Long Term Care BULLETIN. Visit the Long Term Care section on the NHIC Web site at LTC Bulletin, No. 15, Contents

Transcription

1 August 2003, No. 15 Long Term Care Visit the Long Term Care section on the NHIC Web site at HIPAA: Will You Be Ready? BULLETIN LTC Bulletin, No. 15, Contents Health Insurance Portability and Accountability Act Awareness Overview Enforcement of HIPAA Regulations HIPAA Privacy State HIPAA Project Team Update Privacy Activities Frequently Asked Questions (FAQs) Business Associate Contracts Electronic Data Interchange Activities Security Activities LTC HIPAA EDI IMPLEMENTATION The Solution Companion Guides Vendor Specifications Nurse Aide Training (NAT) and Expedited Claims Remittance and Status (835, R&S), Eligibility Benefit Inquiry Response (271, MESAV), and Claims Status Inquiry (277, CSI) Claim Status Inquiry (276-CSI) HIPAA Claim Formats National HCPCS and CPT Sets Claims for Dates of Service (DOS) Before October 16, 2003, Filed On or After October 16, Exceptions Units Budget Number Paper Claims Updates to May 2003 LTC Bulletin, No. 14 Articles Provider Number Qualifier The National Heritage Insurance Company (NHIC) is the insurer and contract administrator for the Texas Medicaid Program under contract with the Texas Health and Human Services Commission (HHSC)

2 LTC Bulletin, No. 15, Contents continued Header Adjustment Claims Service Group Budget Number Nurse Aide Training (NAT) and Expedited Payment Claims Billing, Service, Procedure, and Item s Explanation of Benefits (EOB) s Claim Adjustments Billed Unit Rate Maximum Number of Details Client Name Field Sizes Contract Number/Client ID Field Sizes Patient Account Number (formerly Client Control Number) Decimal Fields Inappropriate Qualifiers Remittance and Status Reports (R&S) Claim Status Inquiry Medicaid Eligibility Service Authorization Verification (MESAV) TDHconnect Software TDHconnect, Version 3.0 Installation Steps Important Dates for October 16, 2003 Implementation of HIPAA Transaction and Sets Twelve Month Claims Filing Deadline DHS TDMHMR Vendor and Provider Testing Service Table Place of Service (POS) Table Definitions Using the LTC Bill Crosswalk Table Directions How to Use the LTC Bill Crosswalk Table Long Term Care Bill Crosswalk Table Explanation of Benefits (EOB) Table Nursing Facility and Community Based Alternatives Workshops 2003 NHIC Nursing Facility and CBA Workshop Schedule Workshop Registration Form Helpful Hints LTC Web Site Reminders Resources for LTC Questions General Table All Providers TDMHMR/ICF MR DHS Provider Claims Services DHS LTC NHIC Your NHIC Training Specialists by Territory Glossary of Terms LTC Bulletin 2 2 August 2003, No. 15

3 Health Insurance Portability and Accountability Act Awareness Overview Congress enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to reform the health care insurance market and simplify health care administrative processes. Entities covered by HIPAA (covered entities), including Medicaid providers, must comply with HIPAA regulations. Covered entities include health plans (health insurers, HMOs, Blue Cross/Blue Shield, Medicare, Medicaid, ERISA), health care providers (hospitals, physicians, clinics, contracted providers who do business electronically), and health care clearinghouses. Covered entities were required to implement privacy provisions by April 14, 2003, and must comply with HIPAA Electronic Data Interchange (EDI) requirements by October 16, Covered entities must also comply with HIPAA Security requirements by April 21, National Hertitage Insurance Company (NHIC) conducted EDI vendor workshops in April and May The state began conducting Long Term Care (LTC) provider EDI workshops in July Your NHIC provider relations training specialist is available to answer your questions and to provide additional training. You may contact your provider relations training specialist directly. Refer to the NHIC Web site to determine the training specialist for your area (see address below). Visit the following Web sites for information and other helpful links: Centers for Medicare and Medicaid Services (CMS): Provider workshops: Provider relations training specialists: imagemap.html Frequently Asked Questions: EDS-NHIC LTC home page: Approved HIPAA implementation guides and current listing of the remark and reason codes: Health and Human Services Commission (HHSC): NDISTaskForce.html Texas Department of Human Services: Privacy: Other helpful links: Enforcement of HIPAA Regulations The Department of Health and Human Services (HHS) has determined that the Office for Civil Rights (OCR) in HHS will enforce the privacy standards. The Centers for Medicare and Medicaid Services is responsible for enforcing the EDI transactions and code set standards, as well as security and identifiers standards when those are published. The Centers for Medicare and Medicaid Services will also continue to enforce the insurance portability requirements under Title I of HIPAA. The Texas Health and Human Services Commission (HHSC), the Texas Department of Human Services (DHS), and NHIC are not responsible for enforcing HIPAA provisions. August 2003, No LTC Bulletin

4 Providers will be contacted if a complaint has been filed with the Centers for Medicare and Medicaid Services that the provider is not sending in HIPAA-formatted claims. This is the primary way that the Centers for Medicare and Medicaid Services will enforce compliance with HIPAA regulations. There will not be a crossreference of providers who did not submit an extension. If a complaint is filed, the Centers for Medicare and Medicaid Services will contact providers and will require them to provide a corrective action plan of how they will come into compliance. The Centers for Medicare and Medicaid Services will then monitor the provider to ensure they come into compliance. Risks of noncompliance are fines and, in the case of intentional privacy violations, other legal ramifications. HIPAA Privacy HIPAA Privacy regulations must be implemented by all covered entities no later than April 14, HHSC has been assessed to be a HIPAA-covered entity. Therefore, effective April 14, 2003, NHIC started operating as a HIPAA Business Associate of HHSC as defined by the federally mandated rules of HIPAA. The HIPAA Privacy regulations are intended to protect individually identifiable health information by: Restricting disclosure of Protected Health Information (PHI) Establishing certain administrative requirements Establishing requirements for business partners Establishing certain rights of individuals with respect to their personal health information In accordance with HIPAA Privacy regulations, the state of Texas must make a Notice of Privacy Practices available to all Texas Medicaid households. As one of the steps in this process, the state of Texas mailed a Notice of Privacy Rights to Medicaid households in March The Notice informed Texas Medicaid clients of: Privacy policies, agency responsibilities, and client rights under HIPAA Privacy Client-complaint procedures Be aware that Medicaid clients will have this information before the implementation date of the rule, April 14, Clients will be instructed to contact the Medicaid hotline at if they feel they need more information. To prepare to respond to questions on this topic, view the DHS mailout to clients through a link to the DHS document at HIPAA.htm. For further information on privacy regulations, visit the Centers for Medicare and Medicaid Services (CMS) Web site at hipaa. State HIPAA Project Team Update Privacy Activities This article provides a status update on the Texas Department of Human Services (DHS) HIPAA activities reported in the May 2003 LTC Bulletin, No. 14. Frequently Asked Questions (FAQs) The Texas Department of Health (DHS), Texas Department of Mental Health and Mental Retardation (TDMHMR), and the Texas Health and Human Services Commission (HHSC) collaborated to create a list of HIPAA privacy frequently asked questions (FAQs). The FAQs and answers, along with the HIPAA Privacy Notice, are available on the DHS Web site located at hipaa/index.html. Business Associate Contracts DHS continues to identify business associate contracts that require specific language relating to HIPAA Privacy provisions. Under the privacy rules, DHS is a health plan because it administers part of the Texas Medicaid Program. A health plan is not a business LTC Bulletin 4 4 August 2003, No. 15

5 associate of a health care provider when the provider merely discloses protected health information for payment purposes. Thus, the usual relationship between DHS and the entities that provide services to DHS clients is not a business associate relationship. In the guidance the Office of Civil Rights (OCR), U.S. Department of Health and Human Services (HHS), issued December 3, 2002, and revised April 3, 2003, OCR states that the relationship between a health care provider and a health plan does NOT require a business associate contract. OCR says that a business associate relationship is not established where a health care provider submits claims for payment to a health plan. Under these circumstances, each covered entity is acting on its own behalf. HIPAA privacy provisions require that current DHS business associate contracts must be amended no later than April 14, Refer to sections (e), (e), (d), and (e) in title 45 of the of Federal Regulations (CFR) to view the regulations about business associate relationships and contracts. A detailed explanation of when business associate contracts are required may be found at the following link on the OCR Web site: hipaa/guidelines/businessassociates.pdf. Electronic Data Interchange Activities Covered entities, such as DHS and TDMHMR, must comply with HIPAA Electronic Data Interchange (EDI) provisions by October 16, The joint DHS/TDMHMR LTC HIPAA project team (team) continues to work with NHIC on achieving Long Term Care (LTC) Claims Management System (CMS) compliance with the HIPAA EDI transaction standards. The team and NHIC have completed the business design phase of EDI compliance efforts and are well along in technical design. The business design phase identified the complexity of the compliance solution for the Claims Management System, with the EDI team doing a thorough analysis of all transactions until a workable solution was achieved. Specific business design changes are described in the LTC HIPAA EDI Implementation section of this bulletin. To comply with HIPAA EDI provisions, the state determined the most feasible solution was to convert the national procedure codes submitted by providers back to the local codes (bill code, service code) in order to retain the current claims processing system. The state HIPAA EDI team has analyzed local bill codes to determine which should be converted to appropriate national standard codes. In some cases, DHS and TDMHMR will retain the local code for services and reimbursements not covered by HIPAA rules. Refer to the Long Term Care Bill Crosswalk Table on page 27 of this bulletin. DHS and TDMHMR conducted LTC provider training in July to help mitigate potential problems associated with HIPAA EDI implementation. Security Activities The Centers for Medicare and Medicaid Services published the final security rules on February 12, Under HIPAA security standards, covered entities must establish procedures and mechanisms to protect the confidentiality, integrity, and availability of electronic-protected health information (PHI). The rules require covered entities to implement administrative, physical, and technical safeguards to protect electronic PHI in their care. The security standards work in concert with the final privacy standards. The two sets of standards use many of the same terms and definitions in order to make it easier for covered entities to comply. The security standards become effective on April 21, Small health plans have an additional year to comply. August 2003, No LTC Bulletin

6 For more information, refer to 45 CFR Parts 160, 162, and 164 Health Insurance Reform: Security Standards; Final Rule. You can view the rule on the following link: 14mar /edocket.access.gpo.gov/ 2003/pdf/ pdf. LTC HIPAA EDI IMPLEMENTATION The Solution HIPAA EDI requires Texas Medicaid Long Term Care to accept, process, and return HIPAA-compliant electronic transactions for claims, eligibility inquiries, claim status inquiries, remittance and status, and prior authorization by October 16, The state, along with its claims administrator, NHIC analyzed the Claims Management System with respect to HIPAA EDI requirements, and determined the best solution was to retain the existing claims processing system for paying claims. Given this decision, and the need to become HIPAA-compliant, all transactions coming in would be HIPAA-compliant, but would be translated back into the old bill format in order to process and pay claims. For example, a claim coming into the Claims Management System for payment would contain the national procedure code, Place of Service (POS), and other requisite information; once received by NHIC, it would be converted back to the old bill code to process as usual using information contained on the claim plus that contained in various state systems. The derivation of the old bill code from the national code requires the provider to submit not only the national procedure code, but also additional information to help point to the correct bill code. This information must be submitted in HIPAA-compliant formats. Throughout the process of HIPAA compliance, providers will be requested to learn new terms, submit HIPAA-compliant claims, and receive HIPAA-compliant transactions. The DHS/ TDMHMR EDI Team has worked diligently to keep the impact to a minimum. This bulletin will hopefully help guide you in that process. Companion Guides Companion Guides are documents that NHIC developed, with state input, to provide American National Standards Institute providers with the specific data sets that EDS/ NHIC requires for HIPAA compliance and LTC claims processing. Companion Guides for covered transactions have been placed at This is the location that providers and vendors currently go to look for information related to Texas Medicaid Program, CSHCN, Family Planning, and Long Term Care. Directions to locate the documents have been added to the EDS-NHIC.com Web site in the HIPAA folder. Vendor Specifications Vendor specifications are documents that NHIC developed, with state input, to provide ANSI providers with the specific data sets that EDS/NHIC requires for noncovered transactions. These specifications have been placed at HIPAA. The following vendor specifications information is very important. Nurse Aide Training (NAT) and Expedited Claims ANSI submitters filing Nurse Aide Training (NAT) and Expedited claims will be expected to use the EDS proprietary file format. This format allows the claims to bypass the front end HIPAA edits. Vendor specifications for NAT and Expedited Claims can be found on TexMedNet.com. Remittance and Status (835, R&S), Eligibility Benefit Inquiry Response (271, MESAV), and Claims Status Inquiry (277, CSI) The HIPAA-compliant X12 transactions for the 835, 271, and 277 will no longer contain a significant amount of data that providers currently receive. In an effort to provide all needed data and remain HIPAA-compliant, LTC Bulletin 6 6 August 2003, No. 15

7 beginning October 16, 2003, NHIC will transmit a supplemental file with each of these responses. Vendor specifications for the 835, 271, 277, and their respective supplemental files can be found on Claim Status Inquiry (276-CSI) Effective October 16, 2003, providers will submit electronic CSI requests using the HIPAA-compliant 276 transaction format and CSI responses will be returned using the HIPAA-compliant 277 transaction. HIPAA Privacy requirements specify that Client ID (client Medicaid number) must accompany all 276 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 have one interactive CSI request: Interactive Claim by Internal Control Number (ICN). There are two types of batch requests: Batch Inquiry by ICN Batch Inquiry by Service Date Span. All these inquiries will include the provider and client information as well as the other HIPAA required information. 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 are not covered transactions under HIPAA since CSI Transmission ID (or Batch ID) is not a 276 data element and will no longer be available. HIPAA Claim Formats HIPAA requires three different claim formats depending upon the service provided: 837 Institutional (I), 837 Professional (P), and 837 Dental (D). The DHS/TDMHMR Claims Management System (CMS) will process all three types. To determine which format to use, go to the bill code table, locate the service group, service code, and bill code for the service for which you wish to bill. If the table shows the revenue code field populated (even if the HCPCS fields are also populated), you will file the 837 I (Institutional). If you are filing a claim for dental services as noted by a HCPCS code beginning with D, you must file the 837 D (Dental). All other claims will use the 837 P (Professional). Exceptions to the above rule apply for NAT and Expedited claims. These claims will use the EDS proprietary format. Vendor specifications for ANSI submitters may be found on the NHIC Web site or at TDHconnect users will find a NAT and on Expedited claim tab (in addition to the 837s noted above) when using the TDHconnect claim selection window. National HCPCS and CPT Sets The standard medical data code sets from the Health Care Finance Administration Common Procedural Coding System (HCPCS) and Current Procedural Terminology, Fourth Edition (CPT-4) are the National cross-referenced code sets used to match or map to the Texas LTC local bill codes in the table that follows. In an effort to standardize transmission of code sets, HIPAA requires the elimination and replacement of all medical service local code sets. However, HIPAA allows for nonmedical or nonhealthcare or atypical services to be exempt from the standard code set requirement and will allow each state to continue to use their local code designator for atypical services only (i.e., home modifications). The 2001/2002/2003 HCPCS and CPT code sets were used in the mapping exercise. They are downloadable from the BBS from NHIC procedures code file, and are available as hard copy from NHIC printout sorted by service code type - acute care. August 2003, No LTC Bulletin

8 Claims for Dates of Service (DOS) Before October 16, 2003, Filed On or After October 16, 2003 Claims for dates of service (DOS) before HIPAA implementation (October 16, 2003), but filed on or after October 16, 2003, must adhere to the HIPAA regulations about format and fields. However, the code used in the procedure code field will be that which was effective on the DOS except those noted below. For example, if you provided LVN Nursing Services on September 1, 2003, for a service group 17 client with a 13A service code and billed on or after October 16, 2003, use the local bill code in effect on the DOS, which was G0302. If you provided and billed the same service on October 18, 2003, to the same client with the same authorizations, bill using HCPCS code S9124 or T1003. Exceptions Nursing Facility/Hospice/ICF-MR Daily Care: Services for daily care by nursing facility, hospice, and ICF-MR providers will be billed using the revenue code only (as listed in the bill code table) for dates of service on or after October 16, For dates of service before October 16, 2003, but billed after HIPAA implementation (i.e., October 16, 2003, or later) both the revenue code listed in the bill code table and the local bill code used before HIPAA implementation must be used. Hospice Physician Services: Hospice physician services will be billed using the national revenue code and the appropriate CPT-4 code regardless of the date of service if filed after October 16, Adaptive Aids/DME: Services provided under the Adaptive Aids/DME local code (G0500) will be billed after HIPAA implementation using the appropriate national code, regardless of the date of service. Consult the bill code table for the appropriate code(s) to use. Dental: Dental services claimed on or after 10/16/03 will be billed using the national code for the dental service provided regardless of the date(s) of service using the dental claim form. Consult the bill code table for the appropriate code. Other Exceptions: If the bill code table shows a revenue code for the service, the revenue code listed will be used regardless of the date of service. If the DOS is prior to October 16, 2003, the revenue code must be accompanied by the local bill code in the procedure code field. If the DOS is on or after October 16, 2003, if a HCPCS code or CPT4 code is noted in the appropriate column of the bill code table, this code must be entered in the procedure code field. Units DHS/TDMHMR has chosen to retain the units as defined today. If you billed dollars in the unit field previously for the bill code, you will bill dollars in the unit field when you bill the national code mapped to the bill code. If you previously billed in time increments in the unit field, you will continue to bill time increments in the unit field using the national code. If your unit rate is hourly, you will enter.25 in the unit field for each 15 minutes of service. Example 1: If you provide 25 hours and 30 minutes of service, enter in the Units field. Example 2: The new national code for PAS services is in 15-minute increments; whereas the previous local bill code utilized hourly units. If you provide one hour of PAS services, you will enter a 1 in the unit field (4 x.25). Exception. For Psychological Services, the units should be entered according to the following ranges: minutes = 1.25 units minutes =.75 units minutes =.50 units LTC Bulletin 8 8 August 2003, No. 15

9 Budget Number If your contract has multiple budget numbers, you will have to identify the budget to be debited using an appropriate modifier in modifier field 2 on the claim detail line. U1 has been defined as budget number 1 and U2 has been defined as budget number 2. If you currently submit a budget number for billing, you will need to fill in this field or the claim may be denied. Paper Claims Form 1290, Long Term Care Claim and Instructions, have been revised to include the changes described in this bulletin. Form 1290 and instructions will be mailed to all providers (TDHconnect and Paper Submitters) in or around August The form will also be available on the DHS Web site at index.htm. Although the form may be received in August, it will become effective for claims received on or after October 14, 2003, and should not be used until then. Note the following: The revised Form 1290 must be used for claims submitted and received by NHIC on or after October 14, Revised 1290 s received on or after October 14, 2003 will be processed on or after October 14, Claims received by NHIC, on the previous version of the Form 1290 (9/99), on or after October 14, 2003, will be returned to providers for resubmission on the revised Form Claims received by NHIC, on the revised Form 1290, before October 14, 2003, will be returned to the provider. Updates to May 2003 LTC Bulletin, No. 14 Articles The state and NHIC have made significant progress since the May 2003 LTC Bulletin, No. 14 was published. This progress has resulted in the need to update several articles from the May LTC Bulletin. In some cases, the original article is reprinted and any changes are identified by bold print. In other cases, the original article has been completely rewritten and significant points are emphasized by bold print. Provider Number Qualifier With the implementation of HIPAA, provider identifiers (contract/vendor numbers) will need to be preceded by a qualifier. LTC ANSI claim submitters will need to enter G5 (Provider Site Number) in the secondary provider ID qualifier field. For TDHconnect submitters and paper submitters, the Provider Site Number fills automatically. Header Adjustment Claims After HIPAA implementation, providers will no longer be able to adjust Header information on claims that have been processed by the Claims Management System. This includes providers who currently use TDHconnect, submit paper claims, or submit electronic (ANSI format) claim files. Header items include: Total Approved to Pay Amount, Service Group, Provider Number, Client/ Medicaid Number, Client Last Name, and Client First Name. Any changes to the Header information requires providers to either: (1) rebill the claim completely for denied claims, or (2) submit a negative line item adjustment canceling the existing claim and rebill a new claim using the correct header information. Service Group HIPAA-compliant claim (837 transaction) formats professional (P), institutional (I), and dental (D) do not include a field for providers to submit the client's Service Group. NHIC will take the service group from the provider contract information file in order to correctly process and pay the claim. In instances where a contract has multiple service groups providers will be required to report which service group applies to the detail line by supplying the appropriate code in modifier field 1. Refer to the modifier table (page 25) to determine the modifier appropriate for the service group of the client receiving services. August 2003, No LTC Bulletin

