REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Substance Use Disorder Residential PY-0137 01/01/2021-5/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 6 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 6 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry – stan dard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of dis ease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of go od medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Ev idence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be sub ject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. 2 A. SubjectSubstance Use Disorder Residential Substan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. T he inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Substance Use Disorder (SUD) services are provided on a continuum of care where the level of care varies dependent on the type and intensity of se rvices provided. This policy address the Residential level of care. This type of care provides an intensive residential program f or members with SUD. It is considered transitional with the goal of returning the member to the community with a less restricti ve level of care. C. Def initions Residential level of care for SUD – A residential program must meet all of the f ollowing: o Staf f ed 24 hours a day o Follow nationally recognized medical standards o Be an Ohio Department of Mental Health and Addiction Services (OhioMHAS) certif ied/licensed f acility to provide residential SUD treatment o Have an active provider agreement with ODM o All practitioners of the SUD treatment service must meet applicable state requirements o Establish individualized treatment plans o Start discharge planning at time of admission o Schedule a f ollow-up visit within 7 days of discharge f or af tercare o Provide Medication Assisted Treatment (MAT) or linkage to a prescriber f or MAT o Ensure accessibility to all behavioral and physical health medication upon discharge CareSource does not consider a residential program appropriate f or: o Intensive medical monitoring needed f or severe or lif e threatening medical or physical condition o A memb er who is unable to actively participate due to Severe symptoms of co-existing mental or physical condition; or Severe withdrawal symptoms 3 D. PolicySubstan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 I. CareSource requires a prior authorization (PA) for the f ollowing: A. For the f irst and second admission per calendar year, a prior authorization is only required f or an admission exceeding 30 consecutive days. B. For admissions exceeding the two admissions per calendar year, a prior authorization is required f rom the f irst day of admission. C. Changes in level of care: 1. When step-up or step-down occurs between two SUD residentia l level of care codes within the same residential provider agency, and there is consecutive billing, it is counted as a single event . When step-up or step-down occurs between two SUD residential level of care codes and billing is not consecutive, the even ts will be considered separate events and PAs may be required depending on the members utilization in that calendar year. a. If the step-up or step-down occurs during the f irst 30-days of 1 st or 2 nd of the 2 allowed SUD Residential events, no PA is required f or the step-up or step-down. b. If the step-up or step-down occurs af ter a PA has been authorized, either because the LOS has exceeded 30-days or this is the 3 rd or more event in a calendar year, then t he step-up or step-down does require a new/updated PA. D. SUD Residential Facility Transf ers 1. Prior Authorization is required f or a same level-of-care admission/transfer between two SUD Residential Facilities (NPIs and/or TINs) when the total number of days at that level-of-care exceeds 30-calendar days and there is not a break in stay that is greater than 24-hours between admissions, indicating two separate events. If the admission has already required prior authorization, f or any reason, the transition admi ssion will require prior authorization be obtained by the receiving facility f rom the date of admission. 2. Same level-of-care admissions/transfers between two SUD Residential Facilities (NPIs and/or TINs) without a break in stay of greater than 24-hours is not considered a separate event and will not accumulate as a separate events. 3. If there is a break in stay that is greater than 24-hours between a same level – of-care admissio n/transf er between two SUD Residential Facilities (NPIs and/or TINs), the admission to the receiving f acility is considered a separate event and is subject to prior authorization f rom date of admission, beginning with the third admission in a calendar year and will accumulate as separate events. NOTE: It is the responsibility of the f acility to check the annual service usage to avoidgetting a claim denial f or no prior authorization.II. Documentation A. At least one documented f ace-to-face interaction must be pr ovided by a clinical/treatment team member with the member at the substance use residential site in order to bill per diem. B. Members medical record must show evidence of medical necessity of services. C. The residential program has a written Af f iliation Agreement so that members are 4 Substan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 connected/ensured access to outpatient care in timely manner upon discharge. The residential program has policies and procedures in place to monitor its af f iliations. III. Medical Necessity CriteriaA. CareSource f ollows The ASAM Criteria as required by the Ohio Department of Medicaid. IV. BillingA. Residential level of care admission one admission is considered one length of stay 1. Any stay under 30 consecutive days counts as a f ull 30 day occurrence. 2. Service gaps in excess of 24 hours are considered a termination of one admission. 3. Leaving the SUD residential treatment f acility associated with signif icant changes in health status such as leaving against medical advice, step-ups (including acute medical admissions) or step-downs in level of care, and/or incarceration are considered a termination of one admission. 