REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 03/08/2017 03/08/2018 12/01/2017 Policy Name Policy Number Non-Invasive Vascular Studies PY-0168 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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. Contents of Policy RE IMBURSEMENT POL IC YS TATEMENT …………………………………………………………………. 1 TABLE OF CONTENTS ……………………………………………………………………………………………….. 1 A. SUBJECT …………………………………………………………………………………………………………… 2 B. BACKGROUND ………………………………………………………………………………………………….. 2 C. DEFINITIONS …………………………………………………………………………………………………….. 2 D. POL IC Y ……………………………………………………………………………………………………………… 2 E. COND ITIONS OF COVERAGE ………………………………………………………………………….. 3 F. RELATED POL IC IES/RULES …………………………………………………………………………….. 4 G. REVIEW /REV IS ION HIS TORY…………………………………………………………………………… 4 H. REFERENCES …………………………………………………………………………………………………… 4 Non-Invas ive Vas cular Tes ting OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2017 2 A. SUBJECT Non-Invasive Vascular Studies B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse providers, for non-invasive vascular studies to CareSource members, as set forth in this policy. Non-invasi ve vascular studies may be used interchangeably with Duplex scan or Duplex ultrasound for the purposes of this policy. C. DEFINITIONS Duple x Ultra sound is a test to see how blood moves through the arteries and veins of the body. D. POLICY I. CareSource does not require a prior authorization for a non-invasive vascular study. II. A non-invasive vascular study may be reimbursed according to Centers for Medicare & Medicaid Services (CMS)/LCD guidelines using appropriate CPT and/or HCPCS and modifier codes (if applicable). III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the non-invasi ve vascular study CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. V. To be considered medically necessary the ordering physician must have reasonable expectation that the non-invasi ve vascular study results will potentially impact the clinical management of the patient. VI. To be considered medically necessary the following conditions must be met: A. Significant signs/symptoms of arterial or venous disease are present B. The information is necessary for appropriate medical and/or surgical management C. The test is not redundant of other diagnostic procedures that must be performed. VII. It is the responsibility of the physician/provider to ensure the medical necessity of procedures and documentation of such in the medical record. Non-Invas ive Vas cular Tes ting OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2017 3 Note : Although a Non-Invasi ve Vascular Study does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule https://www.cms.gov/apps/physician-fee-sched ule/sea rch/searc h-crite ria.aspx 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. Ple a se re fe r to the a bove re fe re nce d source for the most curre nt coding informa tion. CPT Code s De finition 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 93998 Unlisted noninvasive vascular diagnostic study ICD-10 De finition I70.0 Atherosclerosis of aorta I72.4 Aneurysm of artery of lower extremity S85.142A Laceration of anterior tibial artery, left leg, initial encounter S45.002A Unspecified injury of axillary artery, left side, initial encounter Q87.82 Arterial tortuosity syndrome Non-Invas ive Vas cular Tes ting OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2017 4 S85.819A Laceration of other blood vessels at lower leg level, unspecified leg, initial encounter I82.419 Acute embolism and thrombosis of unspecified femoral vein S35.319S Unspecified injury of portal vein, sequela F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DAT EACT ION Date Issued 03/08/2017 Date Revised 04/02/2019 Revised CMS LCD link in references link was broken Date Effective 12/01/2017 H. REFERENCES 1. Physician Fee Schedule Search. (2017, January 1). Retrieved 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 92 5&M=5 2. Duplex Ultrasound | Society for Vascular Surgery. (2017, February 10). Retrieved 2/10/2017 from https://vascular.org/patient-reso urces/ vascular-tests/duplex-ultraso un d 3. MedlinePlus-Search Results for: ultrasound. (2017, February 10). Retrieved 2/10/2017 from https://vsearch.nlm.nih.gov/ vi visimo/cgi-bi n/qu ery-meta?v%3Aproject=medline plus& v%3Asou rces=medlin epl us-bundle&query=ultrasound& _g a=1.23 90 609 34.7 98 803 35 4.14 84 937 05 2 4. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2017, January 1). Retrieved 4-2-2019 from https://www.cms.gov/medicare-coverage-data base/d etails/lcd-details.aspx?LCDId=3404 5& ver=2 2&Date=12% 2f17%2 f201 8&DocID=L3 40 45&Se arch Typ e=Advanced&bc=KAAAABAAAAAA& The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT MARKETPLACE PLANS Original Issue Date Next Annual Review Effecti ve Date 03/08/2017 05/01/2018 05/01/2017-12/31/2021 Policy Nam e Policy Number Vitamin DA ss ay Te s ti ng PY-0228 Policy Type Med ic al A d m i nis trati ve Pharmac y RE I MBURS EMENT Contents of PolicyREIMBURSEMENT PO LI CY STATEMENT ……………………………………………………………….1 TABLE OF CONTENTS ……………………………………………………………………………………………1 A. SUBJECT ………………………………………………………………………………………………………2 B. BACKGROUND ……………………………………………………………………………………………..2 C. DEFINITIONS ………………………………………………………………………………………………..2 D. POLICY ………………………………………………………………………………………………………..2 E. CONDITIONS OF COVERAGE ……………………………………………………………………….3 F. RELATED POLICIES/RULES ………………………………………………………………………….3 G. REVIEW/REVISION HISTORY………………………………………………………………………..3 H. REFERENCES ………………………………………………………………………………………………3 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billin g , coding a nd documentation guidelines. Co din g methodology, regulatory requirements, industry-s t andard 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, medi c al necessity, adherence to pla n po licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd ap p lica ble re f e rral, 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 with o u t wh ich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of func tion, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or 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. 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 t his Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlli ng document used to make the determination. CS MG Co . and its affiliates may use reasonable discretion in interpreting and applying this Po licy to services provided in a particular case and may modify this Policy at any time. 2 Vitamin DAs s ay Testing Mark etp l ac e Pl an s PY-0228 Effec ti v e Date: 05/01/2017A. SUBJECTVita min DAssay Te s t ing B. BACKGROUND Reimb urs ement p olicies are d esigned to assist you when s ubmitting c l a im s to CareSource. 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 g uarantee of payment. Reimb urs em ent for c laims 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 actual services prov ided to a member and will be determined when the claim is rec eived for proc essing. Health c are p ro viders and their office s taff are enc ouraged to use s elf-s ervice c hannels to verify memb ers eligibility. It i s the res p o nsibility of the submitting pro vider to submit the most ac curate and appropriate CP T/ HCP CS c ode(s ) for the p roduct o r s ervice that is being provided. Th e inclusio n of a c ode d o es not imply any rig ht to reimbursement or g uarantee c laims pay ment. Altho ugh an ex ces s of vitamin Dis rare it c an lead to hyperc alc emia. Vitamin Ddefic iency may lead to numerous disorders, the most wid ely known is ric kets. As sessing patients v itamin Dlev els is ac hieved by measuring the level of 25-hy droxyv itamin D . Evaluation of o ther metabolites is g enerally no t medically nec es sa ry . C. DEFINITIONSSev ere d ef iciency: 25(OH)D : 80 ng/ml D. POLICYI. CareSo urc e d oes not require a p rior authorization for Vitamin Dtesting. II. CareSo urc e c onsiders Vi ta m in Dlev els testing medically necess ary for patients wit h the f o llowing: A. Chro nic k idney disease s tage III or g reater B. Os teo porosis C. Os teo malacia D. Os teo penia E. Hy p o ca lce m ia F. Hy p erc alciura G. Hy p o parathyroidis m H. Malab s orption s tates I. Cirrho s is J. Hy p erv itaminosis DK. Os teo sclerosis/petros is L. Rickets M. Lo w ex p o sure to sunlight N. Vitamin Ddeficiency to monitor the ef f icacy of rep lac ement therapy III. Reimb urs ement is based on s ubmitting a claim wi th the ap propriate ICD-10 diagnosis c ode to matc h the Vitamin DAs say Tes ting CPT c o de. IV . If the ap p ro priate ICD-10 diagnosis code is not s ubmitted wit h the CPT c ode, the claim will be d enied . 