Texas Medicaid Special Bulletin Update. Bulletin Contents, No. 174

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1 2003 HIPAA Special Bulletin Update, No. 174 Texas Medicaid Special update to the 2003 HIPAA Special Bulletin, No Special Bulletin Update Imptant Dates f HIPAA Implementation Refer to page 19 to review imptant dates f HIPAA Transaction and Sets implementation. Bulletin Contents, No. 174 HIPAA Awareness th Legislative Session Policy Changes th Legislative Changes Overview... 4 Change in Medically Needy Program f Clients Age 19 Years and Older... 4 Elimination of Chiropractic Services f Clients Age 21 Years and Older... 4 Elimination of Direct Graduate Medical Education f Ting Hospitals... 4 Elimination of Eyeglass and Contact Lens Services f Clients Age 21 Years and Older... 4 Elimination of Hearing Aid f Clients Age 21 Years and Older... 5 Elimination of Mental Health Counseling and Psychological Services f Clients Age 21 Years and Older... 6 Elimination of Services Provided by Podiatrists f Clients Age 21 Years and Older... 7 Medicaid Eligibility Fm (3087) Eligibility Indicats f Hearing Aid and Vision Services... 7 Primary Care Case Management (PCCM) Fee Reduction... 7 Professional Providers and Outpatient Facilities Reimbursement Reduction... 7 All Providers Changes to Electronic Eligibility Inquiries and Responses ( )... 8 Crections to 2003 HIPAA Special Bulletin, No Enfcement of s Procedure, Modifier, and Diagnosis ER&S Redesign and Balancing HIPAA Transaction and Sets Claim Status Inquiry HIPAA Transaction and Set Law and Other Insurance Submission Guidelines Imptant Dates f HIPAA Transaction and Sets Implementation New Claim Filing Indicat s Outpatient Hospital Services Release of Protected Health Infmation (PHI) Texas Medicaid Claim Details Changes, SP01 (50/99) Traditional, Managed Care, and MCO SSI Authizations Use of ICD-9-CM Diagnosis s Vend and Provider Testing Ambulance Providers Ambulance Reimbursement Changes Air Transpt Reimbursement Heritage Insurance Company (NHIC) is the insurer and contract administrat f the Texas Medicaid Program under contract the Texas Health and Human Services Commission (HHSC).

2 Bulletin Contents, continued Dental Providers Crections to Current Dental Terminology-4 (CDT-4)...29 Orthodontic Appliances...30 Paper Claim Fm Change f THSteps Dental Providers...30 Family Planning Providers Funds Gone EOB...31 IUD Devices...31 Labaty Handling Fee Update...31 Home Health and THSteps-CCP Providers Nutritional Supplements and Supplies...31 Genetics Providers Electronic Claim Submissions...50 Licensed Marriage and Family Therapists (LMFT) Providers LMFT Services...50 MHMR Providers Mental Health Rehabilitative Services Community Suppt...51 SHARS Providers SHARS Changes...52 THSteps Medical Providers THSteps Condition Indicats...53 THSteps Tuberculosis (TB) Screening...54 Vision Providers Vision Care Changes...54 Fms ADA Dental Claim Fm Instructions ADA Dental Claim Fm Sample...57 Note: This bulletin contains changes required by the Federal Health Insurance Ptability and Accountability Act of 1996 (HIPAA). The Medicaid Program rules implementing these changes are in process No HIPAA Special Bulletin Update

3 HIPAA Awareness Congress enacted the Health Insurance Ptability and Accountability Act of 1996 (HIPAA) to refm the health care insurance market and simplify the health care administrative processes. As a Medicaid provider, you will be required to comply HIPAA Electronic Data Interchange (EDI) and Privacy Regulations. Entities covered by HIPAA (called covered entities ) must comply the HIPAA EDI and Privacy Regulations. Covered entities include the following: Health plans, which include health insurers and health maintenance ganizations (HMOs) Blue Cross Blue Shield Medicare Medicaid Employee Retirement Income Security Act of 1974 (ERISA) defined Group Health Plans Health care providers who transmit any health infmation in electronic fm in connection transactions referred to in section 1173(a)(i) of the act Health care clearinghouses The Texas Medicaid Program filed an extension the Centers f Medicare and Medicaid Services (CMS) and will implement HIPAA EDI requirements by October 16, HIPAA requires covered entities that exchange covered transactions to comply national EDI standards. You can find extensive infmation about covered entities and covered transactions on the Centers f Medicare and Medicaid Services (CMS) Web site, Providers who use vend software TDHconnect 2.0 will be impacted by this mandate. HIPAA also requires the use of national standard codes. Medicaid local procedure codes and s currently in use also will be impacted. Look f me infmation in upcoming bulletins and wkshops about Texas Medicaid s implementation of these national standard codes. Imptant dates to remember Privacy Implementation Date: April 14, 2003 EDI Implementation Date: October 16, 2003 Privacy provisions should have been implemented by April 14, TDHconnect 3.0 will contain enhancements to ensure that providers submit HIPAA-compliant transactions after October 16, These enhancements will require changes to the infmation providers input. Watch f imptant infmation on HIPAA in future bulletins, banner messages, and provider wkshops. Visit the following Web sites f infmation and other helpful links: Resource Centers f Medicare and Medicaid Services Provider wkshops NHIC Provider Relations Training Specialists HIPAA Frequently Asked Questions (FAQs) Approved HIPAA Implementation Guides and Current listing of the Reason and Remark codes Health and Human Services Commission Privacy Other helpful links Web Site Address HIPAA Special Bulletin Update 3 No. 174

4 78th Legislative Session Policy Changes 78th Legislative Changes Overview The 78th Texas Legislature, Regular Session, House Bill 1 is the General Appropriations Bill f the Biennium. This bill s money f the suppt of the judicial, executive, and legislative branches of the government f the period beginning September 1, 2003, and ending August 31, 2005, authizing and prescribing conditions, limitations, rules, and procedures f allocating and expending the d funds. Specifically, Article II of this bill s money f the suppt, maintenance improvement of designated health and human service agencies. The 78th Texas Legislature, Regular Session, House Bill 2292 implements changes in health and human service policy necessary to ensure that Texas continues to serve its citizens who are most in need of health and human service assistance, and enacts measures that are necessary to deal the current budget crisis. Change in Medically Needy Program f Clients Age 19 Years and Older This article applies to all providers. Pursuant to the 78th Texas Legislative Session and changes to Medical Policy, the Medically Needy Program will no longer be available f clients age 19 years and older effective f dates of service on and after September 1, This coverage change includes both Spend down and ongoing coverage cases. The Clearinghouse will process Medically Needy Program cases certified by the TDHS befe September 1, Clients currently in the Medically Needy Program who qualify f other Medicaid programs will automatically be transferred to the Medicaid program befe September 1, Elimination of Chiropractic Services f Clients Age 21 Years and Older This article applies to providers of chiropractic services. As a result of budget cuts made by the 78th Texas Legislature, House Bill 1 Appropriations, effective f dates of service on and after September 1, 2003, chiropractic services will no longer be a benefit of the Texas Medicaid Program f clients age 21 years and older. Services will continue to be reimbursed f clients younger than age 21 years. Medicare coinsurance and deductible payments f clients age 21 years and older are not affected by this benefit reduction. The affected chiropractic procedure codes types of service (TOS) are: , , and Elimination of Direct Graduate Medical Education f Ting Hospitals This article applies to all ting hospitals in the Texas Medicaid Program. As per the 78th Texas Legislature, Regular Session, House Bill 2292, Section 2.100, effective f dates of service on and after September 1, 2003, direct graduate medical education (DGME) will no longer be reimbursed f ting hospitals in the Texas Medicaid Program. Hospitals reimbursed under the DRG methodology will no longer receive monthly payments f DGME and there will no longer be a reimbursement f DGME in the cost rept settlement, including the Children s ting hospitals. The interim rate used in the processing of claims f Children s ting hospitals will be modified to reflect the elimination of DGME. Elimination of Eyeglass and Contact Lens Services f Clients Age 21 Years and Older This article applies only to Vision Care providers. As a result of budget cuts made by the 78th Texas Legislature, House Bill 1 Appropriations, effective f dates of service on and after October 16, 2003, prosthetic and nonprosthetic eyeglass and contact lens services (excluding eye exams) will no longer be a benefit of the Texas Medicaid Program f clients age 21 years and older. Services will continue to be reimbursed f clients younger than age 21 years. Medicare coinsurance and deductible payments f clients age 21 years and older are not affected by this benefit reduction. No HIPAA Special Bulletin Update

5 The client s Medicaid eligibility Fm 3087 may continue to indicate that clients age 21 years and older are eligible f vision services f dates of service on after October 16, Regardless of this indicat on the Fm 3087, services rendered to clients age 21 years older are no longer eligible f vision benefits. The Texas Department of Human Services (TDHS) will update the Vision indicat on Fm 3087 at a later date and a mail stuffer explaining this eligibility Fm 3087 discrepancy to clients in the August 2003, Fm 3087 monthly mailing(s). The affected national eyeglass and contact lens procedure codes are listed below. Any reference to these procedure codes in the 2003 HIPAA Special Bulletin, No. 170 now applies only to clients younger than age 21 years. Affected Procedure s V2521 E-V2107 E-V2206 E-V V2522 E-V2108 E-V2207 E-V V2523 E-V2109 E-V2208 E-V V2530 E-V2110 E-V2209 E-V V2531 E-V2111 E-V2210 E-V V2500 E-V2020 E-V2112 E-V2211 E-V V2501 E-V2025 E-V2113 E-V2212 E-V V2502 E-V2100 E-V2114 E-V2213 E-V V2503 E-V2101 E-V2200 E-V2214 E-V V2510 E-V2102 E-V2201 E-V2300 E-V V2511 E-V2103 E-V2202 E-V2301 E-V V2512 E-V2104 E-V2203 E-V2302 E-V V2513 E-V2105 E-V2204 E-V2303 E-V V2520 E-V2106 E-V2205 E-V2304 E-V2755 Elimination of Hearing Aid f Clients Age 21 Years and Older This article applies to providers of hearing aid services. As a result of budget cuts made by the 78th Texas Legislature, House Bill 1 Appropriations, effective f dates of service on and after September 1, 2003, hearing aids, the exception of assessments, will no longer be a benefit of the Texas Medicaid Program f clients age 21 years and older. Medicare coinsurance and deductible payments f clients age 21 years and older are not affected by this benefit reduction. The client s Medicaid eligibility Fm 3087 may continue to indicate that clients age 21 years and older are eligible f hearing aids on after September 1, Regardless of this indicat on Fm 3087, services rendered to clients age 21 years older are no longer eligible f hearing aids. TDHS will update the Hearing Aid indicat on Fm 3087 at a later date and a mail stuffer explaining this eligibility Fm 3087 discrepancy to clients in the August 2003, Fm 3087 monthly mailing(s). The affected hearing aid procedure codes TOS are: R-Z5007, R-Z5008, R-Z8007, R-Z8008, R-Z8009, R-Z9070, and R-Z9999. Note: Clients younger than age 21 years will continue to receive services through HHSC s Program f Amplification f Children of Texas (PACT). The following national hearing aid procedure codes printed in the 2003 HIPAA Special Bulletin, No. 170, which would have become effective October 16, 2003 HIPAA, will not be implemented due to the elimination of hearing aid services: Affected Procedure s R R-V5100 R-V5220 R-V5253 R TG R-V5110 R-V5240 R-V5254 R R-V5120 R-V5241 R-V5255 R TG R-V5130 R-V5242 R-V5256 R-V5011 R-V5140 R-V5243 R-V5257 R-V5030 R-V5160 R-V5248 R-V HIPAA Special Bulletin Update 5 No. 174

6 Affected Procedure s R-V5040 R-V5170 R-V5249 R-V5259 R-V5050 R-V5180 R-V5250 R-V5260 R-V5060 R-V5200 R-V5251 R-V5261 R-V5090 R-V5210 R-V5252 R-V5264 Elimination of Mental Health Counseling and Psychological Services f Clients Age 21 Years and Older This article applies specifically to the following providers: Licensed Master Social Wker Advanced Clinical Practitioners (LMSW-ACP), Licensed Professional Counsels (LPC), Licensed Marriage and Family Therapists (LMFT), Licensed Psychologists, and Federally Qualified Health Centers (FQHC). As a result of budget cuts made by the 78th Texas Legislature, House Bill 1 Appropriations; Senate Bill 810; Section of House Bill 2292, effective f dates of service on and after October 16, 2003, mental health counseling and psychological services billed perfmed by an LMSW-ACP, an LPC, an LMFT, a Licensed Psychologist, an FQHC will no longer be a benefit of the Texas Medicaid Program f clients age 21 years and older. Services will continue to be reimbursed f clients younger than age 21 years. Medicare coinsurance and deductible payments f clients age 21 years and older are not affected by this benefit reduction. The following table lists the affected mental health counseling and psychological procedure codes TOS: Procedure Psychiatric diagnostic interview examination Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, other mechanisms of communication / * Individual psychotherapy, insight-iented, behavi-modifying and/ supptive, in an office outpatient facility, approximately 20 to 30 minutes face-to-face the patient / * Individual psychotherapy, insight-iented, behavi-modifying and/ supptive, in an office outpatient facility, approximately 45 to 50 minutes face-to-face the patient / * Individual psychotherapy, insight-iented, behavi-modifying and/ supptive, in an office outpatient facility, approximately 75 to 80 minutes face-to-face the patient / * Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, other mechanisms of nonverbal communication, in an office outpatient facility, approximately 20 to 30 minutes face-to-face the patient / * Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, other mechanisms of nonverbal communication, in an office outpatient facility, approximately 45 to 50 minutes face-to-face the patient / * Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, other mechanisms of nonverbal communication, in an office outpatient facility, approximately 75 to 80 minutes face-to-face the patient / * Individual psychotherapy, insight-iented, behavi-modifying and/ supptive, in an inpatient hospital, partial hospital residential care setting, approximately 20 to 30 minutes face-to-face the patient / * Individual psychotherapy, insight-iented, behavi-modifying and/ supptive, in an inpatient hospital, partial hospital residential care setting, approximately 45 to 50 minutes face-to-face the patient / * Individual psychotherapy, insight-iented, behavi-modifying and/ supptive, in an inpatient hospital, partial hospital residential care setting, approximately 75 to 80 minutes face-to-face the patient / * Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital residential care setting, approximately 20 to 30 minutes face-to-face patient / * Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital residential care setting, approximately 45 to 50 minutes face-to-face patient * These procedure codes should be billed by a psychiatrist and in conjunction the AM ; these codes should be billed only by a physician, specifically a psychiatrist. The AM must be present at the detail level f of these procedure codes billed. If the AM is not present and the client is age 21 years older, the service will be denied. No HIPAA Special Bulletin Update

