REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Unlisted and Miscellaneous Codes-MP-PY-1459 08/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Unlisted and Miscellaneous Codes-MP-PY-1459Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. Subject Unlisted and Miscellaneous Codes B. BackgroundCurrent Procedure Terminology (CPT) codes are used to describe medical procedures and physician services. The American Medical Association (AMA) maintains and distributes CPT codes. Health Care Common Procedure Coding System (HCPCS) code set represents ite ms, supplies, and non-physician services not addressed by the CPT codes. The Centers for Medicare and Medicaid Services (CMS) establishes and maintains the HCPCS codes. These code sets were established so providers can use the most specific and appropriate code when submitting claims for reimbursement of services rendered to members. Occasionally, a CPT/HCPCS code may not be available for a procedure or service if it israrely used, unusual, or new. Only then would providers use an unlisted, unclassified, not otherwise specified (NOS), not otherwise classified (NOC), unlisted, miscellaneous, or generic code for any such proced ure, service, item, supply, or non-physician service.C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Miscellaneous ( Unlisted, Unclassified, Not Otherwise Specified (NOS ,) or Not Otherwise Classified [NOC ]) Codes Submitted by a supplier for an item or service for which there is no existing code that adequately describes the item or service being billed. Unlisted Code A code represent ing an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code. D. PolicyI. All unlisted or miscellaneous codes require a prior authorization and medical necessity review. II. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.III. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.IV. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review:A. A complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges, including an invoice . B. A statement that no other code exists that would be more appropriate . Unlisted and Miscellaneous Codes-MP-PY-1459Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Any other information requested by CareSource .V. Unlisted/non-specific codes used for procedures deemed to be experimental and investigational may be denied. VI. WarrantyCareSource may request warranty information regarding the DME item or supply when an unlisted or miscellaneous code is used. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the pri or authorization. VII. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly.Code DescriptionA4335 Incontinence supply; miscellaneousA4421 Ostomy supply; miscellaneous A9999 Miscellaneous DME supply or accessory, not otherwise specified B9998 Not otherwise classified ( NOC) for enteral supplies E1399 Durable medical equipment, miscellaneous K0108 Wheelchair component or accessory, not otherwise specified Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device E. State-Specific InformationNA F. Conditions of CoverageA. All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review and prior authorization. B. Prior authorization is not a guarantee of payment. C. Claims must include an invoice. D. CareSource may verify the use of any code through post-payment audit. E. If a more appropriate code is discovered, CareSource may request recoupmen t. G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 11/08/2023 New policy. Approved at Committee.Date Revised 05/07/2025 Periodic review. Updated references. Approved at Committee. Unlisted and Miscellaneous Codes-MP-PY-1459Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Date Effective 08/01/2025Date Archived I. References1. CPT overview and code approval. American Medical Association. Accessed April 29, 2025. www.ama-assn.org 2. Durable Medical Equipment (DME). Accessed April 29, 2025. www.healthcare.gov 3. Healthcare Common Procedure Coding System (HCPCS). American Medical Association. Accessed April 29, 2025. www.ama-assn.org
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifiers-MP-PY-1392 08/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Modifiers-MP-PY-1392Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement modifiers are a two-digit code that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) manuals. Use of a modifier does not change the code or the codes definition. Examples of modifiers use includes: Differentiation between the surgeon, assistant surgeon, and facility fee claims for the same procedure . Indicat ing that a procedure was performed on the left side, right side, or bilaterally . Report ing multiple procedures performed during the same session by the same health care provider . Participation of multiple health care professionals in the procedure . Indication of a subsequent procedure due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Inappropriate use of a modifier can result in a claim denial or incorrect reimbursement for a product or service . All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive): A. National Correct Coding Initiative (NCCI) editing guidelines B. American Medical Association (AMA) guidelines C. American Hospital Association (AHA) billing rules Modifiers-MP-PY-1392Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. Current Procedural Terminology (CPT)E. Healthcare Common Procedure Coding System (HCPCS) F. ICD-10 CM and PCS G. National Drug Codes (NDC) H. Diagnosis Related Group (DRG) guidelines I. CCI table edits II. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment.III. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.E. State-Specific InformationNA F. Conditions of CoverageI. Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual CMS fee schedule for appropriate codes. II. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies apply to both participating and nonparticipating providers and facilities.G. Related Policies/Rules NA H. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022 New policyDate Revised 09/27/2023 05/07/2025 Updated references. Approved at Committee. Periodic review. Updated references. Approved at Committee. Date Effective 08/01/2025 Date Archived I. References1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS) . US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed March 26, 2025. www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed March 26, 2025. www.ama-assn.org Modifiers-MP-PY-1392Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 3. Medicare Claims Processing Manual, XII: Physicians/Nonphysician Practitioners . USCenters for Medicare and Medicaid Services ; 2024. Accessed March 26, 2025. www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers . US Centers for Medicare and Medicaid Services ; 2023. Accessed March 26, 2025. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers – MP-PY-1368 08/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundModifiers can be used to further describe a product or service rendered. Some modifiers are for informational purposes only, while other modifiers are used to report additional information to the code description of the product or service. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. The purpose of this policy is to simplify and standardize the use of modifiers when billingfor rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU . CareSource expects providers to use the modifiers stated in this policy to increase efficiency and timely reimbursement. Any other appropriate modifier per national or state billing standards can be appended t o a DME item along with the modifiers addressed in this policy (LT, RT, etc.). The modifiers addressed in this policy are not an all-inclusive list , and providers should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed within this policy. C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. PolicyI. This policy outlines the use of DME modifiers for the rental and/or purchase of Durable Medical Equipment (DME). II. DME items can beA. purchased B. rented C. rented on a short-term basis and then purchased at the end of the rental period III. DME items must be billed with appropriate HCPCS codes along with appropriatemodifiers when applicable:A. Purchase Modifier – NU 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment. Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 B. Rental Modifier – RR1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment. a. The combined total reimbursement for rental and subsequent purchase of a DME item cannot exceed the maximum fee. b. At the end of the rent to purchase period, the DME becomes the property of the member.C. Disposable supplies do not require a modifier.IV. Modifiers that are not to be used for claims submission for DME equipmentA. LL – Lease/rentalB. NR – New when rented C. RB – Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are new equipment) V. CareSource considers a replacement part as a new equipment purchase , andmodifier NU should be used instead of modifier RB.VI. DME items submitted for reimbursement without a modifier are considered apurchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource may verify the use of any modifier through post payment audit and proper reimbursement adjustment will occur. All information regarding the use of these modifiers must be made available upon CareSources request. VII. KX ModifierA. The KX modifier indicates that the supplier has ensured that coverage criteria for the DMEPOS billed is met and that documentation does exist to support the medical necessity of the item. Documentation must be available upon request.1. The K Xmodifier must be appended as required by the specific DMEPOS item. 2. Claims that do not have the KX modifier appended in accordance with the policy will be denied. E. Conditions of CoverageModifier Description KX Confirmation that services are medically necessary RR Rental (use the RR modifier when DME is to be rented) NU Purchase New Equipment (use the NU modifier when DME is to be purchased) Reimbursement policies are designed to assist providers when submitting claims toCareSource . 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 Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 08/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 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 office staff are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. F. State-Specific InformationNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022 New policyDate Revised 10/11/2023 05/07 /2025Annual review. Added KX modifier language. Updated references. Approved at Committee.Periodic review. Updated KX modifier requirement. Updated references. Approved at Committee. Date Effective 08/01/2025 Date Archived I. References1. Durable Medical Equipment (DME). Accessed March 31, 2025. www.healthcare.gov 2. Healthcare Common Procedure Coding System (HCPCS). Accessed March 31, 2025 . www.nlm.nih.gov 3. Use of the KX modifier. Medicare Claims Processing Manual: Chapter 5-Part B Outpatient Rehabilitation and CORF/OPT Services. US Centers for Medicare and Medicaid Services; 2021. Rev 11129. Accessed March 31, 2025. www.cms.gov 4. What are medical coding modifiers? 2022. American Academy of Professional Coders. Accessed March 31, 2025. www.aapc.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Temporary Codes-MP-PY-1413 07/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-MP-PY-1413Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes B. BackgroundReimbursement policies are designed to assist providers 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 wi ll be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for emerging technologies, services, and procedures , which support data collection to substantiatewidespread use and/or provide documentation for the Food and Drug Administration(FDA) approval process. Many of these codes have not been proven medically necessary and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist . Temporary HCPCS codes may be established by the Centers for Medicare and Medicaid Services (CMS) to report drugs, biologicals, devices, and procedures , to identify services and procedures under FDA review or address miscellaneous services, procedures, and supplies . Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) may develop temporary HCPCS codes to report supplies and other products for which a national code has not yet been de veloped. Temporary HCPC S codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is under the discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource con siders temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code . B. A more specific code is not available to describe the service/procedure . C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & CodeTemporary Codes-MP-PY-1413Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided.III. Providers must use industry standard code sets and must use specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract. IV. If specific codes are not available, unlisted codes require plan preauthorization.E. State-Specific Information NA F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 03/26/2025Annual rev iew: updated references, approved atCommittee. Review: updated references, approved at Committee. Date Effective 07/01/2025 Date Archived I. References1. American Academy of Professional Coders. What is HCPCS? Accessed March 10, 2025. www.aapc.com 2. CPT Professional 202 5. American Medical Association; 2025. 3. HCPCS Codes Temporary Codes for Use with Outpatient Prospective Payment System. Accessed March 10, 2025. www.hcpcs.codes 4. Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule. American Medical Association. Accessed March 10, 2025. www.assets.ama-assn.org
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY – 1594 07/01/2025 Kentucky Inactive 01/01/2026Policy TypeREIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. 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 Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDiagnostic Colonoscopy and/or Sigmoidos copy B. BackgroundColo no scopies and sigmoidoscopies pertain to procedures that involve direct visual examination of the lower gastrointestinal tract using a flexible tube fitted with a camera. The procedures identify polyps, tumors, and other intestinal irregularities or health issues and are performed by medical prof essionals, typically gastroenterologists or colorectal surgeons. Both procedures are valuable tools in diagnosing and monitoring gastrointestinal conditions. Specific clinical indications and area of examination determine w hich procedure will be utilized. There are different billing procedures for screening versus diagnostic colonoscopies andsigmoidoscopies. Screening procedures are typically performed as part of preventive services for cancer or other health issues. Diagnostic procedures can include patient signs or symptoms in the lower gastrointestinal tract (eg, constipation, rectal bleeding, blood in stool, diarrhea), polyps within the past 10 years or other positive-stool-based tests or computed tomography (C T) colonographies that require follow-up. Similarly, some screening procedures can become diagnostic procedures if practitioners find health issues necessitating treatment (eg, mass needing biopsy, polyps) while performing initial screening procedures . Both screening and diagnostic procedures utilize the same equipment, so providers must maintain thorough documentation in the members medical record to substantiate medical necessity of these tests and differentiate between screening and diagnostic tests . This policy exclusively pertains to diagnostic colonoscopies and does not apply topreventive screenings that follow US Preventive Services Task Force (USPSTF) or other preventive guidelines. Refer to the appropriate Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes for screenings (ie, G0104, G0105, G0121). Providers are encouraged to use modifiers when procedures meet modifier criteria. C. Definitions Colonoscopy A procedure in which a physician inserts a flexible tube fitted with a camera through the anus into the rectum to examine the entire length of the colon from the rectum to the cecum and may include the terminal ileum allowing for screening and diagnosis of health issues. Sigmoidoscopy A procedure similar to a colonoscopy that examines the lower third of the large intestine , the rectum, sigmoid colon and possibly a portion of the descending colon, for screening and diagnosing health conditions. D. PolicyI. CareSource requires appropriate documentation of medical necessity and valid diagnosis codes for reimbursement of diagnostic colonoscopies and Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 sigmoidoscopies. Claims submitted without supporting medical necessity or correct coding will be denied. Documentation requirements includeA. an assessment of the member by the ordering provider as related to the complaint for that visit B. relevant medical history C. results of pertinent tests/procedures , if known , or if results are normal or did not provide a diagnosis during a diagnostic colonoscopy, the symptom(s) for which the endoscopy was performed D. signed and dated office visit record/operative report E. precise areas scoped and depth reached during the procedure II. CareSource follow s Centers for Medicaid and Medicare Services (CMS) guidelines regarding billing for diagnostic colonoscopies and sigmoidoscopies . A. Reimbursement requests must include a procedure code with a diagnosis code that best describes the condition for which the service was performed. B. If the service begins as a screening procedure but results in a diagnostic or therapeutic procedure at the same operative session, health care providers should report an appropriate screening I nternational Classification of Diseases (ICD) diagnosis code as the primary diagnosis and the diagnostic or abnormal finding ICD diagnosis code as the secondary or subsequent diagnosis. C. If the member is symptomatic or the claim for these services indicates a primary diagnosis of