REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies pr epared 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 facto rs 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 editin g logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and ne cessary 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 functi on, dysfunction of a body organ or part, or significant pain and discom fort. 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 defin ed 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 t o 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 Marketplac e(s): Georgia Indiana Kentucky Ohio West VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Po licy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifier 59, XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist p roviders when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary polici es 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 rece ived for processing. Reimbursement modifiers are two-digit code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource a ccepts the use of modifiers, use does not guarantee reimbursement. 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 prepayment and post-paym ent audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together, either in all situat ions or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together but are appropriate under the patients specific circumstance. National Correct Cod ing Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surger ies are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Serv ices (CMS) established four HCPCSmodifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions o f modifier 59. 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 AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to audit any submission at any time to ensure correct coding standards and guidelines are met. II. It is the responsibility of the submitting provider to submit accurate documentation of services performed when requested from CareSource. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support t he claims submission, this will also result in a claims denial. III. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding audit. Once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. IV. Modifiers X {EPSU} should be used prior to using modifier 59.V. Modifier X {EPSU} (or 59 , when applicable) may only be used to indicate that a distinct procedural ser vice was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, sep arate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty . A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgi cal therapeutic procedures, or diagnostic procedures that: 1. Are performed at different anatomic sites; and 2. Are not ordinarily performed or encountered on the same day; and 3. Cannot be described by one of the more specific anatomic NCCI P rocedure to Procedure (P TP )-associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI). Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed d uring different patient encounters ; and 2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (i.e., 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two timed procedures are performed during th e same encounter but occur one after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are perf ormed at separate anatomic sites ; or 2. Are performed at separate patient encounters on the same date of service . E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when: 1. The diagnost ic procedure is the basis for performing the therapeutic procedure; and 2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and 3. Provides clearly the information needed to decide whether to proc eed with the therapeutic procedure; and 4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separat ely. F. Modifiers XU (or 59, when applicable) may be used for a diagnostic procedure is performed after a therapeutic procedure only when: 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure; and 2. It occurs a fter the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires; and 3. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post – procedure service of th e surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted wi thin the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.Modifier 59, XE, XP, XS, XU-MP-PY-1367Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/RulesModifier 25 Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued Not SetDate Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Centers for Medicare & Medicaid Services. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 24, 2022 from www.cms.gov . 2. Centers for Medicare & Medicaid Service s. (2022 March). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Rev. 11288 . Retrieved June 24, 2022 from www.cms.gov . 3. Centers for Medicare & Medicaid Services (2022 March). M LN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. Retrieved July 12, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. Retrieved August 2, 2022 from www.cms.gov. 5. Centers for Medicare & Medicaid Services (2014 August). Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. Retrieved July 12, 2022 from www.cms.gov . I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effective: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effectiv e: 11/01/2022
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-OH MCD-PY-1364 12/01/2022 Policy Type REIMBURSEMENT 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 Reimburseme nt 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 t he 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 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 Addi ction 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 ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-OHMCD-PY-1364Effective Dat e: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifier 59 , XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide 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. Reimbursement modifiers are two-digit code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their us e does not guarantee reimbursement. 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 prepayment and post-payment audit. Using a modifier ina ppropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is u sed to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surgeries are performed at separate anatomic site s, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCSmodifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a differ ent practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-OHMCD-PY-1364Effective Dat e: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. 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 AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to audit any submission at any time to ensure correct coding standards and guidelines are met. II. It is the responsibility of the submitting provider to submit accurate documentation of services performed when requested from CareSource. Failure to submit accurate and complete documentation may result in a denial. If t he documentation does not support the claims submission, this will also result in a claims denial. III. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding audit. Once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. IV. Modifiers X {EPSU} should be used prior to using modifier 59.V. Modifier X {EPSU} (or 59 , when applicable) may only be used to indi cate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed at different anatomic sites; and 2. Are not ordinarily performed or encountered on the same day; and 3. Cannot be described by one of the more specific an atomic NCCI Procedure to Procedure (PTP) -associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI). Modifier 59, XE, XP, XS, XU-OHMCD-PY-1364Effective Dat e: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed during different patient encounters ; and 2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (i.e., 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two tim ed procedures are performed during the same encounter but occur one after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed at separate anatomic sites ; or 2. Are performed at separate patient encounters on the same date of service . E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeu tic procedure only when: 1. The diagnostic procedure is the basis for performing the therapeutic procedure; and 2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and 3. Provides clearly the informa tion needed to decide whether to proceed with the therapeutic procedure; and 4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical pro cedure, it cannot be reported separately. F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when: 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure; and 2. It occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires; and 3. Does not constitute a service that would have otherwise been req uired during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it c annot be reported separately. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless ot herwise noted within the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.Modifier 59, XE, XP, XS, XU-OHMCD-PY-1364Effective Dat e: 12/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the gover ning document.F. Related Policies/RulesModifier 25 Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective 12/01/2022 Date Archived H. References1. Centers for Medicare & Medicaid Services. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 24, 2022 from www.cms.gov . 2. Centers for Medicare & Medicaid Service s. (2022 March). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Rev. 11288 . Retrieved June 24, 2022 from www.cms.gov . 3. Centers for Medicare & Medicaid Services (2022 March). M LN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. Retrieved July 12, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. 5. Centers for Medicare & Medicaid Services (2014 August). Transmittal R1422 OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. Retrieved July 12, 2022 from www.cms.gov.
REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Modifier 25-DSNP-PY-1371 IN, GA, KY: 11/01/2022 OH: 12/01/2022 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its aff iliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual ag reement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or tre atment of disease, illness, 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 s tandards 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 cover age 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 t o 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): Geor gia Indiana Kentucky Ohio Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Modifier 25-DSNP-PY-1371Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide 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. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by s ome specific circumstance. Modifier -25 is used to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Associati on (AMA) Current Procedural Terminology (CPT) book defines modifier -25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier -25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separatelyidentifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be pr ompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier -25 to the approp riate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier -57. For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their 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 prepay ment and post-payment edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. CareSource uses published guidelines from CPT Modifier 25-DSNP-PY-1371Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. Definitions Current Procedural Terminology (CPT) Codes that are issue d, 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 provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Failure may result in prepayment and post-payment audit and unpaid claims. II. Provider claims billed with modifier -25 may be flagged for either a prepayment clinical validation or prepayment medical record coding audit and be selected for a post payment medical re cord review. Once the claim has been clinically validated, it is either released for payment or denied for incorrect use of the modifier. III. Modifier -25 may only be used to indicate that a significant, separately identifiable evaluation and management serv ice [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier -25, the code may be denied. IV. Appending modifier -25 to an E/M service is considered inappropriate in the fol lowingcircumstances:A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service i s reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. Modifier 25-DSNP-PY-1371Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. The preventative E/M service is performed at the same time as a preventative care visit (e.g., a preventative E/M service and a r outine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to t he individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the g overning document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17 /2022 New PolicyDate Revised Date Effective GA, IN, KY: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. American College of Cardiology Foundation. (2022). Appropriate Use of Modifier 25. Retrieved June 17, 2022 from www.acc.org. 2. Centers for Medicare and Medicaid Services. Chapter 1 General Correct Coding Policies for National Correct Coding Init iative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 17, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. CPT Modifier 25. Retrieved June 17, 2022 from w ww.palmettogba.com. 4. Centers for Medicare and Medicaid Services. (Rev. 11288, 2022, March 4). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. Retrieved June 17, 2022 from www.cms.gov. 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag. 2004;11(9):21-22. Retrieved June 17, 2022 from www.aafp.org . Modifier 25-DSNP-PY-1371Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effective: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022
REIM BURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 25-MP-PY-1363 IN, GA, WV, KY: 11/01/2022 OH: 12/01 /2022 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, regula tory 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 da te 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 incl ude, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, i mpairment 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 an d the plan contract (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 VirginiaTable of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Modifier 25-MP-PY-1363Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a gua rantee 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 process ing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier -25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care profession al. The American Medical Association (AMA) Current Procedural Terminology (CPT) book defines modifier -25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the s ame day of the procedure or other service. There must be documentation that substantiates the use of modifier -25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed , the patient’s condition required a significant, separatelyidentifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separ ately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/Ms ervice). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier -25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier -57. For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. 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 prepayment and post-payment edit or audit. Using a modifierinappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made avail able upon CareSources request. CareSource uses published guidelines from CPTModifier 25-MP-PY-1363Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.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 provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Failure may result in prepayment and post-payment audit and unpaid claims. II. Provider claims billed with modifier -25 may be flagged for either a prepayment clinical validation or prepayment medical record coding audit and be selected for a post payment medical record review. Once the claim has been clinically validated, i t is either released for payment or denied for incorrect use of the modifier. III. Modifier -25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier -25, the code may be denied. IV. Appending modifier -25 to an E/M service is considered inappropriate in the followingcircumstances:A. The initial decision to perform a majo r procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service t hat is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. Modifier 25-MP-PY-1363Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. The preventative E/M service is performed at the same time as a preventative care visit (e.g., a preventative E/ Mservice and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. P lease refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or offi ce notes. Unless otherwise noted within the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contra ct will be the governing document.F. Related Policies/Rules Modifiers policy G. Review/Revision HistoryDATE ACTIONDate Issued 07/20/2022 New PolicyDate Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. American College of Cardiology Foundation. (2022). Appropriate Use of Modifier 25. Retrieved June 17, 2022 from www.acc.org. 2. Centers for Medicare and Medicaid Services. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 17, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. CPT Modifier 25. Retrieved June 17, 2022 from www.palmettogba.com. 4. Centers for Medicare and Medicaid Services. (Rev. 11288, 2022, March 4). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practi tioners. Retrieved June 17, 2022 from www.cms.gov. 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag. 2004;11(9):21-22. Retrieved June 17, 2022 from www.aafp.org. Modifier 25-MP-PY-1363Effective Dat e: 11/01/2022The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effectiv e: 11/01/2022 C. Kentucky 1. Effect ive: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022
REIMBURSEMENT POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Modifier 25-OH MCD-PY-1360 12/01/2022 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, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, 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 t he 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 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 Addi ction 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 ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Modifier 25-OH MCD-PY-1360Effective Dat e: 12/01/2022The REIMBUR SEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide 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. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier -25 is use d to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CPT) book defines modifier -25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of mo difier -25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separatelyidentifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be pr ompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier -25 to the approp riate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier -57. For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their 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 prepayment and post-paym ent edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. CareSourc e uses published guidelines from CPT Modifier 25-OH MCD-PY-1360Effective Dat e: 12/01/2022The REIMBUR SEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. Definitions Current Procedural Terminology (CPT) Codes that are issue d, updated, and maintained by the Amer ican 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 provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along wi th a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Failure may result in prepayment and post-payment audit and unpaid claims. II. Provider claims billed with modifier -25 may be flagged for either a prepayment clinical validation or prepayment medical record coding audit and be selected for a post payment medical record review. Once the claim has bee n clinically validated, it is either released for payment or denied for incorrect use of the modifier. III. Modifier -25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same phys ician on the same day of the procedure or other service. If documentation does not support the use of modifier -25, the code may be denied. IV. Appending modifier -25 to an E/M service is considered inappropriate in the followingcircumstances:A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is re ported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usu al pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-oper ative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. Modifier 25-OH MCD-PY-1360Effective Dat e: 12/01/2022The REIMBUR SEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.H. The preventative E/M service is performed at the same time as a preventative care visit (e.g., a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are pre ventative, only one should be reported.I. The routine use of the modifier is reported without supporting clinical documentation. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with a ppropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on allclaims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17 /2022 New PolicyDate Revised Date Effective 12/01/2022 Date Archived H. References1. American College of Cardiology Foundation. (2022). Appropriate Use of Modifier 25. Retrieved June 17, 2022 from www.acc.org. 2. Centers for Medicare and Medicaid Services. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. Revised January 1, 2022. Retrieved June 17, 2022 from www.cms.gov. 3. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. CPT Modifier 25. Retrieved June 17, 2022 from www.palmettogba.com. 4. Centers for Medicare and Medicaid Services. (Rev. 11288, 2022, March 4). Medicare Claims Processing Man ual Chapter 12 Physicians/Nonphysician Practitioners. Retrieved June 17, 2022 from www.cms.gov. 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag. 2004;11(9):21-22. Retrieved June 17, 2022 from www.aafp.org.
ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Impacted Cerumen Removal-OH MCD-AD-1059 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services . Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Eviden ce of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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 Impacted Cerumen Removal-OH MCD-AD-1059 Effective Date: 12/01/2022 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.A. Subject Impacted Cerumen Removal B. Background Cerumen or ear wax is a normal substance that cleans, protects, and lubricates the ear canal. The cerumen can block the ear canal causing symptoms such as pain, hearing loss, fullness, itching, and tinnitus. Methods to removal the cerumen include irrigation, manual removal with instrumentation, and cerumenolytic agents . C. Definitions Cerumen Impaction An accumulation of cerumen that is associated with symptoms and/or prevents a necessary ear examination. D. Policy I. Claims submission for cerumen impaction should include the appropriate CPT code and ICD-10 , such as: A. ICD-10 1. Impacted cerumen, unspecified ear; 2. Impacted cerumen, right ear ; 3. Impacted cerumen, left ear; or 4. Impacted cerumen, bilateral. B. CPT 1. Removal impacted cerumen using irrigation/lavage, unilateral; 2. Removal impacted cerumen requiring instrumentation, unilateral; or 3. Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing. NOTE: Visualization aids, such as, but not limited to binocular microscopy, are considered to be included in the CPT code and should not be billed separately . II. Evaluation and management (E&M) visit A. Impacted cerumen 1. An E&M service may not be billed when the sole reason for the visit is to remove symptomatic impacted cerumen. 2. An E&M service on the same day as removal of impacted cerumen may not be billed unless it represent s and is documented to be a significant, separately identifiable service on the same day. B. Non impacted cerumen 1. For removal of cerumen that is not impacted, use the E&M service code . III. For bilateral procedures, use Centers for Medicare & Medicaid Services (C MS) g uidelines. Impacted Cerumen Removal-OH MCD-AD-1059 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.IV. Modifiers A. Use modifier 50 , when appropriate. B. Follow NCCI guidelines , and use appropriate modifiers , as applicable. E. Conditions of Coverage NA F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 12/01/2020Date Revised 07/07/2021 07/20/2022Removed no prior authorization needed. Added CMS reference. Referenced MM-1033. Removed Medical policy reference. Updated other references. No other changes.Date Effective 12/01/2022 Date Archived H. References 1. Centers for Medicare & Medicaid Services. Local Coverage Determination Cerumen Removal L33945. (2021, February 4). Retrieved July 5, 2022 from www.cms.gov . 2. Schwartz, S., Magit, A., and Rosenfeld, R. (2017, January 3). Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). 156(1). Suppl. 2017 S1-S29. www. doi.org.
REIMBURSEMENT POLICY STATEMENTD-SNP Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-DSNP-PY-1376 IN, GA, KY: 11/01/2022 OH: 12/01/ 2022 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, regulato ry 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 includ e, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, imp airment 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 ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying t his 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 foll owing Marketplace(s): Georgia Indiana Kentucky Ohio Table of Contents A. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 5 Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.A. SubjectModifier 59, XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary polic ies 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 rec eived for processing. Reimbursement modifiers are two-digit codes that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. 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 prepayment and po st-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medic are National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations o r in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding I nitiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surgeries a re performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct bec ause it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more spec ific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. 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, u pdated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information a bout the service or procedure rendered. D. PolicyI. CareSource reserves the right to audit any submission at any time to ensure correct coding standards and guidelines are met. II. It is the responsibility of the submitting provider to submit accurate documentati on of services performed when requested from CareSource. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. III. Provider claims b illed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding audit. Once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the mo difier. IV. Modifiers X {EPSU} should be used prior to using modifier 59.V. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed at different anatomic sites; and 2. Are not ordinarily performed or encountered on the same day; and 3. Cannot be described by one of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, L D, RC, LM, RI). Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed during different patient encounters; and 2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (i.e., 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two timed procedures are performed during the same encounter but occur one after another (the first service must be completed befor e the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: 1. Are performed at separate anatomic sites; or 2. Are performed at separate patient encounters on t he same date of service. E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when: 1. The diagnostic procedure is the basis for performing the therapeutic procedure; and 2. It occurs befor e the therapeutic procedure and is not mingled with services the therapeutic intervention requires; and 3. Provides clearly the information needed to decide whether to proceed with the therapeutic procedure; and 4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately. F. Modifiers XU (or 59, when applicabl e) may be used when a diagnostic procedure is performed after a therapeutic procedure only when: 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure; and 2. It occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires; and 3. Does not constitute a service that would have otherwise been required during the therapeuti c intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separatel y. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please re fer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes . Unless otherwise noted within the policy, this policy applies to bothparticipating and nonparticipating providers and facilities.Modifier 59, XE, XP, XS, XU-DSNP-PY-1376Effective Dat e: 11/01/2022 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will b e the governing document.F. Related Policies/RulesModifier 25 G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. Centers for Medicare & Medicaid Services. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. R evised January 1, 2022. Retrieved June 24, 2022 from www.cms.gov. 2. Centers for Medicare & Medicaid Services. (2022 March). Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners. Rev. 11288. Retrieved June 24, 2022 from www.cms .gov. 3. Centers for Medicare & Medicaid Services (2022 March). MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. Retrieved July 12, 2022 from www.cms.gov. 4. Centers for Medicare & Medicaid Services. (2022). National Correct Coding Initiative (NCCI) Tool. 5. Centers for Medicare & Medicaid Services (2014 August). Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. Retrieved July 12, 2022 from www.cms.gov. I. State-Specific Information A. Georgia 1. Effective: 11/01/2022 B. Indiana 1. Effective: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022
