REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Durable Medical Equipment (DME) Modifiers PY-0022 10/01/2020 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 lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan po licies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care service s or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. 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 servic es 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 authoriz ation 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), the n 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 c ase and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favora ble than the limitations that apply to medical conditions as covered under this policy.Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……….. ……………………………………………………………………………………………………… 2 B. Background …………………………………………………………………………………………………… ……. 2 C. Definitions ………………………………………………………………………………………………….. ………. 2 D. Policy ………………………………………………………………………………………………. ………………… 2 E. Conditions of Coverage ……………………………………………………………… …………………………. 4 F. Related Policies/Rules ……………………………………………………………………………………….. …. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …….. ………………………………………………………………………………………………….. 4 Durable Medical Equipment (DME) ModifiersOHIO MEDICAIDPY-0022 Effective Date: 10/01/2020 2A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundReimbursement policies are designed to assist you when submitt ing 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 member s 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 reimb ursement or guaranteeclaims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description , of the product or service. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service.The purpose of this policy is to simplify and standardize the use of modifiers, when billing for rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR andthe new equipment purchase modifier NU. CareSource expects providers to use the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DMEitem along with the modifiers addressed in this policy (LT, RT, etc.). C. Definitions Durable Medical Equipment (DME) equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding S ystem (HCPCS) are codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier two-characte r codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. Policy I. This policy outlines the use of DME modifiers for the rental and/or purchase of Durable Medical Equipment (DME). Durable Medical Equipment (DME) ModifiersOHIO MEDICAIDPY-0022 Effective Date: 10/01/2020 3NOTE: This policy addresses modifiers associated with billing, not specific DMEequipment coverage. Some DME equipment may have individual policies which can be referenced for detailed information. The modifiers addressed in this policy is not an all-inclusive list a nd providers should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed within this policy. II. DME items can be:A. Purchased; B. Rented; or C. Rented on a short-term basis and then purchased at the end of the rental period. III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable:A. Purchase Modifier – NU:1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier – RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. 2. All rental authorizations are based on: a. A calendar month authorization period, through the month in which the member becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in the OAC 5160-10-01, the initial re ntal period must not exceed six months. a. After the initial six month rental period, additional rental months may be authorized if medically necessary. 4. The combined total reimbursement for rental and subsequent purchase of a DME item, cannot exceed t he Medicaid maximum fee. 5. At the end of the rent to purchase period, the DME becomes the property of the member. IV. Disposable supplies do not require a modifier.A. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource will review the claim during a post-payment audit and proper reimbursement adjustment will occur. V. Modifiers that are not to be used for claims submission for DME equipment:A. LL – Lease/rental B. NR – New when rented C. RB – Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are new equipment) Durable Medical Equipment (DME) ModifiersOHIO MEDICAIDPY-0022 Effective Date: 10/01/2020 4VI. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB. NOTE: CareSource may verify the use of any modifier through post-payment audit.All information regarding the u se of these modifiers must made available upon CareSources request. 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 t he 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. Modifier Description RR Rental (use the RR modifier when DME is to be rented) NU Purchase New Equipment (use the NU modifier when DME is to be purchased) F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020 New policyDate Revised Date Effective 10 /01/2020 Date Archived H. References1. 5160-10-01 Durable medical equipment, prostheses, orthoses, and supplies general provisions. (01/01/2019). Retrieved on May 1, 2020 from www.codes.ohio.gov. 2. Durable Medical Equipment (DME). (n.d.). Retrieved on May 1, 2020 from www.healthcare.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 Screening and Surveillance for Colorectal Cancer PY-0072 09/01/2020 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, regulator y 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 polic ies 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 o r 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 par t, 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 authorizati on 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 t he 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.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 ………………………….. ………………………….. ………………………….. …….. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Screening and Surveillance for Colorectal CancerOHIO MEDI CAIDPY-0072 Effective Date: 09/01/2020 2 A. SubjectScreening and Surveillance for Colorectal Cancer 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 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 s ervice that is being provided. Theinclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Of malignancies affecting both men and women in the US, colorectal cancer (CRC) is the 3rd most common resulting in over 100,000 deaths annually and rising to the 2nd leading cause of cancer deaths overall. Uncommon before the age of 40, the incidence rises successively especially after the age of 50. Over the past two decades there has been a gradu al decline in the incidence of CRC likely as a result of increased screening promoting identification and removal of early-stage cancer and adenomatous polyps. The evidence is convincing that appropriate screening reduces colorectal cancer mortality in adults 50-75 years of age. The benefit of early detection of and interventionfor colorectal cancer declines after 75 years of age. African Americans have been shown to have higher CRC rates of incidence and it is recommended by both the American College o f Gastroenterology and the American Society for Gastrointestinal Endoscopy that CRC screening begin at 45 years of age. C. Definitions Colorectal Cancer Screening – Detects early stage colorectal cancer and precancerous lesions in asymptomatic members with an average risk of colorectal cancer. Surveillance for Colorectal Cancer – For members who are at increase or high risk for colorectal cancer. Colonoscopy – An endoscopic procedure allowing direct inspection of the lining of the entire colo n with biopsy sampling and/or removal of polyps or early stage cancers . CT Colonography – Also known as virtual colonoscopy utilizing advanced computed tomography (CT) to produce 2 and 3 dimensional images of the colon and rectum to identify early cance rous and precancerous lesions . Fecal Immunochemical Testing (FIT or iFOBT) – A home screening test unaffected by food or medicines that utilizes a chemical reaction with hemoglobin to detect human blood from the lower intestine . Screening and Surveillance for Colorectal CancerOHIO MEDI CAIDPY-0072 Effective Date: 09/01/2020 3 Fec al Occult Blood Testing (FOBT) – A home screening test that detects hidden blood arising from anywhere in the digestive tract in the stool through a chemical reaction . Flexible Sigmoidoscopy – An endoscopic examination of the lower half of the colon . Multi-Targeted Stool DNA (Cologuard) – A home screening test utilizing an algorithmic analysis of stool DNA amplified by polymerase chain reaction (PCR) in combination with a fecal immunochemical test (FIT) test . Adenoma – Polyps that require surveillance as they have the potentia l to be malignant. Average risk – Per United States Preventive Service Task Force (USPSTF), members who are at average risk for colorectal cancer do not have: o Family history of known genetic disorders that predisposes them to a high lifetime risk of colore ctal cancer (i.e. lynch syndrome or familial adenomatous polyposis) ; o Personal history of inflammatory bowel disease ; o A previous adenomatous polyp ; or o Previous colorectal cancer . Increased or high risk – Per USPSTF, members who are at increased or high risk for colorectal cancer include: o Family history of known genetic disorders that predisposes them to a high lifetime risk of colorectal cancer (i.e. lynch syndrome or familial adenomatous polyposis) ; o Personal history of inflammatory bowel disease ; o A prev ious adenomatous polyp ; or o Previous colorectal cancer . D. Policy I. Colorectal Cancer Screening A. Prior authorization is not