May/June 2010 Texas Medicaid Bulletin, No. 229

Transcription

Texas Medicaid Bulletin
Bimonthly update to the Texas Medicaid Provider Procedures Manual
May/June 2010
No. 229
Provider Enrollment on the
Portal (PEP) Enhancements
The following enhancements to Provider Enrollment
on the Portal (PEP) will implement on May 3, 2010:
• Providers can create templates, which make it easier
to submit multiple enrollment applications.
• Providers who enroll as a group can assign portions
of the application to performing providers to
complete. Performing providers can complete their
portion of a group application by logging into PEP
with their unique user name and password.
CONTENTS
All Providers
1
Provider Enrollment on the Portal (PEP) Enhancements . . . . . . . . . . . . . . . . . . . . . . . 1
2010 Claims Filing Deadline Calendar is Now Available for All Medicaid
and CSHCN Services Program Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Claim Forms No Longer Needed with Paper Appeals . . . . . . . . . . . . . . . . . . . . . . . . . 2
Pediatric Critical Care Services Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Providers Must Maintain Accurate Records of Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Adult Preventive Care Benefits Changed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Provider License Renewal Reminder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Benefits to Change for Nonsurgical Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Procedure Code Review Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Benefit Criteria Changed for Some Vision Surgical Services . . . . . . . . . . . . . . . . . . 16
Update to the Field Description on the Static Fee Schedule . . . . . . . . . . . . . . . . . 17
Orthopedic Dynamic Device Benefit Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
• Providers can navigate to completed sections of
the application without having to click through all
pages of the application.
Additional Procedure Code Updates for February 1, 2010 . . . . . . . . . . . . . . . . . . . 18
• Information that is on file for owners and subcontractors of the applying provider are auto-populated
in the application.
Consultation Procedure Codes to Remain a Benefit for Texas Medicaid
and the CSHCN Services Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
• Before submitting an application to TMHP for
processing, providers are required to review a
portable document format (PDF) copy of the
application and verify it is complete.
Providers are able to edit submitted applications to
correct identified deficiencies.
Providers Must Have Correct Physical Address on File . . . . . . . . . . . . . . . . . . . . . . . . 17
Scheduled System Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Updates for IV Therapy and Urinalysis Services Procedure Codes . . . . . . . . . . . . 19
Claims Filing and Reimbursement Reminder for Hearing
Services Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Increased Reimbursement for Vagal Nerve Stimulator Devices . . . . . . . . . . . . . . . 21
Informational Claim Submissions Transitions to TMHP . . . . . . . . . . . . . . . . . . . . . . 22
Obtaining Authorization for Outpatient Radiology Services . . . . . . . . . . . . . . . . 23
Cardiac Catheterization Procedure Codes Updated . . . . . . . . . . . . . . . . . . . . . . . . . 24
Cardiac Nuclear Imaging Studies Prior Authorization Requirement . . . . . . . . . 24
Benefits for Home Health Power Wheelchairs to Change . . . . . . . . . . . . . . . . . . . 25
Prior Authorization Requirements Changed for Some Unlisted
Procedure Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
2010 Claims Filing Deadline
Calendar is Now Available
for All Medicaid and CSHCN
Services Program Providers
The 2010 claims filing deadline calendar is
now available for Medicaid and the Children
with Special Health Care Needs (CSHCN)
Services Program providers. The 2010 claims
filing deadline calendar can be found on
page 147 of this bulletin.
Augmentative Communication Device Benefit Criteria Change . . . . . . . . . . . . . 29
Changes to the Personal Care Services Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Texas Medicaid Sleep Studies Benefits Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Nonsolid Organ Transplant Benefits Changed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
OFL Updated for Some Radiology Procedure Codes . . . . . . . . . . . . . . . . . . . . . . . . 36
Reimbursement Rates Changed for DME Services . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Limitations Change for Laboratory Services Procedure Codes . . . . . . . . . . . . . . . 37
Physical, Occupational, and Speech Therapy for CCP Clarification . . . . . . . . . . 39
Renal Dialysis Services Criteria Changed for Texas Medicaid . . . . . . . . . . . . . . . . 40
Updates to the 2010 HCPCS Special Bulletin, No. 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
HCPCS Procedure Code 93290 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2009 HCPCS Benefits for Medical and DME Procedure Codes . . . . . . . . . . . . . . . . 42
Procedure Code Review Updates for February 2010 . . . . . . . . . . . . . . . . . . . . . . . . . 43
Continued on page 2
Copyright Acknowledgments
Use of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is
copyright 2009 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.
Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.”
The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “Current Dental Terminology (including procedure codes,
nomenclature, descriptors, and other data contained therein) is copyright © 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS restrictions apply.”
All Providers
CONTENTS
Continued from page 1
ACIP Recommended Vaccines That are Not a Benefit . . . . . . . . . . . . . . . . . . . . . . . . 46
Reimbursement for Medicare and MAP Secondary Claims . . . . . . . . . . . . . . . . . . . 47
New and Improved PCCM Inpatient/Outpatient Authorization Form . . . . . . . 48
Global Surgical Periods to Change for Texas Medicaid . . . . . . . . . . . . . . . . . . . . . . . 49
Postexposure Prophylaxis for Rabies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Billing for Influenza A and B Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Radiology Procedure Codes Being Reinstated for NP, CNS, PA, and
Radiation Treatment Center Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Medical Records Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Procedure Code Review Effective February 6, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Medical, Surgery, and DME Services Reimbursement Rates Changed . . . . . . . 58
April Procedure Code Review Updates Now Available . . . . . . . . . . . . . . . . . . . . . . . 59
Non-Attested TPIs Without Claims or Encounters for at Least 24 Months
to Be End-Dated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
CCP Benefits Changed for Orthoses and Prostheses . . . . . . . . . . . . . . . . . . . . . . . . . 82
Claim Forms No Longer
Needed with Paper Appeals
If a provider determines that a claim cannot
be appealed electronically or through the
Automated Inquiry System (AIS), the claim
may be appealed on paper by completing the
following:
• Submit a copy of the Remittance and Status
(R&S) Report page on which the claim is paid
or denied. A copy of any other official notification from TMHP may also be submitted.
• Submit one copy of the R&S Report page for
each claim appealed.
May 2010 Procedure Code Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
• Circle only one claim per R&S Report page.
Change to Reimbursement Rates for Some Surgery Services
Procedure Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
• Identify the reason for the appeal.
Therapeutic Radiopharmaceutical Benefits Have Changed . . . . . . . . . . . . . . . . . 107
Texas Medicaid Claims Reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Assistant Surgery Claims Reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Brachytherapy Claims Reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Family Planning Reimbursement Rate Change . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Hepatitis A and B Vaccine for Clients Who Are 21 Years of Age or Older . 108
Radiology Services Reimbursement Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Sign Language Reimbursement Rates Change . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Reimbursement Rates Changes Effective January, March,
and April 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Claims Reprocessing for Procedure Code 43520 . . . . . . . . . . . . . . . . . . . . . . . . . 108
Updates to Previously Published Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Update to “2009 HCPCS 1Q and 2Q New Benefits for Some
Medical Procedure Codes” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Correction to 2010 HCPCS Update for “Incontinence Supplies and
Equipment – Home Health” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Update to “Procedure Code Review Updates for February 2010” . . . . . . . . 109
Correction to “Benefit Update for Botulinum Toxin Type A (Botox)” . . . . . 109
• If applicable, indicate the incorrect
information, and provide the correct
information that should be used to appeal the
claim.
• Attach a copy of any supporting medical
documentation that is required or has been
requested by TMHP. Supporting documentation must be on a separate page and
not copied on the opposite side of the R&S
Report.
For more information, refer to the 2009 Texas
Medicaid Provider Procedures Manual, section
6.1.4, “Paper Appeals” on Page 6-3, and the
2009 Children with Special Health Care Needs
Services Program Provider Manual, section 7.3.3,
“Paper Appeals,” on Page 7-5.
Medical Nutritional Counseling Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Correction to Radiation Therapy in the Texas Medicaid Provider
Procedures Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Taxonomy Codes Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Correction to “Update to Out-of-State Providers Who Perform
Services to Migrant Farm Workers” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Ambulance Providers
114
Facility Requests for Nonemergency Ambulance Prior Authorization . . . . . . 114
Behavioral Health Providers
115
Clarification to “Behavioral Health Services Performed by Licensed
Psychological Associates Are Benefits” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Family Planning Providers
115
Family Planning Funds Gone - Accounts Receivable
Reconciliation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Continued on page 3
Texas Medicaid Bulletin, No. 229
Contact Information
For additional information about Texas
Medicaid, call the TMHP Contact Center
at 1‑800‑925‑9126.
For additional information about Primary
Care Case Management (PCCM) articles
in this bulletin, call the PCCM Provider
Helpline at 1‑888‑834‑7226.
For additional information about articles
pertaining to the Children with Special
Health Care Needs (CSHCN) Services
Program, call the TMHP‑CSHCN Contact
Center at 1‑800‑568‑2413.
May/June 2010
CPT only copyright 2009 American Medical Association. All rights reserved.
All Providers
CONTENTS
CONTENTS
Continued
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Reprocessing Family Planning Title V and XX Claims with Procedure
Code 99203 and 99204 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Home Health Providers
116
Benefit Criteria Changed for Bath and Bathroom Equipment . . . . . . . . . . . . . . . . 116
Home Health Fee Schedule and Online Fee Lookup . . . . . . . . . . . . . . . . . . . . . . . . 117
Managed Care Providers
118
PCCM THSteps Wants to Partner With Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
FQHC and RHC Claims For PCCM Clients Require Referring Provider . . . . . . . 119
TMHP Routinely Audits PCCM Primary Care Providers Medical Records . . . . 120
Updates to Services Provided to PCCM Clients by FQHCs and RHCs . . . . . . . . . 121
THSteps Dental Providers
122
Updates for THSteps Diagnostic Dental Services and Opthalmic
Ultrasound Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
THSteps Medical Providers
125
THSteps-CCP Blood Pressure Device Benefits Changed . . . . . . . . . . . . . . . . . . . . . 125
Women’s Health Program Providers
129
Women’s Health Program (WHP) Providers and Performance
of Elective Abortion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Title XX Claims Filing Procedures for WHP Wrap-Around Services . . . . . . . . . . 129
Excluded Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Electronic Funds Transfer (EFT) Authorization Agreement . . . . . . . . . . . . . . . . . . 133
Provider Information Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Revised Crossover Claim Type 30 (MRAN) Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Crossover Claim Types 31 and 50 (MRAN) Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
Crossover Claim Type 30 Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Crossover Claim Types 31 and 50 Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Primary Care Case management (PCCM) Inpatient/Outpatient
Authorization Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Radiology Prior Authorization Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Nonemergency Ambulance Prior Authorization Request Form . . . . . . . . . . . . 145
2010 Claims Filing Deadline Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Pediatric Critical Care Services Update
Effective for dates of service on or after March 1, 2010, benefit
criteria for pediatric critical care changed for Texas Medicaid.
• Subsequent inpatient pediatric critical care (procedure codes
99472 or 99476) will be denied as part of the initial inpatient
pediatric critical care (procedure codes 99471 or 99475) when
billed on the same day, by the same provider.
• Subsequent intensive care (procedure codes 99478, 99479, or
99480) is no longer denied when billed on the same date of
service by the same provider as pediatric critical care procedure
code 99475 or 99476.


Providers Must Maintain
Accurate Records of Drugs
Reminder: Providers are required to maintain
accurate records of the total number of units of
drugs purchased, administered, and wasted for
each client. Texas Medicaid reimburses providers
for waste only if a partial vial is actually wasted
and not if the partial vial is used for another
patient.
To bill for waste, providers must include the
number of units wasted in the total number of
units billed. For example, if 180 mg of a drug is
administered to a client and 20 mg is wasted, the
provider should bill a quantity of 200 units.
To calculate the number of units to bill for most
drugs, providers should refer to the Healthcare
Common Procedure Coding System (HCPCS)
procedure code description for the unit amount.
For procedure code 90378, however, providers
must bill per milligram.
How to Report Waste, Abuse, and Fraud
Individuals with knowledge about suspected
Medicaid waste, abuse, or fraud must report the
information to the HHSC Office of Inspector
General (OIG). To make a report, call the toll free
OIG hotline at 1-800-436-6184. Providers may
also access the website at www.hhsc.state.tx.us
and select the link for “Reporting Waste, Abuse,
and Fraud.”
All information provided in a report to OIG is
confidential by law and protected from disclosure
by Section 531.102(g) of the Government Code
and other applicable law. This means that the
information provided will remain confidential,
including informant identifying information.
Providers are also strongly encouraged to monitor
themselves and investigate possible fraud, waste,
abuse, or receipt of inappropriate payments of
Medicaid funds. Providers are expected to make a
self report to HHSC/OIG whenever they discover
fraud, waste, abuse, or receipt of overpayments.
HHSC/OIG endeavors to work collaboratively
with providers who self report. For additional
information including how to make a self-report,
go to the following web address: www.oig.hhsc
.state.tx.us/ProviderSelfReporting/Self_
Reporting.aspx.

May/June 2010
All Providers
Adult Preventive Care Benefits Changed
Effective for dates of service on or after January 1, 2010,
adult preventive care is a benefit of Texas Medicaid.
Adult preventive services (procedure codes 99385,
99386, 99387, 99395, 99396, and 99397) are a benefit
of Texas Medicaid for clients who are 21 years of age
and older. Procedure codes 99385 and 99395 are
restricted to clients who are 21 through 39 years of age
when billing for adult preventive services.
Exception: Rural Health Clinics (RHC) must bill
using their encounter code T1015.
Note: For clients who are birth through 20 years of age,
refer to Section 43, “Texas Health Steps,” in the 2009
Texas Medicaid Provider Procedures Manual. For
women’s health services clients, refer to Appendix O,
Women’s Health Program, in the 2009 Texas Medicaid
Provider Procedures Manual.
The following are the new rates for adult preventive
services:
Procedure
Code
99385
99386
99387
99395
99396
99397
Rates
$80.46 (2.95 RVUs, $27.276 CF)
$94.10 (3.45 RVUs, $27.276 CF)
$103.10 (3.78 RVUs, $27.276 CF)
$69.83 (2.56 RVUs, $27.276 CF)
$76.37 (2.80 RVUs, $27.276 CF)
$85.65 (3.14 RVUs, $27.276 CF)
RVU =Relative value units, CF=Conversion factor
Preventive care services are comprehensive visits that
may include counseling, anticipatory guidance, and risk
factor reduction interventions. Documentation must
indicate the anticipatory guidance rendered.
Providers must provide adult preventive services in
accordance with the U.S. Preventive Services Task
Force (USPSTF) recommendations with grades A or
B. Labs, immunizations, or diagnostic procedures
recommended by USPSTF are covered benefits and
may be billed separately as clinically indicated.
Services exceeding USPSTF recommendations are
not considered a screening and require medical documentation justifying medical necessity for the services
performed.
USPSTF recommendations, with specific age and
frequency guidelines, are located on the Agency
for Healthcare Research and Quality website at
www.ahrq.gov/clinic/uspstfix.htm.
The following screenings are covered benefits in addition to
USPSTF recommendations:
• Tuberculosis screening
• Prostate cancer screening; prostate specific antigen (PSA)
for men 50 through 64 years of age
The following USPSTF recommendations are not
reimbursed separately but must be provided when
applicable as part of the routine preventive exam:
• Counseling to prevent tobacco use and tobacco caused
disease
• Behavioral counseling in primary care to promote a
healthy diet
• Behavioral interventions to promote breast feeding
• Screening for obesity in adults (with intensive counseling
and interventions)
• Screening and behavioral counseling interventions in
primary care to reduce alcohol misuse
• Screening for depression
The following USPSTF recommendations are not a benefit
of Texas Medicaid:
• Chemoprevention of breast cancer
• Varicella immunization
Adult preventive services are limited to one service
per rolling year, any provider, and must be billed with
diagnosis code V700. Adult preventive services may be
billed by physicians, family planning clinics, federally
qualified health centers (FQHCs), RHC, nurse practitioners, clinical nurse specialists, and physician assistants in
the office and outpatient hospital setting.
Laboratory, immunizations, and diagnostic procedures
must be billed using the most appropriate diagnosis code
that represents the client’s condition.
Diagnosis code V700 may be used once each rolling year
for each screen if no other diagnosis is appropriate for the
service rendered, but cannot be used more frequently than
recommended by the USPSTF.
A new patient visit is limited to once every three years same
provider, when no other professional services have been
billed by the physician or another physician of the same
specialty who belongs to the same group practice, within
the past three years.
Modifier 25 must be submitted when the services rendered
are performed for a significant, separately identifiable
service by the same physician or physician group on the
May/June 2010
All Providers
same date of service. Modifier 25 is required when the provider
submits a claim with the following:
• A second office or outpatient visit on the same day as another
office or outpatient visit.
• An office or outpatient visit beyond the usual preoperative
care associated with the procedure that was performed.
Medical documentation must be maintained in the client’s
medical record to support all services billed. The documentation must clearly indicate what the significant problem or
abnormality was that required additional work and must
support that the requirements for the level of service billed
were met or exceeded. A different diagnosis is not required
for the second service, but the documentation in the client’s
medical record must outline the important, distinct correlation
with signs and symptoms to demonstrate a distinctly different
problem. The date and time of both services performed must
be outlined in the medical record and the time of the second
service must be different than the time of the first service.
Human papilloma virus (procedure code 90649) may be
reimbursed for female clients who are 21 through 26 years of age.
Procedure code G0389 may be reimbursed for male clients who
are 65 through 75 years of age with diagnosis codes V700 or
V1582 to the following:
Procedure
Code
G0389–
Total
component
G0389 with
TC modifier–
Technical
component
G0389 with
26 modifier–
Professional
interpretation
component
POS
Provider Types
Office
Physician
Outpatient Hospitals
Office
Office,
Inpatient
Outpatient
Portable X-ray
suppliers,
radiological lab,
physiological
lab
Physicians
Hospitals
Rates
$84.01
(3.08 RVUs,
$27.276 CF)
$61.10
(2.24 RVUs,
$27.276 CF)
$22.91
(0.84 RVU,
$27.276 CF)
RVU=Relative value units, CF=Conversion factor
Procedure code G0389 is limited to once per lifetime any
provider.
Procedure codes G0104 and G0106 may be reimbursed using
diagnosis codes V700, V7650, and V7652.
Claims Reprocessing
Claims submitted with adult preventive care procedure codes
with dates of service from January 1, 2010, to January 29, 2010,
will be reprocessed, and payments will be adjusted accordingly.
No action on the part of the provider is required.
May/June 2010
Provider License
Renewal Reminder
To continue to participate in Texas state
health-care programs, providers who are
licensed or certified to practice in Texas
must provide TMHP with proof of a
current license or certification. TMHP
receives licensure information directly
from the Texas Medical Board, the Texas
State Board of Dental Examiners, and the
Texas Board of Nursing.
Providers who are licensed by these three
boards do not need to provide TMHP
with renewal information. All other
licensed providers must send TMHP their
updated licensure or certification when it
is renewed.
All licensed providers who are enrolled
in Texas state health-care programs will
receive a reminder letter 60 days before
the expiration of their licenses. The letter
will notify providers that they must keep
their licensure current to continue their
enrollment with Texas state health-care
programs.
After renewal of their license, providers
who are licensed by the Texas Medical
Board, the Texas State Board of Dental
Examiners, or Texas Board of Nursing,
do not need to contact TMHP with
renewal information. All other licensed
providers must submit a copy of their
license renewal to TMHP.
If a provider’s license has expired, a
termination letter will be sent to the
provider, and all claims filed on or after
the expiration date will be denied. To
have claim payments resumed, providers
must renew their licenses and, if necessary,
provide proof of the renewal to TMHP.
Payment will be considered for dates of
service on or after the date of return to
active license status.
Details of provider licensure requirements
can be found in the in the 2009 Texas
Medicaid Provider Procedures Manual
on Page 1-7.
All Providers
Benefits to Change for Nonsurgical Vision Services
Effective for dates of service on or after April 1, 2010,
benefit criteria for nonsurgical vision services changed for
Texas Medicaid.
Procedure
Codes
92317
The procedure codes in the following table are benefits of
Texas Medicaid:
Procedure
Codes
76514 –
Professional
interpretation
component
76514 –
Technical
component
76514 –
Total
component
92310
92311
92312
92313
POS
Office,
inpatient,
outpatient
Office
Physician, optometrist,
portable X‑ray supplier
Office
Outpatient
Physician, optometrist,
portable X‑ray supplier,
Hospital
Physician, nurse practitioner (NP), clinical nurse
specialist (CNS), physician
assistant (PA), optometrist,
portable X‑ray supplier
Physician, NP, CNS, PA,
optometrist, portable X‑ray
supplier
optometrist, portable
X‑ray supplier, radiological
laboratory, physiological
laboratory
laboratory
laboratory
laboratory
optometrist, portable X‑ray
supplier
Office,
outpatient
Office,
outpatient
Office,
outpatient
Office,
outpatient
92314
Office,
outpatient
92315
Office,
outpatient
92316
Providers That May Be
Reimbursed
Physician, optometrist
Office,
outpatient
POS
Office,
outpatient
92325
Office,
outpatient
V2784
Office,
outpatient,
other (POS
9)
Providers That May Be
Reimbursed
laboratory
laboratory
Physician, optometrist, optician, dispensing optical
company
POS=Place of service
The following are the rates for the new procedure codes:
Procedure
Code
92310
92310
21 years of age
or older
92311
20 years of age
or younger
92311
21 years of age
or older
92312
20 years of age
or younger
92312
21 years of age
or older
92313
20 years of age
or younger
92313
21 years of age
or older
92314
20 years of age
or younger
21 years of age
or older
92314
Age
20 years of age
or younger
Rates
$71.31
(2.49 RVUs,
$28.640 CF)
$67.92
(2.49 RVUs,
$27.276 CF)
$71.31
(2.49 RVUs,
$28.640 CF)
$67.92
(2.49 RVUs,
$27.276 CF)
$80.76
(2.82 RVUs,
$28.640 CF)
$76.92
(2.82 RVUs,
$27.276 CF)
$69.31
(2.42 RVUs,
$28.640 CF)
$66.01
(2.42 RVUs,
$27.276 CF)
$56.42 (1.97 RVUs,
$28.640 CF)
$53.73 (1.97 RVUs,
$27.276 CF)
May/June 2010
All Providers
Procedure
Code
92315
92315
92316
92316
92317
92317
92325
92325
76514 – Total
Component
76514 – Total
Component
76514 –
Interpretation
Component
76514 –
Interpretation
Component
76514 –
Technical
Component
76514 –
Technical
Component
V2784
Age
20 years of age
or younger
21 years of age
or older
20 years of age
or younger
21 years of age
or older
20 years of age
or younger
21 years of age
or older
20 years of age
or younger
21 years of age
or older
20 years of age
or younger
21 years of age
or older
20 years of age
or younger
Rates
$50.12 (1.75 RVUs,
$28.640 CF)
$47.73 (1.75 RVUs,
$27.276 CF)
$66.16 (2.31 RVUs,
$28.640 CF)
$63.01 (2.31 RVUs,
$27.276 CF)
$55.85 (1.95 RVUs,
$28.640 CF)
$53.19 (1.95 RVUs,
$27.276 CF)
$22.91 (0.80 RVU,
$28.640 CF)
$21.82 (0.80 RVU,
$27.276 CF)
$10.60 (0.37 RVU,
$28.640 CF)
$10.09 (0.37 RVU,
$27.276 CF)
$7.45 (0.26 RVU,
$28.640 CF)
21 years of age
or older
$7.09 (0.26 RVU,
$27.276 CF)
20 years of age
or younger
$3.15
(0.11 RVU,
$28.640 CF)
$3.00 (0.11 RVU,
$27.276 CF)
21 years of age
or older
All ages
Clients who are 21 years of age or older are eligible for an
eye examination with refraction testing for the purpose
of obtaining eyeglasses or contact lenses once every two
state fiscal years (September 1 through August 31). The
limitation on these examinations may be exceeded for
clients who are 21 years of age or older only when there
is a significant change in vision, and documentation
supports a change of 0.5d or more in the sphere, cylinder,
or prism measurement.
A new patient eye examination in any place of service
will be denied if history shows that the same provider or
same group practice has furnished a medical service, a
surgical service, or a consultation service within the past
three years.
The following procedure codes may be used for eye
examinations and refraction testing:
Procedure Code
92002
92004
92015
S0620
Procedure codes 92002, 92004, 92012, and 92014 may
be reimbursed to optometrists when one of the following
diagnosis codes is submitted:
Diagnosis Codes
05320
05321
05441
05442
0760
0761
0772
0773
07799
0903
0909
09150
09841
09842
11512
11592
1901
1902
1906
1907
2241
2242
2246
2247
24900
24901
24921
24930
24950
24951
24971
24980
25000
25001
25011
25012
25022
25023
$43.06
Eye Examinations
Clients who are birth through 20 years of age are eligible
for an eye examination with refraction testing for the
purpose of obtaining eyeglasses or contact lenses once
every state fiscal year (September 1 through August 31).
The limitation on these examinations may be exceeded
for clients who are birth through 20 years of age only
when one of the following occurs:
• The school nurse, teacher, or parent requests the
refraction testing because of medical necessity.
• There is significant change in vision, and documentation supports a change of 0.5d or more in the sphere,
cylinder, or prism measurement.
92014
Procedure codes 92002, 92004, 92012, and 92014 may
be reimbursed to ophthalmologists with an appropriate
diagnosis.
RVU = Relative value units, CF = Conversion factor
May/June 2010
92012
S0621
05322
05443
0769
0774
0905
09151
09843
1301
1903
1908
2243
2248
24910
24931
24960
24981
25002
25013
25030
05329
05444
0770
0778
0906
09152
09849
1302
1904
1909
2244
2249
24911
24940
24961
24990
25003
25020
25031
05440
05449
0771
07798
0907
09840
11502
1900
1905
2240
2245
2340
24920
24941
24970
24991
25010
25021
25032
All Providers
Diagnosis Codes
25033
25040
25050
25051
25061
25062
25072
25073
25083
25090
36000
36001
36011
36012
36020
36021
36030
36031
36040
36041
36050
36051
36055
36059
36063
36064
36089
3609
36103
36104
36110
36111
36119
3612
36133
36181
36202
36203
36207
36210
36214
36215
36220
36221
36225
36226
36231
36232
36236
36237
36243
36250
36254
36255
36261
36262
36266
36482
36503
36504
36513
36514
36522
36523
36541
36542
36552
36559
36563
36564
36589
3659
36721
36722
36751
36752
3679
36800
36810
36811
36815
36816
36832
36833
36842
36843
25041
25052
25063
25080
25091
36002
36013
36023
36032
36042
36052
36060
36065
36100
36105
36112
36130
36189
36204
36211
36216
36222
36227
36233
36240
36251
36256
36263
36500
36510
36515
36524
36543
36560
36581
3670
36731
36753
36801
36812
3682
36834
36844
25042
25053
25070
25081
25092
36003
36014
36024
36033
36043
36053
36061
36069
36101
36106
36113
36131
3619
36205
36212
36217
36223
36229
36234
36241
36252
36257
36264
36501
36511
36520
36531
36544
36561
36582
3671
36732
36781
36802
36813
36830
36840
36845
Diagnosis Codes
36847
36851
36855
36859
36863
36869
36901
36902
36906
36907
36912
36913
36917
36918
36923
36924
36960
36961
36965
36966
36970
36971
36975
36976
37001
37002
37006
37007
37023
37024
37034
37035
37050
37052
37060
37061
3708
3709
37103
37104
37112
37113
37120
37121
37130
37131
37141
37142
37146
37148
37152
37153
37157
37158
37170
37171
37182
37189
37202
37203
37210
37211
37215
37220
37231
37233
37241
37242
37250
37251
37255
37256
37264
37271
37275
37281
37301
37302
3732
37331
3734
3735
37400
37401
37405
37410
25043
25060
25071
25082
25093
36004
36019
36029
36034
36044
36054
36062
36081
36102
36107
36114
36132
36201
36206
36213
36218
36224
36230
36235
36242
36253
36260
36265
36502
36512
36521
36532
36551
36562
36583
36720
3674
36789
36803
36814
36831
36841
36846
36852
36860
3688
36903
36908
36914
36920
36925
36962
36967
36972
3698
37003
37020
37031
37040
37054
37062
37100
37105
37114
37122
37132
37143
37149
37154
37160
37172
3719
37204
37212
37221
37234
37243
37252
37261
37272
37289
37311
37332
3736
37402
37411
36853
36861
3689
36904
36910
36915
36921
3693
36963
36968
36973
3699
37004
37021
37032
37044
37055
37063
37101
37110
37115
37123
37133
37144
37150
37155
37161
37173
37200
37205
37213
37222
37239
37244
37253
37262
37273
3729
37312
37333
3738
37403
37412
36854
36862
36900
36905
36911
36916
36922
3694
36964
36969
36974
37000
37005
37022
37033
37049
37059
37064
37102
37111
37116
37124
37140
37145
37151
37156
37162
37181
37201
37206
37214
37230
37240
37245
37254
37263
37274
37300
37313
37334
3739
37404
37413
May/June 2010
All Providers
Diagnosis Codes
37414
37420
37430
37431
37441
37443
37450
37451
37455
37456
37484
37485
3749
37500
37511
37512
37516
37520
37531
37532
37543
37551
37555
37556
37581
37589
37603
37604
37613
37621
37632
37633
37640
37641
37645
37646
37652
3766
3769
37700
37704
37710
37714
37715
37723
37724
37733
37734
37743
37749
37754
37761
37772
37773
37992
37993
74310
74311
74322
74330
74334
74335
74341
74342
74346
74347
74352
74353
74357
74358
74363
74364
7438
7439
8702
8703
8710
8711
8715
8716
9181
9182
9212
9213
9302
9308
37421
37432
37444
37452
37481
37486
37501
37513
37521
37533
37552
37557
37600
37610
37622
37634
37642
37647
37681
37701
37711
37716
37730
37739
37751
37762
37775
74300
74312
74331
74336
74343
74348
74354
74559
74365
7840
8704
8712
8717
9189
9219
9309
37422
37433
37445
37453
37482
37487
37502
37514
37522
37541
37553
37561
37601
37611
37630
37635
37643
37650
37682
37702
37712
37721
37731
37741
37752
37763
3779
74303
74320
74332
74337
74344
74349
74355
74361
74366
8700
8708
8713
8719
9210
9300
9400
May/June 2010
Diagnosis Codes
9402
9403
V431
V5861
V5865
V5866
37423
37434
37446
37454
37483
37489
37503
37515
37530
37542
37554
37569
37602
37612
37631
37636
37644
37651
37689
37703
37713
37722
37732
37742
37753
37771
37991
74306
74321
74333
74339
74345
74351
74356
74362
74369
8701
8709
8714
9180
9211
9301
9401
9404
V5862
V5867
9405
V5863
V5869
9409
V5864
V720
Procedure codes S0620 and S0621 may be reimbursed
when one of the following diagnosis codes is submitted:
Diagnosis Code
24941
24950
24970
24971
24991
25000
25010
25011
25021
25022
25032
25033
25043
25050
25060
25061
25071
25072
25082
25083
25093
36201
36205
36206
36223
36224
3670
3671
36731
36732
36753
36781
V720
24951
24980
25001
25012
25023
25040
25051
25062
25073
25090
36202
36207
36225
36720
3674
36789
24960
24981
25002
25013
25030
25041
25052
25063
25080
25091
36203
36220
36226
36721
36751
3679
24961
24990
25003
25020
25031
25042
25053
25070
25081
25092
36204
36222
36227
36722
36752
37182
Ophthalmological Examination and Evaluation
with General Anesthesia
An ophthalmological examination and evaluation under
general anesthesia (procedure code 92018 or 92019) may
be medically necessary when a client has a significant
injury or cannot otherwise tolerate the examination
while conscious.
Procedure codes 92018 or 92019 may be reimbursed to
physicians in the office, inpatient, and outpatient hospital
setting and to outpatient ambulatory surgical centers in
the outpatient hospital setting.
Corneal Topography
Corneal topography (procedure code 92025) is limited to
one per eye, per day, any provider. Procedure code 92025
must be billed with modifier LT (left) or RT (right) to
identify the eye on which the service was performed.
Corneal topography may be reimbursed on the same date
of service by the same provider as an eye examination
visit or consultation.
All Providers
Procedure code 92025 may be reimbursed when one of
the following diagnosis codes is submitted:
Diagnosis Codes
37000
37001
37005
37006
37102
37103
37122
37123
37146
37148
37162
37170
37234
37240
37244
37245
8711
9402
V425
V4561
37002
37007
37104
37140
37149
37171
37241
37281
9403
V4569
37003
37100
37120
37141
37160
37172
37242
37289
9404
Diagnosis Codes
36254
36255
36261
36262
36266
36270
36274
36275
36282
36283
36340
36341
36362
36363
36441
36481
36601
36602
36610
36611
36615
36616
36620
36621
36631
36632
36642
36643
36650
36651
3669
37100
37104
37105
37113
37114
37121
37122
37131
37132
37142
37143
37148
37149
37153
37154
37458
37160
37171
37172
37189
3719
37931
37932
37992
74330
74334
74335
8704
8715
9302
9308
37004
37101
37121
37142
37161
37173
37243
8710
99651
Ophthalmic Ultrasound
The following procedure codes may be used for
ophthalmic ultrasound:
Procedure Codes
76510
76511
76516
76519
76512
76529
76513
76999
76514
Ophthalmic ultrasound procedure codes are limited to
one per eye, per day, any provider. These procedure codes
may be reimbursed with the following diagnosis codes:
Diagnosis Codes
1900
1901
2388
23981
24951
24960
24980
24981
25051
25052
36052
36053
36060
36061
36065
36069
36103
36104
36110
36111
36119
3612
36133
36181
36202
36203
36207
36210
36214
36215
36220
36221
36225
36226
36231
36232
36236
36237
36243
36250
1984
2441
24961
24990
25053
36054
36062
36100
36105
36112
36130
36189
36204
36211
36216
36222
36227
36233
36240
36251
2240
24941
24970
24991
36050
36055
36063
36101
36106
36113
36131
3619
36205
36212
36217
36223
36229
36234
36241
36252
2340
24950
24971
25050
36051
36059
36064
36102
36107
36114
36132
36201
36206
36213
36218
36224
36230
36235
36242
36253
36256
36263
36271
36276
36284
36342
36370
36482
36603
36612
36617
36622
36633
36644
36652
37101
37110
37115
37123
37133
37144
37150
37155
37161
37173
3766
37933
74331
74336
8716
9309
36257
36264
36272
36277
36285
36343
36371
36489
36604
36613
36618
36623
36634
36645
36653
37102
37111
37116
37124
37140
37145
37151
37156
37162
37181
37921
37934
74332
74337
9300
36260
36265
36273
36281
36289
36361
36372
36600
36609
36614
36619
36630
36641
36646
3668
37103
37112
37120
37130
37141
37146
37152
37157
37170
37182
37926
37939
74333
74339
9301
Sensorimotor Examination and Orthoptic
or Pleoptic Training
Sensorimotor examination (procedure code 92060) and
orthoptic or pleoptic training (procedure code 92065) are
limited to two per calendar year, any provider and may be
reimbursed in addition to an eye examination visit.
Procedure codes 92060 and 92065 may be reimbursed
with the following diagnosis codes:
Diagnosis Codes
36800
36801
37801
37802
10
36802
37803
36803
37804
37800
37805
May/June 2010
All Providers
Diagnosis Codes
37806
37807
37812
37813
37817
37818
37823
37824
37833
37834
37842
37843
37851
37852
37856
37860
37871
37872
37951
37952
37956
37957
37808
37814
37820
37830
37835
37844
37853
37861
37873
37953
37958
37810
37815
37821
37831
37840
37845
37854
37862
37883
37954
37959
The following documentation must be submitted with a
request for prior authorization of a corneal bandage:
37811
37816
37822
37832
37841
37850
37855
37863
37950
37955
• Diagnosis that is causing the refractive error, such as
keratoconus.
• The procedure code(s) requested
• The current and new prescriptions supporting a change
of 0.5d or more in the sphere, cylinder, or prism
measurements
• The eye(s) to be treated
The prior authorization request must be signed and dated
by the prescribing physician or optometrist.
Other Professional Services
The following procedure codes may be reimbursed when
medically necessary:
Ophthalmoscopy and Fluorescein Angioscopy
or Angiography
Procedure Codes
92020
92081
92120
92135
92270
92275
Ophthalmoscopy and fluorescein angioscopy or
angiography (procedure codes 92225, 92226, 92230,
and 92235) are considered unilateral procedures and can
be reimbursed for a quantity of two if both the left and
right eyes are evaluated. If two services are billed for the
same date of service, one will be reimbursed at the full
rate, and the other will be reimbursed at 50 percent of
the full rate.
Procedure codes 92081, 92082, and 92083 may be
reimbursed for any appropriate diagnosis and are limited
to two per calendar year, any provider.
Procedure codes 92225 and 92226 are limited to one
service per eye, per day, any provider.
Procedure codes 91235 and 92285 are limited to one
service per eye, per day, any provider.
Procedure codes 92225, 92226, 92230, and 92235 must
be billed with modifier LT or RT to identify the eye on
which the service was performed.
Procedure codes 91235 and 92285 must be billed with
modifier LT or RT to identify the eye on which the
service was performed.
Procedure code 92230 will be denied as part of another
service when billed on the same date of service by the
same provider as procedure code 92235.
Procedure code 92120 may be reimbursed with the
following diagnosis codes:
Diagnosis Codes
24901
24930
24951
24980
25001
25012
25023
25040
25051
25062
36500
36510
36515
36524
Procedure code 92240 will be denied as part of another
service when billed on the same date of service by the
same provider as procedure code 92230 and 92250.
24900
24921
24950
24971
25000
25011
25022
25033
25050
25061
25072
36504
36514
36523
Corneal Bandage
A soft corneal plano bandage lens (procedure code
92070) may be medically necessary for eye protection to
prevent blindness due to a disease process. Prior authorization is not required if placement of the bandage
is an emergency. The emergency condition must be
documented on the claim. Nonemergency placements
require prior authorization that must be obtained before
the lens is dispensed.
Procedure code 92070 is limited to one service per eye,
per day, any provider. Procedure code 92070 must be
billed with modifier LT or RT to identify the eye on
which the service was performed.
May/June 2010
11
92082
92136
92285
24910
24931
24960
24981
25002
25013
25030
25041
25052
25063
36501
36511
36520
36531
92083
92140
92286
24911
24940
24961
24990
25003
25020
25031
25042
25053
25070
36502
36512
36521
36532
92100
92265
92287
24920
24941
24970
24991
25010
25021
25032
25043
25060
25071
36503
36513
36522
36541
All Providers
Diagnosis Codes
36542
36543
36559
36560
36564
36565
36589
3659
36544
36561
36581
36551
36562
36582
The provider must maintain documentation in the
client’s medical record supporting the medical necessity
for the replacement eyeglasses or contact lenses. This
documentation must demonstrate one of the following:
36552
36563
36583
• How the eyeglasses or contact lenses were lost
• A change of 0.5d or more in the sphere, cylinder, or
prism measurement
Eyeglasses or Contact Lenses
Eyeglasses or contact lenses are limited to one pair every
two years. These services may be reimbursed more
frequently when documentation in the client’s medical
record supports medical necessity because of a change of
0.5d or more in the sphere, cylinder, or prism measurements. A benefit period for eyewear begins with the
replacement of nonprosthetic eyewear.
Contact Lenses
The following procedure codes may be used for
prosthetic or nonprosthetic contact lenses:
Procedure Codes
92326
V2500
V2511
V2512
V2522
V2523
Repair
The eyeglass supplier is required to perform, without
charge, minor repairs on eyeglasses that they have
dispensed regardless of the client’s age. Repairs costing
$2 or less are considered minor and are included in the
reimbursement for eyeglasses.
V2501
V2513
V2530
V2502
V2520
V2531
V2510
V2521
V2599
Procedure code 92326 may be reimbursed with the
Diagnosis Codes
37932 37933
37931
37934
74335
V431
Repairs of eyeglasses exceeding $2 are a benefit for
clients who are birth through 20 years of age. The cost
of repair supplies for eyeglasses cannot exceed the cost of
replacement eyeglasses. All repair supplies must be new
and at least equivalent to the original item.
The following procedure codes may be used for contact
lens fitting or modifications:
For major eyeglass repairs, providers must bill procedure
code V2799. Providers must maintain in the client’s
medical record an itemized list of repairs and the
replacement cost to determine whether criteria are met
for repair. Information must be made available for review
upon request.
Frames
Procedure Codes
92070
92310
92314
92315
92312
92317
92313
92325
Procedure codes V2020 or V2025 may be used for frames.
Metal and combination metal/zylonite frames are a benefit
for clients of all ages. Providers must be able to dispense
standard size frames at no cost to the eligible client. For
each type of frame (metal, zylonite, and combination
metal/zylonite), providers must offer a minimum of six
styles in three colors for clients who are 20 years of age or
younger, and a minimum of three styles in three colors for
clients who are 21 years of age or older.
For clients who are 21 years of age or older, repair of
nonprosthetic eyeglasses is not a benefit when the actual
cost of materials exceeds $2.
Replacement
Providers must use modifier RB when billing for
replacement of prosthetic or nonprosthetic eyeglasses or
contact lenses.
Eyeglass Lenses
For Texas Medicaid, high-powered lenses are lenses with
a sphere greater than 7.00d or a cylinder greater than
4.00d.
Replacement of nonprosthetic eyeglasses or contact lenses
because of loss or destruction is a benefit for clients
who are birth through 20 years of age. If the eyeglasses
or contact lenses are lost or destroyed, the client must
sign the Vision Care Eyeglass Patient (Medicaid Client)
Certification Form. The signed form must be maintained
in the client’s medical record.
Eyeglass lenses are not age-restricted.
UV protection (procedure code V2755) may be
reimbursed with the following diagnosis codes:
Diagnosis Codes
37931 37932 37933
Replacement of prosthetic eyeglasses or contact lenses
may be reimbursed because of loss or destruction or
when the client has a significant change in visual acuity,
regardless of age.
92311
92316
12
37934
74335
V431
May/June 2010
All Providers
The following procedure codes may be used for eyeglass
lenses:
Single-Vision Lenses
V2100
V2101
V2102
V2105
V2106
V2107
V2110
V2111
V2112
V2115
V2118
V2121
Bifocal-Vision Lenses
V2200
V2201
V2202
V2205
V2206
V2207
V2210
V2211
V2212
V2215
V2218
V2219
Trifocal-Vision Lenses
V2300
V2301
V2302
V2305
V2306
V2307
V2310
V2311
V2312
V2315
V2318
V2319
Polycarbonate Lens
V2784
V2103
V2108
V2113
V2104
V2109
V2114
V2203
V2208
V2213
V2220
V2204
V2209
V2214
V2221
V2303
V2308
V2313
V2320
V2304
V2309
V2314
V2321
submitting one of the following diagnosis codes for
prosthetic eyeglasses or contact lenses:
Diagnosis Codes
37931 37932 37933
Add-On Lenses
V2430
V2730
V2700
V2755*
V2710
V2770
Nonprosthetic eyeglasses or contact lenses may be
provided to clients of any age when there is no other
option available to correct or ameliorate a visual defect.
Nonprosthetic contact lenses must be prior authorized.
The following documentation must be submitted with
a request for nonprosthetic contact lenses, which has
been signed and dated by the prescribing physician or
optometrist:
• Diagnosis that is causing the refractive error, such as
keratoconus
• The current and new prescriptions that support a
change of 0.5d or more in the sphere, cylinder, or
prism measurements
V2715
V2780
• The eye(s) to be treated
• The procedure code(s) that are requested
• A brief statement that addresses the medical necessity
for vision correction by contact lenses and specifies
why eyeglasses are inappropriate or contraindicated for
the client
Prosthetic Eyeglasses or Contact Lenses
Prosthetic contact lenses do not require prior
authorization.
Prosthetic eyeglasses or contact lenses are lenses that
replace the eye’s organic lens and may be provided based
on medical necessity. Prosthetic contact lenses may be
provided for clients of any age with aphakia as a result
of a congenital abnormality or defect or an acquired
condition due to trauma or cataract removal. Permanent
prosthetic eyeglasses or contact lenses are limited to one
per lifetime.
Provider Type and Place of Service Changes
The following table shows the procedure codes, provider
types, and places of service that may be reimbursed:
Procedure Code
76510 –Total
component
76999 – All
components
Provider must use the VP modifier with a diagnosis
of aphakia. Providers must use the VP modifier when
V431
Nonprosthetic Eyeglasses or Contact Lenses
*Exception: Polycarbonate lens (procedure code V2784) contains
UV protection. UV lenses will not be reimbursed separately
when billed with polycarbonate lenses.
May/June 2010
74335
Temporary prosthetic eyeglasses or contact lenses after
cataract surgery may be reimbursed with diagnosis
code V431. Temporary prosthetic eyeglasses may be
reimbursed for up to four months after the date of
surgery until the client is ready for permanent lenses.
The date of surgery must be submitted on the claim to
determine the convalescence period for the temporary
prosthetic eyeglasses. There are no limitations on the
number of necessary temporary prosthetic lenses during
the postsurgical convalescence period. Temporary lenses
will be denied if they are dispensed more than four
months after the date of surgery.
The following procedure codes are considered add-on
procedure codes and must be billed on the same date of
services same provider as one of the appropriate vision
lens procedure codes listed above. All add-on procedures
are based on medical necessity and must be documented
in the client’s medical record.
V2410
V2718
37934
Provider Types
Optometrist group
Hospital
Optometrist
POS
Office
Outpatient
Office
POS = Place of service
13
All Providers
Procedure Code
76999 – Professional
interpretation
component
83516, 83520, 87075
–Total component
92070
interpretation
component
95930 – Technical
component
interpretation
component
95933 – Technical
component
95933 –Total
component
V2115, V2118,
V2121, V2215,
V2218, V2219,
V2220, V2221,
V2315, V2318,
V2319, V2320,
V2321, V2430,
V2700, V2710,
V2715, V2718,
V2730, V2755,
V2770, V2780
V2410
V2500, V2501,
V2502, V2510,
V2511, V2512,
V2513, V2520,
V2521, V2522,
V2523, V2530,
V2531, V2599
Provider Types
Optometrist
Optometrist
POS
Office,
outpatient,
inpatient
Outpatient
Optometrist
Optometrist
Outpatient
Office
The following procedure codes are limited to one service
per day, any provider:
Procedure Codes
92015
92018
92060
92065
92100
92120
92310
92311
92315
92316
Physician, NP, CNS,
PA, optometrist,
optician, dispensing
optical company
No change
Procedure Codes
92002
92004
Office
92050
92083
92250
92314
92326
92012
92014
In the following table the procedure codes in column A
will be denied if they are submitted on the same date of
service by the same provider as any of the corresponding
procedure codes in column B:
Office
Office,
outpatient,
other
(POS 9)
Column A Procedure
Codes
76511
76512
76516
76519
76529
90760, 90765, 90772,
90774, 90775, 92070,
95060
92002, 92004, 92012,
92014
Office,
outpatient,
other
Other
(POS 9)
POS = Place of service
Other Benefit Changes
PCCM clients do not require a referral by their primary
care physician when procedure code 92018, 92019,
92070, 92135, 92136, 92310, 92311, 92312, or 92325 is
performed by an optometrist or ophthalmologist.
92020
92082
92140
92313
92325
Procedure code 92015 may be reimbursed when
submitted with the following procedure codes:
Physician, NP, CNS, Office
PA, optometrist
No change
Office
Physician, NP, CNS,
PA, optometrist
Portable X‑ray
supplier
Physician, NP, CNS,
PA, optometrist,
optician, dispensing
optical company
92019
92081
92136
92312
92317
14
Column B Procedure Codes
76506, 76510, 76512
76510
76511, 76519
76511
76512, 76513
92018, 92019
96111, 99201, 99202, 99203,
99204, 99205, 99211, 99212,
99213, 99214, 99215, 99217,
99218, 99219, 99220, 99221,
99222, 99223, 99231, 99232,
99233, 99234, 99235, 99236,
99238, 99239, 99241, 99242,
99243, 99244, 99245, 99251,
99252, 99253, 99254, 99255,
99281, 99282, 99283, 99284,
99285, 99291, 99292, 99293,
99294, 99295, 99296, 99298,
99299, 99300, 99304, 99305,
99306, 99307, 99308, 99309,
99310, 99315, 99316, 99318,
99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348,
99349, 99350, 99477
May/June 2010
All Providers
Column A Procedure
Codes
92019
92020
92100
92130, 92260
92140
92230
92270
92325
92504
92541, 92542, 92543,
92544, 92545, 92546,
95867, 95870
92544, 92545, 92546
97803
97802, 97803
97804
99211
36000, 36200, 36215,
36216, 36217, 36218,
36245, 36246, 36247,
36248, 36410, 76000,
76001, 90760, 90765,
90772, 90774, 90775,
93000, 93005, 93010,
93040, 93041, 93042,
99211
36000, 36410, 90760,
90765, 90772, 90774,
90775, 92230, 92250,
93000, 93005, 93010,
93040, 93041, 93042,
99211
36000, 36410, 90760,
90765, 90772, 90774,
90775
Procedure Code Review Updates
Column B Procedure Codes
92018
92018, 92019, 92285
92140
92018
92120, 92130
92235, 92240
95808, 95810, 95811
92225, 92250, 92311, 92312,
92313, 92315, 92316, 92317,
92326
76513
92265
To align with the Centers for Medicare & Medicaid
Services (CMS) requirements for easy access to all Texas
Medicaid fees, provider type, place-of-service (POS), and
type-of-service (TOS) changes have been applied to some
procedure codes, including chelating agent injection
services and osteogenic stimulation services.
The following changes are effective for dates of service on
or after February 1, 2010.
Chelating Agent Injections
Procedure codes J0470, J0600, and J0895 are no longer
reimbursed to hospital, nephrology (hemodialysis, renal
dialysis), renal dialysis facilities, and hospital-based rural
health clinic (RHC) providers in the office setting.
reimbursed to nephrology (hemodialysis, renal dialysis),
renal dialysis facility, and hospital-based RHC providers
in the outpatient hospital setting.
92270
97802
92002, 92004, 92012, 92014
97802, 97803
76519, 92018, 92019, 92020,
92025, 92060, 92065, 92070,
92081, 92082, 92083, 92100,
92120, 92135, 92136, 92140,
92225, 92226, 92230, 92235,
92240, 92250, 92260, 92265,
92270, 92275, 92285, 92286,
92287, 92311, 92312, 92313,
9315, 92316, 92317, 92325,
92326
92230, 92235
reimbursed in the home or extended care facility (ECF)
setting.
Procedure code J3520 is no longer reimbursed to hospital,
nephrology (hemodialysis, renal dialysis), renal dialysis
facility, and hospital-based RHC providers in the office
setting or outpatient hospital setting.
Procedure code J3520 is no longer reimbursed in the
home, inpatient hospital, or ECF setting and is no longer
reimbursed to dentists in the outpatient hospital setting.
Procedure code J3520 may be reimbursed to dentists in
the office setting.
Note: The reimbursement for services rendered by hospitals
and RHCs is included in the diagnosis-related group (DRG)
payment for the hospitals and in the encounter payment for
the RHCs. The changes indicated in this article for hospitals
and RHCs do not affect the DRG or encounter payments.
Osteogenic Stimulation
92240
Surgery procedure code 20975 may be reimbursed to
physician providers in the inpatient hospital or outpatient
hospital setting.
Miscellaneous Drug Procedure Codes
Changes to miscellaneous drug procedure codes were not
implemented on February 1, 2010, as indicated in the
article titled, “Coming Soon: Procedure Code Review
Updates for February 1, 2010,” posted on December 11,
2009, on the TMHP web page at www.tmhp.com.
Providers will be notified of the changes to the miscellaneous drug procedure codes in a future article.
92287
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

May/June 2010
15
All Providers
Benefit Criteria Changed for Some Vision Surgical Services
Effective for dates of services on or after April 1, 2010,
benefit criteria for some vision surgical services changed
for Texas Medicaid.
Procedure
Reimbursement
Code
Age Range
Rate
ASC Service
65780
All
Group 9
V2790
All
$745.00
New Benefits
Procedure code 66990 is a surgical benefit when it
is performed in the office, inpatient hospital, and
outpatient hospital settings by a physician.
Procedure code V2790 is a benefit for ambulatory
surgical centers (ASC) when it is performed in the
outpatient hospital setting.
Age Limitations
The age limitation for procedure code 67229 changed
from birth through 12 months of age to birth through 11
months of age.
Procedure code 65780 is a surgical benefit when it is
performed in the inpatient hospital or outpatient hospital
setting by a physician. Procedure code 65780 is a benefit
for ambulatory surgical centers when it is performed in
Modifier Requirements
The following procedure codes require modifier LT or
RT to identify the eye for which the surgery is being
performed:
Benefits for procedure code 65286 have been expanded
to include services performed in the office setting.
Procedure Codes
67311
67320
67414
V2790
65205
67318
67345
67808
The following procedure codes will be denied when
submitted for reimbursement on the same date of service
by the same provider as procedure code 65780:
Procedure Codes
00140
00142
65222
65270
65280
65285
65430
65435
65805
66999
68320
68325
68335
68340
00144
65272
65286
65436
67500
68326
68360
00145
65273
65290
65450
67515
68328
68362
65220
65275
65400
65800
68200
68330
69990
67314
67332
67801
67316
67334
67805
Benefit Limitations
In the following table, the procedure codes in Column A
may be reimbursed only when at least one corresponding
procedure code from Column B has been paid to the
same provider for the same date of service:
Column A
Procedure Code
66990
Reimbursement
New procedure codes 65780, 66990, and V2790 will be
reimbursed as follows:
67225
67320, 67331,
67332, 67334
67335, 67340
Procedure
Reimbursement
Code
Age Range
Rate
Surgical Services
65780
20 years of age or
$629.51 (21.98 RVUs,
younger
$28.640 CF)
65780
21 years of age or
$599.53 (21.98 RVUs,
older
$27.276 CF)
66990
20 years of age or
$65.59 (2.29 RVUs,
younger
$28.640 CF)
66990
21 years of age or
$62.46 (2.29 RVUs,
older
$27.276 CF)
V2790
Column B Procedure Code
65820, 65875, 65920, 66985,
66986, 67036, 67039, 67040,
67041, 67042, 67043, or 67112
67221
67311, 67312, 67314, 67316, or
67318
67311, 67312, 67314, 67316, or
67318
65780
Procedure codes 67335 and 67340 will be denied as
part of another service when they are submitted for
reimbursement on the same date of service by the same
provider as procedure code 67320, 67331, 67332, or
67334.
For Primary Care Case Management (PCCM) clients,
when procedure codes 65270 and 65275 are performed
67312
67331
67800
16
May/June 2010
All Providers
by an ophthalmologist, they will not require a referral
from a primary care provider or any other type of prior
authorization.
Providers Must Have Correct
Physical Address on File
Diagnosis Restrictions
Reminder: Providers must have their correct physical
addresses on file with TMHP so that clients can
locate them using the Online Provider Lookup (OPL).
Providers that practice at multiple locations must enroll
each location where health-care services will be rendered.
It is important that each location’s correct physical
address is available on the OPL.
The following procedure codes no longer have diagnosis
restrictions:
Procedure Codes
65450
65855
66710
66711
66821
66983
67027
67031
67041
67042
67108
67110
67210
67220
67229
G0186
65860
66761
66984
67036
67043
67112
67221


66600
66762
66985
67039
67105
67113
67225
66605
66770
66986
67040
67107
67145
67228
Providers should verify that the physical address for their
provider identifier is correct on the OPL. Providers can
confirm the address and other demographic information,
on the TMHP website at www.tmhp.com. To locate
the OPL information, providers can sign into the My
Account page and choose the option to Change/verify
address information.

