Wednesday, November 13, 2019

ST Join INJECTION CPT code - 27096, G0259, G0260

CPT Description

64450 Injection, anesthetic agent; other peripheral nerve or branch

27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

G0259 Injection procedure for sacroiliac joint, arthrography.

G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s). [Use when the provider does not use fluoroscopy or CT image guidance].

Billing and Coding Guidelines

L31359 LCD Title Sacroiliac Joint Injections Contractor's Determination Number MS-009 General

1. Procedure code 27096 is to be used only with imaging confirmation of intra-articular needle positioning.
2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection.
3. It is not appropriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
4. Procedure code 27096 represents a unilateral procedure. If bilateral SI joint arthrography is performed, 27096 should be reported with a –50 modifier.
5. A SI joint injection (27096) is not a stand-alone code and one of the following codes should be billed in conjunction with this code:
a. When a formal SI joint arthrography is performed with the SI joint injection, procedure code 73542 should be reported for the radiologic supervision and interpretation of sacroiliac joint arthrography.
b. Do not bill CPT code 73542 (Radiologic examination, sacroiliac joint arthrography, radiological supervision and interpretation) for injection of contrast to verify needle position. The CPT code 73542 is only to be billed for a medically necessary diagnostic study and requires a full interpretation and report.
c. When fluoroscopic guidance is used to locate the specific anatomic site for needle insertion, procedure code 77003 should be reported.
d. When CT guidance is used to locate the specific anatomic site for needle insertion, procedure code 77012 should be reported.
6. CPT code G0260 should be billed by facilities paid by OPPS.
7. Use CPT code 64999 (Unlisted procedure, nervous system) for pulsed radiofrequency and the denervation procedures of the sacro-iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational and therefore, not medically necessary. Sacro-iliac joint/nerve denervation procedures are also considered investigational and not medically necessary.


1. Procedure code 2709 6 is to be used o nly with imaging confirmation of intra -articular needle positioning.
2. If the muscles surrounding the sacroiliac joint are injected in lieu of the joint, then a trigger point injection should be reported and not a sacroiliac joint injection.
3. It is not appr opriate to use CPT code 20610, Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) for SI joint injections.
4. Procedure code 27096 re presents a unilateral proce dure. If bil ateral SI joint arthrography is performed, 27096 should be reported with a –50 modifier.
5. CPT code G0260 should be billed by facilities paid by OPPS.
6. Use CPT code 64999 (Unlisted procedure, ne rvous system) for pulsed radiofrequency and the denervation procedures of the sacro- iliac joint/nerves. Pulsed radiofrequency for denervation is considered investigational a nd therefore, not m edically necessary. Sacroiliac joint/nerve denervation procedures are also considered investigational and not medically necessary.

Spinal Cord Stimulators Description

Spinal cord stimulators, also known as dorsal column stimulators (“stimulators”), are implantable devices used to treat chronic pain. Electrodes are surgically placed within the dura mater via laminectomy, or by percutaneous insertion into the epidural space. Low voltage electrical signals are delivered to the dorsal column of the spinal cord in order to override or mask sensations of pain. The patient’s pain distribution pattern determines the level at which the stimulation lead is placed. The lead may incorporate four (4) to eight (8) electrodes, with 8 electrodes typically used for complex pain patterns, such as bilateral pain or pain extending from the limbs to the trunk. Implantation is typically a 2-step process. Initially, the electrode is temporarily implanted in the epidural space, allowing a trial period of stimulation. Once treatment effectiveness is confirmed (defined as at least 50% reduction in pain), the electrodes and radio receiver/ transducer are permanently implanted.

Extensive programming of the neurostimulators is often required to achieve optimal pain control.

