T exas Medicaid Bulletin

Transcription

1 T exas Medicaid Bulletin Bimonthly update to the Texas Medicaid Provider Procedures Manual May/June 2009 No. 223 Claims Filing Deadline Waived for Providers in Ike Evacuation Areas This is a clarification to information posted on the Hurricane Ike Provider Information web page available at and published in the November/ December 2008 Texas Medicaid Bulletin, No. 219, in the article titled, HHSC Response to Recent Hurricanes. This article also clarifies information posted to the Texas Medicaid & Healthcare Partnership (TMHP) website on January 21, 2009, titled, Hurricane Ike Waivers Will Be Discontinued on February 1, The Texas Health and Human Services Commission (HHSC) directed TMHP to waive the filing deadline for providers whose ZIP Codes have been identified as being in an evacuation area, and the waiver has been discontinued effective February 1, The waiver applies to claims with dates of service on or after September 9, 2008, through January 31, Claims submitted after the filing deadline with dates of service on or after September 9, 2008, through January 31, 2009, will initially be denied but will then be reprocessed by TMHP. No further action on the part of the provider is necessary. Important: The filing deadline waiver for providers whose ZIP Codes have been identified as Hurricane Ike evacuation areas was discontinued effective February 1, Impacted providers must file any remaining claims with dates of service from September 9, 2008, through January 31, 2009, within 95 days of February 1, 2009, (i.e., claims must be received by May 7, 2009). Claims received after May 7, 2009, will be considered for reimbursement only on appeal through HHSC s administrative appeals process if it can be demonstrated that the claim could not be submitted by the filing deadline because of Hurricane Ike. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual Section , Exceptions to the 95-Day Filing Deadline, on page 5-10, for more information. Providers may also refer to the TMHP Continued on page 2 CONTENTS All Providers 1 Claims Filing Deadline Waived for Providers in Ike Evacuation Areas Paper Medicare Claims Reminder Update to Total Parenteral Nutrition Services Benefit Changes for Hearing Devices and Related Services First Quarter Procedure Code Review First Quarter HCPCS Updates Claim Form Required for Paper Appeals Epididymovasostomy is No Longer a Benefit NDC Data Claims Update Unit Calculations for Billing Drugs Texas Medicaid Claims Reprocessing Leuprolide Acetate Injection Update Recommended Immunization Schedules Expanded Age Indication for Boostrix Vaccine/Toxoid Reminder Benefits to Change for Regional Anesthesia Services New Claims Process for Clients with Third-Party Insurance Certified Nurse-Midwife Fee Schedule Osteogenic Stimulator Age Restrictions New Process for Medicare Advantage Plans Claims List of Top Physician-Administered Multiple-Source Drugs Now Available Critical Care Services Are Changing for Texas Medicaid Scheduled System Maintenance Changes for Breast Cancer (BRCA) Testing Transcranial Doppler Studies Update Benefit Changes for Telemedicine Services for Texas Medicaid Telemedicine Facility Fee Reimbursement Rate Reimbursement Rates for Ambulatory Surgical Centers, Dental, and DME Services DSHS Laboratory Criteria Changes Clinical Directed Care Coordination Services Clarification Reimbursement Rates Changed for Physician-Administered Drugs and Biologicals Reimbursement Rate Changes for Medical Services, Surgical, Interpretation, and Total Component Newborn Services Benefits Changed for Texas Medicaid Updates to Previously Published Information Continued on page 2 Copyright Acknowledgments Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2008 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.

2 CONTENTS Continued from page 1 Ambulance Providers 33 Correction to Ambulance Claims Information Home Health Providers 34 Benefits Change for Home Health Bath and Bathroom Equipment Mobility Aids-Home Health Benefits Change Managed Care Providers 37 The 2009 Clinical Decision Support Tool for Advanced Imaging Guide Now Available Smoking Cessation Drugs Exempt from Medicaid Three-drug Limit Influenza Virus Vaccine Claims Reprocessing for Managed Care Providers Colorectal Cancer Procedure No Longer Requires Precertification THSteps-CCP Providers 38 THSteps-CCP Mobility Aids Benefits Change THSteps Dental Providers 40 Benefit Update for THSteps Diagnostic Dental Services Periodontal Maintenance Restrictions Benefits Have Changed for Services by Doctors of Dentistry Practicing as a Limited Physician Reimbursement Rates for Doctor of Dentistry Practicing as a Limited Physician Service New Dental Diagnostic Services are THSteps Benefits Excluded Providers 44 Forms 48 Provider Information Change Form Electronic Funds Transfer (EFT) Authorization Agreement Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Type Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Types 31 and Continued from page 1 Hurricane Response Information web page at for additional Hurricane Ike information. A list of affected ZIP Codes is available on the TMHP website at File Library/IKE_ZIP _Codes_PO_County_ pdf. This information updates any previously-posted web articles and published banner messages and bulletin articles pertaining to the claims filing deadline waiver for providers whose ZIP Codes have been identified as being in an evacuation area. Paper Medicare Claims Reminder Providers submitting paper Medicare claims to TMHP must use one of the following approved Medicare Remittance Advice Notices (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. Claims that do not meet these standards are not processed and are returned to the provider. 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 Texas Medicaid Bulletin, No May/June 2009

3 Update to Total Parenteral Nutrition Services Effective for dates of service on or after July 1, 2009, Texas Medicaid will implement benefit and prior authorization changes for total parenteral nutrition (TPN) services. Texas Medicaid will no longer reimburse procedure codes 1-S9364, 1-S9365, 1-S9366, 1-S9367, or 1-S9368. TPN services must be prior authorized and submitted for reimbursement using the appropriate procedure codes for nursing, equipment and supplies, and parenteral nutrition solutions. Parenteral nutrition solution services may be reimbursed using the following procedure codes: Procedure Codes 9-B B B B B B B B B B B B B B B5200 The following changes apply to parenteral nutrition solution services: The procedure codes may be reimbursed in the home setting when submitted by the following provider types: home health durable medical equipment (DME), medical supplier (DME), or medical supply company. The procedure codes are no longer payable in the office setting when submitted by any provider type. Prior Authorization Requirements Parenteral nutrition solution services must be prior authorized through the TMHP Home Health Services Prior Authorization Department as separate services for nursing, equipment and supplies, and parenteral solutions. For Medicaid clients who are birth through 20 years of age, TPN services that do not meet Home Health guidelines may be prior authorized through the TMHP Comprehensive Care Program (CCP) Prior Authorization Department. Skilled nursing visits to address TPN must: Be provided by a registered nurse (RN) appropriately trained in the administration of TPN. Include education of the client or caregiver regarding the in-home administration of TPN before administration initially begins. Include the use and maintenance of required supplies and equipment. Occur at least once every month to monitor the client s status and to provide ongoing education to the client and/or caregivers regarding the administration of TPN. The skilled nursing services may be prior authorized only for the client/caregiver training in TPN administration. Intermittent skilled nursing visits must be documented on the Home Health Services Plan of Care (POC) and the provider and requesting physician must retain the POC in the client s medical record. For clients who receive private duty nursing (PDN) and also require TPN administration education, intermittent skilled nursing visits may be considered for separate prior authorization when: The PDN provider is not an RN who is trained in the administration of TPN, and the PDN provider is not able to perform the function. There is documentation in the medical record to support the medical need for an additional skilled nurse to perform TPN. The provider and requesting physician must retain documentation for the need for intermittent skilled nursing visits in the PDN POC and must maintain the POC in the client s medical record. If the skilled nursing visit for TPN education occurs while the PDN provider is caring for the client, both the PDN provider and the nurse educator must document in the client s medical record the skilled services individually provided, including, but not limited to: The skilled nursing services that each provided during that time period. The start and stop time of each nursing provider s specialized task(s). The client condition that requires the performance of skilled PDN tasks during the skilled nursing visit for TPN education. Effective July 1, 2009, prior authorization requests for TPN must be submitted to TMHP using the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. The Medical Necessity for In-Home Total Parenteral Hyperalimentation form is no longer accepted by TMHP for dates of service on or after July 1, Prior authori- May/June Texas Medicaid Bulletin, No. 223

4 zation requests that are submitted on the Medical Necessity for In-Home Total Parenteral Hyperalimentation form after July 1, 2009, will be returned to providers. 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. The completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form with the original dated signature must be maintained by the prescribing physician in the client s medical record. A copy of the completed, signed, and dated form must be maintained by the DME provider in the client s medical record. 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 requested. The physician must maintain in the client s medical record documentation of medical necessity. The documentation must include the following: The medical condition that necessitates TPN Documentation of any trials with oral/enteral feedings Percent of daily nutritional needs from TPN A copy of the TPN formula or prescription, including amino acids and lipids, signed and dated by the physician A copy of the most recent laboratory results, which must include potassium, calcium, liver function studies, and albumin The requesting provider may be asked for additional information to clarify or complete a request for TPN services. Retrospective review may be performed to ensure documentation supports the medical necessity of the TPN services. Renewal of the prior authorization will be considered based on medical necessity. Reimbursement The nurse providing the intermittent skilled nurse visit for TPN services will be reimbursed only for time spent delivering client and family instruction and for direct client TPN services. The services delivered must be documented in the client s medical record. PDN and skilled nursing should not routinely be performed on the same date during the same time period. PDN and skilled nursing will not be considered for reimbursement when the services are performed on the same date during the same time period without prior authorization approval. Both the intermittent skilled nurse visit and the PDN services provided during the same time period may be recouped if the documentation does not support the medical necessity of each service provided. The administration of intravenous fluids and electrolytes cannot be billed as in-home TPN. The DME Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the dated signatures of the provider and the client or primary caregiver. This signed and dated DME Certification and Receipt Form must be maintained by the DME provider in the client s medical record. When submitting claims and appeals for DME that meet or exceed a billed amount of $2,500, providers should refer to the 2009 Texas Medicaid Provider Procedures Manual, Section , Durable Medical Equipment (DME) and Supplies, on page for additional requirements. Benefit Changes for Hearing Devices and Related Services Reminder: Effective for dates of service on or after December 2, 2008, hearing aid device revisits must be billed using procedure code or The revisits are limited to 2 per calendar year performed by any provider. Procedure codes and are no longer reimbursed for hearing aid device revisits. Procedure codes and will be denied if submitted with the same date of service by the same provider as procedure code or Details of the hearing devices and services benefit changes were published in the 2009 March/April Texas Medicaid Bulletin, No. 222, and are posted on the TMHP website at Texas Medicaid Bulletin, No May/June 2009

5 First Quarter Procedure Code Review To align with CMS requirements for easy access to all Texas Medicaid fees, TMHP has completed the first quarter procedure code review. Effective for dates of service on or after April 1, 2009, provider type, place of service (POS), and type of service (TOS) changes have been applied to some surgical procedure codes. Provider type changes are available in the updated fee schedules, and providers are encouraged to determine coverage changes by reviewing the fee schedules before submitting claims. Procedure code is no longer reimbursed for the technical or professional components. Procedure code is no longer reimbursed as a surgery. Procedure code T is reimbursed in the inpatient hospital setting. Procedure code is still reimbursed. The following procedure codes are no longer reimbursed to assistant surgeons: Procedure Codes Integumentary System Musculoskeletal System Procedure Codes Musculoskeletal System Respiratory System Cardiovascular System Hemic and Lymphatic Systems Mediastinum and Diaphragm Urinary System Female Genital System Male Genital System Nervous System Eye/Ocular Adnexa Auditory System Digestive System May/June Texas Medicaid Bulletin, No. 223

6 The following procedure codes are now reimbursed in the office setting: Procedure Codes The following procedure codes are now reimbursed in the outpatient setting: Procedure Codes / / The following procedure codes are no longer reimbursed in the office setting: Procedure Codes The following procedure codes are no longer reimbursed in the outpatient setting: Procedure Codes / / / / / / / / Procedure Codes / / / / / The following procedure codes are no longer reimbursed in the settings indicated: Procedure Code , , , Settings No Longer Reimbursed Office Skilled Nursing Facility and Intermediary Care Facility (SNF/ICF) Office , Office Outpatient Office Birthing Center Home , Birthing Center Inpatient Outpatient , SNF/ICF , * Other locations is billed as POS 9 Office Home SNF/ICF and extended care facility Independent laboratory Birthing center Other locations* Providers may refer to the fee schedules available on the TMHP website at for more information about the procedure codes in this article. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual Section , Place of Service (POS) Coding, on page 5-18, for more information about billing place of service codes. Texas Medicaid Bulletin, No May/June 2009