7 Procedure / * Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital residential care setting, approximately 75 to 80 minutes face-to-face patient Psychoanalysis Family psychotherapy (conjoint psychotherapy) ( patient present) Group psychotherapy (other than of a multiple-family group) Interactive group psychotherapy * Narcosynthesis f psychiatric diagnostic and therapeutic purposes (sodium amobarbital interview) Psychological testing Neuropsychological testing battery * These procedure codes should be billed by a psychiatrist and in conjunction the AM ; these codes should be billed only by a physician, specifically a psychiatrist. The AM must be present at the detail level f of these procedure codes billed. If the AM is not present and the client is age 21 years older, the service will be denied. Elimination of Services Provided by Podiatrists f Clients Age 21 Years and Older This article applies only to podiatrists. As a result of budget cuts made by the 78th Texas Legislature, House Bill 1 Appropriations; Section of House Bill 2292, effective f dates of service on and after October 16, 2003, services provided by a podiatrist will no longer be a benefit of the Texas Medicaid Program f clients age 21 years and older. Services provided by a podiatrist will continue to be reimbursed f clients younger than age 21 years. Medicare coinsurance and deductible payments f clients age 21 years and older are not affected by this benefit reduction. Medicaid Eligibility Fm (3087) Eligibility Indicats f Hearing Aid and Vision Services The client s Medicaid eligibility Fm 3087 may continue to indicate that clients age 21 years and older are eligible f hearing aid and vision services f dates of service on after September 1, 2003 and October 16, 2003, respectively. Regardless of this indicat on Fm 3087, services rendered to clients age 21 years older are no longer eligible f vision hearing aid benefits under Medicaid as specified in the Elimination of Hearing Aid f Clients Age 21 Years and Older and 'Elimination of Eyeglass and Contact Lens Services f Clients Age 21 Years and Older' articles. The TDHS will update the Hearing Aid and Vision indicats on Fm 3087 at a later date and a mail stuffer explaining this eligibility Fm 3087 discrepancy to clients in the August 2003, Fm 3087 monthly mailing(s). Primary Care Case Management (PCCM) Fee Reduction The following infmation applies to all Managed Care providers who are participating in the Texas Health Netwk (THN- PCCM). As a result of budget cuts made by the 78th Texas Legislature, House Bill 1 Appropriations; Senate Bill 810; Section of House Bill 2292, effective September 1, 2003, all Primary Care Case Management (PCCM) fees will be reduced by 5 percent. Providers are currently paid $3.00 per member per month f client on their Texas Health Netwk client roster. With this new legislation, this fee will be changed to $2.85 per client. Check distribution and the summary letter f the case management fees will remain the same. Adjustments will be applied to the case management fees as they are currently. Professional Providers and Outpatient Facilities Reimbursement Reduction As per the 78th Texas Legislature, Article II of House Bill 1, and Section 2.03 of House Bill 2292, effective f dates of service on and after September 1, 2003, professional and outpatient services will receive a 5 percent reduction in their final Medicaid payment amount. These reductions apply to Medicaid, Medicaid Managed Care, Family Planning, and the Children Special Health Care Needs (CSHCN) Program. The following services are excluded from the reimbursement reductions: FQHC and Rural Health Clinic (RHC) provider services Public providers that certify funds Family Planning Title X 2003 HIPAA Special Bulletin Update 7 No. 174

8 Durable Medical Equipment (DME) and DME Supplies Children s Hospitals Medicaid and Medicaid Managed Care Inpatient Claims CSHCN outpatient and inpatient claims CSHCN hemophilia claims, drug co-pays, and transptation of remains Medicare Crossover claims All Providers Changes to Electronic Eligibility Inquiries and Responses ( ) The following changes to electronic eligibility inquiries and responses will take effect on and after October 16, 2003: When providers perfm an acute care client eligibility inquiry using the client name, they can enter the clients name using the following fields: Last Name, First Name, MI, and Suffix. When providers receive an electronic acute care client eligibility response, the client suffix is now separated from the last name (f example: SMITH, JOHN C JR). The Medicaid Fm 3087 will continue to show the suffix appended to the last name (f example: SMITHJR, JOHN C). Providers should file their electronic and paper claims the suffix separated from the client s last name. The provider s last name and suffix, as well as the third party resources (TPR) insurance policy name s last name and suffix, will also be separated on the acute care client eligibility response. Authization infmation will no longer be returned on the eligibility responses. Providers may continue to obtain authization infmation through faxbacks and customer service. TPR Relationship to Insured will no longer be returned on the electronic eligibility response. Crections to 2003 HIPAA Special Bulletin, No. 170 DME Modifiers This article crects the DME Modifiers table on page 28 of the 2003 HIPAA Special Bulletin, No The comment associated national UE in the table should have d: Use of UE results in TOS 9 being assigned. Fetal Moniting The article on page 46 of the 2003 HIPAA Special Bulletin, No. 170 was erroneously placed under the Physician Providers heading. This article discusses the fetal moniting codes used by outpatient hospitals and should have appeared on page 43 under the Hospital Providers heading. Appendix A: Medicaid Local to Table The following table includes crections and revisions to the Medicaid local codes that appeared in Appendix A, starting on page 71, in the 2003 HIPAA Special Bulletin, No Revisions are noted grey text. Local Local Special Instructions 0999Y Anesthesia services Discontinued; TOS X Individual counseling services by LMSW-ACPs and LPCs, per hour $ Individual psychotherapy, insight-iented, behavi modifying and/ supptive, in an office outpatient facility, approximately 45 to 50 minutes face-to-face the patient $53.86 No HIPAA Special Bulletin Update

9 Local 1051X 1052X 1150X 1151X 1152X 4001X 4002X 4003X 4004X 5054X 5055X 7011X 7014X Group counseling services by LMSW-ACPs and LPCs, per hour Family counseling services by LMSW-ACPs and LPCs, per hour Individual counseling services by LMFT, per hour Group counseling services by LMFT, per hour Family counseling services by LMFT, per hour Face-to-face case management, pregnant adolescent woman Face-to-face case management, infant Telephone case management, pregnant adolescent woman Telephone case management, infant Addition to lower extremity thosis anteri shell f AFO Addition to lower extremity thosis, fefoot velcro strap, Psychological services, 15 minutes School health services, 15 minutes Local $ Group psychotherapy (other than of a multiple-family group) $ Family psychotherapy (conjoint psychotherapy) ( patient present) $ U8 $ U8 $ U8 $14.67 H0004 AH Individual psychotherapy, insight iented, behavi modifying and/ supptive, in an office outpatient facility, approximately 45 to 50 minutes face-to-face the patient Medicaid level of care 8, as defined by (LMFT) Group psychotherapy (other than of a multiple-family group) Medicaid level of care 8, as defined by (LMFT) Family psychotherapy (conjoint psychotherapy) ( patient present) Medicaid level of care 8, as defined by (LMFT) Behavial health counseling and therapy, per 15 minutes Clinical psychologist $13.47 $53.84 $53.86 $13.47 $53.84 $14.67 $13.06 T1002 RN services, up to 15 minutes $13.06 Special Instructions Discontinued Discontinued Discontinued Discontinued Discontinued Discontinued not payable separately 2003 HIPAA Special Bulletin Update 9 No. 174

10 Local Local Special Instructions 7015X Assessment, 15 minutes $ Psychological testing (includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g., WAIS-R, Rschach, MMPI) interpretation and rept, per hour $77.88 per hour Bill partial hours as 1/10th of an hour, e.g., express 30 minutes as X Individual - community suppt services by professional (MH rehab) $34.56 H2017 HN HO HP TD Psychosocial rehabilitation services, per 15 minutes Bachel s degree level Master s degree level Doctal level RN $17.28 per 15 minutes 8011X Individual - community suppt services by paraprofessional (MH rehab) $25.10 H2017 HM TE Psychosocial rehabilitation services, per 15 minutes Less than bachel s degree level LPN/LVN $12.55 per 15 minutes 8012X Group - community suppt services by professional (MH rehab) $9.49 H2017 HQ and HN HO HP TD Psychosocial rehabilitation services, per 15 minutes Group setting and Bachel s degree level Master s degree level Doctal level RN $4.75 per 15 minutes 8013X Group - community suppt services by paraprofessional (MH rehab) $6.54 H2017 HQ and HM TE Psychosocial rehabilitation services, per 15 minutes Group setting and Less than bachel s degree level LPN/LVN $3.27 per 15 minutes 9100X Comprehensive visit, (face-to-face) $54.58 G9012 s U2 and U5 Other specified case management service not elsewhere classified Medicaid level of care 2, as defined by (Comprehensive needs assessment) and Medicaid level of care 5, as defined by (face-toface) $54.58 If FQHC provider, specific encounter rate Modifier EP will not be required f FQHCs No HIPAA Special Bulletin Update

11 Local 9101X 9102X X9999 X9999 Follow-up visit (face-toface) Follow-up visit (telephone) Surgery, not otherwise classified, same day care included NOC, labaty and pathology $54.58 G9012 s TS and U5 $18.00) G9012 TS Other specified case management service not elsewhere classified Follow-up service and Medicaid level of care 5, as defined by (face-toface) Other specified case management service not elsewhere classified Follow-up service $54.58 If FQHC provider, specific encounter rate $18.00 If FQHC provider, specific encounter rate Modifier EP will not be required f FQHCs Modifier EP will not be required f FQHCs Discontinued; TOS 2 Discontinued; TOS 5 X9999 Crossover lump code Discontinued; TOS X Y7107 Miscellaneous supplies Discontinued; TOS 9: providers should bill the revenue code. Y9999 Surgery, not otherwise classified, min/ diagnostic Discontinued; TOS 2 Y9999 NOC, supply Discontinued; TOS 9 Z9800 Z9801 Z9801 Z9802 Z9802 Z9803 Z9804 Comprehensive (initial hospital care), hospital physician Maintenance IPD session, 20 to 29 hours Intensive (psychiatric/ medical) follow-up care, hospital physician Maintenance IPD session, 30 me hours Systematic (psychiatric/medical) follow-up care, hospital physician Maintenance (psychiatric/medical) follow-up care, hospital physician Individual medical psychotherapy, hospital physician Local Special Instructions Discontinued; TOS 9 Discontinued; TOS 1 Discontinued; TOS 9 Discontinued; TOS 1 Discontinued; TOS 9 Discontinued; TOS 9 Discontinued; TOS HIPAA Special Bulletin Update 11 No. 174

12 Local Z9805 Group medical psychotherapy, hospital physician Discontinued; TOS 9 Z9999 NOC, medical services Discontinued; TOS 1 Z9999 Unlisted surgical procedure including 6 weeks of postoperative care Discontinued; TOS 2 The following table includes additional Medicaid local codes that were omitted from Appendix A in the 2003 HIPAA Special Bulletin, No. 170: Local Local Special Instructions 0999Y Home Health Services Discontinued; TOS C 5061X Wrap around dynamic design AFO molded to patient Discontinued 5065X 5127X Insulin syringes 100 per box (3/10 cc) Electronic blood pressure moniting device (i.e., dynamap) rental, per month 5134X Therapy rolls, wedges, bolsters balls 5160X Sharps container, small medium 5162X Ambu bag Manually reviewed 5188X Bed wetting trainer/ alarm $ E1399 Durable medical equipment, miscellaneous S8999 Resuscitation bag (f use by patient on artificial respiration during power failure other catastrophic event) Manually reviewed $58.26 Discontinued Discontinued; not a benefit Discontinued; not a benefit Discontinued 5190X Oraswabs, Discontinued; not a benefit 5201X Stethoscope Discontinued; not a benefit 5224X Respiraty therapist, home health only Discontinued 5232X Procedure/supply as specified on CCP/PA only Local 5238X Carrie collar $89.00 A9900 Miscellaneous DME supply, accessy, and/ service component of another HCPCS code Manually reviewed Special Instructions Discontinued 5239X Hot cold packs Discontinued 5272X Jobst stockings, 1 pair Discontinued 5285X Diasb tablets, box of 24 Discontinued; not a benefit No HIPAA Special Bulletin Update

13 Local 5306X Shower pack plastic pouches f showering pump, 30 per package Discontinued, not a benefit 5315X Type 2 wafer joint Discontinued thotic, 5317X Dial-a-flow tubing Discontinued 5323X Genu V transfmer Discontinued; not a benefit 5332X Disposable probes f pulse oximeters, Discontinued; not payable separately 5336X Cath-n-Sleeve suction catheters, $2.00 A4609 A4610 Tracheal suction catheter, closed system, f less than 72 hours of use, Tracheal suction catheter, closed system, f 72 me hours of use, 5352X Eye patches, box of 20 $5.00 A6411 Eye pad, non-sterile, $ X Cast shoe Discontinued; not payable separately 5363X Cervical collar/foam Discontinued 5367X Midline catheter, (PICC, landmark, etc.) Discontinued 5374X Cast blast powder, 4.5 oz/can 5449X IV armboard, 2x9, disposable, 10 per package 5453X Suture removal kit, per kit 5460X 5464X 5475X 5633X Huber needle, winged infusion set injection site, 19 gauge x 1.5 in., IV start kit/central-line insertion tray, Adapter plug, male, locking Luer 1 1/2, 2 per package, Medicated shampoo, 4oz Local $2.00 $2.00 Special Instructions Discontinued Discontinued; not payable separately Discontinued Discontinued Discontinued Discontinued Discontinued 5804X Tenodesis splint Discontinued 2003 HIPAA Special Bulletin Update 13 No. 174