General Requirements
Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following:
**  Prescription strength anti-inflammatory medications and analgesics
**  Adjunctive medications such as nerve membrane stabilizers or muscle relaxants
**  Physician-supervised therapeutic exercise program or physical therapy
**  Manual therapy or spinal manipulation
**  Alternative therapies such as acupuncture
**  Appropriate management of underlying or associated cognitive, behavioral, or addiction disorders

Documentation of compliance with a plan of therapy that includes elements from these areas is required. Exceptions may be considered on a case-by-case basis. Reporting of symptom severity – Severity of pain and its impact on activities of daily living (ADLs) is a key factor in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs. Imaging studies -- All imaging must be performed and read by an independent radiologist. If discrepancies should arise in the interpretation of the imaging, the radiologist report will supersede. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.

Indications and Limitations of Coverage and/or Medical Necessity

The sacroiliac (SI) joint is formed by the articular surfaces of the sacrum and iliac bones. The SI joints bear the weight of the trunk and as a result are subject to the development of strain and/or pain. Low back pain of SI joint origin is a difficult clinical diagnosis and often one of exclusion. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source. If the cause of pain in the lower back has been determined to be the SI joint, one of the options of treatment is injecting steroids and/or anesthetic agent(s) into the joint. Therapeutic injections of the SI joint would not likely be performed unless other noninvasive treatments have failed.

Image guidance is crucial to identify the optimal site for access to the joint. Fluoroscopy is often the imaging method of choice. Once the specific anatomy is identified, the needle tip is placed in the caudal aspect of the joint and contrast material is injected. Contrast fills the joint to delineate integrity (or lack thereof) of articular cartilage, as well as morphologic features of the joint space and capsule. Procedure code 27096 describes the injection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid. Since fluoroscopy is the key to precision diagnostic injections and accurate therapeutic injections, procedure code 27096 should be billed when imaging confirmation of intra-articular needle positioning has been performed, since this code includes both the injection and the image guidance procedure.

Medicare will consider the injection procedure of the SI joint medically reasonable and necessary when it is used for imaging confirmation of intra-articular needle positioning for arthrography with or without therapeutic injection. In addition, Medicare will consider the injection procedure of the SI joint medically necessary when an injection is given for therapeutic indications, such as injection of an anesthetic and/or steroid, to block the joint for immediate and potentially lasting pain relief. When therapeutic injections of the SI joint are performed, it would be expected that the record reflects noninvasive treatments (i.e., rest, physical therapy, NSAID’s, etc.) have failed.

Subject: Sacroiliac Joint Injections


The sacroiliac (SI) joint connects the sacrum with the pelvis. The SI joint lies between the sacrum and the ilium, and functions more for stability than for movement. Similar to other structures in the spine, it is assumed that the sacroiliac joint may be a source of low back pain. The sacroiliac joint transmits all the forces of the upper body to the pelvis and legs. The joint’s stability is maintained in part by several large ligaments and muscle groups. Dysfunctions of the sacroiliac joint may be described as sacral, iliac, pubic and sacroiliac joint pain. They are typically without consistent, demonstrable radiographic, or laboratory findings, and most commonly exist in the setting of morphologically normal joints. Pain may arise in the joint itself or in the related muscles and ligaments. Pain may be felt in the lower back or may radiate to one or both hips and/or one or both legs. Clinical tests for sacroiliac joint pain may include various movement tests, palpation to detect tenderness, and pain descriptions by the individual. Conservative treatment for sacroiliac joint dysfunction generally centers on restoring motion in the joint and may include:

**  Medications
**  Physical therapy
**  Chiropractic or osteopathic manipulation
**  Sacroiliac joint injections.

Sacroiliac joint injections are divided into two phases, the diagnostic phase and the therapeutic phase. In the diagnostic phase, an injection is given and if there is pain relief (positive block), additional injections are given as part of the therapeutic phase. A second injection may be needed in the diagnostic phase. If there is no pain relief after the diagnostic injection (s) (negative block), the therapy is not continued.

Sacroiliac joint injections are expected to be given at intervals no sooner than every week during a diagnostic phase and no sooner than every eight (8) weeks during the therapeutic phase.

