band C PY-0447 02 /01 /2021 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 logic, benefits design and other factors are considered in developing Reimburs ement 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 o f disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical 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 mand ate, 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 (ofte n 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), cov erage 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 ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICAIDPY-0447 Effective Date: 02/01/2021 2 A. SubjectMolecular Diagnostic Testing for Hepatitis Band C B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusi on of a code in this policy does not imply any right to reimbursement or guaranteeclaims payment.Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropri atepharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis B is a liver infection caused by the Hepatiti s Bvirus (HBV). Hepatitis Bistransmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or oth er drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approxim ately 90% of infected infants become chronically infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis C is a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis ablood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-term illness but for 70% 85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons migh t not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICAIDPY-0447 Effective Date: 02/01/2021 3 All facilities in the Un ited States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy.III. CareSource does no t consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as serology or blood tests, ar e viewed as low cost andshould be utilized before the higher cost Molecular Diagnostic Testing by PCR.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 n ot be all inclusive and is subject to updates. CPT Code Description 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICAIDPY-0447 Effective Date: 02/01/2021 4 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performedICD-10 Code Description B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta -(super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B18.2 Chronic viral hepatitis C B18.9 Chronic viral hepatitis, unspecified B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis complicating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium F. Related Policies/RulesN/A G. Review/Revision History DATE ACTIONDate Issued 12/01/2018Date Revised 11/07/2018 12/18/2019 09/30/2020 Revised to reflect next review date of 12/01/2019 Addition of code Z20.5 Removed code Z20.5 Date Effective 02/01/2021 Date Archived H. References 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (2015, May 31). Retrieved July 3, 2018, from www.cdc.gov/hepatitis The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center PY-1244 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. 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 applica ble 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 con tract (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 ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 5 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 6 F. Related Policies/Ru les ………………………….. ………………………….. ………………………….. …….. 9 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 9 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 2 A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center 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 a re not a guarantee of payment. Reimbursement for claims may be subject to limitations a nd/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 sel f-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. T heinclusion 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 sim ple 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 ma y 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 paragraph s (A)(1) and (B) of Ohio Administrative Code (OAC) rule 5160-22-01 entitled Ambulatory Surgery Center (ASC) services: provider eligibility, coverage, and reimbursement are subject to the enhanced ambulatory patient grouping system (EAPG) and prospective pa yment 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, en counters, 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) proc edural Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 3 codes and healthcare common procedure coding system (HCPCS)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 software 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 services 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 depa rtment 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 claim. (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 Campus-Outpatient Hospital – A portion of an off-campus hospital provider based department which provides diagnostic, therapeu tic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. On Campus-Outpatient Hospital – A portion of a hospitals main campus which provides diagnostic, thera peutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. Short Procedure U nit (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 developmental disability and without which the person can be Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 4 expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort as def ined 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. 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. Reflex withdrawal from a painful stimulus is NOT conside red a purposeful response. Deep Sedation/Analgesia – A drug-induced depression of consciousness during which patients cannot be easily ar oused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventila tory 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 wh ich 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. Hence, practitioners intending toproduce a given level of seda tion should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (Conscious Sedati on) should be abl e to rescue patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analg esia 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 proficient 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 an d hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 5 D. Policy Most dental care and/or oral surgery is effectively provided in an office sett ing. 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 f or facility related services when dental procedures are rendered in a 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 pr ovision 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 se rvices 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 services, 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 th e 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 an y diagnostic or preventative dental services 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 Facil ity B. Dental Services Autho rization for an 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 t he [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 ambula tory 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 a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 6 1. Upon approval, DentaQuest Participating Providers are required to administer services at CareSource participating hospitals. Upon receipt of approval from DentaQuest, Provider should use the information below for facility authorization as applicable.2. Fo r Medical Prior Authorizations , the Provider (hospital or ASC facility) may submit the request on the CareSource Provider Portal at www.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 AND; b. Review the DentaQuest pre-determination letter (PDL) or authorization AND; c. Determine medical necessity for any other facility-related CPT/HCPCS codes submitted AND; 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 submit s 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) Facility Reimbursement Policy Children’s hospitals, as defined in rule 5160-2-05 of the Administrative Code Use CPT code 41899 as Facility Fee code Will be paid one-thousand sixty-two dollars ($1062.00) Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 7 All other hospitalsUse 41899 as Facility Fee code Will be paid one-thousand one-hundred ninety-two dollars ($1192.00) Discounting Factors Payments shall be multiplied by any applicable discounting factor, rounded to the nearest whole cent. Anesthesia Professional Services Reimbursement Policy CPT Non-Dental Anesthesia Code 00170 Anesthesia for intraoral treatments, including biopsy; not otherwise specified 00170 is calculated in CMS Base units. The Base unit =5 units. The administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners Anesthesia Services – Anesthesiology professional Services for intraoral procedures. Time units for physician and CRNA services-both personally performed and medically dir ected 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 minu tes) 75 = 6 units (of 15 min increments). CMS Base units =5. Maximum state allowances may be applicable. 