MEDICAL POLICY STATEMENT Marketplace Policy Name & Number Date Effective Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliate s are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically neces sary 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Medical Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Medical Policy Statement. If there is a conflict between the Medical Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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 c overed under this policy. This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A.Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 7 F. Related Policies/Rules ………………………………………………………………………………………….. 7 H. References …………………………………………………………………………………………………………. 9 I. State-Specific Information ……………………………………………………………………………………… 9 Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 2 A.Subj ect Applied Behavior Analysis Therapy for Autism Spectrum Disorder B.Background Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms, depending on the developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereoty ped ( repe titive) behavior . Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted,repetitive patterns of behavior, interests , and activities.Ther e is currently no cure for ASD, nor is there any one single treatment for the disorder.I ndividuals with ASD may be managed through a combination of therapies, includi ng behav ioral, cognitive, pharmacological, and educational interventions. The goal of treatment for members with ASD is to minimize the severity of ASD symptoms,maximize learning, facilitate social integration, and improve quality of life for both t he me mbers and their families/ caregivers. ABA services may be provided in centers or at home. Research supports the equivalent effectiveness at both treatment sites . C.Definitions Autism Spectrum Disorder (ASD) – A neurological condition as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of t he A merican Psychiatric Association.A pplied Behavior Analysis (ABA) – A treatment for ASD. Caregiver/Family Training-The goal of caregiver/family training is to maximiz e t he childs outcomes. Caregiver/Family training helps the child generalize their skills taking the skills they are learning in the one to one therapy to the community.Caregiver/Family training sessions focus on providing parents and caregiver with knowledge and skills on behavioral concepts and strategies to maximize a nd r einforce the childs learning and to support the maintenance and generalization of the skills and treatments they are teaching. Caregiver/family are expected t o par ticipate in ABA treatment and if unable to, the provider will assist them i n ac quiring skills to participate. Standardized diagnostic assessment tools-o Autism Diagnostic Observation Schedule (ADOS); or o Autism Diagnostic Int erview Revised (ADI-R).Other known evidence-based diagnostic tools may be used, but only in addition t o t he tools listed above.If submitting standardized instruments that are over one year old, an independent provider must submit recent clinical notes describing behaviors which demonstrat e t he member still has ASD and would benefit from ABA therapy services. SMART goals-Specific, measurable, attainable, relevant, and time-bound. Qualified practitioner-To make a definitive diagnosis of ASDo Pediatric psychiatrist;o Psychologist;o Pediatric neurologist; or o Developmental pediatrician. Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 3 Independent practitioner-To provide ABA therapy :All services provided must be provided by a Behavior Analyst Certification Boar d ( BACB) certified behavior professional/paraprofessional:o Registered Behavioral technician ( RBT);o Behavioral Analyst Certification Board (BACB) certified assistant behavior analyst undergraduate level (BCaBA);o BACB certified behavior analyst graduate level ( BCBA); or o BACB certified behavior analyst doctoral leve ( BCBA-D). Supervision-All supervisory activities as well as supervisor and supervis ee r esponsibilities will be in accordance with the board from which the practitioner received a license.o Services delivered by an RBT or a BCaBA must be supervised by a BCBA,BCBA-Dor a licensed/ registered psychologist certified by the American Board ofProfessional Psychology in Behavioral and Cognitive Psychology who has test ed i n ABA. o A certified RBT, or BCaBA may provide ABA under the supervision of a n i ndependent practitioner (supervisor) must be enrolled in the Marketplac e pr ogram and affiliate with the organization under which they are employed or contracted. o For Ohio see Section I. State-Specific Information D. Policy I.Medical necessity review is required for all ABA services :A. Baseline then every 6 months thereafter or sooner if clinically necessary.B. Medical review documentation must be submitted with appropriate documentation as indicated in section III.I I. CareSource supports medical evidence that suggests ABA therapy should begi n ear ly in life, ideally by the age of 2, typically lasting up to 4 years, and is subject t o t he patients response to intervention. Individuals under the age of 21 years will be assessed and treatment goals and intensity will be based on the individuals needs and progress in treatment to remediate symptoms of the disorder.I II.ABA G eneral Guidelines :A. An independent practitioner will perform a behavior identification assessment and develop a treatment plan before services are provided. Behavioral assessments are generally not to exceed 8 hours every 6 months unless addi tional justification is provided.B. For initiation of ABA services, documentation needs to show medical necessit y t hrough the following criteria:1. Definitive primary diagnos is should be made by a qualified practitioner who has a clinical relationship with the member and is independent of the ABAprovider.2. ABA will be provided by an independent practitioner .3. Behavioral, psychological, developmental, and medical history a.ABA provided as part of the school/home program shoul d be c oordinated to assure medical necessity; and the goals are not to be education related, but will focus on targeted symptoms, behaviors, and functional impairments . The hours spent in a school/home school setting should be included. If submitted, an individualized educational program(IEP) will be included in the review. Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 4 b.Includes a history with symptom intensity and symptom duration; as well as demonstrate how the symptoms affect the members ability to function in various settings such as with family members , peers, and in school01. Includes evidence of previous therapy such as ABA, speech therapy,and occupational therapy if applicable02. Includes type, duration, results of therapy and how the results will influence the proposed treatment c. Includes evidence of coordination with other disciplines involved in t he as sessment such as occupational therapy and speech therapy.4. Treatment plan for child and caregiver/family training must include ALL of the following:a. The treatment plan developed will describe treatment activities and goals and documentation of active participation by the recipient's caregiver/family in the implementation of the treatment program.b. Includes baseline objectives that are clearly related to target behaviors.Measurable SMART goals that define how member improvement will benot ed. Outcome oriented interventions, frequency of treatment (i.e.number of hours per week), and duration of treatment.c. Includes outcome performance-based individualized goals based onbehav ioral assessment and a standardized developmental and/or functional skills assessment/curriculum such as Verbal BehaviorMilestones Assessment and Placement Program (VB-MAPP) orAssessment of Basic Language and Learning Skills (ABLLS-R).d. Includes prescription with number of ABA hours requested per week andm ust be based on the members specific needs and not on a general program structure as evidenced by all of the following:01. Treatment is provided at the lowest level of intensity appropriate to t he m embers clinical needs and goals;02. Detailed description of problems, goals and interventions support the need