REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANTAGE Original Issue Date Next Annual Review Effective Date 04/05/2017 04/05/2018 12/01/2017 Policy Name Policy Number Cardiovascular Nuclear Medicine PY-0236 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 …………………………………………………………………………………………………. 3 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 5 F. RELATED POLICIES/RULES ……………………………………………………………………. 5 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 5 H. REFERENCES ………………………………………………………………………………………… 6 Cardiovascular Nuclear Imaging Ohio Medicare Advantage PY-0236 Effective Date: 12-01-2017 2 A. SUBJECT Cardiovascular Nuclear Medicine B. BACKGROUND Cardiovascular nuclear imaging applies a range of radionuclide agents non-invasively through specific protocols in the evaluation of various functions, including coronary artery flow, myocardial perfusion, and ventricular function. Radionuclide agents and imaging techniques are chosen for specific circumstances. The status of coronary blood flow may be evaluated through a myocardial perfusion scan. The agents selected generate images showing segmental and global myocardial blood flow through radioisotope uptake. Imaging abnormalities occur can indicate myocardial scar and ischemia in the individual, most commonly caused by coronary atherosclerosis. Ventricular function studies employ radioisotope imaging with simultaneous electrocardiography to outline the borders of the ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium. The motion of the left ventricle, synchronized with the electrocardiogram, is used to calculate wall motion and ejection fraction measurements. This information is of diagnostic and prognostic value in patients with a wide range of clinical conditions. Cardiovascular nuclear imaging tests are performed at rest, during exercise, or with pharmacologic intervention to mimic exercise in less active patients. Images acquired and evaluated may be spatially oriented in planar (single plane) or multiple planes utilizing computer integration, such as single-photon emission computer tomography (SPECT). Peripartum cardiomyopathy, although not as common as other varieties, may be associated with considerable morbidity. Onset is usually right after delivery, but may occur during the final weeks of pregnancy or be delayed until several months after delivery. The degree of impact on ventricular function does not consistently correlate with prognosis or the rate of recovery. For example, patients with a very low ejection fraction can eventually completely recover from peripartum cardiomyopathy. The U.S. Preventive Services Task Force reports no preventive care indications for cardiovascular nuclear imaging tests as screening methods for adults or children. C. DEFINITIONS Diagnostic imaging means the production of images used for medical diagnosis using magnetic resonance imaging (MRI), positron emission tomography (PET), computed tomography (CT), nuclear medicine. First-pass study means a form of radionuclide angiography in which a rapid sequence of images is taken immediately after administration of a bolus of radionuclide, recording only the initial transit of the isotope through the central circulation. Metabolic Equivalent (MET) is a physiological measurement of the functional capacity or exercise tolerance of an individual as determined from progressive exercise testing (compared stage by stage) often used to define the physical activities and intensity levels in which a person may participate safely. Cardiovascular Nuclear Imaging Ohio Medicare Advantage PY-0236 Effective Date: 12-01-2017 3 D. POLICY I. CareSource does not require prior authorizations for the cardiovascular nuclear medicine covered by this policy. NOTE: Although the cardiovascular nuclear medicine covered by this policy 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. II. All cardiovascular nuclear tests and stress tests must be ordered by a physician or a qualified non-physician provider. III. Selection of tests should be made within the context of other tests, scheduled and previously performed, so that the anticipated information obtained is unique and not redundant. Decision-making for testing should be made based upon the presence of multiple clinical risk factors, the level of functional capacity, the risk of the surgery (if applicable), and the likelihood that the results of the cardiac testing would change the management. IV. Cardiovascular nuclear imaging is indicated and covered when performed for: A. Assessment of the functional and prognostic importance of angina; B. Diagnostic evaluation of patients with chest pain and uninterpretable or equivocal ECG changes caused by drugs, bundle branch block, or left ventricular hypertrophy; C. Assessment of congenital anomalies of coronary arteries; D. Risk assessment or re-evaluation of disease in patients who are asymptomatic or have stable symptoms, with known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, who have not had a revascularization procedure within the past two years; E. Detection of coronary artery disease in patients, without chest pain syndrome, with new-onset of diagnosed heart failure or left ventricular systolic dysfunction; F. Evaluation of ischemic versus non-ischemic cardiomyopathy when cardiac catheterization / coronary angiography are not planned; G. Evaluation of myocardial perfusion and/or function before and after coronary artery bypass surgery or other re-perfusion procedures H. Quantification and surveillance of myocardial infarction and prognostication in patients with infarction; I. Assessment of congenital anomalies of coronary arteries; J. Preoperative assessment for non-cardiac surgery, when used to determine risk for surgery and/or perioperative management in: 1. patients with poor functional capacity (less than 4 METS) and minor or intermediate clinical risk predictors, as follows: 1.1. History of ischemic heart disease; 1.2. History of compensated or prior heart failure; 1.3. History of cerebrovascular disease; 1.4. Diabetes mellitus; 1.5. Renal insufficiency. 2. patients with intermediate or high likelihood of coronary heart disease, or patients with poor functional capacity (less than 4 METS) undergoing high risk non-cardiac surgery, where: 2.1 High risk surgery: aortic and peripheral vascular surgery; 2.2 Intermediate risk surgery: intraperitoneal and intrathoracic surgery, carotid endarterectomy, head & neck surgery, orthopedic surgery, prostate surgery;Cardiovascular Nuclear Imaging Ohio Medicare Advantage PY-0236 Effective Date: 12-01-2017 4 2.3 Low risk surgery: endoscopic procedures, superficial surgery, cataract surgery, breast surgery, ambulatory surgery. K. Evaluation of ventricular function in patients with non-ischemic myocardial disease; L. Evaluation of patients in whom an accurate measure of the ejection fraction is needed to make a determination of whether to implant a defibrillator or biventricular pacemaker; M. Evaluation of a patient receiving chemotherapeutic drugs which are potentially cardiotoxic (e.g., adriamycin). V. First pass studies will be covered only when the information sought is immediately relevant to the management of the patients clinical condition, and has not been previously obtained or likely to be obtained from other planned tests such as echocardiography or equilibrium gated blood pool studies. First pass studies may be indicated for the assessment and identification of shunts. VI. Infarct avid scintigraphy is indicated in patients in whom it is not possible to make a definitive diagnosis of myocardial infarction by ECG or enzyme testing. Patient selection should be based on clinical grounds: A. Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making. B. Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question. VII. Special Equipment Requirements A. Given the limitations of uptake, low photon energy and redistribution, the cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. However, in light of the predictive value of exercise-induced changes in ejection fraction, an exception will be made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who bill this service must certify within their records that their laboratories are specially equipped to process such studies. B. The rapid uptake, relatively low photon energy and redistribution of thallium 201 preclude its application to studies for gated images (78478 and 78480, for dates of service prior to 01/01/2010) in most laboratories. Therefore, CPT procedure codes 78478 and 78480 (for dates of service prior to 01/01/2010) are generally not payable with HCPCS code A9505 (thallous chloride). However, an exception will be made to allow this combination for laboratories that have at least double-headed cameras and the appropriate software to facilitate the count. Such providers must certify that their laboratories are specially equipped to process such studies. C. Cardiac blood pool imaging studies are described by the codes 78472, 78473, 78481, 78483, 78494 (with add-on code 78496). Only one code from the series (with appropriate add-on) may be reported on a single date of service. D. All stress tests must be performed under the direct supervision of a physician. The nuclear test components must be performed under the general supervision of a physician. VIII. If criteria are met for selected cardiovascular nuclear imaging to evaluate left ventricular ejection fraction, CareSource covers the evaluation of peripartum cardiomyopathy. Cardiovascular Nuclear Imaging Ohio Medicare Advantage PY-0236 Effective Date: 12-01-2017 5 IX. Services Not Covered A. Myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc.). B. Tests that are anticipated to provide information duplicative of another test already performed. C. Tests performed when the results would not be anticipated to influence medical management decisions. D. Myocardial perfusion studies performed subsequent to a diagnostic myocardial PET scan. E. Infarct avid scintigraphy if the diagnosis of myocardial infarction has already been confirmed by enzymes and/or ECG. F. Tests performed unrelated to changes in a patient’s signs or symptoms, or unrelated to an immediate pre-operative evaluation. G. Tests performed for risk assessment prior to high risk non-cardiac surgery in asymptomatic patients within one year following normal catheterization or non-invasive test. H. Tests performed for preoperative evaluation in patients undergoing low-risk surgery. