REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANT AGE Policy Name Policy Number Effective Da te Molecular Diagnostic Testing f or Streptococcus A an d BInf ection PY-0869 12/01/2019-0 9/ 30 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t ………………………………………………………………………………….1 A. Subject ………………………………………………………………………………………………………………2 B. Bac k g r ou nd ………………………………………………………………………………………………………..2 C. Def initions …………………………………………………………………………………………………………..2 D. Policy ………………………………………………………………………………………………………………..3 E. Conditions of Co ve r age …………………………………………………………………………………………3 F. Related Policies/Rules …………………………………………………………………………………………..4 G. Review/Revision History ………………………………………………………………………………………..4 H. Ref er en ce s …………………………………………………………………………………………………………4 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tMo l ec ul ar Diagnostic Tes ti n g fo r Strep to c oc cus A an d BIn fec ti o n OHIO MEDICARE ADVANT AG EPY-0869 Effec ti v e Date: 12/01/2019Molecular Diagnostic Testing for Streptococcus A and BI nfection B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the c laim is rec eived for proces sing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. Mo lec ular testing, following a d iagnosis or s uspected diagnosis c an help guide appropriate therap y by identifying spec ific therap eutic t ar g e ts and appropriate pharmaceutical interventions . Mo lec ular d iagnostic testing utilizes Poly merase Chain Reac tion (PCR), a g enetic amplification tec hniq ue that only requires s mall quantities of DNA, for ex ample, 0.1 mg of DNA from a s ingle c ell, to ac hiev e DNA analysis in a s horter laboratory p rocessing time. Knowing the gene s eq uenc e, or at minimum the b orders of the target s egment of DNA to b e amplified, is a p rereq uis ite to a s uc cessful PCR amplification of DNA. Illnes s es c aus ed b y Streptococc us A include Phary ngitis (s trep throat), Sc arlet Fever, Acute Rheumatic Fev er and Pos t Streptococcal Glomerulonephritis . Illnes ses c aused by Streptoc occus Binc lud e Bacteremia, Seps is , Pneumonia, s kin and s oft tissue infections, bone and jo int inf ec tions, meningitis (although t h is is a rare o ccu rrenc e in adults). Sc reening for Streptococcus Bs ho uld be d one b etween 35 and 37 week s in ev ery p regnant wo men, as it is most c ommonly p as s ed to newb orns during the birthing p rocess . All f ac ilities in the United States that perform laboratory testing on human spec imens for health as s es s ment or the diagnosis, p revention, or treatment of diseas e are reg ulated under the Clinical Lab o ratory Improvement Amendments of 1988 (CLIA ). Waiv ed t ests include test s yst em s c leared b y the FD A for ho me us e and those tests ap proved for waiver und er the CLIA c riteria. Although CLIA req uires that waiv ed tests must be s imple and have a lo w ris k for erro neous res ults, this does not mean that waived tests are c ompletely error-proof. CareSource may periodically require rev iew o f a p roviders offic e tes ting policies and p rocedures when p erforming CLIA-waived tests. C. Def initions Polym erase Ch ain Reaction (P CR) – a g enetic amplification technique als o known as a Nuc leic Ac id Amplification Tes t (NAAT). Medically Necessary-Health c are s ervices or s upplies needed to diagnosis or treat an illness, injury, condition, d is ease or its sy mptoms and that meet the accepted standards of med ic ine. 3 D. Polic yMo l ec ul ar Diagnostic Tes ti n g fo r Strep to c oc cus A an d BIn fec ti o n OHIO MEDICARE ADVANT AG EPY-0869 Effec ti v e Date: 12/01/2019I. No Prio r Authorization is req uired for the Molecular Diagnos tic Tes ting by PCR addres sed in this p o lic y when the following c riteria are met: A. Co nv entional testing, such as the ra p id s trep t est (thro at culture), has been performed wi th a neg ativ e res ult on the s ame date of serv ice as the req uested molecular diagnostic test, A ND ; B. Th e memb er p resents wi th c ard inal streptoc occus A and/or Bs ympt oms to include but no t limited to: 1. red , swo llen tonsils 2. whit e or y ellow c o ating or patches on the t o ns il s 3. s o re throat 4. d i f f ic u lt or painful s wallowing 5. f ev er 6. b ad b reath 7. stiff neck 8. enlarg ed , tender g lands (l y mph nodes) in t he neck II. CareSo urc e c ons iders Molecular Diagnos tic Tes ting by PCR for Streptococc us A and Strep toc occus Binfection appropriate as the f irst line of testing only when s ubmitted wi th any c o mb ination of the CPT and ICD-10 diagnosis c odes listed in the Conditions of Co verage in this p o licy.III . Co nv entional testing, such as the ra p id s trep t est (throat c ulture) for Streptoc occus A; c ultures o f s terile b ody fluids and / o r v aginal and rec tal c ultures in pregnant women for Streptococ cus B, are v iewed as effective, low c ost and s hould b e utilized before the higher c ost Molecular Diag no stic Tes ting by PCR. E. Conditions of Cov erageReimb urs ement is dependent o n, b ut not limited to, s ubmitting Centers for Medicare & Med ic aid Serv ices (CM S) ap proved HCPCS and CPT c o des along wi th appropriate modifiers. Pleas e ref er to the CMS fee s chedule for appropriate codes. The following l i st(s) of codes is provided as a reference. This list may n ot be all inclusive and is subject to updates. CPT Code Description87651 Inf ec tious agent detection by nuc leic a cid (D NA or RNA ); Streptoc occus, g roup A, amp lified p robe technique 87653 Inf ec tious agent detection by nuc leic a cid (D NA or RNA ); Streptoc occus, g roup B, amp lified p robe technique ICD-10 Code Description A38.0 Sc arlet fev er wi th otitis media A38.1 Sc arlet fev er wi th myocarditis A38.8 Sc arlet fev er wi th other c o mplications A38.9 Sc arlet f ever, uncomplicated A40.0 Sep s is due to s treptococ cus, group A A40.1 Sep s is due to s treptococ cus, group B A40.3 Sep s is due to Streptoc occus pneumoniae A40.8 Other s trep toc occal s ep s i s A40.9 Strep toc occal s epsis, uns pec ified 4 Mo l ec ul ar Diagnostic Tes ti n g fo r Strep to c oc cus A an d BIn fec ti o n OHIO MEDICARE ADVANT AG EPY-0869 Effec ti v e Date: 12/01/2019A41.9 Sepsis, uns pecified o rganism B95.0 Strep toc occus, g roup A, as the c aus e of diseases c lassif ied els ewhere B95.1 Strep toc occus, g roup B, as the c aus e of diseases c la s sif i e d elsewhere G00.2 Streptococcal mening itis I00 Rheumatic f ever without heart inv olvement I01.0 Ac ute rheumatic pericarditis I01.1 Ac ute rheumatic endocarditis I01.2 Ac ute rheumatic myocarditis I01.8 Other ac ute rheumatic heart d is ea s e I01.9 Ac ute rheumatic heart d isease, unspecified J02.0 Streptococcal p hary ngitis J03.00 Ac ute s treptococc al to nsillitis, unspecified J03.01 Ac ute rec urrent s treptococcal tonsillitis J13 Pneumo nia d ue to Streptococcus pneumoniae J15.3 Pneumo nia d ue to s treptococcus, g roup B J15.4 Pneumo nia d ue to other st reptococ ci J20.2 Ac ute b ronchitis due to streptococcus M72.6 Nec ro tizing fasciitis N00.9 Ac ute nep hritic s yndrome wit h uns pecified morphologic changes O99.511 Dis eas es of the res piratory system c omplicating p regnancy, f irst trimester O99.512 Dis eas es of the res piratory s yst em c omplic ating p regnancy, s econd trimester O99.513 Dis eas es of the res piratory system c omplicating p regnancy, t hird trimester O99.519 Dis eas es of the res piratory s yst em complic ating pregnanc y, uns pecified trimester O99.52 Dis eas es of the res piratory system c omplicating c hildbirth O99.53 Dis eas es of the res piratory system complicating the p uerperium O99.820 Strep toc occus Bc arrier state c omplicating p regnancy O99.824 Strep toc occus Bc arrier state c omplicating c hildbirth O99.825 Strep toc occus Bc arrier state c omplicating the p uerperium P23.3 Co ng enital p neumonia d ue to s trep tococc us, g roup B P36.0 Sep s is of newborn d ue to s treptoc occus, g roup B Z05.1 Ob s erv ation and ev aluation of newb orn f or s uspected infectious c o ndition ruled o ut Z22.330 Carrier of Gro up Bst rept ococcus F. Related Polic ies/RulesN/A G. Rev iew/Rev ision History DATE ACTIONDate Issued 12/01/2019 New Po licyDate Revised Date Effecti ve 12/01/2019 Date Archived 09/30/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . H. Ref erenc es 1. Gro up BS t rep | GB S | Ho me | Streptococ cus | CD C. (2019, June 25). Retriev ed 7/29/19 from www.c d c.gov/groupbstrep. 2. Gro up A St rep | Home | Group A Streptoc occus | GAS | CD C. (2018, No vember 1). Retrieved 7/29/19 f ro m www.cdc .gov/groupAstrep. 