10 Additionally, when a Hospice provider is submitting claims for an ICF/MR client, they will need to indicate the client's service group prior to entering hospice care. Budget Number As previously reported in this bulletin, if your contract has multiple budget numbers, you must identify the budget to be debited by using an appropriate modifier in modifier field 2 on the claim detail line. U1 has been defined as budget number 1 and U2 has been defined as budget number 2. If you currently submit a budget number for billing, fill in this field or the claim may be denied. Nurse Aide Training (NAT) and Expedited Payment Claims Providers will submit claims for NAT using the EDS proprietary format. TDHconnect users will see no change. ANSI providers must review and adhere to the vendor specifications as published by NHIC and posted on TexMedNet. Billing, Service, Procedure, and Item s Procedure and items codes as used in the current billing process may be changed and/or eliminated for services provided after October 16, The existing procedure and item codes that are national codes will continue with the provider submitting these codes in the procedure code field of the new claim form. Item codes that were not national codes have been mapped to national codes. Refer to the LTC Local Bill Crosswalk Table (page 27 ) to identify what codes you should use. Explanation of Benefits (EOB) s HIPAA requires the use of new standard national EOB codes, which will appear on the provider's Remittance and Status (R&S) report. Since the new Remittance Advice Remark s (RARC) do not sufficiently explain the reason for the claim status, the state has elected to provide the old codes in addition to the new codes as a supplement for our LTC providers. Refer to the Explanation of Benefits (EOB) Table on page 59 of this bulletin for information about these codes. Claim Adjustments The process for adjusting existing paid claims will change. The Adjustment Indicator column is no longer needed. The present billing system requires the user to identify the line item that a positive line replaces. Currently, the first line of an adjustment claim is always negative. All subsequent positive lines must be linked back to one of the negative lines, using the Adjustment Indicator column. The HIPAA-compliant billing process allows negative adjustments to existing paid claims; however, negative amounts are considered adjustments, and positive line items are considered rebills. If the negative adjustment does not process, it is possible for the rebill to be paid if sufficient authorized units exist for the service being billed, and the claim passes duplication edits. Billed Unit Rate The 837P and the 837D transaction formats do not provide a Billed Unit Rate field for the billed line item. The DHS/TDMHMR Claims Management System calculates the Billed Unit Rate by dividing the Billed line item Total by the Units Billed. Maximum Number of Details The maximum number of details on one claim remains 28. Client Name Field Sizes The Client Last Name field, currently 25 characters in length, will be reduced to 13 characters. The Client First Name field, currently 12 characters in length, will be reduced to 10 characters in length. LTC Bulletin 10 10August 2003, No. 15

11 Contract Number/Client ID Field Sizes The current number of characters for both Contract Number and Client ID is nine. In the present claims processing environment, if the provider submits more than nine characters, the claim is processed while the system ignores additional characters. In the HIPAA environment, the claim will fail an inappropriate ID edit if it contains more than nine characters in either of these two fields. Patient Account Number (formerly Client Control Number) The maximum number of characters for the Patient Account Number increases from the current value of 18 to a maximum value of 38. Decimal Fields HIPAA requires providers to enter a decimal in monetary fields. If the provider makes an error in the placement of the decimal (e.g., has more than two places to the right of the decimal), NHIC is not going to accept the information. If the error occurs at the header level, the entire claim is rejected or denied. If the error occurs at the detail/line level, only that detail/line item is rejected or denied. Inappropriate Qualifiers Qualifiers may appear at either a claim header or a claim detail level. If the provider uses an inappropriate qualifier at the claim header level, the claim may reject. If the provider uses an inappropriate qualifier at the claim detail level, the claim will be accepted, and only the line item(s) may reject. Remittance and Status Reports (R&S) HIPAA requires changes to the current R&S (known to ANSI providers as the 835 X12 transaction). Currently, providers receive two reports, the pending and nonpending R&S. The nonpending R&S shows claims that have been finalized and/or resulted in money that has been paid to the provider by the state Comptroller. The pending R&S shows claims that have been received by NHIC but have not yet been paid. These two reports are currently available for electronic download each Monday and show all claims paid or submitted in the prior week. In addition, the provider also receives a Weekly Financial Summary as part of the R&S. Effective October 16, 2003, providers will receive three separate reports: 835 R&S currently known as the nonpending remittance and status report; Claims Activity Report currently known as the pending remittance and status report; and Weekly Financial Summary The 835 R&S is the HIPAA-mandated report, which will detail the claims finalized in the previous week and will contain all HIPAA required fields and data elements. Finalized claims include nonpending claims having the status of Paid, Paid Zero, Paid Force Transferred, Paid Transferred, and Denied. The provider will receive one 835 R&S for each warrant issued, so it will be possible for a provider to have more than one R&S per week. Pending claims will not be shown on the 835 R&S. The Claims Activity Report will contain claim and supporting information used to process all claims within the reporting period. Processed claims in this report include Suspended, Transferred, Force Transferred, Approved to Pay, Paid, Paid Zero, Paid Force Transferred, Paid Transferred, and Denied. Only one report for the weekly report period will be issued. The Weekly Financial Summary will contain financial summary information for the reporting period, and will remain essentially as it exists today, except it will also contain the warrant summary for the period. The supplemental file will contain a summary of all financial withholdings and payments for the week, along with a listing of all warrant information found on the 835 R&S for the reporting period. August 2003, No LTC Bulletin

12 The reporting period will remain Saturday through Friday, with NHIC distributing the reports on Monday to the BBS. The provider will have 30 days to download the files; once downloaded, the files cannot be downloaded again. If the files are not retrieved from the BBS within 30 days, NHIC will archive the files then purge them from the provider s mailbox. At the provider s request, NHIC Help Desk can restore the archived files to the provider s mailbox IF the request is made within 30 days of purging. The HIPAA 835 R&S will contain the data submitted by the provider (procedure code, revenue code, modifiers, billed units, etc.). The report will also contain information as to paid amount and warrant number. The HIPAA-compliant 835 R&S will not include all data elements the provider receives today. It was determined that supplemental information should be transmitted to the provider as a Claims Activity Report so providers will be able to determine the basis of the paid amount. The claims activity report will have the same fields and layout as the current pending claims R&S, but all claim activity will be reported, including paid and denied claims. In order to reconcile what was billed by the provider and what was paid, the provider will need to look at both the 835 R&S and the Claims activity report to see what bill code was derived and paid based on the information submitted by the provider. The Weekly Financial Summary will allow the provider to determine the number of R&S for that week. Paper providers will not see any changes to the paper R&S reports. If you relied on CSI for yearly cost report information, it is recommended that you begin to keep copies of your R&S reports to assist you in completing the yearly cost reports. Claim Status Inquiry The current TDHconnect system contains a very useful application called Claims Status Inquiry (CSI) that provides claims payment information that is easier to read than the existing R&S Report. For ANSI providers, the CSI equates to the 277 X12 transaction. CSI allows providers to independently verify and research payment problems to resolve discrepancies. It also provides the functionality of electronically downloading paid, denied, and pending claims information into a spreadsheet and using the information for internal reports, annual cost reports, and accounting system updates. HIPAA-compliant changes affect the functionality of the CSI. Presently, providers have the ability to request CSI in up to threemonth increments by either provider contract or by individual client. The information can be obtained for any services that are less than three years from the date requested. Effective October 16, 2003, providers will no longer be able to query by provider contract number. HIPAA EDI transaction format requirements stipulate that the only way to request the information will be by the individual claim number (ICN). To expedite data entry, TDHconnect will have the ability to use the magnifying glass icon to search for and populate the required client information from your client claims database. This will eliminate the need to individually type in each client name, Medicaid number, and service dates every time you want to obtain payment information for a three-month period for your client population. You will be required to click the magnifying glass icon to locate each client and populate the request. Provider s have used CSI to obtain information needed for the yearly cost report. Since providers will no longer be able to query on contract number,it is suggested the electronic R&S be considered a replacement. It must be noted, however, that the electronic R&S is only available for a very short window of time (30 days). It is recommended that you begin saving your R&S so that you will have them available to compile the annual cost report. To assist in resolving payment problems, provide payment research information, and to prepare for your annual cost report, it is highly recommended that every provider obtain at least a complete year's worth of CSI information electronically as close to October 16, 2003 as possible. It will also be helpful to have available one year of R&S LTC Bulletin 12 12August 2003, No. 15

13 reports per contract number. This will provide some historical payment information. The state and its claims administrator will continue to explore ways to improve the information reporting function for the future. Medicaid Eligibility Service Authorization Verification (MESAV) With the implementation in October 2003 of the HIPAA-compliant transaction for eligibility inquiry responses (known to ANSI providers as the x transaction), there will be two ways for you to obtain your client eligibility information from Medicaid Eligibility Service Authorization Verification (MESAV). One way will be to do interactive inquiries and receive a HIPAA-compliant response (the 271). The alternative way will be through a batch submission. With both the batch and interactive submissions, ANSI providers will receive the HIPAA-compliant 271 response and a supplemental file. The 271, when used in conjunction with the supplemental file, will provide all current data plus additional data elements required by HIPAA. TDHconnect users will see the additional information merged onto existing screens. TDHconnect Software TDHconnect is a software package designed to encourage the submission of electronic claims, rather than paper claims. HIPAA requires all electronic transactions to be in the X12 format, and the current TDHconnect transaction formats do not meet this requirement. NHIC will make enhancements to TDHconnect to ensure that providers submit HIPAA-compliant transactions on and after October 16, Here is a summary of the minimum PC requirements to use TDHconnect 3.0: Operating System Microsoft Windows 95, 98, ME, megabytes (MB) of RAM Windows NT MB of RAM Note: NHIC will not support Microsoft Windows XP. Hardware Intel Pentium II, 400 megahertz (MHz) processor 128 MB of RAM Free disk space equal to 3 times the size of current TDHconnect 2.0 databases plus 100 MB available for installation 50 MB of hard disk space per user per year for databases 800 X 600 VGA (monitor resolution), 256 colors CD-ROM Drive Modem that supports 9600 bps (Recommended: bps or greater) Software Microsoft Internet Explorer (I.E.) 4.01 Service Pack 2 or higher Adobe Acrobat 4.0 TDHconnect, Version 3.0 Installation Steps 1. Verify the following minimum TDHconnect 3.0 hardware, operating system, and software requirements. (See previous article.) 2. Receipt of TDHconnect 3.0 CD in the mail by October 10, 2003, or contact the EDI Helpdesk. 3. Verify that Internet Explorer (IE) 4.01 Service Pack (SP) 2 or higher is installed. Note: To verify the version of IE, start it, click Help, then select About Internet Explorer. The Software Version and Updated Versions will display. 4. If Acrobat Reader 3.0 is installed, it must be uninstalled for a new installation of TDHconnect (no previous version of TDHconnect installed). If TDHconnect is currently installed, skip to step Create an external backup (tape, CD-ROM, copy to separate machine) of TDHconnect 2.0 or higher data and save. August 2003, No LTC Bulletin

14 6. Perform a purge of old TDHconnect 2.0 records or compress databases. To perform a purge, follow the steps below: a. To purge old records, from the TDHconnect Explorer, click the plus sign (+) next to System, then doubleclick Database Utilities. b. On the Purge tab, under Purge, click the name of the program to be purged. c. In the Age In Days box, to select records to purge that are older than the number shown, type or use the arrows to select a number of days. d. Click Purge. e. When the Purge process is finished, click Cancel to exit. f. To compress a database, from the TDHconnect Explorer, click the plus sign (+) next to System, then doubleclick Database Utilities. g. On the Compress tab, under Select, click the program name of the database you want to compress. h. Click Compress. i. When the Compress process is finished, click Cancel to exit. 7. Exit all open applications on the desktop. 8. Install TDHconnect 3.0 from the TDHconnect 3.0 Installation CD-ROM by following the instructions found inside the CD package. 9. For new installations of TDHconnect (no previous version of TDHconnect installed), set up the modem in the Windows operating system by following the instructions found inside the CD package. If TDHconnect is currently installed, skip to step Download the latest TDHconnect service pack by connecting to the Texas Medicaid Network (TexMedNet) Web site and install the service pack. 11. Open and log on to TDHconnect For new installations of TDHconnect (no previous version of TDHconnect installed), select a modem. If TDHconnect is currently installed, skip to step For new installations of TDHconnect (no previous version of TDHconnect installed), configure system settings for the Electronic Commerce Management System (ECMS). If TDHconnect is currently installed, skip to step If in a multi-user environment, map network drive. 15. Exit TDHconnect Your system administrator (or appropriate technical assistance group) should test to ensure that TDHconnect 3.0 has not disabled other applications. 17. If other applications are installed after TDHconnect 3.0 has been installed, your system administrator (or appropriate technical assistance group) should test TDHconnect 3.0 to ensure these other applications did not disable it. 18. Use the TDHconnect 3.0 Convert Data tool to convert existing TDHconnect 2.0 or higher data. 19. Perform a download and update of reference codes. a. From the TDHconnect System Totals window, go to the Retrieve Other tab. b. Select the necessary Reference codes (select the All Reference s). c. Click the download button. d. TDHconnect will then dial out and start connecting. e. Files will be downloaded and TDHconnect will disconnect when the download is complete and will be updated in the database. LTC Bulletin 14 14August 2003, No. 15

15 Important Dates for October 16, 2003 Implementation of HIPAA Transaction and Sets 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 Long Term Care Providers. Review the table below for activities that impact your office. All Electronic Transactions (MESAV, Claims, Claim Status Inquiries, Adjustments, ER&S) 10/15/2003 6:00 p.m. NHIC s last download from the BBS of transactions that are not HIPAA-compliant. 10/15/ /17/2003 6:01 p.m. 12:00 a.m. CMS is unavailable for any electronic transaction (MESAV, Claims, Claim Status Inquiries, Adjustments, ER&S). 10/17/ :01 a.m. First submission of HIPAA-compliant transactions for Claims Management System (CMS) (Long Term Care). TDHconnect /02/ /29/2003 TDHconnect 3.0 training offered to providers. 09/26/2003 Software is mailed to all current users. 10/01/2003 Providers begin receiving TDHconnect 3.0 CD-ROM. 10/10/2003 Providers should contact the EDI Helpdesk if they have not received TDHconnect 3.0. Before 10/16/2003 Before 10/16/2003 Before 10/16/2003 It is recommended that providers download and update TDHconnect 2.0 with Service Pack 7 before installing TDHconnect 3.0. Providers must install TDHconnect 3.0. Last transaction should be completed by the provider before this task is performed by the provider. Providers must download and install Service Pack 1 after the 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. ( Providers must convert databases from TDHconnect 2.0 to TDHconnect 3.0. Providers should install TDHconnect 3.0 and convert TDHconnect 2.0 databases. Last transaction should be completed by the provider before this task. 10/15/2003 6:00 p.m. Last transactions must be completed using TDHconnect /17/ :01 a.m. Transactions must be sent using TDHconnect 3.0. ER&S files not downloaded in TDHconnect 2.0 can be downloaded with TDHconnect 3.0. Paper Claims for Long Term Care 10/13/2003 Last day for NHIC to accept current LTC 1290 claim forms. If the new LTC claim form is received on or before this date, it will be returned to the provider. 10/14/2003 First day NHIC will accept new LTC Claim form. If old claim form is received on or after this date, it will be returned to the provider. 10/14/ /15/2003 NHIC will hold new LTC claim forms. 10/16/2003 NHIC will begin processing new LTC Claim forms received October 14 through 15, 2003 that were being held. August 2003, No LTC Bulletin

16 Twelve Month Claims Filing Deadline DHS The of Federal Regulations (CFR), Title 42, (d)(1) states that the Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Since November 1, 2002, the Texas Department of Human Services (DHS) has required provider agencies to submit claims for services to DHS within this timeframe. Although the rules were effective November 1, 2002, they will not be applied to claims until on or after November 1, Electronic versions of the complete information letters and the CFR can be found at the following addresses: For LTC Community Care Providers: communitycare/infoletters/ cbaccadletters.html under CMS (CBA/ CCAD). For Hospice and Nursing Facility Providers: index.html under Communications Provider Letters. TDMHMR The CFR, Title 42, (d)(1) states that the Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Since January 6, 2003, the Texas Department of Mental Health and Mental Retardation (TDMHMR) has required provider agencies to submit claims for services to DHS within this time frame. Although the rules were effective January 5, 2003, they will not be applied to claims until on or after January 5, The information letter and the CFR were sent to TDMHMR providers. Vendor and Provider Testing Vendors and providers not using TDHconnect to submit claims, eligibility requests, or to receive an ER&S report will be requested to test transactions with NHIC to assure they can send HIPAA-compliant transactions by October 16, Organizations who wish to test with NHIC are requested to complete a vendor intake form (found in the NHIC Companion Guides for each transaction type) identifying a contact and the transaction(s) used, and send it to Nhichipaavendors@eds.com. A Test Facilitator will contact each organization to schedule a test time. Phase one of the testing process is scheduled to begin in July. During this phase, an organization s ability to transmit HIPAA-compliant transactions will be verified. Files will be submitted through the EBX Model Office BBS. Phase two will occur from August 2003 through October 2003 for Acute Care (Compass21). This phase involves sending files and receiving responses to and from NHIC. Files submitted during Phase one testing of the mapping process may be used in Phase two. Phase three will occur from September 2003 through October 2003 for validation of Long Term Care submitters sending files to CMS. During this phase, providers will be able to send and receive HIPAA-compliant files to and from NHIC. If you have any questions regarding the testing process at NHIC, send an to Nhichipaavendors@eds.com. LTC Bulletin 16 16August 2003, No. 15

17 Service Table The following table lists the service codes and their definitions. Service s Table Service Definition of Service 1 Daily Care 1T Daily Care - Transitional Add-On 3 ECF 4 Ventilator(s) 5 Dental 5A Dental - Waiver Programs 6 Nurse Aid Training 7 Occupational Therapy/Assessment 7A Occupational Therapy - Nursing Facility Specialized Services 8 Physical Therapy/Assessment 8A Physical Therapy - Nursing Facility Specialized Services 9 Speech-Language Pathology/Assessment 9A Speech Therapy - Nursing Facility Specialized Services 10 Habilitation 10A Habilitation-Delegated Nursing 10B Habilitation - Supportive Employment/Prevocational 10C Habilitation - Day 11 Respite - In Home 11A Respite - Out of Home 11B Respite - Foster Care 11C Respite - Assisted Living Apt 11CV VFI Respite - Assisted Living Apt 11D Respite - Assisted Living Apt 11DV VFI Respite - Assisted Living RC Apt 11E Respite - Assisted Living RC Non-Apt 11EV VFI Respite - Assisted Living RC Non-Apt 11F Respite - Nursing Facility 11FV VFI Respite - Nursing Facility 11G Respite - Camp 11H Respite - Day Care/Licensed Child Care Facility 11J Respite - Licenses Special Care Facility 11K Respite - ICF/MR 11L Respite - Hospital 11M Respite - HCSS (RN/LVN) 11N Respite - LVN 11P Respite - RN 11Q Respite - PAS Delegated 11R Adjunct - PAS HCSS 11S Adjunct - LVN 11T Adjunct - RN August 2003, No LTC Bulletin

18 Service Service s Table Definition of Service 11U Adjunct - PAS HCSS 11V Adjunct - PAS Delegated 12 Case Management 12A Targeted Case Management 13 Nursing Services 13A Nursing Services - LVN 13B Nursing Services - RN 14 Psychological Services 15 Adaptive Aids/DME 16 Home Modifications 17 Personal Assistance Services (PAS) 17A PAS Delegated 17B PAS Protective Supervision 17V VFI - Personal Assistance Services (PAS) 17C PAS Family Care 17CV VFI - PAS Family Care 17D PAS Frail Elderly (1929b) 17DV VFI - PAS Frail Elderly (1929b) 17E PAS Chore 18 Adult Foster Care 19 Assisted Living Apartment 19A Assisted Living - Residential Care - Nonapartment 19B Assisted Living - Residential Care - Apartment 19C Assisted Living - Personal Care 3 19D Assisted Living - Emergency Care 19E Assisted Living - Habilitation Hours 19F Assisted Living - Habilitation Less than 24 Hours 19G Assisted Living - Family Surrogate Services 19H Assisted Living - Bed Hold 20 Emergency Response Services 21 Prescriptions 22 Medical Supplies 24 Tracheostomy Cleaning (NF Only) 25 Meals 26 In-Home Family Support Program 27 Consumer Managed Personal Attendant Services (CMPAS) 27A CMPAS - Voucher Fiscal Intermediary 28 Special Services to Persons with Disabilities (SSPD) - Case Management 28A Special Services to Persons with Disabilities (SSPD) 29 Day Activity/Health Services - Title XIX 29A Day Activity/Health Services - Title XX 30 Physician Directed Care 31 Nursing Facility Room and Board LTC Bulletin 18 18August 2003, No. 15

