Program Integrity Provider Prepayment Review

ADMINISTRATIVE POLICY STATEMENTOhio Medicaid Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH MCD-AD-0767 12/01/2022 Policy Type ADMINISTRATIVE Administrative Policy Statement prepared by CareSource and i ts affiliates are derived from literature based on and supported by clinical guidelines, nationally recognized utilization and technology assessment guidelines, other medical management industr y standards, and published MCO clinical policy guidelines. Medi cally 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 l ocal 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 procedur es. 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 Ad ministrative 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 dete rmination. 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 appl y to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.A. SubjectPro g ram Integrity Provider Prepayment Review B. Background This policy applies to participating (PAR) providers only. CareSo urce Pro gram Integrity (PI ) o perates a p rovider prepayment review program to detect, p revent , and correct fraud, waste , and abuse , and to facilitate accurate claim p ayments. Physicians and o ther healthca re professiona ls may have the right to ap peal results of reviews. C. Def initions Provider Prepayment Review – Reviews of medical record documentation and compar ison billed services. Prog ram Integrity (PI) – The proper management and f unction ing of a health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste. Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice , outpatient setting , or hospital. Reg istered Health Information Administrator (RHIA) – A prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules. Registered Health Information Technician (RHIT) – A certif ied professional who stores and verif ies the accuracy and completeness of electronic health records and analyzes patient data with the goal of controlling healthcare costs and improving patient care. D. PolicyI. A pro vider pre pay review involves reviewing medical record s compared to services b illed p rio r to claim adjudication. Providers are p laced o n pre pay review to monitor for improper b illing of medical claims including b ut not limited to the following reasons: A. Overutilization o f services B. Billing for items or services not rendered C. Selection of wro ng CPT/HCPCS code o r supplies D. Lack o f medical necessity E. Billing /dispensing unnecessary services F. Pro ced ure repetition G. Up co ding H. Billing for service s outside of p rovider specialty II. Placemen t on p repayment review will req uire the provider to submit medical records with each claim allo wing CareSource to review the medical records in comparison to the billed services. CareSource will p rovide a written 30-day no tice to the provider/provider gro up ad vising them of the effective date of prepayment review. A. Prep ayment review will be implemented for a p eriod of 6 months . B. The 6-mo nth p eriod b egins up on the first successful adjudication of a claim submission und er p rep ayment review. Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.C. Med ical records MUST b e submitted via paper format to the P .O. Box listed on the p ro vider p repayment notification letter. D. All claims must b e submitted with medical record s. E. Failure to sub mit medical records to CareSource in accordance with this p rovision will result in claim d enial. F. Failure to meet minimal documentation standards such as member name and date of service o n each page of the medical record, a signed d ated ord er and a valid provider sig nature will result in claim d enial. G. Pro viders must b ill timely and accurate claims during the prepayment review period. III. CareSo urce utilizes a p ublished decision hierarchy to cond uct reviews . In ad d ition,CareSo urce may use the following: A. Centers f o r Medicare and Medicaid Services ( CMS ) g uidelines , as stated in Medicare manuals . B. Med icare lo cal and national coverage determinations . C. All CareSo urce published policies (Administrative, Medical and Reimbursement), code – ed iting policies and CareSource p rovider manuals. D. Natio nal Unif orm Billing Guidelines fro m the National Billing Committee . E. American Med ical Association Current Procedural Terminology (CPT) g uidelines . F. Current American Medical Association Healthcare Co mmon Procedure Co ding System (HCPCS) Level II . G. ICD 10-CM o f ficial g uidelines for coding and reporting . H. American Association of Medical A udit Specialists national healthcare billing aud it g uid elines . I. Ind ustry-standard utilization management criteria and /or care guidelines , such as MCG g uid elines (current edition o n date of service) . J. Fo o d and Drug Administration guidance . K. Natio nal p rofession al medical societys guidelines and consensus statements . L. Pub lication from specialty societies, such as the American Society for Parenteral and Enteral Nutritio n, the Substance Abuse and Mental Health Service Administration, and the American Association of Neuromuscular & Mental Health Services Administration . M. Natio nally recognized , evidence-b ased published literature including, b ut not limited to, so urces , such as Medscape, the American Academy of Pediatrics (AAP) and the American Co llege of Obstetricians and Gynecologists (ACOG) . IV. The P ro g ram Integrity Provider Prepayment Review Team is comprised of clinical review andco d ing specialists who maintain CPC, RHIA, o r RHIT d esignation s.A. The team reviews p rovider d ocumentation to determine whether the claim is appropriate f o r p ayment based on criteria including, b ut not limited to, provider d ocumentation which estab lishes that: 1. Services were p rovided according to CareSource policy req uirements . 2. Billed services were medically necessary and appropriate and not in excess of the memb ers need . 3. Memb ers were b enefit eligible on the d ate the services were p rovided . 4. Prio r autho rization was o btained , if required b y policy . 5. Pro viders and staff were q ualifie d, as req uired by state or f ederal law . 6. The p ro vider p ossessed the p roper license, certification , or o ther accreditation req uirements specific to the providers scope of p ractice at the time the service was p ro vided to the member. V. Pro viders whose claims are d etermined not payable may send in new corrected claim s, a d isp ute , or an ap peal, whichever is ap propriate, within timely filing limitations as o utlined in the p ro vide r manual. A. Pro viders and/or billing managers m ay reach out directly to the program integrity p rep ayment review team to discuss specific claim denials. Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.VI. Pro viders are p rohibited from b illing covered individuals for services determined not payable as a result o f the p repayment review p rocess, whether d ue to fraud, abuse, waste of any o ther b illing issue, or f or failure to submit medical records as set forth ab ove. VII. On co mp letion of the 6 mo nth review period :A. CareSo urce will d etermine if the p rovider is eligib le for release from prepayment review if: 1. The p ro vider has achieved an 85% o r more approval rate o n claim submissions for 3 co nsecutive months , and 2. The vo lume of claims submissions remained within 10% of the volume b efore p rep ayment review . B. If the p ro vider successfully complete s both requirements under A ab ove before the 6 mo nth d eadline , the provider may be removed from the p repayment review p rocess at the d iscretion of CareSource. C. If the p ro vider fails to satisfy the requirements ab ove , an ad ditional 6 month p repayment review p erio d may b e necessary, and the provider may be req uired to submit a corrective actio n p lan. 1. If af ter the second 6 month interval p rescribed und er sub se ction Cthe p rovider fails to satisfy the r eq uirements under sub sections A1 and A2 , CareSource may do the f o llowing : a. Deny p ayment for medical assistance services rendered d uring a specified period o f time b . Terminate the p ro vider ag reement c. Req uire a co rrective action plan 2. Pro viders who d emonstrate accurate billing practices and have b een removed from prep ayment review may be subject to future follow up reviews to ensure continued co mp liance with billing p ractices. 3. If a p ro vider has been on a p repayment review for 12 months , CareSource may terminate the p rovider ag reement if: a. There has b een no b illing activity for 6 months; o r b . The vo lume of claim submissions during review period is not within 10% of the vo lume b efore p repayment review. 4. Up o n co mpletion of the prepayment review period, the p rovider/provider g roup will receive no tification in writing as to the effective end d ate of review. E. Conditions of Coverage N/A F. Related Policies/Rules N/A G. Review/Revision History DATES ACTIONDate Issued 01/08/2020 New Po licyDate Revised 08/19/2020 07/20/2022 Up d ated Section VII , Ed itorial updates o nly. Date Effective 12/ 01/2022 Date Archived Pro g ram In teg rity Pro vid er Prep aymen t Review-OH MCD-AD-0767 Effective Dat e: 12/25/2030 The ADMINISTRATIVE Policy Statement detailed abo ve has recei ved d ue con sideration as defined in theADMINISTRATIVE Policy Statement Policy and is app roved.H. Ref erencesN/A