1) Payment for an anesthesia service is the lesser of the provider’s submitted charge or the Medicaid maximum, which is determined by a formula. (a) T he amount is the product of three factors: 1. The sum of the base unit value and the time unit value; 2. The appropriate conversion factor; and 3. The relevant multiplier. Conversion Factors and Multipliers CDT Dental Anesthesia Codes D9222, D9223 Deep Sedation/General Anesthesia, D9239, D9243 Monitored Anesthesia Care Payment for intravenous conscious sedation/analgesia services is limited to one unit of the first 15 minutes and up to four units of subsequent 15-minute increments per date of service Payment for deep sedation/general anesthesia services is limited to one unit of the first 15 minutes and up to four units of subsequent 15-minute increments per date of service. Provisions governing payment for anesthesia as a dental service are set forth in Chapter 5160-5 of the Administrative Code Inpatient Hospital Facility POS ( 21) All services as well as any additional Room and Board fees would have to be pre-certified and receive medical necessity review. Services are subject to benefit provisions Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 8 Ambulatory Surgical Center POS (24)CPT Code DescriptionPayments for covered dental services may be made for all line items grouping to EAPG grouping code Use code 41899 for facility feeReimbursement for claims assigned to a dental service EAPG type will be paid as follows:Reimbursement for dental services will be nine – hundre d fifty-three dollars and sixty cents. ($953.60) Payments for dental services will be made in accordance with the discounting factors as determined by the EAPG grouper. Anesthesia Professional Services Reimbursement Policy CPT 00170 00170 is calculated in CMS Base units. The Base unit =5 units. See formula under Hospital section above. Dental/Oral Surgery Professional Services 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. The professional dental procedure codes listed are f or reference only and do not imply coverage of dental procedures. Information on dental benefits, please consult our partnered dental vendor DentaQuest Office Reference Manual for clinical guidelines, policies and procedures CPT Code Description (D0000-D9999) Reimbursed according to provider contractual rate Dental service charges will be paid directly to the TREATING DENTIST PAYEE GROUP All dental services that require authorization must receive prior authorization via DentaQuest Dental Management. (a) For a service rendered by a provider whose office address (specified in the provider agreement) is in a non-rural Ohio county or a county outside Ohio, payment is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code. (b) For a service rendered by a provider whose office address is in a rural Ohio county, payment is the lesser of the submitted charge or one hundred five per cent of the amount listed in appendix DD to rule 5160-1-60 of the Ad ministrative Code. ICD-10 and CPT code for Oral or Maxillofacial region (2) For a covered dental service that is identified by a current procedural terminology (CPT) code, such as oral surgery, payment is the lesser of the submitted charge or the amount listed in appendix DD to rule 5160-1-60 of the Administrative Code, regardless of whether the service is provided in a rural or non-rural county. Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterOHIO MEDICAIDPY-1244 Effective Date: 01/01/2021 9 CPT codes – Follow applicable benefit guidelines in CareSource Provider ManualAll medical services of the oral, maxillofacial, head and neck regions performed in the hospital/ASC must receive prior authorization from the CareSource M edical Management team F. Review/Revision History DATE ACTIONDate Issued 09/16/2020 New PolicyDate Revised Date Effective 01/01/2021 Date Archived G. References1. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. (2018, October 23). Retrieved July 30, 2020, from www.asahq.org 2. American Academy of Pediatric Dentistry. Oral Health Po licies and Recommendations. (2019). Retrieved July 20, 2020 from www.aapd.org 3. American Association of Oral and Maxillofacial Surgeons, Ambulatory Surgical Center Coding and Billing. Retrieved April 5, 2019 from www.aaoms.org 4. Ohio Administrative Code. Ambulatory Surgery Center Services 5160-22. Retrieved from: https://codes.ohio.gov/oac/5160-22-01 Ohio Administrative Code. Dental Services 5160-5. Retrieved from: codes.ohio.gov/oac/5160-5 5. Ohio Administrative Code. Anesthesia Services. 5160-4-21. Retrieved from: http://codes.ohio.gov/oac/5160-4-21Ohio Administrative Code. Hospit al Services 5160-2. Retrieved from: http://codes.ohio.gov/oac/5160-2-03 6. Ohio Administrative Code. Outpatient hospital reimbursement 5160-2-75 Retrieved from: http://codes.ohio.gov/oac/5160-2-75 7. Ohio Department of Medicaid. Hospital Billing Guide. Retrieved from: https://www.medicaid.ohio.gov/Portals/0/Resources/Publications/Guidance/BillingInstructions/HospitalBillingGuidelines-20180701.pdf The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Transcutaneous Electrical Nerve Stimulation (TENS) PY-0039 01/01 /2021 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 logic, benefits design and other factors are considered in developing Reimburseme nt 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, an d 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 d isease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical 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 r eferred 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 docume nt 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 ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Transcutaneous Electrical Nerve Stimulation (TENS)OHIO MEDICAIDPY-0039 Effective Date: 01/01/2021 2 A. SubjectTranscutaneous Electrical Nerve Stimulation (TENS) 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. Reimb ursement 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 verif y 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 t o reimbursement or guaranteeclaims payment.Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the mem bers painful area via electrodes applied to themembers skin. CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day (1 month) t rial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. C. Definitions Transcutaneous electrical nerve stimulation (TENS) – is the application of mild electrical stimulation, t o skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. Accessories – includes but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches and covers. Supplies – includes but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries and battery charger for rechargeable batteries. D. Policy I. CareSource requires a prior authorization (PA) for a TENS unit. A. E0720 Two-lead unit. B. E0730 Four-lead unit. II. Supplies (A4595) do not require a prior authorization.A. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. Transcutaneous Electrical Nerve Stimulation (TENS)OHIO MEDICAIDPY-0039 Effective Date: 01/01/2021 3 C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-Lead TENS unit (E0720) or 2units per month for a 4-Lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed , at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for individual supply items. E. If a submitted claim does not include a modifier, or includes an inco rrect or inappropriate modifier, the claim may den y. 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. 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 E0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers Description NU Purchase of new equipment RR Rental (use the ‘RR’ modifier when DME is to be rented) F. Related Policies/Rules Ohio Administrative Code 5160-10-15 G. Review/Revision History DATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09 /16 /2020 Updated policy to align with OAC updates Updated prior authorization requirement. Date Effective 01/ 01 /2021 Date Archived Transcutaneous Electrical Nerve Stimulation (TENS)OHIO MEDICAIDPY-0039 Effective Date: 01/01/2021 4 H. References1. Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) Appendix to rule 5160-10-01. (2019, January 1). Retrieved 1/20/2019 from www. codes.ohio.gov . 2. Lawriter – OAC – 5160-10-15 DMEPOS: transcutaneous electrical nerve stimulation (TENS) units. (2018, July 16). Retrieved 1/20/2019 from www. codes.ohio.gov. 3. Using TENS for pain control: the state of the evidence. (2015, March 1). Retrieved 1/20/2019 from www.ncbi.n lm.nih.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.
