REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Temporary Codes-OH MCD-PY-1414 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or si gnificant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Rei mbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan c ontract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may mod ify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the lim itations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-OH MCD-PY-1414Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be estab lished based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or gua rantee claims payment.Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for emerging technologies, services, and procedures which support data collection to s ubstantiatewidespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessary and are considered to be experimental or investigational based on a lack of pe er-reviewed scientific literature.A variety of temporary HCPCS codes exist. Temporary HCPCS codes may beestablished by the Centers for Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures, identify services and procedures under FDA review, or address miscellaneous services, procedures, and supplies. Durable MedicalEquipment (DME) Medicare Administrative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPCS codes may also be developed by commercial paye rs to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource considers temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code. B. A more specific code is not available to describe the service/procedure. C. The service provide d is within the scope of the members benefit plan. Temporary Codes-OH MCD-PY-1414Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & Code Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided. III. Providers must use industry standard code sets and specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract.IV. If specific codes are not available, unlisted codes require plan preauthorization.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 re fer to the individual fee schedule for appropriate codes. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 03/26 /2025Annual review: updated references. Approved at Committee.Review: updated references, approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. American Academy of Professional Coders. What is HCPCS? Accessed March 10, 2025 . www.aapc.com 2. CPT Professional 202 5. American Medical Association ; 202 5. 3. HCPCS Codes – Temporary Codes for Use with Outpatient Prospective Payment System. Acce ssed March 10, 2025 . www.hcpcs.codes 4. Understanding the HIPAA standard transactions: the HIPAA transactions and code set rule. American Medical Association. Access ed March 10, 2025 . www.assets.ama-assn.org Approved by ODM on 04/11/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of care that a newborn with specified diagnoses and symptoms require. All four levels of care are represented by a uniquerevenue code . Any inpatient revenue codes not billed as levels 2-4 will be recognized as level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy are not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms require s. Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well Baby Care Services A basic level of care to neonates who are low risk. D. PolicyI. Per federal mandate, newborn members are covered at an inpatient facility for a 2 – day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with revenue codes 0170/0171 and a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to submit documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn require s a NICU admission or a higher IOC service, anauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, an authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed during transitional time.VI. Clinical review will determine appropriate IOC utilizing MCG standards. Care Source will adjust IOC reimbursement if clinical documentation does not support the IOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria , as well as CareSource policy.VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to reference MCG guidelines as well as the clarifications and specific details below . Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 NICU LevelRevenue CodeDescription MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care ( LOC-010 ) Neonatal care may be indicated for the p hysiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn care Evaluation and care of neonates with conditions that require inpatient services available at Level I Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues (eg , sustained weight gain, poor PO feeding ), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medications Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 20172: Newborn Level IIIntensity of Care Criteria 2 Continuing Care (LOC-011 ) Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation ( 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation ( NIPPV ) o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min of IV treatment or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W ) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermia Surgical conditions requiring general anesthesia up to 2 days post-op , if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation , or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013 ) Includes Level 3 requirements and 1 or more of the following: Perioperative care following surgical repair of severe neonatal conditions, for example: o bowel resection for necrotizing enterocolitis (NEC) o tracheoesophageal fistula or esophageal atresia repair o cardiac surgery excluding PDA ligation o myelomeningocele closure (up to 48 hours post-op) o organ transplant Medically necessary inhaled nitric oxide (iNO) Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange transfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing IV fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusion CPR in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation (eg, hemolytic anemia, disseminated intravascular coagulation, hemorrhage) E. Conditions of CoverageI. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align with authorized levels of care and/or clinically validate diagnoses, procedures , and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care Issue a base DRG payment Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping, A request for complete medical records and/or itemized statements to support the services on the claim may be made II. In the event of any conflict between this policy and any written agreement betweenthe provider and CareSource, that written agreement will be the governing document.F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/13/202 3 New policy . Approved at Committee.Date Revised 03/12/2025 Periodic review. Updated definitions, section D. and references. Approved at Committee. Date Effective 07/01/2025 Date Archived Neonatal Intensive Care Unit (NICU) Level of Care-OH MCD-PY-1430 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 H. References 1. About preterm labor and birth. National Institutes of Health (NIH). Reviewed May 9, 2023. Accessed January 30, 2025. www.nichd.nih.gov 2. Admission to NICU. Specification Manual for Joint Commission National Quality Measures . The Joint Commission; 2024. Version 2024B1. www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care. LOC-010 (ISC GRG). MCG Health. 2 8th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care. LOC-011 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care. LOC-012 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care. LOC-013 (ISC GRG). MCG Health. 2 8th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III, and IV. Pediatrics . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 Approved ODM 03/20/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifiers-OH MCD-PY-1345 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 2 E. Conditions of coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related policies/rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/revision history ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ………………….. 4 Modifiers-OH MCD-PY-1345Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement modifiers are two-digit code s that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both CPT and HCPCS manuals. Use of a modifi er does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure . To indicate that a procedure was performed on the left side, right side, or bilaterally . To report multiple procedures performed during the same session by the same health care provider . To indicate multiple health care professionals participated in the procedure . To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier throu gh post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive) : National Correct Coding Initiative (NCCI) editing guidelines American Medical Association (AMA) guidelines American Hospital Association (AHA) billing rules Modifiers-OH MCD-PY-1345Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) ICD-10 CM and PCS National Drug Codes (NDC) Diagnosis Related Group (DRG) guidelines CCI table edits . The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of coverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement is dependent up on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. In the absence of State specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource policies applyto both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related policies/rules NA G. Review/revision historyDATE ACTIONDate Issued 09/01/2019 New policyDate Revised 04/15/2020 10/13/2021 10/12/202209/27/202304/ 09/2025 Added Place of Service 19 to Modifier SA Removed modifiers, changed background and policy sections to simplify language No changes. Updated references. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Modifiers-OH MCD-PY-1345Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Date Effective 07/01/2025Date Archived H. References1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS) . US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed March 26, 2025 . www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed March 26, 2025 . www.ama-assn.org 3. Medicare Claims Processing Manual, XII: Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services. Issued December 19, 2024 . Accessed March 26, 2025 . www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers . US Centers for Medicare and Medicaid Services. March 24, 2023. Accessed March 26, 2025 . www.cms.gov Approved ODM 04/14/202 5