Program Integrity Provider Prepayment Review

ADMINISTRATIVE POLICY STATEMENT Ohio Medicare Advantage Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH MA AD-0768 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 industr y standards, and published MCO clinical policy guidelines. Medically necessary services include, but are not limited to, those hea lth 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, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically ne cessary 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 it s 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 A dministrative 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 Addictio n 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 Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only.CareSource Program Integrity (PI ) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other he althcare professiona ls may have the right to appeal results of reviews . C. Def initionsProvider Prepayment Review-reviews medical record documentation and compares it to billed services.Program Integrity (PI) – Program integrity ref ers to the proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The certified professional coder credential is of f ered through the American Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice, outpatient setting, or hospital.Registered Health Information Administrator (RHIA) – A registered health inf ormation administrator (RHIA) is a prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insura nce Portability and Accountability Act and other privacy and security rules.Registered Health Information Technician (RHIT) – An RHIT is a certif ied prof essional who stores and verif ies the accuracy and completeness of electronic health records. An RHIT also analyzes patient data with the goal of controlling healthcare costs and improving patient care.D. PolicyI. A Provider pre pa y review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on pre pay review to monitor f or improper billing of medical claims including but not limited to the f ollowing reasons:1. Overutilization of services2. Billing f or items or services not rendered3. Selection of wron g CPT/HCPCS code or supplies4. Lack of medical necessity5. Billing/dispensing unnecessary services6. Procedure repetition7. Upcoding8. Billing f or service s outside of provider specialty Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. II. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparison to the billed services.A. CareSource will provide a written 30-day notice to the provider/provider group advising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period begins upon the f irst successful adjudication of a clai m submission under prepayment review.3. All claims must be submitted with medical records.4. Medical records may be submitted in one of the f ollowing ways :a. Electronically with a claim .b. Submitted via the provider portal.Note: CareSource will not accept medical records via f ax. 5. Failure to submit medical records to CareSource in accordance with this provision will result in claim denial.6. Failure to meet minimal documentation standards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7. Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes the published decision hierarchy to conduct reviews, in additionCareSource may use:A. Centers f or Medicare and Medicaid Services guidelines as stated in Medicare manuals .B. Medicare local coverage determinations and national coverage determinations .C. All CareSource published policies (Administrative, Medical and Reimbursement),Code-editing policies and CareSource provide r manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee .E. American Medical Association Current Procedural Terminology (CPT) guidelines .F. American Medical Association Healthcare Current Common Procedure CodingSystem (HCPCS) Level II .G. ICD 10-CM of ficial guidelines f or coding and reporting .H. American Association of Medical Audit Specialists national healthcare billing audit guidelines .I. Industry-standard utilization management criteria and/ or care guidelines such asMCG guidelines (current edition on date of service) .J. Food and Drug Administration guidance .K. National prof essional medical societys guidelines and consensus statements .L. Publication f rom specialty societies, such as the American Society f or Parenteral and Enteral Nutrition, Substance Abuse and Mental Health ServiceAdministration, and the American Association of Neuromuscular & Mental HealthServices Administratio n.M. Nationally recognized, evidence-based published literature including, but not limited to, sources such as: Medscape, American Academy of Pediatrics (AAP)and the American College of Obstetricians and Gynecologists (ACOG) .IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation. Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. The team reviews provider documentation to determine whether the claim is appropriate f or payment based on criteria including, but not l imited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements .2. Billed services were medically necessary and appropriate, and not in excess of the member s need .3. Members were benefit eligible o n the date the services were provided .4. Prior authorization was obtained if required by policy .5. Providers and their staf f were qualif ie d as required by state or f ederal law .6. The provider possessed the proper license, certification, or other accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not payable may send in new corrected claim s , a dispute or an appeal, whichever is appropria te, within timely f iling limitations as outlined in their provide r manual.A. Providers and/or billing managers m ay reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited f rom billing covered individu als f or services we have determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste of any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the six month review periodA. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or more approval rate on claim submissions f or 3 consecutive months and2. The vol ume of its claims submissions remained within 10% of the volume bef ore prepayment reviewB. If the provider successfully complete s both requirements under A above bef ore the six-month deadline the provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider f ails to satisf y the requirements above they may be placed under an additional 6 month prepayment review period and be required to s ubmit a corrective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the r equirements under sub sections A1 and A2 ,CareSource may do the f ollowing a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan2. Providers who are able to demonstrate accurate billing practices and removed f rom prepayment revi ew may be subject to f uture f ollow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 months CareSource may terminate the provider agreement if :a. There has been no billing activ ity f or 6 months; or Pro gram In teg rity Pro vid er Prep aymen t Review-OH MA AD-0768 Effective Date 12/01/2022 The ADMINIS TRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. b. The volume of claim submissions during review period is not within 10% of its volume bef ore prepayment review.4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writings as to the ef fective end date of review.E. Conditions of CoverageN/AF. Related Policies/RulesN/AG. Review/Revision HistoryDATES ACTION Date Issued 01/08/2020 New Po licy Date Revised 0 8/19/2020 08/13/2022 Up d ated Section VII , up dated title . Remo ved req uirement for paper format f o r submission; instead claims should be sub mitted electronically . Date Effective 12/01/2022 H. Ref erencesI. Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual (April21, 2022). Retrieved July 11, 2022 f rom www.cms.gov