REIMBURSEMENT POLICY STATEMENTOHIO M EDICAID Policy Name Policy Number Effective Date Screening for Sexually Transmitted Infections PY-0436 01/01/2021-06/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, 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 lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy . Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 3 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 4 F. Related Policies/Rules …………………………………………………………………………………………….. 4 G. Revie w/Revision History ………………………………………………………………………………………….. 4 H. References ……………………………………………………………………………………………………………. 5 Screening for Sexually Transmitted Infections OHIO MEDICAID PY-0 436 Effective Date: 01/01/20212A. SubjectScreening for Sexually Transmitted Infections 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 inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment Sexually transmitted infections (STIs) cause significant morbidity and mortality in the United States each year. The United States Preventive Services Task Force (USPSTF) recommends that women at increased risk of infection be screened for chlamydia, gonorrhea, human immunodeficiency virus, and syphilis. Men at increased risk should be screened for human immunodeficiency virus and syphilis. All pregnant women should be screened for hepatitis B, human immunodeficiency virus, and syphilis; pregnant women at increased risk also should be screened for chlamydia and gonorrhea. Non-pregnant women and men not at increased risk do not require routine screening for sexually transmitted infections. Engaging in high-risk sexual behavior places persons at increased risk of sexually transmitted infections. The USPSTF recommends that all sexually active women younger than 25 years be considered at increased risk of chlamydia and gonorrhea. Because not all communities present equal risk of sexually transmitted infections, the USPSTF, the US Centers for Disease Control (CDC), the American College of Obstetricians and Gynecologists (ACOG) and other authorities encourage physicians to consider expanding or limiting the routine sexually transmitted infection screening they provide based on the community and populations they serve. CareSource encourages screening for Sexually Transmitted Infections consistent with the grade A and Brecommendations of the USPSTF and the Centers for Medicare & Medicaid (CMS ) National Coverage Determination (NCD) Policy 210.10 for Screening for Sexually Transmitted Infections. In addition to these recommendations, CareSource encourages screening for Sexually Transmitted Infections for men and women at increased risk. CareSource has eliminated the annual scr een limitations set forth in the NCD as well as the order of billing STI diagnosis codes. Screening for Sexually Transmitted Infections OHIO MEDICAID PY-0 436 Effective Date: 01/01/20213C. Definitions Sexually Transmitted Infections (STI) infections that are passed from one person to another through sexual contact Nucleic Acid Amplification Tests (NAATs) gene amplification tests such as Polymerase Chain Reaction (PCR) that are cleared by the United States Food and Drug Administration ( FDA) and are recommended for detection of genital tract infections caused by Chlamydia trachomatis and Neisseria gonorrhea, with or without symptoms. High Intensity Behavioral Counseling (HIBC ) to prevent STIs (per the Centers for Medicare & Medicaid Ser vices) a program intended to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing flexibility for appropriate patient focused elements: o Education o Skills Training o Guidance on how to change sexual behavior Screening the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease High risk behaviors (related to acquiring a STI) as outlined by the U.S. Preventive Services Task Force (USPSTF) and documented in the medical record are: o Early sexual activity, for example before age 18 o Multiple sex partners. o Sex with a high-risk partner (one who has multiple sex partners or other risk factors). o Unprotected intercourse without consistent use of correct male or female condom use, except in a long-term, single partner (monogamous) relationship. o Unprotected mouth to genital contact, except in a long term, single partner (monogamous) relationship. o Having anal sex or a partner who does, except in a long term, single partner (monogamous) relationship. o Having sex with a partner who injects or has ever injected drugs. o Exchange of sex (sex work) for drugs or money. o Having had a sexually transmitted disease in the past. D. Policy I. Prior authorization is not required for medically necessary STI screenings. A. CareSource may request the complete and appropriate medical documentation to support and validate the medical necessity of these services. II. Sexually Transmitted Infections A. Chlamydia 1. CareSource considers screening for Chlamydia trachomatis infections medically necessary for these member groups: a. All pregnant women. b. All sexually active women aged 24 or younger . c. Women with high-risk behaviors of any age for Chlamydia trachomatis. 2. Routine repeat testing of NAAT-positive genital tract specimens is not recommended because the practice does not improve the positive predictive value of the test. Screening for Sexually Transmitted Infections OHIO MEDICAID PY-0 436 Effective Date: 01/01/20214B. Gonorrhea 1. CareSource considers screening for Neisseria gonorrhea infections medically necessary for these member groups: a. All pregnant women. b. All sexually active women younger than 25 years of age. c. Women with high-risk behaviors of any age for Neisseria Gonorrhea. 2. Routine repeat testing of NAAT-positive genital tract specimens is not recommended because the practice does not improve the positive predictive value of the test. C. HIV 1. Everyone aged 15 to 65 should be screened for HIV (Human Im munodeficiency Virus) Infection. 2. People younger than age 15 and adults older than 65 should be screened if they are at increased risk for HIV infection, based on high-risk behaviors (as defined above). 3. All pregnant women, including women in labor or delivery should be screened for HIV infection. D. Syphilis 1. All pregnant women should be tested for syphilis as early as possible when they first present to care. If a woman has not received prenatal care prior to delivery, she should be tested at the time she presents for delivery . 2. Men and women with high risk behaviors for syphilis infection. E. Hepatitis B 1. All pregnant women. 2. Men and women with high-risk behaviors for h epatitis Binfection. III. Documentation of High Intensity Behavioral Counseling must be present in the medical record when routine screening for STI related to high risk sexual behaviors is performed. IV. Screening for STI for men and women who are not at increased risk, as outlined in this policy is not considered medically necessary and will not be covered or reimbursed . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 01/01/2019 New policyScreening for Sexually Transmitted Infections OHIO MEDICAID PY-0 436 Effective Date: 01/01/20215Date Revised 09/02/2020 Removed modifier list ; Updated references . Removed men from chlamydia screening. Re vised pregnancy testing language. Date Effective 09/01/2021 Date Archived 06/30/2021 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. References 1. Decision Memo for Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to prevent STIs (CAG-00426N). 2011. Retrieved July 22, 2020 from https://www.cms.gov . 2. Centers for Disease Control and Prevention (CDC). 