something other than preventive or wellness, colonoscopy examinations will be covered under a diagnostic benefit, not a Preventive Health Care Services benefit. E. Conditions of CoverageI. ICD-10 codes must be coded to the highest level of specificity. CareSource develops reimbursement policy guidelines following evaluation and validation of provider billing in accordance with various methodologies (eg, CPT publications, AMA publications, Medicare ). CareSource uses clinical editing software to evaluate the accuracy of diagnosis and procedure codes on submitted claims to ensure that claims are processed consistently, accurately and efficiently and strives to follow the prevailing National Corr ect Coding Initiative (NCCI) edits as maintained by CMS . Coding industry standards, such as the CPT Manual , CCI and input from medical specialty societies , are used to review multiple aspects of a claim for coding reasonableness , including diagnosis to procedure matching , currently valid CPT/HCPCS codes, modifier usage or bundling issues . Any specific claim is subject to current CareSource claim logic and other established coding benchmarks. Any consideration of a providers claim payment concern regarding clinical edit logic will be based upon review of generally accepted coding standards and the clinical information particular to the specific claim in question. II. CareSource reserves the right to request medical record documentation from providers.Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 F. Related Policies/RulesMedical Necessity Determinations Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 03/26/2025 New policy. Approved at Committee.Date Revised Date Effective 07/01/2025 Date Archived H. References1. American Society for Gastrointestinal Endoscopy Standards of Practice Committee; Early DS, Ben-Menachem T, Decker G, et al . Appropriate use of GI endoscopy. Gastrointest Endosc . 2012;75(6):1127-1131. doi:10.1016/j.gie.2012.01.1 2. Colonoscopy ACG: A-0129. MCG. 28th ed. Updated March 14, 2024. Accessed March 10 , 2025. www.careguidelines.com 3. Colonoscopy. American Cancer Society. Accessed March 10 , 2025. www.cancer.org 4. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions. 42 CFR 410.32 (2024). 5. Flexible sigmoidoscopy. Mayo Clinic. Accessed March 10 , 2025. www.mayoclinic.org 6. Georgia Marketplace Evidence of Coverage . CareSource; 2025. Accessed March 10 , 2025. www.cares ource.com 7. Georgia Marketplace Provider Manual . CareSource; 2025. Accessed March 10, 2025. www.caresource.com 8. Indiana Marketplace Evidence of Coverage . CareSource; 2025. Accessed March 10 , 2025. www.cares ource.com 9. Indiana , Kentucky and West Virginia Marketplace Provider Manual . CareSource; 2025. Accessed March 10, 2025. www.caresource.com 10. Kentucky Marketplace Evidence of Coverage . CareSource; 2025. Accessed March 10 , 2025. www.cares ource.com 11. LCD Reference Article: Billing and Coding: Colonoscopy and Sigmoidoscopy – Diagnostic. Medicare Coverage Database; 2019. LCA ID A56394. Revised January 1, 2025. Accessed March 10 , 2025. www.cms.gov 12. LCD Reference Article: Billing and Coding: Colonoscopy and Sigmoidoscopy – Diagnostic. Medicare Coverage Database; 2019. LCA ID A 56456 . Revised February 6, 2025. Accessed March 10 , 2025 . www.cms.gov 13. LCD Reference Article: Billing and Coding: Colonoscopy/Sigmoidoscopy/ Proctosigmoidoscopy. Medicare Coverage Database; 2019. LCA ID 56632. Revised January 1, 2025. Accessed March 10 , 2025. www.cms.gov 14. Local Coverage Determination: Colonoscopy and Sigmoidoscopy-Diagnostic. Medicare Coverage Database; 2015. LCD ID L34614. Revised August 29, 2024. Accessed March 10 , 2025. www.cms.gov Diagnostic Colonoscopy and/or Sigmoidoscopy-MP-PY-1594Effective Dat e: 07/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 15. Local Coverage Determination: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy. Medicare Coverage Database; 2015. LCD ID L34005. Revised February 6, 2025. Accessed March 10 , 2025. www.cms.gov16. Local Coverage Determination: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy. Medicare Coverage Database; 2015. LCD ID L34454. Revised December 19, 2024. Accessed March 10 , 2025. www.cms.gov 17. Ohio Marketplace Evidence of Coverage . CareSource; 2025. Accessed March 10 , 2025. www.cares ource.com 18. Ohio Marketplace Provider Manual . CareSource; 2025. Accessed March 10, 2025. www.caresource.com 19. Sigmoidoscopy ACG: A-0128. MCG. 28th ed. Updated March 14, 2024. Accessed March 10 , 2025. www.careguidelines.com 20. West Virginia Marketplace Evidence of Coverage . CareSource; 2025. Accessed March 10 , 2025. www.caresource.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 06/01/202 5 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the Am erican College of Obstetriciansand Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Le vel IV Regional Neonatal Intensive CareUnit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification. The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination ofadvanced technology and a NICU team of licensed professionals.NICU levels of care are based on the complexity of care that a newborn with specified diagnoses and symptoms requires. All four levels of care are represented by a unique revenue code . Any inpatient revenue codes not billed as levels 2-4 will be recognized asa level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also couldbe admitted to the NICU for associated maternal risk factors or complicated deliveries.Although the list of criteria used to determine the NICU levels of care in this policy is not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Level of Care (LOC) – Care based on the complexity of care that a newborn with specified diagnoses and symptoms requires. Newborn CareServices – Services performed from birth to four weeks. Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Neonatal Intensive Care Services (NICU) – Critical care services for a newborn. Well baby care services – A basic level of care to neonates who are low risk. D. PolicyI. As per federal mandate, newborn members are covered at an inpatient facility for a 2-day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with revenue codes 0170/0171 and a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , preauthorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to provide documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn require s a NICU admission or a higher LOC service, a priorauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, a prior authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed duringtransitional time.VI. Clinical review will determine appropriate LOC utilizing MCG standards. CareSource will adjust LOC reimbursement if clinical documentation does not support the LOCbilled.VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiat e the level of care and length of stay. A continued authorization will bebased on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria , as well as CareSource policy.VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to follow MCG guidelines along with the criteria below .NICU LevelRevenue Code Description MCG NICU Intensity of Care Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Level 1 0171: Newborn Level IFor NICU Intensity of Care Criteria 1(See MCG Care Guidelines LOC: LOC-010 (ISC, GRG) ) Level 1 – Neonatal care may be indicated for a newborn or neonate with ALL of the following: Physiologically stable (eg , no apnea, bradycardia, or unstable temperature) In need of care consisting of one or more of the following: o Routine newborn care o Evaluation and care of neonates with conditions that require inpatient services available at Level I o Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues, (eg: Sustained weight gain, poor PO feeding ) Establishment of safe discharge destination and plan o Uncomplicated jaundice treated only with phototherapy and requiring bilirubin checks while inpatient at intervals of greater than 6 hours o Absence of parenteral medications o Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level IIFor NICU Intensity of Care Criteria 2(See MCG Care Guidelines LOC: LOC-011 (ISC, GRG) ) Level 2 – Neonatal care may be indicated for one or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen, ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation o IV heparin lock medications; or o IV medications in a physiologically/clinically stable infant; or o IV treatment of hypoglycemia Weaning from nasogastric (NG) or naso-jejunal (NJ) tube feedings while attempting to increase oral intake Apnea, bradycardia, or desaturation, but with rare episodes requiring stimulation, or only self-limited episodes; OR o apnea countdown OR o weaning caffeine Services for neonatal abstinence syndrome (NAS) requiring medication (weaning) when the Finnegan score is 8 or less or Eat Sleep Console (ESC) scores are improving Monitoring of jaundice during phototherapy with bilirubin levels at intervals of less than 6 hours Temperature control system, e.g., incubator, radiant warmer, in otherwise stable infant. Evaluation for sepsis NOT toxic appearing but on antibiotics Clinically stable infections completing course of IV medications Continued inpatient care during convalescence from condition(s) treated in Level Ill care Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Dat e: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 W ithdrawal of Life support; end of life care; palliative careLevel 3 0173: Newborn Level III For NICU Intensity of Care Criteria 3 (See MCG Care Guidelines LOC: LOC012 (ISC, GRG) ) Level 3 – Neonatal care includes Level 2 requirements and one or more of the following: Respiratory support using one of the following: o HFNC with > 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), NIPPV o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes or UAC. Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia (glucose
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Facility Charges for Hospital-Based Outpatient Clinics-OH MP-PY-1600 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Facility Charges for Hospital-Based Outpatient Clinics-OH MP-PY-1600 Effective Dat e: 05/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectFacility Charges for Hospital-Based Outpatient Clinics B. BackgroundThis policy outlines the guidelines for facility charges associated with services provided in hospital-based outpatient clinics. Patients receiving care in these settings may notice a facility charge on their bill, which is distinct from the fees for the s pecific procedures or treatments. These charges are typically billed using a UB-04 institutional claim form. C. Definitions CMS-1500 A standard claim form that professional providers and medical billing professionals use to bill insurance companies for health care services. Facility Charges A charge that is part of the overhead cost of a hospital, which supports the location and other services the hospital must provide and are not directly related to the care a patient receives. Also known as a facility fee. Hospital-Based Outpatient Clinics An outpatient facility that may or may not be on the hospital grounds, is operating under the ownership or administrative control of the hospital and offers the same or similar services as the hospital. Network Provider Healthcare professionals in good standing who have successfully passed a CareSource credentialing or recredentialing program. Participation Agreement An agreement between a health plan and providers or hospitals, which includes terms, such as information about compensation, billing, payment, network participation, provider licensing and insurance, provider credentialing, maintenance of records, termi nation, and state contracting and filing requirements. Health plans compensate providers for covered services rendered to members and compensate hospitals through facility charges under the terms of the agreement. Revenue Code A 4-digit number that is used on hospital bills to inform insurance companies either where the