7 First Quarter HCPCS Updates On April 1, 2009, TMHP implemented first quarter 2009 Healthcare Common Procedure Coding System (HCPCS) additions, changes, and deletions effective for dates of service on or after April 1, Deleted procedure codes are no longer benefits of Texas Medicaid fee-for-service, Medicaid Managed Care, or the CSHCN Services Program. Details of these changes are available on the TMHP website at Claim Form Required for Paper Appeals Reminder: Paper appeal requests submitted to TMHP require a completed claim form with a copy of the Remittance and Status (R&S) Report. All claim adjustment and appeal requests must be received within 120 days from the date of the R&S Report and must be finalized within the 24-month payment deadline. Epididymovasostomy is No Longer a Benefit Effective April 1, 2009, procedure codes 2/F and 2/F are no longer benefits of Texas Medicaid and the CSHCN Services Program. Reminder: Texas Medicaid and the CSHCN Services Program do not cover fertility services. NDC Data Claims Update Effective January 30, 2009, claims submitted for professional, outpatient, and family planning services that include physician-administered prescription drug procedure codes will no longer require the National Drug Code (NDC) unit of quantity or the NDC unit of measurement codes. On or after January 30, 2009, claims submitted with physician-administered prescription drug procedure codes only require N4 (the NDC X12 qualifier) and the 11-digit NDC number. Providers who choose to continue submitting the NDC unit of quantity and the NDC unit of measurement codes must submit both codes. Claims submitted with only one of the two codes will be rejected or denied. Unit Calculations for Billing Drugs Providers that request reimbursement for drugs must bill the number of units based on the number of HCPCS units actually administered. Providers should refer to the HCPCS procedure code description for the unit amount to calculate the number of units to be billed. The specific NDC of the drug actually dispensed should be entered on the claim form. Additional information about entering NDC codes, and the NDC-to-HCPCS crosswalk is available on the TMHP website at on the NDC page. TMHP has identified leucovorin calcium, botulinum toxin Type A and B, medroxyprogesterone acetate (Depo-Provera), and respiratory syncytial virus immune globulin (RSV Prophylaxis) as drugs that are often billed incorrectly. The following are examples of how these drugs should be billed: The HCPCS description for procedure code 1-J0640 states 50 mg. A provider administering 100 mg of leucovorin calcium should bill a quantity of 2 units (100 mg divided by the HCPCS unit amount of 50 mg equals 2 units). Procedure code 1-J0585 is a per unit code. A provider administering 20 units of botulinum toxin A should bill a quantity of 20 units. Procedure code 1-J0587 is billed per 100 units. Bill the amount of the injection per 100 units used. A provider administering 2,500 units should bill a quantity of 25. Procedure code 1-J1051 is for 50 mg. A provider administering 250 mg of Depo-Provera should bill a quantity of 5 units, not 250 units (250 mg divided by the HCPCS unit amount of 50 mg equals 5 units). Exception: The HCPCS description for procedure code states 50 mg, but must be billed per milligram. When billing procedure code , the provider must include the number of units wasted. For example, if a provider administers 180 mg to a child and 20 mg is wasted, the provider should bill a quantity of 200 units not 4 units. Claims submitted with incorrect unit calculations may cause delay or incorrect payment. May/June Texas Medicaid Bulletin, No. 223

8 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. Hearing Aid Revisit Procedure Codes TMHP has identified an issue affecting claims that were submitted with dates of service on or after December 2, 2008, and hearing aid revisit procedure code or These claims may have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Outpatient Hospital Claims with Revenue Code B-636 TMHP has identified an issue that impacts outpatient hospital claims submitted with revenue code B-636 and dates of service on or after April 1, These claims may have been denied in error. Affected claims will be reprocessed, and claims will be adjusted accordingly. No action on the part of the provider is necessary. Outpatient Hospital Crossover Claim Duplicates TMHP has identified an issue that impacts outpatient hospital claims that are duplicates of outpatient hospital crossover claims. Outpatient hospital claims with dates of service on or after December 1, 2004, that are duplicates of outpatient hospital crossover claims may have been paid in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Outpatient Hospital High-Volume Provider Claims TMHP has identified an issue that may have caused incorrect payments to high-volume outpatient hospital providers. Claims with dates of service from September 1, 2008, through January 29, 2009, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Screening and Diagnostic Studies of the Breast TMHP has identified an issue that affects claims submitted with dates of service on or after May 1, 2008, and the following procedure codes: Procedure Codes 4/I/T /I/T /I/T /I/T /I/T /I/T-G0202 4/I/T-G0204 4/I/T-G0206 These claims may have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Reminder: Effective for dates of service on or after May 1, 2008, screening and diagnostic studies of the breast, procedure code 4/I/T-77051, must be billed in conjunction with procedure code 4/I/T-77055, 4/I/T-77056, 4/I/T-G0204, or 4/I/T-G0206, and procedure code 4/I/T must be billed in conjunction with procedure code 4/I/T or 4/I/T G0202. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, Mammography (Screening and Diagnostic Studies of the Breast) on page Leuprolide Acetate Injection Update Effective for dates of service on or after March 1, 2009, leuprolide acetate injection procedure code 1-J9217 is allowed for use in monthly, 3-month, 4-month, and 6-month doses instead of one dose every 28 days. Providers must bill the following dosage increments: A monthly dose of 7.5 mg must be billed with a quantity of 1 and is only reimbursed once per month. A 3-month dose of 22.5 mg must be billed with a quantity of 3 and is only reimbursed once every 3 months. A 4-month dose of 30 mg must be billed with a quantity of 4 and is only reimbursed once every 4 months. A 6-month dose of 45 mg must be billed with a quantity of 6 and is only reimbursed once every 6 months. Texas Medicaid Bulletin, No May/June 2009

9 Recommended Immunization Schedules For Persons Birth Through 18 Years of Age United States, 2009 The Advisory Committee on Immunization Practices (ACIP) has updated the recommended 2009 immunization schedules for clients in the United States who are birth through 18 years of age. Printable versions of the schedule are available at the Centers for Disease Control and Prevention (CDC) website at -schedule.htm#printable. For detailed information about changes and updates to the 2009 schedule, visit the CDC website at Expanded Age Indication for Boostrix The Food and Drug Administration (FDA) has approved Boostrix (Tetanus Toxoid, Reduced Diptheria Toxoid, and Acellular Pertussis Vaccine [Tdap], Adsorbed) for use in adults 19 through 64 years of age. Previously, Boostrix was approved only for patients 10 through 18 years of age. Since October 2005, ACIP has recommended the administration of a single dose of Tdap for adults 19 through 64 years of age to replace the next booster dose of tetanus and diphtheria toxoids vaccine (Td). For complete prescribing information, refer to the Boostrix package insert, located at /label/boostrixlb.pdf. Vaccine/Toxoid Reminder Providers may not charge for vaccines obtained from Texas Vaccines for Children (TVFC). If a vaccine is available from TVFC, Texas Medicaid does not reimburse for the vaccine for clients who are birth through 18 years of age. Vaccines are reimbursed only if they are not available from TVFC. When submitting a claim for a vaccine that is not available from TVFC, providers must use modifier U1 in combination with the vaccine procedure code. HHSC must have notified TMHP of the vaccine shortage before TMHP can consider modifier U1 claims for reimbursement. Benefits to Change for Regional Anesthesia Services Effective for dates of service on or after April 1, 2009, regional anesthesia services criteria have changed for Texas Medicaid. Procedure codes and are no longer reimbursed to certified registered nurse anesthetists (CRNAs). The following procedure codes are no longer reimbursed to advanced practice nurses (APNs), physician assistants (PAs), and RN/certified nurse-midwife (CNM): Procedure Codes The following procedure codes must be billed together with the same date of service by the same provider to be reimbursed: Procedure code must be billed with procedure code Procedure code must be billed with procedure code Procedure code must be billed with procedure code Procedure code must be billed with procedure code Regional anesthesia procedure codes may be subject to the CMS National Correct Coding Initiative (NCCI) Edits relationships. Providers may refer to the CMS website at for NCCI correct-coding guidelines and specific applicable code combinations. The correct-coding-initiative relationships that were effective for Medicare on June 26, 2008, are now effective for Texas Medicaid. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, Section , Anesthesia, on page 36-13, for information about anesthesia services. May/June Texas Medicaid Bulletin, No. 223

10 New Claims Process for Clients with Third-Party Insurance On September 27, 2008, TMHP implemented a new process to forward electronic institutional claims to AIM Healthcare Services Inc. (AIM) for research to determine whether a client has other insurance. Beginning February 2009, if AIM determines a client has other, valid insurance for an institutional claim s date of service, AIM will forward the claim to the other insurance carrier on behalf of the provider. Beginning February 2009, when AIM determines a client has other, valid insurance for an institutional claim s date of service the following process occurs: 1) 2) 3) 4) 5) AIM forwards the claim to the other insurance carrier on behalf of the provider. The other insurance carrier processes the claim forwarded by AIM. TMHP denies the claim submitted by the provider. The denial explanation of benefits (EOB) message on the TMHP R&S Report will indicate that TMHP forwarded the claim to the client s other insurance carrier and TMHP will take no further action on the claim. If the other insurance carrier denies the claim, the provider must exhaust all avenues to appeal the claim with the other insurance carrier. If the final disposition is a denial, the provider may appeal the claim to TMHP using the other insurance carrier s EOB showing the denial. Providers must review their TMHP R&S Reports to ensure that any follow-up action is taken within the appeal deadlines. Texas Medicaid remains the payer of last resort. The following claims types are not eligible for forwarding: Electronic claims that are rejected by TMHP Electronic fee-for-service and PCCM adjustments Suspended or finalized claims Claims that are part of mass adjustments originating from TMHP All paper claims Medicare crossover claims National Provider Identifier (NPI) contingent claims School Health and Related Services (SHARS) claims Case Management for Early Childhood Intervention (ECI) claims CSHCN Services Program claims County Indigent Health Care Program (CIHCP) claims Personal Care Services (PCS) claims Case Management for Children and Pregnant Women (CPW) claims Texas Health Steps (THSteps) medical claims THSteps dental claims Family Planning claims Certified Nurse-Midwife Fee Schedule Osteogenic Stimulator Age Restrictions Effective for dates of service on or after February 1, 2009, the age restriction for procedure codes 9-E0749 and J-E0760 has been removed. These procedure codes are payable for clients of all ages. Reminder: The Medicaid rate for CNM services is 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. The 92 percent fee is not reflected within the fee schedule and is applied before the payment is processed. Providers can reference the fee schedules on the TMHP website at Texas Medicaid Bulletin, No May/June 2009

11 New Process for Medicare Advantage Plans Claims HHSC and TMHP are finalizing a process that will allow providers who participate in Medicare Advantage Plans (MAPs) to submit claims to TMHP for reimbursement of the coinsurance or deductible for services rendered to dual-eligible clients for dates of service from January 1, 2005, through December 31, As part of this process, TMHP will allow MAPs providers to submit two new MAPs Submission Forms with a copy of their claim form. These new forms can be submitted to TMHP only for dates of service from January 1, 2005, through December 31, Institutional inpatient claims are processed based on admission date. Starting May 1, 2009, providers can submit the new MAPs Submission Form for Crossover Claim Type 30 and MAPs Submission Form for Crossover Claim Types 31 and 50 to TMHP, along with a copy of an approved claim form for services rendered to dual-eligible clients with dates of services from January 1, 2005, through December 31, TMHP will accept these claims until October 31, Claims submitted on or after November 1, 2009, or for dates of services before January 1, 2005, or after December 31, 2007, will not be processed and will be returned to the provider. For paper appeals, providers must follow the paper appeal guidelines as described in the 2009 Texas Medicaid Provider Procedures Manual, section 6.1.4, Paper Appeals on page 6-3. Services rendered to dual-eligible clients for dates of service on or after January 1, 2008, are excluded from this process; and are covered under the monthly capitated arrangement available to HHSC contracted MAPs. Additional information regarding this arrangement was previously published in the following bulletins: September/October 2008 Texas Medicaid Bulletin, No. 218 page 7 January/February 2009 Texas Medicaid Bulletin, No. 220 page 43 The MAPs Submission Form for Crossover Claim Type 30 and the MAPs Submission Form for Crossover Claim Types 31 and 50 are available on pages 50 through 55 of this bulletin. List of Top Physician-Administered Multiple-Source Drugs Now Available The Texas Medicaid and CSHCN Services Program Top Physician-Administered Multiple-Source Drugs List is now available on the NDC page of the TMHP website at The Texas Medicaid and CSHCN Services Program Top Physician- Administered Multiple-Source Drugs list are those physician-administered, multiple-source drugs that the U.S. Secretary of Health and Human Services has determined to have the highest dollar volume of physician-administered drugs that are dispensed through Texas Medicaid. The list includes only the physician-administered multiple-source drugs that are applicable to Texas Medicaid and the CSHCN Services Program. Providers should monitor future notifications for updates to the list. Reminder: NDC information is required for professional, outpatient, and family planning services that include physician-administered prescription drug charges. Claims that are submitted without NDC information will be denied, even if they have been prior authorized. May/June Texas Medicaid Bulletin, No. 223

12 Critical Care Services Are Changing for Texas Medicaid Effective for dates of service on or after September 1, 2008, the benefit criteria for critical care services and cardiopulmonary resuscitation (CPR) changed for Texas Medicaid. Note: The following article incorporates the 2009 HCPCS updates that were effective for dates of service on or after January 1, For dates of service before January 1, 2009, the appropriate procedure codes should be used when billing for these services. Critical Care Critical care services (procedure codes , , , , , and ) are benefits of Texas Medicaid. Retrospective review may be performed to ensure documentation supports the medical necessity of the service and any modifier used when billing the claim. In accordance with current procedural terminology (CPT), critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the client, provided that the client s condition continues to require the level of physician attention described in this article. Separate charges for the following services performed by the same provider during the critical care period are denied as included in procedure codes and (this list is not all-inclusive): Procedure Codes /I/T /I/T /I/T T I /I/T /I/T /I/T /I /I /I /I /I /I G M0064 The following procedure codes will be denied as part of procedure code : Procedure Codes Only the provider rendering the critical care service at the time of crisis may bill the following procedure codes: Procedure Codes While providers from various specialties may be consulted to render an opinion or to assist in the management of a particular portion of the care, only the provider managing the care of the critically ill client during a life-threatening crisis may bill the critical care procedure codes. Critical care procedure codes and are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured client, even if the time spent by the physician on that date is not continuous. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate evaluation and management (E/M) procedure code. Critical care procedure code is limited to six units per day any provider. If the number of units is not stated on the claim, only a quantity of one will be allowed. Services for a client who is not critically ill and unstable but who happens to be in a critical care unit must be reported using subsequent hospital visit codes or hospital consultation codes. Prolonged physician service (procedure codes , , , and ) will be denied when billed on the same date of service by the same provider as the following critical care procedure codes: Procedure Codes Separate charges for the following procedure codes performed during the critical care period and billed by Texas Medicaid Bulletin, No May/June 2009

