T exas Medicaid Bulletin

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1 T exas Medicaid Bulletin Bimonthly update to the Texas Medicaid Provider Procedures Manual March/April 2010 No. 228 FDA Authorized Peramivir EAU On October 23, 2009, the U.S. Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for the investigational antiviral drug Peramivir intravenous (IV) in certain adult and pediatric patients who are admitted to a hospital with confirmed or suspected 2009 H1N1 influenza infection. This is in response to a request from the U.S. Centers for Disease Control and Prevention (CDC). IV Peramivir is authorized only for hospitalized adult and pediatric patients for whom therapy with an IV drug is clinically appropriate, based on one or more of the following reasons: The patient is not responding to either oral or inhaled antiviral therapy. Drug delivery by a route other than an IV route e.g., enteral (absorbed by the intestines) or inhaled is not expected to be dependable or feasible. For adults only, when the clinician judges IV therapy is appropriate due to other circumstances. The FDA has reviewed the available scientific data and has concluded that the criteria for authorizing the emergency use of IV Peramivir have been met. There are no FDA-approved intravenously administered antivirals for the treatment of influenza. Peramivir is the only intravenously administered influenza treatment currently authorized for use under EUA for 2009 H1N1 infections. The EUA authority allows the FDA, based on the evaluation of available data, to authorize the use of unapproved or uncleared medical products or unapproved or uncleared uses of approved or cleared medical products following a determination and declaration of emergency, provided certain criteria are met. The authorization will end when the declaration of emergency is terminated or the authorization is revoked by the agency. For more information, refer to the CDC website at or call CDC-INFO ( ). CONTENTS All Providers 1 FDA Authorized Peramivir EAU Scheduled System Maintenance Changes to the Personal Care Services Benefit Non-Specific Patient Education is No Longer a Benefit of Texas Medicaid New Web Page for Medicare/Medicaid Dual-Eligible Claims Subcutaneous Injection Port Device is a Benefit Updated Cardiac Nuclear Imaging Guidelines Available Radio TMHP: Radiology Services Episode Authorization Periods Increased for Private Duty Nursing (CCP) Provider Identifiers Terminated After 24 Months of No Claim Activity Update to Closure of Wounds Services Special Medical Prior Authorization (SMPA) Request Form To Be Required.. 11 Screening, Brief Intervention, and Referral for Treatment Efforts Underway to Increase THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families Extracorporeal Membrane Oxygenation Updates Cardiac Rehabilitation Services are a Benefit Osteopathic Manipulative Treatment Benefits to Change Reimbursement Rates Changed for Durable Medical Equipment Coinsurance and Deductible Reimbursement for Noncontracted MAPs HCPCS Updates Contraceptive Implant System is a Benefit for FQHCs and RHCs Authorization Requests for PET and Cardiac Nuclear Imaging Services Botulinum Toxin Type A (Botox) Benefit Update Revised Provider Enrollment Applications Available Genetic Services Benefit Criteria Changed Updated List of Drugs Requiring NDC for Reimbursement New Online Provider Lookup Enhancements Texas Medicaid Claims Reprocessing Billing and Prior Authorization for Palivizumab (Synagis) FQHC Providers Claims Reprocessing FMAP Rate Increases Hydration Intravenous Infusion Reprocessing of Claims Immunization Procedure Codes Reprocessing PT and OT Claims Reprocessing Surgical Procedure Codes Claims Reprocessing Urinalysis Procedure Code Claims Reprocessing Benefit Update for Obstetrics Services Updates to Previously Published Information Procedure Codes Added During the 2009 HCPCS Update Additional Second and Third Quarter Procedure Code Review Updates. 28 Correction to Cytogenetics Testing 2010 ICD-9-CM Update Update to Home Health Skilled Nursing (SN) Services Benefits Online Fee Lookup and Static Fee Schedule Note Codes Correction Continued on page 2

2 CONTENTS Continued from page 1 Update to Out-of-State Providers Who Perform Services to Migrant Farm Workers Physical, Occupational, and Speech Therapy Benefits to Change for CCP Update Reimbursement Rate Changes for Ambulance Services Correction Correction to Reimbursement Rates for Specific Procedure Codes Will Change THSteps PCS Reimbursement Rates Have Changed Correction Prior Authorization is Required for Surgical Procedure Codes Behavioral Health Providers 32 Documentation Requirement Update for Psychological and Neuropsychological Testing Services Behavioral Health Form Changes Family Planning Providers 33 Reprocessing Claims with WHP Procedure Codes Benefit Changes for Family Planning Titles V and XX Services Correction to Changes to Women s Health Program - Family Planning Benefits and Claims Filing Criteria Using Current Version of the Sterilization Consent Form THSteps Dental Providers 36 Benefit Update for THSteps Preventive Dental Services Dental Sedation Procedures Not Limited to One per Day Dental Comprehensive Evaluation Claims Reprocessing Excluded Providers 37 Forms 37 Provider Information Change Form Electronic Funds Transfer (EFT) Authorization Agreement PCCM Community Health Services Referral Request Form Special Medical Prior Authorization (SMPA) Request Form Outpatient Psychotherapy/Counseling Request Form Psychological/Neuropsychological Testing Request Form Radiology Prior Authorization Request Form The following is an excerpt from the presidential proclamation in response to H1N1 influenza virus that was delivered on October 24, 2009: Accordingly, I hereby declare that the Secretary (of Health and Human Services) may exercise the authority under section 1135 of the SSA to temporarily waive or modify certain requirements of the Medicare, Medicaid, and State Children s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule throughout the duration of the public health emergency declared in response to the 2009 H1N1 influenza pandemic. The full text of the presidential proclamation can be viewed at Contact Information For additional information about Texas Medicaid, call the TMHP Contact Center at For additional information about Primary Care Case Management (PCCM) articles in this bulletin, call the PCCM Provider Helpline at For additional information about articles pertaining to the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP CSHCN Contact Center at Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled as follows: Sunday, March 14, 2010, from 6:00 p.m. until midnight. Sunday, April 11, 2010, from 6:00 p.m. until midnight. During system maintenance, some applications related to the claims engine will be unavailable. Specific details about the affected applications are posted on the TMHP website at Copyright Acknowledgments Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2009 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS restrictions apply. Texas Medicaid Bulletin, No March/April 2010

3 Changes to the Personal Care Services Benefit Eligible Texas Medicaid clients who are enrolled in a waiver program through the Department of Aging and Disability Services (DADS) may also receive personal care services (PCS) as long as the services that are provided through the waiver program do not duplicate PCS. Also, effective January 15, 2010, the U8 modifier for procedure code T1019, which is used by Consumer Directed Services agencies (CDSA) to submit claims for the monthly administrative fee, must be prior authorized. Texas Medicaid clients who are enrolled in the following DADS waiver programs may access the PCS benefit if they meet the eligibility requirements for PCS: Community Living Assistance and Support Services (CLASS) Deaf/Blind Multiple Disabilities (DBMD) Community-Based Alternatives (CBA) Consolidated Waiver Program (CWP) Medically Dependent Children Program (MDCP) Texas Home Living Waiver (TxHmL) Youth Empowerment Services (YES) Home and Community Services (HCS) Important: Clients who receive HCS Residential Support Services, Supervised Living Services, or Foster/Companion Care Services are not eligible to receive attendant care services through the PCS benefit. Effective December 14, 2009, clients who meet the eligibility requirements of more than one program, must choose through which program to receive attendant care. Clients have the following options for how attendant care services are delivered: The client can receive all attendant care services through Texas Medicaid PCS, and receive additional services offered through the waiver program, such as habilitation, respite, therapies, and nursing. If the waiver offers attendant care, the client can decline Texas Medicaid PCS and receive all attendant care services through the waiver program, as well as any additional services offered through the waiver. Under the Consumer Directed Services (CDS) option, clients must choose one CDS agency to provide services through Texas Medicaid PCS and also the waiver program, if the clients are receiving services through both programs. CDSAs are permitted to file the Financial Management Services (FMS) fee, also known as the monthly administrative fee, through one program. The CDSA should file the FMS claim through the program with the highest reimbursement rate. Currently, the waiver programs have a higher reimbursement rate for the FMS fee than the Texas Medicaid PCS benefit, so CDSA should file claims for the monthly FMS fee through the waiver programs. Effective January 15, 2010, the U8 modifier for PCS, which is used when submitting claims for the monthly administrative fee, must be prior authorized. This will affect only authorizations granted on or after January 15, 2010, for clients who are using the CDS option. The Department of State Health Services (DSHS) case managers will have two options when sending a prior authorization request for PCS to TMHP. If a client is using the CDS option for Texas Medicaid PCS only, the case managers will submit a prior authorization request to TMHP approving either the U7 or UB modifier as well as the U8 modifier. In this case the provider authorization notification letter will include the U8 modifier, in addition to the U7 or UB modifier. If a client is using the CDS option for both Texas Medicaid PCS and a waiver program, the case managers will submit a prior authorization request to TMHP approving either the U7 or UB modifier. The U8 modifier will not be prior authorized in this situation. When a provider authorization notification letter is received by a CDSA, the provider should verify that the correct modifier(s) has been prior authorized for each March/April Texas Medicaid Bulletin, No. 228

4 The provider should verify that the correct modifier has been prior authorized for each PCS client. PCS client. Providers that think the approved modifiers are incorrect should contact the DSHS case manager and ask for the correct modifiers to be submitted to TMHP for prior authorization. Claims for Texas Medicaid PCS must be billed using procedure code T1019 and the appropriate modifier. The following table provides the modifiers that may be authorized for PCS clients and a description of each modifier: Modifier Provider Type Description U6 U7 U8 UA UB All PCS providers (except CDSA) CDSA under the CDS option CDSA under the CDS option All PCS providers (except CDSA) CDSA under the CDS option Attendant fee each 15 minutes Attendant fee each 15 minutes Administrative fee once a month (U8 will not be authorized if the client is using the CDS option for PCS and for services through a waiver program) Behavioral enhanced rate attendant fee each 15 minutes Behavioral enhanced rate attendant fee each 15 minutes Non-Specific Patient Education is No Longer a Benefit of Texas Medicaid Effective February 1, 2010, procedure code S9445 is no longer a benefit of Texas Medicaid for medical services. Providers should refer to the Current Procedural Terminology (CPT) Code book for a more specific procedure code. New Web Page for Medicare/ Medicaid Dual-Eligible Claims TMHP has noted that some providers are submitting claims for Medicare dualeligible clients incorrectly, which is causing a high number of claim denials and delaying reimbursement. To help providers file Medicare claims correctly, TMHP has added a web page to the TMHP website at The web page includes links to the forms needed to submit claims for Medicare (Parts A and B) and Medicare Advantage Plan (MAP) (Medicare Part C) claims. The web page also includes instructions for completing the forms and a link to the list of the MAP providers that are contracted with HHSC. Medicare Crossover Claims Must Use Approved MRAN and Appropriate Paper Claim Form Reminder: Providers that submit paper Medicare crossover claims to TMHP must use an approved Medicare Remittance Advice Notice (MRAN) and the appropriate paper claim form or claims will be denied. The following are approved MRANs: Paper MRANs from Medicare or a Medicare intermediary. MRANs from the Centers for Medicare & Medicaid Services (CMS)-approved software Medicare Remit Easy Print (MREP) for professional services or PC- Print for institutional services. TMHP Standardized MRAN Form. MRANs must be submitted with a completed claim form, must be legible, and must identify only one client per page. Providers must not submit handwritten MRANS. Claims that do not meet these standards will not be processed and will be returned to the provider. Providers must submit the appropriate paper claim form with the MRAN form: CMS-1500 paper claim form for professional services UB-04 CMS-1450 paper claim form for institutional services Crossover claims that are submitted with the wrong paper claim form will be denied. Texas Medicaid Bulletin, No March/April 2010

5 Subcutaneous Injection Port Device is a Benefit Effective November 25, 2009, for dates of service on or after October 1, 2009, the subcutaneous injection port device is a benefit of Texas Medicaid. A subcutaneous injection port is a sterile medication delivery device through which physician-prescribed medications can be injected directly into the subcutaneous tissue using a standard syringe and needle, an injection pen, or other manual injection device. The device can be used for multiple subcutaneous injections for a period of up to 72 hours, thereby avoiding repeated needle punctures of the skin. The device cannot be used with an injection pump. A subcutaneous injection port, such as the I-Port or Insuflon, is a benefit of Texas Medicaid as a Title XIX Home Health service with prior authorization. Procedure code A4211 submitted with modifier U4 may be reimbursed for subcutaneous injection ports at the rate of $9.75. Texas Medicaid may reimburse the device for clients who require multiple daily injections of a physicianprescribed medication and who meet the criteria outlined in this article. The subcutaneous injection port is not a benefit of Texas Medicaid as an item of convenience or for clients already receiving the medication through an ambulatory infusion pump. The device is considered an item of convenience if the client does not meet the criteria for medical necessity that are outlined in this article. Authorization Requirements Prior authorization is required for a subcutaneous injection port. The initial request for prior authorization must include documentation that indicates the client meets the following criteria for medical necessity: The client has a medical condition that requires multiple (i.e., two or more) subcutaneous, selfadministered injections on a daily basis and has a current prescription for the injectable medication. Documentation must indicate the specific medical condition that is being treated, the name of the injectable medication, and the dosage and frequency of the injections. Note: Self-administered includes those injections administered by the client through a subcutaneous injection or by the caregiver to the client through a subcutaneous injection. The client or the caregiver has been unsuccessful with the self-administration of injections using a standard needle and syringe because the client demonstrates trypanophobia (i.e., severe needle phobia), as evidenced by documented physical or psychological symptoms. Documented symptoms may include, but are not limited to, the following: Vaso-vagal trypanophobia Physical symptoms such as changes in blood pressure, syncope, sweating, nausea, pallor, and tinnitus. Associate trypanophobia Psychological symptoms such as extreme anxiety, insomnia, and panic attacks. Resistive trypanophobia Signs and symptoms such as combativeness, elevated heart rate, high blood pressure, and violent resistance to procedures involving needles or injections. The prescribing physician must include with the prior authorization request a written statement of medical necessity that identifies the client as an appropriate candidate for the subcutaneous injection port device. The physician s statement or medical record documentation that is submitted with the prior authorization request must indicate the following: The client or caregiver has received instruction during an office visit on the proper placement and use of the device, with successful return demonstration. (Prior authorization requests for skilled nursing visits for the sole purpose of client instruction on the use of the subcutaneous injection port device will not be approved. Necessary instruction must be performed as part of the office visit with the prescribing physician.) The client has no known allergies or sensitivities to adhesives, silicone, or similar materials. The client has no skin infection at potential injection sites. The client s most recent lab results related to the medical condition requiring treatment with daily subcutaneous injections must also be submitted with the prior authorization request. Lab results may include, but are not limited to, hemoglobin A1c (HbA1c) levels for clients with insulin dependent diabetes mellitus (IDDM) and partial thromboplastin time (PTT) for clients receiving anticoagulant therapy. To request prior authorization for DME or supplies, providers must submit a completed Home Health Services March/April Texas Medicaid Bulletin, No. 228