patient was when they received treatment, or what type of item a patient may have received as a patient. UB-04 Claim form used by hospitals and other providers to bill for institutional services. A valid procedure code must accompany a revenue code for it to be accepted by the insurance provider. D. PolicyI. CareSource does not provide reimbursement for facility charges associated with clinic services rendered by a network provider for any hospital-based outpatient clinics when billed using the UB-04 form. Specifically, facility charges billed with revenue code 510 are n ot reimbursed. as these charges are not considered covered services under the health plan participation agreements. II. CareSource will only reimburse for clinic services provided for a member that are rendered on the same day in which the treatment is rendered at the hospital-basedoutpatient clinic when billed on a CMS-1500 professional claim form.Facility Charges for Hospital-Based Outpatient Clinics-OH MP-PY-1600 Effective Dat e: 05/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 III. Hospitals are prohibited from seek ing reimbursement for facility charges at hospital-based outpatient clinics from CareSource, CareSource members, or CareSource subsidiaries when billed using revenue code 510. E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource. These policies are routinely updated to promote accurate coding and policy clarification. There 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 o ffice staff are encouraged to use self-service channels to verify members eligibility. Reimbursement id dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individu al fee schedule for appropriate codes. The following list of revenue codes are provided as a reference and are not reimbursable.Revenue Code Description0510 General F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 03/12/2025 New policy. Approved at Committee.Date Revised Date Effective 05/01/2025 Date Archived H. References1. Brocks J. Health plan network provider agreement essentials. LexisNexis. Published April 20, 2019. Accessed November 6, 2024. www.lexisnexis.com 2. Facility fees and how they affect health care prices. Health Care Cost Institute. Accessed November 6, 2024. www.healthcostinstitute.org 3. Professional paper claim form (CMS-1500). Centers for Medicare & Medicaid Services. Accessed November 6, 2024. www.cms.gov 4. What is outpatient facility coding and reimbursement. AAPC. Reviewed December 14, 2023. Accessed November 6, 2024. www.aapc.com
REIMBURSEMENT POLICY STATEMENTOhio Marketplace Policy Name & Number Date Effective Chiropractic Care-OH MP-PY-1445 05/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Chiropractic Care-OH MP-PY-1445Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers 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 office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.C. Definitions Chiropractor A Doctor of Chiropractic licensed and qualified to provide chiropractic services. Chiropractic Therapy Therapy that focuses on joints of the spine and the nervous system, while osteopathic therapy includes equal emphasis on the joints and surrounding muscles, tendons and ligaments. Manipulation Therapy Osteopathic/chiropractic therapy used for treating problems associated with bones, joints and the back. Medically Necessary/Medical Necessity Health care services that a provider would render to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (i) in accordance with generally accepted standards of medical practic e; and (ii) clinically appropriate in terms of type, frequency, extent, and duration. D. PolicyI. A covered chiropractic service that is legally performed will not be denied when such covered service is rendered by a n in-network , licensed chiropractor in the state when the covered service is performed. II. All services are subject to members share of cost (deductible, co-insurance and/orco-pays). This varies based on the members plan enrolled at the time of service.III. When manipulation services are provided in addition to an evaluation andmanagement (E/M) office visit, modifier 25 should be appended to the E/M code.This distinguishes a significant , separately identifiable E/M office visit from the additional manipulation service. Chiropractic Care-OH MP-PY-1445Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. Scope of practiceChiropractors must follow the states scope of practice. Any training or certification required by the state must be available to CareSource, upon request . V. Chiropractic patients whose diagnosis is not within the chiropractic scope of practice, shall be referred , by the chiropractor , to a medical doctor or other licensed healthpractitioner for treatment of that condition.VI. Manipulation therapyA. Chiropractic manipulation therapy used for treating problems associated with bones, joints and the back is included . Chiropractors are limited to subluxations of the articulations of the human spine and the adjacent tissue. B. Annual benefit limits apply. It is the providers responsibility to validate the available remaining quantity before rendering service. Manipulations performed will be counted toward any maximum for manipulation therapy services as specified in the member s Evidence of Coverage (EOC) or Schedule of Benefits regardless if billed as the only procedure or done in conjunction with an exam and billed as an office visit . C. The members plan does not provide benefits for manipulation therapy services provided in the home as part of Home Health Care Services. D. Modifier AT is required to be appended to any manipulation code. E. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patients neuromusculoskeletal condition. VII. All codes contained within this policy are not all inclusive but provide a general reference of covered codes based on what chiropractors are allowed to perform. Codes contained within this policy that may or may not require a review of medical necessity p rior to the service should be confirmed by accessing the Provider Look-upTool on the CareSource website (www.procedurelookup.caresource.com). VIII. The following are a list of codes that may be covered and do not require a review of medical necessity prior to service: A. Evaluation and management (E/M) codes (99202-99204, 99211-99214) B. 