4. Brief leave of absences (24 hours or less, except in rare instances) when supported by members individualized treatment plan should be documented in the members treatment plan, and the provider should continue to bill f or treatment services during these times. a. Brief leave of absences include but are not limited to the f ollowin g: 01. Family visits 02. Religious services 03. Same day health services 04. Social support group attendance B. The benef it f ollows the member not the providers tax identification number. C. CareSource only processes claims f rom 1. Provider type of 95 OhioMHAS certified/licensed treatment program; 2. Provider specialty 954 OhioMHAS certif ied/licensed SUD residential f acility; and 3. Place of service code 55 Residential Substance Abuse Treatment Facility. D. Claims billed out of sequence from date of service may cause claims to deny inappropriately f or no prior authorization. E. Claims are paid as they are received. If member receives services f rom more than one provider, claims are paid to providers that submit f irst regardless of date of service. F. SUD residential is paid per diem. Per Diem does not include room and board costs/payments. G. CareSource does not reimburse separately f or services provided by th e residential treatment service including: 1. Ongoing assessments and diagnostic evaluations. 2. Crisis intervention. 3. Individual, group, f amily psychotherapy and counseling. 4. Case management. 5. Substance use disorder peer recovery services. 5 6. Urine drug screens.7. Medical services. 8. Medication administration Substan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 H. A member can only receive services through one level of care at a time. 1. CareSource considers the f ollowing services non-billable when member is in residential level of care a. Therapeutic behavioral services. b. Psychosocial rehabilitation. c. Community psychiatric supportive treatment. d. Mental health day treatment. e. Assertive community treatment. f. Intensive home based treatment. 2. CareSource does consider select BH services provided to a member f rom practitioners not af f iliated (based on billing group TIN) with the residential treatment program as billable concurrent to the SUD Residential admission when the service is medically necessary and the treatment is outside of the scope of the residential tr eatment program. Examples include medication assisted treatment (MAT) and psychiatry. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description H2034 Clinically Managed Low-Intensity Residential Treatment ASAM 3.1 H2036 Clinically Managed High Intensity Residential Treatment ASAM 3.5 Procedure Modifier Description HI Clinically Managed Population-Specif ic High Intensity Residential Treatment ASAM 3.3 (Adults) May be used with H2036.TG Medically Monitored Intensive Inpatient Treatment (Adults) and MedicallyMonitored High-Intensity Inpatient Services (Adolescent) ASAM 3.7 May be used with H2036. 6 F. Related Policies/RulesMedical Necessity Determinations G. Review/Revision HistorySubstan ce Use Diso rd er Resid en tialOHIO MEDICAID PY-0137 Effective Date: 01/01/2021 DATE ACTIONDate Issued 08/17/2017Date Revised 05/15/2019 Updated def inition, medical necessary criteria, and billing Date Effective 09/16/2020 12/28/202001/01/2021Updated def inition, added note under D. I. Added D. I. C.; D.1. IV. A. 5 and IV. B. Added related policy. Revised D. IV. H. 2. Revised I. C. D. and E. Provided clarif ication of policy per ODM D. 1. C, D, and E; and D. IV. A. DateArchived 5/31/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rule s inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erences1. Lawriter – OAC – 5160-27-01 Eligible provider f or behavioral health services. (2019, November 29) Retrieved June 1, 2020 f rom www.codes.ohio.gov 2. Lawriter OAC 5160-27-02 Coverage and limitations of behaviora l health services. (2018, May 30) Retrieved June 1, 2020 f rom www.codes.ohio.gov 3. Lawriter OAC 5160-27-09 Substance use disorder treatment services. (2018. January) Retrieved June 1, 2020 f rom www.codes.ohio.gov 4. Ohio Department of Medicaid. (2020, April 9). Medicaid Behavioral Health Sta te Plan Services Provider Requirements and Reimbursement Manual. Retrieved June 1, 2020 f rom www.bh.medicaid.ohio.gov 5. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co – Occurr ing Conditions , Third Edition. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Hysterectomy Po l i c y CareSource provides coverage for hysterectomy when it meets the criteria outlined in this policy. The physician is responsible for obtaining the state – appropriate signed informed consent form from the membe r. De f i n i t i o n sHysterectomy , means a medical procedure or operation for the purpose of removing the uterus. (From 42 CFR 441.251) Institutionalized individual , means an individual who is (a) involuntarilyconfined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or (b) confin ed, under a voluntary commitment, in a mental hospital or other facility for the care and treatment of mental illness. (From 42 CFR 50.202) Mentally incompetent individual , means an individual who has been declaredmentally incompetent by a Federal, State, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to steriliz ation. (From 42 CFR 50.202)Sterilization , means any medical procedure, treatment, or operation for thepurpose of rendering an individual permanently incapable of reproducing. ((From42 CFR 441.251) Pr o v i d e r Re i m b u r s e m e n t Gu i d e l i n e sPrior Authorization CareSource requires prior authorization only for inpatient hysterectomy. ReimbursementCareSource will reimburse Medicaid providers for hysterectomy only if:Written consent to the hysterectomy procedure is obtained from members on the appropriate form. The primary surgeon performing the hysterectomy is responsible for securing the mem bers consent to the procedure. A copy of the state-appropriate signed/approved form is provided for all hysterectomies, whether performed as a primary or secondary procedure, or for medical procedures directly related to such hysterectomies. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 The form should include the appropriate, legible signature(s) and must be submitted to CareSource with the cl aim.CareSource will not reimburse providers for hysterectomy if: The hysterectomy was performed solely for the purpose of rendering an individual permanently incapable of reproducing; orThere was more than one purpose to the hysterectomy, and it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing; orThe requirements of this policy and 42 C.F.R. part 441 subpart F (Code of Federal Regulations) are not met. BillingThe appropriate documentation must be attached to the claim form, or sent separately to CareSource for claims submitted electronically. All providers rendering hysterectomy related services (e.g. anesthesiologi st, etc.) must attach an exact photocopy of the appropriate sterilization acknowledgement or physician certification statement(s) to the claim(s). To ensure timely reimbursement, the primary service provider is advised to forward copies of the sterilizat ion acknowledgement or physician certification statement(s) to these related service providers. Providers must submit the professional service using Current Procedural Terminology.R e l a t e d Po l i c i es & Re f e r e n c e sOAC 5160-21-02.2, Medicaid Covered Reproductive Health Services: permanent contraception/sterilization services and hysterectomy 907 KAR 1:054. Primary care center and federally-qualifi ed health centerservicesKAR 3:005 Physicians Services; Section 4 (10) (f)CareSource – Provider Manual St a t e Ex c e p t i o n sNONE Do c u m e n t Re v i s i o n Hi s t o r y10/31/2013 OAC Rule renumbered from 5101:3-21-02.2, per Legislative Service Commission Guidelines.