6 (Title XIX) Durable Medical Equipment (DME)/ Medical Supplies Physician Order Form that has been signed and dated by a physician who is familiar with the client. All signatures and dates must be current, unaltered, original, and handwritten. Computerized or stamped signatures or dates will not be accepted. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form must include the procedure codes and quantities for services requested. Copies of the completed, signed, and dated form must be maintained by the DME provider and the prescribing physician in the client s medical record. The form with the original dated signature must be maintained by the prescribing physician. Requests for prior authorization must be submitted to the Home Health Services Department through the TMHP website or by telephone, fax, or mail at: Texas Medicaid & Healthcare Partnership Home Health Services PO Box Austin, TX Telephone: Fax: To submit the authorization request through the TMHP website, providers may access and click Submit a Prior Authorization under the I would like to section of the homepage. Note: For clients who are 20 years of age or younger and who do not meet the criteria for coverage by Title XIX Home Health, the device may be considered through the Texas Health Steps-Comprehensive Care Program (THSteps- CCP). Requests for prior authorization must be submitted to the CCP Department through the TMHP website or by telephone, fax, or mail at: Texas Medicaid & Healthcare Partnership Comprehensive Care Program (CCP) PO Box Austin, TX Telephone: Fax: Initial prior authorizations will be issued for a trial period of up to three months. Requests for the renewal of the prior authorization after the initial trial period has ended must include documentation of the following: Ongoing signs and symptoms associated with the client s trypanophobia. Improved compliance with the physician-prescribed injection regimen. Successful use of the device with no persistent pattern of the client s dislodging the device during the initial trial period. Results of relevant lab tests performed upon completion of the initial trial period, including, but not limited to, HbA1c levels for clients with IDDM and PTT for clients who are receiving anticoagulant therapy. Note: For clients with IDDM, if the HbA1c level has not declined with use of the subcutaneous injection port, additional documentation must be submitted by the physician who documents the clinical determination about the lack of significant improvement in the HbA1c level. The renewal of the prior authorization will not be approved without this information. Prior authorizations that are issued after the successful completion of the initial trial period may be issued for a period of up to six months. Prior authorizations for subcutaneous injection ports are limited to a quantity of ten individual ports per month. Additional ports will be considered for prior authorization with documentation of medical necessity. To facilitate determination of medical necessity and to avoid unnecessary denials, the physician must provide correct and complete information, including documentation of medical necessity for the equipment or supplies that are being requested. The physician must maintain documentation of medical necessity in the client s medical record. The requesting provider may be asked for additional information to clarify or complete the request. Retrospective review may be performed to ensure that the documentation in the client s medical record supports the medical necessity of the subcutaneous injection port. For more information about Title XIX Home Health services, providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, section , Durable Medical Equipment (DME) and Supplies, on page Claims Reprocessing Claims submitted with subcutaneous injection port procedure codes with dates of service from October 1, 2009, to November 24, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Texas Medicaid Bulletin, No March/April 2010

7 Updated Cardiac Nuclear Imaging Guidelines Available Effective for dates of service on or after February 1, 2010, cardiac nuclear imaging procedures require prior authorization by MedSolutions, Inc., which performs radiology authorization services on behalf of TMHP. MedSolutions has updated the Clinical Decision Support Tool for Advanced Imaging Guide to expand the guidelines for cardiac nuclear imaging prior authorizations to address non-imaging heart function and cardiac shunt imaging. A PDF version of the Cardiac Imaging Guidelines published by MedSolutions, is available on the TMHP website at These clinical guidelines are available to providers to facilitate the identification of the most appropriate imaging procedure for the patient s clinical condition. In addition to cardiac nuclear imaging procedures, the guidelines cover imaging studies that include, but are not limited to, computed tomography (CT), computed tomography angiography (CTA), magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and positron emission tomography (PET) imaging. Imaging guidelines are available for head, neck, chest, cardiac, peripheral vascular disease, abdomen, pelvis, musculoskeletal, spine, peripheral nerve disorders, and oncology. Imaging guidelines for the pediatric population follow those of adults unless specific pediatric guidelines are highlighted. The guidelines are based on the following: American College of Radiology (ACR) Appropriateness Criteria. The National Comprehensive Cancer Network (NCCN) Clinical Guidelines in Oncology. Evidence-based clinical data to the extent available. Consensus statements from specialty societies such as the American College of Cardiology, the American Heart Association, the American Academy of Neurology, the Institute for Clinical Systems Improvement, and the American Academy of Orthopedic Surgeons. Published literature in peer-reviewed journals. Input from health plans. Input from practicing clinicians from academic institutions as well as community-based physicians. For more information about radiology prior authorization requests, providers may refer to the TMHP Providers Radiology Prior Authorization Services web page on the TMHP website, and the 2009 Texas Medicaid Provider Procedures Manual section 5.1.3, Online Radiology Prior Authorizations, on page 5-7, and section , CT, CTA, MRI, and MRA, on pages Radio TMHP: Radiology Services Episode Beginning December 18, 2009, TMHP Radio which is available on the TMHP website at began featuring a frequentlyasked-question (FAQ) segment that provides details about the transition of prior authorization for positron emission tomography (PET) scans and the new requirement for cardiac nuclear imaging. The transtition and new requirement affects services rendered to clients who are enrolled as fee-for-service or Primary Care Case Management (PCCM) clients. The changes do not affect services rendered to Children with Special Health Care Needs (CSHCN) Services Program clients or clients enrolled with managed care organizations (MCOs). For more information and announcements about the transition, providers can access Radio TMHP on the TMHP website by clicking on the Radio TMHP link. Radio TMHP focuses on healthcare industry topics, which include changes in the policies and procedures of Texas state health-care programs. March/April Texas Medicaid Bulletin, No. 228

8 Authorization Periods Increased for Private Duty Nursing (CCP) Private duty nursing (PDN) is a benefit only when services are provided by a registered nurse (RN) or a licensed vocational nurse (LVN). A qualified aide, working under the supervision of an RN, cannot provide or be reimbursed for PDN services. Effective January 1, 2010, the prior authorization period for initial PDN requests increased from 60 days to 90 days. Recertifications are authorized for a period up to six months. The following criteria must be met for consideration of a six month recertification request: The client must have received PDN services for at least three months. No significant changes have occurred in the client s condition for at least three months. No significant changes in the client s condition are anticipated. The client s parent or guardian, physician, and provider agree the recertification is appropriate. A request for a client that does not satisfy the criteria listed above for a six month authorization may be authorized for a period of time less than six months. When requesting a recertification, the provider is responsible for ensuring that the physician reviews and signs the plan of care (POC) within 30 calendar days of the expiration of the authorization period. A revision request for a client that does not meet the criteria for a 6-month authorization may be authorized for a period of up to 3 months. The provider is responsible for ensuring that the physician reviews and signs POC within 30 calendar days of the start date of the revised authorization period, or more often if required by the client s condition or agency licensure. PDN providers should not submit a revised POC unless they are requesting a revision. The provider must maintain all physician-signed POCs in the client s record. Provider Identifiers Terminated After 24 Months of No Claim Activity Beginning April 26, 2010, payment denial codes will be applied to a Texas Provider Identifier (TPI) that has had no claim activity for a period of 24 months or greater. The TPI will be considered inactive and cannot be used to submit claims. A courtesy letter will be sent to all providers whose TPIs have been identified as not having any claims activity over the previous 18 months. Providers will have six months to submit claims and prevent the TPI from being terminated. If a provider is enrolled in both Medicaid and the CSHCN Services Program, the provider identifiers for both programs will be examined to determine whether any claims activity has occurred. After 24 months without claim activity, providers will be sent a termination letter, and a payment denial code will be applied to the provider identifier. If a provider s Medicaid TPI is terminated, any enrollments with the PCCM Program or the CSHCN Services Program will also be terminated. Claims that are submitted for a terminated TPI after the payment denial code has been applied will be denied. To have the payment denial code removed from a provider identifier, providers must submit a completed application for the state health-care program in which they wish to enroll, and the application must be approved. The information on this application must match exactly the information currently on the provider s file for the payment denial code to be removed. In addition to claims received by the Texas Medicaid & Healthcare Partnership (TMHP), claim activity for providers enrolled in Texas Medicaid MCOs will also be monitored. Claims inactivity with the MCOs will result in termination of the provider s agreement with Texas Medicaid. Texas Medicaid Bulletin, No March/April 2010

9 Update to Closure of Wounds Services Effective November 25, 2009, for dates of service on or after October 1, 2009, benefit criteria for closure of wounds have changed for Texas Medicaid. Wound closure procedure codes are restricted to wounds closed with sutures, staples, or tissue adhesives. Wounds closed with adhesive strips must not be reported using wound closure procedure codes. When adhesive strips are the only wound closure material used, providers must report the most appropriate E/M visit procedure code on their claim. Wound debridement rendered during the same surgical session as a wound closure is considered inclusive to the closure and is not reimbursed separately. Wound debridement may be reimbursed separately when the procedure meets at least one of the following criteria: It is provided without immediate primary closure. Gross contamination requires prolonged cleansing. Large amounts of devitalized or contaminated tissue are removed. Simple exploration of nerves, blood vessels, or tendons exposed in an open wound is considered inclusive to the wound closure and will not be reimbursed separately. The lengths of multiple closures of wounds must be added together and billed as one procedure code if they meet at least one of the following criteria: The closures have the same Current Procedural Terminology (CPT) classification (see Repair [Closure] in the CPT manual). The closures are in anatomic sites that are grouped together in the same procedure code descriptor. Providers must submit the procedure code which represents the total length of the repairs. Lengths of repairs from different CPT classifications or groupings of anatomic sites must be billed as separate procedure codes. Multiple wounds on the same day will be reimbursed the full allowed amount for the major wound (largest total length of the repair at the same anatomic site) and onehalf the allowed amount for each additional laceration (total length of the repair at the same anatomic site). No separate payment will be made for incision closures billed in addition to a surgical procedure when the closure is part of that surgical procedure. No separate payment will be made for supplies in the office. Limitations Procedure codes and may be reimbursed to podiatrists and podiatry groups for surgery in the office, inpatient hospital, and outpatient hospital setting. Procedure codes 12051, 12052, and may be reimbursed to freestanding ambulatory surgical centers (ASCs) and hospital-based ambulatory surgical centers (HASCs) in the outpatient hospital setting. Procedure codes 12051, 12052, and will be reimbursed under ASC Group 1. In the following table the procedure codes in Column A will be denied when submitted for the same date of service by the same provider as any of the corresponding procedure codes in Column B: Column A Procedure Codes Column B Procedure Codes , 11010, 11011, 11012, or , 13101, 13120, 13121, 13131, 13132, 13150, 13151, 13152, or or or , 12013, 12051, 12052, 12053, or or , 12002, 12004, 12005, 12032, 12042, 12044, 13100, 13101, 13120, 13121, 13131, 13132, 13150, 13151, 13152, or , 12020, 12031, or , 12002, 12004, 12005, 12006, 12011, 12013, 12015, 12020, 12031, 12032, 12034, 12035, 12042, 12051, 12052, 12054, 13100, 13101, 13120, 13121, 13131, 13132, 13150, 13151, 13152, , 12034, 12035, 12036, 12037, 12044, 12046, 13100, 13101, 13120, 13121, 13131, 13132, 13150, 13151, 13152, or or or March/April Texas Medicaid Bulletin, No. 228

