T exas Medicaid Bulletin

Transcription

1 T exas Medicaid Bulletin Bimonthly update to the Texas Medicaid Provider Procedures Manual SEPTEMBER/OCTOBER 2011 NO. 237 Weight Watchers Available at No Cost for Participants of the Texas Medicaid Wellness Program Weight Watchers is now available at no cost to eligible Medicaid fee-for-service and Primary Care Case Management (PCCM) clients who are participating in the Texas Medicaid Wellness Program. The Wellness Program is a care management program that is provided by the Texas Health and Human Services Commission (HHSC) and McKesson Health Solutions Care Management for certain fee-for-service and PCCM clients. The Wellness Program engages Medicaid clients who are at risk of developing or have developed chronic disease and who are also identified as being at risk for future complications. Care manager nurses from the Wellness Program develop personalized care plans to teach participants about better ways to manage their conditions. Community-based care team members also provide personal coaching sessions. Weight Watchers is available through the Wellness Program for Medicaid clients who are 18 years of age and older, and who have a body mass index (BMI) of 25 or greater and who have an interest in losing weight. If the client meets the criteria for the Weight Watchers benefit but is not currently participating in the Wellness Program, providers may refer Medicaid fee-for-service and PCCM clients to the Wellness Program. Clients will be contacted by a community-based nurse and a dietician to determine whether they meet program qualifications and whether the program is a good fit for them. As part of the Weight Watchers benefit, qualifying clients will receive ongoing weight loss support and 10 Weight Watchers vouchers. The vouchers can be redeemed at participating Weight Watchers locations. For more information, providers can Dr. Esteban Lopez, program director and medical director, Texas Medicaid Wellness Program, at esteban.lopez@mckesson.com. WEIGHT WATCHERS is the registered trademark of Weight Watchers International, Inc. Contact Information For additional information about Texas Medicaid, call the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center at For additional information about articles pertaining to the CSHCN Services Program, call the TMHP-CSHCN Contact Center at 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 2010 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 Regula tion System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to gov ernment 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 2009 American Dental Association. All Rights Reserved. Applicable FARS/DFARS restrictions apply.

2 CONTENTS All Providers 1 Weight Watchers Available at No Cost for Participants of the Texas Medicaid Wellness Program...1 THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families...4 PCCM Service Area Changing in September Provider Relations Territory Telephone Numbers and Voic Boxes Being Phased Out July 2011 Second Quarter NCCI Updates Microsoft Internet Explorer 9 Incompatible with TexMedConnect... 9 New Version of TexMedConnect Available...10 Refill and Maintenance of Implantable Pump to Be a Benefit When Performed by an Advanced Practice Registered Nurse...16 Physician Assistants and Advanced Practice Registered Nurses Must Attest Taxonomy Codes Valid NDC Codes Added Retroactively...19 Claims for Early Childhood Intervention Services to Be Submitted to TMHP Effective October 1, Services Rendered by Out-of-State Medicaid Providers Plan of Care for Private Duty Nursing Services Must Comply with Licensure Requirements NCCI Guidelines Will Not Be Applied to Prior Authorized Therapy Procedure Codes Effective August 26, Second Quarter 2011 HCPCS Updates Scheduled System Maintenance...27 Benefit Criteria for Vitamin and Mineral Products to Change for Texas Medicaid Zero-Paid Claims Resubmissions and Appeals Must Meet Filing Deadlines Durable Medical Equipment and Qualified Rehabilitation Professional Provider Enrollment Forms Now Available July 2011 Benefit Changes for Comprehensive Care Program and Home Health Mobility Aids Services July 2011 Benefit Changes for Limited Physician Services Rendered by Doctors of Dentistry Reimbursement Rates Established for Some Otology and Audiometry Services Procedure Codes Reimbursement Rates for Some Substance Use Disorder Services Have Changed...47 Reimbursement Rates Established for Some Surgery and DME Services Procedure Codes Reimbursement Rates Established for Tubeless External Insulin Infusion Pump Reimbursement Rates for Some Mobility Aids Services Have Changed Reimbursement Rate Changes for Some Procedure Codes Taxonomy Code X Now Available for DME/DMEH Providers...51 Benefit Updates for Some Texas Medicaid Radiology Diagnostic Imaging Procedure Codes...51 Diagnosis Restrictions for Renal Dialysis Services Have Changed P-Alpha Hydroxyprogesterone Caproate Benefits Have Changed for Texas Medicaid Clients Who Are Eligible for Both Texas Medicaid and the CSHCN Services Program Online Fee Lookup Returns Provider-Specific Rates for Procedure Codes with Modifiers and Age-Range Criteria Reimbursement Rates for Incontinence Supplies Procedure Code A4335 Have Changed Procedure Code Updates for Some Services...57 Texas Medicaid Claims Reprocessing Appealed Claims for Laboratory Services to be Reprocessed Some Critical Care Procedure Codes May be Reimbursed Within Six Weeks of an Anesthesia Service Texas Medicaid Bulletin, No September/October 2011

3 CONTENTS Services That Are Diagnosis- and Age-Restricted Claims Reprocessing Extremity Study Services will be Reprocessed Claims with Modifier 25 to Be Reprocessed Advanced Practice Registered Nurse and Physician Assistant Providers May Sign on Behalf of the Physician for Some Comprehensive Care Program Services Updates to Previously Published Information Correction to Benefit Criteria for Diabetic Equipment and Supplies Home Health Services Changing July 1, Reprocessing Claims Incorrectly Denied as Paid to Another Provider Correction Correction to Reimbursement Rate for Procedure Code A Correction to Benefit Change for Surgery Procedure Codes 11981, 11982, and Pending June 2011 Benefit Criteria Changes for Substance Use Disorder Services (Abuse and Dependence) Update...91 Retroactive Authorizations for Radiology Procedure Codes 74176, 74177, and Claims Reprocessing Correction to Tubeless Insulin Pump Added as a CCP Benefit Effective July 1, Update to New Surgical Services Benefits Effective July 1, Corrections to the 2011 Texas Medicaid Provider Procedures Manual Audiology Claims Filing for Managed Care Clients Correction Provider Enrollment Section Correction Provider Re-enrollment Section Correction Ambulance Services Handbook Correction Certified Registered Nurse Anesthetist Modifier Combinations Correction Update to the STAR Program Client Eligibility Chart Update to the STAR+PLUS Program Service Area Chart Family Planning Providers 99 Reimbursement Rate Changes for Some Titles V and XX Family Planning Services Correction to Title V, X, and XX Family Planning Billing Instructions in the 2011 Texas Medicaid Provider Procedures Manual Managed Care Providers 100 Translation Services Available for PCCM Clients and Providers THSteps Dental Providers 101 Changes Coming for Medicaid and CHIP Dental Services Beginning March 1, Dental Sealant Is a Benefit Once Every Three Years When Performed by the Same Provider Claims for Dental Services to Be Reprocessed THSteps Medical Providers 102 Reimbursement Rate for Developmental Testing to Change for THSteps Medical Providers Excluded Providers 103 Forms 106 External Insulin Pump Prior Authorization Form Electronic Funds Transfer (EFT) Notification Provider Information Change Form Wheeled Mobility Systems Group Enrollment Application September/October Texas Medicaid Bulletin, No. 237

4 ALL PROVIDERS THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families The Texas Medicaid & Healthcare Partnership (TMHP) works closely with HHSC to educate migrant farm workers and their children about services covered by Medicaid and the importance of receiving timely Texas Health Steps (THSteps) medical and dental checkups. The children of migrant farm workers are identified as needing additional assistance because of unconventional living conditions, migratory work patterns, unhealthy working conditions, poverty, poor nutrition, lack of education, and illiteracy all factors that contribute to poor health. TMHP is continuing its efforts to increase the number of children who receive their THSteps medical and dental checkups on time. Children of migrant farm workers who are three years of age or older are considered due for a THSteps medical checkup on their birthday and are encouraged to have a yearly checkup as soon as they become due. A THSteps checkup should occur on or as soon after a child s birthday as is practical, but will not be considered late unless the child does not have the checkup before their next birthday. Providers can perform one THSteps checkup per year for a child who is three years of age or older and can submit a claim and still receive reimbursement, even for a checkup performed prior to the birth date/due date. Providers can refer their PCCM clients and migrant families to PCCM Community Health Services coordinators for assistance by faxing the PCCM Community Health Services Referral Request Form, to (512) or by calling The form is also available on the TMHP website at and in the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, Managed Care, subsection 8.7, Forms, on page PCCM Community Health Services coordinators identify and provide outreach to the children of the migrant farm worker population in Texas. Migrant families are educated on the availability of accelerated services for their children s THSteps medical and dental checkups. Coordinators also educate migrant families on all available PCCM benefits and services as well as confirming that families have an established primary care provider. In addition, TMHP continues to partner and build relationships with state and community agencies, independent school districts, migrant licensed-housing facilities, regional education service centers, and local business to identify and reach out to PCCM clients who are birth through 20 years of age in migrant farm families. For more information about community health services, providers can refer to 2011 the Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection , Client Support and Education, on page For more information about billing an exception-to-periodicity dental checkup, providers can refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, section 4, Texas Health Steps (THSteps) Dental, subsection , Periodicity for THSteps Dental Services, on page CH-149. For more information about THSteps medical checkups, providers can refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, section 5, THSteps Medical on page CH-204. Texas Medicaid Bulletin, No September/October 2011

5 PCCM Service Area Changing in September 2011 STAR Expanding to 28 Counties; STAR+PLUS Expanding to 21 PCCM Counties PCCM Medicaid clients in 28 of the counties contiguous to existing State of Texas Access Reform (STAR) and STAR+PLUS service areas will no longer receive Medicaid-covered health care services from PCCM. Based on the type of Medicaid they receive, PCCM clients in these counties will move to either STAR or STAR+PLUS managed care. However, Supplemental Security Income (SSI) children remain voluntary enrollees in managed care, and SSI adults are voluntary STAR enrollees if STAR+PLUS is not available in their county. These changes to PCCM, STAR, and STAR+PLUS Medicaid Managed Care Program service areas become effective September 1, The Harris Service Area, which consists of Harris County, and the Harris Expansion Service Area, which consists of Brazoria, Fort Bend, Galveston, Montgomery, and Waller counties will be combined into a single service area. A new service area called Jefferson will also be created. The Jefferson Service Area is part of the expansion into the Harris contiguous counties. It has been separated from the Harris Service Area for administrative reasons and renamed Jefferson to avoid confusion with the current Harris Expansion Service Area. The Jefferson Service Area will consist of Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, and Walker counties. PCCM Medicaid Clients (non- SSI or SSI-related) Non-SSI or SSI-related PCCM Medicaid clients living in the Bexar, El Paso, Harris, Jefferson, Lubbock, Nueces, and Travis service areas will be transitioned into the STAR program (Medicaid Managed Care). SSI-Related PCCM Medicaid Clients SSI and SSI-related PCCM Medicaid clients who live in the Bexar, Harris, Jefferson, Nueces, and Travis service areas will be transitioned into the STAR+PLUS program. SSI and SSI-related PCCM Medicaid clients who live in the El Paso and Lubbock service areas are voluntary enrollees into the STAR program. STAR Program The principal objectives of the STAR Program are to emphasize early intervention and to promote improved access to quality care, thereby significantly improving health outcomes for the target populations, with a special focus on prenatal and well-child care. Medicaid providers who are in the STAR service areas and who would like to participate in the STAR Program must complete a separate contract and credentialing process with the health maintenance organizations (HMOs) of their choice. Providers and hospital representatives who are interested in contracting with a STAR HMO should contact the HMO. HMO contact information is included in the table on page 7. STAR+PLUS The STAR+PLUS program integrates acute care and long-term services and supports into a Medicaid managed care delivery system for the aged, blind, and disabled (ABD). Enrollment in STAR+PLUS is mandatory for SSI or SSI-related clients who are 21 years of age and older, but it is voluntary for SSI and SSI-related clients who are 20 years of age and younger. Medicaid providers who are in STAR+PLUS service areas and who would like to participate in the STAR+PLUS Program must complete a separate contract and credentialing process with the HMOs of their September/October Texas Medicaid Bulletin, No. 237

6 choice. Providers or hospital representatives who are interested in contracting with a STAR+PLUS HMO should contact the HMO. STAR and STAR+PLUS Expansion Chart Medicaid STAR and STAR+PLUS are coming to these counties: STAR only Carson Deaf Smith Hudspeth Hutchinson Potter Randall Swisher STAR and STAR+PLUS Austin Bandera Brooks Chambers Fayette Goliad Hardin Jasper Jefferson Karnes Kenedy Liberty Live Oak Matagorda Newton Orange Polk San Jacinto Tyler Walker Wharton PCCM counties effective September 1, 2011: PCCM Counties Anderson Andrews Angelina Archer Armstrong Bailey Baylor Bell Blanco Borden Bosque Bowie Brazos Brewster Briscoe Brown Burleson Callahan Cameron Camp Cass Castro Cherokee Childress Clay Cochran Coke Coleman Collingsworth Colorado Comanche Concho Cooke Coryell Cottle Crane Crockett Culberson Dallam Dawson Delta DeWitt Dickens Dimmit Donley Duval Eastland Ector Edwards Erath Falls Fannin Fisher Foard Franklin Freestone Frio Gaines Gillespie Glasscock Gonzales Gray Grayson Gregg Grimes Hall Hamilton Hansford Hardeman Harrison Hartley Haskell Hemphill Henderson Hidalgo Hill Hopkins Houston Howard Irion Jack Jackson Jeff Davis Jim Hogg Jones Kent Kerr Kimble King Kinney Knox La Salle Lamar Lampasas Lavaca Leon Limestone Lipscomb Llano Loving Madison Marion Martin Mason Maverick McCulloch McLennan McMullen Menard Midland Milam Mills Mitchell Montague Moore Morris Motley Nacogdoches Nolan Ochiltree Oldham Palo Pinto Panola Parmer Pecos Presidio Rains Reagan Real Red River Reeves Roberts Robertson Runnels Rusk Sabine San Augustine San Saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Taylor Terrell Throckmorton Titus Tom Green Trinity Upshur Upton Uvalde Val Verde Van Zandt Ward Washington Webb Wheeler Wichita Wilbarger Willacy Winkler Wood Yoakum Young Zapata Zavala Texas Medicaid Bulletin, No September/October 2011

7 STAR and STAR+PLUS HMO representative contact information is as follows: Representative Telephone number address Aetna Better Health Brooke Burnside Amerigroup Aron Head (DFW) Roland Valle (Travis/Bexar) (512) Jennifer Gonzalez (Nueces) Jo Lynn Turner (Harris/ Jefferson) Community First Health Plans Martin Jimenez Community Health Choice Mark Kline Beth Rossi Driscoll Children s Health Plan Melinda Lopez El Paso First or melinda.lopez@dchstx.org Frank Dominguez Ext fdominguez@epfirst.com Evercare Thomas Hicks (512) thomas_g_hicks@uhc.com FirstCare Marcella Webb mwebb@firstcare.com Molina Joe McGrath Ext joe.mcgrath@molinahealthcare.com RosCet Varner Ext roscet.varner@molinahealthcare.com Troy Eubank troy.eubank@molinahealthcare.com Superior Health Plan Network Development Ext SHP-NetworkDevelopment@centene.com Texas Children s Health Plan Debra Sparks dwsparks@tchp.us United Health Plans Lucie Lara lucie_lara@uhc.com For additional information, refer to the TMHP website at Click on Providers at the top of the page, then click on PCCM at the top of the next page and click we re going places! on the blue bar at the right side of the page. September/October Texas Medicaid Bulletin, No. 237

8 Provider Relations Territory Telephone Numbers and Voic Boxes Being Phased Out Individual telephone numbers that are directed to the voic boxes of Provider Relations territory representatives are being phased out, and providers are being directed to call the TMHP Contact Center at or the TMHP- Children with Special Health Care Needs (CSHCN) Services Program Contact Center at to speak to a representative who can answer questions. Calls to individual territory telephone numbers will be redirected to the TMHP Contact Center starting August 1, This change is being made to provide better customer service to providers by: Helping providers get their questions answered and concerns addressed more quickly. Eliminating the need for providers to leave a message. Creating documentation for all calls, questions, and concerns. Freeing up time for Provider Relations representatives to work directly with providers in the field. Providers will continue to have the ability to requests for the following: In-person visits In-service training Rescheduling or canceling a visit Training on submitting claims links to a Provider Relations mailbox have been added to the regional support pages for each Provider Relations representative. Effective June 27, 2011, the Contact Us option was updated to include a link for Provider Relations. The following is an example of the Category Provider Relations Selection that is available to providers: Note: If an request does not require direct involvement of a Provider Relations territory representative, the request will be redirected to the appropriate Contact Center to be handled. Texas Medicaid Bulletin, No September/October 2011

9 After August 1, 2011, providers may also leave messages for Provider Relations representatives about a visit, in-service, or training by calling the TMHP Contact Center or TMHP-CSHCN Services Program Contact Center. Resources that can help providers resolve Medicaid questions and concerns include the following: The TMHP website at gives access to the Texas Medicaid Provider Procedures Manual, past issues of the Texas Medicaid Bulletin, and website articles. The secure provider portal, which providers can access from the TMHP website at which has applications to help providers verify client eligibility, submit claims, check claim status, view Remittance and Status (R&S) Reports, view panel reports, and so on. Automated Inquiry System (AIS) to check client eligibility, claim status, and benefit limitations. Helpful TMHP Telephone Numbers TMHP Contact Center TMHP-CSHCN Services Program Contact Center Telephone Appeals THSteps Dental Inquiries THSteps Medical Inquiries TMHP EDI Help Desk , option 3 Automated Inquiry System , select option from menu July 2011 Second Quarter NCCI Updates Effective July 29, 2011, the second quarter 2011 National Correct Coding Initiative (NCCI) updates apply for dates of service on or after July 1, 2011, for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program. Providers may refer to the Centers for Medicare & Medicaid Services (CMS) website at for the updated Medicaid NCCI rules, relationships, and general information. Claims with dates of service between July 1, 2011, and July 29, 2011, that are affected by the NCCI second-quarter changes will be reprocessed, and payments may be decreased for NCCI code pairs or medically unlikely edits (MUEs) that are added. Payments may be increased for NCCI code pairs or MUEs that are deleted. Providers are encouraged to monitor the CMS website for updates to the Medicaid NCCI rules and guidelines. A link to the CMS Medicaid NCCI website is also available through the TMHP website on the Code Updates NCCI Compliance web page at Microsoft Internet Explorer 9 Incompatible with TexMedConnect TMHP has identified an issue that may affect users who submit claims through TexMedConnect. Microsoft Internet Explorer 9 is not compatible with TexMedConnect. Until further notice, users should use Internet Explorer versions 6, 7, or 8 to submit TexMedConnect claims. September/October Texas Medicaid Bulletin, No. 237

10 New Version of TexMedConnect Available This is a correction to an article titled Electronic Data Interchange Version 5010 Implementation Reminder, which was published on the TMHP website at on January 28, The article stated incorrectly that the implementation of the Electronic Data Interchange (EDI) version 5010 would not directly affect users of TexMedConnect. The correct information is that effective June 27, 2011, Acute-Care TexMedConnect was updated to be compatible with the changes in EDI version The following changes apply to Acute-Care TexMedConnect: On the Other Insurance/Submit Claim tab the Group/Employer Name is no longer a required field. Texas Medicaid Bulletin, No September/October 2011

11 On the Diagnosis tab for all claim types except Inpatient, a total of 8 Diagnosis Code rows can be displayed. For Inpatient, a total of 10 rows can be displayed. On the Details tab a new column, OB.Ane. (Obstetric Anesthesia [Additional]) Units, has been added with room for 0 through 999 units. This is not a required field. On the Details tab, the value ME (milligram) has been added to the UOM drop-down box. September/October Texas Medicaid Bulletin, No. 237

12 On the Provider tab codes FA, L1, and TL have been deleted and 77 Facility is now the only option. On the Other Insurance/Submit Claim tab in the Source of Payment drop-down box, codes 09, 10, and L1, which were no longer valid, have been deleted. Texas Medicaid Bulletin, No September/October 2011

