REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1084 04/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement 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 lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Sacroiliac Joint Procedures OHIO MEDICARE ADVANTAGE PY-1084 Effective Date: 04/01/2020 2 A. Subject Sacroiliac 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 clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long-term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Sacroiliac Joint Procedures: corticosteroid and local anesthetic therapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required for each sacroiliac joint injection for pain management. Documentation, including dates of service, for conservative therapies are not required for PA, but must be available upon request. B. Sacroiliac joint injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic effect, repeating no more than once every seven (7) days and with at least a 75% or > reduction in pain after the first injection. 2. Once the diagnostic injections are performed and the diagnosis is established, two (2) therapeutic injections per joint may be performed over a 12-month period. 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of four (4) injections (including both diagnostic and therapeutic) per joint in 12 months. Sacroiliac Joint Procedures OHIO MEDICARE ADVANTAGE PY-1084 Effective Date: 04/01/2020 3 C. Radiofrequency Facet Ablation for Sacroiliac Pain 1. Thermal or pulsed, cooled neurotomy by Radiofrequency Facet Ablation (RFA) or other techniques for sacroiliac pain are NOT covered. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS Physicians 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. Sacroiliac Joint Procedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed F. Related Policies/Rules Sacroiliac Joint Procedures MM-0776 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 04/01/2020 Date Archived H. References 1. 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.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Positive Airway Pressure Devices for Pulmonary Disorders PY-085 0 04/01/2020-04/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, 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. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject ………………………………………………………………………………………………………………….. 2 B. Background ……………………………………………………………………………………………………………. 2 C. Definitions ……………………………………………………………………………………………………………… 2 D. Policy ……………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules …………………………………………………………………………………………….. 4 G. Review/Revision History ………………………………………………………………………………………….. 4 H. References ……………………………………………………………………………………………………………. 4 Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICARE ADVANTAGE PY-0850 Effective Date: 04/01/20202A. Subject Positive Airway Pressure Devices for Pulmonary Disorders B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submit ting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to treat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bi-level or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulmonary disease (COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome. C. Definitions Adherence-is defined as the use of a PAP device for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial usage. Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. D. Policy I. CareSource requires a prior authorization for PAP machines (CPAP/BiPAP). A. CPAP (E0601) and BiPAP (E0470, E0471 and E0472) machines are a 13 month rent to purchase. CareSource prior authorizations are for 3 months initial rental for PAP machines. B. After initial 3 months rental, providers must submit documentation for continued rental that shows the members adherence with the use of the PAP machine during the first 3 months of use. Prior authorization may be obtain for the remaining rental period (months 4-13). C. CareSource follows Centers for Medicare & Medicaid Serv ices (CMS) guidelines for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea for medical necessity determination. II. Providers that dispense the PAP machine must ensure and document the members adherence with its use. Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICARE ADVANTAGE PY-0850 Effective Date: 04/01/20203A. CareSource considers adherence with the use of PAP as the following: 1. In accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines, adherence is defined as the use of a PAP device for 4 or more hours per night on 70% of nights du ring a consecutive 30-day period anytime during the first 3 months of initial usage. 2. If there is a discontinuation of use at any time, the PAP supplier is expected to ascertain adherence and stop billing for the equipment, related accessories and supplies. III. When lack of adherence of a PAP machine is confirmed, further rental and providers claims will be denied. A. Any reimbursement, for the PAP machine, that was dispensed during the time of non-adherence will be recouped by CareSource. B. Any reimbursement, for the supplies, that were dispensed during the time of non-adherence will be recouped by CareSource. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers , if applicable. 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 A4604 Tubing with integrated heating element for use with positive airway pressure device A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each A7028 Oral cushion for combination oral/nasal mask, replacement only, each A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair A7030 Full fac e mask used with positive airway pressure device, each A7031 Face mask interface, replacement for full face mask, each A7032 Cushion for use on nasal mask interface, replacement only, each A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Headgear used with positive airway pressure device A7035 Headgear used with positive airway pressure device A7036 Chinstrap used with positive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, nondisposable, used with positive airway pressure device A7044 Oral interface used with positive airway pressure device, each A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Positive Airway Pressure Devices for Pulmonary Disorders OHIO MEDICARE ADVANTAGE PY-0850 Effective Date: 04/01/20204E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasi ve interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) E0561 Humidifier, non-heated, used with positive airway pressure device E0562 Humidifier, heated, used with positive airway pressure device E0601 Continuous positive airway pressure (CPAP) device Modifiers Description RR Rental (use the RR ‘ modifier when DME is to be rented) NU New equipment (use the NU modifier when DME is purchase d) F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 04/01/2020 New policyDate Revised Date Effective 04/01/2020 Date Archived 04/30 /2021 This Po licy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H. References 1. CPAP-NHLBI, NIH. (2019 , July 29). Retrieved 7/ 29/19 from https://www.nhlbi.nih.gov/health-topics/cpap. 2. DME19-A. (2019, February 5). Retrieved 7/29/19 from https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME19-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSort Dir=descending 3 . Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstru ctive Sleep Apnea (L33718) (2019, January 1). Retrieved 7/ 29/19 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33718&ver=16&SearchType=Advanced&CoverageSelection=Local&Artic leType=SAD%7cEd&PolicyType=Both&s=42&KeyWord=Positive+Airway+Pressure+(PAP)+Devices+for+the+Treatment+of+Obstructive +Sleep+Apnea&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA& 4 . Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/ . 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 STATEMENT OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Glycosylated Hemoglobin A1C PY-0162 03/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement 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 lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Glycosylated Hemoglobin A1C OHIO MEDICARE ADVANTAGE PY-0162 Effective Date: 03/01/2020 2 A. Subject Glycosylated Hemoglobin A1C B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Glycated hemoglobin/protein testing is widely accepted as medically necessary for the management and control of diabetes. Glycosylated hemoglobin A1C/protein levels are used to determine long-term glucose control in diabetes. Glycosylated hemoglobin levels reflect the average level of glucose in the blood over a three-month period. C. Definitions Glycosylated Hemoglobin (A1C) a blood test that measures your average blood sugar levels over the past 3 months. It is one of the commonly used tests to diagnose prediabetes and diabetes. Glycated protein-a blood test that is used to assess glycemic control over a period of 1-2 weeks and long-term control in diabetic patients with abnormalities of erythrocytes. D. Policy I. Prior authorization is not required for participating providers for glycosylated hemoglobin (A1C)/protein blood testing. Note: Although CareSource does not require a prior authorization for glycosylated hemoglobin (A1C)/protein blood testing, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II. CareSource considers screening for the diagnosis of diabetes as medically necessary preventive care for the following member groups according to the United States Preventive Services Task Force (USPSTF): A. Asymptomatic members age 40 to 70 years who are overweight or obese B. Asymptomatic members of any age or weight who are in the following high-risk groups: 1. Immediate family history of diabetes 2. History of gestational diabetes or polycystic ovarian syndrome 3. African Americans 4. Native Americans 5. Alaskan Natives 6. Asian Americans Glycosylated Hemoglobin A1C OHIO MEDICARE ADVANTAGE PY-0162 Effective Date: 03/01/2020 3 7. Hispanics and Latinos 8. Native Hawaiians 9. Native Pacific Islanders C. Asymptomatic pregnant women who have reached 24 weeks of gestation. III. CareSource considers diagnostic testing for the management of diabetes as medically necessary for the following member groups, with the specified frequencies: A. Members whose diabetes is controlled, once every 3 months B. Members whose diabetes is not controlled may require testing more than four times a year C. Pregnant women, once per month Note: CareSource may request documentation to support medical necessity, if testing is in excess of the above guidelines. IV. Alternative testing, including glycated protein, for example, fructosamine, may be indicated for monitoring the degree of glycemic control. A. It is therefore conceivable that a patient will have both a glycated hemoglobin and glycated protein ordered on the same day. B. This should be limited to the initial assay of glycated hemoglobin, with subsequent exclusive use of glycated protein. C. These tests are not considered to be medically necessary for the diagnosis of diabetes. V. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the CPT code listed within this policy. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes and the appropriate modifiers, if applicable. 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 82985 Glycated protein 83036 Hemoglobin; glycosylated (A1C) ICD-10 Description D13.7 Benign neoplasm of endocrine pancreas E08. Diabetes mellitus due to underlying condition with (Any ICD-10 starting with E08.) E09. Drug or chemical induced diabetes mellitus with (Any ICD-10 starting with E09.) E10. Type 1 diabetes mellitus with (Any ICD-10 starting with E10.) E11. Type 2 diabetes mellitus with (Any ICD-10 starting with E11.) E13. Other specified diabetes mellitus with (Any ICD-10 starting with E13.) E15 Nondiabetic hypoglycemic coma E16.0 Drug-induced hypoglycemia without coma E16.1 Other hypoglycemia E16.2 Hypoglycemia, unspecified E16.3 Increased secretion of glucagon E16.8 Other specified disorders of pancreatic internal secretion E16.9 Disorder of pancreatic internal secretion, unspecified Glycosylated Hemoglobin A1C OHIO MEDICARE ADVANTAGE PY-0162 Effective Date: 03/01/2020 4 E31.0 Autoimmune polyglandular failure E31.1 Polyglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E31.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E74.8 Other specified disorders of carbohydrate metabolism E79.0 Hyperuricemia without signs of inflammatory arthritis and tophaceous disease E83.10 Disorder of iron metabolism, unspecified E83.110 Hereditary hemochromatosis E83.111 Hemochromatosis due to repeated red blood cell transfusions E83.118 Other hemochromatosis E83.119 Hemochromatosis, unspecified E83.19 Other disorders of iron metabolism E88.02 Plasminogen deficiency E89.1 Postprocedural hypoinsulinemia H44.2E1 Degenerative myopia with other maculopathy, right eye H44.2E2 Degenerative myopia with other maculopathy, left eye H44.2E3 Degenerative myopia with other maculopathy, bilateral eye I21.9 Acute myocardial infarction, unspecified I21.A1 Myocardial infarction type 2 I21.A9 Other myocardial infarction type K86.0 Alcohol-induced chronic pancreatitis K86.1 Other chronic pancreatitis K91.2 Postsurgical malabsorption, not elsewhere classified L97. Non-pressure chronic ulcer of other part of (Any ICD-10 starting with L97.) L98.415 Non-pressure chronic ulcer of buttock with muscle involvement without evidence of necrosis L98.416 Non-pressure chronic ulcer of buttock with bone involvement without evidence of necrosis L98.418 Non-pressure chronic ulcer of buttock with other specified severity L98.425 Non-pressure chronic ulcer of back with muscle involvement without evidence of necrosis L98.426 Non-pressure chronic ulcer of back with bone involvement without evidence of necrosis L98.428 Non-pressure chronic ulcer of back with other specified severity L98.495 Non-pressure chronic ulcer of skin of other sites with muscle involvement without evidence of necrosis L98.496 Non-pressure chronic ulcer of skin of other sites with bone involvement without evidence of necrosis O24. Pre-existing type 1 diabetes mellitus, in pregnancy (Any ICD-10 starting with O24.) O30. Pregnancy(Any ICD-10 starting with O30.) O99.810 Abnormal glucose complicating pregnancy O99.815 Abnormal glucose complicating the puerperium R73.01 Impaired fasting glucose R73.02 Impaired glucose tolerance (oral) R73.03 Prediabetes R73.09 Other abnormal glucose R73.9 Hyperglycemia, unspecified R78.71 Abnormal lead level in blood R78.79 Finding of abnormal level of heavy metals in blood Glycosylated Hemoglobin A1C OHIO MEDICARE ADVANTAGE PY-0162 Effective Date: 03/01/2020 5 R78.89 Finding of other specified substances, not normally found in blood R79.0 Abnormal level of blood mineral R79.89 Other specified abnormal findings of blood chemistry R79.9 Abnormal finding of blood chemistry, unspecified T38.3X1A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter T38.3X2A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, intentional self-harm, initial encounter T38.3X3A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, assault, initial encounter T38.3X4A Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, undetermined, initial encounter Z00.00 Encounter for general adult medical examination without abnormal findings Z00.01 Encounter for general adult medical examination with abnormal findings Z01.812 Encounter for preprocedural laboratory examination Z13.1 Encounter for screening for diabetes mellitus Z13.9 Encounter for screening, unspecified Z79.3 Long term (current) use of hormonal contraceptives Z79.4 Long term (current) use of insulin Z79.84 Long term (current) use of oral hypoglycemic drugs Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.31 Personal history of diabetic foot ulcer Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 03/01/2020 Date Revised Date Effective 03/01/2020 New policy Date Archived H. References 1. Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. (2015, October). Retrieved 8/29/2019 from https://www.uspreventiveservicestaskforce.org/Page/Document/Update SummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=diabetes. 2. Centers for Medicare and Medicaid Services. (2019). NCD 190.21-Glycated Hemoglobin/Glycated Protein (190.21). 3. Gestational Diabetes Mellitus, Screening. (2014, January). Retrieved 8/29/2019 from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/gestatio nal-diabetes-mellitus-screening?ds=1&s=diabetes. 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 PLANS Policy Name Policy Number Effective Date Robotic-Assisted Surgery PY-0952 03/01/2020-05/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ……………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………….. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 3 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 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, regulato ry requir ements, 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, dysfuncti on of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medicall y 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 en sure 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. SubjectRobotic-Assisted Surgery Ro bo tic-Assisted Surg eryOHIO MEDICARE ADVANTAGE PLANS PY-0952 Effective Date: 3/1/2020 B. Background Reimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are no t a g uarantee of p ayment. Reimbursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be determined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a code in this p o licy does no t imply any right to reimbursement o r guarant ee claims p ayment. Ro b o t-assisted surgery involves the use of a robot and computer technology under the direction and g uid ance of a surgeon. These surg eries are minimally invasive p rocedures using robotic d evices d esigned to access surgical locations thro ugh smaller incisions or ports. There surg eries are g enerally p erformed using a wo rkstation console containing remote controls for the surg ical instruments as well as a computer equipped with a three-dimensional magnified video monitor of the surg ical site through use of miniature cameras. The p rimary d ifference between ro botic and co nventional laparoscopic procedures is that the surgical instrume nts are manipulated indirectly thro ug h computer controls rather than manually by the surgeon. The ro b otic contro ls allow the surg ical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar f ashion as would be done in an o pen p rocedure. Examples of robotic surgical systems includ e the d a Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Ro botic Surgical System (Computer Motion, Inc.) C. Def initions Robotic Assisted Surgery – is def ined as the perf ormance of operative procedures with the assistance of robotic technology. D. PolicyI. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modif ier 22 (increased procedural services):1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased dif ficulty of procedures, or severity of patients conditi on a. These complications and their reasons must be supported by proper documentation. 