for requested intensity of treatment; and03.Number of hours requested reflects actual number of hours inten ded t o be provided.e. Includes a plan to modify intensity and duration over time based on the childs progress. Discharge plan should be individualized and specific to each childs treatment needs.f. Caregiver/Family Training (as described above in the definitions) also includes the following:01. Will be individualized to the caregiver/family needs, values, priorities,and circumstances.02. Will be performance-based and based on childs assessment and treatment needs such as teaching parents to implement behavioral techniques in the home; or work on adaptive living skills in the home environment.03. Will be include d in the treatment plan with a focus on target ed s ymptoms, behaviors, and functional impairments.g. ABA services must include documentation of parent/family training. I V. Initial Authorization for ABA Evaluation and Treatment Plan CreationA. A licensed ABA practitioner will perform a behavior identification assessment and develop a treatment plan before services are provided. Behavioral Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 5 assessments are generally not to exceed 8 hours every 6 months unless additional justification is provided. B. For initiation of ABA services, documentation needs to show medical necessity through the following criteria:1. Diagnosis should be made and confirmed in early childhood by a qualifi ed heal thcare provider as outlined above.2. Completion of a comprehensive diagnostic evaluation should include a referral for ABA Therapy services, using one of the following standardiz ed di agnostic assessment tools as described above in the definitions.3. The final diagnosis must be made by a licensed psychologist, physician or other licensed practitioner acting within their scope of practice under state law. V. A uthorization for Initial Course of TreatmentA. PA requests must document the following:1.Once ABA evaluation is authorized and completed, treatment plan goals a nd hour s must be submitted for approval.2. Individual treatment plan submitted by the treating BCBA,including:a.The patients behavioral, psychological, medical and family concerns.b. Previous ABA Therapy services including:01.Durati on 02.Ty pe of therapy received03. Results c. When previous ABA Therapy information is unknown, provi de doc umentation regarding why the information is not accessible and how this will affect treatment.d. Quantitative goals based on standardized assessments addressi ng behav iors the treatment plan is designed to treat, i ncluding:01. Base line measurements02. Progress reports03. Timelines to reach treatment goals according to the initial assessment and period assessments over the course of treatment.e. The specific number of hours a week requested for treatment based o n t he members needs. Benefit has been shown at various intensities of service.01. CareSource will approve a range of hours depending on the following:(1)Members needs;(2) Clinical-based evidence models supporting treatment efficacy and efficiency;(3) Clear clinical documentation of target behaviors;(4) Members response to treatment;(5) Parental participation; an d ( 6)Utilization of prior approved hours.f. Regular review and adjustment of hours per week is required t o addr essbehavioral goals. When original authorized treatment plan hours vary, documentation regarding must be provided.3. Parent/guardian training individualized for each members needs, including:a.Documented plans for the training;b. Parent/guardians ability to and willingness to learn and use therapy techniques in the home setting;4. School transition plans: Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 6 a.Attendance at school if age appropriate;b. Plans to transition to school if not currently attending; and c. plans to be able to attend school without additional ABA therapy outsi de t he school setting.5. Documentation that a licensed or certified behavior analyst will be providi ng t he ABA therapy services. VI.Fo r continuation of ABA services, documentation needs to show ALL of the followi ng c riteria :A. Definitive diagnosis of autism persists, and member continues to demonstrat e A SD symptoms that will benefit from treatment.B. Treatment plan as noted in I II.5. plu s the following updates:1. An updated progress report including treatment plan and assessment scores that notes improvement/members response to treatment from baseline targeted symptoms, behaviors, and functional impairments.2. There is a reasonable expectation based upon a CareSource medical necessity determination that the member would benefit from continued ABAtherapy. VII. D iscontinuation of ABA TherapyA. Generally accepted medical research and practice indicates that ABA therapy is not intended to be a lifelong treatment, and when treatment isnt maki ng s ignificant meaningful progress , it should be titrated and discontinued.B. A ny of the following criteria may result in a discontinuation of ABA therapy (this list is not all inclusive):1. M ember is unable to demonstrate meaningful progress in members behavior for two successive authorization periods as demonstrated through standardized assessments;2. A BA therapy is making symptoms worsen; or3. Members symptoms have stabilized to where the member can be dischar ged t o a less intensive type of treatment to manage their symptoms VIII. Tel ehealthA. Caregiver/Family Training and supervision may be provided by telehealth ; how ever, ABA 1:1 therapy will not be reimbursed. IX .E xclusionsA. Only evidence-based interventions based in behavior analysis will ber eimbursed.B. Reimbursement is not permitted under any of the following situations:1.Services or activities not stated in the treatment plan;2. Services or activities based on experimental behavior methods or mode3. Education and related services or activities as described for the individual under the Individuals with Disabilities Education Improvement Act of 2004,20 U.S.C. 1400 et seq. (IDEA);4. Services or activities that are vocational in nature and otherwise available t o t he recipient through a program funded under Section 110 of t he R ehabilitation Act of 1973; or5. Services or activities that are a component of adult day care programs.C. When solely based on the benefit of the family, caregiver or therapist;D. When solely focused on recreational or educational outcomes;E. When making symptoms worse or when member is showing regression; Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 7 F.For symptoms and/or behaviors that are not part of core symptoms of AS D ( e.g., impulsivity due to ADHD, reading difficulties due to learning disabilities, or excessive worry due to an anxiety disorder). Other treatments will bec onsidered to treat symptoms not associated with autism;G. If academic or adaptive deficits are included in the treatment plan, the focus should be on addressing autistic symptoms that are impeding these deficits i n t he home environment (i.e. reduce frequency of self-stimulatory behavior t o al low child to be able to follow through with toilet training or complete a m athematic sorting task) rather than on any academic targets;H. When ABA therapy services are not expected to bring measurable functional improvement or measurable functional improvement is not documented;I. When therapy services are duplicative in addressing the same behavioral goals using the same techniques as the treatment plan, including services perform ed under an IEP;J. For more than one program manager/lead behavioral therapist for a member at any one ti me;K. For more than one agency/organization providing ABA therapy services for a member at any one time;L. Services provided by family or household members are not covered.M. Treatment will not be covered if the care is primarily custodial in nature (that do not require the special attention of trained/professional ABA staff), shadow, para-professional, or companion services in any setting.N. Personal training or life coaching.O. Services that are more costly than an alternative service or services, which are at least as likely to produce equivalent diagnostic or therapeutic results for th e pat ients disorder.P. Any program or service performed in