13 On the Provider tab, the fields EIN/SSN and ID Type have been deleted from the Facility and Attending, and ID Qualifier and Other ID have been deleted from Referring/Other Provider Header. With EDI version 5010, these fields are no longer acceptable at this level. On the Provider tab under the Billing Provider Heading, Employer ID and Social Security No. have been added to the ID Type drop-down. September/October Texas Medicaid Bulletin, No. 237

14 On the details tab, the code ZZ has been deleted from the Proc ID column drop-down list. Code ZZ does not apply to Acute Care. On the Outpatient claim type in the Claim tab, the fields Patient Status, Type, and Source have been added. The Type and Source fields capture information about how the patient was admitted. Texas Medicaid Bulletin, No September/October 2011

15 On the Ambulance claim type in the Claim tab, the Type of Transport field has been deleted and the Purpose of Round Trip is now a required field when the Round Trip checkbox is selected. On the Ambulance claim type in the Claim tab, the question Was the patient confined to a bed or a chair? has been added. On the Ambulance claim type in the Claim tab, the fields in Ambulance Pick Up Location, and Ambulance Drop Off Location are now required. September/October Texas Medicaid Bulletin, No. 237

16 On the Ambulance claim type in the Details tab, only codes 41, 42, and 99 are displayed in the POS drop-down list. All non-ambulance place of service codes have been removed. On the Inpatient claim type in the Diagnosis tab, the code 1-exempt from POA has been removed. Providers should direct all questions and support requests to the EDI Version 5010 Implementation address at Refill and Maintenance of Implantable Pump to Be a Benefit When Performed by an Advanced Practice Registered Nurse Effective June 1, 2011, procedure codes is a benefit when performed by an advanced practice registered nurse (APRN) in the outpatient hospital setting. Procedure code is a benefit when performed by an APRN in the office or outpatient hospital setting. Note: For the purposes of this article, the term APRN includes clinical nurse specialist (CNS), nurse practitioner (NP), and physician assistant (PA) providers. Texas Medicaid Bulletin, No September/October 2011

17 Physician Assistants and Advanced Practice Registered Nurses Must Attest Taxonomy Codes By October 30, 2011, PA, NP, and CNS providers must have the appropriate primary taxonomy code that reflects their provider type and specialty on file with TMHP. Physician Assistants Physician assistant providers who are enrolled in Texas Medicaid or the CSHCN Services Program without a physician assistant primary taxonomy code must complete a paper Provider Information Change (PIC) form and submit it to TMHP with a physician assistant primary taxonomy code listed on the form. (See Submitting a Provider Information Change Form below.) The following PA taxonomy codes are currently accepted by TMHP: Taxonomy Code 363A00000X 363AM0700X 363AS0400X Description Physician Assistant Physician Assistant- Medical Physician Assistant- Surgical Taxonomy codes for enrolled PAs who do not have a PA taxonomy code on record with TMHP by October 30, 2011, will be defaulted to 363A00000X (Physician Assistant). Nurse Practitioners and Clinical Nurse Specialists APRN providers who are enrolled in Texas Medicaid or the CSHCN Services Program without a corresponding NP or CNS primary taxonomy code must complete a paper PIC form and submit it to TMHP with an NP or CNS primary taxonomy code listed on the form. (See Submitting a Provider Information Change Form on the following page.) The following NP and CNS taxonomy codes are currently accepted by TMHP: Taxonomy Code X 363L00000X 363LA2100X 363LA2200X 363LC0200X 363LC1500X 363LF0000X 363LG0600X 363LN0000X 363LN0005X 363LP0200X 363LP0222X 363LP0808X 363LP1700X 363LP2300X 363LS0200X Description Single Specialty Group Nurse Practitioner Nurse Practitioner - Acute Care Nurse Practitioner - Adult Health Nurse Practitioner - Critical Care Medicine Nurse Practitioner - Community Health Nurse Practitioner - Family Nurse Practitioner - Gerontology Nurse Practitioner - Neonatal Nurse Practitioner - Neonatal, Critical Care Nurse Practitioner - Pediatrics Nurse Practitioner - Pediatrics, Critical Care Nurse Practitioner - Psychiatric/ Mental Health Nurse Practitioner - Perinatal Nurse Practitioner - Primary Care Nurse Practitioner - School September/October Texas Medicaid Bulletin, No. 237

18 Taxonomy Code 363LW0102X 363LX0001X 363LX0106X 364S00000X 364SA2100X 364SA2200X 364SC0200X 364SC1501X 364SC2300X 364SE0003X 364SE1400X 364SF0001X 364SG0600X 364SH0200X 364SH1100X 364SI0800X 364SL0600X 364SM0705X 364SN0000X 364SN0800X 364SP0200X 364SP0807X 364SP0808X 364SP0809X 364SP0810X Description Nurse Practitioner - Women s Health Nurse Practitioner - Obstetrics & Gynecology Nurse Practitioner - Occupational Health Clinical Nurse Specialist Clinical Nurse Specialist - Acute Care Clinical Nurse Specialist - Adult Health Clinical Nurse Specialist - Critical Care Medicine Clinical Nurse Specialist - Community Health/ Public Health Clinical Nurse Specialist - Chronic Care Clinical Nurse Specialist - Emergency Clinical Nurse Specialist - Ethics Clinical Nurse Specialist - Family Health Clinical Nurse Specialist - Gerontology Clinical Nurse Specialist - Home Health Clinical Nurse Specialist - Holistic Clinical Nurse Specialist - Informatics Clinical Nurse Specialist - Long-Term Care Clinical Nurse Specialist - Medical-Surgical Clinical Nurse Specialist - Neonatal Clinical Nurse Specialist - Neuroscience Clinical Nurse Specialist - Pediatrics Clinical Nurse Specialist - Psychiatric/Mental Health, Child & Adolescent Clinical Nurse Specialist - Psychiatric/Mental Health Clinical Nurse Specialist - Psychiatric/Mental Health, Adult Clinical Nurse Specialist - Psychiatric/Mental Health, Child & Family Taxonomy codes for enrolled NP or CNS providers who do not have an NP or CNS taxonomy code on record with TMHP by October 30, 2011, will be defaulted to 363L00000X (Nurse Practitioner). Submitting a Provider Information Change (PIC) Form A copy of the PIC form is available on page 109 of this bulletin, and providers can download the PIC form from the TMHP website at PIC forms need to include the updated taxonomy code, as well as the following information, or they will be returned to the provider: The nine-digit Texas Provider Identifier (TPI) and corresponding National Provider Identifier (NPI)/ Atypical Provider Identifier (API). Providers should mail or fax the completed PIC form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: (512) Texas Medicaid Bulletin, No September/October 2011

19 Providers can view the taxonomy codes currently on record for each of their provider identifiers by logging into the Provider Information Management System (PIMS). To log into PIMS, follow these steps: 1) Log into your secure provider account from any provider page on the TMHP website. 2) Select Provider Information Management System. The primary taxonomy code assigned to the provider identifier appears at the top of the page. Valid NDC Codes Added Retroactively Effective June 6, 2011, the following National Drug Codes (NDCs) have been added retroactively as valid to submit with Texas Medicaid claims for medical services procedure codes J2469, J9060, J9217, and J9265: Procedure Code NDCs J , , and J , , , and J J Affected claims that were submitted within the last 24 months will be reprocessed. When the claims are reprocessed, providers may receive additional payment, which will be reflected on R&S Reports. Note: The Noridian NDC/HCPCS crosswalk at provides a listing of NDCs that are assigned to Healthcare Common Procedure Coding System (HCPCS) procedure codes. The crosswalk is a valuable resource for providers, but it may not contain a complete listing of all NDCs for any given procedure code. Providers who believe that NDCs are missing for a specific HCPCS procedure code may send an to oversight@hhsc.state.tx.us to request that research be performed. The provider will need to provide the procedure code in question and the corresponding NDCs that the provider believes are missing from the Noridian crosswalk. All HCPCS procedure codes that are on the Noridian NDC/HCPCS crosswalk, with the exception of durable medical equipment (DME) procedure codes, require an NDC to be submitted with the HCPCS procedure code. Our State s most Vulnerable kids need you! Help the children in your community who need it most. Enroll in the Children with Special Health Care Needs (CSHCN) Services Program today. Go to to learn more about the program, then visit the TMHP website at to enroll. September/October Texas Medicaid Bulletin, No. 237

20 Claims for Early Childhood Intervention Services to Be Submitted to TMHP Effective October 1, 2011 Effective for dates of service on or after October 1, 2011, Early Childhood Intervention (ECI) providers who have an active contract with the Department of Assistive and Rehabilitative Services (DARS) will submit claims to TMHP for the services listed in this article. ECI services are provided to clients who are eligible for THSteps, are birth through 35 months of age, and have a developmental delay, atypical development, or a medically diagnosed condition as established by DARS at ECI services are family-centered and delivered in the client s natural environment, as defined in Title 40 Texas Administrative Code (TAC), Part 2, Chapter 108. Prior authorization is not required for the ECI services included in this article. A signed individualized family service plan (IFSP) serves as the prior authorization for ECI services. The IFSP is retained in the client s record and is subject to retrospective review. Physical Therapy, Occupational Therapy, and Speech Therapy ECI providers may submit claims for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services that are included in the client s IFSP. Claims must include the ECI provider identifier and EC1 benefit code. ECI providers will continue to submit claims for PT, OT, and ST evaluation and re-evaluation to the CCP and these claims must include the CCP provider identifier and CCP benefit code. For additional PT, OT, and ST services not addressed below, providers can refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, subsection 2.10, Therapy Services (CCP). Providers must follow all therapy guidelines and requirements for any additional PT, OT, and ST services addressed in section The CCP ECI Request for Initial/Renewal Outpatient Therapy form will no longer be used to request prior authorization for therapy services through CCP. The following PT, OT, and ST procedure codes may be reimbursed for therapy services: PT and OT Procedure Codes * 97033* 97034* 97035* 90736* 97110* 97112* 97113* 97116* 97124* 97140* 97150* 97530* 97535* 97542* 97750* 97760* 97761* 97762* ST Procedure Codes 92507* 92508* 92526* * Services submitted in 15-minute increments. All claims for reimbursement are based on the actual amount of billable time associated with the service. The unit of service is 15 minutes (1 unit = 15 minutes), and partial units should be rounded to the nearest quarter hour. Texas Medicaid Bulletin, No September/October 2011

21 The following table shows the time intervals for 1 through 8 units: Units Number of Minutes 0 units 0 minutes through 7 minutes 1 unit 8 minutes through 22 minutes 2 units 23 minutes through 37 minutes 3 units 38 minutes through 52 minutes 4 units 53 minutes through 67 minutes 5 units 68 minutes through 82 minutes 6 units 83 minutes through 97 minutes 7 units 98 minutes through 112 minutes 8 units 113 minutes through 127 minutes Claims for PT, OT, and ST services must include a procedural modifier. The following table shows the modifiers to use: Service PT OT ST Modifier GP GO GN PT, OT, and ST equipment and supplies used during therapy visits are included in the therapy visit and are not reimbursed separately. A client may receive co-therapy or a combination of PT, OT, or ST in the home or community setting when the IFSP indicates medical necessity and the parents or other routine caregivers have agreed to the co-therapy treatment. Physical Therapy Physical therapy includes services to address the promotion of sensory and motor function through enhancement of musculoskeletal status, neurobehavioral organization, perceptual and motor development, cardiopulmonary status, and effective environmental adaptation. The following applies to PT services: All services must be delivered according to 22 TAC, Part 16, Chapter 322, PT services must be identified on the IFSP and prescribed by a physician. Services may be performed in an individual or group setting. PT services are provided in an outpatient, home, or other natural environment setting. PT services are provided by an ECI provider. The ECI provider ensures that PT services are performed by one of the following: A licensed physical therapist who meets the requirements of 42 Code of Federal Regulations (CFR) (a). A licensed physical therapy assistant (LPTA) when the assistant is acting under the direction of a licensed physical therapist in accordance with 42 CFR and all other applicable state and federal laws. September/October Texas Medicaid Bulletin, No. 237

22 Occupational Therapy Occupational therapy includes services to address the functional needs of a client related to adaptive development; adaptive behavior and play; and sensory, motor, and postural development. These services are designed to improve the client s functional ability to perform tasks in the home and community settings. The following applies to OT services: All services must be delivered according to of the Texas Occupations Code. OT services must be identified on the IFSP and prescribed by a physician. Services may be performed in an individual or group setting. OT services are provided in an outpatient, home, or other natural environment setting. OT services are provided by an ECI provider. The ECI provider ensures that services are performed by one of the following: A licensed occupational therapist who meets the requirements of 42 CFR (b). A certified occupational therapist assistant (COTA) when the assistant is acting under the direction of a licensed occupational therapist in accordance with 42 CFR and all other applicable state and federal laws. Speech Therapy Speech and language therapy includes services designed to promote rehabilitation and remediation of delays or disabilities in language-related symbolic behaviors, communication, language, speech, emergent literacy, or feeding and swallowing behavior. The following applies to ST services: All services must be delivered according to (6) of the Texas Occupations Code. ST services must be identified on the IFSP. Services may be performed in an individual or group setting. ECI services are family-centered and delivered in the client s natural environment ST services are provided in an outpatient setting, home, or other natural environment setting. ST services are provided by an ECI provider. The ECI provider ensures that services are performed by one of the following: A licensed speech-language pathologist (SLP) who meets the requirements of 42 CFR (c) and all other applicable state and federal law. A licensed assistant in speech language pathology when the assistant is acting under the direction of a licensed SLP in accordance with 42 CFR A licensed intern when the intern is acting under the direction of a licensed SLP in accordance with 42 CFR and all other applicable state and federal law. Texas Medicaid Bulletin, No September/October 2011

23 Specialized Skills Training Providers may submit claims for specialized skills training (SST) services that are included in the client s IFSP. Claims must include the ECI provider identifier and EC1 benefit code. Providers must submit procedure code T1027 for SST services, which are billed in 15-minute increments. All claims for reimbursement are based on the actual amount of billable time associated with the service. The unit of service is 15 minutes (1 unit = 15 minutes), and partial units should be rounded to the nearest quarter hour. The following table shows the time intervals for 1 through 8 units: Units Number of Minutes 0 units 0 minutes through 7 minutes 1 unit 8 minutes through 22 minutes 2 units 23 minutes through 37 minutes 3 units 38 minutes through 52 minutes 4 units 53 minutes through 67 minutes 5 units 68 minutes through 82 minutes 6 units 83 minutes through 97 minutes 7 units 98 minutes through 112 minutes 8 units 113 minutes through 127 minutes Services may be performed in an individual or group setting. Providers must submit procedure code T1027 when services are performed in a group setting or T1027 with modifier U1 when performed in an individual setting. SST (developmental services) are rehabilitative services to promote age-appropriate development by providing skills training to correct deficits and teach compensatory skills for deficits that directly result from medical, developmental, or other health-related conditions. Services must include all of the following: Create learning environments and activities that promote the client s acquisition of skills in one or more of the following developmental areas: physical or motor, communication, adaptive, cognitive, and social or emotional. Include skills training and anticipatory guidance for family members, or other significant caregivers, to ensure effective treatment and to enhance the client s development. Be provided in the client s natural environment, as defined in 34 CFR Part 303, unless the criteria listed at 34 CFR are met and documented in the client s medical record. In addition to the above criteria, services that are performed in a group setting must include the following: Be recommended by the interdisciplinary team and documented on the IFSP. Be employed only when participation in the group will assist the client reach the outcomes in the IFSP. Be planned as part of an IFSP that also contains individual services. Be limited to no more than four clients and their parents or other significant caregivers. September/October Texas Medicaid Bulletin, No. 237

24 Documentation of each specialized skills-training visit must include all of the following: Name of the client Name of the ECI contractor and early intervention specialist Date, time, duration, and place of service Type of service (individual or group) Description of the contact, including a summary of activities and the family or primary caregiver s level of involvement IFSP goal that was the focus of the intervention Client s progress Relevant new information about the client that was provided by the family or other significant caregiver Signature of the early intervention specialist SST services are coordinated by an ECI provider. The ECI provider ensures that SST services are provided by an early intervention specialist who meets the criteria established in 40 TAC Part 2, Chapter 108. Targeted Case Management Providers may submit claims for targeted case management (TCM) services that are included in the client s IFSP. Claims must include the ECI provider identifier and EC1 benefit code. Providers must use procedure code T1017 for TCM services, which are billed in 15-minute increments. Procedure code G9012 will no longer be reimbursed for TCM services. All claims for reimbursement are based on the actual amount of billable time associated with the service. The unit of service is 15 minutes (1 unit = 15 minutes), and partial units should be rounded to the nearest quarter hour. The following table shows the time intervals for 1 through 8 units: Units Number of Minutes 0 units 0 minutes through 7 minutes 1 unit 8 minutes through 22 minutes 2 units 23 minutes through 37 minutes 3 units 38 minutes through 52 minutes 4 units 53 minutes through 67 minutes 5 units 68 minutes through 82 minutes 6 units 83 minutes through 97 minutes 7 units 98 minutes through 112 minutes 8 units 113 minutes through 127 minutes TCM services are provided to help eligible clients and their families to gain access to the rights and procedural safeguards under Part C of the Individuals with Disabilities Education Act (IDEA) and to needed medical, social, educational, developmental, and other appropriate services. TCM services may be delivered face-to-face or by telephone. Providers must use procedure code T1017 for telephone interaction and T1017 with modifier U1 for face-to-face interaction. Texas Medicaid Bulletin, No September/October 2011

25 Claims may be submitted to Texas Medicaid when the interaction is directly with the client or the client s parents, as defined in 20 United States Code (U.S.C.) 1401, or other routine caregivers. Providers may contact other individuals when the contact is directly related to identifying the eligible client s needs, helping the eligible client access services, identifying needs and supports to assist the eligible client in obtaining services, providing the service coordinator with useful feedback, and alerting the service coordinator to changes in the eligible client s needs. These contacts must be documented in the client s record, but claims may not be submitted to Texas Medicaid for reimbursement. TCM services include: Coordinating the performance of evaluations and assessments. Facilitating and participating in the development, review, and evaluation of the IFSP, which is based on the client s applicable history, the parent s or other routine caregiver s input, and the results of all evaluations and assessments. Helping families or other routine caregivers to identify available service providers and making appropriate referrals to obtain services from medical, social, and educational providers to address identified needs and achieve goals in the IFSP. Following up with families or other routine caregivers to assist with timely access to services, to discuss the disposition of the referral with the family, and to determine whether the services have met the client s needs. Monitoring and reassessing the delivery of, and effectiveness of services through contacts with the client, family members, service providers, routine caregivers, or other relevant entities that are conducted as frequently as necessary and at least once every six months to determine whether services are being provided in accordance with the IFSP, whether services are adequate, and to adjust the IFSP and service arrangements to address identified new or changed needs of the client. Informing families of the availability of advocacy services. Coordinating with medical and other health providers. Facilitating the client s transition to preschool or other appropriate services. All documentation must be retained in the client s record and available upon request. The documentation must include all of the following: Plan of care that is specified in the IFSP and related to the ECI services provided Name of the client Name of the ECI contractor and assigned service coordinator The date, time, duration, and place of service Type of service (face-to-face or telephone) Description of the contact, including all referrals made and the disposition of the referral Any relevant information that is provided by the family or other individual or entity Signature of the service coordinator TCM services are provided by an ECI provider. The ECI provider ensures that TCM services are performed by a service coordinator who meets the criteria established in 40 TAC Part 2, Chapter 108. September/October Texas Medicaid Bulletin, No. 237