14 Local Local Special Instructions X2998 Adenoidectomy and bilateral myringotomy insertion of tubes ASC: Group and Adenoidectomy, primary; under age 12 Adenoidectomy, primary; age 12 over Adenoidectomy, secondary; under age 12 Adenoidectomy, secondary; age 12 over and Tympanostomy (requiring insertion of ventilating tube), local topical anesthesia Tympanostomy (requiring insertion of ventilating tube), general anesthesia ASC: Group 2 ASC: Group 4 ASC: Group 2 ASC: Group 4 ASC: Group 1 ASC: Group 3 When multiple procedures are billed, the procedure the highest group payment will be paid. Y9999 Genetics procedure not otherwise classified Manually reviewed Unlisted special service, procedure rept Manually reviewed Enfcement of s Procedure, Modifier, and Diagnosis Covered entities under HIPAA are required to conduct covered transactions in standard fmats as of October 16, 2003 if they submitted a compliance plan by October 15, The Texas Medicaid Program and the Health and Human Services Commission will require the use of national procedure codes and s effective f dates of service on and after October 16, Refer to: Appendices A, B, and C in the 2003 HIPAA Special Bulletin, No. 170 f the Local changes. Section 532 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) authizes the Secretary of Health and Human Services to allow the public to continue using HCPCS Level III codes through December 31, BIPA defines HCPCS Level III codes as the alphanumeric codes f local use under the Health Care Financing Administration [now Healthcare] Common Procedure Coding System (HCPCS). The Centers f Medicare & Medicaid Services (CMS) has determined that the term HCPCS Level III codes, as used in this BIPA provision, applies both to the codes that Medicare has approved f local contract use and to the local codes that Medicaid agencies and SCHIP programs have developed and used f their own purposes. Therefe, Centers f Medicare & Medicaid Services (CMS) is allowing the use of local codes developed by Medicaid and SCHIP programs through December 31, ER&S Redesign and Balancing This article summarizes modifications to the 835 Health Care Claim Payment/Advice to meet HIPAA compliance. The Finalized Electronic and Remittance & Status (ER&S) interface file is produced weekly during the Compass21 Financial Processing Cycle. Finalized ER&S recds are then translated to produce the 835 Health Care Claim Payment/ Advice. Modifications are required to the Compass21 system to generate HIPAA-compliant 835 Health Care Claim Payment/Advices, which are then fwarded to the provider community. The ER&S rept is a subset of the infmation that appears on a provider s paper Remittance & Status (R&S) rept. The R&S rept itemizes all claim infmation as well as other transactions considered during provider payment processing. The ER&S rept includes finalized claim and provider payment adjustment infmation. The following claim statuses are considered finalized and appear on the Finalized ER&S rept: P D F Paid Claims including Adjustment Claims Denied Claims including Adjustment Claims Family Planning Funds Gone Claims No HIPAA Special Bulletin Update

15 I X A Infmational Claims Denied Claims not used f Auditing Histy Adjusted Claims (new to finalized ER&S HIPAA) ER&S Rept Changes To achieve HIPAA compliance, new fields have been added, some have been modified, and others have been deleted on the 835 Health Care Claim Payment/Advice. The following sections list the modifications to the 835 Health Care Claim Payment/Advice. New Fields The following fields have been added to the HIPAA-compliant 835 Health Care Claim Payment/Advice fields: Field Name Facility Type First and second positions of Type of Bill f claim types 023, 031, 040, 050 (institutional) Place of Service f all other claims Claim Frequency Type Third position of Type of Bill. Specific to institutional claims (claim types 023, 031, 040, 050). Procedure Qualifier Identifies the source of the procedure code: AD American Dental Association s f Dental Claims HC HCPCS s f all other claims Submitted Procedure Identifies the source of the submitted procedure code: Qualifier AD American Dental Association s f Dental Claims HC HCPCS s f all other claims Submitted Procedure Procedure code as submitted on claim; populated only when procedure code is changed during adjudication. Submitted Modifiers Modifiers as submitted on claim; populated only when is changed during adjudication. Submitted PCN PCN as submitted on claim; populated only when PCN is changed during adjudication. Patient Middle Initial and The middle initial and suffix of the patient as submitted on claim. Suffix Payer Infmation Payee DFI and Bank Account Number Payee Account Type Adjudication Cutoff Date Claim Filing Indicat Line Item Control Number DRG Weight Discharge Fraction Patient Identification Qualifier Perfming Provider Reference Identification Qualifier Populated only when payment is via electronic funds transfer (EFT): Federal Tax Identification NHIC Federal Tax ID NHIC Deposity Financial Institution (DFI) Bank Account Number Street Address Populated only when payment is via EFT: Provider s DFI and Bank Account Number. Populated only when payment is via EFT: C Checking S Savings Financial Cycle Date TV Title V: Family Planning Title V claims OF Other Federal Program: Family Planning Title X XX claims DS Disability: CSHCN claims MC Medicaid: All other claims As submitted on claim. Relative Weight; specific to DRG claims. Days of Stay divided by Average Length of Stay (specific to institutional claims). MI Member Identification Number 1D Medicaid Provider Number 2003 HIPAA Special Bulletin Update 15 No. 174

16 Field Name Receiver Not Payee Indicat Provider's Last Day of Fiscal Year Always blank Always yyyy1231 where yyyy = current year Deleted Fields The following fields have been deleted from the HIPAA-compliant 835 Health Care Claim Payment/Advice: Provider Address 2; provider street address is limited to one line Vend ID R&S Number Provider Physical Address Diagnosis on Claim Detail EOB s Patient Status New Patient Indicat Outlier Amount Other Insurance Amount Other Insurance Phone 1 Other Insurance Phone 2 Other Insurance Name 3 Other Insurance Phone 3 Expanded Fields The following fields have been expanded to provide a HIPAA-compliant 835 Health Care Claim Payment/Advice: Field Name Medical Recd Number Patient Account Number Other Insurance Carriers of Change The length is being increased from 17 to 30 characters. The length is being increased from 17 to 38 characters (although claims may only submit 20 characters). The Other Insurance carriers transmitted on the finalized ER&S has been reduced from three to two. Converting Explanation of Benefit (EOB) s The following sections explain the conversion of local EOB codes to HIPAA-compliant nationally standardized codes. Claim Payment Adjustments Currently, the 835 Health Care Claims Payment/Advice contains a claim s billed and paid amounts along one me EOB codes some of which explain variances between the two amounts. EOB code(s), billed amount and paid amount are included f service (claim detail) as well as at the claim header level. HIPAA requires that the 835 Health Care Claim Payment/Advice be expanded to include Claim Adjustment Segments (CAS) to provide the specific reason and amount of adjustment the payer made to the iginal submitted charges. The summation of the payment adjustments at the claim and service levels is the total payment adjustment f the claim. Service level payment adjustments (CAS) are not repeated at the claim header level. HIPAA requires that CAS include a standardized Claim Adjustment Reason (CARC) to explain payment adjustments. HIPAA prohibits the use of local EOB codes on the 835 Health Care Claim Payment/Advice. EOB codes associated the Payment Adjustment will be converted to the HIPAA-compliant CARC. Each CARC is categized by a Claims Adjustment Group (CAGC). The CAGC, CARC, and amount of the payment adjustment will be included in the CAS. No HIPAA Special Bulletin Update

17 Health Claim Remarks Local EOB codes are attached to claims during adjudication to explain benefits and convey adjudication remarks. Up to four EOB codes per claim header and up to five EOB codes per claim detail are currently repted on the 835 Health Care Claim Payment/Advice. HIPAA requires the use of standard Remittance Advice Remark s (RARC) and prohibits local EOB codes on the 835 Health Care Claim Payment/Advice. EOB codes attached to a claim will convert to the associated RARC(s). RARC codes are carried on the LQ Segment of the 835 Health Care Claim Payment/Advice. LQ Segments are restricted to the claim service detail level. Header-level RARC codes will appear on the LQ Segment(s) f every detail on the claim. RARC codes attached to a given claim detail will appear on the LQ Segment(s) f that detail only. RARC codes will not be duplicated on LQ Segment(s) f any one detail. F claims that do not include detail service infmation, such as DRG claims, no RARC codes will be included on the 835 Health Care Claim Payment/ Advice. Provider-level Payment Adjustments Currently, provider-level payment adjustments are reflected as Cash Transactions on the 835 Health Care Claim Payment/Advice an EOB denoting the type and reason f the transaction and the amount of the payment adjustment. The HIPAA-compliant 835 Health Care Claim Payment/Advice includes PLB Segments to convey providerlevel payment adjustments. HIPAA requires the use of standardized Provider-Level Adjustment Reason s (PARC) to indicate the reason f the adjustment and prohibits the use of local EOB codes on the 835 Health Care Claim Payment/Advice. EOB codes will be converted to the cresponding national PARC. ER&S Rept Balancing The HIPAA-compliant 835 Health Care Claim Payment/Advice must balance whenever remittance infmation is included in an 835 Transaction Set. F a balanced 835 Health Care Claim Payment/Advice, the total payment must agree the remittance infmation detailing the payment. The remittance infmation must also reflect an internal numeric consistency. Balancing edits are perfmed on the Claim Detail, Claim Header, and Provider levels. Specific infmation about type of balancing is discussed in the following sections. Claim Detail Balancing Claim detail billed amount plus/minus claim detail payment adjustment amount(s) (Detail CAS) must equal the claim detail paid amount. Claim Header Balancing When no claim details are being sent on the ER&S, claim header billed plus/minus claim header payment adjustment amount(s) (Header CAS) must equal claim header paid amount. When claim details are included on the ER&S, claim header billed amount plus/minus the sum of the claim header payment adjustment amount(s) (Header CAS) and the claim detail payment adjustment amount(s) (Detail CAS) must equal the claim header paid amount. Provider-level Balancing Total of provider s claim header paid amounts f the ER&S plus/minus all provider-level payment adjustments (PLB) must equal the provider s actual payment amount. Note: F claim header and detail payment adjustments (CAS) and provider-level payment adjustments (PLB): (+) Positive Amount Decreases Payment (-) Negative Amount Increases Payment Provider-Level Balancing Family Planning Titles V, X, XX Funds Gone Claims Family Planning claims in Funds Gone status are finalized but not paid denied. On the 835 Health Care Claim Payment/Advice the claim reflects the would-have-paid amount; however, would-have-paid amount(s) are not added to the provider s payment amount. Because HIPAA requires that the Finalized ER&S balance at the provider level, the finalized ER&S process will generate a provider-level adjustment to offset the total of the provider s Funds Gone claims HIPAA Special Bulletin Update 17 No. 174

18 Denied and Infmational Details on Paid Claims Paid claims may contain claim details that have been denied marked as infmational only. The finalized ER&S process will generate offsetting adjustments to bring the ER&S claim into balance. Denied and Infmational Claims Denied and infmational claims are considered finalized and are repted on the 835 Health Care Claim Payment/ Advice. These claims are held to the same HIPAA balancing standards as other types of claims on the Finalized ER&S rept. Offsetting claims adjustments are included on the finalized ER&S rept to balance denied and infmational claims. Adjustment Claims & Balancing F claim adjustment, the 835 Health Care Claim Payment/Advice contains the iginal claim monetary balancing amounts reversed. Since HIPAA balancing rules apply to adjustment claims, any finalized ER&S claim detail and/ CAS segments that existed on the iginal claim when it was paid, must be included in the reversal. When a claim is adjusted and the adjustment claim is f the same provider and program as the iginal claim, both claims appear on the same Finalized ER&S rept. If, however, the adjustment claim is f a provider and/ program different than the iginal claim, the mother and daughter claims appear on separate 835 Health Care Claim Payment/ Advice transaction sets. When required, the finalized ER&S process will generate offsetting provider-level Payment Adjustments to ensure 835 Health Care Claim Payment/Advice balancing. Changes to the Paper R&S Rept The following changes will be made to the paper R&S rept to accommodate other HIPAA-related changes in the Compass21 system: The paper R&S rept will display the submitted procedure code instead of the processed (adjudicated) procedure code. The fmat of the paper R&S rept will be changed f the following programs: 100 (Medicaid) 200 (Managed Care) 400 (CSHCN) The Patient Account number has been expanded to 20 characters and is located below the Patient Name field on the paper R&S rept. The Medical Recd Number Field has been expanded to 30 characters, but has not moved on the paper R&S rept. F program 300 (Family Planning), the length of the Medical Recd Number and Patient Account Number fields will also be expanded on the paper R&S rept, but will remain in their current locations. Providers will continue to receive the paper R&S rept after October 16, HIPAA Transaction and Sets Claim Status Inquiry HIPAA requirements specify that a Client ID must accompany all 276 Claim Status Inquiry (CSI) requests. Inquiries by Provider ID only (Interactive Claim Request, Batch Claims Request, and Batch Provider Claims Request) are no longer valid. Under HIPAA, NHIC will use only one interactive CSI request, the Interactive Claim by ICN. Two types of batch requests exist: Batch Inquiry by ICN Batch Inquiry by Service Date Span. All these inquiries will include the provider and client infmation as well as the other HIPAA-required infmation. If both ICN and Date Range are provided, Batch Inquiry by ICN will be assumed. The Batch Transmission Detail Request and the Interactive Transmission Summary Request CSI inquiries are not covered transactions under HIPAA because CSI Transmission ID ( Batch ID) is not a 276 data element and will no longer be available. No HIPAA Special Bulletin Update