19 Service s Table Service Definition of Service 32 Medicare Pharmacy Coinsurance 33 Medicare Respite Coinsurance 34 Dietary 35 Audiology 36 Social Work 37 Supported Employment 38 Residential Support 39 Monthly Premium 40 Assessment (Full/Partial/Annual) 40A Pre-Assessment 41 Requisition Fees - Adaptive Aids 41A Requisition Fees - Medical Supplies 41B Requisition Fees - Minor Home Modifications 41C Specifications - Adaptive Aids 41D Specifications - Home Modifications 41E Requisition Fees - Dental 42 Specialized Therapies 43 Behavior Communication Specialist 44 Orientation and Mobility 45 Intervenor 46 MHMR Night Residential Support Services 47 MHMR Supervised Living Services 48 Transportation 49 Child Support Services 50 Personal Needs Allowance 51 Independent Advocacy 52 Community Support Services 53 Transitional Services 53A Transitional Support Services 60 Unlimited Prescriptions 99 Expedited Services August 2003, No LTC Bulletin

20 Place of Service (POS) Table The following table lists each Place of Service (POS) by code, name, and description. Note that some numbers are not assigned. The POS is a required field on all claims. Place of Service (POS) Table Place of Service (s) Place of Service Name Place of Service Description Unassigned Not applicable 03 School A facility whose primary purpose is education 04 Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters) 05 Indian Health Service Free- Standing Facility 06 Indian Health Service Provider- Based Facility A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients 07 Tribal 638 Free-Standing Facility A facility or location, owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization 08 Tribal 638 Provider-Based Facility A facility or location, owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients Unassigned Not applicable 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis 12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence 13 Assisted Living Facility* Congregate residential facility with self-contained living units providing assessment of each resident s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services * New Place of Service code, effective October 1, ** Revised Place of Service code, effective October 1, Source: DHHS Transmittal, B , August 7, LTC Bulletin 20 20August 2003, No. 15

21 Place of Service (POS) Table Place of Service (s) Place of Service Name Place of Service Description 14 Group Home* Congregate residential foster care setting for children and adolescents in state custody that provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into that community 15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services Unassigned Not applicable 20 Urgent Care Facility Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention 21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions 22 Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization 23 Emergency Room Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided 24 Ambulatory Surgical Center A freestanding facility, other than a physician s office, where surgical and diagnostic services are provided on an ambulatory basis 25 Birthing Center A facility, other than a hospital s maternity facilities or a physician s office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of newborn infants 26 Military Treatment Facility A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF) Unassigned Not applicable 31 Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital 32 Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals * New Place of Service code, effective October 1, ** Revised Place of Service code, effective October 1, Source: DHHS Transmittal, B , August 7, August 2003, No LTC Bulletin

22 Place of Service (POS) Table Place of Service (s) Place of Service Name Place of Service Description 33 Custodial Care Facility A facility which provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component 34 Hospice A facility, other than a patient s home, in which palliative and supportive care for terminally ill patients and their families are provided Unassigned Not applicable 41 Ambulance-Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured 42 Ambulance-Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured Unassigned Not applicable 49 Independent Clinic* A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only 50 Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under general direction of a physician 51 Inpatient Psychiatric Facility A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician 52 Psychiatric Facility-Partial Hospitalization A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility 53 Community Mental Health Center A facility that provides one or more of the following mental health services: Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC s mental health services area who have been discharged from inpatient treatment at a mental health facility 24-hour a day emergency care services Day treatment Partial hospitalization services Psychosocial rehabilitation services Screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission Consultation services Education services * New Place of Service code, effective October 1, ** Revised Place of Service code, effective October 1, Source: DHHS Transmittal, B , August 7, LTC Bulletin 22 22August 2003, No. 15

23 Place of Service (POS) Table Place of Service (s) Place of Service Name Place of Service Description 54 Intermediate Care Facility- Mentally Retarded (ICF-MR) 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 57 Nonresidential Substance Abuse Treatment Facility* A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or skilled nursing facility A facility that provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing and room and board A facility or distinct part of a facility for psychiatric care that provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing Unassigned Not applicable 60 Mass Immunization Center A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting 61 Comprehensive Inpatient Rehabilitation Facility 62 Comprehensive Outpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services Unassigned Not applicable 65 End-Stage Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis Unassigned Not applicable 71 Public Health Clinic** A facility maintained by either a State or local health departments that provides ambulatory primary medical care under the general direction of a physician * New Place of Service code, effective October 1, ** Revised Place of Service code, effective October 1, Source: DHHS Transmittal, B , August 7, August 2003, No LTC Bulletin

24 Place of Service (POS) Table Place of Service (s) Place of Service Name Place of Service Description 72 Rural Health Clinic A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician Unassigned Not applicable 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or physician s office Unassigned Not applicable 99 Other Place of Service Other place of service not identified above * New Place of Service code, effective October 1, ** Revised Place of Service code, effective October 1, Source: DHHS Transmittal, B , August 7, LTC Bulletin 24 24August 2003, No. 15

25 Definitions The Health Insurance Portability and Accountability Act (HIPAA) solution chosen for the DHS/ TDMHMR Claims Management System (CMS) is to recreate the state-defined local codes from the HIPAA-compliant information being sent by the provider and supplemental information found in our various subsystems (i.e., provider, client). The HIPAA-compliant information may include, depending on the service, a revenue code, a HCPCS code, HCPCS modifiers, place of service, and others. In certain instances, to accurately recreate the bill codes, the solution requires the use of modifiers to define or clarify service group, budget, service provider type, occupancy, dwelling type, and so on. The following table depicts the modifiers to be used, modifier description, and modifier field placement. Because the circumstances requiring the use of a modifier vary, and the dependencies cannot always be accurately depicted in a chart, it is not possible to show definitively when a modifier will be used (i.e., modifier U1, in field 1 will only be used if the provider contract has two service groups indicated, and the provider is billing for service group 1). Refer to the Long Term Care Bill Crosswalk Table on page 27 to determine if modifiers are necessary to bill for your particular service: Field # Description 1 U1 Service Group 1 1 U3 Service Group 3 1 U4 Service Group 4 1 U5 Service Group 5 1 U6 Service Group 6 1 U7 Service Group 7 1 U9 Service Group 9 2 U1 Budget #1 2 U2 Budget #2 2 U3 Level /Priority 1 2 U4 Level 2 2 U5 Level 3 2 U6 Level 4 2 U7 Level 5 2 U8 Level 6 2 U9 Level 7 2 UA Level 8 2 TG Complex/High Tech Level of Care 3 U1 Assisted Living /Single Occupancy 3 U2 Residential Care/ Double Occupancy 3 U3 Training** 3 U4 Pre-Vocational Services** 3 U5 Activities of Daily Living** 3 U7 Full 3 U8 Partial 3 GO Services Provided by an Occupational Therapist 3 GP Services Provided by a Physical Therapist 3 GN Services Provided by a Speech-Language Pathologist August 2003, No LTC Bulletin

26 Field # Description 3 AJ Clinical Social Worker 3 TD Registered Nurse (RN) 3 TE Licensed Practical/Vocational Nurse (LPN/LVN) 4 U1 Apartment 4 U2 Non-Apartment 4 U4 Participating Provider 4 U5 Nonparticipating Provider Using the LTC Bill Crosswalk Table Directions How to Use the LTC Bill Crosswalk Table The left side of the LTC Bill Crosswalk Table provides the Texas LTC Local s for the service group, bill code, service code, and bill code description used to bill for services before HIPAA. The right side of the table identifies the National Standard s you will use on your claims effective October 16, Your contract and MESAV information will tell you the service codes and service groups for which you have authorization to provide services. To use the table, follow the guidelines below: 1. Find your service group, service code, and, if possible, the bill code you have used in the past to bill for the service(s) and follow the row across to the National s section to find the new codes to use effective October 16, If the bill code has been mapped to a national HCPCS code, you will find an entry of HC or AD in the procedure code qualifier field and information in either the HCPCS or CPT code fields (or, in some cases, in the HCPCS or CPT and the revenue code fields). If the bill code only has a national revenue code shown, no entry will be found in the procedure code qualifier field. 3. If there are entries in the modifier fields, you will need to use those modifiers in the designated fields when completing the detail line for that service. 4. If there is a ZZ in the procedure code qualifier field, you will continue to use the existing bill code to claim reimbursement. 5. The table contains a field called End Date. If this field has an entry, it means that services provided after the stated end date will not be paid. LTC Bulletin 26 26August 2003, No. 15

27 Long Term Care Bill Crosswalk Table The following table lists the Texas Long Term Care bill codes and the new national HCPCS bill codes that will replace them. Use this table to map the current Texas LTC local codes to the new National codes. Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue Definition/Comments End Date 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 N NF - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care With Add On 8/31/03 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 V VA Daily Care - Tile All-Inclusive Room & Board Plus Ancillary 1 N Medicare Deductible Coinsurance 0100 All-Inclusive Room & Board Plus Ancillary 1 N Ventilator - Full HC U7 Ventilation assist and management, initiation of pressure and volume preset ventilators for assisted or controlled breathing, subsequent days 1 N Ventilator - Partial HC U8 Ventilation assist and management, initiation of pressure and volume preset ventilators for assisted or controlled breathing, subsequent days 1 N Emergency Dental AD D0140 Emergency Oral Exam 1 N Emergency Dental AD D9110 Emergency Palliative Exam 1 N Emergency Dental AD D0220 X-Rays, First Film 1 N Emergency Dental AD D0230 X-Rays, Second and Each Film 1 N Emergency Dental AD D7110 Simple Extraction - Single Tooth 1 N Emergency Dental AD D7120 Simple Extraction - Second and Each Tooth 1 N Emergency Dental AD D7130 Extraction Root Removal - Exposed Roots 1 N Emergency Dental AD D7210 Surgical Removal of Erupted Tooth Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. August 2003, No LTC Bulletin

28 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 1 N Emergency Dental AD D7220 Removal of Impacted Tooth - Soft Tissue 1 N Emergency Dental AD D7230 Removal of Impacted Tooth - Partially Bony 1 N Emergency Dental AD D7240 Removal of Impacted Tooth - Completely Bony 1 N Emergency Dental AD D7241 Removal of Impacted Tooth - Completely Bony, with Unusual Complications 1 N Emergency Dental AD D7250 Surgical Removal of Residual Tooth Roots 1 N Emergency Dental AD D7510 Incision and Drainage of Abscess - Intraoral Soft Tissue 1 N Emergency Dental AD D7520 Incision and Drainage of Abscess - Extraoral Soft Tissue 1 N Emergency Dental AD D9215 Local Anesthesia 1 N Emergency Dental AD D9220 General Anesthesia - First 30 Minutes 1 N Emergency Dental AD D9221 General Anesthesia - Each Additional 15 Minutes 1 N Nurse s Aid Training - Training Course ZZ Local code to be retained. 1 N Nurse s Aid Training - Skills Test - Passed ZZ Local code to be retained. 1 N Nurse s Aid Training - Skills Test - Failed ZZ Local code to be retained. 1 N Nurse s Aid Training - Written Test - Passed ZZ Local code to be retained. 1 N Nurse s Aid Training - Written Test - Failed ZZ Local code to be retained. 1 N Nurse s Aid Training - Oral Test - Passed ZZ Local code to be retained. 1 N Nurse s Aid Training - Oral Test - Failed ZZ Local code to be retained. 1 N Nurse s Aid Training - Training Materials ZZ Local code to be retained. 1 N Nurse s Aid Training - Incomplete Training Course ZZ Local code to be retained. 1 G OT Rehab HC Unlisted modality 1 G OT Assessment-Rehabilitative Service HC Occupational Therapy Evaluation 1 G OT Habilitation Assessments 8/31/03 1 G PT Rehab HC Unlisted modality 1 G PT Assessment-Rehabilitative Service HC Physical Therapy Evaluation 1 G PT Habilitation Assessments 8/31/03 1 G ST-Rehabilitative Service HC Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual 1 G ST Assessment-Rehabilitative Service HC Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 1 G ST Assessment-Rehabilitative Service HC V Dysphagia screening 1 G ST Habilitation Assessments 8/31/03 1 G DME/Adaptive Aids HC E Multipositional patient support system, with integrated lift, patient 1 G DME/Adaptive Aids HC E Rollabout Chair, any and all types with castors 5 or greater 1 G DME/Adaptive Aids HC E Standard Wheelchair, fixed full length arms, fixed or swing away detachable 1 G DME/Adaptive Aids HC E Durable Medical Equipment, Miscellaneous 1 G DME/Adaptive Aids HC E Oxygen Concentrator, manufacturer-specified maximum flow rate does not exceed 2 1 G DME/Adaptive Aids HC E Communication Board, Nonelectronic Augmentative or Alternative Communication 1 G DME/Adaptive Aids HC E Electronic Communication Device 1 N Child Tracheostomy Care HC Unlisted Special Procedure 1 G0446 7A OT Special Services HC Unlisted modality 1 G0447 7A OT Assessment-Specialized Service HC Occupational Therapy Evaluation 1 G0448 8A PT-Specialized Service HC Unlisted modality 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

29 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 1 G0449 8A PT Assessment-Specialized Service HC Physical Therapy Evaluation 1 G0450 9A ST-Specialized Service HC Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual 1 G0451 9A ST Assessment-Specialized Service HC Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 1 G0451 9A ST Assessment-Specialized Service HC V Dysphagia screening 2 G Occupational Therapy HC G0152 GO Services of a occupational therapist in a home health setting; per 15 minutes 2 G Physical Therapy HC G0151 GP Services of a physical therapist in a home health setting; per 15 minutes 2 G Speech Therapy HC G0153 GN Speech or language pathologist in home health setting; per 15 minutes 2 S Habilitation - Training HC T2016 U3 Habilitation, residential, waiver; per 15 minutes 2 S Habilitation - ADL's HC T2021 U5 Day habilitation, waiver; per 15 minutes 2 S Habilitation - Delegated Nursing 8/31/03 2 S Habilitation - Supportive Employ Employment 8/31/03 2 S Habilitation - Prevocational 8/31/03 2 S Habilitation VFI - Agency ZZ Local code to be retained. 2 G Respite ZZ Local code to be retained. 2 G Respite - In-Home VFI ZZ Local code to be retained. 2 G Respite - Out-of-Home 8/31/03 2 G In-Home Respite VFI - Agency ZZ Local code to be retained. 2 G Case Management 8/31/03 2 G Case Management - Fixed Rate HC T2022 Case management, per month 2 G Nursing - RN HC S9123 TD Nursing Care in the Home, by RN 2 G Nursing - RN HC T1001 TD Nursing assessment/evaluation 2 G Nursing - RN HC T1002 TD RN services up to 15 minutes 2 G Nursing - LVN HC S9124 TE Nursing Care in the Home, by LVN 2 G Nursing - LVN HC T1003 TE LPN/LVN services up to 15 minutes 2 G Psychological Services HC Psychiatric diagnostic interview examination 2 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately minutes face-to-face with the patient 2 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately minutes face-to-face with the patient 2 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately minutes face-to-face with the patient 2 G Psychological Services HC Individual psychotherapy, insight oriented, behavior modifying and/ or supportive, in an inpatient hospital, partial hospital, or residential care setting, approximately minutes face-to-face with patient 2 G Psychological Services HC Individual psychotherapy, insight oriented, behavior modifying and/ or supportive, in an inpatient hospital, partial hospital, or residential care setting, approximately minutes face-to-face with patient 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

30 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 2 G Psychological Services HC Individual psychotherapy, insight oriented, behavior modifying and/ or supportive, in an inpatient hospital, partial hospital, or residential care setting, approximately minutes face-to-face with patient 2 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately minutes face-to-face with the patient 2 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately minutes face-to-face with the patient 2 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately minutes face-to-face with the patient 2 G Psychological Services HC Psychoanalysis 2 G Psychological Services HC Family psychotherapy (conjoint counseling) with patient present 2 G Psychological Services HC Pharmacological management, including prescription/use/review of medication 2 G Psychological Services HC Psychological testing 2 G Adaptive Aids AD D9999 Unspecified Adjunctive Procedure, by Report 2 G DME/Adaptive Aids HC T2003 Nonemergency transportation; encounter/trip 2 G DME/Adaptive Aids HC T2039 Vehicle Modifications, waiver; per service 2 G DME/Adaptive Aids HC S5199 Personal Care Item, NOS, each 2 G DME/Adaptive Aids HC E0636 Multipositional patient support system, with integrated lift, patient 2 G DME/Adaptive Aids HC E1031 Rollabout Chair, any and all types with castors 5 or greater 2 G DME/Adaptive Aids HC E1130 Standard Wheelchair, fixed full length arms, fixed or swing away detachable 2 G DME/Adaptive Aids HC E1399 Durable Medical Equipment, Miscellaneous 2 G DME/Adaptive Aids HC E1400 Oxygen Concentrator, manufacturer-specified maximum flow rate does not exceed 2 2 G DME/Adaptive Aids HC E1900 Synthesized Speech Augmentative Communication Device with Dynamic Display 2 G DME/Adaptive Aids HC E1902 Communication Board, Nonelectronic Augmentative or Alternative Communication 2 G DME/Adaptive Aids HC T2029 Specialized medical equipment, not otherwise specified, waiver 2 G Home Modifications HC S5165 Home Modifications; per service 2 G Personal Assistance Services - Level 2 - Priority 8/31/03 2 G Medical Supplies HC T2028 Specialized Supply, Not otherwise specified, waiver 2 G Consumer Managed Personal Attendant Services 8/31/03 2 G Client Managed Attendant Services - Voucher 8/31/03 2 G Pre-Assessment 8/31/03 2 G Case Management Partial Assessment HC T1001 U8 Nursing Assessment/evaluation 2 G Case Management Partial Assessment HC T1023 U8 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

31 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 2 G Direct Provider Full Assessment HC T1023 U7 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter 2 G Annual Assessment 8/31/03 2 G Annual Assessment 8/31/03 2 G Specifications HM Mods 8/31/03 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees ZZ Local code to be retained. 2 G ADP Aides/Requisition Fees OVER ZZ Local code to be retained. 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees /31/03 2 G MH Mods/Requisition Fees OVER 8/31/03 2 G Specialized Therapies HC Q0082 Activity therapy furnished in connection with partial hospitalization, i.e., music, art, dance, or play therapies that are not primarily recreational, per visit 2 G Specialized Therapies HC Self care/home management training (i.e., activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact by provider, each 15 minutes 2 G Specialized Therapies HC Community/work reintegration training (i.e., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis), direct one on one contact by provider, each 15 minutes 2 S A Habilitation - Delegated Nursing HC S5125 Attendant Care Services, per 15 minutes 2 S A Habilitation - Delegated Nursing HC T1019 Personal Care Services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF-MR or IMD, part of the individualized plan of treatment (not to be used for services provided by a home health aide or certified nurse assistant) 2 S B Habilitation - Supportive Employment HC T2019 Habilitation, Supportive Employment, per 15 minutes 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