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. 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. F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 04/05/2017 New policy. Date Revised Date Effective 12/01/2017 Cardiovascu lar Nu clear Medicin e-MCR Codes. pdf Cardiovascular Nuclear Imaging Ohio Medicare Advantage PY-0236 Effective Date: 12-01-2017 6 H. REFERENCES 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (n.d.). Retrieved March 31, 2017, from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33960&ContrId=239&ver=11&ContrVer=1&CntrctrSelected=239*1&Cntr ctr=239&name=CGS+Administrators%2c+LLC+(15101%2c+MAC+-+Part+A)&DocType=Active&LCntrctr=239*1&bc=AgACAAQAAAAAAA%3d%3d& 2. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease, Michael J. Wolk, Steven R. Bailey, John U. Doherty, Pamela S. Douglas, Robert C. Hendel, Christopher M. Kramer, James K. Min, Manesh R. Patel, Lisa Rosenbaum, Leslee J. Shaw, Raymond F. Stainback, Joseph M. Allen, Journal of the American College of Cardiology Feb 2014, 63 (4) 380-406; DOI: 10.1016/j.jacc.2013.11.009 3. American College of Cardiology-Self Assessment Program Syllabus 4. Botnovich E, Dae M, O’Connell W, Ortendahl D, Hatner R. The scinitigraphic evaluation of the cardiovascular system. Cardiology Parmley (Ed).1994. 5. Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology. J. Am Coll Cardiology (2005);46:1587-1605. 6. Committee on Exercise Testing, ACC/AHA Guidelines for Exercise Testing. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JAm Coll Cardiol. July 1997;30(1):260-311. 7. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. JAm Coll Cardiol (2007);50:1707-1732. 8. Johnson LL, Rodney RA, Vaccarino RA, et al. Left ventricular perfusion and performance from a single radiopharmaceutical and one camera. JNucl Med 1992;33:1411-1416. 9. Klocke FJ, Baird MG, Bateman TM, et al. ACC/AHA/ASNC Guidelines for the clinical use of cardiac radionuclide imaging: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to revise the 1995 guidelines for the clinical use of radionuclide imaging). 2003: downloaded from http://www.acc.org/clinical/guidelines/radio/rni_fulltext.pdf. 10. Lee T, Cardiac Noninvasive Testing. In: Braunwald E, Goldman L. editors, Primary Cardiology. 2nd edition. Elsevier Science 2003:47-61. 11. Mariano-Goulart D, Dechaux L, Rouzet F, et al. Diagnosis of diffuse and localized arrhythmogenic right ventricular dysplasia by gated blood-pool SPECT. The Journal of Nuclear Medicine. Sept 2007;48(9):1416-1423. 12. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. NEJM 2004;351:2795-2804 13. Palmas W, Friedman JD, Diamond GA, Silber H, Kiat H, Berman D. Incremental value of simultaneous assessment of myocardial function and perfusion with technetium-99m sestamibi for prediction of extent of coronary artery disease. JACC. 1995;25(5):1024-1031. 14. Shaw LJ, Heinle SK, Borges-Neto S, Kesler K, Coleman RE, Jones RH for the Duke Noninvasive Research Working Group. Prognosis by measurements of left ventricular function during exercise. JNucl Med 1998;39:140-146. Cardiovascular Nuclear Imaging Ohio Medicare Advantage PY-0236 Effective Date: 12-01-2017 7 15. St John Sutton, MG, Rutherford JD, editors. Clinical Cardiovascular Imaging: A Companion to Braunwald’s Heart Disease. Elsevier Saunders. 2004. 16. Wachers FJ, Soufer R, Zaret BL. Nuclear Cardiology. In: Heart Disease: A textbook of Cardiovascular Medicine. 6th edition. Braunwald E, Zipes Dand Libby P, editors. 2001:273-304 17. Ward RP, Mouaz HA, Grossman GB, et al. American Society of Nuclear Cardiology review of the ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). JNucl Cardiol 2007;14:e26-38. 18. Zaret BL, Beller GA. Nuclear Cardiology, State of the Art and Future Directions. Mosby 1999. 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 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 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 ……………………………………………………………………. 4 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 4 H. REFERENCES ………………………………………………………………………………………… 4 Non-Invasive Vascular Testing 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-invasive vascular studies may be used interchangeably with Duplex scan or Duplex ultrasound for the purposes of this policy. C. DEFINITIONS Duplex Ultrasound 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-invasive 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-invasive 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-Invasive Vascular Testing OHIO MEDICARE ADVANTAGE PY-0168 Effective Date: 12/01/2017 3 Note: Although a Non-Invasive 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-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 source for the most current coding information. CPT Codes Definition 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; completestudy 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 Definition 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-Invasive Vascular Testing 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 DATE ACTION Date Issued 03/08/2017 Date Revised Date Effective 12/01/2017 H. REFERENCES 1. Physician Fee Schedule Search. (2017, January 1). Retrieved from https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=3&H1=93925&M=5 2. Duplex Ultrasound | Society for Vascular Surgery. (2017, February 10). Retrieved 2/10/2017 from https://vascular.org/patient-resources/vascular-tests/duplex-ultrasound 3. MedlinePlus-Search Results for: ultrasound. (2017, February 10). Retrieved 2/10/2017 from https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=ultrasound&_ga=1.239060934.798803354.1484937052 4. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2017, January 1). Retrieved 2/10/2017 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34045&ver=14&CoverageSelection=Local&ArticleType=All&PolicyType=Final&CptHcpcsCode=93880&bc=gAAAACAAAAAAAA%3d%3d& 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 03/08/2017 03/08/2018 12/01/2017 Policy Name Policy Number Thyroid Testing PY-0223 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 ………………………………………………………………….. 31 G. REVIEW/REVISION HISTORY ………………………………………………………………… 31 H. REFERENCES ………………………………………………………………………………………. 31 Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 2 A. SUBJECT Thyroid Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Thyroid function studies are used to detect the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. CareSource considers testing thyroid function medically necessary for members consistent with symptoms of thyroid disease. C. DEFINITIONS Hyperthyroidism: Condition occurs when the thyroid gland produces too much thyroxine causing sudden weight loss, rapid or irregular heartbeat, sweating and nervousness Hypothyroidism: Condition occurs when the thyroid gland doesnt produce enough hormones causing weight gain, joint pain, infertility and heart disease. D. POLICY I. CareSource does not require a prior authorization for thyroid testing. II. CareSource considers thyroid function testing medically necessary for the following: A. Members who are clinically stable up to 2 times per year B. Members who have symptoms consistent with hypothyroidism C. Members who have symptoms consistent with hyperthyroidism D. Members who are asymptomatic and 60 years of age or older, performed every 5 years E. Members who are asymptomatic but are considered high risk due to the following: 1. Family or personal history of thyroid disease, this should be limited to a one time screening 2. Family or personal history of Type I Diabetes or other autoimmune disorder, this should be limited to a one time screening 3. Member who is prescribed medications that may interfere with thyroid function III. Reimbursement is based on submitting a claim with the appropriate ICD-10 diagnosis code to match the thyroid testing CPT code. IV. If the appropriate ICD-10 diagnosis code is not submitted with the CPT code, the claim will be denied. Note: Although this service does not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 3 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 Ohio Medicaid fee schedule. http://medicaid.ohio.gov/Portals/0/Providers/FeeScheduleRates/App-DD.pdf 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. CPT Codes Definition 84436 Thyroxine: total 84339 Thyroxine: free 84443 TSHThyroid Stimulating Hormone 84479 Thyroid Hormone Uptake (T3 or T4) or thyroid hormone binding ration (THBR) ICD-10-CM Definition E03.9 Hypothyroidism, unspecified A18.81 Tuberculosis of thyroid gland C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C56.9 Malignant neoplasm of unspecified ovary C73 Malignant neoplasm of thyroid gland C75.8 Malignant neoplasm with pluriglandular involvement, unspecified C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D09.3 Carcinoma in situ of thyroid and other endocrine glands D09.8 Carcinoma in situ of other specified sites D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D27.9 Benign neoplasm of unspecified ovary D34 Benign neoplasm of thyroid gland D35.2 Benign neoplasm of pituitary gland D35.3 Benign neoplasm of craniopharyngeal duct D44.0 Neoplasm of uncertain behavior of thyroid gland D44.2 Neoplasm of uncertain behaviorof parathyroid gland D44.9 Neoplasm of uncertain behavior of unspecified endocrine gland D49.7 Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 4 D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D53.9 Nutritional anemia, unspecified D59.0 Drug-induced autoimmune hemolytic anemia D59.1 Other autoimmune hemolytic anemias D64.9 Anemia, unspecified D89.82 Autoimmune lymphoproliferative syndrome [ALPS] D89.89 Other specified disorders involving the immune mechanism, not elsewhere specified E00.0 Congenital iodine-deficiency syndrome, neurological type E00.1 Congenital iodine-deficiency syndrome, myxedematous type E00.2 Congenital iodine-deficiency syndrome, mixed type E00.9 Congenital iodine-deficiency syndrome, unspecified E01.0 Iodine-deficiency related diffuse (endemic) goiter E01.1 Iodine-deficiency related multinodular (endemic) goiter E01.2 Iodine-deficiency related (endemic) goiter, unspecificied E01.8 Other iodine-deficiency related thyroid disorders and