26 Services Rendered by Out-of-State Medicaid Providers Reminders Reminder: Texas Medicaid covers medical assistance services that are provided to eligible Texas Medicaid clients while they are in a state other than Texas; however, clients are not covered if they leave Texas to receive out-of-state medical care that can be received in Texas. Services that are provided outside of the state are covered by Texas Medicaid to the same extent that medical assistance is furnished and covered in Texas when the service meets one or more requirements of 1 TAC (TAC) Note: Border state providers (providers that render services within 50 miles of the Texas border) are considered in-state providers for Texas Medicaid. Services that are rendered outside of the state must be prior authorized by Texas Medicaid and TMHP must receive claims from out-of-state providers within 365 days of the date of service. Out-of-state providers that seek reimbursement for services that are rendered outside of the state must submit a Texas Medicaid Provider Enrollment application and be approved for enrollment in Texas Medicaid. Transplant services that are provided out-of-state but available in Texas will not be reimbursed by Texas Medicaid. When requesting an out-of-state prior authorization for a pre-transplant evaluation, the provider must submit a copy of the transplant evaluation performed by a Texas facility to support the need for an out-of-state pre-transplant evaluation. Medical assistance and transplant services that are provided to eligible Texas Medicaid clients must meet the criteria included in the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection 1.5, Enrollment Criteria for Out-of-State Providers. If services that are rendered to eligible Texas Medicaid clients do not meet the criteria, the services are not a benefit of Texas Medicaid and will not be considered for reimbursement. Plan of Care for Private Duty Nursing Services Must Comply with Licensure Requirements Reminder: Providers who render private duty nursing (PDN) services must maintain a plan of care (POC) with dates of service up to six months depending on the authorization request and agency licensure requirements. The POC dates may not exceed the authorization period requested (up to a maximum of six months) and must comply with applicable Home and Community Support Services Agencies (HCSSA) licensure requirements. Providers are responsible for ensuring that the physician reviews and signs the POC within 30 calendar days of the start date of the revised authorization period or more often if required by the client s condition or agency licensure. The provider must maintain the physician-signed POC in the client s medical record. PDN providers should not submit a revised POC unless they are requesting a revision. Providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, subsection 2.9, Private Duty Nursing (CCP), for more information. Texas Medicaid Bulletin, No September/October 2011

27 NCCI Guidelines Will Not Be Applied to Prior Authorized Therapy Procedure Codes Effective August 26, 2011 Reminder: All professional and outpatient hospital services are subject to National Correct Coding Initiative (NCCI) guidelines unless otherwise indicated in previous articles. Beginning August 26, 2011, NCCI guidelines will not be applied to therapy procedure codes if a valid prior authorization number is submitted on the claim. For dates of service on or before August 25, 2011, therapy procedure codes are subject to the NCCI guidelines even if the therapy services have been prior authorized. Therapy services that do not comply with NCCI guidelines may be considered for reimbursement when medical necessity documentation or a prior authorization letter is submitted with the new claim or appeal. Second Quarter 2011 HCPCS Updates The second quarter 2011 HCPCS additions, changes, and deletions, were implemented on July 1, 2011, and are now available. Second Quarter 2011 HCPCS Procedure Code Additions The following procedure codes were added as noncovered procedure codes for Texas Medicaid and the CSHCN Services Program: Procedure Code C9283 C9284 C9285 C9365 C9406 C9730 C9731 K0741 K0742 K0743 K0744 K0745 K0746 Q2041 Q2042 Q2043 Q2044 Discontinued Procedure Codes Noncovered procedure codes C9273, C9729, S3628, and S9075 have been discontinued by the Centers for Medicare & Medicaid Services (CMS) and have no replacements. Discontinued procedure codes will not be reimbursed after June 30, Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled as follows: Sunday September 11, 2011, 4:00 p.m. until midnight Sunday October 9, 2011, 4:00 p.m. until midnight During scheduled system maintenance, some applications related to the claims engine will be unavailable. Details about the affected applications are available on the TMHP website at September/October Texas Medicaid Bulletin, No. 237

28 Benefit Criteria for Vitamin and Mineral Products to Change for Texas Medicaid Effective for dates of services on or after August 1, 2011, benefit criteria for vitamin and mineral products will change for Texas Medicaid. Benefits Vitamin and mineral products prescribed or ordered by a physician to treat various conditions will be a benefit of Texas Medicaid through the CCP for clients who are 20 years of age and younger. The following vitamin and mineral products, which will be manually priced, will be a benefit when they are prior authorized and submitted with the corresponding procedure code and state-identified modifier: Vitamin or Mineral Procedure Code State Identified Modifier Beta-carotene A9152 U1 Vitamin A (retinol) A9152 Biotin A9152 U2 Boric acid A9152 U3 Copper A9152 Iodine A9152 Phosphorus A9152 Zinc A9152 Calcium A9152 U4 Chloride A9152 U5 Iron A9152 U6 Magnesium A9152 U7 Vitamin B1 (thiamin) A9152 U8 Vitamin B2 (riboflavin) A9152 Vitamin B3 (niacin) A9152 Vitamin B5 (pantothenic acid) A9152 Vitamin B6 (pyridoxine, pyridoxal 5-phosphate) A9152 Vitamin B9 (folic acid) A9152 Vitamin B12 (cyanocobalamin) A9152 Vitamin C (ascorbic acid) A9152 U9 Vitamin D (ergocalciferol) A9152 UA Vitamin E (tocopherols) A9152 UB Vitamin K (phytonadione) A9152 UC Multiminerals A9153 U1 Multivitamins A9153 U2 Trace elements A9153 U3 Miscellaneous A9152 or A9153 UD Note: Claims for multivitamins with any combination of additives must be submitted with modifier U2. Texas Medicaid Bulletin, No September/October 2011

29 Vitamin and mineral products may be indicated for, but are not limited to, treatment of the following conditions: Vitamin or Mineral Beta-carotene Biotin Boric acid Calcium Chloride Copper Iodine Iron Magnesium Phosphorus Vitamin A (retinol) Vitamin B1 (thiamin) Vitamin B2 (riboflavin) Condition Vitamin A deficiency Cystic fibrosis Disorders of porphyrin metabolism Intestinal malabsorption Biotin deficiency Biotinidase deficiency Carnitine deficiency Recalcitrant vulva vaginitis Calcium deficiency Disorders of calcium metabolism Chronic renal disease Pituitary dwarfism, isolated growth hormone deficiency Hypocalcemia and hypomagnesaemia of the newborn Intestinal disaccharidase deficiencies and disaccharide malabsorption Allergic gastroenteritis and colitis Hypocalcemia due to use of Depo-Provera contraceptive injection Hypochloremia Hypercapnia with mixed acid-base disorder Bronchopulmonary dysplasia Disorders of copper metabolism Iodine deficiency Simple and unspecified goiter and nontoxic nodular goiter Disorders of iron metabolism Iron deficiency anemia Sideroachrestic anemia Magnesium deficiency Hypoparathyroidism Disorders of phosphorus metabolism Vitamin A deficiency Intestinal malabsorption Disorders of the biliary tract Cystic fibrosis Vitamin B1 deficiency Disturbances of branched-chain amino-acid metabolism (e.g., maple syrup urine disease) Disorders of mitochondrial metabolism Wernicke-Korsakoff syndrome Vitamin B2 deficiency Disorders of fatty acid oxidation Riboflavin deficiency, ariboflavinosis Disorders of mitochondrial metabolism September/October Texas Medicaid Bulletin, No. 237

30 Vitamin or Mineral Vitamin B3 (niacin) Vitamin B5 (pantothenic acid) Vitamin B6 (pyridoxine, pyridoxal 5-phosphate) Vitamin B9 (folic acid) Vitamin B12 (cyanocobalamin) Vitamin C (ascorbic acid) Vitamin D (ergocalciferol) Vitamin E (tocopherols) Condition Vitamin B3 deficiency Disorders of lipid metabolism, (e.g., pure hypercholesterolemia) Vitamin B5 deficiency Vitamin B6 deficiency Sideroblastic anemia Vitamin B9 deficiency Folate-deficiency anemia Combined B12 and folate-deficiency anemia Disorders of mitochondrial metabolism Sickle-cell disease Pernicious anemia Vitamin B12 deficiency Disturbances of sulphur-bearing amino-acid metabolism (e.g., homocystinuria and disturbances of metabolism of methionine) Pernicious anemia Combined B12 and folate-deficiency anemia Vitamin C deficiency Anemia due to disorders of glutathione metabolism Disorders of mitochondrial metabolism Vitamin D deficiency Galactosemia Glycogenosis Disorders of magnesium metabolism Intestinal malabsorption Chronic renal disease Cystic fibrosis Disorders of phosphorus metabolism Hypocalcemia Disorders of the biliary tract Hypoparathyroidism Intestinal disaccharidase deficiencies and disaccharide malabsorption Allergic gastroenteritis and colitis Vitamin E deficiency Inflammatory bowel disease (e.g., Crohn s, granulomatous enteritis, and ulcerative colitis) Disorders of mitochondrial metabolism Chronic liver disease Intestinal malabsorption Disorders of the biliary tract Cystic fibrosis Texas Medicaid Bulletin, No September/October 2011

31 Vitamin or Mineral Vitamin K (phytonadione) Zinc Multi-minerals Multi-vitamins Trace elements Condition Vitamin K deficiency Congenital deficiency of other clotting factors Hypoprothrombinemia of the newborn Hemorrhagic disease of the newborn Intestinal malabsorption Acquired coagulation factor deficiency Cystic fibrosis Disorders of the biliary tract Chronic liver disease Zinc deficiency Wilson s disease Acrodermatitis enteropathica Other and unspecified protein-calorie malnutrition Cystic fibrosis Other and unspecified protein-calorie malnutrition Mineral deficiency Prior Authorization Prior authorization for vitamin and mineral products must be requested using the CCP Prior Authorization Request Form. Requests for prior authorizations must be submitted and approved before the date of dispensing the vitamin or mineral products. Prior authorization requests for vitamin and mineral products that are initiated before the date of the physician s order will not be approved. The following documentation must be submitted with the prior authorization request: A physician s prescription with the name of the vitamin or mineral product, dosage, frequency, duration, and route of administration The manufacturer s suggested retail price (MSRP) or average wholesale price (AWP), whichever is applicable, or the provider s documented invoice price The calculated price per dose Documentation that supports the medical necessity of the requested vitamin or mineral The following sample tables, taken from the CCP Prior Authorization Request Form, are examples of the information that is required to submit a request for vitamin and mineral products: Example 1: Vitamin D HCPCS Code Brief Description of Requested Services Retail Price A9152 UA Vitamin D (ergocalciferol) 10 ml bottle (8000 units/ml) $40.00/bottle Dose: 400 units (0.05 ml) $0.20/dose Route: PO Frequency: QD Note: HCPCS codes and descriptions must be provided. September/October Texas Medicaid Bulletin, No. 237

32 Example 2: Multivitamin Tablets HCPCS Code Brief Description of Requested Services Retail Price A9153 U2 Centrum Kids (80 tablets/bottle) $8.99/bottle Dose: 1 tablet $0.11/dose Route: PO Frequency: QD Note: HCPCS codes and descriptions must be provided. Example 3: Poly-Vi-Sol Drops with Iron HCPCS Code Brief Description of Requested Services Retail Price A9153 U1 Poly-Vi-Sol with Iron (50 ml bottle) $10.05/bottle Dose: 1 ml $0.20/dose Route: PO Frequency: QD Note: HCPCS codes and descriptions must be provided. Example 4: Fer-In-Sol Iron Supplement HCPCS Code Brief Description of Requested Services Retail Price A9153 U1 Fer-In-Sol (50 ml bottle) 30 mg BID $10.75/bottle Dose: 2 ml (15 mg/ml) $0.43/dose Route: PO Frequency: BID Note: HCPCS codes and descriptions must be provided. Prior authorization requests for products, conditions, or quantities other than those described in the Benefits section of this article will be considered on a case-by-case basis after review by the medical director. Providers must submit documentation that the prescribed products are for a medically accepted indication. Documentation must include one of the following: Food and Drug Administration (FDA) approval The use is supported by one or more citations that are included or approved for inclusion in the following compendia: The American Hospital Formulary Service Drug Information The United States Pharmacopoeia-Drug Information (or its successor publications) The DRUGDEX Information System Two articles from major medical peer-reviewed literature that demonstrate validated, uncontested data for the use of the agent in a specific medical condition that is safe and effective Prior authorization of vitamin and mineral products may be granted for up to six months, and for a quantity up to a 30-day supply. Requests for additional vitamin and mineral products must be submitted before the current authorized period expires, but no more than 30 days before the expiration. Note: Prior authorization requests that were approved before August 1, 2011, will remain valid until the authorized period expires; services must be billed as authorized. Texas Medicaid Bulletin, No September/October 2011

33 Claims Filing and Reimbursement Claims for vitamin and mineral products must be submitted with procedure code A9152 or A9153, the appropriate modifier, and the corresponding NDC. Units must be based on the quantity dispensed, for up to a 30-day supply. For purposes of billing, one unit is equal to one dose. The total billable units are equal to the total doses requested on the prior authorization. Providers may be reimbursed for vitamin and mineral products at the lesser of: The provider s billed charges. The published fee determined by HHSC. Manual price as determined by HHSC, which is based on one of the following: MSRP less 18 percent or AWP less 10.5 percent with the calculated price per dose, whichever is applicable. The provider s documented invoice cost. Providers must dispense the most cost-effective product prescribed in accordance with a prescription from a licensed physician. Organic products will not be reimbursed unless medical documentation is provided to substantiate the need for that formulation. Zero-Paid Claims Resubmissions and Appeals Must Meet Filing Deadlines Claims listed on the R&S Report with $0 allowed and $0 paid may be resubmitted as electronic appeals. Previously, these claims were only accepted as paper claims and were not accepted as electronic appeals. Appeals may be submitted through a third party biller or through TexMedConnect. Zero-paid claims that are still within the 95-day filing deadline should be submitted as new day claims, which are processed faster than appeals. Claims can be resubmitted electronically past the 95-day deadline as new day claims if the following fields have not changed: Provider identifiers Client Medicaid number Dates of service Total billed amount Claims that are past the 95-day filing deadline and require changes to the fields listed above must be appealed on paper, with a copy of the R&S report. Important: Initial zero paid claims and appeal submissions must meet the 95-day deadline and 120-day appeal deadline outlined in the Texas Medicaid Provider Procedures Manual, Vol.1, General Information, subsection 6.1.3, Claims Filing Deadlines and related bulletin articles. September/October Texas Medicaid Bulletin, No. 237

34 Durable Medical Equipment and Qualified Rehabilitation Professional Provider Enrollment Forms Now Available Providers of services for the Texas Medicaid custom wheeled mobility systems benefit may now begin the group enrollment process. Currently enrolled DME providers that want to continue to supply custom wheeled mobility systems to Texas Medicaid and PCCM clients must re-enroll in Texas Medicaid as specialized/custom wheeled mobility system group providers and have at least one qualified rehabilitation professional (QRP) as a performing provider. Certified QRP providers must enroll in Texas Medicaid as performing providers under specialized/custom wheeled mobility system groups. From May 11, 2011, through August 15, 2011, currently enrolled DME providers may complete the one-page Wheeled Mobility Systems Group Enrollment Application to re-enroll as specialized/custom wheeled mobility system group providers and to enroll one or more QRP providers under their groups. Wheeled Mobility Systems Group Enrollment Process Providers that are currently enrolled with Texas Medicaid as a DME (Home Health) provider or as a DME medical supplier (CCP) provider may complete the following shortened enrollment process to enroll as a specialized/custom wheeled mobility system group. A separate application must be completed for each type of enrollment (Home Health or CCP). 1) Complete the Wheeled Mobility Systems Group Enrollment Application. 2) Submit the form and the required attachments to the address noted on the form. 3) For the QRP performing provider enrollment, the group provider or the QRP must complete the following forms with the QRP s information: a) HHSC Medicaid Provider Agreement (must include the QRP s original signature) (pages 6.1 through 6.5 of the Texas Medicaid Provider Enrollment Application) b) Provider Information Form 1 (PIF-1) In order to complete the enrollment, the group provider must have at least one QRP provider enrolled as a performing provider. The application will be returned as incomplete if information for a QRP performing provider is not included with the enrollment application. The Wheeled Mobility Systems Group Enrollment Application is available on page 111 of this bulletin. The Provider Information Change Form is available on page 109. Additional Information For more information, providers may refer to the following articles that were published on the TMHP website at Coming Soon: Provider Enrollment for DME and QRP Providers to Prepare for Wheeled Mobility Systems Benefit Changes (article published on February 25, 2011) Update to DME Provider Taxonomy Code Changes (article published on February 25, 2011) DME Provider Taxonomy Code Changes (article published on February 11, 2011) Texas Medicaid Bulletin, No September/October 2011

35 July 2011 Benefit Changes for Comprehensive Care Program and Home Health Mobility Aids Services Important: The benefit changes that are indicated in this article apply to wheeled mobility systems that will be delivered on or after September 1, Current guidelines will continue to apply for wheeled mobility systems that are delivered between July 1, 2011, and August 31, Wheeled Mobility Systems Benefit Overview Senate Bill (S.B.) 1804, 81st Legislature, Regular Session, 2009, and TAC require the participation of a QRP during a seating assessment for a wheeled mobility system that is delivered on or after September 1, The statute also requires the QRP to conduct the fitting of the system at the time of delivery. To comply with the statute, the following applies for wheeled mobility systems that are delivered to clients on or after September 1, 2011: The device must be provided by a specialized/custom wheeled mobility group provider who employs or contracts with a QRP. The specialized/custom wheeled mobility provider must complete the group enrollment process and receive a provider number for the group. A QRP provider must complete the performing provider enrollment process and receive a performing provider number under the specialized/custom wheeled mobility group prior to participating in the seating assessment for the wheeled mobility system. The QRP performing provider who participates in the seating assessment of the wheeled mobility system must perform the fitting of the system. The specialized/custom wheeled mobility group provider must obtain authorization/prior authorization for the QRP s participation in the seating assessment, the wheeled mobility system, and the fitting of the system. Definition of Wheeled Mobility Systems The following definitions will apply to wheeled mobility systems that are delivered on or after September 1, 2011, as Title XIX home health services. Wheeled mobility systems are scooters or customized power or manual wheelchairs that contain a customized feature or component of a mobility device, including, but not limited to, the following: Seated positioning components Powered or manual seating options Specialty driving controls for powered chairs Adjustable frame Other complex or specialized components September/October Texas Medicaid Bulletin, No. 237

36 The following table includes types of wheeled mobility systems and the corresponding references in the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook: Type of Wheeled Mobility System Tilt-in-space (manual) wheelchairs Pediatric Size (manual) wheelchairs and strollers Custom Ultra Lightweight (manual) wheelchairs DME Handbook Reference Subsection , Manual Wheelchairs Standard, Standard Hemi, Standard Reclining, Tilt-in-Space Subsection , Manual Wheelchairs Pediatric Size Subsection Manual Wheelchairs Custom (Includes Custom Ultra-Lightweight) All Power Wheelchairs (PWC) Subsection , PWC- Group 1 through Group 5 All Scooters Subsection , Scooters Note: PWC are now referred to as wheeled mobility systems or powered mobility devices (PMD). Providers can refer to the DME Handbook for definitions and prior authorization requirements for each of the wheeled mobility systems identified in the above table. The following table includes types of manual wheelchairs that do not meet the definition of a wheeled mobility system: Type of Mobility Aid Manual wheelchairs standard, standard hemi, standard reclining Manual wheelchairs lightweight and high-strength lightweight Manual wheelchairs heavy-duty and extra-heavy-duty DME Handbook Reference Subsection , Manual Wheelchairs Standard, Standard Hemi, Standard Reclining, Tilt-in-Space Subsection , Manual Wheelchairs Lightweight and High- Strength Lightweight Subsection , Manual Wheelchairs Heavy-Duty and Extra-Heavy-Duty Wheeled mobility systems delivered on or after September 1, 2011, as CCP services for clients who are 20 years of age and younger include strollers. Strollers are defined as multipositional client transfer systems with integrated seats and operated by the client s caregiver. Refer to: The 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, subsection , Strollers, for more information including prior authorization information. Provider Type Definitions and Responsibilities The following definitions apply to providers who perform assessments or fittings for wheeled mobility systems that are delivered to home health or CCP clients on or after September 1, 2011: Term Occupational therapist (OT) Physical therapist (PT) Qualified rehabilitation professional (QRP) Definition/Description A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice occupational therapy A person who is currently licensed by the Executive Council of Physical Therapy & Occupational Therapy Examiners to practice physical therapy A QRP is a person who meets one or more of the following criteria: Holds a certification as an Assistive Technology Professional (ATP) or a Rehabilitation Engineering Technologist (RET) issued by, and in good standing with, the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) Texas Medicaid Bulletin, No September/October 2011