32 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 2 S B Habilitation - Prevocational HC T U4 Habilitation, Prevocational, Waiver, per hour. 2 S B Habilitation - Prevocational 0942 U4 Education/Training 2 G A Respite - Out-of-Home HC S5151 Unskilled Respite Care, per diem 2 G A Out of Home Respite VFI ZZ Local code to be retained. 2 G A Nursing Services - LVN HC S9124 Nursing Care in the Home, by LVN 2 G A Nursing Services - LVN HC T1003 LPN/LVN services up to 15 minutes 2 G B Nursing Services - RN HC S9123 Nursing Care in the Home, by RN 2 G B Nursing Services - RN HC T1001 Nursing assessment/evaluation 2 G B Nursing Services - RN HC T1002 RN services up to 15 minutes 2 S C Nursing Services by Highly Technical RN, per hour HC S9800 TG Home Therapy; provision of infusion, specialty drug administration, and/or associated nursing services and procedures, by highly technical RN, per hour 2 T D Nursing Services LVN HC T1003 TG LPN/LVN services, up to 15 minutes 2 G A PAS Delegated (For Future Use) ZZ 2 G B PAS Protective Supervision (For Future Use) ZZ 2 G E Assisted Living - Habilitation 24 hour 8/31/03 2 G F Assisted Living - Habilitation Less Than 24 hour 8/31/03 2 G A CMPAS - Voucher Fiscal Intermediary ZZ Local code to be retained. 2 G A Pre-Assessment HC T2024 Service assessment/plan of care development, waiver 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees ZZ Local code to be retained. 2 G B MH Mods/Requisition Fees Over ZZ Local code to be retained. 2 G C Specifications Adaptive Aids ZZ Local code to be retained. 2 G D Specifications HM Mods ZZ Local code to be retained. 2 N0600 5A Dental Services 8/31/03 3 G Occupational Therapy HC G0152 GO Services of a occupational therapist in a home health setting; per 15 minutes 3 G Physical Therapy HC G0151 GP Services of a physical therapist in a home health setting; per 15 minutes 3 G Speech Therapy HC G0153 GN Speech or language pathologist in home health setting; per 15 minutes 3 G Respite - In-Home ZZ Local code to be retained. (VFI Payment) 3 G Respite - Adult Foster Care - Level 1 8/31/03 3 G Respite - Adult Foster Care - Level 3 8/31/03 3 G Respite - Assisted Living - Apt (Level 6) 8/31/ Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

33 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 3 G Respite - Residential Care - Apt (Level 6) 8/31/03 3 G Respite - Residential Care - Non Apt (Level 6) 8/31/03 3 G Respite - Adult Foster Care - Level 2 8/31/03 3 G In-Home Respite VFI - Agency ZZ Local code to be retained. 3 G Respite - Assisted Living - Apt (Level 5) 8/31/03 3 G Respite/Residential Care - Apt (Level 5) 8/31/03 3 G Respite/Residential Care - Non Apt (Level 5) 8/31/03 3 G Respite - Assisted Living - Apt (Level 4) 8/31/03 3 G Respite/Residential Care - Apt (Level 4) 8/31/03 3 G Respite/Residential Care - Non Apt (Level 4) 8/31/03 3 G Respite - Assisted Living - Apt (Level 3) 8/31/03 3 G Respite/Residential Care - Apt (Level 3) 8/31/03 3 G Respite/Residential Care - Non Apt (Level 3) 8/31/03 3 G Respite - Assisted Living - Apt (Level 2) 8/31/03 3 G Respite/Residential Care - Apt (Level 2) 8/31/03 3 G Respite/Residential Care - Non Apt (Level 2) 8/31/03 3 G Respite - Assisted Living - Apt (Level 1) 8/31/03 3 G Respite/Residential Care - Apt (Level 1) 8/31/03 3 G Respite/Residential Care - Non Apt (Level 1) 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Respite - In-Home 8/31/03 3 N Ventilator - Full 8/31/03 3 N Ventilator - Partial 8/31/03 3 G Case Management 8/31/03 3 G Nursing - RN HC S9123 TD Nursing Care in the Home, by RN 3 G Nursing - RN HC T1001 TD Nursing assessment/evaluation 3 G Nursing - RN HC T1002 TD RN services up to 15 minutes 3 G Nursing - LVN HC S9124 TE Nursing Care in the Home, by LVN 3 G Nursing - LVN HC T1003 TE LPN/LVN services up to 15 minutes 3 G Adaptive Aids AD D9999 Unspecified Adjunctive Procedure, by Report 3 G DME/Adaptive Aids HC T2039 Vehicle Modifications, waiver; per service 3 G DME/Adaptive Aids HC E0636 Multipositional patient support system, with integrated lift, patient 3 G DME/Adaptive Aids HC E1031 Rollabout Chair, any and all types with castors 5 or greater 3 G DME/Adaptive Aids HC E1130 Standard Wheelchair, fixed full length arms, fixed or swing away detachable 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

34 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 3 G DME/Adaptive Aids HC E1399 Durable Medical Equipment, Miscellaneous 3 G DME/Adaptive Aids HC E1400 Oxygen Concentrator, manufacturer-specified maximum flow rate does not exceed 2 3 G DME/Adaptive Aids HC E1900 Synthesized Speech Augmentative Communication Device with Dynamic Display 3 G DME/Adaptive Aids HC E1902 Communication Board, Non-electronic Augmentative or Alternative Communication 3 G DME/Adaptive Aids HC T2029 Specialized medical equipment, not otherwise specified, waiver 3 G Home Modifications HC S5165 Home Modifications; per service Expedited Payment ZZ Local code to be retained. 3 G Personal Assistance Services - Level 3 8/31/03 3 G Personal Assistance Services - Level 2 - Priority HC S5125 Attendant Care Services, per 15 minutes 3 G Adult Foster Care - Level 1 HC S A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 3 G Adult Foster Care - Level 2 HC S A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 3 G Adult Foster Care - Level 3 HC S A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 3 G Assisted Living - Apt (Level 6) HC T2031 U1 U1 Assisted living, waiver; per diem 3 G Residential Care - Apt (Level 6) 8/31/03 3 G Residential Care - Non Apt (Level 6) 8/31/03 3 G Assisted Living/Residential Care - Personal Care 8/31/03 3 G Assisted Living - Apt (Level 5) HC T2031 U1 U1 Assisted living, waiver; per diem 3 G Residential Care - Apt (Level 5) 8/31/03 3 G Residential Care - Non Apt (Level 5) 8/31/03 3 G Assisted Living - Apt (Level 4) HC T2031 U1 U1 Assisted living, waiver; per diem 3 G Residential Care - Apt (Level 4) 8/31/03 3 G Residential Care - Non Apt (Level 4) 8/31/03 3 G Assisted Living - Apt (Level 3) HC T2031 U1 U1 Assisted living, waiver; per diem 3 G Residential Care - Apt (Level 3) 8/31/03 3 G Residential Care - Non Apt (Level 3) 8/31/03 3 G Assisted Living - Apt (Level 2) HC T2031 U1 U1 Assisted living - Apt (Level 2) - CT202 3 G Assisted Living - Apt (Level 2) HC T2031 U1 U1 Assisted living - Apt (Level 2) - CT206 3 G Assisted Living - Apt (Level 2) HC T2031 U1 U1 Assisted living - Apt (Level 2) - CT207 3 G Residential Care - Apt (Level 2) 8/31/03 3 G Residential Care - Non Apt (Level 2) 8/31/03 3 G Assisted Living - Apt (Level 1) HC T2031 U1 U1 Assisted living, Apt (Level 1) - CT201 3 G Assisted Living - Apt (Level 1) HC T2031 U1 U1 Assisted living, Apt (Level 1) - CT203 3 G Assisted Living - Apt (Level 1) HC T2031 U1 U1 Assisted living, Apt (Level 1) - CT204 3 G Assisted Living - Apt (Level 1) HC T2031 U1 U1 Assisted living, Apt (Level 1) - CT205 3 G Residential Care - Apt (Level 1) 8/31/03 3 G Residential Care - Non Apt (Level 1) 8/31/03 3 G Emergency Response Services HC S5160 Installation and Testing 3 G Emergency Response Services HC S5161 Monthly Service Fee (excludes installation and testing) 3 G Emergency Response Services HC S5162 Purchase Only 3 G Prescriptions - discontinued N/A 8/31/ Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

35 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 3 G DME/Adaptive Aids HC T2028 Specialized Supply, Not otherwise specified, waiver 3 G Medical Supplies HC S5199 Personal Care Item, NOS, each 3 C Home Delivered Meals 8/31/03 3 C Title XIX CBA Meals HC S5170 Per meal, includes preparation and delivery 3 G Pre-Assessment 8/31/03 3 G Annual Assessment 8/31/03 3 G Specifications HM Mods 8/31/03 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees ZZ Local code to be retained. 3 G ADP Aides/Requisition Fees OVER ZZ Local code to be retained. 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees /31/03 3 G MH Mods/Requisition Fees OVER 8/31/03 3 G Prescription/Requisition Fees N/A 8/31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees /31/03 3 G Medical S/Requisition Fees OVER 8/31/03 3 G A Respite - Out-of-Home 8/31/ Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

36 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s 3 G B Respite - Adult Foster Care - Level 1 HC S5151 U3 Unskilled Respite Care, per diem 3 G B Respite - Adult Foster Care - Level 1 HC S U3 Unskilled Respite Care, per diem 3 G B Respite - Adult Foster Care - Level 2 HC S5151 U4 Unskilled Respite Care, per diem 3 G B Respite - Adult Foster Care - Level 2 HC S U4 Unskilled Respite Care, per diem 3 G B Respite - Adult Foster Care - Level 3 HC S5151 U5 Unskilled Respite Care, per diem 3 G B Respite - Adult Foster Care - Level 3 HC S U5 Unskilled Respite Care, per diem 3 G B Adult Foster Care VFI - Agency ZZ Local to be retained. 3 G C Respite - Assisted Living - Apt (Level 6) HC S U8 U1 U1 Unskilled Respite, per diem 3 G C Respite - Assisted Living - Apt (Level 5) HC S U7 U1 U1 Unskilled Respite, per diem 3 G C Respite - Assisted Living - Apt (Level 4) HC S U6 U1 U1 Unskilled Respite, per diem 3 G C Respite - Assisted Living - Apt (Level 3) HC S U5 U1 U1 Unskilled Respite, per diem 3 G C Respite - Assisted Living - Apt (Level 2) HC S U4 U1 U1 Unskilled Respite, per diem 3 G C Respite - Assisted Living - Apt (Level 1) HC S U3 U1 U1 Unskilled Respite, per diem 3 G CV Respite Assisted Living, Apt VFI - Participant ZZ Local code to be retained. 3 G CV Respite Assisted Living Apt VFI - Agency ZZ Local to be retained. 3 G D Respite - Residential Care - Apt (Level 6) HC S U8 U2 U1 Unskilled Respite, per diem 3 G D Respite - Residential Care - Apt (Level 5) HC S U7 U2 U1 Unskilled Respite, per diem 3 G D Respite - Residential Care - Apt (Level 4) HC S U6 U2 U1 Unskilled Respite, per diem 3 G D Respite - Residential Care - Apt (Level 3) HC S U5 U2 U1 Unskilled Respite, per diem 3 G D Respite - Residential Care - Apt (Level 2) HC S U4 U2 U1 Unskilled Respite, per diem 3 G D Respite - Residential Care - Apt (Level 1) HC S U3 U2 U1 Unskilled Respite, per diem 3 G DV Respite Residential Care Apt VFI - Participant ZZ Local code to be retained. 3 G DV Respite Residential Care Apt VFI - Agency ZZ Local code to be retained. 3 G E Respite - Residential Care - Non Apt (Level 6) HC S U8 U2 U2 Unskilled Respite, per diem 3 G E Respite - Residential Care - Non Apt (Level 5) HC S U7 U2 U2 Unskilled Respite, per diem 3 G E Respite - Residential Care - Non Apt (Level 4) HC S U6 U2 U2 Unskilled Respite, per diem 3 G E Respite - Residential Care - Non Apt (Level 3) HC S U5 U2 U2 Unskilled Respite, per diem 3 G E Respite - Residential Care - Non Apt (Level 2) HC S U4 U2 U2 Unskilled Respite, per diem 3 G E Respite - Residential Care - Non Apt (Level 1) HC S U3 U2 U2 Unskilled Respite, per diem 3 G EV VFI-Respite Residential Care - Non-Apartment, ZZ Local code to be retained. Participant 3 G EV VFI-Respite Residential Care - Non-Apartment, ZZ Local code to be retained. Agency 3 N F Respite NF - Tile 201 ZZ Local code to be retained. 3 N F Respite NF - Tile 202 ZZ Local code to be retained. 3 N F Respite NF - Tile 203 ZZ Local code to be retained. 3 N F Respite NF - Tile 204 ZZ Local code to be retained. 3 N F Respite NF - Tile 205 ZZ Local code to be retained. 3 N F Respite NF - Tile 206 ZZ Local code to be retained. 3 N F Respite NF - Tile 207 ZZ Local code to be retained. 3 N F Respite NF - Tile 208 ZZ Local code to be retained. 3 N F Respite NF - Tile 209 ZZ Local code to be retained. 3 N F Respite NF - Tile 210 ZZ Local code to be retained. 3 N F Respite NF - Tile 211 ZZ Local code to be retained. 3 N F Respite NF - Tile 212 ZZ Local code to be retained. CPT s Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

37 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 3 G FV VFI-Respite Nursing Facility - Participant ZZ Local code to be retained. 3 G FV VFI-Respite Nursing Facility - Agency ZZ Local code to be retained. 3 G A Targeted Case Management 8/31/03 3 G A Nursing Services - LVN HC S9124 Nursing Care in the Home, by LVN 3 G A Nursing Services - LVN HC T1003 LPN/LVN services up to 15 minutes 3 G B Nursing Services - RN HC S9123 Nursing Care in the Home, by RN 3 G B Nursing Services - RN HC T1001 Nursing assessment/evaluation 3 G B Nursing Services - RN HC T1002 RN services up to 15 minutes 3 S C Nursing Services by Highly Technical RN, per hour HC S9800 TG Home Therapy; provision of infusion, specialty drug administration, and/or associated nursing services and procedures, by highly technical RN, per hour 3 T D Nursing Services LVN HC T1003 TG LPN/LVN services, up to 15 minutes 3 G V VFI-PAS-Participant ZZ Local code to be retained. 3 G V VFI-PAS-Agency ZZ Local code to be retained. 3 G A AL Residential Care - Apt (Level 6) HC T2031 U2 U1 Assisted living, waiver; per diem 3 G A AL Residential Care - Apt (Level 5) HC T2031 U2 U1 Assisted living, waiver; per diem 3 G A AL Residential Care - Apt (Level 4) HC T2031 U2 U1 Assisted living, waiver; per diem 3 G A AL Residential Care - Apt (Level 3) HC T2031 U2 U1 Assisted living, waiver; per diem 3 G A AL Residential Care - Apt (Level 2) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 2) CT G A AL Residential Care - Apt (Level 2) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 2) CT G A AL Residential Care - Apt (Level 2) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 2) CT G A AL Residential Care - Apt (Level 1) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 1) CT G A AL Residential Care - Apt (Level 1) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 1) CT G A AL Residential Care - Apt (Level 1) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 1) CT G A AL Residential Care - Apt (Level 1) HC T2031 U2 U1 Assisted living, AL Residential Care - Apt (Level 1) CT G B AL Residential Care - Non Apt (Level 6) HC T2031 U2 U2 Assisted living, waiver; per diem 3 G B AL Residential Care - Non Apt (Level 5) HC T2031 U2 U2 Assisted living, waiver; per diem 3 G B AL Residential Care - Non Apt (Level 4) HC T2031 U2 U2 Assisted living, waiver; per diem 3 G B AL Residential Care - Non Apt (Level 3) HC T2031 U2 U2 Assisted living, waiver; per diem 3 G B AL Residential Care - Non Apt (Level 2) HC T2031 U2 U2 Assisted living, AL Residential Care - Non-apt (Level 2) CT G B AL Residential Care - Non Apt (Level 2) HC T2031 U2 U2 Assisted living, AL Residential Care - Non-apt (Level 2) CT G B AL Residential Care - Non Apt (Level 2) HC T2031 U2 U2 Assisted living, AL Residential Care - Non-apt (Level 2) CT G B AL Residential Care - Non Apt (Level 1) HC T2031 U2 U2 Assisted living, AL Residential Care - Non-apt (Level 1) CT G B AL Residential Care - Non Apt (Level 1) HC T2031 U2 U2 Assisted living, AL Residential Care - Non-apt (Level 1) CT G B AL Residential Care - Non Apt (Level 1) HC T2031 U2 U2 Assisted living, AL Residential Care - Non-apt (Level 1) CT G B AL Residential Care - Non Apt (Level 1) HC T2031 U2 U2 Assisted living. AL Residential Care - Non-apt (Level 1) CT G C Assisted Living - Personal Care 3 HC T2031 U1 Assisted living, waiver; per diem 3 G A CMPAS - Voucher Fiscal Intermediary ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

38 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees ZZ Local code to be retained. 3 G A Medical S/Requisition Fees OVER ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees ZZ Local code to be retained. 3 G B MH Mods/Requisition Fees Over ZZ Local code to be retained. 3 G C Specifications Adaptive Aids ZZ Local code to be retained. 3 G D Specifications HM Mods ZZ Local code to be retained. 3 N0600 5A Dental Services 8/31/03 4 F ICF/MR Campus/State - LOC 1 Contract Specific 0100 All-Inclusive Room & Board Plus Ancillary 4 F ICF/MR Campus/State - LOC 5 Contract Specific 0100 All-Inclusive Room & Board Plus Ancillary 10/31/02 4 F ICF/MR Campus/State - LOC 6 Contract Specific 0100 All-Inclusive Room & Board Plus Ancillary 10/31/02 4 F ICF/MR Campus/State - LOC 8 Contract Specific 0100 All-Inclusive Room & Board Plus Ancillary 4 F ICF/MR Campus/State -LOC 1 4/30/96 4 F ICF/MR Campus/State -LOC 5 4/30/96 4 F ICF/MR Campus/State -LOC 6 4/30/96 4 F ICF/MR Campus/State -LON 1 8/31/03 4 F ICF/MR Campus/State -LON 5 8/31/03 4 F ICF/MR Campus/State -LON 6 8/31/03 4 F ICF/MR Campus/State -LON 8 8/31/03 4 F ICF/MR Campus/State -LON 9 8/31/03 4 Z Nonrecoupable administrative claim - group 4 ZZ Local code to be retained. 4 Z Recoupable administrative claim - group 4 ZZ Local code to be retained. 5 F ICF/MR State/Community Residential LOC All-Inclusive Room & Board Plus Ancillary Contract Specific 5 F ICF/MR State/Community Residential LOC All-Inclusive Room & Board Plus Ancillary Contract Specific 5 F ICF/MR State/Community Residential LOC 5 10/31/02 Contract Specific 5 F ICF/MR State/Community Residential LOC 6 10/31/02 Contract Specific 5 F ICF/MR State/Community Residential LOC 1 4/30/96 5 F ICF/MR State/Community Residential LOC 5 4/30/96 5 F ICF/MR State/Community Residential LOC 6 4/30/ Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

39 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 5 F ICF/MR State/Community Residential LOC 8 4/30/96 5 F ICF/MR State/Community - LON 1 8/31/03 5 F ICF/MR State/Community - LON 5 8/31/03 5 F ICF/MR State/Community - LON 6 8/31/03 5 F ICF/MR State/Community - LON 8 8/31/03 5 F ICF/MR State/Community - LON 9 8/31/03 5 Z Nonrecoupable administrative claim - group 5 ZZ Local code to be retained. 5 Z Recoupable administrative claim - group 5 ZZ Local code to be retained. 6 F ICF/MR Non-State Community Residential LOC 1 12/31/96 6 F ICF/MR Non-State Community Residential LOC 5 12/31/96 6 F ICF/MR Non-State Community Residential LOC 6 12/31/96 6 F ICF/MR Non-State Community Residential LOC 6A 12/31/96 6 F ICF/MR Non-State Community Residential LOC 8 12/31/96 6 F ICF/MR Non-State Community Residential LON All-Inclusive Room & Board Plus Ancillary 6 F ICF/MR Non-State Community Residential LON All-Inclusive Room & Board Plus Ancillary 6 F ICF/MR Non-State Community Residential LON All-Inclusive Room & Board Plus Ancillary 6 F ICF/MR Non-State Community Residential LON All-Inclusive Room & Board Plus Ancillary 6 F ICF/MR Non-State Community Residential LON All-Inclusive Room & Board Plus Ancillary 6 G DME/Adaptive Aids - LON 5 HC E Standing Board 6 G DME/Adaptive Aids - LON 5 HC S Gait Trainers 6 G DME/Adaptive Aids - LON 5 HC E Wheelchair 6 G DME/Adaptive Aids - LON 5 HC E Electronic Communication Device 6 G DME/Adaptive Aids - LON 5 HC E Communication Device 6 G DME/Adaptive Aids - LON 5 HC E Travel Chair 6 G DME/Adaptive Aids - LON 5 HC E Air Flotation Mattress 6 G DME/Adaptive Aids - LON 5 HC E Adaptive Stroller 6 G DME/Adaptive Aids - LON 5 HC E Refurbished/Modified Wheelchair 6 G DME/Adaptive Aids - LON 5 HC L Prosthetic/Orthotic 6 G DME/Adaptive Aids - LON 5 HC E Hospital Waterbed 6 G DME/Adaptive Aids - LON 6 HC E Standing Board 6 G DME/Adaptive Aids - LON 6 HC S Gait Trainers 6 G DME/Adaptive Aids - LON 6 HC E Travel Chair 6 G DME/Adaptive Aids - LON 6 HC E Air Flotation Mattress 6 G DME/Adaptive Aids - LON 6 HC E Adaptive Stroller 6 G DME/Adaptive Aids - LON 6 HC E Refurbished/Modified Wheelchair 6 G DME/Adaptive Aids - LON 6 HC L Prosthetic/Orthotic 6 G DME/Adaptive Aids - LON 6 HC E Wheelchair 6 G DME/Adaptive Aids - LON 6 HC E Electronic Communication Device 6 G DME/Adaptive Aids - LON 6 HC E Communication Device 6 G DME/Adaptive Aids - LON 6 HC E Hospital Waterbed 6 G DME/Adaptive Aids - LON 8 HC E Wheelchair 6 G DME/Adaptive Aids - LON 8 HC E Electronic Communication Device 6 G DME/Adaptive Aids - LON 8 HC E Communication Device 6 G DME/Adaptive Aids - LON 8 HC E Standing Board 6 G DME/Adaptive Aids - LON 8 HC S Gait Trainers 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