19 HIPAA Transaction and Set Law and Other Insurance Submission Guidelines With the implementation of HIPAA Transaction and Set rules, Texas Medicaid providers are still required to submit the same Other Insurance infmation as required presently on all claims submissions. Although the HIPAA Transaction claim does not specifically account f the infmation surrounding verbal denials, Other Insurance Company Address, and the 110-Day Rule, these requirements have not been altered. While the type of infmation to be submitted f Other Insurance has not changed, the procedure f submitting it has changed. This infmation will now be submitted through the Paperwk (PWK) segment of the claim submission. The specific segments used will be PWK01, 02, 05, and 06. Detailed infmation on the fmat f submitting this infmation can be found in the HIPAA Transaction Standard Companion Guides f Institutional, Professional, and Dental Claims. Instructions f obtaining these guides can be found on the Internet at To verify that providers are submitting the crect infmation, review the 2003 Texas Medicaid Provider Procedures Manual. Ensure that the required infmation will be submitted in the proper fmats befe the scheduled October HIPAA Transaction and Set rule implementation, the submitted claims will be at risk of denial f lack of Other Insurance infmation. Imptant Dates f HIPAA Transaction and Sets Implementation To ensure the timeliness and accuracy of the implementation of HIPAA Transaction and Sets on October 16, 2003, NHIC has established several deadlines and cutover dates that affect Texas Medicaid providers. Review the following table f dates and activities that impact your office: All Electronic Transactions (Eligibility, Claims, Claim Status Inquiries, Appeals, and ER&S repts) Date Time 10/15/2003 6:00 p.m. NHIC s last download of transactions from the BBS that are not HIPAA-compliant. 10/15/2003 6:01 p.m. 11:59 p.m. TDHconnect 3.0 Compass21 system unavailable f any electronic transactions (Eligibility, Claims, Claim Status Inquiries, Appeals, ER&S repts). AIS will be available during this time period. 10/16/ :01 a.m. First submission of HIPAA-compliant transactions f Compass21 system (Acute Care). Date Time 09/02/2003 to 09/29/2003 TDHconnect 3.0 training offered to providers. 09/26/2003 Software is mailed to all current users (Acute Care). 10/01/2003 Providers begin receiving TDHconnect 3.0 CD-ROM in the mail. 10/10/2003 Providers should contact the EDI Helpdesk if they have not received TDHconnect 3.0. Befe 10/16/2003 It is recommended that providers download and update TDHconnect 2.0 Service Pack 7 befe installing TDHconnect 3.0. Befe 10/16/2003 Providers must install TDHconnect 3.0. Last transaction should be completed by the provider befe this task is perfmed. The provider must have downloaded all response files using TDHconnect 2.0. Providers must download and install Service Pack 1 after installation of TDHconnect 3.0 from the CD-ROM has been completed (SP 1 will be available at in the TDHconnect File Libraries). Providers must download and update the reference files after TDHconnect 3.0 has been installed and Service Pack 1 has been downloaded and installed. (updated reference codes will be available at Providers must convert databases from TDHconnect 2.0 to TDHconnect /15/2003 6:00 p.m. Last transactions must be completed using TDHconnect /16/ :01 a.m. Transactions must be sent using TDHconnect 3.0. ER&S repts not downloaded TDHconnect 2.0 can be downloaded TDHconnect HIPAA Special Bulletin Update 19 No. 174

20 Authizations Date 09/02/2003 Authizations may be submitted national codes in lieu of local procedure codes (refer to the article titled Traditional, Managed Care, and MCO SSI Authizations on page 28 ). Providers may submit new authization requests f dates of service on and after October 16, 2003 the national codes. Providers may resubmit authization requests f approved authizations where the local code(s) iginally used and approved was mapped to multiple national codes. ADA Paper Claim Fms Date 10/15/2003 Last day f NHIC to accept old ADA Dental Claim fms from providers. If 2002 ADA Claim fms are received befe this date, NHIC will return the claims to the provider a cover letter. 10/16/2003 First day NHIC will accept new 2002 ADA Dental claim fm. If old ADA Claim fms are received on after this date, NHIC will return the claims to the provider a cover letter. New Claim Filing Indicat s With the implementation of HIPAA on October 16, 2003, several new Claim Filing Indicat s have been added and the usage of some existing codes will change. HIPAA legislation also requires that Texas Medicaid return the indicat code back to the provider on the ER&S rept. To meet this requirement the following Claim Filing Indicat s have been assigned: Texas Medicaid/Medicaid Managed Care claims will continue to be submitted using the MC value. Medicare Part A claims are currently submitted using the general Medicare code (MB). As of October 16, 2003, Medicare Part A claims will be submitted the MA value. Medicare Part B claims will continue to be submitted the MB value. CSHCN claims are currently submitted the ZZ value. As of October 16, 2003, CSHCN claims will be submitted the DS value. Note: The meaning of Claim Filing Indicat, ZZ has changed from Other to Mutually Defined-Unknown. Family Planning Title V is currently submitted the general Medicaid code, MC. As of October 16, 2003, Family Planning Title V claims will be submitted the TV value. Family Planning Title X and Title XX are currently submitted under the general Medicaid MC value. As of October 16, 2003, Family Planning Title X and Title XX will be submitted the OF value, Other Federal Programs. The ER&S rept now includes a field f Claim Filing Indicat. The value returned on the ER&S rept will be the same value submitted on the claim. If a claim is received a value other than a HIPAA-mandated value, the claim will be rejected a message to the provider indicating the general nature of the problem. No HIPAA Special Bulletin Update

21 Outpatient Hospital Services Effective f dates of service on after October 16, 2003, providers must use the revenue code when billing f outpatient hospital services. In some instances the HCPCS procedure code may be necessary, in addition to the revenue code, to further specify the service f accurate claims processing. The following table lists and describes outpatient hospital service revenue codes and identifies those that will require the HCPCS procedure code: Revenue Comments Pharmacy 250 General classification 251 Generic drugs 252 Nongeneric drugs 253 Take home drugs Not a benefit 254 Drugs incident to other diagnostic services 255 Drugs incident to radiology 256 Experimental drugs Not a benefit 257 Nonprescription drugs 258 IV solutions 259 Other pharmacy 631* Single source drug HCPCS code required 632* Multiple source drug HCPCS code required 633* Restrictive prescription HCPCS code required 634* Erythropoietin (EPO) less than 10,000 units HCPCS code required 635* Erythropoietin (EPO) 10,000 me units HCPCS code required 636* Drugs requiring detailed coding HCPCS code required 637 Self-administrable drugs Not a benefit IV Therapy 260 General classification 261 Infusion pump 262 IV therapy/pharmacy services 263 IV therapy/drug/supply delivery 264 IV therapy/supplies 269 Other IV therapy Medical/Surgical Supplies and Devices 270 General classification 271 Nonsterile supply 272 Sterile supply 273 Take home supplies Not a benefit 274* Prosthetic/thotic devices HCPCS code required 275 Pacemaker 276 Intraocular lens 277 Oxygen, take home Not a benefit 278* Other implants HCPCS code required 279* Other supplies/devices HCPCS code required 621 Supplies incident to radiology 622 Supplies incident to other diagnostic services * HCPCS procedure code is required in addition to revenue code f accurate claims processing HIPAA Special Bulletin Update 21 No. 174

22 Revenue Comments 623 Surgical dressings 624 FDA investigational devices Not a benefit Oncology 280 General classification 289 Other oncology Labaty 300* General classification HCPCS code required 301* Chemistry HCPCS code required 302* Immunology HCPCS code required 303* Renal patient (home) HCPCS code required 304* Nonroutine dialysis HCPCS code required 305* Hematology HCPCS code required 306* Bacteriology & microbiology HCPCS code required 307* Urology HCPCS code required 309* Other labaty HCPCS code required Labaty Pathological 310* General classification HCPCS code required 311* Cytology HCPCS code required 312* Histology, not a benefit HCPCS code required 314* Biopsy HCPCS code required 319* Other pathology HCPCS code required Radiology Diagnostic 320* General classification HCPCS code required 321* Angiocardiography HCPCS code required 322* Arthrography HCPCS code required 323* Arteriography HCPCS code required 324* Chest X-ray HCPCS code required 329* Other diagnostic radiology HCPCS code required Radiology Therapeutic 330* General classification HCPCS code required 331* Chemotherapy, injected HCPCS code required 332* Chemotherapy, al HCPCS code required 333* Chemotherapy, radiation therapy HCPCS code required 335* Chemotherapy, IV HCPCS code required 339* Other therapeutic radiology HCPCS code required Nuclear Medicine 340* General classification HCPCS code required 341* Diagnostic HCPCS code required 342* Therapeutic HCPCS code required 349* Other nuclear medicine HCPCS code required CT Scan 350* General classification HCPCS code required 351* Head scan HCPCS code required 352* Body scan HCPCS code required 359* Other CT scans HCPCS code required * HCPCS procedure code is required in addition to revenue code f accurate claims processing. No HIPAA Special Bulletin Update

23 Revenue Comments Operating Room Services 360 General classification 361 Min surgery 369 Other operating room services Anesthesia 370 General classification 371 Anesthesia incident to radiology 372 Anesthesia incident to other diagnostic services 374 Acupuncture Not a benefit 379 Other anesthesia Blood 380* General classification HCPCS code required 381* Packed red cells HCPCS code required 382* Whole blood HCPCS code required 383* Plasma HCPCS code required 384* Platelets HCPCS code required 385* Leucocytes HCPCS code required 386* Other components HCPCS code required 387* Other derivatives (cryoprecipitates) HCPCS code required 389* Other blood HCPCS code required Blood Stage and Processing 390 General classification 391 Blood administration Not a benefit 399 Other blood stage and processing Not a benefit Other Imaging Services 400* General classification HCPCS code required 401* Diagnostic mammography HCPCS code required 402* Ultrasound HCPCS code required 403* Screening mammography HCPCS code required 404* Positron emission tomography HCPCS code required 409* Other imaging services HCPCS code required Respiraty Services 410 General classification 412 Inhalation services 413 Hyperbaric oxygen therapy 419* Other respiraty services HCPCS code required Physical Therapy 420* General classification HCPCS code required 421* Visit charge HCPCS code required 422* Hourly charge HCPCS code required 423* Group rate HCPCS code required 424* Evaluation re-evaluation HCPCS code required 429* Other physical therapy HCPCS code required Occupational Therapy 430* General classification HCPCS code required * HCPCS procedure code is required in addition to revenue code f accurate claims processing HIPAA Special Bulletin Update 23 No. 174

24 Revenue Comments 431* Visit charge HCPCS code required 432* Hourly charge HCPCS code required 433* Group rate HCPCS code required 434* Evaluation re-evaluation HCPCS code required 439* Other occupational therapy HCPCS code required Speech-language Pathology 440* General classification HCPCS code required 441* Visit charge HCPCS code required 442* Hourly charge HCPCS code required 443* Group rate HCPCS code required 444* Evaluation re-evaluation HCPCS code required 449* Other speech-language pathology HCPCS code required Emergency Room 450 General classification 456 Urgent care 459 Other emergency room Pulmonary Function 460* General classification HCPCS code required 469* Other pulmonary function HCPCS code required Audiology 470* General classification HCPCS code required 471* Diagnostic HCPCS code required 472* Treatment HCPCS code required 479* Other audiology HCPCS code required Cardiology 480* General classification HCPCS code required 481* Cardiac cath lab HCPCS code required 482* Stress test HCPCS code required 483* Echocardiography HCPCS code required 489* Other cardiology HCPCS code required Clinic 510 General classification 511 Chronic pain center 512 Dental clinic 513 Psychiatric clinic 514 OB-GYN clinic 515 Pediatric clinic 516 Urgent care clinic 517 Family practice clinic 519 Other clinic Freestanding Clinic 520 General classification 523 Family practice clinic 526 Urgent care clinic 529 Other freestanding clinic * HCPCS procedure code is required in addition to revenue code f accurate claims processing. No HIPAA Special Bulletin Update

25 Revenue Comments Magnetic Resonance Technology (MRT) 610* General classification HCPCS code required 611* MRI brain (including brainstem) HCPCS code required 612* MRI spinal cd (including spine) HCPCS code required 619* Other MRT HCPCS code required Cast Room 700 General classification 709 Other cast room Recovery Room 710 General classification 719 Other recovery room Lab Room/Delivery 720 General classification 721 Lab 722 Delivery 723 Circumcision 724 Birthing center 729 Other lab room/delivery EKG/ECG (Electrocardiogram) 730* General classification HCPCS code required 731* Holter monit HCPCS code required 732* Telemetry HCPCS code required 739* Other EKG/ECG HCPCS code required EEG (Electroencephalogram) 740* General classification HCPCS code required 749* Other EEG HCPCS code required Gastrointestinal Services 750 General classification 759 Other gastrointestinal Treatment Observation Room 760 General classification 761 Treatment room 762 Observation room 769 Other treatment/observation room Preventive Care Services 770* General classification HCPCS code required 771* Vaccine administration HCPCS code required 779* Other preventive care services HCPCS code required Lithotripsy 790* General classification HCPCS code required 799* Other lithotripsy HCPCS code required Other Diagnostic Services 920* General classification HCPCS code required 921* Peripheral vascular lab HCPCS code required 922* Electromyelogram HCPCS code required * HCPCS procedure code is required in addition to revenue code f accurate claims processing HIPAA Special Bulletin Update 25 No. 174