Providers can update their physical addresses online; no
additional action is necessary. Providers who have e-mail
addresses on file with TMHP will receive a confirmation
e-mail from TMHP when a physical address has been
updated. Providers can make other demographic changes
online; however, providers must print and sign the form
and mail it to TMHP, as indicated on the printed copy.
Update to the Field Description
on the Static Fee Schedule
Effective May 3, 2010, TMHP will update the field
description for “Access-Based or Max Fee” on the static
fee schedule.
Providers can enroll a new location using the Provider
Enrollment on the Portal tool on the TMHP website. If
a provider is already enrolled and chooses to add another
enrollment, the online enrollment application is automatically populated with the current information that
the provider has on file with TMHP. This saves providers
time by reducing the amount of information they must
enter into the form manually.
The updated field description will inform providers
how to calculate the Medicare-payable rate and solecommunity-hospital rate for clinical laboratories. This
update will apply to all static fee schedules.
For calculating the Medicare-payable rate, the static fee
schedule will display the following: “To calculate the
Medicare payable rate for clinical laboratories, multiply
the access-based or max fee by 104.17 percent.”
Physical address changes may also be communicated in
writing to TMHP on the Provider Information Change
Form, which is available on page 151 of this bulletin, and
in the 2009 Texas Medicaid Provider Procedures Manual
in Appendix B, “Forms” on page B-81.
For calculating the sole-community-hospital rate, the
static fee schedule will display the following: “To
calculate the sole-community-hospital rate for clinical
laboratories, multiply the access-based or max fee by
103.35 percent.”
Orthopedic Dynamic Device Benefit Change
Effective for dates of service on or after February 1,
2010, orthopedic dynamic device procedure codes
E1802, E1812, and E1840 may be reimbursed by the
Texas Medicaid Comprehensive Care Program (CCP)
and the Children with Special Health Care Needs
(CSHCN) Services Program. The reimbursement
rate for each procedure code is as follows:
May/June 2010
• Procedure code E1802 (purchase) reimbursement
rate is $3,431.00.
• Procedure code E1812 (rental) reimbursement rate
is $90.29.
• Procedure code E1840 (rental) reimbursement rate
is $401.85.
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17
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All Providers
Additional Procedure Code Updates for February 1, 2010
To align with the Centers for Medicare & Medicaid
type-of-service (TOS) changes were applied to some
radiology, laboratory, and surgical procedure codes.
Procedure
Codes
Changes Applied
93982
Professional interpretation and technical
components: Is no longer reimbursed.
Total laboratory component: Is no longer
reimbursed.
Total radiology component: May be
reimbursed to radiological and physiological
laboratories in the office setting.
Effective for dates of service on or after February 1, 2010,
the following changes were applied to procedure codes
75952, 75953, 79300, 79445, 92979, 93016, 93722, and
93982:
Effective February 1, 2010, for dates of service on or
after July 1, 2009, the following changes were applied to
procedure codes 92978, 93350, and 95920:
Procedure
Codes
Changes Applied
75952,
Total component: Is no longer reimbursed.
75953
Professional interpretation component:
May be reimbursed to nurse practitioner
(NP), clinical nurse specialist (CNS), physician assistant (PA), physician, certified nurse
midwife (CNM), radiation treatment center,
hospital, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, radiological
and physiological laboratory, and hospitalbased rural health clinic (RHC) providers in
the office setting; and may be reimbursed to
radiation treatment center hospital, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, radiological and physiological laboratory, and hospital-based RHC
providers in the outpatient hospital setting.
79300
Total component: Is no longer reimbursed.
Professional interpretation component: May
be reimbursed to physicians and radiological
and physiological laboratories in the office
setting; and may be reimbursed to hospitals
79445
Technical component: Is no longer
reimbursed.
92979
Surgery component: Is no longer
reimbursed.
May be reimbursed to physicians in the office, inpatient hospital, or outpatient hospital
setting.
93016
Professional interpretation component: Is
no longer reimbursed.
Total laboratory component: May be reimbursed to physicians in the office, inpatient
hospital, or outpatient hospital setting.
93722
Professional interpretation component: Is
no longer reimbursed.
Total radiology component: May be
reimbursed to NP, CNS, PA, physician, and
CNM providers in the inpatient hospital or
Procedure
Codes
92978,
93350,
95920
Changes Applied
May be reimbursed to NP, CNS, PA, physician, and CNM providers in the inpatient
hospital or outpatient hospital setting.
Technical component: May be reimbursed
to NP, CNS, PA, physician, CNM, and
hospital providers in the inpatient hospital or
Claims submitted with procedure code 92978, 93350, or
95920 and dates of service from July 1, 2009, through
January 31, 2010, will be reprocessed, and payments will
be adjusted accordingly. No action on the part of the
provider is necessary.
Scheduled System
Maintenance
System maintenance for the TMHP claims
processing system is scheduled as follows:
• Sunday, May 16, 2010, from 6:00 p.m.
until midnight.
• Sunday, June 13, 2010, from 6:00 p.m.
until midnight.
During system maintenance, some applications related to the claims engine will be
unavailable. Specific details about the affected
applications are posted on the TMHP website
at www.tmhp.com.
18
May/June 2010
All Providers
Updates for IV Therapy and Urinalysis Services Procedure Codes
Reimbursement Rates for New IV Therapy
Equipment and Supplies Procedure Codes
to align with the Centers for Medicare & Medicaid
Services (CMS) requirements for easy access to all
Texas Medicaid fees, provider type, place-of-service
(POS), and type-of-service (TOS) changes have been
made to intravenous (IV) therapy equipment and
supplies, and urinalysis services.
The following rates will be applied to the new benefits
indicated:
Procedure
Code
A4248
K0455
K0552
K0601
K0602
K0603
K0604
K0605
S5036
Intravenous (IV) Therapy Equipment and
Supplies
The following equipment and supplies procedure codes
used in the delivery of intravenous (IV) therapy are
benefits of Texas Medicaid Title XIX Home Health
Services and may be reimbursed to home health
durable medical equipment (DME) providers and
DME medical suppliers in the home setting.
Prior authorization is required.
Procedure Codes
A4248
K0455
K0603
K0604
K0552
K0605
K0601
S5036
K0602
*
*
*
$1.16
$6.68
$0.60
$6.39
$15.33
Manually priced
Procedure codes A4248, K0455, and K0552 are pending
a Texas Medicaid rate hearing. These procedure codes are
effective for dates of service on or after April 1, 2010, and
may be submitted as the services are provided. Services
provided before the rates are adopted will be denied with
the following explanation of benefits (EOB) code until
the applicable reimbursement rates are adopted:
Replacement batteries for client-owned pumps
(procedure codes K0601, K0602, K0603, K0604, and
K0605) are limited to one battery every six months or
180 days.
• 02008: This procedure code has been approved
as a benefit pending the approval of expenditures.
Providers will be notified of the effective dates of
service in a future notification if expenditures are
approved.
Repairs within the first six months after delivery
are considered part of the purchase price. Necessary
repairs at or after seven months may be prior
authorized with documentation of a client-owned
device.
The client cannot be billed for these services. Providers
are encouraged to begin submitting the procedure codes
as the services are performed so that the claims meet the
initial 95-day filing deadline. Once the reimbursement
rate is implemented, TMHP will automatically reprocess
claims, and no further action on the part of the provider
will be required. Providers will be notified of the rates
and the reprocessing effort in a future notification.
If procedure code A4221 is used for dressing changes
to the IV insertion site, catheter care items may not be
billed separately.
Providers may refer to the 2009 Texas Medicaid
Provider Procedures Manual section 24.4.22,
“Intravenous (IV) Therapy Equipment and Supplies,”
on page 24-38, for more information about prior
authorization requests and other IV therapy
equipment and supplies benefits.
Reimbursement Rate
(*) Rate hearing required for Texas Medicaid.
(Manually priced) This procedure code requires prior authorization and will be priced based on the provider’s intended fee
when the authorization is requested.
Procedure code K0455 (monthly rental of a pump for
uninterrupted infusion) will be denied when billed
with procedure code K0552.
May/June 2010
Age
All ages
All ages
All ages
All ages
All ages
All ages
All ages
All ages
All ages
19
All Providers
Urinalysis
Procedure codes 81001, 81003, 81005, and 81020 are
no longer reimbursed to physician, podiatrist, CNM,
radiation treatment center, FQHC, family planning
clinic, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, and freestanding and hospital-based
RHC providers in the outpatient hospital setting.
The following changes apply to the laboratory procedure
codes indicated:
Procedure codes 81000, 81002, and 81015
The total laboratory component for procedure codes
81000, 81002, and 81015 are no longer reimbursed to
an independent laboratory, podiatrist, certified nurse
midwife (CNM), radiation treatment center, federally
qualified health center (FQHC), hospital, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, freestanding and hospital-based rural health clinic (RHC)
providers in the office setting.
Procedure code 82044
The total laboratory component for procedure code
82044 is no longer reimbursed to independent laboratory,
optometrist, podiatrist, CNM, radiation treatment
center, hospital, nephrology (hemodialysis, renal dialysis),
renal dialysis facility, and hospital-based RHC providers
in the office setting.
Procedure codes 81000, 81002, and 81015 are no longer
reimbursed to physician, podiatrist, CNM, radiation
treatment center, FQHC, family planning clinic,
facility, freestanding and hospital-based RHC, and
optometric group providers in the outpatient hospital
setting.
Procedure code 82044 is no longer reimbursed in the
inpatient hospital setting.
Procedure code 82044 is no longer reimbursed to
independent laboratory, radiation treatment center,
facility, and hospital-based RHC providers in the
reimbursed to physician, and podiatry group providers in
the independent laboratory setting.
radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospitalbased RHC providers in the independent laboratory
setting.
Procedure codes 81001, 81003, 81005, and 81020
The total laboratory component for procedure codes
81001, 81003, 81005, and 81020 are no longer
reimbursed to independent laboratory, podiatrist, CNM,
radiation treatment center, FQHC, hospital, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, and
freestanding and hospital-based RHC providers in the
office setting.
Note: The changes noted in this article do not affect the
RHC encounter reimbursement, the FQHC encounter reimbursement, or the hospital diagnosis-related group (DRG)
reimbursement.
Consultation Procedure Codes to Remain a Benefit
for Texas Medicaid and the CSHCN Services Program
Effective January 1, 2010, Medicare eliminated
payment for Current Procedural Terminology
(CPT) consultation procedure codes, including
inpatient, office, and outpatient consultations, but
excluding telemedicine consultation G-codes.
For Medicaid Qualified Medicare Beneficiary
(MQMB) clients, the provider must follow the
Medicare program rules before the service will
be considered by Medicaid for coinsurance and
deductible. The Medicare explanation of benefits
(EOB) that contains the relevant claim denial
must be submitted to TMHP with the completed
claim form within 95 days of the Medicare
disposition date and 365 days of the date of service.
These claims will be processed as Medicaid-only
claims.
Texas Medicaid and the Children with Special
Health Care Needs (CSHCN) Services Program
currently have no plans to follow Medicare policy
in the elimination of payment for CPT consultation procedure codes. Consultation codes that are
currently a benefit for Texas Medicaid and the
CSHCN Services Program will remain payable.
20
May/June 2010
All Providers
Claims Filing and Reimbursement Reminder for Hearing
Services Providers
The date of service indicated on the claim for the hearing
device procedure code must be the date the device is
dispensed to the client. Texas Medicaid and the Children
with Special Health Care Needs (CSHCN) Services
Program reimburse providers only for rendered services
and for equipment and supplies received by the client.
Future services and undelivered equipment and supplies
cannot be billed for reimbursement.
After providing the services, supplies, or equipment,
providers must file claims electronically or on the
appropriate Centers for Medicare & Medicaid Services
Texas Medicaid providers may refer to the 2009 Texas
(CMS) paper claim form. All claims must be true, accurate,
Medicaid Provider Procedures Manual, section 1.4.10,
and complete according to documentation in the client’s
“General Medical Record Documentation Requirements,’
medical record.
on page 1-17; section 1.5, “Medicare/Medicaid Waste,
The Texas Health and Human Services Commission
Abuse, and Fraud Policy,” on page 1-18; and section
(HHSC), the CSHCN Services Program, and TMHP
1.4.8, “Provider Certification/Assignment,” on page 1-15,
routinely perform retrospective reviews of all providers.
for more information about provider responsibilities and
HHSC ultimately is responsible for Texas Medicaid
claims filing requirements.
utilization review activities. The Department of State Health
CSHCN Services Program providers may refer to
Services (DSHS) is ultimately responsible for utilization
the 2009 CSHCN Services Program Provider Manual,
review activities for the CSHCN Services Program. This
section 2.3.2, “General Medical Record Documentation
review includes comparing services billed to the client’s
Requirements,” on page 2-9, through section 2.3.7,
clinical record. Billing or causing claims to be filed for
“Provider Certification/Assignment,” on page 2-11, and
services or merchandise that were not provided to the client
chapter 19, “Hearing Services,” on page 19-1, for more
are grounds for any of the following:
information about provider responsibilities and the
• Administrative enforcement by the Office of the
hearing services benefit.
Inspector General (OIG)
Providers may also refer to the article published in the
• Referral for criminal, civil, or licensure or certification
November/December 2009 Texas Medicaid Bulletin,
investigation
No. 226, titled, “Changes to Texas Medicaid Hearing
Services Benefits to Accompany PACT Transition,” and
• Judicial action for program violations by any provider or
to the article published in the November 2009 CSHCN
person (Violations result from a provider or person who
Services Program Provider Bulletin, No. 72, titled,
knew or should have known they were violations.)
“Hearing Services Benefits (PACT Transition),” for more
• Administrative sanctions by the CSHCN Services
information about the hearing services benefit.
Program
Increased Reimbursement for Vagal Nerve Stimulator Devices
Effective for dates of services on or after April 1,
2010, vagal nerve stimulator (VNS) devices will be
prior authorized and reimbursed at an increased
rate of $17,938.00, when procedure code L8686
is submitted with modifier TG. Providers must
bill procedure code L8686 with modifier TG to
May/June 2010
identify the service as a VNS device and receive the
increased reimbursement.
Prior authorization requests for all neurostimulators
and related procedures must include the provider
identifiers for both the surgeon and the facility.
21
All Providers
Informational Claim Submissions Transitions to TMHP
Effective February 22, 2010, Informational Claims
processing transitioned from the Health and Human
Services Commission (HHSC) to TMHP.
If a provider has not received confirmation that TMHP
has received the informational claim within 30 days, the
provider should contact the TMHP Third Party Resource
Department at 1-800-846-7307, option 3 to validate the
status of the request.
If providers determine that a third party resource may be
liable for a Medicaid client’s accident related claim, they
can submit an informational claim to the TMHP Tort
Department to indicate that a third party is being pursued
for payment. This allows providers to secure the 95-day
claims filing deadline in the event that the payment is not
received from the third party.
If providers have submitted an informational claim to TMHP
but have not received payment from the third party resource,
they must make one of the following determinations and
notify TMHP within 18 months of the date of service:
• Providers can continue to pursue a claim for payment
against the third party and forego the right to convert
an informational claim to a claim for payment by Texas
Medicaid.
TMHP processes informational claims for Primary Care
Case Management (PCCM), STAR+PLUS, and Medicaid
fee-for-service clients. The provider cannot submit an informational claim to TMHP for Medicaid clients who are receiving
benefits from a Managed Care Organization (MCO).
• Providers can submit a request to convert to the informational claim to a claim for payment consideration from
Texas Medicaid.
Providers must submit informational claims to TMHP by
certified mail on one of the following forms:
Providers that decide to convert an informational claim to
a claim for payment consideration must submit a request to
TMHP. The request must be submitted as follows:
• UB-04 CMS-1450 or CMS-1500 paper claim form.
Informational claims cannot be submitted to TMHP electronically or by fax.
• On provider letterhead.
• Informational Claims Submission Form. Providers should
complete only one form per client, regardless of how many
separate informational claims are being submitted with the
form.
Forms must be submitted within the 95-day claims filing
deadline. Informational claims will not be accepted after the
95-day claims filing deadline.
• With the client’s name and Medicaid ID, the date of
service, and the total billed amount that was originally
submitted on the UB-04 CMS-1450 or CMS-1500 paper
claim form.
• By fax to 1-512-514-4225.
• By mail to:
Providers may refer to section 5.1.7, Claims Filing Deadlines,”
in the 2009 Texas Medicaid Provider Procedures Manual, on
page 5-8 for more information about claims filing deadlines.
Providers must complete either the Insurance Information
field (third party resource) or the Attorney Information field
on the Informational Claims Submission Form. Providers
must send the informational claims and the Informational
Claims Submission Form by certified mail to:
TMHP will not accept any conversion request that is
submitted more than 18 months after the date of service,
regardless of whether an informational claim was submitted
timely to TMHP. All payment deadlines are enforced
regardless of whether the provider decides to pursue a third
party claim. The conversion of informational claims to actual
claims is not a guarantee of payment by TMHP.
TMHP/Tort Department
PO Box 202948
Austin, TX 78720-2948
All informational claims that are still within 18 months of
the date of service and that are pending a provider’s final
determination will be transferred from HHSC to TMHP
for processing. Providers with pending informational claims
must contact TMHP, not HHSC, to convert the informational claim to a claim for payment consideration.
TMHP will send providers a letter to confirm that the informational claim was received. The letter will provide the date
on which TMHP must receive a request from the provider
to convert the informational claim to a claim for payment.
If TMHP receives an informational claim that cannot be
processed, TMHP will notify the provider of the reason.
Providers should refer to Section 4, “Client Eligibility” in the
2009 Texas Medicaid Provider Procedures Manual, for more
information about third party resources and accident related
claims.
Providers can inquire about the status of an informational
claim by calling TMHP at 1-800-846-7307, option 3.
TMHP/Tort Department
PO Box 202948
Austin, TX 78720-2948
22
May/June 2010
All Providers
Obtaining Authorization for Outpatient Radiology Services
Reminder: Outpatient diagnostic radiology services,
including computed tomography (CT), magnetic
resonance, positron emission tomography (PET), and
cardiac nuclear imaging, require prior authorization
for Texas Medicaid fee-for-service clients and Primary
Care Case Management (PCCM) clients. Authorization
requests must be submitted to MedSolutions, which
is the TMHP subcontractor that authorizes radiology
services for Texas Medicaid clients.
Retroactive authorization is considered for outpatient
emergent studies when both of the following criteria are
met:
• The physician determines that a medical emergency
that imminently threatens life or limb exists.
• The medical emergency requires advanced diagnostic
imaging.
• Retroactive authorization is considered for outpatient
urgent studies when both of the following criteria are
met:
Prior Authorization and Retroactive Authorization
Nonemergent radiology studies providers must receive
prior authorization before they perform the services. For
urgent or emergent situations providers may request
retroactive authorization. Authorization is considered
on an individual basis. Each authorization request is
reviewed for its adherence to standard clinical evidencebased guidelines. Documentation must support the
medical necessity of the study and must be maintained
in the client’s medical record by both the physician
ordering the test and the facility performing the study.
- During the provision of prior-authorized services,
the physician performing the imaging study
determines that additional or alternate procedures
are medically necessary.
- The urgent condition requires additional or
alternate advanced diagnostic imaging.
Note: Outpatient emergent and urgent studies may
also be prior authorized if submitted by telephone to
ensure a timely response.
MedSolutions evaluates authorization requests using
nationally-accepted guidelines and radiology protocols
that are based on the medical literature. Providers can
access the current Clinical Decision Support Tool for
Advanced Imaging Guide on the TMHP website at
www.tmhp.com. This tool includes information that was
developed by MedSolutions to help providers determine
the most appropriate imaging procedure for each patient
at the most appropriate time during the diagnostic and
treatment cycle. The guidelines are updated annually.
The retroactive authorization request must be submitted
no later than 14 calendar days after the day on which the
study was completed. Retroactive authorization requests
are accepted by telephone, fax, or mail, but they are not
accepted online. The request may be submitted by the
physician or by the facility with the available clinical
information to justify the request.
In the absence of an authorization, reimbursement will
be denied for both the technical and professional interpretation components.
Prior authorization is required for outpatient,
nonemergent radiology studies (i.e. those studies that are
planned or scheduled) and must be obtained before the
service is rendered.
Authorization Requests Submitted
to MedSolutions
MedSolutions office hours are 7 a.m. to 7 p.m., Central
Time, Monday through Friday, except Texas state
holidays.
Requests for prior authorization can be submitted
online through the MedSolutions website at
www.medsolutionsonline.com, by telephone at
1-800-572-2116, by fax at 1-800-572-2119, or by mail to:
Effective February 1, 2010, the Radiology Prior
Authorization Request Form was updated. Providers
must begin using the new form effective for dates of
service on or after February 1, 2010. The Radiology
Prior Authorization Request Form is available on
page 144 of this bulletin and on the TMHP website at
www.tmhp.com, under “Provider Forms.”
Texas Medicaid & Healthcare Partnership
730 Cool Springs Blvd, Suite 800
Franklin, TN 37067
When the requested study is not the most clinicallyappropriate study, a different study may be offered to the
requesting provider when an alternate is available.
May/June 2010
Requests for authorization may be submitted to
MedSolutions online at www.medsolutionsonline.com,
23
All Providers
by telephone at 1-800-572-2116, by fax at
1-800-572-2119, or by mail to:
730 Cool Springs Blvd, Suite 800
Franklin, TN 37067
Note: Access to the MedSolutions online prior authorization portal is also available from www.tmhp.com and the
TMHP prior authorization portal.
Prior authorization for PET or cardiac nuclear imaging
services is required for Texas Medicaid fee-for-service
and PCCM clients. For information about prior
authorization requests for Texas Medicaid clients with
eligibility under a program other than Texas Medicaid
fee-for-service and PCCM, such as a Texas Medicaid
health maintenance organization (HMO) or Medicare,
providers should call the TMHP Contact Center at
1-800-925-9126.
Cardiac Catheterization
Procedure Codes Updated
Effective January 20, 2010, for dates of service on or after
July 1, 2009, the following procedure codes were updated
as indicated:
Procedure Codes
93501
93505
93514
93524
93529
93530
Cardiac Nuclear Imaging Studies
Prior Authorization Requirement
93510
93527
93532
93511
93528
93533
The surgical component for the procedure codes above
may be reimbursed to physicians in the outpatient
hospital setting.
January 1, 2010, procedure codes 78451, 78452, 78453,
and 78454 were made benefits of Texas Medicaid
during the 2010 Healthcare Common Procedure
Coding System (HCPCS) update. Procedure codes
78451, 78452, 78453, and 78454 do not require prior
authorization for dates of service from January 1, 2010,
through January 31, 2010. Prior authorization is
required for dates of service on or after February 1,
2010, and must be submitted to MedSolutions.
Note: The surgical component may now be reimbursed to
physicians and radiological and physiological laboratories in
the office setting and to physicians in the outpatient hospital
setting.
The technical component for the procedure codes above
may be reimbursed to physicians in the outpatient
hospital setting.
Claims submitted with dates of service from January 1,
2010, through January 31, 2010, and procedure codes
78451, 78452, 78453, and 78454 were denied
incorrectly as requiring prior authorization. The claims
were also denied appropriately as requiring a rate
hearing and approval of expenditures. Once the rates
for the 2010 HCPCS added procedure codes have been
adopted and implemented, TMHP will automatically
reprocess claims affected by the incorrect denial and the
denial for pending rate hearing. No action on the part
of the provider is required.
Note: The technical component may now be reimbursed to
the office setting.
Procedure Code 93503
The surgical component for procedure code 93503 may
be reimbursed to physicians in the outpatient hospital
setting.
Note: The surgical component may now be reimbursed to
the office setting and to physicians in the outpatient hospital
setting.
Providers may refer to the article published on
December 11, 2009, on the Radiology Prior
Authorization Services web page on the TMHP website
titled, “Authorization Requests for PET and Cardiac
Nuclear Imaging Services,” for more information about
cardiac nuclear imaging services.
93508
93526
93531
Affected claims that were submitted between July 1,
2009, and January 19, 2010, will be reprocessed, and
payments will be adjusted accordingly. No action on the
part of the provider is required.
24
May/June 2010
All Providers
Benefits for Home Health Power Wheelchairs to Change
Effective for dates of service on or after March 1, 2010,
the prior authorization criteria for home health power
wheelchairs changed for Texas Medicaid.
The following are five PWC groups that must have all the
specified basic components and meet all requirements
under the specific group.
Power Wheelchairs
Group 1 Power Wheelchairs:
A power wheelchair (PWC) is a professionally manufactured
device that provides motorized wheeled mobility and body
support specifically for individuals with impaired mobility.
Power wheelchairs are four- or six-wheeled motorized
vehicles whose steering is operated by an electronic device
or joystick to control direction, turning, and alternative
electronic functions, such as seat controls. PWC for use only
outside the home is not a benefit of Texas Medicaid.
• Standard integrated or remote proportional joystick
• Nonexpandable controller
• Incapable of upgrade to expandable controller
• Incapable of upgrade to alternative control devices
• May have crossbrace construction
• Accommodates nonpowered options and seating
systems (e.g., recline-only backs, manually elevating
leg rests [except captains chairs])
The following definitions apply to PWCs:
• No-Power Option. A category of PWCs that cannot
accommodate a power tilt, recline, seat elevation, or
standing system. A PWC that can accept only powerelevating leg rests is considered to be a no-power-option
chair.
• Length – less than or equal to 40 inches
• Width – less than or equal to 24 inches
• Minimum top end speed – 3 mph
• Minimum range – 5 miles
• Single-Power Option. A category of PWCs that can accept
and operate a power tilt, power recline, power standing, or
a power seat elevation system but not a combination power
tilt and recline seating system. A single-power-option
PWC might be able to accommodate power elevating leg
rests, seat elevator, or standing system in combination with
a power tilt or power recline. A PWC does not have to be
able to accommodate all features to meet this definition.
• Multiple-Power Option. A category of PWCs that can
accept and operate a combination power tilt and recline
seating system. A multiple-power-option PWC might also
be able to accommodate power elevating leg rests, a power
seat elevator, or a power standing system. A PWC does not
have to accommodate all features to qualify to meet this
definition.
• Minimum obstacle climb – 20 mm
• Dynamic stability incline – 6 degrees
• May have crossbrace construction
• Accommodates seating and positioning items (e.g., seat
and back cushions, headrests, lateral trunk supports,
lateral hip supports, medical thigh supports [except
captain chairs])
• Lap belt or safety belt (This does not include multipleattachment-point positioning belts or padded belts.)
• Battery charger, single mode
• Batteries (initial)
• Complete set of tires and casters, any type
• Leg rests
• Capable of upgrade to expandable controller
• Foot rests/foot platform
• Capable of upgrade to alternative control devices
• Arm rests
• May not have crossbrace construction
• Any weight-specific components (braces, bars,
upholstery, brackets, motors, gears, and so on) as
required by client weight
• Controller and input device
May/June 2010
25
All Providers
Group 2 through Group 4 Multiple-Power
Option
lateral hip supports, medial thigh supports [except
captains chairs])
• Drive wheel suspension to reduce vibration
• Meets the definition of multiple-power option
• Minimum top end speed – 4.5 mph
• Accommodates a ventilator
• Standard integrated or remote joystick
• Dynamic stability incline – 7.5 degrees
• Seat width – minimum of 5 one-inch options
• Seat depth – minimum of 3 one-inch options
• Seat height – adjustment requirements = 3 inches
• Back height – adjustment requirements minimum of 3
options
• May not have crossbrace construction
• Seat-to-back angle range of adjustment – minimum of
12 degrees
lateral hip supports, medial thigh supports [except
captains chairs])
systems
lateral hip supports, medial thigh supports)
• Adjustability for growth (minimum of 3 inches for
width, depth, and back height adjustment)
• Special developmental capability (i.e., seat to floor,
standing)
The following are additional requirements that Group 2
through Group 4 PWCs must meet in addition to all of
the specified basic components previously listed:
Group 2 through Group 4 No-Power Option
• Incapable of upgrade to expandable controller
• Incapable of upgrade to alternative control devices
• Passed crash test
• Meets the definition of no-power option
The following are additional requirements that Group 5
PWCs must have in addition to the specified basic
components previously listed:
systems (e.g., recline-only backs, manually elevating
leg rests [except captains chairs])
Group 5 Single-Power Option
Group 2 through Group 4 Single-Power Option
• Single-Power Option PWC that can accept and
operate a power tilt, power recline, power standing,
or power seat elevation system but not a combination
power tilt and recline seating system. This PWC may
also be able to accommodate power elevating leg rests,
• Meets the definition of single-power option
26
May/June 2010
All Providers
seat elevator, or standing system in combination with a
power tilt or power recline.
The client has a documented medical need for a feature
that is not available on a lower level PWC.
The submitted documentation for a Group 4 PWC must
include a complete assessment that is signed and dated
by the physician or a licensed physical or occupational
therapist and includes the following:
Group 5 Multiple- Power Option
• Multiple-Power Option PWC that can accept and
operate a combination power tilt and recline seating
system. This PWC may also be able to accommodate
power elevating leg rests, a power seat elevator, or a
power standing system.
• A description of the environment where the PWC will
be used in the routine performance of MRADLs.
• A listing of the MRADLs that would be possible with
the use of a Group 4 PWC that would not be possible
without the Group 4 PWC.
• Accommodates a ventilator.
Prior Authorization
The following is a list of additional prior authorization
criteria a client must meet for each wheelchair group to
be considered for prior authorization for the rental or
purchase of a powered wheelchair.
• The distance the client is expected to routinely travel
on a daily basis with the Group 4 PWC.
Group 1 Power Wheelchair:
Note: The enhanced features found on a Group 4 PWC
must be medically necessary to meet the client’s routine
MRADL and will not be approved for leisure or recreational activities.
• The client will use the PWC indoors on smooth, hard
surfaces.
• The client weighs less than 125 pounds.
• The client will not encounter obstacles in excess of .75
inch.
• The client may grow up to 5 inches in width.
• The client will use the PWC for less than 2 hours per
day.
Group 5 Pediatric Power Wheelchair
• The client is expected to grow in height.
Group 2 Power Wheelchair
• The client may require a change in seat to floor height
up to 3 inches.
• The client will not routinely use the PWC for MobilityRelated Activities of Daily Living (MRADL) outside
the home.
• The client may require a seat-to-back angle range of
adjustment in excess of 12 degrees.
• The client will use the PWC for 2 or more hours per day.
• The client requires special developmental capability
(i.e., seat to floor, standing, and so on).
• The client will not encounter obstacles in excess of 1.5
inches.
Group 5 Pediatric Power Wheelchair with SinglePower Option
• The client meets criteria for a Group 5 PWC.
• The client’s mobility limitation is due to a neurological
condition, myopathy, or congenital skeletal deformity.
• The client requires a drive control interface other
than a hand- or chin-operated standard proportional
joystick (examples include, but are not limited to, head
control, sip -and-puff, switch control).
• The client may routinely use the PWC for MRADLs
outside of the home.
• The client will use the PWC primarily on smooth or
paved surfaces.
Group 5 Pediatric Power Wheelchair with
Multiple-Power Option
• The client will not encounter obstacles in excess of 2.5
inches.
• The client meets criteria for a Group 5 PWC.
• The client requires a drive control interface other
than a hand- or chin-operated standard proportional
joystick (examples include, but are not limited to, head
control, sip-and-puff, switch control).
• The client will routinely use the PWC on rough,
unpaved, or uneven surfaces.
• The client has a documented medical need for a power
tilt and recline seating system and the system is being
used on the wheelchair or the client uses a ventilator
that is mounted on the wheelchair.
• In addition to using the PWC in the home, the client
will routinely use the PWC for MRADLs outside the
home.
• The client will encounter obstacles in excess of 2.25
inches.

May/June 2010
27


All Providers
Prior Authorization Requirements Changed for Some
Unlisted Procedure Codes
prior authorization requirements changed for some
unlisted procedure codes.
• Documentation that this procedure is not investigational or experimental.
• Place of service in which the procedure is to be
performed.
Required Prior Authorization
providers must obtain Primary Care Case Management
(PCCM) prior authorization (precertification) for the
following procedure codes:
Procedure Codes
76496
76497
77399
77499
78399
78499
78999
79999
86849
86999
88399
89240
91299
92499
96999
97139
A0999
B9999
D3999
D4999
D7999
D9999
76499
78099
78599
81099
87999
90749
93799
97799
C9399
D5899
J7599
76999
78199
78699
84999
88199
90899
94799
99199
D0999
D5999
J9999
• The physician’s intended fee for this procedure
including the manufacturers suggested retail price
(MSRP) or other payment documentation.
The prior authorization number must appear on the
claim when it is submitted to TMHP. Claims submitted
without the appropriate prior authorization will be
denied.
77299
78299
78799
85999
88299
90999
96549
99499
D2999
D7899
Authorization Options for Fee-for-Service
The following procedure codes do not require prior
authorization for services to fee-for-service clients, but
a prior authorization may be obtained if all necessary
information is available before the service is rendered:
Procedure Codes: Fee-For-Service Prior
Authorization to Be Optional
20999
21089
21499
21899
22999
23929
24999
25999
27299
27599
27899
28899
29999
30999
31299
31599
32999
38129
38589
40799
41599
41899
42299
42999
43499
43999
44799
44979
46999
47379
47399
47999
49329
49659
49999
50549
51999
53899
54699
55559
58579
58679
58999
59899
66999
67299
67399
67599
68399
68899
76496
76497
76999
77299
77399
77499
78199
78299
78399
78499
78699
78799
78999
79999
84999
85999
86849
86999
88199
88299
88399
89240
90999
91299
92499
93799
96549
96999
97139
97799
99499
A0999
D0999
D2999
D4999
D5899
D5999
D7899
D9999
providers must obtain fee-for-service prior authorization
for the following procedure codes:
Procedure Codes
90749
B9999
C9399
J7599
J9999
Authorization Requirements for PCCM and Feefor-Service Clients
When requesting a PCCM or fee-for-service prior authorization for an unlisted procedure code, providers must
submit the following information with the prior authorization request:
• Client’s diagnosis.
• Medical records that show the prior treatment for this
diagnosis and the medical necessity of the requested
procedure.
• A clear, concise description of the procedure to be
performed.
• Reason for recommending this particular procedure.
• A procedure code that is comparable to the procedure
being requested.
28
22899
26989
29799
31899
40899
43289
45999
48999
50949
55899
64999
67999
76499
78099
78599
81099
87999
90899
94799
99199
D3999
D7999
May/June 2010
All Providers
For the unlisted procedure codes in the preceding
table, providers will have the following options:
Augmentative
Communication Device
Benefit Criteria Change
• Providers may request authorization before
rendering the service.
• After the service has been rendered, providers may
submit all required medical necessity documentation with the claim according to current process.
Effective for dates of service on or after April 1,
2010, benefit criteria for augmentative communication device systems (ACDs) changed for Texas
Medicaid.
Important: Claims submitted for any of these
unlisted procedure codes without prior authorization
will not be denied for lack of authorization, neither is
authorization a guarantee of payment.
The purchase of a carrying case (procedure code
E2599 and modifier U1) is a benefit of Texas
Medicaid when prior authorized with documentation of medical necessity. The prior authorization request must include the make, model, and
purchase date of the ACD system. Modifier U1
must be submitted with procedure code E2599
for reimbursement and prior authorization consideration of a carrying case. Procedure code E2599
with modifier U1 is payable to home health durable
medical equipment (DME) providers and medical
supplier (DME) providers in the home setting, with
a reimbursement rate of $87.40. Carrying cases are
limited to one every three years.
Requesting Optional Prior Authorization
Providers have the option to obtain prior authorization before rendering the service if all of the required
information is available. When requesting a prior
authorization for an unlisted procedure code for
a fee-for-service client, providers must submit the
following information with the prior authorization
request:
• Client’s diagnosis.
• Medical records that show the prior treatment for
this diagnosis and the medical necessity of the
requested procedure.
The trial period for an ACD system changed from
six months to three months. Purchase of an ACD
system will be prior authorized only after the client
has completed a three-month trial period that
includes experience with the requested ACD system.
The trial period may be completed through rental
of the ACD system, use in the school setting, or use
in another setting determined by a licensed speechlanguage pathologist. In a situation where an ACD
is not available for rental and the client has recent
documented experience with the requested ACD
system, purchase can be considered.
performed.
• Reason for recommending this particular
procedure.
• A procedure code that is comparable to the
procedure being requested.
• Place of service in which the procedure is to be
performed.
ACD systems, equipment, and accessories that
are purchased are expected to last a minimum of
three years, instead of five years. Prior authorization
for replacement will be considered when one of the
following occurs:
including the manufacturers suggested retail price
(MSRP) or other payment documentation.
If any of this information is unavailable at the time
the prior authorization is requested, the request will
be returned as incomplete; however, this is not a
denial of reimbursement. If the required information
becomes available before the service is performed, the
prior authorization request can be resubmitted, or the
required medical necessity and payment documentation can be submitted with the claim after the service
is provided to be considered for reimbursement.
May/June 2010
• The client’s condition has changed such that
the current device no longer meets the client’s
communication needs.
• The ACD system is no longer functional, and it is
either not possible or not cost-effective to repair.

29


All Providers
Changes to the Personal Care Services Benefit
Eligible Texas Medicaid clients who are enrolled in a
waiver program through the Department of Aging and
Disability Services (DADS) may also receive personal care
services (PCS) as long as the services that are provided
through the waiver program do not duplicate the PCS.
Also, effective January 15, 2010, the U8 modifier for
procedure code T1019, which is used by Consumer
Directed Services agencies (CDSA) to submit claims for
the monthly administrative fee, must be prior authorized.
Texas Medicaid clients who are enrolled in the following
DADS waiver programs may access the PCS benefit if they
meet the eligibility requirements for PCS:
• Community Living Assistance and Support Services
(CLASS)
• Deaf/Blind Multiple Disabilities (DBMD)
• Community-Based Alternatives (CBA)
• Consolidated Waiver Program (CWP)
• Medically Dependent Children Program (MDCP)
• Texas Home Living Waiver (TxHmL)
• Youth Empowerment Services (YES)
• Home and Community Services (HCS)
Important: Clients who receive HCS Residential Support
Services, Supervised Living Services, or Foster/Companion
Care Services are not eligible to receive attendant care
services through the PCS benefit.
Effective December 14, 2009, clients who meet the
eligibility requirements of more than one program, must
choose through which program to receive attendant care.
Clients have the following options for how attendant care
services are delivered:
• The client can receive all attendant care services through
Texas Medicaid PCS, and receive additional services
offered through the waiver program, such as habilitation,
respite, therapies, and nursing.
programs have a higher reimbursement rate for the FMS fee
than the Texas Medicaid PCS benefit, so CDSA should file
claims for the monthly FMS fee through the waiver programs.
Effective January 15, 2010, the U8 modifier for PCS, which is
used when submitting claims for the monthly administrative
fee, must be prior authorized. This will affect only authorizations granted on or after January 15, 2010, for clients who
are using the CDS option. The Department of State Health
Services (DSHS) case managers have two options when
sending a prior authorization request for PCS to TMHP.
• If a client is using the CDS option for Texas Medicaid PCS
only, the case managers will submit a prior authorization
request to TMHP approving either the U7 or UB modifier
as well as the U8 modifier. In this case the provider authorization notification letter will include the U8 modifier, in
addition to the U7 or UB modifier.
• If a client is using the CDS option for both Texas Medicaid
PCS and a waiver program, the case managers will submit
a prior authorization request to TMHP approving either
the U7 or UB modifier. The U8 modifier will not be prior
authorized in this situation.
When a provider authorization notification letter is received
by a CDSA, the provider should verify that the correct
modifiers have been prior authorized for each PCS client.
Providers that think the approved modifiers are incorrect
should contact the DSHS case manager and ask for the
correct modifiers to be submitted to TMHP for prior
authorization.
Claims for Texas Medicaid PCS must be billed using
procedure code T1019 and the appropriate modifier. The
table below provides the modifiers that may be authorized for
PCS clients and a description of each modifier (Mod).
Mod Provider Type
U6
All PCS providers
(except CDSA)
U7
CDSA under the
CDS option
U8
CDSA under the
CDS option
• If the waiver offers attendant care, the client can decline
Texas Medicaid PCS and receive all attendant care
services through the waiver program, as well as any
additional services offered through the waiver.
Under the Consumer Directed Services (CDS) option,
clients must choose one CDS agency to provide services
through Texas Medicaid PCS and also the waiver program,
if the clients are receiving services through both programs.
CDS agencies (CDSA) are permitted to file the Financial
Management Services (FMS) fee, also known as the
monthly administrative fee, through one program. The
CDSA should file the FMS claim through the program
with the highest reimbursement rate. Currently, the waiver
UA
UB
Description
Attendant fee each 15 minutes
Attendant fee each 15 minutes
Administrative fee once a
month (U8 will not be authorized if the client is using
the CDS option for PCS and
for services through a waiver
program)
All PCS providers Behavioral enhanced rate atten(except CDSA)
dant fee each 15 minutes
CDSA under the Behavioral enhanced rate attenCDS option
dant fee each 15 minutes