allied conditions E02 Subclinical iodine-deficiency hypothyroidism E03.0 Congenital hypothyroidism with diffuse goiter E03.1 Congenital hypothyroidism without goiter E03.2 Hypothyroidism due to medicaments and other exogenous substances E03.3 Postinfectious hypothyroidism E03.4 Atrophy of thyroid (acquired) E03.5 Myxedema coma E03.8 Other specified hypothyroidism E03.9 Hypothyroidism, unspecifide E04.0 Nontoxic diffuse goiter E04.1 Nontoxic single thyroid nodule E04.2 Nontoxic multinodular goiter E04.8 Other specified nontoxic goiter E04.9 Nontoxic goiter, unspecified E05.00 Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm E05.01 Thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm E05.10 Thyrotoxicosis with toxic single thyroid nodule without thyrotoxic crisis or storm E05.11 Thyrotoxicosis with toxic single thyroid nodule with thyrotoxic crisis or storm Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 5 E05.20 Thyrotoxicosis with toxic multinodular goiter without thyrotoxic crisis or storm E05.21 Thyrotoxicosis with toxic multinodular goiter with thyrotoxic crisis or storm E05.30 Thyrotoxicosis from ectopic thyroid tissue without thyrotoxic crisis or storm E05.31 Thyrotoxicosis from ectopic thyroid tissue with thyrotoxic crisis or storm E05.40 Thyrotoxicosis factitia without thyrotoxic crisis or storm E05.41 Thyrotoxicosis factitia with thyrotoxic crisis or storm E05.80 Other thyrotoxicosis without thyrotoxic crisis or storm E05.81 Other thyrotoxicosis with thyrotoxic crisis or storm E05.90 Thyrotoxicosis, unspecified without thyrotoxic crisis or storm E05.91 Thyrotoxicosis, unspecified with thyrotoxic crisis or storm E06.0 Acute thyroiditis E06.1 Subacute thyroiditis E06.2 Chronic thyroiditis with transient thyrotoxicosis E06.3 Autoimmune thyroiditis E06.4 Drug-induced thyroiditis E06.5 Other chronic thyroiditis E06.9 Thyroiditis, unspecified E07.0 Hypersecretion of calcitonin E07.1 Dyshornogenetic goiter E07.89 Other specified disorders of thyroid E07.9 Disorder of thyroid, unspecified E08.00 Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E08.01 Diabetes mellitus due to underlying condition with hyperosmolarity with coma E08.10 Diabeted mellitus due to underlying condition with ketoacidosis without coma E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma E08.21 Diabetes mellitus due to underlying condition with diabetic mephropathy E08.22 Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29 Diabeted mellitus due to underlyin condition with other diabetic kidney complication E08.311 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular edema E08.319 Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular edema Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 6 E08.321 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy with macular edema E08.329 Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy without macular edema E08.331 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy with macular edema E08.339 Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy without macular edema E08.341 Diabetes mellitus due to underlying condition with severe nonprolifeartive diabetic retinopathy with macular edema E08.349 Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy without macular edema E08.351 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy with macular edema E08.359 Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy without macular edema E08.36 Diabetes mellitus due to underlying condition with diabetic cataract E08.39 Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication E08.40 Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41 Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42 Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44 Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49 Diabetes mellitus due to underlying condition with diabetic neurological complication E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E08.59 Diabetes mellitus due to underlying condition with other circulatory complications E08.610 Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E08.618 Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.620 Diabetes mellitus due to underlying condition with diabetic dermatitis E08.621 Diabetes mellitus due to underlying condition with foot ulcer E08.622 Diabetes mellitus due to underlying condition with other skin ulcer E08.628 Diabetes mellitus due to underlying condition with other skin complicatiosn E08.630 Diabetes mellitus due to underlying condition with periodontal disease E08.638 Diabetes mellitus due to underlying condition with other oral complications E08.641 Diabetes mellitus due to underlying condition with hypoglycemia with coma Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 7 E08.649 Diabetes mellitus due to underlying condition with hypoglycemia without coma E08.65 Diabetes mellitus due to underlying condition with hyperglycemia E08.69 Diabetes mellitus due to underlying condition with other specified complication E08.8 Diabetes mellitus due to underlying condition with unspecified complications E08.9 Diabetes mellitus due to underlying condition with complications E09.00 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E09.01 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma E09.21 Drug or chemical induced diabetes mellitus with diabetic nephropathy E09.22 Drug or chemical induced diabetes mellitus with diabetic chronic kidney disease E09.29 Drug or chemical induced diabetes mellitus with other diabetic kidney complication E09.311 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema E09.319 Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy without macular edema E09.321 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E09.329 Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E09.331 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.339 Drug or chemical induced diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E09.341 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E09.349 Drug or chemical induced diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E09.351 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy with macular edema E09.359 Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema E09.36 Drug or chemical induced diabetes mellitus with diabetic cataract E09.39 Drug or chemical induced diabetes mellitus with other diabetic ophthalmic complication E09.40 Drug or chemical induced diabetes mellitus with neurological complications with diabetic neuropathy, unspecified E09.41 Drug or chemical induced diabetes mellitus with neurological complications with diabetic mononeuropathy E09.42 Drug or chemical induced diabetes mellitus with neurological complications with diabetic polyneuropathy Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 8 E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E09.44 Drug or chemical induced diabetes mellitus with neurological complications with diabetic amyotrophy E09.49 Drug or chemical induced diabetes mellitus with neurological complications with other diabetic neurological complications E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E09.59 Drug or chemical induced diabetes mellitus with other circulatory complications E09.610 Drug or chemical induced diabetes mellitus with diabetic neuropathic arthropathy E09.618 Drug or chemical induced diabetes mellitus with other diabetic dermatitis E09.620 Drug or chemical induced diabetes mellitus with diabetic dermitis E09.621 Drug or chemical induced diabetes mellitus with foot ulcer E09.622 Drug or chemical induced diabetes mellitus with other skin ulcer E09.628 Drug or chemical induced diabetes mellitus with other skin complications E09.630 Drug or chemical induced diabetes mellitus with periodontal disease E09.638 Drug or chemical induced diabetes mellitus with other oral complications E09.641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma E09.649 Drug or chemical induced diabetes mellitus with hypoglycemia without coma E09.65 Drug or chemical induced diabetes mellitus with hyperglycemia E09.69 Drug or chemical induced diabetes mellitus with other specified complications E09.8 Drug or chemical induced diabetes mellitus with unspecified complications E09.9 Drug or chemical induced diabetes mellitus without complications E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complications E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edems E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 9 E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.36 Type 1 diabetes mellitus with diabetic cataract E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10..628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 10 E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.36 Type 2 diabetes mellitus with diabetic cataract E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy E11.618 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 11 E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E13.00 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) E13.01 Other specified diabetes mellitus with hyperosmolarity with coma E13.10 Other specified diabetes mellitus with ketoacidosis without coma E13.11 Other specified diabetes mellitus with ketoacidosis with coma E13.21 Other specified diabetes mellitus with diabetic nephropathy E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease E13.29 Other specified diabetes mellitus with other diabetic kidney complication E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema E13.36 Other specified diabetes mellitus with diabetic cataract E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 12 E13.41 Other specified diabetes mellitus with diabetic mononeuropathy E13.42 Other specified diabetes mellitus with diabetic polyneuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E13.44 Other specified diabetes mellitus with diabetic amyotrophy E13.49 Other specified diabetes mellitus with other diabetic neurological complication E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene E13.59 Other specified diabetes mellitus with other circulatory complications E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy E13.618 Other specified diabetes mellitus with other diabetic arthropathy E13.620 Other specified diabetes mellitus with diabetic dermatitis E13.621 Other specified diabetes