This CareSource Management Group proprietary policy is not a guarantee o f payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment PolicySubject: Healthcare Acquired Conditions, Provider Preventable Conditions, and Conditions Present on AdmissionPrograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program,OH MyCare, and OH Just4Me TM Po l i c yCareSource will, as applicable, deny claims for or reduce the reimbursement amounts for claims by providers that include healthcare acquired conditions or other provider-preventable conditions , or where one of the reported conditions was not present on admission for an inpatient stay, in accordance with CMS guidelines and protocols. De f i ni t i on sHealthcare acquired condition (HAC ), means a condition occurring in any inpatient hospital setting which has a negative consequence for the member and which was not present in the member upon admission to that facility. (from Affordable Care Act of 2010, Section 2702 ) Provider preventable condition , means a condition occurring in anyhealthcare setting that is either a healthcare acquired condition or is another condition which has been found by the applicable state to be reasonably preventable by the provider through the application of procedures supported by evidence-based medical guidelines, and which has a negative consequence for the member. These types of conditions include, but are not limited to, wrong surgical or other invasive procedures, sur gical or other invasive procedures performed on the wrong body part, or surgical or other invasive procedures performed on the wrong patient. (from 42 CFR 447.26) Pr o v i d er R e i m b u r s e m e n t Gu i d e l i n es Healthcare Acquired ConditionsCareSource will not reimburse providers for healthcare acquired conditions in its members, in accordance with CMS guidelines.Provider Preventable ConditionsCareSource will not reimburse providers for provider preventable conditions in its members. If CareSource can reasonably identify and isolate the portion of the claim which is directly related to the treatment of the provider preventable condition, then Ca reSource will reduce the reimbursement of the claim by that specific amount related to the provider preventable condition. CareSource will not, however, impose a reduction in reimbursement on any claim when a provider preventable condition is found in a CareSource member to have been This CareSource Management Group proprietary policy is not a guarantee o f payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 present and in existence prior to the providers treatment of that member. This CareSource Management Group proprietary policy is not a guarantee o f payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 2 CareSource will take all necessary actions in order for any state to comply with and implement applicable federal and state laws, regulations, policy guidance and any state policies and procedures relating to the identification, reporting, andnon-paymen t of claims with provider preventable conditions. CareSource requires providers to comply with all federal, state, and CareSource-issued reporting requirements around provider preventable conditions as a condition of claims reimbursement. Conditions Pr esent on AdmissionHospitals will not receive additional payment for inpatient claims in which one of the conditions reported on the claim was not present when the CareSource member was admitted to the facility. Any such claim will be paid as though the se condary diagnosis were not present.In accordance with CMS guidelines, CareSource requires facilities to promptly report present on admission information for both primary and secondary diagnoses when submitting claims NOTE : Regardless of how CareSource reimburses, reduces reimbursement for,or denies any claims under this policy, providers may not deny access to healthcare services to any CareSource member based on a healthcare acquired condition or provider preventable co ndition contracted by that member. R e l a t e d Po l i c i e s & R e f e r e n c e sDeficit Reduction Act of 2005, Section 5001(c), Hospital quality improvement.Affordable Care Act of 2010, Section 2702, Payment adjustment for healthcare acquired conditions. 42 USC 1396b-1, Payment adjustment for healthcare acquired conditions. 42 CFR 447.26, Prohibition on payment for provider-preventable conditions. 907 KAR 14:005, Healthcare acquired conditions and other provider preventable conditions. OH Department of Medicaid Hospital Handbook, HHTL 3352-13-05, Inpatient Hospital Reimbursement on or after July 1, 2013. St a t e Exc ep t i o n sNONE Do c um e n t Hi s t or y
R EIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled Cost PY-0004 12 /01 /2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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 neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, 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, dysfu nction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy d oes not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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. Backgr ound ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 9 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 9 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 2A. Subject Obstetrical Care Unbundled Cost B. Background Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e i ve i n a h o s p i t a l o r b ir t h in g c e n t e r a s we l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. This policy is for practitioners that meet either of the following: Obstetrical practitioners who are not part of a Free Standing Birthing Center ;or Obstetrical practitioners who are part of a Free Standing Birthing Center when any of the following occur: o It is their preferred method of billing; o The member has a change of insurer during pregnancy ; o The member has received part of the antenatal care elsewhere, e.g. from another group practice ; o The member leaves your group practice before the global obstetrical care is complete ; o The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery ; or o The member has an unattended precipitous delivery ; and o Terminati on of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy) . 