2014 Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhoeae. Retrieved August 18, 2020 from www.cdc.gov. 3. Centers for Disease Control and Prevention (CDC). STD Screening Recommendations-2015 STD Treatment Guidelines. (2016, August 22). Retrieved July 22, 2020 from www.cdc.gov . 4. EncoderPro, Optum 360 Access (Online Medical Coding Software) . ICD-10-CM Official Guidelines for Coding and Reporting 2020 . (2020). Retrieved July 22, 2020 from www.encoderprofp.com . 5. U.S. Preventive Services Task Force. Screening for Chlamydia and Gonorrhea. Retrieved July 22, 2020 from www.uspreventiveservicestaskforce.org. 6. U.S. Preventive Services Task Force. Screening for Human Immunodeficiency Virus (HIV). Retrieved July 22, 2020 from www.uspreventiveservicestaskforc e.org. The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1076 01/01/2021-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical 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 ens ure 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectImplantable Spinal Cord Stimulator Imp lan table Sp in al Co rd Stimulato rOHIO MEDICAID PY-1076 Effective Date: 01/01/2021 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualif ications. 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 f or processing. Health care providers and the ir of f ice 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) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment. Nearly 84% of adults experience back pain during their lif etime. Long term outcomes are largely f avorable f or most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is def ined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures f or management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments inclu de promoting patient self – management and aim to reduce the impact of pain on a patient’s daily lif e, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be prov ided only by physicians qualif ied to deliver these health services. C. Def initions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain. D. PolicyI. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required f or all implantable spinal cord stimulators, including short-term trial placement, permanent placement and removal and revision of the implanted device. 1. Prior authorizations f or implantable spinal cord stimulator services are not required f or the following: a. Implantable device and device components are considered part of the procedure and does not require a separate PA. 3 b. Elect ronic analysis/studies post implantation Imp lan table Sp in al Co rd Stimulato rOHIO MEDICAID PY-1076 Effective Date: 01/01/2021 B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria f ound in the Implantable Spinal Cord Stimulator Medical policy MM-0076. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule 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. Implantable Spinal Cord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy f or implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including f luoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including f luoroscopy, when perf ormed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including f luoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including f luoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording f rom the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording f rom the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 4 Imp lan table Sp in al Co rd Stimulato rOHIO MEDICAID PY-1076 Effective Date: 01/01/2021 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording f rom the central nervous system; in upper and lower limbs 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, f requency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, a nd passive parameters) by physician or other qualif ied health care prof essional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming 95971 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, f requency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualif ied health care prof essional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualif ied health care professional 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, f requency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualif ied health care pro f essional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualif ied health care professional L8679 Implantable neurostimulator, pulse generator, any type L8682 Implantable neurostimulator radiofrequency receiver L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS Lcode C1767 Generator, neurostimulator (implantable), nonrechargeable C1778 Lead, neurostimulator (implantable) C1787 Patient programmer, neurostimulator C1816 Receiver and/or transmitter, neurostimulator (implantable) C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system C1822 Generator, neurostimulator (implantable), high f requency, with rechargeable battery and charging system C1823 External recharging system f or battery (external) f or use with implantable neurostimulator, replacement only C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) 5 Imp lan table Sp in al Co rd Stimulato rOHIO MEDICAID PY-1076 Effective Date: 01/01/2021 C1897 Lead, neurostimulator test kit (implantable) F. Related Policies/RulesImplantable Spinal Cord Stimulator MM-0076 G. Review/Revision HistoryDATE ACTIONDate Issued 07/26/2016Date Revised 05/13/2020 08/26/2020Added Codes: L8682PA is now required f or removal/revision of thedevice.Date Effective 01/01/2021 Date Archived 05/31/2021 This Policy is no longer active and has beenarchived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f ormal documented PolicyH. Ref erences1. CMS Physician’s Fee Schedule. Retrieved on April 22, 2020 from www.cms.gov 2. CMS Durable Medical Equipment, Prosthetics/Orthotics and Supplies (DMEPOS) Fee Schedule. Retreived on March 4, 2020 f rom www.cms.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Implantable Pain Pump PY-1070 01/0 1/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Polici es. 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 applica ble 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 t o 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 t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Cov erage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Implantable Pain PumpOHIO MEDICAIDPY-1070 Effective Date: 01/01/2021 2 A. SubjectImplantable Pain Pump 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 limitati ons 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 us e 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 p olicy does not imply any right to reimbursement or guaranteeclaims payment.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are ca tegorized as chronic. Chronic pain is defined by the International Association for theStudy of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months.Interventional procedures for management of acute and ch ronic pain are part of acomprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient ‘s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Implant able Pain Pump – Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for conti nuous or variable rates of infusion . D. Policy I. Prior authorization is required for all implantable pain pumps, including trial administration , permanent placement , single shot intrathecal injections and removal and revision of the implanted devi ce. Prior authorization is not required when the drug is prescri bed under one of the following circumstances: A. To an individual who is a hospice patient in a hospice care program; B. To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program; and Implantable Pain PumpOHIO MEDICAIDPY-1070 Effective Date: 01/01/2021 3 C. To an individual who has cancer or another condition associated with the individuals cancer or history of cancer.II. Prior authorization for implantable pain pump services are not required for the following:A. Implantable device is considered part of the procedure and does not require a separate PA. B. Analysis post implantation. C. Refilling and maintenance of the implanted device. III. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria foun d in the Implantable Pain Pump medical policy MM-0077 . E. Conditions of Coverage Reimbursement i s 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. Thi s list may not be all inclusive and is subject to updates. Implantable Pain Pump Description 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62355 Removal of previously implanted intrathecal or epidural catheter 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming 62365 Removal of subcutaneous reservoir o r pump, previously implanted for intrathecal or epidural infusion 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming Implantable Pain PumpOHIO MEDICAIDPY-1070 Effective Date: 01/01/2021 4 62369 Electronic ana lysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualified health care professional) 95990 Refilling and mainten ance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; 95991 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when performed; requiring skill of a physician or other qualified health care professional C1772 Infusion pump, programmable (implantable E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter) F. Related Policies/Rules Implantable Pain Pump MM-0077 G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 07/08/2020 08/ 26/2020Annual Update : Addition of PA non-requirement criteria . PA is now required for removal/revision of theimplanted device.Date Effective 01/01/2 021 Date Archived H. References1. Ohio Department of Medicaid Fee Schedules and Rates. Retrieved on April 15, 2020 from www.medicaid.ohio.gov 2. Ohio Revised Code. ORC 1751.691 (2017, April 6) Prior authorization requirments or other utlilzation review measures as conditions of providing cove rage of an opioid analgesic. Retrieved on July 1, 2020 from codes.ohio.gov Implantable Pain PumpOHIO MEDICAIDPY-1070 Effective Date: 01/01/2021 5 The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Nutritional Supplements PY-0779 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing 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 co ntractual 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 diag nosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These service s 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 condition s as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Nutritional SupplementsOHIO MEDICAIDPY-0779 Effective Date: 01/01/202 1 2 A. SubjectNutritional Supplements 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 inclusion of a code inthis policy does not imply any right to reimbursement or guarantee claims payment.Nutrition may be delivered through a tube into the stomach or small i ntestine . Ent eralNutrition may be medically necessary for dietary management to provide sufficient caloric and nutrition needs as a result of limited or impaired ability to ingest, digest, absorb or metabolize nutrients ; or for a special medically determined nutrient requirement. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enteral nutrition may be either for total enteral nutrition or for supplemental enter al nutrition . Parenteral nutrition is nutrition provided through an intravenous line. Home Infusion Therapy is NOT covered in this policy .This policy includes nutrition that is for medical purposes only.C. Definitions Enteral Nutrition Nutrition deli vered through an enteral access device into the gastrointestinal tract bypassing the oral cavity . Medical Food Food specially formulated and processed to be consumed or administered by oral intake or enteral access device. The intent is to meet distinctive nutritional requirements of a disease or condition when dietary management cannot be met by modifying a nor mal diet. Enteral Access Device A tube or stoma is placed directly into the gastrointestinal tract for the delivery of nutrients. Inborn Errors Of M etabolism (IEM) Inherited biochemical disorders resulting in enzyme defec ts that interfere with normal m etabolism of protein, fat, or carbohydrate. Therapeutic oral non-medical nutrition o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens. i.e. diabetes mell itus, celiac disease Nutritional SupplementsOHIO MEDICAIDPY-0779 Effective Date: 01/01/202 1 3 o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional food Food that is fortified to produce specific beneficial health effects. o Texture M odified Food and Thickened Fluids Liquidized/thin puree, thick puree, finely minced or modified normal. o Modified Normal Eating normal foods, but avoiding particulate foods that are a choking hazard. Unit 100 calories = 1 unit . D. Policy I. Prior Authorization A. Prior authorization is NOT required for 1. HCPCS code B4162 or B4157 . 2. B4088 Gastrostom y/Jejunostomy Tube, Low-profile. B. Prior authorization is required for 1. Oral nutrition (except for HCPCS code B4162 and B4157 ). 2. Enteral nutrition (except for HCPCS code B416 2 and B4157 ). 3. Food supplements, nutritional supplements and infant formula when a. Requesting greater than 72 units per month ; or b. Member is under the age of five and does not meet criteria for any other local, state, or federal program. 4. Donor human milk . C. Pr ior authorization is required for n on-participating providers . II. Quantity LimitsA. Nutritional counseling is limited to one visit per calendar year for diagnosis of obesity . B. CareSource provides enteral nutrition through participating durable medical equipment (DME) providers allowing home delivery of medically necessary enteral nutrition. III. Enteral Nutrition A. CareSource pays for the dispensing and shipping/delivery of enteral nu trition B. CareSource does NOT reimburse for the following 1. Based on the Ohio Administrative Code 1 a. Ordinary prepared food; b. Commercial products that serve as ordinary food (e.g., shakes, smoothies, energy bars, vitamin or mineral supplements, baby food); c. Food products to be eaten as part of a diet related to diabetes, obesity, gastric bypass, or bariatric surgery; d. Food products for which a provider receives Medicaid per diem payment; and e. Standard infant formula (not used to treat errors of metabolism) for which payment may be made through a program other than Medicaid . 1 http://ohrules.elaws.us/oac/5160-10-26Nutritional SupplementsOHIO MEDICAIDPY-0779 Effective Date: 01/01/202 1 4 2. Quantities that exceed a one months supply3. Supplies dispensed greater than one week before scheduled date 4. Enteral nutrition for members with advanced dementia 5. When use of product is for c onvenience or preference of member/caregiver. 6. B4104 enteral formula additive. Enteral formula codes include all nutrient components. IV. Human Donor MilkA. CareSource only provides payment if the provider is a member in good standing with the human milk banking association of North America B. CareSource reimburses for the processing and delivery/shipping C. CareSource does NOT reimburse for 1. Payment s to a provider for supplying the donor human milk 2. Payment s for the milk itself E. Conditions of Coverage Reimburseme nt 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 B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE, PER DAY B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED, PER DAY B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED (PER DAY, INCLUDES BAGS/CONTAINERS) B4081 NASOGASTRIC TUBING WITH STYLET B4082 NASOGASTRIC TUBING WITHOUT STYLET B4083 STOMACH TUBE, LEVINE TYPE B4087 GASTROSTOMY/JEJUNOSTOMY TUBE, STANDARD B4088 GASTROSTOMY/JEJUNOSTOMY TUBE, LOW-PROFILE B4100 FOOD THICKENER, ORAL, PER OUNCE B4105 IN-LINE CARTTRIDGE CONTAINING DIGESTIVE ENZYM(S) FOR ENERAL FEEDING, EACH B4149 ENTERAL FORMULA, MANUFACTURED BLENDERIZED NATURAL FOODS WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4150 ENTERAL FORMULA, NUTRITIONALLY COMPLETE WITH INTAC T NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, Nutritional SupplementsOHIO MEDICAIDPY-0779 Effective Date: 01/01/202 1 5 VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNITB4152 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, CALORICALLY DENSE (EQUAL TO OR GREATER THAN 1 .5 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS,CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4153 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, HYDROLYZED PROTEINS (AMINO ACIDS ANDPEPTIDE CHAIN), INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1UNIT B4154 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS, EXCLUDES INHERITED DISEASE OF METABOLISM, INCLUDES ALTERED COMPOSITION OF PROTEINS,FATS, CARBOHYDRATES, VITAMINS AND/OR MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4155 ENTERAL FORMULA, NUTRITIONALLY INCOMPLET E/MODULAR