10 Column A Procedure Codes Column B Procedure Codes , 12037, 12044, or or or , 11056, 11719, or or , 11900, or , 13122, 13133, or , 11900, 11901, 36000, 36410, 37202, 51701, 51702, 51703, 62318, 62319, 64415, 64416, 64417, 64450, 64470, or , 12002, 12004, 12005, 12006, 12007, 12011, 12013, 12014, 12015, 12016, 12017, 12018, 12020, 12021, 12031, 12032, 12034, 12035, 12036, 12037, 12041, 12042, 12044, 12045, 12046, 12047, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13100, 13101, 13120, 13121, 13131, 13132, 13150, 13151, 13152, or , 12002, 12041, or , 12004, 12005, 12006, or , 12005, 12006, or or or , 12014, 12015, 12016, or , 12013, 12014, , or , 12015, 12016, or , 12016, or or or or , 12035, 12036, or , 12036, or or Column A Procedure Codes Column B Procedure Codes , 12044, 12045, 12046, or , 12045, 12046, or , 12046, or or , 12053, 12054, 12055, 12056, or , 12054, 12055, 12056, or , 12055, 12056, or , 12056, or or or or In the following table, which applies only to ASCs, the procedure codes in column A will be denied when submitted for the same date of service by the same provider as any of the corresponding procedure codes in Column B: Column A Procedure Codes 11042, 11043, 11100, 62318, 62319, 64415, 64416, 64417, 64470, or Column B Procedure Codes 12005, 12006, 12007, 12016, 12017, 12018, 12020, 12021, 12031, 12032, 12034, 12035, 12036, 12037, 12041, 12042, 12044, 12045, 12046, 12047, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13100, 13101, 13120, 13121, 13131, 13132, 13150, 13151, 13152, Texas Medicaid Bulletin, No March/April 2010

11 Column A Procedure Codes Column B Procedure Codes , 13122, 13133, or or or or or , 12035, or , 12032, 12034, , or or or , 12042, or or , 12042, 12044, , or or , 12052, or , 12055, or , 12052, 12053, , 12055, or or Column A Procedure Codes Column B Procedure Codes or or In the following table the procedure codes in Column A must be billed with the corresponding procedure codes in Column B to be considered for reimbursement: Column A Procedure Codes Column B Procedure Codes Claims Reprocessing Claims submitted with suture of wound procedure codes with dates of service between October 1, 2009, and November 24, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Special Medical Prior Authorization (SMPA) Request Form To Be Required Effective May 1, 2010, providers must use the new Special Medical Prior Authorization (SMPA) Request Form for all prior authorization requests submitted to the TMHP-SMPA department. After April 30, 2010, provider authorization requests that are submitted without the Special Medical Prior Authorization (SMPA) Request Form will not be processed and will be returned to the provider. In addition to the completed form, providers may fax additional clinical information to the TMHP- SMPA department if there is insufficient space in section C of the form. The Special Medical Prior Authorization (SMPA) Request Form is available on page 44 of this bulletin and on the TMHP website at March/April Texas Medicaid Bulletin, No. 228

12 Screening, Brief Intervention, and Referral for Treatment Effective November 25, 2009, for dates of service on or after October 1, 2009, screening, brief intervention, and referral to treatment (SBIRT) is a benefit of Texas Medicaid. SBIRT is a comprehensive, public health approach to the delivery of early intervention and treatment services for clients with substance use disorders and those at risk of developing such disorders. Substance abuse includes, but is not limited to, the abuse of alcohol and the abuse of, improper use of, or dependency on illegal or legal drugs. SBIRT is used for intervention directed to individual clients and not for group intervention. SBIRT is targeted to clients who are from 14 years of age through 20 years of age and who present to the hospital emergency department for a traumatic injury, condition, or accident related to substance abuse. SBIRT may also be medically necessary for clients who are from 10 years of age through 13 years of age. SBIRT may be submitted for reimbursement using procedure code H0050. The first SBIRT session, including screening and brief intervention, must be billed by the hospital using an appropriate revenue code and procedure code H0050. Brief treatment is performed during the second, third, and fourth sessions, outside of the hospital. The second, third, and fourth sessions cannot be billed if they were not referred from the hospital. Additional services, outside the four sessions, will not be provided as SBIRT. Screening Screening identifies clients with problems related to substance use. This component must be performed during the first session in the hospital emergency department or inpatient setting but will not be separately reimbursed. Screening may be completed through interview and self-report, blood alcohol content (BAC), toxicology screen, or by using a standardized tool. Standardized tools that may be used include, but are not limited to, the following: Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) Drug Abuse Screening Test (DAST) Alcohol Use Disorders Identification Test (AUDIT) Cut-down, Annoyed, Guilty, Eye-opener (CAGE ) questionnaire Car, Relax, Alone, Forget, Family or Friends, Trouble (CRAFFT) questionnaire Binge drinking questionnaire Brief Intervention Brief intervention is performed during the first session, following a positive screen or a finding of at least moderate risk for substance abuse. A brief intervention is a motivational discussion focused on raising the client s awareness of his or her substance abuse and its consequences. The brief intervention is intended to motivate the client toward behavioral change. If the client is currently under the care of a behavioral health provider, the client must be referred to that provider. Brief Treatment A client found to have a moderate-to-high risk for substance abuse should be referred for brief treatment. Brief treatment is performed during the second, third, and fourth sessions, outside of the hospital emergency department or inpatient setting. Brief treatment, although it includes a motivational discussion and client empowerment, is a more comprehensive intervention than the first session. Brief treatment includes assessment, education, problem solving, coping mechanisms, building a supportive social environment, goal setting, and a plan of action. Procedure code H0050 will be eligible for reimbursement to the following provider types for the second, third, and fourth sessions: NP CNS PA Licensed professional counselor (LPC) Social worker enrolled in the CCP Physician and physician group Psychologist and psychologist group Licensed clinical social worker (LCSW) Referral to Treatment If the provider determines that the client is in need of more extensive treatment or has a severe risk for substance abuse, the client must be referred to an appropriate chemical dependency treatment center or outpatient behavioral health provider. Texas Medicaid Bulletin, No March/April 2010

13 Referral to more extensive treatment is a proactive process that facilitates access to care for clients who require a more extensive level of service than SBIRT provides. Referral is an essential component of the SBIRT intervention because referral ensures that all clients who are screened have access to the appropriate level of care. Referral to more extensive treatment must be integrated during the second, third, and fourth SBIRT sessions, if necessary, unless the client s condition changes. Referral to more extensive treatment may also occur during the first session. Providers must refer the client to more extensive treatment as soon as the need is determined. Reimbursement and Limitations SBIRT is limited to clients who are from 10 years of age through 20 years of age. SBIRT is limited to a maximum of 3 dates of service following the first session, per calendar year, by any provider. If a client requires more than 3 dates of services per year, the client must be referred for chemical dependency treatment. Procedure code H0050 must be submitted in 15-minute increments, with a maximum of 3 units (45 minutes) per date of service by any provider. Procedure code H0050 will be denied if it is billed for the same date of service, by the same provider, as any of the following procedure codes: Procedure Codes H0004 H0005 M0064 The reimbursement rate for procedure code H0050 is $26.93 per 15 minutes. Claims submitted with procedure code H0050 for dates of service from October 1, 2009, through November 24, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Documentation Requirements Client record documentation must support medical necessity for the services provided and must be maintained and made readily available for review when requested by the Health and Human Services Commission (HHSC) or its designee. SBIRT documentation must include the following: An indication that the client has an alcohol- or drugrelated traumatic injury or condition Positive screening by a standardized substance-abuse screening tool Laboratory results, such as BAC, toxicology screen, or other measures, that show at least a moderate risk for substance abuse If a referral is made, the name, address, and telephone number of the provider to whom the client was referred A written, client-centered plan for the delivery of medically necessary SBIRT. The plan must be completed at the time the client is admitted to the second session (referral). The plan must include the following: Real-life goals expected Strategies to achieve the goals Support system such as family members, a legal guardian, friends, or anyone the client identifies as important to them A mechanism for following up with the client to ensure that the client keeps appointments for additional sessions The provider who performed the screening must document that a follow-up appointment was made for a subsequent session. If inappropriate payments are identified on retrospective review for any provider, the payments will be recouped. March/April Texas Medicaid Bulletin, No. 228

14 Efforts Underway to Increase THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families TMHP is working closely with HHSC to educate migrant farm workers and their children about services covered by Medicaid and the importance of receiving timely Texas Health Steps (THSteps) medical and dental checkups. The children of migrant farm workers were identified as needing additional assistance because of unconventional living conditions, migratory work patterns, unhealthy working conditions, poverty, poor nutrition, lack of education, and illiteracy all factors that contribute to poor health. Efforts are underway to increase the number of children who receive their THSteps medical and dental checkups on time. Exceptions to the periodicity schedule are offered to allow children to receive their THSteps medical and dental checkups before their families migrate to another area for work. THSteps providers are required to bill claims as an exception to periodicity when the visit is outside of the periodicity schedule because of extenuating circumstances. For more information on billing an exception-to-periodicity checkup, providers can refer to the 2009 Texas Medicaid Provider Procedures Manual, section on page 43-9 and section on page Providers can refer their PCCM clients and migrant families to PCCM Community Health Services coordinators for assistance by faxing the PCCM Community Health Services Referral Request Form, which is available on page 43 of this bulletin, on the TMHP website at and on page B-73 in the 2009 Texas Medicaid Provider Procedure Manual, or by calling For more information on community health services, providers can refer to 2009 Texas Medicaid Provider Procedure Manual, section on page PCCM Community Health Services coordinators have begun an initiative to identify and provide outreach to the children of the migrant farm worker population in south Texas. Migrant families are educated on the availability of accelerated services for their children s THSteps medical and dental checkups. Coordinators also educate migrant families on all available PCCM benefits and services as well as confirming that families have an established primary care provider. In addition, TMHP is continuing to partner and build relationships with state and community agencies, independent school districts, migrant licensed-housing facilities, Regional Education Service Centers, and local business to identify and reach out to PCCM clients who are birth through 20 years of age in migrant farm families. Extracorporeal Membrane Oxygenation Updates Effective for dates of service on or after December 1, 2009, some provider type and place-of-service (POS) limitations have changed for extracorporeal membrane oxygenation procedure codes. Procedure code is a benefit as assistant surgery and may be reimbursed to nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), and physician providers in the inpatient hospital setting. Procedure code may be reimbursed once per day. Procedure code will be denied if billed with the same date of service as procedure code Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, section , Extracorporeal Membrane Oxygenation (ECMO), on page 36-37, for more information. Texas Medicaid Bulletin, No March/April 2010

15 Cardiac Rehabilitation Services are a Benefit Effective November 25, 2009, for dates of service on or after October 1, 2009, cardiac rehabilitation services are a benefit of Texas Medicaid. Coverage of cardiac rehabilitation programs is considered reasonable and necessary only for clients for whom there is documentation of any of the following conditions within the 12 months immediately preceding the beginning of the program: Acute myocardial infarction Coronary artery bypass surgery Percutaneous transluminal coronary angioplasty or coronary stenting Heart valve repair or replacement Major pulmonary surgery Sustained ventricular tachycardia or fibrillation Class III or class IV congestive heart failure Chronic stable angina Note: A cardiac rehabilitation program that includes remote cardiac monitoring using telephonically transmitted electrocardiograms (ECGs) is not a benefit of Texas Medicaid. Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use. A cardiac rehabilitation program has three phases: inpatient, outpatient, and maintenance. Phase I: Inpatient. Cardiac rehabilitation is performed in the inpatient hospital setting following a cardiac event. This phase of cardiac rehabilitation is considered part of the hospital stay and is included in the inpatient hospital reimbursement. Phase II: Outpatient. The outpatient phase begins after the client has been discharged from the hospital. A physician s prescription is required after the acute convalescent period and after the physician has determined that the client s clinical status and capacity allows for safe participation in an individualized progressive exercise program. Phase II requires close monitoring and direct supervision by a physician (i.e., the physician is on the hospital premises or within 250 yards of the hospital) and includes the following: - Medical evaluation that is performed by the physician who prescribed the client s rehabilitation program. (The medical evaluation includes a clinical examination, a medical history, and an initial plan or goal.) Program to modify risk factors including, but not limited to, nutritional counseling, stress reduction, smoking cessation, and weight loss. Prescribed exercise with and without ECG monitoring. Education and counseling. Services that are performed in an approved facility by trained professionals. Phase III: Maintenance. Maintenance is designed by a medical professional to be performed in absence of supervision and monitoring on an on-going basis. Texas Medicaid does not reimburse providers for the maintenance phase. Cardiac rehabilitation is limited to two or three sessions per week for 12 to 18 weeks per rolling year, not to exceed 36 sessions. Cardiac rehabilitation may be considered medically necessary beyond 36 sessions if the client has another documented cardiac event or if the prescribing physician documents that a continuation of cardiac rehabilitation is medically necessary. To confirm that a continuation of cardiac rehabilitation is at the request of, or is coordinated with the attending physician, the medical record must include evidence of communication between the cardiac rehabilitation staff and either the medical director or the referring physician. If the physician responsible for such followup is the medical director, then the physician s notes must be evident in each client s chart. Additional cardiac rehabilitation sessions must be prior authorized and must not exceed a total of 72 sessions for 36 weeks. If no clinically-significant arrhythmia is documented during the first three weeks of the program, the physician may give the order for the client to complete the remaining portion of the cardiac rehabilitation without telemetry monitoring. Although cardiac rehabilitation may be considered a form of physical therapy, it is a specialized program that is conducted by personnel who are not physicians, but are trained in both basic and advanced cardiac life support techniques and exercise therapy for coronary disease and who provide the services under the direct supervision of a physician. March/April Texas Medicaid Bulletin, No. 228