37 Term QRP Definition/Description continued Holds a certification as a Seating and Mobility Specialist (SMS) issued by, and in good standing with, RESNA Holds a certification as a Certified Rehabilitation Technology Supplier (CRTS) issued by, and in good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS) For wheeled mobility systems delivered on or after September 1, 2011, a QRP must be present and involved in a seating system assessment. The assessment, for the rental or purchase of a wheeled mobility system, is performed by the practitioner (physician, PT, or OT) and the QRP must be present at the time. The QRP must also be present at the time of delivery of the wheeled mobility system to direct the fitting of the system and ensure the following: The system has been properly fitted to the client. The system will meet the client s functional needs for seating, positioning, and mobility. The client or caregiver has received training and instruction regarding the wheeled mobility system s proper use and maintenance. Important: If an OT or PT is also credentialed as a QRP, the therapist may not perform both roles during the seating assessment. A therapist may either perform the seating assessment as a therapist with the assistance of another QRP, or may assist another therapist as a QRP. If the therapist performs the role of the QRP, the therapist must meet the credentialing requirements and must be enrolled in Texas Medicaid as a QRP. QRP Affiliation The PT or OT and the QRP must adhere to the following affiliation requirements with the DME provider: For clients who are 21 years of age and older, the PT or OT may be employed by the specialized/custom wheeled mobility group provider that supplies the wheeled mobility system. For clients who are 20 years of age and younger, the PT or OT who performs the seating assessment must not be associated with the specialized/custom wheeled mobility group provider who supplies the wheeled mobility system. For clients of any age, the QRP must be directly employed by or contracted with the specialized/custom wheeled mobility group provider that supplies the wheeled mobility system. Authorization Requirements Effective July 1, 2011, authorization for the QRP s participation in the seating assessment must be obtained after the seating assessment is completed and before the claim is submitted. Prior authorization for the wheeled mobility system, accessories, and fitting must be obtained before the services are rendered. The following equipment and related services must be submitted on the same prior authorization request form by the specialized/custom wheeled mobility group provider: The QRP s participation in the seating assessment performed on or after July 1, The wheeled mobility system and accessories to be delivered on or after September 1, The fitting to be performed by the QRP who participated in the seating assessment. September/October Texas Medicaid Bulletin, No. 237

38 Important: Authorization for the equipment and related services must be requested at the same time and on the same authorization form. Authorization is not required for the seating assessment of the wheeled mobility system performed by the PT, OT, or physician. Seating Assessment Authorization for the QRP Effective for dates of service on or after July 1, 2011, the QRP s participation in the seating assessment may be authorized to the specialized/custom wheeled mobility group provider using procedure code with modifier U1. Authorization is required for the specialized/custom wheeled mobility group provider to be considered for reimbursement of the QRP s participation in the seating assessment. Up to four units (one hour) may be authorized unless medical necessity for additional time is provided. The authorization number must be on the claim at the time of submission. Note: Within the first six months after delivery, all modifications and adjustments to a wheeled mobility system, as well as the associated services by the QRP for the seating assessment and fitting, are considered part of the purchase price and will not be reimbursed separately. Rental or Purchase Wheeled mobility systems may be prior authorized for short-term rental or for purchase. Prior authorization requests must be submitted with documentation that supports medical necessity and an assessment of the accessibility of the client s residence to ensure the device is usable in the home (i.e., doors and halls wide enough, no obstructions). The wheelchair must be able to accommodate a 20 percent change in the client s height and weight. When medically necessary, prior authorization may also be considered for the rental or purchase of an alternative wheelchair on a case-by-case basis, as follows: A manual wheelchair will be considered for a client who owns or is requesting a power wheeled mobility system with no custom features. A manual wheelchair or a manual wheeled mobility system will be considered for a client who owns or is requesting a power wheeled mobility system with custom features. Prior Authorization for Fitting Time Prior authorization for the fitting of any manual or power wheeled mobility system at the time of delivery may be issued to the QRP in 15-minute increments, for a time period of up to 2 hours (8 units). Up to one additional hour (four units) may be prior authorized with documentation of medical necessity that the fitting of three or more major systems is required or that additional client training is required for the system being fitted. Major systems include, but are not limited to, the following: Complete complex seating system (planar system with trunk supports and hip supports or abductor or custom contoured seating system such as a molded system) (Off-the-shelf seat and back cushions do not constitute a complex seating system.) Alternative drive controls (such as a head array, mini-proportional system, etc.) Additional specialty control features (such as infrared access) Power positioning features (such as power tilt, power recline) Specific purpose specialty features (such as power seat elevation systems, power elevating leg rests) Texas Medicaid Bulletin, No September/October 2011

39 Documentation Requirements The wheeled mobility group provider must submit the following forms and documentation as appropriate to request authorization for the participation of the QRP in the seating assessment and prior authorization for the wheeled mobility system, accessories, and the associated fitting: Form Documentation Signatures CCP Prior Authorization Request Form Request authorization for the QRP assessment and prior authorization for the wheeled mobility system, accessories, and fitting. Documentation required. Refer to: Children s Services Handbook subsection , Strollers. Signed and dated by the prescribing physician familiar with the client Home Health Services (Title XIX) DME/ Medical Supplies Physician Order Form (Title XIX form) Note: This form cannot be accepted beyond 90 days from the date of the prescribing physician s signature. Request authorization for the QRP assessment and prior authorization for the wheeled mobility system, accessories, and fitting. Documentation required. Refer to: Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection , Prior Authorization. Signed and dated by the prescribing physician and the representative of the DME/medical supply provider familiar with the client Wheelchair/ Scooter/Stroller Seating Assessment form Note: This form cannot be accepted beyond 90 days from the date of the prescribing physician s signature. Documentation supporting medical necessity of all accessories. Refer to: Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection , Documentation Requirements, for home health benefit information and Children s Services Handbook, subsection , Strollers, for CCP benefit information. Signed and dated by the practitioner who completes the assessment (PT, OT, or physician) and the participating QRP Note: All signatures and dates must be current, unaltered, original, and handwritten. Computerized or stamped signatures and dates will not be accepted. Seating Assessment The information in this section updates the 2011 Texas Medicaid Provider Procedures Manual as follows: For home health services, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection , Seating Assessment for Manual and Power Custom Wheelchairs For CCP, Children s Services Handbook, subsection , Strollers A seating assessment is required for the following: A request for the rental or purchase of a device that meets the definition of a wheeled mobility system A request for the rental or purchase of a device that meets the definition of a wheelchair or a wheeled mobility system, and the client has a congenital or neurological condition, myopathy, or skeletal deformity and requires the use of a wheelchair or wheeled mobility system September/October Texas Medicaid Bulletin, No. 237

40 Unless the client has a congenital or neurological condition, myopathy, or skeletal deformity, a seating assessment is not required for wheelchairs that do not meet the definition of a wheeled mobility system. Seating Assessment Documentation Requirements A seating assessment must include seating measurements and be completed by a physician or a licensed OT or PT with the participation of a QRP. A QRP must be in the room with the OT, PT, or physician at the time of the assessment and participating in the assessment with the OT, PT, or physician. The seating assessment and measurements must include specifications for the exact mobility or seating equipment that is required and all of the necessary accessories. Upon completion of the seating assessment, the QRP must attest to his or her participation in the assessment by signing the Wheelchair/Scooter/Stroller Seating Assessment form, which has been revised to include the QRP information and signature. This form must be submitted with the prior authorization request for the wheeled mobility system. A new seating assessment must be completed by a qualified practitioner (OT, PT, or physician) with the participation of a QRP when a major modification to a wheeled mobility system is necessary. A major modification is the addition of, or modification to, a custom feature or component of a wheeled mobility system, including but not limited to, the following: Home Health Seated positioning components Powered or manual seating options Specialty driving controls Adjustable frame Other complex or specialized components CCP Seated positioning components Manual seating options Adjustable frame Other complex or specialized components Seating Assessment Reimbursement for the QRP Effective for dates of service on or after July 1, 2011, the QRP s participation in the seating assessment may be authorized to the specialized/custom wheeled mobility group provider using procedure code with modifier U1. Authorization is required for the specialized/custom wheeled mobility group provider to be considered for reimbursement of the QRP s participation in the seating assessment. Up to four units (one hour) may be authorized unless medical necessity for additional time is provided. The authorization number must be on the claim at the time of submission. Note: Within the first six months after delivery, all modifications and adjustments to a wheeled mobility system, as well as the associated services by the QRP for the seating assessment and fitting, are considered part of the purchase price and will not be reimbursed separately. Claims Filing for the QRP Seating Assessment Services The procedure code for the QRP s participation in the seating assessment must be billed on the CMS-1500 paper claim form or the electronic equivalent with the specialized/custom wheeled mobility group provider s provider number and billing information in Block 33, and the QRP s performing provider number in Block 24-J. Providers must use the information provided in their specialized/custom wheeled mobility group enrollment letter and the QRP performing provider enrollment letter to complete the claim forms. Texas Medicaid Bulletin, No September/October 2011

41 Providers may refer to the CMS-1500 Instruction Table in the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection 6.5.4, CMS-1500 Instruction Table, for additional information about filing claims as group providers with performing provider information. To meet the 95-day filing deadline, the claim for the QRP s participation in the seating assessment must be submitted with the authorization number when the authorization is obtained. The seating assessment should not be submitted on the same claim as the equipment and fitting. Claims submitted more than 95 days from the date of service will be denied. Note: Claims with dates of service between July 1, 2011, and August 31, 2011, for the QRP s participation in the seating assessment must not be submitted before September 1, The same authorization number will be used on the claim for the equipment and fitting after the equipment has been delivered and the fitting has been completed. Seating Assessment Reimbursement and Claims Filing for the Practitioner (OT, PT, or Physician) For the home health benefit, effective for dates of service between July 1, 2011, and August 31, 2011, providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection , Seating Assessment for Manual and Power Custom Wheelchairs, for the seating assessment reimbursement for the practitioner (OT, PT, or physician) seating assessment services. For the CCP benefit, effective for dates of service between July 1, 2011, and August 31, 2011, providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, subsection , Strollers, for the seating assessment reimbursement to the practitioner (OT, PT, or physician) seating assessment services. The current processes for billing of the OT or PT practitioner s participation in the seating assessment will not change for dates of service from July 1, 2011, through August 31, Providers will be notified in a future article of benefit changes that will be applied to the seating assessment services for the OT or PT practitioner for dates of service on or after September 1, If a physician completes the seating assessment, the seating assessment is considered part of the evaluation and management service and is not separately reimbursed. Additional Information Providers may refer to the following articles that are published on the TMHP website at for more information: DME Provider Taxonomy Code Changes published on February 11, 2011 Update to DME Provider Taxonomy Code Changes published on February 25, 2011 Coming Soon: Provider Enrollment for DME and QRP Providers to Prepare for Wheeled Mobility Systems Benefit Changes published on February 25, 2011 DME and QRP Provider Enrollment Forms Now Available published on May 12, 2011 September/October Texas Medicaid Bulletin, No. 237

42 July 2011 Benefit Changes for Limited Physician Services Rendered by Doctors of Dentistry Effective for dates of service on or after July 1, 2011, some provider type and place-of-service (POS) limitations have changed for dentist providers who render services as limited physicians. The changes in this article apply to dentist providers for the following services: Medical services Surgical services Anesthesia services Radiology services Medical Services The following changes apply to the medical services procedure codes indicated: Procedure Code Settings to Be Reimbursed Settings No Longer Reimbursed Office Inpatient hospital Inpatient hospital, outpatient hospital N/A J0475 Home, inpatient hospital, skilled nursing N/A facility (SNF), independent care facility (ICF), outpatient hospital, or extended care facility (ECF) J0744 N/A Home, inpatient hospital, or ECF J1094 Office, inpatient hospital, outpatient hospital, N/A ECF J1571 Office N/A J1631 N/A Inpatient hospital, outpatient hospital, or ECF J1700, J1710, J1720, J2690, J2920, J2930, J3010, and J3490 Office Inpatient hospital, outpatient hospital, ECF J2765 and J3480 Office Inpatient hospital, outpatient hospital, or ECF The following medical services procedure codes are no longer reimbursed for services that are rendered in the home, inpatient hospital, outpatient hospital, or ECF setting: Procedure Codes J0120 J0280 J0290 J0295 J0330 J0360 J0670 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0710 J0715 J0720 J0780 J0945 J1020 J1030 J1040 J1100 J1165 J1170 J1200 J1364 J1580 J1630 J1730 J1790 J1800 J1840 J1850 J1885 J1890 J1940 J1990 J2010 J2060 J2175 J2180 J2360 J2370 J2400 J2410 J2460 J2510 J2515 J2540 J2550 J2560 J2650 J2700 J2770 J2800 J2810 J3000 J3260 J3301 J3302 J3303 J3310 J3320 J3360 J3370 J3410 J3430 J3485 S0021 Texas Medicaid Bulletin, No September/October 2011

43 Surgical Services The following surgical services procedure codes may be reimbursed for services that are rendered in the office setting: Procedure Codes The following surgical services procedure codes may be reimbursed for services that are rendered in the office, inpatient hospital, or outpatient hospital services: Procedure Codes The following surgical services procedure codes are no longer reimbursed for services that are rendered in the office setting: Procedure Codes The following surgical services procedure codes may be reimbursed for services that are rendered in the inpatient hospital or outpatient hospital setting but are not reimbursed for services that are rendered in the office setting: Procedure Codes September/October Texas Medicaid Bulletin, No. 237

44 The following changes apply to the surgical services procedure codes indicated: Procedure Code Settings to Be Reimbursed Settings No Longer Reimbursed 10120, ECF N/A SNF, ICF, ECF N/A 10160, 11000, 20600, N/A Home 20605, and N/A SNF, ICF, or ECF 11305, 11306, 11307, and , 15782, and , 15793, 61501, 61559, 61575, 61576, 61580, and , 20551, and Office, inpatient hospital, SNF, ICF, outpatient hospital, ECF Office, inpatient hospital, outpatient hospital Office, outpatient hospital Office, inpatient hospital, outpatient hospital Home Home, SNF, ICF, or ECF N/A Home and N/A Home, SNF, ICF, independent laboratory, birthing center, ECF, or other location 21141, 21142, and Outpatient hospital Office Inpatient hospital, outpatient hospital N/A and Office, inpatient hospital, outpatient hospital 40899, 41599, 42299, and Office, inpatient hospital, outpatient hospital and Outpatient hospital N/A Anesthesia Services The following changes apply to the anesthesia services procedure codes indicated: Home, SNF, ICF, independent laboratory, birthing center, ECF, or other location Home, SNF, ICF, independent laboratory, birthing center, ECF, or other location Procedure Code Settings to be Reimbursed Settings No Longer Reimbursed and N/A Office Office N/A Radiology Services The following changes apply to the radiology services procedure codes indicated: Procedure Code Settings to Be Reimbursed Settings No Longer Reimbursed 70100, 70110, 70120, 70140, 70150, 70160, 70200, 70300, 70310, 70320, and N/A Total component: Inpatient hospital or outpatient hospital Technical component: Home, SNF, ICF, independent laboratory, or ECF Texas Medicaid Bulletin, No September/October 2011

45 Procedure Code Settings to Be Reimbursed Settings No Longer Reimbursed Technical component: Office and N/A Total component: Outpatient hospital Total component: Inpatient hospital, outpatient hospital Professional interpretation component: Home, SNF, ICF, ECF and N/A Technical component: Home, SNF, ICF, independent laboratory, ECF Total component: Inpatient hospital, outpatient hospital Total and technical components: Office Technical component: Home, SNF, ICF, ECF N/A N/A Total component: Inpatient hospital, outpatient hospital Professional interpretation component: Office, inpatient hospital, outpatient hospital Technical component: Office Professional interpretation component: SNF, ICF Total component: Inpatient hospital, outpatient hospital Technical component: Home, SNF, ICF, independent laboratory, ECF N/A Total component: Inpatient hospital, outpatient hospital and , 70482, 70486, 70487, 70488, 70490, 70491, and Professional interpretation component: Office, inpatient hospital, outpatient hospital Technical component: Office, inpatient hospital, outpatient hospital Total, professional interpretation, and technical components: Office Total component: Inpatient hospital, outpatient hospital Technical component: Home, SNF, ICF, ECF N/A September/October Texas Medicaid Bulletin, No. 237

46 Procedure Code Settings to Be Reimbursed Settings No Longer Reimbursed Total component: Office Total component: Inpatient hospital, outpatient hospital Professional interpretation component: Office, inpatient hospital, outpatient hospital Technical component: Office Professional interpretation component: Home, SNF, ICF, ECF Technical component: Home, SNF, ICF, independent laboratory, ECF Note: All computed tomography (CT) and magnetic resonance (MRI) procedures require prior authorization, which must be requested through MedSolutions. For more information about radiology prior authorization requests, providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection 5.4.3, Radiology Prior Authorizations Through MedSolutions, and the Radiology and Laboratory Handbook, subsection 3.2.5, Authorization Requirements for CT, CTA, MRI, fmri, MRA, PET, and Cardiac Nuclear Imaging Services. Reimbursement Rates Established for Some Otology and Audiometry Services Procedure Codes Reimbursement rates have been established for otology and audiometry services procedure codes that are benefits of Texas Medicaid effective for dates of service on or after July 1, Details of the new benefits were previously published in the article titled Benefits to Change for Texas Medicaid Otology and Audiology Services Effective July 1, 2011 which was published on the TMHP website at on May 13, The following table includes the reimbursement rates for procedure codes and 92583, which are a benefit of Texas Medicaid effective for dates of service on or after July 1, 2011: TOS Procedure Code Age Range Birth through 20 years of age years of age and older Birth through 20 years of age years of age and older Previous Reimbursement Rate $3.72 (0.13 RVUs, $ conversion factor Conversion Reimbursement RVU Factor Rate 0.16 $ $4.58 Not a benefit 0.16 $ $4.36 Not a benefit 0.99 $ $28.35 Not a benefit 0.99 $ $27.00 TOS = Type of service, TOS 1 = Medical Services, 5 = Laboratory Services, RVU = Relative value units Note: The age ranges that are indicated for the rates in the above table reflect the rate for a child (birth through 20 years of age), an adult (21 years of age or older), or a client of any age. The age ranges may not reflect a specific age limitation that has been established that may limit services to a specific client age. To obtain specific age limitations for individual procedure codes, providers can refer to the current Texas Medicaid Provider Procedures Manual, Texas Medicaid Bulletins, Current Procedural Terminology (CPT) coding manual, or Healthcare Common Procedure Coding System (HCPCS) coding manual. Texas Medicaid Bulletin, No September/October 2011

47 Reimbursement Rates for Some Substance Use Disorder Services Have Changed Effective for dates of service on or after June 1, 2011, the reimbursement rates for some substance use disorder (SUD) medical services procedure codes have changed for Texas Medicaid. The following table includes the procedure code reimbursement rate changes that are effective for dates of service on or after June 1, 2011: TOS Procedure Code Modifier 1 Modifier 2 Provider Type Age Range Previous Medicaid Fee Medicaid Fee 1 H0012 HF 8 All ages NAB $ H0032 HF 8 All ages $25.27 NAB 1 H2010 HG UA 8, 19, 20, 21, 22 All ages $11.00 $ H2010 HG U1 8, 19, 20, 21, 22 All ages $11.00 $ H2010 HF 8, 19, 20, 21, 22 All ages $13.00 $ H2017 HF 8 All ages $31.20 NAB 1 T1007 HF 8 All ages NAB $25.27 TOS = Type of service, TOS 1 = Medical Services, Provider Types: 8 = Chemical Dependency Treatment Facility, 19 = Physician (Doctor of Osteopathy [DO]), 20 = Physician (Doctor of Medicine [MD]), 21 = Physician Groups (DOs), 22 = Physician Groups (MDs), NAB = Not a benefit Modifiers: HG = Opioid addiction treatment program, HF = Substance abuse program in a facility, UA = Face-to-face administration, U1 = Take-home administration Note: For medication assisted therapy services, modifier HF is used for non-opioid treatment. Providers can refer to the article titled Pending June 2011 Benefit Criteria Changes for Substance Use Disorder Services (Abuse and Dependence), which was published on the TMHP website April 15, 2011, for benefit changes and claim submission information. Note: The age ranges that are indicated for the rates in the above table reflect the rate for a child (birth through 20 years of age), an adult (21 years of age or older), or a client of any age. The age ranges may not reflect a specific age limitation that has been established and that may limit services to a specific client age. To obtain specific age limitations for individual procedure codes, providers can refer to the current Texas Medicaid Provider Procedures Manual, CSHCN Services Program Provider Manual, Texas Medicaid Bulletins, CSHCN Services Program Provider Bulletins, Current Procedural Terminology (CPT) coding manual, or Healthcare Common Procedure Coding System (HCPCS) coding manual. Want to Know More? You may be eligible for continuing education credits by participating in THSteps Online Provider Education training opportunities. To find out more, visit the THSteps Online Provider Education website at September/October Texas Medicaid Bulletin, No. 237