mellitus with foot ulcer E13.622 Other specified diabetes mellitus with other skin ulcer E13.628 Other specified diabetes mellitus with other skin complications E13.630 Other specified diabetes mellitus with periodontal disease E13.638 Other specified diabetes mellitus with other oral complications E13.641 Other specified diabetes mellitus with hypoglycemia with coma E13.649 Other specified diabetes mellitus with hypoglycemia without coma E13.65 Other specified diabetes mellitus with hyperglycemia E13.69 Other specified diabetes mellitus with other specified complication E13.8 Other specified diabetes mellitus with unspecified complications E13.9 Other specified diabetes mellitus without complications E20.0 Idiopathic hypoparathyroidism E20.1 Pseudohypoparathyroidism E20.8 Other hypoparathyroidism E20.9 Hypoparathyroidism, unspecified E22.1 Hyperprolactinemia E22.8 Other hyperfunction of pituitary gland E22.9 Hyperfunction of pituitary gland, unspecified E23.0 Hypopituitarism E23.1 Drug-induced hypopituitarism E23.6 Other disorders of pituitary gland E25.0 Congenital adrenogenital disorders associated with enzyme deficiency Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 13 E25.8 Other adrenogenital disorders E25.9 Adrenogenital disorder, unspecified E27.1 Primary adrenocortical insufficiency E27.2 Addisonian crisis E27.3 Drug-induced adrenocortical insufficiency E27.40 Unspecified adrenocortical insufficiency E27.49 Other adrenocortical insufficiency E28.310 Symptomatic premature menopause E28.319 Asymptomatic premature menopause E28.39 Other primary ovarian failure E29.1 Testicular hypofunction E31.0 Autoimmune polyglandular failure E31.1 Polyglandular hyperfunction E31.20 Multiple endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multiple endocrine neoplasia [MEN] type I E31.22 Multiple endocrine neoplasia [MEN] type IIA E31.23 Multiple endocrine neoplasia [MEN] type IIB E31.8 Other polyglandular dysfunction E31.9 Polyglandular dysfunction, unspecified E35 Disorders of endocrine glands in diseases classified elsewhere E43 Unspecified severe protein-calorie malnutrition E44.0 Moderate protein-calorie malnutrition E44.1 Mild protein-calorie malnutrition E45 Retarded development following protein-calorie malnutrition E46 Unspecified protein-calorie malnutrition E53.0 Riboflavin deficiency E64.0 Sequelae of protein-calorie malnutrition E67.1 Hypercarotinemia E78.0 Pure hypercholesterolemia E78.2 Mixed hyperlipidemia E78.4 Other hyperlipidemia E78.5 Hyperlipidemia, unspecified E83.50 Unspecified disorder of calcium metabolism E83.51 Hypocalcemia Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 14 E83.52 Hypercalcemia E83.59 Other disorders of calcium metabolism E83.81 Hungry bone syndrome E87.0 Hyperosmolality and hypernatremia E87.1 Hypo-osmolality and hyponatremia E89.0 Postprocedural hypothyroidism E89.2 Postprocedural hypoparathyroidism E89.3 Postprocedural hypopituitarism E89.6 Postprocedural adrenocortical (-medullary) hypofunction F03.90 Unspecified dementia without behavioral disturbance F05 Delirium due to known physiological condition F06.0 Psychotic disorder with hallucinations due to known physiological condition F06.1 Catatonic disorder due to known physiological condition F06.2 Psychotic disorder with delusions due to known physiological condition F06.30 Mood disorder due to known physiological condition, unspecified F06.31 Mood disorder due to known physiological condition with depressive features F06.32 Mood disorder due to known physiological condition with major depressive-like episode F06.33 Mood disorder due to known physiological condition with manic features F06.34 Mood disorder due to known physiological condition with mixed features F06.4 Anxiety disorder due to known physiological condition F06.8 Other specified mental disorders due to known physiological condition F07.0 Personality change due to known physiological condition F22 Delusional disorders F23 Brief psychotic disorder F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode, severe, without psychotic symptoms F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 15 F31.0 Bipolar disorder, current episode hypomanic F31.10 Bipolar disorder, current episode manic without psychotic features, unspecified F31.11 Bipolar disorder, current episode manic without psychotic features, mild F31.12 Bipolar disorder, current episode manic without psychotic features, moderate F31.13 Bipolar disorder, current episode manic without psychotic features, severe F31.2 Bipolar disorder, current episode manic severe with psychotic features F31.30 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified F31.31 Bipolar disorder, current episode depressed, mild F31.32 Bipolar disorder, current episode depressed, moderate F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features F31.60 Bipolar disorder, current episode mixed, unspecified F31.61 Bipolar disorder, current episode mixed, mild F31.62 Bipolar disorder, current episode mixed, moderate F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features F31.70 Bipolar disorder, currently in remission, most recent episode unspecified F31.71 Bipolar disorder, in partial remission, most recent episode hypomanic F31.72 Bipolar disorder, in full remission, most recent episode hypomanic F31.73 Bipolar disorder, in partial remission, most recent episode manic F31.74 Bipolar disorder, in full remission, most recent episode manic F31.75 Bipolar disorder, in partial remission, most recent episode depressed F31.76 Bipolar disorder, in full remission, most recent episode depressed F31.77 Bipolar disorder, in partial remission, most recent episode mixed F31.78 Bipolar disorder, in full remission, most recent episode mixed F31.81 Bipolar II disorder F31.89 Other bipolar disorder F31.9 Bipolar disorder, unspecified F32.0 Major depressive disorder, single episode, mild F32.1 Major depressive disorder, single episode, moderate F32.2 Major depressive disorder, single episode, severe without psychotic features Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 16 F32.3 Major depressive disorder, single episode, severe with psychotic features F32.4 Major depressive disorder, single episode, in partial remission F32.5 Major depressive disorder, single episode, in full remission F32.8 Other depressive episodes F32.9 Major depressive disorder, single episode, unspecified F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate F33.2 Major depressive disorder, recurrent severe without psychotic features F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in full remission F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified F34.8 Other persistent mood [affective] disorders F34.9 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F41.0 Panic disorder [episodic paroxysmal anxiety] without agoraphobia F41.1 Generalized anxiety disorder F41.3 Other mixed anxiety disorders F41.8 Other specified anxiety disorders F41.9 Anxiety disorder, unspecified F53 Puerperal psychosis F63.3 Trichotillomania G25.0 Essential tremor G25.1 Drug-induced tremor G25.2 Other specified forms of tremor G25.70 Drug induced movement disorder, unspecified G25.71 Drug induced akathisia G25.79 Other drug induced movement disorders G25.89 Other specified extrapyramidal and movement disorders G25.9 Extrapyramidal and movement disorder, unspecified G26 Extrapyramidal and movement disorders in diseases classified elsewhere G30.0 Alzheimer’s disease with early onset Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 17 G30.1 Alzheimer’s disease with late onset G30.8 Other Alzheimer’s disease G30.9 Alzheimer’s disease, unspecified G31.01 Pick’s disease G31.09 Other frontotemporal dementia G31.1 Senile degeneration of brain, not elsewhere classified G31.84 Mild cognitive impairment, so stated G47.00 Insomnia, unspecified G47.01 Insomnia due to medical condition G47.09 Other insomnia G47.30 Sleep apnea, unspecified G47.39 Other sleep apnea G47.62 Sleep related leg cramps G47.8 Other sleep disorders G47.9 Sleep disorder, unspecified G56.00 Carpal tunnel syndrome, unspecified upper limb G56.01 Carpal tunnel syndrome, right upper limb G56.02 Carpal tunnel syndrome, left upper limb G60.9 Hereditary and idiopathic neuropathy, unspecified G71.9 Primary disorder of muscle, unspecified G72.9 Myopathy, unspecified G73.3 Myasthenic syndromes in other diseases classified elsewhere G73.7 Myopathy in diseases classified elsewhere G93.3 Postviral fatigue syndrome H02.531 Eyelid retraction right upper eyelid H02.532 Eyelid retraction right lower eyelid H02.533 Eyelid retraction right eye, unspecified eyelid H02.534 Eyelid retraction left upper eyelid H02.535 Eyelid retraction left lower eyelid H02.536 Eyelid retraction left eye, unspecified eyelid H02.539 Eyelid retraction unspecified eye, unspecified lid H02.841 Edema of right upper eyelid H02.842 Edema of right lower eyelid H02.843 Edema of right eye, unspecified eyelid Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 18 H02.844 Edema of left upper eyelid H02.845 Edema of left lower eyelid H02.846 Edema of left eye, unspecified eyelid H02.849 Edema of unspecified eye, unspecified eyelid H05.20 Unspecified exophthalmos H05.221 Edema of right orbit H05.222 Edema of left orbit H05.223 Edema of bilateral orbit H05.229 Edema of unspecified orbit H05.241 Constant exophthalmos, right eye H05.242 Constant exophthalmos, left eye H05.243 Constant exophthalmos, bilateral H05.249 Constant exophthalmos, unspecified eye H05.251 Intermittent exophthalmos, right eye H05.252 Intermittent exophthalmos, left eye H05.253 Intermittent exophthalmos, bilateral H05.259 Intermittent exophthalmos, unspecified eye H05.89 Other disorders of orbit H11.421 Conjunctival edema, right eye H11.422 Conjunctival edema, left eye H11.423 Conjunctival edema, bilateral H11.429 Conjunctival edema, unspecified eye H11.431 Conjunctival hyperemia, right eye H11.432 Conjunctival hyperemia, left eye H11.433 Conjunctival hyperemia, bilateral H11.439 Conjunctival hyperemia, unspecified eye H49.00 Third [oculomotor] nerve palsy, unspecified eye H49.01 Third [oculomotor] nerve palsy, right eye H49.02 Third [oculomotor] nerve palsy, left eye H49.03 Third [oculomotor] nerve palsy, bilateral H49.10 Fourth [trochlear] nerve palsy, unspecified eye H49.11 Fourth [trochlear] nerve palsy, right eye H49.12 Fourth [trochlear] nerve