13 any provider will be denied as included in procedure codes , , , and : Procedure Codes /I/T /I/T /I/T T I /I/T /I/T /I/T /I /I /I /I /I /I Procedure Codes G M0064 Procedure code will be denied when billed with the same date of service by the same provider as procedure code Inpatient critical care services provided to infants 29 days through 24 months of age are reported with pediatric critical care codes and The pediatric critical care codes are reported as long as the infant or young child qualifies for critical care services during the hospital stay through 24 months of age. Procedure codes , , , and are limited to once per day. If an inpatient or outpatient E/M service is billed with the same date of service as pediatric critical care by the same provider, the E/M is denied. An E/M service performed by the same physician on the same day as critical care services may only be reimbursed after submitting an appeal with medical documentation. This documentation must show that the E/M procedure is a separately-identifiable service. Documentation includes, but is not limited to, office or hospital medical records, such as medical history, physical progress notes, and lab results. Modifier 25 must be submitted with the E/M code. If the same physician provides critical care services for a neonatal or pediatric client in both the outpatient and inpatient settings on the same day, providers must bill only the appropriate neonatal or pediatric critical care procedure code. Actual time spent with the individual client should be recorded in the client s record and reflect the time billed on the claim. The time that can be reported as critical care is the time spent engaged in work directly related to the individual client s care, whether that time was spent at the immediate bedside or elsewhere on the floor or unit. Time spent in activities that occur outside of the unit or off the floor may not be reported as critical care since the physician is not immediately available to the client. Time spent in activities that do not directly contribute to the treatment of the client may not be reported as critical care, even if they are performed in the critical care unit. Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time. May/June Texas Medicaid Bulletin, No. 223

14 Cardiopulmonary Resuscitation (CPR) CPR (procedure code ) is a benefit of Texas Medicaid and may be reimbursed in the office, home, inpatient hospital, outpatient hospital, independent laboratory, birthing center, nursing home, and other locations (POS 9) when submitted by the following provider types: CRNAs, CRNA groups, APNs, physicians, physician groups, RNs, and CNMs. CPR may be reimbursed when medical necessity is documented in the client s medical record. Only the primary provider performing CPR may be reimbursed for procedure code CPR billed as an ambulance service by an ambulance provider will be denied. CPR may be billed with the same date of service as critical care when reported as a separately identifiable procedure. The time spent performing CPR should not be included in the time reported as critical care. The following services performed during the CPR period will be denied when billed with the same date of service by the same provider: Procedure Codes CPR will be denied as part of another service when billed with the same date of service by the same provider as the following services: Procedure Codes Changes for Breast Cancer (BRCA) Testing Effective for dates of service on or after March 1, 2009, the prior authorization guidelines and documentation requirements for breast cancer (BRCA) testing changed for gene mutation analysis (procedure codes 5-S3820, 5-S3822, and 5-S3823). The BRCA testing policy for Texas Medicaid will be revised to match national standards. Prior authorization requests for procedure codes 5-S3820, 5-S3822, and 5-S3823 must include documentation that indicates the client meets one or more of the following criteria: A woman who is 18 years of age or older, has no personal history of breast cancer or epithelial ovarian cancer, and has one of the following: Two first-degree or second-degree relatives with epithelial ovarian or breast cancer who were 50 years of age or younger when they were diagnosed with breast cancer or were any age when they were diagnosed with epithelial ovarian cancer. A combination of three or more first- or second-degree relatives with breast or epithelial ovarian cancer. One or more first- or second-degree relatives with epithelial ovarian cancer and one or more first- or second-degree relatives with breast cancer. A male relative with a history of breast cancer. One or more first- or second-degree relatives who have one of the following: Epithelial ovarian cancer and one or more first- or second-degree relatives with breast cancer. Multiple primary or bilateral breast cancers in a single individual and another first- or second-degree relative diagnosed with breast cancer at 50 years of age or younger. Scheduled System Maintenance System maintenance to the TMHP claims processing system is scheduled for: Sunday, May 10, 2009, 6:00 p.m. to 11:59 p.m. Sunday, June 14, 2009, 6:00 p.m. to 11:59 p.m. During system maintenance, some of the applications related to the claims engine will be unavailable. Specific details about the affected applications are posted on the TMHP website at Texas Medicaid Bulletin, No May/June 2009

15 Multiple primary or bilateral breast cancers in a single individual and another first- or seconddegree relative with epithelial ovarian cancer. Both breast and ovarian cancer. Breast cancer or epithelial ovarian cancer and an increased risk for specific mutations due to ethnic background (for example, Ashkenazi Jewish descent). One or more relatives with a breast cancer 1 (BRCA1) or breast cancer 2 (BRCA2) mutation. A woman who has a personal history of breast cancer, including a diagnosis of carcinoma in situ (DCIS) and one of the following: Breast cancer that was diagnosed at 50 years of age or younger, with or without family history. Breast cancer that was diagnosed at any age and one of the following: A personal history of epithelial ovarian cancer. At least two relatives with breast cancer or epithelial ovarian cancer. Two primary breast cancers in a single individual and at least one relative who was diagnosed with breast cancer at 50 years of age or younger. Two primary breast cancers in a single individual and at least one relative with epithelial ovarian cancer. A male relative with breast cancer. At least one relative who has a BRCA1 or BRCA2 mutation. Ashkenazi Jewish descent or another ethnic descent that is associated with deleterious mutations (for example, populations of Icelandic, Swedish, or Hungarian descent), with or without family history. A woman who has a personal history of epithelial ovarian cancer (includes fallopian tube cancer and primary peritoneal carcinoma) A man who has a personal history of breast cancer and one of the following: At least one male relative with breast cancer. At least one female relative with breast or epithelial ovarian cancer. At least one relative who has a BRCA1 or BRCA2 mutation. Ashkenazi Jewish descent, with or without family history. Note: The term relative refers to close, blood relatives, including first-degree male and female relatives (e.g., parents, siblings, children), second-degree relatives (e.g., aunts, uncles, grandparents, nieces, nephews), and third-degree relatives (e.g., first cousin, great grandparent), all of whom are on the same side of the family as the client. The medical record that is submitted as documentation by the physician must establish the client s diagnosis or family history. Requisition forms from the laboratory are not sufficient for the establishment of a client s personal or family history. The medical record must include documentation of formal, pre-test counseling, including an assessment of the client s ability to understand the risks and limitations of the test and a record that the client made an informed choice to proceed with the testing for BRCA1 and BRCA2 mutations. The medical record is subject to retrospective review. Transcranial Doppler Studies Update Effective for dates of service on or after February 5, 2009, procedure codes 4/I/T and 4/I/T are payable for diagnosis codes 28260, 28261, 28262, 28263, 28264, 28268, and for clients 2 years of age through 16 years of age. Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, Section , Doppler Studies, on page for additional payable diagnosis codes for clients of all ages. May/June Texas Medicaid Bulletin, No. 223

16 Benefit Changes for Telemedicine Services for Texas Medicaid Effective for dates of service on or after April 1, 2009, benefit criteria for telemedicine services changed for Texas Medicaid. Telemedicine is defined as the practice of health-care delivery by a provider who is located at a site other than the site where the patient is located, for the purposes of evaluation, diagnosis, consultation, or treatment that requires the use of advanced telecommunications technology. Only those services that involve direct, face-to-face, interactive video communication between the client and the distant site provider constitute a telemedicine interactive video consultation. Telephone conversations, chart reviews, electronic mail messages, and facsimile transmissions alone do not constitute a telemedicine interactive video consultation and will not be reimbursed as telemedicine services. Documentation for a service provided via telemedicine must be the same as for a comparable in-person service. The provider requesting the telemedicine service must maintain medical record documentation that indicates the medical necessity for the service. The referring provider is responsible for contacting the distant-site provider and arranging for the telemedicine service. In the absence of a referring provider, the distantsite provider is responsible for arranging the telemedicine service. Distant Site A distant site is the location of the physician rendering the service. The distant-site provider must be a physician or physician group enrolled as a Texas Medicaid provider. The distant-site provider must maintain medical record documentation that: Indicates the reason for the telemedicine service. Includes the name of the referring provider, if any, and the name of the client s primary care physician, if any. Includes a copy of the distant-site provider s findings, diagnosis, POC, and treatment recommendations. The following procedure codes when they are billed with the GT modifier will be a benefit for distant-site providers: Procedure Codes Patient Site A patient site is where the client is physically located while the service is rendered. Patient-site providers must be located in a rural or underserved area. A rural area is defined as a county that is not included in a metropolitan statistical area as defined by the U.S. Office of Management and Budget (OMB) according to the most recent United States Census Bureau population estimates. An underserved area is an area that meets the U.S. Department of Health and Human Services (DHHS) Index of Primary Care Underservice criteria. Procedure code 1-Q3014 may be a benefit for patientsite providers enrolled in Texas Medicaid that are not otherwise excepted from such reimbursement. Procedure code 1 Q3014 is payable to physicians and physician groups, PAs, and APNs in the office and outpatient hospital settings, and to hospitals in the outpatient hospital setting. A telepresenter who meets one of the qualifications listed below must be at the patient site when the service is provided via telemedicine: An individual who is licensed or certified in Texas to perform health-care services and who presents or is delegated tasks and activities only within the scope of the individual s licensure or certification. A qualified mental health professional (QMHP) as defined in Title 25 Texas Administrative Code (TAC) (31). All patient sites must maintain documentation for each service, including: The date of the service. The name of the patient. The name of the distant-site provider. The patient site that bills for the service must maintain records that document: The name of the referring and/or requesting provider. The name of the telepresenter. A patient site that does not bill for the patient-site service must also maintain this documentation when it is available. Texas Medicaid Bulletin, No May/June 2009

17 Telemedicine Facility Fee Reimbursement Rate Effective for dates of services on or after April 1, 2009, telemedicine facility fee (procedure code 1-Q3014) is a benefit of Texas Medicaid with a reimbursement rate of $ This initial reimbursement rate was adopted following a public rate hearing that was held on February 17, The following reimbursement rate for telemedicine facility fees is effective April 1, 2009: TOS Procedure Code Reimbursement Rate 1 Q3014 $23.72 Reimbursement Rates for Ambulatory Surgical Centers, Dental, and DME Services Effective for dates of service on or after January 1, 2008, Texas Medicaid reimbursement rates for 2008 HCPCS procedure codes have changed for ambulatory surgical centers, dental, and DME services. The new reimbursement rates were adopted following a public rate hearing on November 17, Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. The following reimbursement rates for 2008 HCPCS procedure codes for ambulatory surgical, dental, and DME services are effective for dates of service on or after January 1, The 2009 HCPCS replacement codes included in the following table are effective for dates of services on or after January 1, TOS Procedure Code 2009 HCPCS Replacement Procedure Code Medicaid Reimbursement Rate Ambulatory Surgical Centers F Not applicable Group 9 F Not applicable Group 1 Dental D2970 Not applicable $ DME Services 9 A5083 Not applicable $0.63 J E0856 Not applicable $ J E2227 Not applicable $1, J E2228 Not applicable $ L7611 L6711 $ L7612 L6712 $1, L7613 L6713 $1, L7614 L6714 $1, L7621 L6721 $2, L7622 L6722 $1, May/June Texas Medicaid Bulletin, No. 223

18 DSHS Laboratory Criteria Changes Effective March 12, 2009, the Texas Department of State Health Services (DSHS) Laboratory has new specimen acceptance criteria for specimens submitted for syphilis (RPR and TPPA), Human Immunodeficiency Virus (HIV), and Hepatitis C testing. To maintain high testing standards, the DSHS Laboratory has implemented more stringent acceptance/rejection criteria for specimens submitted for syphilis (RPR and TPPA), HIV, and Hepatitis C (HBV/HCV) testing. Effective March 12, 2009, the DSHS laboratory only accepts serum specimens shipped cold and received within five days of specimen collection. Providers can collect serum specimens in one of the following ways: The specimen may be collected in a red-top blood collection tube and centrifuged within 2 hours of collection. The serum must then be poured into a transport tube, which is shipped overnight cold, on cold packs. The specimen may be collected in a serum separator tube (SST), centrifuged within two hours of collection, and the SST shipped overnight cold, on cold packs. With an SST the fill volume in the tube is critical. Tubes with volumes that are not within plus or minus 10 percent of the indicated appropriate fill volume will be rejected and not tested. The DSHS Laboratory can help providers implement the new requirements in the following ways: If a provider is able to collect, centrifuge, and ship the specimens using the methods specified above, the DSHS Laboratory can provide the following supplies: Tubes for specimen collection (either the red-top blood collection tubes or SST, based on the provider s preference). Transport tubes in which to pour specimens for providers that choose to use the red-top blood collection tubes. Containers and cold packs for shipping specimens. Air bills to cover overnight shipment costs. Providers that have no means to centrifuge specimens within two hours of collection should contact Susan Hoffpauir at , ext. 6030, or by at labinfo@dshs.state.tx.us In addition, THSteps providers have the option to use commercial laboratories instead of the DSHS Laboratory for these specific tests. The procedures for THSteps providers to follow are posted on the DSHS website at /lab/serumspecimencriteria.shtm. The DSHS Laboratory provides instructions on how to request necessary supplies. Providers that do not have experience with centrifuging blood specimens will receive safety instructions and training materials. Updated information will be posted on the DSHS website. Providers are encouraged to check the DSHS website regularly for the most current information. Clinical Directed Care Coordination Services Clarification This is a clarification to an article that was published in the January/February 2009 Texas Medicaid Bulletin, No. 220, and on the TMHP website at on October 24, 2008, titled Clinician-Directed Care Coordination Services Changes for THSteps-CCP. The limitation for telephone consultations is on a per-client basis. The complete limitation is as follows: Telephone consultations are limited to 2 every 6 months, per client, same provider, and are not reimbursed to the clinician providing the medical home. Texas Medicaid Bulletin, No May/June 2009