3 Vitamin DAs s ay Testing Mark etp l ac e Pl an s PY-0228 Effec ti v e Date: 05/01/2017Note: Altho ug h this s erv ic e does no t req uire a p rior authorization, CareSource may req ues t d ocumentation to s upport medical neces sity. Ap propriate and complete d o c umentation m ust be presented at the t i me of rev iew to validate medic al nec essity.E. CONDITIONS OF COVERAGE Reimb urs ement is dependent on, b ut not limited to, s ubmitting CMS ap proved HCPCS and CP Tc o d es alo ng with appropriate modifiers. Pleas e ref er to the CMS fee sc hedule ht t p s: // www. cms.gov/ apps/physician-fee-schedule/search/search-criteria.aspx Th e f o llowing list(s ) of c odes is p rovided as a ref erence. This lis t may no t b e all inclusive and is s ub jec t to updates . Pleas e refer to the above referenced s ource for the mos t c urrent c o d ing information. CP T Codes Definition82306 VITA MIN D; 25 HY DROXY , INCLUD ES FRA CTION(S ), IF PE RFORMED I CD 10 codes DescriptionE20.0 Idiopathic hypoparathyroidism E20.8 Other hy p oparathyroidism E20.9 Hy p o parathyroidis m, unspecified E21.0-E21.3 Primary hy p erparathyroidism-Hy perparathy roidis m, unspecified E41 Nutritio nal marasmus E43 Uns p ec ified s evere protein-calorie malnutrition E55.0 Rickets, ac ti ve E55.9 Vitamin Dd ef iciency, unspecified E67.3 Hy p erv itaminosis D E67.8 Other s p ec ified hyperalimentation E68 Seq uelae of hyperalimentation E83.31 Familial hy p ophosphatemia E83.32 Hered itary vitamin D-dependent ric kets (t ype 1) (t y pe 2) E83.39 Other d is orders of phos phorus metabolism E83.51 Hy p o ca lce m ia E83.52 Hy p erc alcemia E84.0 Cystic fibrosis wit h pulmonary manifestations E84.11 Mec o nium ileus in c yst ic fibrosis E84.19 Cystic fibrosis wi th o ther intestinal manifestations E84.8 Cystic fibrosis wit h other manifestations E89.2 Po s tprocedural hypoparathy roidism K50.00 Cro hn’ s d isease of small intes tine without complications 4 Vitamin DAs s ay Testing Mark etp l ac e Pl an s PY-0228 Effec ti v e Date: 05/01/2017K 50.011 Cro hn' s d isease of s mal l intestine wit h rec tal bleeding K50.012 Cro hn' s d isease of s mal l intestine wit h intestinal obs truction K50.013 Cro hn' s d isease of small intestine wit h f ist u la K50.014 Cro hn' s d isease of small intestine wi th ab scess K50.018 Cro hn' s d isease of s mal l intestine wit h other complication K50.111 Cro hn' s d isease of large intestine wit h rec tal bleeding K50.112 Cro hn' s d isease of large intestine wit h intestinal obstruction K50.113 Cro hn' s d isease of large intes tine wi th fistula K50.114 Cro hn' s d isease of large intes tine wi th abs cess K50.118 Cro hn' s d isease of large intes tine wi th o t he r c omplic ation K50.80 Cro hn' s d isease of both s mal l and large intestine without c omplic ations K50.811 Cro hn' s d isease of b oth s m a ll and large intestine wit h rec tal bleeding K50.812 Cro hn' s d isease of both s m a ll and large intes tine wi th intestinal o b s tructi on K50.813 Cro hn' s d isease of b oth s mal l and large intestine wit h fistula K50.814 Cro hn' s d isease of b oth s mal l and large intestine wit h abscess K50.818 Cro hn' s d isease of both s m a ll and large intestine wi th o ther c o mplication K50.90 Cro hn' s d is eas e, unspec ified, without complications K50.911 Cro hn' s d isease, unspecified, with rec tal b leeding K50.912 Cro hn' s d is ease, uns pecified, wit h intestinal obstruction K50.913 Cro hn' s d is ease, uns pecified, wit h f i stu la K50.914 Cro hn' s d is ease, uns pecified, wit h abscess K50.918 Cro hn' s d is ease, uns pecified, wit h o ther complication K51.00 Ulc erativ e (c hro nic) pancolitis without complic ations K51.011 Ulc erativ e (c hronic) p ancolitis wit h rec tal bleeding K51.012 Ulc erativ e (c hronic) p ancolitis wit h intes tinal obstruc tion K51.013 Ulc erativ e (c hronic) p ancolitis wi th fistula K51.014 Ulc erativ e (c hronic) p anc olitis wi th abs ces s K51.018 Ulc erativ e (c hronic) p ancolitis wit h o t he r c omplic ation K51.20 Ulc erat ive (c hro nic) proc ti ti s without complications K51.211 Ulc erativ e (c hro nic ) proc ti ti s wit h rec tal bleeding K51.212 Ulc erativ e (c hronic) proctitis wi th intestinal o bstruction K51.213 Ulc erativ e (c hronic) p roctitis with fistula K51.214 Ulc erativ e (c hronic) p roctitis with absc es s K51.218 Ulc erativ e (c hronic) p roct itis wit h other complication 5 Vitamin DAs s ay Testing Mark etp l ac e Pl an s PY-0228 Effec ti v e Date: 05/01/2017K51.30 Ulc erativ e (c hro nic) rec tosigmoiditis without complicationsK51.311 Ulc erativ e (c hronic) rec tosigmoiditis wit h rec tal bleeding K51.312 Ulc erativ e (c hronic) rec tos igmoiditis wi th intestinal o bstruction K51.313 Ulc erativ e (c hronic) rec tos igmoiditis wi th fistula K51.314 Ulc erativ e (c hronic) rec tos igmoiditis wi th ab scess K51.318 Ulc erativ e (c hronic) rec tos igmoiditis wi th o ther c omplication K51.40 Inf lammatory polyps of c olon without complications K51.411 Inf lammatory p oly ps of c olon wit h rec tal bleeding K51.412 Inf lammatory polyps of colon wit h intestinal obstruction K51.413 Inf lammatory p oly ps of c olon wit h fistula K51.414 Inf lammatory p oly ps of c olon wit h ab scess K51.418 Inf lammatory polyps of c olon wit h o ther c omplication K51.50 Lef t s ided colitis without c omplications K51.511 Lef t sid ed colitis with rec tal bleeding K51.512 Lef t s ided colitis wi th intes tinal obstruc tion K51.513 Lef t s ided colitis wit h f ist u la K51.514 Lef t s ided colitis wit h abscess K51.518 Lef t s ided colitis wi th o ther c omplic ation K52.0 Gas tro enteritis and colitis due to radiation K70.2 Alco holic f ib ro si s and sc le ro s is of liver K70.30 Alco holic cirrhos is of liver without as cites K70.31 Alco holic c irrho sis of liver with a s c it es K74.1 Hep atic s clerosis K74.2 Hep atic fibrosis wit h hepatic sc lerosis K76.9 Liv er d is ease, unspec ified K90.0 Celiac d isease K90.1 Tropical s prue K90.2 Blind lo op s yndrome, not elsewhere classif ied K90.3 Panc reatic steatorrhea K90.41 No n-c eliac gluten sensitivity K90.49 Malab s orption due to intolerance, no t elsewhere c l a ssif ie d K90.89 Other intes tinal malabsorption K90.9 Intes tinal malab sorption, unspecified K91.2 Po s tsurgical malabsorption, not els ewhere cl ass if ie d 6 Vitamin DAs s ay Testing Mark etp l ac e Pl an s PY-0228 Effec ti v e Date: 05/01/2017M 80.00XA Age-related osteoporos is wi th c urrent p athological fracture, uns p ec ified s ite, initial encounter for fracture M80.011A Age-related os teoporosis wit h c urrent pathological frac ture, right s ho uld er, initial enc ounter for frac ture M80.012A Age-related osteoporos is wi th c urrent pathological fracture, left s ho uld er, initial enc ounter for frac ture M80.021A Age-related os teoporosis wit h c urrent pathological frac ture, right humerus , initial enc ounter for frac ture M80.022A Age-related osteoporos is wi th c urrent p athological fracture, l ef t humerus , initial enc ounter for frac ture M80.031A Age-related os teoporosis wit h c urrent pathological frac ture, right f o rearm, initial enc ounter for f racture M80.032A Age-related osteoporos is wi th c urrent p athological fracture, l ef t f o rearm, initial enc ounter for f racture M80.041A Age-related os teoporosis wit h current pathological frac ture, right hand, initial enc o unter for f racture M80.042A Age-related osteoporos is wit h c urrent p athologic al f racture, left hand , initial enc o unter for f racture M80.051A Age-related o steoporosis wit h c urrent pathologic al frac ture, right f emur, initial enc ounter for frac ture M80.052A Age-related osteoporos is wi th c urrent p athological fracture, left f emur, initial enc o unter for f racture M80.061A Age-related osteoporos is wi th c urrent pathological fracture, rig ht lower leg , initial en c ounter for frac ture M80.062A Age-related osteoporos is wi th c urrent pathological frac ture, left lower leg , initial enc ounter for frac ture M80.071A Age-related os teoporosis wit h c urrent pathological fracture, right ank le and f o ot, initial encounter for fracture M80.072A Age-related o steoporosis wit h c urrent p athologic al f racture, l ef t ank le and f o ot, initial encounter for fracture M80.08XA Age-related o steoporosis wit h c urrent p athologic al f racture, v ert eb ra(e), in itial encounter f or fracture M81.0 Age-related os teoporosis without current pathological f racture M81.6 Lo c alized osteoporos is [Lequesne] M81.8 Other o s teoporosis without current pathological f racture M83.0-M83.5 Puerp eral o s teomalacia-Other drug-induc ed o steomalac ia in ad ults M83.8 Other ad ult os teomalacia M85.80 Other s p ec ified d is orders of b o ne d ensity and s truc ture, unspecified site M85.811 Other s p ec ified disorders of bone density and st ruct ure, right shoulder M85.812 Other s p ec ified disorders of b one d e ns it y and s truc ture, left shoulder M85.821 Other s p ec ified d is orders of bone d ensity and s truc ture, right up per arm M85.822 Other s p ec ified disorders of bone dens ity and s tructure, left up per arm M85.831 Other s p ec ified disorders of bone density and st ruct ure, right f orearm M85.832 Other s p ec ified disorders of bone dens ity and s truc ture, l ef t f orearm M85.841 Other s p ec ified disorders of bone density and structure, right hand 7 Vitamin DAs s ay Testing Mark etp l ac e Pl an s PY-0228 Effec ti v e Date: 05/01/2017M85.842 Other s p ec ified disorders of b one density and struc ture, left handM85.851 Other s p ec ified disorders of bone density and st ruct ure, right thigh M85.852 Other s p ec ified disorders of b one d e ns it y and s truc ture, left t hi g h M85.861 Other s p ec ified disorders of bone density a nd s truc ture, right lower leg M85.862 Other s p ec ified disorders of b one density and structure, left lower leg M85.871 Other s p ec ified d is orders of bone d e ns it y and s tructure, right ankle and f o ot M85.872 Other s p ec ified disorders of bone density a nd s tructure, l ef t ankle and f o ot M85.88 Other s p ec ified disorders of bone dens ity and structure, o ther s ite M85.89 Other s p ec ified disorders of bone density and structure, multiple si tes M89.9 Dis o rder of bone, unspecified M94.9 Dis o rder of c artilage, unspecified N18.3-N18.6 Chro nic k idney d isease, s t ag e 3 (moderate) – End s tage renal diseas e N25.81 Sec o ndary hyperparathyroidis m of renal o rig i n Q78.2 Os teo porosis AUTHORI ZATION PER I ODF. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 03/08/2017 Date Revised 03/19/2019 Up d ated c ode l is t b ased on LCD ed i t Date Effecti ve 05/01/2017 Date Archived 12/31/2021 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. REFERENCES1. Lo c al Co verage Determination (LCD ) Vitamin DAs say Tes ting (L33996). Retrieved Marc h 19, 2019 2. Vitamin DIns ufficiency. Retrieved March 2, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912737/ 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 Avastin for use in Ophthalmology Billing Guideline PY-0739 05/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Avastin for use in Ophthalmology Billing Guideline OHIO MEDICARE ADVANTAGE PY-0739 Effective Date: 05/01/2019 2 A. Subject Avastin for use in Ophthalmology Billing Guideline 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. Avastin is a drug used in the treatment of wet age-related macular degeneration, diabetic eye disease and other problems of the retina. Avastin is injected into the eye and helps to slow down disease related vision loss. The use of Avastin to treat eye disease is considered off-label, which is allowed by the FDA when doctors are well informed regarding the drug and there are studies that prove its an effective treatment option. There is no cure for macular degeneration, treatment is aimed at slowing down the progression of the disease and preventing vision loss. C. Definitions Macular Degeneration a progressive vision impairment resulting from deterioration of the central part of the retina, known as macula. D. Policy I. CareSource does not require a Prior Authorization for the use of Avastin in Ophthalmology, when billed with the following codes: A. J3490 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement up to $140.00 for both eyes, per calendar month. B. J3590 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement up to $140.00 for both eyes, per calendar month. E. Conditions of Coverage HCPCS J3490, J3590 NDC 50242-0061-01 or 50242-0060-01 F. Related Policies/Rules N/A Avastin for use in Ophthalmology Billing Guideline OHIO MEDICARE ADVANTAGE PY-0739 Effective Date: 05/01/2019 3 G. Review/Revision History DATE ACTION Date Issued 05/01/2019 New policy Date Revised Date Effective 05/01/2019 H. References 1. Boyd, K. (2018, May 22). What Is Avastin? Retrieved October 29, 2018, from https://www.aao.org/eye-health/drugs/avastin 2. “Off-Label” and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices-Information Sheet. (2018, July 12). Retrieved October 29, 2018, from https://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE Policy Name Policy Number Effective Date Readmission PY-0774 3/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its 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………………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………….. 5 F. Related Policies/Rules………………………………………………………………………………………………. 5 G. Review/Revision History ……………………………………………………………………………………………. 5 H. References………………………………………………………………………………………………………………. 6 Readm ission OHIO MEDICARE PY-0774 Effective Date: 3/1/2019 2 A. Subject Re a dmission B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims of Readmissions for our Medicare Advantage members may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Following a hospitalization, readmission within 30 days is often a costly preventable event and is a quality of care issue. It has been estimated that readmissions within 30 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result from many situations but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progression of the disease state or due to chronic conditions. The purpose of this policy is to improve the quality of inpatient and transitional care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission: a subsequent inpatient admission to any acute care facility which occurs within 30 days of the discharge date; excluding planned adm is s ions . Planned Readmission: a non-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Potentially Preventable Readmission (PPR): a readmission within a specific time frame that is clinically related and may have been prevented had appropriate care been provided during the initial hospital stay and discharge process. A PPR is determined when, based on CareSource guidelines, it is determined that the patient was discharged prematurely. Premature discharge evidence can be described as, Readm ission OHIO MEDICARE PY-0774 Effective Date: 3/1/2019 3 but not limited to, elevated fever at the time of discharge, abnormal lab results or evidence of infection or bleeding a wound. Same or Similar Condition: a condition or diagnosis that is the same or a similar condition as the diagnosis or condition that is documented on the initial admission. Same Day: CareSource delineates same day as midnight to midnight of a single day. D. Policy I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observational services for the following categories: A. Same day readmission or observational stay for a related condition B. Same day readmission or observational stay for an unrelated condition C. Planned Readmissions and/or leave of absence D. Unplanned admissions to an acute, general, short-term hospital occurring within 30 calendar days from the date of discharge from the same or another acute, general, short-term hospital II. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim. III. An administrative review of all readmissions will take place based on the following Medicare readmission review criteria: A. Same day readmission or observational stay for a related condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed bas ed on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital combine the two admissions on one claim. 2. If the member is readmitted during the same day as the initial admission for the same or a related condition and both the initial and the subsequent admission are billed separately, CareSource will deny the claim as separate DRGs. The facility must submit the initial admission and the subsequent admission on one claim to receive reimbursement. B. Same day readmission or observational stay for an unrelated condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed bas ed on Chapter 3, Sec tion 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital to bill the claims separately but the claim that contains an admission date that is the same as the discharge date must include condition code B4 as indicated in the Medicare billing guidelines . C. Planned readmission and/or leave of absence criteria: Readm ission OHIO MEDICARE PY-0774 Effective Date: 3/1/2019 4 1. When a readmission to the same acute care facility or inpatient hospital is expected and the member does not require a hospital level of care during the timeframe between the two admissions, the member may be placed on leave of absence by the provider. a. CareSource follows the Medicare Inpatient Hospital Services billing guidelines found in the Medic are Claim s Proc es s ing Manual, Chapter 3 for leave of absence billing guidelines which requires that the facility submit one claim and receive one combined DRG payment for both admissions both are for the treatment of the same episode of illness. b. Examples of a planned readmission include, but are not limited to, situations where surgery could not be scheduled immediately due to scheduling availability, a specific surgical team that is needed for the procedure is not available, bilateral staged surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin at the time of initial admission. c. CareSource reserves the right to request medical records to determine if the claim was properly billed. d. Leave of absence does not apply to cancer chemotherapy or similar repetitive treatments. D. Determination of Unplanned Readmissions criteria: 1. CareSource will review the clinical documentation on all potential readmissions to determine if the admission was a potentially preventable readmission (PPR) based on the following Medicare guidelines: a. Premature discharge of patient that resulted in subsequent readmission of patient to same hospital. Premature discharge includes when a patient is discharged even though he/she should have remained in the hospital for further testing or treatment or was not medically stable at the time of discharge. A patient is not medically stable when, in CareSource judgement, the patient’s condition is such that it is medically unsound to discharge or transfer the patient. Evidence such as elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a patient may have been prematurely discharged from the hospital; b. When a patient is readmitted to a hospital for care that, pursuant to professionally recognized standards of health care, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during the first admission. c. The readmission is the result of a lack of documentation and/or coordination of care between the inpatient and outpatient team in regards to post discharge care and coordination with a CareSource Care Manager for the member. E. The following readmission criteria listed below are excluded from this readmission policy and if billed appropriately, claims will be reviewed for payment: Readm ission OHIO MEDICARE PY-0774 Effective Date: 3/1/2019 5 a. If the member is being transferred from an out-of-network to an in-network facility or if the member is being transferred to a facility that provides care that was not available at the initial facility; b. Transfers to distinct psychiatric units within the same facility. When transferring within the same facility, documentation must show that the diagnosis necessitating the transfer was psychiatric in nature and that the patient received active psychiatric treatment. c. If the readmission is part of planned repetitive treatments or staged treatments, such as chemotherapy or staged surgical procedures; d. Readmissions where the discharge status of the first discharge was left against medical advice (AMA); e. Obstetrical readmissions. IV. Post Payment Review and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissions to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical records for both admissions must be included with the claim submission to determine if the admission(s) is appropriate or is considered a readmission. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. If the included documentation determines the readmission to be an inappropriate or medically unnecessary, the hospital must be able to provide additional documentation to CareSource upon request or the claim will be denied. c. If the readmission is determined at the time of documentation review to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admission and paid as one claim to cover both, or all, admissions. 2. Appeals Process a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer review or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT IONReadm ission OHIO MEDICARE PY-0774 Effective Date: 3/1/2019 6 Da te Issue d 3/1/2019 Da te Re vise d Da te Effe ctive 3/1/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-803.McIlvenn an, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation, 131(20), 1796-803. 2. Hospital Readmission Reduction Program. (2018, December 04). Retrieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://www.cms.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 01/01/2019 01/01/2020 01/01/2019 Policy Name Policy Number Provider Home Visits PY-0444 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY ………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ………………………………………………………………….. 14 G. REVIEW/REVISION HISTORY ………………………………………………………………… 14 H. REFERENCES ………………………………………………………………………………………. 14 Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 2 A. SUBJECT Provider Home Visits 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. Provider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Place of Service (POS) – A two-digit code that indicates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner or a physician assistant. Home An individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. D. POLICY I. CareSource does not require a prior authorization for home/domicile visits for participating providers. A. CareSource reimburses for home visit services per the Medicare fee schedule. B. Claims submission must include the appropriate CPT codes along with any applicable modifier with the appropriate place of service (POS) code. II. Place of service (POS) for provider services in the home or domicile include the following: A. POS 12 Home B. POS 13 Assisted Living C. POS 14 Group Home D. POS 31 Skilled Nursing Facility (SNF) E. POS 32 Nursing Facility F. POS 33 Long-term Facility III. Home services for CareSource members: A. CareSource members do not need to be confined to their home to receive home services, provided by a physician. Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 3 B. The CareSource members medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. C. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiarys home. Note: Although CareSource does not require a prior authorization for provider home visits, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes and the appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following PDF list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Place of Service Description 12 Location, other than a hospital or other facility, where the patient receives care in a private residence. Code Description 99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. 99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. 99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family. 99344 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 4 99345 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family. 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. 99350 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. Place of Service Description 13 Congregate residential facility with self-contained living units providing assessment of each residents needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health careProvider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 5 professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 6 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Place of Service Description 14 A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration). Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 7 nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Place of Service Description 31 A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. Code Description Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 8 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 9 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 10 and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit. Place of Service Description 32 A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to individuals other than those with intellectual disabilities. Code Description 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 11 family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 12 Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit. Place of Service Description 33 A facility which provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 13 comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Modifiers Description 24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service 33 Preventive Services 57 Decision for Surgery 59 Distinct Procedural Service A1 Dressing for one wound AI Principal physician of record AM Physician, team member service Provider Home Visits OHIO MEDICARE ADVANTAGE PY-0444 Effective Date: 01/01/2019 14 AQ Physician providing a service in an unlisted health professional shortage area (HPSA) CC Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) GC This service has been performed in part by a resident under the direction of a teaching physician GV Attending physician not employed or paid under arrangement by the patient’s hospice provider GW Service not related to the hospice patient’s terminal condition HE Mental health program HO Masters degree level Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Q8 Two Class Bfindings RT Right side (used to identify procedures performed on the right side of the body) SA Nurse practitioner rendering service in collaboration with a physician F. RELATED POLICIES/RULES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 01/01/2019 New policy Date Revised Date Effective 01/01/2019 H. REFERENCES 1. Medically Necessary-HealthCare.gov Glossary. (2018, July 1). Retrieved 7/1/2018 from https://www.healthcare.gov/glossary/medically-necessary. 2. Medicare Claims Processing Manual. (2018, June 13). Retrieved 7/1/2018 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 3. Place of Service Codes-Centers for Medicare & Medicaid Services. (2012, March 5). Retrieved 7/1/2018 from https://www.cms.gov/Medicare/Coding/place-of-service-codes/index.html. 4. Place of Service Code Set-Centers for Medicare & Medicaid Services. (2016, November 17). Retrieved 7/1/2018 from https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html. 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 Original Issue Date Next Annual Review Effective Date 10/31/2013 11/29/2018 01/01/2018 Policy Name Policy Number Drug Testing PY-0088 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 2 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 3 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 6 F. RELATED POLICIES/RULES ……………………………………………………………………. 7 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 7 H. REFERENCES ………………………………………………………………………………………… 7 Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 2 A. SUBJECT Drug Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Monitoring for controlled substances is performed to detect the use of prescription medications and illegal substances of concern for the purpose of medical treatment. Monitoring for controlled substances plays a key role particularly in the care of persons undergoing medical treatment with chronic pain therapy and substance use disorder (SUD). Drug testing that is medically necessary for the management of members being treated with drugs that are potentially abusive or addictive such as opioids and related medications, or for members suspected of using illicit drugs solely or in combination with prescribed controlled substances is billable to CareSource. Qualitative/presumptive drug testing performed as part of routine, prenatal care for pregnant members is also billable to CareSource. Providers should have a working knowledge of analytic detection including primary agents, metabolites, lab threshold concentrations, and time periods involved in detection. The combination of a patient’s self-report and drug testing results serve as important tools in controlled substance monitoring, as well as a point of patient engagement. Qualitative/presumptive testing is a routine part of care, used when immediate results are needed, knowing results may be less accurate than quantitative/confirmatory tests. Quantitative/confirmatory testing is used when results may affect changes in medication, when patients dispute presumptive/qualitative results, or in treatment transitions. Anecdotal evidence to support testing for individual patients should be balanced with the limited population evidence for added value of multiple tests for chronic pain patients or SUD patients. For example, in a 2015 evaluation of 2,551,611 de-identified patients urine drug test results over four years in the U.S., Quest Diagnostics identified that the best achieved yearly inconsistency rate (when the results of a drug screen are not consistent with the patients history and prescribed medicines) in all urine drug tests was 53% (in 2014 vs 63% in 2011). C. DEFINITIONS Qualitative analysis-The testing of a substance or mixture to determine its chemical constituents, also known as presumptive testing. Quantitative test-A test that determines the amount of a substance per unit volume or weight, also known as confirmatory testing. Random alcohol and drug test a lab test administered at an irregular interval which is not announced in advance to the person being tested, and which detects the presence of alcohol, drugs or substances in the individual. Independent laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 3 Participating/Non-participating Participating means in-network and contracted with CareSource. Non-participating means out-of-network, not contracted by CareSource. For further definitions please refer to CareSource Drug Testing Medical Policy (MM-0065) posted here: https://www.caresource.com/providers/medicare-medical-policies/ D. POLICY I. Prior Authorization: Prior Authorization is required for drug testing as outlined in this policy. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care. 1. For all members, prior authorization for drug testing is not required in the emergency room (ER) setting when it is needed to evaluate acute overdose. 2. For members age 7 and older, prior authorization for drug testing is required when: 2.1 The member reaches the limits imposed by this policy within the rolling 90-day time period (See Section D-IX below); or, 3. The type of drug test or type of sample used for the drug testing is not covered by this policy. NOTE: Although the drug testing covered by this policy may or may not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II. General Criteria for Coverage: Clinical guidelines, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0065. Please refer to this policy for in-depth information on medical necessity for drug testing, documentation required for claims, and CareSource monitoring and review of drug testing claims. III. Individualized Testing: In all cases other than routine qualitative/presumptive drug testing as part of prenatal care, medical necessity for submitted charges must be individualized and documented in the members medical record and included in the treatment plan of care. CareSource does not provide coverage for drug testing for forensic, legal, employment, transportation, or school purposes or other third party requirement. IV. Non-Urine Testing: CareSource will reimburse blood testing without a prior authorization in emergency department settings only, to evaluate acute overdose. Drug testing with blood samples performed in any other setting outside of an ER requires the provider or lab to obtain prior authorization in order to be reimbursed. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered without prior authorization. Additionally, when non-urine drug testing is prior authorized, that non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing. NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. V. Urine Testing: Urine for clinical drug testing is the specimen of choice because of its high drug concentrations and well-established testing procedures. Nevertheless, urine is one of the easiest specimens to adulterate. A. If the provider suspects such an occurrence, the provider may choose to evaluate specimen validity using validity tests. Specimen validity testing is considered to be a Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 4 quality control issue and is included in the CPT code payment. Additional codes for specimen validity testing should not be separately billed to CareSource. Tests for creatinine, specific gravity, temperature, or nitrates are not billable to and will not be reimbursed by CareSource when submitted simultaneously with a drug testing CPT code and ICD-10 substance use disorder code. Failure to back up customized tests with medical necessity information for each individual member and for each of the drug tests ordered will be considered by CareSource to be routine test orders and are excluded from our members coverage and will result in the denial of the claim for reimbursement, audit, and/or overpayment requests, and any other program means for enforcing this policy. B. Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse. C. Orders for custom profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or to conduct additional testing as needed, are not billable to CareSource. D. Testing on a routine basis is neither random nor individualized. Routine or reflex testing is not billable to and will not be reimbursed by CareSource unless a prior authorization has been obtained by the provider or lab. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random. E. CareSource does not provide coverage for drug testing as a requirement to stay in a facility, for example, in sober living or residential locations. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. F. Providers and labs must ensure specimen integrity appropriate for the stability of the drug agent being tested (for example, freezing the specimen) until the prior authorization process is completed. VI. Provider Orders: CareSource requires that the ordering providers name appear in the appropriate lines of the claim forms; any claim that does not include this information is incomplete and therefore not billable to and will not be reimbursed by CareSource. A signed and dated provider order for the drug testing is required. The providers order must specifically match the number, level and complexity of the testing components performed. VII. Non-participating Providers: Non-participating providers are not covered for drug testing laboratory services. Out-of-network providers may use participating laboratories for drug testing services. VIII. Documentation Requirements: All documentation must be accurate, complete, maintained in the members medical record and available to CareSource upon request. The following documentation requirements apply: A. Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering provider/treating provider must indicate the medical necessity for performing a qualitative drug test. B. Every page of the record must be legible and include appropriate member identification information (e.g., complete name, dates of service(s)). C. The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the member. D. The submitted medical record should support the use of the selected ICD-10-CM code(s) with appropriate indications for urine drug testing. E. The submitted CPT/HCPCS code should accurately describe the service performed. F. Copies of test results alone without the proper providers order for the test are not sufficient documentation of medical necessity to support a claim. G. Drug testing records and related entries in a members medical record must be provided Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 5 to CareSource upon request for auditing of medical necessity. Documentation must support medical necessity and specify why each test is ordered. Documentation must also support the number of analytes requested for testing, and what action the provider will take upon the findings. IX. Quantity Limitations A. CareSource will reimburse for up to 5 qualitative/presumptive tests in any rolling 90-day period for each member. B. CareSource will reimburse 5 dates of service for quantitative/confirmatory tests in any rolling 90-day period for each member. C. Within these limits, only 1 multi-panel test, (i.e., testing for each category of a drug class, including metabolite(s), if performed,) may be billed per day (same date of service (DOS)) unless the ordering provider or providing lab has obtained prior authorization from CareSource. D. CareSource will cover only one qualitative/presumptive test per date of service. E. Each CPT code is counted as a test toward these limits. F. Prior authorization must be obtained by the ordering/referring provider or lab for any drug testing performed exceeding these limits. CareSource will consider all such requests when they are medically necessary to the members line of treatment. X. Confirmatory and Duplicative Testing A. Routine multi-drug quantitative/confirmatory testing is not billable to and will not be reimbursed by CareSource. Quantitative/confirmatory testing must be individualized and medically necessary. Routine confirmations (quantitative) of drug tests with negative results are not deemed medically necessary and are not covered by CareSource without a review and prior authorization. Quantitative/confirmatory testing is covered for a negative drug/drug class test when the negative finding is inconsistent with the members documented medical history and/or current documented chronic pain medication list. B. Routine nonspecific or wholesale orders for drug testing (qualitative), confirmation, and quantitative drugs of abuse testing are not billable. XI. Independent Laboratories A. Drug testing conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. CareSource may require documentation of FDA-approved complexity level for instrumented equipment, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab. C. Both participating providers and non-participating providers may potentially order laboratory tests for CareSource members E. Only participating independent laboratories can bill for quantitative/confirmatory drug tests. F. Laboratories must have the appropriate level of CLIA certification for the tests performed and be contracted (participating) with CareSource. G. Claims are not billable to CareSource if submitted by laboratories that are non-participating (not contracted) with