40 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 6 G DME/Adaptive Aids - LON 8 HC E Travel Chair 6 G DME/Adaptive Aids - LON 8 HC E Air Flotation Mattress 6 G DME/Adaptive Aids - LON 8 HC E Adaptive Stroller 6 G DME/Adaptive Aids - LON 8 HC E Refurbished/Modified Wheelchair 6 G DME/Adaptive Aids - LON 8 HC L Prosthetic/Orthotic 6 G DME/Adaptive Aids - LON 8 HC E Hospital Waterbed 6 G DME/Adaptive Aids - LON 9 HC E Standing Board 6 G DME/Adaptive Aids - LON 9 HC S Gait Trainers 6 G DME/Adaptive Aids - LON 9 HC E Travel Chair 6 G DME/Adaptive Aids - LON 9 HC E Air Flotation Mattress 6 G DME/Adaptive Aids - LON 9 HC E Adaptive Stroller 6 G DME/Adaptive Aids - LON 9 HC E Refurbished/Modified Wheelchair 6 G DME/Adaptive Aids - LON 9 HC L Prosthetic/Orthotic 6 G DME/Adaptive Aids - LON 9 HC E Wheelchair 6 G DME/Adaptive Aids - LON 9 HC E Electronic Communication Device 6 G DME/Adaptive Aids - LON 9 HC E Communication Device 6 G DME/Adaptive Aids - LON 9 HC E Hospital Waterbed 6 G DME/Adaptive Aids - LON 1 HC E Wheelchair 6 G DME/Adaptive Aids - LON 1 HC E Electronic Communication Device 6 G DME/Adaptive Aids - LON 1 HC E Communication Device 6 G DME/Adaptive Aids - LON 1 HC E Standing Board 6 G DME/Adaptive Aids - LON 1 HC S Gait Trainers 6 G DME/Adaptive Aids - LON 1 HC E Travel Chair 6 G DME/Adaptive Aids - LON 1 HC E Air Flotation Mattress 6 G DME/Adaptive Aids - LON 1 HC E Adaptive Stroller 6 G DME/Adaptive Aids - LON 1 HC E Refurbished/Modified Wheelchair 6 G DME/Adaptive Aids - LON 1 HC L Prosthetic/Orthotic 6 G DME/Adaptive Aids - LON 1 HC E Hospital Waterbed 6 F0220 1T Transitional Add-On/Non-State Operated LON All-Inclusive Room & Board Plus Ancillary 6 F0221 1T Transitional Add-On/Non-State Operated LON All-Inclusive Room & Board Plus Ancillary 6 F0222 1T Transitional Add-On/Non-State Operated LON All-Inclusive Room & Board Plus Ancillary 6 F0223 1T Transitional Add-On/Non-State Operated LON All-Inclusive Room & Board Plus Ancillary 6 F0224 1T Transitional Add-On/Non-State Operated LON All-Inclusive Room & Board Plus Ancillary 7 G Respite - Adult Foster Care - Level 1 8/31/01 7 G Respite - Adult Foster Care - CCAD Level 8/31/03 7 G Respite - Personal Assistance Services 8/31/01 7 G Respite - Personal Assistance Services HC S5150 Unskilled respite care, not hospice; per 15 minutes 7 G Respite - Sitter Services ZZ Local code to be retained. 7 G Respite - Adult Day Care 8/31/03 7 G Respite - Nursing Facility 8/31/03 7 G Respite - Hospital 8/31/03 7 G Assisted Living CCAD RC Apt. 8/31/03 7 G Assisted Living CCAD RC Non Apt. 8/31/ Expedited Payment ZZ Local code to be retained. 7 G Personal Assistance Services - Level 2 - Priority HC S5125 Attendant Care Services, per 15 minutes 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

41 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 7 G Personal Assistance Services - Level 1 - HC S5125 Attendant Care Services, per 15 minutes Nonpriority 7 G FC Priority Prior to 9/1997 8/31/03 7 G FC Nonpriority Prior to 9/1998 8/31/03 7 G Adult Foster Care - Level 1 Not a valid combination 8/31/03 7 G Adult Foster Care - CCAD LEVEL HC S Adult foster care, per diem 7 G Assisted Living - Bed Hold 8/31/03 7 G Assisted Living - Emergency Care 8/31/02 7 G Assisted Living - Residential Care Apartment 8/31/03 7 G Assisted Living - Residential Care Non- Apartment 8/31/03 7 G Emergency Response Services HC S5160 Installation and Testing 7 G Emergency Response Services HC S5161 Monthly Service Fee (excludes installation and testing) 7 G Emergency Response Services HC S5162 Purchase Only 7 C Home Delivered Meals HC S5170 Per meal, includes preparation and delivery 7 C Home Delivered Meals 8/31/03 7 C IHFS Capital Expenditures ZZ Local code to be retained. 7 C IHFS Subsidy Grants ZZ Local code to be retained. 7 C SSI Client Payment 8/31/03 7 G Supported Home Living - LON 1 8/31/03 7 G Consumer Managed Personal Attendant Services ZZ Local code to be retained. 7 G Client Managed Attendant Services - Voucher 8/31/03 7 C SSPD - Day Care HC S Day Care Services, Adult, per half day 7 C SSPD - 24 hour Attendant Care HC S5126 Attendant Care, per diem 7 C SSPD - 24 Hour Attendant Care HC T1020 Personal Care Services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant 7 C SSPD - Other ZZ Local code to be retained. 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Respite - In-Home 0660 Respite Care 7 N Ventilator - Full 8/31/03 7 N Ventilator - Partial 8/31/03 7 N Respite NF - Tile 201 ZZ Local code to be retained. 7 N Respite NF - Tile 202 ZZ Local code to be retained. 7 N Respite NF - Tile 203 ZZ Local code to be retained. 7 N Respite NF - Tile 204 ZZ Local code to be retained. 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

42 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s 7 N Respite NF - Tile 205 ZZ Local code to be retained. 7 N Respite NF - Tile 206 ZZ Local code to be retained. 7 N Respite NF - Tile 207 ZZ Local code to be retained. 7 N Respite NF - Tile 208 ZZ Local code to be retained. 7 N Respite NF - Tile 209 ZZ Local code to be retained. 7 N Respite NF - Tile 210 ZZ Local code to be retained. 7 N Respite NF - Tile 211 ZZ Local code to be retained. 7 N Respite NF - Tile 212 ZZ Local code to be retained. 7 C Day Activity/Health Services (DAHS) HC S5101 Day Care Services, Adult, per half day 7 C Day Activity/Health Services - DAHS Title XX Negotiated Rate 7 G A Respite - Adult Day Care ZZ Local code to be retained. 7 G A Respite - Hospital 0660 Respite Care, general (Note: Providers must use a valid and accurate Place of Service (POS) code. 7 G B Respite - Adult Foster Care - CCAD Level 0660 Respite, Adult Foster Care 7 G D Respite - Residential Care - Apt (CCAD) HC S U2 U1 Unskilled Respite, per diem 7 G E Respite - Residential Care - Non Apt (CCAD) HC S U2 U2 Unskilled Respite, per diem 7 G F Respite - Nursing Facility 0660 Respite Care, general (Note: Providers must use a valid and accurate Place of Service (POS) code. 7 G C PAS Family Care - Level 2 (Priority) HC S5125 Attendant Care Services, per 15 minutes 7 G C PAS Family Care - Level 1 (Nonpriority) HC S5125 Attendant Care Services, per 15 minutes 7 G CV PAS Family Care - VFI-Participant ZZ Local code to be retained. 7 G CV PAS Family Care Level 1 (Nonpriority) VFI ZZ Local code to be retained. 7 G CV PAS Family Care - VFI - Agency ZZ Local code to be retained. 7 G D PAS Frail Elderly (1929B) - Level 2 (Priority) HC S5125 Attendant Care Services, per 15 minutes 7 G D PAS Frail Elderly (1929B) - Level 1 (Nonpriority) HC S5125 Attendant Care Services, per 15 minutes 7 G DV PAS Frail Elderly Level 1 (Nonpriority) VFI ZZ Local code to be retained. 7 G DV PAS Frail Elderly Level 2 (Priority) VFI ZZ Local code to be retained. 7 G DV PAS Frail Elderly - VFI - Agency ZZ Local code to be retained. 7 G V VFI-PAS-Participant ZZ Local code to be retained. 7 G V PAS Level 1 (Nonpriority) VFI ZZ Local code to be retained. 7 G V VFI-PAS-Agency ZZ Local code to be retained. 7 G A Assisted Living - Residential Care Apartment HC T U2 U1 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 7 G A Assisted Living - Residential Care Apartment HC T1020 U2 U1 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 7 G B Assisted Living - Residential Care Nonapartment HC T U2 U2 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 7 G B Assisted Living - Residential Care Nonapartment HC T1020 U2 U2 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 7 G D Assisted Living - Emergency Care HC T All-Inclusive Room & Board Plus Ancillary 7 G H Assisted Living - Bed Hold HC T Leave of Absence (LOA) 7 G H Assisted Living - Bed Hold HC T Leave of Absence (patient convenience) Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date 8/31/03 LTC Bulletin August 2003, No. 15

43 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s 7 G H Assisted Living - Bed Hold HC T Leave of Absence (Therapeutic) 7 G H Assisted Living - Bed Hold HC T Leave of Absence (Other) 7 G I Assisted Living - Bed Hold- Non-Apartment HC T U2 U2 Leave of Absence (LOA) 7 G I Assisted Living - Bed Hold- Non-Apartment HC T U2 U2 Leave of Absence (Patient convenience) 7 G I Assisted Living - Bed Hold- Non-Apartment HC T U2 U2 Leave of Absence (Therapeutic) 7 G I Assisted Living - Bed Hold- Non-Apartment HC T U2 U2 Leave of Absence (Other) 7 G A CMPAS - Voucher Fiscal Intermediary ZZ Local code to be retained. 7 C A SSPD - Case Management HC T1016 Case Management, each 15 minutes 7 C A Day Activity/Health Services (DAHS) - Title 20 HC T1020 Day Care Services, Adult, per half day 8 T Routine in Home Care 0651 Routine hospice care services, in home, for a terminally ill patient if he/she elects these services in lieu of other services for the terminal condition 8 T Continuous Home Care 0652 Continuous hospice care services, in home, for a terminally ill patient if he/she elects these services in lieu of other services for the terminal condition 8 T Inpatient Respite Care 0655 Hospice Inpatient Respite Care 8 T General Inpatient Care 0656 General Inpatient Care (non-respite) for hospice patient 8 T Physician Direct Care HC Placement central venous catheter; percutansious, over age 2 8 T Physician Direct Care HC Insertion of implantable venous access port with or without subcutaneous reservoir 8 T Physician Direct Care HC Peritoneocentesis, abdominal paracentesis or peritoneal lavage (diagnostic or therapeutic) initial 8 T Physician Direct Care HC Radiologic examination; chest; single view frontal 8 T Physician Direct Care HC Radiologic examination; abdomen; single anteroposterior view 8 T Physician Direct Care HC Radiologic examination; abdomen; complete, including decubitus and/or erect views 8 T Physician Direct Care HC Blood count; hemogram and platelet count, auto, and manual differential WBC count (CBC) 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of a new patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of a new patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of a new patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of a new patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of a new patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of an established patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of an established patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of an established patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of an established patient 8 T Physician Direct Care HC Office or other outpatient visit for the evaluation and management of an established patient Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

44 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s 8 T Physician Direct Care HC Initial hospital care, per day for the evaluation and management of patient; low complexity 8 T Physician Direct Care HC Initial hospital care, per day for the evaluation and management of patient; moderate complexity 8 T Physician Direct Care HC Initial hospital care, per day for the evaluation and management of patient; high complexity 8 T Physician Direct Care HC Subsequent hospital care, per day, for the evaluation and management of a patient with two of three key components 8 T Physician Direct Care HC Subsequent hospital care, per day, for the evaluation and management of a patient with two of three key components 8 T Physician Direct Care HC Subsequent hospital care, per day, for the evaluation and management of a patient with two of three key components 8 T Physician Direct Care HC Hospital discharge day management ; 30 minutes or less 8 T Physician Direct Care HC Hospital discharge day management ; more than 30 minutes 8 T Physician Direct Care HC Initial inpatient consultation for a new/established patient, which requires three key components 8 T Physician Direct Care HC Initial inpatient consultation for a new/established patient, which requires three key components 8 T Physician Direct Care HC Initial inpatient consultation for a new/established patient, which requires three key components 8 T Physician Direct Care HC Initial inpatient consultation for a new/established patient, which requires three key components 8 T Physician Direct Care HC Initial inpatient consultation for a new/established patient, which requires three key components 8 T Physician Direct Care HC Follow-up inpatient consultation for an established patient requiring two of three key components 8 T Physician Direct Care HC Follow-up inpatient consultation for an established patient requiring two of three key components 8 T Physician Direct Care HC Follow-up inpatient consultation for an established patient requiring two of three key components 8 T Physician Direct Care HC Evaluation and management of new or established patient involving annual nursing facility assessment with three components 8 T Physician Direct Care HC Evaluation and management of new or established patient involving nursing facility assessment with three components 8 T Physician Direct Care HC Evaluation and management of new or established patient involving annual nursing facility at initial admit/readmit with three components 8 T Physician Direct Care HC Subsequent nursing facility, per day, for the evaluation and management of new or established patient requiring two of three components 8 T Physician Direct Care HC Subsequent nursing facility, per day, for the evaluation and management of new or established patient requiring two of three components 8 T Physician Direct Care HC Subsequent nursing facility, per day, for the evaluation and management of new or established patient requiring two of three components 8 T Physician Direct Care HC Domiciliary or rest home visit for the evaluation and management of a new patient requiring three components 8 T Physician Direct Care HC Domiciliary or rest home visit for the evaluation and management of a new patient requiring three components Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

45 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 8 T Physician Direct Care HC Domiciliary or rest home visit for the evaluation and management of a new patient requiring three components 8 T Physician Direct Care HC Domiciliary or rest home visit for the evaluation and management of an established patient requiring two of three components 8 T Physician Direct Care HC Domiciliary or rest home visit for the evaluation and management of an established patient requiring two of three components 8 T Physician Direct Care HC Domiciliary or rest home visit for the evaluation and management of an established patient requiring two of three components 8 T Physician Direct Care HC Home visit for the evaluation and management of a new patient, requiring three key components 8 T Physician Direct Care HC Home visit for the evaluation and management of a new patient, requiring three key components 8 T Physician Direct Care HC Home visit for the evaluation and management of a new patient, requiring three key components 8 T Physician Direct Care HC Home visit established patient, three key component; 75 minutes with patient and/or family 8 T Physician Direct Care HC Home visit established patient, three key component; 15 minutes with patient and/or family 8 T Physician Direct Care HC Home visit established patient, three key component; 25 minutes with patient and/or family 8 T Physician Direct Care HC Home visit established patient, three key component; 40 minutes with patient and/or family 8 T Physician Direct Care HC Home visit established patient, three key component; 60 minutes with patient and/or family 8 T Physician Direct Care HC Home visit for the evaluation and management of an established patient, requiring two of three key components 8 T Physician Direct Care HC Prolonged physician in the office or other outpatient setting, first hour 8 T Physician Direct Care HC Prolonged physician in the office or other outpatient setting, requiring contact beyond, each additional 30 minutes 8 T Physician Direct Care HC Prolonged physician visit, inpatient setting, first hour 8 T Physician Direct Care HC Prolonged physician visit, inpatient setting, each additional 30 minutes 8 T Physician Direct Care HC Office Consult New/Established Patient, Requires Three Key Components 8 T Physician Direct Care HC Office Consult New/Established Patient, Requires Three Key Components 8 T Physician Direct Care HC Office Consult New/Established Patient, Requires Three Key Components 8 T Physician Direct Care HC Office Consult New/Established Patient, Requires Three Key Components 8 T Physician Direct Care HC Home Visit New Patient 8 T Physician Direct Care-Special 8/31/03 8 F ICF-MR-State (Loc 1) HC SS Hospice LTC Room & Board 8 F ICF-MR-State (Loc 1) HC SS Other (Hospice LTC Room & Board) 8 F ICF-MR-State (Loc 5) Hospice LTC Room & Board 10/31/02 8 F ICF-MR-State (LOC 6) Hospice LTC Room & Board 10/31/02 8 F ICF-MR Campus/State LOC 8 Contract Specific HC SS Hospice LTC Room & Board 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

46 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 8 F ICF-MR State/Community Residential LOC 8 HC SS Hospice LTC Room & Board Contract Specific 8 F ICF-MR State/Community Residential LOC 1 HC SS Hospice LTC Room & Board Contract Specific 8 F ICF-MR State Community Residential LOC 5 10/31/02 Contract Specific 8 F ICF-MR State Community Residential LOC 6 10/31/02 Contract Specific 8 F ICF-MR State Community Residential (LOC 5) 4/30/96 8 F ICF-MR State Community Residential (LOC 6) 4/30/96 8 F ICF-MR Non-State Community Residential (LON 1) HC SS Hospice LTC Room & Board 8 F ICF-MR Non-State Community Residential (LON 1) HC SS Other (Hospice LTC Room & Board) 8 F ICF-MR Non-State Community Residential (LON 5) HC SS Hospice LTC Room & Board 8 F ICF-MR Non-State Community Residential (LON 5) HC SS Other (Hospice LTC Room & Board) 8 F ICF-MR Non-State Community Residential (LON 6) HC SS Hospice LTC Room & Board 8 F ICF-MR Non-State Community Residential (LON 6) HC SS Other (Hospice LTC Room & Board) 8 F ICF-MR Non-State Community Residential (LON 8) HC SS Hospice LTC Room & Board 8 F ICF-MR Non-State Community Residential (LON 8) HC SS Other (Hospice LTC Room & Board) 8 F ICF-MR Non-State Community Residential (LON 9) HC SS Hospice LTC Room & Board 8 F ICF-MR Non-State Community Residential (LON 9) HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 201 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 201 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 202 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 202 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 203 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 203 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 204 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 204 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 205 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 205 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 206 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 206 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 207 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 207 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 208 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 208 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 209 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 209 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 210 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 210 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 211 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 211 HC SS Other (Hospice LTC Room & Board) 8 N Nursing Facility, Tile 212 HC SS Hospice LTC Room & Board 8 N Nursing Facility, Tile 212 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 201 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 201 HC SS Other (Hospice LTC Room & Board) 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