Myoelectric Lower Extremity Prosthetic Technology

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 IN, GA, WV, KY: 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical 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. 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 confl ict 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 covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West VirginiaTable of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 4 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 5 B. State-Specific Information ……………………………………………………………………………………… 5Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.A. Subject Myoelectric Lower Extremity Prosthetic Technology B. Background The policy addresses the computerized limb prosthesis that is a nonstandard, external prosthetic device incorporating a microprocessor for movement control. These devices are equipped with a sensor that detects when the knee is in full extension and adjusts the swing phase automatically, permitting a more natural walking pattern of varying speeds . C. Definitions Myoelectric Lower Extremity Prosthetic Technology Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type. Classification Level Rehabilitation potential as described by Centers for Medicare & Medicaid Services : Lev el 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility a. The individual does not have sufficient cognitive ability to safely use a prosthes is with or without assistance. b. The individual requires assistance from equipment or caregiver to transfer and use of a prosthesis does not improve mobility or independence with transfers. c. The individual is wheelchair dependent for mobility and use of a prosthesis does not improve transfer abilities. d. The individual is bedridden and has no need or capacity to ambulate or transfer. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence, typical of the limited and unlimited household ambulator. a. The individual has sufficient cognitive ability to safely use a prosthesis with or without an assistive device and/or the assistance/supervision of one person. b. The individual is capable of safe but limited ambulation within the home with or without an assistive device and/or with or without the assistance/supervision of one person. c. The individual requires the use of a wheelchair for most activities outside of their residence. d. The individual is not capable of most of the functional activities designated in Level 2. Myoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.Level 2: Has the ability or potential for ambu lation with the ability to transverse low level environmental barriers such as curbs, stairs or uneven surfaces. This level is typical of the limited community ambulator. a. The individual can ambulate with or without an assistive device (which may inc lude one or two handrails) and/or with or without the assistance/supervision of one person: i. Perform the Level 1 tasks designated above ii. Ambulate on a flat, smooth surface iii. Negotiate a curb iv. Access public or private transportation v. Negotiate 1-2 stairs vi. Negotiate a ramp built to ADA specifications. b. The individual may require a wheelchair for distances that are beyond the perimeters of the yard/driveway, apartment building, etc. c. The individual is only able to increase his/her generally observed speed of walking for short distances or with great effort. d. The individual is generally not capable of accomplishing most of the tasks at Level 3 (or does so infrequently with great effort). Level 3: Has the ability or potential for ambulation with variable cadence, typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that d emands prosthetic utilization beyond simple locomotion. a. With or without an assistive device (which may include one or two handrails), the individual is independently capable (i.e. requires no personal assistance or supervision) of performing the Level 2 tasks above and can: i. Walk on terrain that varies in texture and level (e.g., grass, gravel, uneven concrete) ii. Negotiate 3-7 consecutive stairs iii. Walk up/down ramps built to ADA specifications iv. Open and close doors v. Ambulate through a crowded area (e.g., grocery store, big box store, restaurant) vi. Cross a controlled intersection within his/her community wi thin the time limit provided (varies by location) vii. Access public or private transportation viii. Perform dual ambulation tasks (e.g. carry an item or meaningfully converse while ambulating) b. The individual does not perform the activities of Level 4. Level 4: Has the ability or potential for prosthetic ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress or energy levels typical of the prosthetic demands of the child, active adult, or athlete. With or without an assistiv e device , which may include one or two handrails, this individual is independently capable (i.e. , requires no personal assistance or supervision) of performing high impact domestic, vocational or recreational activities such as: a. Running b. Repetitiv e stair climbing c. Climbing of steep hills d. Being a caregiver for another individualMyoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolicy Stateme nt det ailed a bove has r eceived due consideration as defined in the MEDICALPo licy Stateme nt Po licy a nd is a pprove d.e. Home maintenance (e.g. repairs, cleaning) NOTE: Consideration is given to bilateral amputees who often cannot be strictly bound by the Classification Levels .D. PolicyI. CareSource considers myoelectric lower limb prosthetic technology medically necessary when the following criteria are met: A. The member is 18 years of age or older . B. Has a lower extremity prosthesis( es). C. Documentation submitted supports medical necessity and includes the following: 1. A written order/prescription from a treating practitioner for the additional technology ; 2. Sufficient documentation of the rehabilitation potential including, but not limited to clear documentation supporting the expected potential classification l evel of K3 or above; and 3. Member: a. Is emotionally ready; b. Is able and willing to participate in training; c. Is able and willing to care for the technology; d. Is physically able to use the equipment; and e. Has adequate cardiovascular and pulmonary reserve for ambulation at faster than normal walking speed. NOTE: Documentation for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies is followed E. Conditions of Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 07/20/2022Date Revised Updated references; no changes Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedMyoelectric Lower Extremity Prosthetic Technology MP-MM-1327 Effective Date: 11/01/2022 The MEDICALPolic y St ate m ent d etail ed a bo ve h a s r eceiv ed due con sidera tio n a s d e fin ed i n the MEDICAL Polic y St ate m ent Po lic y a nd is a pp rove d.H. References 1. Centers for Medicare & Medicare Services Health Technology Assessment. (2017, September). Lower Limb Prosthetic Workgroup Consensus Document. Retrieved July 5, 2022 from www.cms.gov . 2. Centers for Medicare & Medicare Services. (2020, December 30). Medicare Program Integrity Manual Chapter 5 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations. Retrieved July 5, 2022 from www.cms.gov . 3. Centers for Medicare & Medicare Services . (2 020, January 10. Local Coverage Determination Lower Limb Prosthesis L33787). Retrieved July 5, 2022 from www.cms.gov . 4. MCG.MCG Guidelines. 26th edition (2022). A-0487 (AC). Lower Limb Prosthesis. Retrieved July 5, 2022 from www.careweb.careguidelines.com . 5. Optum 360. EncoderProc.om for Payers Professional. (2005, January 1). HCPCS Code Detail L5856-L5859. Retrieved July 5, 2022 from www.encoderprofp.com .B. State-Specific Information A. Georgia 1. Effective: 11/01/2022 B. Indiana 4. Effectiv e: 11/01/2022 C. Kentucky 1. Effective: 11/01/2022 D. Ohio 1. Effective: 12/01/2022 E. West Virginia 1. Effective: 11/01/2022