19 Reimbursement Rates Changed for Physician-Administered Drugs and Biologicals Effective for dates of services on or after April 1, 2009, Texas Medicaid reimbursement rates changed for physician-administered drugs and biologicals procedure codes. The vaccine reimbursement rates are in effect only if the vaccine is not available from TVFC for a TVFC-eligible client or if the client is not eligible for TVFC. Not available is defined as a new vaccine: approved by ACIP that has not been negotiated or added to a TVFC contract; for which TVFC has not yet established funding: or where national supply or distribution issues limit availability. Providers will be notified when Medicaid recognizes that a vaccine meets the definition of not available. Not all vaccines are available for adults. The following reimbursement rates for physician administered drugs and biologicals are effective April 1, 2009: TOS Procedure Code Reimbursement Rate $ $ $ $ /S* $ /S* $ /S* $ /S* $ /S* $ /S* $ /S* $ /S $ /S $ /S $ /S $ /S* $ /S* $ /S* $ /S* $ /S* $ /S* $ /S $ /S* $30.81 * Available through TVFC Type of Service S - THSteps TOS Procedure Code Reimbursement Rate 1/S $ /S* $ /S* $ /S $ /S* $ /S* $ /S $ $ J0129 $ J0130 $ J0132 $ J0133 $ J0135 $ J0150 $ J0152 $ J0170 $ J0180 $ J0205 $ J0207 $ J0210 $ J0215 $ J0220 $ J0256 $ J0278 $ J0280 $ J0282 $ J0285 $ J0287 $ J0288 $ J0289 $ J0290 $ J0295 $ J0300 $ J0330 $ J0348 $ J0360 $ J0364 $3.71 * Available through TVFC Type of Service S - THSteps May/June Texas Medicaid Bulletin, No. 223

20 TOS Procedure Code Reimbursement Rate 1 J0456 $ J0460 $ J0470 $ J0475 $ J0476 $ J0480 $1, J0500 $ J0515 $ J0530 $ J0540 $ J0550 $ J0560 $ J0570 $ J0580 $ J0583 $ J0585 $ J0587 $ J0592 $ J0594 $ J0595 $ J0600 $ J0610 $ J0636 $ J0637 $ J0640 $ J0670 $ J0690 $ J0692 $ J0694 $ J0696 $ J0697 $ J0698 $ J0702 $ J0706 $ J0713 $ J0720 $ J0725 $ J0735 $ J0740 $ J0743 $13.68 * Available through TVFC Type of Service S - THSteps TOS Procedure Code Reimbursement Rate 1 J0744 $ J0760 $ J0770 $ J0780 $ J0795 $ J0800 $2, J0835 $ J0878 $ J0881 $ J0882 $ J0885 $ J0886 $ J0894 $ J0895 $ J0970 $ J1000 $ J1020 $ J1030 $ J1040 $ J1051 $ J1070 $ J1080 $ J1100 $ J1110 $ J1120 $ J1160 $ J1162 $ J1165 $ J1170 $ J1190 $ J1200 $ J1205 $ J1212 $ J1230 $ J1240 $ J1245 $ J1250 $ J1260 $ J1265 $ J1270 $3.31 * Available through TVFC Type of Service S - THSteps Texas Medicaid Bulletin, No May/June 2009

21 TOS Procedure Code Reimbursement Rate 1 J1327 $ J1335 $ J1364 $ J1380 $ J1390 $ J1410 $ J1430 $ J1435 $ J1438 $ J1440 $ J1441 $ J1450 $ J1451 $ J1455 $ J1457 $ J1458 $ J1460 $ J1470 $ J1480 $ J1490 $ J1500 $ J1510 $ J1520 $ J1530 $ J1540 $ J1550 $ J1560 $ J1561 $ J1562 $ J1566 $ J1568 $ J1569 $ J1570 $ J1571 $ J1572 $ J1573 $ J1580 $ J1595 $ J1600 $ J1610 $74.95 * Available through TVFC Type of Service S - THSteps TOS Procedure Code Reimbursement Rate 1 J1626 $ J1630 $ J1631 $ J1642 $ J1644 $ J1645 $ J1650 $ J1652 $ J1670 $ J1720 $ J1740 $ J1742 $ J1743 $ J1745 $ J1756 $ J1785 $ J1790 $ J1800 $ J1825 $ J1830 $ J1840 $ J1850 $ J1885 $ J1931 $ J1940 $ J1945 $ J1950 $ J1955 $ J1956 $ J1980 $ J2010 $ J2060 $ J2150 $ J2175 $ J2185 $ J2210 $ J2248 $ J2260 $ J2270 $ J2271 $2.44 * Available through TVFC Type of Service S - THSteps May/June Texas Medicaid Bulletin, No. 223

22 TOS Procedure Code Reimbursement Rate 1 J2275 $ J2300 $ J2310 $ J2320 $ J2321 $ J2322 $ J2323 $ J2325 $ J2353 $ J2354 $ J2355 $ J2357 $ J2360 $ J2370 $ J2400 $ J2405 $ J2410 $ J2425 $ J2430 $ J2440 $ J2469 $ J2501 $ J2503 $1, J2504 $ J2505 $2, J2510 $ J2515 $ J2540 $ J2543 $ J2545 $ J2550 $ J2560 $ J2590 $ J2597 $ J2675 $ J2680 $ J2690 $ J2700 $ J2720 $ J2730 $89.34 * Available through TVFC Type of Service S - THSteps TOS Procedure Code Reimbursement Rate 1 J2760 $ J2765 $ J2770 $ J2778 $ J2780 $ J2788 $ J2790 $ J2791 $ J2792 $ J2794 $ J2800 $ J2810 $ J2820 $ J2916 $ J2920 $ J2930 $ J2993 $ J2997 $ J3000 $ J3010 $ J3030 $ J3070 $ J3105 $ J3120 $ J3130 $ J3230 $ J3240 $ J3243 $ J3246 $ J3250 $ J3260 $ J3265 $ J3285 $ J3301 $ J3303 $ J3315 $ J3360 $ J3370 $ J3396 $ J3410 $0.25 * Available through TVFC Type of Service S - THSteps Texas Medicaid Bulletin, No May/June 2009

23 TOS Procedure Code Reimbursement Rate 1 J3411 $ J3415 $ J3420 $ J3430 $ J3465 $ J3470 $ J3472 $ J3473 $ J3480 $ J3485 $ J3487 $ J3488 $ J7187 $ J7189 $ J7190 $ J7193 $ J7194 $ J7197 $ J7198 $ J7321 $ J7322 $ J7323 $ J7324 $ J7501 $ J7504 $ J7505 $1, J7511 $ J7513 $ J7516 $ J7525 $ J7611 $ J7612 $ J7613 $ J7614 $ J7620 $ J7674 $ J9000 $ J9001 $ J9010 $ J9015 $ * Available through TVFC Type of Service S - THSteps TOS Procedure Code Reimbursement Rate 1 J9020 $ J9025 $ J9027 $ J9031 $ J9035 $ J9040 $ J9041 $ J9045 $ J9050 $ J9055 $ J9060 $ J9062 $ J9065 $ J9070 $ J9080 $ J9090 $ J9091 $ J9092 $ J9093 $ J9094 $ J9095 $ J9096 $ J9097 $ J9100 $ J9110 $ J9120 $ J9130 $ J9140 $ J9150 $ J9151 $ J9160 $1, J9170 $ J9178 $ J9181 $ J9185 $ J9190 $ J9200 $ J9201 $ J9202 $ J9206 $21.72 * Available through TVFC Type of Service S - THSteps May/June Texas Medicaid Bulletin, No. 223

24 TOS Procedure Code Reimbursement Rate 1 J9208 $ J9209 $ J9211 $ J9212 $ J9213 $ J9214 $ J9217 $ J9218 $ J9219 $4, J9225 $1, J9226 $14, J9230 $ J9245 $1, J9250 $ J9260 $ J9261 $ J9263 $ J9264 $ J9265 $ J9266 $2, J9268 $1, J9280 $ J9290 $ J9291 $ J9293 $ J9300 $2, J9303 $ J9305 $ J9310 $ J9320 $ J9340 $ J9350 $ J9355 $ J9360 $ J9370 $ J9375 $ J9380 $ J9390 $ J9395 $ J9600 $2, * Available through TVFC Type of Service S - THSteps TOS Procedure Code Reimbursement Rate 1 Q2009 $ Q2017 $ Q3025 $ Q3026 $ Q4081 $ S0020 $ S0023 $ S0145 $ J7304 $ J7307 $ * Available through TVFC Type of Service S - THSteps Reminder: Providers that request reimbursement for drugs must bill using the correct unit calculations. Claims submitted with incorrect unit calculations may cause a delay or incorrect payment. Providers can refer to the article that was published on the TMHP website at titled Unit Calculations for Billing Drugs for details about the following topics: Billing the correct number of HCPCS units Billing using the correct NDC information Billing for leucovorin calcium, botulinum toxin A (Botox), medroxyprogesterone acetate (Depo-Provera), respiratory syncytial virus immune globulin (RSV Prophylaxis) Exceptions for billing procedure code Texas Medicaid Bulletin, No May/June 2009

25 Reimbursement Rate Changes for Medical Services, Surgical, Interpretation, and Total Component Effective for dates of service on or after April 1, 2009, the reimbursement rates for some medical services, surgical, interpretation, and total component procedure codes changed for Texas Medicaid. The reimbursement rates were adopted following a public rate hearing that was held on February 17, The following reimbursement rates are effective April 1, 2009, for clients of all ages: TOS Procedure Code Reimbursement Rate Medical Services $33.51 (1.17 relative value units [RVUs], $45.25 (1.58 RVUs, $46.97 (1.17 RVUs, 1* $ * $37.80 (1.32 RVUs, 1* $35.51 (1.24 RVUs, 1* $63.58 (2.22 RVUs, $ conversion factor Surgical Services $ (3.61 RVUs, $ $ $ $ $ (20.70 RVUs, $ (29.41 RVUs, * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. TOS Procedure Code Surgical Services Reimbursement Rate $1, $1, $1, $1, $1, $2, $2, $1, $ $2, $1, $1, $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $ $ $1, $ $ $ $ * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. May/June Texas Medicaid Bulletin, No. 223

26 TOS Procedure Code Surgical Services Reimbursement Rate $ $ Interpretations I $75.65 I $37.30 I $14.32 (0.50 RVU, I $16.04 (0.56 RVU, I $13.17 (0.46 RVU, I $5.41 I $10.31 (0.36 RVU, I $9.16 (0.32 RVU, I $11.46 (0.40 RVU, I $79.05 (2.76 RVUs, I $63.87 (2.23 RVUs, I $ I $ (6.81 RVUs, I $ (6.54 RVUs, I $ I $ (8.00 RVUs, I $ (11.01 RVUs, * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. TOS Procedure Code Interpretations Reimbursement Rate I $ (11.03 RVUs, I $ I $ I $ (13.68 RVUs, I $ (7.63 RVUs, I $ I $ I $ I $ (10.16 RVUs, I $78.76 (2.75 RVUs, I $61.86 (2.16 RVUs, I $ I $ I $ I $ I $ I $ I $ I $40.67 (1.42 RVUs, I $69.61 I $ I $ I $ I $ I $ * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. Texas Medicaid Bulletin, No May/June 2009

27 TOS Procedure Code Interpretations Reimbursement Rate I $ (4.46 RVUs, I $ I $ I $ I $ I $ I $ I $62.03 Total Component T $27.74 T $40.89 T $19.19 (0.67 RVU, T $29.21 (1.02 RVUs, T $33.80 (1.18 RVUs, T $22.00 T $27.49 (0.96 RVU, T $26.35 (0.92 RVU, T $52.12 (1.82 RVUs, T $ T $63.87 T $ T $ (13.89 RVUs, T $ (22.87 RVUs, * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. TOS Procedure Code Total Component Reimbursement Rate T $1, T $1, T $ T $1, T $1, T $1, T $1, T $1, T $ T $1, T $1, T $1, T $ T $88.65 T $81.94 T $44.87 T $70.11 T $ T $56.99 T $67.47 T $ T $10.10 T $28.33 T $ T $ T $ T $10.27 T $ T $1, T $63.39 T $6.22 T $ T $ T $ T $67.44 * These reimbursement rate changes also apply to radiological labs, portable X-ray suppliers, and physiological labs. May/June Texas Medicaid Bulletin, No. 223