CareSource. H. The ordering/referring provider must include the clinical indication/medical necessity and any prior authorizations in the order for the drug test as outlined above. I. The independent laboratory performing the drug testing must maintain hard copy documentation of the lab results, along with copies of the ordering/referring providers order for the drug test and any required prior authorizations. J. Participating laboratories performing drug testing services must bill CareSource directly. CareSource does allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider but are performed by a person Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 6 or entity other than that provider or a direct employee of that provider, is not billable to CareSource. XII. Non-Billable Drug Testing A. Standing orders set up between a provider and laboratory which are prewritten and/or result in the same drugs and drug classes to be tested on a routine, repeat basis, are not billable to and will not be reimbursed by CareSource. B. Drug testing is not billable to and will not be reimbursed by CareSource if required by a third party such as: 1. For medico-legal purposes (e.g., court-ordered drug testing); 2. For employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment); 3. As a condition of: 3.1 Participation in school or community athletic activities or programs 3.2 Participation in school or community extra circular activities or programs 4. As a component of a routine physical/medical examination; e.g. (enrollment in school, enrollment in the military, etc.) 5. As a component of medical examination for any other administrative purposes not listed above (e.g., for purposes of marriage licensure, insurance eligibility, etc.). 6. As a program requirement to live in sober housing or residential services. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the CMS fee schedules. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. Code Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 7 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service G0480 Drug test def 1-7 classes G0481 Drug test def 8-14 classes G0482 Drug test def 15-21 classes G0483 Drug test def 22+ classes G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes AUTHORIZATION PERIOD F. RELATED POLICIES/RULES See CareSource Drug Testing Medical Policy (MM-0065) G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 01/01/2014 New Policy. Date Reviewed 10/01/2017 11/29/2017 Updated limits, prior authorization requirements, and covered/defunct codes. Date Effective 01/01/2018 H. REFERENCES 1. Physician Fee Schedule Search. (2017, January 1). Retrieved 2/6/2017 from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx 2. A. Barthwell, “Statement of Consensus on the Proper Utilization of Urine Testing in Identifying and Treating Substance Use Disorders,” 2015. [Online]. Available: http://farronline.org/wp-content/uploads/2015/11/Final-Report-Statement-of-Consensus-on-the-Proper-Utilization-of-Urine-Testing-in-Identifying-and-Treating-Substance-Abuse-Disorders.pdf 3. A. Pesce, C. West, K. Egan City and J. Strickland, “Interpretation of urine drug testing in pain patients,” Pain Medicine, vol. 13, no. 7, pp. 868-85, 2012. 4. Mayo Clinic, “Approximate detection times of drugs of abuse,” Oct 2016. [Online]. Available: http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html 5. K. E. Moeller, K. C. Lee and J. C. Kissack, “Urine drug screening: Practical guide for clinicians,” Mayo Clinic Proceedings, vol. 83, no. 1, pp. 66-76, Jan 2008. Drug Testing Ohio Medicare Advantage PY-0088 Effective Date: 01/01/2018 8 6. S. Vakili, S. Currie and N. el-Guebaly, “Evaluating the utility of drug testing in an outpatient addiction program,” Addictive Disorders and their Treatment, vol. 8, no. 1, pp. 22-32, 2009. 7. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye, “Review and recommendations for drug testing in substance use treatment contexts,” Journal of Reward Deficiency Syndrome and Addiction Science, vol. 2, no. 1, pp. 28-45, 2016. 8. K. Dolan, D. Rouen and J. Kimber, “An overview of the use of urine, hair, sweat and saliva to detect drug use,” Drug and Alcohol Review, vol. 23, no. 2, pp. 213-217, 2004. 9. A. G. Verstraete, “Detection times of drugs of abuse in blood, urine, and oral fluid,” Therapeutic Drug Monitoring, vol. 26, no. 2, pp. 200-205, 2004. 10. ASAM, Principles of Addiction Medicine, 5th Edition ed., R. K. Ries, D. A. Fiellin, S. C. Miller and R. Saitz, Eds., Philadelphia, PA: Lippincott Williams & Wilkins, 2014. 11. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik, “Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study, “International Journal of Mental Health and Addiction, vol. 14, no. 1, pp. 64-80, 2016. 12. J. Dupouy, V. Macmier, H. Catala, M. Lavit, S. Oustric and M. Lapeyre-Mestre, “Does urine drug abuse screening help for managing patients? A systematic review,” Drug and Alcohol Dependence, vol. 136, pp. 11-20, 2014. 13. E. Y. Hilario, M. L. Griffin, R. K. McHugh, K. A. McDermott, H. S. Connery, G. M. Fitzmaurice and R. D. Weiss, “Denial of urinalysis-confirmed opioid use in prescription opioid dependence, “Journal of Substance Abuse Treatment, vol. 48, no. 1, pp. 85-90, 2015. 14. ASAM, “Drug Testing: A White Paper of the American Society of Addiction Medicine,” American Society of Addiction Medicine, Chevy Chase, MD, 2013. 15. Quest Diagnostics Health Trends Prescription Drug Monitoring Report 2015, Prescription Drug Misuse in America, Diagnostic Insights in the Continuing Drug Epidemic Battle. Accessed on December 8, 2016. Located at https://www.questdiagnostics.com/dms/Documents/health-trends/Health_Trends_27281_MI4854_V5_LG_082715_Small.pdf This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 10/04/2013 07/01/2019 07/01/2018 Policy Name Policy Number Telemedicine Services PY-0108 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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 ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………… 6 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………. 6 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 6 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in an y 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 ref er to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e. , Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SUBJECTTelemedicine Services B. BACKGROUNDTelemedicine ServicesOHIO MEDICARE ADVANTAGE PY-0108 Effective Date: 07/01/2018 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 sta ff 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 inclusi on of a code does not imply any right to reimbursement or guarantee claims payment. Telemedicine is used to support health care when the provider and patient are physically separated. Typically, the patient communicates with the provider via interactive m eans that is sufficient to establish the necessary link to the provider who is working at a different location from the patient. CareSource will reimburse participating providers, for telemedicine services, who are credentialed to deliver telemedicine services rendered to CareSource members, as set forth in this policy. C. DEFINITIONS Asynchronous store and forward technologies – is the transmission of a patients medical information from an originating site to the physician or practitioner at the distant site. Distant Site – is the location of the physician or provider rendering health care services, via a telecommunications system. Interactive telecommunications system – is multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system. Originating Site – is the location of a CareSource member at the time the service, via a telecommunications system, occurs. Place of Service Codes (POS) – are codes that specifically indicate where a service or procedure was performed. Telemedicine – is the direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. Telemedicine vendor – is the participating provider with CareSource that renders the telemedicine services. Note: Telehealth is sometimes used interchangeably with telemedicine in CurrentProcedural Terminology (CPT)/and Healthcare Common Procedure Coding System (HCPCS) code descriptions of services. D. POLICYI. CareSource does not require prior authorization for Telemedicine services. II. Telemedicine services may be reimbursed according to Medicare guidelines set forth byCenters for Medicare & Medicaid Services (CMS) and using appropriate CPT and/or HCPCS and modifier codes. 