Sacroiliac joint injection performed under fluoroscopy or with arthrography meets the definition of medical necessity when ALL the following criteria are met:

**  Sacroiliac joint pain for more than 3 months; AND
**  Sacroiliac joint injections are part of a comprehensive pain treatment plan; AND
**  Continued pain after 6 weeks with ALL of the following treatments:
**  NSAIDS ≥ 4 weeks (if not contraindicated); AND
**  Activity modification ≥ 6 weeks; AND
**  Physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks; OR
**  Worsening pain after 2 weeks with ALL of the following treatments:
**  NSAIDS (if not contraindicated); AND
**  Activity modification; AND
**  Physical therapy, chiropractic therapy or home exercise program.
**  In the diagnostic phase, up to two (2) injections may be administered, at intervals of no sooner than one (1) week.
**  In the therapeutic phase, each subsequent injection requires that prior injection provided ≥ 50% pain reduction for at least six (6) weeks.

Sacroiliac joint injections do not meet the definition of medical necessity if medical documentation indicates the injection procedures are not effective. Sacroiliac joint injection performed with ultrasound guidance is considered experimental or investigational. There is insufficient evidence to support conclusions regarding effects on net health outcomes.

NOTE: It is not expected that epidural blocks, multiple facet joint injections, sacroiliac joint injections, and sympathetic nerve blocks in any and all combinations would be administered to the same individual on the same day. If the first procedure used to treat the presumptive diagnosis fails to produce improvement and rules out that possibility, then it may be appropriate to proceed to the next logical treatment.

CPT Coding:
27096 Injection procedure for sacroiliac joint, anesthetic/ steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

HCPCS Coding:
G0259 Injection procedure for sacroiliac joint; arthrography
G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid AND/OR other therapeutic agent, with or without arthrography

ICD-10 Diagnosis Codes That Support Medical Necessity:
M46.1 Sacroiliitis, not elsewhere classified
M47.898 Other spondylosis, sacral and sacrococcygeal region
M48.08 Spinal stenosis, sacral and sacrococcygeal region
M53.2X8 Spinal instabilities, sacral and sacrococcygeal region
M54.18 Radiculopathy, sacral and sacrococcygeal region
M54.30 – M54.32 Sciatica
M54.40 – M54.42 Lumbago with sciatica
M54.5 Lower back pain
M54.6 Pain in thoracic spine
S33.2XXA, D, S Dislocation of sacroiliac and sacrococcygeal joint
S33.6XXA, D, S Sprain of sacroiliac joint

Tuesday, October 8, 2019

Modifier UB, UC, UA - Billing Guidelines

Modifier  Description
UB Medically necessary delivery prior to 39 weeks of gestation
UC Delivery at 39 weeks of gestation or later
UA Nonmedically necessary delivery prior to 39 weeks of gestation

EED Policy Components

•  GAMMIS is being configured to link practitioners’ induction and delivery claims to the hospital’s induction and delivery claims

•  Induction and delivery claims that are submitted with medical conditions that do not warrant an exception for an induction or delivery prior to 39 weeks gestation will deny payment

•  For non-medically necessary deliveries:–  The practitioner’s claim will fully deny–  The hospital’s claim will deny for the induction and/or delivery portion

•  Practitioners and hospitals may submit an appeal for the denial (DMA 520-A form) to the DCH Medicaid peer review organization, Georgia Medical Care Foundation

•  Compliance will be monitored by DCH and the Centers for Medicare and Medicaid Services through Georgia’s reporting of the Early Elective Deliveries measure 14 found in the Initial Core Set of Health Quality Measures for Medicaid Eligible Adults

•  These specifications contain the same exclusions as the JCAHO list of exclusions•  CY 12 data will serve as the baseline for this CMS measure

Purpose of EED Policy

•  Guide providers and hospitals to sound practice recommendations made by ACOG and others
•  Reduce morbidity in neonates from birth trauma and fetal immaturity
•  Reduce non-medically necessary deliveries less than 39 weeks gestation
•  Encourage greater collaborations between hospitals and their physicians in developing quality improvement initiatives aimed at improving birth outcomes

Modifier/condition codes needed for maternity services/obstetric delivery - Unicare insurance billing