Nutritional Supplements

MEDICAL POLICY STATEMENTMarketplace Policy Name & Number Date Effective Nutritional Supplements-MP-MM-1330 IN, GA, WV, KY : 11/01/2022 OH: 12/01/2022 Policy Type MEDICAL Medical Policy Statement prepared by CareSource and its affiliates are derived from literature based on and supported by clin ical 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, dysfunctio n of a body o rgan 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 necessar y 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 Sta tement 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 determinatio n. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), co verage 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 ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 7 H. References ………………………….. ………………………….. ………………………….. ……………………. 7 I. State-Specific Information ………………………….. ………………………….. ………………………….. … 8 Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.A. SubjectNutritional Supplements B. BackgroundNutrition may be delivered through oral intake or through a tube into the stomach or small intestine. Enteral nutrition may be medically necessary to maintain optimal health status for individuals with diseas es or structural defects of the gastrointestinal ( GI ) tract that interfere with transport, digestion, or absorption of nutrients. Such conditions may include anatomic obstructions due to cancer motility disorders such as gastroparesis or metabolic absorpti ve disorders such as PKU. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enteral nutrition may be either for total enteral nutrition or for supplem ental enteral nutrition. C. Definitions Chronological Age The time elapsed after birth, usually described in days, weeks, months, and/or years. Corrected Age A term most appropriately used to describe children up to 3 years of age who were born preterm or before gestational age of 37 weeks. This term represents the age of the child from the expected date of delivery (mothers due date). Corrected age is calcula ted by subtracting the number of weeks born before 40 weeks of gestation from the chronological age. Donor Human Milk Breast milk that is expressed by a mother and processed by a human milk bank for use by a recipient that is not the donor mothers own i nfant. Enteral Nutrition Nutritional support given via the gastrointestinal (GI) tract, either directly or through any of a variety of tubes used in specific medical conditions. This includes oral feeding, as well as feeding using tubes such as orogastri c, nasogastric, gastrostomy, and jejunostomy tubes. Human Milk Bank A service which recruits human breast milk donors, collects, pasteurizes, and stores donor human milk, tests the donor milk for bacterial contamination, and distributes donor human milk to recipient infants in need. Inborn Errors of Metabolism (IEM) Inherited biochemical disorders resulting in enzyme defects that interfere with normal metabolism of protein, fat, or carbohydrate. Medical Food Specially formulated and processed for indi viduals who are seriously ill or who require the product as a major treatment modality. This term does not pertain to all foods fed to ill individuals. Medical foods are intended solely to meet the nutritional needs of individuals who have specific metabol ic or physiological limitations restricting their ability to digest regular food. This can include specially formulated infant formulas. According to the Food and Drug Administrations (FDA), a product must meet all the following minimum criteria to be cons idered a medical food: o The product must be a food for oral or tube feeding. o The product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements. o The product m ust be used under the supervision of a physician. Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved. Oral Nutrition (oral feeding) Nutritional support given via the oral route. RELiZORB The only FDA-approved product indicated to hydrolyze (break down) fats in enteral feeding. RELiZORB is indicated for use in pediatric patients (ages 5 years and older) and adult patients. Standard Food Regular grocery products including typical, not specially formulated, infant formulas. Supplemental Nutrition Fewer than 50% of daily calories are supplied by enteral nutrition products. Therapeutic Oral Non-Medical Nutrition : o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens (e.g., diabetes mellitus, celiac disease). o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional Food Food that is fortified to produce specific beneficial health effects. o Texture Modified Food and Thickened Fluids Liquidized/thin puree , thick puree, finely minces, or modified normal. o Modified Normal Eating normal foods by avoiding particulate foods that are a choking hazard. Total Enteral Nutrition (TEN) More than 50% of daily calories are supplied by enteral nutrition products. D. Po licyI. Oral Nutrition : Prior authorization is required except for inborn error of metabolism conditions. A. Total oral nutrition is considered medically necessary when ALL the following criteria are met: 1. The product must be a medical food for oral feeding; 2. The product must be used under medical supervision; 3. The member has the ability to swallow without increased risk of aspiration; 4. The product is documented to make up more than 50% of the members daily intake, which, by definition, is the members primary source of nutrition; 5. The product must be labeled and used for nutritional management of a members specific medical condition without which serious morbidities (physical or mental) may develop OR the product is used to promote normal development or function for the member; 6. The member must have one of the following medical conditions: a. A condition caused by an inborn error of metabolism, including but not limited to the following: Phenylketonuria; Homocystinuria; Methylmalonic academia; Galactosemia; OR b. A condition that interferes with nutrient absorption and digestion, including, but not limited to: Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.01. Current