16 Benefits and Limitations Cardiac rehabilitation procedure codes and may be reimbursed when submitted by physicians in the outpatient hospital setting. Procedure code S9472 may be reimbursed when submitted by hospitals in the outpatient hospital setting. Procedure code S9472 must be billed by the facility in conjunction with revenue code 943. The appropriate procedure code must be billed with one of the following diagnosis codes: Diagnosis Codes V151 V421 V422 V433 V4581 V4582 The evaluation that is provided at the beginning of each cardiac rehabilitation session is not considered a separate service and will be included in the reimbursement for the cardiac rehabilitation session. E/M services unrelated to cardiac rehabilitation may be billed with modifier 25 appended to the E/M code when supporting documentation demonstrates a separately identifiable E/M service was provided on the same day by the provider that rendered cardiac rehabilitation. Physical and occupational therapy will not be reimbursed when furnished in addition to cardiac rehabilitation exercise program services unless there is also a diagnosis of a noncardiac condition that requires such therapy, e.g., a client who is recuperating from an acute phase of heart disease has a stroke that requires physical or occupational therapy. Client education services, such as formal lectures and counseling on diet, nutrition, and sexual activity, that help a client adjust living habits because of the cardiac condition, will not be separately reimbursed when the services are provided as part of the cardiac rehabilitation program. Hospitals that provide cardiac rehabilitation must submit claims that include both revenue code 943 and procedure code S9472. Only procedure code S9472 will be eligible for reimbursement. When procedure code is submitted for reimbursement by any provider with the same date of service as procedure code 93798, procedure code will be denied as part of another service. The following cardiography and pulmonary procedure codes will be denied if they are submitted for reimbursement by any provider with the same date of service as cardiac rehabilitation procedure code 93798: Procedure Codes Authorization Requirements Prior authorization is not required for the initial 36 sessions of cardiac rehabilitation. Cardiac rehabilitation may be considered medically necessary beyond 36 sessions if the documentation in the medical record supports that the client has had another cardiac event or if the prescribing physician documents that a continuation of cardiac rehabilitation is medically necessary. Medical necessity may be determined by any of the following: Progress made from the beginning of the cardiac rehabilitation period to the current service request date, including progress towards previous goals Information that supports the client s capability of continued measurable progress A proposed treatment plan for the requested extension dates with specific goals related to the client s individual needs Requests for prior authorization for additional sessions that exceed a total of 72 sessions in 36 weeks will not be granted. Prior authorization must be obtained through the TMHP SMPA department. Authorizations may be submitted online to by fax at , or by mailing to the following address: Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization Department B Riata Trace Parkway, Suite 150 Austin TX Providers may use the form of their choice to submit the required information to the SMPA department. Claims Reprocessing Claims that were submitted with cardiac rehabilitation services procedure codes and dates of service from October 1, 2009, to November 24, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Texas Medicaid Bulletin, No March/April 2010

17 Osteopathic Manipulative Treatment Benefits to Change Effective for dates of service on or after January 1, 2010, benefit criteria for osteopathic manipulative treatment (OMT) have changed for Texas Medicaid. OMT is a covered service when it is performed with the expectation of restoring the patient s level of function, which has been lost or reduced by injury or illness. Manipulations should be provided in accordance with an ongoing, written treatment plan that supports medical necessity. A model of documentation that supports medical necessity for the treatment plan includes the following: Specific modalities/procedures to be used in treatment Diagnosis Region treated Degree of severity Impairment characteristics Physical examination findings (X-ray or other pertinent findings) Specific statements of long- and short-term goals Reasonable estimate of when the goals will be reached (estimated duration of treatment) Frequency of treatment (number of times per week) Equipment and techniques used The treatment plan must be updated as the client s condition changes. Treatment plans must be maintained in the medical records and are subject to retrospective review. The acute modifier AT must be submitted with the claim. Paper claims submitted without modifier AT will be denied; electronic claims will be rejected. The AT modifier is described as representing treatment provided for an acute condition, or an exacerbation of a chronic condition, which persists less than 180 days from the start date of therapy. If the condition persists for more than 180 days from the start of therapy, the condition is considered chronic, and treatment is no longer considered acute. Providers may file an appeal for claims denied as being beyond the 180 days of therapy with supporting documentation that the client s condition has not become chronic and the client has not reached the point of plateauing. Plateauing is defined as the point at which maximal improvement has been documented and further improvement ceases. The following limitations apply to procedure codes 98925, 98926, 98927, 98928, and 98929: These procedure codes are limited to one per day for each client, by any provider. These procedure codes will be denied when billed on the same day by the same provider as any of the following procedure codes: Procedure Codes The following limitations apply to evaluation and management (E/M) procedure codes when billed with OMT: Providers must submit modifier 25 with the E/M procedure code to identify a separate and distinct service rendered on the same date of service as OMT. The E/M procedures are restricted to significant and separate identifiable issues beyond the usual pre- and post-omt work. This restriction applies even if the E/M and OMT are related to the same symptom or diagnosis. Documentation must be submitted on appeal when it is medically necessary to render distinct services. March/April Texas Medicaid Bulletin, No. 228

18 Coinsurance and Deductible Reimbursement for Noncontracted MAPs Beginning January 4, 2010, TMHP processes claims with dates of service on or after January 1, 2008, for coinsurance and deductibles for dual-eligible clients who are enrolled in a Medicare Advantage Plan (MAP) that is not contracted with HHSC. Reimbursement Rates Changed for Durable Medical Equipment Effective for dates of services on or after January 1, 2010, reimbursement rates have changed for some durable medical equipment (DME) procedure codes. The following DME reimbursement rates are effective January 1, 2010, for Texas Medicaid: TOS Procedure Code Reimbursement Rate J E0240 $95.00 L E0424 $ L E0439 $ J E0445 $ J E0445 w/tg Modifier $ L E0445 $58.30 L E0445 w/tg Modifier $ J E0779 $ L E0779 $17.57 J E0780 $10.89 L E0780 $1.09 L E0840 $16.10 L E0850 $12.88 L E0860 $5.81 L E0880 $17.60 L E1020 $22.01 L E1232 $ L E1235 $ L E1236 $ J E2368 $ J E2369 $ J E2601 $55.35 TOS = Type of service, J = New DME, L = Leased or Rental A list of contracted plans can be found on the TMHP website at Providers must submit claims for coinsurance and deductibles using the revised MRAN/MAP Templates. Providers must attach the appropriate paper claim form to the completed MRAN form: CMS-1500 paper claim form for professional services. UB-04 CMS-1450 paper claim form for institutional services. Providers must attach a copy of the completed CMS-1500 paper claim form to the completed MRAN form. The new templates and instructions are available on the TMHP website at Beginning January 4, 2010, providers may submit claims to TMHP with dates of service on or after January 1, Providers will have until March 31, 2010, to submit claims with dates of service from January 1, 2008 through January 3, Claims that are submitted may initially be denied for exceeding the filing deadline; however, TMHP will reprocess these claims. No action on the part of the provider is necessary. Claims with dates of service on or after January 4, 2009, must be submitted to TMHP following current claim filing deadlines. TMHP will not reprocess the following claims: Claims with dates of service on or after January 4, Claims with dates of services from January 1, 2008 through January 3, 2010, that are submitted after March 31, Claims that were denied for reasons other than filing deadline. MRANs must be submitted with a completed claim form, must be legible, and must identify only one client per page. Providers must not submit handwritten MRANS. Claims that do not meet these standards will not be processed and will be returned to the provider. Texas Medicaid Bulletin, No March/April 2010

19 2009 HCPCS Updates Procedure Codes Added During the 2009 HCPCS Update This is an update to an article published on the TMHP web page at titled Updated Procedure Codes Added During the 2009 HCPCS Update. In addition to the procedure codes listed in the article, procedure codes and may be reimbursed to physicians in the outpatient hospital setting. This change is effective December 23, 2009, for dates of service on or after January 1, Affected claims submitted with dates of service from January 1, 2009, through December 22, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Procedure Codes Reinstated During the 2009 HCPCS Update Effective December 4, 2009, the following information was updated retroactively for the procedure codes indicated: Procedure Codes Effective for dates of service on or after January 1, 2009, these procedure codes were reimbursed in the office setting only. Effective December 4, 2009, for dates of service on or after January 1, 2009, these procedure codes may additionally be reimbursed to physicians in the outpatient hospital setting. Claims submitted with any of these procedure codes and dates of service from January 1, 2009, through December 3, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required HCPCS First and Second Quarter New Benefits for Some Medical Procedure Codes The following first and second quarter 2009 HCPCS procedure codes are effective for dates of service on or after October 1, 2009, and are new benefits of Texas Medicaid. Nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), and physician providers may be reimbursed in the office setting. Hospitals may be reimbursed in the outpatient hospital setting. Additionally, procedure codes Q4115 and Q4116 may be reimbursed to podiatrist and podiatrist group providers in the office setting: TOS Procedure Code Reimbursement Rate *Diagnosis Restrictions 1 C9249 $ Q2023 $ , 2861, 2862, 2863, 2864, 2865, 2866, 2867, 2869, V Q4115 $9.54 N/A 1 Q4116 $34.98 N/A TOS = Type of service, * Procedure codes must be submitted with the specific diagnosis codes that appear in this column. N/A indicates that there are no diagnosis restrictions. Note: Effective for dates of service on or after January 1, 2010, procedure codes C9249 and Q2023 were discontinued by CMS for the 2010 HCPCS update. Contraceptive Implant System is a Benefit for FQHCs and RHCs Effective for dates of service on or after January 25, 2010, procedure code J7307 is a benefit for FQHC and rural health clinic (RHC) providers for Texas Medicaid and may be reimbursed once every 3 years. FQHC providers must submit claims for procedure code J7307 with their FQHC provider identifier and will be reimbursed at the encounter rate. RHC providers must submit claims for procedure code J7307 with the provider identifier of a physician or nurse practitioner (NP) instead of the RHC provider identifier and must use the appropriate national place of service (72) for an RHC setting. Claims for procedure code J7307 that are submitted by RHC providers with the provider identifier of a physician or NP will be reimbursed at the encounter rate. Providers must append the appropriate family planning diagnosis code to claims that are submitted with procedure code J7307. March/April Texas Medicaid Bulletin, No. 228

20 Authorization Requests for PET and Cardiac Nuclear Imaging Services Effective for dates of service on or after February 1, 2010, the prior authorization process and some benefits have changed for outpatient diagnostic positron emission tomography (PET) and cardiac nuclear imaging services. Effective for dates of service on or after February 1, 2010, prior authorization is required for outpatient diagnostic cardiac nuclear imaging services. Effective for dates of service on or after February 1, 2010, authorization requests for outpatient diagnostic PET and cardiac nuclear imaging services for Texas Medicaid feefor-service clients and PCCM clients must be submitted to MedSolutions instead of TMHP. MedSolutions is the TMHP subcontractor that currently authorizes CT and magnetic resonance services. Important: Prior authorization requests must not be submitted to MedSolutions before February 1, Providers will have 14 days after the day on which the study was completed to request authorization for dates of service on or after February 1, Requests for outpatient diagnostic PET and cardiac nuclear imaging services will be rejected if they are submitted to MedSolutions before February 1, Authorization requests for PET procedures that are granted by TMHP before February 1, 2010, will be valid until the authorized dates of service have expired. Providers must submit claims to TMHP, and claims must include the prior authorization number. If the prior authorization number is not on the claim when it is submitted to TMHP for processing, the claim will be denied. Authorization Requests Submitted to MedSolutions Requests for authorization may be submitted to MedSolutions online at by telephone at , by fax at , or by mailing to: Texas Medicaid & Healthcare Partnership 730 Cool Springs Blvd, Suite 800 Franklin, TN Note: Access to the MedSolutions online prior authorization portal is also available from and the TMHP prior authorization portal. Requests for authorization must be submitted using the Radiology Prior Authorization Request Form. Providers must complete the paper version of the Radiology Prior Authorization Request Form regardless of the method used to request the authorization. The completed Radiology Prior Authorization Request Form and an original signature must be maintained in the client s medical record by the physician who orders the tests. Note: The paper version of the Radiology Prior Authorization Request Form has been updated to include PET scans and Cardiac Nuclear Imaging. Providers must begin using the new form effective for dates of service on or after February 1, The Radiology Prior Authorization Request Form must be completed and signed as follows: Section 1 must be completed, signed, and dated by the ordering physician before submitting a request for the prior authorization of a PET or cardiac nuclear imaging procedure, regardless of the method used to submit the request for authorization. Note: Residents, physician assistants, and nurse practitioners may order radiological procedures and complete and sign section 1 of the Radiology Prior Authorization Request Form. The provider number of the group or the provider number of the supervising provider must be included on the authorization form. Section 2 must be completed, signed, and dated by the physician who performs an urgent or emergent imaging study before retroactive authorization is requested. The physician s signature must be current, unaltered, original, and handwritten. A computerized or stamped signature will not be accepted. Providers may be asked to provide additional documentation regardless of the method of submission. Electronic Authorization Requests Providers that make requests electronically must complete the authorization requirements through an approved electronic method and retain a copy of the signed and dated Radiology Prior Authorization Request Form in the client s medical record at the provider s place of business. Providers must be prepared to provide Texas Medicaid Bulletin, No March/April 2010