nonconventional settings (even if t h e se rvices are primarily performed by a licensed provider), including: spas/resorts;vocational or recreational settings; Outward Bound; and wilderness, camp or ranch programs. NO TE : Compliance with the provisions in this policy may be monitored and addr essed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E.C onditions of CoverageNA F. Related Policies/Rules Applied Behavior Analysis for Autism Spectrum Disorder Administrative policiesMedical Records Documentation for Practitioners policyMedical Necessity policy Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 8 G.Review /Revision History DATE ACTION Date Issued 10/04/2018 Date Revised 01/27/2020 01/ 25/2021 08/ 31/2021 08/ 17/2022 Added program attributes, definitions of provider types and of ABA, title changed, clarified services needing a PA, changed NP to health care provider trained in ASD, added IV, added willingness to participate in program, added description of plan of care, added ages, clarified provider requirements, added must have ASD diagnosis, added home school and IEP, added documentation requirements, added must include type of ASD treatment program with PA, revised continuation of AGA therapy requirements, Added AFLS, ESDM and PEAK-DT assessments, revised discontinuation criteria, added section on transitioning ABA therapy to school environment, revised exclusions, and removed PA checklist. Clarified telehealth coverage, moved documentation requirements to Medical Records Documentation for Practitioners policy, and removed transition to school section/updated school section. Updated definitions. Updated ABA criteria. Updated RBT supervision. Background added ABA services may be provided in centers or at home. To sec. DIII 5.g. ABA services must include parent/family training or may be subject to denial. Edited Sec. V. Removed VII. A Used combined template. Updated references. Removed Sec. III.B.2. stating that an ABA order/recommendation from a provider other than one who has a financial relationship with the ABA entity that is planning to provide these services; Called out the distinct s eparate steps for Initial Authorization for ABA Evaluation and Treatment Plan Creation, Authorization for Initial Course of Treatment, and Continuation of ABA Services; Combined telehealth. Added VIII. A. Only evidence-based interventions based in behavior analysis will be reimbursed . In VIII. P, we state that for program or service performed in nonconventional settings (even if the services are primarily performed by a licensed provider ). Date Effective 11/01/2022 Date Archived Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 9 H.References1.American Academy of Pediatrics (n.d.). Autism Initiatives. Retrieved August 4, 2022from www.aap.org.2. The Behavior Analyst Certification Board. (2020. November). BCBA HandbookRetrieved on August 4, 2022 from www.bacb.com . 3.The B ehavior Analyst Certification Board. (2020, November). Registered BehavioralTechnician Handbook. Retrieved August 4, 2022 from www.bacb.com.4. The Council of Autism Service Providers. (2020). Applied Behavior AnalysisTreatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved on August 4, 2022 from www.casproviders.org.5. Crockett, J. L., & Fleming, R. K. (2007). Parent training: Acquisiti on and gener alization. Research in Developmental Disabilities, 28, 23-36.6. Dixon, Mark. (n.d.). PEAK Relational training system Evidence-based autism assessment and treatment.7. Gresham, F. M., Beebe-Frankenberger, M. E., & MacMillan, D. L. (1999). A selectiv e r eview of treatments for children with autism: Description and methodological considerations. School Psychology review, 559-575.8. Lord C, Rutter M, Goode S, et al. (1989). Autism diagnostic observation schedule: as tandardized observation of communicative and social behavior . JAutism De v Dis ord 19 (2): 185 212 9.P artington, J. & Mueller, M. (n.d.). AFLS – The Assessment of Functional Livi ng S kills. Retrieved July 20, 2022 from www.partingtonbehavioranalysts.com10. Partingon, J. (2006). (ABLLS-R) Assessment of Basic Language and Learning Skills,Revised.11. Rogers, S. & Dawson, G. (2010). Early Start Denver Model for Young Children withAutism Checklist.12. Rutter, M., LeCouteur A. et al. (2003). AIDTM-R Autism Diagnostic interview, Revised 13. S undberg, M. (n.d.). Verbal Behavioral Milestones Assessment and PlacementProgram. Retrieved August 4, 2022 from www.vbmappapp.com .14. Susan L. Hyman, Susan E. Levy, Scott M. Myers and Council on children wit h di sabilities, section on developmental and behavioral pediatrics. Pediatrics January2020, 145 (1) e20193447; DOI: https://doi.org/10.1542/peds.2019-3447.15. Volkmar, F, et al. (2014) . Practice Parameter for the Assessment and Treatment ofChildren and Adolescents With Autism Spectrum Disorders . Retrieved August 4,2022 from www.aacap.org.16. Weissman, L. (2018, June 28). Autism Spectrum Disorders in Children an d A dolescents: Behavioral and Educational Interventions. Retrieved August 4, 2022from www.uptodate.com I. S tate-Specific InformationA. Georgia1. References a.GA-Evidence of Coverage and Health Insurance Contract Georgia2. Effective: 11/01/2022B. Indi ana 1. R eferences a. Evidence of Coverage and Health Insurance Contract Indiana Applied Behavior Analysis Therapy for Autism Spectrum Disorder MP-MM-1329 Effective Date: 11/01/2022 10 b.Indiana Department of Insurance. (2015, June 17). Payment of UndisputedABA Treatment During Appeals Process. Bulletin 216. Retrieved July 20,2022 from https://www.in.gov c. Indiana Department of Insurance. (2006, March 30). Insurance Coverage forPervasive Development Disorders Bulletin 136. Retrieved July 20, 2022 from www.in.gov d. Indiana Department of Insurance. (2010, April 27). Pervasive DevelopmentalDisorders Coverage Clarification Bulletin 179. Retrieved July 20, 2022 from www.in.gov2. Effective: 11/01/2022 b. K entuckyEvidence of Coverage and Health Insurance Contract Kentucky1. Effective: 11/01/2022 c.O hioEvidence of Coverage and Health Insurance Contract Ohio I n Ohio, in order to independently practice and supervise others in ABA, one must also be certified under the Ohio Board of Psychology in one of the following areas: o BCBA (Certified Ohio Behavioral Analyst-COBA) o BCBA-D (COBA) 1. Effective: 12/01/2022 d.W est VirginiaEvidence of Coverage and Health Insurance Contract West Virginia i. Effective: 11/01/2022 The Med ical Policy Stateme nt det ailed a bo ve has received due con side ration as defined in the Medical Policy Stateme nt Po licy a nd is a pprove d.
ADMINISTRATIVE POLICY STATEMENT Ohio Medicaid Policy Name & Number Date Effective Hospice Services OH-MCD-AD-1065 12/01/2022Policy TypeADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behav ioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medic al conditions as covered under this policy. Table of Contents A.Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Hospice Services OH-M CD-AD-1 065 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.A. SubjectHospice Services B.Background Hospice services are provided to individuals who are terminally ill and at the end of life.These services are intended to provide comfort or palliative care. Hospice care is a ty pe of care that focuses on the palliation of a terminally ill patient's pain and symptomsand at tending to their emotional and spiritual needs. Hospice care has a palliative focus without curative intent. Usually, it is used for patients with no further options for curi ng di sease or who have decided not to pursue further options that are arduous, likely t o c ause more symptoms, and unlikely to succeed. C. Definitions Hospice Care Program-A coordinated program of home, outpatient, and inpatient care and services operated by a person or public agency that provides the followi ng c are and services to hospice patients and to hospice patients' families thro ugh a m edically-directed interdisciplinary team:o Nursing care by or under the supervision of a registered nurse o Physical, occupational, or speech or language therapy, unless waived by t he depar tment of health o Medical social services by a social worker under the direction of a physician o Services of a home health aide o Medical supplies, including drugs