28 Newborn Services Benefits Changed for Texas Medicaid Effective for dates of service on or after September 1, 2008, the benefit criteria for newborn services changed for Texas Medicaid. Note: The following article incorporates the 2009 HCPCS updates that were effective for dates of service on or after January 1, For dates of service before January 1, 2009, the appropriate procedure codes should be used when billing for these services. Routine newborn care, attendance at delivery, newborn resuscitation, neonatal critical care, and intensive (noncritical) care services are benefits of Texas Medicaid for clients birth through 28 days of age. The following procedure codes may be used to bill newborn services: Procedure Codes Note: Some of these services may also be provided to clients 29 days of age or older. Retrospective review may be performed to ensure documentation supports the medical necessity of the service and any modifier used when billing the claim. THSteps Newborn Examination and Routine Newborn Care Providers do not have to be enrolled as THSteps providers to bill newborn examination procedure codes , , , and Newborn examinations billed with procedure codes and may be counted as a THSteps medical checkup when all necessary components are completed and documented in the medical record. Providers may refer to the 2008 Texas Medicaid Provider Procedures Manual, Section , Newborn Examination, for a list of required components for an initial THSteps examination. Providers may submit a claim to TMHP using their non- THSteps provider identifier. If a brief newborn examination is performed that does not fulfill THSteps medical checkup criteria, procedure code or may be reimbursed when billed with modifier 52. Procedure code is limited to one per date of service by any provider and will be denied when billed for the same date of service by the same provider as procedure code or Procedure codes and are limited to once per lifetime, any provider, when provided in the hospital or birthing room (either hospital or birthing center) setting. Hospital discharge (procedure codes and ) is denied when billed for the same date of service by the same provider as newborn care (procedure code , , or ). The following procedure codes will be denied when billed for the same date of service by the same provider as , , or : Procedure Codes T I /I /I /I /I /I /I G0102 Procedure code may be reimbursed when newborns are admitted and discharged on the same day from the hospital or birthing room (either hospital or birthing center) setting. If the client is readmitted within the first 28 days of life, the provider must bill an initial hospital E/M admission (procedure code , , or ). The following procedure codes will be denied when billed on the same date of service by the same provider as procedure code : Procedure Codes /I /I /I /I /I /I G0102 Procedure code will be denied when billed for the same date of service as procedure code Attendance at Delivery, Newborn Resuscitation, Critical Care, and Intensive Care An E/M service performed by the same physician on the same day as the attendance at delivery, newborn resuscitation, neonatal critical care, intensive (noncritical care), or other service may only be reimbursed after submitting an appeal with medical documentation. This documentation must show that the E/M procedure is a separately- Texas Medicaid Bulletin, No May/June 2009

29 identifiable service. Documentation includes, but is not limited to, office or hospital medical records, such as medical history, physical progress notes, and lab results. Modifier 25 must be submitted with the E/M code. Attendance at Delivery Attendance at the delivery (procedure code ) may be reimbursed once per lifetime and only on the day of delivery. This procedure code must be billed by a physician other than the delivering physician. The following procedure codes will be denied when billed for the same date of service by the same provider as procedure code : Procedure Codes /I /I /I /I /I /I G0102 Newborn Resuscitation Newborn resuscitation (procedure code ) may be reimbursed when billed for the same date of service as initial hospital care (procedure code ). The following procedure codes will be denied when billed for the same date of service by the same provider as procedure code : Procedure Codes /I /I /I /I /I /I G0102 Critical Care Newborn critical care must be billed using procedure code or If a second physician provides critical care on the same day at a separate time from the first service, the physician must bill procedure code or Newborn critical care provided in an outpatient setting (e.g., emergency room) that does not result in admission must be billed using procedure codes and Services for a client who is not critically ill or unstable but who is treated in a critical care unit must be reported as subsequent hospital care (procedure code , , or ) or a hospital consultation (procedure code , , , , or ). Intensive Care Initial hospital care provided to newborns who require intensive observation, frequent interventions, and other intensive services must be billed using procedure code Procedure code must be billed daily irrespective of the time that the provider spends with the client. Procedure codes and will be denied when billed for the same date of service by the same provider with procedure code Procedure code , , or must be billed for subsequent care provided to newborns who do not meet the definition of critically ill but who continue to require intensive observation, frequent interventions, and other intensive services only available in the intensive care setting. When the present body weight of a newborn exceeds 5,000 g, subsequent hospital care (procedure code , or ) must be billed. Procedure codes , , and will be denied when billed by any provider for the same date of service as procedure code or Procedure codes and will be denied when billed for the same date of service by the same provider as procedure code , , or Additional Limitations Initial newborn critical and intensive care (procedure codes and ) may be reimbursed once per admission by any provider. For subsequent admissions during the first 28 days of life, procedure codes and may be reimbursed on appeal. Subsequent critical and intensive care (procedure codes , , , and ) may be reimbursed once per day by any provider. Procedure May/June Texas Medicaid Bulletin, No. 223

30 code will be denied when billed for the same date of service as procedure code or Separate charges for any of the procedures listed in the table below will be denied when billed for the same date of service as neonatal critical care (procedure code or ), initial intensive care (procedure code ), and intensive (noncritical) care (procedure code , , or ). Procedure Codes / /F /I/T /I/T /I/T T I /I/T /I/T /I/T /I /I /I /I /I /I / / / / / / *Procedure codes are not bundled with procedure codes , , and **Procedure codes are not bundled with procedure code Procedure Codes 1/ /2/G /2/G /2/G /P /G /G /G /G ** ** ** ** ** ** ** ** ** ** ** ** ** ** 1/ / / / / * * G M0064 *Procedure codes are not bundled with procedure codes , , and **Procedure codes are not bundled with procedure code Texas Medicaid Bulletin, No May/June 2009

31 Updates to Previously Published Information Correction to Hearing Aid Devices Limited to Every 5 Years TMHP has identified an issue that impacts claims that were submitted with dates of service on or after December 2, 2008, and the following hearing aid device procedure codes: Diagnosis Codes V5011 V5014 V5030 V5040 V5090 V5100 V5110 V5160 V5170 V5180 V5200 V5210 V5220 V5240 V5241 V5244 V5249 V5250 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5264 V5265 V5275 Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual, Section 23, Hearing Aid and Audiological Services, on page 23-1, and TAC effective October 1, 2005, for information about the hearing aid benefit effective for dates of service on or before December 1, Effective for dates of service on or after December 2, 2008, the limitation for hearing aid devices for clients 21 years of age or older has changed. The following may be billed every five years without prior authorization: One monaural procedure code may be billed every 5 years with modifier LT (i.e., for the left ear). More than one monaural procedure code billed with modifier LT will not be reimbursed within the same 5-year period. One monaural procedure code may be billed every 5 years with modifier RT (i.e., for the right ear). More than one monaural procedure code billed with modifier RT will not be reimbursed within the same 5-year period. Note: If the hearing devices for both ears were purchased at different times, each monaural hearing device (i.e., one for the right ear and one for the left ear) has the limitation of one every 5 rolling years. One binaural procedure code may be billed every 5 years (i.e., one set of hearing aid devices). More than one binaural procedure code will not be reimbursed within the same 5-year period. The binaural procedure code must be billed with a quantity of one. Important: A monaural procedure code and a binaural procedure code will not be reimbursed within the same 5-year period without prior authorization. Claims may have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. Note: These limitations do not affect Program for Amplification for Children in Texas (PACT) services. Correction to Reminder for FQHC Providers Article This is a correction to an article published in the November/December 2008 Texas Medicaid Bulletin, No. 219, titled Reminder for FQHC Providers. Some procedure codes were omitted from the THSteps Medical Services and Copayment sections of the table. Procedure code S should be included in the THSteps Medical Services section, and procedure code 1-CP002 should be included in the Copayments section. The complete tables can be found in the 2009 Texas Medicaid Provider Procedures Manual, Section 21.3, Benefits and Limitations, on page Correction to Restriction Changes for 2008 HCPCS Procedure Codes This is a correction to an article published in the July/ August 2008 Texas Medicaid Bulletin, No. 216, titled Restriction Changes for 2008 HCPCS Procedure Codes. The article did not include a POS change for procedure code Effective for dates of service from June 1, 2008, through December 31, 2008, procedure code is not reimbursed in the home setting. Procedure code may be reimbursed in the office setting to APNs, PAs, physicians, podiatrists, and CCP providers. The extended care facility (ECF) is no longer reimbursed. Note: Procedure code is discontinued as of January 1, 2009, and is no longer reimbursed. Technetium TC 99M Correction Article This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, Section , Technetium TC 99M, on page , and also to a banner message that was published on November 23, The banner May/June Texas Medicaid Bulletin, No. 223

32 message and manual incorrectly state that procedure codes 9-A9500 and 9-A9502 are limited to 3 per day, any provider. The correct statement is as follows: Procedure codes 9-A9500 and 9-A9502 are limited to 3 per day, same provider. Correction to the 2009 HCPCS Special Bulletin, No. 221 This is a correction to the 2009 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin, No The bulletin indicates incorrect benefit information for the following procedure codes: Procedure Codes The bulletin incorrectly indicates that procedure code is limited to diagnosis code V202. Effective for dates of service on or after January 1, 2009, procedure code is not reimbursed when billed with diagnosis code V202. Providers may appeal denied claims with an appropriate diagnosis code. Procedure codes , , , , and were incorrectly added to the 2009 HCPCS Procedure Code Additions table in the bulletin indicating that the procedure codes were not covered by Texas Medicaid. These procedure codes are replacement codes and were correctly added to the Replacement Procedure Codes table. Procedure codes , , , , and are benefits of Texas Medicaid and replace discontinued procedure codes , , , , and These procedure codes are not covered by the CSHCN Services Program. The following table provides the location of each of the affected procedure codes in the 2009 HCPCS Special Bulletin No. 221: Procedure Code Article and Page Number(s) HCPCS Procedure Code Additions on page 5 Replacement Procedure Codes on page 10 Critical Care Services on pages 14 and 15 Newborn Services on pages Outpatient Behavioral Health Services on page 20 THSteps Periodic Visits on page HCPCS Procedure Code Additions on page 5 Replacement Procedure Codes on page 10 Critical Care Services on pages 14 and 15 Newborn Services on pages Outpatient Behavioral Health Services on page HCPCS Procedure Code Additions on page 5 Replacement Procedure Codes on page 10 Critical Care Services on pages 14 and 15 Newborn Services on pages Outpatient Behavioral Health Services on page HCPCS Procedure Code Additions on page 5 Replacement Procedure Codes on page 10 Newborn Services on pages Outpatient Behavioral Health Services on page HCPCS Procedure Code Additions on page 5 Correction to 2009 Texas Medicaid Provider Procedures Manual Section This is a correction to the 2009 Texas Medicaid Provider Procedures Manual. Section titled Maintenance of Provider Information on page 1-11 contains an incorrect page reference. The following is the correct information. Providers must, within 10 calendar days of occurrence, report changes in address (physical location or accounting), telephone number, name, ownership status, tax ID, and any other information pertaining to the structure of the provider s organization (for example, performing providers). Changes in address, office telephone, fax number, and address should be updated online Texas Medicaid Bulletin, No May/June 2009

33 /Ambulance Providers using the online provider lookup update page. Alternately, providers may update their address information using either the Provider Information Change (PIC) Form on page B-80 and B-81 or the Demographic Update (DU) Form on the TMHP website at Correction to 2009 Texas Medicaid Provider Procedures Manual Section This is a correction to the 2009 Texas Medicaid Provider Procedures Manual. Section , Pulse Oximetry on page incorrectly states that pulse oximeters are a benefit of Home Health Services. Pulse oximeters are not a benefit of Home Health Services, but they are a benefit of Texas Medicaid through THSteps-CCP. Refer to the 2009 Texas Medicaid Provider Procedures Manual, Section , Croup Tent/Pulse Oximeter, on page for additional information on pulse oximeters. Clarification to the 2009 Texas Medicaid Provider Procedures Manual Laboratory Panel-Related Sections This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, Section , Hospital Laboratory Services, on page 25-32, and Section , Organ or Disease Panel, on page 26-7 for laboratory panel procedure code The following are the correct procedure code combinations included in laboratory panel 80055: Panel must include: PLUS either Or and Or and Or and Correction to 2009 Texas Medicaid Provider Procedures Manual Section This is a correction to the 2009 Texas Medicaid Provider Procedures Manual. Section , Medicaid Clinical Criteria for Inpatient Psychiatric Care for Clients on page incorrectly states the client must have a valid Axis II, DSM-IV-TR diagnosis as the principal admitting diagnosis. The correct statement is as follows: The client must have a valid Axis I, DSM-IV-TR diagnosis as the principal admitting diagnosis, and outpatient therapy or partial hospitalization must have been attempted and failed, or a psychiatrist must have documented reasons why an inpatient level of care is required. Ambulance Providers Correction to Ambulance Claims Information This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, Section 8.8, Claims Information, on page This section contains an incorrect CMS-1500 claim form reference to Block 9 for nonemergency hospital-to-hospital transfers. The complete, corrected paragraph is as follows: Nonemergency claims filed electronically must include the prior authorization number in the appropriate field. For nonemergency hospitalto-hospital transfers, indicate the services required from the second facility that are unavailable at the first facility in Block 19 of the CMS-1500 claim form. If the destination is a hospital, enter the name and address and the provider identifier of the facility in Block 32. Update to 2009 Texas Medicaid Provider Procedures Manual Section This is an update to the 2009 Texas Medicaid Provider Procedures Manual, Section , Authorization Requirements, on page Effective for dates of service on or after January 1, 2007, magnetic resonance imaging (MRI) procedure code 4/I/T requires prior authorization and is included in the procedure code table. May/June Texas Medicaid Bulletin, No. 223