NUTRIENTS, INCLUDES SPECIFIC NUTRIENTS, CARBOHYDRATES (E.G. GLUCOSE POLYMERS), PROTEINS/AMINO ACIDS (E.G. GLUTAMINE, ARGININE), FAT (E.G. MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATION, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 U NIT B4157 ENTERAL FORMULA, NUTRITIONALLY COMPLETE, FOR SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIE S = 1 UNIT B4158 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UN IT B4159 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE SOY BASED WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER AND/OR IRON, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4160 ENTERAL FORMULA, FOR PEDIATRICS, NUTRITIONALLY COMPLETE CALORICALLY DENSE (EQUAL TO OR GREATER THAN 0.7 KCAL/ML) WITH INTACT NUTRIENTS, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT B4161 ENTERAL FORMULA, FOR PEDIATRICS, HYDROLYZED/AMINO ACIDS AND PEPTIDE CHAIN PROTEINS, INCLUDES FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALORIES = 1 UNIT Nutritional SupplementsOHIO MEDICAIDPY-0779 Effective Date: 01/01/202 1 6 B4162 ENTERAL FORMULA, FOR PEDIATRICS, SPECIAL METABOLIC NEEDS FOR INHERITED DISEASE OF METABOLISM, INCLUDES PROTEINS, FATS, CARBOHYDRATES, VITAMINS AND MINERALS, MAY INCLUDE FIBER, ADMINISTERED THROUGH AN ENTERAL FEEDING TUBE, 100 CALO RIES = 1 UNITB9002 ENTERAL NUTRITION INFUSION PUMP – WITH ALARM B9998 ENTERAL SUPPLIES, NOT OTHERWISE SPECIFIED T2101 BREAST MILK PROC/STORE/DIST, PER OZ Modifiers Description U1 USED TO DIFFERENTIATE B4100 AS A CONCENTRATED FORMULA BO ADMINISTRATION BY MOUTH RATHER THAN BY FEEDING TUBE F. Related Policies/Rules Nutritional Supplements MM-0024 G. Review/Revision History DATE ACTIONDate Issued 09/09/2019Date Revised 04/01/2020 08/19/2020 Added Relizorb as coveredUpdated PA , Removed medical nutritional therapy Date Effective 01/01/2021 Date Archived H. References1. Ohio Administrative Code. (2018, July 16). 5160-10-26 DMEPOS: nutrition products. Retrieved August 12, 2020 from www.codes.ohio.gov/oac 2. Ohio Administrative Code. (2016, May 8). 5160-8-41 Medical nutrition therapy services. Retrieved August 12, 2020 from www.codes.ohio.gov/oac The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Date Effective Drug Test ing PY-0020 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing logic, benefits design and other factors are considered in developing Reimburs ement 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 o f disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical 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 mand ate, 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 (ofte n 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 doc ument 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 und er this policy.Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 2 A. Subject Drug TestingB. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Hea lth 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 ser vice that is being provided. Theinclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members with substance use disorder (SUD); for members who are at r isk for abuse/misuse of drugs; or for other medical conditions. The drug testguides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern.Urine is the most common specimen to monitor drug use. There are two main type s ofurine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test – The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory /Quantitative test – A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) – This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test – A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory – A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating – Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSource. Qualified Laboratories – When an out-of-network qualified laboratory provides toxicology test results to the referring health care provider within two business days of receipt of the test specimen, the MCP shall pay that laboratory at least sixty percent of the Medicaid laborator y services fee schedule. For the purposes of this Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 3 requirement, a qualified laboratory is a laboratory that is enrolled with Medicaid as an independent laboratory, and that meets all of the following conditions : 1. Is accredited by the College of American Pathologists; and 2. Is approved by the New York Clinical Laboratory Evaluation Program; and 3. Indicates to the MCP that it is providing services and billing as a qualified laboratory Residential services – Ohio Administrative code defines residential se rvices as These services are co-occurring capable, co-occurring enhanced, and complexity capable in nature and provided by addiction treatment, mental health and general medical personnel in a twenty four hour treatment setting. Services are provided in Ohio department of mental health and addiction services certified permanent facilities which are staffed twenty four hours a day. 1 NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing areoutlined in detail within the CareSource Drug Testing Medical Policy, MM-0054 . Please refer to this policy for in-depth information on medical necessity for drug testing, d ocumentation requirements , and CareSource monitoring and review of drug testing claims. D. PolicyThis policy is not applicable to drug testing rendered by hospital lab oratorie s; itis only applicable to independent lab orator ies .I. General Criteria for CoverageA. Documentation must support medical necessity.B. Documentation must include the ICD-10 code demonstrating an appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA)A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. CareSource will require a PA for UDT tests >30 presumptive and/or > 12 confirmatory UDT per member per calendar year. Prior authorization will be required for confirmatory drug tests involving 22 or more drug classes. (G0483) . a. The Ohio Department of Medicaid Standard UDT PA Form must be provided along with the appropriate su pporting documentation when requesting a PA. b. Appropriate clinical documentation must be included with PA request to determine appropriate medical necessity. 1 http://codes.ohio.gov/oac/5160-27-09v1 Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 4 01. PA needs to make a clear case for medical necessity for the level of testing being requested, it ma y include but is not limited to: (1) Phase of treatment (e.g. assessment, early recovery, induction, stabilization, maintenance). (2) Current level of care (e.g. use of ASAM levels). (3) Member drug(s) of choice. (4) Days since last drug test with unexpected results. (5) Current prescribed drugs including over-the-counter drugs and illicit drugs that have had unexpected results in recent tests. (6) Member current active symptoms that led to the request. (7) Provider actions taken on recent unexpected test results and member respon se to that action. (8) The clinical documentation shows that the member is contesting the result of an unexpected presumptive test. (9) The test is not being requested for third party reasons, or as a condition to stay in sober housing or residential facility (see additional information below). (10) Results of any pill counts performed by treatment team. 2. PA is also required for a. Any non-participating provider with CareSource for non-emergency room setting. b. Any non-participating, non-qualified lab/facility with CareSourc e for non – emergency room setting. c. Any non-participating, qualified lab/facility with CareSource for non – emergency room setting. 3. PA is NOT required in an emergency room setting. Confirmatory testing is rarely needed in this setting. UDT utilization will be monitored by CareSource. B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezing specimen. C. If needed, the licensed practitioner that is op erating in his/her scope of practice must obtain the prior authorization. III. Quantity LimitationsA. CareSource will cover up to 30 presumptive and 12 definitive UDT per member per calendar year. 1. CareSource will cover up to 30 presumptive UDT per member per calendar year. 2. CareSource will cover up to 12 definitive UDT per member per calendar year. B. Each CPT code is counted as one test. IV. LaboratoryA. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider, but are Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 5 performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSourc e. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care s ervice for children under age 21 .VI. Non-Urine TestingA. CareSource will reimburse blood testing in emergency room settings . B. Drug testing with blood samples performed in any other setting outside of an emergency room is a non-covered benefit. C. Hair or body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered . 1. Point-of-service testing (H0048), which includes both urine and saliva, is a covered service for Community Behavioral Health Centers (CBHCs). VII. Confirmatory TestingA. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist and one of the following: a. Presumptive testing was negative for prescription medications and provider was expecting the test to be positive for p rescribed medication and member reports taking medication as prescribed ; b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider and the member disputes the presumptive testing results ; c. Presumptive testing was positive for illegal drug and the member disputes the presumptive testing results ; or d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug TestingA. Testing that is not individualized such as 1. Reflexive testing; 2. Routine orders; 3. Standard orders; 4. Preprinted orders; 5. Requesting a broad spectrum of tests that a machine is capable of doing solely b ecause a result may be positive; 6. Large arbitrary panels; 7. Universal testi ng; or 8. Conduct additional testing as needed. B. Testing re quired by third parties such as Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 6 1. Testing ordered by a court or other medico-legal purpose such as child custody ; 2. Testing for pre-employment or random testing that is a requirement of employment ; 3. Physicians health programs (recovery for physicians, dentists, ve terinarians, pharmacists, etc.); 4. School entry or testing for athletics ; 5. Testing required for military service; 6. Testing in residential faci lity, partial hospital, or sober living as a condition to rem ain in that community; 7. Testing with another pay source that is primary such as a county, state or federal agency; 8. Testing for mar riage license; 9. Foren sic; 10. Testing for other admin purposes; or 11. Rout ine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen 1. It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair or other body fluid testing for controlled substance monitoring, except for point-of-service testing (H0048), which includes both urine and saliva, when rendered by a CBHC. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale ord ers including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as nee ded orders. J. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits , recovery of overpayments identified, and provider prepay review . 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. F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 7 G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 11/29/2017Date Revised 03/08/2017 05/31/2017 10/ 01/2017 11/29/2017 02/16/2018 05/13/2019 07/01/2019 07/08/201909/24 /201906/10/2020 08/19/2020 11/12/2020Updated clinical indications, quantity limits, and PA requirements Updated qualified laboratories per ODM guidance Added ODM PA form Update with ODM requirement to allow saliva for point – of-service testing (H0048) for CBHCs . Removed codes. Updated per ODM Medicaid Advisory Letter 650 . Removed appendix A. Date Effective 01/01/2021 Date Archived H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016, January). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . 2(1): 28-45. doi: 10.17756/jrdsas.2016-025 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance – use patients: A qualitative study. International Journal of Mental Health and Addiction. (14) 64-80. doi: 10.1007/s11469-015-9569-7 3. American Society of Addiction Medicine. (2017, May/June). Appropriate use of drug testing in clin ical addiction medicine. 11(3) 163-173. doi: 10.1097/ADM.0000000000000323 4. Andersson, H. W., Wenaas, M., & Nordfjrn, T. (2019). Relapse after inpatient substance use treatment: A prospective cohort study among users of illicit substances. Addictive Behavio rs, (90)222-228. doi:10.1016/j.addbeh.2018.11.008 5. American Society of Addiction Medicine (2010, October) . Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings . Retrieved Augus t 12, 2020 from www.asam.org. 6. Dowell, D., Haegerich, T. M., & Chou, R. (2016, March). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 . Retrieved August 12, 2020 from www.cdc.gov 7. eCFR Code of Federal Regulations. 42 Code of Fe deral Regulations (CFR) Part 8. (n.d.). Retrieved August 12, 2020 from www.ecfr.gov 8. Gourlay, D. L., Heit, H. H., & Caplan, Y. H. (2015, August 31). Urine Drug Testing in Clinical Practice The Art and Science of Patient Care (Edition 6). PharmaCom Group Inc./Center for Independent Healthcare Education Drug TestingOHIO MEDICAIDPY-0020 Effective Date: 01/01/2021 8 9. Jarvis, M, Williams, J, Hurford, M, L indsay, D, Lincoln, P, Giles, L, Luongo, P,..Safarian, T. (2017, April 5). Appropriate Use of Drug Testing in Clinical Addiction Medication. Journal of Addiction Medicine . Retrieved August 12, 2020 from www.dca.ca.gov 10. Medicare Learning Network. (2020, Ma y). CLIA Program and Medicare Laboratory Services. Retrieved August 12, 2020 from www.cms.gov 11. National Academies of Sciences, Engineering, and Medicine. 2017. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use . Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24781 . 12. Owen, G, Burton, A, Schade, C, Passik, S. (2012). Urine Drug Testing: Current Recommendations and Be st Practices. Pain Physician Journal . 15, ES119-ES133. Retrieved August 12, 2020 from www.painphysicianjournal 13. Reisfield, MD, G. M., Webb, PhD, F. J., Bertholf, PhD, R. L., Sloan, MD, P. A., & Wilson, MD, G. R. (2007). Family physicians proficiency in uri ne drug test interpretation. Journal of Opioid Management , 3(6), 333. doi:10.5055/jom.2007.0022 14. Substance Abuse and Mental Health Services Administration. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. 15. Stanos, S. P. (2017, October 10). Presidents Message. National Academies of Sciences, Engineering, and Medicine (NASEM). Pain Medicine. 18(10). 1835-1836. doi :10.1093/pm/pnx224 16. U.S. Department of Veterans Affairs. (2017, February). VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. Retrieved August 12, 2020 from www.va.gov 17. Agency Medical Directors Group. (2010). Interagency Guideline on Opi oid Dosing for Chronic Non-cancer Pain. Retrieved August 12, 2020 from www.agencymeddirectors.wa.gov 18. Ohio Department of Medicaid (2020. November 3), Medicaid Advisory Letter (MAL) No. 650. Retrieved November 5, 2020 from www.medicaid.ohio.gov 19. Ohio Department of Medicaid . (2019, September 9). Ohio Urine Drug Tes ting Prior Authorization (PA) Request Form. Retrieved November 6, 2020 from www.bh.medicaid.ohio.gov/manuals The Reimbursement Policy Statement detailed abo ve has recei ved due consideration as defined in theReimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Substance Use Disorder Residential PY-0137 01/01/2021-5/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 6 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 6 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry – stan dard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of dis ease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of go od 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, Ev idence 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 contr act (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 sub ject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. 2 A. SubjectSubstance Use Disorder Residential Substan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. 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 f or processing. Health care providers and their of f ice 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) f or the product or service that is being provided. T he inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. 