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 1 http://codes.ohio.gov/orc/3702.141 Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 3 Unbundled obstetrical c are – The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care – Is for basic care (including taking and subsequent updating of medical hist ory, physical examination, recording of vital signs, and routine chemical urinalysis) provided monthly up to 28 weeks gestation, biweekly therefore up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery – Includes admission to facility, medi cal history during admission, physical examinations, management of labor (either vaginal delivery or by cesarean section )2. o Postpartum care – The period that, begins on the last day of pregnancy and extends through the end of the month in which the 60 day period following termination of pregnancy ends 3. The American College of Obstetricians and Gynecologists ( ACOG ) recommends contact within the first 3 weeks postpartum. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delive ry 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 whe n services were provi ded to diagnose the pregnancy. These are not part of antepartum care . B. Risk Appraisal-Case Management Referral 1. 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. Please use code H1000 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors li sted 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. Unbundled Obstetric Care – Report the services performed using the most accurate, most comprehensive procedure code available based on what services the practitioner performed. The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 2 http://codes.ohio.gov/oac/5160-21-04v1 3 https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=1&SID=fabf1d19393c9f6586501c8e23999687&ty=HTML&h=L&mc=true&n=pt42.4.440&r=PART Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 41. Antepartum care only Antepartum care only does not include delivery or postpartum care : a. Use the appropriate CPT and trimester code (s) : CPT Code Description59425 Antepartum care only; 4-6 visits59426 Antepartum care only; 7 or more visits E/M For antepartum care for 1-3 visits b. Use the appropriate modifier (This list may not be all inclusive):Modifier Description24 Unrelated evaluation and management service by the same physician or other qualified health care professional during the postoperative period c. E/M codes for antepartum care are limited to 3.d. Only one code, either 59425 or 59426 can be billed per pregnancy.e. Antepartum care only code includes the following (This list may not be all inclusive ): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly from 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent history 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery 09. Routi ne chemical urinalysis 10. Termination of pregnancy by abortion 11. Referral to another physician for delivery 2. Delivery only Use i f only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the approp riate CPT and delivery outcome code (s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 559620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive)Services included that may NOTbe billed separately Services excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Cesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as deliveryDelivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of delivery d. ModifiersObstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 601. Use the appropriate modifier (This list may not be all inclusive): CPT Code Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 80 Assistant surgeon – may be used for delivery only if no antepartum or postpartum care was performed 3. Delivery and postpartum care only If only delivery and postpartum care were provided a. Use the appropriate CPT and trimester code: CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care59515 Cesarean delivery only; including postpartum care59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care b. Services included in the delivery only and postpartum care codes;and therefore are NOT allowed to be billed separately (This list may not be all inclusive): 01. Admission history 02. Admission to hospital 03. Artificial rupture of membranes 04. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. Hospital/office visits following cesarean section or vaginal delivery 06. Management of unco mplicated labor 07. Physical exam 08. Vaginal delivery with or without episiotomy or forceps 09. Caesarean delivery 10. Classic cesarean section 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery 13. Previous cesarean delivery who present with t he expectation of a vaginal delivery Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 714. Caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery 4. Postpartum care only-If postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code . This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care ma y include; and therefore are not allowed to be billed separately (This list may not be all inclusive ) the following : 01. Hospital, o ffice , and outpatient visits following cesarean section or vaginal delivery ; or 02. Qualified health care professional providing all or portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion . e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. Conditions unrelated t o pregnancy i.e. respiratory tract infection ; or 02. Treatment and management of c omplications during the postpartum period that require additional services . II. Member eligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner must use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical or normal hospital evaluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services including laboratory services are reimbursable . III. Multiple gestations.A. Include diagnosis code for multiple gestations . B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multip le procedures were performed . C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. IV . High risk deliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 8B. 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 provide d. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.Codes Description 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits E/M For antepartum care for 1-3 visits 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59515 Cesarean delivery only; including postpartum care59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care 59430 Postpartum care only.Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during the postoperative period 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 procedure /service Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 980 Assistant surgeon – may be used for delivery only if no antepartum or postpartum care was performed F. Related Policies/RulesObs tetrical Care Hospital Admissions MM-0897Obstetrical Care Total Cost PY-0939 G. Review/Revision HistoryDATE ACTION Date Issued 06/10/2015 Date Revised 10/18/2017 07/22/2020 Updated codes, template Date Effective 12/01/2020 New title was Preferred Obstetrical Services;policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Clarified who can bill unbundled charges Date Archived H. References1. 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 Assistant . 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved 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 Payers 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). Retrieved Ju ne 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, D ecember). 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. Ret rieved 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 Obstetrical Care Unbundled CostOHIO MEDICAIDPY-0004 Effective Date: 12/01/2020 1012. 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). Prete rm Labor and Birth. Retrieved A ugu st 1, 2019 from https://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). Modifiers Recognized by Ohio Medicaid. Retrieved August 1, 2019 f rom https://www.medicaid.ohio.gov 16. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved August 1, 2019 from http://codes.ohio.gov 17. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrieved August 1, 201 9 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. Retr ieved August 1, 2019 from http://codes.ohio.gov 20. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health service s; 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 The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Facet Joint Interventions PY-1167 12/01/2020 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 logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Pari ty Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Revie w/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Facet Joint InterventionsOHIO MEDICAIDPY-1167 Effective Date: 12/01/2020 2 A. SubjectFacet Joint Interventions 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 actu al 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 sub mitting provider to submit the most accurate andappropriate 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. Interventiona l procedures for management of acute and chronic pain are part of acomprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and ai m 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 t he 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. PolicyI. Facet Joint Interventions A. A p rior 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. Facet Joint InterventionsOHIO MEDICAIDPY-1167 Effective Date: 12/01/2020 3 II. Medial Branch Nerve Block InjectionsA. Up to two medial branch nerve block injections in the cervical/thoracic or lumbar regions are considered medically necessary. 1. Only three (3) spinal levels (unilateral or bilateral) may be treated at the same time (maximum amount of six injections per rolling 12 months); 2. A response of at least 50% pain relief must be achieved before the second injection is performed; and 3. Injectio ns should be at least two (2) weeks apart. 4. Maximum number of benefit limits in this policy are based on medial necessity. 5. The member must meet the medically necessary criteria in the corresponding Facet Join t Interventions medical policy, before a diagno stic injection is performed. III. Per CPT guidelines, imaging guidance and any injec tion of contrast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. IV. Radiofrequency Facet AblationA. 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 . B. A maximum of four (4 ) radiofrequency facet ablation s per rolling twelve (12) months (two left and two right per spinal region: cervical, thoracic or lumbar). C. Repeat Radiofrequency Facet Ablation in the same spin al region and side is considered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy 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. The following list(s) of co des is provided as a reference. This list may not be all inclusive and is subject to updates. Facet Joint InterventionsOHIO MEDICAIDPY-1167 Effective Date: 12/01/2020 4 F. Related Policies/RulesFacet Joint Interventions MM-0967 G. Review/Revision History DATE ACTIONDate Issued 05/13/2020 This policy replaces the Facet Medial BranchNerve Block and Radiofrequency Facet Ablation policies. Date Revised 07/22/2020 11/11/2020Revisions: Medial Branch Nerve Block injection clinical criteria; requirement of one successful RFA session.Revision: RFA language revised around benefitlimit for clarity. (This revision does not require a network notification or a change of the Effective Date). Date Effective 12/01/2020 Date Archived H. References 1. Ohio Department of Medicaid Fee Schedules and Rates. Retrieved on April 15, 2020 from www.medicaid.ohio.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
R EIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Total Cost for FreeStanding Birthing Centers PY-0939 12/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, 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 service s 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 morbid ity, 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 conven ience 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 policie s and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Po licy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to 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. Backgr ound ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Obstetrical Care Total Cost for Free Standing Birthing CentersOHIO MEDICAIDPY-0939 Effective Date: 12/01/2020 2A. SubjectObstetrical Care Total Cost for FreeStanding Birthing CentersB. Background Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e i v e in a h o s p i t a l o r b ir t h in g c e n t e r a s we l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. The t otal obstetrical care code is only to be used by Freestanding Birthing Centers. Allother practitioners must not bill and will not be reimbursed for total care obstetrical codes.C. Definitions Frees tanding 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. 