21 information about the medical necessity of the test through approved electronic methods. Information may include, but is not limited to, the diagnosis, treatment history, treatment plan, medications, and previous imaging results. Note: Retroactive authorization requests are not accepted electronically. Providers should refer to the Prior Authorization and Retroactive Authorization section of this article for more information about retroactive authorization requests. Telephone Authorization Requests Providers that submit requests by telephone must be prepared to provide information about the medical necessity of the test, including but not limited to, the diagnosis, treatment history, treatment plan, current medications, and previous imaging results. Providers may be asked to provide additional documentation. Important: All prior authorization requests for outpatient urgent and emergent PET and cardiac nuclear imaging procedures should be made by phone in order to ensure a timely response. Providers may refer to the Prior Authorization and Retroactive Authorization section of this article for more information about prior authorization requests. Fax and Mail Authorization Requests Providers that submit requests by fax or mail must submit the Radiology Prior Authorization Request Form to MedSolutions for consideration. The form must include information related to the medical necessity of the test, including the diagnosis, treatment history, treatment plan, current medications, and previous imaging results. Providers may be asked to provide additional documentation. Note: The paper version of the Radiology Prior Authorization Request Form has been updated to include PET scans and Cardiac Nuclear Imaging. Providers must begin using the new form effective for dates of service on or after February 1, Prior Authorization and Retroactive Authorization The prior authorization of nonemergent PET and cardiac nuclear imaging studies and the retroactive authorization of urgent or emergent studies will be considered on an individual basis. Each prior authorization request will be reviewed for its adherence to standard clinical evidencebased guidelines. Documentation must support the medical necessity of the study and must be maintained in the client s medical record by both the physician ordering the test and the facility performing the study. MedSolutions evaluates authorization requests using nationally-accepted guidelines and radiology protocols that are based on the medical literature. These guidelines and protocols include, but are not limited to, the following: American College of Radiology (specifically, their Appropriateness Criteria) American Academy of Neurology American Academy of Orthopedic Surgeons American College of Cardiology American Heart Association National Comprehensive Cancer Care Network Prior authorization is required for outpatient, nonemergent PET and cardiac nuclear imaging studies (i.e. those studies that are planned or scheduled) and must be obtained before the service is rendered. Requests for prior authorization can be submitted online through the MedSolutions website or by telephone, fax, or mail. Retroactive authorization is considered for emergent and urgent studies when the following criteria are met: Outpatient Emergent Studies (both of the following criteria must be met): - - The physician determines that a medical emergency that imminently threatens life or limb exists. The medical emergency requires advanced diagnostic imaging. Outpatient Urgent Studies (both of the following criteria must be met): - During the provision of prior-authorized services, the physician performing the imaging study determines that additional or alternate procedures are medically necessary. March/April Texas Medicaid Bulletin, No. 228

22 - The urgent condition requires additional or alternate advanced diagnostic imaging. The PET scan procedure codes are subject to the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) relationships. Any Note: Outpatient emergent and urgent studies may also be exceptions to NCCI code relationships are specifically prior authorized if submitted by telephone to ensure a timely noted below. Providers can refer to the CMS NCCI web response. page at for the correct coding guidelines and specific applicable code combinations. The retroactive authorization request must be submitted no later than 14 calendar days after the day on which the study was completed. Retroactive authorization requests are accepted by telephone, fax, or mail, but they are not accepted online. Providers can access the current Clinical Decision Support Tool for Advanced Imaging Guide on the TMHP website at This tool includes information that was developed by MedSolutions to help providers determine the most appropriate imaging procedure for each patient at the most appropriate time during the diagnostic and treatment cycle. The guidelines are updated annually. In the absence of an authorization, reimbursement is denied for both the technical and professional interpretation components. Services That Do Not Require Authorization Authorization is not required for radiology services that are performed as emergency department services, outpatient observation services, or inpatient hospital services. If emergency PET scans or cardiac nuclear imaging services are provided in an emergency department and submitted on the professional claim form (CMS-1500), then providers must use modifier U6. If the services are provided in an emergency department and submitted on the institutional claim form (CMS-1450), then providers must use the appropriate, corresponding emergency services revenue code. PET Scans Procedure code 78608, 78811, 78812, 78813, 78814, 78815, or may be reimbursed for PET scans and must be prior authorized. Note: Prior authorization requests for procedure code that are granted by MedSolutions include the total component (type of service [TOS] 4). Texas Medicaid reimburses providers for the professional component only (TOS I). The difference in the TOS will not affect claims processing. Procedure code must be billed with modifier 26. In the following table the procedure codes in Column A will be denied if they are billed with the same date of service by the same provider as the corresponding procedure codes in Column B: Column A (Denied) Column B and , 78812, and , 78812, 78813, and , 78812, 78813, 78814, and The radiopharmaceutical can be reimbursed separately from the PET scan procedure. Providers can refer to the Texas Medicaid fee schedule for diagnostic radiopharmaceutical procedure codes that are reimbursed by Texas Medicaid. Cardiac Nuclear Imaging Studies The following procedure codes may be reimbursed for cardiac nuclear imaging procedures and must be prior authorized: Procedure Codes The cardiac nuclear imaging procedure codes are subject to the CMS NCCI relationships. Any exceptions to NCCI code relationships are specifically noted below. Providers may refer to the CMS NCCI web page at for the correct coding guidelines and specific applicable code combinations. Texas Medicaid Bulletin, No March/April 2010

23 In the following table the procedure codes in Column A will be denied if they are billed with the same date of service by the same provider as the corresponding procedure codes in Column B: Column A (Denied) Column B 78472, 78473, 78481, 78483, and , 78472, 78481, , 78461, 78472, 78473, 78481, 78483, and , 78461, 78464, 78472, 78473, 78481, , and , 78472, 78481, 78483, 78494, and , 78472, 78481, 78494, and and The radiopharmaceutical can be reimbursed separately from the cardiac nuclear imaging procedure. Providers can refer to the Texas Medicaid fee schedule for diagnostic radiopharmaceutical procedure codes that are reimbursed by Texas Medicaid. Refer to page 47 of this bulletin for a copy of the Radiology Prior Authorization Request Form. Botulinum Toxin Type A (Botox) Benefit Update Effective for dates of service on or after February 1, 2010, benefit criteria for Botulinum Toxin Type A (Botox) changed for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program. Effective February 1, 2010, procedure code J0587 has a billing quantity limit of 150 units. Providers must bill Botox drugs using procedure code J0587 for the amount of the injection per 100 units used. For example, a provider administering 2,500 units must bill a quantity of 25 quantity units. Any claim billed in excess of 150 billing quantity units will be denied with explanation of benefits (EOB) (services exceed allowed benefit limitations). Revised Provider Enrollment Applications Available Effective February 1, 2010, revised enrollment applications for each of the state health-care programs are available for providers on the TMHP website at The revisions to the applications reflect enhancements that were made to Provider Enrollment on the Portal (PEP). The following changes have been made to the enrollment applications: Providers are required to list their nine-digit federal tax identification number instead of their Texas Comptroller Number on the line labeled EIN. Providers are required to submit a Principal Information Form (PIF) 2 for any subcontractors with whom they have a relationship. Title 1, Texas Administrative Code (TAC) Section states that a provider is subject to sanction for billing Texas Medicaid or any other federally funded health-care program for items or services provided by, or under the direction of, a person or entity that is excluded from federal health-care program participation. Resulting sanctions may include recoupment of all funds paid for the items or services, the imposition of penalties, and/or the provider being excluded from participation in federally funded health-care programs. Accordingly, as part of the revised application procedures, current providers and those applying to participate in state health-care programs must have screened all employees and contractors and confirmed that none are excluded from participation in federally funded health-care programs. The provider will be required to certify that this screening has been completed, and that it will be performed on an ongoing basis as a condition of the provider s enrollment or reenrollment into state health-care programs. A provider must screen the provider s employees and contractors by checking both the federal List of Excluded Individuals and Entities (LEIE), and the state database of excluded persons and entities. The federal LEIE may be accessed at The state database of excluded persons and entities may be accessed at the following internet address: March/April Texas Medicaid Bulletin, No. 228

24 Genetic Services Benefit Criteria Changed Effective for dates of services on or after February 1, 2010, benefit criteria for genetic services changed for Texas Medicaid. Genetic services may be used to diagnose a condition, optimize disease treatment, predict future disease risk, and prevent adverse drug response. Genetic services may be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist and typically include one or more of the following: Comprehensive physical exams Diagnosis, management, and treatment for clients with genetically related health problems Evaluation of family histories for the client and the client s family members Genetic risk assessment Genetic laboratory tests Interpretation and evaluation of laboratory test results Education and counseling of clients, their families, and other medical professionals on the causes of genetic disorders Consultation with other medical professionals to provide treatment Pharmacogenetics encompasses the use of information encoded in clients DNA to help predict their responses to medicines and to enhance the effectiveness and safety of medicines for individual clients. Testing for drug efficacy is not a benefit of Texas Medicaid. Family History It is important for primary care providers to recognize potential genetic risk factors in a client so that they can make appropriate referrals to a genetic specialist. Obtaining an accurate family history is an important part of clinical evaluations, even when genetic abnormalities are not suspected. Knowing the family history may help health-care providers identify single-gene disorders or chromosomal abnormalities that occur in multiple family members or through multiple generations. Some genetic disorders that can be traced through an accurate family history include diabetes, hypertension, certain forms of cancer, and cystic fibrosis. Early identification of the client s risk for one of these diseases can lead to early intervention and preventive measures that can delay onset or improve health conditions. Using a genetics-specific questionnaire helps to obtain the information needed to identify possible genetic patterns or disorders. The most commonly used questionnaires are provided by the American Medical Association and include the Prenatal Screening Questionnaire, the Pediatric Clinical Genetics Questionnaire, and the Adult History Form. Using a genetics-specific questionnaire helps to obtain the information needed to identify possible genetic patterns or disorders Genetic Tests Diagnostic tests to check for genetic abnormalities must be performed only if the test results will affect treatment decisions or provide prognostic information. Tests for conditions that are treated symptomatically are not appropriate since the treatment would not change. Providers who are uncertain whether a test is appropriate are encouraged to contact a geneticist or other specialist to discuss the client s needs. Any genetic testing and screening procedures must be accompanied by appropriate non-directive counseling, both before and after the procedure. Information must be provided to the client and family (if appropriate) about the possible risks and purpose and nature of the tests being performed. The interpretation of certain tests, such as nuchal translucency, requires additional education and experience. Texas Medicaid supports national certification standards when available. Laboratory Practices For many heritable diseases and conditions, test performance and interpretation of test results require information about client race/ethnicity, family history, and other pertinent clinical and laboratory information. To facilitate test requests and ensure prompt initiation of appropriate testing procedures and accurate interpretation of test results, the requesting provider must be aware of the specific client information needed by the laboratory before tests are ordered. To help providers make appropriate test selections and requests, handle and submit specimens, and provide Texas Medicaid Bulletin, No March/April 2010

25 clinical care, laboratories that perform molecular genetic testing for heritable diseases and conditions must educate providers that request services about the molecular genetic tests the laboratory performs. For each molecular genetic test, the laboratory must provide the following information: Indications for testing Relevant clinical and laboratory information Client race and ethnicity Family history Pedigree Testing performed on a client to provide genetic information for a family member, and testing performed on a non-medicaid client to provide genetic information for a Medicaid client are not benefits of Texas Medicaid. Genetic Counselors Genetic counselor services may be billed by a physician when the genetic counselor is under physician supervision and is an employee of the physician. Services provided by independent genetic counselors are not a benefit of Texas Medicaid. Updated List of Drugs Requiring NDC for Reimbursement Effective for dates of services on or after February 1, 2010, procedure codes J0207, J1040, and J1566 must be submitted with an 11-digit National Drug Code (NDC). If these procedure codes are submitted on a claim without the NDC number, the claim will be denied, even if it was prior authorized. The NDC number that is submitted to Texas Medicaid or the CSHCN Services Program must be the NDC number on the package or container from which the medication was administered. The following table shows the procedure codes that must be submitted with an NDC number: Procedure Codes J0640 J9390 J7190 J1100 J7192 J1631 J2430 J9000 J3010 J9040 J1260 J9045 J2550 J9060 J1885 J9217 J0696 J J9206 J2405 J1626 J9178 J3370 J1170 J9293 J9190 J9062 J1566 J0207 J1040 New Online Provider Lookup Enhancements Effective March 1, 2010, enhancements to the Online Provider Lookup (OPL) are being made to improve overall functionality. The enhancements to the OPL include the following: Each provider specialty and subspecialty will have a corresponding definition. Users can view the definitions by clicking more information on either the basic or advanced search page or by hovering over the specialty on the results page. The definitions have been added to help clients locate the correct type of provider. PCCM Multispecialty providers will be able to self-declare as many as four subspecialties to identify the services they offer. All other providers will be able to self-declare as many as three subspecialties to identify the services they offer. Providers may declare only subspecialties that are within the scope of their practice. Users will be able to search for a provider on the OPL using these subspecialties. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will appear in the PCCM Provider Directory. Providers who make address updates may receive a confirmation from TMHP after the address has been verified and if their address has been provided. Users will be able to search for providers within a ZIP Code that crosses multiple counties. Beginning March 1, 2010, providers will have the option to provide feedback on their experience with the OPL and Provider Enrollment on the Portal (PEP) by completing surveys about the online tools. Data collected from these surveys will help TMHP continue to improve OPL and PEP. March/April Texas Medicaid Bulletin, No. 228

