Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015

Transcription

1 1. Programs: 100/200 DRT Analyst: Phillip Rackley at or DRT Backup: Donna Shaver at or State Stakeholders: Donna Claeys at SR Banner/Website Website instructions: Program: Medicaid Category: General Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015

2 Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015 Information posted September 11, 2015 Effective for dates of service on or after November 1, 2015, benefit criteria for pathology and laboratory services-drug testing and therapeutic drug assays will change for Texas Medicaid. Benefit changes will be applied to the following drug testing and therapeutic drug assays laboratory services procedure codes: Procedure Codes Benefit Changes *G0434 Total component: Services rendered in an office setting may be reimbursed to physicians, physician assistants, nurse practitioners and clinical nurse specialists, certified nurse midwives, and licensed midwives. Services rendered in an outpatient hospital setting may be reimbursed to hospital providers. Services rendered in an independent laboratory setting may be reimbursed to independent laboratory providers. *= CLIA waived. Note: The procedure code above does not require prior authorization. Refer to the Healthcare Common Procedure Coding System (HCPCS) manual for information on procedure code G0434. Documentation Requirements All services are subject to retrospective review. Documentation in the client s medical record must be maintained by the physician and support the medical necessity for the services provided. Providers are encouraged to reference the American Board of Internal Medicine (ABIM) Foundation s Choosing Wisely lists to determine appropriateness of laboratory tests. For more information, call the TMHP Contact Center at

3 2. Programs: 100/200 DRT Analyst: Phillip Rackley at or DRT Backup: Donna Shaver at or State Stakeholders: Estrellita Martinez at SR Banner/Website Website instructions: Program: Medicaid Category: General Correction to August 2015 TMPPM about Modifier U8 in the Claims Filing Section

4 Correction to August 2015 TMPPM about Modifier U8 in the Claims Filing Section Information posted September 11, 2015 There is a correction to the August 2015 release of the Texas Medicaid Provider Procedures Manual, Volume 1, General information, subsection 6.3.5, Modifiers. The correction is that providers must begin using the U8 modifier for 340B clinicianadministered drugs for dates of service on or after September 1, The provider manual will be updated in the October release to reflect these changes. Providers can refer to the article titled 340B Providers Must Use Modifier U8 When Submitting Claims for 340B clinician-administered Drugs, which was published on this website on July 16, The article provided information about using modifier U8 for 340B clinician-administered drugs. For more information, call the TMHP Contact Center at

5 3. Programs: 100/200 DRT Analyst: Elisha Ramos at or DRT Backup: Meredith Vasquez at or State Stakeholders: Joanna Seyller at or SR Banner/Website Website instructions: Program: Medicaid Category: Benefits Benefits for Brachytherapy Services to Change for Texas Medicaid November 1, 2015

6 Benefits for Brachytherapy Services to Change for Texas Medicaid November 1, 2015 Information posted September 11, 2015 Note: All new and updated procedure codes and their associated reimbursement rates are proposed benefits pending a rate hearing and approval of expenditures. Providers will be notified when the rates and expenditures are approved. Note: This article applies only to claims submitted to TMHP for processing. Refer to the Medicaid managed care organizations (MCOs) for information about MCO benefits, limitations, prior authorization, reimbursement, and MCO specific claim processing procedures. Effective for dates of service on or after November 1, 2015, benefits for brachytherapy services will change for Texas Medicaid. Procedure codes and will no longer be age restricted. The professional and technical components of procedure codes and will be a benefit as follows: Type of Service (TOS) Place of Service Provider Types Professional Component (TOS I) Office, outpatient hospital Inpatient hospital Physician and radiation treatment center providers Physician providers Technical Component (TOS T) Office Outpatient hospital Physician and radiation treatment center providers Radiation treatment center providers Radiation treatment center and hospital providers will be added as payable provider types for the total component (TOS 6) of procedure codes and when services are performed in the outpatient hospital setting. Procedure codes and are limited to once per two calendar months. Documentation that supports the provision of special procedures must be maintained in the client s medical record and made available upon request. For more information, call the TMHP Contact Center at

7 4. Programs: 400 DRT Analyst: Phillip Rackley at or DRT Backup: Donna Shaver at or State Stakeholders: SR Banner/Website Website instructions: Program: CSHCN Service Program Category: General Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015