This provider bulletin is an update to information in the provider manual. For access to the latest manual, go to Virginia is ranked 44thby America’s Health Rankings for infant mortality; nearly eight (7.4) of every 1,000 children die before their first birthday. Infant mortality is a multi factorial health problem, and improving West Virginia’s infant mortality rate will require a multifaceted approach. One of the approaches of UniCare Health Plan of West Virginia, Inc. (UniCare)is to reduce early elective deliveries (EEDs) prior to 39 weeks of gestation. The initiative of reducing EEDs has received national attention from many organizations, including the Centers for Medicare & Medicaid Services (CMS), the March of Dimes, the American Congress of Obstetricians and Gynecologists (ACOG), and The Joint Commission.

Additionally, many West Virginia hospitals and their medical staffs have responded to this initiative by adopting policies that ensure early inductions and cesarean deliveries are medically necessary. UniCare is aligning its obstetric services policy with the goal of improving neonatal and maternal health outcomes. Deliveries that occur prior to 39 weeks, either due to spontaneous labor or as the result of a medically-indicated induction or cesarean section, will continue to remain covered; however,for claims to pay, a modifier or condition code is needed. Deliveries prior to 39 weeks, unless documented as a medical necessity or spontaneous labor, are not a covered benefit.

* Effective for dates of service on or after October 1, 2016,UniCare will require the above modifiers to be used when submitting a claim,or the claim will deny.

Effective for dates of admission on or after October 1, 2016, the following condition codes will be required on the CMS1450 (UB-04)claim form when billing for obstetric delivery services. Condition codes are to be placed in fields 18-24 of theCMS1450 (UB-04)claim form.

Condition code  Description

81 Cesarean sections or inductions performed at less than 39 weeks’ gestation for medical necessity

82 Cesarean sections or inductions performed at less than 39 weeks’ gestation electively

83 Cesarean sections or inductions performed at 39 weeks’ gestation or greater

 Coding for Maternity Care - Medicaid Guidelines

Gestational Age

Providers are required to report the gestational age of the fetus by using the appropriate ICD-10 diagnosis codes Z3A.00 through Z3A.49 on all delivery claims.

Modifier UC

Providers are required to append modifier UC on claims of deliveries 39 weeks or less that are medically necessary or on deliveries 39 weeks or more, whether spontaneous or elective.  If the modifier “UC” is not appended to the claim, it is understood that the claim was for an early elective delivery less than 39 weeks and 0 days and will be denied.  Providers are responsible for ensuring that the codes (and modifiers when applicable) submitted for reimbursement accurately
reflect the diagnosis and procedure(s) reported.

Modifier 22

All obstetrical and delivery procedure codes submitted with modifier 22 require submission of documentation (e.g., operative report) for review prior to payment.  Services for enhanced payment with the 22 modifier include multiple gestations or complications during the delivery which place the mother or fetus at risk of adverse outcome.

Wednesday, September 4, 2019

CPT 99500, 99502, 99504, 99511, 99601, G0068, G0070 - Home health codes

CPT Code Description

99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring99501Home visit for postnatal assessment and follow-up care

99502 Home visit for newborn care and assessment

99503 Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)

99504 Home visit for mechanical ventilation care

99505 Home visit for stoma care and maintenance including colostomy and cystostomy99506Home visit for intramuscular injections

99507 Home visit for care and maintenance of catheter(s) (e.g., urinary, drainage, and enteral)

99511 Home visit for fecal impaction management and enema administration99512Home visit for hemodialysis

99601 Home infusion/specialty drug administration, per visit (up to 2 hours);

99602 Home infusion/specialty drug administration, per visit (up to 2 hours);each additional hour (List separately in addition to code for primary procedure)

G0068 Professional services for the administration of anti infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual's home, each 15 minutes

G0069 Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes

G0070 Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes

What Is Home Health Care?

Home health care includes skilled nursing care, as well as other skilled care services, like physical and occupational therapy, speech-language therapy, and medical social services. These services are given by a variety of skilled health care professionals at home.