30


May/June 2010
All Providers
Texas Medicaid Sleep Studies Benefits Change
sleep study benefits changed for Texas Medicaid. The
following sleep study procedure codes may be reimbursed
by Texas Medicaid, prior authorization is not required:
under the direct supervision of a polysomnographic
technician, polysomnographic technologist, or a
physician (Doctor of Medicine [MD] or Doctor of
Osteopathy [DO]).
• 95803 for actigraphy
Note: Direct supervision means that the supervising
licensed/certified professional must be present in the office
suite or building and immediately available to furnish
assistance and direction throughout the performance of the
service. It does not mean that the supervising professional
must be present in the room while the service is provided.
• 95805 for multiple sleep latency testing (MSLT)
• 95807 for pneumocardiograms
• 95808, 95810, and 95811 for polysomnography
Procedure code 95806 is not a benefit of Texas Medicaid.
• The polysomnographic technologist provides comprehensive evaluation and treatment of sleep disorders
under the general supervision of the clinical director
who must be an MD or DO.
will be denied if billed on the same date of service as the
corresponding procedure codes in Column B:
Column A (Denied)
95803
95810, 95811
95811
Column B
95807, 95808, 95810, 95811
95808
95810
• The polysomnographic technician provides comprehensive polysomnographic testing and analysis and
associated interventions under the general supervision
of a polysomnographic technologist or clinical director
(MD or DO).
Note: The procedure codes in this article are subject to
the Centers for Medicare & Medicaid Services (CMS)
National Correct Coding Initiative (NCCI) relationships.
Any exceptions to NCCI code relationships are specifically noted in this table. Providers may refer to the CMS
website at www.cms.hhs.gov/NationalCorrectCodInitEd/ for
more information about NCCI correct coding guidelines
and specific applicable code combinations.
• The supervising physician must be readily available to
the performing technologist throughout the duration
of the study, but is not required to be in the building.
The sleep facility must have one or more supervising
physicians who are responsible for the direct and ongoing
oversight of the quality of the testing performed, the
proper operation and calibration of equipment used to
perform tests, and the qualifications of the nonphysician
staff who use the equipment.
Sleep Facility/Laboratory Benefits and
Limitations
Services provided without the required level of
supervision are not reasonable and necessary.
Sleep facilities that perform services for Texas Medicaid
clients must follow current American Academy of Sleep
Medicine (AASM) practice parameters and clinical
guidelines.
Actigraphy testing and the performance of pneumocardiograms are not subject to sleep lab restrictions.
Physicians who provide supervision in sleep facilities
must be board-certified or board-eligible, as outlined in
the AASM guidelines.
Actigraphy
Actigraphy (procedure code 95803) may be reimbursed
to physicians in the office or outpatient hospital setting
with a limit of two per rolling year (but not on the same
day) any provider.
Sleep facility technicians, technologists, and trainees
must demonstrate that they have the skills, competencies, education, and experience that are set forth by
their certifying agencies and AASM as necessary for
advancement in the profession.
Claims denied for more than two times per year may be
appealed with documentation of medical necessity.
Actigraphy may be reimbursed as follows:
The polysomnographic technologists, technicians,
and trainees must meet the following supervision
requirements:
Client Age
Total Component
Birth through 20 years
of age
• The polysomnographic trainee provides basic polysomnographic testing and associated interventions
May/June 2010
Reimbursement Rate
31
$94.80
(3.31 RVUs, $28.640 CF)
All Providers
Client Age
• When more objective information regarding the dayto-day timing or the amount or patterns of a patient’s
sleep is necessary for optimal clinical decision-making.
Reimbursement Rate
Total Component
21 years of age or older
$90.28
(3.31 RVUs, $27.276 CF)
• When the severity of a sleep disturbance reported
by the patient or caretaker seems inconsistent with
clinical impressions or laboratory findings.
Professional Interpretation Component
of age
$22.63
(0.79 RVU, $28.640 CF)
$21.55
(0.79 RVU, $27.276 CF)
• To clarify the effects of, and under some instances,
compliance with pharmacologic, behavioral, phototherapeutic, or chronotherapeutic treatment.
Technical Component
of age
• In symptomatic patients for whom an accurate history
cannot be obtained and at least one of the following is
true:
$72.17
(2.52 RVUs, $28.640 CF)
$68.74
(2.52 RVUs, $27.276 CF)
- A polysomnographic study has already been
conducted.
RVU=Relative value unit, CF=Conversion factor
- A polysomnographic study is considered unlikely
to be of much diagnostic benefit.
Actigraphy (procedure code 95803) must be billed with
one of the following diagnosis codes:
Diagnosis Codes
32700
32701
32711
32712
32719
32730
32734
32735
32751
33394
32702
32713
32731
32736
78052
32709
32714
32732
32737
78054
- A polysomnographic study is not yet clearly
indicated (because of the absence of accurate
historical data).
32710
32715
32733
32739
78055
- A polysomnographic study is not immediately
available.
Actigraphy may be useful in the assessment of specific
aspects of the following disorders:
• Insomnia. Assessment of sleep variability, measurement
of treatment effects, and detection of sleep phase
alterations in insomnia secondary to circadian rhythm
disturbance.
If the primary care physician performs the actigraphy,
the technical component must be billed (procedure code
95803 with modifier TC).
Actigraphy can be performed as a stand-alone procedure
or as an adjunct to polysomnography or MSLT.
• Restless legs syndrome or periodic limb movement disorder.
Assessment of treatment effects.
Documentation of actigraphy testing must include a
hard-copy printout or electronic file. Interpretation and
treatment recommendations must be completed by a
sleep specialist.
Multiple Sleep Latency Test (MSLT)
MSLT procedure code 95805 may be reimbursed as
follows:
The physician’s professional interpretation and report
must include inspection of the entire recording and
integration of the information gathered from other
professionals’ analysis and observations. Documentation
of the interpretation must be maintained by the interpreting physician.
• Total component. May be reimbursed to physicians and
radiological and physiological laboratory providers in
the office setting; no longer reimbursed to radiological
and physiological laboratories and hospital-based
rural health clinics (RHCs) in the outpatient hospital
setting; and no longer reimbursed in the independent
laboratory setting.
Under the following conditions, actigraphy may be a
useful adjunct to a detailed history, examination, and
subjective sleep diary for the diagnosis and treatment
of insomnia, circadian-rhythm disorders, and excessive
sleepiness under any of the following conditions:
• Professional interpretation component. May be
reimbursed to physicians in the office setting; no
longer reimbursed in the independent laboratory
setting; and no longer reimbursed to radiological and
physiological laboratory providers in the outpatient
hospital setting.
• When demonstration of multiday rest-activity patterns
is necessary to diagnose, document severity, and guide
the proper treatment.
32
May/June 2010
All Providers
• Technical component. May be reimbursed to radiological and physiological laboratory providers in the
office setting; no longer reimbursed in the independent
laboratory setting; and no longer reimbursed in the
MSLT procedure code 95805 must be performed in
conjunction with polysomnography procedure code
95808, 95810, or 95811. Polysomnography must be
performed on the date before MSLT. MSLT that is not
performed in conjunction with polysomnography will be
denied, but may be considered on appeal with documentation that explains why the polysomnography did not
occur.
MSLTs are limited to two per rolling year (not on the
same day) when billed by any provider. Claims denied
for more than two times per year may be appealed with
documentation of medical necessity.
Pneumocardiograms
Pneumocardiograms (procedure code 95807) are limited
to clients who are birth through 12 months of age.
Providers may refer to the Online Fee Lookup and
appropriate Texas Medicaid fee schedule available on
the TMHP website at www.tmhp.com for payable sleep
study procedure codes.
Procedure code 95807 may be reimbursed as follows:
• Total component. May be reimbursed to hospitals in the
outpatient hospital setting with a reimbursement rate
of $391.80 (RVUs 13.68 / CF 28.640).
MSLT may be reimbursed for diagnosing narcolepsy and
other hypersomnias and must be billed with one of the
Diagnosis Codes
32700
32701
32751
33394
34711
78053
32702
34700
32709
34701
reimbursed to physicians in the office, inpatient
hospital, or outpatient hospital setting with a reimbursement rate of $63.58 (RVUs 2.22 / CF 28.640).
32743
34710
Pneumocardiograms are limited to two per rolling year
(not on the same day) any provider. Claims denied for
more than two times per year may be appealed with
documentation of medical necessity.
Documentation of MSLT must be maintained in the
client’s medical record at the sleep lab and include
hard copy or electronic copy of four to five, 20-minute
recordings of sleep-wake states and stages spaced at twohour intervals throughout the day, taking approximately
seven to nine hours to complete. In addition, documentation must include the physiological recordings typically
made during daytime testing. These typically include:
Procedure code 95807 must be billed with one of the
Diagnosis Codes
32723
77081
77982
79982
32721
32727
77981
79902
• Electroencephalogram (EEG)
• Electro-oculogram (EOG)
• Electromyogram (EMG)
• Audio and video recordings made during the
monitored portion of the day
Documentation must also include the technologist’s
analysis and report, the patient’s subjective report, and
the influence of intervention applied during the night.
32726
77084
78604
The physician’s interpretation and report must include
inspection and integration of the information gathered
from all physiological systems and other professionals’
analysis and observations.
Interpretation and treatment recommendations must be
completed by a sleep specialist. The physician’s interpretation and report must include inspection of the entire
recording, examination of the technologist’s analysis and
observations, and integration of the information gathered
from all physiological systems. Documentation of the
interpretation must be maintained in the sleep lab and by
the interpreting physician.
32725
77083
78603
Documentation of the complete readings associated with
the pneumocardiogram and the physician’s interpretation
must be maintained in the client’s medical record in a
hard-copy printout or electronic file at the facility where
the procedure is performed.
• Electrocardiogram (EKG)
May/June 2010
32724
77082
7825
Polysomnography
The polysomnography procedure codes 95808, 95810,
and 95811 may be reimbursed as follows:
• Total component. May be reimbursed to physicians and
radiological and physiological laboratory providers
in the office setting; no longer reimbursed to radiological and physiological laboratory and hospital-based
33
All Providers
rural health clinic (RHC) providers in the outpatient
hospital setting; and no longer reimbursed in the
independent laboratory setting.
Documentation of the polysomnography testing must
be maintained in the client’s medical record at the
sleep lab and include approximately 1,000 pages or the
electronically-stored equivalent of data during a single
nighttime recording. Each record must be for sleep-wake
states and stages, cardiac arrhythmias, respiratory events,
motor activity, oxygen desaturations, and behavioral
observations.
reimbursed to physicians in the office setting; no
longer reimbursed in the independent laboratory
setting; and no longer reimbursed to radiological and
physiological laboratory providers in the outpatient
hospital setting.
Documentation must also include the technologist’s
analysis and report, the patient’s subjective report, and
the influence of intervention applied during the night.
• Technical component. May be reimbursed to radiological and physiological laboratory providers in the
office setting; no longer reimbursed in the independent
laboratory setting; and no longer reimbursed in the
Interpretation and treatment recommendations must be
completed by a sleep specialist. The physician’s professional interpretation and report must include inspection
of the entire recording, examination of the technologist’s analysis and observations, and integration of the
information gathered from all physiological systems.
Documentation of the interpretation must be maintained
in the sleep lab and by the interpreting physician.
Polysomnograpy is limited to two per rolling year (not
on the same day), any provider. Claims denied for more
than two times per year may be appealed with documentation of medical necessity.
Providers may refer to the Online Fee Lookup and
appropriate Texas Medicaid fee schedule available on the
TMHP website for payable sleep study procedure codes.
Polysomnography is distinguished from sleep studies by
the inclusion of sleep staging, which includes a 1-4 lead
EEG, EOG, and a limb or submental EMG. Additional
parameters of sleep that are evaluated in polysomnography may include, but are not limited to, the following:
Polysomnography (procedure codes 95808, 95810, and
95811) must be billed with one of the following diagnosis
codes:
Diagnosis Codes
29182
30743
30748
32711
32720
32725
32731
32736
32742
32752
3350
3439
34711
51883
7564
78054
78059
27801
30742
30747
32710
32719
32724
32730
32735
32741
32751
33394
34120
34710
47410
7560
78053
78058
29285
30744
32700
32712
32721
32726
32732
32737
32743
32753
33511
34400
3481
60784
78050
78055
78603
30740
30745
32701
32713
32722
32727
32733
32739
32744
32759
33519
34700
3590
7428
78051
78056
79902
• EKG
• Airflow (by thermistor or intranasal pressure
monitoring)
30741
30746
32702
32715
32723
32729
32734
32740
32749
3278
33520
34701
3591
7483
78052
78057
• Respiratory effort
• Adequacy of oxygenation by oximetry or transcutaneous monitoring
• Extremity movement and motor activity
• EEG monitoring for sleep staging
• Nocturnal penile tumescence
• Esophageal pH or intraluminal pressure monitoring
• Continuous blood pressure monitoring
• Snoring
• Body positions
• Adequacy of ventilation by end-tidal or transcutaneous
CO2 monitoring
The information in this article updates the 2009 Texas
Medicaid Provider Procedures Manual, section 36.4.42,
“Polysomnography,” on page 36-106.
For a study to be reported as polysomnography, sleep
must be recorded and staged for a minimum of four
hours.
34
May/June 2010
All Providers
Nonsolid Organ Transplant Benefits Changed
benefits for stem cell transplant services changed for Texas
Medicaid.
In the following table the procedure codes in
Column A will be denied if they are billed with the same
date of service by the same provider as the corresponding
procedure codes in Column B:
Column A (Denied)
36000, 36410, 36430, 37202, 51701, 51702,
51703, 62318, 62319, 64415, 64417, 64450,
64470, 64475, 96360, 96365, 96372, 96374,
96375
36000, 36410, 36430, 37202, 62318, 62319,
64415, 64417, 64450, 64470, 64475, 96360,
96365, 96372, 96374, 96375
86890, 86891
86950
Benefits are not available for any experimental or
investigational services, supplies, or procedures.
The following transplant benefits were added:
• Autologous islet cell transplantation associated with the
complete or partial removal of the pancreas (procedure
code 48160) is a benefit of Texas Medicaid only for
clients with a diagnosis of chronic pancreatitis (diagnosis
code 5771). Allogeneic islet cell transplantation is not a
benefit.
The following table includes the changes that apply to the
indicated procedure codes:
Procedure
Code
Reimbursement Changes
38206
Surgical component: May be reimbursed
to nurse practitioner (NP), clinical nurse
specialist (CNS), and physician assistant
(PA) providers in the inpatient hospital or
38240,
Surgical component: May be reimbursed to
38241
NP, CNS, PA, physician, and ambulatory
surgical center providers in the outpatient
hospital setting.
May be reimbursed to ambulatory surgical
centers according to the Group 4 rate.
48160
physician providers in the inpatient hospital
setting.
Assistant surgery component: May be
reimbursed to NP, CNS, PA, and physician
providers in the inpatient hospital setting.
S2142
Surgical component: May be reimbursed
to NP, CNS, PA, and physician providers in
the inpatient hospital or outpatient hospital
settings. May be reimbursed to ambulatory
surgical center providers in the outpatient
hospital setting.
38240,
38241
38206
38240,
38241,
38242
99201, 99202, 99203, 99204, 99205, 99211, 38206
99212, 99213, 99214, 99215, 99217, 99218,
99219, 99220, 99221, 99222, 99223, 99231,
99232, 99233, 99234, 99235, 99236, 99238,
99239, 99241, 99242, 99243, 99244, 99245,
99251, 99252, 99253, 99254, 99255, 99281,
99282, 99283, 99284, 99285, 99291, 99293,
99294, 99295, 99296, 99298, 99299, 99300,
99304, 99305, 99306, 99307, 99308, 99309,
99310, 99315, 99316, 99318, 99324, 99325,
99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350, 99477
• Surgical procedure code S2142 replaced procedure code
38999 for umbilical cord blood transplants. Procedure
code 38999 is no longer reimbursed for umbilical cord
blood transplants. Providers must use procedure code
S2142.
May/June 2010
Column B
38206,
38230,
38242
Note: The procedure codes included in this article are subject to
Correct Coding Initiative (CCI) relationships. Any exceptions to
CCI code relationships are specifically noted. Providers may refer
to CCI on the Centers for Medicare & Medicaid Services (CMS)
website for correct coding guidelines and specific applicable code
combinations.
Under current Texas Medicaid policy, procedures are
considered to be medically necessary and reasonable
based on safety and efficacy, as demonstrated by
scientific evidence and by controlled clinical studies.
Nonsolid organ transplants covered by Texas Medicaid
include allogeneic and autologous stem cell transplantation, allogeneic and autologous bone marrow transplantation, and autologous islet cell transplantation.
Benefits are not available for any experimental or investigational services, supplies, or procedures.
Authorization Requirements
All nonsolid organ transplants require prior authorization and must be performed in a Texas facility that is a
designated children’s hospital or a facility in compliance
35
All Providers
Reimbursement Rates Changed
for DME Services
with the criteria set forth by the Organ Procurement and
Transportation Network (OPTN), the United Network
for Organ Sharing (UNOS), or the National Marrow
Donor Program (NMDP).
reimbursement rates changed for some durable medical
equipment (DME) services procedure codes.
The reimbursement rates for DME services in the
following table apply to clients of all ages:
TOS
J
J
J
L
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
J
The prior authorization is effective for the date span
specified on the prior authorization approval letter. If
the transplant has not been performed by the end of the
authorization period, the provider must apply for an
extension.
Documentation supplied with the prior authorization
request must include all of the following:
• A complete history and physical
• A statement of the client’s current medical condition
and the expected long-term prognosis for the client
from the proposed procedure
Each subsequent transplant procedure requires a separate
prior authorization.
For more information, providers may refer to the
2009 Texas Medicaid Provider Procedures Manual,
section 25.2.3.7, “Organ/Tissue Transplant Services,”
on page 25-12 and section 36.4.32, “Organ/Tissue
Transplants,” on page 36-87.
Procedure
Code
Modifier
E0184
E0186
E0303
E0303
E0445
TF
E0950
E0958
E0971
E1016
E1020
E1235
E1236
E2218
E2222
E2225
E2226
E2321
E2329
E2330
E2370
E2371
E2376


Reimbursement Rate
$479.07
$1,716.28
$4,883.62
$488.36
$1,336.60
$176.30
$697.00
$55.35
$130.38
$229.60
$2,897.00
$3,182.00
$45.10
$60.68
$41.00
$51.66
$1,763.00
$2,237.38
$3,333.27
$876.15
$186.00
$1,342.24

OFL Updated for Some Radiology Procedure Codes
The online fee lookup (OFL) has been updated to include the following radiology procedure codes that did not display
correctly:
Procedure Codes
70170
73530
74363
74400
75807
75810
75992
76001
74190
74410
75894
76125
74235
74415
75896
76930
74300
74420
75898
76932
74301
74425
75900
76940
74305
74445
75940
76945
74328
74450
75945
76975
74329
74470
75946
74330
75801
75970
74355
75803
75980
74360
75805
75982
The static fee schedules will be updated with the regularly scheduled quarterly update.
36
May/June 2010
All Providers
Limitations Change for Laboratory Services Procedure Codes
after January 1, 2009, the limitations for some laboratory
services procedure codes changed for Texas Medicaid
(CSHCN) Services Program. Affected claims will be
reprocessed, and payments will be adjusted accordingly.
No action on the provider is required.
Type of
Service
5
5
5
5
5
5
5
5
The following table shows the revised limitations for
laboratory services procedure codes that are effective for
dates of service on or after January 1, 2009:
Type of
Service
5
5
5
5
5
5
5
5
5
5
5
5
3
5
Procedure
Code
80048
80051
80053
80055
80069
80101
80102
80176
80190
80192
80196
80198
80500
81020
5
81050
5
82040
5
5
5
5
5
5
5
5
5
5
82042
82127
82128
82131
82136
82139
82172
82190
82247
82310
5
5
82330
82331
Limitations
2 per day, same provider
2 per day any provider
1 per day, any provider, 6 per
calendar month, any provider
4 per day, same provider, 4 per
2 per day, any provider
Unlimited
May/June 2010
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
37
Procedure
Code
Limitations
82379
3 per say, same provider
82435
82491
82550
82552
82553
82554
82565
82657
82658
82784
82787
82926
82928
82952
82962
Unlimited
83015
83018
83020
83021
83050
83080
2 per 210 days, any provider
83735
83883
83912
83914
83918
83919
83921
83925
84132
84157
84182
84295
84520
All Providers
Type of
Service
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Procedure
Code
84600
85732
86000
86001
86003
86146
86147
86160
86161
86171
86185
86235
86255
86256
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
86317
86356
86376
86403
86406
87015
87046
87076
87077
87088
87106
87107
87116
87118
87140
87147
87181
87184
87186
87187
87188
87190
87206
87209
87252
87253
87254
Limitations
Unlimited
Unlimited
3 per day, same provider, same
procedure
38
Type of
Service
5
5
5
5
5
5
5
Procedure
Code
87279
87299
87300
87449
87798
87799
87901
5
87903
5
5
5
5
5
87904
88104
88106
88107
88125
5
5
5
5
5
5
5
5
5
5
88141
88142
88143
88147
88148
88150
88152
88153
88154
88160
5
88161
5
5
5
5
5
88164
88165
88166
88167
88172
5
88173
5
5
5
5
88174
88175
88185
88237
5
88239
Limitations
rolling year
rolling year
procedure
procedure
procedure
procedure
procedure
rolling year, any provider
rolling year, any provider
May/June 2010
All Providers
Type of
Service
5
5
5
Procedure
Code
88240
88285
88291
5
5
5
5
5
5
5
5
5
88300
88302
88304
88305
88307
88311
88312
88313
88314
5
88318
5
5
5
5
5
88319
88329
88331
88332
88334
5
5
5
5
88342
88346
88347
88360
5
88361
5
88365
5
88367
5
88368
5
5
5
5
5
5
88372
Q0112
S3620
S3625
S3626
S3840
Limitations
2 per day any provider
procedure
procedure
procedure
procedure
procedure
procedure
procedure
procedure
procedure
1 per life any provider
2 per pregnancy
2 per pregnancy
1 per lifetime any provider


Physical, Occupational,
and Speech Therapy for
CCP Clarification
Procedure code 97535 is used for speech therapy
(ST) services for training for augmentative
communication devices (ACD). To request prior
authorization for procedure code 97535 for ST
services, providers must submit procedure code
97535 with the GN modifier. Additionally, all
claims for procedure code 97535 for ST services
must be billed with the GN modifier.
Effective January 1, 2010, providers must
specifically request procedure code 97535
separate from requests for other therapy
services (physical [PT], occupational [OT],
and ST). Procedure code 97535 is not included
in PT and OT authorizations unless specifically requested. Prior authorization requests
for procedure code 97535 must include the
appropriate modifier for the type of therapy
being requested and specify the amount of time
requested for this procedure code.
When requesting prior authorization for PT,
OT, and ST services, providers must include
the frequency and amount of time they are
requesting.

May/June 2010
39
All Providers
Renal Dialysis Services Criteria Changed for Texas Medicaid
Effective for dates of service on or after March 1, 2010, benefit
criteria for renal dialysis services changed for Texas Medicaid.
Physician Services
Physician evaluation procedure codes 90935, 90937, 90945,
and 90947 are a benefit as shown in the following table:
Place of
Services
Service
End-stage renal Inpatient
disease (ESRD)
Non-ESRD
Inpatient
Outpatient,
office
• Antibiotics, except when prescribed for clients to treat
infections or peritonitis related to peritoneal dialysis
• Hematinics
Physician
Physician, nurse practitioner (NP), clinical
nurse specialist (CNS),
physician assistant
• Anabolics
• Muscle relaxants
• Analgesics
• Sedatives
• Tranquilizers
• Thrombolytics used to declot central venous catheters
Physician supervision of outpatient ESRD services includes
services provided by the attending physician in the course of
office visits where any of the following occur:
• Intravenous levocarnitine (procedure code J1955),
for ESRD clients who have been on dialysis for a
minimum of three months with one of the following
indications (All other indications for levocarnitine are
not covered.):
• The routine monitoring of dialysis.
• The treatment or follow-up of complications of dialysis,
including:
- The evaluation of related diagnostic tests and procedures.
- Services involved in prescribing therapy for illnesses
unrelated to renal disease, if the treatment occurs without
increasing the number of physician-client contacts.
Providers must use the following procedure codes when billing
for physician supervision of outpatient ESRD services:
Procedure Codes
90952
90957
90962
90967
90953
90958
90963
90968
90954
90959
90964
90969
Procedure Codes
90952 90953
90958 90959
90964 90965
90954
90960
90966
90955
90961
- Carnitine deficiency, defined as a plasma free
carnitine level less than 40 micromoles per liter
- Signs and symptoms of erythropoietin–resistant
anemia that has not responded to standard erythropoietin with iron replacement, and for which
other causes have been investigated and adequately
treated
- Hypotension on hemodialysis that interferes with
delivery of the intended dialysis despite application
of usual measures deemed appropriate (e.g., fluid
management). Such episodes of hypotension
must have occurred during at least two dialysis
treatments in a 30-day period.
90955
90960
90965
90970
Procedure codes 90967, 90968, 90969, and 90970 will be
denied when billed within the same calendar month by any
provider as the procedure codes in the following table. Only
one of the procedure codes in the following table will be
reimbursed per calendar month, any provider.
90951
90957
90963
Medically necessary drugs that are not included in the
composite rate may be separately reimbursed when
provided by and administered in the dialysis facility by
facility staff. Staff time and supplies used to administer
the drugs are included in the composite rate.
Examples include, but are not limited to:
Provider Type
Physician
Only one of procedure code 90935, 90937, 90945, or 90947
may be reimbursed per day, any provider.
90951
90956
90961
90966
Drugs
Note: Continued use of levocarnitine is not covered if
improvement has not been demonstrated within six months
of the initiation of treatment.
The ordering physician must maintain documentation in
the client’s medical record to support medical necessity.
procedure code J1955 is no longer age-restricted and is
a benefit for services that are provided by a physician,
NP, CNS, physician assistant, renal dialysis facility, or
nephrology provider in an office setting, and for services
provided by a hospital in an outpatient setting.
90956
90962
40
May/June 2010
All Providers
Updates to the 2010 HCPCS Special Bulletin, No. 2
Home Health Mobility Aids Services
This is a correction to the 2010 Healthcare Common
Procedure Coding System (HCPCS) Special Bulletin, No. 2,
which was posted on December 31, 2009, on the TMHP
website at www.tmhp.com. Some information has been
updated and corrected for hearing services, botulinum
toxin type A and type B services, radiology services, cleftcraniofacial teams services, and home health mobility
aids services.
The 2010 HCPCS Special Bulletin incorrectly indicated
that home health mobility aids procedure code E2329
had been discontinued. The correct information is as
follows:
procedure code E2329 may continue to be reimbursed
by the Texas Medicaid home health program. Procedure
code E2393 is discontinued and will not be reimbursed
after December 31, 2009.
2010 HCPCS Procedure Code Additions
– Correction
The added procedure codes table incorrectly indicated
that procedure code A9604 was a proposed benefit
pending approval of expenditures for Texas Medicaid
(CSHCN) Services Program. The correct information is
that effective January 1, 2010, procedure code A9604 is
not covered by Texas Medicaid or the CSHCN Services
Program.
Otology and Audiometry Services
The following procedure codes are benefits of Texas
Medicaid as indicated:
The medical service component for procedure code 92540
may be reimbursed to physician and radiological and
physiological laboratory providers in the office setting.
Procedure code 92540 may be reimbursed to physician
The professional interpretation component may be reimbursed to physician providers in the office, inpatient hospital,
or outpatient hospital setting.
The technical component for procedure code 92540 may be
reimbursed to physician and radiological and physiological
laboratory providers in the office setting.
Note: Procedure code 92540 will not be reimbursed to
audiology, NP, CNS, or PA providers.
Texas Medicaid Benefit Changes – Updates
and Corrections
Gynecological and Reproductive Health Services
Effective January 1, 2010, procedure code A4264 has
been added.
Procedure code A4264 may be reimbursed to nurse practitioner (NP), clinical nurse specialist (CNS), physician
assistant (PA), physician, and family planning clinic
providers in the office setting and to ambulatory surgical
center providers in the outpatient hospital setting.
Procedure code A4264 may be reimbursed once per
lifetime for the occlusive sterilization device provided to
female clients who are 21 years of age or older.
Procedure codes 92550 and 92570
The total component for procedure codes 92550 and
92570 may be reimbursed to physician and audiologist
Procedure codes 92550 and 92570 may be reimbursed to
hospital providers in the outpatient hospital setting.
Reminder: Added procedure codes and their corresponding limitations are proposed changes pending
approval of expenditures. Providers will be notified of the
effective dates of service in a future notification.
Note: Procedure codes 92550 and 92570 will not be
reimbursed to NP, CNS, or PA providers in the office setting
or to independent laboratory providers in the independent
laboratory setting.
procedure code E1399 with modifier UD will no longer
be reimbursed for the occlusive sterilization device. Claims
submitted with procedure code E1399 and modifier UD
may be appealed using procedure code A4264.
Providers may refer to the 2009 Texas Medicaid Provider
Procedures Manual, section 36.4.15.5, “Hysteroscopic
Sterilization,” on page 36-40, and section 20.7.5,
“Contraceptive Devices and Related Procedures,” on
page 20-10, for more information about gynecological
and reproductive health services.
May/June 2010
Provider Procedures Manual, section 23.3.1, “Otology
and Audiological Screening,” on page 23-2, for more
information about hearing testing, screening, and
diagnostics.
41
All Providers
CSHCN Services Program Benefit Changes
– Updates and Corrections
HCPCS Procedure Code 93290
TMHP has identified an issue that affects claims
submitted with procedure code 93290 and dates of
service from January 1, 2009, through December 31,
2009. The 2009 Healthcare Common Procedure Coding
System (HCPCS) Special Bulletin, No. 221, correctly
indicates that procedure code 93290 is not covered by
Texas Medicaid or the Children with Special Health
Care Needs (CSHCN) Services Program; however,
claims were denied with explanation of benefit (EOB)
code 02008, which indicates that procedure code 93290
is a benefit pending a Health and Human Services
Commission (HHSC) rate hearing. The bulletin was
correct; procedure code 93290 is not covered by Texas
Medicaid or the CSHCN Services Program and will not
be reimbursed.
Botulinum Toxin Type A and Type B
In addition to the information provided in the 2010
HCPCS Special Bulletin, procedure code J0586 may be
reimbursed to podiatrist providers in the office setting.
Cleft-Craniofacial Teams Services
The assistant surgery component for procedure code
14302 is not a benefit of the CSHCN Services Program.
Hearing Services
The following procedure codes are benefits of the
CSHCN Services Program as indicated:
The medical service component for procedure code 92540
may be reimbursed to physician and radiological and
physiological laboratory providers in the office setting.
Procedure code 92540 may be reimbursed to physician
2009 HCPCS Benefits for Medical
and DME Procedure Codes
The professional interpretation component may be
reimbursed to physician providers in the office, inpatient
The technical component may be reimbursed to physician
and radiological and physiological laboratory providers in
the office setting.
Note: Procedure code 92540 is not reimbursed to audiologists or advanced practice registered nurse (APRN) providers.
procedure codes C9250, C9360, C9361, and C9362,
from the second and third quarter 2009 Healthcare
Common Procedure Coding System (HCPCS) updates
are benefits of Texas Medicaid. Affected claims will be
NP, CNS, PA, and physician providers may be
reimbursed for these procedures in an office setting.
Hospitals may be reimbursed for these procedures only
in the outpatient hospital setting. Ambulatory surgical
centers may be reimbursed for procedure codes C9360,
C9361, and C9362 only in an outpatient hospital setting.
Procedure codes 92550 and 92570
The total component for procedure codes 92550 and
92570 may be reimbursed to physician and audiologist
Procedure codes 92550 and 92570 may be reimbursed to
hospital providers in the outpatient hospital setting.
Note: Procedure codes 92550 and 92570 are not reimbursed
to APRN providers in the office setting or to independent laboratory providers in the independent laboratory setting.
Note: For the purposes of this article, “advanced practice
registered nurse (APRN)” includes nurse practitioners and
clinical nurse specialists.
The following table shows the reimbursement rates for
the procedure codes that became effective for dates of
service on or after January 1, 2010:
Procedure
Code
Reimbursement Rate
Medical Services
C9250
$155.00
Durable Medical Equipment (DME) Services
C9360
$10.57
C9361
$124.55
C9362
$56.71
TOS
1
9
9
9
Providers may refer to the 2009 CSHCN Services
Program Provider Manual, section 19.2.3, “Audiological
Testing,” on page 19-3, for more information about
hearing testing benefits.
TOS = Type of service
1 = Medical
9 = DME

42


May/June 2010
All Providers
Procedure Code Review Updates for February 2010
the total and technical components have been updated
for some radiology procedure codes.
Procedure Codes
95875
95900
95926
95927
95936
95937
after July 1, 2009, physicians in the office setting may
be reimbursed for the technical component for the
following procedure codes:
Procedure Codes
92541
92542
92546
93225
93236
93303
93320
93321
93508
93510
93526
93527
93531
93532
93571
93572
93609
93610
93623
93721
93799
93975
93980
93981
95813
95816
95921
95922
95956
95958
95904
95929
95999
95925
95934
G0255
the following procedure codes were updated as indicated.
The following changes apply to procedure code 70170:
92543
93226
93304
93325
93511
93528
93533
93600
93612
93724
93976
93982
95819
95923
G0130
92544
93231
93307
93501
93514
93529
93555
93602
93615
93740
93978
94725
95822
95950
92545
93232
93308
93505
93524
93530
93556
93603
93616
93770
93979
95812
95827
95954
• Total component. No longer reimbursed to certified
nurse midwife (CNM), radiation treatment center,
hospital, nephrology (hemodialysis, renal dialysis),
renal dialysis facility, or hospital-based rural health
clinic (RHC) providers in the office setting; and
no longer reimbursed to radiation treatment center,
facility, radiological or physiological laboratory, or
hospital-based RHC providers in the outpatient
hospital setting.
• Technical component. No longer reimbursed to CNM,
radiation treatment center, radiological or physiological
laboratory, or dentistry group providers in the office
setting; and no longer reimbursed in the home, skilled
nursing facility (SNF), intermediate care facility (ICF),
or extended care facility (ECF) setting.
Claims submitted by physicians with the technical
component of any of the procedure codes in the above
table and with dates of service from July 1, 2009,
through January 31, 2010, will be reprocessed, and
payments will be adjusted accordingly. No action on the
part of the provider is required.
• Total component. No longer reimbursed to CNM,
radiation treatment center, hospital, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, or
hospital-based RHC providers in the office setting;
the following procedure codes may be reimbursed only
to physicians and radiological and physiological laboratories in the office setting:
Procedure Codes
93306
93618
93622
93624
93660
94010
94200
94240
94360
94370
94620
94680
94750
94770
95861
95863
95867
95868
95903
95928
95955
93619
93631
94060
94250
94375
94681
94799
95864
95869
93620
93640
94070
94260
94400
94690
95824
95865
95870
May/June 2010
• Technical component. No longer reimbursed to dentist,
CNM, or radiation treatment center providers in the
office setting; and no longer reimbursed in the home,
SNF, ICF, independent laboratory, or ECF setting.
93621
93641
94150
94350
94450
94720
95860
95866
95872
The following changes apply to procedure codes 73530,
74235, 74300, 74301, 74305, 74328, 74329, 74330,
74340, 74360, 74363, 74400, 74410, 74415, 74425,
74445, 74450, 74470, 75801, 75803, 75805, and 75807:
43
All Providers
hospital setting.
hospital setting.
• Technical component. No longer reimbursed to CNM
or radiation treatment center providers in the office
setting; and no longer reimbursed in the home, SNF,
ICF, outpatient hospital, or ECF setting.
ICF, or ECF setting.
The following changes apply to procedure codes 75810,
75894, 75896, 75898, 75900, 75940, 75970, 75980,
76125:
(hemodialysis, renal dialysis), renal dialysis facility,
radiological or physiological laboratory, or hospitalbased RHC providers in the office setting; and no
longer reimbursed to radiation treatment center,
hospital setting.
and no longer reimbursed to radiation treatment
center, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, radiological or physiological laboratory,
or hospital-based RHC providers in the outpatient
hospital setting.
ICF, independent laboratory, or ECF setting.
The following changes apply to procedure codes 74355
and 74420:
hospital, nephrology (hemodialysis, renal dialysis),
renal dialysis facility, radiological or physiological
laboratory, or hospital-based RHC providers in the
office setting; and no longer reimbursed to nephrology
radiological or physiological laboratory, or hospitalbased RHC providers in the outpatient hospital setting.
hospital setting.
• Technical component. No longer reimbursed to
CNM providers in the office setting; and no longer
reimbursed in the home, SNF, ICF, independent
laboratory, or ECF setting.
setting.
longer reimbursed in the radiation treatment center,
hospital setting.
radiological or physiological laboratory, or hospitalbased RHC providers in the office setting; no longer
reimbursed in the inpatient hospital setting; and
44
May/June 2010
All Providers
setting; may be reimbursed to nurse practitioner (NP),
clinical nurse specialist (CNS), physician assistant
(PA), or physician providers in the office setting;
and no longer reimbursed in the home, SNF, ICF,
independent laboratory, or ECF setting.
and 76932:
and is no longer reimbursed in the radiation treatment
dialysis facility, or hospital-based RHC providers in
• Total component. No longer reimbursed to podiatrist,
CNM, radiation treatment center, hospital, nephrology
hospital setting.
radiological or physiological laboratory, or hospitalbased RHC providers in the office setting; no longer
reimbursed in the inpatient hospital setting; and no
hospital setting.
• Total component. No longer reimbursed to hospital,
may be reimbursed to NP, CNS, or PA providers in
the office setting; no longer reimbursed to physician,
• Technical component. May be reimbursed to NP, CNS,
and PA providers in the office setting; no longer
reimbursed in the home, SNF, ICF, independent
laboratory, or ECF setting.
hospital setting.
hospital, renal dialysis facility, radiological or physiological laboratory, or hospital-based RHC providers
in the office setting; and no longer reimbursed to
hospital setting.
• Technical component. No longer reimbursed to hospital,
facility, or hospital-based RHC providers in the office
May/June 2010
45
All Providers
or nephrology (hemodialysis, renal dialysis) providers
in the office setting; and no longer reimbursed in the
home, SNF, ICF, or ECF setting.
after July 1, 2009, the interpretation component for the
following procedure codes may be reimbursed to NP,
CNS, and PA providers in the office setting:
Procedure Codes
74190
74328
74360
74420
75801
75810
75940
75982
76932
78414
92546
93308
93505
93524
93530
93556
93603
93616
93770
93979
94725
95819
95923
73530
74305
74355
74415
74470
75809
75900
75980
76930
78282
92545
93307
93501
93514
93529
93555
93602
93615
93740
93978
94720
95816
95922
G0130
radiation treatment center, hospital, renal dialysis
hospital setting.
and 78414:
• Total component. No longer reimbursed to independent
laboratory, CNM radiation treatment center, hospital,
inpatient hospital or independent laboratory setting.
• Technical component. No longer reimbursed to
CNM or radiation treatment center providers in the
office setting; and no longer reimbursed in the home,
SNF, ICF, or ECF setting.
Note: These changes do not affect the hospital diagnosisrelated group (DRG) payment or the federally qualified
health center (FQHC) or RHC encounter reimbursement.
74235
74329
74363
74425
75803
75894
75945
75992
76940
92542
93303
93320
93508
93526
93531
93571
93609
93623
93799
93980
94750
95822
95954
74300
74330
74400
74445
75805
75896
75946
76001
76945
92543
93304
93321
93510
93527
93532
93572
93610
93660
93975
93981
95812
95827
95956
74301
74340
74410
74450
75807
75898
75970
76125
76975
92544
93306
93325
93511
93528
93533
93600
93612
93724
93976
93982
95813
95921
95958
Claims submitted by NP, CNS, and PA providers with
any of the procedure codes in the above table and dates
of service between July 1, 2009, and January 31, 2010,
will be reprocessed, and payments will be adjusted
accordingly. No action on the part of the provider is
required.
ACIP Recommended Vaccines That are Not a Benefit
The Advisory Committee on Immunization
Practices (ACIP) recommendations for adults
includes vaccines that are not a benefit of Texas
Medicaid. Texas Medicaid will not reimburse those
vaccines that are not a benefit, even if recommended
by ACIP. Procedure codes 90581, 90650, 90736,
and 90738 are not a benefit of Texas Medicaid for
clients of any age. Procedure codes 90660, 90716,
and 90734 are not a benefit of Texas Medicaid for
clients who are 21 years of age or older. Providers
may be reimbursed only for the administration fee
for procedure code 90663.
46
May/June 2010
All Providers
Reimbursement for Medicare and MAP Secondary Claims
Medicare Parts A and B
Medicare Denials (Not a Benefit/Exceeds
Benefit Limitations)
Providers are allowed to file Medicare primary paper
claims to TMHP for payment of coinsurance or
deductibles for claims that fail to crossover from Medicare
electronically. Providers that submit a paper crossover
claim must submit a completed claim form along with a
Medicare Remittance Advance Notice (MRAN) in one of
the following approved formats:
TMHP is processing claims for Medicare Qualified
Medicaid Beneficiary (MQMB) clients enrolled in a
MAP. TMHP considers a claim for reimbursement if
the claim meets the following requirements:
• The date of service is on or after January 1, 2008.
• The MAP denied the claim for one of the following
reasons:
• Medicare Remit Easy Print (MREP)
• PC-Print
- Not a benefit.
• Paper MRAN from Medicare or a Medicare
intermediary
- Services exceed benefit limitations.
• Services included in the claim are benefits of Texas
Medicaid.
• TMHP standardized MRAN form
Paper crossover claims that contain multiple MRAN
forms with conflicting information are returned to the
provider or denied. MRANs must be submitted with
a completed claim form, must be legible, and must
identify one client per page. Providers must not submit
handwritten MRANs. Claims that do not meet these
standards will be returned to the provider without
processing.
Claims must first be submitted to the MAP. If the MAP
issues a denial that indicates “not a benefit” or “exceeds
benefit limitations,” the claim can be submitted to
TMHP with a copy of the MAP explanation of benefits
(EOB) attached.
TMHP will not process claims that were denied by the
MAP for reasons other than “not a benefit” or “exceeds
benefit limitations.”
Providers must submit the appropriate paper claim form
with the MRAN form:
Contracted and Non-Contracted MAPs
Contracted MAPs
• CMS-1500 paper claim form for professional services.
The Texas Health and Human Services Commission
(HHSC) now contracts with MAPs and offers a perclient-per-month payment. The payment to the MAP
includes all costs associated with the Medicaid cost
sharing for dual-eligible clients. TMHP does not
reimburse the copayment, coinsurance, or deductible
amounts for these claims.
• UB-04 CMS-1450 paper claim form for institutional
services.
Crossover claims that are submitted with the wrong paper
claim form will be denied.
Medicare Part C/ Medicare Advantage Plan
(MAP) Information
MAPs that contract with HHSC will reimburse
providers directly for the cost sharing obligations that
are attributable to dual-eligible clients enrolled in the
MAP. These payments are included in the capitated rate
paid to the Health Maintenance Organization (HMO)
and must not be billed to TMHP or a Medicaid client.
Providers now receive information about a client’s Medicare
Part C eligibility through TexMedConnect or Electronic
Data Interchange (EDI). In response to an eligibility
inquiry, providers will receive the client’s Medicare Part C
eligibility effective date, end date, and add date (the date
the eligibility was added to the TMHP system).
Non-Contracted MAPs
Additionally, the Managed Care segments section of
TexMedConnect displays the CMS Contract ID and a link
to a list of MAP carrier names and telephone numbers.
Coinsurance and Deductibles
Beginning January 4, 2010, TMHP will process claims
with dates of service on or after January 1, 2008, for
coinsurance and deductibles for dual-eligible clients
who are enrolled in a MAP that is not contracted with
HHSC.
For more information, refer to the list of MAP carriers
on the TMHP website at www.tmhp.com under the
“Software, Fee Schedules, Reference Codes” heading as
well as on the EDI home page.
May/June 2010
47
All Providers
Providers must submit claims for coinsurance and
deductibles using the revised MRAN/MAP templates.
Providers must attach the appropriate claim to the
completed MRAN form. The new templates and instructions are available starting on page 137 of this bulletin.
• Claims with dates of service from January 1, 2008,
through January 3, 2010, that are submitted after
March 31, 2010
• Claims that were denied for reasons other than filing
deadline
Date of services January 1, 2008 –
January 3, 2010
MRANs must be submitted with a completed claim
form, must be legible, and must identify only one
client per page. Providers must not submit handwritten
MRANs. Claims that do not meet these standards will
not be processed and will be returned to the provider.
Effective January 3, 2010, providers may submit claims
to TMHP with dates of service on or after January 1,
2008. Providers will have until March 31, 2010, to
submit claims with dates of service from January 1, 2008,
through January 3, 2010. Claims that are submitted
may initially be denied for exceeding the filing deadline;
however, TMHP will reprocess these claims. No action
on the part of the provider is required.
HMO and PPO Copayments
TMHP has resumed processing Medicare HMO and
Preferred Provider Organization (PPO) copayment
claims for dates of service on or after January 1, 2008.
These copayment claims are considered only for
Qualified Medicare Beneficiary (QMB) or Medicaid
Qualified Medicare Beneficiary (MQMB) dual-eligible
clients who are enrolled in a MAP that is not contracted
with HHSC. Providers should file Medicare copayment
claims using the following codes: CP003, CP004,
CP007, or CP008.
Date of service on or after January 4, 2010
Claims with dates of service on or after January 4, 2010,
must be submitted to TMHP following current claim
filing deadlines.
TMHP will not reprocess the following claims:
• Claims with dates of service on or after January 4, 2010
MAP Contracted
Status/Services
HMO/PPO Copayment
Contracted with HHSC Reimbursement is included
in the payment from HHSC
to MAP. MAP reimburses
the provider
Not contracted with
Bill to TMHP
HHSC
Coinsurance/Deductible
Reimbursement is included in
the payment from HHSC to
MAP. MAP reimburses the
provider.
Bill to TMHP


Medicaid only (Not a
Medicare benefit/exceeds
benefit limitation
Bill to TMHP
Bill to TMHP