26 Revenue Comments 923* Pap smear HCPCS code required 924* Allergy test HCPCS code required 925* Pregnancy test HCPCS code required * HCPCS procedure code is required in addition to revenue code f accurate claims processing. Hospitals must continue to bill scheduled day surgeries under their HASC TPI using the HCPCS surgical procedure code. If no procedure code in the fee schedule covers the services, use an unlisted CPT surgical code and give a description of the service. Release of Protected Health Infmation (PHI) The Privacy Standards were amended in August 2002 to delete the requirement that consent be obtained befe a covered entity could disclose protected health infmation (PHI) f treatment, payment, and health care operations (45 CFR and 506). This amendment allows HIPAA-covered entities who deliver services that are paid f by Health and Human Services Commission (HHSC)-administered programs who are Texas Department of Health (TDH) grant recipients, to use and disclose PHI out the individual s authization to HHSC and HHSC-operating agencies (TDH, DHS, Mental Health and Mental Retardation [MHMR]) to comply funding source grant requirements. F example, federal grants (including Medicaid, Title V, Title XX, Ryan White, CDC grants, and others) require the agency administering the grants to conduct quality moniting, contract compliance moniting, financial audits, and fraud and abuse prevention and detection. These activities require a subrecipient, contract, enrolled provider to provide access to individual patient recds. Under the amended regulations, the HIPAA-covered entity therefe, may use disclose PHI out the individual s authization. These disclosures do not have to be documented by the covered entity under the Accounting f Disclosures provisions of 45 CFR Crection to the Provider Responsibility section of the 2003 Texas Medicaid Provider Procedures Manual TDH was inadvertently omitted from the list of entities that may request documentation from a provider and from the list of entities to which a provider may release confidential client infmation out the client s authization. Providers may release retained documentation to TDH. Providers may release confidential infmation to TDH out the client s authization. The crected sections are as follows: Retention of Recds The provider must maintain and retain all necessary recds, R&S repts, and claims to fully document the services and supplies provided to a client Medicaid coverage f full disclosure to HHSC. These recds and claims must be retained f a minimum period of five years from the date of service until all audit questions, appeal hearings, investigations, court cases are resolved. Freestanding rural health clinics (RHCs) must retain their recds f a minimum of six years, and hospital-based RHCs must retain their recds f a minimum of 10 years. These recds must be made available promptly on request to employees agents of the HHSC Office of Investigations and Enfcement (OIE), the Texas Attney General s Medicaid Fraud Control Unit, NHIC, TDH, the Department of Protective and Regulaty Service (PRS), the Texas Department of Human Services (TDHS), United States Department of Health and Human Services (HHS) representatives. The provider is required to provide iginal recds to representatives of the above ganizations. As mentioned above, these recds include, but are not limited to, documents related to diagnostic tests, treatment, service, labaty results, and X-rays. Accessible infmation must include infmation that is necessary f the agencies specified in this paragraph to perfm statuty functions. At the discretion of these representatives, the provider may be required to provide copies, in lieu of iginals, notarized recds/affidavits on individual recd documentation, promptly and at no cost. Failure to supply these recds in the time frame specified may result in a payment hold to the provider s Medicaid payments, recoupment of payments f all claims related to the missing recds, and/ contract cancellation and exclusion from the Medicaid program. Upon request, the provider will submit copies of such recds at no cost to representatives of the above ganizations. If the provider places the required infmation in another legal entity s recds, such as a hospital, the provider is responsible f obtaining a copy of these recds f use by TDH, TDHS, HHSC, NHIC, PRS, HHSC OIE, the Texas Attney General's Medicaid Fraud Control Unit, HHS representatives. No HIPAA Special Bulletin Update

27 These recds must be available as requested by one of these entities, during any investigation study of the ness of the Medicaid claims submitted by the provider Release of Confidential Infmation Infmation about the diagnosis, evaluation, treatment of a client Medicaid coverage by a person licensed certified to perfm the diagnosis, evaluation, treatment of any medical, mental, emotional disder, drug abuse, is usually confidential infmation that the provider may disclose only to authized people. Family planning infmation is sensitive, and confidentiality must be ensured f all clients, especially mins. Only the client may give written permission f release of any pertinent infmation befe client infmation can be released, and confidentiality must be maintained in all other respects. The client's signature is not required on the claim fm f payment of a claim, but NHIC strongly recommends the provider obtain written authization from the client befe releasing confidential medical infmation. A release may be obtained by having the client sign the indicated block on the claim fm after the client has read the ment of release of infmation that is printed on the back of the fm. The client's authization f release of such infmation is not required when the release is requested by and made to TDH, TDHS, HHSC, NHIC, PRS, HHSC OIE, the Texas Attney General's Medicaid Fraud Control Unit, HHS. Texas Medicaid Claim Details Changes, SP01 (50/99) HIPAA legislation requires that Texas Medicaid be able to receive electronic professional claims and electronic institutional claims up to 50 and 999 details, respectively. F Texas Medicaid, HHSC will meet this requirement in two phases. The first of those phases will be implemented by October 16, Upon completion of that first phase, the electronic clearinghouse through which Texas Medicaid receives claims will be able to accept professional claims up to 50 details and institutional claims up to 999 details. However, at that time, Texas Medicaid will maintain its current practice of processing claims no me that 28 details. During the interval between the completion of phase one and the beginning of phase two, Texas Medicaid will accept claims up to 50/999 details, but will subsequently reject deny those claims that cannot be merged to 28 fewer details f processing. Texas Medicaid will not be able to process claims 999 details until phase two, which will be implemented after October 16, The remainder of this article describes the changes that will and will not be made during Texas Medicaid s first phase of implementation. Policies That Stay the Same Texas Medicaid will maintain its rule that it does not process claims that cannot be reduced to 28 fewer details. F inpatient claims that are submitted me than 28 details, Texas Medicaid will continue to attempt to merge such claims to a claim 28 fewer details. Meover, Texas Medicaid will maintain its current practice of paying outpatient crossover claims at that header level. Outpatient crossover claims submitted me than 28 details will not be denied n rejected f having too many details. However, all other claim types may potentially be denied rejected f having too many details. A claim is defined as having too many details if it meets all the following criteria: The claim is not an outpatient crossover claim. The claim was submitted me than 28 details. If the claim is an inpatient claim, the claim continues to have me than 28 details after like details have been merged. Policies That Will Change During the first phase of becoming HIPAA-compliant, Texas Medicaid will make the following changes by October 16, 2003: Electronic claims that are submitted too many details (as defined in the above section) will be rejected, rather than denied as they are today. Paper claims that are submitted too many details will continue to deny. New EOB and RARC codes will be used f claims that are denied f having too many details. Claims denied f having too many details will appear on the paper R&S rept EOB 00398, The claim details exceed our 28 character limit; combine like revenue codes send multiple claims. Claims denied f having too many details will appear on the ER&S rept RARC N61, Rebill services on separate claims HIPAA Special Bulletin Update 27 No. 174

28 Although the description associated the RARC N61 does not suggest that providers attempt to merge like revenue codes, the description associated EOB does make that suggestion. When inpatient claims are repted as denied RARC N61, it is preferable that providers combine like revenue codes and resubmit the claim rather than splitting the claim as the RARC suggests. When outpatient crossover claims are submitted me than 28 details, Texas Medicaid will ste balancing infmation in the 28th detail of those claims. The balancing infmation sted in the 28th detail will recd values f all truncated details f of the following fields: Billed Amount, Medicare Paid Amount, Medicare Coinsurance Amount, Medicare Allowed Amount, Medicare Regular Deductible, and Medicare Blood Deductible. By using the 28th detail to recd infmation on truncated details, Texas Medicaid will be able to rept those claims on the ER&S rept in such a way that they balance from the detail level to the header level. Additionally, the dump code 002 type of service B will be sted in the 28th detail of outpatient crossover claims when that detail is used to ste balancing infmation. Traditional, Managed Care, and MCO SSI Authizations All current authizations dates of service on after October 16, 2003, that contain the following local codes need to be resubmitted beginning September 2, 2003, the national codes. This resubmission is necessary f authizations to be effective f dates of service on after October 16, Current authizations containing the following local codes will not be valid f dates of service on after October 16, Claims submitted f the local codes listed below dates of service on after October 16, 2003, will be rejected denied. If your current authization dates of service on after October 16, 2003 does not contain the local codes listed below, you do not need to resubmit your authization request. The following table lists the affected local codes: Local s X J-53ECD X 2-X X X J-53FCD J-55ACD 2-X X X J-53HCD J-55DCD 2-X Y X J-53ICD J-55FCD 2-X Y X J-53MCD J-57BCD 2-X Y X J-53NCD X 2-X Y X J-53PCD X 2-X Y6104 J-530CD J-53QCD X 2-X Y X J-53RCD X 2-X Y X J-53TCD X 2-X0160 R-Z8007 J-53ACD J-53UCD X 2-X0161 R-Z8009 J-53BCD J-53XCD X 2-X Z9812 J-53CCD J-53YCD X 2-X2998 J-53DCD X X F-X2998 Use of ICD-9-CM Diagnosis s Effective October 16, 2003, the use of diagnosis codes will be required on all electronic claim submissions. The local diagnosis code V7999, Labaty and X-ray services, will be discontinued f dates of service on after October 16, Texas Medicaid will require the following providers to use the indicated ICD-9-CM codes, when : THSteps CCP Pharmacies The 2003 Texas Medicaid Provider Procedures Manual, paragraph , indicates the use of local diagnosis code V7999. THSteps CCP Pharmacies should use ICD-9-CM diagnosis code V7285, Other specified examination, on all claims (paper electronic). Independent Labaties When the primary diagnosis is not provided by the referring provider, the independent labaty provider may use ICD-9-CM diagnosis code V726, Labaty examination, on their electronic claim (paper claims may continue to be submitted the diagnosis code field left blank). No HIPAA Special Bulletin Update

29 Radiology Providers When the primary diagnosis is not provided by the referring provider, the radiology provider may use ICD-9-CM diagnosis code V725, Radiological examination, not elsewhere classified, on their electronic claim (paper claims may continue to be submitted the diagnosis code field left blank). Vend and Provider Testing Vends and providers not using TDHconnect to submit claims, eligibility requests, to receive an ER&S rept will be requested to test transactions NHIC to assure they can send HIPAA-compliant transactions by October 16, Organizations who wish to test NHIC are requested to complete a Vend Intake fm (found in the NHIC Companion Guides f transaction type) identifying a contact and the transaction(s) used, and it to Nhichipaavends@eds.com. A test facilitat will contact ganization to schedule a test time. Phase I of the testing process is scheduled to begin in July. During this phase, an ganization s ability to transmit HIPAA-compliant transactions will be verified. Files will be submitted through the EBX Model Office bulletin board system (BBS). Phase II will occur from August 2003 through October 2003 f acute care (Compass21) submitters. This will entail NHIC receiving HIPAA-compliant files NHIC-specific data sets, the processing of these files through EBX maps and Claims Engine the return of a HIPAA-compliant response file where applicable. Phase III will start in September and continue through October f validating of Long Term Care (LTC) submitters. LTC submitters will send files through EBX maps to Claims Management System (CMS) f Validation of HIPAA-compliant files NHIC-specified data sets. NHIC will in turn send a HIPAA-compliant response to the Submitter where applicable. If you have questions about the testing process at NHIC, send an to Nhichipaavends@eds.com. Ambulance Providers Ambulance Reimbursement Changes This article crects the Ambulance Reimbursement Changes article that appeared on page 17 of the 2003 HIPAA Special Bulletin, No The article should have d, If A0425 is billed out A0429 A0428, the claim will be denied. A0425 is the procedure code f mileage, which cannot be billed out the procedure code f base rate (A0428 A0429). Air Transpt Reimbursement The 2003 HIPAA Special Bulletin, No. 170 s that air transpts will be billed either A0430 and A0435 A0431 and A0436. Additionally, if A0435 is billed out A0430 A0436 is billed out A0431, the claim will be denied. Dental Providers Crections to Current Dental Terminology-4 (CDT-4) The following crection applies to the CDT-4 Procedure s- Changes table in the 2003 HIPAA Special Bulletin, No Procedure code D0150, Comprehensive al evaluation, was published N/C, indicating the procedure is not covered. This pricing infmation is increct. The procedure sustained a change in description only and continues to be reimbursed at $ The following crections apply to the CDT-4 Procedure s-additions table in the 2003 HIPAA Special Bulletin, No Procedure code D7972, Surgical reduction of fibrous tuberosity, was published comments indicating the procedure cannot be paid in addition to procedure D7271, which is an invalid procedure code. The procedure cannot be paid in addition to procedure D7971, Excision periconal gingiva HIPAA Special Bulletin Update 29 No. 174

30 Procedure code D7261, Primary closure of a sinus perfation, was published comments indicating the procedure applies to tooth identification (TIDs) This TID infmation is increct. The procedure applies to TIDs Procedure code D5670, Replace all teeth and acrylic on cast metal framewk (maxillary), was published comments indicating that D5670 cannot be paid in addition to D5640, D5211, D5212, D5213, D5214, and D5281. This reimbursement is increct. D5670 cannot be paid in addition to D5640, D5211, D5213, and D5281. Procedure code D5671, Replace all teeth and acrylic on cast metal framewk (mandibular), was published comments indicating that D5671 cannot be paid in addition to D5640, D5211, D5212, D5213, D5214, and D5281. This reimbursement is increct. D5671 cannot be paid in addition to D5640, D5212, D5214, and D5281. Orthodontic Appliances This article updates the Fixed Design and Removeable Design local code tables on pages of the 2003 HIPAA Special Bulletin, No Effective f dates of service on after October 16, 2003, all removable fixed thodontic appliances must be billed national procedure code D8210, Removable appliance therapy D8220, Fixed appliance therapy. To ensure claims processing, the local procedure code reflecting the specific service is also required. Providers should adhere to the following steps f electronic claim submissions so that NHIC can accurately apply the crect local procedure code to the claim detail: 1. The DPC prefix must be submitted in the first three bytes of the NTE02 at the 2400 loop. The DPC prefix should only be submitted once. 2. In bytes 4-8, submit the remark code (local procedure code) der of the claim detail (see the following examples). Do not enter any spaces punctuation between remark codes. Example 1 F a claim 3 details, where details 1 and 3 are submitted procedure code D8210 and detail 2 is not submitted procedure code D8210, enter the following infmation in the NTE02 at the 2400 loop: DPC1014D 1046D. Example 2 F a claim 3 details, where details 2 and 3 are submitted procedure code D8210 and detail 1 is not submitted procedure code D8210, enter the following infmation in the NTE02 at the 2400 loop: DPC 1014D1046D. Example 3 F a claim 3 details, where all three details are submitted procedure code D8210, enter the following infmation in the NTE02 at the 2400 loop: DPC1047D1063D1075D. F paper claim submissions, enter the local procedure code in Block 35 (Remarks) on the 2002 ADA Dental Claim Fm. Paper Claim Fm Change f THSteps Dental Providers Effective f claims received on after October 16, 2003, all participating Texas Health Steps Dental providers are required to submit a 2002 American Dental Association (ADA) Dental claim fm f paper claim submissions to Texas Medicaid. These fms may be obtained by contacting the ADA at An example of this fm is located on page 57 of this bulletin. Any dental paper claims submitted on any other version of a dental claim fm on after October 16, 2003, will not be processed and will be returned to the submitter. Refer to: Future banner and/ bulletin publications f additional updates. No HIPAA Special Bulletin Update

