Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 07|01|2005 POLICY LAST UPDATED: 01|18|2023 OVERVIEW This policy documents the coverage determination for Asthma Management Services. Asthma Management Services are used to teach members and/or families how to successfully manage Asthma.
PRIOR AUTHORIZATION Not applicable MEDICAL CRITERIA Not applicable POLICY STATEMENT Medicare Advantage Plans and Commercial Products Asthma Management Services are covered only when ordered by a physician and provided by certified asthma educators or hospital-based clinics.
Physicians, nurse practitioners, and physician assistants should utilize evaluation and management codes unless certified as an asthma educator.
Asthma Management Services are covered when rendered in a physician’s office, outpatient department of a hospital, or a hospital-based clinic.
NOTE: Services are not separately reimbursed when they are rendered on an inpatient basis. BACKGROUND Asthma Management Services are used to teach members and/or families how to successfully manage asthma. Successful management of asthma requires that the patient or patient’s caregiver have a fundamental understanding of and skills for following the therapeutic recommendations, including pharmacotherapy and measures to control factors that contribute to asthma severity. The ultimate goal of both expert care and patient self-management is to reduce the impact of asthma on related morbidity, functional ability, and quality of life. The benefits of educating people who have asthma in the self-management skills of self-assessment, use of medications, and actions to prevent or control exacerbations, include reduction in urgent care visits and hospitalizations, reduction of asthma-related health care costs, and improvement in health status. Asthma management services may use a group education component. The National Asthma Educator Certification Board exam is a voluntary testing program used to assess qualified health professionals’ knowledge in asthma education. It is an evaluative process that demonstrates that rigorous education and experience requirements have been met. Certification is voluntary and is not required by law for employment in the field. COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage, Subscriber Agreement for applicable office visit and/or coverage. CODING Payment Policy |Asthma Management Services

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Medicare Advantage Plans and Commercial Products Only certified asthma educators may only use the code(s) listed here when filing for asthma education services. The following HCPCS code(s) is covered under the member's office visit/clinic benefit/coverage: S9441 Asthma education, non-physician provider, per session.

RELATED POLICIES None

PUBLISHED Provider Update, March 2023 Provider Update, March 2020 Provider Update, September 2018 Provider Update, May 2017 Provider Update, May 2013

REFERENCES https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/health-professionals-educators https://www.cdc.gov/asthma/management.html
https://health.ri.gov/programs/detail.php?pgm_id=5

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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