Banner Message for the 01/16/06 ER&S and the 01/20/06 R&S Reports This file contains abbreviated messages meant to provide timely notifications that affect all provider groups (physicians, dentists, and so forth). Additional current and historic information affecting the Medicaid, Medicaid Managed Care, and Children with Special Health Care Needs (CSHCN) provider community may be found in the earlier postings of these files in the TMHP banner library at www.tmhp.com as well as in the bi-monthly editions of the Texas Medicaid Bulletin and the quarterly CSHCN Bulletin, which update the Texas Medicaid Provider Procedures Manual and CSHCN Provider Manual, respectively. Copyright Acknowledgements 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 2005 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: CDT4/2004 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. 2002 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/ DFARS) restrictions apply. Microsoft Corporation requires the following notice in publications containing trademarked productnames: Microsoft and Windows are either registered trademarks or trademarks of Microsoft Corporation in the United States and/or other countries. Total Messages (32) 1 (01/20/06 through 02/17/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after March 15, 2005, procedure code 90784 was discontinued and is no longer a benefit of the Texas Medicaid Program when performed in inpatient and outpatient hospital settings and nursing facilities. Claims submitted for dates of service on or after March 15, 2005, through December 31, 2005, that included procedure code 90784 will be recouped and payments adjusted accordingly. No action on the part of the provider is necessary. Procedure code 90784 was replaced with procedure code 90774 effective January 1, 2006, during the 2006 Healthcare Common Procedure Coding System (HCPCS) implementation and is also not a benefit when performed in inpatient and outpatient settings and nursing facilities. 1 of 9
2 (01/13/06 through 02/10/06)*****Attention All Medicaid Providers***** Beginning March 1, 2006, eyewear billed with a diagnosis of Aphakia will be a benefit of the Texas Medicaid Program for clients birth through 20 years of age effective for dates of service on or after October 16, 2003. Clients 21 years of age and older will receive this benefit effective for dates of service on or after October 1, 2005. Claims submitted from October 16, 2003, through March 1, 2006, that include this service, will be reprocessed for clients under 21 years of age and payments will be adjusted accordingly. Claims submitted from October 1, 2005, through March 1, 2006, that include this service, will be reprocessed for clients over 21 years of age and older and payments will be adjusted accordingly. No action on the part of the provider is necessary. 3 (01/13/06 through 02/10/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after March 1, 2006, procedure codes 80197 and J7525 will no longer have diagnosis restrictions for the Texas Medicaid Program. For more information, contact the TMHP Call Center at 1-800-925-9126. 4 (01/13/06 through 02/10/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after March 1, 2006, procedure codes 6-77301, I-77301, T-77301, and T-77418 will be benefits of the Texas Medicaid Program with the following allowable fees: 6-77301 = $1,100.86, I-77301 = $298.67, T-77301= $802.19, and T-77418 = $495.06. 5 (01/13/06 through 02/10/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after December 1, 2005, procedure codes 78814, 78815, and 78816 are benefits of the Texas Medicaid Program with the following allowable relative value units (RVUs): 78814 for TOS 4 = 3.53, TOS I = 3.07, and TOS T =.46 78815 for TOS 4 = 3.90, TOS I = 3.39, and TOS T =.51 78816 for TOS 4 = 3.99, TOS I = 3.47, and TOS T =.52 These procedure codes may have inappropriately denied as not a benefit. Claims submitted for dates of service on or after December 1, 2005, that include these procedure codes will be reprocessed. No action on the part of the provider is required. 6 (1/13/06 through 2/10/06) *****Attention All Medicaid Providers***** As previously published in the 2006 ICD-9-CM Implementation article beginning on page 2 of the November/December 2005 Texas Medicaid Bulletin, No. 191, V5811 is a valid diagnosis code effective for dates of service on or after October 1, 2005. Effective for dates of service on or after October 1, 2005, procedure code J0880 is a benefit of the Texas Medicaid Program when billed with diagnosis code V5811. 2 of 9