31 Funds Gone EOB Family Planning Providers This article replaces the Family Planning Funds Gone EOB article on page 29 of the 2003 HIPAA Special Bulletin, No Effective f dates of service on after October 16, 2003, local EOB code 30000, Approved to Pay Funds Gone, will be replaced national standard code N14, Payment based on a contractual amount agreement, fee schedule, maximum allowable amount, on ER&S repts. standard code N14 is also replacing many other local EOB codes. Paper R&S repts will continue to rept local EOB code Family planning providers must use the paper R&S repts if they need to identify claims in Approved to Pay Funds Gone status. IUD Devices This article crects the IUD Devices article on page 29 of the 2003 HIPAA Special Bulletin, No The crect procedure code f intrauterine copper contraceptive is J7300, not J730D. Labaty Handling Fee Update This article updates the Labaty Handling Fee article on page 29 of the 2003 HIPAA Special Bulletin, No Effective f dates of service on after October 16, 2003, Title XIX Family Planning Providers (Medicaid only) can bill procedure code 99000, Handling and/ conveyance of specimen f transfer from the physician s office to a labaty, FP, Service provided as part of Medicaid Family Planning Program. This combination should be billed if the provider collects and fwards a specimen that was collected by routine venipuncture catheterization through a Family Planning encounter. Only one handling fee may be charged per day, per client, unless the specimens are sent to two different labaties. This fee must be documented on the claim. Title V, X, and XX providers will not be reimbursed f this lab handling fee procedure code. Home Health and THSteps-CCP Providers Nutritional Supplements and Supplies Medicaid Local to Table Effective f dates of service on after October 16, 2003, the Medicaid local codes in the following table will be discontinued. Providers must bill using the national codes that are also indicated in the following table. Local 5001X Fibersource, 250 ml, per can Local Special Instructions $1.96 B4150 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5004X Fibersource, 1 liter $11.66 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 2003 HIPAA Special Bulletin Update 31 No. 174

32 Local 5005X Fibersource, 1.5 liter $17.56 B X Fibersource HN, 250 ml, per can U5 $1.92 B4150 U3 5007X Fibersource HN, 1 liter $11.18 B4150 U5 5008X Fibersource HN, 1.5 liter $16.78 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 3, as defined by 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 5, as defined by 5009X Isosource, 250 ml, per can $1.65 B = 1 unit 5011X Isosource, 1 liter $9.30 B4150 U4 5012X Isosource, 1.5 liter $14.00 B X Isosource HN, 250 ml, per can Local U4 $1.78 B4150 U3 100 = 1 unit Medicaid level of care 4, as defined by 100 = 1 unit Medicaid level of care 4, as defined by 100 = 1 unit Medicaid level of care 3, as defined by $1.05 ) $0.70 ) $1.05 ) $1.05 ) $0.61 ) $0.85 ) $0.85 ) $0.70 ) Special Instructions No HIPAA Special Bulletin Update

33 Local 5014X Isosource HN, 1 liter $9.69 B4150 U5 5015X Isosource HN, 1.5 liter $14.71 B X 5021X 5023X Resource just f kids, liquid, 237 ml, any flav, Resource, liquid, 237 ml, any flav, Vivonex pediatric, powder, 48.5 gm, packets, U5 $1.98 B4150 U4 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 4, as defined by $1.43 B = 1 unit $4.20 B4153 U7 5025X Neocate powder, 400 gm $27.97 B X 5029X 5030X Neocate one plus liquid, 237 ml Neocate one plus powder, 100gm Phenylade mix, amino acid blend, powder, 454 gm, Local U6 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 7, as defined by Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 6, as defined by $3.64 B4153 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit $7.83 B4153 U7 $91.74 B4154 UB Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 7, as defined by 100 = 1 unit Medicaid level of care 11, as defined by $1.05 ) $1.05 ) $0.85 ) $0.61 ) $2.00 ) $1.70 ) $1.74 ) $2.00 ) $5.00 ) Special Instructions 2003 HIPAA Special Bulletin Update 33 No. 174

34 Local 5033X 5035X 5036X 5037X 5038X Nubasics, fiber, vanilla, 250 ml, Nubasics, plus, vanilla, chocolate, strawberry, 250 ml, Nutren, Jr, vanilla, 250 ml, Nubasics, 250 ml, vanilla, chocolate, strawberry, ea Nubasics, VHP, 250 ml, vanilla, $1.21 B = 1 unit $1.34 B4152 U3 $1.61 B4150 U3 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 3, as defined by 100 = 1 unit Medicaid level of care 3, as defined by $1.20 B = 1 unit $1.18 B4152 U2 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by 5077X Compleat ml - $3.00 B4151 Enteral fmulae; categy I; natural intact protein/protein isolates, administered through an enteral feeding tube, 100 = 1 unit 5078X 5079X 5080X Compleat pediatric, 250 ml, Ensure, liquid, 240 ml, Ensure, liquid, 960 ml, Local $2.57 B4151 U5 Enteral fmulae; categy I; natural intact protein/protein isolates, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by $1.50 B = 1 unit $4.14 B4150 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.61 ) $0.70 ) $0.70 ) $0.61 ) $0.50 ) $1.43 ) $1.05 ) $0.61 ) $0.50 ) Special Instructions No HIPAA Special Bulletin Update

35 Local 5081X Ensure, powder, 420 gm, $7.18 B4150 U2 5082X Ensure bottles 8 oz, $1.98 B X Ensure pudding, powder, 150 gm, U4 $1.09 B4152 U3 100 = 1 unit Medicaid level of care 2, as defined by 100 = 1 unit Medicaid level of care 4, as defined by Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 3, as defined by 5084X Isocal, liquid, 237 ml, $1.54 B = 1 unit 5085X Isocal, liquid, 946 ml, $5.86 B = 1 unit 5086X Jevity, liquid, 240 ml, $1.52 B = 1 unit 5087X Jevity, liquid, 960 ml, $5.62 B = 1 unit 5088X 5089X Jevity plus, ready to hang, 1000 ml, Nutramigen, liquid, Cnt. 390 ml, Local $11.33 B4150 U5 $4.82 B4153 U5 100 = 1 unit Medicaid level of care 5, as defined by Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by $0.50 ) $0.85 ) $0.70 ) $0.61 ) $0.61 ) $0.61 ) $0.61 ) $1.05 ) $1.05 ) Special Instructions 2003 HIPAA Special Bulletin Update 35 No. 174

36 Local Local Special Instructions 5090X Nutramigen, ready-to-use, liquid, 960 ml, $6.32 B4153 U5 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5091X Nutramigen, powder, 480 gm, $23.10 B4153 U5 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5093X Osmolite, liquid, 240 ml, $1.35 B = 1 unit $0.61 ) 5094X Osmolite ready-to-use, liquid, 960 ml, $4.86 B4150 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5095X Osmolite, ready-to-hang, 1000 ml, $9.79 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5096X Pediasure, liquid, 240 ml, $1.59 B4150 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5097X Polycose, liquid, 126 ml, $1.79 B4155 U4 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 4, as defined by $0.85 ) 5098X Polycose, powder, 350 gm, $5.93 B4155 U2 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5099X Sustacal, 8 oz 240 ml, $1.47 B = 1 unit $0.61 ) No HIPAA Special Bulletin Update

37 Local 5120X 5121X 5122X 5123X 5138X 5139X Pulmocare, liquid, 240 ml, Two-cal, liquid, 237 ml, Pregestimil, powder, 454 gms Reabilan, liquid, 375 ml, Vivonex ten, pdr, 80.4 gm packets, Thick it, powder, 240 gm, $1.90 B4154 U3 $1.94 B4152 U2 $23.87 B4154 U5 $8.05 B4154 U7 $5.46 B4154 U7 100 = 1 unit Medicaid level of care 3, as defined by Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 7, as defined by 100 = 1 unit Medicaid level of care 7, as defined by $0.70 ) $0.50 ) $1.05 ) $2.00 ) $2.00 ) $3.42 B4100 Food thickener, administered ally, per ounce Manually reviewed 5140X Ensure fiber nutrafla $1.05 B = 1 unit 5142X 5149X Vital high nitrogen, powder, packet, Alimentum iron, liquid, 960 ml, Local $7.06 B4153 U8 $7.20 B4153 U5 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 8, as defined by Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by $0.61 ) $2.50 ) $1.05 ) Special Instructions 2003 HIPAA Special Bulletin Update 37 No. 174

38 Local Local Special Instructions 5150X Provimin, powder, 150 gm, $12.52 B4155 U8 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 8, as defined by $2.50 ) 5151X MSUD maxamaid, powder, 454 gm, $65.73 B4154 UA 100 = 1 unit Medicaid level of care 10, as defined by $4.00 ) 5152X Promod powder, 291 gm, $11.75 B4155 U5 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5154X Ptagen, powder, 454 gm, $20.07 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5181X Fmula not elsewhere listed Discontinued 5182X Suplena, liquid, 240 ml, $2.35 B4154 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5183X MCT, oil 960 ml, $49.35 B4155 U3 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5184X Prosobee, Isomil, Similac, SMA, Enfamil liquid, cnt. 390 ml, $2.79 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5185X Prosobee, Isomil, Similac, SMA, Enfamil powder, 420 gm, $10.07 B4150 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) No HIPAA Special Bulletin Update

39 Local 5186X Prosobee, Isomil, Similac, SMA, Enfamil liquid, 240 ml, $1.47 B4150 U4 5212X Mic - key G tube $ B9998 U2 5213X Mic - key extension set $8.25 B9998 U3 5214X Gastrostomy tube, mic/ flexiflow $3.00 B9998 U4 5215X Mic extension set $3.00 B9998 U5 5216X 5217X 5228X 5231X 5234X 5235X 5237X Enteral nutritional container preattached pump set, Prosobee, Isomil, Similac, SMA, Enfamil liquid, 960 ml, Impact, liquid, 250 ml, Vitaneed fmula, 8 oz can Gastrostomy button, obturated, mushroom type Gastrostomy kit, nonobturated, balloon type Lipisb, powder, 454 gm, Local 100 = 1 unit Medicaid level of care 4, as defined by NOC f enteral supplies Medicaid level of care 2, as defined by NOC f enteral supplies Medicaid level of care 3, as defined by NOC f enteral supplies Medicaid level of care 4, as defined by NOC f enteral supplies Medicaid level of care 5, as defined by $0.85 ) $ $8.25 $45.00 $3.00 $14.35 B4035 Enteral feeding supply kit; pump fed, per day $10.19 $4.22 B4150 U3 $6.89 B4154 U9 $2.33 B4151 U5 $15.65 B4154 UB 100 = 1 unit Medicaid level of care 3, as defined by 100 = 1 unit Medicaid level of care 9, as defined by Enteral fmulae; categy I; natural intact protein/protein isolates, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 11, as defined by $0.70 ) $3.00 ) $1.05 ) $5.00 ) Special Instructions Discontinued Discontinued 2003 HIPAA Special Bulletin Update 39 No. 174

40 Local Local Special Instructions 5240X Product 80056, powder, 454 gm, $6.96 B4154 U1 100 = 1 unit Medicaid level of care 1, as defined by $0.30 ) 5241X Lipisb, liquid, 240 ml, $2.34 B4154 U4 100 = 1 unit Medicaid level of care 4, as defined by $0.85 ) 5244X Tolerex pdr, 80 gm packet, $4.56 B4156 U6 Enteral fmulae; categy VI; standardized nutrients, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 6, as defined by $1.70 ) 5246X L-citrulline, 500 mg caps, per 50 $14.54 A9150 Non-prescription drugs Manually reviewed 5251X Ultracal, liquid, 237 ml, $1.13 B4152 U2 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5256X Compleat-modified, liquid, 250 ml, $3.19 B4151 Enteral fmulae; categy I; natural intact protein/protein isolates, administered through an enteral feeding tube, 100 = 1 unit $1.43 ) 5260X Scandishake, powder, 540 gm, $9.44 B = 1 unit $1.64 ) 5275X Nutren 1.0 /out fiber, liquid, 250 ml, $1.51 B = 1 unit $0.61 ) 5276X Nutren 1.5, liquid, 250 ml, $1.54 B4152 U2 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) No HIPAA Special Bulletin Update

