REIMBURSEMENT POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Modifiers-OH MA-PY-1351 04/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, 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 mo dify 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 li mitations 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 ………………………….. ………………………….. ………………………….. ……………………. 4 Modifiers-OH MA-PY-1351Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifiers 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 their office staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers c an be found in the appendices of bothCurrent Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modifier does not change the code or the codes definition. Examples of modifiers use includes: To different iate 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 s ame 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, use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Using a modifier inappropriately can result in the denial of a 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 issue d, 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 b y 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. Modifier – two-character codes used along with a CPT or HCPCS code to provide additional inf ormation about the service or supply rendered. Modifiers-OH MA-PY-1351Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.D. Policy It 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; Current Procedural Termin ology (CPT); Healthcare Common Procedure Coding System (HCPCS); ICD-10 CM and PCS; National Drug Codes (NDC); Diagnosis Related Group (DRG) guidelines; and CCI table edits. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to th e CMS 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 otherw ise noted within the policy, CareSource policies applyto both participating and nonparticipating providers and facilities .Note: 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 N/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2019 New policyDate Revised 12/15/2021 Annual review. Removed modifiers, changed background and policy sections to simplify language . New policy number created and converted from PY – 0716 due to extensive edits Date Effective 04/01/2022 Date Archived Modifiers-OH MA-PY-1351Effective Dat e: 04/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. References 1. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved November 17, 2021 from www.cms.gov . 2. CPT overview and code approval. (2019, March 22). Retrieved November 17, 2021 from www.ama-assn.org. 3. Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved November 17, 2021 from www.cms.gov . 4. Medicare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, December 22). Retrieved November 17, 2021 from www.cms.gov. 5. Optum360 EncoderProForPayers.com – Login. (2019, February 18). Retrieved November 17, 2021 from www.encoderprofp.c om.
REIMBURSEMENT POLICY STATEMENTOhio Medicare Advantage Policy Name & Number Date Effective Overpayment Recovery-OH MA-PY-1116 04/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, 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 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 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 li mitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement …………………………………………. Error! Bookmark not defined. A. Subject ………………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………… 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………… 5 F. Related Policies/Rules …………………………………………………………………………………………….. 5 G. Review/Revision History ………………………………………………………………………………………….. 5 H. References ……………………………………………………………………………………………………………. 5 Overpayment Recovery-OH MA-PY-1116 Effective Dat e: 04/01/2022 The REIMBURSEMENTPolic y Sta te me nt d etai le d a bo ve h as receiv ed due consi de ra tio n a s defin ed i n the REIMBURSEMENTPolic y Sta te me nt Polic y and i s appro ve d.A. Subject Overpayment Recovery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service ch annels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring ac curacy in the payment process. CareSource will request voluntary repayment from providers when an overpayment i s identified. Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years. C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously paid and is being updated for one of the following reasons: o Denied as a zero payment, a partial payment, a reduced payment, a penalty applied, an additional payment or a supplemental payment. Overpayme nt Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. EOP The EOP or Explanation of Payment contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o Payments made for an ineligible member; Overpayment Recovery-OH MA-PY-1116 Effective Dat e: 04/01/2022 The REIMBURSEMENTPolic y Sta te me nt d etai le d a bo ve h as receiv ed due consi de ra tio n a s defin ed i n the REIMBURSEMENTPolic y Sta te me nt Polic y and i s appro ve d.o Ineligible service payments; o Payments made for a service not received; and o Duplicate payments. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. PLB (Provider Level Balancing) Adjustments to the total check / remit amount oc cur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR, which means total payment within the EOP). Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past claim has been adjusted to a different dollar amount and that funds are owed to CareSource. D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. The name and patient account number of the member to whom the service(s ) were provided; B. The date(s) of services provided; C. The amount of overpayment; D. The reason for the recoupment; and E. That the provider has appeal rights . II. Overpayment Recoveries A. Lookback per iod is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit Recoveries A. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility Recoveries A. Lookback period is 24 months from date CareSource is notified by CMS of the updated eligibility status. B. Advanced notification will occur 30 days in advance of recovery. Overpayment Recovery-OH MA-PY-1116 Effective Dat e: 04/01/2022 The REIMBURSEMENTPolic y Sta te me nt d etai le d a bo ve h as receiv ed due consi de ra tio n a s defin ed i n the REIMBURSEMENTPolic y Sta te me nt Polic y and i s appro ve d.C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing gui delines. V. Management of Claim Credit Balances. A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. 1. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D. IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negativ e balances through (EOPs) and 835s. 1. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances. E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. 1. Providers are expected to maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances when they occur. VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document. Overpayment Recovery-OH MA-PY-1116 Effective Dat e: 04/01/2022 The REIMBURSEMENTPolic y Sta te me nt d etai le d a bo ve h as receiv ed due consi de ra tio n a s defin ed i n the REIMBURSEMENTPolic y Sta te me nt Polic y and i s appro ve d.E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. http://codes.ohio.gov/pdf/oh/admin/2016/5160-10- 03_ph_ff_a_app2_20160321_1242.pdf F. Related Policies/Rules CareSource Provider Agreement, ARTICLE V. CLAIMS AND PAYMENTS G. Review/Revision History DATE ACTIONDate Issued 04/29/2020 New policyDate Revised 12/01 /2021 Updated definitions. Added D. V. and D. VI. Updated references. Approved at PGC. Date Effective 04/01/2022 Date Archived H. References 1. Center of Medicare & Medicaid Services. (2008, September 12). Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments. Retrieved October 4 , 2021 from https://www.hhs.gov
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Interest Payments PY-1321 08/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify thi s Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 2 E. Conditions of Cov erage …………………………………………………………………………………………… 3 F. Related Policies/Rules …………………………………………………………………………………………….. 3 G. Review/Revision History ………………………………………………………………………………………….. 3 H. References ……………………………………………………………………………………………………………. 3 Interest Payments OHIO MEDICARE ADVANTAGE PY-1321 Effective Date: 08/01/20212A. Subject Interest Paym ents B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the respons ibility 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 has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and addi tional elements, or revisions to data elements, attachments and additional elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements. D. Policy I. We strictly adhere to all regulatory guidelines relating to interest. We follow the guidelines outlined in Prompt Payment regulations. ( ORC 3901.389 ) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims starts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim within Interest Payments OHIO MEDICARE ADVANTAGE PY-1321 Effective Date: 08/01/20213the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay ti meframe. V. CareSource only pays interest on claim payment that is occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment. VI. CareSource performs regular reviews of our paid claims to correct claim payment. A. Reviews can include items such as retroactive eligibility updates, authorization updates, COB updates, and fee schedule updates. B. Reviews include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers , if applicable. Please refer to the individual f ee schedule for appropriate codes. F. Re lated Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 03/31/2021 New PolicyDate Revised Date Effective 08/01/2021 Date Archived H. References 1. Legal Information Institute. 42 CFR 422.520-Prompt payment by MA organization. Retrieved 16 February 2021 from www.law.cornell.edu 2. Social Security Association. Sec 1816(c)(2)(B. Retrieved 16 February 2021 from www.ssa.gov 3. Social Security Association . Sec 1842(c)(2)(B). Retrieved 16 February 2021 from www.ssa.gov 4. United States Government Publishing Office. Title 31, Section 3902. Retrieved 16 February 2021 from www.govinfo.gov 5. United States Government Publishing Office. Title 42, Section 7109. Retrieved 16 February 2021 from www.govinfo.gov 6. Federal Register. Prompt Payment Interest Rate; Contract Disputes Act. Retrieved 16 February 2021 from www.fiscal.treasury.gov Interest Payments OHIO MEDICARE ADVANTAGE PY-1321 Effective Date: 08/01/202147 . Bureau of the Fiscal Service. (2013, January-2021, June). Interest Rates. Retrieved 16 February 2021 from www.fiscal.treasury.gov 8. Centers for Medicare & Medicaid Services. (2019, January). Notice of New Interest Rate for Medicare Overpayments and Underpayments-2nd Qtr. Retrieved 16 February 2021 from www.cms.gov 9. Law