required for par providers. B. Benefit coverage is for members 45 years of age and older . C. For CT colonography – Providers are to contact NIA at 1-800-424-5600 or use their web portal for all CT, CTA, MRI, MRA, PET Scans. D. Screening for colorectal cancer claim s must be submitted with one of the following ICD-10 codes: 1. Z12.1 0 Encounter for screening for malignant neoplasm of intestinal trac t, unspecified ; 2. Z12.11 Encounter for screening for malignant neoplasm of colon ; 3. Z12.12 Encounter for screening for malignant neoplasm of rectum ; or 4. Z12.13 Encounter for screening for malignant neoplasm of small intestine . E. Screening frequencies as follows: 1. FOBT every year 2. FIT every year 3. FIT-DNA every year 4. Colonoscopy every 10 years 5. CT colonography every 5 years 6. Flexible sigmoidoscopy every 5 years 7. Flexible sigmoidoscopy every 10 years plus FIT ever y year F. A follow-up colonoscopy is reimbursed as part of the screening process when a noncolonoscopy test is positive. Screening and Surveillance for Colorectal CancerOHIO MEDI CAIDPY-0072 Effective Date: 09/01/2020 4 G. Screening with plasma or serum markers is not covered.H. PT modifier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure . II. Colonoscopy Survei llance for Colorectal Cancer A. Prior authorization is not required for par providers. B. Surveillance for colorectal cancer claim must be submitted with one of the following ICD-10 codes: 1. Z84.81 Family history of carrier of genetic disease ; 2. Z15.89 Genetic susceptibility to other disease ; 3. Z83.71 Family history of colonic polyps ; 4. Z85.038 Personal history of other malignant neoplasm of large intestine ; 5. Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus ; 6. Z80.0 Family history of malignant neoplasm of digestive organs ; 7. Z86.010 Personal history of colonic polyps ; or 8. K50 through K52 category codes Noninfective enter itis and colitis ; 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.Codes Description44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 44389 Colonoscopy through stoma; with biopsy, single or multiple 44390 Colonoscopy through stoma; with removal of foreign body(s) 44391 Colonoscopy through stoma; with control of bleeding, any method 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dialation and guide wire passage, when performed) 44402 Colonoscopy through stoma; with endoscopic stent placement (including pre-and post-dilation and guide wire passage, when performed) 44403 Colonoscopy through stoma; with endoscopic mucosal resection Screening and Surveillance for Colorectal CancerOHIO MEDI CAIDPY-0072 Effective Date: 09/01/2020 5 44404 Colonoscopy through stoma; with directed submucosal injection(s), any substance44405 Colonoscopy through stoma; with transendoscopic ballon dilation 44406 Colonoscopy through stom a; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 44407 Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 44408 Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus , megacolon), including placement of decompression tube, when performed 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45334 Sigmoidoscopy, flexible; with control of bleeding, any method 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wir e passage, when performed) 45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre-and post-dilation and guide wire passage, when performed) 45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection 45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Screening and Surveillance for Colorectal CancerOHIO MEDI CAIDPY-0072 Effective Date: 09/01/2020 6 45386 Colonoscopy, flexible; with transendoscopic balloon dilation45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed 45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre – and post-dilation and guide wire passag e, when performed) 45390 Colonoscopy, flexible; with endoscopic mucosal resection 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45393 Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 45398 Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 74263 Computed tomographic (CT) colonography, screening, including image postprocessing (Not covered by Medicare) 74270 Radiologic examination, colon; contrast (e.g., barium) enema, with or without KUB 74280 Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hem oglobin, utilizing stool, algorithm reported as a positive or negative result (Cologuard) 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm sc reening (i.e., patient was provided 3 cards or single triple card for consecutive collection) 82272 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1 – 3 simultaneous determinations, performed for other than colorectal neoplasm screening 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations G0104 Colorectal cancer screening; flexible sigmoidscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema. G0121 Colorectal cancer screening; colonoscopy on ind ividual not meeting criteria for high risk G0122 Colorectal cancer screening; barium enema Screening and Surveillance for Colorectal CancerOHIO MEDI CAIDPY-0072 Effective Date: 09/01/2020 7 F. Related Policies/RulesG. Review/Revision History DATE ACTIONDate Issued 05/17/2016Date Revised 11/ 01/2017 04/29/2020 06/24/2020Clarified limits, ages, NIA, modifier, and ICD-10codes Updated frequencies of screening tests Date Effective 09/01/2020 Date Archived H. References 1. Wolf, A., Fontha m, E., Church, T., Flowers, C… .Smith, Robert. (2018). Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. Retrieved November 7, 2019 from www. onlinelibrary.wiley.com 2. Rex, D., Boland, Richard, Dominitz, J., Giardiello, F ., Johnson, D., Kaltenbach, T. Robertson, D. (2017). Colorectal cancer screening: Recommendations for physicians. GASTROINTESTINAL ENDOSCOP Y, 86 (1), 18 33. doi: http://dx.doi.org/10.1016/j.gie.2017.04.003 www.asge.org/ 3. Wilkins, T., Mcmechan, D., Talukder, A. (2018, May 15). Colorectal Cancer Screening and Prevention. Retrieved November 7, 2019 from www.aafp..org 4. Lieberman, D., Rex, D., Winawer, S., Giardiello, F., Johnson, D., & Levin, T. (2012, September). Guidelines for Colonoscopy Surveillance After Screening. Retrieved November 7, 2019 fr om www. acgcdn.gi.org 5. Qaseem, A., Crandall, C. J., Mustafa, R. A., Hicks, L. A., & Wilt, T. J. (2019, November 5). Screening for Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians. Retrieved November 6, 2019, from www. annals.org 6. Doubeni, C. (2019, June 28). Tests f or screening for colorectal cancer. Retrieved November 6, 2019 from www.uptodate.com 7. Centers for Medicare and Medicaid Services. (n.d.). Information on Essential Health Benefits (EHB) Benchmark Plans. Retrieved January 7, 2020 from www.cms.gov 8. American Co llege of Surgeons. (2016, May 1). Coding and reimbursement for colonoscopy. Retrieved January 31, 2020 from www. bulletin.facs.org 9. EncoderPro. (n.d.). ICD10 CM Guidelines . Retrieved January 31, 2020 from www.encoderprofp.com 1. United States Preventive Services Task Force. (2016, June). Final Update Summary: Colorectal Cancer: Screening. Retrieve d November 6, 2019 from www.uspreventiveservicestaskforce.org 2. Ohio Administrative Code. (2017, October). 5160-1-16 Preventive Services . Retrieved November 6, 2019 from www. codes.ohio.gov 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 STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1092 09/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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 requirements, industry-standard claims e diting 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 re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. 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. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sacro iliac Jo in t Pro ced uresOHIO MEDICAIDPY-1092 Effective Date: 09/01/2020 2 A. SubjectSacroiliac Joint Procedures 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 q ualif 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 staf f are encouraged to use self-servi ce 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 n ot imply any right to reimbursement or guaranteeclaims payment.Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be ef f ective for diagnostic purposes , but provide limited short-term relieff rom pain resulting f rom SI joint dysf unction.C. Def initions Sacroiliac Joint Injections – corticosteroid and local anesthetic the rapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies . Radiofrequency Facet Ablati on (RFA) – is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required f or each sacroiliac joint procedure for pain management. Documentation, including dates of service, f or conservative therapies are not required f or PA, but must be available upon request. B. Sacroiliac Joint Injection Codes 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. C. Sacroiliac Joint I njections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic ef f ect, repeating no more than once every seven (7) d ays and with at least a 75% or greater reduction in pain af ter the f irst injection. 2. Once the diagnostic injections are perf ormed and the diagnosis is established, two (2) therapeutic injections per joint may be perf ormed over a 12 month period. Sacro iliac Jo in t Pro ced uresOHIO MEDICAIDPY-1092 Effective Date: 09/01/2020 3 3. Injections should not be repeat ed more frequently than every two (2) months with no more than a total of f our (4) injections (including both diagnostic and therapeutic) per joint in 12 months. D. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately F. Initial Radiof requency Ablation of the SI Joint 1. A maximum of one (1) radiof requency ablation f or SI Joint pain per side per rolling twelve (12) months when CareSource medical policy MM-0010 clinical criteria has been met. G. Repeat Radiof requency Ablation of the SI Joint 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain f or at least twelve (12) months or more f rom the initial RFA within the last thirty-six (36) months. 2. When there has not been a repeat RFA in the last thi rty-six (36) months, a diagnostic injection is required. 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 fe e schedule f or appropriate codes. The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac JointProceduresDescription 27096 Injection procedure f or sacroiliac joint, anesthetic/steroid, with image guidance (f luoroscopy or CT) including arthrography when perf ormed 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography 64625 Radiof requency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography) G0260 Injection procedure f or sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography F. Related Policies/Rules Sacroiliac Joint Procedures MM-0010 Sacro iliac Jo in t Pro ced uresOHIO MEDICAIDPY-1092 Effective Date: 09/01/2020 4 G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 09/08/2016 05/13/2020Revised to add coverage f or ablation of the SI Joint; added code s: 64451 64625 G0260. Date Effective 09/01/2020 Date Archived 05/31/2021 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy H. Ref erences 1. Ohio Depa rtme nt of Medicaid Fee Schedules. Re trieved May 5 , 2020 f rom www.medicaid.ohio.gov 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 Sacroiliac Joint Fusion PY-1159 09/01/2020-05/31/2021 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 ………………………….. ………………………….. ………………………….. …. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 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 requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfun ction 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. Med ically 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services prov ided in aparticular case and may modify this Policy at any time.2 A. SubjectSacroiliac Joint Fusion Sacro iliac Jo in t FusionOHIO MEDICAID PY-1159 Effective Date: 09/01/2020 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 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) f or the product or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The sacroiliac (SI) joints are f ormed by the connection of the sacrum and the right and lef t iliac bones. The sacrum is the triangular-shaped bone in the lowe r portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of f ive vertebrae that are f used together and do not move. The iliac bones are the two large bones that make up the pelvis. A s a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of translation at these joints. Sacroiliac Joint (SIJ) dysf unction is indicated by the abnormal movement or malalignment of the sacroiliac joint and is the main source of lower back pain in 15% to 30% of patients. The condition causes disability and pain and may be caused by prior lumbar sacral f usion, trauma, inf lammatory arthritis, sacral tumors, osteoarthritis or pregnancy. Patients may present with low back, groin and/or gluteal pain. SI joint pain can of ten appear to be disogenic o r radicular back pain. This can lead to the potential f or inaccurate diagnosis and treatment, reviews caution dif f icult diagnosis and evidence for ef f icacy. Open SIJ f usion typically involves opening the SIJ, denuding of cartilage, and bone graf ting. To stabilize the SIJ, the iliac crest bone and the sacrum are typically held together by plates or screws or an interbody f usion cage until the 2 bones fuse. C. Def initions Conservative Therapy – is a multimodality plan of care. Multimodality care plans include ALL of the f ollowing: o Active Conservative Therapies – such as physical therapy, occupational therapy, a physician supervised home exercise program (HEP), or chiropractic care. 3 Sacro iliac Jo in t FusionOHIO MEDICAID PY-1159 Effective Date: 09/01/2020 Home Exercise Program (HEP) – includes two components that are both required to meet CareSource policy for completion of conservative therapy: An exercise prescription and/or plan documented in the medical record. A f ollow up documented in the medical record regarding completion of a HEP (af ter suitable six (6) week period), or inability to complete a HEP due to a stated physical reason-i.e. increased pain, inability to physically perf orm exercises. (Patient inconvenience or noncompliance without explanation does not constitute inability to complete). o Passive Conservative Therapies – such as rest, ice, heat, medical devices, acupuncture, TENS unit and prescription medications D. Policy I. Sacroiliac Joint Fusion A. Prior authorization is required f or minimally invasive f usion/stabilization of the sacroiliac joint (SIJ) f or the treatment of back pain when the medically necessary criteria in the Sacroiliac Joint Fusion Medical policy, MM-0838, has been met. II. Exc lusionsA. Percutaneous SIJ f usion for SIJ pain is NOT indicated in the presence of : 1. Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis; 2. Generalized pain behavior (e.g. somatof orm disorder) or generalized pain disorder (e.g. fibromyalgia); 3. Inf ection, tumor, or f racture; 4. Acute, traumatic instability of the SIJ; 5. Neural compression as seen on an MRI or CT that correlates with the patients symptoms or other more likely source f or their pain. 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 r eference. This list may not be all inclusive and is subject to updates. CPT Code Description 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graf t when performed, and placement of transf ixing device 4 F. Related Policies/RulesSacroiliac Joint Fusion MM-0838 G. Review/Revision HistorySacro iliac Jo in t FusionOHIO MEDICAID PY-1159 Effective Date: 09/01/2020 DATE ACTIONDate Issued 05/13/2020 New PolicyDate Revised Date Effective 09/01/2020 Date Archived 05/31/2021 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy. H. Ref erences1. Ohio Department of Medicaid Fee Schedules and Rates. Retrieved on April 15, 2020 f rom www.medicaid.ohio.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 Da te Reimbursement Modifiers PY-0715 09/01/2020-02/28/2022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….2 D. Policy ………………………………………………………………………………………………………………..2 E. Conditions of Co ve r age……………………………………………………………………………………… 11 F. Related Policies/Rules ………………………………………………………………………………………. 11 G. Review/Revision History …………………………………………………………………………………….. 11 H. Ref er en ce s ……………………………………………………………………………………………………… 11 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 requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose 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, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly 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. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tReimbursement Modifiers Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020B. 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 ar e 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 ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their of f ice 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) f or the product or service that is being provided. The inclusion of a code in this policy does not imply an y right to reimbursement or guarant ee claims payment. Modif iers can be used to f urther describe a product or service rendered. Some modif iers are f or inf ormational purposes only, while other modifiers are used to report additional inf ormation, to the code description, of the product or ser vice. Although CareSource accepts the use of modif iers specific to this policy, not all modif iers are included within this policy. The modif iers included within this policy are those modif iers that af f ect the reimbursement of a service. Using a modif ier inappropriately c an result in the d e nial of a claim or an incorrect reimbursement for a product or service. CareSource may verif y the use of any modif ier through post-payment audit. All inf ormation regarding the use of these modif iers must be made availabl e upon CareSources request. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing d oc ume nt . C. Def initions Current Procedural Terminology (CPT) – codes that are issued, upda ted and maintained by the Ame r ic an Medical Association (AMA) t h at provides a standard language f or coding and billing medical services and procedures. Healthcare Co mmo n Pro ced ure Co ding System (HCPCS) – codes t h at ar e issued, updated and maintained by the American Medical Association (AMA) that provides a standard language f or coding and billing of products, supplies, and services not included in the CPT codes. Modifier-two-c h ar ac t e r codes used along with a CPT or HCP CS code to provide additional inf ormation about the service or supply rendered.D. Polic yI. Modifier 22-Increased Procedural Services A. Modif ier 22 is used to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater t h an typically required. The 3 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020extra work may be identif ied by appending modifier 22 to the usual procedure code. B. Procedure codes with modifier 22 appended may be reimbursed up to 120% of the f ee schedule amount. Note: This modif ier is not appended to E/M services (99201-9949 9) . Claims f or 99201-99499 with modif ier 22 will be denied. Medical records ARE required with the claim an d mu st support the use of this modifier. Claims with procedures including 22 and no supporting documentation will be denied.II . Modifier 50-Bilat e r al Procedures A. Prof essional Claims Only Append modif ier 50 to the ap p r op riat e unilateral code on a single claim line and indicate 1 unit in the unit f ield of that claim line. B. Modif ier 50 applies to surgical procedures (CPT codes 10040-69990) an d to radiology procedures performed bilaterally. C. Applies to an y b ilat e r al procedure p er f or me d on b ot h sides at the s ame session. D. The use of modif ier 50 is NOT appropriate in the f ollowing s it u at io ns : 1. Using modif ier 50 on a b ilat e r al procedure performed on different ar e as of the right and lef t sides of the body. 2. Appending modif ier 50 to a procedure code t h at is def ined by CPT as primarily bilateral or a bilateral service. 