diagnosis of non-IgE-mediated cows milk allergy (CMA) as defined by any of the following: (1). Abnormal stools, defined as hemoccult positive, mucous – containing, foam-containing, or diarrheal; (2). Poor weight gain trajectory for age (e.g., failure to thrive); (3). Atopic dermatitis: age of onset less than 3 months, severe eczema, exacerbation of eczema noted with introduction of cows milk, cow s milk formula, or maternal ingestion of cows milk (if breastfed); 02. Allergy to specific foods, including food-induced anaphylaxis, or severe food allergy indicating a sensitivity to intact protein product, as diagnosed through a formal food challenge; 03. All ergic eosinophilic enteritis (colitis/proctitis, esophagitis, gastroenteritis); 04. Cystic fibrosis with malabsorption ; 05. Diarrhea or vomiting resulting in clinically significant dehydration requiring treatment by a medical provider; 06. Malabsorption unresponsive t o standard age-appropriate interventions when associated with failure to gain weight or meet established growth expectations; 07. Failure to thrive unresponsive to standard age-appropriate interventions (e.g., nutritionally complete liquid meal supplements) wh en associated with weight loss, failure to gain weight, or to meet established growth expectations, including but not limited to: (1). Premature infants who have not achieved the 25 th percentile for weight based on their corrected gestational age; (2). Individuals w ith end-stage renal disease and hypoalbuminemia (albumin less than 4gm/dl); 7. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care pro vider authorized to prescribe dietary treatments; 8. Approval duration can be up to 12 months for all oral nutrition products. B. Oral supplemental nutrition is considered medically necessary when ALL the following apply: 1. The members diet consists of less than 50% enteral nutrition and more than 50% standard diet for age; 2. The product is used as part of a defined and limited plan of care for a member transitioning from total enteral nutrition to standard diet for age; 3. Documentation of a medical basis for the members inability to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic oral nutrition; 4. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 5. The primary reason is not for convenience of the member or caregiver; Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.6. All avenues of coverage available must be exhausted first. For example,members eligible for their county Women, Infant, and Children (WIC) program must apply for an eligibility evaluation before supplemental nutrition coverage will be considered; 7. Approval duration can be up to 12 months for all oral suppl emental nutrition products. Documentation of ongoing evidence of members positive response to the oral nutrition is required for future approvals. II. Enteral Nutrition via Tube : Prior authorization is required except for inborn error of metabolism condition s and for low-profile gastrostomy/jejunostomy/gastrojejunostomy tubes. A. Total enteral nutrition via tube feeing is considered medically necessary when the member has a functioning, accessible gastrointestinal tract, and ALL the following: 1. Enteral nutrition comprises the majority (greater than 50%) of the members diet; 2. The product is used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authorized to prescribe dietary treatments; 3. There is documentation that the member cannot ingest nutrients orally dur to a medical condition (physical or mental) which: a. Interferes with swallowing (e.g., dysphagia from a neurological condition, severe chronic anorexia nervosa or serious cases of oral aversion in children, which render member unable to maintain weight and nutritional status with oral nutrition alone); OR b. Puts member at risk for aspiration if nutrition is given by oral route; OR c. Is associated with anatomical abnormality of the proximal GI tract (e.g., tumor of the esophagus causing obstruction); 4. Approval duration can be up to 12 months for all enteral nutrition products. B. Enteral supplemental nutrition via tube is considered medically necessary when ALL the following are met: 1. The members diet consists of less than 50% enteral nutrition and more than 50% standard diet for age; 2. The enteral product is used as part of a defined and limited plan of care for a member transitioning from total enteral nutrition to standard diet for age; 3. Documentation of a medical basis for the inability of the member to maintain appropriate body weight and nutritional status (initial and ongoing) with normal or therapeutic enteral nutrition; 4. Documentation of ongoing evi dence of members positive response to the enteral nutrition; 5. The product must be used under the supervision of a physician, physicians assistant, or nurse practitioner, or ordered by a registered dietician upon referral by a health care provider authoriz ed to prescribe dietary treatments; 6. The primary reason is not for convenience of the member or caregiver; 7. All avenues of coverage available must be exhausted first (e.g., members eligible for their county Women, Infant, and Children (WIC) program must appl y for an eligibility evaluation before supplemental nutrition coverage will be considered); Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.8. Approval duration can be up to 12 months for all supplemental enteral nutrition products.III. Donor breast milk : p rior authorization is required. See Section I for add itional criteria for Kentucky and Georgia. A. CareSource considers human milk medically necessary when ALL the following criteria are met: 1. Provider must be in good standing with the Human Milk Banking Association of North America; 2. Documentation support s medical necessity; 3. Documentation support s that the provider has attested to educating the member in the donation process and about human milk; and 4. Documentation supports that the provider discussed the risks and benefits with the member . B. Per the Food & Dr ug Administration, only human milk banks that screen their milk donors and take precautions to ensure the safety of its milk should be utilized. IV. CareSource does NOT consider the following medically necessary:A. Nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not require either a written prescription or dispensing by a licensed pharmacist. B. Use of a nutritional product for the convenience or preference of the mem ber or caregiver. C. Therapeutic diets where non-medical foods are tolerated , including any of the following: 1. Food modification . 