Writer Ohio Laws and Rules. (24 July 2002). Computation of Interest. Retrieved 16 March 2021 from http://codes.ohio.gov/orc/3901.389 The Reimbursement Polic y Sta te ment d etai le d a bo ve h as r ecei ved due c on siderati on a s d efi n ed i n the Reimbursement Polic y Sta te m ent Polic y a nd i s a pp ro ved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANT AGE Policy Name Policy Number Effective Da te Molecular Diagnostic Testing f or Respiratory Virus PY-0880 01/01/2021-09/30/2022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions ………………………………………………………………………………………………………….3 D. Policy ………………………………………………………………………………………………………………..3 E. Conditions of Co ve r age…………………………………………………………………………………………3 F. Related Policies/Rules ………………………………………………………………………………………….3 G. Review/Revision History ………………………………………………………………………………………..3 H. Ref er en ce s …………………………………………………………………………………………………………3 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd documentation guidelines. Coding methodology, regulatory requirements, industry-stan dard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to se rv ices 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 t h at a re le ss favorable than the limita tio n s t h at apply to medical conditions as covered under this policy. 2 A. Subjec tMo l ec ul ar Diagnostic Tes ti ng fo r Res p irato ry Vi r us OHIO MEDICARE ADVANT AG EPY-0880 Effec ti v e Date: 01/01/2021Molecular Dia gn os tic Testing for Respiratory Viru s B. Bac k groundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies ar e not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accura te and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply an y right to reimbursement or guarantee claims payment. Molecular testing, f ollowing a diagnosis or suspected dia gnosis can help guide appropriate therapy by identif ying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplif ication technique t h at only requires s mall quantities of DNA, f or example, 0.1 mg of DNA f rom a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplif ied, is a prerequisite to a successf ul PCR amplif ication of DNA. Molecular Diagnostic testing f or the respiratory viruses known as Adenovirus, Influenza Virus, Coronavirus, Metapneumovirus, Parainf luenza Virus, Respiratory Syncytial Virus (RSV) an d Rhinovirus c an be utilized in the presence of symp t o ms such as cough, fever, headache, f atigue, rhinorrhea, pharyngitis and a general unwell f eeling, that would c r e at e a clinical picture of a respiratory virus. Molecular Diagnostic testing f or respiratory viruses is not indicated f or every patient that presents with these signs and symptoms, as treatment is generally the same f or all of the viruses and resolve with little to no pharmacological treatment, except in immunocompromised patients. All f acilities in the United States that per f orm laboratory testing on human specimens f o r health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA f or home use and those tests approved f or waiver under the CLIA criteria. Although CLIA r e q uir es t h at waiv e d tests must be simple and have a low risk f or erroneous results, this does not mean that waived tests are completely error-pr o of . CareSource may peri odically require r e v iew of a providers office testing policies and procedures when performing CLIA-waived tests.3 C. Def initionsMo l ec ul ar Diagnostic Tes ti ng fo r Res p irato ry Vi r us OHIO MEDICARE ADVANT AG EPY-0880 Effec ti v e Date: 01/01/2021Polymerase Chain Reaction (PCR) – a genetic amplif ication technique als o known as a Nucleic Acid Amplif ication Test (NAAT). D. Polic yI. Prior authorization is required for the Mo lec u lar Diagnostic Tes t in g by PCR addressed in this policy. A. Documentation mu st be submitted with the prior authorization indicating t h at the lower cost test was perf ormed and a negative result was conf irmed. II. Conventional testing, such as r ap id antigen direct tests, direct f luorescent an t ibody testing and cultures, are viewed as low cost and mu st be utilized bef ore t h e h igher cost Molecular Diagnostic Testing by PCR. E. Conditions of Cov erageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Ple as e ref er to the individual f ee schedule f or appropriate codes. F. Related Polic ies/RulesG. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 12/01/2019 New p o licyDate Revised 12/02/2020 Up d ated the p rior authorization requirement. Remo v ed CP Tand ICD-10 codes. Up dated d efinitions and ref erenc es. Date Effecti ve 01/01/2021 Date Archived 09/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . H. Ref erenc es1. NREVSS | Ho me | Nat io n al Respiratory an d Enteric Virus Surv System | CDC (2020, November 19). Retrieved 11/20/2020 f rom www.cdc.gov. 2. Polymerase Chain Reaction (PCR) (2017, November 09). Retrieved 11/20/20 f r om www.ncbi.nlm.nih.gov. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANT AGE Policy Name Policy Number Effective Da te Molecular Diagnostic Testing f or Hepatitis Band C PY-0874 02/01/2021-0 9/ 30 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ……………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………….. 2 B. Bac k g r ou nd ……………………………………………………………………………………………………. 2 C. Def initions ……………………………………………………………………………………………………… 3 D. Policy ……………………………………………………………………………………………………………. 3 E. Conditions of Co ve r age…………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………… 4 G. Review/Revision History ……………………………………………………………………………………. 