3. Appending modif ier 50 to a surgical CPT code, the description of which contains the words one or both. E. Do not report two line it e ms to indicate a b ilat e r al procedure. F. Procedure code with modifier 50 appended will reimburse 1 unit at 150% of t he f ee schedule amount.III. Modifier 51-Multiple Pr o c ed ur es A. Modif ier 51 is used to report multiple procedures, other than E/M services, are perf ormed at the s ame session by the s ame individual, the primary procedure or service is reported as listed. B. The additional procedure(s) or service(s) may be identified by ap p ending modifier 51 to the additional procedure or service code(s). C. Modif ier 51 should not be appended to designated " ad d-on " codes. D. Procedure code with modifier 51 appended will reimburse 5 0% of the f ee listed on the Medicaid Physician Fee Schedule f or the service. I V. Modifier 52-Reduced services A. Under c e r t ain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualif ied health care prof essional.1. Modif ier 52 is used f or reporting reduced services when the procedure was terminated after the patient was prepped an d brought to the r o om where t he service was to be perf ormed. B. Modif ier 52 may be used to report r e du c ed radiology procedures. 1. The correct reporting is to assign the CPT code to the extent of the procedure perf ormed. 2. This modif ier is used only to report a radiology procedure t h at h as been reduced when no other code exists to report what has been done. 4 3. Report the intended code with modif ier 5 2. Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020 a. Example, if the planned procedure is a two-view chest x-r ay an d only one view of the chest is perf ormed, do not report CPT code 71020-52 (for x-ray chest, two views-reduced service). Instead, report CPT code 71010 (x-ray chest, single view). b. Example, if a barium swallow is not completed because the patient cannot handle the barium, report CPT code (74270-5 2) . C. Modif ier 52 does not provide for reimbursement of an ineligible service. D. For hospital outpatient r e p or t ing of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or af ter administration of anesthesia, see modif iers 73 and 74. E. Procedure code with modifier 52 appended will reimburse at 50% of the f e e schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier. The extenuating circumstances preventing the completion of the procedure mu st als o be documented.V. Modifier 53-Discontinued Procedure A. Under c e r t ain circumstances, the physician or other qualified h ealt h c ar e prof essional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances or those t h at t h r eat e n the well-being of t he patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but disc ontinued after anesthesia is administered to the patient. 2. Modif ier 53 is used to indicate t h at the physician terminated a surgical/diagnostic procedure due to the patients well-being. B. This modif ier is not used to report an elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. C. Modif ier 53 c a nn ot be u s ed when a laparoscopic or endoscopic procedure is converted to an open procedure. D. Modif ier 53 d oe s n ot p r ov i de for reimbursement of an ineligible service. E. Modif ier 53 c a nno t be appended to E/M codes. F. For outpatient hospital/ambulatory surgery center (ASC) r e p or t ing of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or af ter administration of anesthesia, see modif iers 73 and 74. G. Procedure code with modifier 53 appended will reimburse at 25% of the f e e schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier. Documentation must include a statement indicating at what point the procedure was discontinued. The extenuating circumstances preventing the completion of the procedure must also be documented.5 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020 VI. Modifier 54-Surgical Car e Only A. Modif ier 54 is r e p or t ed when one physician performed a surgical procedure o nly ; another physician provides the preoperative and/or postoperative management. B. Modif ier 54 mu st only be appended to the s u r gic al procedure code. C. Procedure code with modifier 54 appended will reimbursed at 70% of the f ee schedule amount.Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier. VII . Modifier 55-Postoperative Management Only A. Modif ier 55 is reported when 1 physician or other qualif ied health care prof essional performed the postoperative management an d another performed the surgical procedure, the postoperative component may be identif ied by appending modif ier 55 to the procedure code. B. Modif iers 55 mu st only be appended to the surgical procedure code. C. Procedure code with modifier 55 appended will reimburse at 15% of the f e e schedule amount.Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier.VIII. Modifier 56-Preoperative Management Only A. Modif ier 56 is reported when 1 physician perf ormed the preoperative care and evaluation an d another physician perform ed the s u r gic al procedure. Modifier 56 is appended to the surgical code. BModif iers 56 mu st only be appended to the surgical procedure code. C. Procedure code with modifier 56 appended will reimburse at 15% of the fee schedule amount.Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier.I X. Modifier 62-Two Surgeons A. Modif ier 62 is r e p or t ed when 2 surgeons work together as primary surgeons perf orming distinct part(s) of a procedure. 1. Each surgeon mu st report his/her distinct operative work by adding the modif ier 62 to the procedure code and any associated add-on codes(s) f or t h at procedure as long as both surgeons continue to work together as primary surgeons. 2. Each surgeon mu st report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedures(s) are perf ormed during the s ame surgical session, s e p ar at e co d e( s ) may als o be reported without the modifier 62 added. 3. I f a c o-surgeon acts as an assistant in the perf ormance of additional procedure(s) during the s ame surgical session, those services may be 6 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020reported using separate procedure code(s) with the modifier 80 or 82 added, as appropriate. B. Procedure code with modifier 62 appended will be reimbursed at 62.5% of the f ee schedule amount. Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier.X. Modifier 66-Surgical Te am A. Modif ier 66 is reported when three or more surgeons work together during a highly complex procedure are carried out under the "surgical team" concept. Such circumstances may be identif ied by each participating individual with the addition of modif ier 66 to the b as ic procedure c o de used for reporti ng services. B. Claims submitted by t e am surgeons ar e identif ied with modifier 6 6. C. The Centers f or Medicare & Medicaid Services (CMS) established a Te am Surgery Indicator (T EAM SURG) f ound in the CMS Nat io n al Physician Fee Schedule Relative Value File. Values are: 1. 0-Te am surgeons not permitted f or this p ro c ed ur e. 2. 1-Te am surgeons may be paid; supporting documentation is required to establish medical necessity. 3. 2-Te am surgeons permitted. 4. 9-Te am surgeon concept does not apply. D. Codes with CMS Te am Surgery Indicators of 0 an d 9 should not be billed with modif ier 66. E. Modif ier 66 should not be u s ed if a surgeon ac t s as an assistant surgeon on a separate procedure not included in the team surgery. F. Only one surgeon may b e be considered the primary surgeon. CareSource will not reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon. G. Eac h physician participating in the surgical t e am mu st bill the applicable procedure code(s) for their individual services with Modifier 66. H. Procedure code with modifier 66 appended will reimburse at 150% of t h e established f ee, divided equally between the team surgeons. I. For t e am surgery with three surgeons, e ac h surgeon will be reimbursed at 50% of the f ee schedule amount. Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier. XI. Modifier 73-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prio r to the Administration of Anesthesia A. Modif ier 73 is reported to a service to indicate that due to extenuating circumstances or those t h at threaten the well-being of the patient, a surgical or diagnostic procedure at an outpatient hospital or ambulatory surgical center (ASC) was discontinued p rio r to the administration of anesthesia. B. Modif ier 73 is only appropriate f or use by an ASC. C. Modif ier 53 should not be used for an y ASC service as the modif ier is used exclusively on a prof essional claim.7 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020D. Procedure code with Modifier 73 appended will reimburse at 50% of the ASCs f ee schedule amount. Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier. XII . Modifier 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia A. Modif ier 74 is reported when due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia or af ter the procedure was started (incision made, intubation started, scope inserted.) B. Modif ier 74 is not appropriate f or the elective cancellation or postponement of a procedure based on the physician or patients choice. C. Modif ier 74 is not appropriate when the termination of the procedure occurs p rior to the beginning of the procedure or the administration of anesthesia. D. Modif ier 74 is not f or physician use. It is only appropriate f or the ASC. E. Procedure code with modifier 74 appended will be reimbursed at 100% of the f ee schedule amount.Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier.XIII. Modifier 78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualif ied Health Car e Prof essional Following Initial Procedure f or a Related Procedure During the Postoperative Period A. Modif ier 78 is reported to indicate t h at another procedur e was perf ormed d u r ing the postoperative period of the initial procedure (unplanned procedure f ollo wing initial procedure). 1. When this procedure is related to the f irst, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to t he related procedure. 2. Modif ier 78 should be appended when: a. The return to the operating room is unplanned. b. The service is perf ormed by s ame physician who performed the initial procedure. c. The service is related to the initial procedure. d. The service is performed during the postoperative period of the initial procedure (10-9 0 d ay s ) . B. Procedure code with modifier 78 appended will be reimbursed at 70% of the f ee schedule amount. Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier. XI V. Modifier 80-Assistant Surgeon A. Modif ier 80 is reported to indicate surgical assistant services by a physician and is applied to the surgical procedure code(s).8 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020B. Assistant Surgeon provides f ull assistance to the primary surgeon an d is capable of taking over the surgery should the primary surgeon become incapacitated. C. Modif ier 80 will not be accepted f rom non-physicians. Modifier AS should be used. D. Procedure code with modifier 80 appended will be reimbursed at 25% of the f ee schedule amount. Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier and operative notes must contain suf f icient inf ormation to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon f or what was perf ormed by the assistant the claim would be denied.XV. Modifier 81-Minimum Assistant Surgeon A. Modif ier 81 is reported to indicate min imu m surgical assistant services an d is applied to the surgical procedure code(s). B. Minimum Assistant Surgeon is a n assistant who does not p ar t ic ip at e in the entire procedure but provides minimal assistance to the primary surgeon. C. Modif ier 81 will not be accepted f rom non-physicians. Modifier AS should be used. D. Procedure code with modifier 81 appended will be reimbursed at 25% of the f ee schedule amount.Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support to use of this modif ier and operative notes must contain suf f icient inf ormation to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon f or what was perf ormed by the assistant the claim would be denied.XVI. Modifier 82-Assistant Surgeon (when qualif ied resident surgeon not av ailab le ) A. Modif ier 82 is reported to indicate when surgical assistance is needed, but a qualif ied resident was not available. B. Modif ier 82 is used primarily in teaching hospitals to indicate t h at a qualif ied resident surgeon is unavailable. C. The unavailability of a qualif ied resident surgeon is a prerequisite f or the use of this modif ier. The assistant must provide documentation (certification) stating that a qualif ied resident was not available f or this procedure and why the resident was not available. D. Procedure code with modifier 82 appended will be reimbursed at 25% of the f ee schedule amount. Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support the use of this modif ier and operative notes must contain suf f icient inf ormation to support the medical9 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020necessity of an assistant at surgery and why a qualif ied resident was not available. If there is no accounting by the surgeon for what was perf ormed by the assistant the claim would be denied. XVII. Modifier AA-Anesthesia services perf ormed personally by an anesthesiologist A. Modif ier AA is used to report when the anesthesia services ar e personally perf ormed by an Anesthesiologist. B. Procedure code with modif ier AA appended will be reimbursed at 100% of the f ee schedule amount.XVIII. Modifie r AD-Anesthesia services supervised by an anesthesiologist: mo r e t h an 4 concurrent anesthesia procedures. A. Modif ier AD is used to report when the anesthesia services ar e supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. B. Procedure code with modif ier AD appended will be reimbursed at 100% of the f ee schedule amount. XI X. Modifier QK-Medical direction of 2, 3 or 4 concurrent anesthesia services involving qualif ied individuals. A. Modif ier QK is used to report when medical direction of 2, 3 or 4 concurrent anesthesia services involving qualif ied individuals. B. Procedure code with modif ier QK appended will be reimbursed at 50% of the f ee schedule amount.XX. Modifier QX-Anesthesia services performed by a CRNA with medical direction by an anesthesiologist. A. Modif ier QX is used to report when the anesthesia services ar e perf ormed by a CRNA with medical direction by an anesthesiologist. B. Procedure code with modif ier QX appended will be reimbursed at 50% of the f ee schedule amount.XXI. Modifier QY-Anesthesia services when an Anesthesiologist medically directs one CRNA. A. Modif ier QY is used to report when an Anesthesiologist medically directs one CRNA. B. Procedure code with modif ier QY appended will be reimbursed at 50% of the f ee schedule amount.XXII. Modifier QZ-Anesthesia services perf ormed personally by a CRNA without medical direction by a physician. A. Modif ier QZ is used to report when the anesthesia services ar e personally perf ormed by a CRNA. B. Procedure code with modif ier QZ appended will be reimbursed at 100% of the f ee schedule amount.XXIII. Modifier AE-Registered dietician A. Modif ier AE is reported to indicate when a registered dietician provides the service. B. Procedure code with modifier AE appended will be reimbursed at 85% of the f ee schedule amount.10 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020XXIV. Modifier AS-Physician Assistant (PA), Nurse Practitioner (NP) or Certif ied Nurse Specialist (CNS) served as the assistant at surgery. A. Modif ier AS mu st only be used if the PA, NP or CNS was ac t in g as a surgical assistant in place of another surgeon. B. Procedure code with modif ier AS appended will be reimbursed at 25% of the base code allowable f ee schedule before multiple surgery reductions are taken.Note: Medical records ar e not required with the claim, but mu st be av ailab le upon CareSources request. Clinical inf ormation documented in the patient's records must support the use of this modif ier and operative notes must contain suf f icient inf ormation to support the medical necessity of an assistant at sur gery. If there is no accounting by the surgeon f or what was perf ormed by the assistant the claim would be denied.XXV. Modifier JW-Drug amount discarded (wasted)/not administered to an y patient A. CareSource will consider reimbursement f or: 1. A single-dose or single-use v ial drug t h at is wasted, when Modifier JW is appended. 2. The was t e d amount when billed with the amount of the drug t h at was administered to the member. 3. The was t e d amount billed t h at is not administered to another p at ie nt . B. CareSource will NOT consider reimbursement f o r: 1 The was t e d amount of a mu lt i-dose v ial drug. 2. Any drug was t e d t h at is billed when none of the drug was administered to the patient. 3. Any drug was t e d t h at is billed without using the mo st appropriate size vial, or combination of vials, to deliver the administered dose. XXVI. Modifier SA-Nurse practitioner (NP) rendering service in collaboration with a physician A. Procedure code with modif ier SA appended will be reimbursed at 100% of the f ee schedule when billed with Plac e of Service (POS) other t h an 19, 21, 22 or 23. B. Procedure code with modifier SA appended will be reimbursed at 85% of the f ee schedule amount when billed with Place of Service (POS) 19, 21, 22 or 23. XXVII. Modifier SE-Drug acquired through the 340B drug pricing p r o gr am. State and/or f ederally-funded programs/services.XXVIII. Modifier TC-Technical Component A. Technical component ch arges ar e institutional charges an d not billed separately by physicians. B. A charge may be mad e f or the technical component alone. Under those circumstances the technical component charge is identif ied by adding Modif ier TC to the usual procedure code.11 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020XXIX. Modifier UD Physician Assistant (PA) rendering service in collaboration with a physician A. Modif ier UD is reported to indicate when a supervising physician is billing on behalf of a PA f or non-surgical services. B. Modif ier UD is used when the PA is assisting with an y other procedure that DOES NOT include surgery. C. Procedure code with modifier UD appended will be reimbursed at 85% of t he f ee schedule amount. XXX. Modifier 26-Prof essional Component A. Certain procedures ar e a combination of a physician component an d a technical component. B. When