2. Texture modified food . 3. Thickened fluids . 4. Fortified food . 5. Functional food . 6. Modified normal . 7. Flavorings . D. Relizorb ( insufficient publ ished evidence). E. Oral nutrition products for meal replacements or snack alternatives. F. Feeding tubes for individuals with a dvanced dementia . G. Products administered in an outpatient provider setting. These items are not separately reimbursable. E. Conditions of CoverageNA F. Related Policies/RulesNA Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised Date Effective GA, IN, KY, WV: 11/01/2022 OH: 12/01/2022 Date ArchivedH. References1. American Geriatric Society Committee and Clinical Practice and Models of Care Committee. (2014). American Geriatrics Society feeding Tubes in Advanced Dementia Position Statement. JAmerican Geriatric Society. 2014;62(8):1590-1593. Retrieved July 26, 2022 from www.agsjournals.onlinelibrary.wiley.com . 2. Burris A, Burris J, Jarvinen. Cows Milk Protein Allergy in Term and Preterm Infants: Clinical Manifestations, Immunologic Pathophysiology, and Management Strategies. NeoReviews. 2020 December; 21(12):e795-e80 8. 3. Cederholm T, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clinical Nutrition. 2017;36(1):49-64. Doi:10.1016/j.clnu.2016.09.004. 4. Dipasquale V, Ventimiglia M, Gramaglia SMC, et al. Health-related quality of life and home enteral nutrition in children with neurological impairment: report from a multicenter survey. Nutrients. 2019;11(12):2968. 5. Druyan ME, Compher C, Boullata JI, et al. Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pedia tric Patients: applying the GRADE system to development of A.S.P.E.N. clinical guidelines. JParenter Enteral Nutr. 2012;36(1):77-80. 6. Klek S, Hemanowicz A, Dziwiszek G, et al. Home enteral nutrition reduces complications, length of stay, and health care co sts: results from a multicenter study. Am JClin Nutr. 2014;100(2):609-615. 7. Marchand V, Motil KJ. NASPGHAN Committee on Nutrition. Nutrition support for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroe nterology, Hepatology, and Nutrition. JPediatr Gastroenterol Nutr. 2006;43(1):123-135. 8. Moro GE, Billeaud C, Rachel B, et al. Processing of donor human milk: update and recommendations from the European Milk Bank Association (EMBA). Front Pediatr. 2019;7(4 9):1-10. 9. Robinson D, et al. (2018, May). American Society for Parenteral and Enteral Nutrition (ASPEN) Definition of Terms, Style, and Conventions Used in ASPEN Board of Directors-Approved Documents. Retrieved July 26, 2022 from www.nutritioncare.org . 10. U.S. Food and Drug Administration (FDA). Center for Food Safety and Applied Nutrition. Office of Nutritional Products, Labeling, and Dietary Supplements. May 2016: Frequently Asked Questions about Medical Foods. Retrieved July 26, 2022 from www.fda.gov . 11. U.S. F ood and Drug Administrations (FDA). (2017, December 6). Medical Foods Guidance Documents & Regulatory Information. Retrieved July 26, 2022 from www.fda.gov . Nutritional Supplements-MP-MM-1330Effective Dat e: 11/01/2022The MEDICAL Policy Statement detailed above has recei ved due consideration as defined in theMEDICAL Policy Statement Policy and is approved.12. U.S. Food and Drug Administrations (FDA). Regulatory Information. Section 5 of Orphan Drug Act. Ret rieved July 26, 2022 from www.fda.gov .13. U.S. Social Security Administration (SSA). Disability Evaluation under Social Security. 105.08 Digestive System Childhood. Retrieved July 26 , 2022 from www.ssa.gov . 14. U.S. Social Security Administration (SSA). P rogram Operations Manual System (POMS). DI 24598.002. Failure to Thrive. March 2017. Retrieved 2022 from www.secure.ssa.gov . 15. Wanden-Berghe C, et al. Complications associated with enteral nutrition: CAFANE study. Nutrients. 2019;11(9):2041. 16. Worthington P, e t al. When is Parenteral Nutrition Appropriate? JParent er Enteral Nutr . 2017;41(3):324-377. doi:10.1177/0148607117695251. I. State-Specific InformationA. Georgia 1. Effective: 11/01/2022 2. Additional donor milk cover age criteria: As per the evidence of coverage, a benefit is provided for 100% human diet, if the 100% human diet and supplemented milk fortifier products are prescribed for the prevention of necrotizing enterocolitis and associated co-morbidities and admi nistered under the direction of a physician. 100% human diet means the supplementation of a mothers expressed breast milk or donor milk with a milk fortifier. 3. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Georgia (2022). Retrieved July 26, 2022 from www.caresource.com. B. Indiana 1. Effective: 11/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Indiana (2022). Retrieved July 26, 2022 from www.caresource.com. C. Kentucky 1. Effective: 11/01/2022 2. Additional donor milk coverage criteria: As per the evidence of coverage, a benefit is provided for 100% human diet, if the 100% human diet and supplemented milk fortifier products are prescribed for the prevention of necrotizing enterocolitis and associated co-morbidities and administered under the direction of a physician. 100% human diet means the supplementation of a mothers expressed breast milk or dono r milk with a milk fortifier. 3. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Kentucky (2022). Retrieved July 26, 2022 from www.caresource.com. D. Ohio 1. Effective: 12/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, Oh io (2022). Retrieved July 26, 2022 from www.caresource.com. E. West Virginia 1. Effective: 11/01/2022 2. Evidence of Coverage and Health Insurance Contract. Marketplace Plan, West Virginia (2022). Retrieved July 26, 2 022 from www.caresource.com.