and biologicals, and the use of medical appliances o Physician services o Short-term inpatient care, including both palliative and respite care , and procedures o Counseling for hospice patients and families o Services of volunteers under the direction of the provider of the hospice car e pr ogram o Bereavement services for hospice patients' families .These services are provided under interdisciplinary plans of care establis hed pur suant to section 3712.06 of the Revised Code to meet the physical,psychological, social, spiritual, emotional, and other special needs experienc ed dur ing the final stages of illness, dying, and bereavement.Hospice Patient-A patient, other than a pediatric respite care patient, who has been diagnosed with a terminal illness, has a life expectancy of six months or less,and has voluntarily requested and is receiving care from a person or public agency licensed under Ohio law to provide a hospice care program.Palliative Care-Speciali zed care for a patient of any age who has been diagnos ed wit h a serious or life-threatening illness that is provided at any stage of the illness by an interdisciplinary team working in consultation with other health care professionals,including those who may be seeking to cure the illness aims to do all of the following: o R elieve the symptoms, stress, and suffering resulting from the illness o Improve the quality of life of the patient and the patient's family Hospice Services OH-M CD-AD-1 065 Effective Date: 12/01/2022 The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.o Address the patient's physical, emotional, social, and spiritual needs o Facilitate patient autonomy, access to information, and medical decision making. Pediatric Hospice Care-A program operated by a person or public agency that provides inpatient respite care and related services to pediatric respite care patients and the patients' families to meet the physical, psychological, social, spiritual, and other special needs experienced during or leading up to the final stages of illness,dying, and bereavement .Terminal Il lness-A qualifying condition for which a prospective patient has receiveda diagnosis for a life expectancy of six months or less if the illness runs its normal course. D. Policy I. CareSource considers hospice services a covered service with the followi ng r equirements:A. Election of hospice benefits form must be signed by the CareSource member and submitted.B. Provider must produce and submit a Certificate of Terminal Illness form.C. CareSource may request documentation to support medical necessity.Appropriate and complete documentation must be presented upon CareSourc e r equest to validate medical necessity.D. Criteria for determination of terminal illness:1.Hospice care is provided for two ninety-day periods followed by increments o f si xty-day periods, as recertifications occur .2. Patient must have a qualifying condition with a diagnosis of a life expectancy of six months or less if the illness runs its normal course.3. At the start of the first ninety-day benefit period, the patient must be certifi ed a s terminally ill.4. The patient must be recertified as terminally ill at the start of each benefit period following the first ninety-day period by the hospice physician.E. Short-term inpatient care may be provided in hospital, hospice inpatient unit, or a participating Skilled Nursing Facility or Nursing Facility on an intermittent, non-routine basis :1. For relief of the individual's caregivers, and/or2. General inpatient care for the purpose of respite, pain control and acute or chronic symptom management that cannot feasibly be provided in other settings.F. When an individual younger than age 21 elects to receive hospice care, it does not constitute a waiver of any rights of the individual to receive curative services related to the treatment of a terminal condition.G. When an adult over the age of 21 elects to receive hospice care, he or sh e agr ees to waive Medicaid services provided to him or her for the cure and treatment of the terminal condition.H. Ohio law considers people who are 18 years of age or older capable of givi ng v alid, legally enforceable consent to receive hospice services.II. Hospice care for under age 18 years requires the consent of a parent or guardi an unl ess certain exceptions exist as noted under Ohio law . Hospice Services OH-M CD-AD-1 065 Effective Date: 12//01/2022The ADMINISTRATIVEPolicy Stateme nt det ailed a bove has received due con side ration as defined in the ADMINISTRATIVEPo licy Stateme nt Po licy a nd is a pprove d.III. When the reason for discharge from hospice care is death, r outine home car e pr ovided in an in-home visit by a registered nurse and/or a social worker during the last seven days of a patients life requires documentation of medical necessity . I V. Billing for Hospice ServicesA. Professional claims must be billed on a CMS 1500 (HCFA) form with t he f ollowing documentation:1. The name of the nursing facility where the services were delivered and2. The National Provider Identifier (NPI) of the service facility .3. Consistent with the current process set forth by the OAC, providers must submit claims as a single line with date of service span and units billed to match .B. Institutional claims must be billed on a UB04 form with the followi ng doc umentation:1. The name of the nursing facility where the services were delivered.2. If the hospice services are billed in a Health Care Isolation Center (HCIC)Room and Board, the claims must be billed using the HCIC revenue codes as provided in the Ohio Department of Medicaid guidance.C. Hospice providers that deliver any component of services via telehealth must add the GT modifier on those claims, in addition to the appropriate procedure code. V. For the administration of Hospice Services, CareSource follows the rules sets forth inChapter 5160-56, Medicaid Hospice Program in the Ohio Administrative Code (OAC)and Chapter 3712, Hospice Care in the Ohio Revised Code (ORC). E.Conditions of Coverage N/A F.Related Policies/Rules N/A G.Review/Revision History DATES ACTION Date Issued 07/21/2021 New Policy Date Revised 08/17/2022 Updated references; no changes Date Effective 12/01/2022Date ArchivedH.References 1. OAC-5160-1- 18. Telehealth (2020, November 150). Retrieved August 2, 2022 fro m w ww.codes.ohio.gov.2. OAC-5160-56-01 Hospice services; definitions . Retrieved August 2, 2022 fro m w ww.codes.ohio.gov. Hospice Services OH-MCD-AD-1065 Effective Date: 01/01/2023 The ADMINISTRATIVEPolic y St ate m ent d e tail ed a bo ve h a s receiv ed due c on side ra tio n a s d e fin ed i n the ADMINISTRATIVEPo lic y St ate m ent Polic y a nd i s a pp rove d.3. OAC-5160-56-02 Hospice services; eligibility and election requirements . Retrieved August 2, 2022 from www.codes.ohio.gov. 4. OAC-5160-56-03 Hospice services; discharge requirements . Retrieved August 2, 2022 from www.codes.ohio.gov. 5. OAC-5160-56-04 Hospice services; provider requirements, Retrieved August 2, 2022 from www.codes.ohio.gov. 6. OAC-5160-56-05 Hospice services; covered services . Retrieved August 2, 2022 from www.codes.ohio.gov. 7. OAC-5160-56-0 6 Hospice services; reimbursement . Retrieved August 2, 2022 from www.codes.ohio.gov . 8. ODM. Telehealth Billing Guidelines for Dates of Service on or after 11/15/2020. Retrieved August 2, 2022 from www.medicaid.ohio.gov 9. ORC-2317.54 Informed consent to surgical or medical procedure or course of procedures. Retrieved August 2, 2022 from www.codes.ohio.gov. 10. ORC 2907.29 Hospital emergency services for victims of sexual offenses. Retrieved August 2, 2022 from www.codes.ohio. gov. 11. ORC 2919.121 Unlawful abortion upon minor. Retrieved August 2, 2022 from www.codes.ohio.gov. 12. ORC 3709.241 Minor may give consent for diagnosis or treatment of venereal disease. Retrieved August 2, 2022 from www.codes.ohio.gov. 13. ORC-Chapter 3712 Hospice Care . Retrieved August 2, 2022 from www.codes.ohio.gov . 14. ORC-3719.012 Minor may give consent to diagnosis or treatment of condition caused by drug or alcohol abuse. Retrieved August 2, 2022 from www.codes.ohio.gov. 15. ORC-5122.04 Outpatient services f or minors without knowledge or consent of parent or guardian. Retrieved August 2, 2022 from www.codes.ohio.gov.