41 Local 5277X 5278X 5279X 5280X 5281X 5282X Nutren 2.0, liquid, 250 ml, Peptamen, liquid, 250 ml, Replete, liquid, 250 ml, Replete fiber, 250 ml, Nutrivent 1.5, liquid, 250 ml, Neutra, phos (1.25 gm packets), 100 unit dose pack $1.64 B4152 U2 $6.59 B4154 U9 $1.74 B4154 U3 $1.86 B4154 U4 $1.99 B4154 U3 5283X Nepro, liquid, 240 ml, $3.02 B4154 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by 100 = 1 unit Medicaid level of care 9, as defined by 100 = 1 unit Medicaid level of care 3, as defined by 100 = 1 unit Medicaid level of care 4, as defined by 100 = 1 unit Medicaid level of care 3, as defined by $0.50 ) $3.00 ) $0.70 ) $0.85 ) $0.70 ) $24.07 B9998 NOC f enteral supplies Manually reviewed U3 100 = 1 unit Medicaid level of care 3, as defined by 5309X Sustacal gel, 150 gm, $1.43 B = 1 unit 5310X MSUD diet, powder, 480 gm, Local $20.56 B4154 U5 100 = 1 unit Medicaid level of care 5, as defined by $0.70 ) $0.61 ) $1.05 ) Special Instructions 2003 HIPAA Special Bulletin Update 41 No. 174

42 Local 5311X 5312X 5313X 5314X 5319X 5320X 5326X MSUD-1, powder, 500 gm, MSUD-2, powder, 500 gm, Ketonex-1 iron, powder, 400 gm, Ketonex-2, powder, 400 gm, Cyclinex-1, iron, powder, 400 gm, Cyclinex-2, powder, 400 gm, Flavonex, powder, 600 gm, $69.33 B4154 UB $81.92 B4154 UB $32.22 B4154 U7 $64.55 B4154 UB $16.11 B4154 U4 $32.27 B4154 U7 100 = 1 unit Medicaid level of care 11, as defined by 100 = 1 unit Medicaid level of care 11, as defined by 100 = 1 unit Medicaid level of care 7, as defined by 100 = 1 unit Medicaid level of care 11, as defined by 100 = 1 unit Medicaid level of care 4, as defined by 100 = 1 unit Medicaid level of care 7, as defined by $5.00 ) $5.00 ) $2.00 ) $5.00 ) $0.85 ) $2.00 ) $47.89 B9998 NOC f enteral supplies Manually reviewed 5328X Nutra-thick, 8 oz can, $5.41 B4100 Food thickener, administered ally, per ounce Manually reviewed 5329X 5331X Nutra-thick, single ption packettes, Sustacal, powder, 454 gm, Local $0.44 B4100 Food thickener, administered ally, per ounce Manually reviewed $8.28 B4150 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) Special Instructions No HIPAA Special Bulletin Update

43 Local Local Special Instructions 5335X Isomil-DF, liquid, 960 ml, $4.47 B4150 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5340X Alitraq, powder, 80 gm packets, $9.67 B4154 U9 100 = 1 unit Medicaid level of care 9, as defined by $3.00 ) 5341X Respal, liquid, 237 ml, $2.46 B4152 U3 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5342X Lacto-free, powder, 420 gm, $9.59 B4150 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5343X Neutra-phos, 64 gm, bottle, $10.19 B4154 UD 100 = 1 unit Medicaid level of care 13, as defined by Manually reviewed 5345X Similac special care iron, liquid, 120 ml, $1.62 B4152 U6 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 6, as defined by $1.70 ) 5347X Microlipid, 89 ml, $2.54 B4155 U3 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5348X Pediasure fiber, liquid, 240 ml, $1.68 B4150 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 2003 HIPAA Special Bulletin Update 43 No. 174

44 Local 5349X Alimentum iron, liquid, 240 ml, $1.75 B4153 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit 5350X Profiber, liq, 250 ml, $1.19 B = 1 unit 5354X Resource plus, liquid, 237 ml, any flav, 5360X Lacto-free, liquid, cnt. 390 ml, 5361X 5362X 5369X 5372X 5373X Lacto-free, ready-to-use, liquid, 960 ml, Disposable G tube adapter set, Isomil SF, liquid, Cnt. 390 ml, UCD 1 UCD 2, 500 gm, Human milk ftifier, per packet Local $1.62 B4152 U2 $2.92 B4150 U5 $4.64 B4150 U3 $7.65 B9998 U1 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 3, as defined by NOC f enteral supplies Medicaid level of care 1, as defined by $2.99 B = 1 unit $1.74 ) $0.61 ) $0.50 ) $1.05 ) $0.70 ) $7.65 $0.61 ) $ B9998 NOC f enteral supplies Manually reviewed $0.90 B4155 UC 5390X Periflex, 454 gm, per can $35.44 B4154 U7 Enteral fmulae; categy V; modular components, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 12, as defined by 100 = 1 unit Medicaid level of care 7, as defined by $6.00 ) $2.00 ) Special Instructions No HIPAA Special Bulletin Update

45 Local Local Special Instructions 5391X Similac PM, 60/40, powder, 480 gm, $14.16 B4154 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5393X Kindercal ready-to-use, liquid, 237 ml, $1.47 B = 1 unit $0.61 ) 5394X Next Step, soy only, 12 oz powder $5.32 B4151 U1 Enteral fmulae; categy I; natural intact protein/protein isolates, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 1, as defined by $0.30 ) 5395X Peptamen Jr, liquid, 250 ml, $7.05 B4153 U9 Enteral fmulae; categy III; hydrolized protein/amino acids, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 9, as defined by $3.00 ) 5396X Nursoy, concentrate, 390 ml $2.85 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5397X Nursoy, ready-to-use, 960 ml $4.26 B4150 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) 5398X Nursoy, powder, 453 grams $10.08 B4150 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5413X Lofenalac, powder, 454 gm, $19.26 B4154 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5414X Phenylfree powder, 480 gm, $25.72 B = 1 unit $1.64 ) 2003 HIPAA Special Bulletin Update 45 No. 174

46 Local Local Special Instructions 5415X XP maxamaid, 454 gm, flaved unflaved $36.35 B4154 U8 100 = 1 unit Medicaid level of care 8, as defined by $2.50 ) 5417X XP analog, powder, 400 gm, $15.39 B4154 U4 100 = 1 unit Medicaid level of care 4, as defined by $0.85 ) 5418X XP maxamum, 454 gm, flaved unflaved $55.10 B4154 UA 100 = 1 unit Medicaid level of care 10, as defined by $4.00 ) 5420X PKU 2, powder, 500 gm, $81.95 B4154 UC 100 = 1 unit Medicaid level of care 12, as defined by $6.00 ) 5421X PKU 3, powder, 500 gm, $81.92 B4154 UC 100 = 1 unit Medicaid level of care 12, as defined by $6.00 ) 5422X Phenex-1, powder 400 gm, $17.15 B4154 U5 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) 5423X Phenex-2, powder 400 gm, $34.50 B4154 U8 100 = 1 unit Medicaid level of care 8, as defined by $2.50 ) 5424X Product 3200 AB/diet, pdr 454 gm $15.79 B4154 U3 100 = 1 unit Medicaid level of care 3, as defined by $0.70 ) No HIPAA Special Bulletin Update

47 Local Local Special Instructions 5425X Hom 2, powder, 500 gm, $83.20 B4154 UB 100 = 1 unit Medicaid level of care 11, as defined by $5.00 ) 5432X Glutarex-1, powder 400 gm, $32.22 B4154 U7 100 = 1 unit Medicaid level of care 7, as defined by $2.00 ) 5433X Glutarex-2, powder 400 gm, $64.55 B4154 UB 100 = 1 unit Medicaid level of care 11, as defined by $5.00 ) 5434X Hominex-1, powder 400 gm, $32.22 B4154 U7 100 = 1 unit Medicaid level of care 7, as defined by $2.00 ) 5435X Hominex-2, powder 400 gm, $64.55 B4154 UB 100 = 1 unit Medicaid level of care 11, as defined by $5.00 ) 5436X Product 3232 A-diet, powder, 454 gm, $50.52 B4154 U7 100 = 1 unit Medicaid level of care 7, as defined by $2.00 ) 5437X Hom-1, 500 gm $79.18 B4154 UA 100 = 1 unit Medicaid level of care 10, as defined by $4.00 ) 5439X Ensure plus, liquid, 240 ml, any flav, $1.70 B4152 U2 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5442X Generic medical nutritional products Discontinued 2003 HIPAA Special Bulletin Update 47 No. 174

48 Local Local Special Instructions 5467X Acerflex pdr, 454 gm $35.44 B4154 UD 100 = 1 unit Medicaid level of care 13, as defined by Manually reviewed 5468X Crucial liq, 250 ml $8.81 B4154 U7 100 = 1 unit Medicaid level of care 7, as defined by $2.00 ) 5469X Pro-phree powder 400 gm $7.89 B4154 U2 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5470X RCF liq, 13 oz, $5.03 B4154 U7 100 = 1 unit Medicaid level of care 7, as defined by $2.00 ) 5471X Sustacal plus liquid, 237 ml, $1.67 B4152 U2 Enteral fmulae; categy II; intact protein/ protein isolates (calically dense), administered 100 = 1 unit Medicaid level of care 2, as defined by $0.50 ) 5472X Tyrex 1 powder, 500 gm $87.67 B4154 UA 100 = 1 unit Medicaid level of care 10, as defined by $4.00 ) 5472X Tyrex 2 powder, 500 gm $87.67 B4154 UB 100 = 1 unit Medicaid level of care 11, as defined by $5.00 ) 5473X Tyromex-1 powder, 350 gm $28.19 B4154 U6 100 = 1 unit Medicaid level of care 6, as defined by $1.70 ) No HIPAA Special Bulletin Update

49 Local 5476X Scandical, 8 oz can, $5.74 B X 5491X Glucerna liquid, 240 ml, L-arginine L-arginine MCH, 1000 gm, powder U5 $2.31 B4154 U5 Enteral fmulae; categy VI; standardized nutrients, administered through an enteral feeding tube, 100 = 1 unit Medicaid level of care 5, as defined by 100 = 1 unit Medicaid level of care 5, as defined by $1.05 ) $1.05 ) $ A9150 Nonprescription drugs Manually reviewed 5495X Human milk, per ounce $2.50 B9998 NOC f enteral supplies Manually reviewed 5848X Y9801 Nutren Jr, fiber, vanilla, 250 ml, Enteral feeding pump (rental only) Local $1.68 B4150 U3 100 = 1 unit Medicaid level of care defined by 3, as defined by $0.70 ) Special Instructions Discontinued Refer to: The Texas Medicaid/STAR Programs 2003 DME and Supplies Update, dated April 22, 2003, f the Nutritional Products, Supplies, and Equipment policy f Home Health, and the Nutritional Products policy f CCP. Additionally, the following nutritional supply codes will be valid effective October 16, 2003: Procedure Allowed Amount B9000 NU B9000 RR B9002 NU B9002 RR Enteral nutrition infusion pump - out alarm New equipment Enteral nutrition infusion pump - out alarm Rental Enteral nutrition infusion pump - alarm New equipment Enteral nutrition infusion pump - alarm Rental $ $71.47 per month $1, $ per month 2003 HIPAA Special Bulletin Update 49 No. 174

50 Genetics Providers Electronic Claim Submissions This article updates the Genetics Procedure s article on page 30 of the 2003 HIPAA Special Bulletin, No Effective f dates of service on after October 16, 2003, DNA testing and labaty enzyme tests must be billed procedure code 84999, Unlisted chemical procedure. To ensure claims processing, the local procedure code reflecting the specific service is also required. Providers shoudl adhere to the following steps f electronic claim submissions so that NHIC can accurately apply the crect local procedure code to the claim detail: 1. The GPC prefix must be submitted in the first three bytes of the NTE02 at the 2400 loop. The GPC prefix should only be submitted once. 2. In bytes 4-8, submit the remark code (local procedure code) der of the claim detail (see the following examples). Do not enter any spaces punctuation between remark codes. Example 1 F a claim 3 details, where details 1 and 3 are submitted procedure code and detail 2 is not submitted procedure code 84999, enter the following infmation in the NTE02 at the 2400 loop: GPC4841Z 4964Z. Example 2 F a claim 3 details, where details 2 and 3 are submitted procedure code and detail 1 is not submitted procedure code 84999, enter the following infmation in the NTE02 at the 2400 loop: GPC 4841Z4964Z. Example 3 F a claim 3 details, where all three details are submitted procedure code 84999, enter the following infmation in the NTE02 at the 2400 loop: GPC4941Z4861ZY8158.F paper claim submissions, enter the local procedure code in Block 19 of the HCFA-1500 claim fm. LMFT Services Licensed Marriage and Family Therapists (LMFT) Providers Page 45 of the 2003 HIPAA Special Bulletin, No. 170 instructed LMFTs to replace local codes 1150X, 1151X, and 1152X national codes 90806, 90853, and 90847, effective f dates of service on after October 16, LMFTs must use U8, Medicaid level of care 8, as defined by, when billing these national codes. Modifier U8 indicates that the provider of the service is an LMFT. These services will continue to be reimbursed at an hourly rate. No HIPAA Special Bulletin Update

51 The following table describes these local codes and their cresponding national codes: Local 1150X Individual counseling services by LMFT, per hour U8 1151X Group counseling services by LMFT, per hour U8 1152X Family counseling services by LMFT, per hour U8 Individual psychotherapy, insight-iented, behavi modifying and/ supptive, in an office facility outpatient facility, approximately 45 to 50 minutes, face-to-face patient Medicaid level of care 8, as defined by (Service provided by LMFT) Group psychotherapy, other than of a multiple-family group Medicaid level of care 8, as defined by (Service provided by LMFT) Family psychotherapy, conjoint psychotherapy, patient present Medicaid level of care 8, as defined by (Service provided by LMFT) MHMR Providers Mental Health Rehabilitative Services Community Suppt This article changes the replacement f discontinued local codes 8010X, 8011X, 8012X, and 8013X, as described in the 2003 HIPAA Special Bulletin, No. 170, page 45. Effective f dates of service on after October 16, 2003, Mental Health Rehabilitative Services Community Suppt Services must be billed procedure code H2017, Psychosocial Rehabilitation Services, per 15 minutes, instead of procedure code H0046. Use HQ, Group Setting, when the service is rendered in a group setting and the following s to indicate the level of the practitioner: Modifier HN HO HP TD HM TE Bachels degree level Masters degree level Doctal level Registered nurse (RN) Less than Bachels degree level LPN/LVN Individual services by a professional (H2017 HN, HO, HP TD) will be reimbursed at $17.28 per 15 minutes. Individual services by a paraprofessional (H2017 HM TE) will be reimbursed at $12.55 per 15 minutes. The billing limitation f individual community suppt services is 24 units (6 hours) per calendar day, in any combination. Group services by a professional (H2017 HQ and HN, HO, HP TD) will be reimbursed at $4.75 per 15 minutes. Group services by a paraprofessional (H2017 HQ and HM TE) will be reimbursed at $3.27 per 15 minutes. The billing limitation f group community suppt services is 24 units (6 hours) per calendar day, in any combination HIPAA Special Bulletin Update 51 No. 174