Program Integrity Provider Prepayment Review

ADMINISTRATIVE POLICY STATEMENT Ohio D-SNP Policy Name & Number Date Effective Program Integrity Provider Prepayment Review-OH DSNP-AD-1229 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 industr y s tandards, 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 wit hout which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction o f a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or 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 Cove rage) 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 limita tions that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. SubjectProgram Integrity Provider Prepayment ReviewB. BackgroundThis policy applies to participating (PAR) providers only .CareSource Program Integrity (PI) operates a provider prepayment review program to detect, prevent and correct fraud, waste and abuse and to f acilitate accurate claim payments. Physicians and other healthcare professionals may have the right to appeal resu lts of reviews. C. Def initionsProvider prepayment review-Reviews medical record documentation and compares it to billed services.Program Integrity ( PI) – The proper management and f unction of the health insurance program to ensure it is providing quality and ef f icient care while using f unds taxpayer dollars appropriately and with minimal waste.Certified Professional Coder (CPC) – The CPC credential is of f ered through theAmerican Academy of Prof essional Coders (AAPC). Professional coding is medical coding that is conducted in a prof essional environment such as a physician’s of f ice ,outpatient setting , or hospital.Reg istered Health Information Administrator (RHIA) – A prof essional who handles patient health inf ormation. The RHIA role requires certification and must adhere to standards such as the Health Insurance Portability and Accountability Act and other privacy and security rules.Registered Health Information Technician (RHIT) – A certif ied professional who stores and verif ies the accuracy and completeness of electronic health records. AnRHIT also analyzes patient data with the goal of controlling healthcare costs and improving patient care.D. PolicyI. A p rovider prepay review involves reviewing medical records compared to services billed prior to claim adjudication.A. Providers are placed on prepay review to monitor f or improper billing of claims including but not limited to the f ollowing reasons:1. Overutilization of services2. Bill ing f or items or services not rendered3. Selection of wrong CPT/HCPCS code or supplies4. Lack of medical necessity5. Billing/dispensing unnecessary services6. Procedure repetition7. Upcoding8. Billing f or services outside of provider specialtyII. Placement on prepayment review will require the provider to submit medical records with each claim allowing CareSource to review the medical records in comparison to the billed services. Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. A. CareSource will provide a written 30 day notice to the provider/provider group adv ising them of the ef fective date of prepayment review.1. Prepayment review will be implemented f or a period of 6 months2. The 6 month period begins upon the f irst successful adjudication of a claim submission under prepayment review.3. All claims must be submitted with medical records.4. 4. Medical records may be submitted in one of the f ollowing ways :a. Electronically with a claim .b. Submitted via the provider por tal.Note: CareSource will not accept medical records via f ax. 5. Failure to submit medical records to CareSource in accordance with this provision will result in claim denial.6. Failure to meet minimal documentation standards such as member name and date of service on each page of the medical record, a signed dated order and a valid provider signature will result in claim denial.7. Providers must bill timely and accurate claims during the prepayment review period.III. CareSource utilizes our published decision hierarchy to conduct our reviews . I n addition we may use:A. Centers f or Medicare and Medicaid Services ( CMS ) guidelines as stated inMedicare manuals.B. Medicare local coverage determinations and national coverage determination s .C. All CareSource published policies (Administrative, Medical and Reimbursement),c ode-editing policies and CareSource provider manuals.D. National Unif orm Billing Guidelines f rom the National Billing Committee.E. American Medical Association Current Procedural Terminology (CPT) guidelines.F. American Medical Association Healthcare current Common Procedure CodingSystem (HCPCS) Level II.G. ICD 10-CM of ficial guidelines f or coding and reporting.H. American Association of Medical Audit Specialists national healthcare billing audit guidelines.I. Industry-standard utilization management criteria and/or care guidelines such asMCG guidelines (current editio n on date of service).J. Food and Drug Administration guidance.K. National prof essional medical societys guidelines and consensus statements.L. Publication