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 week s. 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/3702.141 Obstetrical Care Total Cost for Free Standing Birthing CentersOHIO MEDICAIDPY-0939 Effective Date: 12/01/2020 31. 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 o f pregnancy. Use code H1000 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the form is qualified for case management services for pregnant women and should be refe rred 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. Billing for total obstetrical care cannot be done until the date of delivery . 2. Total obstetrical care c ode : a. Total obstetrical care code is 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care b. A corresponding obs tetrical 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. 3. Services included that are not to be billed separately (this list may not be all inclusive) : a. Admission history b. Admission to hospital c. Artificial rupture of membranes d. Care provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum e. Visits each month up to 28 weeks gestation f. Visits every other week from 29-36 weeks gestation g. Visits weekly from 36 weeks until delivery h. Fetal heart tones i. Hospital/office visits following vaginal delivery j. Initial/subsequent history k. Management of uncomplicated labor l. Physical exams m. Recording of weight/blood pressures n. Routine chemical urinalysis o. Routine prenatal visits p. Successful vaginal delivery after previous cesarean delivery q. Vaginal delivery with or without episiotomy or forceps E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.Obstetrical Care Total Cost for Free Standing Birthing CentersOHIO MEDICAIDPY-0939 Effective Date: 12/01/2020 4Codes Description 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care H1000 Prenatal care, at-risk assessment F. Related Policies/RulesObstetrical Care – Hospital Admissions MM-0897 Obstetrical Care Unbundled Cost PY-0939 G. Review/Revision HistoryDATE ACTIONDate Issued 07/22/2020 New policyDate Revised Date Effective 12/01/2020 Date Archived H. References1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpartum Visit. Retrieved June 27, 2019, from www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved June 14, 2019 from www.aapc.com 5. American Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on August 1, 2019 from www.aapc .com 6. EncoderPro.com for Payers Professional. (2019) Retrieved June 27, 2019, from www.encoderprofp.com 7. The American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved June 27, 2019, from www.ac og.org 8. The American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modifier 22. Retrieved June 27, 2019, from www.acog.org 9. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Induction of Labor. Retrieved July 31, 2019, from www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved July 31, 2019 from www.acog.org 11. Ameri can College of Obstetricians and Gynecologists . (2019 ), April Correct Coding Initiative Version 25.1. Retrieved June 14, 2019 from www.acog.org 12. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Care. Retrieved August 1 , 2019, from www.acog.org 13. American College of Obstetricians and Gynecologists. (2019, January). Prete rm Labor and Birth. Retrieved A ugust 1, 2019 from www.acog.org Obstetrical Care Total Cost for Free Standing Birthing CentersOHIO MEDICAIDPY-0939 Effective Date: 12/01/2020 514. Ohio Administrative Code. (2017). 3701-4-01 Definitions . Retrieved August 1, 2019, from www .codes.ohio.gov 15. Ohio Administrative Code. (2015). 5160-1-10 Limitations on Elective Obstetric Deliveries. Retrieved August 1, 2019 from www. codes.ohio.gov 16. Ohio Administrative Code. (2018). 4723-8-01 Definitions. Retrieved August 1, 2019 from www. codes.ohio.gov 17. Ohio Administrative Code. (2019). 5160-26 Managed health care programs; definitions. Retrieved August 1, 2019 from www. codes.ohio.gov 18. Ohio Revised Code. (2012). 3702.141 Rules may apply to existing health care facility. Retrieved August 1, 2019 from www. codes.ohio.gov 19. Ohio Administrative Code. (2017). 5160-21-04 Reproductive health services; pregnancy-related services. Retrieved August 1, 2019 from www. codes.ohio.gov 20. Ohio Revised Code (2017). 4723.43 Scope of specialized nursing services . Retrieved August 1, 2019 from www. codes.ohio.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
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 Implantable Pain Pump PY-1070 11/01/2020-12/31/2020 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 ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 42 A. Subject Implantable Pain Pump Implantable Pain Pump OHIO MEDICAID PY-1070 Effective Date: 11/01/2020 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. 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 Pain Pump-Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for continuous or variable rates of infusion . D. PolicyI. Prior authorization is required for all implantable pain pumps, including trial administration, permanent placement, single shot intrathecal injections and removal and revision of the implanted device. Prior authorization is not required when the drug is prescribed under one of the following circumstances: A. To an individual who is a hospice patient in a hospice care program; B. To an individual who has been diagnosed with a terminal condition but is not a hospice patient in a hospice care program; and 3 Implantable Pain Pump OHIO MEDICAID PY-1070 Effective Date: 11/01/2020 C. To an individual who has cancer or another condition associated with the individuals cancer or history of cancer. II. Prior authorization for implantable pain pump services are not required for the following: A. Implantable device is considered part of the procedure and does not require a separate PA. B. Analysis post implantation. C. Refilling and maintenance of the implanted device. III. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump medical policy MM-0077. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules Implantable Pain Pump MM-0077 G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 07/08/2020 08/26/2020Annual Update: Addition of PA non-requirement criteria. PA is now required for removal/revision of the implanted device. Date Effective 11/01/2020 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 rulesincorporated 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 2. Ohio Revised Code. ORC 1751.691 (2017, April 6) Prior authorization requirments or other utlilzation review measures as conditions of providing coverage of an opioid analgesic. Retrieved on July 1, 2020 from codes.