There was a system error causing claims submitted from October 1, 2005, through December 31, 2005, that included these procedure and diagnosis codes to deny inappropriately. These claims will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. 7 (1/13/06 through 2/10/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after December 31, 2005, claims submitted for services rendered to a client enrolled in Primary Care Case Management by a provider who is not the client s assigned primary care provider (PCP) must include the assigned PCP s Texas Provider Identifier (TPI) number in the Referring Physician field of the claim form. Claims that do not include the assigned PCP s TPI will be denied. There are some services that do not require a PCP referral. Details of these services are available on page 20 of the January/February 2006 Texas Medicaid Bulletin, No. 192. For more information, call the Primary Care Case Management (PCCM) Provider Helpline at 1-888-834-7226. 8 (01/06/06 through 02/24/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after March 1, 2006, diagnosis codes 2863 (congenital deficiency of other clotting factors) and 2869 (other and unspecified coagulation defects) may reimburse when billed for procedure code Q0187. Additionally, procedure codes J7190, J7191, J7192, J7193, J7194, J7195, J7197, J7198, J7199, Q0187, and Q2022 will no longer be a benefit for the following provider types: Podiatrist, APN, Registered Nurse/Nurse Midwife, Medical supplier (DME), Radiation Treatment Centers, and Podiatry Group. Provider types FQHC, Rural Health Clinics, and Hemophelia Factor may bill procedure codes J7190, J7191, J7192, J7193, J7194, J7195, J7197, J7198, J7199, Q0187, and Q2022 for reimbursement consideration. For more information call the TMHP Contact Center at 1-800-925-9126. 9 (12/30/05 through 1/27/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after October 14, 2005, Synagis became available to providers for administering to Medicaid clients through the Medicaid Vendor Drug Program (VDP). This new option allows providers to have Synagis shipped directly to their office from a network pharmacy. Physicians will not need to purchase the drug. Providers that obtain Synagis through the VDP may not bill Medicaid for the drug. A revised Synagis (Palivizumab) Prescription Form is available in the News Archive section on the TMHP website at www.tmhp.com, under the October 2005 releases. The form will also be available in the Forms section of the 2006 Texas Medicaid Provider Procedures Manual. Please note that this form is intended for use only during the 2005 2006 Respiratory Syncytial Virus (RSV) season. The Texas Health and Human Services Commission (HHSC) and TMHP will notify providers of any changes in the RSV Prophylaxis policy for the 2006 2007 season (including a modified form, if appropriate) through articles in future editions of the Texas Medicaid Bulletin. 3 of 9
10 (12/23/05 through 01/20/06)*****Attention All Medicaid Providers***** This is an update to information published in the DME Supplies Reimbursed article on page 18 of the January/February 2006 Texas Medicaid Bulletin, No. 192. The insulin pump procedure codes listed in this article are incorrect. Following are the correct procedure codes. Effective for dates of service on or after December 1, 2005, the following insulin pump procedure codes are a benefit of the Texas Medicaid Program when billed separately and are limited to the amounts shown: A4230 = 10 per month, A4231 = 15 per month, A4232 = 10 per month, A6257 = 15 per month, A6258 = 15 per month, A6259 = 15 per month, and A4632 = 1 per month. 11 (12/23/05 through 1/13/06) *****Attention All Medicaid Providers***** Beginning January 1, 2006, the 2006 Healthcare Common Procedure Coding System (HCPCS) deleted procedure codes will no longer be a benefit of the Texas Medicaid Program. Beginning January 16, 2006, providers who received prior authorizations for a 2006 HCPCS deleted procedure code, for dates of service on or after January 1, 2006, must contact TMHP Prior Authorization to update the authorization for those services. Prior authorizations for the following HCPCS procedure codes will be updated by TMHP and require no action on the part of the provider: A5119, B4184, E0972, K0618 through K0620, K0630 through K0649, K0670, L0860, L8100, L8110, L8120, L8130, L8140, L8150, L8160, L8170, L8180, L8190, L8195, L8200, L8210, L8220, L8230, L8239, 97504, 97520, 97703, 33918, 33919, and 44200. 