New and Improved PCCM Inpatient/Outpatient Authorization Form
All Primary Care Case Management (PCCM) prior
authorization requests must be submitted on the updated
PCCM Inpatient/Outpatient Authorization Form
effective March 1, 2010. All authorization requests
received using the previous version of the form will not be
processed and will be returned to providers.
The PCCM Inpatient/Outpatient Authorization Form
has been revised as follows:
• A new field has been added to identify the Prior
Authorization Number (PAN) of a request to be
updated.
• Section 1 has been revised to include client, facility,
and physician information.
• A revised section 2 labeled “Request Information” to be
completed for all requests.
• Additional detailed instructions are provided for
submitting the form.
• Additional detailed instructions are provided for
submitting the form.
• Request Type subsections “New Request” and “Update
Request” have been revised.
The new PCCM Inpatient/Outpatient Authorization
form can found on page 143 of this bulletin.
48
May/June 2010
All Providers
Global Surgical Periods to Change for Texas Medicaid
Effective for dates of service on or after May 1, 2010, the
global surgical period and the usage of certain modifiers
will change for Texas Medicaid.
of the surgery, and any associated services that are
provided for up to 90 days after the surgical procedure.
Procedure codes that are designated as “Carrier
Discretion” will have their global periods determined by
HHSC.
Providers who perform surgical procedures before May 1,
2010, must continue to bill services using the current
process.
Modifiers
The following changes apply to surgical procedures that
are performed on or after May 1, 2010.
Texas Medicaid will add certain modifiers that are
related to surgical services, in alignment with CMS. For
the correct reimbursement of services that are rendered
in the preoperative, intraoperative, or postoperative
period, providers must use the appropriate modifiers
from the following table. Failure to use the appropriate
modifier may result in recoupment.
Texas Medicaid uses global surgical periods to determine
reimbursement for services that are related to surgical
procedures. Medicaid global periods will align with the
Medicare global periods that are set by the Centers for
Medicare & Medicaid Services (CMS). For information
about global surgical periods for individual procedure
codes, providers can refer to the Medicare Physician Fee
Schedule Database (MPFSDB), which is located on the
CMS website at www.cms.hhs.gov/PhysicianFeeSched.
Modifiers
24
25
58
62
The following services are included in the global surgical
period:
• Hospital admission work-up.
56
78
57
79
Documentation Requirements
• Anesthesia (when administered and monitored by the
primary surgeon).
For services that are billed with any of the listed
modifiers to be considered for reimbursement, providers
must maintain in the client’s medical record documentation that supports the medical necessity of the services.
Acceptable documentation includes, but is not limited to,
progress notes, operative reports, laboratory reports, and
hospital records.
• Surgical procedure (intraoperative).
• Postoperative follow-up and related services.
• Complications following the surgical procedure that
do not require return trips to the operating room.
Texas Medicaid will adhere to a global fee concept
for minor and major surgeries and invasive diagnostic
procedures. Global surgical periods are defined as
follows:
On a case-by-case basis, providers may be required to
submit additional documentation that supports the
medical necessity of services before the claim will be
reimbursed.
• 0-day Global Period—Reimbursement includes the
surgical procedure and any associated services that are
provided on the same day.
Note: Retrospective review may be performed to ensure
that the submitted documentation supports the medical
necessity of the surgical procedure and any modifier used to
bill the claim.
• 10-day Global Period—Reimbursement includes the
surgical procedure, any associated services that are
provided on the same day of the surgery, and any
associated services that are provided for up to 10 days
after the surgical procedure.
Authorization
There are no changes to authorization requirements.
Providers can refer to the 2009 Texas Medicaid Provider
Procedures Manual for additional information about
surgical procedures.
• 90-day Global Period—Reimbursement includes
the surgical procedure, preoperative services that are
provided on the day before the surgical procedure, any
associated services that are provided on the same day
55
77
If a physician provided all of the preoperative, intraoperative, and postoperative care, claims may be considered
for reimbursement when they are submitted without a
modifier.
• Preoperative care, including history and physical.
May/June 2010
54
76
Reimbursement
The global surgical fee period will apply to both
emergency and nonemergency surgical procedures.
49
All Providers
Physicians in the same group practice and specialty must
bill, and will be reimbursed, as if they were a single
provider.
be considered for reimbursement when they are billed
with the modifier 57. The client’s medical record should
clearly indicate when the initial decision to perform the
procedure was made.
Evaluation and Management (E/M) Services
Intraoperative Services
E/M services that are rendered on the day of the surgical
procedure are generally not payable for procedures that
have a 0-day global period.
Physicians who performed a surgical procedure with a
10- or 90-day global period but do not render postoperative services must bill the surgical procedure code
with the modifier 54. Modifier 54 indicates that the
surgeon is relinquishing all of the postoperative care to
a physician outside of the same group. Documentation
in the medical record must support the transfer of care
and must indicate that an agreement has been made
with another physician to provide the postoperative
management.
E/M services that are rendered on the day of the surgical
procedure or during the 10-day postoperative period are
generally not payable for procedures that have a 10-day
global period.
E/M services that are rendered on the day before the
surgical procedure, on the day of the surgical procedure
or service, or during the 90-day postoperative period are
generally not payable for procedures that have a 90-day
global period.
Co-surgeons may be reimbursed for surgical procedures
that are billed with modifier 62 if the CMS fee schedule
indicates that the procedure allows for co-surgeons.
Claims will be suspended for manual review of the documentation of medical necessity. Reimbursement will be
calculated at 62.5 percent of the amount allowed for the
intraoperative portion of the surgical procedure’s fee.
Preoperative Services
Preoperative physician E/M services (such as office or
hospital visits) that are provided during the preoperative
limitation period and are directly related to the planned
surgical procedure will be denied if they are billed by
the surgeon or anesthesiologist who was involved in the
surgical procedure.
Postoperative services
Postoperative services that are directly related to the
surgical procedure are included in the global surgical fee
and are not separately reimbursed. Postoperative services
include, but are not limited to, all of the following:
Reimbursement will be considered when the E/M
services are performed for distinct reasons that are
unrelated to the procedure. E/M services that meet the
definition of a significant, separately identifiable service
may be billed with modifier 25 if they are provided
on the same day by the same provider as the surgical
procedure.
• Follow-up visits (any place of service).
• Pain management.
• Miscellaneous services, including:
Modifier 25 is not used to report an E/M service that
results in a decision to perform a surgical procedure.
Medical record documentation must substantiate the use
of modifier 25.
- Dressing changes.
- Local incision care.
- Platelet gel.
If the decision to perform a minor procedure is made
during an E/M visit immediately before the surgical
procedure, the E/M visit is considered a routine preoperative service and is not separately billable.
- Removal of operative packs.
- Removal of cutaneous sutures, staples, lines, wires,
drains, casts, or splints.
Physicians who provide only preoperative services for
surgical procedures with a 10- or 90-day global period
may submit claims using the surgical procedure code
with the identifying modifier 56. Reimbursement will
be limited to a percentage of the Medicaid fee for the
surgical procedure.
- Replacement of vascular access lines.
- Insertion, irrigation, and removal of urinary
catheters, routine peripheral intravenous lines,
nasogastric tubes, and rectal tubes.
- Changes or removal of tracheostomy tubes.
E/M services that are provided during the preoperative
period (one day before or on the same day) of a major
surgical procedure (90-day global period) and result in
the initial decision to perform the surgical procedure may
Note: Removal of postoperative dressings or anesthetic
devices is not eligible for separate reimbursement as the
removal is considered part of the allowance for the primary
surgical procedure.
50
May/June 2010
All Providers
Staged or related surgical procedures or services that
are performed during the postoperative period may be
reimbursed when they are billed with modifier 58. A
postoperative period will be assigned to the subsequent
procedure. Documentation must indicate that the
subsequent procedure or service was not the result of a
complication or any of the following:
• It was planned at the time of the initial surgical
procedure.
• It is more extensive than the initial surgical procedure.
If the surgeon provides both the surgery and the preoperative care for a procedure that has a 10- or 90-day global
period, the surgeon must include the following details on
the claim form:
• It is for therapy following an invasive diagnostic
surgical procedure.
Note: Modifier 58 does not apply to procedure codes that
are already defined as staged or sessioned services in the
Current Procedural Terminology (CPT) Manual (e.g.,
65855 or 66821).
• The surgical procedure, date of the surgery, and
modifier 54, which indicates that he or she was the
surgeon.
E/M services that are provided by the same provider
for reasons that are unrelated to the operative surgical
procedure may be considered for reimbursement if they
are billed with modifier 24. The submitted documentation must substantiate the reasons for providing E/M
services.
• The surgical procedure, date of service, and modifier
56 to denote the preoperative care.
If the surgeon provides both the preoperative care and
the postoperative care for a procedure that has a 10- or
90-day global period, the surgeon must include the
following details on the claim form:
• Modifier 24 must be billed with modifier 25 if a
significant, separately identifiable E/M service that was
performed on the day of a procedure falls within the
postoperative period of another unrelated procedure.
The postoperative modifier should always be billed
before any other modifiers.
• The surgical procedure, date of service, and modifier 55
to denote the postoperative care.
• The surgical procedure, date of service, and modifier
56 to denote the preoperative care.
For postoperative care that is rendered by physicians
other than the surgeon for procedures that have a 10- or
90-day global period, the following conditions apply:
• Modifier 24 must be billed with modifier 57 if an E/M
service that was performed within the postoperative
period of another unrelated procedure results in the
decision to perform major surgery.
• When transfer occurs immediately after surgery, the
physician who assumes in-hospital postoperative
care must bill subsequent care code 99231, 99232, or
99233.
Preoperative, Intraoperative, and Postoperative
Periods
If the surgeon provides both the surgery and the postoperative care for a procedure that has a 10- or 90-day
global period, the surgeon must include the following
details on the claim form:
• Physicians who provide postdischarge care must
bill the appropriate surgical code with modifier 55.
Reimbursement will be limited to a percentage of the
Medicaid fee for the surgical procedure.
• The surgical procedure, date of the surgery, and
modifier 54, which indicates that he or she was the
surgeon.
• Documentation in the medical record must include all
of the following:
- A copy of the written transfer agreement.
• The surgical procedure, date of service, and modifier 55
to denote the postoperative care.
- The dates the care was assumed and relinquished.
Note: Providers must not submit a claim for a procedure
until after the client has been seen during a face-to-face
follow-up visit.
May/June 2010
• The claim must indicate in the comments field of the
claim form the dates on which care was assumed and
relinquished, and the units field must reflect the total
51
All Providers
number of postoperative care days provided. Claims
that are submitted on the CMS-1500 paper claim form
must include the date of surgery in Block 14 and the
dates on which care was assumed and relinquished in
Block 19.
Note: Only the intraoperative portion of the global surgical
fee for the subsequent procedure will be reimbursed.
Reimbursement for the postoperative period of the first
surgical procedure includes follow-up services from
both surgical procedures, and no additional postoperative reimbursement is allotted. The global period will be
based on the first surgical procedure.
Postoperative care may be billed only once by the same
provider.
Billing with modifier 78 does not begin a new global
period.
Claims that are submitted by an assistant surgeon will
not be considered for reimbursement under the following
conditions:
Surgical procedures that are performed by the same
provider during the postoperative period may be
considered for reimbursement when billed they are with
modifier 79 for any of the following:
• When billed with modifier 58.
• When billed with modifier 78 as a return trip to the
operating room for a related procedure during the
postoperative period.
• When the same procedure is performed with a
different diagnosis.
• When billed with modifier 79 as an unrelated
procedure or service by the same provider during the
postoperative period.
• When the same procedure is performed on the left
and right side of the body in different operative
sessions and that procedure is billed with the RT or LT
modifier.
Return Trips to the Operating Room
Return trips to the operating room for a repeat surgical
procedure on the same part of the body may be
considered for reimbursement when billed with modifiers
76 and 77 to indicate that it is a repeat procedure. Billing
with modifiers 76 and 77 initiates the beginning of a
new global period. Medical record documentation must
support the need for a repeat procedure.
• When a different procedure is performed with the
same diagnosis.
• When a different procedure is performed with a
different diagnosis.
Billing with Modifier 79 initiates a new global surgical
period.
All surgical procedure codes with a predefined limitation
(e.g., once per lifetime or one every five years) must not
be submitted with modifier 76 or 77.
For services that are billed with modifier 54, 55, or 56,
medical record documentation must be maintained by
both the surgeon and the physician who provide preoperative or postoperative care. Where a transfer of postoperative care occurs, the receiving physician cannot
bill for any part of the global services until at least one
service has been provided. The claim must reflect the
date of the surgery and the appropriate modifiers. The
physician who provides the postoperative care must also
include the date on which care was assumed until it was
relinquished.
For modifiers 76 and 77, the repeated procedure must
be the same as the initial surgical procedure. The repeat
procedure should be billed with the appropriate modifier.
The reason for the repeat surgical procedure should be
entered in the narrative field on the claim form.
Return trips to the operating room for surgical
procedures that are related to the initial surgery (i.e.,
complications) may be considered for reimbursement
when they are billed with modifier 78 by the same
provider.
Reimbursement for claims associated with modifiers 54,
55, or 56 is limited to the same total amount as would
have been paid if only one physician provided all of the
care, regardless of the number of physicians who actually
provide the care.
• When a surgical procedure has a "000" global period,
the full value of the surgical procedure will be paid
since these codes have no preoperative, postoperative,
or intraoperative values.
Unless otherwise stated in the Texas Medicaid Provider
Procedures Manual, no additional reimbursement
is provided to physicians who elect to use special
instruments or advanced technology to accomplish a
surgical procedure.
• When an unlisted procedure is billed because no code
exists to describe the treatment for the complications,
reimbursement is a maximum of 50 percent of the
value of the intraoperative services that were originally
performed.
52
May/June 2010
All Providers
Postexposure Prophylaxis for Rabies
Postexposure prophylaxis for rabies is a benefit of Texas
Medicaid. The reimbursement rates are as follows:
Procedure Codes
90375
90376
90675
and HRIG may inhibit the immune response to the
vaccine.
The recommended dose of HRIG is 20 IU/kg body
weight. This formula is applicable to all age groups,
including children.
Reimbursement Rate
$124.11
$124.17
$160.69
The postexposure treatment will also include five doses
of rabies vaccine (1.0 ml. intramuscular). The first dose
should be given as soon as possible after the exposure
(day 0). Additional doses should be given on days 3, 7, 14,
and 28 after the first shot. For an exposed person who
has previously been vaccinated with a complete pre- or
postexposure vaccine series, two doses of rabies vaccine
should be given on days 0 and 3.
Procedure codes 90375, 90376, and 90675 may be
reimbursed to the following provider types in the
following places of service:
Places of Service
Provider Types
Office, other
locations
Advanced practice registered nurse
(APRN), physician assistants, (PAs),
physicians, physician groups
APRN, PAs, physicians, physician
groups
APRN, PAs, physicians, physician
groups, hospitals
Home
Outpatient
hospital
Health care providers, who determine their client
requires the preventative rabies vaccination series after
valid rabies exposure, may obtain the biologicals directly
from the manufacturer or through one of the Texas
Department of State Health Services (DSHS) depots
around the state.
Rabies vaccine for pre-exposure (procedure code 90676)
is not a benefit of Texas Medicaid.
Injection administration is a benefit for administration of
rabies vaccine for post exposure.
Animal bites to people must be reported as soon as
possible to the Local Rabies Control Authority (LRCA).
Authorization is not required for postexposure rabies
vaccine. The physician must maintain documentation of
the exposure in the client’s medical record.
Postexposure prophylaxis for rabies is not necessary
following exposure to an animal that tests negative for
the rabies virus.
Postexposure rabies vaccine is limited to clients with
diagnosis code V015.
An exposed person who has never received a complete
pre- or postexposure rabies vaccine series will first receive
a dose of rabies immune globulin (HRIG). This is a
blood product that contains antibodies against rabies and
gives immediate, short-term protection. The injection
should be given in or near the wound area.
Reimbursement
Reimbursement for postexposure rabies vaccine is limited
to one per client per day, by any provider.
Reimbursement for postexposure rabies vaccine is limited
to five occurrences per 90 rolling days. Claims billed for
any vaccine given beyond 90 rolling days will be denied.
HRIG that is not administered when vaccination begins
can be administered up to seven days after the administration of the first dose of vaccine. Beyond the seventh
day, HRIG is not recommended since an antibody
response to the vaccine is presumed to have occurred,
Procedure code 90376 will be denied if it is billed for the
same date of service by the same provider as procedure
code 90375.
Billing for Influenza A and B Testing
Providers that test clients for influenza A and
influenza B on the same date of service and use
procedure code 87804 to bill for each test must
submit two separate details on the claim submission.
Modifier 91 must be added to the second test to
May/June 2010
indicate a repeated clinical laboratory test billed more
than once per day. Although the different strains of
influenza require different tests, each test is billed
using the same procedure code, so the second test is
considered a repeated test.
53
All Providers
Radiology Procedure Codes Being Reinstated for NP, CNS, PA,
and Radiation Treatment Center Providers
after July 1, 2009, the total, professional interpretation,
and technical components for the following radiology
procedure codes may be reimbursed to nurse practitioner
(NP), clinical nurse specialist (CNS), and physician
assistant (PA) providers, and radiation treatment center
providers in the office, inpatient hospital, or outpatient
hospital setting:
Procedure Codes
70010 70015
70240 70330
70470 70480
70488 70490
70540 70542
70547 70548
70554 71023
71100 71101
71250 71260
71552
71555
72052 72069
72090 72100
72126 72127
72132 72133
72148 72149
72170 72190
72195 72196
72220 72240
72285 72295
73040 73050
73090 73092
73140 73200
73219
73220
73500 73510
73550 73560
73590 73592
73706 73718
73723 73725
74150
74160
74183
74185
74241 74245
70030
70360
70481
70491
70543
70549
71030
71110
71270
72010
72070
72110
72128
72141
72156
72191
72197
72255
73000
73060
73110
73201
73221
73520
73562
73615
73719
74000
74170
74210
74246
70134
70373
70482
70492
70544
70551
71034
71111
71275
72020
72072
72114
72129
72142
72157
72192
72198
72265
73010
73070
73115
73202
73222
73525
73564
73700
73720
74010
74175
74220
74247
70210
70450
70486
70496
70545
70552
71040
71120
71550
72040
72074
72120
72130
72146
72158
72193
72200
72270
73020
73080
73120
73206
73223
73540
73565
73701
73721
74020
74181
74230
74249
Procedure Codes
74251 74260
74291 74320
74475 74480
75559
75560
75600 75605
75658 75660
75680 75685
75724 75726
75743 75746
75820 75822
75840 75842
75885 75887
75902 75960
75968 75978
76010 76080
76150
76350
70220
70460
70487
70498
70546
70553
71060
71130
71551
72050
72080
72125
72131
72147
72159
72194
72202
72275
73030
73085
73130
73218
73225
73542
73580
73702
73722
74022
74182
74240
74250
74270
74327
74485
75561
75625
75662
75705
75731
75756
75825
75860
75889
75961
75984
76100
76376
74280
74430
74710
75562
75630
75665
75710
75733
75774
75827
75870
75891
75962
75989
76101
76377
74283
74440
75557
75563
75635
75671
75716
75736
75790
75831
75872
75893
75964
75995
76102
76380
74290
74455
75558
75564
75650
75676
75722
75741
75809
75833
75880
75901
75966
76000
76120
76390
The radiology procedure codes listed in the preceding table
may be reimbursed as follows:
• Professional Interpretation Component. May be
reimbursed to NP, CNS, PA, and physician providers
May be reimbursed to physicians in the inpatient
• Technical Component. May be reimbursed to NP, CNS,
PA, physician, radiation treatment center, and radiological and physiological laboratory providers in the
office setting.
May be reimbursed to radiation treatment center
• Total Component. May be reimbursed to NP, CNS, PA,
physician, radiation treatment center, and radiological
and physiological laboratory providers in the office
setting.
May be reimbursed to hospitals and radiation
treatment center providers in the outpatient hospital
setting.
Affected claims submitted with dates of service from
July 1, 2009, through February 10, 2010, will be
No action on the part of the providers is required.
54
May/June 2010
All Providers
Medical Records Requirements
The Administrative Simplification provisions of the
Health Insurance Portability and Accountability Act
(HIPAA) of 1996 mandate the use of national coding
and transaction standards. HIPAA requires providers
to use the CPT system to report professional services,
including physician services.
descriptors of key/contributory components with level
of service descriptions are used to evaluate the selection
of levels of service.
• Support in the history and physical documents for the
presenting complaint with appropriate subjective and
objective information.
The level of service that is provided and documented
must be medically necessary based on the clinical
situation and needs of the client.
• Clear documentation of the services that were
provided, including all pertinent information about
the client’s condition to substantiate the need and
medical necessity for the services.
The Health and Human Services Commission (HHSC)
and TMHP routinely perform retrospective reviews
of all providers. HHSC has the ultimate responsibility
to review for Texas Medicaid utilization. This review
includes a comparison of the services billed to the client’s
clinical record.
• Medically necessary diagnostic lab and X-ray results
with explicit notation of abnormal findings and followup plans.
• Necessary follow-up visits with time of return specified
by at least the week or month.
The following are general requirements for all providers.
The record for each patient must include patient identification information, progress notes, laboratory, referral,
and consultation notes. All entries must be legible to
individuals other than the author, dated (month, day,
and year), and signed by the performing provider. Each
page of the medical record must include the client’s name
and Texas Medicaid number.
• Unresolved problems.
The medical record should also contain the following
desirable information:
• Notation that immunizations are complete or
up-to-date.
The medical record must contain the following
mandatory information:
• Personal data about the client, including address,
employer, home and work telephone numbers, sex,
marital status, and emergency contacts.
• For any item or service that requires prior authorization, a copy of the actual authorization from HHSC or
its designee (e.g., TMHP).
Any mandatory information that is not present in the
client’s medical record subjects the associated services to
recoupment.
• Prominent notation of allergies and adverse reactions
(including immunization reactions).
Note: These lists are not all-inclusive. Additional and more
specific requirements may apply to special services areas.
Providers can refer to the 2009 Texas Medicaid Provider
Procedures Manual for specific additional documentation
requirements.
• Support for the selection of evaluation and
management codes (levels of service). The CPT
May/June 2010
55
All Providers
Procedure Code Review Effective February 6, 2010
Effective February 6, 2010, for dates of service on or after April 1, 2009, the following changes apply to the procedure codes
indicated:
Procedure Code
19001, 19030,
19100, 19101,
20205, 20661,
21030, 21451,
61563, 64613,
64999
58140, 58267,
58540, 58825,
60210
19260, 19271,
19272, 22534
40819, 68705
64472, 64475,
64476, 64479,
64480, 64483,
64484
64831, 64832
64834, 64837
11752
17999
19020
36522
41140
42806
42972
44899
49905
55250
57170
57423
57425
Changes
Surgery component: No longer reimbursed to nurse practitioner (NP), clinical nurse specialist (CNS),
and physician assistant (PA) providers in the inpatient hospital or outpatient hospital setting.
Assistant surgery component: May be reimbursed to NP, CNS, and PA providers in the inpatient
hospital setting.
Surgery component: May be reimbursed to NP, CNS, and PA providers in the office setting.
Surgery component: No longer reimbursed to NP, CNS, and PA providers in the office, inpatient
May be reimbursed to certified registered nurse anesthetist (CRNA) providers in the office, inpatient
Surgery component: May be reimbursed to podiatrists in the office, inpatient hospital, or outpatient
hospital setting.
Surgery component: May be reimbursed to podiatrists in the inpatient hospital or outpatient hospital
setting.
Surgery component: No longer reimbursed to NP, CNS, and PA providers in the outpatient hospital
setting.
Surgery component: No longer reimbursed to NP, CNS, and PA providers in the office setting.
Surgery component: No longer reimbursed in the office setting.
No longer reimbursed to NP, CNS, and PA providers in the inpatient hospital or outpatient hospital
setting.
Surgery component: No longer reimbursed to NP, CNS, and PA providers in the inpatient hospital
setting.
Assistant surgery component: May be reimbursed to dentists in the inpatient hospital setting.
Surgery component: May be reimbursed to dentists in the inpatient hospital or outpatient hospital
setting.
May be reimbursed to NP, CNS, PA, and dentist providers in the office setting.
Surgery component: May be reimbursed to dentists in the inpatient hospital or outpatient hospital
setting.
Assistant surgery component: No longer reimbursed to certified nurse-midwife (CNM) providers in
the inpatient hospital or outpatient hospital setting.
Surgery component: No longer reimbursed to ambulatory surgical center (ASC) providers in the inpatient hospital or outpatient hospital setting.
Surgery component: No longer reimbursed to hospital-based rural health clinic (RHC) providers in
Surgery component: May be reimbursed to physicians and CNM providers in the outpatient hospital
setting.
No longer reimbursed in the office setting.
Assistant surgery component: No longer reimbursed in the office setting.
56
May/June 2010
All Providers
Procedure Code Changes
58554
hospital setting.
61140
Assistant surgery component: No longer reimbursed in the outpatient hospital setting.
No longer reimbursed to NP, CNS, and PA providers in the inpatient hospital setting.
62319
Surgery component: No longer reimbursed to NP, CNS, PA, and CNM providers in the inpatient
64605
Surgery component: No longer reimbursed to NP, CNS, PA, and dentist providers in the office, inpatient hospital, or outpatient hospital setting.
64610
64704
Surgery component: No longer reimbursed to NP, CNS, or PA providers in the inpatient hospital or
May be reimbursed to podiatrists in the inpatient hospital or outpatient hospital setting.
64721
Surgery component: No longer reimbursed to podiatrists in the office setting.
64726
May be reimbursed to podiatrists in the office, inpatient hospital, or outpatient hospital setting.
Affected claims submitted between April 1, 2009, and February 5, 2010, will be reprocessed, and payments will be adjusted
accordingly. No action on the part of the provider is required.
Effective February 6, 2010, for dates of service on or after July 1, 2009, the following changes apply to the procedure codes
indicated:
Procedure Code
59070, 59074,
59076
74000, 74010
76880
83719, 83721,
84478, 84578,
84580, 84583
93790
64910
75978
76150
77301
92612
92625
Changes
Assistant surgery component: May be reimbursed to NP, CNS, PA, and CNM providers in the inpatient hospital or outpatient hospital setting.
Professional interpretation component and technical component: No longer reimbursed to family
planning clinics in the office setting.
Total radiology component: No longer reimbursed to family planning clinics in the office setting.
Total laboratory component: No longer reimbursed to family planning clinics in the office setting.
Total radiology component: No longer reimbursed to hospitals in the inpatient hospital or outpatient
hospital setting.
Total radiology component: May be reimbursed to hospitals in the outpatient hospital setting.
Total radiology component: No longer reimbursed to CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers in the
office setting.
No longer reimbursed to radiation treatment centers, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, radiological and physiological laboratories, and hospital-based RHC providers in the
Total radiation therapy component: No longer reimbursed to hospital-based RHC providers in the
Surgery component: No longer reimbursed to NP, CNS, and PA providers in the inpatient hospital or
Medical service component: May be reimbursed to radiological and physiological laboratories in the
office setting.
May/June 2010
57
All Providers
Procedure Code
93270
95070
G0130
Changes
Total laboratory component: No longer reimbursed to independent laboratories, CNM providers,
hospitals, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC
No longer reimbursed to independent laboratories, CNM providers, hospitals, nephrology (hemodialysis, renal dialysis), renal dialysis facility, radiological and physiological laboratories, and hospitalbased RHC providers in the inpatient hospital setting.
No longer reimbursed to NP, CNS, PA, physician, independent laboratory, CNM, nephrology (hemodialysis, renal dialysis), renal dialysis facility, radiological and physiological laboratories, and hospital-based
Medical service component: No longer reimbursed to CNM providers in the office setting.
Total radiology component: No longer reimbursed to physicians in the outpatient hospital setting.
Affected claims submitted between July 1, 2009, and February 5, 2010, will be reprocessed, and payments will be adjusted
Medical, Surgery, and DME Services Reimbursement Rates Changed
Effective for dates of service on or after January 1, 2010, some medical, surgery, assistant surgery, and durable medical
equipment (DME) services reimbursement rates changed for Texas Medicaid. Affected claims will be reprocessed, and
payments will be adjusted accordingly. No action on the part of the provider is required.
Reimbursement rates for the following procedure codes are effective for dates of service on or after January 1, 2010:
TOS
1
1
1
1
1
1
1
1
1
2
8
2
8
2
Procedure Age Range/
Reimbursement
Code
Provider Type
Rate
Medical Services
S0620
Birth through 20
$65.00
years of age
S0620
21 years of age or
$65.00
older
S0621
Birth through 20
$68.00
years of age
S0621
21 years of age or
$68.00
older
S8990
All ages
$140.00
S9445
21 years of age or
$31.97
older
S9445
All ages
$31.97
family planning
S9445
Birth through 20
$31.97
years of age
S9470
Birth through 20
$49.00
years of age
Surgery and Assistant Surgery
S2053
All ages
$7,042.00
S2053
All ages
$1,126.72
S2068
All ages
$15,582.67
S2068
All ages
$2,493.23
S2079
All ages
$950.85
TOS
2
2
2
2
2
2
8
2
9
9
9
9
J
J
J
Procedure Age Range/
Reimbursement
Code
Provider Type
Rate
Surgery and Assistant Surgery (continued)
S2095
All ages
$445.92
S2117
All ages
$602.87
S2225
All ages
$86.78
S2230
All ages
$753.23
S2235
All ages
$827.98
S2325
All ages
$667.31
S2325
All ages
$106.77
S8030
All ages
$1,091.47
Durable Medical Equipment
S0515
All ages
Manually
reviewed
S1015
All ages
$10.50
S1040
All ages
$2,418.18
S8101
All ages
$37.00
S8185
All ages
$40.92
S8270
All ages
$64.31
S8999
All ages
$58.26
TOS = Type of service
1 = Medical
2 = Surgery
8 = Assistant Surgery
9 and J = DME

58


May/June 2010
All Providers
April Procedure Code Review Updates Now Available
type-of-service (TOS) changes were applied to a number
of services.
Diagnosis Codes
4957
501
5060
5069
5081
7864
4956
500
505
5064
5080
51919
Abatacept (Orencia)
Procedure code J0129 is no longer reimbursed to
podiatrist, certified nurse midwife (CNM), and hospitalbased rural health clinic (RHC) providers in the office
setting.
Procedure
Code
Changes
94640
Medical component: Is no longer reimbursed to independent laboratory and
CNM providers in the office setting.
May be reimbursed to portable X-ray suppliers and radiological and physiological
laboratories in the office setting.
Is no longer reimbursed to NP, CNS, PA,
physician, independent laboratory, CNM,
portable X-ray supplier, and radiological
and physiological laboratory providers in
94642
Medical component: Is no longer reimbursed to CNM providers in the office
setting
physician, CNM, radiation treatment center,
nephrology (hemodialysis, renal dialysis),
renal dialysis facility, and hospital-based
RHC providers in the outpatient hospital
setting.
94644
Medical component: Is no longer reimbursed to independent laboratory, CNM,
and renal dialysis facility providers in the
office setting.
renal dialysis facility, portable X-ray supplier,
and radiological and physiological laboratory providers in the outpatient hospital
setting.
Aerosol Treatments – Outpatient Setting
The following aerosol treatment procedure codes are
benefits of Texas Medicaid and may be reimbursed to
nurse practitioner (NP), clinical nurse specialist (CNS),
physician assistant (PA), physician, portable X-ray
supplier, and radiological and physiological laboratory
The following aerosol treatment procedure codes may be
reimbursed to hospitals in the outpatient hospital setting:
J7631
These new aerosol treatment procedure codes may be
reimbursed when submitted with any of the following
diagnosis codes:
46611
4880
49121
4928
49311
49381
4940
4953
46619
4881
49122
49300
49312
49382
4941
4954
May/June 2010
496
504
5063
5078
51911
The following changes were applied to the medical
procedure codes indicated.
RHC encounter reimbursement.
Diagnosis Codes
0115
27702
48242
486
4911
49120
4919
4920
49302
49310
49321
49322
49391
49392
4951
4952
4959
503
5062
5071
5089
Additional diagnosis codes may be considered with prior
authorization. Documentation must support medical
necessity.
home or extended care facility (ECF) setting or to
hospital-based RHC providers in the outpatient hospital
setting.
Procedure Codes (Aerosol Treatment)
J7605
J7608
J7622
J7626
J7633
J7639
J7644
J7682
4958
502
5061
5070
5088
74861
4801
4910
4918
49301
49320
49390
4950
4955
59
All Providers
Procedure
Code
Changes
94760,
Total laboratory component: Is no longer
94761
reimbursed to independent laboratory,
CNM, durable medical equipment (DME)
medical supplier, Coordinated Care Program (CCP), hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility,
and hospital-based RHC providers in the
office setting.
Is no longer reimbursed in the home setting.
DME medical supplier, CCP provider,
radiological and physiological laboratory,
Note: Pulse oximetry (procedure codes 94760
or 94761) is considered part of an evaluation
and management visit and is not reimbursed
separately.
J2545
Medical component: Is no longer reimbursed to CNM providers in the office
setting.
Is no longer reimbursed in the home, skilled
nursing facility (SNF), intermediary care
facility (ICF), or ECF setting.
physician, CNM, radiation treatment center,
Procedure Code
J7631
J7633
J7639
J7644
J7682
hospital-based RHC providers in the office or outpatient
hospital setting.
home or ECF setting.
Allergy Testing
Procedure codes 95027, 95199, and Q3031 are benefits
of Texas Medicaid and may be reimbursed as follows:
Procedure code 95027 may be reimbursed to physicians
in the office setting and may be reimbursed to hospitals
in the office setting and may be reimbursed to hospitals
Procedure code 95199 may be reimbursed to independent
laboratories in the independent laboratory setting.
Procedure code Q3031 may be reimbursed to physicians
and dentists in the office setting and may be reimbursed
to hospitals in the outpatient hospital setting.
Procedure code Q3031 may be reimbursed to independent
laboratories in the independent laboratory setting.
The following procedure codes will be denied when billed
with the same date of service by the same provider as
intracutaneous (intradermal) test procedure code 95027:
Procedures Manual, section 25.3.3.1, “Aerosol Treatment,”
on page 25-28, and section 36.4.1, “Aerosol Treatment,”
on page 36-11, for more information.
Procedure Codes
95024
99201
99205
99211
99215
99217
99221
99222
99233
99234
99239
99241
99245
99251
99255
99281
99285
99291
99307
99308
Reimbursement Rates for New Aerosol
Treatment Procedure Codes
The following rates were applied to the new benefits
indicated:
Age
All ages
All ages
All ages
All ages
Reimbursement Rate
$0.45
$5.69
$22.72
$0.20
$67.40
Alglucosidase alfa (Myozyme)
RHC encounter reimbursement or the hospital diagnosisrelated group (DRG) reimbursement.
Procedure Code
J7605
J7608
J7622
J7626
Age
All ages
All ages
All ages
All ages
All ages
Reimbursement Rate
$5.08
$1.86
$60.84
$6.09
60
99202
99212
99218
99223
99235
99242
99252
99282
99304
99309
99203
99213
99219
99231
99236
99243
99253
99283
99305
99310
99204
99214
99220
99232
99238
99244
99254
99284
99306
99315
May/June 2010
All Providers
Procedure Codes
99316
99318
99327
99328
99337
99341
99345
99347
99354
99356
99463
99464
99471
99472
99478
99479
99324
99334
99342
99348
99460
99465
99475
99480
99325
99335
99343
99349
99461
99468
99476
service performed. Every effort should be made to bill
with the appropriate procedure code that describes the
procedure being performed. If a code does not exist to
describe the service performed, prior authorization may
be requested using unlisted procedure code 95199 and
with appropriate documentation to assist in determining
coverage.
99326
99336
99344
99350
99462
99469
99477
The documentation submitted with the prior authorization request must include all of the following:
• The client’s diagnosis.
• Medical records indicating prior treatment for this
procedure.
Collagen Skin Test
Collagen skin tests (procedure code Q3031) are administered to detect a hypersensitivity to bovine collagen,
and are given four weeks before any type of surgical
procedure which utilizes collagen. Prior authorization may be requested for the treatment of abnormal
structures of the body caused by congenital defects,
developmental abnormalities, trauma, infection, tumors,
or disease. The surgery is generally performed to improve
function. Collagen injections/implants used for cosmetic
surgery are not a benefit of Texas Medicaid.
performed.
• The reason for recommending this particular
procedure.
• A procedure code that is comparable to the procedure
being requested.
The physician may submit prior authorization requests
for Primary Care Case Management (PCCM)
clients to the PCCM Outpatient Prior Authorization
Department online at www.tmhp.com, by telephone at
1-888-302-6167, or by fax at 1-512-302-5039 using the
Primary Care Case Management (PCCM) Inpatient/
Outpatient Authorization Form.
• Place of service the procedure is to be performed.
• The physician’s intended fee for this procedure.
The physician may submit prior authorization requests for PCCM clients to the PCCM
Outpatient Prior Authorization Department online
at www.tmhp.com, by telephone at 1-888-302-6167,
or by fax at 1-512-302-5039 using the Primary Care
Case Management (PCCM) Inpatient/Outpatient
Authorization Form.
for fee-for-service clients to the Special Medical
Prior Authorization (SMPA) department online at
www.tmhp.com, by fax at 1-512-514-4213, or by mail to:
Special Medical Prior Authorization Department
12357-B Riata Trace Parkway, Suite 150
Austin TX 78727
for fee-for-service clients to the Special Medical
Prior Authorization (SMPA) department online at
www.tmhp.com, by fax at 1-512-514-4213, or by mail to:
Austin TX 78727
Documentation that supports medical necessity for the
requested device, service, or supply must be submitted
to the SMPA Department with the prior authorization
request. Prior authorization is a condition for reimbursement; it is not a guarantee of payment.
Documentation that supports medical necessity for the
requested device, service, or supply must be submitted
to the SMPA Department with the prior authorization
request. Prior authorization is a condition for reimbursement; it is not a guarantee of payment.
Unlisted Procedure Code
Procedure code 95199 is for an unlisted allergy or clinical
immunologic services or procedures and may be used
if there is no specific procedure code that describes the
May/June 2010
61
All Providers
Reimbursement Rates for New Allergy Testing
Procedure Codes
radiation treatment center, nephrology (hemodialysis,
renal dialysis), renal dialysis facility, and hospital-based
The following rates have been applied to the new benefits
indicated:
Procedure
Code
Age
95027
Birth through 20
years of age
95027
21 years of age or
older
95199
All ages
Q3031
Birth through 20
years of age
Q3031
21 years of age or
older
hospital diagnosis-related group (DRG) reimbursement.
Reimbursement
Rate
$3.72
Bariatric Surgery Procedures
$3.55
The following benefit changes apply to procedure codes
43644, 43659, 43843, 43886, 43887, 43888:
Manually priced*
$3.72
The assistant surgery component may be reimbursed to
NP, CNS, and PA providers in the inpatient hospital or
The assistant surgery component for procedure code
43848 may be reimbursed to NP, CNS, and PA providers
in the inpatient hospital setting.
$3.55
* This procedure code requires prior authorization and will be
priced based on the provider’s intended fee when the authorization is requested.
The following procedure codes will no longer be
reimbursed to ambulatory surgical center (ASC)
providers:
Augmentative Communicative Device (ACD)
Systems
Procedure Codes
43644
43645
43772
43773
43846
43847
Procedure code V5336 is a benefit of Texas Medicaid and
may be reimbursed to home health DME providers and
DME medical suppliers in the office, home, or “other
location” setting.
43770
43842
43771
43843
Procedure code 43845 is a benefit of Texas Medicaid.
The Surgery component may be reimbursed to physicians
in the inpatient hospital or outpatient hospital setting.
Procedure code V5336 may be reimbursed for clients
who are one year of age or older.
The assistant surgery component may be reimbursed to
NP, CNS, PA, and physician providers in the inpatient
Provider Procedures Manual, section 24.4.16.3, “NonCovered ACD System Items,” on page 24-33, for more
information and prior authorization and other benefit
information.
The following procedure codes will be denied if billed
procedure code 43845:
Reimbursement Rates for New ACD Systems
Procedure Code
Procedure code V5336 is a benefit of Texas Medicaid for
clients of all ages. Procedure code V5336 reimbursement
rate is manually priced (i.e., will be priced based on the
manufacturer’s suggested retail price [MSRP] or average
wholesale price [AWP] and the provider’s documented
invoice cost).
Procedure Codes
Procedure code V5336 requires prior authorization.
Bacillus Calmette-Guérin (BCG) Vaccine
radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospitalbased RHC providers in the office setting.
43659
43774
43848
62
44950
49000
49002
49010
49255
49560
49561
49565
49566
49570
51701
51702
51703
62310
62311
62318
62319
64400
64402
64405
64408
64410
64412
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64470
64475
64479
64483
64505
64508
May/June 2010
All Providers
Replacement parts may be reimbursed if the client already
owns a breast pump device. The prior authorization request
must include documentation of a client-owned device.
Additional documentation such as the purchase date,
serial number, and purchasing entity of the device may be
required.
Procedure Codes
64510
64517
64520
64530
93000
93040
93041
93318
93318
93318
94002
94200
94200
94200
94250
94250
94250
94680
94680
94680
94681
94681
94681
94690
94690
94690
94770
94770
94770
95812
95812
95812
95813
95813
95813
95816
95816
95816
95819
95819
95819
95822
95822
95822
95829
95829
95829
95955
95955
95955
96360
96365
96365
96372
96374
93374
96375
93375
96376
Note: Replacement equipment will not be prior authorized
when the equipment has been abused or neglected by the client,
client’s family, or caregiver.
Procedures Manual, section 24.4.19, “Breast Pumps,” on
page 24-37, for more information about breast pumps.
Reimbursement Rates for New Breast Pump
Procedure Codes
The following rates apply to the new benefits indicated:
Procedure
Code
A4281
A4282
A4283
A4284
A4285
A4286
Procedures Manual, section 36.4.5, “Bariatric Surgery,”
on page 36-19, for more information about bariatric
surgery and prior authorization requirements.
Reimbursement Rates for New Bariatric Surgery
Procedure Code
Procedure code 43845 is a benefit for all ages. The reimbursement rate for the surgical component is $1,333.80.
The reimbursement rate for the assistant surgery component
is $213.30.
reimbursed in the home setting.
Replacement parts procedure codes A4281, A4282, A4283,
A4284, A4285, and A4286 are benefits of Texas Medicaid
and may be reimbursed to home health DME providers and
DME medical suppliers in the home setting.
Provider Procedures Manual, section 18.3, “Benefits and
Limitations,” on page 18-2, for more information about
chiropractic manipulative treatment benefits.
Procedure codes A4281, A4282, A4283, A4284, A4285,
and A4286 may be reimbursed when there is a purchase
of a breast pump (procedure code E0602 or E0603). Prior
authorization is required.
Clinical Pathology Consultations
Procedure codes 99241, 99242, 99243, 99244, and
99245 are no longer reimbursed to CNM providers in
the office or outpatient hospital setting.
Prior authorization may be considered for replacement
parts when loss or irreparable damage has occurred. The
medical necessity documentation must accompany the prior
authorization request and must include a statement from
the provider indicating the cause of the loss or damage
and what measures will be taken to prevent reoccurrence.
A copy of the police or fire report must also be submitted
when appropriate.
Reimbursement Rate
$3.65
$0.49
$0.54
$7.13
$2.26
$0.45
Chiropractic Manipulative Treatment (CMT)
Breast Pump
May/June 2010
Age
All ages
All ages
All ages
All ages
All ages
All ages
99255 are no longer reimbursed to CNM providers in
the inpatient hospital setting.
99255 are no longer reimbursed in the SNF, ICF, or ECF
setting.
63
All Providers
Gynecological and Reproductive Health Services
Changes apply to the medical component of the following procedure codes as indicated:
Procedure
Code
11975,
11976,
11977
51925
Changes
Surgery component: No longer reimbursed to NP, CNS, and PA providers in the inpatient hospital or outpatient hospital setting.
Surgery component: No longer reimbursed to NP, CNS, PA, and CNM providers in the inpatient hospital
Assistant surgery component: No longer reimbursed to CNM providers in the inpatient hospital or outpatient hospital setting.
56805,
Assistant surgery component: No longer reimbursed to CNM providers in the inpatient hospital or outpa57335,
tient hospital setting.
57410
Surgery component: No longer reimbursed to NP, CNS, PA, and CNM providers in the inpatient hospital
58267
Assistant surgery component: May be reimbursed to NP, CNS, and PA providers in the inpatient hospital or
58300,
Surgery component: May be reimbursed to CNM providers in the office, inpatient hospital, or outpatient
58301
hospital setting.
Note: Procedure codes J7300 and J7302 must be billed with procedure code 58300.
59850,
Surgery component: No longer reimbursed in the office or outpatient hospital setting.
59856
No longer reimbursed to NP, CNS, PA, and CNM providers in the inpatient hospital setting.
No longer reimbursed to ASC providers.
Procedure codes 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58548, 59830, 59851, and 59855 are
no longer reimbursed to ASC providers.
74740
Total radiology component: No longer reimbursed to hospital-based RHC providers in the office and outpatient hospital setting.
Technical component: No longer reimbursed in the independent laboratory setting.
87480,
Total laboratory component: No longer reimbursed to NP, CNS, PA, independent laboratory, CNM, radia87510,
tion treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital87800
based RHC providers in the office setting.
No longer reimbursed to independent laboratory, radiation treatment center, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, and hospital-based RHC providers in the outpatient hospital setting.
No longer reimbursed to radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, and hospital-based RHC providers in the independent laboratory setting.
87660
Total laboratory component: No longer reimbursed to NP, CNS, PA, independent laboratory, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray
supplier, radiological and physiological laboratory, and hospital-based RHC providers in the office setting.
No longer reimbursed to independent laboratory, radiation treatment center, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, and hospitalbased RHC providers in the outpatient hospital setting.
dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, and hospital-based RHC
providers in the independent laboratory setting.
87797
Total laboratory component: No longer reimbursed to NP, CNS, PA, independent laboratory, optometrist,
podiatrist, CNM, radiation treatment center, FQHC, hospital, nephrology (hemodialysis, renal dialysis),
renal dialysis facility, and hospital-based RHC providers in the office setting.
No longer reimbursed in the inpatient hospital setting.
No longer reimbursed to independent laboratory, radiation treatment center, FQHC, family planning clinic,
nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers in the
dialysis facility, and hospital-based RHC providers in the independent laboratory setting.
64
May/June 2010
All Providers
Procedure
Code
99201,
99202,
99205,
99211,
99212
99204,
99215
99203,
99213
99214
J7302
J7307
S4993
Changes
Medical component: No longer reimbursed in the SNF, ICF, or ECF setting.
Medical component: No longer reimbursed in the SNF, ICF, birthing center, or ECF setting.
Medical component: No longer reimbursed in the SNF, ICF, birthing center, or ECF setting.
No longer reimbursed to maternity service clinics and family planning clinics in the outpatient hospital
setting.
No longer reimbursed to RHC providers in the office or outpatient hospital setting.
Medical component: No longer reimbursed to RHC providers in the office or outpatient hospital setting.
No longer reimbursed in the SNF, ICF, birthing center, or ECF setting.
No longer reimbursed to family planning clinics in the outpatient hospital setting.
Medical component: No longer reimbursed to family planning clinics and hospital-based RHC providers in
Medical component: No longer reimbursed to federally qualified health center (FQHC) providers in the
office setting.
No longer reimbursed to hospital-based RHC providers in the outpatient hospital setting.
May be reimbursed to CNM providers in the office setting.
Medical component: No longer reimbursed to FQHC providers in the office or outpatient hospital setting.
Note: The changes noted in this article do not affect the RHC encounter reimbursement, the FQHC encounter reimbursement, or
the hospital diagnosis-related group (DRG) reimbursement.
The following procedure codes are new benefits and may be reimbursed as indicated:
Procedure
Code
Reimbursement Information
56805
May be reimbursed to ambulatory surgical center (ASC) providers in the outpatient hospital setting.
May be reimbursed for female clients who are birth through 20 years of age.
Prior authorization (precertification) is required for PCCM clients.
58356
Surgery component: May be reimbursed to physicians in the inpatient hospital or outpatient hospital setting.
May be reimbursed to ASC providers in the outpatient hospital setting.
May be reimbursed for female clients who are 10 through 55 years of age.
58400,
58410
Assistant surgery component: May be reimbursed to NP, CNS, PA, and physician providers in the inpatient
58770
59135
hospital setting.
May be reimbursed for clients who are 10 years of age through 55 years of age.
May/June 2010
65
All Providers
Prior authorization is required for procedure code 58770.
The prior authorization request must include documentation of one or more of the following conditions:
Column A (Denied)
Column B
36000, 36400, 36405, 36406, 36410,
58400,
36420, 36425, 36430, 36440, 36600,
58410
36640, 37202, 43752, 44005, 44180,
44820, 44850, 44950, 49000, 49002,
49010, 49255, 49570, 50715, 51701, 51702,
51703, 57410, 62310, 62311, 62318, 62319,
64400, 64402, 64405, 64408, 64410,
64412, 64413, 64415, 64416, 64417,
64418, 64420, 64421, 64425, 64430,
64435, 64445, 64446, 64447, 64448,
64449, 64450, 64470, 64475, 64479,
64483, 64505, 64508, 64510, 64517,
64520, 64530, 93000, 93040, 93041,
93318, 94002, 94200, 94250, 94680,
94681, 94690, 94770, 95812, 95813,
95816, 95819, 95822, 95829, 95955, 96360,
96365, 96372, 96374, 96375, 96376
Procedure code 58356 will be denied if billed with the
same date of service by the same provider as the following procedure codes: 58150, 58152, 58180, 58200, 58210,
58240, 58260, 58262, 58263, 58267, 58270, 58275,
58280, 58285, 58290, 58291, 58292, 58293, and 58294
00940, 36000, 36400, 36405, 36406,
58356
36410, 36420, 36425, 36430, 36440,
36600, 36640, 37202, 43752, 51701,
51702, 51703, 57180, 57400, 57410, 57452,
57500, 57800, 58100, 58120, 58558, 62310,
32311, 32318, 32319, 64400, 64402,
64405, 64408, 64410, 64412, 64413,
64415, 64416, 64417, 64418, 64420,
64421, 64425, 64430, 64435, 64445,
64446, 64447, 64448, 64449, 64450,
64470, 64475, 64479, 64483, 64505,
64508, 64510, 64517, 64520, 64530, 76700,
76830, 76856, 76857, 76942, 93000,
93040, 93041, 93318, 94002, 94200,
94250, 94680, 94681, 94690, 64770,
95812, 95813, 95816, 95819, 95822, 95829,
95955, 96360, 96365, 96372, 96374,
96375, 96376
• Ectopic pregnancy
• Hydrosalpinx unrelated to infertility
• Salpingitis unrelated to infertility
• Torsion of the fallopian tube
• Abscess of the fallopian tube
• Peritubal adhesions unrelated to infertility
• Cyst or tumor of the fallopian tube unrelated to
infertility
• Hematosalpinx
The procedure codes in Column A of the following table
will be denied if billed with the same date of service by
the same provider as the procedure codes in Column B:
Column A (Denied)
58400
58353
36400, 36405, 36406, 36410, 36420,
36425, 36430, 36440, 36600, 36640,
37202, 43752, 44005, 44180, 44820,
44850, 44950, 49000, 49002, 49010,
49255, 49570, 50715, 51701, 51702, 51703,
57410, 58660, 58673, 58805, 58900,
62310, 62311, 62318, 62319, 64400,
64402, 64405, 64408, 64410, 64412,
64413, 64415, 64416, 64417, 64418,
64420, 64421, 64425, 64430, 64435,
64445, 64446, 64447, 64448, 64449,
64450, 64470, 64475, 64479, 64483,
64505, 64508, 64510, 64517, 64520, 64530,
93000, 93040, 93041, 93318, 94002,
94200, 94250, 94680, 94681, 94690,
94770, 95812, 95813, 95816, 95819, 95822,
95829, 95955, 96360, 96365, 96372,
96374, 96375, 96376
Column B
58410
58356
58770
Procedures Manual, section 36.4.16, “Gynecological
Health Services,” on page 36-40, for more information
about gynecological and reproductive health services
benefits.
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May/June 2010
All Providers
Reimbursement Rates for New Gynecological
and Reproductive Health Services
Procedure Codes
Hepatitis Prophylaxis
(Hepatitis B Immune Globulin)
The following benefit changes apply to hepatitis
prophylaxis procedure codes as indicated:
indicated:
Procedure
Code
56805
58356
58356
58356
58400
58400
58400
58400
58410
58410
58410
58410
58770
58770
58770
58770
Age
All ages
Birth through 20
years of age
21 years of age or
older
All ages
Birth through 20
years of age
21 years of age or
older
Birth through 20
years of age
21 years of age or
older
Birth through 20
years of age
21 years of age or
older
Birth through 20
years of age
21 years of age or
older
Birth through 20
years of age
21 years of age or
older
Birth through 20
years of age
21 years of age or
older
Procedure
Code
90371
Reimbursement Rate
ASC: Group 6
Surgery component:
$271.22
Surgery component:
$258.30
ASC: Group 9
Surgery component:
$343.39
Surgery component:
$327.04
Assistant surgery component: $54.99
Surgery component:
$623.78
Surgery component:
$594.07
Surgery component:
$654.71
Surgery component:
$623.53
96372,
96374
J1571,
J1573
RHC encounter reimbursement.
Orthognathic Surgery
The following changes will apply to the procedure codes
indicated:
Procedure
Code
21010
Changes
Surgery component: May be reimbursed
to physicians and dentistry groups in the
office setting.
No longer reimbursed to NP, CNS, PA,
and CNM providers in the inpatient hospital or outpatient hospital setting.
21031, 21032 Surgery component: May be reimbursed
to NP, CNS, and PA providers in the
office setting.
Is now a benefit for ASC providers.
Hematopoietic Injections
Hematopoietic injection procedure codes J0881,
J0882, J0885, and J0886 are no longer reimbursed to
CNM providers in the office setting, and are no longer
reimbursed in the home, SNF, ICF, or ECF setting.
Procedure codes J0881, J0882, J0885, and J0886 may be
reimbursed to nephrology (hemodialysis, renal dialysis)
providers in the office setting, and may be reimbursed to
renal dialysis facilities in the outpatient hospital setting.
May/June 2010
Changes
No longer reimbursed to CNM, CCP,
RHC providers in the office setting.
No longer reimbursed in the home or ECF
setting.
physician, CNM, CCP, nephrology
(hemodialysis, renal dialysis), renal dialysis
facility, and hospital-based RHC providers
No longer reimbursed to CCP providers
No longer reimbursed in the home or
No longer reimbursed to dentist, DME
medical supplier, radiation treatment
center, and oral maxillofacial surgeon
No longer reimbursed to nephrology
in the outpatient hospital.
No longer reimbursed in the home, ECF,
or “other location” setting.
67
All Providers
Procedure
Code
21050
Procedure
Code
21122, 21123,
21145, 21146,
21147, 21150,
21151, 21154,
21155, 21159,
21160, 21172,
21175, 21179,
21180, 21181,
21182, 21183,
21184, 21188,
21193, 21194,
21195, 21196,
21206, 21209,
21210, 21244,
21247, 21255,
21256, 21260,
21261, 21263,
21267, 21268,
21275
21125
Changes
office setting.
Assistant surgery component: No longer
reimbursed to CNM providers in the
inpatient hospital or outpatient hospital
setting.
21060, 21121, Surgery component: May be reimbursed
21127, 21240, to physicians and dentistry groups in the
21242, 21243, office setting.
21299
setting.
21073
Surgery component: No longer reimbursed to NP, CNS, PA, and oral maxillofacial surgeon providers in the office,
inpatient hospital, or outpatient hospital
setting.
21100
Surgery component: No longer reimbursed to podiatrist and CNM providers
in the office, inpatient hospital, or outpatient hospital setting.
21110
Surgery component: No longer reimbursed to podiatrist and CNM providers
in the office, inpatient hospital, or outpatient hospital setting.
21120
office setting.
setting.
21137, 21138,
21139, 21198
21199
21208,
21230, 21235,
21295, 21296,
40843,
40844,
40845
68
Changes
setting
office setting.
setting.
setting.
May/June 2010
All Providers
Procedure
Code
Changes
21215, 21280, Surgery component: May be reimbursed
21282
office setting.
21245, 21246, Surgery component: No longer reim21270
bursed in the office setting.
Assistant surgery component: Is now a
benefit and may be reimbursed to NP,
CNS, PA, physician, and dentist providers in the inpatient hospital or outpatient
hospital setting.
29804
office setting.
CNS, PA, physician, dentist, and podiatrist providers in the inpatient hospital or
40842
office setting.
S8262
Is now a benefit and may be reimbursed
to physicians in the office or outpatient
hospital setting. Prior authorization is
required. A narrative explaining medical necessity must be provided with the
authorization request.
Procedure
Code
Age
21198
All ages
21245
Birth through
20 years of age
21245
21 years of age
or older
21246
Birth through
20 years of age
21246
21 years of age
or older
21270
Birth through
20 years of age
21270
21 years of age
or older
29804
Birth through
20 years of age
29804
21 years of age
or older
S8262
All ages
Panniculectomy and Abdominoplasty
Procedure codes 15830 and 15847 are benefits of Texas
Medicaid and may be reimbursed as follows:
• Surgery component. May be reimbursed to physicians in
the inpatient hospital or outpatient hospital setting.
May be reimbursed to ASC providers in the outpatient
hospital setting. Prior authorization is required.
• Assistant surgery component. May be reimbursed to NP,
CNS, and PA providers in the inpatient hospital or
outpatient hospital setting. Procedure code 15847 may
be reimbursed for clients who are birth through 20
years of age.
Panniculectomy and abdominoplasty procedures must
be prior authorized.
All medical record documentation pertinent
Reimbursement Rates for New Benefits
Procedure
Code
21031
21032
21110
21125
21137
21138
21139
Age
All ages
All ages
All ages
All ages
All ages
All ages
All ages
to the individual’s evaluation and treatment
must support medical necessity
Reimbursement Rate
ASC: Group 1
ASC: Group 1
ASC: Group 1
ASC: Group 8
ASC: Group 8
ASC: Group 9
ASC: Group 9
May/June 2010
Reimbursement Rate
ASC: Group 9
Assistant surgery
component: $75.32
Assistant surgery
component: $71.74
Assistant surgery
component: $106.54
Assistant surgery
component: $101.47
Assistant surgery
component: $99.67
Assistant surgery
component: $94.92
Assistant surgery
component: $81.05
Assistant surgery
component: $77.19
$900.00
To avoid unnecessary denials, the physician must provide
correct and complete information, including documentation establishing medical necessity of the service
requested. This documentation must remain in the
client’s medical record and is subject to retrospective
review.
69
All Providers
billed with the same date of service by by the same
provider as procedure code 15830:
Procedure Codes
12001
12007
12036
14001
36406
36440
51701
62318
64408
64417
64430
64448
64479
64517
93041
94680
95813
95955
96375
11100
12006
12035
14000
36405
36430
43752
62311
64405
64416
64425
64447
64475
64510
93040
94250
95812
95829
96374
12002
12031
12037
14300
36410
36600
51702
62319
64412
64418
64435
64449
64483
64520
93318
94681
95816
96360
96376
12004
12032
13100
36000
36420
36640
51703
64400
64413
64420
64445
64450
64505
64530
94002
94690
95819
96365
12005
12034
13101
36400
36425
37202
62310
64402
64415
64421
64446
64470
64508
93000
94200
94770
95822
96372
Panniculectomy
A panniculectomy for clients who are birth through
20 years of age may be reimbursed with prior authorization for one of the following conditions when the
panniculus hangs to or below the level of the pubis:
• A panniculus has recurrent non-healing ulcers.
• Client is insulin dependent with recurring infection
and causing the prolapse of a ventral hernia.
• Panniculus diretly causes significant clinical
functional impairment.
Panniculectomy is not a benefit when one of following
is the primary purpose:
• To remove excess skin and fat from the middle
and lower abdomen in order to contour and alter
the appearance of the abdominal area to improve
appearance.
• Dissatisfaction with personal body image.
• To minimize the risk of ventral hernia formation of
recurrence.
Panniculectomy may be prior authorized when the client
meets one of the following:
• Panniculectomy is planned and there is no history of
significant weight loss or gastric bypass surgery.
• Panniculectomy is planned without history of gastric
bypass surgery but with significant weight loss and the
paniculus hangs to or below the level of the pubis.
• Panniculectomy is planned with history of gastric bypass
surgery or abdominoplasty and the client is 12 months
post-surgery.
If a panniculectomy is planned and there is no history
of significant weight loss or gastric bypass surgery, or a
panniculectomy is planned without history of gastric
bypass surgery but with significant weight loss and the
paniculus hangs to or below the level of the pubis, one of
the following must be met:
• Documentation of recurrent episodes of infection or
recurrent non-healing ulcers over three months that
are non-responsive to treatment or appropriate medical
therapy, such as oral or topical prescription.
• The client is insulin-dependent and has a serious
infection control problem and the panniculus is causing
the prolapse of a ventral hernia.
• Documentation by the treating physician that the
panniculus directly causes significant clinical functional
impairment. Clinical functional impairment may be
indicated by associated musculoskeletal dysfunction or
interference with activities of daily living and there is
reasonable evidence to support that this surgical intervention will correct the condition.
If a panniculectomy is planned with a history of gastric
bypass surgery or abdominoplasty and the client is 12
months post-surgery, the following must be met:
• Documentation that the panniculus hangs to or below
the level of the pubis and the individual has maintained
a significant (100 pounds or more), stable weight loss
for at least six months. Documentation must include
the weight loss history, prior and current height, and
prior and current weight, and the history and physical
including all previous surgeries.
• Documentation of recurrent episodes of infection or
recurrent non-healing ulcers over three months that
are non-responsive to treatment or appropriate medical
therapy, such as oral or topical prescription. The 12month post-gastric bypass requirement may be waived.
• For the sole purpose of treating neck or back pain.
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May/June 2010
All Providers
• The client is insulin-dependent and has a serious
infection control problem and the panniculus is
causing the prolapse of a ventral hernia. The 12-month
post-gastric bypass requirement may be waived.
• Documentation by the treating physician that
the panniculus directly causes significant clinical
functional impairment. The 12-month post-gastric
bypass requirement may be waived. Clinical functional
impairment may be indicated by associated musculoskeletal dysfunction or interference with activities
of daily living and there is reasonable evidence to
support that this surgical intervention will correct the
condition.
All medical record documentation pertinent to the individual’s evaluation and treatment must support medical
necessity of the panniculectomy. Documentation may
include the following:
• Office records
• Consultation reports
• Operative reports
• Other hospital records (examples: pathology report,
history and physical)
Documentation to support the panniculectomy must be
submitted with the request for prior authorization. In
addition to medical record documentation, the provider
may also submit a letter of support or an explanation to
substantiate medical necessity.
This service is typically expected to be limited to once
per lifetime; however, repeat panniculectomies may be
considered for prior authorization upon submission of
supporting documentation as outlined above.
A panniculectomy provided as a secondary surgery
may be considered for prior authorization when the
panniculus interferes with a medically necessary intraabdominal surgery (e.g., abdominal hernia repair or
hysterectomy) or to facilitate an improved anatomical
field in order to provide radiation treatment to abdomen.
Documentation of medical necessity must include:
• The comorbidity for the diagnosis of the primary
surgery or for the nature of the condition undergoing
radiation treatment.
• Documentation supporting the need for the panniculectomy as the panniculus hangs below the level of
the pubis and will significantly interfere with planned
surgical procedure, or the abdominal structures
May/June 2010
identified as requiring radiation therapy will not be
adequately treated due to the size of the panniculus.
A panniculectomy provided as a secondary surgery may be
considered when the primary surgery was performed for an
urgent condition defined as a symptom or condition that
is not an emergency, but requires further diagnostic workup or treatment within 24 hours to avoid a subsequent
emergent situation.
The need for the panniculectomy as a secondary surgery
in conjunction with a primary urgent surgery must be
supported by retrospective review of submission of all of
the following documentation:
• History and physical and the operative report.
• The panniculus hangs below the level of the pubis and
would have significantly interfered with the urgent
primary surgical procedure.
Abdominoplasty
An abdominoplasty for a client who is birth through 20
years of age may be reimbursed with prior authorization
for one of the following conditions:
• Prune belly.
• Diastasis recti in the presence of a true midline hernia
(ventral or umbilical).
Abdominoplasty is not a benefit when one of the following
is the primary purpose:
• To remove excess skin and fat and tighten abdominal
wall from the middle and lower abdomen in order to
contour and alter the appearance of the abdominal area
to improve appearance.
• Dissatisfaction with personal body image.
• To repair diastases recti (unless prior authorization as
outlined below has been met).
Abdominoplasty may be prior authorized when the client
meets all of the following criteria:
• Documented diagnosis of prune belly (i.e., Eagle Barret
syndrome) or repair of diastasis recti in the presence of a
true midline hernia (ventral or umbilical).
• Documentation for reconstructive surgery that must
include, appropriate historical medical record documentation and may include any of the following:
- Consultation reports.
- Operative reports or other applicable hospital
records (examples: pathology report, history and
physical).
71
All Providers
- Office records.
Procedure
Code
Age
15847
Birth through
20 years of age
15847
Birth through
20 years of age
15847
All ages
- Letters with pertinent information from provider.
(When medical records are requested, a letter of
support or explanation may be helpful, but alone
will not be considered sufficient documentation to
make a medical necessity determination.)
• For repair of diastasis recti with a true midline hernia,
documentation must also include all of the following:
Penile and Testicular Prosthesis
The following services may be reimbursed by Texas
Medicaid with prior authorization:
- The size of the hernia.
- Whether it is reducible, painful, or other
symptoms.
• Removal of a penile prosthesis without replacement.
• Insertion of testicular prosthesis for the replacement of
congenitally absent testes or testes lost due to disease,
injury, or surgery.
- Whether there is a defect rather than just thinning
of the abdominal fascia.
• Consideration of other abdominal diagnosis may be
considered for prior authorization with the submission
of additional supporting documentation that may
include the following:
Procedure codes 54406 and 54415 are benefits of Texas
Medicaid and may be reimbursed to physicians in the
inpatient hospital or outpatient hospital setting for male
clients who are 21 years of age or older.
- Consultation reports.
- Operative reports or other applicable hospital
records (examples: pathology report, history and
physical).
in the inpatient hospital or outpatient hospital setting for
male clients who are birth through 20 years of age.
- Office records.
Prior authorization is required for testicular prosthesis
(procedure code 54660) with the following criteria:
- Letters with pertinent information from provider
(When medical records are requested, a letter of
support or explanation may be helpful, but alone
will not be considered sufficient documentation to
make a medical necessity determination.)
• The male client is birth through 20 years of age.
• The client has lost a testicle as a result of cancer or
trauma or has congenital absence of a testicle.
• The loss of the testicle has resulted in detrimental
psycho-social sequelae, as evidenced by a psychiatric
evaluation.
Reimbursement Rates for New Panniculectomy
and Abdominoplasty Procedure Codes
indicated:
Procedure
Code
Age
15830
Birth through
20 years of age
15830
21 years of age
or older
15830
Birth through
20 years of age
15830
21 years of age
or older
15830
All ages
Removal of a penile prosthesis may be considered for
prior authorization with documentation submitted
indicating the prosthetic has resulted in infection,
erosion, or pain.
Reimbursement Rate
Surgery component:
$858.05
Surgery component:
$817.19
ASC: Group 6
Reimbursement Rate
Surgery component:
$831.99
ASC: Group 6
Prior authorization requests for PCCM clients must be
submitted by the physician to the PCCM Outpatient
Prior Authorization Department. Authorizations may
be submitted online at www.tmhp.com, by telephone at
1-888-302-6167, or by fax to 1-512-302-5039. Providers
must use the PCCM Inpatient/Outpatient Authorization
Form. The request must be submitted with documentation that supports medical necessity.
72
May/June 2010
All Providers
All other requests for prior authorization must be
submitted by the physician to the SMPA department
using the Special Medical Prior Authorization (SMPA)
Request Form. Authorizations may be submitted online
at www.tmhp.com, by fax to 1-512-514-4213, or by
mail at:
Procedure
Code
Age (Years)
54415
21 years of age
or older
54415
Birth through
20 years of age
54415
21 years of age
or older
54415
All ages
54660
Birth through
20 years of age
54660
21 years of age
or older
54660
All ages
Austin TX 78727
The request must be submitted with documentation that
supports medical necessity.
submitted with the same date of service as procedure
code 54406 or 54415:
Procedure Codes
36000
36400
36420
36425
36640
37202
62318
62319
64450
64475
64508
64510
93000
93040
94200
94250
94770
95812
95822
95829
96374
96375
36405
36430
43752
64415
64479
64517
93041
94680
95813
95955
96376
36406
36440
51703
64416
64483
64520
93318
94681
95816
96365
Pulmonary Function Studies
Procedure codes 94452 and 94453 (high altitude
simulation tests [HAST] pulmonary function studies)
are benefits of Texas Medicaid for clients who are
one year of age or older. Procedure codes 94452 and
94453 may be reimbursed to NP, CNS, PA, physician,
independent laboratory, hospital, portable X‑ray supplier,
and radiological and physiological laboratory providers
in the office, inpatient hospital, outpatient hospital, or
36410
36600
54470
64417
64505
64530
94002
94690
95819
96372
HAST must be billed with one of the following diagnosis
codes:
Diagnosis Codes
27700*
27701
4160*
4161*
4911*
49120*
4919*
4920*
500*
5080*
515
5160
5168
5169
7485
74861
Reimbursement Rates for New Penile and
Testicular Prosthesis Procedure Codes
Procedure
Code
Age (Years)
54406
Birth through
20 years of age
54406
21 years of age
or older
54406
Birth through
20 years of age
54406
21 years of age
or older
54406
All ages
54415
Birth through
20 years of age
Reimbursement Rate
Surgery component:
$600.29
Surgery component:
$571.70
Assistant surgery
component: $96.23
Assistant surgery
component: $91.65
ASC: Group 9
Surgery component:
$432.46
May/June 2010
Reimbursement Rate
Surgery component:
$411.87
Assistant surgery
component: $69.02
Assistant surgery
component: $65.74
ASC: Group 9
Surgery component:
$290.12
Surgery component:
$276.31
ASC: Group 6
27702*
4168*
49121*
4928*
5081
5161
5181
7707*
27703*
4169*
49122*
4940*
5088*
5162
5183*
27709*
4910*
4918*
4941*
5089*
5163
51883
* When billing for HAST with one of these diagnosis codes,
evidence of hypoxemia must be documented in the client’s
medical record.
The physician must maintain correct and complete
information, including documentation establishing
medical necessity of the service requested. This documentation must be kept in the client’s medical record and
is subject to retrospective review.
73
All Providers
will be denied when billed on the same date of service by
the same provider as the corresponding procedure codes
in Column B:
Column A (Denied)
Column B
94760, 94761
94452, 94760, and 94761
94452
94453
The following changes apply to the procedure codes as
indicated:
Procedure
Codes
94010
94014
Procedure
Codes
94015
Changes
Total laboratory component: No longer
CNM, hospital, nephrology (hemodialysis,
renal dialysis), renal dialysis facility, and
hospital-based RHC providers in the office
setting.
No longer reimbursed in the inpatient hospital or independent laboratory setting.
No longer reimbursed to physician, independent laboratory, CNM, nephrology
facility, portable X‑ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in the outpatient
hospital setting.
No longer reimbursed to independent
laboratory, CNM, hospital, nephrology
hospital setting.
Technical component: No longer reimbursed in the home, SNF, ICF, independent laboratory, or ECF setting.
94016
94060
74
Changes
renal dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, and hospital-based
RHC providers in the office or outpatient
hospital setting.
Total component: No longer reimbursed
to independent laboratory, CNM, hospital,
RHC providers in the office setting.
No longer reimbursed in the inpatient hospital, outpatient hospital, or independent
laboratory setting.
setting.
hospital setting.
May be reimbursed to physicians in the
office setting.
No longer reimbursed to CNM, portable
X‑ray supplier, and radiological and physiological laboratory providers in the inpatient
Technical component: No longer reimbursed in the independent laboratory
setting.
May/June 2010
All Providers
Procedure
Codes
94070
94150,
94240,
94400,
94450,
94620
Procedure
Codes
94200,
94375
Changes
setting.
hospital setting.
office setting.
setting.
hospital setting.
office setting.
May/June 2010
94250,
94260,
94350,
94360,
94370
75
Changes
setting.
hospital setting.
office setting.
Technical component: No longer reimbursed in the independent laboratory
setting.
setting.
hospital setting.
office setting.
All Providers
Procedure
Codes
94621
Procedure
Code
Age (Years)
94453
21 years of age
or older
94453
Birth through
20 years of age
94453
21 years of age
or older
94453
Birth through
20 years of age
94453
21 years of age
or older
Changes
setting.
office setting.
Technical component: No longer reimbursed to physician, CNM, and radiation
treatment center providers in the office
setting.
No longer reimbursed in the home, SNF,
ICF, independent laboratory, or ECF
setting.
Services Incidental to Surgery or Anesthesia
The following changes apply to the surgery procedure
codes indicated:
Procedure
Codes
31500,
36420,
36425
36010
36430
RHC encounter reimbursement or the hospital diagnosisrelated group (DRG) reimbursement.
Reimbursement Rates for New Benefits
36440
Procedure
Code
Age (Years)
94452
Birth through
20 years of age
94452
21 years of age
or older
94452
Birth through
20 years of age
94452
21 years of age
or older
94452
Birth through
20 years of age
94452
21 years of age
or older
94453
Birth through
20 years of age
Reimbursement Rate
Total laboratory
component: $55.10
Professional interpretation component: $14.89
Technical component:
$42.96
$40.91
Reimbursement Rate
Total laboratory
component: $42.96
Total laboratory
component: $40.91
$117.42
$111.83
Total laboratory
component: $57.85
33970
36555
76
Changes
Surgery component: No longer reimbursed to CNM providers in the office,
setting.
Surgery component: No longer reimbursed to CNM providers in the inpatient
Surgery component: No longer reimbursed to CNM providers in the office
setting.
No longer reimbursed in the home setting.
May be reimbursed to physicians and hospitals in the outpatient hospital setting.
Surgery component: No longer reimbursed to CNM providers in the office
setting.
Surgery component: No longer reimbursed to NP, CNS, PA, and CNM providers in the inpatient hospital setting.
No longer reimbursed in the outpatient
hospital setting.
CNS, PA, and physician providers in the
May/June 2010
All Providers
Procedure
Codes
36557,
36560
36558,
36561,
36563,
36565,
36566
36620,
36625,
93503
36420
82800,
82803,
82805,
82810,
82820
93005,
93041
Procedure
Codes
93561,
93562
Changes
May be reimbursed to certified registered
nurse anesthetist (CRNA) providers in the
inpatient or outpatient hospital setting.
to CRNA providers in the office, inpatient
Surgery component: No longer reimbursed to CNM providers in the office,
setting.
No longer reimbursed to NP, CNS, and
PA providers in the inpatient hospital or
for Texas Medicaid clients who are birth
through 11 months of age.
optometrist, podiatrist, CNM, radiation
treatment center, hospital, nephrology
facility, and hospital-based RHC in the
office setting.
No longer reimbursed in the inpatient
hospital setting.
laboratory, radiation treatment center,
RHC providers in the outpatient hospital
setting.
No longer reimbursed to radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis
in the independent laboratory setting.
Technical component: No longer reimbursed in the home, inpatient hospital,
SNF, ICF, independent laboratory, or ECF
setting.
independent laboratory, hospital, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, and hospital-based RHC
No longer reimbursed in the outpatient
hospital setting.
May/June 2010
94010
77
Changes
CNM, and hospital providers in the office
setting.
laboratory and CNM providers in the
physician, independent laboratory, and
CNM providers in the outpatient hospital
setting.
No longer reimbursed in the independent
laboratory setting.
office setting.
Technical component: No longer reimbursed in the inpatient hospital or outpatient hospital setting.
May be reimbursed to physicians, portable X‑ray suppliers, and radiological and
physiological laboratory providers in the
office setting.
hospital-based RHC providers in the office setting.
hospital or independent laboratory setting.
renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in
No longer reimbursed to a NP, CNS,
PA, CNM, portable X‑ray supplier, and
radiological and physiological laboratory
providers in the inpatient hospital or outpatient hospital setting.
office setting.
All Providers
Procedure
Codes
94060
94680,
94681,
94690,
94770
94760,
94761
93312
Procedure
Codes
93313,
93314,
93315
Changes
hospital or independent laboratory setting.
renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in
No longer reimbursed to a NP, CNS,
PA, CNM, portable X‑ray supplier, and
office setting.
CNM, DME medical supplier, CCP,
dialysis), renal dialysis facility, and hospital-based RHC providers in the office
setting.
DME medical supplier, CCP, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, portable X‑ray supplier,
and hospital-based RHC in the outpatient
hospital setting.
Total radiology component: No longer
reimbursed to radiation treatment center,
dialysis), renal dialysis facility, portable
X‑ray supplier, radiological and physiological laboratory, and hospital-based RHC
No longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable
93316,
93317
94002,
94003
99231,
99232,
99233
99291,
99292
Changes
reimbursed to CNM, radiation treatment
center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility,
portable X‑ray supplier, radiological and
physiological laboratory, and hospitalbased RHC providers in the office setting.
No longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable
reimbursed to CNM, radiation treatment
center, hospital, nephrology (hemodialysis,
renal dialysis), renal dialysis, and hospitalbased RHC providers in the office setting.
No longer reimbursed to radiation treatment center, nephrology (hemodialysis,
renal dialysis), renal dialysis, and hospitalbased RHC providers in the outpatient
hospital setting.
CNM, portable X‑ray supplier, and
providers in the inpatient hospital setting
No longer reimbursed to CNM providers
in the inpatient hospital setting.
May be reimbursed to optometric group
providers in the inpatient hospital setting.
No longer reimbursed to dentist and
CNM providers in the inpatient hospital
Procedure code 99143 will be denied when billed
procedure code 99144.
The procedure codes in the following table will be denied
when billed with the same date of service by the same
provider as procedure code 99143 or 99144:
In the following table the procedure codes in Column A
will be denied when billed with the same date of service
by the same provider as the corresponding procedure
codes in Column B:
Procedure Codes
36000
36400
36420
36425
78
36405
93000
36406
93040
36410
93041
May/June 2010
All Providers
Procedure Codes
93042
94760
96372
96373
99201
99202
99211
99212
99217
99218
99222
99223
99234
99235
99241
99242
99251
99252
99281
99282
99291
99292
99307
99308
99316
99318
99327
99328
99337
99341
99345
99347
99354
99355
99469
99471
99477
99478
94761
96374
99203
99213
99219
99231
99236
99243
99253
99283
99304
99309
99324
99334
99342
99348
99356
99472
99479
96360
96375
99204
99214
99220
99232
99238
99244
99254
99284
99305
99310
99325
99335
99343
99349
99357
99475
99480
Procedure
Code
Age (Years)
76998
21 years of age
or older
99143
All ages
99144
All ages
99145
All ages
L8603
All ages
L8606
All ages
96365
96376
99205
99215
99221
99233
99239
99245
99255
99285
99306
99315
99326
99336
99344
99350
99468
99476
Skin Therapy
The following benefit changes apply to the procedure
codes as indicated:
Procedure
Code
Changes
96900,
Medical component: No longer reimbursed
96910
to CNM providers in the office or outpatient
hospital setting.
96912
hospital setting.
No longer reimbursed in the inpatient hospital, SNF, ICF, or ECF setting.
96913
hospital setting.
96999
hospital setting.
96920
NP, CNS, and PA providers in the office or
96921
96922
NP, CNS, and PA providers in the office or
No longer reimbursed to ASC providers.
11900
Surgical component: No longer reimbursed
11901
to CNM providers in the office, inpatient
May be reimbursed to dentistry group
providers in the office, inpatient hospital, or
17999
Surgical component: No longer reimbursed
to ASC providers.
RHC encounter reimbursement or the hospital DRG
reimbursement.
Reimbursement Rates for New Procedure Codes
for Services Incidental to Surgery or Aneshtesia
indicated:
Procedure
Code
Age (Years)
33970
Birth through
20 years of age
33970
21 years of age
or older
76998
Birth through
20 years of age
76998
21 years of age
or older
76998
Birth through
20 years of age
76998
21 years of age
or older
76998
Birth through
20 years of age
Reimbursement Rate
Assistant surgery
component: $47.83
Assistant surgery
component: $45.55
Total radiology
component: $139.76
Total radiology
component: $133.11
$88.78
May/June 2010
Reimbursement Rate
$84.56
$28.69
$33.00
$9.00
$394.97
$198.49
79
All Providers
The following procedure codes are benefits for Texas
Medicaid and may be reimbursed as indicated:
Procedure Codes
64479
64483
64517
64520
93041
93318
94680
94681
95813
95816
95955
96360
96375
96376
Procedure
Code
15782,
May be reimbursed to NP, CNS, and PA
15783
office, inpatient hospital, or outpatient
hospital setting.
May be reimbursed for clients who are one
year of age or older.
15792,
May be reimbursed to NP, CNS, and PA
15793
office, inpatient hospital, or outpatient
hospital setting.
May be reimbursed for clients who are one
year of age or older.
• A diagnosis of actinic keratosis with more than three
lesions.
• Failed conservative treatment or documentation that
conservative treatment is contraindicated.
procedure codes 15792 or 15793:
Procedure Codes
36000
36400
36420
36425
36640
37202
51703
62310
64400
64402
64412
64413
64418
64420
64435
64445
64449
64450
64483
64505
64520
64530
93318
94002
94681
94690
95816
95819
96360
96365
96376
Dermabrasion procedures (procedure codes 15782 and
15783) may be prior authorized when documentation is
submitted that supports that the client meets all of the
following criteria:
• A diagnosis of actinic keratosis with more than
three lesions.
• Failed conservative treatment or documentation that
conservative treatment is contraindicated.
procedure code 15782 or 15783:
36405
36430
43752
62311
64405
64415
64421
64446
64470
64510
93040
94250
95812
95829
96374
Chemical peel procedures (procedure codes 15792 and
15793) may be prior authorized when the client meets all
of the following criteria:
Dermabrasion Procedures
36400
36425
37202
62310
64402
64413
64420
64445
64450
64508
93000
94200
94770
95822
96372
Chemical Peel Procedures
Procedure codes 15782, 15783, 15792, and 15793
will require prior authorization. To avoid unnecessary
denials, the physician must provide correct and complete
information, including documentation establishing
medical necessity of the service requested. This documentation must remain in the client’s medical record and
is subject to retrospective review.
Procedure Codes
11010
36000
36410
36420
36600
36640
51702
51703
62319
64400
64410
64412
64417
64418
64430
64435
64448
64449
64505
64530
94002
94690
95819
96365
36406
36440
51701
62318
64408
64416
64425
64447
64475
36405
36430
43752
62311
64405
64415
64421
64446
64470
64508
93000
94200
94770
95822
96372
36406
36440
51701
62318
64408
64416
64425
64447
64475
64510
93040
94250
95812
95829
96374
36410
36600
51702
62319
64410
64417
64430
64448
64479
64517
93041
94680
95813
95955
96375
Procedure code 15792 will additionally be denied when
billed with the same date of service by the same provider
as procedure code 15793.
Unlisted Procedures
For those procedures that do not have a specific
procedure code that describes the procedure, prior authorization may be requested with unlisted procedure code
80
May/June 2010
All Providers
17999. The prior authorization request must include the
following documentation:
performed.
• Reason for recommending this particular procedure.
• Documentation that a specific procedure code is not
available for the procedure requested.
• The client’s diagnosis.
• Medical records indicating prior treatment for this
procedure.
Non-Attested TPIs Without
Claims or Encounters for at Least
24 Months to Be End-Dated
• Place of service the procedure is to be performed.
including a comparable procedure code.
TMHP is collaborating with the Texas Health and
Human Services Commission (HHSC) and the
Department of State Health Services (DSHS) to improve
provider information databases by removing inactive
provider records.
Prior Authorization Requests
Prior authorization requests for PCCM clients must be
submitted by the physician to the PCCM Outpatient
Prior Authorization Department. All other requests for
prior authorization must be submitted by the physician
to the Special Medical Prior Authorization (SMPA)
department with documentation supporting the medical
necessity of the anticipated procedure.
Effective May 23, 2008, providers were required to attest
their National Provider Identifier (NPI) for each of their
enrolled Texas Provider Identifiers (TPIs). Since that
time, any claim that was submitted without an attested
NPI has been rejected. On May 1, 2010, TPIs without
attested NPIs and without associated claim activity for at
least 24 months will be terminated.
Reimbursement Rates for New Skin Therapy
Procedure Codes
Procedure
Code
Age
15782
Birth through
20 years of age
15782
21 years of age
or older
15783
Birth through
20 years of age
15783
21 years of age
or older
15792
Birth through
20 years of age
15792
21 years of age
or older
15793
Birth through
20 years of age
15793
21 years of age
or older