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 Date Trigger Point Injections PY-1100 10/01/2020 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, 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 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Trigger Point InjectionsOHIO MEDICAIDPY-1100 Effective Date: 10/01/2020 2 A. SubjectTrigger Point Injections B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual 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 su bmitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes arelargely 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 Stud y 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 conserva tive treatment ina 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 fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Trigger Point Injections – A trigger point is a hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a sin gle substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. D. Policy I. Trigger Point Injections A. A prior authorization ( PA) is required for each trigger point injection for pain management. B. Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. Trigger Point InjectionsOHIO MEDICAIDPY-1100 Effective Date: 10/01/2020 3 C. For trigger-point injections of a local anesthetic or a steroid, payment will be mad e for no more than eight dates of service per calendar year per patient. OAC 5160 4-12(4) . D. Injections may be repeated only with documented positive results to prior trigger point injection of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning and activity tolerance. E. Localization techniques to image or otherwise identify tri gger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. F. Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date. OAC 5160 4-12(3) G. A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and man agement procedure code) that a separate evaluation and management service was performed. OAC 5160 4-12(2 ) E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Ohio Medicaid approved HCPCS and CPT codes alo ng with appropriate modifiers. 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. Trigger Point InjectionsDescription 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles F. Related Policies/RulesTrigger Point Injections MM-0011 G. Review/Revision History DATE ACTIONDate Issued 07/26/2016Date Revised 06/ 10/2020 Annu al Update : A pr ior autho rization is now required . Date Effective 10/01/2020 Date Archived Trigger Point InjectionsOHIO MEDICAIDPY-1100 Effective Date: 10/01/2020 4 H. References1. Ohio Administrative Code . 5160-4-12(D) (1 ). (11 /1/201 7). Immunizations, injections and infusions (including trigger-point injections), and provider-administered pharmaceuticals. Retrieved on May 15, 2020 from ww w.oac.gov 2. Ohio Depament of Medicaid Fee Schedules and Rates . Retrieved on May 15, 2020 from www .med icaid.ohio .gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICAID Policy Name Policy Number Effective Date Orthotics PY-1151 10/01/2020-02/28/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 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, 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 Orth o ticsOHIO MEDICAID PY-1151 Effective Date: 10/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy 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 purpose of this policy is to reinf orce CareSources ability to audit post payment claims and to ensure that reimbursement was justif ied by reviewing prov iders documentation to conf irm medical necessity. C. Def initions Certificate of medical necessity (CMN) – is a written statement by a practitioner attesting that a particular item or service is medically necessary f or an individual. Orthotics – means the evaluation, measurement, design, f abrication, assembly, f itting, adjusting, servicing, or training in the use of an orthotic device, or the repair, replacement, adjustment, or service of an existing orthotic device. Orthotic device – means a cu stom f abricated or f itted medical device used to support, correct, or alleviate neuromuscular or musculoskeletal dysf unction, disease, injury, or def ormity. D. PolicyI. This policy is specif ic to f ollowing orthotic devices: A. That have been dispensed to an eligible CareSource member. B. Ordered by provider that met the criteria f ound within this policy. C. Includes all orthotics that are considered f or, back, lumbar, spinal, cervical, thoracic, f oot, ankle and knee. II. CareSource may request documentation f rom the o rdering physician and the dispensing Durable Medical Equipment (DME) provider to conf irm medical necessity of the orthotic device. A. The orthotic device must be a covered orthotic device and ordered and f urnished by an eligible provider to an eligible CareSource member. B. CareSource may request the CMN af ter the claim has been submitted. A. SubjectOrthotics 3 C. An illegible CMN will not be accepted.Orth o tics OHIO MEDICAID PY-1151 Effective Date: 10/01/2020 III. Eligible Medicaid providers of the f ollowing types having prescriptive authority under Ohio law may certif y the medical necessity of an Orthotic device: A. A physician; B. A podiatrist; C. An advanced practice registered nurse with a relevant specialty (e.g., clinical nurse specialist, certif ied nurse practitioner); or D. A physician assistant. IV. The f ollowing eligible providers may dispense/f urnish an orthotics device:A. For orthotic devices a provider enrolled in Medicaid as a DME supplier. B. A medically necessary orthotic device requires a prescription. 1. Bef ore writing a prescription f or an orthotic device, a practitioner must conduct a f ace-to-f ace encounter with the Medicaid CareSource member. 2. The date of a prescription cannot precede the date of the related encounter nor can it be more than one hundred eighty days af terward. 3. The encounter must be documented in the CareSource members medical record. 