4 H. Ref er en ce s …………………………………………………………………………………………………….. 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding b illin g , coding a nd documentation guidelines. Coding methodology, regulatory requirements, industry-stan dard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of dis ease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Ev idence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to se rv ices 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 t h at a re le ss favorable than the limita tio n s t h at apply to medical conditions as covered under this policy. 2 A. Subjec tMo l ec ul ar Diagnostic Tes ti n g fo r Hep ati ti s Ban d COHIO MEDICARE ADVANT AG EPY-0874 Effec ti v e Date: 02/01/2021Molecular Dia gn os tic Testing for Hepatitis Band C B. Bac k ground Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the ac t u al services provided to a member an d will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accura te and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply an y right to reimbursement or guarantee claims payment. Molecular testing, f ollowing a diagnosis or suspected dia gnosis can help guide appropriate therapy by identif ying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplif ication technique t h at only requires s mall quantities of DNA, f or example, 0.1 mg of DNA f rom a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplif ied, is a prerequisite to a successf ul PCR amplif ication of DNA. Hepatitis Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronically infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-term illness but for 70% 8 5% o f people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) 3 Mo l ec ul ar Diagnostic Tes ti n g fo r Hep ati ti s Ban d COHIO MEDICARE ADVANT AG EPY-0874 Effec ti v e Date: 02/01/2021All f acilities in the United States that perf orm laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA f or home use and those tests approved f or wa iver under the CLIA criteria. Although CLIA r e qu ir es t h at waiv e d tests must be simple and have a low risk f or erroneous results, this does not mean that waived tests are completely error-pr o of . CareSource may periodically require r e v iew of a providers offic e testing policies and procedures when performing CLIA-waived tests.C. Def initionsPolymerase Chain Reaction (PCR) – a genetic amplif ication technique als o known as a Nucleic Acid Amplif ication Test (NAAT). Medically Necessary-Health c ar e services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Polic yI. No Prior Authorization is required for the Mole c u lar Diagnostic Tes t in g by PCR addressed in t his policy. II. CareSource considers Mole c u lar Diagnostic Tes t in g by PCR medically necessary f or Hepatitis Band Cinf ection, when submitted with any combination of the CPT and diagnosis codes listed in the Conditions of Coverage in this policy. III. CareSource does not consider Mo le c ular Diagnostic Testing by PCR f or Hepatitis Ban d Cto be medically necessary when billed with an y other diagnosis code an d will not provide reimbursement for those services. IV. Conventional testing, such as serology or blood tests, ar e viewed as low cost and should be utilized bef ore the higher cost Molecular Diagnostic Testing by PCR.E. Conditions of Cov erage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Ple as e ref er to the individual f ee schedule f or appropriate codes. The following list(s) of codes is provided as a r eference. This list may not be all inclusive and is subject to updates. CPT Code Description 87516 Inf ectious agent detection by nucleic ac id (DNA or RNA); hepatitis B virus, amplif ied probe technique 87517 Inf ectious agent detection by nucleic ac id (DNA or RNA); hepatitis B virus, quantif ication 4 Mo l ec ul ar Diagnostic Tes ti n g fo r Hep ati ti s Ban d COHIO MEDICARE ADVANT AG EPY-0874 Effec ti v e Date: 02/01/202187521 Inf ectious agent detection by nucleic ac id (DNA or RNA); hepatitis C, amplif ied probe technique, includes reverse t r an s c r ipt io n when perf ormed 87522 Inf ectious agent detection by nucleic ac id (DNA or RNA); hepatitis C, quantif ication, includes reverse transcription when performed ICD-10 Code Description B16.0 Acute hepatitis Bwith delta-agent with hepatic co ma B16.1 Acute hepatitis Bwith delta-agent without hepatic co ma B16.2 Acute hepatitis Bwithout delta-agent with hepatic co ma B16.9 Acute hepatitis Bwithout delta-agent an d without h e pat ic co ma B17.0 Acute delta -(super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic co ma B17.11 Acute hepatitis Cwith hepatic co ma B18.0 Chronic v ir al hepatitis Bwith delta-agent B18.1 Chronic v ir al hepatitis Bwithout delta-agent B18.2 Chronic v ir al hepatitis C B18.9 Chronic v ir al hepatitis, unspecified B19.10 Unspecif ied v ir al hepatitis Bwithout hepatic co ma B19.11 Unspecif ied v ir al hepatitis Bwith hepatic co ma B19.20 Unspecif ied v ir al hepatitis Cwithout hepatic co ma B19.21 Unspecif ied v ir al hepatitis Cwith hepatic co ma O98.411 Vir al hepatitis complicating pregnancy, third trimester O98.412 Vir al hepatitis complicating pregnancy, second trimester O98.413 Vir al hepatitis complicating pregnancy, third trimester O98.419 Vir al hepatitis complicating pregnancy, unspecified trimester O98.42 Vir al hepatitis complicating childbirth O98.43 Vir al hepatitis complicating the puerperium F. Related Polic ies/RulesN/A G. Re v iew/Rev ision History DATE ACTIONDate Issued 12/01/2019 New p o licyDate Revised 12/18/2019 09/30/2020 Ad d ition of c ode Z20.5 Remov ed c o d e Z20.5 Date Effecti ve 02/01/2021 Date Archived 09/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uid elines without a f ormal doc umented Policy. H. Ref erenc es 1. Division of Vir al Hepatitis Ho me Pag e | Division of Vir al Hepatitis | CDC. (2019, July 23). Retrieved 7/29/19 f rom www.cdc.gov/hepatitis. 