the physician component is reported separately, the service may be identif ied by adding the modif ier 26 to the usual procedure number. E. Conditions of Cov erage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved CPT/HCPCS codes along with appropriate modif iers, if applicable. Please ref er to the individual Ohio Medicaid f ee schedule for appropriate codes. Providers mu st f ollow proper billing, industry standards, an d state compliant codes on all claim submissions. The use of modif iers must be f ully supported in the medical record and/or of f ice notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and f acilities. Note: In the event of an y conf lict between this policy an d a providers contract with CareSource, the providers contract will be the governing document. F. Related Polic ies/Rules N/ A G. Rev iew/Rev ision History DATE ACTIONDate Issued 09/01/2019 New policyDate Revised 04/15/2020 Added Plac e of Service 19 to Modifier SA Date Effective 09/01/2020 Date Archived 02/28/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed . Please no te that there c ould be o ther Po lic ies that may hav e s ome of the s ame rules inc o rp orated and CareSource res erves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Polic y. H. Ref erenc es1. Appendix to rule 5160-4- 21. (2016, June 30). Retrieved 3/22/2019 f rom https://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/5160-4- 21-phf fnapp1-20160630-1 04 5. pd f 2. Billing 340B Modif iers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 3/22/2019 from h t t p s : / / s 3 .amaz o n aws . c om/ b iop olic y / po rt al/ f ab 42 15 3-0f 1f-4e a9-9db6-263c144aa972?response-c on t en t- 12 Rei mb urs emen t Mo d if i ers OHIO MEDICAID PY-0715 Effec ti v e Date: 09/01/2020dispositio n=inline%3B%20filename%3D%2259485-1143476.pdf%22&response-content-type=application%2Fpdf&X-Amz-Co nt en t-Sha256=e3b0c44298fc1c149af bf4c8996fb92427ae41e4649b934ca495991b7852b8 55&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWB6UVO57LSG6L2A%2F2019 0322%2Fus-e as t-1%2Fs3%2Faws4_request&X-Amz-Dat e=2 01 90 32 2T 14 24 29 Z&X-Amz-SignedHeaders=Host&X-Amz-Ex pir es =18 00 &X-Amz-Signature=689299099b6b1cc8481ca23fce721228a74bfef30ea4bc2e95a7cd5870bd2 98d 3. CPT overview and code approval. (2019, March 22). Retrieved f rom https://www.ama-as s n . o rg / pr ac t ice-management/cpt/cpt-overview-an d-code-approval 4. Medicare Claims Processing Man u al Chapter 12-Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved February 18, 2019 from https://www.cms.gov/Regulations-an d-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 5. Medicare Claims Processing Man u al Chapter 14-Ambulatory Surgical Centers. (2017, December 22). Retrieved February 18, 2019 from https://www.cms.gov/Regulations-an d-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf. 6. Modif iers Recognized by Ohio Medicaid. (2018, November 1). Retrieved from https://medicaid.ohio.gov/Portals/0/Resources/Publications/Guidan ce/BillingInstructio ns/ModifiersODM.pdf 7. Optum360 EncoderProForPayers.com-Login. (2019, February 18). Retrieved February 18, 2019 f rom https://www.encoderprofp.com/e pro4payers/allModifiersHandler.do?_k=101*0 &_a=li stRelated&menu=4. 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 Overpayment Recovery PY-1115 09/01/2020-07/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 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 requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursemen t 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 prov ided in a particular case and may modify this Policy at any time. 2 A. SubjectOverpayment Recovery Overp aymen t Reco veryOHIO MEDICAID PY-1115 Effective Date: 09/01/20 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 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 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) 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 guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment f rom providers when an overpayment is identif ied. Fraud, waste and abuse investigations are an exc eption to this policy. In these investigations, the look back period may go beyond 2 years. C. Def initions Overpayment – A payment that exceeds amounts properly payable to a provider. These commonly are discovered during a post-payment review. Examples inclu de but are not limited to incorrect coding, non-covered services, and billing discrepancies. Coordination of benefits (COB) – A payment f rom another carrier that is received af ter a payment f rom CareSource; and the other carrier is the primary insurance for the member. Retroactive eligibility – A payment f or a member who was retroactively terminated by the state. Member is not eligible f or benefits. Improper payment – A payment that should not have been made or an overpayment was made. Examples include but are not limited to payment made f or the ineligible member, ineligible service, payment made f or a service not received, and duplicate payments. D. PolicyI. CareSource will provide all the f ollowing information when seeking recovery of an overpayme nt made to a provider: A. The name and patient account number of the member to whom the service(s) were provided; 3 B. The date(s) of services provided;C. The amount of overpayment; D. The reason f or the recoupment; and E. That the provider has appeal rights. Overp aymen t Reco veryOHIO MEDICAID PY-1115 Effective Date: 09/01/2020 II. Overpayment RecoveriesA. Lookback period is 24 months f rom the claim paid date. B. Advanced notif ication will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely f iling limits, the corrected claim submission timef rame is 60 days f rom the date of the recovery. Normal timely f iling limits apply to corrected claims being submitted wit hin original claim timely f iling guidelines. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months f rom claim paid date. B. Advanced notif ication will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely f iling limits, the corrected claim submission timef rame is 60 days f rom the date of the recovery. Normal timely f iling limits apply to corrected claims being submitted within original claim timely f iling guidelines. IV. Retro Active Eligibility Recoveries A. Lookback period is 24 months f rom date CareSource is notif ied by Medicaid of the updated eligibility status. B. Advanced notif ication will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely f iling limits, the corrected claim submission timef rame is 60 days f rom the date of the recovery. Normal timely f iling limits apply to corrected claims being submitted within original claim timely f ili ng guidelines. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. F. Rela ted Policies/Rules CareSource Ohio Provider Manual National Agreement, Article V. CLAIMS AND PAYMENTS, 5.11 (d). G. Review/Revision History DATE ACTIONDate Issued 04/29/2020 New policyDate Revised Date Effective 09/01/2020 Date Archived 07/31/2021 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 rules inco rp orated and Care Source reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy 4 H. Ref erencesOverp aymen t Reco veryOHIO MEDICAID PY-1115 Effective Date: 09/01/2020 1. Ohio Revised Code. (2002, July 24). 3901.38 Payments considered final overpayment. Retrieved January 8, 2020 f rom www.codes.ohio.gov 2. Ohio Department of Medicaid. (2020, January). The Ohio Department of Medicaid Ohio Medical Assistance Provider Agreement for Managed Care Plan . Retrieved January 8, 2020 f rom www.medicaid.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 l ocal 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. 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. REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1076 09/01/2020-12/31/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules …………………………………………………………………………………………… 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References ………………………………………………………………………………………………………….. 5Implantable Spinal Cord Stimulator OHIO MEDICAID PY-1076 Effective Date: 09/01/2020 2 A. SubjectImplantable Spinal Cord Stimulator B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office 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. 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 categorized as chronic. Chronic pain is defined by the International Association for the Study 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 chronic pain are part of a comprehensive 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 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. Policy I. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required for all implantable spinal cord stimulators, including short-term trial placement and permanent placement. 1. Prior authorizations for implantable spinal cord stimulator services are not required for the following: a. Implantable device and device components are considered part of the procedure and does not require a separate PA. b. Removal/revision of implanted device Implantable Spinal Cord Stimulator OHIO MEDICAID PY-1076 Effective Date: 09/01/2020 3 c. Electronic analysis/studies post implantationB. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria found in the Implantable Spinal Cord Stimulator Medical policy MM-0076. 