26 Texas Medicaid Claims Reprocessing The following claims issues have been identified. All affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Billing and Prior Authorization for Palivizumab (Synagis) TMHP has identified an issue that impacts claims submitted with procedure code and dates of service on or after October 1, These claims might have been denied in error. Affected claims received between October 1, 2009, and December 11, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Reminder: Procedure code requires prior authorization. When billing for procedure code 90378, the billing or performing provider identifier on the claim must match the requesting or performing provider identifier on the prior authorization submitted with the claim. Since provider groups have multiple performing providers that may administer the drug to the same client, prior authorizations should be requested using the group provider identifier. Individual providers who administer the drug to the same client at multiple locations should request prior authorization and submit claims using their individual provider identifier. If different vial sizes (e.g., 50 mg vial and 100 mg vial) are required for the appropriate dosage on the same date of service, providers must bill each vial separately on the same claim and include the appropriate National Drug Code (NDC) for each detail. Providers that are no longer administering palivizumab (Synagis) from their stock, but are administering palivizumab (Synagis) that has been dispensed through the Vendor Drug Program (VDP), may bill Texas Medicaid for the administration of the drug only. Physicians will be required to send a prescription for palivizumab (Synagis) with supporting clinical information on the Texas Medicaid Vendor Drug Program Palivizumab (Synagis) Prescription Form to a Texas Medicaid-enrolled pharmacy that is a member of the Synagis Distribution Network. A list of participating pharmacies, which is updated on a regular basis, is available on the Vendor Drug Program website at FQHC Providers Claims Reprocessing TMHP has identified an issue that affects claims submitted by Federally Qualified Health Center (FQHC) providers with dates of service from July 1, 2009, through December 2, 2009, and procedure codes 99204, 99214, J7300, or J7302. An encounter rate might have been paid in error for these procedure codes when they were submitted without a family planning diagnosis code. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. As a reminder, an FQHC provider must bill for a general family planning visit with the most appropriate E/M procedure code and a family planning diagnosis code. An annual family planning examination must be billed with the most appropriate E/M procedure code, a family planning diagnosis code, and modifier FP. FMAP Rate Increases Effective for dates of service on or after October 1, 2009, the Federal Medical Assistance Percentage (FMAP) has increased from percent to percent as part of the federal stimulus package recently passed by congress. This change is effective for the first quarter of FFY 2010 as published by CMS. FMAP is the federal government s contribution to states for Medicaid expenditures and is used for Medicaid fee-for-service and managed care. The FMAP change affects only providers that certify expenses and are paid only the federal share of their claims. Hydration Intravenous Infusion Reprocessing of Claims TMHP has identified an issue that impacts claims submitted by acute care hospital providers with dates of service on or after January 1, 2006, and procedure code performed in the outpatient hospital setting. Claims might have been reimbursed incorrectly. Immunization Procedure Codes Reprocessing TMHP has identified an issue with claims that were submitted with dates of service on or after October 1, 2009, and influenza or pneumonia immunization procedure codes. These claims might have been denied incorrectly for diagnosis. Texas Medicaid Bulletin, No March/April 2010

27 PT and OT Claims Reprocessing TMHP has identified an issue with claims that were submitted by home health, comprehensive outpatient rehabilitation facility (CORF), and outpatient rehabilitation facility (ORF) providers with dates of service from December 19, 2008, through December 17, 2009, and physical therapy (PT) or occupational therapy (OT) codes. These claims may have been denied inappropriately for exceeding the limitation. Surgical Procedure Codes Claims Reprocessing TMHP has identified an issue that affects claims submitted by physicians and dentists with dates of service from February 1, 2008, through April 1, 2009, and certain surgical procedure codes in the office, inpatient hospital and outpatient hospital settings. Claims for the surgical procedure codes were denied pending a rate hearing which has been completed. Affected claims with the following surgical procedure codes will be reprocessed, and payments will be adjusted accordingly: Surgical Procedure Codes to Be Repocessed Urinalysis Procedure Code Claims Reprocessing TMHP has identified an issue that affects claims submitted with dates of service on or after April 20, 2008, and procedure code Procedure code might have been denied in error when billed with procedure code 81003, 81005, or Benefit Update for Obstetrics Services Effective for dates of service on or after December 1, 2009, benefit criteria for obstetrics services changed for Texas Medicaid. Effective for dates of service on or after December 1, 2009: Procedure code 99215, for services rendered in a birthing center, is no longer reimbursed to an advanced practice nurse (APN), CNS, or PA. Procedure code will continue to be reimbursed to certified nurse midwives (CNMs) and physicians for services rendered in a birthing center. Procedure codes and in a birthing center have been suspended pending a hearing for changes in the rates associated with these procedure codes. If a client is discharged from a birthing center before delivery, providers may bill for labor services only by submitting procedure code without the TH modifier. Claims for any E/M service on the same date of service as a delivery will be denied as part of the delivery. March/April Texas Medicaid Bulletin, No. 228

28 Updates to Previously Published Information The following are updates and corrections to articles that were published in previous bulletins or on the TMHP website at as either banner messages or web articles. Procedure Codes Added During the 2009 HCPCS Update This is an update to an article published on the TMHP Code Updates HCPCS web page at titled Updated Procedure Codes Added During the 2009 HCPCS Update. In addition to the procedure codes listed in the article, effective December 23, 2009, for dates of service on or after January 1, 2009, procedure codes and may be reimbursed to physicians in the outpatient hospital setting. Effective December 4, 2009, the following information was updated retroactively for the procedure codes indicated: Procedure Codes Effective for dates of service on or after January 1, 2009, these procedure codes were reimbursed in the office setting only. Effective December 4, 2009, for dates of service on or after January 1, 2009 these procedure codes may additionally be reimbursed to physicians in the outpatient hospital setting. Claims submitted with any of these procedure codes and dates of service from January 1, 2009, through December 3, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Affected claims submitted with dates of service from January 1, 2009, through December 22, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Additional Second and Third Quarter Procedure Code Review Updates This is an update involving several procedure codes that were changed during the second and third quarter procedure code reviews. Effective December 4, 2009, the details for procedure codes 77427, 80050, 93016, and were updated retroactively. The changes are as follows: Effective for dates of service on or after July 1, 2009, the radiation therapy total component for procedure code may be reimbursed to physicians and radiation treatment centers in the office setting and to hospitals in the outpatient hospital setting. Effective December 4, 2009, for dates of service on or after July 1, 2009, the total component for procedure code may additionally be reimbursed to physicians in the outpatient hospital setting. Claims submitted with procedure code and dates of service from July 1, 2009, through December 3, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Effective for dates of service on or after July 1, 2009, NP, CNS, and PA providers were no longer reimbursed for procedure code Effective December 4, 2009, for dates of service on or after July 1, 2009, NP, CNS, and PA providers may be reimbursed for procedure code Claims submitted with procedure code and dates of service from April 1, 2009, through December 3, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Effective for dates of service on or after July 1, 2009, the professional interpretation component for procedure code may be reimbursed to physicians in the office and outpatient hospital setting. Effective December 4, 2009, for dates of service on or after July 1, 2009, the professional interpretation component may additionally be reimbursed to physicians in the inpatient hospital setting. Claims submitted with procedure code and dates of service from July 1, 2009, through December 3, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Effective for dates of service on or after July 1, 2009, home health agency providers were no longer reimbursed for medical procedure code in the office, home, or outpatient hospital setting. Effective December 4, 2009, for dates of service on or after July 1, 2009, procedure code may be reimbursed to home health agencies in the office, home, Texas Medicaid Bulletin, No March/April 2010

29 or outpatient hospital setting. The AT modifier is not required. Claims submitted with procedure code and dates of service from July 1, 2009, through December 3, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary Correction to Cytogenetics Testing 2010 ICD-9-CM Update This is a correction to an article that was published on the TMHP website at on September 25, 2009, titled, 2010 ICD-9-CM Updates Now Available. The article indicated that diagnosis codes and were to be added to cytogenetics testing procedure codes. The correct information is as follows: No new diagnosis codes were added, revised, or discontinued for cytogenetics testing for Texas Medicaid or the CSHCN Services Program. The tables have been revised as follows: Procedure Codes for Texas Medicaid For more information, providers should refer to the 2009 Texas Medicaid Provider Procedures Manual, section , Cytogenetics Testing, on page Procedure Codes for CSHCN Services Program For more information, providers should refer to the 2009 CSHCN Services Program Provider Manual, section , Cytogenetics Testing, on page Update to Home Health Skilled Nursing (SN) Services Benefits This is an update to the 2009 Texas Medicaid Provider Procedures Manual, Section , Home Health Skilled Nursing (SN) Services on page Effective November 25, 2009, for dates of service on or after October 1, 2009, skilled nursing visits will not be approved for the sole purpose of instructing the client on the use of the subcutaneous injection port device. Any necessary instruction for the use of the device must be performed as part of the office visit with the prescribing physician. Online Fee Lookup and Static Fee Schedule Note Codes Correction TMHP has identified an issue with note codes 15 and 16 that appear in the Online Fee Lookup (OFL) and static fee schedules on the TMHP website at Note codes 15 and 16 displayed incorrect note messages. The following are the correct note messages: Note code 15: Displayed fee reflects reimbursement for the service rendered in a non-facility location. Note code 16: Displayed fee reflects reimbursement for the service rendered in a facility location. The note messages have been corrected in both the OFL and the static fee schedules. Update to Out-of-State Providers Who Perform Services to Migrant Farm Workers This is an update to an article that was published in the July/August 2009 Texas Medicaid Bulletin, No. 224, titled Out-of-State Providers Who Perform Services to Migrant Farm Workers. Effective for dates of service on or after April 1, 2009, out-of-state and border-state providers do not need a referral from a client s primary care provider when they render services to PCCM clients who are 20 years of age or younger and are either migrant farm workers or the children of migrant farm workers. Providers that submit claims for services rendered to these clients must include modifier UC with each procedure code they bill. For PCCM clients who are 21 years of age or older, primary care provider referrals are still required on claims for services rendered by out-of-state and border-state providers. Physical, Occupational, and Speech Therapy Benefits to Change for CCP Update This is an update to an article that was published on the TMHP website at on July 10, 2009, titled Physical, Occupational, and Speech Therapy Benefits to Change for CCP. The article did not include procedure code as payable for speech therapy (ST). Procedure code is used for ST services for training for augmentative communication devices (ACD). To request prior authorization for for ST services, providers must submit the procedure code with the GN modifier. All claims for for ST services must be billed with the GN modifier. March/April Texas Medicaid Bulletin, No. 228

30 Effective January 1, 2010, providers must specifically request procedure code separate from requests for other therapy services (PT, OT, and ST). Procedure code is not included in PT and OT authorizations unless specifically requested. Prior authorization requests for procedure code must include the appropriate modifier for the type of therapy being requested and specify the amount of time requested for this procedure code. When requesting prior authorization for PT, OT, or ST, service providers must include the frequency and amount of time they are requesting. Reimbursement Rate Changes for Ambulance Services Correction This is a correction to an article that was published in the November/December 2009 Texas Medicaid Bulletin, No. 226, titled Reimbursement Rate Changes for Ambulance Services. The article listed some incorrect procedure code reimbursement rates. The following table lists the correct rates that are effective for dates of service on or after September 1, 2009: TOS Procedure Code Reimbursement 9 A0398 $ A0425 $ A0426 $ A0427 $ A0428 $ A0429 $ A0430 $3, A0431 $3, A0433 $ A0434 $ A0435 $ A0436 $23.53 TOS=Type of Service Correction to Reimbursement Rates for Specific Procedure Codes Will Change This is a correction to an article that was published on the TMHP website at on December 3, 2009, titled Reimbursement Rates for Specific Procedure Codes Will Change for Texas Medicaid and PCCM Programs. The article included procedure codes that have not completed rate hearings and one procedure code that is not a benefit. Additionally, relative value units (RVUs) were missing from the medical services, surgery, and assistant surgery procedure codes. The table as originally published included the following errors: Procedure code is not a benefit for assistant surgery. The following procedure codes and types of service should not have been included because rate hearings are still pending: Radiology procedure codes 74190, 74151, 93312, and for the technical component. Procedure code for surgery. Procedure codes 33426, 33430, and for assistant surgery. Relative Value Units (RVUs) should have been included for the medical services, surgery, and assistant surgery types of service for the procedure codes in the table. The following table shows the correct reimbursement rates that are effective January 1, 2010, for clients of all ages: TOS Procedure Code Reimbursement Rate DME Services 9 L2397 $ L5925 $ L5962 $ L5964 $ L5966 $ L5981 $2, Medical Services, Surgery, and Assistant Surgery $ (3.67 RVUs, $ (29.83 RVUs, $ (4.77 RVUs, $ (31.37 RVUs, $ (5.02 RVUs, $ (18.15 RVUs, $79.21(2.90 RVUs, TOS = Type of Service: 9 = DME, 1 = Medical Service, 2 = Surgery, 8 = Assistant Surgery, RVUs = relative value units Texas Medicaid Bulletin, No March/April 2010

31 TOS Procedure Code Reimbursement Rate Medical Services, Surgery, and Assistant Surgery (continued) $ (36.10 RVUs, $1, (53.61 RVUs, $ (8.58 RVUs, $1, (41.63 RVUs, $ (6.66 RVUs, $1, (60.56 RVUs, $ (9.69 RVUs, $67.10 (2.46 RVUs, $57.83 (2.12 RVUs, $1, (72.31 RVUs, $ (11.57 RVUs, $ (33.66 RVUs, $ (5.39 RVUs, $1, (37.19 RVUs, $ (5.95 RVUs, $ (23.79 RVUs, $ (3.81 RVUs, $ (7.19 RVUs, $1, (38.48 RVUs, $ (6.16 RVUs, $ (16.14 RVUs, TOS = Type of Service: 9 = DME, 1 = Medical Service, 2 = Surgery, 8 = Assistant Surgery, RVUs = relative value units TOS Procedure Code Reimbursement Rate Medical Services, Surgery, and Assistant Surgery (continued) $70.44 (2.58 RVUs, $1, (49.42 RVUs, $ (7.91 RVUs, $ (12.46 RVUs, $54.38 (1.99 RVUs, $1,175.3 (43.09 RVUs, $ (6.89 RVUs, $1, (39.21 RVUs, $ (4.67 RVUs, $ (19.21 RVUs, $ (5.00 RVUs, TOS = Type of Service: 9 = DME, 1 = Medical Service, 2 = Surgery, 8 = Assistant Surgery, RVUs = relative value units THSteps PCS Reimbursement Rates Have Changed Correction This is a correction to an article that was published in the November/December 2009 Texas Medicaid Bulletin, No.226, titled THSteps PCS Reimbursement Rates Have Changed. The article was published on the TMHP website at with the title THSteps-CCP PCS Reimbursement Rates Have Changed. The articles listed an incorrect reimbursement rate for procedure code T1019 with modifier U6. Effective for dates of service on or after August 1, 2009, the correct reimbursement rate for procedure code T1019 with modifier U6 is $2.92. Prior Authorization is Required for Surgical Procedure Codes Effective for dates of service on or after March 1, 2010, procedure codes 56620, 58673, and require prior authorization. March/April Texas Medicaid Bulletin, No. 228