5 Mo l ec ul ar Diagnostic Tes ti n g fo r Strep to c oc cus A an d BIn fec ti o n OHIO MEDICARE ADVANT AG EPY-0869 Effec ti v e Date: 12/01/20193. Lic ens e Ag reement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medic are/Medicare-Fee-f or-S ervice-Pay ment/Clinic alLabFeeSched/Downloads /19CLABQ1.zip. 4. Med ically Neces sary. (2019, Jul y 29). Retrieved 7/29/19 f ro m https://www.healthcare.gov/glos sary/medically-necessary/. The Reimbursement Po l icy 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 Molecular Diagnostic Testing for Respiratory Virus PY-0880 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 …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Molecular Diagnostic Testing for Respiratory Virus OHIO MEDICARE ADVANTAGE PY-0880 Effective Date: 12/01/2019 2 A. Subject Molecular Diagnostic Testing for Respiratory Virus 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. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Molecular Diagnostic testing for the respiratory viruses known as Adenovirus, Influenza Virus, Coronavirus, Metapneumovirus, Parainfluenza Virus, Respiratory Syncytial Virus (RSV) and Rhinovirus can be utilized in the presence of symptoms such as cough, fever, headache, fatigue, rhinorrhea, pharyngitis and a general unwell feeling, that would create a clinical picture of a respiratory virus. Molecular Diagnostic testing for respiratory viruses is not indicated for every patient that presents with these signs and symptoms, as treatment is generally the same for all of the viruses and resolve with little to no pharmacological treatment, except in immunocompromised patients. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Molecular Diagnostic Testing for Respiratory Virus OHIO MEDICARE ADVANTAGE PY-0880 Effective Date: 12/01/2019 3 D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR for Respiratory Virus medically necessary when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage in this policy. III. CareSource does not consider Molecular Diagnostic Testing by PCR for Respiratory Virus to be medically necessary when billed with any other ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as rapid antigen direct tests, direct fluorescent antibody testing and cultures, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87631 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87632 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87633 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets ICD-10 Code Description B30.2 Viral pharyngoconjunctivitis B34.0 Adenovirus infection, unspecified B34.2 Coronavirus infection, unspecified B97.0 Adenovirus as the cause of diseases classified elsewhere B97.21 SARS-associated coronavirus as the cause of diseases classified elsewhere B97.29 Other coronavirus as the cause of diseases classified elsewhere B97.4 Respiratory syncytial virus as the cause of diseases classified elsewhere B97.81 Human metapneumovirus as the cause of diseases classified elsewhere Molecular Diagnostic Testing for Respiratory Virus OHIO MEDICARE ADVANTAGE PY-0880 Effective Date: 12/01/2019 4 B97.89 Other viral agents as the cause of diseases classified elsewhere J00 Acute nasopharyngitis [common cold] J05.0 Acute obstructive laryngitis [croup] J06.9 Acute upper respiratory infection, unspecified J09.X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia J10.08 Influenza due to other identified influenza virus with other specified pneumonia J10.1 Influenza due to other identified influenza virus with other respiratory manifestations J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to unidentified influenza virus with myocarditis J10.83 Influenza due to other identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations J11.81 Influenza due to unidentified influenza virus with encephalopathy J11.82 Influenza due to unidentified influenza virus with myocarditis J11.83 Influenza due to unidentified influenza virus with otitis media J11.89 Influenza due to unidentified influenza virus with other manifestations J12.0 Adenoviral pneumonia J12.1 Respiratory syncytial virus pneumonia J12.2 Parainfluenza virus pneumonia J12.3 Human metapneumovirus pneumonia J12.81 Pneumonia due to SARS-associated coronavirus J12.9 Viral pneumonia, unspecified J20.4 Acute bronchitis due to parainfluenza virus J20.5 Acute bronchitis due to respiratory syncytial virus J20.6 Acute bronchitis due to rhinovirus J20.9 Acute Bronchitis, unspecified J21.0 Acute bronchiolitis due to respiratory syncytial virus J21.9 Acute bronchiolitis, unspecified O98.511 Other viral diseases complicating pregnancy, first trimester Molecular Diagnostic Testing for Respiratory Virus OHIO MEDICARE ADVANTAGE PY-0880 Effective Date: 12/01/2019 5 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 12/01/2019 New Policy Date Revised Date Effective 12/01/2019 Date Archived H. References 1. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 2. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. 3. NREVSS | Home | National Respiratory and Enteric Virus Surv System | CDC. (2019, July 24). Retrieved 7/29/19 from https://www.cdc.gov/surveillance/nrevss/index.html. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, 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 exp ected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost altern ative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Influenza Virus Infection PY-0886 12/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement 1 A. Subject. 2 B. Definitions 2 C. Policy 2 D. Conditions of Coverage 3 E. Related Policies/Rules.. 4 F. Review/Revision History… 4 G. References.. 4 2 A. SubjectMolecular Diagnostic Testing for Influenza Virus InfectionOHIO MEDICARE ADVANTAGE PY-0886 Effective Date: 12/01/2019 Molecular Diagnostic Testing for Influenza Virus Infection B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and polic y 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 appropriateCPT/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. Molecular testing, following a diagnosis or suspect ed diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only req uires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequis ite to a successful PCR amplification of DNA. Molecular diagnostic testing for Influenza Virus can detect influenza viral RNA or nucleic acids in respiratory specimens with high sensitivity and specificity. The detection of influenza viral RNA or nucleic acids is not necessarily indicative of a viable or ongoing influenza viral replication. In cases where there is known active influenza virus and the clinical picture of the patient shows signs and symptoms of the influenza virus, molecular diagnostic testi ng is not needed. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean th at waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary – Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. PolicyI. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy when the following criteria are met: 3 Molecular Diagnostic Testing for Influenza Virus InfectionOHIO MEDICARE ADVANTAGE PY-0886 Effective Date: 12/01/2019 A. Conventional testing, such as a nasal swab has been performed with a negative result on the same date of service as the requested molecular diagnostic test, AND; B. The member presents with cardinal influenza virus infection symptom s to include but not limited to: 1. Fever over 100.4 F 2. Aching muscles 3. Chills and sweats 4. Headache 5. Dry, persistent cough 6. Fatigue and weakness 7. Nasal congestion 8. Sore throat II. CareSource considers Molecular Diagnostic Testing by PCR for Influenza Virus Infection ap propriate as the first line testing only when submitted with any combination of the CPT andICD-10 diagnosis codes listed in the Conditions of Coverage in this policy. III. Conventional testing, such as nasal swabs and nasopharyngeal swabs, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types ICD-10 Code Description J09.X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia J10.08 Influenza due to other identified influenza virus with other specified pneumonia J10.1 Influenza due to other identified influenza virus with other respiratory manifestations 4 Molecular Diagnostic Testing for Influenza Virus InfectionOHIO MEDICARE ADVANTAGE PY-0886 Effective Date: 12/01/2019 J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to other identified influenza virus with myocarditis J10.83 Influenza due to other identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations J11.81 Influenza due to unidentified influenza virus with encephalopathy J11.82 Influenza due to unidentified influenza virus with myocarditis J11.83 Influenza due to unidentified influenza virus with otitis media J11.89 Influenza due to unidentified influenza virus with other manifestations O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 12/01/2019 New PolicyDate Revised Date Effective 12/01/2019 Date Archived 02/02/2021 H. References1. Information on Rapid Molecular Assays, RT-PCR, and other Molecular Assays for Diagnosis of Influenza Virus Infection | Seasonal Influenza (Flu) | CDC. (2019, March 4). Retrieved 7/29/19 from www.cdc.gov/flu/professionals/diagnosis/molecular-assays.htm. 2. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service – Payment/ClinicalL abFeeSched/Downloads/19CLABQ1.zip. 3. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https:// www.healthcare.gov/glossary/medically-necessary/. 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 Molecular Diagnostic Testing for Hepatitis Band CPY-0874 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 …………………………………………………………………………………………………………… 3 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICARE ADVANTAGE PY-0874 Effective Date: 12/01/2019 2 A. Subject Molecular Diagnostic Testing for Hepatitis Band CB. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or 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. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Hepatitis Bis a liver infection caused by the Hepatitis Bvirus (HBV). Hepatitis Bis transmitted when blood, semen, or another body fluid from a person infected with the Hepatitis Bvirus enters the body of someone who is not infected. This can happen through sexual contact; sharing needles, syringes, or other drug-injection equipment; or from mother to baby at birth. For some people, hepatitis Bis an acute, or short-term, illness but for others, it can become a long-term, chronic infection. Risk for chronic infection is related to age at infection: approximately 90% of infected infants become chronically infected, compared with 2%6% of adults. Chronic Hepatitis Bcan lead to serious health issues, like cirrhosis or liver cancer. The best way to prevent Hepatitis Bis by getting vaccinated. (1) Hepatitis Cis a liver infection caused by the Hepatitis Cvirus (HCV). Hepatitis Cis a blood-borne virus. Today, most people become infected with the Hepatitis Cvirus by sharing needles or other equipment to inject drugs. For some people, hepatitis Cis a short-term illness but for 70%85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis Cis a serious disease than can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis Cis by avoiding behaviors that can spread the disease, especially injecting drugs. (1) All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICARE ADVANTAGE PY-0874 Effective Date: 12/01/2019 3 C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for Hepatitis Band Cinfection, when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage in this policy. III. CareSource does not consider Molecular Diagnostic Testing by PCR for Hepatitis Band Cto be medically necessary when billed with any other ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as serology or blood tests, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the (CMS) fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis Bvirus, quantification 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed ICD-10 Code Description B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta-(super) infection of hepatitis Bcarrier B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent Molecular Diagnostic Testing for Hepatitis Band COHIO MEDICARE ADVANTAGE PY-0874 Effective Date: 12/01/2019 4 B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B18.2 Chronic viral hepatitis CB18.9 Chronic viral hepatitis, unspecified B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma O98.411 Viral hepatitis complicating pregnancy, third trimester O98.412 Viral hepatitis complicating pregnancy, second trimester O98.413 Viral hepatitis complicating pregnancy, third trimester O98.419 Viral hepatitis complicating pregnancy, unspecified trimester O98.42 Viral hepatitis complicating childbirth O98.43 Viral hepatitis complicating the puerperium F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 12/01/2019 New Policy Date Revised Date Effective 12/01/2019 Date Archived H. References 1. Division of Viral Hepatitis Home Page | Division of Viral Hepatitis | CDC. (2019, July 23). Retrieved 7/29/19 from www.cdc.gov/hepatitis. 2. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 3. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. 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 Molecular Diagnostic Testing for Gastrointestinal Illness PY-0858 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 …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Molecular Diagnostic Testing for Gastrointestinal Illness OHIO MEDICARE ADVANTAGE PY-0858 Effective Date: 12/01/2019 2 A. Subject Molecular Diagnostic Testing for Gastrointestinal Illness 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. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Gastrointestinal illness, as addressed in this policy, include Clostridium difficile, E. Coli, Salmonella, Shigella, Norovirus and Giardia. These infection and illnesses of the intestine can cause symptoms such as diarrhea, nausea, vomiting and abdominal cramping. There are three basic modes of transmission: in food, in water and person to person. While some of these illnesses will resolve on their own, others can spread throughout the body and require treatment to prevent a more devastating illness. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Molecular Diagnostic Testing for Gastrointestinal Illness OHIO MEDICARE ADVANTAGE PY-0858 Effective Date: 12/01/2019 3 D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR medically necessary for the following gastrointestinal illnesses, when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage of this policy. A. Clostridium Difficile B. Salmonella C. Shigella D. Norovirus E. Giardia F. E. coli III. CareSource does not consider Molecular Diagnostic Testing by PCR medically necessary for gastrointestinal illnesses when billed with any other ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as stool and saliva samples for these illnesses is viewed as low cost and given that not all cases of acute diarrhea are indicative of these illnesses, institutions should utilize these before the higher cost Molecular Testing by PCR as the first testing option for the initial clinical presentation of acute diarrhea. 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. 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 87493 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique-Not on physician look up 87505 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targetsMolecular Diagnostic Testing for Gastrointestinal Illness OHIO MEDICARE ADVANTAGE PY-0858 Effective Date: 12/01/2019 4 ICD-10 Code Description A04.71 Enterocolitis due to Clostridium difficile, recurrent A04.72 Enterocolitis due to Clostridium difficile, not specified as recurrent A02.0 Salmonella enteritis A03.0 Shigellosis due to Shigella dysenteriae A03.1 Shigellosis due to Shigella flexneri A03.2 Shigellosis due to Shigella boydii A03.3 Shigellosis due to Shigella sonnei A03.8 Other shigellosis A03.9 Shigellosis, unspecified A04.0 Enteropathogenic Escherichia coli infection A04.1 Enterotoxigenic Escherichia coli infection A04.2 Enteroinvasive Escherichia coli infection A04.3 Enterohemorrhagic Escherichia coli infection A04.4 Other intestinal Escherichia coli infections A07.1 Giardiasis [lambliasis] A08.11 Acute gastroenteropathy due to Norwalk agent A09 Infectious Gastroenteritis and colitis, unspecified O99.611 Diseases of the digestive system complicating pregnancy, first trimester O99.612 Diseases of the digestive system complicating pregnancy, second trimester O99.613 Diseases of the digestive system complicating pregnancy, third trimester O99.619 Diseases of the digestive system complicating pregnancy, unspecified trimester O99.62 Diseases of the digestive system complicating childbirth O99.63 Diseases of the digestive system complicating the puerperium F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 12/01/2019 New Policy Date Revised Date Effective 12/01/2019 Date Archived H. References 1. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 2. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. 3. Multiplexed Molecular Diagnostics for Respiratory, Gastrointestinal, and Central Nervous System Infections. (2016, July 16). Retrieved 7/29/19 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091344/ext. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANT AGE Policy Name Policy Number Effective Da te Vaccinations an d Immunizations PY-0079 10/01/2019-0 3/ 31 /2 022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of ContentsReimbursement Policy St at e men t …………………………………………………………………………………..1 A. Subject ……………………………………………………………………………………………………………….2 B. Bac k g r ou nd …………………………………………………………………………………………………………2 C. Def initions …………………………………………………………………………………………………………..2 D. Policy …………………………………………………………………………………………………………………2 E. Conditions of Co ve r age………………………………………………………………………………………….2 F. Related Policies/Rules …………………………………………………………………………………………..5 G. Review/Revision History …………………………………………………………………………………………5 H. Ref er en ce s ………………………………………………………………………………………………………….5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable r e f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. Subjec tVaccinations and I mmun iza tio ns Vaccinations and Immun i zati o ns OHIO MEDICARE ADVANT AG EPY-0079 Effec ti v e Date: 10/01/2019B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. CareSo urc e c ov ers and reimburses for vac cinations/immunizations b ased on the rec o mmendations from the Centers for Diseas e Co ntrol and Prevention (CDC) and the A dvisory Co mmittee o n Immunization Prac tices (ACIP). CareSo urc e follows Medic are guidelines for the purposes of determining c overage. It is expected p ro v iders retain o r have ac cess to appropriate d ocumentation when req uested to s upport c o v erage.C. Def initi ons Immunity-is protec tion f rom an infectious disease. Immunization-is an ino c ulation ag ainst a v accine preventable disease. Vaccination-the ac t of introducing a vacc ine into the body to produce immunity to a s pecif ic d is ease. Vaccine-a p ro d uct that s timulates a pers ons immune sy stem to produce immunity to a specific disease, p rotecting the p er s o n from that disease. Vacc ines are usually ad ministered thro ug h need le injec tions, b ut c an also b e administered by mouth or s prayed into the nose. D. Polic yI. CareSo urc e may reimburse f or v acc inations according to the CD Cvacc ination/immunization s c hed ule and ACIP rec ommendations. II. Pro v iders may be reimbursed for the vacc ine and ad ministration provided to CareSource memb ers.Note: Vac c ines and immunizations for the s ole purpose of travel outside of t he c ontinental United States are no t c overed.E. Conditions of Cov erageReimb urs ement is dependent o n, b ut not limited to, s ubmitting The Centers for Medicare & Med ic aid Ser v i c e s (CM S) ap proved HCP CS and CP Tc odes along wit h appropriate modifiers , if ap p lic able. Pleas e refer to the individual CMS fee sc hedule for appro priate c odes . 3 Vaccinations and Immun i zations OHIO MEDICARE ADVANT AG EPY-0079 Effec ti v e Date: 10/01/2019 The following l i st(s) of codes is provided for reference purposes only and may n ot be all inclusive and is subject to updates. Listing of a code in this guideline does not im ply that the service described by the code is a covered or non-covered health service. CPT Code Description90460 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, with c ounseling b y phy sician o r other qualified health care p ro f es sional; f irs t or o n ly c omponent of each v accine or toxoid administered 90461 Immunizatio n ad ministration through 18 y ears of age v ia any ro ute of ad minis tration, with c ounseling b y phy sician o r other qualified health care p ro f es sional; each additional vaccine or toxoid component administered (Li s t s ep arately in addition to c ode for primary proc edure) 90471 Immunizatio n ad ministration (inc ludes p ercutaneous , intradermal, s ubcutaneous , o r intramus c ular injec tions); 1 v accine (s ingle o r c ombination v accine/toxoid) +90472 Immunizatio n ad ministration (inc ludes p ercutaneous , intradermal, s ubcutaneous , o r intramus c ular injec tions); each ad ditional v acc ine (s ingle or c ombination v ac c ine/toxoid) (Lis t s eparately in addition to c ode for p rimary proc edure) 90473 Immunizatio n adminis tration by intranasal or oral r o ut e ; 1 v accine (single or c o mb ination v acc ine/toxoid) +90474 Immunizatio n adminis tration by intranasal or oral route; each additional v accine (s ing le o r c ombination v accine/toxoid) (Lis t s eparately in ad dition to code for p rimary p rocedure) 90585 Bacillus Calmette-Guerin vacc ine (B CG) for tuberculosis, l iv e , for percutaneous us e 90586 Bacillus Calmette-Guerin vac cine (BCG) for bladder c ancer, live, for intrav esical us e 90630 Inf luenza v irus v accine, quadrivalent (IIV 4), sp l it virus , preserv ative free, f or intrad ermal us e 90632 Hep atitis A v acc ine (Hep A ), adult d osage, for intramuscular us e 90633 Hep atitis A vaccine (HepA), pediatric/adoles cent dos age-2 d ose schedule, f or intramus c ular us e 90634 Hep atitis A vaccine (HepA), pediatric/adoles cent dos age-3 d ose schedule, f or intramus c ular us e 90636 Hep atitis A and hepatitis Bv acc ine (Hep A-HepB), adult dos age, f or intramus cular us e 90647 Haemo p hilus influenzae t ype b vac cine (Hib), PRP-O MP conjugate, 3 dose s c hed ule, for intramuscular us e 90648 Haemo p hilus influenzae t ype b vaccine (Hib), PRP-T c o njugate, 4 d ose schedule, f o r intramuscular us e 90649 Human Pap illomav irus vacc ine, ty pes 6, 11, 16, 18, q uadrivalent (4vHP V), 3 dose s c hed ule, for intramuscular us e 90650 Human Pap illomavirus vacc ine, ty p es 16, 18, bivalent (2v HPV), 3 dos e s chedule, f o r intramuscular us e 90651 Human Pap illomav irus vac cine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9v HPV), 2 o r 3 d o se sc hedule, for intramuscular us e 90653 Inf luenza v ac c ine, inac tiv ated (IIV ), s ub unit, ad juvanted, for intramuscular use 90654 Inf luenza v irus v accine, trivalent (IIV 3), split virus, pres ervativ e-free, for intradermal us e 4 Vaccinations and Immun i zations OHIO MEDICARE ADVANT AG EPY-0079 Effec ti v e Date: 10/01/201990655 Inf luenza v irus v accine, trivalent (IIV 3), s p l it virus, preserv ative free, 0.25 mL d o s age, for intramuscular us e 90656 Inf luenza v irus v accine, trivalent (IIV 3), s p l it virus , pres erv ative free, 0.5 mL d o s age, for intramuscular us e 90657 Inf luenza v irus v accine, trivalent (IIV 3), s p li t virus, 0.25 mL dosage, f or intramus c ular us e 90660 Inf luenza v irus vaccine, triv alent, live (LA IV 3), for intranas al us e 90661 Inf luenza v irus v accine, trivalent (c cIIV 3), derived f rom c e ll c ultures, s ubunit, p res erv ative and antibiotic free, 0.5 mL d osage, for intramuscular us e 90662 Inf luenza v irus v ac cine (IIV ), split virus, pres ervative free, enhanced immuno genicity via increased antigen c ontent, for intramuscular use 90670 Pneumo c occal c onjugate v accine, 13 v alent (P CV13), for intramusc ular us e 90672 Inf luenza v irus v ac c ine, q uadrivalent, live (LA IV 4), for intranas al us e 90673 Inf luenza v irus v ac cine, trivalent (RIV3), d erived from rec ombinant DNA, hemag g lutinin (HA) p rotein only, preservative and antibiotic free, for intramuscular us e 90674 Inf luenza v irus v accine, quadrivalent (ccIIV 4), derived f rom c ell c ultures, subunit, p res erv ative and antibiotic free, 0.5 mL d osage, for intramuscular us e 90675 Rab ies v ac c ine, for intramuscular use 90676 Rab ies v ac c ine, for intradermal use 90680 Ro tav irus vacc ine, p entavalent (RV 5), 3 d os e s chedule, live, f or o ral us e 90682 Inf luenza v irus v ac cine, quadrivalent (RIV4), derived from recombinant DNA, hemag g lutinin (HA) p rotein only, p reservativ e and antibiotic free, for intramuscular us e 90685 Inf luenza v irus v ac c ine, q uadriv alent (IIV 4), s p l it v irus, p reservat ive free, 0.25 mL, for intramusc ular us e 90686 Inf luenza v irus v accine, q uadriv alent (IIV 4), split v irus, p reservativ e free, 0.5 mL d o s age, for intramuscular us e 90687 Inf luenza v irus v accine, q uadriv alent (IIV 4), split v irus, 0.25 mL d osage, f or intramus c ular us e 90688 Inf luenza v irus v accine, q uadrivalent (IIV 4), split v irus, 0.5 mL dosage, f or intramus c ular us e 90689 Inf luenza v irus v ac cine quadrivalent (IIV 4), inac