12 (12/23/05 through 1/20/06) *****Attention All Medicaid Providers***** This is an update to the Reimbursement and Payment Methodology Changing for Texas Health Steps- Comprehensive Care Program (THSteps-CCP) Therapy Services Provided by CORFs and ORFs article located on the TMHP website at www.tmhp.com, under TMHP News. The article has been updated with new information that contains details of additional reimbursement changes. Refer to the revised article Reimbursement and Payment Methodology Changing for THSteps-CCP Therapy Services Provided by CORFs and ORFs: Article Revised December 16, 2005. Details of these changes will also be available in the March/April 2006 Texas Medicaid Bulletin, No. 194. 13 (12/16/05 through 01/13/06)*****Attention All Medicaid Providers***** This is an update to a banner message that appeared on providers September 16, 2005, Remittance and Status (R&S) report. The correct procedure code to submit for verteporfin is J3396 and not the previously stated procedure code J3395. Following is the complete article with the correct procedure code. Effective for dates of service on or after November 1, 2005, diagnosis code 36252 (Exudative senile macular degeneration) will be a payable diagnosis for procedure codes J3396, 67221, and 92235. No action on the part of the provider is necessary. Additionally, this update applies to the Exudative Senile Macular Degeneration article published on page 9 of the November/December 2005 Texas Medicaid Bulletin, No. 191. 4 of 9
14 (12/16/05 through 01/13/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after February 1, 2006, procedure code J1595 will be a benefit of the Texas Medicaid Program with an allowable fee of $35.73. 15 (12/16/05 through 01/13/06)*****Attention All Medicaid Providers***** Effective for dates of service on or after February 1, 2006: Procedure code G0121 will be a benefit of the Texas Medicaid Program with an allowable fee of $148.93. Procedure code G0121 will be limited to diagnosis code V76.51 (Special screening for malignant neoplasmscolon). Procedure codes G0104 through G0106 and G0120 will no longer be limited for diagnosis codes 5582 (Toxic gastroenteritis) and 5583 (Allergic gastroenteritis and colitis). Procedure codes G0104 and G0106 will be a benefit when billed with diagnosis code V76.51 (limited to once every five years). The allowable fee for procedure code 45378 will be adjusted to $148.93. 16 (12/16/05 through 01/13/05)*****Attention All Medicaid Providers***** This is an update to information previously published in a banner message that appeared on providers September 16, 2005, Remittance and Status (R&S) report and a bulletin article published in the November/ December 2005 Texas Medicaid Bulletin, No. 191. Diagnosis code V581 (Chemotherapy encounter) was discontinued effective for dates of service on or after October 1, 2005, and is not a benefit of the Texas Medicaid Program when billed with procedure code Q0137. Diagnosis codes V5811 (Encounter for antineoplastic chemotherapy) and V5812 (Encounter for immunotherapy for neoplastic condition) may reimburse with procedure code Q0137. Following is the complete article with the correct procedure and diagnosis codes. Effective for dates of service on or after November 1, 2005, procedure code Q0137 will have an allowable fee of $4.24 and will be limited to the following non-end stage renal disease (ESRD) diagnosis codes: 20300 through 20301, 28521, 28522, 2858 through 2859, 40301, 40311, 40391, 40402, 40403, 40412, 40413, 40492, 40493, 585, 586, V5811, and V5812. For payment consideration, providers must appeal denied claims with a corrected diagnosis. Details of these changes are available on the TMHP website at www.tmhp.com. 17 (12/02/05 through 01/27/06)*****Attention All Medicaid Providers***** This message is intended only for providers who receive certification of funds letters. TMHP will not include Hurricane Katrina waiver claims in the providers quarterly certification of funds letter. When reconciling the certification of funds letter, do not include claims paid under the Katrina waiver. Providers will be reimbursed 100 percent for paid Hurricane Katrina claims. 5 of 9