2. License Agreement. (2019, January 15). Retrieved 7/29/19 from www. c ms . g o v / ap p s/ ama/ lic e n s e. as p ?f ile=/ Me dic ar e/ Me dic ar e-Fe e-f or-Se rv i ce-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 5 Mo l ec ul ar Diagnostic Tes ti n g fo r Hep ati ti s Ban d COHIO MEDICARE ADVANT AG EPY-0874 Effec ti v e Date: 02/01/20213. Medically Necessary. (2019, July 29). Retrieved 7/29/19 f r om www.healthcare.gov/glossary/medically-ne c es s ar y/ . The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Trigger Point Injections PY-1093 10/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidenc e of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Trigger Point InjectionsOHIO MEDICARE ADVANTAGEPY-1093 Effective Date: 10/01/2020 2 A. SubjectTrigger Point Injections B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes arelargely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Stud y of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conserva tive treatment ina multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Trigger Point Injections – A trigger point is a hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a sin gle substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. D. Policy I. Trigger Point Injections A. A prior authorization ( PA) is required for each trigger point injection for pain management. B. Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. Trigger Point InjectionsOHIO MEDICARE ADVANTAGEPY-1093 Effective Date: 10/01/2020 3 C. For trigger-point injections of a local anesthetic or a steroid, payment will be mad e for no more than eight dates of service per calendar year per patient. D. Injections may be repeated only with documented positive results to prior trigger point injection of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning and activity tolerance. E. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. F. Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date. G. A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indicat ion on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates Trigger Point Injections Description 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles F. Related Policies/RulesTrigger Point Injections MM-0753 G. Review/Revision History DATE ACTIONDate Issued 12/11/2019Date Revised 06/10 /2020 Annu al Update: No changes Date Effective 10/01/ 2020 Date Archived Trigger Point InjectionsOHIO MEDICARE ADVANTAGEPY-1093 Effective Date: 10/01/2020 4 H. References1. Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule. Retrieved on April 15, 2020 from cms.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Overpayment Recovery PY-1116 09/01/2020-03/31/202 2 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ens ure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services prov ided in a particular case and may modify this Policy at any time. 2 A. SubjectOverpayment Recovery Overp aymen t Reco veryOHIO MEDICARE ADVANTAGE PY-1116 Effective Date: 09/01/2 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or c laims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. Th e inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment f rom providers when an overpayment is identif ied. Fraud, waste and abuse investigations are an exc eption to this policy. In these investigations, the look back period may go beyond 2 years. C. Def initions Overpayment – A payment that exceeds amounts properly payable to a provider. These commonly are discovered during a post-payment review. Examples include but are not limited to incorrect coding, non-covered services, and billing discrepancies. Coordination of benefits (COB) – A payment f rom another carrier that is received af ter a payment f rom CareSource; and the other carrier is the primary insurance for the member. Retroactive eligibility – A payment f or a member who was retroactively terminated f rom CMS. Member is not eligible f or benefits. Improper payment – A payment that shoul d not have been made or an overpayment was made. Examples include but are not limited to payment made f or the ineligible member, ineligible service, payment made f or a service not received, and duplicate payments. D. PolicyI. CareSource will provide all the f o llowing information when seeking recovery of an overpayment made to a provider: A. The name and patient account number of the member to whom the service(s) were provided; B. The date(s) of services provided; 3 C. The amount of overpayment;D. The reason f or the recoupment; and E. That the provider has appeal rights. Overp aymen t Reco veryOHIO MEDICARE ADVANTAGE PY-1116 Effective Date: 09/01/2020 II. Overpayment RecoveriesA. Lookback period is 24 months f rom the claim paid date. B. Advanced notif ication will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely f iling limits, the corrected claim submission timef rame is 60 days f rom the date of the recovery. Normal time ly f iling limits apply to corrected claims