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. Implantable Spinal Cord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, 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 from 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 from 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 Implantable Spinal Cord Stimulator OHIO MEDICAID PY-1076 Effective Date: 09/01/2020 4 95938 Short-latency somatosensory evoked potential study, stimulation ofany/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs95939 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, frequency [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 qualified health care professional; 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, frequency [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 qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [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 qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified 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 frequency, with rechargeable battery and charging system C1823 External recharging system for battery (external) for use with implantable neurostimulator, replacement only C1883 Adaptor/extension, pacing lead or neurostimulator lead (implantable) Implantable Spinal Cord Stimulator OHIO MEDICAID PY-1076 Effective Date: 09/01/2020 5 C1897 Lead, neurostimulator test kit (implantable)F. Related Policies/RulesImplantable Spinal Cord Stimulator MM-0076G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 05/13/2020 Added Codes: L8682 Date Effective 09/01/2020 Date Archived 12/31/2020 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. References1. 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 from www.cms.govThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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. REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Facet Joint Interventions PY-1167 09/01/2020-11/30/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 52 A. Subject Facet Joint Interventions Facet Joint Interventions OHIO MEDICAID PY-1167 Effective Date: 09/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office 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. Interventional procedures for 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 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 Zygapophyseal (aka facet) Joint Level refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint. Diagnostic Medial Branch Nerve Block Injection refers to the diagnosis of facet-mediated pain requiring the establishment of pain relief following medial branch blocks (MBB) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish the facet joint as the pain source. Radiofrequency Facet Ablation (RFA) is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. Policy I. Facet Joint Interventions A. A prior authorization (PA) is required for each facet joint intervention for pain management. Documentation, including dates of service, for conservative therapies are not required for PA, but must be available upon request. 3 Facet Joint Interventions OHIO MEDICAID PY-1167 Effective Date: 09/01/2020 II. Diagnostic Medial Branch Nerve Block Injections A. An initial medial branch nerve block injection in the lumbar and cervical/thoracic region is required for diagnosis. Diagnostic injections are necessary due to the high false positive rates of single injections. 1. Maximum number of benefit limits in this policy are based on medial necessity. 2. The member must meet the medically necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967, before a diagnostic injection is performed. III. Medial Branch Nerve Block Injections A. Once a positive diagnostic medial branch nerve block injection has been established, injections are generally limited to a maximum of six (6) performed in the cervical/thoracic spine and six (6) in the lumbar spine per rolling twelve (12) month period. B. Per CPT guidelines, imaging guidance and any injection of contrast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. IV. Radiofrequency Facet Ablation A. Radiofrequency Facet Ablations are considered medically necessary when the member meets ALL of the medically necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967. B. A member can generally receive a maximum of two (2) radiofrequency facet ablations per rolling 12 months for each spinal region (cervical/thoracic or lumbar) involving no more than four (4) joints per session (e.g., two (2) bilateral levels or four (4) unilateral levels). 1. Repeat Radiofrequency Facet Ablation in the same spinal region and vertebral location is considered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy, MM-0967 has been met. V. Sedation A. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. 1. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. 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. 4 F. Related Policies/Rules Facet Joint Interventions MM-0972 G. Review/Revision History Facet Joint Interventions OHIO MEDICAID PY-1167 Effective Date: 09/01/2020 DATE ACTIONDate Issued 05/13/2020 This policy replaces the Facet Medial Branch Nerve Block and Radiofrequency Facet Ablation policies. Date Revised Date Effective 09/01/2020 Date Archived 11/30/2020 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. References1. Ohio Department of Medicaid Fee Schedules and Rates. Retrieved on April 15, 2020 from www.medicaid.ohio.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Durable Medical Equipment (DME) Modifiers PY-0022 09/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-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, 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 Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Durable Medical Equipment (DME) Modifiers OHIO MEDICAID PY-0022 Effective Date: 09/01/2020 2 A. Subject Durable Medical Equipment (DME) Modifiers B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies a re 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 t he 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 s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Modifi ers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code descript ion, of the product or service. Using a modifier ina ppropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. The purpose of this policy is to simplify and standardize the use of modifiers, when billing for rented, purchased, or rent to purchase DME equipmen t. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment p urchase modifier NU. CareSource expects providers to use the modifiers stated in this policy to increase efficiency and t imely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers addressed in this policy (LT, RT, etc.) . C. Definitions Durable Medical Equipment (DME) e quipment and supplie s ordered by a health care provider for everyday or extended use . Healthcare Common Procedure Coding System (HCPCS) are codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding a nd billing of products, supplies, and services not included in the CPT codes. Modifier t wo-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. Policy I. This policy outlines the use of DME modifiers for the rental and/or purchase of Durable Medical Equipment (DME). Archived Durable Medical Equipment (DME) Modifiers OHIO MEDICAID PY-0022 Effective Date: 09/01/2020 3 NOTE : This policy addresses modifiers associated with billing, not specific DME equipment coverage. Some DME equipment may have individual pol icies which can be referenced for detailed information. The modifiers addressed in this policy is not an all-inclusive list and providers should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed within this policy. II. DME items can be : A. Purchased ; B. Rented ; or C. Rented on a short-term basis and then purchased at the end of the rental period . III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable : A. Purchase Modifier-NU: 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier-RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. 2. All rental authorizations are based on: a. A calendar month authorization period, through the month in which the member becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in the OAC 5160-10-01, the initial rental period must not exceed six months. a. After the initial six month rental period, additional rental months may be authorized if medically necessary. 4. The combined total reimbursement for rental and subsequent purchase of a DME item, cannot exceed the Medicaid maximum fee. 5. At the end of the rent to purchase period , the DM Ebecomes the property of the member. IV. Disposable supplies do not require a modifier. A. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource will review the claim during a post-payment audit and proper reimbursement adjustment will occur. V. Modifiers that are not to be used for claims submission for DME equipment: A. LL-Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price). B. NR-New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased) Archived Durable Medical Equipment (DME) Modifiers OHIO MEDICAID PY-0022 Effective Date: 09/01/2020 4 C. RB-Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are new equipment) VI. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB. NOTE : CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must made available upon CareSources request. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Modifier Description RR Rental (use the RR modifier when DME is to be rented) NU Purchase New Equipment (use the NU modifier when DME is to be purchased) F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 05/13/2020 New policy Date Revised Date Effective 09/01/2020 Date Archived H. References 1. 5160-10-01 Durable medical equipment, pros theses, orthoses, and supplies general provisions . (01/01/2019). Retrieved on May 1, 2020 from www. codes.ohio.gov. 2. Durable Medical Equipment (DME). (n.d. ) . Retrieved on May 1, 2020 from www.healthcare.gov. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