8 Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015 Information posted September 11, 2015 Effective for dates of service on or after November 1, 2015, pathology and laboratory services-drug testing and therapeutic drug assays will become a benefit of the Children with Special Health Care Needs Services (CSHCN) Program. Procedure code G0434 will be a benefit of the CSHCN Services Program for the following provider types and place of services: Procedure Codes Benefit Changes *G0434 Total component: Services rendered in an office setting may be reimbursed to physicians. Services rendered in an outpatient hospital setting may be reimbursed to hospital providers. Services rendered in an independent laboratory setting may be reimbursed to independent laboratory providers. *= CLIA waived. Authorization Requirements Prior authorization is not required. Reimbursement Procedure code G0434 may be reimbursed for pathology and laboratory services. Refer to the Healthcare Common Procedure Coding System (HCPCS) manual for information on procedure code G0434. Documentation Requirements All services are subject to retrospective review. Documentation in the client s medical record must be maintained by the physician and support the medical necessity for the services provided. For more information, call the TMHP-CSHCN Services Program Contact Center at

9 5. Programs: 400 DRT Analyst: Elisha Ramos at or DRT Backup: Meredith Vasquez at or State Stakeholders: Sandra Owen at or SR Banner/Website Website instructions: Program: CSHCN Category: Benefits Preventive Care Medical Checkup Benefit Criteria to Change for the CSHCN Services Program Effective November 1, 2015

10 Preventive Care Medical Checkup Benefit Criteria to Change for the CSHCN Services Program Effective November 1, 2015 Information posted September 11, 2015 Note: For the purposes of this article, advanced practice registered nurse (APRN) includes nurse practitioner (NP) and clinical nurse specialist (CNS) providers only. Effective for dates of service on or after November 1, 2015, benefit criteria for preventive care medical checkups will change for the Children with Special Health Care Needs (CSHCN) Services Program. Diagnosis codes Z00121 and Z00129 will be added as payable diagnosis codes for procedure codes and Preventive care medical checkups are not a benefit of a telemedicine or telehealth service. Screenings Developmental Screening The CSHCN Services Program recognizes the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT R/F) as a standardized tool for completing development screening. Mental Health Screening Mental health screening will be a benefit at each preventive care medical checkup when it is provided in accordance with accepted guidelines or when a parent expresses concern about the client s mental health. Mental health screening using one of the following validated, standardized mental health screening tools recognized by the CSHCN Services Program is required once, for all clients who are 12 through 18 years of age: Pediatric symptom checklist (PSC-35) Pediatric symptom checklist for youth (Y-PSC) Patient health questionnaire (PHQ-9) Procedure code must be submitted for the required mental health screening. Procedure code will be a benefit for clients who are 12 through 18 years of age when services are provided by APRN, physician assistant, physician, and federally qualified health center (FQHC) providers in the office setting. Mental health screening at other medical checkups does not require the use of a validated, standardized mental health screening tool. Procedure code must be submitted on the same date of service and by the same provider as procedure codes 99384, 99385, 99394, or Procedure code will be limited to once per lifetime.

11 The client s medical record must include documentation identifying the tool that was used, the screening results, and any referrals.. For more information, call the TMHP-CSHCN Services Program Contact Center at

12 6. Programs: 400 DRT Analyst: Elisha Ramos at or DRT Backup: Meredith Vasquez at or State Stakeholders: Jolene Harvey at or SR Banner/Website Website instructions: Program: CSHCN Category: Benefits Benefits for Radiation Therapy Services to Change for the CSHCN Services Program November 1, 2015

13 Benefits for Radiation Therapy Services to Change for the CSHCN Services Program November 1, 2015 Information posted September 11, 2015 Effective for dates of service on or after November 1, 2015, benefits for radiation therapy services will change for the Children with Special Health Care Needs (CSHCN) Services Program. Pancreatic adenocarcinoma has been added as a condition for which stereotactic radiosurgery and stereotactic body radiation therapy is considered investigational, and therefore not a benefit of the CSHCN Services Program. Providers may refer to the current Children with Special Health Care Needs Services Program Provider Manual, section , "Stereotactic Radiosurgery," for a list of medical conditions that may be considered for prior authorization of stereotactic radiosurgery and stereotactic body radiation therapy. New Benefits Procedure codes and will be a benefit as follows: Type of Service (TOS) Place of Service Provider Types Total Component (TOS 6) Office Physician and radiation treatment center providers Professional Component (TOS I) Outpatient hospital Office, outpatient hospital, inpatient hospital Radiation treatment center and hospital providers Physician providers Technical Component (TOS T) Office Physician and radiation treatment center providers Outpatient hospital Radiation treatment providers Documentation which supports the provision of special procedures must be maintained in the client s medical record and made available upon request. For more information, call the TMHP-CSHCN Services Program Contact Center at