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers 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 wi ll 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 guarant eeclaims payment.Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Using a modifi erinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service.The purpose of this policy is to simplify and standardize the use of modifiers, when billing for rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU. CareSource expects providers touse the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers addressed in this policy ( eg, LT, RT, etc.). Some DME equipment may have individual policies which can be referenced for detailed information. The modifiers addressed in this policy is not an all-inclusive list andproviders should adhere to national and state billing guidelines for modifier usage fo r all other modifiers not addressed within this policy. C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated , and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. This policy outlines the use of Durable Medical Equipment (DME) modifiers for the rental and/or purchase of DME. II. DME items can be:A. purchasedB. rented or C. rented on a short-term basis and then purchased at the end of the rental period III. DME items must be billed with appropriate HCPCS codes along with appropriate modifiers when applicable:A. Purchase Modifier – NU: 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. B. Rental Modifier – RR: 1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. 2. All rental authorizations are based on: a. A calendar month authorization period, through the month in which the member becomes ineligible; b. The item is no longer medically necessary; or c. The maximum amount allowable is reached. 3. Unless otherwise outlined in the O hio Administrative Code (OAC) 5160 – 10-01, the initial rental period must not exceed 6 months. a. After the initial 6 month rental period , additional rental months may be authorized if medically necessary. 4. The combined total reimbursement for rental and subsequent purchase of a DME item, cannot exceed the Medicaid maximum fee. 5. At the end of the rent to purchase period, the DME becomes the property of the member. IV. Disposable supplies do not require a modifier.A. DME items that are submitted for reimbursement without a modifier are considered a purchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource will review the claim during a post-payment audit and p roper reimbursement adjustment will occur. V. Modifiers that are not to be used for claims submission for DME equipment include :A. LL Lease/rental B. NR New when rented Durable Medical Equipment (DME) Modifiers-OH MCD-PY-0022 Effective Dat e: 07/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 C. RB Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are considered new equipment) VI. CareSource considers a replacement part as a new equipment purchase and modifier NU should be used instead of modifier RB.NOTE: CareSour ce may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must made available upon CareSources request. E. Conditions of CoverageF. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020 New policyDate Revised 09/14/2022 10/1 1/2023 04/09/2025 No changes. Updated references. Annual review. Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Date Effective 07/01/2025 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS): General Provisions, OHIO ADMIN CODE 5160-10-01 (2024). 2. Medical Equipment. Accessed March 31, 2025. www.medicaid.ohio.gov 3. Healthcare Common Procedure Coding System (HCPCS). Accessed March 31, 2025. www.cms.gov 4. What are medical coding modifiers? 2022. American Academy of Professional Coders. Accessed March 31, 2025. www.aapc.com Approved ODM 04 /14/202 5
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Doula Services-OH MCD-PY-1591 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and util ization 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 ca n 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 co st 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 con tract (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 t o services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Doula Services-OH MCD-PY-1591Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDoula Services B. BackgroundDoula services have been shown to improve maternal and birth outcomes and maternal experiences and reduce health care disparities, Doulas provide advocacy, physical, educational, and emotional support during pregnancy and reimbursement of doula services wi ll be conducted according to the Ohio Administrative Code (OAC) 5160-8-43 and Ohio Medicaid fee schedule. C. Definitions Doula A trained, nonmedical professional who advocates for, and provides continuous physical, emotional, and informational support to, a pregnant woman through the delivery of a child and immediately after the delivery, including during any of the following periods: o The antepartum period o The intrapartum period o The postpartum period D. PolicyI. CareSource follows the O AC for Doula services reimbursement . II. CareSource may reimburse for the allowed hours set forth by the OAC.III. If additional hours are needed that exceed the allowed hours set forth by the OAC,CareSource will perform a review of medical necessity. Documentation must be submitted upon CareSources request . IV. Doula services are not intended for routine childcare, meal prep, cleaning and other domestic servic es not typically covered by the Ohio Department of Medicaid (ODM) .CareSource may request post payment documentation to confirm services were medically necessary. Post payment recoupment may occur if services are found to not be in alignment with our membe rship and the OAC rule. E. Conditions of CoverageA. Claims submission must include a ppropriate HCPCS codes and any applicable modifiers. B. Documentation must be submitted upon CareSources request . C. Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Doula Services-OH MCD-PY-1591Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Providers must follow pr oper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participati ng and nonparticipating providers and facilities. D. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 03/12/2025 New policy. Approved at Committee.Date Revised Date Effective 07/01/2025 Date Archived H. References1. Doula Services, OHIO ADMIN . CODE 5160-8-43 (2024). Appr oved by ODM 04/ 01/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Diagnostic Colonoscopy and/or Sigmoidoscopy-OH MCD-PY-1592 07/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Obstetrical Care Unbundled Cost-OH MCD-PY-0004 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are 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 Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………… 2 B. Background ………………………….. ………………………….. ………………………….. ………………….. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………. 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 7 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 7 H. References ………………………….. ………………………….. ………………………….. …………………… 8 Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care-Unbundled Cost B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verif y a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology ( CPT )/Healthcare Common ProcedureCoding System ( HCPCS )/International Classification of Disease-10( ICD-10 ) code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply a right to reimbursement or guarantee claims payment. Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include s care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members r e c e iv e in a h o s p it a l o r b ir t h in g c e n t e r a s we l l as all associated outpatient services . The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. 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 CPT codes, HCPCS codes and/or revenue codes. The codes denote services and/or procedure s performed. The billed codes must be fully supported in the medical record. Unless otherwise noted, this policy applies only to participating providers and facilities. This policy is for practitioners who meet either of the following: Obstetrical practitioners not part of a free standing birthing center Obstetrical practitioners part of a Free Standing Birthing Center when any of the following occur: o It is the preferred method of billing . o The member has a change of insurer during pregnancy . o The member has received part of the antenatal care elsewhere (eg , from another group practice ). o The member leaves the practitioners group practice before the global obstetrical care is complete . o The member must be referred to a provider from another group practice or a different licensure (eg , midwife to medical doctor) for a cesarean delivery . o The member has an unattended precipitous delivery . Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 o Termination of pregnancy without delivery (eg , miscarriage, ectopic pregnancy) .C. Definitions Initial and Prenatal Visit A practitioner visit to determine whether a member is pregnant. Freestanding Birthing Center (FBC) Birth centers are freestanding facilities that are not considered hospitals , provid ing peripartum care for low-risk women with uncomplicated singleton term vertex pregnancies who are expected to have an uncomplicated birth . High Risk Delivery Labor management and delivery for an unstable or critically ill pregnant patient. Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. Premature Birth Delivery before 37 weeks of pregnancy is completed. Prenatal Profile Initial laboratory services. Unbundled Obstetrical Care The practitioner bil ls delivery, antepartum care, and postpartum care independently. o Antepartum Care Defines basic care (including obtaining and updating subsequent medical history, physical examination, recording of vital signs, and routine chemical urinalysis) provided monthly up to 28 weeks gestation, biweekly there after up to 36 weeks gestation, and weekly thereafter until delivery. o Delivery Includes admission to a facility, medical history during admission, physical examinations, and management of labor (either by vaginal delivery or by cesarean section). o Postpartum Care The time period that begins on the last day of pregnancy and extends through the end of the month in which the 60 day period following termination of pregnancy ends. The American College of Obstetricians and Gynecologists (ACOG) recommends contact within the first 3 weeks post partum. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile – Evaluation and management (E/M) codes are utilized for t he initial visit , prenatal profile , and antepartum care. B. Risk Appraisal – Case Management Referral 1. Providers may complete the Pregnancy Risk Assessment Form (PRAF) and will be paid for the completion of the form . Providers are encouraged to submit a PRAF any time there is a change in condition during the pregnancy. Please use code H1000 and append modifier 33 on the associated claim to indicate that an assessment form was submitted. 