ADMINISTRATIVE POLICY STATEMENT Marketplace Policy Name & Number Date Effective Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industry standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of 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 Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Administrative Policy Statements prepared by CareSource and its affiliates do not ensure an authorization or payment of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced in the Administrative Policy Statement. If there is a conflict between the Administrative Policy Statement and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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 b Indiana b Kentucky b Ohio b West Virginia Table of Contents A.Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 I. State-Specific Information ……………………………………………………………………………………… 5 Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 2 A.Subject Applied Behavior Analysis Therapy for Autism Spectrum Disorder B.Background Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms dependi ng on t he developmental level and chronological age of the patient. ASD is often defined by specific impairments that affect socialization, communication, and stereoty ped ( repetitive) behavior. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted,repetitive patterns of behavior, interests and activities.Ther e is currently no cure for ASD, nor is there any one single treatment for the disorder.Individuals with ASD may be managed through a combination of therapies, includi ng behav ioral, cognitive, pharmacological, and educational interventions. The goal of treatment for members with ASD is to minimize the severity of ASD symptoms,maximize learning, facilitate social integration, and improve quality of life for both t he m embers and families and/or caregivers. C. Definitions Autism Spectrum Disorder – (ASD) Any of the following pervasive developmental disorders as defined by the most recent version of the Diagnostic and StatisticalManual of Mental Disorders (American Psychiatric Association): Autism; Asperger'sDisorder; or other condition that is specifically categorized as a pervasiv e dev elopmental disorder in the Manual . Applied Behavior Analysis – (ABA) A preventive service for ASD. Board Certified Assistant Behavior Analyst ( BCABA) A professional provider of applied behavioral analysis services who has obtained an undergraduate-leve l c ertification . BCBA-BACB certified behavior analyst graduate level. BCBA-D – BACB certified behavior analyst doctoral level. RBT-BACB Registered Behavioral Technician. Supervision-All supervisory activities as well as supervisor and supervis ee r esponsibilities will be in accordance with the board from which the practitioner received a license.o Services delivered by a RBT must be supervised by a qualified RBT supervisor. o Services delivered by a BCaBA must be supervised by a BCBA, BCBA-D or a l icensed/ registered psychologist certified by the American Board of ProfessionalPsychology in Behavioral and Cognitive Psychology who has tested in ABA. o A registered behavior technician (RBT), certified by the national behavior analyst certification board (BACB), may provide ABA under the supervision of an independent practitioner. In order to provide services, they have to enroll i n t he Marketplace program and affiliate with the organization under which they are employed or contracted. Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 3 RBT Supervision-Ongoing supervision must be at a minimum of 5% of the hours spent providing behavior-analytic services per month 1. This includes a minimum of 2 f ace-to-face contacts per month. D. Policy I. Medical necessity review is required for all ABA services:A. At b aseline, then again every 6 months thereafter or sooner if clinically necessary.B. Medical review documentation must be submitted with appropriate documentation as indicated in the medical policy.I I. A n ASD diagnosis is required in order for services to be reviewed for approval.III. Li mitationsA. A Medically Unlikely Edit (MUE) for a CPT code is the maximum units of servic e t hat a provider can report for one member on one date of service.1. Maximum units allowed per CPT: CPT Max unit allowed 97151 32 97152 16 97153 32 97154 18 97155 24 97156 16 97157 16 97158 16 0362T 16 0373T 32 N OTE: If CMS updates the MUE list ,which generally occurs on a quarterly basis, the update will take precedence over the MUEs in this policy . B . E ach RBT must obtain ongoing supervision for a minimum of 5% of the hours spent providing behavior-analytic services per month.C. The treatment codes are based on daily total units of service in 15-minute i ncrements. A unit of time is attained when the mid-point is passed.1. Ti me interval examples: Units Number of minutes 1 unit >8 minutes through 22 minutes 2 units >23 minutes through 37 minutes 3 units >38 minutes through 52 minutes 4 units >53 minutes through 67 minutes 1 www.bacb.com Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 4 5 units >68 minutes through 82 minutes 6 units >83 minutes through 97 minutes 7 units >98 minutes through 112 minutes 8 units >113 minutes through 127 minutes E.Conditions of Coverage Payments may be subject to limitations and/or qualifications and will be determi ned w hen the claim is received for processing. Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers.Prog ram Integrity will be engaged for an annual review of data. F.Related Policies/Rules Applied Behavior Analysis for Autism Spectrum DisorderEvidence of Coverage and Health Insurance Contract G.Review/Revision History DATES ACTION Date Issued 11/29/2018 Date Revised 04/12/2019 01/27/2020 02/ 02/2021 08/ 31/2021 08/ 17/2022 Removed U3 & U5 modifiers Revised definitions, clarified PA requirements, added ASD diagnosis as primary, added specificity to reimbursement, updated limitations, added MUE, added time intervals, added specificity to concurrent billing Updated definitions, Removed transition ABA therapy, Removed codes. Changed from PY policy. Removed coding portions in policy . Updated MUE table: 97152 MUE went from 8 to 1697154 MUE went from 12 to 180362T MUE went from 8 to 16Added Program Integrity will be engaged for an annual review of data New composite MP template; updated references; no change to MUE table. Date Ef fective 11/01/2022 Date Archived H.References 1. American Medical Association. (2018). Coding Update: Reporting Adaptive BehaviorAssessment and Treatment Services in 2019. CPT Assistant, 28(11).2. Behavior Analyst Certification Board. (2018, October 8). Adaptive BehaviorAssessment and Treatment Code Conversion Table. Retrieved August 3, 2022 fro m w ww.bacb.com . Applied Behavior Analysis for Autism Spectrum Disorder-MP-AD-1223 Effective Date: 11/01/2022 5 3.Behavior Analyst Certification Board. (2019, February). Clarifications Regardi ng A pplied Behavior Analysis Treatment of Autism Spectrum Disorder. (2nd ed.).Retrieved August 3, 2022 from www.bacb.com.4. The Council of Autism Service Providers. (2020). Applied Behavior AnalysisTreatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers. Retrieved on August 3, 2022 from www.caseproviders.org. I.State-S pecific InformationA. Georgia1. Effective: 11/01/2022B. Indiana1. Effective: 11/01/2022C. Kentucky1. Effective: 11/01/2022D. Ohio1. Effective: 12/01/2022E. Wes t Virginia1. Effective: 11/01/2022 Th e Administrative Policy Stateme nt det ailed a bove has r eceived due con side ration as defined in the Administrative Policy Stateme nt Po licy a nd is a pprove d.
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