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions C. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions D. 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions E. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions F. X-rays [radiologic examination (RE) ] for diagnostic purposes IX. Codes that may be covered but require a review of medical necessity prior to service or treatment :A. 97 010 hot or cold packsB. 97012 traction C. 97014 electrical stimulation D. 97035 ultrasound Chiropractic Care-OH MP-PY-1445Effective Dat e: 05/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 E. 97139 unlisted therapeutic procedureF. 97140 manual therapy technique X. CareSource follows the Centers for Medicare and Medicaid (CMS) analysis stating that acupuncture includes dry needling. Acupuncture is not a covered benefit. The following exclusions/services are not medically necessary and, therefore, not covered for chiropractors:A. 20560 needle insertion(s) without injection(s); 1 or 2 muscle(s) -dry needling B. 20561 needle insertion(s) without injection(s); 3 or more muscles-dry needling E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 Reimbursement policy Marketplace Plan Evidence of Coverage G. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022 New policyDate Revised 09/27/2023 01/ 29 /2025Policy number changed from PY-1358. Updated references . Approved at Committee. Periodic review. Updated VII, VIII, IX, and Xand references. Approved at Committee. Date Effective 05/01/2025 Date Archived H. References1. Local Coverage Determination: Chiropractic Services L37254. Medicare Coverage Database. November 6, 2017. Revised February 1, 2024. Accessed December 2, 2024. www.cms.gov 2. National Coverage Analysis: Acupuncture for Chronic Low Back Pain CAG-00452N. Medicare Coverage Database. January 21, 2020. Accessed December 2, 2024. www.cms.gov 3. Practice of Chiropractic Defined, OHIO REV . CODE 4734.01 (2001) 4. Scope of Practice of Chiropractic – Permissible Titles, OHIO REV . CODE 4734.15 (2020) 5. Use of the AT Modifier for Chiropractic Billing . US Centers for Medicare and Medicaid Services; 2021. Accessed December 2, 2024. www.hhs.gov www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387 04/01/2025 Kentucky inactive as of 01/01/2026 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 I. References ………………………….. ………………………….. ………………………….. …………………….. 4 Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulation (TENS) B. BackgroundTranscutaneous electrical nerve stimulat ors (TENS) are device s that produce mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the skin. C. Definitions Accessories Reusable items used with a TENS machine, which includes, but is not necessarily limited to, adapters, clips, additional connecting cable for lead wires, carrying pouches, and covers. Supplies Typically disposable items used with a TENS machine, which includes, but is not necessarily limited to , electrodes of any type, lead wires, conductive paste or gel, adhesive, adhesive remover, skin preparation materials, batteries, and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation to skin electrodes placed over an area of the body experiencing pain, which causes interference with the transmission of pain. TENS requires a stimulator, a type of durable medical equipment (DME). D. PolicyI. TENS units may require medical necessity review. II. CareSource reimburses for TENS units and supplies based on the Centers for Medicare & Medicaid Services (CMS) guidelines.III. TENS units are reimbursed on a 13-month rent to purchase basis, after a successful1-month, non-reimbursable trial period. IV. DocumentationA. The provider of the TENS unit must complete the Certificate of Medical Necessity-Transcutaneous Electrical Nerve Stimulator (TENS) Form , CMS-848. B. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than 30 days is needed for acute pain following surgery and includes the date of surgery. C. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain must be completed and available for review upon CareSources request. D. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request before reimbursement is made for supplies or repair. E. The provider must also provide the member with verbal instruction on the use of the TENS unit. Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 F. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record.V. Rental of a TENS unit to treat post-operative pain is limited to a single 30-day period and may not be extended. Modifier RR should be used in this case. VI. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units (after the successful 1-month, non-reimbursable trial period).VII. SuppliesA. Supplies are not reimbursable during the trial period.B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-lead TENS unit (E0720) or 2 units per month for a 4-lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for individual supply items. E. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny. E. State-Specific InformationNA F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes are provided as a reference. This list may not be all inclusive and is subject to updates.HCPCS CodeDescription E0720 TENS unit, 2-lead, localized stimulation (includes supplies during rental ) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation ( includes supplies during rental ) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead ( for a recipient-owned unit ) Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Modifiers DescriptionRR Rental (use the ‘RR’ modifier when DME is to be rented) NU Purchase of new equipment G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 10/26/2022Date Revised 12/13/2023 12/18 /2024Annual review: updated code list and references. Approved at Committee.Review: updated references, approved at Committee. Date Effective 04/01/2025 Date Archived I. References1. Gibson W, Wand BM, Meads C, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 2. Johnson MI, Paley CA, Wittkopf PG, et al. Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina (Kaunas) . 2022;58(6):803. doi:10.3390/medicina58060803 3. Local Coverage Article: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database. A52520. Revised January 1, 2023. Accessed December 18 , 2024 . www.cms.gov 4. Local Coverage Determination: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database. L33802. Revised January 1, 2024 . Accessed December 18 , 2024 . www.cms.gov 5. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina. 2022;58(10):1332. doi:10.3390/medicina58101332
MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Left Ventricular Assist Device (LVAD) Supplies- MP-PY-1465 04/01/2025 Kentucky inactive as of 1/1/2026 Policy Type MEDICAL Reimbursement Policies prepared by CareSource and its affiliates 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. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents Table of Contents ……………………………………………………………………………………………………….. 1A. Subject ………………………………………………………………………………………………………………. 2B. 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 Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectLeft Ventricular Assist Device (LVAD) Supplies B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. A left ventricular assist device (LVAD) is a surgically implanted battery-operated, mechanical pump, which helps the left ventricle (main pumping chamber of the heart) pump blood to the rest of the body. It is a treatment for a weakened heart or end stage heart failure. LVADs can be used as: Bridge-to-transplant therapy: A life-saving therapy for patients awaiting a heart transplant. Patients use the LVAD until a heart becomes available. In some cases, the LVAD is able to restore the failing heart, eliminating the need for a transplant. Destination therapy: Some patients are not candidates for heart transplants. In this case, patients can receive long-term treatment using an LVAD, which can prolong and improve patients' lives. C. Definitions Heart Failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently causing symptoms to occur throughout the body. Left-sided heart failure occurs when the heart loses its ability to pump blood preventing organs from receiving enough oxygen. The condition can lead to complications that include right-sided heart failure and organ damage. Ventricular Assist Device (VAD) A surgically attached device to one or both intact ventricles used to assist or augment the ability of a damaged or weakened native heart to pump blood. Improvement in the performance of the native heart may allow the device to be removed. D. PolicyI. Dressings and supplies A. CareSource considers reimbursement for LVAD dressings a covered service when all the following criteria are met: 1. The initial dressings supplied under the bundled in-patient benefit at the facility where the LVAD was implanted are expended. Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 2. Dressings necessary for the effective use of a LVAD must be billed using the appropriate supply code. B. LVAD dressings are a disposable supply and, therefore, a purchase-only item. C. Supplies billed with miscellaneous code E1399 will be denied if a more appropriate code is available. II. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly. Code Description E1399 Durable medical equipment, miscellaneous Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device III. BatteriesA. Batteries for LVADs should be billed using the following codes: 1. Q0503: Battery for pneumatic ventricular assist device, replacement only, each. 2. Q0506: Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only B. Batteries billed with miscellaneous code E1399 will be denied. C. A rechargeable battery may be approved with a spare for uninterrupted use. IV. WarrantyCareSource may request warranty information regarding the DME item or supply. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization. V. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review: A. a complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges B. any other information requested by CareSource VI. Non-covered services A. monitoring of LVADs B. multiple battery packs beyond the pair required for continuous use E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Codes in this policy reflect Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465Effective Date: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 those found in CMS Transmittal 10837 for National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs). A. All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review and prior authorization. B. Prior authorization is not a guarantee of payment. C. Claims must include an invoice. D. CareSource may verify the use of any code through post-payment audit. E. If a more appropriate code is discovered, CareSource may request recoupment. F. Related Policies/Rules Unlisted and Miscellaneous Codes G. Review/Revision History DATE ACTIONDate Issued 12/13/2023 New Policy, approved at Committee.Date Revised 12/18/2024 Added Unlisted and Miscellaneous Codes to section F. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Artificial Hearts and Related Devices, Including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Medicare Coverage Database; 2020. Decision Memo CAG-00453N. Centers for Medicare & Medicaid Services. Accessed November 11, 2024. www.cms.gov 2. Heart failure. National Heart, Blood and Lung Institute. Accessed November 11, 2024. www.nhlbi.nih.gov 3. Left ventricular assist devices (LVADs). Cleveland Clinic. Accessed November 11, 2024. www.my.clevelandclinic.org 4. NCD-Ventricular Assist Devices (VADs) (20.9.1). Centers for Medicare & Medicaid Services. Accessed November 11, 2024. www.cms.gov
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