48 Reimbursement Rates Established for Some Surgery and DME Services Procedure Codes Reimbursement rates have been established for some previously announced surgery and DME services procedure codes that are benefits of Texas Medicaid effective for dates of service on or after July 1, Details of these benefits were previously published in the article titled New Surgical Services Benefits Effective July 1, The following table includes the reimbursement rates for the procedure codes that are a benefit of Texas Medicaid effective for dates of service on or after July 1, 2011: TOS Procedure Code Age Range RVU Conversion Factor Medicaid Reimbursement Rate Birth through 20 years of age 3.07 $ $ years of age and older 3.07 $ $ Birth through 20 years of age $ $1, years of age and older $ $1, Birth through 20 years of age 9.45 $ $ years of age and older 9.45 $ $ Birth through 20 years of age $1, years of age and older $ Birth through 20 years of age $ years of age and older $ Birth through 20 years of age $ $2, years of age and older $ $2, Birth through 20 years of age $ $ years of age and older $ $ C9359 All ages $ L8630 All ages $ L8631 All ages $1, L8641 All ages $ L8642 All ages $ L8658 All ages $ L8659 All ages $1, S2118 All ages $1, S years of age and older $1, * TOS 2 = Surgery, 8 = Assistant Surgery, 9 = DME (Other Supplies) Note: Procedure codes L8630, L8631, L8641, L8642, L8658, and L8659 will only be a benefit for clients who are birth through 20 years of age. The age ranges that are indicated for the rates in the above table reflect the rate for a child (birth through 20 years of age), an adult (21 years of age or older), or a client of any age. The age ranges may not reflect a specific age limitation that has been established that may limit services to a specific client age. To obtain specific age limitations for individual procedure codes, providers can refer to the current Texas Medicaid Provider Procedures Manual, Texas Medicaid Bulletins, Current Procedural Terminology (CPT) coding manual, or Healthcare Common Procedure Coding System (HCPCS) coding manual. Texas Medicaid Bulletin, No September/October 2011

49 Reimbursement Rates Established for Tubeless External Insulin Infusion Pump Reimbursement rates have been established for the tubeless external insulin infusion pump benefit, which are effective for dates of service on or after July 1, Details of this benefit were previously published on the TMHP website at in the article titled Tubeless Insulin Pump Added as CCP Benefit Effective July 1, The following table includes the reimbursement rates for procedure codes A9274 and E0784-U1, which are effective for dates of service on or after July 1, 2011: TOS Procedure Code Modifier Age Range 9 A9274 Birth through 20 years of age Current Medicaid Reimbursement Rate Medicaid Reimbursement Rate Not a benefit $43.50 J E0784 U1 All ages Not a benefit $ L E0784 U1 All ages Not a benefit $66.33 TOS = Type of Service, TOS 9 = Durable Medical Equipment (DME) Supplies, J = DME New, L= DME Rental Note: The age ranges that are indicated for the rates in the above table reflect the rate for a child (birth through 20 years of age), an adult (21 years of age or older), or a client of any age. The age ranges may not reflect a specific age limitation that has been established that may limit services to a specific client age. To obtain specific age limitations for individual procedure codes, providers can refer to the current Texas Medicaid Provider Procedures Manual, Texas Medicaid Bulletins, Current Procedural Terminology (CPT) coding manual, or Healthcare Common Procedure Coding System (HCPCS) coding manual. Clients who use the tubeless external insulin infusion pump (procedure code A9274) will also require the use of the wireless insulin pump program device (procedure code E0784 with the U1 modifier). Clients who use other external insulin pumps (procedure code E0784 without modifier) will not require either procedure code A9274 or E0784-U1. Reimbursement Rates for Some Mobility Aids Services Have Changed Effective for dates of service on or after July 1, 2011, the reimbursement rates for some mobility aids services procedure codes have changed for Texas Medicaid. The following table includes the procedure codes with rate changes that are effective for dates of service on or after July 1, 2011: TOS Procedure Code Modifier 1 Age Range Medicaid Fee U1 All ages $ U1 All ages $ U1 All ages $ U2 All ages $8.25 TOS = Type of Service, TOS 1 = Medical Services Providers will be notified in a future article of the benefit and limitation restrictions for these services. September/October Texas Medicaid Bulletin, No. 237

50 Reimbursement Rate Changes for Some Procedure Codes Effective for dates of service on or after July 1, 2011, reimbursement rates for the following services have changed for Texas Medicaid. Allergy Testing Services Auditory System Surgery Services Blood Products Services Cardiovascular Services Chemotherapy Services Echocardiography and Electrocardiography Services Esophageal Motility, Function, and Reflux Testing Services Hemodialysis and End-Stage-Renal-Disease Services Intravenous and Infusion Treatment Services Male Genital System Surgery Services Medical and Surgical Supplies-Services (A codes) Medicine (Other)-Radiology Services, Technical Component, Professional Component, Surgery Services, and Tuberculosis Services Noninvasive Cranial Test and Vascular Studies Ophthalmological Services Other Medical Services (M Code) Outpatient Prospective Payment System (OPPS or C Codes) Special Procedures of the Ears, Nose, and Throat Speech and Hearing Tests and Devices The tables that show the rate increases are available on the TMHP website at Rate increases are presented in green, and rate decreases are presented in red. Note: The age ranges that are indicated for the rates in the tables reflect the rate for a child (birth through 20 years of age), an adult (21 years of age or older), or a client of any age. The age ranges may not reflect a specific age limitation that has been established that may limit services to a specific client age. To obtain specific age limitations for individual procedure codes, providers can refer to the current Texas Medicaid Provider Procedures Manual, CSHCN Services Program Provider Manual, Texas Medicaid Bulletins, CSHCN Services Program Provider Bulletins, Current Procedural Terminology (CPT) coding manual, or Healthcare Common Procedure Coding System (HCPCS) coding manual. Texas Medicaid Bulletin, No September/October 2011

51 Taxonomy Code X Now Available for DME/DMEH Providers Taxonomy code 335E00000X (Prosthetic/Orthotic Supplier) is available as of June 2, 2011, to DME and home health durable medical equipment (DMEH) providers that are currently enrolled or are enrolling into Texas Medicaid or the CSHCN Services Program. Benefit Updates for Some Texas Medicaid Radiology Diagnostic Imaging Procedure Codes This article updates information for radiology diagnostic imaging procedure codes 74775, 75956, 75957, 75958, and 75959, which became benefits of Texas Medicaid effective for dates of service on or after January 1, 2011, for clients who are 20 years of age and younger. These procedure codes were included in the article titled Reimbursement Rates Will Implement January 2011 for Some Procedure Codes That Are New Benefits of Texas Medicaid, which was published on November 30, 2010, on the TMHP website at The following information is included in this article: Details for procedure codes 74775, 75956, 75957, 75958, and including benefit and limitation information that was effective for dates of service on or after January 1, An additional limitation change that is effective for dates of service on or after August 1, 2011, for fluoroscopy procedure codes 75956, 75957, 75958, and Radiography Effective for dates of service on or after January 1, 2011, periogram procedure code is a benefit of Texas Medicaid and may be reimbursed for radiography services that are rendered to clients who are 20 years of age and younger. Prior authorization is not required. The following table shows the place of service and provider type limitations for procedure code 74775: Component Places of Service Provider Types Total Office NP, CNS, PA, and physician providers Outpatient hospital Hospital providers Professional Interpretation Office, inpatient hospital, or outpatient hospital NP, CNS, PA, and physician providers Technical Office NP, CNS, PA, physician, portable X-ray supplier, radiological laboratory, and physiological laboratory providers Fluoroscopy Effective for dates of service on or after January 1, 2011, fluoroscopy procedure codes 75956, 75957, 75958, and are benefits of Texas Medicaid for endovascular aortic repair services for clients who are 20 years of age and younger. September/October Texas Medicaid Bulletin, No. 237

52 Effective for dates of service on or after August 1, 2011, procedure codes 75956, 75957, 75958, and are a benefit for clients of all ages. The professional interpretation component for these procedure codes may be reimbursed to physician providers for services rendered in the inpatient hospital setting. Note: The technical component for these services is included in the diagnostic related group (DRG) payment to the facility, so the technical and total components are not reimbursed separately. Prior authorization is not required. In the following table, the procedure code in Column A must be submitted with the corresponding procedure code in Column B: Column A procedure code Column B must be submitted with procedure code Providers may submit a claim for one procedure per day. Claims must include an appropriate diagnosis code. If an additional procedure is medically necessary, providers may submit a claim for the additional procedure using modifier 76. National Correct Coding Initiative Guidelines The procedure codes included in this article are subject to National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) guidelines. Providers should refer to the CMS NCCI web page at for correct coding guidelines and specific applicable code combinations. Diagnosis Restrictions for Renal Dialysis Services Have Changed Effective for dates of services on or after August 1, 2011, diagnosis restrictions for the renal dialysis services included in the following table have changed for Texas Medicaid: Procedure Codes Revenue Codes The following table includes the valid diagnosis codes for renal dialysis services that are effective for dates of service on or after August 1, 2011: Diagnosis Codes Also effective August 1, 2011, diagnosis codes 40390, 40391, and 5830 are no longer valid for renal dialysis services. Texas Medicaid Bulletin, No September/October 2011

53 17P-Alpha Hydroxyprogesterone Caproate Benefits Have Changed for Texas Medicaid Effective for dates of service on or after June 1, 2011, 17P-alpha hydroxyprogesterone caproate benefits have changed for Texas Medicaid. The trademarked version of 17P-alpha hydroxyprogesterone caproate (Makena) is a benefit under certain circumstances. Claims require modifiers to distinguish between the compounded drug and the brand name drug. 17P-alpha hydroxyprogesterone caproate, whether compounded or the trademarked drug, is restricted to diagnosis code V2341, and is a benefit in the following places of service for clients who are 10 through 55 years of age: Place of Service Office Home Outpatient Hospital Provider Type Physician, NP, CNS, PA, or CNM Physician, NP, CNS, PA, or CNM Physician, NP, CNS, PA, CNM, or hospital Compounded 17P-alpha hydroxyprogesterone caproate For 17P-alpha hydroxyprogesterone caproate that has been compounded by a pharmacy provider, prior authorization is not required, and providers are not required to include documentation that supports medical necessity with the claim; however, they must keep the documentation in the client s medical record. Providers must submit claims for a compounded drug using procedure code J3490 with modifier TH. The reimbursement rate for procedure code J3490 with modifier TH will be the lesser of the billed charges or $25. Trademarked 17P-alpha hydroxyprogesterone caproate (Makena) Makena is a benefit when prior authorized. Prior authorization requests must be submitted to the Special Medical Prior Authorization Department using the Special Medical Prior Authorization (SMPA) Request Form. Documentation that supports medical necessity must be submitted with the prior authorization request. Makena is indicated when all of the following criteria are met: The client s treatment is initiated between 16 weeks, 0 days and 20 weeks, 6 days gestation. The client s treatment may continue, as medically indicated, through 36 weeks, 6 days gestation or delivery, whichever occurs first. The client has a singleton pregnancy. The client has had a prior, singleton spontaneous preterm delivery before 37 weeks gestation. The provider lacks access to the compounded product, for one of the following reasons: There is no pharmacy within 50 miles that compounds 17P-alpha hydroxyprogesterone caproate. There is no pharmacy delivery to the prescribing provider s office. Requests for initiation of the client s treatment after 20 weeks, 6 days gestation, but before 24 weeks gestation, must be approved by the Medical Director and must include documentation to support the medical necessity of starting treatment at that stage of gestation. Makena is administered intramuscularly at a dose of 250 mg (1ml) once a week (every 7 days). Prior authorization requests must indicate the total number of doses to be administered during the pregnancy. The maximum prior authorized amount for Makena is 21 doses. September/October Texas Medicaid Bulletin, No. 237

54 Prior authorization requests and claims for Makena must be submitted with procedure code J3490, modifier U1, and the NDC number. Claims submitted without the required information will be subject to retrospective review and recoupment. Procedure code J3490 with modifier U1 (trademarked drug Makena) will be manually priced at the AWP less 10.5 percent. Clients Who Are Eligible for Both Texas Medicaid and the CSHCN Services Program This is a reminder that the CSHCN Services Program is the payer of last resort when clients have other insurance including Texas Medicaid and private carriers. The CSHCN Services Program does not supplement a client s Texas Medicaid benefits; however, services that are not a benefit of Texas Medicaid, such as hospice and medical foods, may be covered by the CSHCN Services Program. New Claim Submissions New claims that are submitted for clients who are eligible for both Texas Medicaid and CSHCN Services Program benefits during the same eligibility period will be processed through the appropriate program and may result in a separate claim for each program. The Medicaid claim number and disposition will be listed under the Claims Paid or Denied section of the Medicaid/Managed Care R&S Report. If the claim includes services that are not benefits of Texas Medicaid but are benefits of the CSHCN Services Program, a claim will be created with a unique claim number that will be listed under the Claims Paid or Denied section of the CSHCN Services Program R&S Report. Note: If all of the services that are submitted on the claim are Texas Medicaid benefits, a CSHCN Services Program claim will not be created. Only a Texas Medicaid claim will be created, and the claim number will appear on the provider s Medicaid/Managed Care R&S Report. Reprocessing CSHCN Services Program Claims When Retroactive Texas Medicaid Eligibility is Granted Claims that have already been paid by the CSHCN Services Program for clients who received retroactive Texas Medicaid eligibility for dates of service covered on the paid claims will be reprocessed to pay under the appropriate program. The reprocessed CSHCN Services Program claim number will appear under the Adjustments Paid or Denied section of the CSHCN Services Program R&S Report. An accounts receivable will be created for services covered by Texas Medicaid that will be reflected on the Financial Transactions page under the Accounts Receivable section of the CSHCN Services Program R&S Report. The claim will be reprocessed to Texas Medicaid and given a new claim number. The new Texas Medicaid claim number and disposition will appear under the Claims Paid or Denied section of the Medicaid/Managed Care R&S Report. TMHP will contact providers when it reprocesses claims for services that require a Texas Medicaid prior authorization. Providers will be informed that a Texas Medicaid prior authorization must be submitted within a specified time frame for the claim to be considered for processing through Texas Medicaid. Texas Medicaid Bulletin, No September/October 2011

55 Online Fee Lookup Returns Provider-Specific Rates for Procedure Codes with Modifiers and Age-Range Criteria Effective June 25, 2011, providers with contracted rates can use the Online Fee Lookup (OFL) on the TMHP website at to view their provider-specific rates for procedure codes that have modifiers and age range criteria. Providers can view their provider-specific rates for procedure codes with modifiers and age range criteria by completing the following steps: 1) Go to the TMHP website at 2) Click the Providers link at the top of the web page. 3) Click Log in to My Account at the top of the web page. 4) Click Fee Schedules. 5) Click Fee Search. 6) Click Contracted Rate Search. 7) Select or Enter the following: NPA/API/Taxonomy/Address/ZIP+4/ Benefit Code Program Code Procedure Code Date of Service Modifier 1 (if applicable) Modifier 2 (if applicable) Modifier 3 (if applicable) Modifier 4 (if applicable) From Age, in years (if applicable) To Age, in years (if applicable) 8) Click Submit. The Contracted Rate Search results page will display the following: Rate Type Rate Start Date End Date (if end-dated) Modifiers (if applicable) Client From Age and To Age (if applicable) September/October Texas Medicaid Bulletin, No. 237

56 The Contracted Rate Search results page will feature a display of contracted rate search criteria and additional columns and rows to display search results. The following is an example of the modified Contracted Rate Search results page: Reimbursement Rates for Incontinence Supplies Procedure Code A4335 Have Changed Effective for dates of service on or after July 1, 2011, the reimbursement rates for incontinence supplies procedure code A4335 have changed for Texas Medicaid. Procedure code A4335 without a modifier remains manually priced. However, procedure code A4335 with modifier U9 has a reimbursement rate of $3.09 for incontinence wipes for Texas Medicaid clients of all ages. Procedure code A4335 is limited to two per month. For clients who are 3 years of age and younger and are also receiving diapers, briefs, or pull-ons that have been prior authorized through CCP, additional boxes of incontinence wipes may be considered beyond the limit of 2 per month if medically necessary. Prior authorization of the additional quantities is required. The following procedure codes are effective for dates of service on or after July 1, 2011: TOS Procedure Code Age Modifier Current Reimbursement Rate Reimbursement Rate 9 A4335 All ages Manually Priced Manually Priced 9 A4335 All ages U9 Not a Benefit $3.09 TOS = Type of Service, TOS 9 = DME purchased used Note: Reimbursement rates apply for CCP and Home Health Providers Texas Medicaid Bulletin, No September/October 2011

57 Procedure Code Updates for Some Services Effective for dates of service on or after July 1, 2011, some provider type and POS limitations have changed for the following Texas Medicaid services: Anesthesia services Medical services Radiology services Surgical Services: Digestive system Integumentary system Musculoskeletal system Nervous system Respiratory system Special otorhinolaryngologic services Anesthesia Services The following changes apply to anesthesia services: Procedure Code Changes to Anesthesia Services Procedure Codes and Services that are rendered in the office setting are no longer reimbursed. Medical Services The following changes apply to medical services: Procedure Codes Changes to Medical Services Procedures Services that are rendered in the inpatient hospital setting are no longer reimbursed , 99116, 99135, and J0120, J0280, J0290, J0295, J0694, J0696, J0697, J0698, J0710, J0715, and J1364 Services that are rendered in the office setting may be reimbursed to certified registered nurse anesthetist (CRNA) and physician providers. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, and hospitalbased rural health clinic (RHC) providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. September/October Texas Medicaid Bulletin, No. 237

58 Procedure Codes J0330, J0945, J1165, J1631, J1730, J1790, J1940, J2370, J2650, J2810, and J3310 Changes to Medical Services Procedures Services that are rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. J0360 Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. J0475 Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital, SNF, ICF, or ECF setting are no longer reimbursed. J0670, J0780, and J1094 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Texas Medicaid Bulletin, No September/October 2011

59 Procedure Codes J0670, J0780, and J1094 J0692 Changes to Medical Services Procedures continued Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the office setting may be reimbursed to podiatrists and nephrology (hemodialysis, renal dialysis) providers. Services rendered in the outpatient hospital setting may be reimbursed to nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers. Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, CNM, hospital, and hospital-based RHC providers. J0702, J0720, J1020, J1030, J1040, J1700, J1710, J1720, J2690, J2920, J2930, and J3010 Services that are rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, and hospital-based RHC providers. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. J0744 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the office setting may be reimbursed to podiatrist, nephrology (hemodialysis, renal dialysis), and renal dialysis facility providers. Services that are rendered in the home setting may be reimbursed to DME medical supplier providers. Services that are rendered in the outpatient hospital setting may be reimbursed to nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers. Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, and hospital-based RHC providers. September/October Texas Medicaid Bulletin, No. 237

60 Procedure Codes J0744 Changes to Medical Services Procedures continued Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, CNM, hospital, and hospital-based RHC providers. Services that are rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, and hospital-based RHC providers. J1100 and J2770 Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. J1170, J1885, and J2765 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, and hospitalbased RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. J1200 and J2400 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Texas Medicaid Bulletin, No September/October 2011

61 Procedure Codes J1561, J1568, J1569, and J1572 J1571 J1580, J2410, and J2550 Changes to Medical Services Procedures Services that are rendered in the home setting may be reimbursed to DME medical supplier providers. Services that are rendered in the home setting may be reimbursed to DME medical supplier providers. Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, and hospitalbased RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. J1630 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. J1800 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. September/October Texas Medicaid Bulletin, No. 237