 The home health staff provides and helps coordinate the care and/ortherapy your doctor orders. Along with the doctor, home health staff create a plan of care, which is a written plan for your care. It tells what services you will get to reach and keep your best physical,mental, and social well-being. The home health staff keeps your doctor up-to-date on how you are doing and updates your plan of care as needed, as authorized by your doctor. More information a bout plans of care can be found on pages 19 and 20.

The need for home health care has grown for many reasons. Medical science and technology have improved. Many treatments that could once be done only in a hospital can now be done at home. Also,home health care is usually less expensive and can often be just as effective as care in a hospital or skilled nursing facility. And just a important, most patients and their families prefer to stay at home rather than be in a hospital or a nursing home.While you get home health care, home health staff teach you (and those who help you) to continue any care you may need, including medication, wound care, therapy, and managing stress.

Since most home health care is intermittent and part-time, patients (and their informal caregivers) should learn how to identify and care for possible problems, like confusion or shortness of breath.The goal of short-term home health care is to provide treatment for an illness or injury. It helps you get better, regain your independence,and become as self-sufficient as possible. The goal of long-term home health care (for chronically ill or disabled people) is to maintain your highest level of ability or health, and help you learn to live with your illness or disability.1 -

How long can I get home health services?

Medicare covers your home health services for as long as you are eligible and your doctor says you need these services. However, the skilled nursing care and home health aide services are only covered on a part-time or “intermittent” basis. This means there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services. Therapy services do not have to be part-time or intermittent.

To decide whether or not you are eligible for home health care,Medicare defines “intermittent” as skilled nursing care that is needed or given on fewer than seven days each week or less than eight hours each day over a period of 21 days (or less) with some exceptions in special circumstances.

What does the Original Medicare Plan pay for and what can I be billed for?

The Original Medicare Plan pays the full approved amount (cost) of all covered home health visits. The home health agency sends bills to Medicare. Before your care begins, the home health agency must tell you how much of your bill Medicare will pay. The agency must also tell you if any items or services they give you are not covered by Medicare, and how much you will have to pay for them. This must be explained both by talking with you and in writing.

You may be charged for

• medical services and supplies that Medicare doesn’t pay for, such as prescription drugs, and

• 20 percent of the approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment. If the home health agency doesn’t supply medical equipment directly,the home health agency staff will arrange for a home equipment supplier to bring the items you need to your home.

Coverage Limitations and Exclusions

Covered pharmaceuticals, drugs, and DME provided in connection with home health services may be subject to separate benefit categories. Reference the Durable Medical Equipment and the Pharmaceutical Products benefit sections of the member specific benefit plan document.Home health care benefits do not include:

* Custodial Care
* Domiciliary care
* Private Duty Nursing[refer to the Coverage Determination Guideline titled Private Duty Nursing (PDN) Services]
*Respite care
* Rest cures and therefore these services are not covered (check the member specific benefit plan document)
* Homemaker services such as home meal delivery services (e.g., Meals-on-Wheels) or transportation services (e.g., Dial-a-Ride)
*Independent nurse hired directly by the family/member
* Personal care attendants (these are not home health aides)
*Home health services beyond benefit limits(e.g., number of visits)We will determine if benefits are available by reviewing both the skilled nature of the service and the need for Physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver.

Home Health Services Medicaid Guideline

Home Health Services are defined as intermittent nursing care provided by certified nursing professionals (registered nurses, licensed practical nurses, skilled nurse aides) in the client’s home when the client’s place of residence is the most appropriate and cost-effective setting consistent with the client’s medical  need. Home health care is to be rendered by a Medicare-certified Home Health Agency.

Covered Services for Home Health Services

Covered procedure codes are: T1001, S9123, T1999, S1030, T1021, T1003, T1031, S9124, T1020, S9122,T1022, S9131, S9128, G0154, S9485, S9480, T1002, G0081.