3 Conditions of CoverageRo bo tic-Assisted Surg eryOHIO MEDICARE ADVANTAGE PLANS PY-0952 Effective Date: 03/01/2020 Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modif iers. Please ref er to the (CMS) fee schedule f or appropriate codes. E. Related Policies/RulesF. Review/Revision HistoryDATE ACTIONDate Issued 03/01/2020 New Po licyDate Revised Date Effective 03/01/202 0 Date Archived 05/31/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same 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 G. Ref erences1. Ro b o tic surgery. MedLine Plus Web site. http ://www.nlm.nih.gov/medlineplus/ency/article/007339.htm . Published May 2013. Accessed Octo ber 8, 2019. 2. Centers f o r Medicare and Medicaid Services, CMS Manual System and other CMS p ub lications and services; http ://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#To pOfPage 3. Ohio Dep artment of Medicaid http://jfs.ohio.gov/ 4. Centers f o r Medicare and Medicaid Services, Healthcare Co mmon Procedure Coding System, HCPCS Release and Code Sets http ://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#To pO fPage 5. Daniel M. Herro n, MD. A consensus Document o n Robotic Surgery. Prepared by the SAGES – MIRA Ro b o tic Surgery Co nsensus g roup. Position Papers/ Statement p ublished o n: 11/2007. Accessed October 8, 2019. Available at URL ad dress: http ://www.sages.org/publications/guidelines/consensus-document-robotic-surgery/ Th is g uid eline co ntains custo m co nten t th at h as been mo d ified fro m th e stan d ard care g uid elin es an d h as not been reviewed o r ap p ro ved by MCG Health , LLC. 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 Reimbursement Modifiers PY-0716 09/01/2019 – 03/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. … 10 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …. 10 G. Review/Revision History ………………………….. ………………………….. ………………………….. .. 10 H. Ref erences ………………………….. ………………………….. ………………………….. ………………… 10 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, illne ss, 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 C overage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectReimbursement Modifiers Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 B. BackgroundReimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are not a g uarantee of payment. Reimb ursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use self-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the product or service that is b eing p rovided. The inclusion of a code in this p o licy does not imply any right to reimbursement o r guarantee claims p ayment. Mo d ifiers can b e used to further describe a product o r service rendered. Some modifiers are for inf o rmational purposes o nly, while other modifiers are used to report additional information, to the co d e d escription, of the p roduct o r servic e. Although CareSource accepts the use of modifiers sp ecific to this policy, no t all modifiers are included within this p olicy. The mo difiers included within this p olicy are tho se modifiers that affect the reimbursement of a service. Using a mo difier inap p ro priately can result in the denial of a claim or an incorrect reimbursement for a p roduct o r service. CareSource may verify the use of any modifier thro ugh post-payment audit. All inf o rmation regarding the use of these modifiers must b e made availabl e up on CareSources req uest. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. C. Def initions Current Procedural Terminology (CPT) – codes that are issued, upda ted and maintained by the American Medical Association (AMA) that provides a standard language for coding and b illing medical services and p rocedures. Healthcare Common Procedure Coding System (HCPCS) – codes that are issued, up d ated and maintained b y the American Medical Association (AMA) that p rovides a stand ard language for coding and b illing of products, supplies, and services not included in the CPT co d es. Modifier – two-character codes used along with a CPT o r HCPCS code to p rovide additional inf o rmation about the service o r supply rend ered. D. PolicyI. Modifier 22 – Increased Pro cedural Services A. Mo d ifier 22 is used to report services (surgical or no nsurgical) when the wo rk req uired to p ro vide a service is substantially g reater than typically req uired. The extra wo rk may be id entified by appending modifier 22 to the usual procedure code. B. Pro ced ure codes with modifier 22 ap pended may b e reimbursed up to 120% of the fee sched ule amount. Note: This mo d ifier is not ap pended to E/M services (99201-99499). Claims for 99201-99499 with mo d ifier 22 will be denied. Medical records ARE required with the 3 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 claim and must support the use of this modifier. Claims with p rocedures including 22 and no sup porting d ocumentation will be denied. II. Modifier 50 – Bilateral Pro ceduresA. Pro f essional Claims Only Append modifier 50 to the appropriate unilateral code on a sing le claim line and indicate 1 unit in the unit field of that claim line. B. Mo d ifier 50 ap plies to surgical procedures (CPT codes 10040-69990) and to rad iology p ro cedures performed bilaterally. C. Ap p lies to any b ilateral p rocedure p erformed on both sides at the same session. D. The use of modifier 50 is NOT ap propriate in the following situations: 1. Using mo difier 50 o n a bilateral p rocedure performed on different areas of the right and lef t sides of the body. 2. Ap p ending modifier 50 to a procedure code that is defined b y CPT as p rimarily b ilateral or a b ilateral service. 3. Ap p ending modifier 50 to a surgical CPT code, the d escription of which contains the wo rd s o ne or b oth. E. Do no t report two line items to ind icate a b ilateral p rocedure. F. Pro ced ure code with modifier 50 ap pended will reimburse 1 unit at 150% of the fee sched ule amount. III . Modifier 51 – Multiple Pro ceduresA. Mo d ifier 51 is used to report multiple procedures, other than E/M services, are p erformed at the same session b y the same ind ividual, the p rimary p rocedure o r service is reported as listed . B. The ad d itional procedure(s) or service(s) may b e identified b y appending modifier 51 to the ad d itional p rocedure or service code(s). C. Mo d ifier 51 should not be appended to designated “add-on” codes. D. Pro ced ure code with modifier 51 ap pended will reimburse 50% of the fee listed on the Med icaid Physician Fee Schedule for the service. IV . Modifier 52 – Red uced servicesA. Und er certain circumstances a service or pro cedure is partially reduced or eliminated at the d iscretion of the p hysician or other qualified health care p rofessional. 1. Mo d ifier 52 is used for reporting reduced services when the procedure was terminated after the patient was prepped and bro ught to the ro om where the service was to be p erformed. B. Mo d ifier 52 may be used to report reduced radiology procedures. 1. The co rrect reporting is to assign the CPT code to the extent of the procedure p erf ormed. 2. This mo d ifier is used o nly to rep ort a rad iology procedure that has been red uced when no o ther co de exists to report what has been done. 3. Rep o rt the intended code with modifier 52. i. Examp le, if the planned p rocedure is a two-view chest x-ray and only one view of the chest is p erformed, d o not rep ort CPT co de 71020-52 (for x-ray chest, two views-red uced service). Instead, rep ort CPT code 71010 (x-ray che st, single view). ii. Examp le, if a barium swallow is not completed because the patient cannot handle the b arium, rep ort CPT co de (74270-52). C. Mo d ifier 52 d oes no t provide for reimbursement of an ineligible service. D. Fo r ho spital o utpatient reporting of a p reviously scheduled pro cedure/service that is p artially red uced or cancelled as a result of extenuating circumstances o r those that threaten the well-b eing of the p atient p rior to or after administration of anesthesi a, see mo d ifiers 73 and 74. E. Pro ced ure code with modifier 52 ap pended will reimburse at 50% of the fee schedule amo unt. 4 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 Note: Med ical records are no t required with the claim, but must be available up on CareSo urces request. Clinical information d ocumented in the patient’s records must support to use of this modifier. The extenuating circumstances preventing the co mpletion of the procedure must also b e documented V. Modifier 53 – Disco ntinued ProcedureA. Und er certain circumstances, the p hysician or o ther qualified health care p rofessional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances o r those that threaten the well-b eing of the patient, it may b e necessary to indicate that a surgical or d iagnostic p rocedure was started b ut d iscontinued after anesthesia is administered to the p atient. 2. Mo d ifier 53 is used to ind icate that the physician terminated a surgical/diagnostic p ro cedure d ue to the p atients well-b eing. B. This mo d ifier is not used to rep ort an elective cancellation of a p rocedure p rior to the p atient’s anesthesia induction and/or surgical preparation in the operating suite. C. Mo d ifier 53 cannot be used when a laparo scopic or end oscopic procedure is converted to an o p en pro cedure. D. Mo d ifier 53 does not pro vide for reimbursement of an ineligible service. E. Mo d ifier 53 cannot be ap pended to E/M codes. F. Fo r o utp atient ho spital/ambulatory surgery center (ASC) reporting of a previously sched uled pro cedure/service that is partially red uced or cancelled as a result of extenuating circumstances or those that threaten the well-b eing of the patient prior to or af ter ad ministration of anesthesia, see modifiers 73 and 74. G. Pro ced ure code with modifier 53 ap pended will reimburse at 25% of the fee schedule amo unt. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical inf ormation documented in the patient’s records must sup port to use of this modifier. Documentation must include a statement ind icating at what point the pro cedure was d iscontinued. The extenuating circumstances preventing the completion of the p rocedure must also be d o cumented. VI. Modifier 54 – Surgical Care OnlyA. Mo d ifier 54 is reported when o ne physician p erformed a surgical pro cedure only; ano ther p hysician provides the preoperative and/or postoperative management. B. Mo d ifier 54 must o nly be appended to the surgical procedure code. C. Pro ced ure code with modifier 54 ap pended will reimbursed at 70% of the fee schedule amo unt. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. VII . Modifier 55 – Po stoperative Management OnlyA. Mo d ifier 55 is rep orted when 1 p hysician or o ther q ualified health care professional p erf ormed the postoperative management and another performed the surgical p ro cedure, the postoperative component may be id entified by appending modifier 55 to the p ro cedure code. B. Mo d ifiers 55 must only be appended to the surgical procedure code. C. Pro ced ure code with modifier 55 ap pended will reimburse at 15% of the fee schedule amo unt. 5 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 Note: Med ical records are no t required with the claim, but must be available up on CareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. VII I. Modifier 56 – Preo p erative Management OnlyA. Mo d ifier 56 is rep orted when 1 p hysician performed the preoperative care and evaluatio n and another physician p erformed the surgical procedure. Modifier 56 is ap p end ed to the surgical code. B. Mo d ifiers 56 must only be appended to the surgical procedure code. C. Pro ced ure code with modifier 56 ap pended will reimburse at 15% of the fee schedule amo unt. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. IX . Modifier 62 – Two Surg eonsA. Mo d ifier 62 is rep orted when 2 surg eons work together as primary surgeons performing d istinct part(s) of a p rocedure. 1. Each surg eon must rep ort his/her distinct o perative wo rk by adding the modifier 62 to the p ro cedure code and any associated add-on codes(s) for that p rocedure as long as b o th surgeons continue to work together as primary surgeons. 2. Each surg eon must rep ort the co-surg ery once using the same procedure code. If ad d itional procedure(s), includi ng add-o n procedures(s) are p erformed d uring the same surg ical session, separate code(s) may also b e reported without the modifier 62 ad d ed . 3. If a co-surg eon acts as an assistant in the p erformance of additional pro cedure(s) d uring the same surgical session , those services may be reported using separate p ro cedure code(s) with the modifier 80 or 82 ad ded, as ap propriate. B. Pro ced ure code with modifier 62 ap pended will b e reimbursed at 62.5% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s reco rds must sup port to use of this mo difier. X. Modifier 66 – Surg ical TeamA. Mo d ifier 66 is rep orted when three o r more surgeons wo rk together d uring a highly co mp lex procedure are carried out und er the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of mo d ifier 66 to the b asic procedure code used for rep orting services. B. Claims sub mitted by team surgeons are id entified with modifier 66. C. The Centers f o r Medicare & Medicaid Services (CMS) established a Team Surgery Ind icato r (TEAM SURG) found in the CMS National Physician Fee Schedule Relative Value File. Values are: 1. 0-Team surg eo ns not permitted for this procedure. 2. 1-Team surg eo ns may be paid; supporting documentation is req uired to establish med ical necessity. 3. 2-Team surg eo ns permitted. 4. 9-Team surg eo n concept does not apply. D. Co d es with CMS Team Surgery Ind icators of 0 and 9 sh ould not be billed with modifier 66. E. Mo d ifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate p ro cedure no t included in the team surgery. 6 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 F. Only o ne surg eon maybe be considered the primary surgeon. CareSource will not reimb urse p rocedures when two surgeons each bill o ne side of bilateral surgery as the p rimary surgeon. G. Each p hysician participating in the surgical team must bill the ap plicable procedure co d e(s) for their ind ividual services with Modifier 66. H. Pro ced ure code with modifier 66 ap pended will reimburse at 150% of the established fee, d ivid ed equally between the team surgeons. I. Fo r team surg ery with three surg eons, each surgeon will be reimbursed at 50% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. XI. Modifier 73 – Discontinued Outpatient Ho spital/Ambulatory Surg ery Center (ASC) ProcedurePrior to the Administration of Anesthesia A. Mo d ifier 73 is rep orted to a service to indicate that due to extenuating circumstances o r tho se that threaten the well-being of the patient, a surgical or d iagnostic p rocedure at an o utp atient hospital o r ambulatory surgical center (ASC) was d iscontinued prior to the ad ministration of anesthesia. B. Mo d ifier 73 is o nly appropriate for use by an ASC. C. Mo d ifier 53 should not be used for any ASC service as the modifier is used exclusively on a p ro fessional claim. D. Pro ced ure code with Modifier 73 ap pended will reimburse at 50% of the ASCs fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. XII . Modifier 74 – Discontinued Outpatient Ho spital/Ambulatory Surgery Center (ASC) ProcedureAfter Ad ministration of Anesthesia A. Mo d ifier 74 is rep orted when d ue to extenuating circumstances or those that threaten the well-b eing of the p atient, the physician may terminate a surgical or d iagnostic procedure after the ad ministration of anesthesia or after the p rocedure was started (incision made, intub ation started, scope inserted.) B. Mo d ifier 74 is not ap propriate for the elective cancellation or p ostponement of a p ro cedure based on the p hysician or patients choice. C. Mo d ifier 74 is not ap propriate when the termination of the procedure occurs prior to the b eg inning of the procedure or the administration of anesthesia. D. Mo d ifier 74 is no t for physician use. It is only appropriate for the ASC. E. Pro ced ure code with modifier 74 ap pended will b e reimbursed at 100% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this mo difier. XII I. Modifier 78 – Unp lanned Return to the Op erating/Procedure Ro om by the Same Physician orOther Qualif ied Health Care Professional Following Initial Procedure for a Related Pro cedure During the Postoperative Period A. Mo d ifier 78 is reported to indicate that another pro cedure was p erformed during the p o stoperative period of the initial pro cedure (unplanned procedure following initial p ro cedure). 7 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 1. When this p ro cedure is related to the first, and requires the use of an o p erating/procedure room, it may be reported by adding modifier 78 to the related p ro cedure. 2. Mo d ifier 78 should be appended when: i. The return to the o perating room is unplanned. ii. The service is performed by same physician who p erformed the initial p ro cedure. iii. The service is related to the initial procedure. i v . The service is p erformed during the postoperative p eriod of the initial pro cedure (10-90 d ays) B. Pro ced ure code with modifier 78 ap pended will be reimbursed at 70% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up on CareSo urces request. Clinical information documented in the p atient’s records must sup port to use of this modifier. XIV . Modifier 80 – Assistant SurgeonA. Mo d ifier 80 is reported to indicate surgical assistant services by a physician and is ap p lied to the surgical pro cedure code(s). B. Assistant Surgeon provides f ull assistance to the p rimary surgeon and is capable of taking o ver the surgery should the primary surgeon become incapacitated. C. Mo d ifier 80 will no t be accepted from non-p hysicians. Mo difier AS should be used. D. Pro ced ure code with modifier 80 ap pended will be reimbursed at 16% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information d ocumented in the patient’s records must sup port to use of this modifier and operative notes must contain suffic ient inf o rmation to support the medical necessity of an assistant at surgery. If there is no accounting b y the surgeon for what was p erformed by the assistant the claim wo uld be denied. XV. Modifier 81 – Minimum Assistant SurgeonA. Mo d ifier 81 is reported to indicate minimum surgical assistant services and is applied to the surg ical procedure code(s). B. Minimum Assistant Surg eon is an assistant who d oes not p articipate in the entire p ro cedure but provides minimal assistance to the primary surgeon. C. Mo d ifier 81 will no t be accepted from non-p hysicians. Modifier AS should be used. D. Pro ced ure code with modifier 81 ap pended will be reimbursed at 16% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical information documented in the patient’s records must sup port to use of this modifier and operative notes must contain sufficient inf o rmation to suppo rt the medical necessity of an assistant at surgery. If there is no accounting b y the surgeon for what was p erformed by the assistant the claim wo uld be denied. XV I. Modifier 82 – Assistant Surg eon (when q ualified resident surgeon no t available)A. Mo d ifier 82 is rep orted to ind icate when surg ical assistance is needed, b ut a q ualified resid ent was not available. B. Mo d ifier 82 is used p rimarily in teaching hospitals to ind icate that a q ualified resident surg eo n is unavailable. 8 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 C. The unavailab ility of a q ualified resident surgeon is a p rerequisite for the use of this mo d ifier. The assistant must p rovide d ocumentation (certification) stating that a q ualifi ed resid ent was not available for this procedure and why the resident was not available. D. Pro ced ure code with modifier 82 ap pended will be reimbursed at 16% of the fee sched ule amount. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical inf ormation documented in the patient’s records must sup port the use of this modifier and operative notes must contain suf ficient information to support the medical necessity of an assistant at surg ery and why a q ualified resident was no t available. If there is no acco unting b y the surgeon for what was p erformed by the assistant the claim wo uld be denied. XV II . Modifier AA – Anesthesia services performed p ersonally by an anesthesiologistA. Mo d ifier AA is used to rep ort when the anesthesia services are personally p erformed by an Anesthesiologist. B. Pro ced ure code with modifier AA appended will be reimbursed at 100% of the fee sched ule amount. XV II I. Modifier AD – Anesthesia services supervised by an anesthesiologist: more than 4co ncurrent anesthesia procedures. A. Mo d ifier AD is used to rep ort when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia pro cedures. B. Pro ced ure code with modifier AD ap pended will be reimbursed at 100% of the fee sched ule amount. XIX . Modifier QK – Med ical direction of 2, 3 or 4 co ncurrent anesthesia services involving q ualif ied individuals. A. Mo d ifier QK is used to rep ort when med ical d irection of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. B. Pro ced ure code with modifier QK appended will be reimbursed at 50% of the fee sched ule amount. XX. Modifier QX – Anesthesia services p erformed by a CRNA with med ical direction by an anesthesiologist. A. Mo d ifier QX is used to rep ort when the anesthesia services are performed by a CRNA with med ical d irection by an anesthesiologist. B. Pro ced ure code with modifier QX appended will be reimbursed at 50% of the fee sched ule amount. XX I. Modifier QY – Anesthesia services when an Anesthesiologist medically d irects one CRNA.A. Mo d ifier QY is used to rep ort when an Anesthesiologist medically directs o ne CRNA. B. Pro ced ure code with modifier QY ap pended will be reimbursed at 50% of the fee sched ule amount. XX II . Modifier QZ – Anesthesia services performed p ersonally by a CRNA witho ut medical d irection by a physician. A. Mo d ifier QZ is used to rep ort when the anesthesia services are p erso nally p erformed by a CRNA. B. Pro ced ure code with modifier QZ appended will be reimbursed at 100% of the fee sched ule amount. XX II I. Modifier AE – Registered dieticianA. Mo d ifier AE is rep orted to indicate when a reg istered dietician p rovides the service. 9 Reimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 B. Pro ced ure code with modifier AE appended will b e reimbursed at 85% of the fee sched ule amount. XX IV . Modifier AS – Physician Assistant (PA), Nurse Practitioner (NP) or Certified NurseSp ecialist (CNS) served as the assistant at surgery. A. Mo d ifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in p lace of another surgeon. B. Pro ced ure code with modifier AS appended will be reimbursed at 16% of the base code allo wab le fee schedule before multiple surgery red uctions are taken. Note: Med ical records are no t required with the claim, but must be available up onCareSo urces request. Clinical inf ormation documented in the p atient’s reco rd s must support the use of this modifier and o perative no tes must co ntain sufficient information to support the medical necessity of an assistant at surg ery. If there is no accounting b y the surg eon for what was performed by the assistant the claim wo uld be d enied. XXV. Modifier JW – Drug amount d iscard ed (wasted)/not administered to any p atientA. CareSo urce will consider reimbursement for: 1. A sing le-dose or single-use vial d rug that is wasted, when Modifier JW is appended. 2. The wasted amount when b illed with the amount of the d rug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSo urce will NOT co nsider reimbursement for: 1. The wasted amount of a multi-dose vial drug. 2. Any d rug wasted that is b illed when no ne of the drug was administered to the p atient. 3. Any d rug wasted that is b illed without using the most ap propriate size vial, or co mb ination of vials, to deliver the administered d ose. XX VI . Modifier SA – Nurse p ractitioner (NP) rend ering service in collaboration with a p hysicianA. Mo d ifier SA is reported to indicate when a supervising physician is billing on behalf of an ANP, o r CRNFA for no n-surgical services. B. Mo d ifier SA is used when the ANP, or CRNFA is assisting with any other p rocedure that DOES NOT include surgery. C. Pro ced ure code with modifier SA appended will be reimbursed at 85% of the fee sched ule amount. XX VI I. Modifier TC – Technical Co mponentA. Technical co mponent charges are institutional charges and no t b illed separately by p hysicians. B. A charg e may b e made for the technical component alone. Under those circumstances the technical co mponent charge is identified by adding Modifier TC to the usual p ro cedure code. XX VI II . Modifier 26 – Pro fessional Co mponentA. Certain p ro cedures are a co mbination of a p hysician component and a technical co mp onent. B. When the p hysician component is reported separately, the service may be identified by ad d ing the modifier 26 to the usual procedure number. 10 E. Conditions of CoverageReimbursemen t Mo d ifiersMEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 Reimb ursement is dependent o n, b ut not limited to, submitting Centers for Medicare and Med icaid Services (CMS) ap proved CPT/HCPCS codes along with appropriate modifiers, if ap p licable. Please refer to the CMS fee schedule for appropriate codes. Pro viders must follow p roper billing, industry standard s, and state compliant codes on all claim sub missions. The use o f modifiers must be fully supported in the medical record and /or office no tes. Unless otherwise noted within the policy, our p olicies ap p ly to both p articipating and no np articipating p roviders and facilities. Note: In the event o f any conflict between this p olicy and a p roviders contract with CareSource, the p ro viders contract will be the governing document. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 09/01/2019 New p o licyDate Revised Date Effective 09/01/2019 Date Archived 03/31/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and Care Source reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erences1. Billing 340B Mo difiers und er the Ho spital Outpatient Pro spective Payment System (OPPS). (2018, Ap ril 2). Retrieved 3/22/2019 f rom https:// www.cms.gov/Medicare/Medicare-Fee-for – Serv i c e-P ay ment /Ho s p i tal Ou tp ati e ntP PS / Do w nl o ad s /B i l l i ng-34 0B-Mo d i f i ers-u nd e r-Ho s p i tal – OPPS.pdf. 2. CPT o verview and code approval. (2019, March 22). Retrieved from https://www.ama – assn.o rg/practice-management/cpt/cpt-overview-and-code-appro val. 3. Med icare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. (2018, No vember 30). R etrieved February 18, 2019 from https ://www .cm s.gov/Regulations – and-Guid ance/Guidance/Manuals/Downloads/clm104c12.pdf. 4. Med icare Claims Processing Manual Chapter 14 – Ambulatory Surgical Centers. (2017, Decemb er 22). Retrieved February 18, 2019 from https ://www.c ms .go v/Regulations-and – Guid ance/Guidance/Manuals/Downloads/clm104c14.pdf. 5. Op tum360 EncoderProForPayers.com – Lo gin. (2019, February 18). Retrieved February 18, 2019 f ro m http s :// www.enc o d erp ro f p .c o m/ep ro 4p ay e rs /al l Mo d i f i ers Ha nd l er.d o ?_k = 1 0 1 * 0& _ a= l i s tR el at e d &menu=4. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Emergency Department Electrocardiogram (EKG/ECG) and Imaging Interpretation PY-0785 08/01/2019 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, 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 lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Emergency Department Electrocardiogram (EKG/ECG) and Imaging Interpretation OHIO MEDICARE ADVANTAGE PY-0785 Effective Date: 08/01/2019 2 A. Subject Emergency Department Electrocardiogram (EKG/ECG) and Imaging Interpretation B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. An electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart. It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardiogram (EKG/ECG) may need to be performed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. C. Definitions Emergency medical condition-is a medical condition with sudden severity and onset that in the absence of immediate medical attention could placing the patient’s health in serious jeopardy. This includes labor and delivery, but not routine prenatal or postpartum care, or services related to an organ transplant procedure. Electrocardiogram (EKG/ECG) is a test that records the electrical activity of the heart. For the purpose of this policy EKG will be used to represent both EKG and ECG. Imaging-Medical imaging refers to several different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs or imaging completed in the Emergency Department (Place of service (POS) 23). II. CareSource will reimburse the first EKG or imaging interpretation claim that is received for the member on the date of service. A. If another claim for the same service EKG or imaging interpretation is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. B. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member, without the appropriate modifier. 