tivated, adjuvanted, preservative f ree, 0.25 mL d osage, for intramuscular us e 90690 Typhoid v ac cine, live, o r al 90691 Typhoid v ac cine, Vi c aps ular p olysac charide (V iCPs), for intramusc ular us e 90698 Dip htheria, tetanus toxoids, ac ellular p ertus sis v accine, Haemophilus influenzae type b, and inac tivated poliovirus v accine, (D Ta P-IP V/Hi b), for intramus cular use 90702 Dip htheria and tetanus toxoids adsorbed (DT) when ad ministered to individuals y o ung er than 7 y ears, for intramusc ular us e 90707 Meas les , mumps and rub ella v irus v accine (MMR), li ve , for s ub cutaneous use 90710 Meas les , mumps, rubella, and varicella vacc ine (MMRV), l iv e , for subcutaneous us e 90713 Po lio virus v acc ine, inac tivated (IP V ), for s ub cutaneous or intramuscular use 90714 Tetanus and d iphtheria toxoids adsorbed (Td ), pres ervativ e free, when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cular us e 90715 Tetanus , d iphtheria toxoids and ac ellular pertussis vac cine (Td ap), when ad minis tered to ind iv iduals 7 y ears or o lder, for intramus cular us e 90716 Varicella v irus vac cine (V AR), live, f or s ubcutaneous us e 90717 Yello w f ever v accine, live, for subcutaneous use 90732 Pneumo c occal p oly saccharide v acc ine, 23-v alent (P PSV23), adult or immuno s uppressed p atient dosage, when administered to individuals 2 y ea r s or o ld er, for s ubcutaneous or intramus cular use 5 Vaccinations and Immun i zations OHIO MEDICARE ADVANT AG EPY-0079 Effec ti v e Date: 10/01/201990733 Mening o cocc al polys accharide vacc ine, serogroups A, C, Y, W-135, q uadriv alent (MPSV4), for s ubcutaneous use 90734 Mening o cocc al c onjugate vacc ine, serogroups A, C, Yand W-135, quadrivalent (MCV4 o r MenACWY), for intramuscular us e 90736 Zo s ter (s hingles) v ac cine (HZV ), live, for s ubc utaneous injection 90739 Hep atitis Bvacc ine (Hep B ), adult dos age, 2 d ose s c hedule, for intramuscular us e 90740 Hep atitis Bv accine (HepB), dialysis or immunosuppres sed patient dos age, 3 dos e s c hed ule, for intramuscular us e 90743 Hep atitis Bvacc ine (HepB ), adolesc ent, 2 d os e s c hedule, for intramusc ular us e 90744 Hep atitis Bvaccine (HepB), pediatric/adoles cent dos age, 3 dose s chedule, for intramus c ular us e 90746 Hep atitis Bvacc ine (Hep B ), adult dos age, 3 d ose s c hedule, for intramuscular us e 90747 Hep atitis Bv accine (HepB), dialysis or immunosuppres sed patient dos age, 4 dos e s c hed ule, for intramuscular us e 90749 Unlis ted vaccine/toxoid 90750 Zo s ter (s hingles) v accine (HZV ), recombinant, subunit, adjuvanted, for intramus c ular us e 90756 Inf luenza v irus v accine, quadrivalent (ccIIV 4), derived f rom c ell c ultures, subunit, antib io tic free, 0.5mL dos age, for intramusc ular us e HCPCS Description Q2034 Inf luenza v irus vaccine, split v irus, for intramuscular us e (A grif lu) Q2035 Inf luenza v irus v accine, s p l it virus, when administered to individuals 3 years of a g e and o ld er, for intramuscular us e (AFLURIA) Q2036 Inf luenza v irus v accine, s p l it virus, when administered to individuals 3 years of a g e and o ld er, for intramuscular us e (FLULAVAL) Q2037 Inf luenza v irus v accine, s p l it virus, when administered to individuals 3 years of a g e and o ld er, for intramuscular us e (FLUVIRIN) Q2038 Inf luenza v irus v accine, s p l it virus, when administered to individuals 3 years of a g e and o ld er, for intramuscular us e (Fluzone) Q2039 Inf luenza v irus v ac c ine, no t o therwis e specified G0008 Ad ministration of influenza v irus vaccine G0009 Ad ministration of p neumococ cal vaccine G0010 Ad ministration of hepatitis Bv accine F. Related Polic ies/RulesG. Rev iew/Rev ision HistoryDATE ACTIONDate Issued 10/01/2019 New p o licyDate Revised Date Effecti ve 10/01/2019 Date Archived 03/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSo urc e res erv es the right to follow CMS/State/NCCI g uid elines without a f ormal doc umented Policy. 6 Vaccinations and Immun i zations OHIO MEDICARE ADVANT AG EPY-0079 Effec ti v e Date: 10/01/2019H. Ref erenc es 1. Ad ult Immunization Schedule by Vac cine and Age Group | CD C. (2019, February 5). Retriev ed May 13, 2019, f rom https : //www.c dc.go v/vaccines/schedules/hcp/imz/adult.html 2. Enc o derProForPayers . (2019). Retriev ed May 13, 2019 f ro m https://www.encoderprofp.com/epro4payers/ 3. Physician Fee Schedule Searc h. (2019, Apri l 5). Retrieved May 13, 2019 f ro m https://www. cms.gov/ apps/physician-fee-schedule/search/search-criteria.aspxThe 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 Transcutaneous Electrical Nerve Stimulation (TENS) PY-0756 09/01/2019 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 Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICARE ADVANTAGE PY-0756 Effective Date: 09/01/2019 2 A. Subject Transcutaneous Electrical Nerve Stimulation (TENS) 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. Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin. CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day (1 month) trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. C. Definitions Transcutaneous electrical nerve stimulation (TENS) – is the application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. Supplies-includes but is not necessarily limited to electrodes of any type, lead wires, and adhesive tape. D. Policy I. CareSource does not require a prior authorization (PA) for a TENS unit or supplies for participating providers. A. Non-participating providers DO require a prior authorization for a TENS unit (E0720 or E0730). B. Non-participating providers DO NOT require a prior authorization for supplies (A4595). II. CareSource reimburses for TENS units and supplies according to the Centers for Medicare and Medicaid Services (CMS) guidelines NCD 160.27 and NCD 10.2 III. TENS units are reimbursed on a 13 month rent to purchase basis, after a successful 1 month non-reimbursable trial period. IV. Documentation A. The provider of the TENS unit must complete the Certificate of Medical Necessity-Transcutaneous Electrical Nerve Stimulator (TENS), Form CMS-848. B. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than thirty days is needed for acute pain following surgery and includes the date of surgery.Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICARE ADVANTAGE PY-0756 Effective Date: 09/01/2019 3 C. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain must be completed and available for review upon CareSources request. D. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request, before reimbursement is made for supplies or repair. E. The provider must also provide the member with verbal instruction on the use of the TENS unit. F. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record. V. Rental of a TENS unit to treat post-operative pain is limited to a single 30 day period and may not be extended. Modifier RR should be used in this case. VI. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units (after the successful 1 month non-reimbursable trial period). VII. Supplies A. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-Lead TENS unit (E0720) or 2 units per month for a 4-Lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed, at a frequency not to exceed once per month. E. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, 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 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. HCPCS Code Description E0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers Description RR Rental (use the ‘RR modifier when DME is to be rented) NU Purchase of new equipment Transcutaneous Electrical Nerve Stimulation (TENS) OHIO MEDICARE ADVANTAGE PY-0756 Effective Date: 09/01/2019 4 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 06/01/2019 New Policy Date Revised Date Effective 09/01/2019 H. References 1. Medicare National Coverage Determinations Manual. (2018, November 21). Retrieved from 3/11/2019 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf 2. Medicare National Coverage Determinations Manual. (2018, November 21). Retrieved 3/11/2019 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part2.pdf 3. Physician Fee Schedule Search. (2019, January 11). Retrieved from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx 4. Using TENS for pain control: the state of the evidence. (2015, March 1). Retrieved 3/11/2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186747/ The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Independent medical review 2/2015