Non Covered Services for Home Health Services

a.      Nursing or aide services requested for convenience of family, i.e., bathing, feeding, exercising, homemaking services, transfer services, giving medication, or acting as a companion or sitter, which do not require training, medical judgment technical skills of a  nurse whether or not another person is available to perform such services, are not covered.

This exclusion applies regardless of whether services were recommended by a provider.

Non-covered services are:
(1)  Private duty nursing.
(2)  Custodial care.
(3)  Respite care.
(4)  Transportation, travel, escort services or food services.


What criteria must be met to qualify for home health services?

Medicare covers home health services when all of these criteria are met:

● The beneficiary to whom services are furnished is eligible and enrolled in Part A and/or Part B of the Medicare Program
● The beneficiary is eligible for coverage of home health services
● The HHA furnishing the services has a valid agreement in effect to participate in the Medicare Program
● The services for which payment is claimed are covered under the Medicare home health benefit
● Medicare is the appropriate payer and
● The services are not otherwise excluded from payment

What criteria must a patient meet to be eligible for home health services?

For a patient to be eligible for Medicare home health services, he or she must meet these criteria:

1.Be confined to the home (that is, home bound)
2.Need skilled services
3.Be under the care of a physician
4.Receive services under a home health plan of care (POC) established and periodically reviewed by a physician and
5.Had a face-to-face encounter related to the primary reason the patient requires home health services with a physician or an allowed NPP no more than 90 days prior to the home health start-of-care date or within 30 days of the start of the home health care

Thursday, July 25, 2019

CPT 21100, 21110, 21120,21121 - 21127 - Orthognathic surgery codes

CPT code and Description

21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)

21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

21121 Genioplasty; sliding osteotomy, single piece

21122 Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin)

21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

21125 Augmentation, mandibular body or angle; prosthetic material

21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft


Orthognathic surgery is the surgical correction of abnormalities of the mandible (lower jaw), the maxilla (upper jaw), or both.  When orthognathic surgery is indicated, it is generally after orthodontic treatment (braces), which is done in order to move the teeth into their new position. 

During the surgical procedure, the jawbones are repositioned to a more “normal” position; in some cases, bone may be added, removed, or reshaped.  Surgical plates, screws, wires and rubber bands may be used to hold the jaws in their new position.  The most common technique is known as the LeFort I (though there are variations of this technique that may be performed, depending on the exact indications for the surgery).

Orthognathic surgery is usually performed by both an oral and maxillofacial surgeon and an orthodontist.  The orthodontist will work to position the teeth in proper alignment and the oral and maxillofacial surgeon does the surgery as needed on the jaw joints and/or other facial bones.

Coverage Limitations
Humana members may NOTbe eligible under the Plan for orthognathic surgeryfor any indications other than those listed above. This technology is considered experimental/investigational or NOT medically necessary if it is not utilized in accordance with nationally recognized standards of medical practice and/or identified as safe, widely used and generally accepted as effective for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOTbe eligible under the Plan for 3-D Computerized Tomography (CT) scan, including in the pre-planning phase of treatment.  This technology is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language

Criteria for a Coverage Determination as Reconstructive and Medically Necessary: 

A requested procedure will be deemed reconstructive and medically necessary and therefore covered when:

1. There is a physical abnormality and/or physiological abnormality that is causing a functional impairment that requires correction;and

2. The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or restore the patient’s physiological function


Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service.The documentation requirements outline below are used to assess whether the member meets the clinical criteria for coverage but do not guarantee coverage of the service requested.

Medical notes documenting all of the following:

** Comprehensive  history of the medical condition(s) requiring treatment or surgical intervention; including all of the following:

A well-defined physical and/or physiological abnormality (e.g., congenital abnormality, functional or skeletal impairments) resulting in a medical condition that has required or requires treatment; The physical and/or physiological abnormality has resulted in a functional deficit; The functional deficit is recurrent or persistent in nature

** Appropriate clinical studies/tests including cephalometric tracings and analysis addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment, with appropriate measurements, when applicable Radiologic film interpretations including lateral cephalometric  radiograph, AP radiograph and panoramic radiograph

** Clinical photographs of the member’s occlusion Diagnostic Polysomnography for obstructive sleep apnea surgery

** Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for the improvement of the functional deficit

** History of previous non-surgical and surgical treatment (e.g.,obstructive sleep apnea


The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable definitions.