1. Example: 93010 is received and is reimbursed. Another 93010 claim is received for the same date of service and is denied as duplicate service. Emergency Department Electrocardiogram (EKG/ECG) and Imaging Interpretation OHIO MEDICARE ADVANTAGE PY-0785 Effective Date: 08/01/2019 3 C. If a second EKG or imaging is medically necessary, on the same date of service, before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG or imaging interpretation for reimbursement. 1. Example: 93010 is received and reimbursed. Another 93010 is completed and submitted for reimbursement. The second 93010 has modifier 76 or 77 (whichever is applicable) appended (93010-76 or 93010-77) to distinguish between the first and second EKG performed on the same member on the same date of service. III. CareSource expects providers to work with other departments, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual 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 70030-77084 Radiography (imaging) 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93226 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report 93227 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional Modifier Description 26 Professional Component 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional Place of Service Description 23 Emergency Room-Hospital-A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. Emergency Department Electrocardiogram (EKG/ECG) and Imaging Interpretation OHIO MEDICARE ADVANTAGE PY-0785 Effective Date: 08/01/2019 4 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 08/01/2019 New policy Date Revised Date Effective 08/01/2019 H. References 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2018, October 1). Retrieved 3/12/2019 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37283&ver=9&DocType=2&Cntrctr=238&CntrctrSelected=238*2&s=42&bc=AAIAAAAAAAAA&. 2. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/health-topics/electrocardiogram 3. Medical Imaging. (2018, August 28). Retrieved 3/12/2019 from https://www.fda.gov/radiation-emitting-products/radiation-emitting-products-and-procedures/medical-imaging. 4. Physician Fee Schedule Search. (2019). Retrieved 3/12/2019 from https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=3&H1=93010&M=5. 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 Policy Name Policy Number Effective Date Readmission PY-0774 3/1/2019 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, 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 lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 5 F. Related Policies/Rules ………………………………………………………………………………………….. 6 G. Review/Revision History ……………………………………………………………………………………….. 6 H. References …………………………………………………………………………………………………………. 6 Readmission OHIO MEDICARE PY-0723 Effective Date: 3/1/2019 2 A. Subject Readmission 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 of Readmissions for our Medicare Advantage members may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Following a hospitalization, readmission within 30 days is often a costly preventable event and is a quality of care issue. It has been estimated that readmissions within 30 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result from many situations but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progression of the disease state or due to chronic conditions. The purpose of this policy is to improve the quality of inpatient and transitional care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission: a subsequent inpatient admission to any acute care facility which occurs within 30 days of the discharge date; excluding planned admissions. Planned Readmission: a non-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Potentially Preventable Readmission (PPR): a readmission within a specific time frame that is clinically related and may have been prevented had appropriate care been provided during the initial hospital stay and discharge process. A PPR is determined when, based on CareSource guidelines, it is determined that the patient was discharged prematurely. Premature discharge evidence can be described as, Readmission OHIO MEDICARE PY-0723 Effective Date: 3/1/2019 3 but not limited to, elevated fever at the time of discharge, abnormal lab results or evidence of infection or bleeding a wound. Same or Similar Condition: a condition or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented on the initial admission. Same Day: CareSource delineates same day as midnight to midnight of a single day. D. Policy I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observational services for the following categories: A. Same day readmission or observational stay for a related condition B. Same day readmission or observational stay for an unrelated condition C. Planned Readmissions and/or leave of absence D. Unplanned admissions to an acute, general, short-term hospital occurring within 30 calendar days from the date of discharge from the same or another acute, general, short-term hospital II. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim. III. An administrative review of all readmissions will take place based on the following Medicare readmission review criteria: A. Same day readmission or observational stay for a related condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed based on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital combine the two admissions on one claim. 2. If the member is readmitted during the same day as the initial admission for the same or a related condition and both the initial and the subsequent admission are billed separately, CareSource will deny the claim as separate DRGs. The facility must submit the initial admission and the subsequent admission on one claim to receive reimbursement. B. Same day readmission or observational stay for an unrelated condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed based on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital to bill the claims separately but the claim that contains an admission date that is the same as the discharge date must include condition code B4 as indicated in the Medicare billing guidelines. C. Planned readmission and/or leave of absence criteria: Readmission OHIO MEDICARE PY-0723 Effective Date: 3/1/2019 4 1. When a readmission to the same acute care facility or inpatient hospital is expected and the member does not require a hospital level of care during the timeframe between the two admissions, the member may be placed on leave of absence by the provider. a. CareSource follows the Medicare Inpatient Hospital Services billing guidelines found in the Medicare Claims Processing Manual, Chapter 3 for leave of absence billing guidelines which requires that the facility submit one claim and receive one combined DRG payment for both admissions both are for the treatment of the same episode of illness. b. Examples of a planned readmission include, but are not limited to, situations where surgery could not be scheduled immediately due to scheduling availability, a specific surgical team that is needed for the procedure is not available, bilateral staged surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin at the time of initial admission. c. CareSource reserves the right to request medical records to determine if the claim was properly billed. d. Leave of absence does not apply to cancer chemotherapy or similar repetitive treatments. D. Determination of Unplanned Readmissions criteria: 1. CareSource will review the clinical documentation on all potential readmissions to determine if the admission was a potentially preventable readmission (PPR) based on the following Medicare guidelines: a. Premature discharge of patient that resulted in subsequent readmission of patient to same hospital. Premature discharge includes when a patient is discharged even though he/she should have remained in the hospital for further testing or treatment or was not medically stable at the time of discharge. A patient is not medically stable when, in CareSource judgement, the patient’s condition is such that it is medically unsound to discharge or transfer the patient. Evidence such as elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a patient may have been prematurely discharged from the hospital; b. When a patient is readmitted to a hospital for care that, pursuant to professionally recognized standards of health care, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during the first admission. c. The readmission is the result of a lack of documentation and/or coordination of care between the inpatient and outpatient team in regards to post discharge care and coordination with a CareSource Care Manager for the member. E. The following readmission criteria listed below are excluded from this readmission policy when the diagnosis for the exclusion is in the admitting or the primary diagnosis position of the claim: Readmission OHIO MEDICARE PY-0723 Effective Date: 3/1/2019 5 a. If the member is being transferred from an out-of-network to an in-network facility or if the member is being transferred to a facility that provides care that was not available at the initial facility; b. Transfers to distinct psychiatric units within the same facility. When transferring within the same facility, documentation must show that the diagnosis necessitating the transfer was psychiatric in nature and that the patient received active psychiatric treatment. c. If the readmission is part of planned repetitive treatments or staged treatments, such as chemotherapy or staged surgical procedures; d. Readmissions where the discharge status of the first discharge was left against medical advice (AMA); e. Obstetrical readmissions. IV. Post Payment Review and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissions to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical records for both admissions may be requested to determine if the admission(s) is appropriate or is considered a readmission. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records when requested will result in an automatic denial of the claim. b. Medical records for both admissions must be submitted with the claim if both admissions originated from the same facility or Tax Identification Number (TIN). 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim c. If the readmission is determined at the time of documentation review to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admission and paid as one claim to cover both, or all, admissions. 2. Appeals Process a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer review or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes.Readmission OHIO MEDICARE PY-0723 Effective Date: 3/1/2019 6 F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 3/1/2019 Date Revised Date Effective 3/1/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-803.McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-803. 2. Hospital Readmission Reduction Program. (2018, December 04). Retrieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://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 Thyroid Testing PY-0223 01/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement 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 lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement………………………………………………………………………………….. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules …………………………………………………………………………………………… 3 G. Review/Revision History ………………………………………………………………………………………… 4 H. References ………………………………………………………………………………………………………….. 4 Thyroid Testing OHIO MEDICARE ADVANTAGE PY-0223 Effective Date: 01/01/2020 2 A. Subject Thyroid Testing B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. Definitions Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness. Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. Policy I. CareSource does not require a prior authorization for thyroid testing. II. Thyroid function tests are used to test for thyroid function and disease. Thyroid testing may be reasonable and necessary to: A. Distinguish between primary and secondary hypothyroidism B. Confirm or rule out primary hypothyroidism C. Monitor thyroid hormone levels (for example, patients with goiter, thyroid nodules, or thyroid cancer) D. Monitor drug therapy in patients with primary hypothyroidism E. Confirm or rule out primary hyperthyroidism F. Monitor therapy in patients with hyperthyroidism III. Thyroid testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyperthyroidism or hypothyroidism are noted. A. When these tests are billed at a greater frequency than the norm (two per year), the ordering physicians documentation must support the medical necessity of this frequency must be made available upon CareSources request. Thyroid Testing OHIO MEDICARE ADVANTAGE PY-0223 Effective Date: 01/01/2020 3 IV. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. V. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes and the appropriate modifiers, if applicable. The appropriate ICD-10 diagnosis code must match the correct CPT and/or HCPCS code within this policy. Please refer to the individual 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 84436 Thyroxine; total 84439 Thyroxine; free 84443 Thyroid stimulating hormone (TSH) 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) F. Related Policies/Rules N/A ICD 10 Codes A18 D3A E06 E24 E43 E88 F32 G47 R06 C56 D44 E07 E25 E44 E89 F33 I48 R61 C73 D49 E08 E27 E45 F03 F34 N91 Z00 C79 D89 E09 E28 E46 F05 F39 N92 Z01 C7A E00 E10 E29 E66 F06 F41 N94 Z86 C7B E01 E11 E31 E67 F07 F53 N97 D09 E02 E13 E35 E78 F22 F63 O90 D27 E03 E20 E40 E79 F23 G25 O92 D34 E04 E22 E41 E83 F30 G30 O99 D35 E05 E23 E42 E87 F31 G31 R00 Thyroid Testing OHIO MEDICARE ADVANTAGE PY-0223 Effective Date: 01/01/2020 4 G. Review/Revision History DATE ACTION Date Issued 01/01/2020 Date Revised 08/21/2019 Revision (updated diagnosis code list) Date Effective 01/01/2020 Date Archived H. References 1. National Coverage Determination (NCD) for Thyroid Testing (190.22). Retrieved July 26, 2019, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved July 26, 2019, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10. pdf 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 Smoking & Tobacco Cessation PY-0383 01/ 01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource ) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbu rsement 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 agreemen t, 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 standar ds 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 ma ndate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (of ten 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 d ocument 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 ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Archived Smoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: TBD 2 A. Subject Smoking & Tobacco Cessation B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment . Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The use of tobacco products generally lead s to tobacco/nicotine dependence 3and often results in serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases . Tobacco/nicotine dependence is a condition that often requires repeated treatments, as nicotine is strongly addictive. Because of this, quitting smoking and ending the use of tobacco use may be a difficult process requiring several, staged attempts, and may involve stress, irritability, and other withdrawal symptoms for those addicted to nicotine 8, 9, 10. However, continued tobacco use in any form is far more harmful. Tobacco smoke contains seriously harmful chemicals and carcinogens 5 , 8, 11and leads to lung and other cancer s , chronic lung disease, heart disease, strokes, vascular dis ease, and infertility. Additionally, s mokeless tobacco is directly linked to cancer s of the mouth, tongue, cheek, gum, esophagus, and pancreas. Counseling and medication are both effective means for ending dependency on tobacco products, and are even mor e effective together than either method alone 10. Counseling can be effective when delivered via individual, group, or telephone counseling, one-on-one brief help sessions with a provider, behavioral therapies, or even through mobile phone apps. Medication s which have been found to be effective include prescription non-nicotine medications such as bupropion SR (Zyban ) and varenicline tartrate (Chantix ), and nico tine replacement products such as nicotine patches, inhalers or nasal sprays available by prescription, and over-the-counter nicotine patches, gums or lozenges 10, 17. The United States government recognizes the health dangers and risks associated with t he use of tobacco in its citizens and has set up a free telephone support service to help people stop smoking and stop the use of tobacco, 1-800-QUIT-NOW. Callers are routed through this service to their states specific resource, and may be able to obtain free support, advice, and counseling from experienced quit-line coaches, a personalized plan to quit, practical information on how to quit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking medications, free or d iscounted medications (available for at least some callers in most states), referrals to other resources, and/or mailed self-help materials. CareSource encourages all of its members to refrain from the use of tobacco, and if using it in any form, to make concerted and ongoing attempts to quit its use as soon as possible. Archived Smoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: TBD 3 C. Definitions Tobacco products means any product containing tobacco or nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, hookahs, kreteks, e-cigarettes, vaporized and other inhaled tobacco and nicotine products, smokeless tobacco (e.g., dip, chew, snuff, snus), dissolvable tobacco (e.g., strips, sticks, orbs, lozenges), or other ingestible tobacco products, and/or chewing tobacco D. Policy I. Prior authorizations are required for participating (contracted) providers only when the services they are providing for tobacco cessation exceed the limits of this policy. II. Non-participating providers (not contracted with CareSource) should contact CareSou rce for prior authorization for these services. III. CareSource will reimburse its participating providers for the following tobacco use intervention and cessation care methods: A. An encounter for evaluation and management of the member on the same day as couns eling to prevent or cease tobacco use; and, B. Screenings for tobacco use as needed for members 20 and younger; C. One screening for tobacco use per calendar year for members 21 and older; and, D. Three individual tobacco cessation counseling attempts per calendar year. 1. Each attempt will not exceed 12 weeks of treatment . 