3 Telemedicine ServicesOHIO MEDICARE ADVANTAGE PY-0108 Effective Date: 07/01/2018 III. As a condition of payment, providers must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the CareSource member, at the originating site. A. The service must be furnished via an interactive telecommunications system. B. The service must be furnished by a physician or authorized practitioner. C. The service must be furnished to an eligible telehealth individual. D. The individual receiving the service must be located in a telehealth originating site. Note: Asynchronous store and forward technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii. IV. For ESRD-related services, a physician, NP, PA, or CNS must furnish at least one hands on visit (not telehealth) each month to examine the vascular access site, for End-Stage Renal Disease (ESRD). V. Originating sites are paid an originating site facility fee for telehealth services as described byHCPCS code Q3014. A. Independent Renal Dialysis Facilities are not considered originating sites B. When a Community Mental Health Centers (CMHCs) serves as an originating site, the originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services. Note: Although telemedicine/telehealth services do not require a prior authorizationCareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Medicare fee schedule https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Codes Description G0108 and G0109Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training G0270 Individual and group medical nutrition therapy G0296Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT) (service is for eligibility determination and shared decision making G0396 and G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services G0425 G0427 Telehealth consultations, emergency department or initial inpatient G0406 G0408 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs G0420 and G0421 Individual and group kidney disease education services G0436 and G0437 Smoking cessation services G0438 Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit 4 Telemedicine ServicesOHIO MEDICARE ADVANTAGE PY-0108 Effective Date: 07/01/2018 G0439 Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit G0442 Annual alcohol misuse screening, 15 minutes G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes G0444 Annual depression screening, 15 minutes G0445High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi – annually, 30 minutes G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes G0447 Face-to-face behavioral counseling for obesity, 15 minutes G0506 Comprehensive assessment of and care planning for patients requiring chronic care management G0508Telehealth Consultation, Critical Care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth G0509Telehealth Consultation, Critical Care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth G0459 Telehealth Pharmacologic Management 90785 Interactive Complexity Psychiatry Services and Procedures 90791 Psychiatric Diagnostic Evaluation w/o Medical 90792 Psychiatric Diagnostic Evaluation w/ Medical 90832 Individual Psychotherapy – 30 minutes 90833 Individual Psychotherapy w/ E/M Service 90834 Individual Psychotherapy 45 minutes 90836 Individual Psychotherapy w/ E/M Service 90837 Individual Psychotherapy 60+ minutes 90838 Individual Psychotherapy w/ E/M Service 90839 Psychotherapy for crisis; first 60 minutes 90840 Psychotherapy for crisis; each additional 30 minutes 90845 Psychoanalysis 90846 Family Psychotherapy w/o patient 50 minutes 90847 Family psychotherapy (conjoint, w/ patient present) 50 minutes 96116 Neurobehavioral Status Exam 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961 End-Stage Renal Disease (ESRD) -related services included in the monthly capitation payment 90963End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) 90964End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) 90965 End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients 12-19 years of age to include monitoring 5 Telemedicine ServicesOHIO MEDICARE ADVANTAGE PY-0108 Effective Date: 07/01/2018 for the adequacy of nutrition, assessment of growth anddevelopment, and counseling of parents.90966 End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients 20 years of age and older. 90967End-Stage Renal Disease (ESRD) -related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age 90968End-Stage Renal Disease (ESRD) -related services for dialysis less than a full month of service, per day; for patients 2-11 years of age 90969End-Stage Renal Disease (ESRD) -related services for dialysis less than a full month of service, per day; for patients 12-19 years of age 90970End-Stage Renal Disease (ESRD) -related services for dialysis less than a full month of service, per day; for patients 20 years of age and older 96116 Neurobehavioral status examination 96150 96154 Individual and group health and behavior assessment and intervention 96160 Health Risk Assessment (eg, health hazard appraisal) 96161 Health Risk Assessment (eg, depression inventory) 97802-97804 Individual and group medical nutrition therapy 99201 99215 Office or other outpatient visits 99231 99233 Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days 99307 99310 Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days 99354 Prolonged service in the office or other outpatient setting requiri ng direct patient contact beyond the usual service; first hour 99355Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes 99356Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service). 99357Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service). 99406 and 99407 Smoking cessation services 99495 Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) 99496 Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) 99497 Advance Care Planning, 30 minutes 99498 Advance Care Planning, additional 30 minutes Q3014 Telehealth originating site facility fee Modifier Description GT Via interactive audio and video telecommunication systems 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System 6 Telemedicine ServicesOHIO MEDICARE ADVANTAGE PY-0108 Effective Date: 07/01/2018 For further information please reference: 1. https:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network – MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf 2. https://www.medicare.gov/coverage/telehealth.html#1368 F. RELATED POLICIES/RULESG. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 10/04/2013Date Reviewed 11/29/2016 02/22/2018 Added 1 modifier and 16 behavioral health codes.Date Effective 07/01/2018Archive Date 03 /05 /2021 H. REFERENCES1. Telehealth – Centers for Medicare & Medicaid Services. (2017, December 1). Retrieved December 1, 2017 from https://www.cms.gov/Medicare/Medicare-General – Information/Telehealth/index.html 2. Telehealth Services. (2016, November). Retrieved December1, 2017 from https://www. cms.gov/Outreach-and-Education/Medicare-Learning-Network – MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf 3. Telehe alth Services (2017, December 1). Retrieved December 1, 2017 from https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec410 – 78.pdf 4. Telehealth | Medicare.gov . (2017, December 1). Retrieved December 1, 2017 from https://www.medicare.gov/coverage/telehealth.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 OHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 09/06/2017 09/06/2018 05/01/2018 Policy Name Policy Number Smoking & Tobacco Cessation PY-0383 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 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 Smoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: 05/01/2018 2 A. SUBJECT Smoking & Tobacco Cessation B. BACKGROUND The use of tobacco products generally leads to tobacco/nicotine dependence6 and often results in serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases. Tobacco/nicotine dependence is a condition that often requires repeated treatments, as nicotine is strongly addictive. Because of this, quitting smoking and ending the use of tobacco use may be a difficult process requiring several, staged attempts, and may involve stress, irritability, and other withdrawal symptoms for those addicted to nicotine 8, 9, 10. However, continued tobacco use in any form is far more harmful. Tobacco smoke contains seriously harmful chemicals and carcinogens 5, 8, 11 and leads to lung and other cancers, chronic lung disease, heart disease, strokes, vascular disease, and infertility. Additionally, smokeless tobacco is directly linked to cancers of the mouth, tongue, cheek, gum, esophagus, and pancreas. Counseling and medication are both effective means for ending dependency on tobacco products, and are even more effective together than either method alone10. Counseling can be effective when delivered via individual, group, or telephone counseling, one-on-one brief help sessions with a provider, behavioral therapies, or even through mobile phone apps. Medications which have been found to be effective include prescription non-nicotine medications such as bupropion SR (Zyban) and varenicline tartrate (Chantix), and nicotine replacement products such as nicotine patches, inhalers or nasal sprays available by prescription, and over-the-counter nicotine patches, gums or lozenges 10, 17. The United States government recognizes the health dangers and risks associated with the use of tobacco in its citizens and has set up a free telephone support service to help people stop smoking and stop the use of tobacco, 1-800-QUIT-NOW. Callers are routed through this service to their states specific resource, and may be able to obtain free support, advice, and counseling from experienced quit-line coaches, a personalized plan to quit, practical information on how to quit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking medications, free or discounted medications (available for at least some callers in most states), referrals to other resources, and/or mailed self-help materials. CareSource encourages all of its members to refrain from the use of tobacco, and if using it in any form, to make concerted and ongoing attempts to quit its use as soon as possible. C. DEFINITIONS Tobacco products means any product containing tobacco or nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, hookahs, kreteks, e-cigarettes, vaporized and other inhaled tobacco and nicotine products, smokeless tobacco (e.g., dip, chew, snuff, snus), dissolvable tobacco (e.g., strips, sticks, orbs, lozenges), or other ingestible tobacco products, and/or chewing tobacco. D. POLICY I. Prior authorizations are required for participating (contracted) providers only when the services they are providing for tobacco cessation exceed the limits of this policy. II. Non-participating providers (not contracted with CareSource) should contact CareSource for prior authorization for these services.Smoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: 05/01/2018 3 III. CareSource will reimburse its participating providers for the following tobacco use intervention and cessation care methods: A. An encounter for evaluation and management of the member on the same day as counseling to prevent or cease tobacco use; and, B. One screening for tobacco use per member per calendar year, if necessary; and, C. Three individual tobacco cessation counseling attempts per calendar year. 1. Each attempt may include a maximum of 4 intermediate or intensive sessions, with a total benefit of up to 12 sessions per calendar year per member. D. Nicotine replacement or non-nicotine medications prescribed and approved for use for tobacco cessation. IV. CareSource will not reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year, unless prior authorization has been obtained by the provider. V. The number of CPT, HCPCs, and diagnosis codes (ICD-10) potentially associated with the diagnosis and treatment of tobacco use and addiction is too great to list. As such the specific tobacco cessation codes provided below are eligible to be reimbursed with anyappropriate, associated code. VI. Evaluation and management service for the member on the same day as counseling to prevent or cease tobacco use should be reported with modifier-25 to indicate that the service is separately identifiable from the counseling. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedules. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODES DESCRIPTION 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes S9453 Smoking cessation classes, non-physician provider, per session F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 09/06/2017 New Policy. Date Revised Date Effective 05/01/2018Smoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: 05/01/2018 4 H. REFERENCES 1. 42 U.S. Code 18021-Qualified health plan defined | US Law | LII / Legal Information Institute. (n.d.). Retrieved from https://www.law.cornell.edu/uscode/text/42/18021 2. CDC-Fact Sheet-Quitting Smoking-Smoking & Tobacco Use. (n.d.). Retrieved August 31, 2017, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm 3. Counseling to Prevent Tobacco Use. (Transmittal 2058, 2010, September 30). Centers for Medicare & Medicaid Services, Department of Health & Human Services. Retrieved September 5, 2017 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ 4. Treating Tobacco Use and Dependence. Clinical Practice Guideline. (n.d.). Fiore, Michael C (panel chair), Guideline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI) )Retrieved August 25, 2017, from http://lib.adai.washington.edu/dbtw-wpd/exec/dbtwpub.dll?AC=GET_RECORD&XC=/dbtw-wpd/exec/dbtwpub.dll&BU=http%3A%2F%2Flib.adai.washington.edu%2Febpchecksearch.ht m&TN=EBP&SN=AUTO30019&SE=457&RN=4&MR=0&TR=0&TX=1000&ES=1&CS=0&XP=&RF=Brief+Display&EF=&DF=Full+Display&RL=1&EL=1&DL=0&NP=3&ID=&MF=searchb utton.ini&MQ=&TI=0&DT=&ST=0&IR=50&NR=0&NB=0&SV=0&SS=0&BG=&FG=000000&QS=&OEX=ISO-8859-1&OEH=ISO-8859-1 5. U.S. Department of Health and Human Services. The Health Consequences of Smoking50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 6. National Institute on Drug Abuse. Research Report Series: Is Nicotine Addictive?. Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2012. 7. American Society of Addiction Medicine. Public Policy Statement on Nicotine Addiction and Tobacco. Chevy Chase (MD): American Society of Addiction Medicine, 2008. 8. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 9. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 10. Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateClinical Practice Guidelines. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008. 11. National Toxicology Program. Report on Carcinogens, Thirteenth Edition. Research Triangle Park (NC): U.S. Department of Health and Human Sciences, National Institute of Environmental Health Sciences, National Toxicology Program, 2014. 12. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 13. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. 14. Centers for Disease Control and Prevention. Quitting Smoking Among AdultsUnited States, 20002015. Morbidity and Mortality Weekly Report 2017;65(52):1457-64. 15. Centers for Disease Control and Prevention. Youth Risk Behavior SurveillanceUnited States, 2015. Morbidity and Mortality Weekly Report [serial online] 2016;66 (SS6):1174. Smoking & Tobacco Cessation OHIO MEDICARE PY-0383 Effective Date: 05/01/2018 5 16. Centers for Disease Control and Prevention. The Guide to Community Preventive Services: Reducing Tobacco Use and Secondhand Smoke Exposure. 17. U.S. Food and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation. FDA Consumer, 2006. This guideline contains custom content that has been modified from the standard care guidelines and has not been reviewed or approved by MCG Health, LLC. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 05/17/2016 11/01/2018 03/01/2018 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0064 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable 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. Contents of Policy REIMBURSEMENT 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 Screening & Surveillance for Colorectal Cancer OHIO MEDICARE PY-0064 Effective: 03/01/2018 2 A. SUBJECT Screening and Surveillance for Colorectal Cancer 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 does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests for colorectal cancer as required by state requirements through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology (ACG). C. DEFINITIONS See Screening and Surveillance for Colorectal Cancer medical policy MM-0039 D. POLICY I. CareSource does not require prior authorization for screening and diagnostic colonoscopies for participating providers II. CareSource reimburses for screening and diagnostic colonoscopies according to CareSource medical policy MM-0039. Members must meet the criteria found in medical policy MM-0039. III. When billing for screening and surveillance colorectal services, providers should use the appropriate CPT/HCPCS codes and modifiers, if applicable. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting The Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes. Please refer to: CALONG https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Code Description G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122 Colorectal cancer screening; barium enema (Not covered by Medicare) Screening & Surveillance for Colorectal Cancer OHIO MEDICARE PY-0064 Effective: 03/01/2018 3 G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 44402 Colonoscopy through stoma; with endoscopic stent placement (including pre-and post-dilation and guide wire passage, when performed) 44403 Colonoscopy through stoma; with endoscopic mucosal resection 44404 Colonoscopy through stoma; with directed submucosal injection(s), any substance 44405 Colonoscopy through stoma; with transendoscopic balloon dilation 44406 Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 44408 Colonoscopy through stoma; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45334 Sigmoidoscopy, flexible; with control of bleeding, any method 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45346 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre-and post-dilation and guide wire passage, when performed) 45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection 45350 Sigmoidoscopy, flexible; with band ligation(s) (e.g., hemorrhoids) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, flexible; with transendoscopic balloon dilation Screening & Surveillance for Colorectal Cancer OHIO MEDICARE PY-0064 Effective: 03/01/2018 4 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre-and post-dilation and guide wire passage, when performed) 45390 Colonoscopy, flexible; with endoscopic mucosal resection 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45393 Colonoscopy, flexible; with decompression (for pathologic distention) (e.g., volvulus, megacolon), including placement of decompression tube, when performed 45395 Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy 45397 Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (e.g., colo-anal anastomosis), with creation of colonic reservoir (e.g., J-pouch), with diverting enterostomy, when performed 45398 Colonoscopy, flexible; with band ligation(s) (e.g., hemorrhoids) 74263 Computed tomographic (CT) colonography, screening, including image postprocessing (Not covered by Medicare) 74270 Radiologic examination, colon; contrast (e.g., barium) enema, with or without KUB 74280 Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (Cologuard) 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection) 82272 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations F. RELATED POLICIES/RULES Screening and Surveillance for Colorectal Cancer, MM-0039 G. REVIEW/REVISION HISTORY H. REFERENCES 1. Centers for Medicare & Medicaid. (2016, April). Retrieved October 9, 2017, from DATE ACTION Date Issued 05/17/2016 New Policy. Date Revised 11/01/2017 Date Effective 03/01/2018Screening & Surveillance for Colorectal Cancer OHIO MEDICARE PY-0064 Effective: 03/01/2018 5 https://www.cms.gov/medicare-coverage-database/(S(v0cxhe45alguxjupvjx24zai))/details/ncd-details.aspx?NCDId=281&ncdver=5&CALId=97&ver=5&CalName=Prothrombin+Time+and+Fecal+Occult+Blood+(Revision+of+ICD-9-CM+Codes+for+Injury+to+Gastrointestinal+Tract)&bc=gAgAAAAAgAIAAA%3D%3D& 2. CMS Decision Memo for Screening for Colorectal Cancer-Stool DNA Testing. (2014, October). Retrieved October 9, 2017, from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=277 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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