47 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 8 V VA Daily Care - Tile 202 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 202 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 203 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 203 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 204 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 204 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 205 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 205 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 206 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 206 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 207 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 207 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 208 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 208 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 209 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 209 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 210 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 210 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 211 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 211 HC SS Other (Hospice LTC Room & Board) 8 V VA Daily Care - Tile 212 HC SS Hospice LTC Room & Board 8 V VA Daily Care - Tile 212 HC SS Other (Hospice LTC Room & Board) 8 T Medicare Pharmacy Coinsurance ZZ Local code to be retained. 8 T Medicare Respite Coinsurance ZZ Local code to be retained. 9 N Ventilator - Full 8/31/03 9 N Ventilator - Partial 8/31/03 9 N Nurse s Aid Training - Training Course 8/31/03 9 N Nurse s Aid Training - Skills Test - Passed 8/31/03 9 N Nurse s Aid Training - Skills Test - Failed 8/31/03 9 N Nurse s Aid Training - Written Test - Passed 8/31/03 9 N Nurse s Aid Training - Written Test - Failed 8/31/03 9 N Nurse s Aid Training - Oral Test - Passed 8/31/03 9 N Nurse s Aid Training - Oral Test - Failed 8/31/03 9 N Nurse s Aid Training - Training Materials 8/31/03 9 N Nurse s Aid Training - Incomplete Training Course 8/31/03 9 G OT Rehab HC Unlisted modality 9 G OT Rehab HC GO Unlisted modality 9 G OT Assessment-Rehabilitative Service HC Occupational Therapy Evaluation 9 G OT Assessment-Rehabilitative Service HC GO Occupational Therapy Evaluation 9 G OT Habilitation Assessments 8/31/03 9 G PT Rehab HC Unlisted modality 9 G PT Rehab HC GP Unlisted modality 9 G PT Assessment-Rehabilitative Service HC Physical Therapy Evaluation 9 G PT Assessment-Rehabilitative Service HC GP Physical Therapy Evaluation 9 G PT Habilitation Assessments 8/31/ Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

48 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 9 G ST-Rehabilitative Service HC Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual 9 G ST-Rehabilitative Service HC Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual 9 G ST Assessment-Rehabilitative Service HC Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 9 G ST Assessment-Rehabilitative Service HC V Dysphagia screening 9 G ST Assessment-Rehabilitative Service HC Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 9 G ST Assessment-Rehabilitative Service HC V5364 Dysphagia screening 9 G ST Habilitation Assessments 8/31/03 9 G DME/Adaptive Aids 8/31/03 9 G0446 7A OT Special Services HC GO Unlisted modality 9 G0447 7A OT Assessment-Specialized Service HC Occupational Therapy Evaluation 9 G0447 7A OT Assessment-Specialized Service HC GO Occupational Therapy Evaluation 9 G0448 8A PT-Specialized Service HC Unlisted modality 9 G0448 8A PT-Specialized Service HC GP Unlisted modality 9 G0449 8A PT Assessment-Specialized Service HC Physical Therapy Evaluation 9 G0449 8A PT Assessment-Specialized Service HC GP Physical Therapy Evaluation 9 G0450 9A ST-Specialized Service HC Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual 9 G0450 9A ST-Specialized Service HC Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual 9 G0451 9A ST Assessment-Specialized Service HC Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 9 G0451 9A ST Assessment-Specialized Service HC V Dysphagia screening 9 G0451 9A ST Assessment-Specialized Service HC Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 9 G0451 9A ST Assessment-Specialized Service HC V5364 Dysphagia screening 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 10 N NF - Tile All-Inclusive Room & Board Plus Ancillary 11 G PACE (Dual Eligible) ZZ Local code to be retained. 11 G A PACE (Medicaid Only) ZZ Local code to be retained. 16 G Occupational Therapy HC G0152 GO Services of a occupational therapist in a home health setting; per 15 minutes 16 G Physical Therapy HC G0151 GP Services of a physical therapist in a home health setting; per 15 minutes 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

49 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 16 G Speech Therapy HC G0153 GN Speech or language pathologist in home health setting; per 15 minutes 16 S Habilitation - ADL's HC T2021 U5 Day habilitation, waiver; per 15 minutes 16 G Respite ZZ Retain local code until further clarification of service is obtained. 16 G Respite - In-Home VFI ZZ Local code to be retained. (VFI Payment) 16 G Respite - Out-of-Home 8/31/03 16 G In-Home Respite VFI - Agency ZZ Local code to be retained. 16 G Case Management HC T1016 Case Management, each 15 minutes 16 G Nursing - RN HC S9123 TD Nursing Care in the Home, by RN 16 G Nursing - RN HC T1001 TD Nursing assessment/evaluation 16 G Nursing - RN HC T1002 TD RN services up to 15 minutes 16 G Nursing - LVN HC S9124 TE Nursing Care in the Home, by LVN 16 G Nursing - LVN HC T1003 TE LPN/LVN services up to 15 minutes 16 G Adaptive Aids AD D9999 Unspecified Adjunctive Procedure, by Report 16 G DME/Adaptive Aids HC T2039 Vehicle Modifications, waiver; per service 16 G DME/Adaptive Aids HC E0636 Multipositional patient support system, with integrated lift, patient 16 G DME/Adaptive Aids HC E1031 Rollabout Chair, any and all types with castors 5 or greater 16 G DME/Adaptive Aids HC E1130 Standard Wheelchair, fixed full length arms, fixed or swing away detachable 16 G DME/Adaptive Aids HC E1399 Durable Medical Equipment, Miscellaneous 16 G DME/Adaptive Aids HC E1400 Oxygen Concentrator, manufacturer-specified maximum flow rate does not exceed 2 16 G DME/Adaptive Aids HC E1900 Synthesized Speech Augmentative Communication Device with Dynamic Display 16 G DME/Adaptive Aids HC E1902 Communication Board, Nonelectronic Augmentative or Alternative Communication 16 G DME/Adaptive Aids HC S5199 Personal Care Item, NOS, each 16 G DME/Adaptive Aids HC T2029 Specialized medical equipment, not otherwise specified, waiver 16 G DME/Adaptive Aids HC T2028 Specialized Supply, Not otherwise specified, waiver 16 G DME/Adaptive Aids HC T2003 Nonemergency transportation; encounter/trip 16 G Home Modifications HC S5165 Home Modifications; per service 16 G Personal Assistance Services - Residential HC T2016 Habilitation, residential, waiver; per 15 minutes 16 G Personal Assistance Services - Chore 8/31/03 16 G Assisted Living - Apt (Level 6) HC T2031 U1 U1 Assisted living, waiver; per diem 16 G Assisted Living (Less Than 24 hour) 8/31/03 16 G AL Residential Care - Habilitation (24 hour) 8/31/03 16 G Prescriptions - discontinued N/A 8/31/03 16 G Consumer Managed Personal Attendant Services ZZ Local code to be retained. 16 G Client Managed Attendant Services - Voucher 8/31/03 16 U Dietary Services HC S9465 Diabetic management, dietician visit 16 U Dietary Services HC S9470 Nutritional counseling, dietician visit 16 U Dietary Services HC Medical nutrition therapy, initial assessment and intervention, each 15 minutes 16 G Pre-Assessment 8/31/03 16 G Behavior Communication Specialist ZZ Local code to be retained. 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

50 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 16 G Orientation and Mobility HC Community/work reintegration training (i.e., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis), direct one on one contact by provider, each 15 minutes 16 G Orientation and Mobility HC Self care/home management training (i.e., activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact by provider, each 15 minutes 16 G Intervenor HC Self care/home management training (i.e., activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact by provider, each 15 minutes 16 G Intervenor VFI - Agency ZZ Local code to be retained. 16 G A Respite - Out of Home - VFI 8/31/03 16 G A Respite - Out-of-Home HC S5151 Unskilled Respite Care, per diem 16 G A Out of Home Respite VFI ZZ Local code to be retained. 16 G A Targeted Case Management 8/31/03 16 S C Nursing Services by Highly Technical RN, per hour HC S9800 TG Home Therapy; provision of infusion, specialty drug administration, and/or associated nursing services and procedures, by highly technical RN, per hour 16 T D Nursing Services LVN HC T1003 TG LPN/LVN services, up to 15 minutes 16 G E PAS Chore HC S5120 Chore Services, per 15 minutes 16 G V VFI-PAS-Participant ZZ Local code to be retained. 16 G V PAS Level 1 (nonpriority) VFI ZZ Local code to be retained. 16 G V VFI-PAS-Agency ZZ Local code to be retained. 16 G E Assisted Living - Habilitation 24 hour HC T2033 U1 Residential care, not otherwise specified (NOS), waiver; per diem 16 G F Assisted Living - Habilitation Less Than 24 hour HC T1020 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 16 G F Assisted Living - Habilitation Less Than 24 hour 0240 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 16 G A CMPAS - Voucher Fiscal Intermediary ZZ Local code to be retained. 16 G A Pre-Assessment HC T2024 Service assessment/plan of care development, waiver 16 N0600 5A Dental Services 8/31/03 17 G Occupational Therapy HC G0152 GO Services of a occupational therapist in a home health setting; per 15 minutes 17 G Physical Therapy HC G0151 GP Services of a physical therapist in a home health setting; per 15 minutes 17 G Speech Therapy HC G0153 GN Speech or language pathologist in home health setting; per 15 minutes 17 S Habilitation - ADLs HC T2021 U5 Day habilitation, waiver; per 15 minutes 17 G Respite - In-Home ZZ Local code to be retained. 17 G Nursing - LVN HC S9124 TE Nursing Care in the Home, by LVN 17 G Nursing - LVN HC T1003 TE LPN/LVN services up to 15 minutes 17 G Psychological Services HC Psychiatric diagnostic interview examination 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

51 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s 17 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately minutes face-to-face with the patient 17 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately minutes face-to-face with the patient 17 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately minutes face-to-face with the patient 17 G Psychological Services HC Individual psychotherapy, insight oriented, behavior modifying and/ or supportive, in an inpatient hospital, partial hospital, or residential care setting, approximately minutes face-to-face with patient 17 G Psychological Services HC Individual psychotherapy, insight oriented, behavior modifying and/ or supportive, in an inpatient hospital, partial hospital, or residential care setting, approximately minutes face-to-face with patient 17 G Psychological Services HC Individual psychotherapy, insight oriented, behavior modifying and/ or supportive, in an inpatient hospital, partial hospital, or residential care setting, approximately minutes face-to-face with patient 17 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately minutes face-to-face with the patient 17 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately minutes face-to-face with the patient 17 G Psychological Services HC Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately minutes face-to-face with the patient 17 G Psychological Services HC Psychoanalysis 17 G Psychological Services HC Family psychotherapy (conjoint counseling) with patient present 17 G Psychological Services HC Pharmacological management, including prescription/use/review of medication 17 G Psychological Services HC Psychological testing 17 G DME/Adaptive Aids HC T2039 Vehicle Modifications, waiver; per service 17 G DME/Adaptive Aids HC E0636 Multipositional patient support system, with integrated lift, patient 17 G DME/Adaptive Aids HC E1031 Rollabout Chair, any and all types with castors 5 or greater 17 G DME/Adaptive Aids HC E1130 Standard Wheelchair, fixed full length arms, fixed or swing away detachable 17 G DME/Adaptive Aids HC E1399 Durable Medical Equipment, Miscellaneous 17 G DME/Adaptive Aids HC E1400 Oxygen Concentrator, manufacturer-specified maximum flow rate does not exceed 2 17 G DME/Adaptive Aids HC E1900 Synthesized Speech Augmentative Communication Device with Dynamic Display Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

52 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 17 G DME/Adaptive Aids HC E1902 Communication Board, Nonelectronic Augmentative or Alternative Communication 17 G DME/Adaptive Aids HC T2029 Specialized medical equipment, not otherwise specified, waiver 17 G Home Modifications HC S5165 Home Modifications; per service 17 G Personal Assistance Services - Level 2 - Priority HC S5125 Attendant Care Services, per 15 minutes 17 G Adult Foster Care - Level 1 HC S U3 Adult foster care, per diem 17 G Adult Foster Care - Level 2 HC S U4 Adult foster care, per diem 17 G Adult Foster Care - Level 3 HC S U5 Adult foster care, per diem 17 G Assisted Living - Apt (Level 6) HC T2031 U1 U1 Assisted living, waiver; per diem 17 G Assisted Living Apartment (Level 5) 8/31/03 17 G Assisted Living Apartment (Level 4) 8/31/03 17 G Assisted Living Apartment (Level 3) 8/31/03 17 G Assisted Living Apartment (Level 2) 8/31/03 17 G Assisted Living Apartment (Level 1) 8/31/03 17 G Emergency Response Services HC S5160 Installation and Testing 17 G Emergency Response Services HC S5161 Monthly Service Fee (excludes installation and testing) 17 G Emergency Response Services HC S5162 Purchase Only 17 G Medical Supplies HC S5199 Personal Care Item, NOS, each 17 G Medical Supplies HC T2028 Specialized Supply, Not otherwise specified, waiver 17 C Home Delivered Meals 8/31/03 17 C Title XIX CBA Meals HC S5170 Per meal, includes preparation and delivery 17 U DIETARY SERVICES HC S9465 Diabetic management, dietician visit 17 U DIETARY SERVICES HC S9470 Nutritional counseling, dietician visit 17 U DIETARY SERVICES HC Medical nutrition therapy, initial assessment and intervention, each 15 minutes 17 U Audiology/AU HC V5008 Hearing Screening 17 U Audiology/AU HC V5010 Hearing Aid Assessment 17 U Audiology/AU HC V5011 Fitting/Orientation of Hearing Aid 17 U Audiology/AU HC V5020 Conformity Evaluation 17 U Social Work/SW HC G0155 Services of a clinical social worker in the home health setting, each 15 minutes 17 U Supported Employment/SE HC T2019 Habilitation, supported employment, waiver; per 15 minutes 17 G Annual Assessment 8/31/03 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees ZZ Local code to be retained. 17 G ADP Aides/Requisition Fees OVER ZZ Local code to be retained. 17 G Behavior Communication Specialist ZZ Local code to be retained. 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

53 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 17 G Orientation & Mobility HC Community/work reintegration training (i.e., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis), direct one on one contact by provider, each 15 minutes 17 G Orientation & Mobility HC Self care/home management training (i.e., activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact by provider, each 15 minutes 17 G Intervenor HC Self care/home management training (i.e., activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact by provider, each 15 minutes 17 G Transportation HC A0100 Nonemergency Transportation; Taxi 17 G Transportation HC A0110 Nonemergency Transportation; Bus 17 G Transportation HC A0120 Nonemergency Transportation; Mini-Bus, other non-profit transport systems 17 G Transportation HC A0130 Nonemergency Transportation; Wheelchair Van 17 G Transportation HC A0160 Nonemergency Transportation; Caseworker or Social Worker 17 G Transportation HC A0170 Nonemergency Transportation; Ancillary; Parking Fees, Tolls, Other 17 G Transportation HC A0210 Nonemergency Transportation; Ancillary; Meals - Escort 17 G Transportation HC T2001 Nonemergency transportation; patient attendant/escort 17 G Transportation HC T2003 Nonemergency transportation; encounter/trip 17 G Transportation HC T2004 Nonemergency transport; commercial carrier, multi-pass 17 G Transportation HC T2005 Nonemergency transportation; Non-ambulatory stretcher van 17 G Child Support Services ZZ Local code to be retained. 17 G Independent Advocacy ZZ Local code to be retained. 17 S B Habilitation - Supportive Employ Employment 8/31/03 17 S B Habilitation - Prevocational HC T2015 U4 Habilitation prevocational, waiver, per hour. 17 S B Habilitation - Prevocational LON 1 Intermittent 8/31/03 17 S B Habilitation - Prevocational LON 5 Limited 8/31/03 17 S B Habilitation - Prevocational LON 6 Pervasive 8/31/03 17 S B Habilitation - Prevocational LON 8 Extensive 8/31/03 17 S C Habilitation - Day Habilitation HC Self care/home management training (i.e., activities of daily living and compensatory training, meal preparation, safety procedures, and instruction in use of adaptive equipment) direct one on one contact by provider, each 15 minutes 17 S C Habilitation - Day Habilitation 0942 Education/Training 17 S C Habilitation - Day Habilitation HC Community/work reintegration training (i.e., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis), direct one on one contact by provider, each 15 minutes 17 S C Habilitation - Day Habilitation LON 1 Intermittent 8/31/03 17 S C Habilitation - Day Habilitation LON 5 Limited 8/31/03 17 S C Habilitation - Day Habilitation LON 6 Pervasive 8/31/03 17 S C Habilitation - Day Habilitation LON 8 Extensive 8/31/03 17 G A Respite-RE-LON 8 8/31/03 17 G A Respite - Out-of-Home HC S5151 Unskilled Respite Care, per diem 17 G B Respite - Adult Foster Care - Level 1 HC S U3 Unskilled Respite Care, per diem 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

54 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 17 G B Respite - Adult Foster Care - Level 1 HC S5151 U3 Unskilled Respite Care, per diem 17 G B Respite - Adult Foster Care - Level 2 HC S U4 Unskilled Respite Care, per diem 17 G B Respite - Adult Foster Care - Level 2 HC S5151 U4 Unskilled Respite Care, per diem 17 G B Respite - Adult Foster Care - Level 3 HC S U5 Unskilled Respite Care, per diem 17 G B Respite - Adult Foster Care - Level 3 HC S5151 U5 Unskilled Respite Care, per diem 17 G C Respite - Assisted Living - Apt (Level 6) HC S U1 U1 17 G C Respite - Assisted Living - Apt (Level 5) 8/31/03 17 G C Respite - Assisted Living - Apt (Level 4) 8/31/03 17 G C Respite - Assisted Living - Apt (Level 3) 8/31/03 17 G C Respite - Assisted Living - Apt (Level 2) 8/31/03 17 G C Respite - Assisted Living - Apt (Level 1) 8/31/03 17 G D Respite - Residential Care - Apt (Level 6) HC S U2 U1 17 G D Respite - Residential Care - Apt (Level 5) 8/31/03 17 G D Respite - Residential Care - Apt (Level 4) 8/31/03 17 G D Respite - Residential Care - Apt (Level 3) 8/31/03 17 G D Respite - Residential Care - Apt (Level 2) 8/31/03 17 G D Respite - Residential Care - Apt (Level 1) 8/31/03 17 G E Respite - Residential Care - Non Apt (Level 6) HC S U2 U2 Unskilled Respite, per diem 17 G E Respite - Residential Care - Non Apt (Level 5) 8/31/03 17 G E Respite - Residential Care - Non Apt (Level 4) 8/31/03 17 G E Respite - Residential Care - Non Apt (Level 3) 8/31/03 17 G E Respite - Residential Care - Non Apt (Level 2) 8/31/03 17 G E Respite - Residential Care - Non Apt (Level 1) 8/31/03 17 N F Respite NF - Tile 201 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 202 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 203 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 204 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 205 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 206 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 207 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 208 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 209 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 210 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 211 ZZ Prior authorization must be obtained prior to providing this service 17 N F Respite NF - Tile 212 ZZ Prior authorization must be obtained prior to providing this service 17 G G Respite - Camp HC T Respite Care, Therapeutic Camping, Day, each session 17 G H Respite - Day Care/Licensed Child Care Facility HC T Respite Care, Specialized Childcare, per day 17 G K Respite - ICF/MR 0660 Respite Care, general (Note: Providers must use a valid and accurate Place of Service code.) 17 G L Respite - Hospital 0660 Respite Care, general (Note: Providers must use a valid and accurate Place of Service code.) 17 G N Respite - LVN 8/31/03 17 G A Targeted Case Management 8/31/03 17 G A Nursing Services - LVN HC S9124 Nursing Care in the Home, by LVN 17 G A Nursing Services - LVN HC T1003 LPN/LVN services up to 15min 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