18 (01/13/05 through 02/10/06)*****Attention All SHARS Providers***** This is an update to a banner message that appeared on providers' December 30, 2005, Remittance and Status (R&S) report regarding the discontinuance of occupational and physical therapy procedure codes 97001, 97003, 97110, and 97530 for School Health and Related Services (SHARS) providers effective for dates of service on or after March 4, 2006. Please disregard that message. Procedure codes 97001, 97003, 97110, and 97530 are reimbursable for Texas Medicaid SHARS providers. 19 (11/25/05 through 01/22/06)*****Attention All CORF and ORF Providers***** Effective for dates of service on or after January 1, 2006, the reimbursement/payment methodology for comprehensive outpatient rehabilitation facilities (CORFs) and outpatient rehabilitation facilities (ORFs) will change to a prospective payment system (PPS) fee schedule. Physical, occupational, and speech therapies provided under the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) will be based on a PPS fee schedule. The current reimbursement methodology is based on reasonable costs with interim payment percentages applied to billed charges. Details regarding reimbursement, authorization, and claims filing are available on the TMHP website at www.tmhp.com and will also be available in the January/February 2006 Texas Medicaid Bulletin, No. 192. 20 (11/18/05 through 01/13/05)*****Attention All Home Health Agencies***** For home health agencies that provide Medicaid home health services and Comprehensive Care Program (CCP) therapy services, please refer to the TMHP webpage (www.tmhp.com) to obtain important updates to the prior authorization and billing requirements under the home health agency statewide visit rate policy published in the September/October Texas Medicaid Bulletin, No. 190, on pages 16-18. These updates take effect immediately. 21 (12/30/05 through 1/27/06) *****Attention All Medicaid and Family Planning Providers***** As a result of Section 24, S.B. 1188, 79th Texas Legislature, Regular Session, 2005, Texas Medicaid providers rendering services to a pregnant Texas Medicaid client must inform the client of the health benefits for which the client or the client s child may be eligible for under the Children s Health Insurance Program (CHIP). Details of these changes are available in the Informing Pregnant Clients About CHIP Benefits article published on page 11 of the January/February Texas Medicaid Bulletin, No.192. 22 (12/23/05 through 01/20/06)*****Attention All Medicaid, Family Planning, and CSHCN Providers***** TMHP will perform system and data maintenance for the RightFax servers on Sunday, January 8, 2006, from 8 a.m. until 6 p.m. TMHP will not be able to receive or send faxes during this time period. For more information concerning the scheduled maintenance, call the Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638. 6 of 9
23 (12/30/05 through 01/27/06)*****Attention All Medicaid, Medicaid Managed Care, and CSHCN Providers***** Effective for dates of service on or after December 16, 2005, procedure code 1-J1565 is no longer a benefit of the Texas Medicaid, Medicaid Managed Care, and the Children with Special Health Care Needs (CSHCN) Services Programs. 24 (1/20/06 through 2/17/06) *****Attention All Medicaid and CSHCN Providers***** Effective for dates of service on or after March 10, 2006, procedure code 99058 will no longer be a benefit of the Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Programs. No action on the part of the provider is necessary. 25 (1/20/06 through 2/17/06) *****Attention All Medicaid and CSHCN Providers***** This is an update to a banner message that appeared on providers' November 18, 2005, Remittance and Status (R&S) report. Reimbursement and benefit changes for neurostimulator procedures and devices will not be implemented for dates of service on or after February 1, 2006. The Health and Human Services Commission (HHSC) and the Children with Special Health Care Needs (CSHCN) Services Program will provide additional information about neurostimulator benefit changes at a future date. Additionally, this update applies to the "Change to Neurostimulator Benefits" article beginning on page 12 of the January/February 2006 Texas Medicaid Bulletin, No. 192 and the "Changes to Neurostimulator Benefits" article beginning on page 16 of the February 2006 CSHCN Provider Bulletin, No. 57. 