Cancer Sequela: An aftereffect resulting from a cancer

Functional/Physical Impairment: A Physical/Functional or Physiological Impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Jaw Surgery: Surgical procedures to address facial trauma, neoplasms, facial clefts, surgical resection and iatrogenic radiation.

Orthognathic Surgery: The surgical correction of skeletal anomalies or malformations involving the mandible (lower jaw) or maxilla (upper jaw). These malformations may be present at birth or may become evident as the individual grows and develops. Causesinclude congenital or developmental anomalies.

Monday, July 1, 2019

CSHCS - Inital and ongoing comprehension evaluation basic


The Initial Comprehensive Evaluation is performed during the CSHCS client’s first visit to the CMDS clinic. The medical team integrates assessments and recommendations and works with the family/beneficiary in the development of a coordinated and comprehensive POC and treatment for the beneficiary. The CMDS POC is required to be recorded. The CMDS clinic will communicate the written CMDS POC to the appropriate health care providers and the family/beneficiary. Written CMDS POCs may be provided to other appropriate health care providers for whom the parent/guardian/beneficiary has signed a medical release form. A copy of the CMDS POC is to be submitted to CSHCS medical consultants for review.

An Initial Comprehensive Evaluation visit must include the following:

* Physician specialist(s) and non-physician professionals examination or assessment of the beneficiary and submission of an established/confirmed diagnosis(es), identification of strengths and needs and, with family/beneficiary input, development of a course of action or plan for treatment;

* Integration of findings and recommendations at team conferences;

* Discussion of the medical findings and treatment recommendations with family/beneficiary in language the family/beneficiary can comprehend;

* Designation of identified staff to teach the family/beneficiary how to assist in the management of the beneficiary’s health problems if appropriate; and

* Compilation of an integrated CMDS POC from the findings of the various health care providers that includes:

* relevant history;

* medical findings by specialty;

* problem areas that may develop and for which the beneficiary should receive care;

* recommendations and prescriptions for braces, shoes, special equipment, medications, etc.;

* referral to physical therapy, speech-language therapy, occupational therapy, public health nurse, CMDS support services; and

* a description of how the CMDS POC will be implemented. Authorization and processes may differ per health plans and Fee-for-Service (FFS).

Reimbursement for the Initial Comprehensive Evaluation fee occurs only once per beneficiary per lifetime regardless of the number of diagnoses and/or CMDS clinics from which the beneficiary may be receiving services. Medical services continue to be billed as usual.


Basic and ongoing comprehensive evaluation is conducted with established CMDS patients. The evaluation(s) may include the entire CMDS clinic staff composition or asdeemed appropriate by each CMDS clinic Medical Director per visit and is documented in  the CMDS POC.

A basic and ongoing comprehensive evaluation may include the following activities:

* Comprehensive beneficiary assessment;

* Evaluation and identification of the beneficiary’s needs;

* Coordination of the beneficiary’s multi-disciplinary needs;

* Review and modification of the comprehensive CMDS POC;

* Assured implementation and follow-up; and

* Referrals to other professionals, resources, and services as applicable.

Reimbursement for the Basic and Ongoing Comprehensive Evaluation fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year regardless of the number of diagnoses or CMDS clinics the beneficiary may have.

Medical services continue to be billed as usual.


Management/follow-up visits to a CMDS clinic may be provided if they are recommended in the CMDS POC. In addition, a referral may be recommended based on a tertiary hospital inpatient discharge plan that was written within the previous 12 months of the referral. Every effort should be made to include all staff identified as participants in theCMDS POC or as recommended by the CMDS clinic Medical Director.