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 se rvices provided. This policy address the Residential level of care. This type of care provides an intensive residential program f or members with SUD. It is considered transitional with the goal of returning the member to the community with a less restricti ve level of care. C. Def initions Residential level of care for SUD – A residential program must meet all of the f ollowing: o Staf f ed 24 hours a day o Follow nationally recognized medical standards o Be an Ohio Department of Mental Health and Addiction Services (OhioMHAS) certif ied/licensed f acility to provide residential SUD treatment o Have an active provider agreement with ODM o All practitioners of the SUD treatment service must meet applicable state requirements o Establish individualized treatment plans o Start discharge planning at time of admission o Schedule a f ollow-up visit within 7 days of discharge f or af tercare o Provide Medication Assisted Treatment (MAT) or linkage to a prescriber f or MAT o Ensure accessibility to all behavioral and physical health medication upon discharge CareSource does not consider a residential program appropriate f or: o Intensive medical monitoring needed f or severe or lif e threatening medical or physical condition o A memb er who is unable to actively participate due to Severe symptoms of co-existing mental or physical condition; or Severe withdrawal symptoms 3 D. PolicySubstan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 I. CareSource requires a prior authorization (PA) for the f ollowing: A. For the f irst and second admission per calendar year, a prior authorization is only required f or an admission exceeding 30 consecutive days. B. For admissions exceeding the two admissions per calendar year, a prior authorization is required f rom the f irst day of admission. C. Changes in level of care: 1. When step-up or step-down occurs between two SUD residentia l level of care codes within the same residential provider agency, and there is consecutive billing, it 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 even ts will be considered separate events and PAs may be required depending on the members utilization in that calendar year. a. If the step-up or step-down occurs during the f irst 30-days of 1 st or 2 nd of the 2 allowed SUD Residential events, no PA is required f or the step-up or step-down. b. If the step-up or step-down occurs af ter a PA has been authorized, either because the LOS has exceeded 30-days or this is the 3 rd or more event in a calendar year, then t he step-up or step-down does require a new/updated PA. D. SUD Residential Facility Transf ers 1. Prior Authorization is required f or a same level-of-care admission/transfer between two SUD Residential Facilities (NPIs and/or TINs) 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, f or any reason, the transition admi ssion will require prior authorization be obtained by the receiving facility f rom the date of admission. 2. Same level-of-care admissions/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 events. 3. If there is a break in stay that is greater than 24-hours between a same level – of-care admissio n/transf er between two SUD Residential Facilities (NPIs and/or TINs), the admission to the receiving f acility is considered a separate event and is subject to prior authorization f rom date of admission, beginning with the third admission in a calendar year and will accumulate as separate events. NOTE: It is the responsibility of the f acility to check the annual service usage to avoidgetting a claim denial f or no prior authorization.II. Documentation A. At least one documented f ace-to-face interaction must be pr ovided by a clinical/treatment team member with the member at the substance use residential site in order to bill per diem. B. Members medical record must show evidence of medical necessity of services. C. The residential program has a written Af f iliation Agreement so that members are 4 Substan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 connected/ensured access to outpatient care in timely manner upon discharge. The residential program has policies and procedures in place to monitor its af f iliations. III. Medical Necessity CriteriaA. CareSource f ollows The ASAM Criteria as required by the Ohio Department of Medicaid. IV. BillingA. Residential level of care admission one admission is considered one length of stay 1. Any stay under 30 consecutive days counts as a f ull 30 day occurrence. 2. Service gaps in excess of 24 hours are considered a termination of one admission. 3. Leaving the SUD residential treatment f acility associated with signif icant 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. 4. 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 f or treatment services during these times. a. Brief leave of absences include but are not limited to the f ollowin g: 01. Family visits 02. Religious services 03. Same day health services 04. Social support group attendance B. The benef it f ollows the member not the providers tax identification number. C. CareSource only processes claims f rom 1. Provider type of 95 OhioMHAS certified/licensed treatment program; 2. Provider specialty 954 OhioMHAS certif ied/licensed SUD residential f acility; and 3. Place 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 f or no prior authorization. E. Claims are paid as they are received. If member receives services f rom more than one provider, claims are paid to providers that submit f irst regardless of date of service. F. SUD residential is paid per diem. Per Diem does not include room and board costs/payments. G. CareSource does not reimburse separately f or services provided by th e residential treatment service including: 1. Ongoing assessments and diagnostic evaluations. 2. Crisis intervention. 3. Individual, group, f amily psychotherapy and counseling. 4. Case management. 5. Substance use disorder peer recovery services. 5 6. Urine drug screens.7. Medical services. 8. Medication administration Substan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 H. A member can only receive services through one level of care at a time. 1. CareSource considers the f ollowing services non-billable when 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 BH services provided to a member f rom practitioners not af f iliated (based on billing group TIN) with the residential treatment program as billable concurrent to the SUD Residential admission when the service is medically necessary and the treatment is outside of the scope of the residential tr eatment program. Examples include medication assisted treatment (MAT) and psychiatry. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule 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 H2034 Clinically Managed Low-Intensity Residential Treatment ASAM 3.1 H2036 Clinically Managed High Intensity Residential Treatment ASAM 3.5 Procedure Modifier Description HI Clinically Managed Population-Specif ic High Intensity Residential Treatment ASAM 3.3 (Adults) May be used with H2036.TG Medically Monitored Intensive Inpatient Treatment (Adults) and MedicallyMonitored High-Intensity Inpatient Services (Adolescent) ASAM 3.7 May be used with H2036. 6 F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistorySubstan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 DATE ACTIONDate Issued 08/17/2017Date Revised 05/15/2019 Updated def inition, medical necessary criteria, and billing Date Effective 09/16/2020 12/28/202001/01/2021Updated def inition, added note under D. I. Added D. I. C.; D.1. IV. A. 5 and IV. B. Added related policy. Revised D. IV. H. 2. Revised I. C. D. and E. Provided clarif ication of policy per ODM D. 1. C, D, and E; and D. IV. A. DateArchived 5/31/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rule s inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erences1. Lawriter – OAC – 5160-27-01 Eligible provider f or behavioral health services. (2019, November 29) Retrieved June 1, 2020 f rom www.codes.ohio.gov 2. Lawriter OAC 5160-27-02 Coverage and limitations of behaviora l health services. (2018, May 30) Retrieved June 1, 2020 f rom www.codes.ohio.gov 3. Lawriter OAC 5160-27-09 Substance use disorder treatment services. (2018. January) Retrieved June 1, 2020 f rom www.codes.ohio.gov 4. Ohio Department of Medicaid. (2020, April 9). Medicaid Behavioral Health Sta te Plan Services Provider Requirements and Reimbursement Manual. Retrieved June 1, 2020 f rom www.bh.medicaid.ohio.gov 5. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co – Occurr ing Conditions , Third Edition. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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