Medicare Advantage Products and Services 1 Payment 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 editin g logic, benefits design and other factors are considered in developing Payment Policies. In addition to this Policy, payment 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 limite d 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 l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provide r. 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 Pol icy does not ensure an authorization or payment 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 service s provided in a particular case and may modify this Policy at any time.PAYMENT POLICY STATEMENT: MEDICARE ADVANTAGE Original Effective Date Next Annual Review Date Last Review / Revision Date 05/17/2016 05/17/2017 05/17/2016 Policy Name Policy Number Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility PY-0059 Policy Type Medical Administrative Payment A. SUBJECTConsultation Services Rendered by a Podiatrist in a Skilled Nursing Facility B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareS ource. 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 determined 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 payme nt.C. DEFINITIONSN/A Medicare Advantage Products and Services 2 D. POLICYI. CareSource will reimburse providers for Consultation Services Rendered by a Podiatrist in a Skilled Nursing Facility when approved by CareSource. II. If required, providers must submit their prior authorization number their claim form, as well as appropriate HCPCS and/or CPT codes along with appropriate modifiers in accordance with CMS. For Medicare Plan members, reference the Applicable National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). Compliance with NCDs and LCDs is requir ed where applicable.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: htt ps://www.cms.gov/Medicare/Medicare.html CPT/HCPCS CodesCode Description 0245Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include: (1) the diagnosis of LOPS, (2) a patient history, (3) a physical examination that consists of at least the following elements: (a) visual inspection of the forefoot, hindfoot, and toe web spaces, (b) evaluation of a protective sensation, (c) evaluation of foot structure and biomechanics, (d) evaluation of vascular status and skin integrity, and (e) evaluation and recommendation of footwear, and (4) patient education AUTHORIZATION PERIODIf applicable, reimbursement is dependent upon products and service s frequency, duration and timeframe set forth by CMS. E. RELATED POLICIES/RULESF. REVIEW/REVISION HISTORYDate Issued: 05/17/2016 Date Reviewed: 05/17/2016 Date Revised: G. REFERENCES1. Centers for Medicare and Medicaid Services. (1989, May). Retrieved May 12, 2016, from https://www.cms.gov/medicare-coverag e-database/details/ncd – details.aspx?NCDId=170&ncdver=1&bc=AgAAQAAAAAAAAA==& The Payment Policy Statement detailed above has received due consideration as defined in the Payment Policy Statement and is approved.
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