The management/follow-up visit may include:

* A physical exam by a pediatrician and/or physician subspecialist(s);

* Assessment by at least two of the clinic staff (in addition to the clinic physicians) designated for the clinic type;

* Follow-up on all components identified in the CMDS POC by appropriate staff;

* Update of condition and treatment, and revision of the CMDS POC; and

* Communication with the family/beneficiary, other providers, and other designated health care providers, including provision of copies of the CMDS POC to the family/beneficiary.

Reimbursement for the management/follow-up visit clinic fee is provided for a maximum of three (3) visits per beneficiary, per 12-month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics may provide support services. Services consists of counseling, specialized training, transition assistance and/or treatment. Support services must be ordered as part of the CMDS POC developed at a CMDS Clinic Initial Comprehensive Evaluation, Basic and Ongoing Comprehensive Evaluation, and/or Management/Follow-up Visit. CMDS clinic support services may be provided by any combination of one or more of the non-physician basic CMDS clinic staff to the family/beneficiary as outlined in the CMDS POC. Support services may be conducted by professional members of the team (i.e., nurses, dietitians, certified diabetes counselors, social workers or other clinical professional staff as appropriate). The presence of a physician is not required.

* The clinical encounter must be substantive with clinical information gathered, treatment recommendations provided, transition needs addressed and an update to the CMDS POC.

* The clinical content of the encounter is documented in the CMDS POC.

CMDS support service visits include and provide two different methods of delivery:

* Face-to-Face meetings between the appropriate clinic professional and thefamily/beneficiary; or

* Telephone meetings between the appropriate clinic professional and the family/beneficiary.

Reimbursement for support services clinic fees can be provided up to a maximum of ten (10) visits per beneficiary as a single method or as a combination of methods, per 12- month CSHCS eligibility year, regardless of the number of diagnoses or CMDS clinics the beneficiary may have. Medical services continue to be billed as usual.


CMDS clinics must establish and maintain an agreement with each Medicaid and MIChild Health Plan for health plan enrolled beneficiaries to ensure coordinated care planning and data sharing.

* CMDS clinics must establish a process for clinical staff to communicate with health plan staff on a regular basis to identify health plan enrollees using the CMDS clinic(s), review testing/assessment/screening results, treatment plans, CMDS POCs, and status of mutually served beneficiaries.

* CMDS clinics must collaborate with health plans on the development of referral procedures and effective means of communicating the need for beneficiary-specific referrals. For beneficiaries enrolled in a health plan, CMDS clinics must bill the Medicaid Health Plan (MHP) for medical services rendered according to the health plan billing rules.

The CMDS clinic fee is billed as a FFS claim through CHAMPS regardless of health plan status.

CMDS clinic fees must be billed according to instructions contained in the Billing & Reimbursement for Professionals Chapter of this Manual. CMDS clinics must bill clinic fees following Uniform Billing (UB) guidelines on the professional CMS-1500 claim format or the electronic Health Care Claim Professional (837) ASC X12N version 5010 information. CHAMPS NPI claim editing will be applied to the billing, rendering, supervising, attending, servicing and referring providers as applicable for payment.

Explanation of Services

In addition to medical services, the CMDS Clinics provide:

• A single place and extended appointment for the family to be seen by their team of pediatric specialty providers as well other appropriate health care professionals during that one appointment;

• An environment where the providers come to the family for the single appointment at the clinic as opposed to the family needing to set separate dates and times to go to each provider as in the usual service methodology;

• Same day, face-to-face care coordination by all of the providers who have seen the beneficiary at that appointment allows for immediate discussion, negotiation, coordination and duty assignment of the decisions made that resulted from the provider meeting that follows the appointment. The family does not need to interpret information from one provider to the next which risks misunderstanding as in the usual
service methodology;

• Development and upkeep of a coordinated and comprehensive plan of care and treatment for beneficiaries including clear statements of current comprehensive assessment and ongoing treatment plans available to the entire team;

• Facilities that are tailored to the needs of children and their families; and

• Opportunity for the parent/beneficiary to participate in treatment planning, allowing for timely feedback and discussion of concerns with specialists and other health care professionals simultaneously when needed.

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