32 Behavioral Health Providers Behavioral Health Providers Documentation Requirement Update for Psychological and Neuropsychological Testing Services Effective December 1, 2009, the documentation requirements for psychological and neuropsychological testing services that are performed by a psychiatrist, psychologist, or a licensed professional associate (LPA) have changed. Providers are no longer required to maintain the original testing material in the client s medical record; however, providers must maintain the original testing material so that it is readily available for retrospective review by the Health and Human Services Commission (HHSC). The treating provider must document in the client s medical record the medical necessity of the chosen treatment and identify the diagnosis code that most accurately describes the client s condition that necessitated the psychological/neuropsychological testing. The medical record (outpatient hospital records, reports, or progress notes) must be signed and dated by the performing provider, be clear and concise, and document the reason(s) for the psychological/neuropsychological testing and the outcome. In addition, the provider must maintain the following documentation in the client s medical record: The extended Outpatient Psychotherapy Counseling Request Form. The name of the test(s) (e.g., WAIS-R, Rorschach, MMPI). The scoring of the test. Where the testing was performed. The name and credentials of each provider involved in administering the test, interpretation, and preparing the report. Interpretation of the test, which must include narrative descriptions of the test findings. Length of time spent by each provider, as applicable, in face-to-face administration, interpretation, reporting the test, integrating the test interpretation, and writing the comprehensive report based on the integrated data. Treatment, including how test results affect the prescribed treatment. Recommendations for further testing, which must include an explanation to substantiate the necessity of retesting, if testing is repeated. Rationale or extenuating circumstances that impact the provider s ability to complete the testing, such as, but not limited to, the client s condition requires testing over two days and client does not return, or the client s condition precludes completion of the testing. Providers must also maintain the original testing material so that it is readily available for retrospective review by HHSC. Texas Medicaid Bulletin, No March/April 2010

33 Behavioral Health Providers/Family Planning Providers Behavioral Health Form Changes Effective for dates of service on or after January 1, 2010, the Extended Outpatient Psychotherapy/Counseling Request Form has been revised. In addition, a new Psychological/Neuropsychological Testing Request Form has been created, and providers are required to use this form to request prior authorization for psychological and neuropsychological testing. The corresponding electronic version of both forms has also been updated. The forms are submitted through the TMHP website at by choosing Submit a Prior Authorization. The forms may also be mailed or faxed to the following address: Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization B Riata Trace Parkway, Suite 150 Austin, TX Fax: Beginning January 1, 2010, all providers are required to use the revised Extended Outpatient Psychotherapy/ Counseling Request Form and the Psychological/ Neuropsychological Testing Request Form to request prior authorization for these services. The changes to the Extended Outpatient Psychotherapy/ Counseling Request Form are as follows: The form name has changed. The Current DSM IV Diagnosis field has been expanded to include Axis I through Axis V diagnoses. The following two new fields have been added to the form: - Court ordered service - DFPS directed service If prior authorization is being requested in accordance with a court order or a Department of Family Protective Services (DFPS) directive, providers must submit the following additional information with the prior authorization request: If there is a court order, the court order signed by the judge must be submitted. If there is a DFPS directive, the DFPS directive or summary signed by the DFPS employee as well as the DFPS employee s name and telephone number must be submitted. The Outpatient Psychotherapy/Counseling Request Form is available on page 45 of this bulletin. The Psychological/Neuropsychological Testing Request Form is available on page 46 of this bulletin. Family Planning Providers Reprocessing Claims with WHP Procedure Codes Texas Medicaid & Healthcare Partnership (TMHP) has identified an issue that impacts claims submitted by Women s Health Program (WHP) providers or family planning providers for dates of service on or after April 1, 2009, and the following procedure codes: 00851, 58340, 58611, 58615, 58670, 74000, 74010, 81005, 87252, 99001, 99243, E1399, or Q0111. These claims might have been processed incorrectly. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Additionally, claims with dates of service on or after January 1, 2010, and procedure code are no longer payable to family planning providers in the office setting (place of service [POS] 1). March/April Texas Medicaid Bulletin, No. 228

34 Family Planning Providers Benefit Changes for Family Planning Titles V and XX Services Effective for dates of service on or after December 7, 2009, benefit criteria for family planning services for Title V and XX have changed for Texas Medicaid. The following tables list procedure codes for additions, reimbursement rate changes, and discontinuations for family planning Titles V and XX services effective for dates of service on or after December 7, 2009: New Procedure Codes for Office Visits Title V Fee Title XX Fee $22.64 $ $35.73 $ $87.83 $ $11.73 $ $19.64 $ $63.83 $63.83 All family planning evaluation and management (E/M) visits must be billed with the most appropriate E/M procedure code for both general family planning visits and the annual family planning examination. Reminder: Effective for dates of service on or after July 1, 2009, only the annual family planning examination requires modifier FP. Claims for all other family planning office visits must omit modifier FP. New Procedure Code for Nutrition Counseling Title V Fee Title XX Fee $17.18 $17.18 Note: Limited to a maximum of 4 15-minute sessions per rolling year. New Procedure Codes for Radiology Services Title V Fee Title XX Fee $74.74 $ $74.74 $ $46.64 $ $67.10 $67.10 New Procedure Codes for Laboratory Services Title V Fee Title XX Fee $0.00* $ $4.40 $ $3.15 $ $4.44 $ $0.00* $23.55 New Procedure Codes for Laboratory Services Title V Fee Title XX Fee $0.00* $ $0.00* $ $0.00* $ $0.00* $ $18.48 $ $27.13 $ $19.22 $ $0.00* $ $0.00* $ $0.00* $ $0.00* $ $0.00* $ $0.00* $ $27.46 $ $5.98 $ $5.98 $ $0.00* $ $0.00* $ $28.10 $ $28.10 $ $0.00* $ $28.10 $ $56.22 $ $16.82 $ $16.82 $ $0.00* $ $0.00* $ $3.73 $3.73 Q0111 $5.98 $5.98 * Title V providers do not receive reimbursement for services performed free of charge by the DSHS Laboratory. For correct tracking of services performed, providers are required to include these services on their Title V Family Planning claims filed with TMHP. If the provider does not perform the laboratory services, procedure code 99000, submitted with a family planning diagnosis code, may be reimbursed for handling or conveyance of the specimen from the provider s office to a laboratory. Only one lab handling fee may be charged per day, per client, unless specimens are sent to two or more different laboratories. Texas Medicaid Bulletin, No March/April 2010

35 Family Planning Providers The following procedure codes are current benefits for Titles V and XX, only the reimbursement rates have changed: Procedure Codes New Fees Title V Fee Title XX Fee $74.74 $ $69.55 $ $0.00* $ $0.00* $ $0.00* $ $0.00* $ $0.00* $ $0.00* $ $48.28 $ $70.64 $70.64 J1055 $53.48 $53.48 J7300 $ $ J7302 $ $ J7303 $40.65 $40.65 J7304 $15.36 $15.36 S4993 $20.88 $20.88 * Title V providers do not receive reimbursement for services performed free of charge by the DSHS Laboratory. For correct tracking of services performed, providers are required to include these services on their Title V Family Planning claims filed with TMHP. The procedure codes in the following table have been discontinued: Procedure Codes S9445 S9470 Refer to previous provider notifications and Texas Medicaid Bulletin articles for Titles V and XX benefit updates. Correction to Changes to Women s Health Program - Family Planning Benefits and Claims Filing Criteria This is a correction to an article that was published in the July/August 2009 Texas Medicaid Bulletin, No. 224, titled Changes to Women s Health Program and Family Planning Benefits and Claims Filing Criteria. The article incorrectly indicated that diagnosis code V615 is a valid Women s Health Program (WHP) diagnosis code for procedure codes 11975, 11977, and Diagnosis code V615 is not a WHP diagnosis code and is not valid with procedure codes 11975, 11977, and Providers may refer to the bulletin article for the complete list of WHP diagnosis codes. Using Current Version of the Sterilization Consent Form Providers that submit claims for family planning procedures that were performed for the purpose of sterilization must use the current version of the Sterilization Consent Form, which has an effective date of January 15, The effective date is located in the lower right corner of the form. The form is available in English and Spanish on the TMHP website at through the TMHP fax-back option which is available on the Automated Inquiry System (AIS) at , and in the 2009 Texas Medicaid Provider Procedures Manual in Appendix B on pages B-100 and B-101. March/April Texas Medicaid Bulletin, No. 228

36 THSteps Dental Providers THSteps Dental Providers Benefit Update for THSteps Preventive Dental Services Effective for dates of services on or after November 1, 2009, benefit criteria for Texas Health Steps (THSteps) preventive dental services changed for Texas Medicaid. Age restrictions for the following procedure codes have changed: Procedure Codes D1120, D1203 The previous age restriction was 1 year of age through 12 years of age. The new age restriction is 6 months of age through 12 years of age. THSteps providers see also: Efforts Underway to Increase THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families on page 14, and THSteps PCS Reimbursement Rates Have Changed Correction in the Updates to Previously Published Information article on page 31. Procedure Code D1206 The previous age restriction was 1 year of age through 20 years of age. The new age restriction is 6 months of age through 20 years of age. Procedure Code D1550 The previous age restriction was 3 years of age through 20 years of age. The new age restriction is 1 year of age through 20 years of age. Dental sealants (procedure code D1351) are limited to one every three years, per tooth, for any provider. Space Maintainers Space maintainers for use after premature loss of a deciduous/primary first and/or second molar are a benefit for clients who are from 1 year of age through 12 years of age. Premature loss is defined as the loss of a tooth prior to the expected or normal life of the tooth. For a deciduous/ primary molar, this occurs before eruption of the comparable bicuspid permanent tooth. The removal of a space maintainer (procedure code D1555) will not be payable to the provider or dental group practice that originally placed the device. The provider may be reimbursed for removal only if the space maintainer was placed by a different provider. Dental Sedation Procedures Not Limited to One per Day TMHP has identified an issue that impacts claims submitted with dates of service on or after December 1, 2006, and procedure code D9221 or D9242. These procedure codes might have denied in error when they were billed for more than one service per day. Procedure codes D9221 and D9242 are not limited to one service per day. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Dental Comprehensive Evaluation Claims Reprocessing This is a follow-up to a banner message that first appeared in the October 30, 2009, Remittance and Status (R&S) Report about reprocessing of claims for procedure code D0150 or D0180. During initial reprocessing, some claims did not have the appropriate cutbacks applied for limitation audits, resulting in radiographic services that were paid in error. Affected claims will be processed again to determine the correct payment amount, and payments will be adjusted accordingly. No action on the part of the provider is required. Texas Medicaid Bulletin, No March/April 2010

37 Excluded Providers Excluded Providers As required by the Medicare and Medicaid Patient Protection Act of 1987, the Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health-care programs. Providers excluded from Texas Medicaid and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries, wages, or benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any client. Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by Texas Medicaid for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of the HHSC exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list periodically and the updates appear on the website weekly. Review the entire Texas Medicaid exclusion list at /Exclusions/Search.aspx. To report Medicaid providers who engage in fraud/abuse, call or , or write to the following address: Provider Brian Klozik, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361 PO Box Austin TX License Number Start Date Type Provider City State Add Date Alexander, Jimmy E Oct-08 Tech Ft. Lewis WA 05-Nov-09 Adams, Jimmie Dec-09 Couns Beaumont TX 16-Oct-09 Almasri, Murad N/A 18-Jun-09 Owner Houston TX 03-Nov-09 Apostol, Elizabeth D Dec-09 RN N Ft Lauderdale FL 20-Jul-09 Arellano, Maryann Nov-08 Tech San Antonio TX 05-Nov-09 Arnst, Brenda C Nov-09 RN Hewitt TX 12-May-09 Aurignac, Fabian K Dec-09 MD San Juan TX 29-May-09 Baltazar, Sonia May-09 LVN Lubbock TX 27-Oct-09 Baptiste, LaSonya M. 24-Nov-09 Owner Port Arthur TX 26-Oct-09 Bartos III, Michael J Dec-09 LPC Bryan TX 29-Nov-09 Benton, Caryl J May-09 RN Robert Lee TX 23-Oct-09 Besetsny, Krisenda D Nov-09 RN Hallettsville TX 12-May-09 Braxton, Shelly S Nov-09 RN Buda TX 12-May-09 Brightbill, Christopher P Dec-09 LVN Garland TX 29-May-09 Broussard, Brad H Jun-09 LVN Bridge City TX 23-Oct-09 Brown, Judy D Dec-09 LVN Tom Bean TX 29-Jul-09 Caplinger, Carolyn S Nov-09 RN Tyler TX 12-May-09 Decker, Cherie M Nov-09 RN Carrollton TX 12-May-09 Dessart, Darin S Nov-09 RN Wylie TX 12-May-09 Dodson, Michal L Dec-09 LVN DeBerry TX 09-Jun-09 Enis, Lou A May-09 RN Deer Park TX 03-Nov-09 March/April Texas Medicaid Bulletin, No. 228