62 Procedure Codes J1840, J1850, J1890, J1990, J2010, J2060, J2175, J2180, J2360, J2460, J2510, J2515, J2540, J2560, J2700, J2800, J3000, J3260, J3301, J3302, J3303, J3320, J3360, J3370, J3410, and J3430 J3480, and J3485 Changes to Medical Services Procedures Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, and hospitalbased RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center and hospital-based RHC providers. Services that are rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. J3490 Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the office setting are no longer reimbursed to NP, CNS, PA, CNM, DME medical supplier, federally qualified health center (FQHC), hospital, psychiatric hospital, family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, FQHC, hospital, psychiatric hospital, family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, FQHC, psychiatric hospital, family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Texas Medicaid Bulletin, No September/October 2011

63 Procedure Codes S0021 Changes to Medical Services Procedures Services that are rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, and hospitalbased RHC providers. Radiology Services Services that are rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital or ECF setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, DME medical supplier, radiation treatment center, and hospital-based RHC providers. The following changes apply to radiology services: Procedure Codes 70100, 70110, 70120, 70140, 70150, and Changes to Radiology Services Procedure Codes Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting may be reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to CNM providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed. September/October Texas Medicaid Bulletin, No. 237

64 Procedure Codes Changes to Radiology Services Procedure Codes Professional interpretation component: Services that are rendered in the office setting may be reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological and physiological laboratory, and hospital-based RHC providers. Professional interpretation component: Services that are rendered in the office setting may be reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to CNM providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Texas Medicaid Bulletin, No September/October 2011

65 Procedure Codes Changes to Radiology Services Procedure Codes continued Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to CNM providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to CNM providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed. September/October Texas Medicaid Bulletin, No. 237

66 Procedure Codes 70300, 70310, 70320, and Changes to Radiology Services Procedure Codes Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to CNM providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Texas Medicaid Bulletin, No September/October 2011

67 Procedure Codes Changes to Radiology Services Procedure Codes continued Technical component: Services that are rendered in the office setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed Total radiology component Services that are rendered in the office or outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to NP, CNS, and PA providers. Technical component: Services that are rendered in the office setting may be reimbursed to radiation treatment center providers. Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to radiologist, CNM, FQHC, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the SNF or ICF setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, radiologist, CNM, FQHC, portable X-ray supplier, and radiological and physiological laboratory providers. September/October Texas Medicaid Bulletin, No. 237

68 Procedure Codes Changes to Radiology Services Procedure Codes continued Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the office setting are no longer reimbursed to NP, CNS, PA, physician, hospital, nephrology (hemodialysis, renal dialysis), and hospital-based RHC providers. Services that are rendered in the outpatient hospital setting are no longer reimbursed to hospital, nephrology (hemodialysis, renal dialysis), portable X-ray supplier, radiology laboratory, physiological laboratory, and hospital-based RHC providers Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting may be reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the office setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Texas Medicaid Bulletin, No September/October 2011

69 Procedure Codes Changes to Radiology Services Procedure Codes Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM providers Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting may be reimbursed to CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. September/October Texas Medicaid Bulletin, No. 237

70 Procedure Codes Changes to Radiology Services Procedure Codes Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM providers Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Texas Medicaid Bulletin, No September/October 2011

71 Procedure Codes Changes to Radiology Services Procedure Codes continued Technical component: Services that are rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM providers Total radiology component: Services that are rendered in the office setting are no longer reimbursed to CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed. Services that are rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X-ray supplier, radiological laboratory, physiological laboratory, and hospitalbased RHC providers. Professional interpretation component: Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, portable X-ray supplier, and radiological and physiological laboratory providers. Technical component: Services rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Services that are rendered in the home, SNF, ICF, independent laboratory, or ECF setting are no longer reimbursed. Services that are rendered in the office setting are no longer reimbursed to CNM providers. Note: All computed tomography (CT) and magnetic resonance (MRI) procedures require prior authorization that must be requested through MedSolutions. For more information about radiology prior authorization requests, providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection 5.4.3, Radiology Prior Authorizations Through MedSolutions, and the Radiology and Laboratory Handbook, subsection 3.2.5, Authorization Requirements for CT, CTA, MRI, fmri, MRA, PET, and Cardiac Nuclear Imaging Services. September/October Texas Medicaid Bulletin, No. 237

72 Surgical Services Digestive System The following changes apply to digestive system procedure codes: Procedure Codes 40490, 40500, 40510, 40520, 40800, 40801, 40804, 40805, 40806, 40808, 40814, 40818, and Changes to Surgical Services Procedure Codes Digestive System Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers , 40650, 40652, and , 40701, 40702, 40720, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office setting are no longer reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers and Services that are rendered in the home, SNF, ICF, independent laboratory, birthing center, ECF, or other location setting are no longer reimbursed , 40812, 40813, 40831, 42665, 42808, and Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting are no longer reimbursed to NP, CNS, and PA providers , 40820, and Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Texas Medicaid Bulletin, No September/October 2011

73 Procedure Codes Changes to Surgical Services Procedure Codes Digestive System Services that are rendered in the office setting are no longer reimbursed to NP, CNS, and PA providers , 40844, and Services that are rendered in the office setting may be reimbursed to physician providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers , 41005, 41010, 41015, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41116, 41250, 41251, 41500, 41800, 41805, 41806, 41820, 41821, 41825, 41826, 41828, 41850, 42000, 42100, 42104, 42106, 42107, 42160, 42180, 42182, 42300, 42305, 42310, 42320, 42330, 42400, 42405, 42408, 42409, 42550, 42650, 42660, 42700, 42720, and , 41007, 41008, and Services that are rendered in the home, SNF, ICF, independent laboratory, birthing center, ECF, or other location setting are no longer reimbursed. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers and Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers and Services that are rendered in the office setting are no longer reimbursed to NP, CNS, or PA providers. September/October Texas Medicaid Bulletin, No. 237

74 Procedure Codes 41135, 41145, 41150, 41153, 41155, 42200, 42210, 42215, 42220, 42225, 42226, 42227, 42235, 42410, 42415, 42420, 42425, 42426, 42842, 42844, 42845, 42892, and Changes to Surgical Services Procedure Codes Digestive System Services that are rendered in the office setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the outpatient hospital may be reimbursed to physician providers , 41822, , 42280, 42281, 42335, 42340, 42440, and , 42299, and Services that are rendered in the inpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers , 42120, 42260, 42500, 42505, 42507, 42508, 42509, 42510, 42600, 42725, 42815, 42890, 42900, and Services that are rendered in the home, SNF, ICF, independent laboratory, birthing center, ECF, or other location setting are no longer reimbursed. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers and Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to oral maxillofacial surgeon providers. Note: This service may be reimbursed to oral maxillofacial surgeons who are enrolled with Texas Medicaid as a dentist provider. Texas Medicaid Bulletin, No September/October 2011

75 Procedure Codes Changes to Surgical Services Procedure Codes Digestive System Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office setting are no longer reimbursed to oral maxillofacial surgeon providers. Note: This service may be reimbursed to oral maxillofacial surgeons who are enrolled with Texas Medicaid as a dentist provider Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers , 42145, and Services that are rendered in the home setting are no longer reimbursed. Services that are rendered in the office setting may be reimbursed to physician providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the outpatient hospital may be reimbursed to physician providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Surgical Services Integumentary System The following changes apply to integumentary system procedure codes: Procedure Codes 10021, 15335, 15820, 15821, 17000, 17003, 17004, 17106, 17107, 17108, and , 13120, 13121, 13122, 13131, 13132, 13133, 13150, 13151, 13152, 13153, 13160, 14020, 14040, 14060, 15004, 15005, 15115, 15116, 15120, 15121, 15135, 15136, 15155, 15156, 15157, Changes to Surgical Services Procedure Codes Integumentary System Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. September/October Texas Medicaid Bulletin, No. 237

76 Procedure Codes continued 15175, 15176, 15240, 15241, 15260, 15261, 15320, 15321, 15336, 15365, 15366, 15420, 15421, 15620, 15760, 15770, 15819, 15822, 15823, 15852, 17111, and and Changes to Surgical Services Procedure Codes Integumentary System Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office, inpatient hospital, SNF, ICF, outpatient hospital, or ECF setting are no longer reimbursed to CNM providers Services that are rendered in the ECF setting may be reimbursed to NP, CNS, PA, physician, and podiatrist providers. Services that are rendered in the office, inpatient hospital, SNF, ICF, or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the SNF, ICF, or ECF setting are benefits and may be reimbursed to NP, CNS, PA, physician, and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers Services that are rendered in the ECF setting are benefits and may be reimbursed to NP, CNS, PA, physician, and podiatrist providers , 11305, 11306, 11307, and , 11001, 11043, 11100, 11200, 11201, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641, 11642, 11643, Services that are rendered in the office, inpatient hospital, SNF, ICF, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office, inpatient hospital, SNF, ICF, outpatient hospital, or ECF setting are no longer reimbursed to CNM providers. Services that are rendered in the home setting are no longer reimbursed. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Texas Medicaid Bulletin, No September/October 2011

77 Procedure Codes continued 11644, 11646, 11900, 11901, 15781, and Changes to Surgical Services Procedure Codes Integumentary System Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office, inpatient hospital, SNF, ICF, outpatient hospital, or ECF setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office, inpatient hospital, SNF, ICF, outpatient hospital, or ECF setting are no longer reimbursed to CNM and physical therapist providers. Services that are rendered in the home setting are no longer reimbursed Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, physician, and podiatrist providers , 11012, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM and physical therapist providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, physician, and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers , 11200, 11201, 11423, and , 11311, 11313, 12001, 12002, 12007, 12011, 12013, 12014, 12015, 12016, 12017, 12018, 12021, 12031, 12032, 12034, 12035, 12036, 12037, 12052, 12053, 12054, 12055, 12056, and Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the inpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the home, SNF, ICF, or ECF setting are no longer reimbursed. September/October Texas Medicaid Bulletin, No. 237

78 Procedure Codes and Changes to Surgical Services Procedure Codes Integumentary System Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital may be reimbursed to podiatrist providers. Services that are rendered in the inpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the inpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to podiatrist providers Services that are rendered in the office setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting are a benefit and may be reimbursed to NP, CNS, PA, physician, and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting are a benefit and may be reimbursed to NP, CNS, PA and physician providers and Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, physician, and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, PA, and podiatrist providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting are no longer reimbursed to podiatrist providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers and , 15786, 15787, 15788, and Services that are rendered in the office, inpatient hospital, or outpatient hospital are no longer reimbursed to podiatrist providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital are no longer reimbursed to podiatrist providers. Services that are rendered in the office or outpatient hospital setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed to CNM providers. Texas Medicaid Bulletin, No September/October 2011

79 Surgical Services Musculoskeletal System The following changes apply to musculoskeletal system procedure codes: Procedure Codes Changes to Surgical Services Procedure Codes Musculoskeletal System Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers , 20205, 21030, 21440, 21450, 21480, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, PA, and podiatrist providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers , 20615, 20650, and , 20551, and and , 21012, 21013, 21014, 21552, and , 20680, 21025, 21031, 21032, 21076, 21310, 21315, 21320, 21337, and Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the home setting are no longer reimbursed. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the home setting are no longer reimbursed. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the inpatient hospital or outpatient hospital may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. September/October Texas Medicaid Bulletin, No. 237

80 Procedure Codes and and Changes to Surgical Services Procedure Codes Musculoskeletal System Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers , 20697, 21400, and Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, physician, and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to podiatrist providers Services that are rendered in the office setting may be reimbursed to physician and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to podiatrist providers , 20912, 20920, 20922, 20926, 21026, 21029, 21034, 21040, 21044, 21452, and , 20956, 20970, 21070, 21325, 21330, 21335, 21336, 21338, 21339, 21340, 21445, 21454, 21461, 21462, 21465, 21470, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Texas Medicaid Bulletin, No September/October 2011

81 Procedure Codes Changes to Surgical Services Procedure Codes Musculoskeletal System Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers and and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office setting may be reimbursed to physician and podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to podiatrist providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers. Services that are rendered in the home, SNF, ICF, independent laboratory, birthing center, ECF, or other location setting are no longer reimbursed. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers , 21045, 21249, 21343, 21344, 21345, 21346, 21347, 21348, 21355, 21356, 21360, 21365, 21366, 21385, 21386, 21387, 21390, 21395, 21423, 21431, 21432, 21433, 21435, and , 21080, 21081, 21082, 21083, 21085, 21087, and Services that are rendered in the office setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to DME medical supplier providers. September/October Texas Medicaid Bulletin, No. 237

82 Procedure Codes Changes to Surgical Services Procedure Codes Musculoskeletal System Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to DME medical supplier providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers , 21142, and Services that are rendered in the outpatient hospital setting may be reimbursed to physician providers. Services that are rendered in the office setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office setting are no longer reimbursed Services that are rendered in the office setting may be reimbursed to physician providers , 21407, 21408, and Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the home, SNF, ICF, independent laboratory, birthing center, ECF, or other location setting are no longer reimbursed , 21550, and Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, CNM, and hospital providers Services that are rendered in the office setting are no longer reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to physician and podiatrist providers. Texas Medicaid Bulletin, No September/October 2011

83 Surgical Services Nervous System The following changes apply to nervous system procedure codes: Procedure Code Changes to Surgical Services Procedure Codes Nervous System Services that are rendered in the office or outpatient hospital setting may be reimbursed to physician providers and Services that are rendered in the office or outpatient hospital setting may be reimbursed to physician providers , 61576, 61580, 61581, 61586, and Services that are rendered in the inpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers. Services that are rendered in the office or outpatient hospital setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office or outpatient hospital setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers Services that are rendered in the outpatient hospital setting may be reimbursed to physician providers. Services that are rendered in the office setting are no longer reimbursed , 67917, 67924, and , 64736, 64738, and Services that are rendered in the inpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital settings are no longer reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers , 67915, 67921, 67935, and Services that are rendered in the office, inpatient hospital, or outpatient hospital settings are no longer reimbursed to CNM providers Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office, inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers. September/October Texas Medicaid Bulletin, No. 237

84 Surgical Services Respiratory System The following changes apply to respiratory system procedure codes: Procedure Codes 30000, 30020, and and Changes to Surgical Services Procedure Codes Respiratory System Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers , 30160, 30310, and Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the inpatient hospital setting may be reimbursed to NP, CNS, PA, and physician providers , 30410, 30420, 30435, and Services that are rendered in the office or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office setting are no longer reimbursed to NP, CNS, and PA providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers Services that are rendered in the office setting are no longer reimbursed and , 30630, 30930, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office setting may be reimbursed to physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Texas Medicaid Bulletin, No September/October 2011

85 Procedure Codes and Changes to Surgical Services Procedure Codes Respiratory System Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers , 30903, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers , 31080, 31081, 31084, 31085, 31086, 31087, and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Services that are rendered in the office setting are no longer reimbursed. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers Services that are rendered in the office setting may be reimbursed to physician providers and and Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers. Services that are rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services that are rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers. Surgical Services Special Otorhinolaryngologic Services The following changes apply to special otothinolaryngologic services: Procedure Code Changes to Surgical Services Procedure Code Special Otorhinolaryngologic Services Services that are rendered in the office, inpatient hospital, or outpatient hospital setting are no longer reimbursed to CNM providers. September/October Texas Medicaid Bulletin, No. 237

86 Texas Medicaid Claims Reprocessing The following claims issues have been identified. All affected claims will be reprocessed, and payments will be adjusted accordingly. When these claims are reprocessed, providers may receive additional payment, which will be reflected on R&S Reports. No action on the part of the provider is necessary. Appealed Claims for Laboratory Services to be Reprocessed TMHP has identified an issue that impacts RN, APRN, and CNM providers who have appealed claims for laboratory services that were rendered in the office, independent laboratory, inpatient hospital, or outpatient hospital settings. Appeals for these services that were submitted with dates of service from July 1, 2009, through June 2, 2011, may have been incorrectly denied payment by Texas Medicaid. The following laboratory services procedure codes were affected: Procedure Codes Type of Service: Technical Type of Service: Professional Type of Service: Laboratory Texas Medicaid Bulletin, No September/October 2011

87 Procedure Codes September/October Texas Medicaid Bulletin, No. 237

88 Procedure Codes Some Critical Care Procedure Codes May be Reimbursed Within Six Weeks of an Anesthesia Service Effective May 26, 2011, for claims with dates of service on or after May 1, 2010, critical care procedure codes 99291, 99292, 99471, 99472, 99475, and may be reimbursed for visits within six weeks of an anesthesia service for a related diagnosis if the critical care and anesthesia services are performed by different providers. Claims may have been incorrectly denied by Texas Medicaid. Services That Are Diagnosis- and Age-Restricted Claims Reprocessing TMHP has identified an issue that impacts claims that were submitted by Medicaid fee-for-service, managed care, and CSHCN Services Program providers. Texas Medicaid Bulletin, No September/October 2011

89 Claims that were submitted to TMHP for dates of service from October 1, 2010, through May 15, 2011, may have been incorrectly denied with an explanation of benefits code 05107, which indicated the diagnosis for the service rendered is invalid for the client s age. TMHP will continue to review services with specific diagnosis and age restrictions, which may result in additional claims reprocessing and payment or recoupment of payments. Extremity Study Services will be Reprocessed TMHP has identified an issue that impacts Medicaid fee-for-service and managed care claims that were submitted for extremity study services. Claims that were submitted for extremity study services that were rendered in the office setting by a physician for dates of service from July 1, 2010, through May 26, 2011, may have been incorrectly denied. The following technical services codes were affected: Procedure Code Claims with Modifier 25 to Be Reprocessed TMHP has identified an issue that impacts claims that were submitted before May 13, 2011, with dates of service on or after October 1, 2010, and procedure code 99201, 99202, 99203, 99211, 99212, 99213, or that included modifier 25. Claims may have been incorrectly denied payment by Texas Medicaid and the CSHCN Services Program. Reminder: Providers must use modifier 25 to describe circumstances in which an acute care evaluation and management (E/M) visit was provided at the same time as a checkup. Providers must submit modifier 25 with the E/M procedure code when the rendered services are distinct and provided for a different diagnosis. Advanced Practice Registered Nurse and Physician Assistant Providers May Sign on Behalf of the Physician for Some Comprehensive Care Program Services Effective immediately, an APRN or a PA may sign all documentation that is related to the provision of PDN, OT, PT, or ST services on behalf of the client s physician if the physician delegates this authority to the APRN or PA. The APRN or PA provider s signature and license number must appear in the physician signature and license number blocks of the forms. Important: APRN and PA providers may sign on behalf of the physician only for those PDN or therapy services that are authorized through CCP for THSteps-eligible clients who are 20 years of age and younger. This information updates the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Children s Services Handbook, subsection 2.9, Private Duty Nursing (CCP), and subsection 2.10, Therapy Services (CCP). September/October Texas Medicaid Bulletin, No. 237

90 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 as either banner messages or web articles. Correction to Benefit Criteria for Diabetic Equipment and Supplies Home Health Services Changing July 1, 2011 This is a correction to an article titled Benefit Criteria for Diabetic Equipment and Supplies Home Health Services Changing July 1, 2011, which was published in the July/August 2011 Texas Medicaid Bulletin, No. 236, and on May 13, 2011, on the TMHP website at The article did not include the correct External Insulin Pump form to submit when requesting prior authorization for external insulin pumps. Providers must use the updated form to request prior authorization for external insulin pumps for dates of service on or after July 1, The updated External Insulin Pump form is available on page 106 of this bulletin. Reprocessing Claims Incorrectly Denied as Paid to Another Provider Correction This is a correction to an article titled Follow-up to Outpatient Facility Benefit Changes for Cardiac Catheter Services, which was published on May 13, 2011, on the TMHP website at The article included incorrect dates and should not have included procedure codes. The following is the correct information: TMHP has identified an issue that impacts claims that were submitted between April 1, 2011, and May 1, 2011, with dates of service on or after January 1, Affected claims may have been incorrectly denied payment by Texas Medicaid or the CSHCN Services Program with explanation of benefits (EOB) 00042, This is a duplicate service that has been paid to another provider. When these claims are reprocessed, providers may receive additional payment, which will be reflected on R&S Reports. Claims that were submitted after May 1, 2011, were not affected and will not be reprocessed. Correction to Reimbursement Rate for Procedure Code A6230 This is a correction to an article titled Reimbursement Rates to Change for Some Procedure Codes Effective July 1, 2011, which was published on the TMHP website at on May 24, In the Medical and Surgical Supplies-Services (A codes) category, the reimbursement rate for procedure code A6230 was incorrect. Procedure code A6230 should have been listed as manually priced, until the effective date of July 1, 2011, when the reimbursement rate changed to $1.80. Correction to Benefit Change for Surgery Procedure Codes 11981, 11982, and This is a correction to an article titled, Benefit Change for Surgery Procedure Codes 11981, 11982, and 11983, which was published on the TMHP website at on May 13, The article incorrectly stated that procedure codes 11981, 11982, are payable for services rendered in an outpatient setting. The correct information is: Surgery procedure codes 11981, 11982, and are payable to physicians for services performed in an inpatient hospital setting. Texas Medicaid Bulletin, No September/October 2011