55 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 17 G B Nursing Services - RN HC S9123 Nursing Care in the Home, by RN 17 G B Nursing Services - RN HC T1001 Nursing assessment/evaluation 17 G B Nursing Services - RN HC T1002 RN services up to 15 minutes 17 G A PAS Delegated (For Future Use) 8/31/03 17 G B PAS Protective Supervision (For Future Use) 8/31/03 17 G E PAS Chore 8/31/03 17 G A AL Residential Care - Apt (Level 6) HC T2031 U2 U1 Assisted living, waiver; per diem 17 G A Assisted Living Residential Care Apartment 8/31/03 (Level 5) 17 G A Assisted Living Residential Care Apartment 8/31/03 (Level 4) 17 G A Assisted Living Residential Care Apartment 8/31/03 (Level 3) 17 G A Assisted Living Residential Care Apartment 8/31/03 (Level 2) 17 G A Assisted Living Residential Care Apartment 8/31/03 (Level 1) 17 G B AL Residential Care - Non Apt (Level 6) HC T2031 U2 U2 Assisted living, waiver; per diem 17 G B Assisted Living Residential Care Non-Apartment 8/31/03 (Level 5) 17 G B Assisted Living Residential Care Non-Apartment 8/31/03 (Level 4) 17 G B Assisted Living Residential Care Non-Apartment 8/31/03 (Level 3) 17 G B Assisted Living Residential Care Non-Apartment 8/31/03 (Level 2) 17 G B Assisted Living Residential Care Non-Apartment 8/31/03 (Level 1) 17 G C Assisted Living - Personal Care 3 HC T2031 U1 Assisted living, waiver; per diem 17 G E Residential Support LOC 1 HC T U2 U2 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G E Residential Support LOC 1 HC T1020 U3 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G E Residential Support LON 5 HC T U2 U2 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G E Residential Support LON 5 HC T1020 U7 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G E Residential Support LON 6 HC T U2 U2 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G E Residential Support LON 6 HC T1020 U8 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G E Residential Support LON 8 HC T U2 U2 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

56 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s 17 G E Residential Support LON 8 HC T1020 UA Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G E Assisted Living - Habilitation 24 hour HC T2033 U1 Residential care, not otherwise specified (NOS), waiver; per diem 17 G G Assisted Living - Family Surrogate Services LON 1 HC T U3 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G G Assisted Living - Family Surrogate Services LON 1 HC T1020 U3 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G G Assisted Living - Family Surrogate Services LON 5 HC T U7 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G G Assisted Living - Family Surrogate Services LON 5 HC T1020 U7 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G G Assisted Living - Family Surrogate Services LON 8 HC T UA A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G G Assisted Living - Family Surrogate Services LON 8 HC T1020 UA Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G G Assisted Living - Family Surrogate Services LON 6 HC T U8 A flat rate charge incurred on either a daily basis or total stay basis for ancillary services only 17 G G Assisted Living - Family Surrogate Services LON 6 HC T1020 U8 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by a home health aide or certified nurse assistant) 17 G A Pre-Assessment HC T2024 Service assessment/plan of care development, waiver 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees ZZ Local code to be retained. 17 G A Medical S/Requisition Fees OVER ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

57 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s Revenue 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees ZZ Local code to be retained. 17 G B MH Mods/Requisition Fees Over ZZ Local code to be retained. 17 G C Specifications Adaptive Aids ZZ Local code to be retained. 17 G D Specifications HM Mods ZZ Local code to be retained. 17 N0600 5A Emergency Dental AD D9999 Unspecified Adjunctive Procedure, by Report 18 N Ventilator - Full 8/31/03 18 G Respite - Personal Assistance Services HC S5150 Unskilled respite care, not hospice; per 15 minutes 18 G Respite - Sitter Services 8/31/03 18 G In-Home Respite VFI - Agency ZZ Local code to be retained. 18 G DME/Adaptive Aids HC T2039 Vehicle Modifications, waiver; per service 18 G DME/Adaptive Aids HC E0636 Multipositional patient support system, with integrated lift, patient 18 G DME/Adaptive Aids HC E1031 Rollback Chair, any and all types with castors 5 or greater 18 G DME/Adaptive Aids HC E1130 Standard Wheelchair, fixed full length arms, fixed or swing away detachable 18 G DME/Adaptive Aids HC E1399 Durable Medical Equipment, Miscellaneous 18 G DME/Adaptive Aids HC E1400 Oxygen Concentrator, manufacturer-specified maximum flow rate does not exceed 2 18 G DME/Adaptive Aids HC E1900 Synthesized Speech Augmentative Communication Device with Dynamic Display 18 G DME/Adaptive Aids HC E1902 Communication Board, Nonelectronic Augmentative or Alternative Communication 18 G DME/Adaptive Aids HC T2029 Specialized medical equipment, not otherwise specified, waiver 18 G DME/Adaptive Aids HC T2028 Specialized Supply, Not otherwise specified, waiver 18 G Home Modifications HC S5165 Home Modifications; per service 18 G Personal Assistance Services - Level 1-8/31/03 Nonpriority 18 G Transitional Services 8/31/03 18 N F Respite NF - Tile 201 ZZ Local code to be retained. 18 N F Respite NF - Tile 202 ZZ Local code to be retained. 18 N F Respite NF - Tile 203 ZZ Local code to be retained. 18 N F Respite NF - Tile 204 ZZ Local code to be retained. 18 N F Respite NF - Tile 205 ZZ Local code to be retained. 18 N F Respite NF - Tile 206 ZZ Local code to be retained. 18 N F Respite NF - Tile 207 ZZ Local code to be retained. 18 N F Respite NF - Tile 208 ZZ Local code to be retained. 18 N F Respite NF - Tile 209 ZZ Local code to be retained. 18 N F Respite NF - Tile 210 ZZ Local code to be retained. 18 N F Respite NF - Tile 211 ZZ Local code to be retained. 18 N F Respite NF - Tile 212 ZZ Local code to be retained. 18 G G Respite - Camp HC T Respite Care, Therapeutic Camping, Day, each session 18 G H Respite - Day Care/Licensed Child Care Facility HC T Respite Care, Specialized Childcare, per day 18 G J Respite - Licensed Special Care Facility HC S Respite Care, unskilled, per 15 minutes 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date August 2003, No LTC Bulletin

58 Service Group Bill Service Long Term Care Bill Crosswalk Table Texas LTC Local s National s Bill Description Procedure Qualifier HCPCS & Proposed HCPCS s CPT s 18 G L Respite - Hospital 0660 Respite Care, general (Note: To map back to the local code, place of service will have to be used in the algorithm) 18 G M Respite - HCSS (RN/LVN) HC S TE Respite Care by an LVN, per hour 18 G M Respite - HCSS (RN/LVN) HC S TD Respite Care by an RN, per hour 18 G N Respite - LVN HC T TE Respite Care by an LVN, per hour 18 G P Respite - RN HC T TD Respite Care by an RN, per hour 18 G Q Respite - PAS Delegated HC T Unskilled respite care, not hospice; per 15 minutes 18 G R Adjunct - HCSS (RN/LVN) HC S9123 Nursing care, in the home; by an RN 18 G R Adjunct - HCSS (RN/LVN) HC S9124 Nursing care, in the home; by an LVN 18 G R Adjunct HCSS (RN/LVN) VFI - Agency ZZ Local code to be retained. 18 G S Adjunct - LVN HC T1003 Nursing care, in the home; by an LVN, per 15 minutes 18 G T Adjunct - RN HC T1002 RN Services, up to 15 minutes 18 G U Adjunct - PAS HCSS HC S5120 Chore Services, per 15 minutes 18 G U Adjunct - PAS HCSS HC S5130 Homemaker service, NOS, per 15 minutes 18 G U Adjunct - PAS HCSS HC S5135 Companion care, adult (i.e., IADL/ADL), per 15 minutes 18 G U Adjunct - PAS HCSS HC T1019 Personal Care Services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF-MR or IMD, part of the individualized plan of treatment (not to be used for services provided by a home health aide or certified nurse assistant) 18 G V Adjunct - PAS Delegated HC S5125 Attendant Care Services, per 15 minutes 18 G A CMPAS - Voucher Fiscal Intermediary ZZ Local code to be retained. Revenue 2 3 Note: The ZZ qualifier must be used for services rendered for 10/16/03 except for: DME/Adaptive Aids, Dental, and Hospice Physician Services. 4 Definition/Comments End Date LTC Bulletin August 2003, No. 15

59 Explanation of Benefits (EOB) Table HIPAA requires the use of new standard EOB codes, which will appear on the provider s Claim Status Inquiry (CSI) and Remittance and Status report (R&S). EOB codes are used to report on claim payment/advice transactions. Because the new standard codes referred to as Remittance Advice Remark s (RARC) do not sufficiently explain the reason for the claim payment/advice, the state elected to provide the old codes in addition to the new codes to assist LTC providers in reviewing the R&S report: Explanation of Benefits (EOB) Table EOB Description RARC Description F0001 Claim Header Record ID is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0002 Test/Production Flag is missing or invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0003 Program Type is a required field. M58 Missing/incomplete/invalid claim information. Resubmit F0004 Claim Type is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0005 Claim Header Source Identifier must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0006 Claim Header Source Identifier is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0007 F0008 Claim header signature indicator is missing or invalid. Claim Header Endorsement Number is an invalid value. M49 M49 Missing/incomplete/invalid value code(s) and/or amount(s). Missing/incomplete/invalid value code(s) and/or amount(s). F0009 Detail Count must be present. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0010 Detail Count is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0011 Total Claim Positive Indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0012 Previous claims indicate more than 5 consecutive days billed. MA32 Missing/incomplete/invalid number of covered days during the billing period. F0013 The claim total amount billed is not in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0014 The Provider Number submitted is not in a valid M57 Missing/incomplete/invalid provider identifier. format. F0016 Last Name must be present in order to process a MA36 Missing/incomplete/invalid patient name. claim. F0018 The Client/Medicaid Number is missing or invalid. MA61 Missing/incomplete/invalid social security number or health insurance claim number. F0021 F0022 Medicaid Patient Days % Positive/Negative Indicator must be present. Medicaid Patient Days % Positive/Negative Indicator is not a valid entry. M58 M49 Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid value code(s) and/or amount(s). F0025 Medicaid Patient Days Percent is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0026 F0028 Medicare Patient Days % Positive/Negative Indicator must be present. Medicare Patient Days % Positive/Negative Indicator is not a valid entry. M58 M49 Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid value code(s) and/or amount(s). F0031 The Private Patient Days % entry is invalid. MA33 Missing/incomplete/invalid number of noncovered days during the billing period. F0032 Medicare Patient Days percent is missing. M58 Missing/incomplete/invalid claim information. Resubmit August 20003, No LTC Bulletin

60 F0060 Special Pay Begin Service Date is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit F0033 F0035 Private Patient Days % Positive/Negative Indicator must be present. Private Patient Days % Positive/Negative Indicator is not a valid entry. M58 M49 Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid value code(s) and/or amount(s). F0037 Private Patient Days % is missing. MA33 Missing/incomplete/invalid noncovered days during the billing period. F0040 Trainee Social Security Number is missing or invalid. MA61 Did not complete or enter correctly the patient's social security number or health F0041 F0042 F0044 F0045 F0046 Service group is missing, invalid, or not currently active. The payee identification number submitted is invalid. Payee Identification Number must be submitted on claim. Claim Header Adjustment Segment Indicator is an invalid value. Claim Header Special Pay Segment Indicator is an invalid value. M58 MA61 M58 M49 M49 Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid social security number or health insurance claim number. Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid value code(s) and/or amount(s). Missing/incomplete/invalid value code(s) and/or amount(s). F0048 Adjustment claims require an original ICN. M58 Missing/incomplete/invalid claim information. Resubmit F0050 Special Pay segment ID is invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0051 Fund is a required field. M58 Missing/incomplete/invalid claim information. Resubmit F0052 PAC is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0053 Special Pay Object is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0054 Special Pay Reason is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0055 Special Pay Type Indicator is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0056 Special Pay Service is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit F0057 Special Pay Agency must be present in order to process a claim. M58 Missing/incomplete/invalid claim information. Resubmit F0058 Special Pay Region/Division is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0059 Special Pay Appropriation is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0060 Special Pay Begin Service Date is missing or invalid. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0061 Special Pay End Service Date is missing or invalid. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0062 Special Pay Expedited Payment Billing Month/Year is missing. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0063 Claim Detail Segment ID is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0064 Detail Number must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0065 F0067 Claim Detail Adjustment Line Reference Number is an invalid value. Detail Number is greater than Detail Count in Header. Explanation of Benefits (EOB) Table EOB Description RARC Description M49 M49 Missing/incomplete/invalid value code(s) and/or amount(s). Missing/incomplete/invalid value code(s) and/or amount(s). LTC Bulletin 60 60August 20003, No. 15

61 F0068 Detail Number is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0069 Detail Numbers are not consecutive. M58 Missing/incomplete/invalid claim information. Resubmit F0070 Line item is missing a Service Begin Date. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0071 Services cannot be before January 1, MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0072 The Service End Date is missing. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0073 F0075 The Service Begin Date must be on or before the Service End Date. The Service Begin Date is not for the same month and year as the Service End Date. MA06 MA06 Missing/incomplete/invalid beginning and/or ending date(s). Missing/incomplete/invalid beginning and/or ending date(s). F0077 Billing not present on claim line item. MA66 Missing/incomplete/invalid principal procedure code or date. F0078 Claim Detail Training Hours Positive/Negative Indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0080 Training Hours must be in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0081 Applied Income Positive/Negative Indicator must be present MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. F0083 Applied Income is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. F0087 Copayment Amount is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. F0089 Copayment Percent Positive/Negative Indicator must be present. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. F0091 Copayment Percentage is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. F0092 Units Billed Pos/Neg indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0094 Number of Units Billed is missing. M53 Did not complete or enter the appropriate number (one or more) of days or unit(s) of service. F0095 Units Rate Pos/Neg indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0097 Unit Rate must is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit F0098 Claim Detail Line Item Total Positive/Negative Indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit F0100 Line Item Total Billed must be in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0101 Claim Header Adjustment Segment is missing. M58 Missing/incomplete/invalid claim information. Resubmit F0102 A Claim Header Adjustment Segment exists, claim header adjustment indicator is 'N. M58 Missing/incomplete/invalid claim information. Resubmit F0106 Claim Leave Days must be in a valid format. MA33 Missing/incomplete/invalid noncovered days during the billing period. F0107 F0108 F0110 The original line item in history is not in an adjustable status. The original line item in history is not in an adjustable status. Matching history detail not found or not in adjustable status. Explanation of Benefits (EOB) Table EOB Description RARC Description N36 N36 N36 Claim must meet primary payer's processing requirements before we can consider payment. Claim must meet primary payer's processing requirements before we can consider payment. Claim must meet primary payer's processing requirements before we can consider payment. F0111 Positive Line Item contains a negative Units Billed. M53 Missing/incomplete/invalid days or units of service. August 20003, No LTC Bulletin

62 F0112 Claim Header contains no details. M58 Missing/incomplete/invalid claim information. Resubmit F0113 F0114 F0115 Number of Details in Claim does not match header count. Unable to determine Service from supplied information, verify Billing. Unable to determine Budget Key from supplied information. M58 M67 M58 Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid other procedure code(s) and/or date(s). Missing/incomplete/invalid claim information. Resubmit F0116 The Units Billed must be greater than zero. M53 Missing/incomplete/invalid days or units of service. F0117 Unit Rate must be greater than zero. M58 Missing/incomplete/invalid claim information. Resubmit F0118 Incorrect number of billed units for this service. M53 Missing/incomplete/invalid days or units of service. F0119 Claims for month following submission must be submitted within last week of month before service. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0121 Late billing - Claim must be filed 95 days from the end of the month of service. MA119 Provider level adjustment for late claim filing applies to this claim. F0123 Original ICN is not on file. M58 Missing/incomplete/invalid claim information. Resubmit F0125 Units billed exceed possible number of Units for M53 Missing/incomplete/invalid days or units of service. Dates of Service. F0126 Claim line items cannot span current Fiscal Years. N61 Rebill services on separate claims. F0128 Provider is not enrolled to provide CMS services, or M57 Missing/incomplete/invalid provider identifier. invalid provider number entered. F0131 Provider has been placed on hold. N36 Claim must meet primary payer's processing requirements before we can consider payment. F0132 F0134 Provider is not authorized to perform this service for these Service Dates, verify Billing. Provider authorized to provide services only to clients residing within Provider Region. N54 N54 Claim information is inconsistent with pre-certified/ authorized services. Claim information is inconsistent with pre-certified/ authorized services. F0136 Provider is not authorized for Expedited Payment. N54 Claim information is inconsistent with pre-certified/ authorized services. F0138 F0139 F0141 F0142 A valid Service Authorization for this client for this Service on these dates is not available. Client/Medicaid Number does not match information on file. Client ID is a previous reference which is not valid for the service dates. Client Medicaid Eligibility is not currently active or is on hold for dates of service. N54 MA61 N30 N30 Claim information is inconsistent with pre-certified/ authorized services. Missing/incomplete/invalid social security number or health insurance claim number. Client ineligible for this service. Client ineligible for this service. F0143 Client last name not on file. MA36 Missing/incomplete/invalid patient name. F0145 Client last name matched with former name on file. MA36 Missing/incomplete/invalid patient name. F0147 Client's LOS Type and Level do not match Service N30 Client ineligible for this service. Group and Billing Requirements. F0148 Provider not authorized to provide services billed for client. N54 Claim information is inconsistent with pre-certified/ authorized services. F0150 F0151 F0152 F0153 Client not living in approved Nursing Facility on Service Dates. Cannot bill for more than five consecutive days for this service. Records show that client has received this service for more than five consecutive days. Client is eligible for Medicare enrollment. Bill Medicare first. Explanation of Benefits (EOB) Table EOB Description RARC Description MA134 M53 M53 N104 Missing/Missing/incomplete/invalid provider number of the facility where the patient resides. Missing/incomplete/invalid days or units of service. Missing/incomplete/invalid days or units of service. This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at LTC Bulletin 62 62August 20003, No. 15

63 F0155 F0163 F0165 F0167 F0168 F0169 Unable to determine appropriate Fund for Service billed, verify Medicaid Eligibility. Item billed is not authorized for the Service provided. This service has already been paid. Do not file for duplicate services. A claim for this procedure for this tooth has already been paid. Claim denied because Trainee has already completed the full training course. Claim denied because Trainee has not completed the full training course. N54 N54 M86 M86 M86 N36 Claim information is inconsistent with pre-certified/ authorized services. Claim information is inconsistent with pre-certified/ authorized services. Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. Claim must meet primary payer's processing requirements before we can consider payment. F0170 Trainee has already passed a Skills Test. M86 Service denied because payment already made for similar procedure within set time frame. F0171 Trainee has not previously passed a Skills Test. N36 Claim must meet primary payer's processing requirements before we can consider payment. F0172 F0173 F0174 F0175 Trainee has previously passed a written or oral examination. Trainee has previously passed a written or oral examination. Claim is for a service group that is mutually exclusive with service group for previous claim. Claim is for a service that is mutually exclusive with a service for previous claim with the same Service Dates. M86 M86 M86 M86 Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. F0177 The Budget number is not valid for provider. M58 Resubmit the claim with the missing /correct information so that it may be processed. F0179 F0181 Claim can not be paid because client is a Managed Care client. Provider has already submitted an expedited payment for the current month. N54 M86 Claim information is inconsistent with pre-certified/ authorized services. Service denied because payment already made for similar procedure within set time frame. F0182 Expedited payment must be for the current month. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0184 F0185 Provider has submitted a claim for the current month of service, for the service code submitted on the claim. Claim cannot process due to balance owed by provider to the State. N54 N36 Claim information is inconsistent with pre-certified/ authorized services. Claim must meet primary payer's processing requirements before we can consider payment. F0187 No units available from client Service Authorization. N54 Claim information is inconsistent with pre-certified/ authorized services. F0189 Amount of claim exceeds available budget. N131 Total payments under multiple contracts cannot exceed the allowance for this service. F0191 Units billed exceeds allowable units for this client. N54 Claim information is inconsistent with pre-certified/ authorized services. F0193 F0194 F0195 F0196 All positive line items must be referenced to a negative line item. Adjustment request received past the filing deadline. Header Adjustment: total paid amount submitted does not match paid amount on history. The sum of the Medicaid Patient Days % and/or Medicare Patient Days % and/or Private Patient Days % does not equal 100. Explanation of Benefits (EOB) Table EOB Description RARC Description M58 MA119 M54 M54 Missing/incomplete/invalid claim information. Resubmit Provider level adjustment for late claim filing applies to this claim. Missing/incomplete/invalid total charges. Missing/incomplete/invalid total charges. F0198 Cannot bill for future Service Dates or current date. MA06 Missing/incomplete/invalid beginning and/or ending date(s). F0200 Procedure code is missing. MA66 Missing/incomplete/invalid principal procedure code or date. August 20003, No LTC Bulletin