38 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Ferguson, Christopher W Nov-09 LVN Tyler TX 12-Nov-08 Finch, Donja L. N/A 20-Nov-09 Aide Austin TX 02-Nov-09 Gordon, Jerry E Dec-09 LPC Ft. Worth TX 16-Oct-09 Gutierrez, Jacqueline V Jan-09 RPh New Braunfels TX 04-Nov-09 Hankins, Edward A Jun-09 RN Copperas Cove TX 03-Nov-09 Hanks, Cynthia A Dec-09 LVN Nederland TX 06-Aug-09 Happawana, Maulie NA 10-Dec-09 Owner Plano TX 20-May-09 Holden, Amanda L Dec-09 LVN Amarillo TX 06-Aug-09 Holtzman, Nicola J Dec-09 LPC Beaumont TX 16-Oct-09 Houpt, Carolyn D Dec-09 LVN Pearland TX 20-May-09 Imoh, Ifiok B. 13-Nov-09 Owner Raymondville TX 18-Jun-09 Lindsey, Rhonda D Nov-09 RN Cleburne TX 09-Jun-09 Marcotte, Lukas E Nov-08 Tech San Antonio TX 05-Nov-09 Martinez, Alyssa D Mar-09 Tech Mesquite TX 04-Nov-09 Molina, Kimberly A Nov-09 RN Nederland TX 09-Jun-09 Ohuonu, Mark U. N/A 20-Jul-09 Inter Houston TX 02-Nov-09 Parada, Diana Feb-09 LVN Tulsa OK 05-Nov-09 Peter, Theresa Dec-09 LVN Richmond TX 20-Jul-09 Reliance Pharmaceutical Inc Dec-08 Arlington TX 05-Nov-09 Scarano, Joseph F Jun-09 RN Austin TX 03-Nov-09 Simmons, Richard H Dec-09 RN Longview TX 04-Aug-09 SWS Pharmacy Services Inc Dec-08 Duncanville TX 05-Nov-09 Tafoya, Jacqueline A Mar-09 Tech Round Rock TX 04-Nov-09 Tri-Phasic Pharmacy Inc Dec-08 Arlington TX 05-Nov-09 Vorheier, Alaine D Nov-09 LVN Cibilo TX 12-May-09 Wilson, Brian K. N/A 09-Oct-09 Mgr Beaumont TX 05-Nov-09 Winnett, Roger L Nov-09 LVN River Oaks TX 23-Apr-09 Texas Medicaid Bulletin, No March/April 2010

39 Forms Provider Information Change Form Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider Date : / / Nine-Digit Texas Provider Identifier (TPI): Provider Name: National Provider Identifier (NPI): Atypical Provider Identifier (API): Primary Taxonomy Code: Benefit Code: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: Physical Address The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form. Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Accounting/Mailing Address All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form. Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Secondary Address Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Type of Change (check the appropriate box) Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance) Comments: Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) Tax ID number: Effective Date: Exact name reported to the IRS for this Tax ID: Provider Demographic Information Note: This information can be updated on Languages spoken other than English: Provider office hours by location: Accepting new clients by program (check one): Accepting new clients Current clients only No Patient age range accepted by provider: Additional services offered (check one): HIV High Risk OB Hearing Services for Children Participation in the Woman s Health Program? Yes No Patient gender limitations: Female Male Both Signature and date are required or the form will not be processed. Provider signature: Date: / / Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: Effective Date_ /Revised Date_ March/April Texas Medicaid Bulletin, No. 228

40 Forms Instructions for Completing the Provider Information Change Form Signatures The provider s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers. Address Performing providers (physicians performing services within a group) may not change accounting information. For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form. For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers. Tax Identification Number (TIN) TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN. Provider Demographic Information An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please visit the OPL at Please review the existing information and add or modify any specific practice limitations accordingly. This will allow clients more detailed information about your practice. General TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box Austin, TX Fax: Texas Medicaid Bulletin, No March/April 2010

41 Forms Electronic Funds Transfer (EFT) Information Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account. The following items are specific to EFT: Pre notification to your bank takes place on the cycle following the application processing. Future deposits are received electronically after pre notification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider s account during the weekly cycle. Specific deposits and associated R&S reports are cross referenced by both the provider identifiers (i.e., NPI, TPI, and API) and R&S number. EFT funds are released by TMHP to depository financial institutions each Friday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received. TMHP must provide the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer s needs. In all cases, credits received should be posted to the customer s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date. To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return the agreement and either a voided check or a statement from your bank written on the bank s letterhead to the TMHP address indicated on the form. Call the TMHP Contact Center at for assistance. March/April 2010 A STATE MEDICAID CONTRACTOR 41 Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No. 228

42 Forms Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form NOTE: Complete all sections below and attach a voided check or a statement from your bank written on the bank s letterhead. Type of Authorization: NEW CHANGE Provider Name Nine Character Billing TPI National Provider Identifier (NPI)/Atypical Provider Identifier (API): Provider Accounting Address Bank Name Primary Taxonomy Code: Benefit Code: Provider Phone Number ( ) Ext. ABA/Transit Number Bank Phone Number Account Number Bank Address Type Account (check one) Checking Savings I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period. I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations. Authorized Signature Date Title Address (if applicable) Contact Name Phone Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box Austin TX DO NOT WRITE IN THIS AREA For Office Use Input By: Input Date: A STATE MEDICAID CONTRACTOR Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No March/April 2010

43 Forms PCCM Community Health Services Referral Request Form Provider Information Name: Contact name: Telephone: Address: NPI: Name: Medicaid number: Telephone: Client Information Reason for Referral TPI: Name: Medicaid number: Telephone: Client Information Reason for Referral Appointment no show Abuse of emergency room Appointment no show Abuse of emergency room Treatment plan adherence Abuse of doctor/staff Treatment plan adherence Abuse of doctor/staff Other: Case Management/Health Education Needs Other: Case Management/Health Education Needs Asthma Childhood illness Asthma Childhood illness Community resources Cardiac Community resources Cardiac Nutrition Transportation Nutrition Transportation Dental Parenting Dental Parenting Behavioral psych disorder Diabetes Behavioral psych disorder Diabetes Prenatal Exercise Prenatal Exercise Tobacco use Child/Adult with Special Health Care Needs Other: Comments: Name: Medicaid number: Telephone: Client Information Reason for Referral Tobacco use Child/Adult with Special Health Care Needs Other: Comments: Name: Medicaid number: Telephone: Client Information Reason for Referral Appointment no show Abuse of emergency room Appointment no show Abuse of emergency room Treatment plan adherence Abuse of doctor/staff Treatment plan adherence Abuse of doctor/staff Other: Case Management/Health Education Needs Other: Case Management/Health Education Needs Asthma Childhood illness Asthma Childhood illness Community resources Cardiac Community resources Cardiac Nutrition Transportation Nutrition Transportation Dental Parenting Dental Parenting Behavioral psych disorder Diabetes Behavioral psych disorder Diabetes Prenatal Exercise Prenatal Exercise Tobacco use Child/Adult with Special Health Care Needs Other: Comments: Tobacco use Child/Adult with Special Health Care Needs Other: Comments: For Primary Care Case Management Clients Only Fax to Community Health Services at (512) Referrals are also received by telephone at (M-F, 8 a.m. to 5 p.m., CST) Effective Date_ /Revised Date_ March/April Texas Medicaid Bulletin, No. 228

44 Forms Special Medical Prior Authorization (SMPA) Request Form Use only for requests submitted to the TMHP-SMPA department. Mail completed form to the TMHP Special Medical Prior Authorization at B Riata Trace Parkway Ste. 150, Austin, TX or fax to Section A: Client information Name: Medicaid number: Date of birth: / / Section B: Requested procedure or service information Type of request: Transplant Surgery Other Expected dates of service: Procedure requested - CPT code Procedure code description Comments: Section C: To be completed by requesting physician or prescribing provider- Additional information may be attached Diagnoses (ICD-9-CM): Statement of medical necessity (Refer to the appropriate section of the Texas Medicaid Provider Procedures Manual for specific prior authorization requirements): Physician s name: Address/City/ZIP: Telephone number: Fax number: TPI: NPI: Taxonomy: Physician s signature: Date signed: Section D: Service provider or facility information - If different than provider in Section C Provider printed name: Contact person: Date: Address/City/ZIP: Telephone number: Fax number: TPI: NPI: Taxonomy: Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No March/April 2010

45 Forms Outpatient Psychotherapy/Counseling Request Form 1. Identifying Information Client Information Medicaid number: Date: / / Client name Last: First: Middle Initial: Date of birth: / / Age: Sex: Began current treatment: / / Current living arrangements: With parent(s) Group/foster home Other (list): Performing provider: Address: Medicaid Provider Identifier (ID): Taxonomy: Provider Information 2. Current DSM IV diagnoses (list all appropriate diagnosis codes): Axis I: Axis II: Axis III: Axis IV: Axis V [GAF*]: NPI: Benefit Code: Telephone: Current substance abuse? None Alcohol Drugs Alcohol and Drugs 3. Court ordered service? Yes No Court order signed by judge must be attached. 4. DFPS directed service? Yes No DFPS directive or summary signed by employee must be attached. DFPS employee s name: 5. Recent primary symptoms that require additional therapy/counseling Include date of most recent occurrence, frequency, duration, and severity: DFPS employee s phone number: 6. History Psychiatric inpatient treatment Yes No Age at first admission: Prior substance abuse? Significant medical disorders: None Alcohol Drugs Alcohol and Drugs 7. Current psychiatric medications (include dose and frequency): 8. Treatment plan Measurable short term goals, specific therapeutic interventions utilized and measurable expected outcome(s) of therapy: 9. Number of sessions requested (limit 10 per request) List the specific procedure codes requested: How many of each type? IND Group Family Dates From (start of visits): / / To (end of planned requested visits): / / List specific procedure codes requested: Provider signature: Date: / / Provider printed name: *GAF = Global Assessment of Functioning Effective Date_ /Revised Date_ March/April Texas Medicaid Bulletin, No. 228

46 Forms Psychological/Neuropsychological Testing Request Form 1. Identifying Information Client Information Medicaid number: Date: / / Client name Last: First: Middle Initial: Date of birth: / / Age: Sex: Previous testing date (NA if not applicable): / / Performing provider: Address: Medicaid Provider Identifier (ID): Taxonomy: Provider Information 2. Current DSM IV diagnoses (list all appropriate diagnosis codes): Axis I: Axis II: Axis III: Axis IV: Axis V [GAF*]: NPI: Benefit Code: Telephone: Current substance abuse? None Alcohol Drugs Alcohol and Drugs 3. Court ordered service? Yes No Court order signed by judge must be attached. 4. DFPS directed service? Yes No DFPS employee s name: DFPS directive or summary signed by employee must be attached. DFPS employee s phone number: 5. Testing requested: Psychological testing Neuropsychological testing (The time spent writing up the findings is included in the time to perform the testing and will not be reimbursed separately.) 6. Number of hours requested: 7. Rationale supporting medical necessity for requested testing Is the requested testing for screening purposes? Yes No If Yes, explain the rationale. Previous testing history and results: 8. List the specific procedure codes requested: Dates From (start of testing): / / To (end of testing): / / Provider signature: Date: / / Provider printed name: *GAF= Global Assessment of Functioning Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No March/April 2010

47 Forms Radiology Prior Authorization Request Form This form is used to obtain prior authorization for elective outpatient services or update an existing outpatient authorization. All fields marked with an asterisk (*) are required. The information in Section 2 is only required for updated or retroactive authorizations. Forms that are submitted without all of the required information will be returned for correction. Telephone number: Fax number: *Date of Request: / / Please check the appropriate action requested: CT Scan CTA Scan MRI Scan MRA Scan PET Scan Cardiac Nuclear Scan Update/change codes from original PA request Client Information *Name: *Medicaid number: *Date of Birth: / / Facility Information *Name: *Address: TPI: Taxonomy: *NPI: Benefit Code: Reference number: *Name: *Address: *Telephone: TPI: Taxonomy: Section 1 Requesting/Referring Physician Information *Fax number: *NPI: Benefit Code: License number: Service Types *Outpatient Service(s) Emergent/Urgent Procedure Date of Service: / / *Procedures Requested: Diagnosis Codes *Primary: Secondary: *Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications, and previous imaging results: *Requesting/Referring Physician (Signature Required): *Print Name: *Date: / / Section 2 Updated Information (when necessary) *Date of Service: / / *Procedures Requested: Diagnosis Codes *Primary: Secondary: *Clinical documentation supporting medical necessity for a procedure code change includes treatment history, treatment plan, medications, and previous imaging results: *Requesting/Referring Physician (signature required): *Print Name: *Date: / / Physician must complete and sign this form prior to requesting authorization. *Requesting/Referring Physician NPI: Requesting/Referring Physician License No.: Requesting/Referring Physician TPI: Effective Date_ /Revised Date_ March/April Texas Medicaid Bulletin, No. 228

48 Texas Medicaid & Healthcare Partnership B Riata Trace Parkway, Ste 150 Austin, TX A STATE MEDICAID CONTR ACTOR PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE March/April 2010 No. 228 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Look inside for these and other important updates: Page 7 Page 7 Page 14 Page 25 Updated Cardiac Nuclear Imaging Guidelines Available Radio TMHP: Radiology Services Episode Efforts Underway to Increase THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families New Online Provider Lookup Enhancements