34 Home Health Providers Home Health Providers Benefits Change for Home Health Bath and Bathroom Equipment Effective for dates of service on or after April 1, 2009, a toilet seat lift mechanism (procedure code J-E0172) is a benefit of Texas Medicaid when prior authorized. Procedure code J-E0172 may be prior authorized for clients who meet all of the following criteria: The client must have severe arthritis of the hip or knee or have a severe neuromuscular disease. The toilet seat lift mechanism must be a part of the physician s course of treatment and be prescribed to correct or ameliorate the client s condition. Once standing, the client must have the ability to ambulate. The client must be completely incapable of standing up from a regular armchair or any chair in the client s home. The client s difficulty or incapability of getting up from a chair is not sufficient justification for a toilet seat lift mechanism. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms. The submitted documentation must include an assessment completed by a physician, physical therapist, or occupational therapist. The assessment must include the following: A description of the client s current level of function without the device An explanation why a non-mechanical toilet elevation device, such as toilet rails, or elevated toilet seat, will not meet the client s needs Documentation identifying how the toilet seat lift mechanism will improve the client s function A list of the mobility-related activities of daily living the client will be able to perform with the toilet seat lift mechanism that the client is unable to perform without the toilet seat lift mechanism and a description of how this will increase the client s independence The client s goals for use of the toilet seat lift mechanism Supporting documentation must be kept in the client s record that all appropriate therapeutic modalities (e.g., medication or physical therapy) have been tried and that they failed to enable the client to transfer from a chair to a standing position. Prior authorization will be given for either mechanical or powered toilet-assist devices, not for both. If a client already owns one or more mechanical toilet-assist devices, a powered toilet seat lift mechanism will not be prior authorized unless there has been a documented change in the client s condition such that the client can no longer use the mechanical equipment. Almost all clients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms. Toilet seat lift mechanisms are limited to those types that operate smoothly, can be controlled by the client, and effectively assist a client in standing up and sitting down without other assistance. A toilet seat lift operated by a spring release mechanism that jolts the client from a seated to a standing position is not a benefit of Texas Medicaid. Toilet seat lift mechanisms are limited to one every 5 years. The Durable Medical Equipment (DME) Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. The DME Certification and Receipt Form must be submitted for DME claims and appeals when: A single item meets or exceeds a billed amount of $2,500. Multiple items submitted on the same date of service meet or exceed a total billed amount of $2,500. Claims submitted without the DME Certification and Receipt Form will be denied. Clients who receive DME that meets or exceeds a total billed amount of $2,500 may be contacted to verify receipt of the equipment. If receipt of the equipment cannot be verified, the claim payment is eligible for recoupment. Texas Medicaid Bulletin, No May/June 2009

35 Home Health Providers Mobility Aids-Home Health Benefits Change Effective for dates of service on or after April 1, 2009, benefit criteria for home health mobility aids have changed for Texas Medicaid. The following mobility aid procedure codes are a benefit of Texas Medicaid with prior authorization: J-E0628, J-E0629, J-E1010, and J-E2300. Power Seat Elevation System Procedure code J-E2300 may be reimbursed with prior authorization to promote independence in a client who meets all of the following criteria: The client does not have the ability to stand or pivot transfer independently. The client requires assistance only with transfers across unequal seat heights. The client has limited reach and range of motion in the shoulder or hand that prohibits independent performance of mobility-related activities of daily living (MRADLs) in the home, such as dressing, feeding, grooming, hygiene, meal preparation, and toileting. The power seat elevation system option will not be reimbursed for the convenience of a caregiver, or if the device will not allow the client to become independent with MRADLs and transfers. The submitted documentation must include an assessment completed, signed, and dated by a physician, physical therapist, or occupational therapist. The assessment must include the following: A description of the client s current level of function without the device Documentation that identifies how the power seat elevation system will improve the client s function What MRADLs the client will be able to perform with the power seat elevation system that the client is unable to perform without the power seat elevation system and how this will increase independence The duration of time the client is alone during the day without assistance The client s goals for use of the power seat elevation system A power seat elevation system is limited to one every five years. Power Elevating Leg Lifts Power elevating leg lifts (procedure code J-E1010) may be reimbursed with prior authorization for clients who have compromised upper extremity function that limits the client s ability to use manual elevating leg rests. The client must meet the criteria for a power wheelchair with a reclining back and one of the following: The client has a musculoskeletal condition such as flexion contractures of the knees and legs, or the placement of a brace that prevents 90-degree flexion at the knee. The client has significant edema of the lower extremities that requires elevating the client s legs. The client experiences hypotensive episodes that require frequent positioning changes. The client needs power tilt and recline and is required to maintain anatomically correct positioning and reduce exposure to skin shear. The submitted documentation must include an assessment completed, signed, and dated by a physician, physical therapist, or occupational therapist that includes the following: A description of the client s current level of function without the device Documentation that identifies how the power elevating leg lifts will improve the client s function A list of MRADLs the client will be able to perform with the power elevating leg lifts that the client is unable to perform without the power elevating leg lifts and how this will increase independence The duration of time the client is alone during the day without assistance The client s goals for use of the power elevating leg lifts A power elevating leg lift is limited to 1 every 5 years. Seat Lift Mechanism A seat lift mechanism (procedure code J-E0628 [electric] or procedure code J-E0629 [non-electric]) may be reimbursed with prior authorization for clients who meet all of the following criteria: The client must have severe arthritis of the hip or knee or have a severe neuromuscular disease. The seat lift mechanism must be a part of the physician s course of treatment and be prescribed to correct or ameliorate the client s condition. May/June Texas Medicaid Bulletin, No. 223

36 Home Health Providers Once standing, the client must have the ability to ambulate. The client must be completely incapable of standing up from a regular armchair or any chair in his or her home. The submitted documentation must include an assessment completed, signed, and dated by a physician, physical therapist, or occupational therapist. Seat lift mechanisms are limited to those types that operate smoothly The assessment must include the following: A description of the client s current level of function without the device Documentation that identifies how the seat lift mechanism will improve the client s function What MRADLs the client will be able to perform with the seat lift mechanism that the client is unable to perform without the seat lift mechanism and how this will increase independence The duration of time the client is alone during the day without assistance The client s goals for use of the seat lift mechanism The client s difficulty or incapability of getting up from a chair is not sufficient justification for a seat lift mechanism. Almost all ambulatory clients can get out of an ordinary chair if the seat height is appropriate and the chair has arms. Supporting documentation must be kept in the client s record that all appropriate therapeutic modalities (e.g., medication or physical therapy) have been tried and that they failed to enable the client to transfer from a chair to a standing position. Seat lift mechanisms are limited to those types that operate smoothly, can be controlled by the client, and effectively assist a client in standing up and sitting down without other assistance. A seat lift operated by a spring release mechanism that jolts the client from a seated to a standing position is not a benefit of Texas Medicaid. The payment for a recliner or chair with the incorporated seat lift mechanism is limited to the amount of the seat lift mechanism. Limitation Changes Effective April 1, 2009, maximum limitations changed for the following procedure codes. The new limitation is 2 per year unless specified. Procedure Code Previous Limitation Procedure Code Previous Limitation J-E per year J-E per year J-E per year J-E0969* 1 per year J-E pair per year J-E per year J-E per year J-E2210** 1 per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years J-E per 5 years *1 per 5 years, **4 per year Reimbursement The DME Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. The DME Certification and Receipt Form must be submitted for DME claims and appeals when: A single item meets or exceeds a billed amount of $2,500. Multiple items submitted on the same date of service meet or exceed a total billed amount of $2,500. Claims submitted without the DME Certification and Receipt Form will be denied. Clients who receive DME that meets or exceeds a total billed amount of $2,500 may be contacted to verify receipt of the equipment. If receipt of the equipment cannot be verified, the claim payment is eligible for recoupment. Texas Medicaid Bulletin, No May/June 2009

37 Managed Care Providers Managed Care Providers The 2009 Clinical Decision Support Tool for Advanced Imaging Guide Now Available The 2009 Clinical Decision Support Tool for Advanced Imaging Guide is now accessible from the Provider Manuals and Guides area on the TMHP website at MedSolutions, Inc., which performs radiology authorization services on behalf of TMHP, annually updates the Clinical Decision Support Tool for Advanced Imaging Guide. These clinical guidelines help providers identify the most appropriate imaging procedure for the client s clinical condition. 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 nuclear medicine imaging. Imaging guidelines are available for head, neck, chest, cardiac, peripheral vascular disease, abdomen, pelvis, musculoskeletal, spine, peripheral nerve disorders, and oncology. Pediatric and congenital imaging guidelines are identified separately from adult guidelines in the table of contents. Pediatric imaging guidelines are available for head, neck and chest, cardiac, spine and peripheral nerve disorders, abdomen, musculoskeletal, and oncology. The following new guidelines have been added to this year s edition: Region Head Cardiac Chest Abdomen Pelvis Musculoskeletal Spine Peripheral nerve disorders Peripheral vascular disease Oncology Pediatric and congenital New Guidelines for Follow-up imaging in acoustic neuroma and meningiomas, cholesteatoma, ear pain (otalgia), repeat sinus imaging Transplant patients COPD exacerbation, lung volume reduction surgery, suspicion of thoracic aortic dissection (TAA) Liver transplant patients Amenorrhea, soft tissue mass/penis Trauma/elbow, knee effusion, leg pain/calf, stress fracture/foot Coccydynia, scoliosis, spondylolisthesis Amyotrophic lateral sclerosis (ALS), peripheral nerve sheath tumors Fibromuscular dysplasia brachial artery, stenting of visceral artery aneurysms, popliteal artery entrapment syndrome Bone sarcomas, gastrointestinal stromal tumors (GIST), adrenal tumors Slipped capital femoral epiphysis, evaluation of suspected retinoblastoma, Tourette s syndrome In addition, existing guidelines have been updated for head cancers (head and neck), chest (breast MRI), cardiac stress testing (MRI), abdomen (pancreatitis and cystic pancreatic lesions), spine, pelvis, oncology, and pediatric and congenital (abdomen/inflammatory bowel disease and cardiac MRI). The guidelines are based on the following: American College of Radiology (ACR) Appropriateness Criteria The National Comprehensive Cancer Network (NCCN) Clinical Guidelines in Oncology May/June Texas Medicaid Bulletin, No. 223

38 Managed Care Providers/THSteps-CCP Providers 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 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 page Influenza Virus Vaccine Claims Reprocessing for Managed Care Providers TMHP has identified an issue affecting Primary Care Case Management (PCCM) claims that were submitted with procedure code and dates of service from August 1, 2008, through December 19, These claims may have been denied in error. Affected claims will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary. Colorectal Cancer Procedure No Longer Requires Precertification Effective for dates of service on or after March 1, 2009, colorectal cancer procedure code 2/F-G0105 no longer requires precertification for PCCM managed care clients. Smoking Cessation Drugs Exempt from Medicaid Three-drug Limit Effective January 1, 2009, smoking cessation drugs are exempt from the threedrug limit in PCCM and Texas Medicaid fee-for-service. Clients 21 years of age or older who are enrolled in PCCM and Texas Medicaid fee-for-service are limited to three prescriptions per month, with the exception of some drugs and supplies, such as family planning drugs and syringes used to administer insulin. HHSC hopes that exempting smoking cessation drugs from the three-drug limit will encourage more healthy lifestyles among Medicaid clients. According to the Centers for Disease Control and Prevention, 35 percent of Medicaid clients in 2006 were smokers, compared to 20.6 percent of the general population. Studies have shown that adding smoking cessation pharmacotherapy and counseling as a benefit in state Medicaid programs has been successful in lowering incidence of smoking among the Medicaid population. A survey of approximately 200 clients who received smoking cessation drugs revealed that almost 20 percent of them quit smoking after taking smoking cessation drugs, a percentage similar to the quit rates in the general population. Physicians are strongly encouraged to inform Texas Medicaid clients about the smoking cessation drug exemption. A free, state hotline offering telephone counseling for clients trying to quit smoking is also available. Research shows that smoking cessation is more successful when support, such as hotline counseling, is given along with pharmacotherapy. Clients can contact the state Quitline at YES-QUIT ( ). THSteps-CCP Providers THSteps-CCP Mobility Aids Benefits Change Effective for dates of service on or after April 1, 2009, benefits for mobility aids for the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) have changed for Texas Medicaid. Procedure code J-E0700 is limited to two per year. Texas Medicaid Bulletin, No May/June 2009

39 THSteps Providers To view the courses online, visit Current Topics New Topics Under Development May/June Texas Medicaid Bulletin, No. 223

40 THSteps Dental Providers THSteps Dental Providers Benefit Update for THSteps Diagnostic Dental Services Effective for dates of service on or after April 1, 2009, benefit criteria for Texas Health Steps (THSteps) dental diagnostic services will change for Texas Medicaid. Dental Home Based on the American Academy of Pediatric Dentistry s definition, Texas Medicaid defines a dental home as the dental provider who supports an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a client s dental home begins no later than 1 year of age and includes referrals to dental specialists when appropriate. In providing a dental home for a client, the dental provider enhances the ability to assist clients and their parents in obtaining optimum oral health care. The first dental home visit can be initiated as early as 6 months of age and should include, but is not limited to, the following: Oral examination Oral hygiene instruction Dental prophylaxis, if appropriate Topical fluoride application using fluoride varnish, if appropriate Caries risk assessment Dental anticipatory guidance Diagnostic services should be performed for all clients, preferably starting within the first 6 months of the eruption of the first primary tooth, but no later than 1 year of age. Dental home providers should record the oral and physical health history, perform a caries assessment, develop an appropriate preventive oral health regimen, and communicate with and counsel the client s parent, legal guardian, or primary caregiver. The dental home provider must retain supporting documentation for procedure code D0145 in the client s record. The supporting documentation must include, but is not limited to, the following: Health history review Dental history review Primary caregiver s oral health Oral evaluation Caries risk assessment Dental prophylaxis, which may include a toothbrush prophylaxis Oral hygiene instruction with parent/caregiver Anticipatory guidance to include the following: Oral health and home care Oral health of primary caregiver/other family members Development of mouth and teeth Oral habits Diet, nutrition, and food choices Fluoride needs Injury prevention Medications and oral health Fluoride varnish application Any referrals, including dental specialist s name Procedure code D0145 is limited to the following: Individual dentists certified by the Department of State Health Services (DSHS) Oral Health Program to perform this service One service per day, any provider Minimum of 60 days between dates of service, any provider Ten services a lifetime, any provider Effective for dates of service on or after April 1, 2009, procedure codes D0160, D0170, D0180, and D8660 are denied when submitted for reimbursement on the same date of service as procedure code D0145 by any provider. Limited Oral Evaluations Documentation supporting medical necessity for procedure codes D0140, D0160, and D0170, must be maintained by the provider in the client s medical record and must include the following: The client complaint supporting medical necessity for the examination Texas Medicaid Bulletin, No May/June 2009