being submitted within original claim timely f iling guidelines. III. Coordination of Benefit RecoveriesA. Lookback period is 12 months f rom claim paid date. B. Advanced notif ication will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely f iling limits, the corrected claim submission timef rame is 60 days f rom the date of the recovery. Normal timely f iling limits apply to corrected claims being submitted within original claim timely f iling guidelines. IV. Retro Active Eligibility RecoveriesA. Lookback period is 24 months f rom date CareSource is notif ied by CMS of the updated eligibility status. B. Advanced notif ication will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely f iling limits, the corrected claim submission timef rame is 60 days f rom the date of the recovery. Normal timely f iling limits apply to corrected claims being submitted within original claim timely f iling guidelines. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. F. Related Policies/Rules National Agreement, Article V. CLAIMS AND PAYMENTS, 5.11 (d). G. Review/Revision History DATE ACTION Date Issued 04/29/2020 New policy Date Revised Date Effective 09/01/2020 Date Archived 03/31/202 2 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy 4 H. Ref erencesOverp aymen t Reco veryOHIO MEDICARE ADVANTAGE PY-1116 Effective Date: 09/01/2020 1. Center of Medicare & Medicaid Services. (2008, September 12). Limitation on Recoupment (935) for Provider, physicians and suppliers overpayments. Retrieved January 28, 2020 f rom www.cms.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-108 4 09/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Table of ContentsRei mbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sacro iliac Jo in t Pro ced uresOHIO MEDICARE ADVANTAGEPY-1084 Effective Date: 09/01/2020 2 A. SubjectSacroiliac Joint Procedures B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or q ualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-servi ce channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code in this policy does n ot imply any right to reimbursement or guaranteeclaims payment.Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be ef f ective for diagnostic purposes , but provide limited short-term relieff rom pain resulting f rom SI joint dysf unction.C. Def initions Sacroiliac Joint Injections – corticosteroid and local anesthetic the rapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies . Radiofrequency Facet Ablation (RFA) – is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required f or each sacroiliac joint procedure for pain management. Documentation, including dates of service, f or conservative therapies are not required f or PA, but must be available upon request. B. Sacroiliac Joint Injection Codes 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together C. Sacroiliac Joint Injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic ef f ect, repeating no more than once every seven (7) days and with at least a 75% or > reduction in pain af ter the f irst injection. 2. Once the diagnostic injections are perf ormed and the diagnosis is established, two (2) therapeutic injections per joint may be perf ormed over a rolli ng 12 month period. Sacro iliac Jo in t Pro ced uresOHIO MEDICARE ADVANTAGEPY-1084 Effective Date: 09/01/2020 3 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of f our (4) injections (including both diagnostic and therapeutic) per joint in a rolling 12 months.D. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately. E. If neural blockade is applied f or dif ferent regions, or different sides, injections are perf ormed at least one week apart. F. Initial Radiof requency Ablation of the SI Joint 1. A maximum of one (1) radiof requency ablation f or SI Joint pain per side per rolling twelve (12) months when CareSource medical policy MM-0010 clinical criteria has been met. G. Repeat Radiof requency Ablation of the SI Joint 1. Conservative therapy and diagnostic injections are not required if there has been a reduction in pain f or at least twelve (12) months or more f rom the initial RFA within the last thirty-six (36) months. 2. When there has not been a repeat RFA in the last thirty-six (36) months, a diagnostic injection is required. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, i f applicable . Please ref er to the individual f ee schedule f or appropriate codes. The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac JointProceduresDescription 27096 Injection procedure f or sacroiliac joint, anesthetic/steroid, with image guidance (f luoroscopy or CT) including arthrography when perf ormed 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography 64625 Radiof requency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography) G0260 Injection procedure f or sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography F. Related Policies/Rules Sac roiliac Joint Procedures MM-0776 Sacro iliac Jo in t Pro ced uresOHIO MEDICARE ADVANTAGEPY-1084 Effective Date: 09/01/2020 4 G. Review/Revision HistoryDATE ACTIONDate Issued 12/11/2019Date Revised 05/13/2020 Revised to add coverage f or ablation of the SI Joint; added codes: 64451 64625 G0260 Date Effective 09/01/2020 Date Archived 05/31/2021 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f o llow CMS/State/NCCI g uidelines without a formal d o cumented Policy. H. Ref erences 1. Centers f or Medicare and Medicaid Services (CMS) Physician Fee Schedule. Retrieved on April 15, 2020 f rom cms.