64 F0201 An Item is required for this service. M58 Resubmit the claim with the missing /correct information so that it may be processed. F0202 This Service requires a Tooth ID. N37 Missing/incomplete/invalid tooth number/letter. F0203 The client's eligibility requires a Budget Number to be submitted. M58 Missing/incomplete/invalid claim information. Resubmit F0204 The Budget Number is invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0205 Medicaid Patient Days % is greater than M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0206 Medicare Patient Days % is greater than M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0207 Private Patient Days % is greater than M49 Missing/incomplete/invalid value code(s) and/or amount(s). F0208 Leave Days may not exceed the Units Billed. MA32 Missing/incomplete/invalid number of covered days during the billing period. F0209 F0211 Expedited claim has suspended, and will be processed beginning on the State-authorized submission date for this month. Expedited claim submitted after the Stateauthorized submission date for this month. N36 N36 Claim must meet primary payer's processing requirements before we can consider payment. Claim must meet primary payer's processing requirements before we can consider payment. F0214 Provider number is missing or invalid. M57 Missing/incomplete/invalid provider identifier. F0215 Unable to determine Rate Key for detail or contract, M58 Missing/incomplete/invalid claim information. Resubmit verify Billing, if correct contact NHIC Helpdesk. F0216 F0218 The payee identification number on the claim is not associated with the Client/Medicaid Number. Expedited ceiling has not been calculated for contract for month of claim - unable to process expedited claims. MA61 N36 Missing/incomplete/invalid social security number or health insurance claim number. Claim must meet primary payer's processing requirements before we can consider payment. F0220 Client/Medicaid Number is missing. MA61 Missing/incomplete/invalid social security number or health insurance claim number. F0222 F0223 F0224 Copayment amount exceeds claim line item amount. Amount reduced, billed amount is greater than maximum allowed. Applied Income amount exceeds claim line item amount. MA34 M54 MA34 Missing/incomplete/invalid number of coinsurance days during the billing period. Missing/incomplete/invalid total charges. Missing/incomplete/invalid number of coinsurance days during the billing period. F0225 Units billed exceeds allowable units for this client. N54 Claim information is inconsistent with pre-certified/ authorized services. F0226 Payable amount is the expedited payment ceiling N45 Payment based on authorized amount. amount. F0228 Units on claim exceeds available budget. M53 Missing/incomplete/invalid days or units of service. F0229 Rate not found. N54 Claim information is inconsistent with pre-certified/ authorized services. F0230 County rate not found. N54 Claim information is inconsistent with pre-certified/ authorized services. F0231 Procedure rate not found. N54 Claim information is inconsistent with pre-certified/ authorized services. F0232 Amount changed due to difference in copayment. N45 Payment based on authorized amount. F0233 Claim has more than 28 details. N36 Claim must meet primary payer's processing requirements before we can consider payment. F0234 Service is duplicate of another line item on same claim for same or overlapping service dates. Explanation of Benefits (EOB) Table EOB Description RARC Description M86 Service denied because payment already made for similar procedure within set time frame. F0235 Positive Line Item contains a negative units billed. M58 Missing/incomplete/invalid claim information. Resubmit LTC Bulletin 64 64August 20003, No. 15

65 F0236 F0237 Unable to determine appropriate state accounting codes for this claim. NHIC is researching this problem. Authorizing agency has changed or is not consistent for dates of service. N36 N54 Claim must meet primary payer's processing requirements before we can consider payment. Payment based on authorized amount. F0238 This line item is approved to pay. N14 Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount. F0239 Claim line item paid amount differs from claim line N45 Payment based on authorized amount. item billed amount. F0240 Provider has an outstanding Sanction. N36 Claim must meet primary payer's processing requirements before we can consider payment. F0241 F0242 F0243 F0244 F0245 F0246 Applied Income or Copay must exist for the dates of service. A change to the client s service authorization has generated a recoupment for services, dates, or units no longer allowed. A change in the rate for this service has generated repayment for this line item. A change to the providers contract has generated a recoupment for services, or dates no longer allowed. A change to the clients applied income or copayment has generated a recoupment for services previously billed. A change to the units authorized for this client has been submitted by a state auditor. M58 MA67 MA67 MA67 MA67 MA67 Missing/incomplete/invalid claim information. Resubmit Missing/incomplete/invalid other procedure code(s) and/or date(s). Missing/incomplete/invalid other procedure code(s) and/or date(s). Missing/incomplete/invalid other procedure code(s) and/or date(s). Missing/incomplete/invalid other procedure code(s) and/or date(s). Missing/incomplete/invalid other procedure code(s) and/or date(s). F0247 The billed tooth ID has been previously billed. M86 Service denied because payment already made for similar procedure within set time frame. F0248 A repayment for this line item was created to adjust a previous payment due to new updates to claim reference data. MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s). F0249 Unable to determine region/division code for client. N36 Claim must meet primary payer's processing requirements before we can consider payment. F0250 Late billing - Claim must be filed 180 days from the end of the month of service or 180 days from the end of the eligibility add date. MA119 Provider level adjustment for late claim filing applies to this claim. F0251 NAT claims may only contain one detail line item. M58 Missing/incomplete/invalid claim information. Resubmit F0252 F0253 F0254 Incorrect number of training hours for this training course billing code. A completed NAT training course has been billed for earlier dates. Only one incomplete training course per trainee is allowed for NAT. M58 M86 M86 Missing/incomplete/invalid claim information. Resubmit Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. F0255 Failed skills test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame. F0256 F0257 This NAT service has been paid the maximum number of times. An incomplete NAT training course has been billed for later dates. M86 M86 Service denied because payment already made for similar procedure within set time frame. Service denied because payment already made for similar procedure within set time frame. F0258 Amount of claim exceeds available budget. N131 Total payments under multiple contracts cannot exceed the allowance for this service. F0259 Failed oral test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame. F0260 Failed written test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame. F0261 Incorrect number of training hours for this training course billing code. Explanation of Benefits (EOB) Table EOB Description RARC Description M49 Missing/incomplete/invalid value code(s) and/or amount(s). August 20003, No LTC Bulletin

66 F0263 F0264 Records show that client has received this service for more than 14 consecutive days. Claim is for a Billing that is mutually exclusive with Billing for previous Claim. M53 M86 Missing/incomplete/invalid days or units of service. Service denied because payment already made for similar procedure within set time frame. F0265 This claim is approved to pay. N14 Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount. F0266 F0267 F0268 F0269 F0270 F0271 Unable to determine appropriate state accounting codes for this claim. NHIC is researching this problem. Unable to determine Budget Number from supplied information. A valid service authorization for client for these service dates not available or claim dates cannot overlap more than one service authorization. Claim Detail is an Exact Duplicate of History Claim Detail. Cannot bill a positive line item for a separated alias client ID. Client has received this service for more than 5 units per billing code per month. N36 M58 N54 M86 MA61 M53 Claim must meet primary payer's processing requirements before we can consider payment. Missing/incomplete/invalid claim information. Resubmit Payment based on authorized amount. Service denied because payment already made for similar procedure within set time frame. Missing/incomplete/invalid social security number or health insurance claim number. Missing/incomplete/invalid days or units of service. F0272 The Billed Unit Rate exceeds the current maximum. M49 Missing/incomplete/invalid value code(s) and / or amount(s). F0273 F0274 F0275 F0276 F0277 F0278 F0999 The Billed Units Count exceeds the current maximum. The Billed Applied Income/ Billed Copay Amount value has more than 2 decimal places. Claim must be filed via a HIPAA-compliant transaction set. Procedure Qualifier is missing, invalid or not payable under the CMS LTC Program. National is missing, invalid, not billable with Procedure Qualifier submitted or not payable under the CMS LTC program. Claim must be filed with the appropriate HCPCS/ CPT or Revenue. Corresponding Negative Line Item or Header Denied. Explanation of Benefits (EOB) Table EOB Description RARC Description M49 M49 N36 N36 N36 M58 N142 Missing/incomplete/invalid value code(s) and / or amount(s). Missing/incomplete/invalid value code(s) and / or amount(s). Claim must meet primary payer's processing requirements before we can consider payment. Claim must meet primary payer's processing requirements before we can consider payment. Claim must meet primary payer's processing requirements before we can consider payment. Missing/incomplete/invalid claim information. Resubmit The original claim was denied. Resubmit a new claim, not a replacement claim. LTC Bulletin 66 66August 20003, No. 15

67 Nursing Facility and Community Based Alternatives Workshops Topics Covered: Roles of the Centers for Medicare and Medicaid, TDHS, HHSC, and NHIC 3619 and 3618 forms - Nursing Facility Workshop Only Proper Purpose Submission What is Medical Necessity? Denial and Appeal Process Electronic Form Submission NHIC Weekly Status Reports (WSR) Minimum Data Set (MDS) - Nursing Facility Workshop only You will learn: How to prevent delay in cash flow through proper form submission Hints to documenting medical necessity for faster processing and approval How to communicate pertinent information to NHIC How to utilize tools available to you to assist with tracking and communicating information Sign-in begins 30 minutes before the workshop start time. Allow adequate time for parking and sign-in. The room temperatures in the workshops may vary, so dress appropriately. NHIC does not provide refreshments NHIC Nursing Facility and CBA Workshop Schedule Consult the following table for the 2003 NHIC Nursing Facility (NF) and Community-Based Alternatives (CBA) workshop near you. Location, Date, and Time Austin TX 07/29/03 CBA 9 a.m.-3 p.m. 07/30/03 NF 9 a.m.-4 p.m. El Paso TX 08/06/03 NF 9 a.m.-4 p.m. 08/07/03 CBA 9 a.m.-3 p.m. Corpus Christi TX 08/12/03 NF 9 a.m.-4 p.m. 08/13/03 CBA 9 a.m.-3 p.m. San Antonio TX 08/14/03 NF 9 a.m.-4 p.m. 08/15/03 CBA 9 a.m.-3 p.m. Tyler TX 08/20/03 NF 9 a.m.-4 p.m. 08/21/03 CBA 9 a.m.-3 p.m. Lubbock TX 09/09/03 NF 9 a.m.-4 p.m. 09/10/03 CBA 9 a.m.-3 p.m. Midland TX 09/11/03 NF 9 a.m.-4 p.m. 09/12/03 CBA 9 a.m.-3 p.m. Houston TX 09/15/03 CBA 11 a.m.-5 p.m. 09/16/03 NF 9 a.m.-4 p.m. Lufkin TX 09/17/03 NF 9 a.m.-4 p.m. 09/18/03 CBA 9 a.m.-3 p.m. Fort Worth TX 09/23/03 NF 9 a.m.-4 p.m. 09/24/03 CBA 9 a.m.-3 p.m. Harlingen TX 09/30/03 NF 9 a.m.-4 p.m. 10/01/03 CBA 9 a.m.-3 p.m. Abilene TX 10/14/03 NF 9 a.m.-4 p.m. 10/15/03 CBA 9 a.m.-3 p.m. Address NHIC Big Thicket Riata Vista Circle Austin TX Clardy Fox Branch El Paso Public Library 5515 Robert Alva Avenue El Paso TX Museum of Science Watergarden Room 1900 N. Chaparral Corpus Christi TX McCreless Public Library 1023 Ada Street San Antonio TX Smith Historical Society Payne Auditorium 125 South College Avenue Tyler TX Memorial Civic Center Room th Street Lubbock TX Permian Basin Center Auditorium 105 W Illinois Midland TX Holiday Inn Biltmore Room 7787 Katy Freeway Houston TX Memorial Medical Center Medical Staff Meeting Room 1201 West Frank Avenue Lufkin TX Huguley Memorial Hospital Fitness Center South Freeway Fort Worth TX Valley Baptist Hospital Woodward Conference Center 2101 Pease Street Harlingen TX Regional Medical Center Your Women s Center 1, 2, & Hwy Abilene TX August 2003, No LTC Bulletin

68 Workshop Registration Form NF Date of Workshop: Facility Name: CBA Workshop City: Vendor or Site Number: Number of Attendees: Attendees (last name, first name): Title Fax completed form to People with disabilities or requiring special services are requested to contact NHIC at so that we may make arrangements. Visit us at: National Heritage Insurance Company Nursing Facility Division Riata Vista Circle Austin TX LTC Bulletin 68 68August 2003, No. 15

69 Helpful Hints Keep in mind the following helpful hints: The NHIC LTC Helpdesk operates Monday through Friday, 8 a.m. to 5 p.m. CST (excluding holidays). Call or Select from the following menu options: Option Description 1 Information about LTC claims Information about technical issues regarding 2 TDHconnect Hear LTC banner messages if you are a paper 3 submitter When contacting the LTC Helpdesk, have your nine-digit provider number ready. Claim form 1290 paper submitters: When submitting claims, be sure to correctly enter your nine-digit provider number in box 1 of claim form Send paper claims to the following address: National Heritage Insurance Company Attention: Long Term Care PO Box Austin TX Note: Delivery to NHIC could take three to five business days. Allow seven business days for the claim to appear in the system. Always have your provider number ready when calling the Helpdesk. Send overnight mail to: National Heritage Insurance Company Attention: Long Term Care Riata Vista Circle Austin TX Note: To avoid processing delays when sending overnight mail, make sure to include Attention: Long Term Care. Delivery to NHIC could take an additional day, depending on the time of day mailed. Allow two to three days for the claim to appear in the system. When calling to check the status, have your tracking number ready for the Helpdesk. LTC Web Site LTC has a page on the NHIC Web site at Refer to this site for helpful information on the LTC Program. Reminders Do not forget to: Download your electronic R&S report weekly. R&S reports are available for 30 days only. Use dates from Friday to the following Monday. Make sure you create a financial summary when you create an R&S report. Download banner pages weekly from the LTCBNPG library on the TexMedNet File Libraries page at library. The banners contain important, helpful information. Telephone the NHIC Helpdesk at if you have questions. Pull a MESAV request before contacting the NHIC LTC Helpdesk and requesting client information if your claim rejects. August 2003, No LTC Bulletin

70 Resources for LTC Questions General Table All Providers If you have questions about... HIPAA Cost Reports information (days paid, services paid) How to prepare a Cost Report (forms, instructions) Then contact... hipaa@hhsc.state.tx.us Information can be obtained by doing a Claim Status Inquiry (CSI) using TDHconnect. index.html or call TDMHMR/ICF MR For questions about TDMHMR/ICF-MR, refer to the resources in the following table: If you have questions about Then contact CARE Helpdesk Provider Warrants Applied Income Medicaid Eligibility (ME) worker for client TPR Issues Health and Human Services Commission Network (HHSCN) ICF/MR Helpdesk Issues Medicaid Administration Enrollment/Deductions Provider vendor holds Provider eligibility Provider systems access forms Medicaid Administration Billing Claims Management System billing claim form request Service authorization Client movement 3618 Durable medical equipment (DME) Medicaid Administration UR/UC MR/RC assessment 3650 LOC claim form Level of Service, LON, LOC User documentation LTC Bulletin 70 70August 2003, No. 15

71 DHS Provider Claims Services For questions about Nursing Facilities, Hospice, Swing Beds, and Rehabilitation Specialized Services, refer to the resources in the following table: If you have questions about Client Service Authorization Service dates Units of service approved Service group service code Level of Service TILE changes Medical necessity Provider Authorization System (PAS) Provider enrollment Deductions Monetary penalties Program enrollment staff issues Provider on hold questions Policy Questions/SAVERR/Client Eligibility Applied income changes Client financial eligibility issues Client name changes Regional Staff Issues Contract manager issues ME, CCAD, CBA worker issues not resolved at local/regional level Administrative, clerical, technical staff issues Caseworker/regional nurse issues Hospice Issues TPR Issues and/or Audits Then contact DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail telephone August 2003, No LTC Bulletin

72 DHS LTC For questions about Community Care - CBA - CLASS - Deaf and Blind - Consolidated Waiver - MDCP, refer to the resources in the following table: If you have questions about Client Service Authorization Client not registered Missing/wrong service dates 2060 scores, priority levels Service group/code Wrong copayment amount Missing/wrong client information Claim Form 3652 Medical necessity TILE Diagnoses PAS and DAHS (SG7-SC 17 and SC29) Prior approval questions Physician orders Policy Questions/SAVERR/Client Eligibility Applied income changes Client financial eligibility issues Client name changes Client-Specific Policies/Procedures Financial/functional eligibility criteria How to read/understand form 2101 or form 3671 Provider Policies/Procedures Program rules Rates Enrollment procedures Provider Agencies Contract Contract not registered Clients not registered to contract Missing/wrong budget/rates Contract numbers Missing/wrong service contract information Provider on hold questions Regional Staff Issues Contract manager issues ME, CCAD, CBA worker issues not resolved at local/regional level Administrative, clerical, technical staff issues Caseworker/regional nurse issues Obtaining a copy of LTC claim form 1290 Then contact Caseworker/Case Manager Caseworker/Case Manager Regional Prior Approval Nurse (PAN) DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail Caseworker/Case Manager Contract Manager Contract Manager ausmis31.dhs.state.tx.us/cmsmail DHS telephone fax ausmis31.dhs.state.tx.us/cmsmail Contract Manager The CLASS Program The Consolidated Waiver Program or The Deaf and Blind Program The Medically Dependent Children s Program (MDCP) Status of claim after it has been transmitted to Fiscal by NHIC (When calling Fiscal, provide the DLN number assigned by NHIC) The Comptroller s Web site: or TDHS Fiscal Office telephone or Contract Manager LTC Bulletin 72 72August 2003, No. 15

73 NHIC For questions about NHIC, refer to the resources in the following table: If you have questions about Using TDHconnect or claim form 1290 Claim form 1290 completion Claim form 1290 required fields Claim adjustment questions Claim status inquiries Claim history questions Claim rejection and denials Understanding R&S Research batch tracking TDHconnect Technical Issues Obtain TDHconnect access Modem and telecommunication issues ANSI ASC X12 specification issues ANSI ASC X12 testing and transmission Obtain User ID and passwords Process provider agreements Verify system screens are functioning Assist software developers with Electronic Data Interchange (EDI) and connectivity Banner Messages in Audio Updated monthly Paper submitters Medical Necessity/Client Appeal Additional information for claim form 3652 Client appeal request Appeal/denial process and guidelines General Inquiry General policy about claim forms 3652, 3618, 3619 Denied Purpose E Status of claim form 3652 TILE level Effective dates of forms Electronic transmission of claim forms 3652, 3618, and 3619 Weekly status reports CARE Claim Form Software (CFS) installation Problems with transmitting forms MDS submission or reports General MDS guidelines Interpreting Quality Indicator (QI) reports Then contact Long Term Care Helpdesk (outside Austin) (Austin) Option 1 EDI Technical Helpdesk (outside Austin) (Austin) Option (outside Austin) (Austin) Option 3 Nursing Facility Division Option 1 (Nurses) Nursing Facility Division Option 2 (Customer Service) Nursing Facility Division (electronic claims submission) Option 3 Nursing Facility Division (electronic claims submission) Option 3 August 2003, No LTC Bulletin

74 Your NHIC Training Specialists by Territory The NHIC has a team of training specialists to serve the Texas Medicaid Program provider community. These training specialists conduct educational workshops such as Success with Medicaid and TDHconnect. Feel free to contact the training specialist assigned to your territory to schedule a visit. You can find more information at Territory Regional Area Training Specialist Telephone Number Address 1 Amarillo, Lubbock Toni Emmons toni.emmons@eds.com 2 Abilene, Odessa Christy Mangum christy.mangum@eds.com 3 El Paso Rick Olivas rick.olivas@eds.com 4 San Angelo Bob Perez bob.perez@eds.com 5 San Marcos, Victoria JoAnn Kunde joann.kunde@eds.com 6 Austin, Georgetown Ginny Mahoney ginny.mahoney@eds.com 7 San Antonio, Eagle Pass Jill Ray jill.ray@eds.com 8 Laredo, Harlingen Cynthia Gonzales cynthia.gonzales@eds.com 9 San Antonio, Corpus Christi Jill Ray jill.ray@eds.com 10 Bastrop, Bryan/College Station Kim Laney-Gonzalez kim.laney-gonzalez@eds.com 11 Fort Worth, Wichita Falls Rita Martinez rita.martinez@eds.com 12 Dallas Stephen Hirschfelder stephen.hirschfelder@eds.com 13 Dallas, Arlington Elaine Watson elaine.watson@eds.com 14 Dallas, Tyler Dawn Pearce dawn.pearce@eds.com 15 Beaumont, Nacogdoches John Miller john.d.miller@eds.com 16 Houston Jennifer Vandiver jennifer.vandiver@eds.com 17 Houston, Galveston TBD TBD 18 Houston Linda Wood linda.wood@eds.com 19 Waco Paul Spock paul.spock@eds.com 20 Austin TBD TBD LTC Bulletin 74 74August 2003, No. 15