41 THSteps Dental Providers The specific area of the mouth that was examined or the tooth involved A description of what was done during the visit Supporting documentation of medical necessity which may include, but is not limited to, radiographs or photographs Documentation supporting medical necessity for procedure code D0180 must be maintained by the provider in the client s medical record and must include the following: The client complaint supporting medical necessity for the examination A description of what was done during the treatment Supporting documentation of medical necessity which may include, but is not limited to, radiographs or photographs The following limitations apply for oral evaluations: Procedure codes D0120 and D0150 are used for periodic and comprehensive oral evaluations and are limited to once every 6 months for the same provider. Procedure code D8660 is denied as part of another service when submitted for reimbursement on the same date of service by the same provider as procedure code D0120 or D0150. Procedure code D0140 is used only for the initial emergency examination of a specific tooth or area of the mouth and is limited to one per day by the same provider and two per day by any provider. Procedure code D0160 is used for a problem-focused, detailed, and extensive oral evaluation. Procedure code D0170 is used as a follow up of a problem-focused evaluation. Procedure codes D0160 and D0170 are limited to one per day by the same provider. Procedure code D0180 is used for extensive periodontal evaluation of pain or problems. Procedure code D0180 is denied as part of another service when submitted for reimbursement on the same date of service by the same provider as procedure code D0120, D0140, D0145, D0150, D0160, or D0170. The provider must document medical necessity and the specific tooth or area of the mouth on the claim for procedure codes D0140, D0160, and D0170. Cone Beam Imaging Cone beam imaging is used to determine the best course of treatment for cleft palate repair, skeletal anomalies, post-trauma care, implanted or fixed prosthodontics, and orthodontic or orthognathic procedures. Cone beam imaging is limited to initial treatment planning, surgery, and postsurgical follow up. Procedure codes D0360, D0362, and D0363 are benefits of Texas Medicaid with prior authorization. To obtain prior authorization, a THSteps Dental Mandatory Prior Authorization Request Form must be submitted with documentation supporting medical necessity and appropriateness. Required documentation includes, but is not limited to, the following: Presenting conditions Medical necessity Status of the client s treatment Procedure codes D0360, D0362, and D0363 are limited to clients who are birth through 20 years of age, with a combined maximum of 3 services per year, any provider. Additional services may be considered with documentation of medical necessity. Photographic Images Oral/facial photographic images (procedure code D0350) are accepted only when diagnostic-quality radiographs cannot be taken. Photographs are limited to clients who are birth through 20 years of age. Supporting documentation and photographs must be maintained in the client s medical record when medical necessity is not evident on radiographs for dental caries or the following procedure codes: Procedure Codes D4210 D4211 D4240 D4241 D4245 D4266 D4267 D4270 D4271 D4273 D4275 D4276 D4355 D4910 Medical necessity must be documented on the electronic or paper claim. Age Limitations The following age limitations are effective for dates of service on or after April 1, 2009: Procedure codes D0120, D0150, D0170, D0240, and D0350 are limited to clients who are birth through 20 years of age. Procedure code D0273 is limited to clients who are 1 year of age through 20 years of age. May/June Texas Medicaid Bulletin, No. 223

42 THSteps Dental Providers Benefit Limitations The following benefit limitations have changed: Procedure codes D0272, D0273, D0274, D0277, D0340, and D0350 are limited to 1 per day by the same provider. Procedure code D0240 is limited to 2 per day by the same provider. Procedure code D0330 is limited to 1 per day by any provider. Procedure code D0330 is limited to 1 every 3 years by the same provider. Procedure codes D0340, D0350, and D0470 are denied when billed with procedure code D8050 or D8080. Procedure code D0460 is not payable for primary teeth and is limited to 1 per day by the same provider. Periodontal Maintenance Restrictions This is a correction to the 2009 Texas Medicaid Provider Procedures Manual. The table in Section titled Periodontal Services on page is missing limitation information for procedure code W-D4910. The following is the correct information: Procedure Code D4910 Maximum Fee $37.50 Limitations: Payable only following active periodontal therapy by any provider as evidenced either by a billed claim for procedure code W-D4240, W-D4241, W-D4260, or W-D4261 or by evidence through client records of periodontal therapy while not Medicaid-eligible. Not payable within 90 days after D4355 or on same date of service as any other evaluation procedure. A 13-20, N, PXR, PHO, CCP A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter Benefits Have Changed for Services by Doctors of Dentistry Practicing as a Limited Physician Effective for dates of service on or after April 1, 2009, benefits for services by doctors of dentistry practicing as a limited physician changed for Texas Medicaid. Cosmetic procedures are not a benefit of Texas Medicaid. Certain procedure codes, including but not limited to the codes in the following table, may be considered cosmetic and are not a benefit except when the procedure is performed as a result of trauma or injury for the purpose of reconstructing tissues or body structures or repairing damaged tissues. Procedure Codes For doctors of dentistry practicing as a limited physician, hepatitis immune globulin injection (procedure code 1-J1571) may be reimbursed only with diagnosis codes 27902, 27905, 27906, 28489, 35800, and 586. Immune globulin injections (procedure codes , 1-J1568, 1-J1569, and 1-J1572) may be reimbursed with diagnosis code Procedure codes , , 2/ , and 2/ may be reimbursed to a dentist or dentistry group. The following procedure codes will no longer be reimbursed to a registered nurse (RN) or certified nurse-midwife (CNM): Procedure Codes / / / Services performed by a doctor of dentistry practicing as a limited physician require mandatory prior authorization and are limited to certain diagnoses. Detailed prior authorization and diagnosis requirements may be found in the 2009 Texas Medicaid Provider Procedures Manual, Section 36.5, Doctor of Dentistry Practicing as a Limited Physician on page Texas Medicaid Bulletin, No May/June 2009

43 THSteps Dental Providers Reimbursement Rates for Doctor of Dentistry Practicing as a Limited Physician Service Effective for dates of services on or after April 1, 2009, some procedure codes for services by doctors of dentistry practicing as a limited physician are a benefit of Texas Medicaid. The initial reimbursement rates were adopted following a public rate hearing that was held on February 17, The following reimbursement rates for services by doctors of dentistry practicing as a limited physician are effective April 1, 2009: Type of Service Procedure Code Reimbursement Rate Doctor of Dentistry as a Limited Physician Service $53.84 (1.88 relative value units [RVUs], $72.17 (2.52 RVUs, $ (3.55 RVUs, $ (4.08 unit RVUs, $ (15.13 RVUs, $ (20.55 unit RVUs, $ (13.16 RVUs, $ (5.86 unit RVU, $34.65 (1.21 RVUs, $ (10.42 RVUs, $ (13.92 RVUs, $ (14.42 RVUs, $ Manually Priced $ (26.93 RVUs, $ (31.92 RVUs, $63.87 (2.23 RVUs, $ $ $ (7.55 RVUs, New Dental Diagnostic Services are THSteps Benefits Effective for dates of service on or after April 1, 2009, dental diagnostic services procedure codes D0360, D0362, and D0363 are benefits of THSteps. The reimbursement rates were adopted following a public rate hearing that was held on February 17, Reimbursement rates for the following dental diagnostic procedure codes are effective April 1, 2009: Procedure Code Reimbursement Rate D0360 $ D0362 $ D0363 $ May/June Texas Medicaid Bulletin, No. 223

44 Excluded Providers Excluded Providers As required by the Medicare and Medicaid Patient Protection Act of 1987, 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 HHSC s 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 Adams, Stephenia D. 25-Nov-08 Arlington TX 30-Dec-08 Allen, Jackie L Feb-08 RN Carrollton TX 27-Jan-09 Alvarado, Ernesto Apr-08 LVN Gruver TX 29-Dec-08 Anderson, Annette Apr-08 RN Tyler TX 07-Jan-09 Ayugi, Mary N. 01-Dec-08 CAN Dallas TX 22-Dec-08 Barikor, Marilyn J May-08 LVN Arlington TX 14-Jan-09 Barrett, Misti L Feb-08 RN Waco TX 29-Jan-09 Beaver, Marguerite L Jun-08 RN Fort Worth TX 07-Jan-09 Belt, David E Mar-08 LVN Hutto TX 17-Feb-09 Bencheck, Anna M May-08 RN Denison TX 13-Feb-09 Borrero, Elihu C Mar-08 LVN Bakersfield CA 17-Feb-09 Brown, Helen A Apr-08 LVN Coldspring TX 29-Dec-08 Buntyn, Theresa K May-08 RN Montgomery TX 27-Jan-09 Calvin, Phillip T Jan-07 DDS San Francisco CA 22-Dec-08 Cash, Amanda B Dec-07 LVN Baytown TX 08-Jan-09 Cassity, Lacey L Jun-08 LVN Stinnett TX 29-Jan-09 Chacha, Imanuel W Aug-08 RN Houston TX 18-Feb-09 Chesser, Rene M Jun-08 LVN Round Rock TX 29-Dec-08 Chuoke, Tanya A Jun-08 RN Pahoa HI 29-Jan-09 Clarke, Terry D May-08 RN Lubbock TX 31-Dec-08 Cobb, Monica C Jun-08 RN Deer Park TX 29-Jan-09 Cook, Terence T Nov-07 LVN Richmond TX 08-Jan-09 Texas Medicaid Bulletin, No May/June 2009

45 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Cunado, Carlos D. K Apr-07 MD Pearland TX 08-Jan-09 Dale-Burt, Angela R Sep-08 LVN Caddo Mills TX 13-Feb-09 Davis, Deborah A Aug-08 LVN Wichita Falls TX 18-Feb-09 Edet, Emmanuel B. 20-Jul-08 DME Mesquite TX 29-Dec-08 Edwards, Angela M Jan-08 RN Fort Worth TX 31-Dec-08 Evans, Cathy L Aug-08 RN Arlington TX 13-Feb-09 Ewing, Tanya Feb-08 RN Plano TX 14-Jan-09 Fells, Charlotte A Mar-08 LVN Bayou Vista TX 17-Feb-09 Ferreira, Carol A Nov-07 LVN Acushnet MA 28-Jan-09 Finley, Michael D Aug-08 LVN DeSoto TX 13-Feb-09 Flores, San Juana Feb-08 LVN San Antonio TX 29-Jan-09 Gaar, Charla K Dec-07 RN Arlington TX 29-Jan-09 Gant, Rebecca D Jun-08 LVN Kilgore TX 31-Dec-08 Garcia, Dena G Mar-08 RN Brighton CO 22-Dec-08 Goins, Sheila R Dec-07 LVN Wichita Falls TX 22-Dec-08 Hannah, Cynthia L Aug-08 LVN Wichita Falls TX 13-Feb-09 Harper, Tacara J Sep-08 Missouri City TX 18-Feb-09 Harrison, Connie L Jan-08 RN Tyler TX 31-Dec-08 Henderson, Mavis N Dec-07 RN Houston TX 27-Jan-09 Henderson, Otrice N Jun-08 LVN Odessa TX 14-Jan-09 Heslep, Jenifer B Jun-08 RN Beaumont TX 29-Dec-08 Hoblit, David L. E Jun-08 MD Dallas TX 30-Dec-08 Hogue, Debbie G Jun-08 LVN Abilene TX 31-Dec-08 Holden, Sandra K Apr-08 RN Seymour TX 27-Jan-09 Horn, William Nov-07 LVN Houston TX 08-Jan-09 Howes, Karen M Oct-07 LVN Tallahassee FL 08-Jan-09 Hoxworth, Cathy V Dec-07 RN Laredo TX 08-Jan-09 Jines, Shelen C Mar-08 LVN Gruver TX 29-Dec-08 Johnson, Anita M Jun-08 LVN Raleigh NC 07-Jan-09 Johnson, Carol A Apr-08 LVN Paris TX 23-Dec-08 Johnson, Morris M Feb-08 LVN Amarillo TX 07-Jan-09 Johnson, Peggy A May-08 RN Decatur TX 17-Feb-09 Kassel, Jerry K / May-08 RN/LVN Harlingen TX 29-Dec-08 Kennedy, Edward J Sep-08 Katy TX 18-Feb-09 King, Dennis M. D Aug-03 MD Gainesville TX 29-Jan-09 Kinsey, Kristine D May-08 LVN Boyd TX 29-Jan-09 Ledesma, Elizabeth A May-08 LVN Webster TX 17-Feb-09 Lewis-Besson, Julie L May-08 RN Shelby NC 29-Jan-09 Litchfield, Christine Aug-08 RN/LVN Lumberton TX 18-Feb-09 Longmoor, Charles E. J Oct-08 MD Euless TX 18-Feb-09 Lowery, Marcia M Dec-07 RN Tyler TX 23-Dec-08 May/June Texas Medicaid Bulletin, No. 223