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Hepatitis Band CPY-08 74 12/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICARE ADVANTAGE PY-08 7 4 Effective Date: 12/01/2019 2 A. Subject Molecular Diagnostic Testing for Hepatitis Band CB. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or quali fications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service c hannels 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 i mply any right to reimbursement or guarantee claims payment. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Mol ecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time . Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis trans mitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronically infected, compared with 2% 6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-term illness but for 70% 85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection beca use they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) All facilities in the United States that perform laboratory te sting on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and th ose tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require r eview of a providers office testing policies and procedures when performing CLIA-waived tests. Archived Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICARE ADVANTAGE PY-08 7 4 Effective Date: 12/01/2019 3 C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-He alth care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Condit ions of Coverage in this policy. III. CareSource does not consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers fo r Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification 87521 Infectious agent detection by nucleic acid (D NA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed ICD-10 Code Description B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwithout hepatic coma Archived Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICARE ADVANTAGE PY-08 7 4 Effective Date: 12/01/2019 4 B17.11 Acute hepatitis Cwith hepatic coma B18.2 Chronic viral hepatitis CB18.9 Chronic viral hepatitis, unspecified B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis compli cating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium Z20.5 Conta ct with and (suspected) exposure to viral hepatitis F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 12/01/2019 New Policy Date Revised 1 2/18/2019 A ddition of code Z20.5 Date Effective 12/01/2019 Date Archived H. References 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (201 9 , July 2 3 ). Retrieved 7/29/19 from www.cdc.gov/hepatitis. 2. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Paym ent/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 3. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increa sed or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainl y 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/o r 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 b etween this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in int erpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Trigger Point Injections PY-1093 04/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. …………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. . 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 A. SubjectTrigger Point Injections Trigger Point InjectionsOHIO MEDICARE ADVANTAGE PY-1093 Effective Date: 04/01/2020 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclus ion of a code inthis policy does not imply any right to reimbursement or guarantee claims payment.Nearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largelyfavorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorpor ates conservative treatment in a multimodalityapproach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. DefinitionsTrigger Point Injections: A trigger point is a hyper excitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the sympt om but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. D. Pol icyI. Trigger Point Injections A. A prior authorization (PA) is required for each trigger point injection for pain management. B. Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. C. Injections may be repeated only with documented positive results to prior trigger point injections of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning and activity tolerance. D. Localization techniques to image or otherwise identify t rigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. 2 Trigger Point InjectionsOHIO MEDICARE ADVANTAGE PY-1093 Effective Date: 04/01/2020 E. Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate proced ure code reported on a claim for service rendered to a particular patient on a particular date. F. A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS Physicians Fee Schedule for appropriate codes. The followi ng list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Trigger Point InjectionsDescription 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles F. Related Policies/RulesTrigger Point Injections MM-0753 G. Review/Revision HistoryDATE ACTIONDate Issued 12/11/2019Date Revised N/A Date Effective 04/01/2020 Date Archived 10/01/2020 H. References1. CMS Physicians Fee Schedule. (n.d.). Retrieved November 8, 2019, from https:// www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. 3
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