CareSource Ohio Medicaid issued comprehensive billing guidance effective September 1, 2026, clarifying six key compliance areas: laboratory services in hospital settings cannot be separately billed, fluoride varnish is limited to 2 applications/year for children under 21, physician interpretation-only codes must not include technical components, GZ modifier usage requires ABN documentation, add-on procedure codes require primary procedure codes, and inpatient ICD-10 codes must specify laterality (right/left/bilateral) rather than using unspecified codes. Providers must immediately review billing practices to avoid claim denials and potential recovery of payments found non-compliant with OAC and CMS rules.
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01Billing team must implement the following compliance measures.
02LABORATORY BILLING: Update billing software to prevent separate billing of lab tests performed as part of hospital diagnostic services; communicate to providers that clinical lab fee schedule and physician fee schedule (with -26 modifier for interpretation) apply only to independent lab services.
03FLUORIDE VARNISH: Configure system to limit fluoride varnish (pediatric patients under age 21) to maximum 2 applications per calendar year; require clinical documentation for any requests exceeding this limit.
04RADIOLOGY CODING: Audit templates to ensure professional interpretation codes (-26 modifier) are never billed with technical component modifiers (-TC); train providers and coders on proper component reporting.
05GZ MODIFIER: Establish protocol requiring Advance Beneficiary Notices (ABN) for any claims submitted with GZ modifier; flag claims without ABN for denial review.
06ADD-ON CODES: Update billing rules to require primary procedure code presence before allowing add-on code submission; implement system edits to reject add-on codes submitted standalone.
07INPATIENT CODING: Audit ICD-10 submissions to eliminate unspecified laterality codes; require specific documentation of right, left, or bilateral condition status in all inpatient records.
08Billing compliance officer should communicate these changes to all clinical and billing staff.
If missed: Failure to comply will result in claim denials and CareSource reserves the right to recover payments made in error.
Original notice
[Ohio] Billing Guidance
caresource.com · Always check the source before changing claims.
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