Also effective May 1, 2010, TMHP will send a courtesy
letter to all providers who have a TPI that has not had
any claims activity during the previous 18 months. The
letter will inform providers that if they want to keep
their TPIs active, they must submit a claim using the
TPI referenced in the letter by November 1, 2010. Going
forward, TMHP will generate courtesy letters whenever
a TPI goes 18 months without claims activity. Providers
who receive these letters will have six months from
the date on the letter to submit a claim using the TPI
referenced in the letter.
Reimbursement Rate
Surgical component:
$398.96
Surgical component:
$379.95
Surgical component:
$342.82
Surgical component:
$326.49
Surgical component:
$293.85
Surgical component:
$279.85
Surgical component:
$331.94
Surgical component:
$316.13

TMHP will apply a payment denial code to any TPI that
has had no claims activity by the deadline in the courtesy
letter and will notify the provider to inform them that
the TPI has been terminated. A provider’s TPI that is
terminated for Traditional Medicaid is also terminated
for all other Texas state health-care programs. Claims
that are submitted with a terminated TPI will be denied.
To reactivate a TPI, the provider must complete an
enrollment application.

May/June 2010
81
All Providers
CCP Benefits Changed for Orthoses and Prostheses
• Custom-fabricated orthosis. An orthosis specially
manufactured for a specific client. This type of device
requires substantial labor to construct and is custommolded to the client’s specific body part
benefit criteria for orthoses and prostheses changed for the
Texas Medicaid Comprehensive Care Program (CCP).
Orthoses
Orthoses, including orthopedic shoes, wedges, and lifts, are
a benefit of Texas Medicaid when provided by a licensed
orthotist or a licensed prosthetist/orthotist under the Texas
Health Steps-Comprehensive Care Program (THStepsCCP) for clients who are birth through 20 years of age.
• Orthoses may be reimbursed using the procedure codes
listed in table A on page 88 of this article.
• Prefabricated splint. An appliance for preventing
movement of joints or for the fixation of a displaced
or movable part. A prefabricated splint is not an
orthosis as defined in this article.
• Orthopedic devices may be reimbursed using the
procedure codes listed in table B on page 89 of this
article.
• Orthopedic shoe. Specialized footwear that requires a
prescription and is available only from a supplier of
orthopedic footwear (i.e., not available from a retail
store). An orthopedic shoe has additional depth,
may be used to accommodate foot deformities, and
is fitted and furnished by a specially trained health
professional. An orthopedic shoe:
The following orthoses are a benefit of Texas Medicaid
when medical necessity criteria are met as outlined in this
article:
• Spinal orthoses and additions to spinal orthoses,
including those for scoliosis
• Thoracic-hip-knee-ankle (THKA) orthoses and hip
orthoses
- Has a full-length, heel-to-toe filler, which, when
removed, provides a minimum of 3/16 inch of
additional depth used to accommodate custommolded or customized inserts.
• Lower-limb orthoses and additions to lower-limb
orthoses, including fracture orthoses
• Foot orthoses, including inserts, orthopedic shoes,
surgical boots, heel lifts, and wedges
- Is made from leather or from other suitable
material of equal quality.
• Upper-limb orthoses and additions to upper-limb
orthoses, including fracture orthoses
- Has some form of closure, such as Velcro, lace, or
zipper.
• Other orthopedic devices as outlined in this article,
including protective helmets and dynamic splints
- Is available in full and half sizes with a minimum
of three widths so that the sole is graded to the
size and width of the upper portions of the shoe
according to the American standard last-sizing
schedule or its equivalent.
Definitions for Orthoses
Texas Medicaid uses the definitions of the Texas State
Board of Orthotics and Prosthetics, as listed in the Texas
Administrative Code (TAC).
• An orthopedic shoe does not include:
The following definitions are not listed in TAC, but help
define the benefits included in this article:
• Direct supervision. The supervising licensed orthotist or
licensed prosthetist/orthotist is in the same office, building,
or facility when and where the service is provided, and is
immediately available to furnish assistance and direction.
• Custom-fitted orthosis. A prefabricated or off-the-shelf
orthosis that is manufactured in quantity without a specific
client in mind and is then trimmed, bent, or otherwise
molded for use by a specific client.
• Brace. An orthosis or orthopedic appliance that
supports or holds in correct position any movable
part of the body and allows for motion of that part. It
must be a rigid or semi-rigid device used to support
a weak or deformed body part or to restrict or
eliminate motion in a diseased or injured body part.
82
- Tennis shoes, even if prescribed by a physician
and worn with a removable brace.
- A shoe insert when it is not part of a modified
shoe or when the shoe in which it is inserted is
not attached to a brace.
Note: An exception is the University of California
at Berkeley (UCB) removable foot insert, which is a
benefit when medical necessity criteria are met.
May/June 2010
All Providers
Prior Authorization Requirements for Orthoses
• Foot inserts. Total-contact, multiple-density, removable
inlays that are directly molded to the plantar surface
of the individual’s foot or a model of the foot. Total
contact means that the insert has continuous physical
contact with the weight-bearing portion of the foot.
Prior authorization is required for all orthoses and related
services.
Before submitting a request for prior authorization for
orthosis, the orthosis provider must have a completed
THSteps-CCP Prior Authorization Form requesting
the orthosis or related services that has been signed and
dated by a physician who is familiar with the client.
All signatures and dates must be current, unaltered,
original, and handwritten. Computerized or stamped
signatures and dates will not be accepted. The completed
THSteps- CCP Prior Authorization Form must include
the procedure codes and quantities for requested services.
A copy of the completed, signed, and dated form must
be maintained by the orthosis provider in the client’s
medical record. The completed THSteps-CCP Prior
Authorization Form with the original dated signature
must be maintained by the prescribing physician in the
client’s medical record.
Noncovered Orthotic Services
The following circumstances are not a benefit of Texas
Medicaid:
• Orthoses whose sole purpose is for restraint
• Orthoses provided solely for use during sports-related
activities in the absence of an acute injury or other
indicated medical condition
• Orthotic devices prescribed by a chiropractor
Diagnoses that are not considered medically necessary
include, but are not limited to, the following:
• Tired feet
• Fatigued feet
• To complete the prior authorization process electronically, the orthosis provider must complete the prior
authorization requirements through any approved
electronic methods and retain a copy of the signed
and dated CCP Prior Authorization Request form in
the client’s medical record at the provider’s place of
business.
• Non-severe bow legs
• Valgus deformity of the foot, except as outlined in this
article
• Pes planus (flat feet), except when there is a coexisting
medical condition as outlined in this article
Orthopedic shoes with deluxe features, such as special
colors, special leathers, and special styles, are not
considered medically necessary, and the features do not
contribute to the accommodative or therapeutic function
of the shoe.
• To complete the prior authorization process by paper,
the orthosis provider must fax or mail the completed
THSteps-CCP Prior Authorization Request Form to
the CCP prior authorization unit and retain a copy of
the signed and dated CCP form in the client’s medical
record at the provider’s place of business.
A foot drop splint and recumbent positioning device
and replacement interface are not considered medically
necessary in a client with foot drop who is nonambulatory, because there are other more appropriate treatment
modalities.
To facilitate determination of medical necessity and
avoid unnecessary denials, the physician must provide
correct and complete information, including documentation for medical necessity of the equipment and supplies
requested. The physician must maintain documentation
of medical necessity in the client’s medical record. The
provider may be asked for additional information to
clarify or complete a request for the service or device.
A static ankle-foot orthosis (AFO) or AFO component is
not medically necessary if:
• The contracture is fixed.
• The client has foot drop without an ankle flexion
contracture.
All requests for prior authorization must include documentation of medical necessity including, but not limited
to, documentation that the device is needed for one of
the following indications:
• The component is used to address knee or hip
positioning, because the effectiveness of this type of
component is not established.
• To reduce pain by restricting mobility of the affected
body part.
A pneumatic thoracic-lumbar-sacral orthosis is
considered experimental and investigational and is not a
benefit of Texas Medicaid.
May/June 2010
• To facilitate healing following an injury to the affected
body part or related soft tissue.
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All Providers
• To facilitate healing following a surgical procedure on
the affected body part or related soft tissue.
previously defined in the Prior Authorization
Requirements section.
• To support weak muscles or a deformity of the affected
body part.
Lower-Limb Orthoses
Lower-limb orthoses include, but are not limited
to, hip orthoses (HO), Legg Perthes orthoses, knee
orthoses (KO), ankle-foot orthoses (AFO), knee-anklefoot orthoses (KAFO), hip-knee-ankle-foot orthoses
(HKAFO), fracture orthoses, and reciprocating gait
orthoses (RGO).
Prior authorization requests for some types of orthosis
require additional documentation which is detailed in
the sections that follow.
The provider must keep the following written documentation in the client’s medical record:
In addition to the indications previously defined in the
Prior Authorization Requirements for Orthoses section,
lower-limb orthoses will be considered for prior authorization with documentation of the following criteria for
specific orthotic devices:
• The prescription for the device.
Note: Orthotic devices must be prescribed by a physician
(Doctor of Medicine [M.D.] or Doctor of Osteopathy
[D.O.]) or a podiatrist. A podiatrist prescription is valid
for conditions of the ankle and foot.
The prescription must be dated on or before the initial
date of the requested dates of service, which can be no
longer than 90 days from the signature date on the
prescription.
Ankle-Foot Orthoses (AFO)
AFOs used during ambulation will be considered for
prior authorization for clients with documentation of all
of the following:
• Weakness or deformity of the foot and ankle.
• Accurate diagnostic information that supports the
medical necessity for the requested device (a retrospective review may be performed to ensure that the
documentation included in the client’s medical record
supports the medical necessity of the requested service
or device).
• A need for stabilization for medical reasons.
• Anticipated improvement in functioning during
activities of daily living (ADLs) with use of the device.
AFOs not used during ambulation (static AFO) will be
considered for prior authorization for clients with documentation of one of the following conditions:
A prior authorization is valid for a maximum period
of six months from the prescription signature date.
At the end of the six-month authorization period, a
new prescription is required for prior authorization of
additional services.
• Plantar fasciitis.
• Plantar flexion contracture of the ankle, with
additional documentation that includes all of the
following:
For the purpose of this article, the actual date of service
is the date the supplier has placed an order for the
equipment and has incurred liability for the equipment.
- Dorsiflexion on pretreatment passive range of
motion testing is at least 10 degrees.
Spinal Orthoses
- The contracture is interfering or is expected to
interfere significantly with the client’s functioning
during ADLs.
Spinal orthoses include, but are not limited to, cervical
orthoses, thoracic rib belts, thoracic-lumbar-sacral
orthoses (TLSO), sacroiliac orthoses, lumbar orthoses,
lumbar-sacral orthoses (LSO), cervical-thoracic-lumbarsacral orthoses (CTLSO), halo procedures, spinal corset
orthoses, and spinal orthoses for scoliosis.
- The AFO will be used as a component of a
physician-prescribed therapy plan care, which
includes active stretching of the involved muscles
or tendons.
Spinal orthoses will be considered for prior authorization
with documentation of one of the indications defined
in the Prior Authorization Requirements for Orthoses
section above.
- There is reasonable expectation that the AFO will
correct the contracture.
Knee-Ankle-Foot Orthoses (KAFO)
Thoracic-Hip-Knee-Ankle (THKA) Orthoses
KAFOs used during ambulation will be considered
for prior authorization for clients with documentation
that supports medical necessity for additional knee
stabilization.
THKA orthoses will be considered for prior authorization with documentation of one of the indications
84
May/June 2010
All Providers
Foot Inserts
KAFOs that are custom-fabricated (molded-to-patient
model) for ambulation will be considered for prior authorization when at least one of the following criteria is met:
Removable foot inserts will be considered for prior authorization for clients with documentation of at least one of
the following medical conditions:
• The client cannot be fit with a prefabricated
AFO/KAFO.
• Diabetes mellitus
• The condition that necessitates the orthosis is expected
to be permanent or of long-standing duration (more
than six months).
• History of amputation of the opposite foot or part of
either foot
• History of foot ulceration or pre-ulcerative calluses of
either foot
• There is a need to control the knee, ankle, or foot in
more than one plane.
• Peripheral neuropathy with evidence of callus
formation of either foot
• The client has a documented neurological, circulatory,
or orthopedic status that requires custom fabrication
to prevent tissue injury.
• Deformity of either foot
• Poor circulation of either foot
• The client has a healing fracture that lacks normal
anatomical integrity or anthropometric proportions.
Removable foot inserts may be covered independently of
orthopedic shoes with documentation that the client has
appropriate footwear into which the insert can be placed.
Reciprocating Gait Orthoses (RGO)
Reciprocating gait orthoses will be considered for prior
authorization for clients with spina bifida or similar
functional disabilities.
A UCB removable foot insert will be considered for prior
authorization with documentation that the device is
required to correct or treat at least one of the following
conditions:
The prior authorization request must include a statement
from the prescribing physician that indicates medical
necessity for the RGO, the physical therapy treatment
plan, and documentation that the client/family is willing
to comply with the treatment plan.
• A valgus deformity and significant congenital pes
planus with pain
• A structural problem which results in significant pes
planus, such as Down syndrome
Foot Orthoses
Foot orthoses include, but are not limited to, foot inserts,
orthopedic shoes, wedges, and lifts.
• Acute plantar fasciitis
Foot orthoses will be considered for prior authorization
for clients with documentation of all the following:
Orthopedic shoes must be prescribed by a licensed
physician (M.D. or D.O.) or a podiatrist. An orthopedic
shoe is used by clients whose feet, although impaired,
are essentially intact. An orthopedic shoe differs from a
prosthetic shoe, which is used by clients who are missing
all or most of the forefoot.
Orthopedic Shoes
• The client has symptoms associated with the particular
foot condition.
• The client has failed to respond to a course of
appropriate, conservative treatment, including physical
therapy, injections, strapping, or anti-inflammatory
medications.
Orthopedic shoes will be considered for prior authorization when at least one of the following criteria is met:
• The shoe is permanently attached to a brace.
• The client has at least one of the following:
- Torsional conditions, such as metatarsus adductus,
tibial torsion, or femoral torsion
• The shoe is necessary to hold a surgical correction,
postoperative casting, or serial or clubfoot casting.
- Structural deformities
An orthopedic shoe may be prior authorized up to one
year from the date of the surgical procedure.
- Hallux valgus deformities
Only one pair of orthopedic shoes will be prior
authorized every three months. Two pairs of shoes
may be purchased at the same time; in such situations,
however, additional requests for shoes will not be
considered for another six months.
- In-toe or out-toe gait
- Musculoskeletal weakness
Additional criteria for specific foot orthoses follow.
May/June 2010
85
All Providers
Requests for orthopedic shoes that do not meet the
criteria listed previously may be considered for prior
authorization with documentation of medical necessity.
was successful and showed improvement in the client’s
condition as measured by the following:
• Demonstrated increase in range of motion
Wedges and Lifts
• Demonstrated improvement in the ability to complete
ADL’s or perform activities outside the home
Wedges and lifts must be prescribed by a licensed
physician (M.D. or D.O.) or a podiatrist and must be for
treatment of unequal leg length greater than one-half inch.
Related Services
Orthotic Device Training
Upper-Limb Orthoses
Training in the use of an orthotic device for a client
who has not worn one previously, has not worn one for
a prolonged period, or is receiving a different type is a
benefit when the training is provided by a physical or
occupational therapist, and Texas Medicaid criteria for
these services are met.
Upper-limb orthoses include, but are not limited to,
shoulder orthoses, elbow orthoses, elbow-wrist-hand
orthoses, elbow-wrist-hand-finger orthoses, wristhand-finger orthoses, wrist-hand orthoses, hand-finger
orthoses, finger orthoses, shoulder-elbow-wrist-hand
orthoses, shoulder-elbow orthoses, and fracture orthoses.
Note: Refer to the 2009 Texas Medicaid Provider
Procedures Manual, sections 43.4.8,”Occupational
Therapists (CCP)” and 43.4.12, “Physical Therapists (CCP)”
for specific benefit criteria for these services.
Upper-limb orthoses will be considered for prior
authorization with documentation of one of the
indications previously defined in the Prior Authorization
Requirements for Orthoses section.
Repairs, Replacements, and Modifications
to Orthoses
Other Orthopedic Devices
Protective Helmets
Repairs, replacements, and modifications to an orthosis
are a benefit when medical necessity criteria are met.
Protective helmets will be considered for prior authorization for clients with a documented medical condition
that makes the client susceptible to injury during ADLs.
Covered medical conditions include the following:
Within the guarantee of the manufacturer, providers
are responsible, without charge to the client or to Texas
Medicaid, for replacement or repair of equipment or any
part thereof that is found to be nonfunctional because
of faulty material or workmanship. Service and repairs
must be handled under any warranty coverage an item
may have.
• Neoplasm of the brain
• Subarachnoid hemorrhage
• Epilepsy
• Cerebral palsy
If there is no warranty, providers may request prior
authorization for the necessary service and repairs.
Requests for all conditions other than those listed above
require submission of additional documentation that
supports the medical necessity of the requested device.
A repair because of normal wear or a modification
because of growth or change in medical status will be
considered for prior authorization if it proves to be more
cost effective than replacing the device.
Dynamic Splints
Dynamic splints such as Dynasplint® will be considered
for prior authorization for a three‑month trial period
when the request is submitted with the following
documentation:
The request for repairs must include a breakdown of
charges for parts and the number of hours of labor
required to complete the repairs. No charge is allowed
for pickup or delivery of the item or for the assembly of
Medicaid-reimbursed parts. The following information
must be submitted with the request:
• Client’s condition
• Client’s current course of therapy
• Rationale for the use of the dynamic splint
• The description and procedure code of the item being
serviced or repaired
• Agreement by the client or family that the client will
comply with the prescribed use of the dynamic splint
• The age of the item
After completion of the three-month trial period, the
provider may submit a request for purchase of the
dynamic splint. Requests for purchase of the splint must
include documentation that the three-month trial period
• The number of times the item has been previously
repaired
• The replacement cost for the item
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May/June 2010
All Providers
The anticipated life expectancy of an orthotic device
is six months. Requests for prior authorization for the
replacement of a device before its usual life expectancy
has ended must include documentation that explains
the need for the replacement.
• Adjustments or modifications of the orthotic device
made when fitting the orthosis and for 90 days from the
date of delivery (Adjustments and modifications during
the first 90 days are considered part of the purchase of
the initial device.)
Replacement of orthotic equipment will be considered
when the item is out of warranty and repairing the item
is no longer cost-effective or when loss or irreparable
damage has occurred. A copy of the police or fire report,
when appropriate, and the measures to be taken to
prevent reoccurrence must be submitted with the prior
authorization request.
Orthopedic shoes that are attached to a brace must be
billed by the vendor that bills for the brace.
In situations where the equipment has been abused
or neglected by the client, the client’s family, or the
caregiver, a referral to the Department of State Health
Services (DSHS) THSteps Case Management unit will
be made by the THSteps-CCP Prior Authorization
unit for clients who are birth through 20 years of
age. Providers will be notified that the state will be
monitoring this client’s services to evaluate the safety of
the environment for both the client and equipment.
Requirements for Dispensing, Fabricating,
and Modifying Orthoses
To be considered for reimbursement, orthoses must
be dispensed, fabricated, or modified by a licensed
orthotist or licensed prosthetist/orthotist enrolled with
Medicare and THSteps-CCP.
• Upper extremity customized splints made with lowtemperature materials and inhibitive casting may be
provided by occupational or physical therapists.
• Other orthopedic devices addressed in this article may
be provided by a Medicaid-enrolled durable medical
equipment (DME) vendor as outlined in this article.
• Orthopedic shoes must be provided by a shoe vendor
enrolled as a DME provider.
The date of service for a custom-made or custom-fitted
orthosis is the date the supplier places an order for the
equipment and incurs liability for the equipment. The
custom-made or custom-fitted orthosis will be eligible
for reimbursement as long as the service is provided
during a month the client is eligible for Medicaid.
The following items and services are included in
the reimbursement for an orthotic device and not
reimbursed separately:
Reimbursement for lifts and wedges may include the cost
of the prescription shoe.
Reimbursement for Orthoses
The DME Certification and Receipt Form is required and
must be completed before reimbursement can be made for
any DME delivered to a client. The certification form must
include the name of the item, the date the client received
the DME, and the dated signatures of the provider and
the client or primary caregiver. This signed and dated form
must be kept by the DME provider in the client’s medical
record.
The DME Certification and Receipt Form must be
submitted for DME claims and appeals when any of the
following occurs:
• A single item meets or exceeds a billed amount of $2,500.
• Multiple items submitted on the same date of service
meet or exceed a total billed amount of $2,500.
Claims submitted without the DME Certification and
Receipt Form (when required) will be denied.
Clients who receive DME that meets or exceeds a total
billed amount of $2,500 may be contacted to verify receipt
of the equipment. If receipt of the equipment cannot be
verified, the claim payment will be eligible for recoupment.
Providers may be reimbursed for items that are addressed
in this article either by the lesser of the provider’s billed
charges or the published fee determined by the Texas
Health and Human Services Commission (HHSC) or
through manual pricing. If manual pricing is used, the
provider must request prior authorization and submit
documentation of either of the following:
• The manufacturer’s suggested retail price (MSRP) or
average wholesale price (AWP), whichever is applicable
• The provider’s documented invoice cost
• Manually priced items are reimbursed as follows as is
appropriate:
- MSRP less 18 percent or AWP less 10.5 percent,
whichever is applicable.
• Client evaluation, measurement, casting, or fitting of
the orthosis
- The provider’s documented invoice cost.
• Repairs due to normal wear and tear during the 90
days following delivery
May/June 2010
87
All Providers
Orthotic and Orthopedic Devices
Procedure Codes
Thoracic–Lumbar–Sacral Orthoses–Initial and
Additions
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
Other Spinal Orthoses
L1300
L1310
L1499
Hip Orthoses
L1600
L1610
L1620
L1630
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
Legg Perthes Orthoses
L1710
L1720
L1730
L1755
Knee Orthoses
L1810
L1820
L1830
L1831
L1832
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1850
L1860
Ankle–Foot Orthoses/Ankle Orthoses
L1900
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
L1990
Knee–Ankle–Foot Orthoses
L2000
L2005
L2010
L2020
L2030
L2034
L2035
L2036
L2037
L2038
Hip–Knee–Ankle–Foot Orthoses
L2040
L2050
L2060
L2070
L2080
L2090
Fracture Orthoses–Lower Extremity
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
Additions to Lower Extremity Orthoses
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2387
L2390
L2395
L2397
L2405
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
The following orthoses procedure codes may be
reimbursed in the home setting to a medical supplier
(DME) provider:
Table A: Orthoses Procedure Codes
Cervical Orthoses
L0112
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
Thoracic Rib Belts
L0220
DeWall Posture Protector
L0430
Thoracic–Lumbar–Sacral Orthoses
L0450
L0452
L0454
L0456
L0458
L0460
L0462
L0464
L0466
L0468
L0470
L0472
L0480
L0482
L0484
L0486
L0488
L0490
L0491
L0492
Sacroiliac Orthoses
L0621
L0622
L0623
L0624
Lumbar Orthoses
L0625
L0626
L0627
Lumbar–Sacral Orthoses
L0628
L0629
L0630
L0631
L0632
L0633
L0634
L0635
L0636
L0637
L0638
L0639
L0640
Cervical–Thoracic–Lumbar–Sacral Orthoses
L0700
L0710
Halo Procedures
L0810
L0820
L0830
L0859
L0861
Spinal Corset Orthoses
L0970
L0972
L0974
L0976
Miscellaneous Devices
L0978
L0980
L0982
L0984
L0999
Spinal Orthosis–Milwaukee Brace
L1000
CTLSO–Infant Size Immobilizer
L1001
Spinal Orthoses for Scoliosis
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
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May/June 2010
All Providers
Additions to Lower Extremity Orthoses (continued)
L2670
L2680
L2750
L2755
L2760
L2768
L2770
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
Miscellaneous Lower Extremity Orthosis
L2999
Foot Orthoses/Inserts and Arch Supports
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3031
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3160
L3170
Orthopedic Shoes and Surgical Boots
L3201
L3202
L3203
L3204
L3206
L3207
L3208
L3209
L3211
L3212
L3213
L3214
L3215
L3216
L3217
L3219
L3221
L3222
L3224
L3225
L3230
L3250
L3251
L3252
L3253
L3254
L3255
L3257
L3260
L3265
Heel Lifts and Wedges
L3300
L3310
L3320
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3485
Additions to Orthopedic Shoes
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
Transfer of Orthosis
L3600
L3610
L3620
L3630
L3640
L3649
Shoulder Orthoses
L3650
L3660
L3670
L3671
L3672
L3673
L3675
L3677
Elbow/Elbow–Wrist–Hand/Elbow–Wrist–Hand–
Finger Orthoses
L3702
L3710
L3720
L3730
L3740
L3760
L3762
L3763
L3764
L3765
L3766
May/June 2010
Wrist–Hand/Wrist–Hand–Finger/Hand–
Finger Orthoses
L3806
L3807
L3808
L3900
L3901
L3904
L3905
L3906
L3908
L3912
L3913
L3915
L3917
L3919
L3921
L3923
L3925
L3927
L3929
L3931
L3933
L3935
Additions to Upper Extremity Joint
L3956
Shoulder–Elbow/Shoulder–Elbow–Wrist–Hand
Orthoses
L3960
L3961
L3962
L3964
L3965
L3966
L3967
L3968
L3969
L3970
L3971
L3972
L3973
L3974
L3975
L3976
L3977
L3978
Fracture Orthoses–Upper Extremity
L3980
L3982
L3984
L3995
Miscellaneous Upper Limb Orthosis
L3999
Orthoses Replacement Procedures
L4000
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
Repair of Orthoses
L4205
L4210
Walking Boots, Foot Drop Splints, and Static Ankle
Foot Orthoses
L4350
L4360
L4370
L4380
L4386
L4392
L4394
L4396
L4398
The following orthopedic device procedure codes may
be reimbursed in the home setting to a medical supplier
(DME) provider:
Table B: Orthopedic Devices Procedure Codes
Protective Helmets
A8000*
A8001*
A8002*
A8003*
A8004*
* These procedure codes may also be payable to home health
(DME) providers in the home setting.
Dynamic Devices (Purchase and Rental)
E1800
E1815
89
E1802
E1820
E1805
E1825
E1810
E1830
E1812
E1840
All Providers
Prostheses
prosthetic shoe can be considered as a terminal device
in that it is a structural supplement replacing a totally
or substantially absent foot).
External prostheses are a benefit of Texas Medicaid when
provided by a licensed prosthetist or licensed prosthetist/
orthotist under the Texas Health Steps-Comprehensive
Care Program (THSteps-CCP) for clients who are birth
through 20 years of age.
Noncovered Prosthetic Services
Prosthetic devices prescribed by a chiropractor are not a
Prostheses may be reimbursed using the procedure codes
listed in table C on page 96 of this article.
A vacuum-assisted socket system (procedure code L5781
or L5782), which is a specialized vacuum pump, is
considered experimental and investigational, and is not a
The following prostheses are a benefit of Texas Medicaid
when medical necessity criteria are met:
• Lower limb
Myoelectric hand prostheses for conditions other the
absence of forearm(s) and hand(s) are considered experimental and investigational and are not a benefit of Texas
Medicaid.
• Upper limb
• Craniofacial
• External breast
A prosthetic device customized with enhanced features is
not considered medically necessary if ADLs can be met
with a standard prosthetic device.
Definitions for Prostheses
Texas Medicaid uses the definitions of the Texas State
Board of Orthotics and Prosthetics, as listed in the TAC.
Accessories that are not required for the effective use of a
prosthetic device are not considered medically necessary.
The following definitions are not listed in TAC, but help
define the benefits as referenced in this article:
Prior Authorization Requirements for Prostheses
Prior authorization is required for all prosthetic devices.
• Direct supervision. The supervising licensed prosthetist
or licensed prosthetist/orthotist is in the same office,
building, or facility when and where the service is
provided, and is immediately available to furnish
assistance and direction.
Before requesting prior authorization for any prosthesis,
the provider must have a completed THSteps-CCP
Prior Authorization Form requesting the prosthesis that
has been signed and dated by a physician familiar with
the client. All signatures and dates must be current,
unaltered, original, and handwritten. Computerized
or stamped signatures/dates will not be accepted. The
completed THSteps-CCP Prior Authorization Form
must include the procedure codes and quantities for
services requested. A copy of the completed, signed,
and dated form must be maintained by the prosthesis
provider in the client’s medical record. The completed
THSteps-CCP Prior Authorization Form with the
original dated signature must be maintained by the
prescribing physician in the client’s medical record.
• Custom-fitted. A prefabricated device which is manufactured in quantity without a specific client in mind,
and is then trimmed, bent, or otherwise molded for
use by a specific client.
• Custom-fabricated. A prosthesis specifically manufactured for a specific client. This type of device requires
substantial labor to construct, and is custom molded
to the client’s specific body part.
• Microprocessor-controlled or computer-controlled
prosthetic device. A type of power enhancement or
power-controlled device.
To complete the prior authorization process electronically,
the prosthesis provider must complete the prior authorization requirements through any approved electronic
methods and retain a copy of the signed and dated CCP
Prior Authorization Request form in the client’s medical
• Myoelectric prosthesis. A prosthetic device whose
movement is controlled by electromyographic (EMG)
signals or potentials on the surface of the skin caused
by voluntarily contracted muscles within a client’s
residual limb.
To complete the prior authorization process by paper,
the prosthesis provider must fax or mail the completed
THSteps-CCP Prior Authorization Request Form to
the CCP prior authorization unit and retain a copy of
the signed and dated CCP form in the client’s medical
• Electric switch prosthesis. A prosthetic device whose
movement is controlled by straps or cables actuated by
body movements that operate switches.
• Prosthetic shoe. A device used when all or a substantial
portion of the front part of the foot is missing (a
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To facilitate determination of medical necessity and avoid
unnecessary denials, the physician must provide correct
and complete information, including documentation for
medical necessity of the equipment or supplies requested.
The physician must maintain documentation of medical
necessity in the client’s medical record. The provider
may be asked for additional information to clarify or
complete a request for the service or device.
For the purpose of this article, the actual date of service
is the date the supplier has placed an order for the
equipment and has incurred liability for the equipment.
Lower-Limb Prostheses
Lower-limb prostheses include, but are not limited to,
the following:
• Partial foot, ankle, and knee disarticulation sockets
All requests for prior authorization must include documentation of medical necessity including, but not limited
to, documentation that the client meets the following
indications for the requested device:
• Above-knee, short prostheses
• The prosthesis replaces all or part of the function of a
permanently inoperative, absent, or malfunctioning
part of the limb. The specific limb which is being
replaced by the prosthesis must be identified.
• Preparatory prostheses
• Hip and knee disarticulation prostheses
• Postsurgical prostheses
• Additions to lower extremity prostheses
• Replacement sockets
• The prosthesis is required for ADLs or for rehabilitation purposes, and identification of the ADLs or rehabilitation purpose for which the prosthesis is required.
A basic lower-limb prosthesis consists of the following:
• The provider must keep the following written documentation in the client’s medical record:
• A suspension mechanism attaching the socket to the
prosthesis
• A socket or connection between the residual limb and
the prosthesis
- The prescription for the device.
Note: Prosthetic devices must be prescribed by a
physician (M.D. or D.O.).
The prescription must be dated prior to or on the
initial date of the requested dates of service, which
can be no longer than 90 days from the signature
date on the prescription.
• A knee joint that provides support during stance,
smooth control during the swing phase, and unrestricted motion for sitting and kneeling
- Accurate diagnostic information that supports
the medical necessity for the requested device (a
retrospective review may be performed to ensure
that the documentation included in the client’s
medical record supports the medical necessity of
the requested service or device).
In addition to the indications previously defined in the
Prior Authorization Requirements for Prostheses section,
the following additional documentation is also required
for all lower-limb prostheses:
• An exoskeleton or endoskeleton pylon (tube or shell)
that attaches the socket to the terminal device
• A terminal device (foot)
• Written documentation of the client’s current and
potential functional levels. A functional level is defined
as a measurement of the capacity and potential of
individuals to accomplish their expected post-rehabilitation daily function. The potential functional ability
is based on reasonable expectations of the treating
physician and the prosthetist and includes, but is not
limited to, the following:
- The specific make, model, and serial number of the
prosthetic components.
- The treatment plan outlining the therapy program
prescribed by the treating physician, including
expected goals with the use of the prosthesis.
- A statement submitted by the physician that
indicates that the client or client’s family or
caregiver demonstrates willingness to comply with
the therapy program.
- The client’s history, including prior use of a
prosthesis, if applicable.
- The client’s current condition, including the status
of the residual limb and any coexisting medical
conditions.
Prior authorization is valid for a maximum period of six
months from the prescription signature date. At the end
of the six-month authorization period, a new prescription
is required for prior authorization of additional services.
May/June 2010
- The client’s motivation to ambulate and ability to
achieve independent transfers or ambulation with
the use of a lower-limb prosthesis.
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The following functional classification levels have
been defined by the Centers for Medicare & Medicaid
Services (CMS):
Level
Description
Level 0
Does not have the ability or potential to
ambulate or transfer safely with or without
assistance, and a prosthesis does not enhance
quality of life or mobility.
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.
Has the ability or potential for ambulation
with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven
surfaces. Typical of the limited community
ambulator.
Has the ability or potential for ambulation
with variable cadence. Typical of the community ambulator who has the ability to traverse
most environmental barriers and may have
vocational, therapeutic, or exercise activity
that demands prosthetic utilization beyond
simple locomotion.
Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills,
exhibiting high-impact, stress, or energy levels.
Typical of the prosthetic demands of the child,
active adult, or athlete.
Level 1
Level 2
Level 3
Level 4
yards) on a daily basis. Use of the limb in the home or
for basic community ambulation is not sufficient to
justify provision of the computerized limb instead of
standard limb applications.
• The individual has a demonstrated need for regular
ambulation on uneven terrain or for regular use on
stairs. Use of the limb for limited stair climbing in the
home or employment environment is not sufficient
evidence for prescription of this device over standard
prosthetic application.
The licensed prosthetist or licensed prosthetist/orthotist
providing the device must be trained in the fitting
and programming of the microprocessor-controlled
prosthetic device.
Foot Prostheses
The following foot prostheses will be considered for prior
authorization for clients whose documented functional
level is 1 or above:
• A solid ankle-cushion heel (SACH) foot
• An external keel SACH foot or single axis ankle/foot
A flexible-keel foot or multi-axial ankle/foot will be
considered for prior authorization for clients whose
documented functional level is 2 or above.
A flex foot system, energy storing foot, multi-axial ankle/
foot, dynamic response, or flex-walk system or equivalent
will be considered for prior authorization for clients
whose documented functional level is 3 or above.
A client whose functional level is zero is not a candidate
for a prosthetic device. The device is not considered
medically necessary.
A prosthetic shoe will be considered for prior authorization if it is an integral part of a prosthesis for clients with
a partial foot amputation.
Microprocessor-Controlled Lower-Limb
Prostheses
Ankle Prosthesis
Microprocessor-controlled lower-limb prostheses (e.g.,
Otto Bock C-Leg, Intelligent Prosthesis, or Ossur
Rheo Knee) will be considered for prior authorization for clients who have a transfemoral amputation
from a nonvascular cause, such as trauma or tumor
and a functional level of 3 or above, and who meet the
following criteria:
An axial rotation unit will be considered for prior authorization for clients whose documented functional level is
2 or above.
Knee Prosthesis
A single-axis, constant-friction knee and other basic knee
systems will be considered for prior authorization for
clients whose documented functional level is 1 or above.
• The individual has adequate cardiovascular reserve
and cognitive learning ability to master the higher
level of technology and to allow for faster than normal
walking speed.
A fluid, pneumatic, or electronic knee prosthesis will
be considered for prior authorization for clients whose
documented functional level is 3 or above.
A high-activity knee control frame will be considered
for prior authorization for clients whose documented
functional level is 4.
• The individual demonstrates the ability to ambulate at
a faster than baseline rate using a standard prosthetic
application with a swing-and-stance-control knee.
• The individual has a demonstrated need for longdistance ambulation at variable rates (greater than 400
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Prosthetic Substitutions or Additions
for Below-Knee Prostheses
Myoelectric Upper-Limb Prostheses
A myoelectric upper-limb prosthetic device is considered
medically necessary when all of the following criteria
have been met:
Procedure codes L5629, L5638, L5639, L5646, L5647,
L5704, L5785, L5962, and L5980 are not considered
medically necessary when an initial below-knee
prosthesis (procedure code L5500) or a preparatory
below-knee prosthesis (procedure codes L5510, L5520,
L5530, or L5540) is provided.
• The client has sufficient neurological, myocutaneous,
and cognitive function to operate the prosthesis
effectively.
• The client has an amputation or missing limb at the
wrist or above (e.g., forearm, elbow, etc).
Prosthetic substitutions or additions (procedure codes
L5620, L5629, L5645, L5646, L5670, L5676, L5704,
and L5962) are not considered medically necessary
when a below-knee preparatory, prefabricated prosthesis
(procedure code L5535) is provided.
• The client is free of comorbidities that could interfere
with maintaining function of the prostheses (e.g.,
neuromuscular disease).
• The client retains sufficient microvolt threshold in
the residual limb to allow proper function of the
prostheses.
Prosthetic Substitutions or Additions
for Above-Knee Prostheses
Sockets
Prior authorization for test (diagnostic) sockets for an
individual prosthesis is limited to a quantity of two test
sockets.
• Standard body-powered prosthetic devices cannot be
used or are insufficient to meet the functional needs of
the client in performing ADLs.
Prior authorization for same-socket inserts for an
individual prosthesis is also limited to a quantity of two.
• The client does not function in an environment
that would inhibit function of the prosthesis (e.g., a
wet environment or a situation involving electrical
discharges that would affect the prosthesis).
Requests for test sockets or same-socket inserts beyond
these limitations must include documentation of medical
necessity that supports the need for the additional
sockets.
External Breast Prostheses
External breast prostheses will be considered for prior
authorization for clients who have congenital absence of
a breast or have had a mastectomy.
Upper-Limb Prostheses
Upper-limb prostheses include, but are not limited to,
the following:
Craniofacial Prostheses
• Partial hand prostheses
Craniofacial prostheses include, but are not limited to,
external nasal, ear, and facial prostheses.
• Wrist and elbow disarticulation prostheses
Craniofacial prostheses will be considered for prior
authorization with documentation that the device is
necessary to correct an absence or deformity of the
affected body part.
• Shoulder and interscapular thoracic prostheses
• Immediate postsurgical or early-fitting prostheses
• Preparatory prostheses
Related Services for Prostheses
• Terminal devices
Accessories to Prostheses
• Replacement sockets
Accessories to prostheses, such as stump stockings and
harnesses will be considered for prior authorization when
they are essential to the effective use of the prosthetic
device.
• Inner sockets-externally powered
• Electric hand, wrist, and elbow prostheses
Upper-limb prostheses will be considered for prior
authorization with documentation of all of the
indications previously defined in the Prior Authorization
Requirements for Prostheses section. The additional
criteria in the following sections apply for specific
prosthetic devices.
May/June 2010
Prosthetic Training
Prosthetic training by a physical or occupational
therapist for a lower-limb prosthesis or an upper-limb
prosthesis is a benefit for clients who have not worn one
previously or for a prolonged period or who are receiving
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a different type. Texas Medicaid criteria for physical or
occupational therapist services must also be met.
that allow for growth or increase the lifespan of the
prosthesis may include the following:
Note: Refer to the 2009 Texas Medicaid Provider
Procedures Manual, sections 43.4.8,”Occupational
Therapists (CCP)” and 43.4.12, “Physical Therapists (CCP)”
for specific benefit criteria for these services.
• Growth-oriented suspension systems and
modifications
• Use of modular systems
• Use of flexible sockets
Repairs, Replacements, and Modifications
to Prostheses
• Use of removable sockets (slip or triple-wall sockets)
Repairs, replacements, and modifications to prostheses
are a benefit when medical necessity criteria are met.
• Use of distal pads
Repairs due to normal wear and tear will be considered
for prior authorization after 90 days from the date of
delivery of the initial prosthesis, when the repair is:
• Increasing or decreasing sock thickness
• Modification of socket liners
Modifications due to growth or change in medical status
will be considered for prior authorization with documentation of medical necessity.
• Necessary to make the equipment functional.
• More cost-effective than the replacement of the
prosthetic device.
Medical necessity for requested components or additions
to the prosthesis is based on the client’s current
functional ability and the expected functional potential
as defined by the prosthetist and the ordering physician.
Providers must include documentation that supports
medical necessity when they request prior authorization. Additional information from the provider may be
requested to determine cost-effectiveness.
Requirements for Dispensing, Fabricating,
and Modifying Prostheses
Replacement of prosthetic equipment will be considered
for coverage when loss or irreparable damage has
occurred. A copy of the police or fire report when
appropriate and the measures to be taken to prevent
reoccurrence must be submitted with the prior authorization request.
To be considered for reimbursement, prostheses must
be dispensed, fabricated, or modified by a licensed
prosthetist or licensed prosthetist/orthotist enrolled with
Medicare and THSteps-CCP.
The date of service for a custom-made or custom-fitted
prosthesis is the date the supplier places an order for the
equipment and incurs a liability for the equipment. The
custom-made or custom-fitted prosthesis will be eligible
for reimbursement as long as the service is provided
during a month the client is eligible for Medicaid.
Socket replacements will be considered for prior authorization with documentation of functional or physiological need, including, but not limited to, changes in
the residual limb, functional need changes, or irreparable
damage or wear due to excessive weight or prosthetic
demands of very active amputees.
The following items and services are included in the reimbursement for a prosthetic device and not reimbursed
separately:
When the equipment has been abused or neglected by
the client, the client’s family or the caregiver, a referral
to the Department of State Health Services (DSHS)
THSteps Case Management unit will be made by the
THSteps-CCP prior authorization unit for clients who
are birth through 20 years of age. Providers will be
notified that the state will be monitoring this client’s
services to evaluate the safety of the environment for
both the client and equipment.
• Evaluation of the residual limb and gait
• Measurement, casting, or fitting of the prosthesis
• Cost of base component parts and labor contained in
the base procedure code description
• Repairs due to normal wear and tear during the 90
days following delivery
Children typically require new prosthetic devices every
12 to 18 months, although the actual lifespan of a device
depends on the child’s rate of skeletal growth. Prosthetic
devices for children must accommodate growth and
other physiological changes. Components and systems
• Adjustments or modifications of the prosthesis or the
prosthetic component made when fitting the prosthesis
or component and for 90 days from the date of delivery
when the adjustments are not necessitated by changes in
the residual limb or the client’s functional ability
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In general, base codes do not represent a complete device.
To include the additional components necessary for a
complete device, providers may bill additional components
with a code that is used in addition to a base code. Addition
codes may also be used to indicate modifications to a device.
The values assigned to the additional codes do not represent
the actual value of the component or modification, but only
the difference between the total value and the value of the
base code. As a result, reimbursement of an addition does
not involve subtraction of any amounts from the base code
allowance.
Reimbursement for Prostheses
The DME Certification and Receipt Form is required
and must be completed before reimbursement can be
made for any DME delivered to a client. The certification form must include the name of the item, the date the
client received the DME, and the dated signatures of the
provider and the client or primary caregiver. This signed
and dated form must be kept by the DME provider in the
client’s medical record.
The DME Certification and Receipt Form must be
submitted for DME claims and appeals when either of the
following occurs:
• A single item meets or exceeds a billed amount of
$2,500.
• Multiple items submitted on the same date of service
meet or exceed a total billed amount of $2,500.
Claims submitted without the DME Certification and
Receipt Form (when required) will be denied.
billed amount of $2,500 may be contacted to verify
receipt of the equipment. If receipt of the equipment
cannot be verified, the claim payment will be eligible for
recoupment.
Providers may be reimbursed for items that are addressed
in this article either by the lesser of the provider’s billed
charges or the published fee determined by HHSC or
through manual pricing. If manual pricing is used, the
provider must request prior authorization and submit
documentation of either of the following:
• The MSRP or AWP, whichever is applicable
Manually priced items are reimbursed as follows as is
appropriate:
Prostheses Procedure Codes
The following prostheses procedure codes may be
reimbursed in the home setting to a medical supplier
(DME) provider:
Table C: Prostheses Procedure Codes
Prosthetic Shoe
L3250
Partial Foot, Ankle and Knee Disarticulation Sockets
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
Above Knee Short Prostheses
L5200
L5210
L5220
L5230
Hip and Knee Disarticulation Prostheses
L5250
L5270
L5280
L5301
L5311
L5321
L5331
L5341
Postsurgical Prostheses
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
Preparatory Prostheses
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
Additions to Lower Extremity Prostheses
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
Replacement Sockets
L5700
L5701
L5702
L5703
Protective Covers
L5704
L5705
L5706
L5707
• MSRP less 18 percent or AWP less 10.5 percent,
whichever is applicable
May/June 2010
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All Providers
Additions to Lower Extremity Prosthesis- Exoskeletal
and Endoskeletal
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
L5858
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5962
L5964
L5966
L5968
All Lower Extremity Prostheses
L5970
L5971
L5972
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
Additions to Lower Limb Prostheses
L5988
L5990
L5999
Partial Hand, Wrist, and Elbow Disarticulation
Prostheses
L6000
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
Shoulder Disarticulation and Interscapular Thoracic
Prostheses
L6300
L6310
L6320
L6350
L6360
L6370
Immediate Postsurgical Wrist, Elbow, or Shoulder
Disarticulation Prostheses
L6380
L6382
L6384
L6386
L6388
Endoskeletal Elbow, Shoulder and Interscapular
Thoracic Prostheses
L6400
L6450
L6500
L6550
L6570
Preparatory Wrist, Elbow and Shoulder
Disarticulation Prostheses
L6580
L6582
L6584
L6586
L6588
L6590
Additions to Upper Extremity Prostheses
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
Additions to Upper Extremity Prostheses (continued)
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
Terminal Devices
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6721
L6722
L6805
L6810
L6881
L6882
Replacement Sockets
L6883
L6884
L6885
Additions- Glove for Terminal Devices
L6890
L6895
Hand Restoration
L6900
L6905
L6910
L6915
Wrist, Elbow and Shoulder Inner Sockets- Externally
Powered
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
Electronic Hand, Elbow and Wrist Prosthetic Device
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7260
L7261
Additions to Upper Extremity Prostheses
L7400
L7401
L7402
L7403
L7404
L7405
Miscellaneous Upper Extremity Prosthesis
L7499
Repair of Prosthetic Device
L7500
L7510
L7520
Prosthetic Donning Sleeve
L7600
Breast Prostheses
L8000
L8001
L8002
L8010
L8015
L8020
L8030
L8035
L8039
Craniofacial Prostheses
L8040
L8041
L8042
L8043
L8044
L8045
L8046
L8047
Prosthetic Sheath, Shrinker or Sock
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8499