2. Any eligible woman who meets any of the risk factors listed on the Pregnancy Risk Assessment Form (PRAF) is qualified for case management services for pregnant women and should be referred to CareSource for further screening for those case management services. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Note: CareSource follows the Ohio Department of Medicaid (ODM) guidance regarding PRAF and can be submitted during any pregnancy stage according to ODM . Beginning 4/1/2025 ODM will allow PRAF submissions for Postpartum care . C. Unbundled Obstetric Care – The practitioner w ill bill antepartum care, delivery,and postpartum care independently of one another. 1. Antepartum care only – do es not include delivery or postpartum care: a. Use the appropriate E/M code and trimester code(s) . b. Use the appropriate modifier , if applicable . 2. Delivery only – Use if only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code(s): c. Services (This list may not be all inclusive):Services included that may NO Tbe 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 deliveryCesarean deliveryCPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Classic cesarean sectionLow cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as delivery Delivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of delivery 3. Delivery and postpartum care only – If only delivery and postpartum care were provided . a. Use the appropriate CPT and trimester code: b. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately ( this list may not be all inclusive): 01. admission history 02. admission to hospital 03. artificial rupture of membranes 04. care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. hospital/office visits following cesarean section or vaginal delivery 06. management of uncomplicated labor 07. physical exam 08. vaginal delivery with or without episiotomy or forceps 09. caesarean delivery 10. classic cesarean section 11. low cesarean section 12. successful vaginal delivery after previous cesarean delivery CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 13. previous cesarean delivery member who present s with the expectation of a vaginal delivery 14. 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 code 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 may include and therefore is not allowed to be billed separately for the following (not an all inclusive list ): 01. office and outpatient visits following cesarean section or vaginal delivery 02. qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. conditions unrelated to pregnancy (eg , respiratory tract infection ) 02. treatment and management of complications 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 GestationsA. Include diagnosis code for multiple gestations. B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed. C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. IV. High Risk DeliveriesObstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 A. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 supervision of high-risk pregnancy.B. Modifier 22 should be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of 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 of codes is provided as a reference. This list may not be all inclusive and is subject to updates.CPT Code DescriptionE/M For antepartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59430 Postpartum care only. 59514 Cesarean delivery only 59515 Cesarean delivery only; including postpartum care 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care F. Related Policies/RulesObstetrical Care-Hospital Admissions Obstetrical Care-Total Cost G. Review/Revision HistoryDATE ACTIONDate Issued 06/10/2015Date Revised 10/18/2017 07/22/2020 09/15/2021Updated codes, templateNew title was Preferred Obstetrical Services; policy broken into two policies. Updated definitions, reorganize topics, removed total care information, updated most content and codes. Clarified who can bill unbundled charges. Obstetrical Care Unbundled Cost-OH MCD-PY-0004Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 10/10/202210/11 /2023 11/20/2024 01/15/2025 Revised antepartum language for clarity. Remov ed modifiers. Updated references. Approved at Committee. Annual review. Updated references. Approved at Committee. Updated D.I.B.1. Approved at Committee. Date Effective 05/01/2025 Date Archived H. References1. 2024 OB/GYN Coding Manual: Components of Correct Coding . American College of Obstetricians and Gynecologists; 2024. Accessed November 11, 2024. www.acog.org 2. American Academy of Professional Coders. Code obstetrical care with confidence. December 1, 2011. Accessed October 14, 2024. www.aapc.com 2. American College of Obstetricians and Gynecologists. Billing for care after the initial outpatient postpartum visit: the fourth trimester. Accessed October 14, 2024. www.acog.org 3. American College of Obstetricians and Gynecologists. Optimizing postpartum care. Obstet Gynecol . ACOG Committee Opinion No. 736. 2018;131(5):e140-e150. Accessed October 14, 2024. www.acog.org 4. American College of Obstetricians and Gynecologists. Preterm labor and birth. Updated April 2023. Accessed October 14, 2024. www.acog.org 8. Cesarean Delivery on Maternal Request . American College of Obstetricians and Gynecologists; 2019. Committee Opinion No. 761. Reaffirmed 2024. Accessed November 1, 2024. www.acog.org 5. Definitions, OHIO ADMIN . CODE 4723-8-01 (2021). 