palsy, left eye H49.13 Fourth [trochlear] nerve palsy, bilateral Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 19 H49.20 Sixth [abducent] nerve palsy, unspecified eye H49.21 Sixth [abducent] nerve palsy, right eye H49.22 Sixth [abducent] nerve palsy, left eye H49.23 Sixth [abducent] nerve palsy, bilateral H49.40 Progressive external ophthalmoplegia, unspecified eye H49.41 Progressive external ophthalmoplegia, right eye H49.42 Progressive external ophthalmoplegia, left eye H49.43 Progressive external ophthalmoplegia, bilateral H49.881 Other paralytic strabismus, right eye H49.882 Other paralytic strabismus, left eye H49.883 Other paralytic strabismus, bilateral H49.889 Other paralytic strabismus, unspecified eye H49.9 Unspecified paralytic strabismus H53.2 Diplopia I10 Essential (primary) hypertension I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease I31.3 Pericardial effusion (noninflammatory) I31.9 Disease of pericardium, unspecified I43 Cardiomyopathy in diseases classified elsewhere I47.1 Supraventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation *I48.1 *Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation I49.2 Junctional premature depolarization Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 20 I49.8 Other specified cardiac arrhythmias I49.9 Cardiac arrhythmia, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9 Heart failure, unspecified I51.7 Cardiomegaly J91.8 Pleural effusion in other conditions classified elsewhere J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia J96.90 Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia J96.91 Respiratory failure, unspecified with hypoxia J96.92 Respiratory failure, unspecified with hypercapnia K14.8 Other diseases of tongue K52.2 Allergic and dietetic gastroenteritis and colitis K52.89 Other specified noninfective gastroenteritis and colitis K56.0 Paralytic ileus K56.7 Ileus, unspecified K59.00 Constipation, unspecified K59.01 Slow transit constipation K59.02 Outlet dysfunction constipation K59.09 Other constipation Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 21 K59.3 Megacolon, not elsewhere classified L11.0 Acquired keratosis follicularis L29.9 Pruritus, unspecified L60.1 Onycholysis L60.2 Onychogryphosis L60.3 Nail dystrophy L60.4 Beau’s lines L60.5 Yellow nail syndrome L60.8 Other nail disorders L62 Nail disorders in diseases classified elsewhere L63.0 Alopecia (capitis) totalis L63.1 Alopecia universalis L63.2 Ophiasis L63.8 Other alopecia areata L63.9 Alopecia areata, unspecified L64.0 Drug-induced androgenic alopecia L64.8 Other androgenic alopecia L64.9 Androgenic alopecia, unspecified L65.0 Telogen effluvium L65.1 Anagen effluvium L65.2 Alopecia mucinosa L65.8 Other specified nonscarring hair loss L65.9 Nonscarring hair loss, unspecified L66.0 Pseudopelade L66.2 Folliculitis decalvans L66.8 Other cicatricial alopecia L66.9 Cicatricial alopecia, unspecified L80 Vitiligo L85.0 Acquired ichthyosis L85.1 Acquired keratosis [keratoderma] palmaris et plantaris L85.2 Keratosis punctata (palmaris et plantaris) L86 Keratoderma in diseases classified elsewhere L87.0 Keratosis follicularis et parafollicularis in cutem penetrans L87.2 Elastosis perforans serpiginosa Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 22 M32.0 Drug-induced systemic lupus erythematosus M32.10 Systemic lupus erythematosus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus erythematosus M32.12 Pericarditis in systemic lupus erythematosus M32.13 Lung involvement in systemic lupus erythematosus M32.14 Glomerular disease in systemic lupus erythematosus M32.15 Tubulo-interstitial nephropathy in systemic lupus erythematosus M32.19 Other organ or system involvement in systemic lupus erythematosus M32.8 Other forms of systemic lupus erythematosus M32.9 Systemic lupus erythematosus, unspecified M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyositis with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with other organ involvement M33.20 Polymyositis, organ involvement unspecified M33.21 Polymyositis with respiratory involvement M33.22 Polymyositis with myopathy M33.29 Polymyositis with other organ involvement M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy M33.99 Dermatopolymyositis, unspecified with other organ involvement M34.0 Progressive systemic sclerosis M34.1 CR(E)ST syndrome M34.2 Systemic sclerosis induced by drug and chemical M34.81 Systemic sclerosis with lung involvement M34.82 Systemic sclerosis with myopathy M34.83 Systemic sclerosis with polyneuropathy M34.89 Other systemic sclerosis M34.9 Systemic sclerosis, unspecified Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 23 M35.00 Sicca syndrome, unspecified M35.01 Sicca syndrome with keratoconjunctivitis M35.02 Sicca syndrome with lung involvement M35.03 Sicca syndrome with myopathy M35.04 Sicca syndrome with tubulo-interstitial nephropathy M35.09 Sicca syndrome with other organ involvement M35.1 Other overlap syndromes M35.5 Multifocal fibrosclerosis M35.8 Other specified systemic involvement of connective tissue M35.9 Systemic involvement of connective tissue, unspecified M36.0 Dermato(poly)myositis in neoplastic disease M36.8 Systemic disorders of connective tissue in other diseases classified elsewhere M60.80 Other myositis, unspecified site M60.811 Other myositis, right shoulder M60.812 Other myositis, left shoulder M60.819 Other myositis, unspecified shoulder M60.821 Other myositis, right upper arm M60.822 Other myositis, left upper arm M60.829 Other myositis, unspecified upper arm M60.831 Other myositis, right forearm M60.832 Other myositis, left forearm M60.839 Other myositis, unspecified forearm M60.841 Other myositis, right hand M60.842 Other myositis, left hand M60.849 Other myositis, unspecified hand M60.851 Other myositis, right thigh M60.852 Other myositis, left thigh M60.859 Other myositis, unspecified thigh M60.861 Other myositis, right lower leg M60.862 Other myositis, left lower leg M60.869 Other myositis, unspecified lower leg M60.871 Other myositis, right ankle and foot M60.872 Other myositis, left ankle and foot M60.879 Other myositis, unspecified ankle and foot Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 24 M60.88 Other myositis, other site M60.89 Other myositis, multiple sites M60.9 Myositis, unspecified M62.50 Muscle wasting and atrophy, not elsewhere classified, unspecified site M62.511 Muscle wasting and atrophy, not elsewhere classified, right shoulder M62.512 Muscle wasting and atrophy, not elsewhere classified, left shoulder M62.519 Muscle wasting and atrophy, not elsewhere classified, unspecified shoulder M62.521 Muscle wasting and atrophy, not elsewhere classified, right upper arm M62.522 Muscle wasting and atrophy, not elsewhere classified, left upper arm M62.529 Muscle wasting and atrophy, not elsewhere classified, unspecified upper arm M62.531 Muscle wasting and atrophy, not elsewhere classified, right forearm M62.532 Muscle wasting and atrophy, not elsewhere classified, left forearm M62.539 Muscle wasting and atrophy, not elsewhere classified, unspecified forearm M62.541 Muscle wasting and atrophy, not elsewhere classified, right hand M62.542 Muscle wasting and atrophy, not elsewhere classified, left hand M62.549 Muscle wasting and atrophy, not elsewhere classified, unspecified hand M62.551 Muscle wasting and atrophy, not elsewhere classified, right thigh M62.552 Muscle wasting and atrophy, not elsewhere classified, left thigh M62.559 Muscle wasting and atrophy, not elsewhere classified, unspecified thigh M62.561 Muscle wasting and atrophy, not elsewhere classified, right lower leg M62.562 Muscle wasting and atrophy, not elsewhere classified, left lower leg M62.569 Muscle wasting and atrophy, not elsewhere classified, unspecified lower leg M62.571 Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M62.572 Muscle wasting and atrophy, not elsewhere classified, left ankle and foot M62.579 Muscle wasting and atrophy, not elsewhere classified, unspecified ankle and foot M62.58 Muscle wasting and atrophy, not elsewhere classified, other site M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites M62.81 Muscle weakness (generalized) M62.9 Disorder of muscle, unspecified M63.80 Disorders of muscle in diseases classified elsewhere, unspecified site M63.811 Disorders of muscle in diseases classified elsewhere, right shoulder M63.812 Disorders of muscle in diseases classified elsewhere, left shoulder Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 25 M63.819 Disorders of muscle in diseases classified elsewhere, unspecified shoulder M63.821 Disorders of muscle in diseases classified elsewhere, right upper arm M63.822 Disorders of muscle in diseases classified elsewhere, left upper arm M63.829 Disorders of muscle in diseases classified elsewhere, unspecified upper arm M63.831 Disorders of muscle in diseases classified elsewhere, right forearm M63.832 Disorders of muscle in diseases classified elsewhere, left forearm M63.839 Disorders of muscle in diseases classified elsewhere, unspecified forearm M63.841 Disorders of muscle in diseases classified elsewhere, right hand M63.842 Disorders of muscle in diseases classified elsewhere, left hand M63.849 Disorders of muscle in diseases classified elsewhere, unspecified hand M63.851 Disorders of muscle in diseases classified elsewhere, right thigh M63.852 Disorders of muscle in diseases classified elsewhere, left thigh M63.859 Disorders of muscle in diseases classified elsewhere, unspecified thigh M63.861 Disorders of muscle in diseases classified elsewhere, right lower leg M63.862 Disorders of muscle in diseases classified elsewhere, left lower leg M63.869 Disorders of muscle in diseases classified elsewhere, unspecified lower leg M63.871 Disorders of muscle in diseases classified elsewhere, right ankle and foot M63.872 Disorders of muscle in diseases classified elsewhere, left ankle and foot M63.879 Disorders of muscle in diseases classified elsewhere, unspecified ankle and foot M63.88 Disorders of muscle in diseases classified elsewhere, other site M63.89 Disorders of muscle in diseases classified elsewhere, multiple sites M79.1 Myalgia M79.7 Fibromyalgia M81.6 Localized osteoporosis [Lequesne] M81.8 Other osteoporosis without current pathological fracture M86.9 Osteomyelitis, unspecified N91.0 Primary amenorrhea N91.1 Secondary amenorrhea N91.2 Amenorrhea, unspecified