91 Pending June 2011 Benefit Criteria Changes for Substance Use Disorder Services (Abuse and Dependence) Update This is an update to an article titled Pending June 2011 Benefit Criteria Changes for Substance Use Disorder Services (Abuse and Dependence), which was published on the TMHP website at on April 15, The benefit changes that are indicated in the article have been approved; the effective date remains June 1, Online Prior Authorization for Residential Detoxification are Available Effective June 25, 2011, chemical dependence treatment facility (CDTF) providers may submit online prior authorization requests for residential detoxification services through the secure area of the TMHP website. Providers may refer to the article titled Online Prior Authorization to Be Available for Substance Use Disorder (Abuse and Dependence) Services Beginning March 25, 2011, on the TMHP website for steps on how to get to the online prior authorization for SUD services. Prior Authorization Clarification Prior authorization requests for clients who are 20 years of age and younger for services that are beyond the limitations for substance use disorder (abuse and dependence) may be considered if a physician provides documentation that supports the medical necessity for continuation of the treatment. The physician does not need to be affiliated with the CDTF. Update to Medication-Assisted Therapy (MAT) As stated in the initial article, MAT may be considered for reimbursement on the same date of service as residential detoxification, ambulatory (outpatient) detoxification, or residential treatment services. For the claim to be considered, providers must: Submit supporting documentation that indicates one of the following: The client is a pregnant woman with an opioid addiction. The client is in current MAT treatment for an opioid addiction and is also receiving residential services for a substance other than opioids. Submit one of each of the following diagnosis codes (opioid, non-opioid, and pregnancy diagnoses) on the claim: Opioid Diagnoses Non-Opioid/Pregnancy Diagnoses September/October Texas Medicaid Bulletin, No. 237

92 Retroactive Authorizations for Radiology Procedure Codes 74176, 74177, and Claims Reprocessing This is an update to an article titled Correction to Radiology Procedure Codes in January 2011 HCPCS Special Bulletin, which was published March 17, 2011, on the TMHP website at The article states that claims for Texas Medicaid fee-for-service and PCCM clients that were submitted with procedure code 74176, 74177, or and dates of service from January 1, 2011, through March 31, 2011, would be reprocessed. The update is that before these claims can be reprocessed, providers that have not previously obtained an authorization from MedSolutions for the procedures will be required to obtain authorization by submitting the authorization requests with documentation of medical necessity to MedSolutions. Obtaining Authorization Providers will have 30 calendar days from August 1, 2011, through August 30, 2011, to submit these retroactive authorizations to MedSolutions by fax or by telephone. Each retroactive authorization request submitted by fax to MedSolutions must be submitted using a separate Radiology Prior Authorization Request Form. Prior authorizations may be submitted to MedSolutions as follows: Prior Authorization Department telephone number: Prior Authorization Department Fax number: Retroactive authorization requests for all radiology procedure codes, including 74176, 74177, or will not be accepted if they are submitted through the MedSolutions online authorization portal from August 1, 2011, through August 30, Retroactive authorizations for procedure code 74176, 74177, or for dates of services from January 1, 2011, through March 31, 2011, will be accepted by MedSolutions only if they are received from August 1, 2011, through August 30, MedSolutions will notify the requesting/referring provider by fax of the determination to approve or deny the request. The authorization determination will also be available on the MedSolutions website at Authorization is a condition for reimbursement consideration but is not a guarantee of payment. Claims may be denied for other reasons even if a valid authorization is on the claim. Important: If authorization requests or claims for procedure code 74176, 74177, or are denied by Texas Medicaid, the clients are not responsible for payment and cannot be billed for the services rendered between January 1, 2011, and March 31, Claims to be Reprocessed After the designated time frame for obtaining retroactive authorization for procedure codes 74176, 74177, or has lapsed, claims will be reprocessed for payment consideration. Retroactive authorization requests that are not received by MedSolutions within the designated time frame or are not approved by MedSolutions, will result in claim denials. Claims that Must be Appealed If the authorization field on the claim is populated with text or a number other than a valid authorization number, the claim cannot be reprocessed. The provider must appeal the claim with a valid authorization number. Reminder: The January 2011 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin, No. 3, page 19, indicated the correct benefit, limitation, and authorization information about procedure codes 74176, 74177, and as follows: Texas Medicaid Bulletin, No September/October 2011

93 Texas Medicaid Benefit Changes The following limitations apply to added CT and MRI procedure codes 74176, 74177, and for Texas Medicaid. Computed tomography procedure codes 74176, 74177, and may be reimbursed as follows: The total component may be reimbursed to NP, CNS, PA, physician, radiation treatment center, portable X-ray supplier, radiological laboratory, and physiological laboratory providers for services that are rendered in the office setting; and to radiation treatment center and hospital providers for services that are rendered in the outpatient hospital setting. The professional interpretation component may be reimbursed to NP, CNS, PA, and physician providers for services that are rendered in the office setting; and to physician providers for services that are rendered in the inpatient hospital or outpatient hospital setting. The technical component may be reimbursed to NP, CNS, PA, physician, radiation treatment center, portable X-ray supplier, radiological laboratory, and physiological laboratory providers for services that are rendered in the office setting; and to radiation treatment center providers for services that are rendered in the outpatient hospital setting. Prior authorization is required and must be submitted to the MedSolutions Radiology Prior Authorization Department. For more information about authorization requirements, providers may refer to the 2011 Texas Medicaid Provider Procedures Manual, (Vol. 2) Radiology and Laboratory Services Handbook, subsection Authorization Requirements for CT, CTA, MRI, fmri, MRA, PET, and Cardiac Nuclear Imaging Services. One radiology procedure code may be reimbursed per day. If an additional radiology procedure is medically necessary, a second procedure code may be reimbursed the same day when it is billed with modifier 76. Rates Effective March 31, 2011, for dates of service on or after January 1, 2011, the following rates for procedure codes 74176, 74177, and apply for Texas Medicaid: Type of service Procedure Code Client Age Range Medicaid Allowable Birth through 20 years of age $ years of age and older $ I Birth through 20 years of age $71.31 I years of age and older $67.92 T Birth through 20 years of age $ T years of age and older $ Birth through 20 years of age $ years of age and older $ I Birth through 20 years of age $74.75 I years of age and older $71.19 T Birth through 20 years of age $ T years of age and older $ Birth through 20 years of age $ years of age and older $ I Birth through 20 years of age $82.77 September/October Texas Medicaid Bulletin, No. 237

94 Type of service Procedure Code Client Age Range Medicaid Allowable I years of age and older $78.83 T Birth through 20 years of age $ T years of age and older $ Correction to Tubeless Insulin Pump Added as a CCP Benefit Effective July 1, 2011 This is a update to an article titled Tubeless Insulin Pump Added as CCP Benefit Effective July 1, 2011, which was published in the July/August 2011 Texas Medicaid Bulletin, No. 236, and on May 13, 2011, on the TMHP website at The article states that prior authorization for tubeless external insulin pumps and related supplies and repairs can be requested by submitting a completed CCP Prior Authorization Request Form signed by a physician. The article neglected to say that providers can request prior authorization for tubeless external insulin pumps and related supplies and repairs by submitting a completed and signed detailed written order provided by a physician, PA, NP, CNS, or a CNM along with a completed and unsigned CCP Prior Authorization Request Form. Requesting Diabetic Equipment and Supplies With a CCP Prior Authorization Request Form The completed CCP Prior Authorization Request Form must be maintained by the dispensing provider and the prescribing physician in the client s medical record. The physician must maintain the original signed and dated copy of the CCP Prior Authorization Request Form. The completed CCP Prior Authorization Request Form is valid for a period up to six months from the physician s signature date. Requesting Diabetic Equipment and Supplies With a Verbal or Detailed Written Order If the dispensing provider does not have a detailed written order, a verbal order is required to be on file until the written order is received from the prescribing provider and before providing diabetic equipment and supplies. The prescribing provider s order may be a written, fax, electronic, or verbal order and must include: A description of the items. The recipient s name. The name of the physician or authorized prescribing provider. The date of the order. A detailed written order must be received by the DME supplier within 90 days from the date of the prescribing provider s signature. For initial orders, the detailed written order for diabetic equipment and supplies is valid for six months from the date of the order or the date of the prescribing provider s signature, whichever is earlier. For renewal orders, the detailed written order is valid for six months from the start date, or in absence of a start date, the date of the authorized prescribing signature. A completed, detailed written order must be signed and dated by the authorized prescribing provider. The prescribing provider is required to retain a copy of the signed and dated detailed written order in the client s medical record. The DME provider must retain the original, faxed, photocopied, or electronic, signed and dated detailed written order in the client s medical record. Texas Medicaid Bulletin, No September/October 2011

95 A completed detailed written order must contain all of the following components: Client s name. The date of the verbal order if different from the date the authorized prescribing provider signed the written order. Description of items to be provided. Quantity to dispense (quantity required per day or month). Diagnosis code or description supporting the medical necessity. Before submitting a claim to Medicaid, DME providers must have on file a detailed written order with the required information. No other documentation is required. External Insulin Pump form The External Insulin Pump form attached to the article was not the correct form to submit when requesting prior authorization for tubeless external insulin pumps. An updated External Insulin Pump form is available on page 106 of this bulletin, and has been updated on the TMHP website at Providers must use the updated form to request prior authorization for tubeless external insulin pumps with dates of service on or after July 1, Update to New Surgical Services Benefits Effective July 1, 2011 This is an update to an article titled New Surgical Services Benefits, which was published in the July/ August 2011 Texas Medicaid Bulletin, No. 236, and an article titled New Surgical Services Benefits Effective July 1, 2011, which was published on May 13, 2011, on the TMHP website at The articles state that procedure codes and S2118 will become a benefit for dates of service on or after July 1, The following additional benefit criteria applies to these procedure codes: Procedure code is restricted to diagnosis code Procedure code S2118 requires prior authorization for PCCM clients. Requests for prior authorization must be submitted to the PCCM Outpatient Prior Authorization department with a completed Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form and documentation that supports medical necessity. Corrections to the 2011 Texas Medicaid Provider Procedures Manual Audiology Claims Filing for Managed Care Clients Correction This is a correction to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection , TMHP Claims Filing Information. This subsection incorrectly states that TMHP processes claims for audiology services and authorization transactions for Texas Medicaid managed care clients of all ages. Managed care clients include clients of PCCM, STAR, STAR+PLUS, and STAR Health. The correct information is: TMHP processes claims for audiology services and authorization services only for managed care clients who are 20 years of age and younger. Provider Enrollment Section Correction This is a correction to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, Provider Enrollment and Responsibilities, Section , Medicare Participation, on page This September/October Texas Medicaid Bulletin, No. 237

96 section incorrectly states Some provider types may apply for a waiver of the Medicare certification requirement of the application process if they do not serve Medicaid-eligible individuals. The correct information is: Some provider types may apply for a waiver of the Medicare certification requirement of the application process if they do not serve Medicare-eligible individuals. Provider Re-enrollment Section Correction This is a correction to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, Section 1, Provider Enrollment and Responsibilities, Provider Re-enrollment, on page Section 1.3 incorrectly states that claims for services rendered to Texas Medicaid clients who do not have Medicare benefits are subject to a filing deadline from the date of service of 95 days for in-state providers and 365 days for out-of-state providers. The correct information is: Claims for services rendered to Texas Medicaid clients are subject to a filing deadline from the date of service of 95 days for in-state providers and 365 days for out-of-state providers. Volume 1 General Information This manual is available for download at and is also available on CD. There are many benefits to using the electronic manual, including easy navigation with bookmarks and hyperlinked cross-references, the ability to quickly search for specific terms or codes, and form printing on demand. T T M & H P TMHP m m T M w T H Ambulance Services Handbook Correction This is an update to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Ambulance Services Handbook, subsection 2.4.6, Emergency Transport Billing and subsection 2.4.7, Nonemergency Transport Billing. All ambulance claims for the transportation of a client must include mileage (procedure code A0425) and transport (procedure code A0425, A0426, A0427, A0429, A0433, or A0434. Claims for ambulance services that are submitted without mileage and transportation procedure codes will be denied. Certified Registered Nurse Anesthetist Modifier Combinations Correction This is a correction to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection 6.3.5, Modifiers. In the table under Anesthesia, the special instructions are incorrect for the modifier combinations to be used by certified registered nurse anesthetist (CRNA) providers to submit claims. The following table shows the correct special instructions: Modifier QX and U2 QZ and U1 Instructions Use to indicate the anesthesia was medically directed by the anesthesiologist. Use to indicate the anesthesia was directed by the surgeon. Reminder: Claims that are submitted for anesthesia services and require a modifier must adhere to the guidelines in the Texas Medicaid Provider Procedures Manual and related bulletin and website articles. Additional information and examples of frequently used anesthesia modifiers can be found in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook in subsection , Anesthesia Modifiers. Texas Medicaid Bulletin, No September/October 2011

97 Update to the STAR Program Client Eligibility Chart This is an update to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, subsection 8.2.2, [STAR Program] Client Eligibility. The chart in this section did not include Dallas and Tarrant service areas (SAs) as a part of the Group 1 SAs in the legend. The following STAR Program client eligibility chart has been revised to include the Dallas and Tarrant SAs: Base Plan Category Program Type Description * SA Group 1 Counties 02 1 Money grant and Medicaid M M M M 02 3 Medical Assistance Only/Retirement Survivors Disability Insurance (MAO/ RSDI) increase months transitional Medicaid resulting M M from increase in earnings months transitional Medicaid resulting M M from receipt of child support months transitional Medicaid M M following end of state time-limited Temporary Assistance for Needy Families (TANF) months transitional Medicaid resulting M M from loss of 90-percent earned income disregard Pregnant women with income < 185 percent M M Federal Poverty Limit (FPL) Children < 1 year of age at 185 percent FPL M M Children 6 years of age through 19 years of M M age at 100 percent FPL Newborn of Medicaid-eligible mother to 1 M M year of age Children ineligible for TANF due to applied M M income of stepparent or grandparent Children 1 year of age through 5 years of M M age at 133 percent FPL TANF state plan, money grant and M M Medicaid or 04 3 MAO/RSDI increase, no Medicare X V or Supplemental Security Income (SSI) X V manually certified adults, no Medicare or SSI manually certified children 20 years of X V age and younger, no Medicare or SSI clients, adults, no Medicare X V or SSI clients, 20 years of age and younger, no Medicare X V ** SA Group 2 September/October Texas Medicaid Bulletin, No. 237

98 Base Plan Category Program Type Description or Disabled Adult Children denied SSI due to increase in RSDI benefits, no Medicare * SA Group 1 Counties X ** SA Group 2 V or Transitional SSI Medicaid, no Medicare X V or Early Age Widows /Widowers, no Medicare X V V= Voluntary, M= Mandatory, X = Not Eligible, * SA Group 1 = Bexar, Dallas, Harris, Harris Expansion, Nueces, Tarrant, and Travis, ** SA Group 2 = El Paso and Lubbock Update to the STAR+PLUS Program Service Area Chart This is an update to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information), subsection , [STAR+PLUS Program] Service Areas (SAs). The chart in this section did not include Amerigroup Community Care as one of the health maintenance organizations (HMOs) for the Tarrant SA. The HMOs for the Tarrant service areas are Amerigroup Community Care and Bravo. The following table shows the updated list of STAR+PLUS Program SA with Amerigroup Community Care included as one of the HMOs for the Tarrant SA: SA Counties HMOs Telephone Number Bexar Harris, Harris Expansion Nueces Travis Dallas Tarrant Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson Brazoria, Fort Bend, Galveston, Harris, Montgomery, Waller Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, Victoria Bastrop, Burnet, Caldwell, Hays, Lee, Travis, Williamson Dallas, Collin, Ellis, Hunt, Kaufman, Navarro, and Rockwall Denton, Hood, Johnson, Parker, Tarrant, Wise Molina Healthcare of Texas Superior HealthPlan, Amerigroup Community Care Amerigroup Community Care Evercare of Texas, Inc. Molina Healthcare of Texas Evercare of Texas, Inc. Superior HealthPlan Amerigroup Community Care Evercare of Texas, Inc. Superior HealthPlan Molina Healthcare of Texas Amerigroup Community Care Bravo , Option , Option , Option , Option Texas Medicaid Bulletin, No September/October 2011

99 Family Planning Providers FAMILY PLANNING PROVIDERS Reimbursement Rate Changes for Some Titles V and XX Family Planning Services Effective for dates of service on or after June 1, 2011, the reimbursement rates for family planning Titles V and XX procedure codes 11975, 11976, 11977, and J1055 have changed. The following procedure codes are effective for dates of service on or after June 1, 2011: TOS Procedure Code Previous Reimbursement Rate Reimbursement Rate Effective June 1, $ $ $ $ $ $ J1055 $53.48 $69.87 TOS = Type or Service, TOS 1 = Medical, 2 = Surgery Correction to Title V, X, and XX Family Planning Billing Instructions in the 2011 Texas Medicaid Provider Procedures Manual This is a correction to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook, subsection 4.3, [Department of State Health Services (DSHS) Titles V, X, and XX Family Planning] Services, Benefits, Limitations, and Prior Authorization. This section incorrectly includes diagnosis code V2562 as valid for claims in conjunction with family planning procedure codes billed for Title V, X, and XX services. The correct diagnosis code is V2652. September/October Texas Medicaid Bulletin, No. 237

100 Managed Care Providers MANAGED CARE PROVIDERS Translation Services Available for PCCM Clients and Providers Reminder: Primary Care Case Management (PCCM) clients who need interpretive and translation services to ensure effective communications about treatment and medical history while in a provider s office can call the PCCM Nurse Helpline toll-free at PCCM clients who need translation services when finding or changing a primary care provider can call the PCCM client help line toll-free at , 7 a.m. to 7 p.m., Central Time, Monday through Friday. Sign language interpreting services are also benefits of Texas Medicaid and are available to PCCM clients. Providers must use the correct procedure code and modifiers when submitting claims. The provider that requests interpreting services must maintain documentation to verify that interpreting services were provided. For more information about sign language interpreting services, providers can refer to the 2011 Texas Medicaid Provider Procedures Manual, Vol. 2, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection , Sign Language Interpreting Services. PCCM Nurse Helpline Offers Interpretive Translation Services to PCCM Clients in Provider Offices The PCCM Nurse Helpline, which is a free service for PCCM clients, can be reached 24 hours a day, 7 days a week, including holidays, by calling The PCCM Nurse Helpline is staffed by registered nurses who, among other services to PCCM clients, can coordinate the interpretive language services that are necessary to ensure effective communication about treatment, medical history, or health education. Language Line Services Offers Additional Translation Services to PCCM Providers If providers or their staff need additional translation services to meet requirements on limited English proficiency, they can call Language Line Services at Language Line Services operates 24 hours a day, 7 days a week. Language Line Services provides over-the-telephone interpretation, video interpreting, document translation, interpreter testing and training, and other language products as well. Language Line Services charges a fee to providers. Language Line Services bills in one-minute increments, and charges begin when the interpreter is connected to the call. The electronic bill that is sent to the provider will include the date, time, and duration of the call, the language, the interpreter number, the personal code of the person placing the call, and a Language Line Services internal reference number. Texas Medicaid Bulletin, No September/October 2011

