Benefit Criteria to Change for Evoked Response Tests and Neuromuscular Procedures for Texas Medicaid Information posted February 15, 2013 Effective for dates of service on or after April 1, 2013, benefit criteria for evoked response tests and neuromuscular procedures will change for Texas Medicaid. Benefit Changes The following electromyography (EMG) procedure codes will no longer be a benefit of Texas Medicaid for the type of service component indicated: Procedure Codes 1 95873, 95874 I/T 95955 1= Medical, T= Technical component, I= Professional interpretation component Procedure codes 95873 and 95874 will no longer be a benefit when rendered in the office or home setting by psychologist providers. The following procedure codes will no longer be reimbursed to the provider types in the place of service indicated: Procedure Codes Place of reimbursed 95921 5 Outpatient hospital Physician 95970, 95971, 95972, 95973, 95974, 95975, 95978, 95979 5 Outpatient hospital Physician, nurse practitioner (NP), al nurse specialist (CNS), physician assistant (PA) 95933 5 Outpatient hospital Physician, federally qualified health center (FQHC) 95928 5 Office Independent, certified nurse midwife, facility, rural health 95860, 95861, 95863, 95864 95860, 95861, 95863, 95864 5 Office Independent, 5 Outpatient Physician, independent, nephrologist, renal
Procedure Codes Place of reimbursed 95865 5 Office Independent, radiation treatment center, facility, rural health 95865 5 Outpatient hospital Physician, independent, nephrologist, renal 95866 5 Office Independent, renal 95866, 95867, 95868, 95869, 95872, 95875 95867, 95868, 95869, 95872, 95875 5 Outpatient hospital Physician, independent, nephrologist, renal 5 Office Independent, 95870 5 Outpatient hospital Physician, independent, podiatrist, facility, rural health 95870 5 Office Independent, podiatrist, radiation treatment center, hospital, nephrologist, renal dialysis facility, rural health 95925, 95926, 95927, 95928, 95929 95831, 95832, 95833, 95834, 95851, 95852 5 Outpatient hospital NP, CNS, PA, physician, independent, certified nurse midwife, facility, rural health, 5 Office Independent, certified nurse midwife,
Procedure Codes 95831, 95832, 95833, 95834, 95852 Place of reimbursed 5 Outpatient hospital NP, CNS, PA, physician, independent, certified nurse midwife, facility, rural health, 95851 5 Office Independent, podiatrist, certified nurse midwife, hospital, facility, rural health 95851 5 Outpatient hospital Physician, independent, podiatrist, certified nurse midwife, hospital, facility, rural health, 95930, 95933 5 Office Optometrist, FQHC 95930 5 Outpatient hospital Optometrist, FQHC 95937 5 Office Independent, 95937 5 Outpatient hospital Physician, independent, nephrologist, renal, 95929 5 Office Independent, facility, rural health 95925, 95926, 95927 5 Office Independent, hospital, certified nurse midwife, nephrologist, renal
Procedure Codes 95831, 95832, 95833, 95834, 95852, 95925, 95926, 95927, 95928, 95929 Place of reimbursed 5 Inpatient hospital NP, CNS, PA, independent, certified nurse midwife, hospital, facility, rural health, 95851 5 Inpatient hospital NP, CNS, PA, independent, podiatrist, certified nurse midwife, hospital, facility, rural health, 95930 5 Inpatient hospital Optometrist, FQHC, portable X-ray supplier, radiological and physiological 95937 5 Inpatient hospital Independent,, 95933 5 Inpatient hospital FQHC 95970, 95971, 95972, 5 Inpatient hospital NP, CNS, PA 95973, 95974, 95975, 95978, 95979 95933 I Inpatient and Optometrist, FQHC 95937, 95860, 95861, 95863, 95864 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95875 95925, 95926, 95927, 95928, 95929 I Inpatient and Portable X-ray supplier, I Inpatient hospital Portable X-ray supplier, I Inpatient and 95928, 95959 I Inpatient and NP, CNS, PA, certified nurse midwife, portable X-ray supplier, radiological and physiological Hospital
Procedure Codes Place of 95930 I Inpatient and reimbursed FQHC 51784, 51785 T Outpatient hospital Hospital 95930, 95933 T Office FQHC 5= Total component, I= Professional component, T= Technical component The following procedure codes will no longer be reimbursed when rendered in the places of service indicated by any provider: Procedure Codes Place of 95865, 95866 T Outpatient hospital 95860, 95861, 95863, 5 Inpatient hospital 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95875 95831, 95832, 95833, 95834, 95851, 95852, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95875, 95925, 95926, 95972, 95973, 95974, 95975, 95978, 95979 5 Independent 5= Total component, T= Technical component The following procedure codes may be reimbursed to the specific providers and places of services indicated: Procedure Code 95921, 95922, 95923, 95970, 95971, 95972, 95973, 95974, 95975 Place of 5 Outpatient hospital Provider Types Hospital 95937, 95933 5 Office NP, CNS, PA, radiation treatment center
Procedure Code 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95875, 95925, 95926, 95927, 95928, 95929, 95937 Place of Provider Types I Office Physician, NP, CNS, PA 51784, 51785 T Office NP, CNS, PA, radiation treatment center, 51784, 51785, 95930, 95933 T Outpatient hospital Radiation treatment center 95930 T Office Radiation treatment center 95933 T Office Radiation treatment center, radiological and physiological 5= Total component, T= Technical component, I= Professional interpretation component Electromyography EMG (procedure codes 95873 and 95874) will be a benefit of Texas Medicaid and will be limited to four occurrences per calendar year, same provider, any procedure. Procedure codes 95873 and 95874 may be reimbursed in the following place of service by the following provider types: Component Places of Provider Types Total Office Physician, NP, CNS, PA, portable X-ray supplier, providers Outpatient hospital Hospital providers Professional Office Physician, NP, CNS, and PA providers Inpatient hospital and Physician Technical Office Physician, NP, CNS, PA, radiation treatment center, and portable X-ray supplier, providers