96


May/June 2010
All Providers
May 2010 Procedure Code Updates
Effective for dates of service on or after May 1, 2010, some provider type and place-of-service (POS) limitations will
change for some Texas Medicaid services.
Antihemophilic Factor (AHF)
Benefit changes will be applied to the following AHF procedure codes:
Procedure
Codes
Changes
J7187
Will no longer be reimbursed to federally qualified health center (FQHC), nephrology (hemodialysis, renal
dialysis), renal dialysis facility, and rural health clinic (RHC) providers in the office setting.
Will no longer be reimbursed in the home setting.
Will no longer be reimbursed to nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant
(PA), physician, FQHC, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and RHC providers
J7189
Will no longer be reimbursed to certified registered nurse anesthetist (CRNA), case management, Comprehensive Care Program (CCP) social worker, optometrist, chiropractor, psychologist, physical therapist,
occupational therapist, audiologist, FQHC, nephrology (hemodialysis, renal dialysis), renal dialysis facility,
RHC, and hemophilia factor providers in the office setting.
May be reimbursed to NP, CNS, and PA providers in the office setting.
Will no longer be reimbursed to physician, FQHC, ambulatory surgical center (ASC), medical supply company, nephrology (hemodialysis, renal dialysis), renal dialysis facility, RHC, and hemophilia factor providers
J7190,
Will no longer be reimbursed to FQHC, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis
J7191,
facility, RHC, and hemophilia factor providers in the office setting.
J7192,
J7194,
J7197,
Will no longer be reimbursed to FQHC, nephrology (hemodialysis, renal dialysis), renal dialysis facility,
J7198,
RHC, and hemophilia factor providers in the outpatient hospital setting.
J7199
J7193
Will no longer be reimbursed to FQHC, hospital, RHC, and hemophilia factor providers in the office setting.
Will no longer be reimbursed to physician, FQHC, RHC, and hemophilia factor providers in the outpatient
hospital setting.
J7195
Will no longer be reimbursed to FQHC, freestanding/independent RHC, and hemophilia factor providers in
the office setting.
Will no longer be reimbursed to FQHC, RHC, and hemophilia factor providers in the outpatient hospital
setting.
Note: These changes will not affect the inpatient hospital diagnosis-related group (DRG) reimbursement or the FQHC or
RHC encounter payments.
Certified Respiratory Care Practitioner (CRCP) Services
Procedure code 99503 will no longer be reimbursed in the office setting.
Colony Stimulating Factors
Benefit changes will be applied to the following colony stimulating factor procedure codes:
Procedure
Codes
J1440,
J1441,
J2820
Changes
Will no longer be reimbursed to hospital and hospital-based RHC providers in the office setting.
Will no longer be reimbursed in the home or extended care facility (ECF) setting.
Will no longer be reimbursed to hospital-based RHC providers in the outpatient hospital setting.
May/June 2010
97
All Providers
Procedure
Codes
Changes
J2505
Will no longer be reimbursed to NP, CNS, PA, physician, and hospital-based RHC providers in the outpatient hospital setting.
Note: These changes will not affect the inpatient hospital DRG reimbursement or the RHC encounter payments.
Complete Blood Count (CBC)
Benefit changes will be applied to the following CBC procedure codes:
Procedure
Codes
Changes
85007
Total laboratory component for Texas Medicaid fee-for-service claims: Will no longer be reimbursed
to independent laboratory, optometrist, podiatrist, radiation treatment center, hospital, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers in the office setting.
Will no longer be reimbursed to independent laboratory, radiation treatment center, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers in the outpatient
hospital setting.
Total laboratory component for Texas Medicaid PCCM claims: Will no longer be reimbursed to NP, CNS,
PA, independent laboratory, optometrist, podiatrist, certified nurse midwife (CNM), radiation treatment
center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC
85008,
Total laboratory component: Will no longer be reimbursed to independent laboratory, optometrist,
85027
podiatrist, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis
facility, hospital-based RHC providers in the office setting.
hospital setting.
85009,
85041,
podiatrist, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis
85044,
facility, hospital-based RHC providers in the office setting.
85045,
Will no longer be reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal
85046,
dialysis facility, and hospital-based RHC providers in the outpatient hospital setting.
85048
85013,
85014,
podiatrist, radiation treatment center, FQHC, hospital, nephrology (hemodialysis, renal dialysis), renal
85025
dialysis facility, and hospital-based RHC providers in the office setting.
Will no longer be reimbursed to radiation treatment center, FQHC, family planning clinic, nephrology
hospital setting.
Will no longer be reimbursed to FQHC and family planning clinic providers in the independent laboratory
setting.
85018
Total laboratory component: Will no longer be reimbursed to independent laboratory, FQHC, and RHC
85032
Total laboratory component: Will no longer be reimbursed to independent laboratory, nephrology
hospital setting.
Will no longer be reimbursed to hospital, nephrology (hemodialysis, renal dialysis), and hospital-based RHC
providers in the independent laboratory setting.
Total laboratory component for Texas Medicaid PCCM claims: Will no longer be reimbursed to renal
dialysis facility providers in the independent laboratory setting.
Note: These changes will not affect the inpatient hospital DRG reimbursement or the FQHC or RHC encounter payments.
98
May/June 2010
All Providers
Continuous Glucose Monitoring (CGM)
Benefit changes will be applied to the following CGM procedure codes:
Procedure
Codes
Changes
82947
podiatrist, radiation treatment center, FQHC, hospital, nephrology (hemodialysis, renal dialysis), renal
Will no longer be reimbursed in the inpatient hospital setting.
Will no longer be reimbursed to NP, CNS, PA, physician, independent laboratory, optometrist, podiatrist,
CNM, radiation treatment center, FQHC, family planning clinic, nephrology (hemodialysis, renal dialysis),
renal dialysis facility, and hospital-based RHC providers in the outpatient hospital setting.
Will no longer be reimbursed to NP, CNS, PA, physician, optometrist, podiatrist, CNM, radiation treatment center, FQHC, hospital, family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis
facility, and hospital-based RHC providers in the independent laboratory setting.
82952
podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal
hospital setting.
Will no longer be reimbursed to radiation treatment center, hospital, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, and hospital-based RHC providers in the independent laboratory setting.
95250
Will no longer be reimbursed to RHC providers in the office setting.
Will no longer be reimbursed to NP, CNS, PA, physician, and RHC providers in the outpatient hospital
setting.
May be reimbursed to hospital providers in the outpatient hospital setting.
95251
Will no longer be reimbursed to RHC providers in the office or outpatient hospital setting.
Note: These changes will not affect the inpatient hospital DRG reimbursement or the FQHC or RHC encounter payments.
Cytogenetics Testing
Benefit changes will be applied to the following cytogenetic testing procedure codes:
Procedure Codes
88230, 88233, 88235, 88237, 88239, 88245, 88248,
88249, 88261, 88262, 88263, 88264, 88271, 88272,
88273, 88274, 88275, 88280, 88283, 88285, 88289,
88291
Changes
Total laboratory component: Will no longer be reimbursed
to independent laboratory, FQHC, and RHC providers in the
Note: These changes do not affect the FQHC and RHC encounter payments.
Dimethyl Sulfoxide (DMSO)
The following benefit changes will be applied to procedure code J1212:
Procedure
Codes
Changes
J1212
Will no longer be reimbursed CNM, radiation treatment center, hospital, and hospital-based RHC providers
Will no longer be reimbursed in the home or ECF setting.
Will no longer be reimbursed to radiation treatment center and hospital-based RHC providers in the
Note: These changes do not affect the inpatient hospital DRG reimbursement or the RHC encounter payment.
May/June 2010
99
All Providers
Electroconvulsive Therapy
The following benefit changes will be applied to procedure code 90870:
Procedure
Codes
Changes
90870
Will no longer be reimbursed in the office setting.
Will no longer be reimbursed to NP, CNS, and PA providers in the inpatient hospital or outpatient hospital
setting.
Hyperbaric Oxygen Therapy
Procedure
Codes
Changes
99183
Will no longer be reimbursed to NP, CNS, and PA providers in the inpatient hospital or outpatient
hospital setting.
Immunosuppressive Drugs
Benefit changes will be applied to the following immunosuppressive drug procedure codes:
Procedure
Codes
J0215
J0480
J1595
J7501,
J7505,
J7516,
J7525
Changes
Will no longer be reimbursed to podiatrist, CNM, durable medical equipment (DME) medical supplier,
radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and
Will no longer be reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center,
hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers
in the home setting.
Will no longer be reimbursed in the skilled nursing facility (SNF), intermediary care facility (ICF), or ECF
setting.
Will no longer be reimbursed to CRNA, case management, CCP social worker, optometrist, chiropractor,
podiatrist, CNM, physical therapist, occupational therapist, audiologist, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, and hospital-based RHC providers in the office setting.
Will no longer be reimbursed to NP, CNS, PA, physician, CNM, ASC, medical supply company,
Will no longer be reimbursed to DME medical supplier, radiation treatment center, hospital, nephrology
Will no longer be reimbursed to NP, CNS, PA, physician, radiation treatment center, hospital, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers in the home setting.
Will no longer be reimbursed in the SNF, ICF, or ECF setting.
Will no longer be reimbursed to NP, CNS, PA, physician, DME medical supplier, radiation treatment center,
Will no longer be reimbursed to DME medical supplier, radiation treatment center, hospital, nephrology
Will no longer be reimbursed to NP, CNS, PA, physician, radiation treatment center, hospital, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers in the home setting.
Will no longer be reimbursed in the SNF, ICF, or ECF setting.
100
May/June 2010
All Providers
Procedure
Codes
J7513
Changes
Will no longer be reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center,
Will no longer be reimbursed in the ECF setting.
Note: These changes do not affect the inpatient hospital DRG reimbursement or the FQHC or RHC encounter payments.
Injections—Interferon
Benefit changes will be applied to the following interferon injection procedure codes:
Procedure Codes
Changes
J1825, J1830, J9212, J9213, J9214,
J9215, J9216, Q3025, Q3026
Will no longer be reimbursed to radiation treatment center providers in the office
Will no longer be reimbursed in the home or ECF setting.
Injections—Vitamin B12 (Cyanocobalamin)
The following benefit changes will be applied to procedure code J3420:
Procedure
Codes
Changes
J3420
Will no longer be reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center,
Will no longer be reimbursed in the ECF setting.
Note: These changes do not affect the inpatient hospital DRG reimbursement or the RHC encounter payments.
Iron Studies
Benefit changes will be applied to the following iron studies procedure codes:
Procedure
Codes
82728,
83540,
83550,
85536
Changes
Will no longer be reimbursed to independent laboratory, FQHC, hospital, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, and freestanding RHC providers in the office setting.
Will no longer be reimbursed to physician, independent laboratory, FQHC, nephrology (hemodialysis, renal
dialysis), renal dialysis facility, and freestanding RHC providers in the outpatient hospital setting.
Will no longer be reimbursed to physician, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis
facility, and freestanding RHC providers in the independent laboratory setting.
May/June 2010
101
All Providers
Laboratory Handling Charge
Benefit changes will be applied to the following procedure codes:
Procedure
Codes
99000
99001
Changes
Will no longer be reimbursed to FQHC and renal dialysis facility providers in the office setting.
May be reimbursed to radiation treatment center providers in the office setting.
Note: FQHC and renal dialysis facility providers may be reimbursed for procedure code 99001.
Will no longer be reimbursed in the home, SNF, ICF, birthing center, ECF, or “other location” setting.
Will no longer be reimbursed to hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and
hospital-based RHC providers in the independent laboratory setting.
Will no longer be reimbursed to independent laboratory and hospital-based RHC providers in the outpatient
hospital setting.
Pediatric Pneumogram
Procedure
Codes
Changes
94772
Total component: Will no longer be reimbursed to NP, CNS, PA, independent laboratory, CNM, hospital,
nephrology (hemodialysis, renal dialysis, renal dialysis facility, and hospital-based RHC providers in the
office setting.
Will no longer be reimbursed to NP, CNS, PA, physician, independent laboratory, CNM, nephrology
(hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological and physiological
laboratory, and hospital-based RHC providers in the outpatient hospital setting.
Will no longer be reimbursed in the independent laboratory setting.
Professional interpretation component: Will no longer be reimbursed to NP, CNS, PA, CNM, portable
X-ray supplier, and radiological and physiological laboratory providers in the office setting.
May be reimbursed to physician providers in the inpatient hospital setting.
Will no longer be reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, and radiological and
physiological laboratory providers in the outpatient hospital setting.
Technical component: May be reimbursed to physician providers in the office setting.
Will no longer be reimbursed in the outpatient hospital or independent laboratory setting.
Physician Inpatient and Outpatient Ventilator Management
Benefit changes will be applied to the following inpatient and outpatient ventilator management procedure codes:
Procedure
Codes
Changes
94002,
Will no longer be reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, and radiological and
94003
physiological laboratory providers in the inpatient hospital setting.
May be reimbursed to physician providers in the outpatient hospital setting for clients who are in outpatient
observation status.
Prognostic Breast and Gynecological Cancer Studies
Benefit changes will be applied to the following laboratory procedure codes:
Procedure
Codes
New Settings To Be Reimbursed
88237,
Total laboratory component: Will no longer be reimbursed to independent laboratory, FQHC, and RHC
88239,
88271,
88274,
88291
102
May/June 2010
All Providers
Procedure
Codes
New Settings To Be Reimbursed
88342
Total laboratory component: Will no longer be reimbursed in the inpatient hospital setting.
Professional interpretation component: May be reimbursed to NP, CNS, PA, and physician providers in the
office setting.
Will no longer be reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory
Technical component: Is a benefit of Texas Medicaid and may be reimbursed to NP, CNS, PA, and physician providers in the office setting. To independent laboratory providers in the independent laboratory
setting.
88360
Total laboratory component: May be reimbursed to NP, CNS, and PA providers in the office setting.
Professional interpretation component: May be reimbursed to NP, CSN, PA, and physician providers in the
office setting.
Will no longer be reimbursed to CNM, hospital, portable X-ray supplier, and radiological and physiological
laboratory providers in the inpatient hospital or outpatient hospital setting.
Technical component: Will be made a benefit of Texas Medicaid and may be reimbursed as follows:
• To NP, CNS, PA, and physician providers in the office setting.
88361
• To independent laboratory providers in the independent laboratory setting.
Total laboratory component: May be reimbursed to NP, CNS, and PA providers in the office setting.
Professional interpretation component: Will no longer be reimbursed to independent laboratory, podiatrist,
CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility,
portable X-ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in the
office setting.
Will no longer be reimbursed to independent laboratory, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in the inpatient hospital or outpatient hospital setting.
Will no longer be reimbursed in the independent laboratory setting.
May be reimbursed to NP, CNS, PA, and physician providers in the inpatient hospital or outpatient hospital
setting.
Technical component: Will be made a benefit of Texas Medicaid and may be reimbursed as follows:
• To NP, CNS, PA, portable X-ray supplier, and radiological and physiological laboratory providers in the
office setting.
• May be reimbursed to independent laboratory provides in the independent laboratory setting.
Respiratory Syncytial Virus Prophylaxis
Procedure
Codes
Changes
90378
May/June 2010
103
All Providers
Screening and Diagnostic Studies of the Breast
Benefit changes will be applied to the following procedure codes for screening and diagnostic studies of the breast:
Procedure
Codes
Changes
76098
Total radiology component: Will no longer be reimbursed to hospital and hospital-based RHC providers in
the office setting.
Will no longer be reimbursed to portable X-ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in the outpatient hospital setting.
Professional interpretation component: Will no longer be reimbursed to NP, CNS, PA, portable X-ray
supplier, and radiological and physiological laboratory in the office, inpatient hospital, or outpatient hospital
setting.
Technical component: Will no longer be reimbursed in the home, SNF, ICF, or ECF setting.
76645
Total radiology component: Will no longer be reimbursed to hospital and hospital-based RHC providers in
the office setting.
Will no longer be reimbursed to portable X-ray supplier, radiological and physiological laboratory, and hospital-based RHC providers in the outpatient hospital setting.
Professional interpretation component: Will no longer be reimbursed to portable X-ray supplier and radiological and physiological laboratory providers in the office, inpatient hospital, or outpatient hospital setting.
setting.
Technical component: Will no longer be reimbursed in the home, SNF, ICF, independent laboratory, or ECF
setting.
77031,
Total radiology component: Will no longer be reimbursed to radiation treatment center providers in the of77055
fice or outpatient hospital setting.
Professional interpretation component: Will no longer be reimbursed to hospital providers in the inpatient
hospital setting.
setting.
Technical component: Will no longer be reimbursed to radiation treatment center providers in the office
setting.
Will no longer be reimbursed in the home, SNF, ICF, outpatient hospital, or ECF setting.
77032,
Total radiology component: Will no longer be reimbursed to radiation treatment center providers in the of77053,
77056,
77057
hospital setting.
setting.
setting.
Will no longer be reimbursed in the home, SNF, ICF, outpatient hospital, independent laboratory, or ECF
setting.
77051,
Total radiology component: Will no longer be reimbursed to radiation treatment center providers in the of77052
Will no longer be reimbursed to NP, CNS, and PA providers in the office setting.
hospital setting.
Will no longer be reimbursed to NP, CNS, and PA providers in the office, inpatient hospital, or outpatient
hospital setting.
Technical component: Will no longer be reimbursed to NP, CNS, PA, and radiation treatment center providers in the office setting.
Will no longer be reimbursed in the home, SNF, ICF, outpatient hospital, independent laboratory, or ECF
setting.
104
May/June 2010
All Providers
Procedure
Codes
Changes
77054
Total radiology component: Will no longer be reimbursed to radiation treatment center providers in the office or outpatient hospital setting.
hospital setting.
setting.
setting.
Will no longer be reimbursed in the home, outpatient hospital, or independent laboratory setting.
G0202,
Total radiology component: May be reimbursed to NP, CNS, and PA providers in the office setting.
G0204,
Professional interpretation component: May be reimbursed to NP, CNS, and PA providers in the office
G0206
setting.
Technical component: May be reimbursed to NP, CNS, and PA providers in the office setting.
Will no longer be reimbursed in the outpatient hospital or independent laboratory setting.
Stereotactic Radiosurgery
Benefit changes will be applied to the following stereotactic radiosurgery procedure codes:
Procedure
Codes
61795,
61796,
61797,
61798,
61799,
63620,
63621
61800
77371,
77372
77421
77520
77525
Changes
Surgical component: May be reimbursed to physician and radiation treatment center providers in the office
setting.
May be reimbursed to radiation treatment center providers in the outpatient hospital setting.
Surgical component: May be reimbursed to radiation treatment center providers in the outpatient hospital
setting.
Total radiation therapy component: Will no longer be reimbursed to hospital-based RHC providers in the
office setting.
Will no longer be reimbursed to physician and RHC providers in the outpatient hospital setting.
office setting.
Professional interpretation component: May be reimbursed to physician providers in the office setting.
Will no longer be reimbursed to NP, CNS, PA, CNM, hospital, portable X-ray supplier, and radiological and
physiological laboratory providers in the inpatient hospital or outpatient hospital setting.
Technical component: May be reimbursed to physician and radiation treatment center providers in the office
setting.
Will no longer be reimbursed in the outpatient hospital setting.
Total radiation therapy component: Will no longer be reimbursed to hospital and hospital-based RHC
Total radiation therapy component: Will no longer be reimbursed to hospital and hospital-based RHC
May/June 2010
105
All Providers
Procedure
Codes
Changes
77422,
77423
office setting.
G0251,
Total radiation therapy component: Will no longer be reimbursed to physician and RHC providers in the
G0339,
G0340
May be reimbursed to physician and radiation treatment center providers in the office setting.
Note: The changes noted in this article will not affect the hospital DRG reimbursement or the RHC encounter payments.
Texas Health Steps (THSteps) Dental Preventive Services
Benefit changes will be applied to the following THSteps dental preventive procedure codes:
Procedure
Codes
D1110,
D1120,
D1351,
D1510,
D1515,
D1520,
D1525,
D1555
D1206
D1330,
D1550
Changes
No longer reimbursed to FQHC providers in the inpatient hospital setting.
No longer reimbursed in the inpatient hospital setting.
No longer reimbursed to FQHC providers in the office, inpatient hospital, or outpatient hospital setting.
Note: The changes noted in this article will not affect the hospital DRG reimbursement or the FQHC encounter payments.



Change to Reimbursement Rates for Some Surgery Services
Procedure Codes
Effective January 22, 2010, the following reimbursement rates are effective for dates of service on or after June 1, 2008:
TOS
2
2
2
2
2
2
2
2
2
Procedure
Code
11055
11056
11056
11057
11057
11719
11719
G0127
G0127
Client Age
Rate
All ages
All ages
All ages
All ages
All ages
$37.23 (1.30 RVUs, $28.640 conversion factor)
$21.00 (0.77 RVU, $27.276 conversion factor)
TOS=Type of service, RVU=Relative value unit, CF=Conversion factor