Reimbursement Policies prepared by 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, 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 ca re 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 necessar y 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 au thorization 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 servic es provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT OHIO MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Total Cost PY-0939 08/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. …………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 6 H. References ………………………….. ………………………….. ………………………….. …………………….. 7 2 Obstetrical Care Total CostOHIO MEDICAID PY-0939 Effective Date: 08/01/2020 A. Subject Obstetrical Care Total Cost B. BackgroundObstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members re ceive in a hospital or birthing center as well all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submi ssions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be f ully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. Following Ohio Department of Medicaids direction, total obstetrical care codes are only to be used by Freestanding Birthing Centers. All other practitioners must not bill and will not be reimbursed for total care obstetrical codes. C. Definitions Freestanding birthing center (FBC) – Any facility in which deliveries routinely occur, regardless of whether the facility is located on the campus of another health care facility, and which is not licensed under Chapter 3711 of the revised code as a level one, two, or three maternity unit or a limited maternity unit .1 Prenatal profile – Initial laboratory services. Initial and prenatal visit – Practitioner visit to determine member is pregnant. Total obstetrical care – Includes antepartum care, delivery, and postpartum care. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 weeks of pregnancy. Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 weeks. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care. B. Risk Appraisal-Case Management Referral 1 http://codes.ohio.gov/orc/3702.1413 Obstetrical Care Total CostOHIO MEDICAID PY-0939 Effective Date: 08/01/2020 Providers may complete the Pregnancy Risk Assessment Form and will be paid for the completion of the form a maximum of three times during the pregnancy. This form should be submitted one time during each trimester of pregnancy. Use code H1000 on the associ ated claim to indicate that an assessment form was submitted. b. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. C. Total Obstetrical Care (for uncomplicated care provided to the member including antepartum, delivery, and postpartum care) 1. If a member meets all of the following criteria, the practitioner designated in the members medical record MUST bill for total obstetrical care under that practitioners number: a. Is eligible for Medicaid for the duration of pregnancy; b. Is cared for by one practitioner or group practice for the antepartum care, delivery, and postpartu m care; and c. Attending physician is designated in the medical record with services billed under that practitioner tax identification number. 2. Billing for total obstetrical care cannot be done until the date of delivery. 3. Total obstetrical care cannot be billed for a delivery of less than 20 weeks gestation. 4. Total obstetrical care codes: a. A corresponding obstetrical diagnosis with appropriate trimester must be listed on the claim. A code from category Z34 should be listed as the first diagnosis for routine obstetric care. b. Reimbursement is provided for one of the following codes per pregnancy: CPT Code Description59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. 5. Modifiers a. Use appropriate modifiers (this list may not be all inclusive): 1. 4 6. Services (this list may not be all inclusive):Obstetrical Care Total CostOHIO MEDICAIDPY-0939 Effective Date: 08/01/2020 Services included that may NOTbe billed separately Services excluded and therefore may be billed separately Admission history Greater than 13 antepartum visits due to high-risk condition Admission to hospital Complications of pregnancy Artificial rupture of membranes Surgical complications or other problems related to pregnancy Care provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum Cephalic version Cesarean delivery Ultrasonography Cesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Fetal nonstress test Classic cesarean section Maternal or fetal echography Each month up to 28 weeks gestation Fetal echocardiography procedures Every other week from 29 to 36 weeks gestation Fetal biophysical profile Fetal heart tones Amniocentesis, any method Hospital/office visits following cesarean section or vaginal delivery Chorionic villus sampling, any method Modifier Description 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 5 Obstetrical Care Total CostOHIO MEDICAID PY-0939 Effective Date: 08/01/2020 Initial/subsequent history Fetal contraction stress test Low cervical cesarean section Hospital and observation care visits for premature labor prior to 36 weeks of gestation Management of uncomplicated labor High risk pregnancies requiring more visits or more laboratory data Physical Exams Conditions unrelated to pregnancy i.e. hypertension, glucose intolerance Recording of weight/blood pressures Treatment and management of complications during the postpartum period that require additional services Routine chemical urinalysis Laboratory tests outside of routine chemical urinalysis Routine prenatal visits Cordocentesis Successful vaginal delivery after previous cesarean delivery OB ultrasounds Patients with previous cesarean delivery who present with the expectation of a vaginal delivery RH immune globulin administration Vaginal delivery with or without episiotomy or forceps Weekly from 36 weeks until delivery II. Multiple gestations A. Include diagnosis code for multiple gestations. B. Total obstetrical care billing for multiple gestations should include one procedure code and a delivery only code for each subsequent delivery with the appropriate diagnosis code and modifier for the multiple gestations. C. When all deliveries w ere performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstra ting the reason and the additional work provided. III. High risk deliveriesA. High risk pregnancy with appropriate trimester should be the first listed diagnosis for prenatal outpatient visits and from the category O09 supervision of high-risk pregnancy. 6 Obstetrical Care Total CostOHIO MEDICAID PY-0939 Effective Date: 08/01/2020 B. Modifier 22 should be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of CoverageReimbursement is dependent on, but n ot 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. Codes Description59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct procedural services F. Related Policies/RulesObstetrical Care – Hospital Admissions MM-0897 Obstetrical Care Unbundled Cost PY-0939 G. Review/Revision HistoryDATE ACTIONDate Issued 04/01/2020Date Revised Date Effective 08/01/2020 New policy Date Archived 12 /01/202 0 7 Obstetrical Care Total CostOHIO MEDICAID PY-0939 Effective Date: 08/01/2020 H. References 1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved June 27, 2019, from https:// www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assista nt. 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved June 14, 2019 from https:// www.aapc.com 5. American Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on August 1, 2019 from https:// www.aapc.com 6. EncoderPro.com for Pay ers Professional. (2019) Retrieved June 27, 2019, from https:// www.encoderprofp.com 7. The American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retriev ed June 27, 2019, from https:// www.acog.org 8. The American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modifier 22. Retrieved June 27, 2019, from https:// www.acog.org 9. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Induction of Labor. Retrieved July 31, 2019, from https:// www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved July 31, 2019 from https:// www.acog.org 11. American College of Obstetricians and Gynecologists. (2019), April Correct Coding Initiative Version 25.1. Retrieved June 14, 2019 from https:// www.acog.org 12. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved August 1, 2019, from https:// www.acog.org 13. American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth. Retrieved August 1, 2019 from http s:// www.acog.org 14. Ohio Administrative Code. (2017). 3701-4-01 Definitions. Retrieved August 1, 2019, from http://codes.ohio.gov 15. Department of Ohio Medicaid. (2019, June). Modi fiers Recognized by Ohio Medicaid. Retrieved August 1, 2019 from https:// www.medicaid.ohio.gov 16. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved August 1, 20 19 from http://codes.ohio.gov 17. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrieved August 1, 2019 from http://codes.ohio.gov 18. Ohio Administrative Code. (2019). 5160-26 Managed health care programs; definitions. Retrieved August 1, 2019 from http://codes.ohio.gov 19. Ohio Revised Code. (2012). 3702.141 Rules may apply to existing health care facility. Retrieved August 1, 2019 from http://codes.ohio.gov 20. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health services; pregnancy-related services. Retrieved August 1, 2019 from http://codes.ohio.gov 21. Ohio Revised Code (2017). 4723.43 Scope of specialized nursing services. Retrieved August 1, 2019 from http://codes.ohio.gov 8 Obstetrical Care Total CostOHIO MEDICAID PY-0939 Effective Date: 08/01/2020 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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