f rom specialty societies such as the American Society f or Parenteral and Enteral Nutrition, Substance Abuse and Mental Health ServiceAdministration, and the American Association of Neuromuscular & Mental HealthServices Administration .M. Nationally recognized, evidenc e-based published literature including, but not limited to, sources such as Medscape, the American Academy of Pediatrics(AAP) and the American College of Obstetricians and Gynecologists (ACOG ).IV. The PI Provider Prepayment Review Team is made up of clinical review and coding specialists who maintain CPC, RHIA, or RHIT designation.A. The team reviews provider documentation to determine whether the claim is appropriate f or payment based on criteria including , but not limited to, provider documentation which establishes that:1. Services were provided according to CareSource policy requirements. Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 2. Billed services were medically necessary and appropriate, and not in excess of the member s need.3. Members were benefit eligible on the date the services were provided.4. Prior authorization was obtained if required by policy.5. Providers and their staf f were qualif ied as required by state or f ederal law.6. The provider possessed the proper license, certification, or othe r accreditation requirements specific to the providers scope of practice at the time the service was provided to the member.V. Providers whose claims are determined not payable may send in new corrected claims, a dispute or an appeal, whichever is appropr iate, within timely f iling limitations as outlined in their provider manual.A. Providers and/or billing managers may reach out directly to the PI prepayment review team to discuss specif ic claim denials.VI. Providers are prohibited f rom billing covered ind ividuals f or services CareSource has determined not payable as a result of the prepayment review process, whether due to f raud, abuse, waste o r any other billing issue, or f or f ailure to submit medical records as set f orth above.VII. On completion of the 6 month review period :A. CareSource will determine if the provider is eligible f or release f rom prepayment review if :1. The provider has achieved an 85% or m ore approval rate on claim submissions f or 3consecutive months and2. The volume of its claims submissions remained within 10% of the volume bef ore prepayment review .B. If the provider successfully completes both requirements under A abov e bef ore the 6 month deadline the provider may be removed f rom the prepayment review process at the discretion of CareSource.C. If the provider f ails to satisf y the requirements above they may be placed under an additional 6 month prepayment review peri od and be required to submit a corrective action plan.1. If af ter the second 6 month interval prescribed under sub section Cthe provider f ails to satisf y the requirements under sub sectio n A1 and A2 ,CareSource may do the f ollowing a. Deny payment f or medical assistance services rendered during a specif ied period of time b. Terminate the provider agreement c. Require a corrective action plan2. Providers who are able to demonstrate accurate billing practices and have been removed f rom prepayment review may be subject to f uture follow up reviews to ensure continued compliance with billing practices.3. If a provider has been on a prepayment review f or 12 months Care Source may terminate the provider agreement if :a. There has been no billing activity f or 6 months; or b. The volume of claim submissions during the review period is not within10% of its volume bef ore prepayment review. Pro gram In teg rity Pro vid er Prep aymen t Review-OH DSNP-AD-1229 Effective Date: 12/01/2022 The ADMINISTRATIVE Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d d ue c on si d e ra t i o n a s d e f i n e d i n the ADMINISTRATIVE Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. 4. Upon completion of the prepayment review period, the provider/provider group will receive notif ication in writing as to the ef f ective end date of the review.E. Conditions of CoverageN/A F. Related Policies/RulesN/AG. Review/Revision HistoryDATES ACTION Date Issued 08/17/2022 New Po licy Date Revised Date Effective 12/01/2022 H. Ref erences1. Centers f or Medicare and Medicaid Services. Medicare Program Integrity Manual(April 21, 2022). Retrieved July 11, 2022 f rom www.cms.govTh is g uid eline co n tains custom co n ten t th at h as been mo d ified fro m th e stan d ard care g uid elin es an d h as n o t been reviewed o r ap p ro ved by MCG Health , LLC. I nd e pe n de nt med i ca l r e v iew

Modifier 59, XE, XP, XS, XU

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

Modifier 59, XE, XP, XS, XU

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.

Modifier 25

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

Modifier 25

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

Modifier 25

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.

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