106

May/June 2010
All Providers
Therapeutic Radiopharmaceutical Benefits Have Changed
therapeutic radiopharmaceutical benefits have changed for
Texas Medicaid.
The following information changed for the therapeutic
radiopharmaceutical benefit:
• Chromic phosphate P-32 may be reimbursed by Texas
Medicaid when used to treat peritoneal or pleural
effusions caused by metastatic disease, cancer. Chromic
phosphate P-32 will not be reimbursed for the treatment
of bone metastases.
• “Samarium Sm-153” is the correct name of the
radiopharmaceutical.
• Procedure code A9563 may be reimbursed when billed
with diagnosis code 1985.
• Contrast Materials/Radiopharmaceuticals Benefits and
Limitations.
Radiopharmaceuticals may be reimbursed by Texas
Medicaid when they are used for therapeutic treatment:
• Strontium-89 chloride, Yttrium y-90, Iodine i-131,
Sodium phosphate P-32, and Samarium Sm-153 are
radionuclides, which have been found to be effective for
the long-term relief of pain due to bone metastases.
• Tositumomab and Ibritumomab tiuxetan may be
reimbursed by Texas Medicaid for the treatment of
patients that have failed Rituximab and have CD20
antigen-expressing relapsed or refractory, low grade,
follicular, or transformed non-Hodgkin’s lymphoma or
refractory non-Hodgkin’s lymphoma.
• Chromic phosphate P-32 may be reimbursed by Texas
Medicaid when used to treat peritoneal or pleural
effusions caused by metastatic disease, cancer.
The following radiopharmaceutical procedure codes may
be reimbursed by Texas Medicaid when they are used for
therapeutic treatment:
• Procedure code 79403 may be reimbursed for
intravenous infusion radiopharmaceutical therapy.
• Procedure code A9563 (Sodium phosphate p-32) may be
reimbursed when billed with any of the following diagnosis
codes:
Diagnosis Codes
1985
20512
20882
20410
20522
20892
20412
20582
2384
20422
20592
20492
20812
20510
20822
• Procedure code A9564 (Chromic phosphate p-32) may be
reimbursed when billed with diagnosis code 1972 or 1976.
May/June 2010
107
• Procedure code A9600 (Strontium Sr-89 chloride)
may be reimbursed once per day when billed by the
same provider, and may be reimbursed a total of 10
mci intravenously injected every 90 days when billed
by any provider. Strontium-89 chloride may be
reimbursed when billed with diagnosis code 1985.
• Procedure code A9605 (Samarium Sm-153) may be
• Procedure code A9699 may be reimbursed for other
medically necessary radiopharmaceutical therapy agents.
Prior authorization is required for procedure
codes A9542, A9543, and A9545. Only one agent,
tositumomab (Iodine I-131, procedure code A9545) or
ibritumomab tiuxetan (Indium In-111, procedure code
A9542 or Yttrium Y-90, procedure code A9543), may
be reimbursed once per lifetime. Prior authorization is
required.
Procedure codes A9542, A9543, and A9545 may be
Modifier 76 must be used for repeat procedures billed
by the same provider with the same date of service.
Authorization Requirements for Tositumomab
or Ibritumomab Tiuxetan
Prior authorization for tositumomab or ibritumomab
tiuxetan may be granted when the request is submitted
with the following documentation:
• A diagnosis of either a low-grade follicular or
transformed B-cell non-Hodgkin’s lymphoma.
• The lymphoma has failed, relapsed, or become
refractory to conventional chemotherapy, and the
following is documented:
- Marrow involvement is less than 26 percent.
- Platelet count is 100,000 cell/mm3 or greater.
- Neutrophil count is 1,500 cells/mm3 or greater.
• A trial of Rituximab has failed.
Providers may fax or mail prior authorization requests
with the appropriate documentation to:
TMHP Special Medical Prior Authorization
Department
Austin, TX 78727
Fax: 1-512-514-4213
Prior authorization is a condition for reimbursement; it
is not a guarantee of payment.
All Providers
Texas Medicaid Claims Reprocessing
The following claims issues have been identified. All affected
claims will be reprocessed, and payments will be adjusted
February 19, 2010, for dates of services on or after
January 1, 2010, for clients of all ages:
Assistant Surgery Claims Reprocessing
TMHP has identified an issue that impacts claims submitted
with the assistant surgery component of procedure code 43653
and dates of service from April 1, 2009, through January 14,
2010. These claims might have been denied in error.
Reminder: Effective for dates of service on or after April 1,
2009, the assistant surgery component of procedure code
43653 is no longer reimbursed to certified nurse midwives
(CNM) in the inpatient hospital or outpatient hospital setting.
Brachytherapy Claims Reprocessing
Procedure
Code
R0070
R0075
R0075
R0075
R0075
R0075
Modifier
UN
UP
UQ
UR
US
Reimbursement
Rate
$183.57
$91.79
$61.19
$45.89
$36.71
$30.60
Sign Language Reimbursement Rates Change
Effective February 19, 2010, for dates of services on or after
January 1, 2010, reimbursement rates for sign language or
oral interpretive services procedure code T1013 with modifier
U1 or UA changed for Texas Medicaid. The reimbursement
rate for procedure code T1013 with modifier U1 is $73.60.
The reimbursement rate for procedure code T1013 with
modifier UA is $14.75.
TMHP has identified an issue with claims that were
submitted by physicians and hospitals with dates of service
of January 1, 2009, through March 11, 2010, and brachytherapy procedure codes 77785, 77786, or 77787. These
claims might have been denied in error.
Family Planning Reimbursement Rate Change
January 1, 2010, reimbursement rates for family planning
services procedure code H1010 changed for Texas Medicaid.
For clients who are birth through 20 years of age, the reimbursement rate for procedure code H1010 is $11.46 (0.40
relative value unit [RVU], $28.640 conversion factor). For
clients who are 21 years of age or older, the reimbursement
rate is $10.91 (0.40 RVU, $27.276 conversion factor).
Hepatitis A and B Vaccine for Clients Who Are 21
Years of Age or Older
TMHP has identified an issue that impacts claims submitted
with procedure code 90636 and dates of service from August
1, 2008, through January 5, 2010, for clients who are 21 years
of age or older. These claims might have been incorrectly
processed as informational.
August 1, 2008, the reimbursement rate for procedure code
90636 is $88.69 for clients who are 21 years of age or older.
Reimbursement Rates Changes
Effective January, March, and April 2010
Reimbursement rates for the following services have
changed for Texas Medicaid: respiratory system surgery,
diagnostic radiology, nuclear medicine, musculoskeletal system surgery, radiopharmaceuticals, and radiology
(portable X-ray) services. Some of these procedure codes
have effective dates of January 1, 2010, March 1, 2010 or
April 1, 2010.
Affected claims will be reprocessed, and payments will be
adjusted accordingly. No action on the part of provider is
required.
Details of the reimbursement rates were posted on the
TMHP website at www.tmhp.com and are located in the
Online Fee Lookup (OFL). Static fee schedule will reflect
the reimbursement rate changes when the quarterly update
has been completed.
Claims Reprocessing for Procedure Code 43520
April 1, 2009, surgical procedure code 43520 may be
reimbursed to physicians in the outpatient hospital setting.
Claims that were submitted by physicians in the outpatient
hospital setting with procedure code 43520 and dates of
service from April 1, 2009, through January 13, 2010, will
be reprocessed, and payments will be adjusted accordingly.
Radiology Services Reimbursement Rates
January 1, 2010, reimbursement rates for some radiology
(portable X-ray) services procedure codes changed for Texas
Medicaid.
The following table shows the revised reimbursement rates
for radiology (portable X-ray) services that are effective
Type of
Service
4
4
4
4
4
4
108
May/June 2010
All Providers
Updates to Previously Published Information
The following are updates and corrections to articles that
were published in previous bulletins or on the TMHP
website at www.tmhp.com as either banner messages or
web articles.
Update to “Procedure Code Review Updates
for February 2010”
This is an update to an article that was published on the
TMHP website at www.tmhp.com on January 8, 2010,
titled “Procedure Code Review Updates for February
2010.”
Update to “2009 HCPCS 1Q and 2Q New
Benefits for Some Medical Procedure Codes”
Effective for dates of service on or after October 1, 2009,
the following procedure codes from the first and second
quarter 2009 Healthcare Common Procedure Coding
System (HCPCS) updates are benefits of Texas Medicaid.
NP, CNS, and physician providers may be reimbursed
for these procedures in an office setting. Hospitals will
be reimbursed for these procedures only in the outpatient
hospital setting. Additionally, procedure codes Q4115
and Q4116 are also reimbursable to podiatrists and
podiatrist groups.
Technical component: Radiation treatment centers may
continue to be reimbursed for services rendered in the
office setting.
Total component: Radiation treatment centers may
office or outpatient hospital setting.
Technical component: Radiation treatment centers
may continue to be reimbursed for services rendered in
the office setting. NP, CNS, and PA providers may be
reimbursed for services rendered in the office setting.
Procedure code 76945 Updates
For the complete list of changes, providers may refer to
the article titled, “Procedure Code Review Updates for
February 2010,” published on January 8, 2010, on the
TMHP website at www.tmhp.com.
* Diagnosis restrictions = Procedure codes must be submitted
with one of the specific diagnosis codes that appears in this
column. N/A indicates that there are no diagnosis restrictions.
Correction to 2010 HCPCS Update
for “Incontinence Supplies and Equipment –
Home Health”
Correction to “Benefit Update for Botulinum
Toxin Type A (Botox)”
Effective February 1, 2010, procedure code J0587 will
have a billing quantity limit of 150 units. Providers must
bill Botulinum Toxin, Type B (myobloc) using procedure
code J0587 for the amount of the injection per 100 units
used. For example, a provider who administers 2,500
units must bill a quantity of 25 billing units. Any claim
billed in excess of 150 billing units will be denied with
explanation of benefits (EOB) 00103 (services exceed
allowed benefit limitations).
This is a correction to the 2010 Healthcare Common
Procedure Coding System (HCPCS) Special Bulletin,
No. 2, which was posted on December 31, 2009, on the
TMHP website at www.tmhp.com. The article titled,
“Incontinence Supplies and Equipment – Home Health”
incorrectly indicates that procedure code A4465 was
added. The correct procedure code is A4456.
Type of Procedure Reimbursement *Diagnosis
Service Code
Rate
Restrictions
1
C9249
$3.52
5550, 5551,
5552, 5559,
7140, 7141,
7142, 71430,
71431, 71432,
71433
1
Q2023
$1.05
2860, 2863,
2865, 2866,
2867, 2869,
V8302
1
Q4115
$9.54
N/A
1
Q4116
$34.98
N/A
May/June 2010
The following are additional updates that were made to
procedure codes 75945, 76940, and 76945.
109
All Providers
Medical Nutritional Counseling Correction
This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, section 43.4.7.3 “Benefits and Limitations”
for medical nutritional counseling on page 43-53. Procedure codes 97802 and 97803 should have been included with
procedure code 97804 as causing procedure code S9470 to be denied when billed on the same date of service by any
provider. The correct information is as follows:
Procedure code S9470 will be denied as part of another service when submitted by any provider on the same date of
service as procedure codes 97802, 97803, or 97804.
Correction to Radiation Therapy in the Texas Medicaid Provider Procedures Manual
The following procedure codes may be reimbursed by Texas Medicaid with prior authorization:
Procedure
Code
Stereotactic Radiosurgery (SRS)
61795
Surgical component: May be reimbursed to physician providers in the inpatient hospital setting.
May be reimbursed to physician and ambulatory surgical center providers in the outpatient hospital setting.
61796,
Surgical component: May be reimbursed to physician providers in the inpatient hospital or outpatient
61797,
hospital setting.
61798,
Procedure code 61796 will not be reimbursed more than once per course of treatment. Providers should not
61799,
bill procedure code 61796 in conjunction with procedure code 61798.
61800
Procedure code 61797 must be billed with primary procedure code 61796 or 61798.
Procedure codes 61797 and 61799 must not be billed more than once per lesion.
Any combination of 61797 and 61799 may be billed up to four times for the entire course of treatment,
regardless of number of lesions treated.
Procedure code 61799 must be billed in conjunction to primary procedure code 61798.
Procedure code 61800 must be billed with primary procedure code 61796 or 61798.
63620,
Surgical component: May be reimbursed to physician providers in the inpatient hospital or outpatient
63621
hospital setting.
Procedure code 63620 must not be billed more than once per course of treatment.
Procedure code 63620 or 63621 must not be billed on the same date of services by the same provider as
procedure code 77435.
Procedure code 63621 must be billed with primary procedure code 63620.
Procedure code 63621 must not be billed more than two times for the entire course of treatment, regardless
of the number of lesions treated.
77371
Total radiation therapy component: May be reimbursed to physician, radiation treatment center, and
hospital-based rural health clinic (RHC) providers in the office setting.
May be reimbursed to physician, radiation treatment center, hospital, and free-standing or hospital-based
77372
77373
Total radiation therapy component: May be reimbursed to physician and radiation treatment center
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May/June 2010
All Providers
Procedure
Code
Stereotactic Radiosurgery (SRS) continued
77421
Total radiation therapy component: May be reimbursed to physician, radiation treatment center, and hospitalbased RHC providers in the office setting.
Professional interpretation component: May be reimbursed to NP, CNS, PA, physician, certified nurse
midwife (CNM), hospital, and radiological and physiological laboratory providers in the inpatient hospital or
Technical component: May be reimbursed to radiation treatment center, hospital, and hospital-based RHC
May be reimbursed to radiological and physiological laboratory providers in the independent laboratory
setting.
G0251
Total radiation therapy component: May be reimbursed to physician, radiation treatment center, hospital,
and free-standing or hospital-based RHC providers in the outpatient hospital setting.
G0339
G0340
Proton-Beam and Helium-Ion Particle Radiosurgery (PRS)
S8030
77520
Total radiation therapy component: May be reimbursed to physician and radiation treatment center
77525
and hospital-based RHC providers in the office setting.
May be reimbursed to physician, radiation treatment center, and hospital providers in the inpatient hospital
setting.
Neutron-Beam PRS
77422
77423
Brachytherapy
The following procedure codes may be reimbursed by Texas Medicaid without prior authorization:
Procedure
Code
19296
Surgical component: May be reimbursed to physician providers in the office or inpatient hospital setting.
19297
May/June 2010
111
All Providers
Procedure
Code
19298
Surgical component: May be reimbursed to physician providers in the office setting.
May be reimbursed to physician and hospital providers in the inpatient hospital setting.
May be reimbursed to physician, hospital, and ambulatory surgical center providers in the outpatient
hospital setting.
31626
Surgical component: May be reimbursed to NP, CNS, PA, physician, and radiation treatment center
providers in the office or outpatient hospital setting.
May be reimbursed to NP, CNS, PA, and physician providers in the inpatient hospital setting.
31627
Surgical component: May be reimbursed to NP, CNS, PA, physician, and radiation treatment center
providers in the office or outpatient hospital setting.
May be reimbursed to NP, CNS, PA, and physician providers in the inpatient hospital setting.
31643
32553
Surgical components: May be reimbursed to physician and radiation treatment center providers in the office
49411
Surgical components: May be reimbursed to physician providers in the inpatient hospital or outpatient
hospital setting.
May be reimbursed to radiation treatment center providers in the office setting.
55860
Surgical components: May be reimbursed to physician providers in the inpatient hospital setting.
Assistant surgery component: May be reimbursed to physician providers in the inpatient hospital or
55862
55865
55875
May be reimbursed to physician, hospital-based RHC, and ambulatory surgical center providers in the
55876
Surgical component: May be reimbursed to physician and radiation treatment center providers in the office
May be reimbursed to ambulatory surgical centers in the outpatient hospital setting.
57155
58346
61770
Surgical and assistant surgery components: May be reimbursed to physician providers in the inpatient
hospital setting.
92974
112
May/June 2010
All Providers
Procedure
Code
Clinical Brachytherapy Services
77750,
Total radiation therapy component: May be reimbursed to physician providers in the office, inpatient
77761,
77762,
77763,
77776,
77777,
77778
77785
Total radiation therapy component: May be reimbursed to physician providers in the office setting.
May be reimbursed to radiation treatment center and hospital providers in the outpatient hospital setting.
Professional interpretation component: May be reimbursed to physician providers in the office, inpatient
Technical component: May be reimbursed to radiation treatment center providers in the outpatient hospital
setting.
77786
setting.
77787
setting.
77789
Professional interpretation component: May be reimbursed to physician providers in the inpatient hospital
Technical component: May be reimbursed to physician, radiation treatment center, hospital, and hospitalbased RHC providers in the outpatient hospital setting.
77799
Professional interpretation component: May be reimbursed to physician providers in the inpatient hospital
Technical component: May be reimbursed to radiation treatment center, hospital, and hospital-based RHC
The following clinical brachytherapy services procedure codes include admission to the hospital and daily care. Initial and
subsequent hospital care will be denied on the same day that clinical brachytherapy services are billed:
Procedure Codes
77750
77761
77762
77763
77776
77777
77778
77785
77786
77787
77789
77799
An office visit provided on the same date of service by the same provider as clinical treatment planning (procedure codes
77261, 77262, 77263, 77280, 77285, 77290, 77295, or 77299) or clinical brachytherapy (77750, 77761, 77762, 77763,
77776, 77777, 77778, 77785, 77786, 77787, 77789, or 77799) is included in the therapeutic radiology procedure and is not
reimbursed separately.
Any evaluation and management (E/M) service will be denied as part of another service when billed for the same date
of service by the same provider as procedure code 77750, 77785, 77786, 77787, or 77789.
Providers may refer to the Online Fee Lookup or the appropriate Texas Medicaid fee schedules for other radiation
therapy procedure codes that may be reimbursed by Texas Medicaid.
May/June 2010
113
All Providers/Ambulance Providers
Taxonomy Codes Update
This is an update to an article that first appeared on
the December 28, 2009, Remittance and Status (R&S)
Report, and to a web article that was posted on the
TMHP website at www.tmhp.com on December 23,
2009, titled “Taxonomy Codes Updated.”
The effective date of January 1, 2010, for the most
recent taxonomy code updates has changed. The revised
effective date was January 11, 2010. Providers are
encouraged to review the taxonomy codes that are now
available and, if necessary, update their attestation data.
Details about these taxonomy codes are available on the
TMHP website at www.tmhp.com.
Ambulance Providers
Facility Requests for
Nonemergency Ambulance
Prior Authorization
Effective for dates of service on or after January 1,
2010, all faxed nonemergency prior authorization
requests must be submitted with the Nonemergency
Ambulance Prior Authorization Request Form,
which is available on page 145 of this bulletin, and
on the TMHP website at www.tmhp.com.
Correction to “Update to Out-of-State Providers
Who Perform Services to Migrant Farm Workers”
This is a correction to an article that was posted on the
TMHP website at www.tmhp.com on December 31,
2009, titled “Update to Out-of-State Providers Who
Perform Services to Migrant Farm Workers.”
Beginning January 1, 2010, TMHP does not
process prior authorization requests that are
submitted with the Physician’s Medical Necessity
Certification for Nonemergency Ambulance
Transports (Texas Medicaid Program) Form or the
Ambulance Fax Cover Sheet. TMHP will return the
forms to providers for resubmission on the approved
form.
The article incorrectly stated that primary care provider
referrals are required for out-of-state or border-state
providers to serve migrant farm workers who are 21 years
of age or older and who are PCCM clients. The correct
information is as follows:
out-of-state or border-state providers that render services
to migrant farm workers and their children and family
members who are PCCM clients do not need a primary
care provider referral. Claims must be submitted with
modifier UC from out-of-state or border-state providers
that render services to migrant farm workers and their
children and family members who are PCCM clients.
Prior authorization requests may be submitted
through the TMHP secure portal or by faxing
the completed Nonemergency Ambulance Prior
Authorization Request Form to the TMHP
Ambulance Unit at 1-512-514-4205, Monday
through Friday, 7 a.m. to 7 p.m., Central Time.
114
May/June 2010
Behavioral Health Providers/Family Planning Providers
Behavioral Health Providers
Family Planning Providers
Clarification to “Behavioral
Health Services Performed
by Licensed Psychological
Associates Are Benefits”
Family Planning Funds
Gone - Accounts Receivable
Reconciliation Process
Beginning with state fiscal year (SFY) 2010, Budget
Period 1, TMHP will implement a new Funds Gone Accounts Receivable reconciliation process for claims
that are submitted by Family Planning Titles V and XX
providers.
This is a clarification to an article that was published in
the November/December 2009 Texas Medicaid Bulletin,
No. 226, and on the TMHP website at www.tmhp.com
on July 24, 2009, titled “Behavioral Health Services
Performed by Licensed Psychological Associates Are
Benefits.” Psychological and neuropsychological testing
may be reimbursed to providers for the time spent faceto-face with the client and also the time spent on scoring
and interpreting the testing.
The new process will reconcile outstanding funds gone
claims against accounts receivable claims for Family
Planning Titles V and XX at the end of each budget
period. The first reconciliation will occur for SFY 2010,
Budget Period 1.
This reconciliation process will affect all Texas Provider
Identifiers (TPIs) associated with a single Title V or
Title XX Department of State Health Services (DSHS)
contract. These TPIs will be reconciled against each
other, which may result in a reduction of outstanding
funds gone and accounts receivable claims for the
contractor.
Reimbursement for the psychological and neuropsychological testing procedure codes (96118 and 96101)
include both the time spent during face-to-face testing
with the client and the time spent scoring and interpreting the results. If the scoring and interpretation are performed on a
different date of service from the testing, then the date of
service on the claim must reflect the date and time spent
for each service performed. Even if scoring and interpretation are completed on a different date from the testing,
providers must submit only one claim for each psychological or neuropsychological test performed. If necessary,
providers can submit the claim with multiple details for
each date of service.
This reconciliation process will affect only claims and
accounts receivable associated with a single DSHS
contract (e.g., Title V funds gone claims will be reduced
in the amount of any outstanding Title V accounts
receivable).
DSHS contractors will be notified by the DSHS
Preventive and Primary Care Unit before the execution
of this reconciliation process.
For more information, providers can refer to the 2009
Texas Medicaid Provider Procedures Manual, section
38.3.1, “Psychological and Neuropsychological Testing,”
on page 38-5 for guidelines, procedure codes, and
diagnosis codes for testing services performed by a
psychologist.
The Summary Page and Adjustments - Paid or Denied
pages of the provider’s Remittance & Status (R&S)
Report will reflect funds gone and claims adjustments.
Reprocessing Family Planning Title V and XX Claims
with Procedure Code 99203 and 99204
TMHP has identified an issue that impacts claims
submitted by family planning (FP) Titles V and XX
providers with dates of service from July 1, 2009,
through December 6, 2009, and procedure code
99203 or 99204 without modifier FP. Claims might
have been denied in error with an explanation of
benefits (EOB) message that the procedure requires
May/June 2010
modifier(s). The FP modifier is required only when
the provider performs an annual family planning
visit.
Affected claims will be reprocessed, and payments
will be adjusted accordingly. No action on the part of
the provider is required.
115
Benefit Criteria Changed for Bath and Bathroom Equipment
benefit criteria for bath and bathroom equipment
changed for Texas Medicaid.
A bath lift is a benefit of Texas Medicaid and may be
reimbursed for procedure code E0625 and, as necessary,
the appropriate modifier (U1, U2, or U3). The following
two types of bath lifts may be reimbursed:
The purchase of a commode chair
• An outside-the-tub bath lift, which is a portable
transfer system used to move a nonambulatory client a
short distance from bed or chair to bath. This type of
lift is either hydraulic or electric and consists of a base
with wheels or casters and a sling which can transfer
the patient into and out of the bath. This type of lift is
designed to accommodate a smaller space.
with an integrated seat-lift mechanism
is limited to one every five years.
A commode chair with an integrated seat-lift mechanism
is a benefit of Texas Medicaid and may be reimbursed
using procedure code E0170 or E0171. The purchase of a
commode chair with an integrated seat-lift mechanism is
limited to one every five years.
• An inside-the-tub bath lift, which is a portable transfer
system used to lower and raise a nonambulatory client
into and out of the bath tub. This type of lift is either
hydraulic or electric and consists of a base which adheres
to the tub surface using suction cups and a seat that will
lower and raise the patient into and out of the tub.
Procedure codes E0170 and E0171 may be reimbursed as
follows:
The bath lift must be freestanding; it cannot be attached
to the floor, walls, or ceiling.
• Procedure code E0170 reimbursement rate is
$1,687.60.
A hydraulic bath lift is for a client who is unable to assist
in their own transfers and is operated by the weight or
pressure of a liquid.
• Procedure code E0171 reimbursement rate is $303.70.
A commode chair with an integrated seat-lift mechanism
for the top of the commode must be prior authorized for
clients who meet all the following criteria:
An electric bath lift may be considered when a hydraulic
lift does not meet the client’s needs.
• The client must have severe arthritis of the hip or knee
or have a severe neuromuscular disease.
There are four levels of bath lifts:
• Level one is an outside-the-tub bath lift (hydraulic
or electric), which must accommodate a client who
weighs 300 pounds or less. Providers must use
procedure code E0625 when billing for the purchase of
a level-one bath lift.
• The client must be completely incapable of standing up
from a regular toilet, commode, or any chair in their
home.
• The commode chair with integrated seat lift must
be a part of the physician’s course of treatment and
be prescribed to correct or ameliorate the client’s
condition.
• Level two is an in-tub bath lift (hydraulic or electric),
which must accommodate a client who weighs 300
pounds or less. Providers must use procedure code
E0625 and the U1 modifier when billing for the
purchase of a level-two bath lift.
• Once standing, the client must have the ability to
ambulate independently for a distance of no more than
10 feet.
• Level three is a bariatric lift (hydraulic or electric,
out-of-tub type), which can lift a client who weighs
more than 300 pounds. Providers must use procedure
code E0625 and the U2 modifier when billing for the
purchase of a level-3 bath lift.
The client’s difficulty or incapability of getting up from
a chair, particularly a low chair, is not sufficient justification for a seat-lift mechanism. Almost all clients who are
capable of ambulating can get out of an ordinary chair if
the seat height is appropriate and the chair has arms.
• Level four is a bariatric lift (hydraulic or electric, intub type), which can lift a client who weighs more
116
May/June 2010
than 300 pounds. Providers must use procedure code
E0625 and the U3 modifier when billing for the
purchase of a level-four bath lift.
allow for bathing, showering, or bathroom use without
assistive equipment.
To be considered through Texas Medicaid Title XIX
Home Health Services, bath and bathroom equipment
must meet the definition of durable medical equipment
(DME). Texas Medicaid defines DME as medical
equipment or appliances that are manufactured to
withstand repeated use, ordered by a physician for use in
the home, and required to correct or ameliorate a client’s
disability, condition, or illness and that meet one or both
of the following criteria:
Procedure code E0625 may be reimbursed as follows:
Procedure Code
E0625
E0625 when billed with U1 modifier
Rate
$600.00
$795.39
$2,911.00
$4,614.96
A bath lift is not a benefit for the convenience of a
caregiver.
• The projected term of use is more than one year.
• Reimbursement is made at a cost more than $1,000.00.
Bath and bathroom equipment may be considered for
those clients who have physical limitations that do not



Home Health Fee Schedule and Online Fee Lookup
Additional OFL and Static Fee Schedule
Corrections
TMHP has identified an issue with the home health
static fee schedules and the Online Fee Lookup (OFL).
The fee schedules listed incorrect or partial reimbursement rates.
Procedure code 97003 displayed only partial fee
information on the static and OFL fee schedules. The
OFL was corrected on February 4, 2010, and the static
fee schedule was corrected on February 15, 2010. Both
now display the complete information.
TMHP implemented revisions on December 22, 2009,
to correct the OFL and static fee schedules for the
following:
The fee schedules have been corrected to remove
some procedure codes that were not eligible for reimbursement to home health agencies. TMHP will not
reimburse home health agencies for the following
durable medical equipment procedure codes:
• The reimbursement rate for procedure codes that were
billed for clients who are birth through 20 years of age
was listed at the lower statewide rate ($118.62 with the
GO modifier and $116.38 with the GP modifier).
• The reimbursement rate for procedure codes submitted
with either the GO or GP modifier, without the AT
modifier (medical services [type of service {TOS} 1]), is
now listed as $140.00 on the home health fee schedule.
Type of Service
2
9
J
J
L
J
The static fee schedule and the OFL now display the
correct fees for the following medical services procedure
codes, all of which are TOS 1:
Procedure Code
97001
97002
97016
97018
97028
97032
97036
97039
97124
97139
97535
97537
97004
97022
97033
97110
97140
97542
97012
97024
97034
97112
97150
97750
May/June 2010
97014
97026
97035
97116
97530
97799
Procedure Code
20974
A4620
E0580
E0585
E1355
E1372
The fee schedules were corrected to indicate that
procedure code 92508 is eligible for reimbursement for
clients who are birth through 20 years of age (reimbursement rate of $70.00) in addition to clients who
are 21 years of age or older (reimbursement rate of
$119.61).
117
PCCM THSteps Wants to Partner With Providers
PCCM Texas Health Steps (THSteps) wants to partner
with providers to increase the number of clients who
receive timely THSteps medical checkups.
• Send reminder appointment postcards to the provider’s
PCCM THSteps clients at no cost to the provider.
• Work with the provider’s office to streamline the
appointment process.
PCCM THSteps can help providers and their clients
schedule THSteps medical checkups. The PCCM
THSteps Appointment Center helps providers increase
the number of clients who get their THSteps medical
checkups and reduces the number of times that PCCM
THSteps Appointment Center or eligible clients contact
the provider’s office about their medical checkup
appointment.
Providers who want to get started can contact any of the
following:
• Their regional TMHP Provider Relations representative. (Providers can access their provider relations
representative by clicking on “Providers” at the top of
the TMHP homepage, and then clicking on “TMHP
Provider Services Representatives” under the heading
titled “Provider Resources on the TMHP website.”
The PCCM THSteps Appointment Center will:
• Work with the provider’s staff to create a block of
available time slots for appointments. (Note: THSteps
clients cannot be restricted to this block of time.)
• The PCCM THSteps Provider Team at
[email protected].
• PCCM Provider Relations THSteps representatives at
1-512-421-3070.
• Retrieve the provider’s list of clients from the PCCM
THSteps database.
PCCM also offers appointment assistance for
those providers who do not want to provide block
appointment times to the call center. Providers
can e-mail the PCCM THSteps Provider Team at
[email protected] for
additional information.
• Contact clients to schedule appointments for the
block of available time slots. The PCCM THSteps
Appointment Center contacts clients on evenings and
weekends when many clients are easier to reach and
most providers’ offices are closed.
Note: The PCCM THSteps Appointment Center’s hours
of operation are:
A PCCM provider who is not enrolled in THSteps but
who wants to become a PCCM THSteps provider can
enroll by completing the THSteps Provider Enrollment
Application on the TMHP website at www.tmhp.com.
The Provider Enrollment on the Portal tool is available
on the homepage by clicking on the “Access Provider
Enrollment” link under “I would like to” in the righthand column.
- Monday, Tuesday, and Friday from 9 a.m. to
7 p.m., Central Time
- Wednesday and Thursday from 9 a.m. to 8 p.m.,
Central Time
- Saturday from 9 a.m. to 6 p.m., Central Time
• Help clients make transportation arrangements to get
to the appointment.
Providers can also download a copy of the paper
THSteps Provider Enrollment Application available
on the TMHP homepage under “Provider Enrollment
Forms” in the right-hand column under the heading
titled” Provider Forms.”
• Send providers the schedules of the appointments at
least two days in advance so that the provider’s staff
can verify eligibility and pull charts.
Managed Care Providers see also:
“New and Improved PCCM Inpatient/Outpatient Authorization Form”
in the All Providers section on page 48.
118
May/June 2010
FQHC and RHC Claims For PCCM Clients Require Referring Provider
Effective April 1, 2010, federally qualified health center
(FQHC) and rural health clinic (RHC) providers must
submit the referring provider’s National Provider Identifier
(NPI) on claims for outpatient hospital or professional
services that are provided to a PCCM client for whom
they are not the primary care provider. If the referring
provider’s NPI is not submitted on a claim for outpatient
hospital or professional services that were provided to a
PCCM client for whom they were not the primary care
provider, the claim will be denied.
FQHC Self-Referred Service
Immunizations
Case management for Early
Childhood Intervention (ECI)
Case management for Children
and Pregnant Women (CPW)
Obstetric services
Gynecological services
Behavioral health services
UB-04 CMS-1450 Instructions
The referring provider’s NPI must be included in block
78 or 79 of the UB-04 CMS-1450 paper claim form. The
block should include the referring provider’s complete
name and NPI. The rest of the claim form should be
completed normally.
RHC providers may submit claims for the following selfreferred services using their facility provider ID:
RHC Self-Referred Service
Obstetric services
The full instructions for completing the UB-04
CMS-1450 paper claim form can be found in the 2009
Texas Medicaid Provider Procedures Manual, section 5.6,
“UB-04 CMS-1450 Claim Filing Instructions,” on
page 5-33.
The referring provider’s NPI must be included in block
17b of the CMS-1500 paper claim form. The referring
provider’s complete name should be included in block 17.
The rest of the claim form should be completed normally.
using their individual provider ID:
Emergency services
Family planning
The full instructions for completing the CMS-1500 paper
claim form can be found in the 2009 Texas Medicaid
Provider Procedures Manual, section 5.5, “CMS-1500
Claim Filing Instructions,” on page 5-26.
THSteps services
Self-Referred Client Services
Immunizations
PCCM clients can refer themselves for some services and,
therefore, do not require a referral from a primary care
provider.
Claim Requirement
Emergency diagnosis
FP diagnosis and
procedure codes
THSteps procedure codes with EP
modifier
May/June 2010
Claim Requirement
Emergency diagnosis
FP diagnosis and
procedure codes
THSteps procedure
codes with national place
of service 72
Immunization and
immunization
administration codes
Reminder: Unless providing after-hours care, claims
submitted for services other than those listed above that
are provided to PCCM clients who are not assigned on
a panel report for an FQHC or RHC must include the
client’s required primary care provider information in the
Referring Provider field on the appropriate claim form.
Claims that are not submitted accordingly are subject to
claims denial.
The following are self-referred services for PCCM clients
and the claim requirements that FQHC providers must
use when submitting claims for these services. FQHC
providers may use their facility provider ID when
submitting:
Texas Health Steps (THSteps)
services
Claim Requirement
TH modifier
GY modifier
Psychological
diagnosis code
Providers performing services at an RHC location may
submit claims for the following self-referred services
CMS-1500 Instructions
FQHC Self-Referred Service
Emergency services
Family planning (FP)
Claim Requirement
Immunization and
immunization
Case management
codes
Case management
codes
TH modifier
GY modifier
Psychological procedure code
Providers can find complete information about selfreferred client services in the 2009 Texas Medicaid
Provider Procedures Manual, section 7.1.18, “Primary
Care Provider Requirements and Information,” on
page 7-10.
119
TMHP Routinely Audits PCCM Primary Care Providers Medical Records
Primary care providers who perform THSteps comprehensive medical checkups must document all components
of the checkup. All components of the age-appropriate
checkup should be completed before a provider bills for
a comprehensive checkup. If the component cannot be
completed due to extenuating circumstances, such as the
client’s illness or lack of cooperation, or the parent’s refusal
to give consent for a specific component, the provider
must document in the client’s medical record why the
component was not completed and must schedule a followup visit as appropriate. A checkup is considered complete
if the provider has attempted to complete all required
components and documentation supports the reason why
the required component could not be completed. Providers
can refer to the 2009 Texas Medicaid Provider Procedures
Manual, section 43.2.2, “Texas Health Steps Medical
Checkups Periodicity Schedule,” on page 43-16, for a list of
criteria that are included in an age-appropriate examination.
As the medical home, primary care providers should
monitor when their clients are due for checkups and
provide that checkup at the appropriate time. If the
provider is not enrolled in THSteps, they should work
with any THSteps provider to get the medical records for
their clients (for example, establish a referral relationship).
The following information is included in the audit:
• The dates of service.
• Clear reference to the previous visit by the same
provider or results obtained from another provider.
• Confirmation that all components of checkups were
completed. In acknowledgment of the practical
situations that occur in the office or clinic settings, the
American Academy of Pediatrics (AAP) has stressed the
philosophy that the components of all medical checkups
should be performed when appropriate to the needs
of the individual client. Consequently, completion of
all recommended components of a THSteps medical
checkup may require follow-up visits. The Centers for
Medicare & Medicaid Services (CMS) has clarified,
in its Medicaid Guide to State Entities, the following
expectations for the content of comprehensive preventive
health visits. The required checkup components as
indicated in the periodicity schedule include:
- Comprehensive health history, including developmental and nutritional assessment and mental
health.
Clinical charts are subject to quality reviews, including
random chart review. An audit is routinely performed
by PCCM staff to confirm that all of the required
components of the THSteps medical checkup are
documented in the client’s medical records and are
appropriate to the client’s age. PCCM providers can
refer to the 2009 Texas Medicaid Provider Procedures
Manual, section 43.2.1, “Documentation of Completed
Checkups,” on page 43-15 for details of the documentation requirements.
- Comprehensive unclothed physical examination,
(head circumference is only until the age of two).
- Appropriate immunizations as indicated in
the Recommended Childhood and Adolescent
Immunization Schedule.
- Age-appropriate laboratory tests for anemia, lead
poisoning, newborn screening, and tuberculosis
screening.
TMHP will contact PCCM primary care providers and
schedule a date for the audit appointment. The provider’s
office can prepare for the audit by having the charts ready
for the coordinators to review.
- Health education, including anticipatory guidance.
Additionally, the provider should document the
following:
• If the office has electronic medical records, the
provider’s office can designate an area to view the
records on a computer. The provider can expedite this
process by assigning someone to help the reviewer
look at the charts or an office employee can print out
the dates of service, screenings, laboratory results, and
immunization records.
• Age-appropriate vision and hearing screening.
• Oral evaluation and fluoride varnish application
beginning at six months of age.
• Direct referral to a dental home beginning at six
months of age if the provider is certified by the Texas
Department of State Health Services (DSHS).
• If the office has paper charts, the charts should be
pulled and ready for the reviewer at the time of the
appointment.
The provider’s office is always welcome to call the
reviewer with a question. The reviewer’s direct line is
located on the bottom of the letter that is mailed to the
provider’s office.

120
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May/June 2010
Updates to Services Provided to PCCM Clients by FQHCs and RHCs
Effective March 1, 2010, claims submitted by federally
qualified health centers (FQHC) and rural health clinic
(RHC) providers for services provided to PCCM clients
are required to include modifiers or diagnosis codes in
the claim details for specific procedures. The following is
required:
FQHC Self-Referred
Service
Texas Health Steps
(THSteps) services
Immunizations
• FQHC and RHC providers who submit claims for
gynecological services provided to PCCM clients must
list the appropriate encounter code and a modifier GY
in the claim details.
Case management for Early
Childhood Intervention
(ECI) services
Case management for Children and Pregnant Women
(CPW) services
Obstetric services
obstetric services provided to PCCM clients must
continue to list the appropriate encounter code and a
modifier TH in the claim details.
after-hours care that is provided to PCCM clients
should use their facility provider ID and must
continue to list modifier TU in the claim details.
Obstetric services
Self-referred services for PCCM Clients
FQHC and RHC providers (both freestanding/
independent and hospital-based) have the same primary
care provider referral requirements that apply to all
PCCM primary care providers, however, some services
do not require a primary care provider referral. These
services are self-referred services for PCCM clients.
FQHC and RHC providers must submit claims for
these services provided to PCCM clients with sufficient
information to determine which self-referred service was
provided. For a list of self-referred services, Medicaid
providers can refer to the 2009 Texas Medicaid Provider
Procedures Manual, section 7.1.8, “Primary Care Provider
Requirements and Information,” on pages 7-10.
Claim Requirement
TH modifier
GY modifier
Psychological
diagnosis code
Emergency services
Family planning services
Claim Requirement
Emergency diagnosis
FP diagnosis and procedure codes
Texas Health Steps (THSteps) THSteps procedure
services
codes with national place
of service 72
Immunizations
Immunization and
immunization
Reminder: Unless providing after-hours care, claims
submitted for services other than those listed above that
are provided to PCCM clients who are not assigned on
a panel report for an FQHC or RHC must include the
client’s required primary care provider information in the
Referring Provider field on the appropriate claim form.
Claim Requirement
Emergency diagnosis
FP diagnosis and procedure codes
TH modifier
GY modifier
Psychological procedure
code
Providers performing services at an RHC location may
submit claims for the following self-referred services
using their individual provider ID:
The following are self-referred services for PCCM clients
and the claim requirements that FQHC providers must
use when submitting claims for these services. FQHC
providers may use their facility provider ID when
submitting:
May/June 2010
Case management codes
RHC providers may submit claims for the following selfreferred services using their facility provider ID:
• RHC providers who submit claims for behavioral
health services provided to PCCM clients must always
include the appropriate behavioral health diagnosis
code in the claim details.
FQHC Self-Referred
Service
Emergency services
Family planning (FP)
services
Claim Requirement
THSteps procedure codes
with EP modifier
Immunization and
immunization
Case management codes
Claims that are not submitted accordingly are subject to
claims denial.
121
Updates for THSteps Diagnostic Dental Services and Opthalmic
Ultrasound Services
Medicaid fees, provider type, place-of-service (POS),
and type-of-service (TOS) changes will be applied to
some procedure codes, including Texas Health Steps
(THSteps) diagnostic dental services and ophthalmic
ultrasound services.
renal dialysis), renal dialysis facility, radiological and
physiological laboratory, and hospital-based RHC
The professional interpretation component is no longer
reimbursed to nurse practitioner (NP), clinical nurse
specialist (CNS), physician assistant (PA), CNM, and
radiological and physiological laboratory providers in the
office setting.
THSteps Diagnostic Dental Services
The following procedure codes are no longer reimbursed
to federally qualified health centers (FQHCs) in the
inpatient hospital setting:
Procedure Codes
D0140
D0220
D0274
D0322
D0460
D0120
D0210
D0272
D0321
D0425
D0150
D0230
D0277
D0330
D0470
D0160
D0250
D0290
D0340
D0999
D0170
D0260
D0310
D0350
Procedure code 76510 is no longer reimbursed to hospital
The technical component is no longer reimbursed to
CNM and radiation treatment center providers in the
office setting.
D0180
D0270
D0320
D0415
skilled nursing facility (SNF), intermediary care facility
(ICF), independent laboratory, or extended care facility
(ECF) setting.
Note: These changes do not affect the FQHC encounter
payment.
Procedure Code 76511:
The total component for procedure code 76511 is no
longer reimbursed to CNM, radiation treatment center,
hospital, nephrology (hemodialysis, renal dialysis), renal
dialysis facility, and hospital-based RHC providers in the
office setting.
Ophthalmic Ultrasound Services
The following benefit changes apply to the procedure
codes as indicated:
The total component for fee-for-service claims is no
longer reimbursed to certified nurse midwife (CNM),
radiation treatment center, and hospital-based rural
health center (RHC) providers in the office setting.
Procedure code 76510 may be reimbursed to optometric
groups in the office setting.
reimbursed to NP, CNS, PA, CNM, and radiological
and physiological laboratory providers in the office,
inpatient hospital, or outpatient hospital setting.
renal dialysis), renal dialysis facility, radiological and physiological laboratory, hospital-based RHC, and optometric
group providers in the outpatient hospital setting.
office setting.
The total component for PCCM claims is no longer
reimbursed to CNM, radiation treatment center,
setting.
home, SNF, ICF, independent laboratory, or ECF setting.
longer reimbursed to CNM, radiation treatment center
122
May/June 2010
office setting.
office setting.
office setting.
office setting.
office setting.
office setting.
office setting.
office setting.
office setting.
May/June 2010
office setting.
123
Diagnosis Codes
For Unlisted Ultrasound Ophthalmic Procedures
36110
36111
36112 36113
36114
36119
3612
36130 36131 36132 36133 36181
3619
36201 36202 36203 36204 36205
36206 36207 36210 36211 36212 36213
36214 36215 36216 36217 36218 36220
36221 36222 36223 36224 36225 36226
36227 36229 36230 36231 36232 36233
36234 36235 36236 36237 36240 36241
36242 36243 36250 36251 36252 36253
36254 36255 36256 36257 36260 36261
36262 36263 36264 36265 36266 36270
36271 36272 36273 36274 36275 36276
36277 36281 36282 36283 36284 36285
36289 36340 36341 36342 36343 36361
36362 36363 36370 36371 36372 36441
36481 36482 36489 36641 37921 37926
37992
For Unlisted A-Scan Ophthalmic
Ultrasound Procedures
36600 36601 36602 36603 36604 36609
36610 36611 36612 36613 36614 36615
36616 36617 36618 36619 36620 36621
36622 36623 36630 36631 36632 36633
36634 36642 36643 36644 36645 36646
36650 36651 36652 36653 3668
3669
37100 37101 37102 37103 37104 37105
37110
37111
37112 37113 37114
37115
37116
37120 37121 37122 37123 37124
37130 37131 37132 37133 37140 37141
37142 37143 37144 37145 37146 37148
37149 37150 37151
37152
37153
37154
37155
37156 37157
37158 37160 37161
37162 37170 37171 37172 37173 37181
37182 37189 3719
37931 37932 37933
37934 37939 74330 74331 74332 74333
74334 74335 74336 74337 74339
For Unlisted Ophthalmic Ultrasound
Foreign Body Localization Procedures
3766
8704
8715
8716
9300
9301
9302
9308
9309
The total component for procedure code 76999 is
no longer reimbursed to podiatrist, CNM, hospital,
setting.
Procedure code 76999 may be reimbursed to optometrist
reimbursed to NP, CNS, PA, CNM, podiatrist, and
radiological and physiological laboratory providers in the
office, inpatient hospital, or outpatient hospital setting.
Procedure code 76999 may be reimbursed to optometrists in the office, inpatient hospital, or outpatient
hospital setting.
podiatrist, CNM, radiation treatment center, and
podiatry group providers in the office setting.
Procedure code 76999 may be reimbursed to optometrist
Unlisted procedure code 76999 requires prior authorization. The provider must submit the following documentation with the following included:
• A clear, concise description of the ophthalmic
ultrasound being performed.
• A procedure code that is comparable to the requested
ophthalmic ultrasound or the provider’s intended fee
for performing the ophthalmic ultrasound.
• One of the following diagnosis codes:
Diagnosis Codes
For Unlisted Ultrasound Ophthalmic Procedures
1900
2388
25052
36054
36063
36102
1901
23981
25053
36055
36064
36103
1984
24950
36050
36059
36065
36104
2240
24951
36051
36060
36069
36105
2241
25050
36052
36061
36100
36106
2340
25051
36053
36062
36101
36107
Note: Services and procedures that are investigational or
experimental are not a benefit of Texas Medicaid.
124
May/June 2010
THSteps-CCP Blood Pressure Device Benefits Changed
Effective for dates of service on or after February 1,
2010, blood pressure device benefits changed for the
Texas Health Step-Comprehensive Care Program
(THSteps-CCP).
• Replacement or repair of components (procedure code
A4660). Prior authorization is required for replacement
or repair of components.
• Replacement or repair of components (procedure code
A4663). One replacement blood pressure cuff per year
may be reimbursed with prior authorization.
The following blood pressure devices and their
components are benefits of THSteps-CCP in the home
setting for self-monitoring when the equipment is
prescribed by a physician:
Note: Finger cuff automated blood pressure devices and
ambulatory blood pressure devices for diagnostic purposes are
not benefits of Texas Medicaid.
• Manual blood pressure device. A device that requires
manual cuff inflation with real-time visualization of
the results displayed on the manometer.
Documentation that supports medical necessity of the
requested equipment must include the diagnosis and
must be maintained in the client’s medical record.
• Automated blood pressure device. A device that inflates
the cuff manually or automatically and displays the
blood pressure results on a small screen.
Manual and Automated Blood Pressure Devices
Manual and automated blood pressure devices
(procedure codes A4660 and A4670) do not require
prior authorization when billed with one of the following
diagnosis codes:
• Hospital-grade blood pressure device. A device that
includes memory for continuous recording, has an
alarm system to notify the caregiver of abnormal
readings, and is capable of frequent or continuous
automatic blood pressure and heart rate monitoring
with correction of motion artifact.
Important: Manual and automated blood pressure
devices are also benefits of Texas Medicaid home health
services, and the changes identified in the article also
apply to the home health services benefit. The hospitalgrade blood pressure device benefit only applies to
THSteps-CCP.
The following procedure codes may be reimbursed for
blood pressure devices:
• Manual device (procedure code A4660) and Automated
device (procedure code A4670). Prior authorization is not
required for the purchase of one per year when billed
with one of the diagnosis codes in the table next column.
• Hospital-grade device (procedure code A9279 with
modifier U1). Prior authorization is required for rental
or purchase.
Note: Procedure code A9279 with modifier U1 replaces
procedure code E1399 for the rental of an electronic blood
pressure monitoring device and may be reimbursed to
durable medical equipment (DME) medical suppliers
in the home setting. Providers are encouraged to update
any authorizations for E1399 with dates of service that
encompass February 1, 2010.
May/June 2010
125
Diagnosis Codes
4010
4011
40211 40290
40311 40390
40403 40410
40491 40492
40519 40591
41519
4160
4240
4241
4253
4254
42613 4262
42652 42653
42682 42689
42731 42732
42821 42822
42833 42840
4580
4581
5831
5832
58389 5839
5849
5851
5856
5859
59372 59373
74519
7452
74561
74569
4019
40291
40391
40411
40493
40599
4161
4242
4260
4263
42654
4269
42781
42823
42841
45829
5834
5845
5852
5880
7450
7453
7457
40200
40300
40400
40412
40501
4150
4162
4243
42610
4264
4266
4270
4280
42830
42842
4588
5836
5846
5853
58889
74510
7454
40201
40301
40401
40413
40509
41511
4168
4251
42611
42650
4267
4271
4281
42831
42843
4589
5837
5847
5854
591
74511
7455
40210
40310
40402
40490
40511
41512
4169
4252
42612
42651
42681
4272
42820
42832
4289
5830
58381
5848
5855
59371
74512
74560
Manual and automated blood pressure devices that have
been purchased are anticipated to last a minimum of one
year and may be considered for replacement when one
year has passed or when the equipment is not functional
and not repairable.
• Hypertensive renal disease
• Acute pulmonary heart disease
• Chronic pulmonary heart disease
• Cardiomyopathy
Prior authorization is not required for one blood pressure
device purchased per year and billed with one of the
diagnosis codes in the preceding table.
• Conduction disorders
• Cardiac dysrhythmias
Prior authorization is required in the following situations:
• Heart failure
• Another blood pressure device is medically necessary
within the same year. Replacement of equipment within
the same year as the purchase requires prior authorization. When equipment needs to be replaced sooner
than the anticipated lifespan, the provider must submit
a copy of the police or fire report, when appropriate,
and the measures to be taken to prevent reoccurrence.
• Acute kidney failure
• Chronic kidney disease
• Hydronephrosis
• Vesicoureteral reflux with neuropathy
• Bulbus cordis anomalies and anomalies of cardiac
septal closure
• The client has a diagnosis code other than those in the
preceding table. If the client has a diagnosis code other
than those listed in the preceding table, a request
for prior authorization for an initial or replacement
device with all necessary documentation supporting
medical necessity of the blood pressure device must
be submitted to TMHP on the THSteps-CCP Prior
Authorization Request Form.
Documentation of medical necessity for the hospitalgrade blood pressure device must support the client’s
need for self-monitoring and address why an automated
blood pressure device will not meet the client’s needs.
The documentation must include:
• All pertinent diagnoses.
• Initial evaluation.
Hospital-Grade Blood Pressure Devices
• Symptoms.
Prior authorization is required for rental or purchase of
a hospital-grade blood pressure device. Reimbursement
for rental, purchase, repair of purchased equipment, or
modification of purchased equipment will be determined
based on the client’s needs, duration of use, and age of
the equipment.
• Duration of symptoms.
• Any recent hospitalizations (within the past 12 months).
• Comorbid conditions.
• How frequent/continuous self-monitoring will affect
treatment.
For clients who are birth through 11 months of age, the
rental or purchase of a hospital-grade blood pressure
device is a benefit with prior authorization. The physician
must provide documentation of medical necessity that
includes an explanation of why the client can not use a
standard automated blood pressure device.
• All pertinent laboratory and radiology results.
• Client’s weight.
• A family or caregiver(s) who has an understanding of
cause and effect and object permanence and who has
agreed to accept the responsibility to be trained to use
the hospital-grade monitor.
For clients who are 12 months of age or older, the rental
or purchase of a hospital-grade blood pressure device is
a benefit with prior authorization on a case-by-case basis.
Supporting documentation of medical necessity must be
provided.
Rental
A hospital-grade blood pressure monitor may be
reimbursed for rental once every calendar month for a
maximum of six months. Prior authorization may be
granted for a six‑month rental period when the request
is submitted with documentation of medical necessity
supporting the client’s need for self-monitoring and
addressing why an automated blood pressure device will
not meet the client’s needs.
The following indications are recognized by Texas
Medicaid for hospital-grade blood pressure devices:
• Hypotension
• Essential hypertension
• Hypertensive heart disease
126
May/June 2010
Purchase of a blood pressure device using procedure code
A9279 with modifier U1 has a reimbursement rate of
$2,287.80.
Blood Pressure Device Components
Replacement and Repair
Replacement of blood pressure cuffs (procedure code
A4663) and other components (procedure code A4660)
may be considered for purchase with prior authorization when the request is submitted with documentation of medical necessity that explains the need for the
replacement.
Prior authorization is required for equipment repair
and will be considered when reparable damage has
occurred. Repair of the equipment may be considered
with documentation supporting the need for repair.
Documentation of medical necessity must be submitted
with the completed THSteps-CCP Prior Authorization
Request Form.
Repair of equipment will be considered after the factory
warranty has expired.
Recertification for one additional six-month period may
be considered when the physician provides current documentation that supports the ongoing medical necessity
for self-monitoring and confirms the client or family is
compliant with its use.
A completed THSteps-CCP Prior Authorization Request
Form prescribing the DME or supplies must be signed
and dated by a physician familiar with the client before
requesting prior authorization for all DME equipment
and supplies. All signatures and dates must be current,
unaltered, original, and handwritten. Computerized or
stamped signatures and dates will not be accepted. For
the hospital-grade blood pressure device, the completed
THSteps-CCP Prior Authorization Request Form must
include the procedure codes and quantities for services
requested. The completed, signed, and dated form must
be maintained by the DME provider and the prescribing
physician in the client’s medical record. The original
signed and dated copy must be kept in the physician’s
medical record for the client.
Rental of equipment includes all necessary supplies,
adjustments, repairs, and replacement parts. Rental using
procedure code A9279 with modifier U1 has a reimbursement rate of $175.98.
Purchase
A hospital-grade blood pressure device will not be
considered for prior authorization of purchase until the
client has completed a six-month trial period.
Purchase of a hospital-grade blood pressure device may be
prior authorized when all of the following criteria are met:
• The client is 12 months of age or older.
The completed THSteps-CCP Prior Authorization
Request Form must be faxed or mailed to the CCP prior
authorization unit at:
• Documentation of medical necessity supports the
client’s need for ongoing self-monitoring and addresses
why an automated blood pressure device will not meet
the client’s needs.
Comprehensive Care Program (CCP)
PO Box 200735
Austin, TX 78720-0735
Fax: 1-512-514-4212
All rental costs of the hospital-grade blood pressure
device apply toward the purchase price.
Hospital-grade blood pressure devices that have been
purchased are anticipated to last a minimum of three
years and may be considered for replacement when
three years have passed or when the equipment is not
functional and not repairable.
May/June 2010
To facilitate determination of medical necessity and avoid
unnecessary denials, the physician must provide correct
and complete information, including documentation of
127
medical necessity for the requested equipment or supplies.
The physician must maintain documentation of medical
necessity in the client’s medical record. The requesting
provider may be asked for additional information to
clarify or complete a request for a hospital-grade blood
pressure monitor.
cannot be verified, the claim payment will be eligible for
recoupment.
Reimbursement
Providers are reimbursed the lesser of the provider’s billed
charges or the published fee determined by the Health
and Human Services Commission (HHSC) or through
manual pricing. If manual pricing is used, the provider
must request prior authorization and submit documentation of one of the following:
Procedures Manual, section 24.2.2, “Prior Authorization,”
on page 24-5, for more information about home health
prior authorizations.
• The manufacturer’s suggested retail price (MSRP) or
average wholesale price (AWP), whichever is applicable
DME Certification and Receipt Documentation
Requirements
Texas Medicaid considers blood pressure devices as
DME, which is defined as medical equipment or
appliances that are manufactured to withstand repeated
use, ordered by a physician for use in the home, and
required to correct or ameliorate a client’s disability,
condition, or illness. The DME Certification and Receipt
Form is required and must be completed before reimbursement can be made for any DME delivered to a
client. The certification form must include the name
of the item, the date the client received the DME, and
the dated signatures of the provider and the client or
primary caregiver. The signed and dated form must be
maintained by the DME provider in the client’s medical
record.
Manually priced items are reimbursed at the MSRP less
18 percent or the AWP less 10.5 percent, whichever is
applicable, or the provider’s documented invoice cost.
Note: Medicaid clients who are 20 years of age or younger are
entitled to all medically necessary DME. DME is medically
necessary when it is required to correct or ameliorate
disabilities or physical or mental illnesses or conditions. Any
numerical limit on the amount of a particular item of DME
can be exceeded for Medicaid clients who are 20 years of
age or younger if medically necessary. Likewise, time periods
for replacement of DME will not apply to Medicaid clients
who are 20 years of age or younger if the replacement is
medically necessary. When prior authorization is required,
the information submitted with the request must be sufficient
to document the reasons why the requested DME item or
quantity is medically necessary.
If the price of the DME exceeds $2,500.00, or if multiple
items submitted with the same date of service meet or
exceed a total billed amount of $2,500.00, the DME
Certification and Receipt Form must be submitted to
TMHP with the claim. Claims submitted without the
DME Certification and Receipt Form will be denied.
Professional Services for Ambulatory Blood
Pressure Monitoring
Procedures Manual, section 36.4.11.1, “Ambulatory Blood
Pressure Monitoring,” on page 36-28, for information
about professional services for ambulatory blood pressure
monitoring.
billed amount of $2,500.00, may be contacted to verify
receipt of the equipment. If receipt of the equipment
128
May/June 2010
Women's Health Program Providers
Women’s Health Program Providers
Women’s Health Program (WHP) Providers and Performance
of Elective Abortion
WHP provides low-income women with family planning
exams, related health screenings, and birth control.
Providers of services to WHP clients must notify the
TMHP Provider Enrollment Department in writing,
via the WHP Provider Certification form, whether
they have performed elective abortions within the past
calendar year.
the WHP. HHSC may also recoup WHP funds it
determines were paid to a provider that has performed
elective abortions during the past calendar year. A
billing provider who is placed on a payment hold should
continue to file Medicaid claims to ensure all claim-filing
deadlines are met.
Effective June 28, 2010, providers will be able to use the
TMHP website to disclose whether they have performed
elective abortions in the past calendar year; however,
providers must also submit a completed copy of the
WHP Provider Certification form including an original,
handwritten signature.
The Health and Human Service Commission (HHSC)
may direct TMHP to deny claims for WHP services
by providers that perform elective abortions or does
not submit the WHP Provider Certification form.
Claims for other Medicaid clients are not impacted. If
a billing provider within a group discloses that he or
she has performed an elective abortion for any patient,
the billing provider is ineligible to receive funds under
Completing this certification will display the provider as
providing WHP services on the provider’s profile on the
Online Provider Lookup (OPL).
Title XX Claims Filing Procedures for WHP Wrap-Around Services
Federally qualified
health centers (FQHCs)
may now receive Title
XX reimbursement
for Women’s Health
Program (WHP) wraparound services that
are provided during a
visit where the primary
purpose of the visit is not
related to contraception
and so is not covered
under WHP.
contractors may be reimbursed for the Pap test, an
appropriate counseling code, and the appropriate visit
code.
Follow-up Visits for STD/STI Testing
To receive Title XX reimbursement for a visit that is
strictly for the purposes of STD/STI testing for a WHP
client, DSHS contractors must file a separate Title XX
claim with a diagnosis code of V016. DSHS contractors
may be reimbursed for STD/STI tests and STD/STI
related services.
Pregnancy-Test-Only Visits
To receive Title XX reimbursement for a visit that is for a
pregnancy test only for a WHP client, DSHS contractors
must file a separate Title XX claim with a diagnosis code
of V7240.
FQHC providers may
bill the following services for Title XX reimbursement
for WHP clients when the primary diagnosis is not
related to contraception.
Claims that are submitted by FQHCs for wrap-around
services but are considered part of a WHP encounter
will be subject to retrospective review as these claims
are not eligible for Title XX reimbursement. Any wraparound services determined to have been paid in error to
FQHCs may be recouped.
Follow-up Pap Tests
To receive Title XX reimbursement for a follow-up
Pap test for WHP clients, Department of State Health
Services (DSHS) contractors must file a separate
Title XX claim with a diagnosis code of 6229. DSHS
May/June 2010
129
Excluded Providers
Excluded Providers
As required by the Medicare and Medicaid Patient Protection Act of 1987, the Health and Human Services Commission
(HHSC) identifies providers or employees of providers who have been excluded from state and federal health-care
programs. Providers excluded from Texas Medicaid and Title XX Programs must not order or prescribe services to
clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an
excluded provider also will be denied. Providers who submit cost reports cannot include the salaries, wages, or benefits
of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid
services to any client.
Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically
thereafter. Providers are liable for all fees paid to them by Texas Medicaid for services rendered by excluded individuals.
Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly
recommended that providers conduct frequent periodic checks of the HHSC exclusion list. The HHSC-Sanctions
Department submits updates to the exclusion list periodically and the updates appear on the website weekly.
Review the entire Texas Medicaid exclusion list at https://oig.hhsc.state.tx.us /Exclusions/Search.aspx.
To report Medicaid providers who engage in fraud/abuse, call 1-512-424-6519 or 1-800-436-6184, or write to the
following address:
Brian Klozik, Director
HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361
PO Box 85200
Austin TX 78708-5200
Provider
Atherton, Brenda L.
BAC and THT Alcohol and
Drug Center
Ballard, Beth A.
Brace, William J.
Brown, Joshua L.
Cabrera, Rene
Cabrera, Rene
Cambron, Sandra P.
Carr, Jessica D
Clark, R. Romola
Corbett, Ashley D.
Davis, Lisa M.
Dreger, Kimberley J.
Ekwere, Aniekan J
Epley, Jack W.
Espree, Aundrea
Fields, Brenda M.
Gabehart, Patricia A.
Gallagher, Mary F.
Garcia, Michael J.
Glinkowski, Tadeusz
License
Number
681295
656365
64449
142510
NA
NA
447868
139406
211962
145912
665455
616168
NA
127415
580901
140032
117342
196577
202984
E5090
Start Date
10-Jan-10
13-Jan-10
Type
Provider
RN
CD
City
Midland
Houston
State
TX
TX
Add Date
10-Feb-09
20-Nov-08
05-Jan-10
05-Jan-10
11-Jan-10
02-Feb-10
02-Feb-10
11-Jan-10
27-Jan-10
12-Jan-10
11-Jan-10
11-Jan-10
11-Jan-10
03-Feb-10
11-Jan-10
05-Jan-10
12-Jan-10
11-Jan-10
11-Jan-10
11-Jan-10
03-Feb-10
RN
RN
Tech
None
None
RN
Tech
RN
Tech
RN
RN
Owner
LVN
RN
LVN
LVN
LVN
LVN
MD
Friendswood
Houston
Levelland
Brownsville
Brownsville
Boone
Houston
Whitehouse
New Boston
Mercedes
Hitchcock
Houston
El Paso
San Antonio
Garland
Amarillo
Euless
Krum
Houston
TX
TX
TX
TX
TX
NC
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
08-Sep-09
18-Aug-09
18-Dec-08
07-Dec-09
07-Dec-09
06-Feb-09
12-Mar-09
10-Sep-09
03-Nov-08
10-Feb-09
10-Feb-09
20-Oct-09
08-Sep-09
08-Sep-09
15-Sep-09
08-Sep-09
08-Sep-09
15-Aug-09
21-Aug-09
130
May/June 2010
Excluded Providers
Provider
Glover, Carol L
Goeckler, Shanyn B.
Gonzalez, Lillian
Gorman, Christopher J.
Guerrero, Isabel T.
Gunn, John C
Hahn, Jeremy S.
Hale, Carmel L
Henke, Karen L
Hillin, Ryan H
Hough, Kimberly Jo R
Johnson, Steven A.
Kirit-Santua, Glenda J.
Lankford, Pamela K.
Legg, Dianne R
Lewis, Linda J.
Littlejohn, William D
Mercadal, Bonnie W.
Morse, Marla M.
Mozingo, Brenda G
Murphy, Jonathan L
Nall, Lawanda C.
Paul, Anastasia N
Payn, Ann M.
Plfeeger, Jonathan K.
Potter, Norma C
Purtle, Karen T.
Resendiz, Claudia D.
Robbins, Carrie D.
Samuel, Matthew N.
Shaver, RoseMarie A.
Short, Waletha
Shows, Timothy A.
Smith, Harvey P
Stevens, Marilyn K.
Stone, Amy K.
Taylor, Judy G
Taylor, Serena K
Tinsley, LaShonda K.
Tucker, Lisa L.
Vallery, Daarina N.
Wesson, Mae E
License
Number
621156
675757
676177
204624
100712
L9039
204896
NA
508183
144427
107340
128438
610432
666773
NA
131032
D4203
72830
187136
127328
141923
545519
141338
568347
702846
614586
126491
193620
193250
114785
135879
139474
101632
N/A
573770
138519
G5680
40168
144156
173924
147589
F2103
May/June 2010
Start Date
25-Jan-10
11-Jan-10
11-Jan-10
11-Jan-10
12-Jan-10
03-Feb-10
11-Jan-10
02-Feb-10
27-Jan-10
27-Jan-10
03-Feb-10
12-Jan-10
05-Jan-10
12-Jan-10
02-Feb-10
11-Jan-10
25-Jan-10
12-Jan-10
12-Jan-10
27-Jan-10
27-Jan-10
12-Jan-10
27-Jan-10
12-Jan-10
12-Jan-10
27-Jan-10
11-Jan-10
11-Jan-10
11-Jan-10
12-Jan-10
11-Jan-10
12-Jan-10
12-Jan-10
25-Jan-10
05-Jan-10
12-Jan-10
03-Feb-10
22-Jan-10
12-Jan-10
11-Jan-10
14-Jan-10
25-Jan-10
Type
Provider
RN
RN
RN
LVN
Tech
MD
LVN
None
RN
Tech
LVN
Tech
RN
RN
None
LVN
MD
LVN
LVN
Tech
Tech
RN
Tech
RN
RN
RN
LVN
LVN
LVN
Tech
LVN
Tech
Tech
Mgr
RN
Tech
MD
LVN
Tech
LVN
Tech
MD
131
City
Amarillo
Houston
North Las Vegas
San Antonio
New Braunfels
Austin
Grovetown
Lubbock
San Antonio
Henderson
Menard
Arlington
Sugarland
Bethany
Alvin
Marshall
Willow Park
Fort Worth
Conroe
Olathe
Corpus Christi
Castleberry
Dallas
San Antonio
Friendswood
San Antonio
Atlanta
Odessa
Texarkana
Pasadena
Austin
Fort Worth
Humble
Pearland
San Antonio
Stephenville
Irving
Waller
Austin
Simms
Houston
Beaumont
State
TX
TX
NV
TX
TX
TX
GA
TX
TX
TX
TX
TX
TX
LA
TX
TX
TX
TX
TX
KS
TX
AL
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Add Date
25-Jan-10
02-Sep-09
12-May-09
18-Aug-09
09-Oct-08
07-Jul-09
18-Aug-09
07-Dec-09
16-Mar-09
10-Mar-09
03-Sep-09
15-Oct-08
18-Aug-09
18-Aug-09
07-Dec-09
05-Aug-09
21-Aug-09
10-Feb-09
10-Feb-09
12-Mar-09
10-Feb-09
22-Feb-08
10-Feb-09
21-Sep-09
18-Aug-09
13-Apr-09
17-Aug-09
17-Sep-09
18-Aug-09
30-Nov-08
18-Aug-09
22-Oct-08
18-Dec-08
25-Jan-10
21-Sep-09
01-Oct-08
21-Aug-09
03-Apr-09
09-Oct-08
18-Aug-09
18-Dec-08
21-Aug-09
Excluded Providers
Provider
Whitfield, Marjorie
Williams, Rhonda K.
Wills, Angela D
Wingate, Amy C
Woods, Patricia A
Woolsey, Misty L
Wright, Olivia T
Zaragoza, Sophia Y
Zavala, Priscilla A.
Zelanko, Michael E
License
Number
145704
120992
185912
172489
190869
137562
205657
202433
158084
455078
Type
Provider
LVN
Tech
LVN
LVN
LVN
LVN
LVN
LVN
Tech
RN
Start Date
22-Jan-10
14-Jan-10
22-Jan-10
22-Jan-10
22-Jan-10
22-Jan-10
27-Jan-10
27-Jan-10
14-Jan-10
27-Jan-10