N91.3 Primary oligomenorrhea N91.4 Secondary oligomenorrhea N91.5 Oligomenorrhea, unspecified Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 26 N92.0 Excessive and frequent menstruation with regular cycle N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified N94.4 Primary dysmenorrhea N94.5 Secondary dysmenorrhea N94.6 Dysmenorrhea, unspecified O90.5 Postpartum thyroiditis O92.29 Other disorders of breast associated with pregnancy and the puerperium O99.280 Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester O99.281 Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester O99.283 Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester O99.284 Endocrine, nutritional and metabolic diseases complicating childbirth O99.285 Endocrine, nutritional and metabolic diseases complicating the puerperium Q38.2 Macroglossia Q89.2 Congenital malformations of other endocrine glands R00.0 Tachycardia, unspecified R00.1 Bradycardia, unspecified R00.2 Palpitations R06.00 Dyspnea, unspecified R06.09 Other forms of dyspnea R06.1 Stridor R06.83 Snoring R06.89 Other abnormalities of breathing R07.0 Pain in throat R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase R13.14 Dysphagia, pharyngoesophageal phase Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 27 R13.19 Other dysphagia R18.0 Malignant ascites R18.8 Other ascites R19.4 Change in bowel habit R19.7 Diarrhea, unspecified R19.8 Other specified symptoms and signs involving the digestive system and abdomen R20.0 Anesthesia of skin R20.1 Hypoesthesia of skin R20.2 Paresthesia of skin R20.3 Hyperesthesia R20.8 Other disturbances of skin sensation R20.9 Unspecified disturbances of skin sensation R23.4 Changes in skin texture R23.8 Other skin changes R23.9 Unspecified skin changes R25.0 Abnormal head movements R25.1 Tremor, unspecified R25.2 Cramp and spasm R25.3 Fasciculation R25.8 Other abnormal involuntary movements R25.9 Unspecified abnormal involuntary movements R27.0 Ataxia, unspecified R27.8 Other lack of coordination R27.9 Unspecified lack of coordination R29.2 Abnormal reflex R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R40.2110 Coma scale, eyes open, never, unspecified time R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance] R40.2112 Coma scale, eyes open, never, at arrival to emergency department R40.2113 Coma scale, eyes open, never, at hospital admission R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission R40.2120 Coma scale, eyes open, to pain, unspecified time Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 28 R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance] R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department R40.2123 Coma scale, eyes open, to pain, at hospital admission R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission R40.2210 Coma scale, best verbal response, none, unspecified time R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance] R40.2212 Coma scale, best verbal response, none, at arrival to emergency department R40.2213 Coma scale, best verbal response, none, at hospital admission R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance] R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission R40.2310 Coma scale, best motor response, none, unspecified time R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance] R40.2312 Coma scale, best motor response, none, at arrival toemergency department R40.2313 Coma scale, best motor response, none, at hospital admission R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission R40.2320 Coma scale, best motor response, extension, unspecified time R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance] R40.2322 Coma scale, best motor response, extension, at arrival to emergency department R40.2323 Coma scale, best motor response, extension, at hospital admission R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance] R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 29 R40.4 Transient alteration of awareness R41.0 Disorientation, unspecified R41.1 Anterograde amnesia R41.2 Retrograde amnesia R41.3 Other amnesia R41.82 Altered mental status, unspecified R41.9 Unspecified symptoms and signs involving cognitive functions and awareness R45.0 Nervousness R45.1 Restlessness and agitation R45.3 Demoralization and apathy R45.4 Irritability and anger R45.81 Low self-esteem R45.82 Worries R45.84 Anhedonia R45.86 Emotional lability R45.87 Impulsiveness R45.89 Other symptoms and signs involving emotional state R47.02 Dysphasia R47.1 Dysarthria and anarthria R47.81 Slurred speech R47.89 Other speech disturbances R47.9 Unspecified speech disturbances R49.0 Dysphonia R49.21 Hypernasality R49.22 Hyponasality R49.8 Other voice and resonance disorders R50.2 Drug induced fever R50.81 Fever presenting with conditions classified elsewhere R50.82 Postprocedural fever R50.83 Postvaccination fever R50.84 Febrile nonhemolytic transfusion reaction R50.9 Fever, unspecified R52 Pain, unspecified R53.0 Neoplastic (malignant) related fatigue Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 30 R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R60.0 Localized edema R60.1 Generalized edema R60.9 Edema, unspecified R61 Generalized hyperhidrosis R63.0 Anorexia R63.2 Polyphagia R63.4 Abnormal weight loss R63.5 Abnormal weight gain R68.0 Hypothermia, not associated with low environmental temperature R68.81 Early satiety R68.83 Chills (without fever) R68.89 Other general symptoms and signs R90.89 Other abnormal findings on diagnostic imaging of central nervous system R93.8 Abnormal findings on diagnostic imaging of other specified body structures R94.6 Abnormal results of thyroid function studies T66.XXXA Radiation sickness, unspecified, initial encounter Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z79.3 Long term (current) use of hormonal contraceptives Z79.891 Long term (current) use of opiate analgesic Z79.899 Other long term (current) drug therapy Z85.020 Personal history of malignant carcinoid tumor of stomach Z85.030 Personal history of malignant carcinoid tumor of large intestine Z85.040 Personal history of malignant carcinoid tumor of rectum Z85.060 Personal history of malignant carcinoid tumor of small intestine Z85.110 Personal history of malignant carcinoid tumor of bronchus and lung Z85.230 Personal history of malignant carcinoid tumor of thymus Z85.520 Personal history of malignant carcinoid tumor of kidney Thyroid Testing Ohio Medicare Advantage PY-0223 Effective Date: 12/01/2017 31 Z85.821 Personal history of Merkel cell carcinoma Z85.850 Personal history of malignant neoplasm of thyroid Z85.858 Personal history of malignant neoplasm of other endocrine glands Z86.2 Personal history of diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Z86.32 Personal history of gestational diabetes Z86.39 Personal history of other endocrine, nutritional and metabolic disease AUTHORIZATION PERIOD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 03/08/2017 New policy. Date Revised Date Effective 012/01/2017 H. REFERENCES 1. National Coverage Determination (NCD) for Thryoid Testing (190.22). Retrieved February 28, 2017, from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report ICD-10-CM. Retrieved February 28, 2017, from https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201601_ICD10.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTOHIO MEDICA RE ADVANTAGE Original Issue Date Next Annual Review Effective Date 10/01/2017 10/01/2018 11/01/2017 Policy Name Policy Number Speech-Language Pathology PY-0180 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 nece ssary 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 f or 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 be tween 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 inter preting and applying this Policy to services provided in a particular case and may modify this Policy at any time.Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A. SUBJECT ……………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………….. 2 C. DEFINITIONS ………………………………………………………………………………………….. 2 D. POLICY …………………………………………………………………………………………………. 2 E. CONDITIONS OF COVERAGE ………………………………………………………………….. 3 F. RELATED POLICIES/RULES ……………………………………………………………………. 3 G. REVIEW/REVISION HISTORY ………………………………………………………………….. 3 H. REFERENCES ………………………………………………………………………………………… 4
REIMBURSEMENT POLICY STATEMENT OHIO MEDICARE ADVANT AGE Original Issue Dat e Next Annual Review Effective Da te 10/01/2017 10/01/2018 11/01/2017-10/29/2020 Policy Name Policy Number Occupational an d Physical Therapy PY-0297 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Contents of PolicyREIMBURSEMENT PO LI CY STATEMENT ……………………………………………………………… 1 TABLE OF CONTENTS …………………………………………………………………………………………… 1 A. SUBJECT …………………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………………. 2 C. DEFINITIONS ………………………………………………………………………………………………. 2 D. POLICY ………………………………………………………………………………………………………. 3 E. CONDITIONS OF COVERAGE ……………………………………………………………………… 4 F. RELATED POLICIES/RULES ………………………………………………………………………… 5 G. REVIEW/REVISION HISTORY ………………………………………………………………………. 5 H. REFERENCES ……………………………………………………………………………………………… 5 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 a ndard 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 p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, a nd applicable re f e rral, authorization, n otifica tion a nd u tiliza tion management gu id eli nes. Me dica lly necessary services include, b ut a re n ot limite d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 Oc c up ati o n al an d Ph y si cal Th erapy Ohio Med i c are Ad v an tage PY-0297 Effec ti v e Date: 11/01/2017A. SUBJECTOccupational and Physical Therapy B. BACKGROUND Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of pay ment. Reimb ursement for claims may be s ubjec t to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing. Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode in this p o lic y does no t imply any right to reimbursement o r guarantee c laims p ayment. Oc c up ational and Phys ic al therapy s erv ic es help improve the lives of patients through c o mp rehensive evaluations, recommendations for adaptiv e equipment and training in its use, and g uid anc e and educ ation for family members and c areg iv ers. Oc c up ational therapy (OT) f ocus es on ad apting the env ironment, of the member, to fit their need s . Th i s inc lud es helping people regain skills after an injury , s upporting older adults that have ex p erienc ed a p hysical o r mental change and teac hing c hildren with d is abilities ho w to increase p artic ipation in s c hool and soci al activities. Physical therapy (PT) f ocuses on inc reasing the members phy sical ability to p articipate in their env iro nment. This inc lud es helping people regain p hysical strength, reduc e pain, function and ind ep endenc e after an injury or mental c hange. PT teac hes members how to manage their p hy s ical c ondition, p revent further injury and achieve long-term health benefits.C. DEFINITIONS Maintenance Program-is a program c reated by a therap ist that m aximizes or maintains t he p ro g ress the p atient has made during therapy o r helps to prev ent o r slow further d eterio ration d ue to a d is eas e or illness. Medically necessary health produc ts, supplies o r serv ices that are nec es sary for the diagnosis or treatment of d is eas e, illness, or injury and meet ac cepted g uidelines of medical p rac tice. Occupational therapy-is a health profes sion that helps patients develop skills in o r d er to ac hiev e ind ependence in their ac tivities of d aily living. Physical Therapy-is a health profes sion that helps patients reduce pain and improve or res to re mo bility to achieve independence in their ac tivities of daily living. Rehabilitative therapy-occ urs when the skills of a therapist (as defined by the s cope of p rac tic e for therapists in eac h s tate) are nec ess ar y to s afely and effectively furnish a rec o g nized therapy s ervice, whos e g oal is improvement of an impairment o r functional limitation. Skilled Therapy is a s ervice c an be only be administered by a therapist. If a service c an b e s elf-administered or s afely and effectiv ely furnis hed b y an uns killed person, without the d irec t o r g eneral s upervision of a therapist, the s ervice c annot b e regarded as a s killed therap y s erv ice even though a therapist ac tually furnishes the s erv ice. Therapist-ref ers to p hysical therapists and oc cupational therapists qualified according to Med ic are p olic y. 3 D. POLICY Oc c up ati o n al an d Ph y si cal Th erapy Ohio Med i c are Advantage PY-0297 Effec ti v e Date: 11/01/2017I. CareSo urc e members may rec eive up to 30 o cc upational therapy s ervices visits and/or 30 p hy s ical therapy services visit s per c alendar y ear (J anuary 1 Dec ember 31 st) without prior autho rizatio n. All p hy sical and oc cupational therapy serv ices must be medical necess ary. II. Reimb urs ement for PT/ OT therap y s erv ices is b ased on Local coverage Determination (LCD) L34049: A. Mus t be medically nec essary and , under acc epted standards of medical prac tice, b e c o ns idered s pecific and effectiv e treatment for the patient's c ondition. B. Serv ic es m ust be skilled therapy and based on individual needs. Serv ic es that do not req uire the p ro fessional sk ills of a therapist to perform o r s upervise are no t medically nec es s ary. C. An initial ev aluation/assess ment of the members need f or OT/ PT therapy s ervices and p ro g ress notes must b e documented and maintained in the members health rec ord whic h inc lud es the following: 1. Do c umentation of the appropriate diagnos is of the disorder or a description of t he p hy s ical o r sens ory functionality d eficit. 2. Do c umentation of eac h service prov ided to the member. 3. Detailed s taf f notes t h at include the members progress towards their goals. 4. Th e d ate of each service. 5. Th e b eg inning and end t im e s of eac h service. 6. Th e s ig nature and ti t le of the individual providing each service. 7. Ratio nale req uiring the uniq ue s kills o f a therapist to ap ply , inc luding the c omplicating f ac tors Area(s ) being treated Subjectiv e findings to include pain ratings, p ain lo c atio n, and ef fect on function 8. Th e Physician/ Non-p hy sician practitioner (NP P) mus t s ign and date along wit h t heir p ro f es sional id entification (MD, DO, PT, OT) D. Memb er mus t be under the care of a p h ys ic ia n or No n-physician practitioner (NPP) E. Serv ic es m ust be under a therapy plan of care that has been c reated and c ertified by the p hy s ician o r NPP F. Th e Plan of Care mus t include: 1. A rehab ilitation d iagnosis 2. Ind iv id ualized p la n bas ed on the members evaluation / examination 3. Sp ecific interventions to be us ed to treat the patients needs 4. Antic ip ated short term and long t erm g oals , expec ted outc omes, any p redicted lev el o f improvement 5. Th e intens ity , frequency , and d uration f or c are. 6. Th e antic ip ated d ischarge p lans. G. Only the ac tual t im e of the pro viders direct o ne-on-one contact wit h the p atient is to be b illed. H. Treatment s ho uld be consistent wit h the nature/ sev erity of illness / injury I. If treatment is g iv e n on the s ame day as the initial ev aluation, the treatment is billed using the ap p ro priate CPT c odes. The d oc umentation must c learly describe the treatment that was p ro v ided in addition to the ev aluation. J. Us e o f these p rocedures req uires the qualified professional/auxiliary pers onnel to hav e d irec t (o ne-on-one) patient cont act. Only the ac tual ti m e of direc t contact wi th the patient p ro v iding a s ervice whic h requires the s kills of a therapist is c onsidered for c ov erag e K. A reev aluatio n may be medically necessary if there has been a s ignificant change in the p atients condition whic h has c aused a c hange in function, long term g oals , and/or treatment p lan. 1. Th e reev aluatio n is focused on evaluation of progress toward c urrent goals a nd mak ing a p rofessional judgment ab out c ontinued c are, modifying g oals and/or treatment, o r terminating s ervices. 2. Do c umentation m ust s how a significant improvement, dec line or c hange in the p atients diagnosis 4 3. 4. Oc c up ati o n al an d Ph y si cal Th erapy Ohio Med i c are Ad v an tage PY-0297 Effec ti v e Date: 11/01/201 7Th e p res enc e of a c o ndition or functional s tatus that was no t anticipated in the c u rrent p lan o f care. Th e p lan of c are may need to be revised and rec ertified, if s ignificant changes are mad e, s uc h as a c hange in the long-term goals. IV. Reimb urs ement is b ased on submitting a claim with the appropriate ICD-10 d iagnosis c ode to matc h the OT/PTs erv ice CPT c ode.V. If the ap p ropriate ICD-10 diagnosis code is not s ubmitted wi th the CPT c o d e, the claim will be d enied . VI. Reimb urs ement is based o n Medicare g uidelines. Fo r further information p leas e refer to: http s://www.cms.gov/medicare-coverage-database/details /lcd-d etails.aspx ?LCDId=34049&ver=18&Cov erageSelec tion=Both&ArticleType=All&PolicyTy pe= Final&s =All&KeyWord=Therapy&KeyWordLookUp=Title&KeyWordSearchTy pe=And&Friendl y Erro r=NoLCDIDVersi on&bc=gAAAA CA AAAA AAA%3d%3d& VI. No n-Co v ered Services A. Dup lic ation o f s erv ic es . CareSo urc e will no t reimb urs e f o r an o c c up ational therapy s erv ic e o r p hy s ical therap y s erv ic e p ro vided, to a memb er, b y mo re than o ne (1) p ro v ider in whic h the serv ice is c overed d uring the s ame time p eriod. B. Serv ic es related to rec reational ac tivities s uch as g o lf, tennis , running , etc ., are not c o v ered as therapy s ervices . C. Therap eutic service modalities that the member c an be trained and educated to u t ilize thems elv es, witho ut a s k illed therap is t, is no t med ic ally nec es sary and theref ore not c o v ered. D. If an ex is ting CP Tcode d oes no t d es cribe the service p erformed, an unlis ted CPT code may be us ed . Th e us e of unlisted codes s hould be rare. If unlis ted codes are b illed, the c laim and med ical rec ord must c learly state what modality or p rocedure is b illed as an unlis ted c ode. If no t, the unlis ted c ode b illed will b e s ub ject to d enial f or ins ufficient inf o rmation. E. Lo w lev el/c old laser lig ht therapy (LLLT) Note: Altho ug h occ upational and phys ic al therapy serv ic es do no t req uire a p rior autho rizatio n for the firs t 30 v isits , CareSource may req uest d ocumentation to s upport med ic al neces sity. Ap propriate and c omplete doc umentation m ust be presented at the time o f review to v alidate medical nec essity .E. CONDITIONS OF COVERAGE Reimb urs ement is dependent o n, b ut not limited to, s ubmitting The Centers for Medicare & Med ic aid Serv ices (CMS) ap proved HCPCS and CPT c o des along wi th appropriate modifiers. Pleas e ref er to the CMS fee s chedule: http s://www.c ms.gov/apps/physician-fee-s c hed ule/s earch/s earch-criteria.aspx The following list(s) of codes is provided as a reference. This list m ay not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Note: Code 97010 is nev er b illed alone or paid s eparately. It may be bundled wit h any therap y c ode. 5 F. RELATED POLICIES/RULESG. REVIEW/REVISION HISTORY Oc c up ati o n al an d Ph y si cal Th erapy Ohio Med i c are Advantage PY-0297 Effec ti v e Date: 11/01/2017DATE ACTIONDate Issued 10/01/2017 New Po licy.Date Revised Date Effecti ve 11/01/2017 Date Archived 10/29/2020 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. About Oc cupational Therapy. (2017). Retrieved 4/5/2017 f ro m http ://www.aota.org/About-Occ upational-Therapy.aspx 2. Current Pro c ed ural Terminology (CPT) and National Uniform Billing Co mmittee (NUBC) Lic ens es . (2017, January 1). Retrieved 4/11/2017 from https://www.cms .gov/medicare-c o v erage-database/details/lcd-d etails.aspx ?LCDId=34049&ver=18&Cov erageSelec tion=Both&ArticleType=All&PolicyTy p e=Final&s=All&KeyWord=Therapy&Key WordLook Up=Title&KeyWordSearchTy pe=And &Friend lyError=NoLCDID Version&bc=gAAAACAAAAAAAA%3d%3d& 3. Med ically Neces sary-HealthCare.gov Glossary | HealthCare.gov. (2017, March 14). Retriev ed 3/14/17 from https ://www.healthcare.gov /glossary /medic ally-nec essary/ 4. Who A re Phy sical Therapis ts? (2017). Retriev ed 4/5/2017 f ro m http ://www.apta.org/AboutPTs / The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT
REIMBURSEMENT POLICY STATEMENTOHIO MEDICARE Original Issue Date Next Annual Review Effective Date 5/12/2017 05/01/2018 5/12/2017-06/30/2021 Policy Name Policy Number Three-Day Payment Window PY-0142 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 ………………………….. ………………………….. ………………………….. …………………. 3 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………….. 4 F. RELATED POLICIES/RULES ………………………….. ………………………….. ……………….. 4 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………….. 4 H. REFERENCES ………………………….. ………………………….. ………………………….. ……….. 4 Medical Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical manage ment industry standards, and published MCO clinical policy 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 diseas e, 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 practi ce 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CSMG Co. and its affiliates (including CareSource) do not ensure an authorization orpayment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s)referenced in the Medical Policy Statement. If there is a con flict between the Medical Policy Statement 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. 2 Th ree-Day Paymen t Win d o wOh io Med icare PY-0142 Effective Date: 05/12/2017 A. SUBJECTThree-Day Payment Window B. BACKGROUND General: Outp atient d iagnostic services and certain outpatient no n-diagnostic services p rovided to Med icare b eneficiaries by a subsection (d ) ho spital subject to the inpatient p rospective p ayment system (IPPS) (ho spital), or an entity wholly o wned o r operated by a hospital, on either the d ate o f a b eneficiary’s admission or d uring the three (3) cal endar d ays immediately preceding the d ate o f a b eneficiary’s inpatient admission to a ho spital, are p aid as p art of the inpatient stay und er the IPPS. This rule is g enerally known as the three-day payment wind ow policy. Under this rule, a ho spital o r its wholly owned/operated entity cannot b ill Medicare separately for o utp atient diagnostic and certain outpatient non-diagnostic services and must include them on the claim f or the p atients inpatient stay. Historically, the three-day p ayment window policy ap plied auto matically to all outpatient d iagnostic services p rovided in the 3-day wind ow and to those o utp atient non-diagnostic services that shared the same diagnosis code as the inpatient ad mission. Sectio n 102 of the Preservation of Access to Care for Medicare Beneficiaries and Pension ReliefAct o f 2010, Pub. L. 111-192 (PACMBPRA), signed into law on June 25, 2010, b roadened and clarif ied the Medicare three-day p ayment window policy. Under the Medicare three-day p ayment wind o w p olicy as broadened by PACMBPRA, a ho spital (or an entity that is who lly o wned or who lly o perated by the hospital) must include o n the claim for a b eneficiary’s inp atient stay no t o nly the d iagnoses, procedures, and charges for all o utpatient diagnostic services, and all non – d iag no stic services that have the same d iagnosis code as the inpatient admission, but also any no n-d iag nostic services that are clinically –related to the inpatient admission. Und er the p ol icy, all o utp atient diagnostic and clinically-related no n-diagnostic services furnished to a Medicare b enef iciary b y an IPPS ho spital (o r an entity who lly owned or o perated b y the hospital), o n the d ate o f a b eneficiary’s ad mission or d uring the 3 days imm ediately p receding the d ate of a b enef iciary’s inpatient hospital ad mission, must b e included on the Part A bill for the beneficiary’s inp atient stay at the hospital. Und er the PACMBPRA, CMS p resumes that all outpatient no n-diagnostic services rend ered in the 3-d ay wind ow are clinically related to the inpatient admission unless the ho spital attests that sp ecific non-diagnostic services are unrelated to the inpatient hospital claim. Fo r no n-IPPS hospitals and units — including p sychiatric hospitals and units, inp atient rehab ilitation hospitals and units, lo ng-term care hospitals, childrens hospitals, and cancer ho sp itals the p re-admission window is 1 d ay instead of 3 d ays. CareSo urce, as a Medicare Advantage p lan, follows the Medicare three-day payment window p o licy for IPPS hospitals, and the one-day p ayment wind ow for no n-IPPS ho spitals, as expanded by PACMBPRA, for services rend ered to CareSource Medicare Advantage beneficiaries. C. DEFINITIONS Fo r p urp oses of this policy, ho spital is d efined as an ad mitting hospital that is a subsection (d ) ho sp ital subject to the inpatient prospective payment system (IPPS), entities who lly o wned or who lly operated by the admitting ho spital, and entities under arrang ements with the ad mitting ho spital. No n-IPPS Ho spital is an ad mitting hospital that is not paid under the Medicare hospital Inp atient Pro spective Payment System, including psychiatric ho spitals and units, inpatient rehab ilitation hospitals and units, lo ng-term care hospitals, childrens hospitals, and cancer ho sp itals. 3 Th ree-Day Paymen t Win d o wOh io Med icare PY-0142 Effective Date: 05/12/2017 Who lly o wned is defined as follows: An entity is wholly owned by the hospital if the hospital is the so le o wner of the entity. (See 42 CFR 412.2) Who lly o perated is d efined as follows: An entity is wholly o perated b y a ho spital if the ho sp ital has exclusive responsibility for conducting and overseeing the entitys ro utine o p erations, regardless of whether the hospital also has p olicymaking authority over the entity. (See 42 CFR 412.2) Diag no stic services": According to CMS Internet Only Manual Publication 100-02, Chapter 6, Sectio n 20.4.1, [a] service is d iagnostic if it is an examination or p rocedure to which the p atient i s subjected, o r which is performed o n materials derived fro m a ho spital outpatient, to o b tain information to aid in the assessment of a medical condition or the id entification of a d isease. Among these examinations and tests are d iagnostic laboratory servi ces such as hemato logy and chemistry, d iagnostic x-rays, isotope studies, EKGs, pulmonary function stud ies, thyroid function tests, p sychological tests, and o ther tests given to determine the nature and severity of an ailment or injury. D. POLICY I. General. As a Med icare Advantage plan, it is the CareSource p olicy that o utpatient d iag no stic services provided to a CareSource member by a hospital o n the date of an inp atient ad mission or within 3 d ays (o r 1 d ay for no n-IPPS ho spitals) p rior to the d ate of the inp atient ad mission are d eemed to b e inp atient services and included in the inpatient p ayment. These services must be bundled on the hospitals claim for the inpatient stay. In ad d ition to diagnostic services, no n-diagnostic services p rovided by a h o spital o n the day of the inp atient admission or o n any of the 3 d ays (o r 1 d ay for a no n-IPPS hospital) immed iately prior to the date of the ad mission must also b e bundled on the claim for the memb ers inpatient stay at the admitting hospital, unless the ho spital attests that the no n – d iag no stic service or services are unrelated to the hospital inpatient stay. II. Services subject to this rule:A. Diag no stic services B. Clinical lab services C. No n-d iag nostic services furnished d uring the 3-d ay (or 1-d ay) payment window that have the same d iagnosis code as the inpatient ad mission D. No n-d iag nostic services furnished during the 3-day (o r 1-d ay) payment wind ow that are clinically-related to the inpatient ad mission III. Co mp liance with Three-Day (and One-Day) Payment Rule.A. All o utp atient claims submitted by a Hospital are subject to this rule and will b e denied if rend ered within three calendar d ays (o r one calendar d ay for non-IPPS ho spitals) p rior to an inp atient ad mission of the same patient receiving the outpatient services. 1. Any p reviously paid outpatient claims, if subject to this rule, will be denied. 2. Claims where a Ho sp ital has b een paid for an inpatient claim and subsequently sub mits a claim for an o utpatient service that was rend ered within three calendar d ays (o r o ne calendar day for non-IPPS hospitals) prior to the inpatient ad mission of that p atient will be d enied. 3. Related entities should ad d Modifier PD to claims for d iagnostic and nondiagnostic services that are subject to the p ayment window rule. 4. Ho sp itals are no t required to bundle with the inpatient claim outpatient no n-diagnostic services provided d uring the p ayment window that are no t clinically related to the inp atient ad missi on. A ho spital must maintain d ocumentation in the medical record to sup p ort its claim that the p readmission o utpatient non-diagnostic services are no t clinically related to the inpatient ad mission. Unrelated o utpatient no n-diagnostic 4 Th re e-Day Paymen t Win d o wOh io Med icare PY-0142 Effective Date: 05/12/2017 services must be billed separately from the hospitals claim for the inpatient ad mission as follows: 4. 1 Examp les: a. Patient A received an o utpatient service from Hospital A o n January 1, 2016. Ho sp ital A submitted the claim as an o utpatient claim. On January 4, 2016, Patient A is ad mitted to Hospital A as an inpatient. The o utpatient service rend ered to Patient A o n Jan uary 1, 2016 will b e denied and is subject to reco up ment because it was rend ered within three calendar d ays of Patient As inp atient admission to Hospital A. b. Patient Breceived an o utpatient service from Hospital Bo n January 1, 2016. On January 5, 2016, Patient Bis admitted to Ho spital Bas an inp atient. The o utp atient service rendered to Patient Bon January 1, 2016 will be approved (p ro vided that it o therwise meets any ap plicable service and reimbursement req uirements) b ecause it was rend ered outside of the three-day payment wind o w. E. CONDITIONS OF COVERAGE F. RELATED POLICIES/RULESG. REVIEW/REVISION HISTORYACTIONDate Issued 05/12/2017Date Rev i s ed Date Effective 05/12/2017 Date Archived 06/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guideline s without a f ormal documented Policy. H. REFERENCES1. 42 CFR 412.2(c)(5) 2. Med icare Claims Processing Manual (Pub. 100-4), Chap ter 3, section 40.3, Outpatient Services Treated as Inp atient Services. The Medical Policy Statement detailed above has received due consideration as defined in theMedical Policy Statement Policy and is approved.
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