Autonomic Function Tests AFTs are a benefit of the Texas Medicaid Program when submitted with procedure codes 95921, 95922, 95923, 95924, and 95943. Procedure codes 95921, 95922, 95923, 95924, and 95943 are limited to one per date of service, by the same provider. Some of the conditions under which AFTs may be appropriate include, but are not limited to, the following: Irregular heart rate Orthostatic symptoms Gastrointestinal dysfunction Excessive sweating Diabetic autonomic neuropathy Amyloid neuropathy Sjogren s syndrome Idiopathic neuropathy Pure autonomic failure Multiple system atrophy Distal small fiber neuropathy Reflex sympathetic dystrophy or causalgia (sympathetically maintained pain) Documentation Requirements for AFTs The reason for the referral, the specific autonomic function being tested, and a clear diagnostic impression must be documented in the client s medical record for each AFT performed. The client's medical records must clearly document the medical necessity for the AFT. The medical record documentation must reflect the actual results of specific tests (such as latency and amplitude). Medical necessity for reevaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client s medical record. Supporting documentation includes, but is not limited to, the following: The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis. Evidence that the client s condition is changing rapidly, supported by the following: o o o o Diagnosis Current al signs and symptoms Prior al condition Expected al disease course
o Clinical benefit of additional studies. The client s medical records are subject to retrospective review. Wave form recordings obtained during the testing will aid documentation requirements in cases where a review becomes necessary. Evoked Potential Tests Each evoked potential (EP) test (procedure codes 92585, 92586, 95925, 95926, 95927, 95928, 95929, 95930, 95938, or 95939) is considered bilateral and will be limited to once per date of service, any provider, regardless of modifiers that indicate multiple sites tested. EP tests may be reimbursed up to four services per rolling year, any combination of services, any provider. Claims that are denied for exceeding the limitation may be considered on appeal with documentation that supports medical necessity. Procedure code 95930 will no longer be diagnosis restricted. Visually Evoked Potential (VEP) Tests Some of the conditions under which VEP testing (procedure code 95930) may be appropriate include, but are not limited to, the following: Identification of persons at increased risk for developing ally definite multiple sclerosis. Diagnosing, monitoring, and assessing treatment response in multiple sclerosis. Localizing the cause of a visual field defect not explained by lesions seen on CT or MRI, or by metabolic disorders or infectious disease. Evaluating the signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons, non-verbal persons). Evaluating clients who experience double vision, blurred vision, loss of vision, eye injuries, head injuries, or weakness of the eyes, arms, or legs. Motion Analysis Motion analysis (procedure codes 96000, 96001, 96002, and 96003) will be a benefit of Texas Medicaid for clients who are 3 through 20 years of age. Procedure codes 96000, 96001, 96002, and 96003 may be reimbursed to physician, NP, CNS, PA, radiological physiological providers in the office setting and to hospital providers in the outpatient setting. Procedure codes 96000, 96001, 96002, or 96003 are limited to one per date of service by the same provider, and two per rolling year, same procedure, any provider. In the following table, the procedure codes in Column A will be denied when they are submitted on the same date of service by the same provider as the procedure codes in Column B: Column A (Denied) Column B 96000 96001
95860, 95861, 95863, 95864, 95865, 95866, 95869, 95870, 96002 or 96003 95872 97116, 97550 96000 or 96001 Documentation for Motion Analysis Documentation must include the following information that indicates the client meets all the requirements for motion analysis studies. The client must be: Ambulatory for a minimum of ten consecutive steps, with or without assistive devices. At least 3 years of age. Physically able to tolerate up to three hours of testing. The reason for the referral and a clear diagnostic impression must be documented in the client s medical record for each motion analysis study performed. The client s medical records must clearly document the medical necessity for the motion analysis study. The medical record documentation must reflect the actual results of specific test. Medical necessity for reevaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client s medical record. Supporting documentation must include, but is not limited to, the following: The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis. Evidence that the client s condition is changing rapidly, supported by the following: o Diagnosis o Current al signs and symptoms o Prior al condition o Expected al disease course Clinical benefit of additional studies The client s medical records are subject to retrospective review. For more information, call the TMHP Contact Center at 1-800-925-9126.