26 (12/23/05 through 1/20/06) *****Attention All Medicaid and CSHCN Providers***** This is an update to a banner message that appeared on providers November 25, 2005, Remittance and Status (R&S) report regarding upcoming reimbursement rates changes for physical, occupational, and speech therapies provided by independently practicing physicians/therapists. These rate changes will apply to both the Medicaid, Managed Care, and Children with Special Health Care Needs (CSHCN) Services Programs. The Therapy Rate Changes for Independently Practicing Physicians/Therapists article that contains details of the reimbursement changes has been updated with new information. Visit the TMHP website at www.tmhp.com to view the revised article Therapy Rate Changes for Independently Practicing Physicians/ Therapists: Article Revised December 16, 2005. Details of these changes will also be available in the March/April 2006 Texas Medicaid Bulletin, No. 194. and the May 2006 CSHCN Provider Bulletin, No. 58. 7 of 9
27 (12/16/05 through 01/13/06)*****Attention All Medicaid and CSHCN Providers***** Effective for dates of service on or after January 20, 2006, procedure code 93272 will be considered as a benefit of the Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Programs when billed with modifier 26. The reimbursement rate will be reduced to 0.73 relative value units (RVUs). No action on the part of the provider is necessary. 28 (01/13/06 through 02/10/06)*****Attention All CSHCN Providers***** Effective for dates of service on or after March 1, 2006, procedure code 1-90586 will no longer be a benefit to outpatient hospitals and home health agencies for the Children with Special Health Care Needs (CSHCN) Services Program. For more information, call the TMHP-CSHCN Contact 29 (01/13/06 through 02/10/06)*****Attention All CSHCN Providers***** Effective for dates of service on or after March 1, 2006, proton beam therapy procedure codes 77520 through 77525 will be considered for reimbursement when submitted with diagnosis code 194.3 (Malignant neoplasm of other endocrine glands and related structures, pituitary gland, and craniopharyngeal duct) for the Children with Special Health Care Needs (CSHCN) Services Program. These procedure codes require prior authorization with documentation of medical necessity. For more information, call the TMHP-CSHCN Contact 30 (12/30/05 through 01/27/06)*****Attention All CSHCN Providers***** Effective for dates of service on or after December 1, 2005, the following insulin pump supply procedure codes are a benefit of the Children with Special Health Care Needs (CSHCN) Services Program and may be reimbursed separately when billed with an insulin pump. The insulin pump supply procedure codes are limited to the amounts shown: A4230 = 10 per month, A4231 = 15 per month, A4232 = 10 per month, A6257 = 15 per month, A6258 = 15 per month, A6259 = 15 per month, and A4632 = 1 per month. For more information, call the TMHP-CSHCN Contact 31 (12/23/05 through 1/20/06) *****Attention All CSHCN Providers***** Effective for dates of service on or after January 1, 2006, the 2006 Healthcare Common Procedure Coding System (HCPCS) deleted procedure codes will no longer be a benefit of the Children with Special Health Care Needs (CSHCN) Services Program. Providers who received prior authorizations for a 2006 HCPS deleted procedure code, for dates of service on or after January 1, 2006, will need to resubmit an authorization request form, that include valid procedure codes, on or after January 16, 2006. Fax the appropriate authorization request form to the TMHP-CSHCN Authorization department at 1-512-514-4222. Authorizations for the following HCPCS procedure codes will be updated by TMHP and require no action on the part of the provider: A5119, K0618 through K0620, K0630 through K0649, L0860, L8100, L8110, L8120, L8130, L8140, L8150, L8160, L8170, L8180, L8190, L8195, L8200, L8210, L8220, L8230, L8239, 97504, 97520, 97520, 97703, 33918, 33919, and 44200. For more information, call the TMHP-CSHCN Contact 8 of 9
32 (01/13/06 through 02/10/06)*****Attention All Family Planning Providers***** Effective January 1, 2006, the Family Planning (Titles V, X, and XX) Remittance and Status (R&S) reports will have two columns for fiscal year (FY) 2006 on the Summary page. The first column will reflect activity for dates of service January 1, 2006, through August 31, 2006. The second column will reflect activity for dates of service September 1, 2005, through December 31, 2005. The columns represent the two contract periods as a result of the competitive Request for Proposal (RFP) process for state fiscal year (SFY) 2006 for family planning providers. 9 of 9