52 SHARS Providers SHARS Changes This article contains an updated table of School Health and Related Services (SHARS) local code changes, to include revisions f discontinued local codes 7011X, 7014X, and 7015X, as described on page 50 of the 2003 HIPAA Special Bulletin, No This also includes the replacement f discontinued local code 4738Z, which was omitted from the table on pages in the 2003 HIPAA Special Bulletin, No Effective f dates of service on after October 16, 2003, SHARS local codes will be replaced national codes as listed in the following table: Local 7007X 7008X 7009X 7010X 7011X 7012X 7013X 7014X Audiology services, 15 minutes Counseling services, 15 minutes Occupational therapy, 15 minutes Physical therapy, 15 minutes Psychological services, 15 minutes Speech therapy, 15 minutes Medical services, 15 minutes School health services, 15 minutes Local $11.86 per 15 minutes $19.04 per 15 minutes $12.05 per 15 minutes $12.05 per 15 minutes $14.67 per 15 minutes $11.86 per 15 minutes $62.71 per 15 minutes $13.06 per 15 minutes H H0004 AH GN Evaluation of speech, language, voice, communication, audity processing, and/ aural rehabilitation status Treatment of speech, language, voice, communication, and/ audity processing disder (includes aural rehabilitation); individual Behavial health counseling and therapy, per 15 minutes Occupational therapy evaluation Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional perfmance), 15 minutes Physical therapy evaluation Therapeutic procedure, one me areas, 15 minutes, therapeutic exercises to develop strength and endurance, range of motion, flexibility Behavial health counseling and therapy, per 15 minutes Clinical psychologist Evaluation of speech, language, voice, communication, audity processing, and/ aural rehabilitation status Treatment of speech, language, voice, communication, and/ audity processing disder (includes aural rehabilitation); individual Services delivered under an outpatient speechlanguage pathology plan of care $11.86 per 15 minutes $19.04 per 15 minutes $12.05 per 15 minutes $12.05 per 15 minutes $14.67 per 15 minutes $11.86 per 15 minutes Unlisted evaluation and management service $62.71 per 15 minutes T1002 RN services, up to 15 minutes $13.06 per 15 minutes No HIPAA Special Bulletin Update

53 Local 7015X 4738Z Assessment, 15 minutes SHARS special transptation, round trip Local $19.47 per 15 minutes $19.03 per round trip Psychological testing (includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, e.g., WAIS-R, Rschach, MMPI) interpretation and rept, per hour $77.88 per hour T2003 Nonemergency transptation; encounter/trip $19.03 per round trip When billing procedure codes H0004, T1002, 92506, 92507, 97001, 97003, 97110, 97530, 99499, providers can bill in increments of 15 minutes. F example, express 30 minutes as a billed of 2.0. When billing procedure code 96100, providers can bill in partial hours, expressed as 1/10th of an hour (6-minute segments). F example, express 30 minutes as a billed of 0.5. THSteps Medical Providers THSteps Condition Indicats HCFA-1500 (Paper Claims) Effective f dates of service on after October 16, 2003, THSteps Medical providers billing on a HCFA-1500 paper claim fm must include EPSDT condition indicats to describe the outcome of the visit. Condition indicats must be indicated on the claim the medical check-up procedure code(s). The condition indicats will be placed at the detail level of the HCFA-1500 paper claim fm in Block 24 J (Codination of Benefits) field. Only one condition indicat per detail is allowed. A referral indicat (Y N) is not required on paper claims. The following condition indicats are valid if a referral is made: Condition Indicat ST New services requested * S2 Under treatment * The ST condition indicat should only be used when a referral is made to another provider the client must be rescheduled f another appointment. It does not include treatment initiated at the time of the visit. The condition indicat NU, Not used, is valid if no referral is made. FQHCs, Home Health Agencies, Hospitals, and Hospital-Based RHCs that render THSteps Medical visits must submit a HCFA-1500 claim fm when billing on paper. 837P (Electronic Filing) Effective f dates of service on after October 16, 2003, THSteps Medical providers billing on an Electronic 837P (Professional claim transaction) will be required to include condition indicats to describe the outcome of the visit. Condition indicats must be indicated on the claim the medical check-up procedure code(s). The condition indicats will be placed at the header level of the professional electronic claim Condition Indicat field. Additional indicats are required based on whether not a referral was made. If the referral was made, the referral indicat of Y must be used one of the following condition indicats: Condition Indicat ST New services requested * S2 Under treatment * The ST condition indicat should only be used when a referral is made to another provider the client must be rescheduled f another appointment. It does not include treatment initiated at the time of the visit HIPAA Special Bulletin Update 53 No. 174

54 If a referral was not made, the referral indicat N must be used the condition indicat code NU, Not used. FQHCs, Home Health Agencies, Hospitals, and Hospital-Based RHCs that render THSteps Medical visits must submit claims using the 837P claim transaction when billing electronically. Refer to: Future banner and bulletin publications f any updates. THSteps Tuberculosis (TB) Screening Page 55 of the 2003 HIPAA Special Bulletin, No. 170 directs the provider to retain the completed TB questionnaire in the client s medical recd. This direction is not a requirement of THSteps and is not consistent the requirements f retention of other questionnaires used by the program. While providers may choose to retain the questionnaire, they must document the screening, any risk facts identified, and any follow-up based on those risk facts. Vision Providers Vision Care Changes Page 64 of the 2003 HIPAA Special Bulletin, No. 170 instructed vision providers to use VP, Aphakic patient, when billing f prosthetic eyewear. Effective f dates of service on after October 16, 2003, prosthetic eyewear does not require VP f reimbursement. However, services f prosthetic eyewear must be billed a diagnosis of aphakia to be considered f reimbursement. The following diagnosis codes should be used when billing f prosthetic eyewear: Diagnosis Aphakia Congenital aphakia Contact lenses require pri authization unless billed a diagnosis of aphakia. Fms 2002 ADA Dental Claim Fm Instructions The following table describes how to complete the new 2002 American Dental Association (ADA) Dental Claim Fm to ensure prompt and accurate reimbursement and reduce follow-up inquiries. ADA Block No. ADA Instructions 1 Type of Transaction F Texas Medicaid, check Statement of Actual Services box. The other two boxes are not applicable. Do NOT use ADA 2002 Claim Fm as a Texas Pri Authization Fm. Refer to Section D of the Texas Medicaid Provider Procedures Manual f the THSteps Dental Mandaty Pri Authization Request Fm. 2 Predetermination/Preauthization Number Enter Pri Authization Number if assigned by Medicaid. 3 Name, Address, City, State, Zip Enter name and address of Texas Medicaid Program Contract payer where the claim is to be sent. 4 Other Dental Medical Coverage? Leave blank if no other Dental Medical coverage (skip Blocks 5-11). Check yes, if other Dental Medical coverage is available if not Medicaid - complete Blocks Subscriber Name Subscriber Name; if non-medicaid insurance. This line refers to the insured and is not necessarily the patient. May be parent legal guardian of client receiving treatment. 6 Date of Birth (MM/DD/CCYY) Enter insured s 8-digit date of birth (MM/DD/CCYY); if non-medicaid insurance. This line refers to the insured and is not necessarily the patient. May be parent legal guardian of client receiving treatment. No HIPAA Special Bulletin Update

55 ADA Block No. ADA Instructions 7 Gender Check insured s crect gender; if non-medicaid insurance. This line refers to the insured and is not necessarily the patient. May be parent legal guardian of client receiving treatment. 8 Subscriber Identifier Enter insured s subscriber identifier; if non-medicaid insurance. This line refers to the insured and is not necessarily the patient. May be parent legal guardian of client receiving treatment. 9 Plan/Group Number Enter insured s plan/group number; if non-medicaid insurance. This line refers to the insured and is not necessarily the patient. May be parent legal guardian of client receiving treatment. 10 Relationship to Primary Subscriber Enter insured s relationship to primary subscriber; if non-medicaid insurance. This line refers to the insured and is not necessarily the patient. May be parent legal guardian of client receiving treatment. 11 Other Carrier Name, Address, City, State, Zip Infmation on other carrier, if applicable. 12 Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Enter client s last name, first name, and middle initial as exactly written on the Texas Medicaid Identification Fm Date of Birth (MM/DD/CCYY) Enter client s 8-digit date of birth (MM/DD/CCYY). 14 Gender Check client's crect gender. 15 Subscriber Identifier Enter client s Medicaid number. 16 Plan/Group Number Not applicable f Texas Medicaid. 17 Employer Name Not applicable f Texas Medicaid. 18 Relationship to Primary Subscriber Not applicable f Texas Medicaid. 19 Student Status F exception to periodicity, check the FTS box and provide a narrative explanation in the Remarks Block Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Must put client name infmation in Block Date of Birth (MM/DD/CCYY) Must put client s 8-digit date of birth infmation in Block Gender Must put client gender infmation in Block Patient ID/Account # (Assigned by Dentist) Used by dental office to identify internal patient account number. This field is optional. Not required to process claim. 24 Procedure Date (MM/DD/CCYY) Enter 8-digit date of service (MM/DD/CCYY). 25 Area of Oral Cavity Not applicable f Texas Medicaid. 26 Tooth System Not applicable f Texas Medicaid. 27 Tooth Number(s) Letter(s) Enter Tooth ID as required f procedure code. Refer to Section 18.6 f the Tooth Identification (TID) System. 28 Tooth Surface Enter Surface ID as required f procedure code. Refer to Section 18.6 f the Surface Identification (SID) System. 29 Procedure Use Current Dental Terminology, fourth edition procedure code (CDT-4). 30 Enter brief description from the CDT-4 procedure code. 31 Fee Enter usual and customary charges f line of service used. Charges must not be higher than the fees charged to private pay patients. 32 Other Fee(s) Enter other fees (f example, other insurance payment). 33 Total Fee Total all fees in column under Block (Place an X on missing tooth) Place an X on missing tooth as required f procedure code. 35 Remarks Use the Remarks space f a narrative explanation f exception to periodicity (Block 19), a Facility name and address if Place of Treatment (Block 38) is not a provider office, an emergency narrative (Block 45), additional infmation such as repts f 999 codes multiple supernumerary teeth. 36 Patient/Guardian signature Not applicable f Texas Medicaid HIPAA Special Bulletin Update 55 No. 174

56 ADA Block No. ADA Instructions 37 Subscriber signature Not applicable f Texas Medicaid. 38 Place of Treatment Check only Provider s office box Hospital box. Use Hospital if a day surgery facility was used. 39 Number of Enclosures Texas Medicaid does not require enclosures to accompany a claim. DO NOT submit radiographs claims. 40 Is Treatment f Orthodontics? Check yes no as. 41 Date Appliance Placed Not applicable f Texas Medicaid. 42 Months of Treatment Remaining Not applicable f Texas Medicaid. 43 Replacement of Prosthesis? Not applicable f Texas Medicaid. 44 Date Pri Placement Not applicable f Texas Medicaid. 45 Treatment Resulting from (Check applicable box) Providers are required to check Other accident box f emergency claim reimbursement. If Other accident box is checked, infmation about the emergency must be provided in Block Date of Accident (MM/DD/CCYY) Not applicable f Texas Medicaid. 47 Auto Accident State Not applicable f Texas Medicaid. 48 Name, Address, City, State, Zip Name and Address of Billing Group Individual provider. (NOT name and address of a provider employed in a Group). 49 Provider ID Must enter REQUIRED Billing Dentist s nine-character Texas Provider Identifier (TPI) f a group a individual (NOT a TPI f a provider employed in a Group). 50 License Number Not applicable f Texas Medicaid. 51 SSN TIN Not applicable f Texas Medicaid. 52 Phone Number Enter area code and phone Billing group individual (NOT the phone number f the provider employed in a Group). 53 Treating Dentist signature Required Signature by treating dentist authized personnel must be in Block Provider ID Must enter REQUIRED Perfming Dentist s nine-character Texas Provider Identifier (TPI) treating the client. 55 License Number Not applicable f Texas Medicaid. 56 Address, City, State, Zip Not applicable f Texas Medicaid. 57 Phone Number Not applicable f Texas Medicaid. 58 Treating Provider Specialty This field is optional. No HIPAA Special Bulletin Update

57 2002 ADA Dental Claim Fm Sample 2003 HIPAA Special Bulletin Update 57 No. 174

58 Notes: No HIPAA Special Bulletin Update

59 Notes: 2003 HIPAA Special Bulletin Update 59 No. 174

60 Visit us online at f the following: Compass21 Fequently Asked Questions (FAQ) Wkshop Schedules and FAQs TDH-NHIC 2003 Publications includes the 2003 Texas Medicaid Provider Procedures Manual, 2003 Texas Medicaid Provider Procedures Manual Texas Health Steps, and Texas Medicaid Bulletins Regional Suppt lists NHIC Training Specialists Heritage Insurance Co Riata Vista Circle Austin TX PRESORTED STANDARD US POSTAGE PAID AUSTIN TX PERMIT 156 ATTENTION: BUSINESS OFFICE