6. Freestanding Birth Center Services, OHIO ADMIN . CODE 5160-18-01 (2023). 7. Limitations on Elective Obstetric Deliveries, OHIO ADMIN . CODE 5160-1-10 (2015). 8. Management of Late-Term and Postterm Pregnancies . American College of Obstetricians and Gynecologists; 2014. Practice Bulletin No. 146. Accessed November 11, 2024. www.acog.org 9. Medically Indicated Late-Preterm and Early-Term Deliveries . American College of Obstetricians and Gynecologists; 2021. Committee Opinion No. 831. Accessed November 1, 2024. www.acog.org 10. Managed Care: Definitions, OHIO ADMIN . CODE 5160-26-01 (2022). 11. Modifiers Recognized by Ohio Medicaid . Ohio Dept of Medicaid; 2011. Revised January 28, 2022. Accessed September 20, 2023. www.medicaid.ohio.gov 12. Reproductive Health Services: Pregnancy-Related Services, OHIO ADMIN . CODE 5160-21-04 (2022). 13. Scope of Specialized Nursing Services, Ohio Rev. Code 4723.43 (2020). ODM Approved on 01/23/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Interest Payments-OH MCD-PY-1324 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 2 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-OH MCD-PY-1324 Effective Date: 05/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim is a claim that can be processed without obtaining additional information from the provider of a service or from a third party and do not include payments made to a provider of service or a third party where the timing of the payment is not directly related to submission of a completed claim by the provider of service or third party. A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical neces sity. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by Ohios Medicaid Prompt Payment rules and contract. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. II. In alignment with the Ohio Administrative Code and the Medicaid Provider Agreement, CareSource does not pay interest on Ohio Medicaid claims. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. Interest Payments-OH MCD-PY-1324 Effective Date: 05/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised 01/05/2022 04/27/2022 04/ 12/2023 01/31/2024 01/15/2025 Updated language and references per Legal. No change; did for review cycle consistency No change; updated references. Approved at Committee. No change; updated references. Approved at Committee. Updated references. Approved at Committee Date Effective 05/01/2025 Date Archived H. References1. Definitions, O HIO REV . CODE 5164.01(C) (2023 ). 2. Ohio Medicaid Contract, Appendix J, 4. Accessed December 3, 2024. www.managedcare.medicaid.ohio.gov 3. Timely Claims Payment, 42 C.F.R. 447.45(b) (2022). Approved by ODM 01/23/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Acupuncture Services-OH MCD-PY-0152 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2025 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Acupuncture Services B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Acupuncture is an ancient Chinese method of treatment based on the theory that stimulation of specific key points on or near the skin by the insertion of needles or by other methods improves vital energy flow . The term acupuncture describes a variety of methods and styles to stimulate specific anatomic points in the body. Acupuncture is used to relieve pain, induce surgical anesthesia, or for therapeutic purposes. It is considered an alternative treatment and an adjunct to standard treatment . C. Definitions Acupuncturist A n individual who holds , at a minimum, a valid certificate to practice as an acupuncturist or as an oriental medicine practitioner. Chiropractor An individual who holds a certificate to practice acupuncture issued by a state chiropractic board. Other Individual Medicaid Provider A physician assistant or an advanced registered nurse practitioner who has a valid certificate as an acupuncturist . Physician An individual who has completed medical training in acupuncture with a current and active designation or an equivalent designation from the National Certification Commission for A cupuncture and Oriental Medicine. D. Policy I. CareSource reimburses for acupuncture services according to the criteria found in Ohio Administrative Code (OAC) 5160-8 -51 for the following conditions: A. m igraines B. low back pain C. cervical (neck) pain D. osteoarthritis hip E. osteoarthritis of knee F. acute post-operative pain Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.3G. a cute nausea and vomiting (pregnancy and chemotherapy-related, not inpatient ) II. CareSource does not require prior authorization for acupuncture services for the first 30 visits per calendar year for participating providers. Although CareSource does not require a prior authorization for the first 30 visits for acupuncture services, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. III. Participating providers must be one of the following: A. A physician who has completed medical training in acupuncture with a current and active designation, or an equivalent designation from the National Certification Commission for Acupuncture and Oriental Medicine. B. A chiropractor with a valid certificate to practice acupuncture. C. Other individual Medicaid provider, including an advanced practice registered nurse or a physician assistant , with a valid certificate as an acupuncturist. IV. Limitations: A. No separate reimbursement will be made for both an evaluation and management service and an acupuncture service performed by the same provider to the same individual on the same day. B. No separate reimbursement will be made for services that are an incidental part of a visit , such as but not limited to, providing instruction on breathing techniques, diet , or exercise. C. No reimbursement will be made for an additional treatment after an initial treatment period if any of the following occur : 1. Symptoms show no evidence of clinical improvement after an initial treatment period. 