46 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Marshall, Harold D. K Apr-08 MD Coppell TX 08-Jan-09 Martin, Cerise L Sep-08 Birdge City TX 18-Feb-09 Mason, Linda W May-08 LVN Peebles OH 29-Jan-09 McDaniel, Ehren E Mar-08 LVN Odessa TX 17-Feb-09 McLean, Vicki H May-08 RN Conroe TX 29-Dec-08 Meador, Sherry D Sep-08 LVN Henderson TX 13-Feb-09 Medina Jr, Lorenzo Mar-08 RN Houston TX 07-Jan-09 Mendoza, Geraldine F Feb-08 LVN Cuero TX 08-Jan-09 Merrick, Stephen D Oct-07 LVN Big Spring TX 29-Jan-09 Miller, Janis L Mar-08 RN Tyler TX 29-Jan-09 Mills, Virginia M. J Aug-08 MD Houston TX 31-Dec-08 Molina, Antonio G Jun-08 LVN Nursery TX 08-Jan-09 Montgomery, Barbara L Nov-07 LVN Dallas TX 28-Jan-09 Morgan, Crystal S May-08 LVN Abilene TX 08-Jan-09 Morrison, Janet P Mar-08 RN Cooper TX 29-Dec-08 Mounts, Charlotte A Jun-08 LVN Alvin TX 07-Jan-09 Mueller, Sandra S Jan-08 RN May TX 08-Jan-09 Nzeadibe, Michael 05-Jan-09 Houston TX 08-Jan-09 Odemwingie, David E. 05-Jan-09 Dallas TX 08-Jan-09 Oliveira, Karen V May-08 RN Allen TX 08-Jan-09 Pepper, Stacy R Aug-08 RN Humble TX 18-Feb-09 Phillips, Tammy C Jun-08 LVN Wolfforth TX 29-Jan-09 Potts, Charles D Mar-08 RN Alamagordo NM 29-Jan-09 Pyle, Mandy Mar-08 RN Whitehouse TX 31-Dec-08 Rager, Shelly J Aug-07 LVN Granbury TX 30-Dec-08 Raines, Annette J May-08 RN Gladewater TX 08-Jan-09 Randall, Linda A Nov-07 LVN Floresville TX 28-Jan-09 Ransom, Janet A May-08 LVN Fort Worth TX 23-Dec-08 Renteria, Mark A Apr-08 LVN San Antonio TX 14-Jan-09 Riggs, Patrick K. H Jun-08 MD Ft. Worth TX 31-Dec-08 Rivera, Esteban Apr-07 LVN Edinburg TX 29-Dec-08 Roberts, Deborah C Apr-08 RN Manor TX 07-Jan-09 Robinson, Brenda C Nov-07 LVN Bridgeport TX 28-Jan-09 Rodriguez, Victor Sep-08 LVN San Antonio TX 13-Feb-09 Rogers, Kathryn E Jun-08 RN Birmingham AL 29-Jan-09 Salazar, Adela S / Dec-07 RN/LVN San Antonio TX 29-Dec-08 Savage, Saundra M Jun-08 RN Bay City TX 30-Dec-08 Seyffert, Debra L Mar-08 RN Alvin TX 29-Dec-08 Sheffield, Janet L Jun-08 RN Lorena TX 31-Dec-08 Sierson, Susan R May-08 LVN Ft Worth TX 28-Jan-09 Smith, Holly J Mar-08 RN/LVN Vidor TX 29-Dec-08 Texas Medicaid Bulletin, No May/June 2009

47 Excluded Providers Provider License Number Start Date Type Provider City State Add Date Smith, Scott W Feb-08 RN Beaverton OR 23-Dec-08 Stoy, Amy D May-08 RN Godley TX 13-Feb-09 Tarrant, Judy A Feb-08 RN Houston TX 29-Dec-08 Taylor, Patti M Oct-08 RN Carthage TX 23-Dec-08 Theagene, Samuel M. J Jun-08 MD Three Rivers TX 31-Dec-08 Thomas, Margaret A Dec-07 LVN Mabank TX 28-Jan-09 Tyner, Sabrina M Mar-08 LVN Ooltewah TN 29-Dec-08 Wells, Rebecca J Feb-08 LVN Victoria TX 29-Dec-08 Wheat, Stephanie L Sep-08 RN/LVN Vidor TX 18-Feb-09 Wheeler, Rachel A May-08 RN Muskogee OK 08-Jan-09 Wiggins, Rhonda K Aug-08 RN Dallas TX 18-Feb-09 Wilson, Jerome M Jul-08 LVN Houston TX 08-Jan-09 Zidd, Edward A. D Dec-08 MD Austin TX 30-Dec-08 May/June Texas Medicaid Bulletin, No. 223

48 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 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_ Texas Medicaid Bulletin, No May/June 2009

49 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: Effective Date_ /Revised Date_ May/June Texas Medicaid Bulletin, No. 223

50 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. A STATE MEDICAID CONTRACTOR Effective Date_ /Revised Date_ Texas Medicaid Bulletin, No May/June 2009

51 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_ May/June Texas Medicaid Bulletin, No. 223

52 Forms Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Type 30 ONLY for use for the submission of services rendered to dual eligible clients of MAPs for services rendered between January 1, 2005, through December 31, Note: Dates outside of this period will not be considered by TMHP. Submissions must be received by TMHP from May 1, 2009, through October 31, 2009, and a legible copy of the original claim must be attached. 1 NPI/API 2 Medicare ID 3 TPI 4 Provider Name 5 Medicaid Client Number 6 Client Last Name 7 Client First Name 8 Medicare Paid Date 9 Medicare ICN 10 Patient HIC Number 11 Detail(s) Information From DOS To DOS POS Units CPT Mods Charges Allow Ded Coins Paid Reason Code 12 Totals Information Charges Allow Ded Coins Paid Reason Code 13 Medicare Prev Paid Texas Medicaid Bulletin, No May/June 2009

53 Forms Medicare Advantage Plan (MAPs) Submission Form Instructions For Crossover Claim Type 30 Instructions Providers can bill professional services claims for services rendered to dual eligible clients of MAPs for services rendered between January 1, 2005, through December 31, Dates outside of this period will not be considered by TMHP. These claims can only be submitted to TMHP from May 1, 2009, through October 31, 2009, and a legible copy of the original claim must be attached. Claims received after October 31, 2009, will be returned to the provider with a message indicating that they have submitted an incorrect Medicare Remittance Advice Notice (MRAN). All fields (excluding Medicaid information fields) on the form must be completed using the Remittance Advice or Remittance Notice that was received from the MAP. The MAP Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Claim Type 30 Submission Form: Block No. Field Description Guidelines 1 NPI/API Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API) for the billing provider. 2 Medicare ID Enter the Medicare Provider ID number of the billing provider listed on the MAP Remittance Advice/Remittance Notice. 3 TPI Enter the Medicaid Texas Provider Identifier (TPI) number of the billing provider. 4 Provider Name Enter the billing provider s name. 5 Medicaid Client Number Enter the client s nine-digit Medicaid number from the Medicaid identification form. 6 Client Last Name Enter the client s last name listed on the MAP Remittance Advice/Remittance Notice. 7 Client First Name Enter the client s first name listed on the MAP Remittance Advice/Remittance Notice. 8 Medicare Paid Date Enter the Medicare Paid Date listed on the MAP Remittance Advice/Remittance Notice. 9 Medicare ICN Enter the Medicare Internal Control Number (ICN) listed on the MAP Remittance Advice/Remittance Notice. 10 Client HIC Number Enter the client s identification number listed on the MAP Remittance Advice/Remittance Notice. 11 From DOS Enter the first date of service (DOS) for each procedure in a MM/DD/YYYY format. 11 To DOS Enter the last DOS for each procedure in a MM/DD/YYYY format. 11 POS Enter the place of service (POS) listed on the MAP Remittance Advice/Remittance Notice. 11 Units Enter the number of units (quantity billed) from the MAP Remittance Advice/Remittance Notice. May/June Texas Medicaid Bulletin, No. 223

54 Forms Block No. Field Description Guidelines 11 CPT Enter the appropriate Current Procedural Terminology (CPT) procedure code for each procedure/service listed on the MAP Remittance Advice/Remittance Notice. Note: The procedure code listed on the MAP Submission Form may not match the procedure code listed on the claim form attached. 11 Mods Enter the modifier (when applicable) listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Charges Enter the Medicare charges (billed amount) listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Allow Enter the Medicare allowed amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Ded Enter the Medicare deductible amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Coins Enter the Medicare coinsurance amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Paid Enter the Medicare paid amount listed on the MAP Remittance Advice/Remittance Notice for each detail. 11 Reason Code Enter Medicare s reason code listed on the MAP Remittance Advice/Remittance Notice for each detail. 12 Total Charges Enter the Medicare total charges (billed amount) listed on the MAP Remittance Advice/Remittance Notice. Note: A provider may attach additional template forms (pages) as necessary. The combined total charges for all pages should be listed on the last page. All other forms must indicate Continue in this block. 12 Total Allow Enter the Medicare total allowed amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Ded Enter the Medicare total deductible amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Coins Enter the Medicare total coinsurance amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Paid Enter the Medicare total paid amount listed on the MAP Remittance Advice/Remittance Notice. 12 Total Reason Code Leave this field blank. 13 Medicare Prev Paid Enter the Medicare previous paid amount listed on the MAP Remittance Advice/Remittance Notice. Texas Medicaid Bulletin, No May/June 2009

55 Forms Medicare Advantage Plans (MAPs) Submission Form For Crossover Claim Types 31 and 50 ONLY for use for the submission of services rendered to dual eligible clients of MAPs for services rendered between January 1, 2005, through December 31, Note: Dates outside of this period will not be considered by TMHP. Submissions must be received by TMHP from May 1, 2009, through October 31, 2009, and a legible copy of the original claim must be attached. Medicare Paid Date: Provider Name: NPI/API /TPI: Medicare ID: Street Address: City: State: ZIP: Bill Type From DOS Through DOS Patient Last Name Patient First Name Medicare HIC Medicare ICN Total Charges Covered Charges Non Covered Charges/Reason Code DRG Amount Deductible Blood Deductible Coinsurance Medicare Paid Amount DRG Code May/June Texas Medicaid Bulletin, No. 223

56 Forms Medicare Advantage Plans (MAPs) Submission Form Instructions For Crossover Claim Types 31 and 50 Providers can bill inpatient and outpatient crossover claims for services rendered to dual eligible clients of MAPs for dates of service from January 1, 2005, through December 31, Dates outside of this period will not be considered by TMHP. These claims can only be submitted to TMHP from May 1, 2009, through October 31, 2009, and a legible copy of the original claim must be attached. Claims received after October 31, 2009, will be returned to the provider with a message indicating that they have submitted an incorrect Medicare Remittance Advice Notice (MRAN). All fields (excluding Medicaid information fields) on the form must be completed using the Remittance Advice or Remittance Notice that was received from the MAP. The MAP Submission Form must be typed or computer-generated. Handwritten forms will not be accepted and will be returned to the provider. The following are the requirements for the Crossover Claim Types 31 and 50 Submission Form: Field Description Medicare Paid Date Provider Name NPI/API/TPI Medicare ID Street Address City State ZIP Bill Type From DOS Through DOS Patient Last Name Patient First Name Medicare HIC Medicare ICN Guidelines Enter the Medicare Paid Date listed on the MAP Remittance Advice/Remittance Notice. Enter the billing provider s name. Enter the National Provider Identifier (NPI)/Atypical Provider Identifier (API)/Texas Provider Identifier (TPI) for the billing provider. Note: NPI/TPI or API/TPI. Enter the Medicare Provider ID of the billing provider number listed on the MAP Remittance Advice/Remittance Notice. Enter the billing provider s street address. Enter the billing provider s city. Enter the billing provider s state. Enter the billing provider s ZIP code. Enter the Medicare Bill Type listed on the MAP Remittance Advice/Remittance Notice. Note: The Medicare Bill Type may not match the type of bill (TOB) listed on the claim form. Enter the first date of service (DOS) for all procedures in a MM/DD/YYYY format. Enter the last DOS for all procedures in a MM/DD/YYYY format. Enter the patient s last name listed on the MAP Remittance Advice/Remittance Notice. Enter the patient s first name listed on the MAP Remittance Advice/Remittance Notice. Enter the patient s Medicare Health Insurance Claim (HIC) number (Medicare Identification number) listed on the MAP Remittance Advice/Remittance Notice. Enter the Medicare Internal Control Number (ICN) listed on the MAP Remittance Advice/Remittance Notice. Texas Medicaid Bulletin, No May/June 2009

57 Forms Field Description Total Charges Covered Charges Non Covered Charges/Reason Code DRG Amount Deductible Blood Deductible Coinsurance Medicare Paid Amount DRG Code Guidelines Enter the Medicare total charges (billed amount) listed on the MAP Remittance Advice/Remittance Notice. Enter the covered charges listed on the MAP Remittance Advice/Remittance Notice. Enter the noncovered charges listed on the MAP Remittance Advice/Remittance Notice followed by the reason code listed on the Medicare Remittance Advice/Remittance Notice. Enter the diagnosis-related group (DRG) amount listed on the MAP Remittance Advice/Remittance Notice for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG amount. Enter the Medicare deductible amount listed on the MAP Remittance Advice/Remittance Notice. Enter the blood deductible listed on the MAP Remittance Advice/Remittance Notice for inpatient claims, if applicable. Note: Outpatient claims do not require a blood deductible amount. Enter the Medicare coinsurance amount listed on the MAP Remittance Advice/Remittance Notice. Enter the Medicare paid amount listed on the MAP Remittance Advice/Remittance Notice. Enter the DRG code listed on the MAP Remittance Advice/Remittance Notice for inpatient claims, if applicable. Note: Outpatient claims do not require a DRG code. May/June Texas Medicaid Bulletin, No. 223

58 Notes

59 Notes

60 Texas Medicaid & Healthcare Partnership B Riata Trace Parkway, Ste 150 Austin, TX A STATE MEDICAID CONTR ACTOR PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE May/June 2009 no. 223 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual Look inside for these and other important updates: Page 1 Page 3 Page 6 Page 10 Claims Filing Deadline Waived for Providers in Ike Evacuation Areas Update to Total Parenteral Nutrition Services First Quarter HCPCS Updates New Claims Process for Clients with Third-Party Insurance