4. Unless a dif f erent length of time is specif ied, the date of a prescription cannot precede the f irst date of service (the date the Orthotic device is dispensed to the member) by more than sixty days. C. The medical practitioner acting as prescriber must be act ively involved in managing the recipient’s medical care. The department may disallow a prescription written by a practitioner who has no prof essional relationship with the recipient. D. The prescribed DME device must be directly related to a medical condition of the recipient that the practitioner evaluates, assesses, or actively treats during the encounter. E. No additional f ace-to-f ace encounter is necessary f or a separate DME device if an encounter conducted within the preceding twelve months addresses the medical condition f or which the DME device is being prescribed. V. Any request f or an orthotic device must originate with an eligible CareSource member, the members authorized representat ive, or a medical practitioner acting as prescriber and must be made with the members f ull knowledge and consent. VI. When instruction must be given in the saf e and appropriate use of an orthotic device,it is the responsibility of the provider to ensure tha t the member or someone authorized to assist the member has received such instruction. VII. Each claim submitted f or payment, a provider must keep supporting documents on f ile: A. Ref er to CareSource Administrative policy Medical Record Documentation Standards f or Practitioners – AD-0753. 4 Orth o ticsOHIO MEDICAID PY-1151 Effective Date: 10/01/2020 VIII. Payment is not available f or an orthotic device that is a duplicate or conflicts with another device currently in the members possession, regardless of payment or supply source. Providers are responsible f or ascertaining whether duplication or conf lict exists. 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. F. Related Policies/RulesMedical Record Documentation Standards f or Practitioners – AD-0753 G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2020Date Revised Date Effective 10/01/2020 New policy Date Archived 02/28/2022 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 formal documented Policy. H. Ref erences1. Ohio Administrative Code. (2001, June 6). Chapter 4779: Orthotists, Prosthetists, Pedorthists. Retrieved June 1, 2020 from www.codes.ohio.gov. 2. Ohio Administrative Code. (2019, January 1). 5160-10-01 Durable medical equipment, prostheses, orthoses, and supplies (DMEPOS): general provisions. Retrieved June 1, 2020 f rom www.codes.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 Date Epidural Steroid Injections PY-1055 10/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard 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 func tion, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or p rovider. 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. 2 A. SubjectEpidural Steroid Injections Ep id ural Stero id In jectionsOHIO MEDICAID PY-1055 Effective Date: 10/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy 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 wi ll be determined when the claim is received f or processing. Health care providers and their of f ice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. 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 th eir lif etime. Long term outcomes are largely f avorable f or most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is def ined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures f or management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approac h. Multidisciplinary treatments include promoting patient self – management and aim to reduce the impact of pain on a patient’s daily lif e, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualif ied to deliver these health services. C. Def initions Epidural Steroid Injections – f or persistent or chronic radicular pain involve injection of corticosteroid, local anesthetic, opioid, or c ombination medication into the epidural space, requiring f luoroscopic imaging and injection of an appropriate agent to achieve a selective reproducible blockage of a specif ic nerve root. Anatomic locations f or epidural injections may involve the interlaminar space at the midline between vertebral bodies, caudal epidural injections or transf oraminal epidural injections. Epidural injections may be diagnostic f or localizing and determining the cause of radiating pain and providing short term pain rel ief . D. Policy I. Epidural Steroid Injections A. A prior authorization (PA) is required f or each epidural injection f or pain management by the same or any physician, excluding labor and delivery in 3 Ep id ural Stero id In jectionsOHIO MEDICAID PY-1055 Effective Date: 10/01/2020 childbirth and f or post surgical pain. Documentation, including dates of service, f or conservative therapies are not required f or PA, but must be available upon request. B. The maximum epidurals of all types of epidural injections a member can receive in a rolling twelve (12) months is a total of six (6), regardless of the number of levels involved. 1. Repeat injections sooner than three (3) weeks may not reach pharmacodynamic ef f ect of the corticosteroid and will not be covered. 2. Requests f or repeat injections beyond three (3) weeks without documentation of suitable pain score reduction and f unctional improvements, or other documented rationale as described in this policy will not be covered. C. For Interlaminar or Caudal Epidural Injections 1. More than one (1) epidural injection per treatment date will not be authorized. 2. Bilateral injections and modif iers will not be recognized and coverage will be denied. D. For Transf oraminal Epidurals or Selective Nerve Root Blocks (SNRBs) 1. Transf oraminal Epidurals provided to more than two (2) vertebral levels per treatment date, whether unilateral or bilateral, will not be authorized and will not be covered. 2. Prior authorization is required f or treatment sessions per each spine region. E. Repeat Therapeutic Injections 1. Epidural injections may be repeated only when considered medically necessary and the criteria is met according to the CareSource Epidural Steroid Injections medical policy. F. Real-time i mage guidance and any injection of contrast are inclusive components of epidural injections and are not compensated f or separately, or unbundled, f or coverage. G. Ultrasound guidance f or epidural injections is inappropriate. H. Conscious sedation, if required f or co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible f or additional reimbursement if administered by a second provider. 1. Coverage f or monitored anesthesia will not be provided as not medically necessary. 2. When anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. 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. F. Related Policies/RulesEpidural Steroid Injectio ns OH MCD MM-0007 4 G. Review/Revision HistoryEp id ural Stero id In jectionsOHIO MEDICAID PY-1055 Effective Date: 10/01/2020 DATE ACTIONDate Issued 07/26/2016Date Revised 09/08/2016 06/01/2020Annual Update: No changesDate Effective 10/01/2020 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 May 20, 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.
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