132
City
Dallas
Sherman
Victoria
Deer Park
Magnolia
Benbrook
Killeen
Wichita Falls
Corpus Christi
Mesquite
State
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
Add Date
10-Feb-09
30-Nov-08
10-Feb-09
10-Mar-09
10-Feb-09
23-Apr-09
20-Feb-09
10-Mar-09
18-Dec-08
02-Apr-09

May/June 2010
Forms
Electronic Funds Transfer (EFT) Authorization Agreement
Enter ONE Texas Provider Identifier (TPI) per Form
NOTE:
Complete all sections below and attach a voided check or a statement from your bank written
on the bank’s letterhead.
Type of Authorization:
NEW
CHANGE
Provider Name
Nine–Character Billing TPI
National Provider Identifier (NPI)/Atypical Provider Identifier (API):
Primary Taxonomy
Code:
Benefit Code:
Provider Accounting Address
Provider Phone Number
(
)
Ext.
Bank Name
ABA/Transit Number
Bank Phone Number
Account Number
Bank Address
Type Account (check one)
Checking
Savings
I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the
bank account referenced above and the depository named above to credit the same to such account. I
(we) understand that I (we) am responsible for the validity of the information on this form. If the company
erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary
debit entries, not to exceed the total of the original amount credited for the current pay period.
I (we) agree to comply with all certification requirements of the applicable program regulations, rules,
handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services
Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from
federal and state funds, and that any falsification or concealment of a material fact may be prosecuted
under federal and state laws.
I (we) will continue to maintain the confidentiality of records and other information relating to clients in
accordance with applicable state and federal laws, rules, and regulations.
Authorized Signature
Date
Title
Email Address (if applicable)
Contact Name
Phone
Return this form to:
ATTN: Provider Enrollment
PO Box 200795
Austin TX 78720–0795
DO NOT WRITE IN THIS AREA — For Office Use
Input By:
Input Date:
23
— A STATE MEDICAID CONTRACTOR
Effective Date_10152007/Revised Date_10152007
May/June 2010
133
Forms
Electronic Funds Transfer (EFT) Information
Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims
approved for payment directly into a provider’s bank account. These funds can be
credited to either checking or savings accounts, provided the bank selected accepts
Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with
mailing and handling paper checks, ensuring funds are directly deposited into a
specified account.
The following items are specific to EFT:
•
•
•
•
•
•
Pre–notification to your bank takes place on the cycle following the application
processing.
Future deposits are received electronically after pre–notification.
The Remittance and Status (R&S) report furnishes the details of individual credits
made to the provider’s account during the weekly cycle.
Specific deposits and associated R&S reports are cross–referenced by both the
provider identifiers (i.e., NPI, TPI, and API) and R&S number.
EFT funds are released by TMHP to depository financial institutions each Friday.
The availability of R&S reports is unaffected by EFT and they continue to arrive in
the same manner and time frame as currently received.
TMHP must provide the following notification according to ACH guidelines:
Most receiving depository financial institutions receive credit entries on the day before the
effective date, and these funds are routinely made available to their depositors as of the
opening of business on the effective date. Please contact your financial institution
regarding posting time if funds are not available on the release date.
However, due to geographic factors, some receiving depository financial institutions do not
receive their credit entries until the morning of the effective day and the internal records of
these financial institutions will not be updated. As a result, tellers, bookkeepers, or
automated teller machines (ATMs) may not be aware of the deposit and the customer’s
withdrawal request may be refused. When this occurs, the customer or company should
discuss the situation with the ACH coordinator of their institution who, in turn should work
out the best way to serve their customer’s needs.
In all cases, credits received should be posted to the customer’s account on the effective
date and thus be made available to cover checks or debits that are presented for payment
on the effective date.
To enroll in the EFT program, complete the attached Electronic Funds Transfer
Authorization Agreement. You must return the agreement and either a voided check or a
statement from your bank written on the bank’s letterhead to the TMHP address
indicated on the form.
Call the TMHP Contact Center at 1–800–925–9126 for assistance.
23
— A STATE MEDICAID CONTRACTOR
134
May/June 2010
Forms
Provider Information Change Form
Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management
(PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this
form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.
Check the box to indicate a PCCM Provider
Date :
/
/
Nine-Digit Texas Provider Identifier (TPI):
Provider Name:
National Provider Identifier (NPI):
Primary Taxonomy Code:
Atypical Provider Identifier (API):
Benefit Code:
List any additional TPIs that use the same provider information:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
TPI:
Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who
change their ZIP Code must submit a copy of the Medicare letter along with this form.
Street address
Telephone: (
City
Fax Number: (
)
County
)
State
Zip Code
Email:
Accounting/Mailing Address—All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form
along with this form.
Street Address
Telephone: (
City
)
Fax Number: (
)
State
Zip Code
State
Zip Code
Email:
Secondary Address
Street Address
City
Telephone: (
)
Fax Number: (
Type of Change (check the appropriate box)
)
Email:

Change of physical address, telephone, and/or fax number

Change of billing/mailing address, telephone, and/or fax number

Change/add secondary address, telephone, and/or fax number

Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field

Other (e.g., panel closing, capacity changes, and age acceptance)
Comments:
Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)
Tax ID number:
Effective Date:
Exact name reported to the IRS for this Tax ID:
Provider Demographic Information—Note: This information can be updated on www.tmhp.com.
Languages spoken other than English:
Provider office hours by location:
Accepting new clients by program (check one): Accepting new clients Current clients only No
Patient age range accepted by provider:
Additional services offered (check one): HIV High Risk OB Hearing Services for Children
Participation in the Woman’s Health Program? Yes
No
Patient gender limitations:
Signature and date are required or the form will not be processed.
Provider signature:
Mail or fax the completed form to:
Texas Medicaid & Healthcare Partnership (TMHP)
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Female
Male
Date:
/
Both
/
Fax: 512-514-4214
May/June 2010
135
Forms
Instructions for Completing the
Provider Information Change Form
Signatures
• The provider’s signature is required on the Provider Information Change Form for any and all changes requested
for individual provider numbers.
• A signature by the authorized representative of a group or facility is acceptable for requested changes to group
or facility provider numbers.
Address
• Performing providers (physicians performing services within a group) may not change accounting information.
• For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing
address require a copy of the W-9 form.
• For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory
Surgical Centers.
Tax Identification Number (TIN)
• TIN changes for individual practitioner provider numbers can only be made by the individual to whom the
number is assigned.
• Performing providers cannot change the TIN.
Provider Demographic Information
An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view
information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please
visit the OPL at www.tmhp.com. Please review the existing information and add or modify any specific practice
limitations accordingly. This will allow clients more detailed information about your practice.
General
• TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier
(NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable)
in order to process the change. Forms will be returned if this information is not indicated on the Provider
Information Change Form.
• The W-9 form is required for all name and TIN changes.
• Mail or fax the completed form to:
Texas Medicaid & Healthcare Partnership (TMHP)
Provider Enrollment
PO Box 200795
Austin, TX 78720-0795
Fax: 512-514-4214
136
May/June 2010
CPT only copyright 2009 American
Medical
Association. All rights reserved.
Effective
Date_09012009/Revised
Date_08212009
May/June 2010
TPI
Provider Name
Medicaid Client
Number
Client Last Name
Client First Name
Medicare Paid Date
Medicare ICN
3
4
5
6
7
8
9
137
Totals Information
Medicare Prev Paid
13
Detail(s) Information
12
11
Patient HIC Number
Medicare ID
2
10
NPI/API
1
From DOS
To DOS
Units
CPT
Mods
Charges
Charges
Effective mmddyyy-Revised 12082009
POS
Allow
Allow
Ded
Ded
Paid
Paid
Save As
Coins
Coins
Reason
Code
Reason
Code
Revised Crossover Claim Type 30
TMHP Standardized Medicare/Medicare Advantage Plan (MAP)
Remittance Advice Notice Form
Forms
Forms
Crossover Claim Types 31 and 50
TMHP Standardized Medicare and
Medicare Advantage Plan (MAP) Remittance
Advice Notice Form
Medicare Paid Date:
Provider Name:
NPI/API/TPI:
Medicare ID:
State:
ZIP:
Street Address:
City:
Bill Type
From DOS
Through DOS
Patient Last Name
Patient First Name
Medicare HIC
Medicare ICN
Total Charges
Covered Charges
Non Covered Charges/Reason
Code
DRG Amount
Deductible
Blood Deductible
Coinsurance
Medicare Paid Amount
DRG Code
Save As
Effective mmddyyyy – Revised 12082009
138
May/June 2010
Forms
Crossover Claim Type 30 Instructions
Providers who bill professional services on the CMS-1500 paper claim form must submit the
Crossover Claim Type 30 template with a copy of a completed claim form. All fields (excluding
Medicaid information fields) on the form must be completed using the Remittance Advice or
Remittance Notice that was received from Medicare or the Medicare Advantage Plan (MAP). In
addition, all details from the Medicare or MAP RA/RN must be included in the template,
regardless of whether a deductible or coinsurance is due.
The TMHP Standardized MRAN Submission Form must be typed or computer-generated.
Handwritten forms will not be accepted and will be returned to the provider.
The following are the requirements for the Crossover Claim Type 30 template:
Block Field Description
No.
Guidelines
1
NPI/API
Enter the National Provider Identifier (NPI) for the billing
provider.
2
Medicare ID
Enter the Medicare Provider ID number of the billing
provider listed on the Medicare or MAP RA/RN.
3
TPI
Enter the Medicaid Texas Provider Identifier (TPI) number
of the billing provider.
4
Provider Name
Enter the billing provider’s name.
5
Medicaid Client
Number
Enter the client’s nine-digit Medicaid number from the
Medicaid identification form.
6
Client Last Name
Enter the client’s last name listed on the Medicare or MAP
RA/RN.
7
Client First Name
Enter the client’s first name listed on the Medicare or MAP
RA/RN.
8
Medicare Paid Date
Enter the Medicare Paid Date listed on the Medicare or
MAP RA/RN.
9
Medicare ICN
Enter the Medicare Internal Control Number (ICN) listed on
the Medicare or MAP RA/RN.
10
Client HIC Number
Enter the client’s identification number listed on the
Medicare or MAP RA/RN.
11
From DOS
Enter the first date of service (DOS) for each procedure in
a MM/DD/YYYY format.
11
To DOS
Enter the last DOS for each procedure in a MM/DD/YYYY
format.
11
POS
Enter the place of service (POS) listed on the MAP
Remittance Advice/Remittance Notice.
11
Units
Enter the number of units (quantity billed) from the
11
CPT
Enter the appropriate Current Procedural Terminology
(CPT) procedure code for each procedure/service listed on
the Medicare or MAP RA/RN
Note: The procedure code listed on the Standardized
MRAN Template may not match the procedure code listed
on the claim form attached.
Effective 12152009 - Revised 12082009
May/June 2010
139
Forms
Block Field Description
No.
Guidelines
11
Mods
Enter the modifier (when applicable) listed on the Medicare
or MAP RA/RN for each detail.
11
Charges
Enter the Medicare charges (billed amount) listed on the
Medicare or MAP RA/RN for each detail.
11
Allow
Enter the Medicare allowed amount listed on the Medicare
or MAP RA/RN for each detail.
11
Ded
Enter the Medicare deductible amount listed on the
11
Coins
Enter the Medicare coinsurance amount listed on the
11
Paid
Enter the Medicare paid amount listed on the Medicare or
MAP RA/RN for each detail.
11
Reason Code
Enter Medicare’s reason code listed on the Medicare or
MAP RA/RN for each detail.
12
Total Charges
Enter the Medicare total charges (billed amount) listed on
Note: A provider may attach additional template forms
(pages) as necessary. The combined total charges for all
pages should be listed on the last page. All other forms
must indicate “Continue” in this block.
12
Total Allow
Enter the Medicare total allowed amount listed on the
12
Total Ded
Enter the Medicare total deductible amount listed on the
12
Total Coins
Enter the Medicare total coinsurance amount listed on the
12
Total Paid
Enter the Medicare total paid amount listed on the
12
Total Reason Code
Leave this field blank.
13
Medicare Prev Paid
Enter the Medicare previous paid amount listed on the
Effective 12152009 - Revised 12082009
140
May/June 2010
Forms
Crossover Claim Types 31 and 50 Instructions
Providers that bill inpatient and outpatient crossover claims on a UB-04 CMS-1450 paper claim
form must submit the Crossover Claim Types 31 and 50 templates with a copy of a completed
claim form. All fields (excluding Medicaid information fields) on the form must be completed
using the Remittance Advice (RA) or Remittance Notice (RN) that was received from Medicare
or the Medicare Advantage Plan (MAP) regardless of whether a deductible or coinsurance is
due.
The TMHP Standardized MRAN Submission Form must be typed or computer-generated.
Handwritten forms will not be accepted and will be returned to the provider.
The following are the requirements for the Crossover Claim Types 31 and 50 templates:
Field Description
Guidelines
Medicare Paid Date
Enter the Medicare Paid Date listed on the Medicare or MAP RA/RN.
Provider Name
Enter the billing provider’s name.
NPI/API/TPI
Enter the National Provider Identifier (NPI)/Atypical Provider Identifier
(API)/Texas Provider Identifier (TPI) for the billing provider.
Note: NPI/TPI or API/TPI.
Medicare ID
Enter the Medicare Provider ID of the billing provider number listed on
Street Address
Enter the billing provider’s street address.
City
Enter the billing provider’s city.
State
Enter the billing provider’s state.
ZIP
Enter the billing provider’s ZIP code.
Bill Type
Enter the Medicare Bill Type listed on the Medicare or MAP RA/RN.
Note: The Medicare Bill Type may not match the type of bill (TOB)
listed on the claim form.
From DOS
Enter the first date of service (DOS) for all procedures in a
MM/DD/YYYY format.
Through DOS
Enter the last DOS for all procedures in a MM/DD/YYYY format.
Patient Last Name
Enter the patient’s last name listed on the Medicare or MAP RA/RN.
Patient First Name
Enter the patient’s first name listed on the Medicare or MAP RA/RN.
Medicare HIC
Enter the patient’s Medicare Health Insurance Claim (HIC) number
(Medicare Identification number) listed on the Medicare or MAP
RA/RN.
Medicare ICN
Enter the Medicare Internal Control Number (ICN) listed on the
Total Charges
Enter the Medicare total charges (billed amount) listed on the
Covered Charges
Enter the covered charges listed on the Medicare or MAP RA/RN.
Non Covered
Charges/Reason
Code
Enter the noncovered charges listed on the MAP RA/RN followed by
the reason code listed on the Medicare RA/RN.
Effective 12152009– Revised 12082009
May/June 2010
141
Forms
Field Description
Guidelines
DRG Amount
Enter the diagnosis-related group (DRG) amount listed on the
Medicare or MAP RA/RN for inpatient claims, if applicable.
Note: Outpatient claims do not require a DRG amount.
Deductible
Enter the Medicare deductible amount listed on the Medicare or MAP
RA/RN.
Blood Deductible
Enter the blood deductible listed on the Medicare or MAP RA/RN for
inpatient claims, if applicable.
Note: Outpatient claims do not require a blood deductible amount.
Coinsurance
Enter the Medicare coinsurance amount listed on the Medicare or
MAP RA/RN.
Medicare Paid
Amount
Enter the Medicare paid amount listed on the Medicare or MAP
RA/RN.
DRG Code
Enter the DRG code listed on the Medicare or MAP RA/RN for
inpatient claims, if applicable.
Note: Outpatient claims do not require a DRG code.
Effective 12152009– Revised 12082009
142
May/June 2010
Forms
Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form
New inpatient and outpatient requests can be submitted by:
x
x
x
Accessing the TMHP website at www.tmhp.com, click on link “Submit a Prior Authorization”
Calling 1-888-302-6167(option 1 inpatient, option 2 outpatient)
Faxing this form to 1-512-302-5039
Update requests can be submitted by:
x
x
Calling 1-888-302-6167 (option 1 inpatient, option 2 outpatient)
Faxing this form to 1-512-302-5039
Request Type (check appropriate box)
New Request
Ƒ
Ƒ
Ƒ
Ƒ
Inpatient Notification of urgent/emergent admit – includes admit following observation
Inpatient Non-routine OB/NB
Prior authorization of scheduled admission/procedures
Outpatient services
Update Request
PAN: _________________________________
Ƒ
DRG
Ƒ Procedure codes Ƒ Outpatient request Ƒ Other, specify change ________________
Section 1 – Client, Facility, and Physician Information
PCN:
Client name:
Date of birth: / /
Facility name:
Telephone number: (
Facility address:
Fax number: (
TPI:
NPI:
Taxonomy:
Benefit code:
Admitting/performing physician’s name:
Telephone number: (
Physician’s address:
Fax number: (
TPI:
NPI:
Taxonomy:
Benefit code:
Form completed by:
Date form completed:
/
) -
) -
) -
) -
/
Section 2 – Request Information
Date of service:
/ /
Discharge date:
/
/
Primary diagnosis code:
Reference number:
DRG code (if applicable):
Secondary diagnosis code(s):
Procedure code:
Quantity:
Procedure code:
Quantity:
Procedure code:
Quantity:
Procedure code:
Quantity:
Procedure code:
Quantity:
Procedure code:
Quantity:
Clinical information supporting medical necessity for new scheduled admission/procedure, outpatient services or non-routine OB/NB
(Use space provided and attach additional pages when necessary) OR Clinical information to support medical necessity of DRG,
procedure code, or other changes:
Effective Date 11012009/Revised Date 11012009
May/June 2010
143
Forms
Radiology Prior Authorization Request Form
This form is used to obtain prior authorization for elective outpatient services or update an existing outpatient authorization. All fields
marked with an asterisk (*) are required. The information in Section 2 is only required for updated or retroactive authorizations. Forms that
are submitted without all of the required information will be returned for correction.
Telephone number: 1-800-572-2116
Fax number: 1-800-572-2119
*Date of Request:
/
/
Please check the appropriate action requested:
Ƒ CT Scan
Ƒ CTA Scan
Ƒ MRI Scan Ƒ MRA Scan Ƒ PET Scan
Ƒ Cardiac Nuclear Scan Ƒ Update/change codes from
original PA request
Client Information
*Name:
*Medicaid number:
*Date of Birth:
/
/
Facility Information
*Name:
Reference number:
*Address:
TPI:
*NPI:
Taxonomy:
Benefit Code:
Requesting/Referring Physician Information
*Name:
License number:
*Address:
*Telephone:
*Fax number:
TPI:
*NPI:
Taxonomy:
Benefit Code:
Section 1
Service Types
Date of Service:
Diagnosis Codes
*Outpatient Service(s)
/
Ƒ
/
Emergent/Urgent Procedure
Ƒ
*Procedures Requested:
*Primary:
Secondary:
*Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications,
and previous imaging results:
*Requesting/Referring Physician (Signature Required):
*Print Name:
*Date:
/
/
Section 2—Updated Information (when necessary)
*Date of Service:
/
Diagnosis Codes
*Primary:
/
*Procedures Requested:
Secondary:
*Clinical documentation supporting medical necessity for a procedure code change includes treatment history, treatment plan,
medications, and previous imaging results:
*Requesting/Referring Physician (signature required):
*Print Name:
*Date:
/
/
Physician must complete and sign this form prior to requesting
authorization.
Requesting/Referring Physician License No.:
*Requesting/Referring Physician NPI:
Requesting/Referring Physician TPI:
144
May/June 2010
Forms
Nonemergency Ambulance Prior Authorization Request
Texas Medicaid Program
1.) Is an ambulance the only appropriate means of transport? Yes
2.) If no, this client does not qualify for nonemergency ambulance transport.
3.) If yes, please complete the remainder of the form.
No
In order for this service to be covered, the service must be medically necessary and reasonable. Medical necessity is established
when the client's medical condition is such that the use of an ambulance is the only appropriate means of transport, and other
alternate means of transport are medically contraindicated. Alternate means of transport include services provided through
Medicaid's Medical Transportation Program or services included in the rate for Long Term Care - Nursing Facilities.
This form is to be completed by the
Requesting Provider
provider requesting nonemergency
Name: _________________________________________________________________
ambulance transportation.
[Reference: Chapter 32.024(t) Texas Provider TPI: ______________ NPI: ______________ Taxonomy: ______________
Human Resources Code]
Contact Name: ________________ Phone: ______________ Fax: ______________
Date Request Submitted:
Ambulance Provider Name: _______________________________________________
______________________
Ambulance Provider Identifier: ________________________
Submit by Fax : 1-512-514-4205
Client Information
Last Name: _________________________________ First Name: ______________________________
DOB: __ __/ __ __/ __ __ __ __
MI: _____
Client Medicaid Number: ______________________________
Client’s Current Condition Affecting Transport
Diagnoses affecting transport: _____________________________
_____________________________________________
(Check each applicable condition)
Client requires monitoring by trained staff because
Oxygen
Airway
Suction
Cardiac
Comatose Life support
Ventilator dependent
Poses immediate danger to self or others
Continuous IV therapy or parenteral feedings **

Physical restraint or chemical sedation **
Decreased level of consciousness **
Isolation precautions (VRE, MRSA, etc.) **
Wound precautions **
Advanced decubitus ulcers **
Contractures limiting mobility **
Must remain immobile (i.e., fracture, etc.) **
Decreased sitting tolerance time or balance **
Active Seizures **
** Provide additional detail (i.e. type of seizure or IV therapy, body part affected, supports needed, or time period for the
condition), or provide detail of the client’s other conditions requiring transport by ambulance.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Extra Attendant
Reason:
Yes No
If yes, expected transport time: ________________
Other purpose: ________________________________________________________
_________________________________ Destination: _____________________________________
Reason for Transport
Origin:
______________________________________________________________
Method of Transport:
Request
Type:

Hospital discharge?
Ground
Fixed Wing
Helicopter
Specialized Vehicle
One Time, Non-repeating Medicaid or Medicare
Short Term (2 - 60 days) Medicaid or Medicare *
Long Term (61 - 180 days) Medicaid Only *
* Physician signature required for Short Term and Long Term
Begin Date:
__ __/ __ __/ __ __ __ __
End Date:
__ __/ __ __/ __ __ __ __
Certification:
I certify that the information supplied in this document constitutes true, accurate, and complete information and
is supported in the medical record of the patient. I understand that the information I am supplying will be utilized to determine
approval of services resulting in payment of state and federal funds. I understand that falsifying entries, concealment of a
material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and / or state law
which can result in fines or imprisonment, in addition to recoupment of funds paid and administrative sanctions authorized by law.
* Name: _________________________________ Title: _____________________ Provider Identifier: __________________
* Signature: ________________________________________________________ Date Signed: __ __/ __ __/ __ __ __ __
May/June 2010
145
Forms
Provider Instructions for Nonemergency Ambulance Prior Authorization Request Form
All nonemergency ambulance transportation must be medically necessary. Texas Medicaid and Medicare have similar
requirements for this service to qualify for reimbursement. This form is intended to accommodate both programs’
requirements. The criteria for determining medical necessity include: the client is bed-confined and other methods of
transportation are contraindicated, or the client’s condition is such that transportation by ambulance is medically required.
For additional information and changes to this policy and process refer to the respective program information: Texas
Medicaid’s Provider Procedures Manual, bulletins and Banner Messages; and to Medicare’s manuals, newsletters and
other publications.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1. Request Date—Enter the date the form is submitted.
2. Requesting Provider Information—Enter the name of the entity requesting authorization. (i.e., hospital, nursing
facility, dialysis facility, physician).
3. Requesting Provider Identifiers—Enter the following information for the requesting provider (facility or physician):
x Enter the Texas Provider Identifier (TPI) number.
x Enter the National Provider Identifier (NPI) number. An NPI is a ten-digit number issued by the National Plan and
Provider Enumeration System (NPPES).
Enter the primary national taxonomy code. This is a ten-digit code associated with your provider type and
specialty. Taxonomy codes can be obtained from the Washington Publishing Company website at www.wpcedi.com.
4. Ambulance Provider Identifier— Enter the TPI or NPI number of the requested ambulance provider. If the
ambulance provider changes from the provider you originally requested, notify TMHP of the new provider by phone
(1-800-925-9126, Option 3) or fax (1-512-514-4205).
5. Client’s Current Condition—This section must be filled out to indicate the client’s current condition and not to list all
historical diagnoses. Do not submit a list of the client’s diagnoses unless the diagnoses are relevant to transport (i.e.,
if client has a diagnosis of hip fracture, the date the fracture was sustained must be included in documentation). It
must be clear to TMHP when reviewing the request form, exactly why the client requires transport by ambulance and
cannot be safely transported by any other means.
6. Isolation Precautions—Vancomycin-Resistant Enterococci (VRE) and Methicillin-Resistant Staphylococcus Aureus
(MRSA) are just two examples of isolation precautions. Please indicate in the notes exactly what type of precaution is
indicated.
7. Details for Checked Boxes—For each checked answer, a detailed explanation is required (i.e., if contractures is
checked, please give the location and degree of contracture[s]). If a client has a decreased tolerance for sitting time,
please indicate why the client has a decreased tolerance as well as the maximum length of time the client is able to sit
upright. Additional documentation can be submitted with this request form if needed.
8. Request Type—Check the box for the request type. A One Time, non-repeating request is for a one day period. A
Short Term request is for a period of 2-60 days when repeated transports are expected to occur; both Medicaid and
Medicare permit short-term requests. A Long Term request is for a period of 61-180 days when repeated transports
are expected to occur; Medicare does not permit a Long Term request. Medicaid requires a physician signature for
Short Term and Long Term requests. Enter the begin and end dates of the authorization period for short and longterm requests.
9. Transport Time—This field must be filled out for all hospital discharge requests. The anticipated time of transport
must be entered in order to ensure the request was initiated prior to the actual time of transport.
10. Name of Person Signing the Request—All request forms require a signature, date, and title of the person signing
the form. A One Time request must be signed and dated by a physician, physician assistant (PA), nurse practitioner
(NP), clinical nurse specialist (CNS), registered nurse (RN), or discharge planner with knowledge of the client’s
condition. A request of a Short Term or Long Term authorization period must be signed and dated by the physician.
The signature must be dated not earlier than the 60th day before the date on which the request for authorization is
made.
11. Signing Provider Identifier—This field is for the TPI or NPI number of the requesting facility or provider signing the
form. The signature must be dated no earlier than 60 days prior to the transport.
x
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08/30
08/31
(172)
(172)
(172)
(173)
(174)
(175)
(176)
(179)
(179)
(179)
(180)
(181)
(182)
(183)
(187)
(187)
(187)
(187)
(188)
(189)
(190)
(193)
(193)
(193)
(194)
(195)
(196)
(197)
(200)
(200)
(200)
(201)
(202)
(203)
(204)
(207)
(207)
(207)
(208)
(209)
(210)
(211)
(214)
(214)
(214)
(215)
(216)
(217)
(218)
(221)
(221)
(221)
(222)
(223)
(224)
(225)
(228)
(228)
(228)
(229)
(230)
(231)
(232)
(235)
(235)
(235)
(236)
(237)
(238)
(239)
(242)
(242)
(242)
(243)
95 Days
07/14
07/15
07/16
07/19
07/19
07/19
07/20
07/21
07/22
07/23
07/26
07/26
07/26
07/27
07/28
07/29
07/30
08/02
08/02
08/02
08/03
08/04
08/05
08/06
08/09
08/09
08/09
08/10
08/11
08/12
08/13
08/16
08/16
08/16
08/17
08/18
08/19
08/20
08/23
08/23
08/23
08/24
08/25
08/26
08/27
08/30
08/30
08/30
08/31
09/01
09/02
09/03
09/06
09/06
09/06
09/08
09/08
09/09
09/10
09/13
09/13
09/13
09/14
09/15
09/16
09/17
09/20
09/20
09/20
09/21
09/22
09/23
09/24
09/27
(195)
(196)
(197)
(200)
(200)
(200)
(201)
(202)
(203)
(204)
(207)
(207)
(207)
(208)
(209)
(210)
(211)
(214)
(214)
(214)
(215)
(216)
(217)
(218)
(221)
(221)
(221)
(222)
(223)
(224)
(225)
(228)
(228)
(228)
(229)
(230)
(231)
(232)
(235)
(235)
(235)
(236)
(237)
(238)
(239)
(242)
(242)
(242)
(243)
(244)
(245)
(246)
(249)
(249)
(249)
(251)
(251)
(252)
(253)
(256)
(256)
(256)
(257)
(258)
(259)
(260)
(263)
(263)
(263)
(264)
(265)
(266)
(267)
(270)
120 Days
05/29
05/30
05/31
06/01
06/02
06/03
06/04
06/05
06/06
06/07
06/08
06/09
06/10
06/11
06/12
06/13
06/14
06/15
06/16
06/17
06/18
06/19
06/20
06/21
06/22
06/23
06/24
06/25
06/26
06/27
06/28
06/29
06/30
07/01
07/02
07/03
07/04
07/05
07/06
07/07
07/08
07/09
07/10
07/11
07/12
07/13
07/14
07/15
07/16
07/17
07/18
07/19
07/20
07/21
07/22
07/23
07/24
07/25
07/26
07/27
07/28
07/29
07/30
07/31
08/01
08/02
08/03
08/04
08/05
08/06
08/07
08/08
08/09
08/10
(149)
(150)
(151)
(152)
(153)
(154)
(155)
(156)
(157)
(158)
(159)
(160)
(161)
(162)
(163)
(164)
(165)
(166)
(167)
(168)
(169)
(170)
(171)
(172)
(173)
(174)
(175)
(176)
(177)
(178)
(179)
(180)
(181)
(182)
(183)
(184)
(185)
(186)
(187)
(188)
(189)
(190)
(191)
(192)
(193)
(194)
(195)
(196)
(197)
(198)
(199)
(200)
(201)
(202)
(203)
(204)
(205)
(206)
(207)
(208)
(209)
(210)
(211)
(212)
(213)
(214)
(215)
(216)
(217)
(218)
(219)
(220)
(221)
(222)
Date of Service
or Disposition
09/01
09/02
09/03
09/06
09/06
09/06
09/08
09/08
09/09
09/10
09/13
09/13
09/13
09/14
09/15
09/16
09/17
09/20
09/20
09/20
09/21
09/22
09/23
09/24
09/27
09/27
09/27
09/28
09/29
09/30
10/01
10/04
10/04
10/04
10/05
10/06
10/07
10/08
10/12
10/12
10/12
10/12
10/13
10/14
10/15
10/18
10/18
10/18
10/19
10/20
10/21
10/22
10/25
10/25
10/25
10/26
10/27
10/28
10/29
11/01
11/01
11/01
11/02
11/03
11/04
11/05
11/08
11/08
11/08
11/09
11/10
11/12
11/12
11/15
(244)
(245)
(246)
(249)
(249)
(249)
(251)
(251)
(252)
(253)
(256)
(256)
(256)
(257)
(258)
(259)
(260)
(263)
(263)
(263)
(264)
(265)
(266)
(267)
(270)
(270)
(270)
(271)
(272)
(273)
(274)
(277)
(277)
(277)
(278)
(279)
(280)
(281)
(285)
(285)
(285)
(285)
(286)
(287)
(288)
(291)
(291)
(291)
(292)
(293)
(294)
(295)
(298)
(298)
(298)
(299)
(300)
(301)
(302)
(305)
(305)
(305)
(306)
(307)
(308)
(309)
(312)
(312)
(312)
(313)
(314)
(316)
(316)
(319)
95 Days
09/27
09/27
09/28
09/29
09/30
10/01
10/04
10/04
10/04
10/05
10/06
10/07
10/08
10/12
10/12
10/12
10/12
10/13
10/14
10/15
10/18
10/18
10/18
10/19
10/20
10/21
10/22
10/25
10/25
10/25
10/26
10/27
10/28
10/29
11/01
11/01
11/01
11/02
11/03
11/04
11/05
11/08
11/08
11/08
11/09
11/10
11/12
11/12
11/15
11/15
11/15
11/16
11/17
11/18
11/19
11/22
11/22
11/22
11/23
11/24
11/29
11/29
11/29
11/29
11/29
11/30
12/01
12/02
12/03
12/06
12/06
12/06
12/07
12/08
(270)
(270)
(271)
(272)
(273)
(274)
(277)
(277)
(277)
(278)
(279)
(280)
(281)
(285)
(285)
(285)
(285)
(286)
(287)
(288)
(291)
(291)
(291)
(292)
(293)
(294)
(295)
(298)
(298)
(298)
(299)
(300)
(301)
(302)
(305)
(305)
(305)
(306)
(307)
(308)
(309)
(312)
(312)
(312)
(313)
(314)
(316)
(316)
(319)
(319)
(319)
(320)
(321)
(322)
(323)
(326)
(326)
(326)
(327)
(328)
(333)
(333)
(333)
(333)
(333)
(334)
(335)
(336)
(337)
(340)
(340)
(340)
(341)
(342)
120 Days
08/11
08/12
08/13
08/14
08/15
08/16
08/17
08/18
08/19
08/20
08/21
08/22
08/23
08/24
08/25
08/26
08/27
08/28
08/29
08/30
08/31
09/01
09/02
09/03
09/04
09/05
09/06
09/07
09/08
09/09
09/10
09/11
09/12
09/13
09/14
09/15
09/16
09/17
09/18
09/19
09/20
09/21
09/22
09/23
09/24
09/25
09/26
09/27
09/28
09/29
09/30
10/01
10/02
10/03
10/04
10/05
10/06
10/07
10/08
10/09
10/10
10/11
10/12
10/13
10/14
10/15
10/16
10/17
10/18
10/19
10/20
10/21
10/22
10/23
(223)
(224)
(225)
(226)
(227)
(228)
(229)
(230)
(231)
(232)
(233)
(234)
(235)
(236)
(237)
(238)
(239)
(240)
(241)
(242)
(243)
(244)
(245)
(246)
(247)
(248)
(249)
(250)
(251)
(252)
(253)
(254)
(255)
(256)
(257)
(258)
(259)
(260)
(261)
(262)
(263)
(264)
(265)
(266)
(267)
(268)
(269)
(270)
(271)
(272)
(273)
(274)
(275)
(276)
(277)
(278)
(279)
(280)
(281)
(282)
(283)
(284)
(285)
(286)
(287)
(288)
(289)
(290)
(291)
(292)
(293)
(294)
(295)
(296)
Date of Service
or Disposition
Note: If the 95th or 120th day falls on a weekend or holiday, the filing deadline is extended to the next business day.
Filing Deadline Calendar for 2010
11/15
11/15
11/16
11/17
11/18
11/19
11/22
11/22
11/22
11/23
11/24
11/29
11/29
11/29
11/29
11/29
11/30
12/01
12/02
12/03
12/06
12/06
12/06
12/07
12/08
12/09
12/10
12/13
12/13
12/13
12/14
12/15
12/16
12/17
12/20
12/20
12/20
12/21
12/22
12/23
12/27
12/27
12/27
12/27
12/28
12/29
12/30
01/03
01/03
01/03
01/03
01/04
01/05
01/06
01/07
01/10
01/10
01/10
01/11
01/12
01/13
01/14
01/18
01/18
01/18
01/18
01/19
01/20
01/21
01/24
01/24
01/24
01/25
01/26
(319)
(319)
(320)
(321)
(322)
(323)
(326)
(326)
(326)
(327)
(328)
(333)
(333)
(333)
(333)
(333)
(334)
(335)
(336)
(337)
(340)
(340)
(340)
(341)
(342)
(343)
(344)
(347)
(347)
(347)
(348)
(349)
(350)
(351)
(354)
(354)
(354)
(355)
(356)
(357)
(361)
(361)
(361)
(361)
(362)
(363)
(364)
(003)
(003)
(003)
(003)
(004)
(005)
(006)
(007)
(010)
(010)
(010)
(011)
(012)
(013)
(014)
(018)
(018)
(018)
(018)
(019)
(020)
(021)
(024)
(024)
(024)
(025)
(026)
95 Days
12/09
12/10
12/13
12/13
12/13
12/14
12/15
12/16
12/17
12/20
12/20
12/20
12/21
12/22
12/23
12/27
12/27
12/27
12/27
12/28
12/29
12/30
01/03
01/03
01/03
01/03
01/04
01/05
01/06
01/07
01/10
01/10
01/10
01/11
01/12
01/13
01/14
01/18
01/18
01/18
01/18
01/19
01/20
01/21
01/24
01/24
01/24
01/25
01/26
01/27
01/28
01/31
01/31
01/31
02/01
02/02
02/03
02/04
02/07
02/07
02/07
02/08
02/09
02/10
02/11
02/14
02/14
02/14
02/15
02/16
02/17
02/18
02/22
02/22
(343)
(344)
(347)
(347)
(347)
(348)
(349)
(350)
(351)
(354)
(354)
(354)
(355)
(356)
(357)
(361)
(361)
(361)
(361)
(362)
(363)
(364)
(003)
(003)
(003)
(003)
(004)
(005)
(006)
(007)
(010)
(010)
(010)
(011)
(012)
(013)
(014)
(018)
(018)
(018)
(018)
(019)
(020)
(021)
(024)
(024)
(024)
(025)
(026)
(027)
(028)
(031)
(031)
(031)
(032)
(033)
(034)
(035)
(038)
(038)
(038)
(039)
(040)
(041)
(042)
(045)
(045)
(045)
(046)
(047)
(048)
(049)
(053)
(053)
120 Days
10/24
10/25
10/26
10/27
10/28
10/29
10/30
10/31
11/01
11/02
11/03
11/04
11/05
11/06
11/07
11/08
11/09
11/10
11/11
11/12
11/13
11/14
11/15
11/16
11/17
11/18
11/19
11/20
11/21
11/22
11/23
11/24
11/25
11/26
11/27
11/28
11/29
11/30
12/01
12/02
12/03
12/04
12/05
12/06
12/07
12/08
12/09
12/10
12/11
12/12
12/13
12/14
12/15
12/16
12/17
12/18
12/19
12/20
12/21
12/22
12/23
12/24
12/25
12/26
12/27
12/28
12/29
12/30
12/31
01/01
(297)
(298)
(299)
(300)
(301)
(302)
(303)
(304)
(305)
(306)
(307)
(308)
(309)
(310)
(311)
(312)
(313)
(314)
(315)
(316)
(317)
(318)
(319)
(320)
(321)
(322)
(323)
(324)
(325)
(326)
(327)
(328)
(329)
(330)
(331)
(332)
(333)
(334)
(335)
(336)
(337)
(338)
(339)
(340)
(341)
(342)
(343)
(344)
(345)
(346)
(347)
(348)
(349)
(350)
(351)
(352)
(353)
(354)
(355)
(356)
(357)
(358)
(359)
(360)
(361)
(362)
(363)
(364)
(365)
(001)
Date of Service
or Disposition
(027)
(028)
(031)
(031)
(031)
(032)
(033)
(034)
(035)
(038)
(038)
(038)
(039)
(040)
(041)
(042)
(045)
(045)
(045)
(046)
(047)
(048)
(049)
(053)
(053)
(053)
(053)
(054)
(055)
(056)
(059)
(059)
(059)
(060)
(061)
(062)
(063)
(066)
(066)
(066)
(067)
(068)
(069)
(070)
(073)
(073)
(073)
(074)
(075)
(076)
(077)
(080)
(080)
(080)
(081)
(082)
(083)
(084)
(087)
(087)
(087)
(088)
(089)
(090)
(091)
(094)
(094)
(094)
(095)
(096)
95 Days
01/27
01/28
01/31
01/31
01/31
02/01
02/02
02/03
02/04
02/07
02/07
02/07
02/08
02/09
02/10
02/11
02/14
02/14
02/14
02/15
02/16
02/17
02/18
02/22
02/22
02/22
02/22
02/23
02/24
02/25
02/28
02/28
02/28
03/01
03/02
03/03
03/04
03/07
03/07
03/07
03/08
03/09
03/10
03/11
03/14
03/14
03/14
03/15
03/16
03/17
03/18
03/21
03/21
03/21
03/22
03/23
03/24
03/25
03/28
03/28
03/28
03/29
03/30
03/31
04/01
04/04
04/04
04/04
04/05
04/06
(053)
(053)
(054)
(055)
(056)
(059)
(059)
(059)
(060)
(061)
(062)
(063)
(066)
(066)
(066)
(067)
(068)
(069)
(070)
(073)
(073)
(073)
(074)
(075)
(076)
(077)
(080)
(080)
(080)
(081)
(082)
(083)
(084)
(087)
(087)
(087)
(088)
(089)
(090)
(091)
(094)
(094)
(094)
(095)
(096)
(097)
(098)
(101)
(101)
(101)
(102)
(103)
(104)
(105)
(108)
(108)
(108)
(109)
(110)
(111)
(112)
(115)
(115)
(115)
(116)
(117)
(118)
(119)
(122)
(122)
120 Days
02/22
02/22
02/23
02/24
02/25
02/28
02/28
02/28
03/01
03/02
03/03
03/04
03/07
03/07
03/07
03/08
03/09
03/10
03/11
03/14
03/14
03/14
03/15
03/16
03/17
03/18
03/21
03/21
03/21
03/22
03/23
03/24
03/25
03/28
03/28
03/28
03/29
03/30
03/31
04/01
04/04
04/04
04/04
04/05
04/06
04/07
04/08
04/11
04/11
04/11
04/12
04/13
04/14
04/15
04/18
04/18
04/18
04/19
04/20
04/21
04/22
04/25
04/25
04/25
04/26
04/27
04/28
04/29
05/02
05/02
Forms
May/June 2010
147
Texas M edicaid & H ealthcare Partnership
12357 ‑ B Riata Trace Parkway, Ste 150
Austin, TX 78727
A STATE MEDICAID CONTR ACTOR
PLACE POSTAGE
HERE
ATTENTION: BUSINESS OFFICE
May/June 2010No. 229
Texas Medicaid
Bimonthly update to the Texas Medicaid Provider Procedures Manual
Look inside for these and other
important updates:
Page 5
Provider License Renewal Reminder
Page 21
Increased Reimbursement for Vagal Nerve
Stimulator Devices
Page 53
Postexposure Prophylaxis for Rabies
Page 118 PCCM THSteps Wants to Partner With Providers