2. Face to face counseling sessions are required every 30 days during each 12 week treatment period. E. Nicotine replacement or non-nicotine medications prescribed and approved for use for tobacco cessati on. IV. CareSource will not reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year , unless prior authorization has been obtained by the provider. V. The number of CPT, HCPCs, and diagnosis codes (ICD-10) potentially associated with the diagnosis and treatment of tobacco use and addiction is too great to list. As such , the specific tobacco cessation codes provided below are eligible to be reimbursed with any appropriate, associated code. VI. Evaluation and Management service for the member which is provided on the same day as counseling to prevent or cease tobacco use , should be reported with modifier-25 to indicate that the E&M service is separately identifiable from the counseling. A. CONDIT IONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Georgia Medicaid fee schedule.ArchivedSmoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: TBD 4 The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual Georgia Medicaid 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 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes S9453 Smoking Cessation classes-non physician provider, per session E. Related Policies/Rules F. Review/Revision History DATE ACTION Date Issued 9/06 /2017 New Policy Date Revised 8/19/2019 Revision Date Effective TBD G. References A. Physician Services Manual, 903.19, “Tobacco cessation services for Me dicaid eligible members.” Ibid. Appendix D, “Health check and adult preventive visit . (2017, July 1). B. CDC-Fact Sheet-Quitting Smoking-Smoking & Tobacco Use. (n.d.). C. Counseling to Prevent Tobacco Use. ( Transmittal 2058, 2010, September 30). Centers for Medicare & Medicaid Services, Department of Health & Human Services. D. Treating Tobacco Use and Dependence. Clinical Practice Guideline. (n.d.). Fiore, Michael C (panel chair), Guideline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI) E. U.S. Department of Health and Hum an Services. The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. F. National Institute on Drug Abuse. Research Repo rt Series: Is Nicotine Addictive? Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2012. G. American Society of Addiction Medi cine. Public Policy Statement on Nicotine Addiction and Tobacco. Chevy Chase (MD): American Society of Addiction Medicine, 2008. H. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-At tributable Disease: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.ArchivedSmoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: TBD 5 I. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Heal th Promotion, Office on Smoking and Health, 2000. J. Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guidelines. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008. K. National Toxicology Program. Report on Carcinogens, Thirteenth Edition. Research Triangle Park (NC): U.S. Department of Health and Human Sciences, National Institute of Environmental Health Sciences, National Tox icology Program, 2014. L. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. M. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Serv ices, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. N. Centers for Disease Control and Prevention. Quitting Smoking Among Adults United States, 2000 2015. Morbidity a nd Mortality Weekly Report 2017: 65(52):1457-64. O. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance United States, 2015. Morbidity and Mortality Wee kly Report [serial online] 2016: 66 (SS 6):1 174. P. Centers for Disease Control and Prevention. The Guide to Community Preventive Services: Reducing Tobacco Use and Secondhand Smoke Exposure. Q. U.S. Food and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation. FDA Consumer, 2006. R. 42 U.S. Code 18021-Qualified heal th plan defined | US Law | LII / Legal Information Institute. (n.d.). Retrieved from https://www.law.cornell.edu/uscode/text/42/18021 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 OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Non-Invasive Vascular Studies PY-0168 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, 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 lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Non-Invasive Vascular Studies OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2019 2 A. Subject Non-invasive Vascular Studies B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Non-invasive vascular studies utilize ultrasound to assess irregularities in blood flow in arterial and venous systems. Testing can be performed in a vascular laboratory, and is often the first step in diagnosing vascular disease. Results may display as a two dimensional image with a spectral analysis and color flow. The results of these test will determine the need for more non-invasive testing or procedures to treat vascular disease. CareSource will reimburse providers, for non-invasive vascular studies to members as set forth in this policy. C. Definitions Duplex scan a non-invasive evaluation of blood flow through the arteries and veins, by combining the use of Doppler ultrasound with two-dimensional structure and motion with time and spectrum analysis and/or color flow velocity or mapping. Non-invasive testing-utilizes various types of technology to evaluate flow, perfusion, and pressures within the vessels at rest and with exercise. D. Policy I. CareSource does not require a prior authorization for a non-invasive vascular study. II. A referral must be on record for each non-invasive study performed. A referral for one type of study does not qualify as a referral for all tests. III. Although CareSource does not require a prior authorization for non-invasive vascular studies, CareSource may request documentation to support medical necessity A. Medical necessity is defined as health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Note: The use of any Doppler device that produces a record, but does not permit analysis of bidirectional vascular flow or that does not provide a hard copy or printout: is part of the physical exam of the vascular system and is not reported separately. IV. Non-Invasive vascular studies must be personally performed by a physician or technologist A. The physician performing and/or interpreting the study must be capable of demonstrating documented training and experience and maintain any applicable documentation upon CareSources request.Non-Invasive Vascular Studies OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2019 3 B. The technician performing the study must be capable of demonstrating documented training and experience and maintain any documentation upon CareSource request. V. All non-invasive vascular diagnostic studies must be performed under at least one of the following settings: A. Performed by a physician who is competent in non-invasive vascular studies or under the general supervision of physicians who have demonstrated minimum entry level competency by being credentialed in vascular technology B. Performed by a technician who is certified in vascular technology C. Performed in facilities with laboratories accredited in vascular technology. VI. Non-invasive vascular study includes: A. Providing patient care during the study B. Supervision of the procedure C. Interpretation of study results with hard copy output or digital storage of imaging is acceptable. Note: Although CareSource does not require a prior authorization for non-invasive vascular studies, CareSource may request documentation to support medical necessity, including the non-invasive vascular study hard copy or digital copy results. VII. Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease, if the physician/provider can document medical necessity in the patients medical record. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers if applicable, with the appropriate ICD-10 diagnosis codes matched to the correct CPT and/ or HCPCS codes within this policy. Please refer to the individual 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 93880 Duplex scan of extracranial arteries; complete bilateral study 93882 Duplex scan of extracranial arteries; unilateral or limited study 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 Transcranial Doppler study of the intracranial arteries; limited study 93890 Transcranial Doppler study of the intracranial arteries; vasoreactivity study 93892 Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection 93893 Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection 93922 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at Non-Invasive Vascular Studies OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2019 4 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) 93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia) 93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 93998 Unlisted noninvasive vascular diagnostic study Non-Invasive Vascular Studies OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2019 5 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 03/08/2017 Date Revised 08/07/2019 Updated codes and reimbursement criteria Date Effective 12/01/2019 H. References 1. Healthcare.gov glossary. (2019, July 16). Retrieved from https://www.healthcare.gov/glossary/medically-necessary/ 2. Leers, S. A. Duplex Ultrasound. (2019, July 3). Retrieved from https://vascular.org/patient-resources/vascular-tests/duplex-ultrasound 3. Medicare Physician Fee Schedule Search. (2019, July 5). Retrieved from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx 4. Non-invasive Testing for Vascular Disease. (2019, January 7). Retrieved from https://my.clevelandclinic.org/health/diagnostics/17545-vascular-disease-non-invasive-testing https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34045&ver=24&SearchType=Advanced&CoverageSelection=Both&Artic leType=SAD%7cEd&PolicyType=Both&s=42&CptHcpcsCode=93880&kq=true&bc=IAAAACAAAAAA& The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. ICD 10 Codes A48 G97 I79-I83 N18 R42 S65 Z95 D57 H34-H35 I85-I87 N28 R47 S75 Z98-Z99 D68 H47 I96-I97 N50-N52 R55 S85 D75 H53 J96 O22 R60 S95 E08-E11 H81 K55 O86-O87 S06 T38 E13 H93 K74-K76 Q27-Q28 S09 T45 F52 I10 L53-L54 R04 S15 T79-T82 G04 I12-I13 L76 R06-R07 S25 T87 G45-G46 I16 L97 R09-R10 S35 Z01 G54 I25-I27 M30-M31 R22 S38 Z09 G81-G83 I60-I63 M79 R26-R27 S45 Z48 G93 I65-I77 M96 R29 S55 Z86
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