101 THSteps Dental Providers THSTEPS DENTAL PROVIDERS Changes Coming for Medicaid and CHIP Dental Services Beginning March 1, 2012 The Texas Health and Human Services Commission (HHSC) offers Children s Health Insurance Program (CHIP) Dental Services though a managed care model. Beginning March 1, 2012, HHSC will expand managed care dental services to include Medicaid. The goal of this expansion is to provide quality, comprehensive dental services to eligible clients. HHSC will select two or more dental contractors to provide services to both Medicaid and CHIP clients. The objectives of dental managed care are to provide services in a manner that improves the oral health of clients through preventative care and health education. Each client will have a main dental home provider that will support an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Main dental home providers will assess the dental needs of clients and coordinate clients care with specialty care providers. Children who are birth through 20 years of age and who are eligible for Medicaid Texas Health Steps (THSteps) and Comprehensive Care Program (CCP) services, including Supplemental Security Income (SSI) recipients, will be able to receive dental services. In addition, all children who are enrolled in the CHIP Program will be eligible to participate. Individuals who are receiving Medicaid and who meet the conditions listed below will continue to receive dental services through their existing service delivery models and not through Medicaid and CHIP Dental Managed Care: Medicaid clients who are 21 years of age and older. All Medicaid clients, regardless of age, who reside in Medicaid-paid facilities such as nursing homes, state supported living centers, or intermediate care facilities for mentally retarded persons (ICF/MR). State of Texas Access Reform (STAR) Health Program clients (foster care). The dental contractors will establish a network to include general, pediatric, and specialty care providers that ensures all clients have sufficient choice and access to care. The dental contractors are responsible for authorizing, arranging, coordinating, and providing medically necessary covered dental services. Members will be eligible for dental services beginning on the member s date of enrollment regardless of pre-existing conditions, prior diagnosis, or receipt of any prior health-care services. Eligible Medicaid and CHIP clients will receive an enrollment packet that will provide information on the dental managed care organizations (DMO) and dental provider choices that are available in their area as well as how to choose a dental plan. HHSC will make DMO award announcements upon selection of the dental contractors and will make available the DMO contact information for providers who are interested in joining a DMO network. For more information, providers can visit the HHSC webpage at: September/October Texas Medicaid Bulletin, No. 237

102 THSteps Dental Providers/THSteps Medical Providers Dental Sealant Is a Benefit Once Every Three Years When Performed by the Same Provider Effective May 26, 2011, for dates of service on or after March 1, 2010, procedure code D1351 (dental sealants) is a benefit once every three years when performed by the same provider. Dental sealants performed more frequently than once every three years by a different provider are also a benefit if the different provider is not associated with the provider or provider group that initially placed the sealant on the tooth. Claims may have been incorrectly denied payment by Texas Medicaid or the Children with Special Health Care Needs (CSHCN) Services program. When these claims are reprocessed, providers may receive additional payment, which will be reflected on Remittance and Status (R&S) Reports. Claims for Dental Services to Be Reprocessed TMHP has identified an issue that impacts claims that were submitted before November 4, 2010, with procedure code D4276, D6056, D6057, D7272, D7286, D7472, or D9951. Claims for procedure codes D7286 and D9951 may have been incorrectly denied for lack of a prior authorization. Claims for procedure codes D4276, D6056, D6057, D7272, and D7472 may have been incorrectly paid even though the claims did not meet prior authorization requirements. When these claims are reprocessed, providers whose claims were incorrectly denied may receive additional payment, and providers whose claims were incorrectly paid may be recouped. Payment changes will be reflected on R&S Reports. THSTEPS MEDICAL PROVIDERS Reimbursement Rate for Developmental Testing to Change for THSteps Medical Providers Effective for dates of service on or after July 1, 2011, the reimbursement rate for developmental testing procedure code has changed for Texas Health Steps (THSteps) medical providers. The previous reimbursement rate was $6.82 (0.25 relative value unit [RVU], $ conversion factor). The reimbursement rate effective for dates of service on or after July 1, 2011, is now $8.49. Texas Medicaid Bulletin, No September/October 2011

103 Excluded Providers 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 To report Medicaid providers who engage in fraud/abuse, call or , or write to the following address: Provider Brian Klozik, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361 PO Box Austin, TX License Number Add Date Type Provider City State Effective Date Ayala, Salina May-11 LVN San Antonio TX 14-Dec-10 Bean, Mary May-11 LVN Texarkana TX 14-Dec-10 Bellah, Freddie M Jun-11 LVN Seymour TX 10-Mar-11 Bernal, Hermelinda May-11 LVN Corpus Christi TX 13-Dec-10 Bledsoe, Marilyn D Jun-11 RN Dallas TX 8-Feb-11 Briones, Katrina May-11 LVN Galveston TX 14-Dec-10 Brookfield Pharmacy LLC Jun-11 Pharmacy Tomball TX 9-Dec-10 Capps, Dawn May-11 LVN LaMarque TX 29-Oct-10 Carmona, Armando May-11 LCDC Vidor TX 20-May-09 Carpenter, Susan M Jun-11 LVN Mexia TX 9-May-11 Cavender, Lundy H May-11 MD Fort Worth TX 27-Aug-10 Collier, Debbie May-11 RN Hermieigh TX 14-Dec-10 Daniels, Melissa L Jun-11 LVN Amarillo TX 9-Nov-10 De Leon, Veronica May-11 LVN Edinburg TX 14-Dec-10 Dodgen, Robert May-11 RN Kingwood TX 14-Dec-10 Drumgoole, Paul E Jun-11 Pharmacist Tomball TX 10-Sep-10 Escalera, Javier P. M Jun-11 MD Lamesa TX 4-Feb-11 September/October Texas Medicaid Bulletin, No. 237

104 Excluded Providers Provider License Number Add Date Type Provider City State Effective Date Ford, Cheryl May-11 LVN Foreman AR 14-Dec-10 Gann, Leslie May-11 RN Sangel TX 14-Sep-10 George, Dennis M Jun-11 Pharmacist Missouri City TX 9-Sep-10 Graham, Deniell May-11 LVN Beaumont TX 27-Jan-11 Green, Terry L Jun-11 Pharmacist Pearland TX 9-Sep-10 Groff, Staci May-11 LVN College Station TX 14-Dec-10 Hamilton, Gary May-11 LVN Midland TX 22-Nov-10 Hansen, Sharma May-11 RN Frisco TX 30-Nov-10 Henderson, Lavonda J Jun-11 LVN Carthage TX 22-Oct-10 Henson, Carolyn May-11 LVN Tyler TX 1-Dec-10 Higgs, Kimberly S Jun-11 LVN Eddy TX 9-Nov-10 Hill, Candace L Jun-11 Dental Assistant Tomball TX 4-Nov-10 Houston, Melanie D Jun-11 LVN Mineral Wells TX 14-Dec-10 Jackson, Angie May-11 LVN Burleson TX 9-Nov-10 Jhagroo, Noel 18-May-11 Owner Oakdale LA 16-May-11 Kirby, Stella L Jun-11 MD San Antonio TX 4-Feb-11 Kruger, Tessa May-11 Pharmacy Tech Benbrook TX 10-Mar-09 Larralde, Julie May-11 RN Texas City TX 9-Nov-10 Lee, Justin M. N Jun-11 MD League City TX 4-Feb-11 McClanahan, Lisa May-11 RN Irving TX 9-Dec-10 McFall, Walter May-11 RN Greenville TX 28-Jan-11 McNac, David R. 14-Jun-11 Director Beaumont TX 10-Jun-11 McVey, Nancy Jun-11 RN Austin TX 8-Feb-11 Merrigan, Thomas May-11 RN Maryville MO 9-Nov-10 Mildren, Whitney G Jun-11 RN Dallas TX 9-Nov-10 Moon, Suzanne May-11 RN Clay MI 14-Dec-10 Mosser, Terry L Jun-11 Dentist Greenville TX 19-Nov-10 Nelson, Starr May-11 RN Selma SC 2-Feb-11 Nolan, Timothy May-11 LVN San Antonio TX 7-Dec-10 Ogboso, Youmay 3733T 16-May-11 Optometrist Houston TX 20-Aug-08 Oliver, Kevin Jun-11 DDS San Antonio TX 6-Jun-11 Olsen, Sandra K Jun-11 RN El Paso TX 9-Nov-10 Omondi, Larry H Jun-11 LVN Longview TX 28-Jan-11 Outen, Shaun J. 14-Jun-11 Director Pollock LA 10-Jun-11 Ozuna, Sylvia B Jun-11 LVN Edinburg TX 9-Nov-10 Palmer, Henrietta Jun-11 LVN Katy TX 9-Nov-10 Price, Elizabeth A Jun-11 LVN Bowie TX 9-Nov-10 Ramirez, Criselda May-11 LVN Monte Alto TX 1-Feb-11 Reddick, Sherrie May-11 RN Pueblo CO 9-Nov-10 Rice, Jackie 13-May-11 Employee Madison AL 9-Nov-10 Rodriguez, Jesse Jun-11 RN Edinburg TX 8-Feb-11 Texas Medicaid Bulletin, No September/October 2011

105 Excluded Providers Provider License Number Add Date Type Provider City State Effective Date Roe, Marilyn May-11 LVN Bastrop TX 14-Dec-10 Rutoskey, John 16-May-11 SNF Owner/ McKinney TX 7-Aug-06 Operator Salazar, Patricia May-11 RN Pearland TX 9-Nov-10 Sanchez, Dawn May-11 RN Stephenville TX 22-Nov-10 Sapp, Linda May-11 RN Round Rock TX 28-Jan-11 Sarandos, Tsarina May-11 LVN Houston TX 27-Jan-11 Sethi, Anand May-11 RN Duncanville TX 11-Jan-11 Severson, Tammy May-11 LVN Lubbock TX 14-Dec-10 Sharma, Arun J May-11 Physician Webster TX 4-Jun-10 Sharma, Kiran J May-11 Physician Webster TX 4-Jun-10 Sheffield, Earl May-11 RN Wallisville TX 30-Nov-10 Simmons, Terri May-11 LVN Flint TX 9-Nov-10 Sims, Ronald E. G Jun-11 MD League City TX 4-Feb-11 Smith, Judy May-11 RN Devol OK 28-Dec-10 Smith, Julie May-11 LVN Valparaiso FL 9-Nov-10 Solis, Rafael H May-11 MD San Antonio TX 4-Feb-11 Stanford, Casandra May-11 RN Houston TX 14-Jan-11 Stennett, Cathy May-11 RN and LVN Lubbock TX 9-Nov-10 Sterling, Sonya May-11 RN Waco TX 21-Jan-11 Trilicek, Bonnie May-11 RN Needville TX 10-Jan-11 Usman, Muhammad N. 14-Jun-11 Owner Seagoville TX 10-Jun-11 Waller, Stephen F May-11 Physician Conroe TX 12-May-10 - Neurology Whitfield, Paula D. 22-Jun-11 Recruiter/ Bryan TX 9-May-11 Marketer Yon, Eva M Jun-11 LVN Colorado Springs CO 9-Nov-10 Zomar, Samantha May-11 RN Hillsboro OR 6-Oct-10 September/October Texas Medicaid Bulletin, No. 237

106 Forms External Insulin Pump Prior Authorization Form Submit requests for a tubeless insulin pump for clients 20 years of age or younger with a completed CCP Prior Authorization Request Form or detailed orders to TMHP CCP Fax: Submit all other requests with a completed Home Health Services (Title XIX) DME/Supplies Physician Order Form or detailed orders to TMHP Home Health Fax: Client Information Client Name Last: First: Middle Initial: Medicaid Number: Date of birth: / / Prescribing Provider Information (must be a physician, physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife) Name : License number: Telephone: TPI: Fax number: NPI: A. Rental of External Insulin Pump For clients diagnosed with Type 1 or Type 2 diabetes, please check which of the following conditions apply (to be considered at least two conditions must apply): Elevated glycosylated hemoglobin level (HbA1c) > 7.0% History of dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl History of severe glycemic excursions with wide fluctuations in blood glucose History of recurring hypoglycemia (less than 60 mg/dl) with or without hypoglycemic unawareness Anticipation of pregnancy within 3 months For clients with gestational diabetes, please check which of the following conditions apply (to be considered at least one condition must apply): Erratic blood sugars in spite of maximal compliance and split dosing Other evidence that adequate control is not being achieved by current methods Describe evidence if checked: B. The prescribing provider signature attests to all of the following: 1. The client and or caregiver possess the cognitive and physical abilities to follow recommended insulin pump treatment regimen, an understanding of cause and effect, and the willingness to support the use of the external insulin pump. 2. A training/education plan will be completed prior to initiation of pump therapy. 3. The client and/or caregiver will be given face-to-face education and instruction and will be able to demonstrate proficiency in integrating insulin pump therapy with their current treatment regimen for ambient glucose control. Prescribing Provider Signature: Date: / / Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No September/October 2011

107 Forms Electronic Funds Transfer (EFT) Notification Electronic Funds Transfer (EFT) is a payment method used to deposit funds directly into a provider s bank account. These funds can be credited to either checking or savings accounts, if the provider s bank accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks by ensuring funds are directly deposited into a specified account. The following items are specific to EFT: Pre-notification to your bank occurs on the weekly cycle following the completion of enrollment in EFT. 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, API) and R&S number. EFT funds are released by TMHP to depository financial institutions each Thursday. 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. 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 a voided check or signed letter from your bank on bank letterhead with the agreement to the TMHP address indicated on the form. Call the TMHP Contact Center at if you need assistance. Rev. 0/22/09 Page EFT Authorization September/October Texas Medicaid Bulletin, No. 237

108 Forms Electronic Funds Transfer (EFT) Notification NOTE: Complete all sections below and attach a voided check or a signed letter from your bank on bank letterhead. Type of authorization: New Change Provider name: Billing TPI: (9-digit) National Provider Identifier (NPI)/Atypical Provider Identifier (API): Primary taxonomy code: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: Provider accounting address: Number Street Suite City State ZIP Provider phone number: Bank name: Bank phone number: ABA/Transit number: Account number: Bank address: Account type: (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 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: address: (if applicable) Contact name: Contact phone number: Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box Austin, TX Rev. 0/22/09 Page 2 EFT Authorization Texas Medicaid Bulletin, No September/October 2011

109 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): Atypical Provider Identifier (API): Primary Taxonomy Code: 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 City County State Zip Code Telephone: ( ) Fax Number: ( ) 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 City State Zip Code Telephone: ( ) Fax Number: ( ) Secondary Address Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Type of Change (check the appropriate box) 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 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: Female Male Both Signature and date are required or the form will not be processed. Provider signature: Date: / / Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: Effective Date_ /Revised Date_ September/October Texas Medicaid Bulletin, No. 237

110 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 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 Austin, TX Fax: Texas Medicaid Bulletin, No September/October 2011

111 Forms Wheeled Mobility Systems Group Enrollment Application: Initial Checklist Preparation Gather the following pieces of information to complete your application: National Provider Identifier (NPI). Primary Taxonomy Code. The only taxonomy code available for custom wheeled mobility systems group providers is 332BC3200X. Texas Provider Identifier (TPI). The existing fee-for-service Medicaid durable medical equipment (DME) TPI. Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) and/or National Registry of Rehabilitation Technology Suppliers (NRRTS) information for the Qualified Rehabilitation Professional (QRP) performing provider. All certifications must be current and not scheduled to expire within 30 days. Tax Identification Number for the wheeled mobility group. Social Security Number (SSN) for the QRP. Palmetto number. Driver's license number and expiration date for the QRP performing provider. Completing the Application The following forms must be completed for the application to be considered complete: Wheeled Mobility Group Enrollment Application. All fields are required. HHSC Medicaid Provider Agreement. This form is found in the Texas Medicaid Provider Enrollment Application on pages , and must be completed for the QRP with an original signature. Provider Information Form 1 (PIF-1). This form is found in the Texas Medicaid Provider Enrollment Application on pages , and must be completed for the QRP. Important: The only taxonomy code available for QRP performing providers is X. Effective Date_ /Revised Date_ September/October Texas Medicaid Bulletin, No. 237

112 Forms Final Review and Submission Review all documents for accuracy. Required forms that must be mailed: o o o Wheeled Mobility Group Enrollment Application Health and Human Services Commission (HHSC) Medicaid Provider Agreement PIF-1 o W-9 o Copies of the QRP s RESNA and/or NRRTS certifications Out-of-state providers (i.e., providers whose primary practice is in a state other than Texas or more than 50 miles from the Texas border) must also provide proof that they meet one of the following: o o o o o o o A medical emergency documented by the attending physician or other provider. The client's health is in danger if he or she is required to travel to Texas. Services are more readily available in the state where the client is located. The customary or general practice for clients in a particular locality is to use medical resources in the other state. All services provided to adopted children receiving adoption subsidies (these children are covered for all services, not just emergency). Other out-of-state medical care may be considered when prior authorized. Other: Please explain. Mail the required forms to the TMHP Provider Enrollment Department at: Mailing Address: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box Austin, TX Physical Address: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment B Riata Trace Pkwy. Austin, TX Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No September/October 2011

113 Forms Wheeled Mobility Systems Group Enrollment Application Currently-enrolled durable medical equipment (DME) providers that render custom DME wheeled mobility systems to Texas Medicaid clients can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail the completed form and the additional required documentation to the address at the bottom of the page. 1. Existing DME 9-digit Texas Provider Identifier (TPI): 2. National Provider Identifier (NPI): 3. DME Provider Name: 4. Primary Taxonomy Code: 332BC3200X (no other options available for the group provider) 5. Physical Address 6. Accounting/Mailing Address City: City: State: ZIP + 4: State: ZIP + 4: Phone: ( ) Phone: ( ) Fax: Private or Public: Fax: Palmetto No.: Qualified Rehabilitation Professional (QRP) Name: 7. Attachments Required: Copy of the QRP s current provider certification from National Registry of Rehabilitation Technology Suppliers (NRRTS) and/or Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) DME s completed W-9 Request for Taxpayer Identification Number and Certification Complete HHSC Medicaid Provider Agreement with the QRP s information and original signature Complete Provider Information From 1 (PIF-1) with the QRP s information Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) 8. Tax ID Number: 9. Exact name reported to the IRS for this Tax ID: I certify that the information I have supplied in this document constitutes true, correct, and complete information. I agree to inform HHSC or its designee, in writing, of any changes or if additional information becomes available. 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. Fraud is a felony, and can result in fines or imprisonment. I understand that any falsification or misrepresentation that, if known, would have resulted in a denial of the application will result in all paid services declared as an overpayment and subject to recoupment. I also understand that other administrative sanctions may be imposed and include payment hold, exclusion, debarment, contract cancellation, and monetary penalties. This Wheeled Mobility enrollment application is valid only for submission through August 31, Accordingly, in order to enroll after the cut off date of August 31, 2011, a completed Texas Medicaid Provider Enrollment application must be submitted 10. Provider Signature: 11. Date: 12. Printed Name Mail the completed form and documentation to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Effective Date_ /Revised Date_ September/October Texas Medicaid Bulletin, No. 237

114 Forms Instructions for Completing this Application Field Number and Name Field 1 9-digit Texas Provider Identifier (TPI) All fields must be completed unless otherwise noted. Description Enter your existing 9-digit TPI if you are already enrolled in the Texas Medicaid program. Field 2 National Provider Identifier (NPI) Field 3 Provider Name Field 4 Primary Taxonomy Code Field 5 Physical Address Field 6 Accounting/Mailing Address Field 7 Attachments Required Field 8 Tax ID number Field 9 Exact name reported to the IRS for this Tax ID Field 10 Provider Signature Field 11 Date Field 12 Printed Name Enter your 10 digit NPI. Enter your Provider Name. Enter your primary taxonomy code. (The only taxonomy code available for custom wheeled mobility system group providers is 332BC3200X.) Enter your physical address including city, state, and ZIP + 4. The physical address cannot be a PO Box. Enter your accounting/mailing address including city, state, and ZIP + 4, if it is different from your physical address. All providers must submit a current copy of licensure that will not expire within 30 days and a completed W- 9. Enter the DME provider s 9-digit tax ID number. It must match the information that is on the W-9. Enter the DME provider s legal name as reported to the IRS. It must match the information that is on the W-9. The original signature of the authorized representative of the provider is required. Enter the date the form was signed. Print the name of the person signing the form. Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No September/October 2011

115 September/October 2011 No. 237 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Contact Information For information about Texas Medicaid, call the TMHP Contact Center at For information about Primary Care Case Management (PCCM) call the PCCM Provider Helpline at For information about the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP-CSHCN Contact Center at