2. Symptoms worsen over a course of treatment . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one on one contact with the patient 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure) Acupuncture Services-OH MCD-PY-0152 Effective Date: 05/01/2025 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d.497813 Acupuncture, 1 or more needles with electrical stimulation, initial 15 minutes of personal one on one contact with patient 97814 Acupuncture, 1 or more needles with electrical stimulation, each addition 15 minutes of personal one on one contact with the patient, with re-insertion of needle(s) (List separately in addition for primary procedure) F. Related Policies/Rules N/AG. Review/Revision History DATE ACTIONDate Issued 10/31/2013 New Policy Date Revised 10/31/2013 06/06/2016 04/30/2020 05/25/2022 05/24/2023 01/17/2024 01/15/2025 New Allowed Services Removed III. D. Shoulder Pain Updated references. No changes. Approved at committee. Updated references. No changes. Approved at Committee Updated references. No changes. Approved at CommitteeDate Effective 05/01/2025Date Archived H. References1. Acupuncture Services , O HIO ADMIN . CODE 5160-8- 51 (2021 ). 2. License to Practice, O HIO REV . CODE 4762.02 (2023) . 3. Non-Institutional Fee Schedule, Appendix DD, O HIO ADMIN . CODE 5160-1- 60 (2024 ). Approved by ODM on 01/23/2025
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -OH MCD-PY-0039 04/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to p rovide 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, 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 t he Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addi ction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Transcutaneous Electrical Nerve Stimulat ors (TENS) -OH MCD-PY-0039Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulat ors (TENS) B. BackgroundTranscutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin. C. Definitions Accessories A collective term that encompasses but is not necessarily limited to adapters, clips, additional connecting cable for lead wires, carrying pouches , and covers. Supplies A collective term that encompasses but is not necessarily limited to electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries , and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. D. PolicyI. CareSource may require medical necessity r eview for a TENS unit. CareSource follows the Ohio Administrative Code for clinical criteria for the following devices: A. E0720 Two-lead unit B. E0730 Four-lead unit II. SuppliesA. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase due to the necessity of continued treatment, the following apply: 1. Separate payment may be made for necessary supplies, which must be dispensed only when needed . 2. CareSource covers 1 unit of su pplies (A4595) per month for a 2-lead TENS unit (E0720) and 2 units per month for a 4-lead TENS unit (E0730). 3. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 4. Separat e payment is not provided for individual supply items. D. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and Transcutaneous Electrical Nerve Stimulat ors (TENS) -OH MCD-PY-0039Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.HCPCS Code DescriptionE0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers DescriptionNU Purchase of new equipmentRR Rental (use the ‘RR’ modifier when DME is to be rented) F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 08/23/2004Date Revised 02/06/2019 09/16/2020 07/15/2022 12/13/202312/18 /2024Updated policy to align with OAC updates . Updated prior authorization requirement. PGC approved via electronic vote. Revised background information. Updated references. Annual review: rearranged criteria, updated references. Approved at Committee. Review: removed PA language, updated references, approved at Committee . Date Effective 04/01/2025 Date Archived H. References1. Durable Medical Equipment, Prostheses, Orthoses, and Supplies (DMEPOS) , OHIO ADMIN . CODE 5160-10-01 (202 4). 2. DMEPOS: Transcutaneous Electrical Nerve Stimulation (TENS) Units , OHIO ADMIN . CODE 5160-10-15 ( 20 24 ). 3. Gibson W, Wand BM, Meads C, et al . Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane Reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 4. Johnson MI, Pal ey CA, Wittkopf PG, et al . Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: Transcutaneous Electrical Nerve Stimulat ors (TENS) -OH MCD-PY-0039Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 a secondary analysis of the meta-TENS study to improve future research. Medicina(Kaunas) . 2022;58(6):803. doi:10.3390/medicina58060803 5. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina . 2022;58(10):1332. doi:10.3390/medicina58101332 ODM Approved 01/ 09/2025
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