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Policy Name Policy Number Effective Date Reimbursement Modifiers PY-0716 09/01/2019 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 …………………………………………………………………………………………10 F. Related Policies/Rules ………………………………………………………………………………………….10 G. Review/Revision History ……………………………………………………………………………………….10 H. References …………………………………………………………………………………………………………10 Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 2 A. Subject Reimbursement Modifiers B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies 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. Modifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Although CareSource accepts the use of modifiers specific to this policy, not all modifiers are included within this policy. The modifiers included within this policy are those modifiers that affect the reimbursement of a service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must be made available upon CareSources request. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. C. Definitions Current Procedural Terminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier-two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. Policy I. Modifier 22-Increased Procedural Services A. Modifier 22 is used to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required. The extra work may be identified by appending modifier 22 to the usual procedure code. B. Procedure codes with modifier 22 appended may be reimbursed up to 120% of the fee schedule amount. Note: This modifier is not appended to E/M services (99201-99499). Claims for 99201-99499 with modifier 22 will be denied. Medical records ARE required with theReimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 3 claim and must support the use of this modifier. Claims with procedures including 22 and no supporting documentation will be denied. II. Modifier 50-Bilateral Procedures A. Professional Claims Only Append modifier 50 to the appropriate unilateral code on a single claim line and indicate 1 unit in the unit field of that claim line. B. Modifier 50 applies to surgical procedures (CPT codes 10040-69990) and to radiology procedures performed bilaterally. C. Applies to any bilateral procedure performed on both sides at the same session. D. The use of modifier 50 is NOT appropriate in the following situations: 1. Using modifier 50 on a bilateral procedure performed on different areas of the right and left sides of the body. 2. Appending modifier 50 to a procedure code that is defined by CPT as primarily bilateral or a bilateral service. 3. Appending modifier 50 to a surgical CPT code, the description of which contains the words one or both. E. Do not report two line items to indicate a bilateral procedure. F. Procedure code with modifier 50 appended will reimburse 1 unit at 150% of the fee schedule amount. III. Modifier 51-Multiple Procedures A. Modifier 51 is used to report multiple procedures, other than E/M services, are performed at the same session by the same individual, the primary procedure or service is reported as listed. B. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). C. Modifier 51 should not be appended to designated “add-on” codes. D. Procedure code with modifier 51 appended will reimburse 50% of the fee listed on the Medicaid Physician Fee Schedule for the service. IV. Modifier 52-Reduced services A. Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. 1. Modifier 52 is used for reporting reduced services when the procedure was terminated after the patient was prepped and brought to the room where the service was to be performed. B. Modifier 52 may be used to report reduced radiology procedures. 1. The correct reporting is to assign the CPT code to the extent of the procedure performed. 2. This modifier is used only to report a radiology procedure that has been reduced when no other code exists to report what has been done. 3. Report the intended code with modifier 52. i. Example, if the planned procedure is a two-view chest x-ray and only one view of the chest is performed, do not report CPT code 71020-52 (for x-ray chest, two views-reduced service). Instead, report CPT code 71010 (x-ray chest, single view). ii. Example, if a barium swallow is not completed because the patient cannot handle the barium, report CPT code (74270-52). C. Modifier 52 does not provide for reimbursement of an ineligible service. D. For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. E. Procedure code with modifier 52 appended will reimburse at 50% of the fee schedule amount. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 4 Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. The extenuating circumstances preventing the completion of the procedure must also be documented V. Modifier 53-Discontinued Procedure A. Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued after anesthesia is administered to the patient. 2. Modifier 53 is used to indicate that the physician terminated a surgical/diagnostic procedure due to the patients well-being. B. This modifier is not used to report an elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. C. Modifier 53 cannot be used when a laparoscopic or endoscopic procedure is converted to an open procedure. D. Modifier 53 does not provide for reimbursement of an ineligible service. E. Modifier 53 cannot be appended to E/M codes. F. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. G. Procedure code with modifier 53 appended will reimburse at 25% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. Documentation must include a statement indicating at what point the procedure was discontinued. The extenuating circumstances preventing the completion of the procedure must also be documented. VI. Modifier 54-Surgical Care Only A. Modifier 54 is reported when one physician performed a surgical procedure only; another physician provides the preoperative and/or postoperative management. B. Modifier 54 must only be appended to the surgical procedure code. C. Procedure code with modifier 54 appended will reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. VII. Modifier 55-Postoperative Management Only A. Modifier 55 is reported when 1 physician or other qualified health care professional performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by appending modifier 55 to the procedure code. B. Modifiers 55 must only be appended to the surgical procedure code. C. Procedure code with modifier 55 appended will reimburse at 15% of the fee schedule amount. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 5 Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. VIII. Modifier 56-Preoperative Management Only A. Modifier 56 is reported when 1 physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code. B. Modifiers 56 must only be appended to the surgical procedure code. C. Procedure code with modifier 56 appended will reimburse at 15% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. IX. Modifier 62-Two Surgeons A. Modifier 62 is reported when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure. 1. Each surgeon must report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons. 2. Each surgeon must report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported without the modifier 62 added. 3. If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or 82 added, as appropriate. B. Procedure code with modifier 62 appended will be reimbursed at 62.5% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. X. Modifier 66-Surgical Team A. Modifier 66 is reported when three or more surgeons work together during a highly complex procedure are carried out under the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure code used for reporting services. B. Claims submitted by team surgeons are identified with modifier 66. C. The Centers for Medicare & Medicaid Services (CMS) established a Team Surgery Indicator (TEAM SURG) found in the CMS National Physician Fee Schedule Relative Value File. Values are: 1. 0-Team surgeons not permitted for this procedure. 2. 1-Team surgeons may be paid; supporting documentation is required to establish medical necessity. 3. 2-Team surgeons permitted. 4. 9-Team surgeon concept does not apply. D. Codes with CMS Team Surgery Indicators of 0 and 9 should not be billed with modifier 66. E. Modifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate procedure not included in the team surgery. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 6 F. Only one surgeon maybe be considered the primary surgeon. CareSource will not reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon. G. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. H. Procedure code with modifier 66 appended will reimburse at 150% of the established fee, divided equally between the team surgeons. I. For team surgery with three surgeons, each surgeon will be reimbursed at 50% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. XI. Modifier 73-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia A. Modifier 73 is reported to a service to indicate that due to extenuating circumstances or those that threaten the well-being of the patient, a surgical or diagnostic procedure at an outpatient hospital or ambulatory surgical center (ASC) was discontinued prior to the administration of anesthesia. B. Modifier 73 is only appropriate for use by an ASC. C. Modifier 53 should not be used for any ASC service as the modifier is used exclusively on a professional claim. D. Procedure code with Modifier 73 appended will reimburse at 50% of the ASCs fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. XII. Modifier 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia A. Modifier 74 is reported when due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia or after the procedure was started (incision made, intubation started, scope inserted.) B. Modifier 74 is not appropriate for the elective cancellation or postponement of a procedure based on the physician or patients choice. C. Modifier 74 is not appropriate when the termination of the procedure occurs prior to the beginning of the procedure or the administration of anesthesia. D. Modifier 74 is not for physician use. It is only appropriate for the ASC. E. Procedure code with modifier 74 appended will be reimbursed at 100% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. XIII. Modifier 78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period A. Modifier 78 is reported to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 7 1. When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. 2. Modifier 78 should be appended when: i. The return to the operating room is unplanned. ii. The service is performed by same physician who performed the initial procedure. iii. The service is related to the initial procedure. iv. The service is performed during the postoperative period of the initial procedure (10-90 days) B. Procedure code with modifier 78 appended will be reimbursed at 70% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support to use of this modifier. XIV. Modifier 80-Assistant Surgeon A. Modifier 80 is reported to indicate surgical assistant services by a physician and is applied to the surgical procedure code(s). B. Assistant Surgeon provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated. C. Modifier 80 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 80 appended will be reimbursed at 16% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XV. Modifier 81-Minimum Assistant Surgeon A. Modifier 81 is reported to indicate minimum surgical assistant services and is applied to the surgical procedure code(s). B. Minimum Assistant Surgeon is an assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon. C. Modifier 81 will not be accepted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 81 appended will be reimbursed at 16% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XVI. Modifier 82-Assistant Surgeon (when qualified resident surgeon not available) A. Modifier 82 is reported to indicate when surgical assistance is needed, but a qualified resident was not available. B. Modifier 82 is used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 8 C. The unavailability of a qualified resident surgeon is a prerequisite for the use of this modifier. The assistant must provide documentation (certification) stating that a qualified resident was not available for this procedure and why the resident was not available. D. Procedure code with modifier 82 appended will be reimbursed at 16% of the fee schedule amount. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery and why a qualified resident was not available. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XVII. Modifier AA-Anesthesia services performed personally by an anesthesiologist A. Modifier AA is used to report when the anesthesia services are personally performed by an Anesthesiologist. B. Procedure code with modifier AA appended will be reimbursed at 100% of the fee schedule amount. XVIII. Modifier AD-Anesthesia services supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. A. Modifier AD is used to report when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. B. Procedure code with modifier AD appended will be reimbursed at 100% of the fee schedule amount. XIX. Modifier QK-Medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. A. Modifier QK is used to report when medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. B. Procedure code with modifier QK appended will be reimbursed at 50% of the fee schedule amount. XX. Modifier QX-Anesthesia services performed by a CRNA with medical direction by an anesthesiologist. A. Modifier QX is used to report when the anesthesia services are performed by a CRNA with medical direction by an anesthesiologist. B. Procedure code with modifier QX appended will be reimbursed at 50% of the fee schedule amount. XXI. Modifier QY-Anesthesia services when an Anesthesiologist medically directs one CRNA. A. Modifier QY is used to report when an Anesthesiologist medically directs one CRNA. B. Procedure code with modifier QY appended will be reimbursed at 50% of the fee schedule amount. XXII. Modifier QZ-Anesthesia services performed personally by a CRNA without medical direction by a physician. A. Modifier QZ is used to report when the anesthesia services are personally performed by a CRNA. B. Procedure code with modifier QZ appended will be reimbursed at 100% of the fee schedule amount. XXIII. Modifier AE-Registered dietician A. Modifier AE is reported to indicate when a registered dietician provides the service. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 9 B. Procedure code with modifier AE appended will be reimbursed at 85% of the fee schedule amount. XXIV. Modifier AS-Physician Assistant (PA), Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) served as the assistant at surgery. A. Modifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in place of another surgeon. B. Procedure code with modifier AS appended will be reimbursed at 16% of the base code allowable schedule before multiple surgery reductions are taken. No multiple surgery reductions will be taken on codes with the AS modifier. Note: Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XXV. Modifier JG-Drug or biological acquired with 340B drug pricing program discount A. Providers are required to report modifier JG on the same claim line as the drug or biological HCPCS code to identify if a drug or biological was acquired under the 340B Program. B. HCPCS code with modifier JG appended will reimburse at the average sales price (ASP) minus 23% for certain separately payable drugs or biologicals that are acquired through the 340B Program. XXVI. Modifier JW-Drug amount discarded (wasted)/not administered to any patient A. CareSource will consider reimbursement for: 1. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. 2. The wasted amount when billed with the amount of the drug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSource will NOT consider reimbursement for: 1. The wasted amount of a multi-dose vial drug. 2. Any drug wasted that is billed when none of the drug was administered to the patient. 3. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. XXVII. Modifier SA-Nurse practitioner (NP) rendering service in collaboration with a physician A. Modifier SA is reported to indicate when a supervising physician is billing on behalf of an ANP, or CRNFA for non-surgical services. B. Modifier SA is used when the ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier SA appended will be reimbursed at 85% of the fee schedule amount. XXVIII. Modifier TB-Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes. A. Modifier TB must be reported to identify if a drug or biological was acquired under the 340B Program. B. The use of modifier TB will not trigger a payment adjustment. Providers will receive the average sales price (ASP), plus 6% for separately payable drugs furnished. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 10 XXIX. Modifier TC-Technical Component A. Technical component charges are institutional charges and not billed separately by physicians. B. A charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding Modifier TC to the usual procedure code. XXX. Modifier 26-Professional Component A. Certain procedures are a combination of a physician component and a technical component. B. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. Note: In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document. F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 09/01/2019 New policy Date Revised Date Effective 09/01/2019 H. References 1. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 3/22/2019 from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/Billing-340B-Modifiers-under-Hospital-OPPS.pdf. 2. CPT overview and code approval. (2019, March 22). Retrieved from https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval. 3. Medicare Claims Processing Manual Chapter 12-Physicians/Nonphysician Practitioners. (2018, November 30). Retrieved February 18, 2019 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 4. Medicare Claims Processing Manual Chapter 14-Ambulatory Surgical Centers. (2017, December 22). Retrieved February 18, 2019 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf. Reimbursement Modifiers MEDICARE ADVANTAGE PY-0716 Effective Date: 09/01/2019 11 5. Optum360 EncoderProForPayers.com-Login. (2019, February 18). Retrieved February 18, 2019 from https://www.encoderprofp.com/epro4payers/allModifiersHandler.do?_k=101*0&_a=listRelated&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) Interpretation PY-0785 08/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable ref erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal 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 ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y 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………………………………………………………………………………………………………………. 4 Em ergency Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICARE ADVANTAGE PY-0785 Effective Date: 08/01/2019 2 A. Subject Eme rge ncy De pa rtme nt Ele ctroca rdiogra m (EKG/ECG) Inte rpre ta tion 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-invasi ve 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 Eme rge ncy me dica l 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. Ele ctroca rdiogra m (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. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs completed in the Emergency Department (Place of service (POS) 23). A. Regardless of POS, the modifier appended to the CPT code determines a duplicate service. II. CareSource will reimburse the first EKG claim that is received for the member of the date of service. A. If another claim for the same service EKG 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. 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. C. If a second EKG is medically necessary, on the same date of service, to determine a cardiac change before the member is discharged, modifier 76 or modifier 77 must be appended to the s ec ond EKG for reimburs ement. Em ergency Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICARE ADVANTAGE PY-0785 Effective Date: 08/01/2019 3 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 follow ing list(s) of code s is provide d a s a re fe re nce . This list ma y not be a ll inclusive a nd is subje ct to upda te s. CPT Code Description 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 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 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 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 F. Related Policies/Rules N/A G. Review/Revision History DAT EACT ION Da te Issue d 08/01/2019 New policy Da te Re vise d Da te Effe ctive 08/01/2019 Em ergency Departm ent Electrocardiogram (EKG/ECG) Interpretation OHIO MEDICARE ADVANTAGE PY-0785 Effective Date: 08/01/2019 4 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-data base/d etails/lcd-details.aspx?LCDId=3728 3& ver=9& Doc Type= 2&Cntrctr=23 8&CntrctrSelected= 23 8*2&s=42&bc=AAIAAAAAAAAA&. 2. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/he alth-to pics/electrocar diog ram 3. Physician Fee Schedule Search. (2019). Retrieved 3/12/2019 from https://www.cms.gov/apps/physician-fee-sched ule/sea rch/searc h-results.aspx?Y=0&T=0&HT=0&CT=3&H1=93 01 0&M=5. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Independent m edical review 2/2015
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12 /01/2017-02/19/2020 Policy Name Policy Number Transtho racic Echocardiogram PY-0187 Policy Type Med ical Ad ministrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case a nd may modify this Policy at any time.Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …….. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. ……. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ……………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ………. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …………. 2 D. POLICY ………………………….. ………………………….. ………………………….. …………………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………….. 2 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 Tran sth o racic Ech o cardio gramOh io Med icare Ad van tag ePY-0187 Effective Date: 12-01-2017 2A. SUBJECT Transtho racic Echocardiogram 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 no t a g uarantee of p ayment. Reimbursement for claims may b e 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 se lf-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 propriate CPT/HCPCS co de(s) for the p roduct o r service that is being pro vided. The inclusion of a coded o es not impl y any rig ht to reimbursement or g uarantee claims payment.CareSo urce will reimburs e participating p roviders, for transthoracic echocardiograms (TTE)rend ered to CareSource members, as set forth in this policy.C. DEFINITIONSTranstho racic E chocardiogram (TTE) – is a typ e of echocardiogram, in which an ultrasound probe (o r ultraso nic transducer) is p laced on the chest o r abdomen of the p atient to o btain various views o f the heart. D. POLICYI. CareSo urce d oes no t req uire a p rior authorization for a transthoracic echocardiogram (TTE). II. A transtho racic echocardiogram may be reimbursed according to Centers for Medicare and Med icaid Services (CMS) LCD 34338 g uidelines using appropriate CPT and modifier codes(if ap p licable).III. A transtho racic echocardiogram may be reimbursed according to Medicaid guidelines using ap p ro priate CPT and /or HCPCS and modifier codes (if applicable).IV. Reimb ursement is based o n submitting a claim with the appropriate ICD-10 d iagnosis code to match the transtho racic echocardiogram CPT code. V. If the ap p ropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will bed enied .Note: Altho ug h a transthoracic echocardiogram d oes not require a p rior authorization, co mp liance with the provisions in this policy may b e monitored and addressed through post p ayment data analysis and subsequent medical review audits. E. CONDITIONS OF COVERAGEReimb ursement is dependent o n, b ut not limited to, submitting CMS ap proved HCPCS and CPT co d es alo ng with appro priate modifiers. Please refer to the Medicare fee schedule: http s ://www.cms.gov/apps/physician-fee-schedule/overview.aspx Tran sth o racic Ech o cardio gramOh io Med icare Ad van tag ePY-0187 Effective Date: 12-01-2017 3F. RELATED POLICIES/RULESG. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 03/08/2017 New p o licy.Date Revised 04/02/ 2019 Remo ved code matching tables from policy. CareSo urce f ollows LCD L34338. Updated CMS LCD link link was b ro ken. Date Effective 12 /01/2017 Date Archived 02/19/2020 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 right to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. Overview of the Medicare Physician Fee Schedule Search. (2017, January 19). Retrieved2/6/2017 f ro m https://www.cms.gov/apps/physician-fee-schedule/overview.aspx2. Echo cardiogram: MedlinePlus Medical Encyclopedia. (2015, April 20). Retrieved2/6/2017f ro m https://medlineplus.gov/ency/article/003869.htm3. Current Pro ced ural Termino logy (CPT) and National Uniform Billing Co mmittee (NUBC)Licenses. (2016, October 1). Retrieved 4/2/2019 from http s://www.cms.gov/medicare-coverage-database/details/lcd – d etails.aspx?LCDId=34338&ver=21&Date=12%2f17%2f2018&DocID=L34338&bc=iAAAABAAAAAA& The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
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