September/October 2004 No. 182 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual BULLETIN Bulletin Contents, No. 182 All Providers A New Era in Human Services... 2 Medicaid Fee Schedule... 2 Oral Appeals... 2 Remittance and Status Delivery... 3 Scheduled System Maintenance... 3 TDHconnect Service Pack 4... 4 Ambulatory Surgical Center/Hospital Ambulatory Surgical Center (ASC/HASC) Providers ASC/HASC HCPCS Update... 5 ASC/HASC Group Rate Revisions... 5 Children and Pregnant Women (CPW) Providers CPW Claim Submissions... 6 Home Health Providers Humidifi cation Units... 6 THSteps Dental Providers Orthodontic Procedures... 7 Excluded Providers Excluded Providers... 9 CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply.
All Providers A New Era of Human Services Under the direction of the Health and Human Services Commission (HHSC), four new departments combine services and programs to eliminate duplication and create efficiencies. In HHSC, a common parent organization handles administrative functions, such as human resources and purchasing. Two departments were launched this spring and two more were launched on September 1, 2004. The new departments are: Department of Family and Protective Services (DFPS) offers the services and programs previously provided by the Department of Protective and Regulatory Services. Department of Assistive and Rehabilitative Services (DARS) offers services previously provided by the Texas Rehabilitation Commission, Commission for the Blind, Commission for the Deaf and Hard of Hearing, and the Interagency Council on Early Childhood Intervention. Department of Aging and Disability Services (DADS), consolidates mental retardation and state school programs of the Department of Mental Health and Mental Retardation, community care and nursing home services programs of the Department of Human Services, and aging services programs of the former Texas Department of Aging. Department of State Health Services (DSHS), consolidates the programs of the Texas Department of Health, the Texas Commission on Alcohol and Drug Abuse, the Health Care Information Council, and mental-health community services and state hospital programs operated by the Department of Mental Health and Mental Retardation. In addition, HHSC directs eligibility determination services, the Office of Family Services including the food stamp program, the Children s Health Insurance Program (CHIP), and Medicaid, along with its many responsibilities as the oversight organization for the entire system. Beginning with this edition of the Texas Medicaid Bulletin, HHSC departments are referred to by their new names and acronyms. For more information on these new departments, their services and areas of responsibility, and an organizational chart, see the HHSC website at www.hhsc.state.tx.us/consolidation/ Consl_home.html. Medicaid Fee Schedule The 2004 Texas Medicaid provider fee schedules will be posted to the TMHP website (www.tmhp.com) on September 30, 2004. The schedules will be available in Microsoft Excel format. Providers may request a paper copy of any fee schedule at no charge by calling the THMP Contact Center at 1-800-925-9126. Oral Appeals Effective August 1, 2004, HHSC s Utilization Review Appeals Unit no longer offers oral appeals. In place of an oral appeal, hospital physicians have the option of an educational conference with the HHSC consultant physician. The educational conference is held by telephone and is between the HHSC physician and the hospital medical director or attending physician involved with the case. It is an opportunity for the physicians to discuss the deciding factors in the case as well as the hospital claims processes that may have affected the adjudication of the case. The conference does not alter the previous appeal decision. To schedule an educational conference following an appeal decision, call 1-512-491-1325. Texas Medicaid Bulletin, No. 182 2 September/October 2004
All Providers Remittance and Status Delivery TMHP is pleased to announce a new feature on the TMHP website (www.tmhp.com). Providers can now elect to update their Remittance and Status (R&S) report delivery option to include a new download method. Providers electing to receive this delivery option will no longer receive a paper version of the R&S report. This newest option allows providers to receive an exact replica of the paper R&S in Adobe Portable Document Format (PDF). PDF files can be viewed on any computer using the free Adobe Reader software, also available for download from the TMHP website. The new downloadable R&S has many advantages to paper, including easy physical storage and the ability to print only required pages (i.e., for a claim appeal). TMHP stores three months of the most current R&S files for those providers electing to download the PDF version. The downloadable version of the R&S report is available each Monday, along with the Electronic Remittance and Status (ER&S) 835 version of the R&S. This eliminates the one-week delay of print and mail time for the provider community. This new functionality does not affect the normal claims payment cycle. Providers receiving physical checks would receive these individually, without an R&S report attached. Providers interested in the PDF version: Visit www.tmhp.com to select this new R&S delivery method. Click View R&S Reports from the I would like to... links located in the top-right corner of the TMHP website homepage. Registration is required. Providers already registered for website access do not need to re-register; however, they are required to associate all provider numbers/tpis with the registration ID. Upon initial login, providers use the designation form to submit their option for the R&S download. For optimal electronic capability, the PDF option is combined with the Electronic Remittance & Status (ER&S, 835 electronic file). These two options may serve different needs within a provider s organization. Providers interested in using the ER&S version can call the EDI Help Desk at 1-888-863-3638. This is a one-time submission, until the time a provider wishes to change his delivery method. Once submitted, the expected timeline for the request to be effective is two R&S report cycles. To download the PDF version of the R&S: Choose the appropriate TPI/Provider Number, program (Medicaid or Managed Care), and the date of the R&S report. (Long Term Care providers will not see a program designation.) After selecting the dated file, the R&S report opens in the reader format. Save the file to either a local computer or network location by using the File>Save menu options. For more information, or for problems with the selection/download process, please contact the EDI Help Desk at 1-888-863-3638. Scheduled System Maintenance TMHP routinely performs diagnostic and corrective maintenance to the claims processing system. The next system maintenance is scheduled to occur on September 19, 2004, from 6:00 p.m. to 11:59 p.m. and October 17, 2004, from 6:00 p.m. to 11:59 p.m. During system maintenance, some claims engine related applications are unavailable. Specific details regarding the affected applications are posted on the TMHP website at www.tmhp.com. Providers requiring additional information concerning the scheduled maintenance may call the EDI Help Desk at 1-888-863-3638. September/October 2004 3 Texas Medicaid Bulletin, No. 182
All Providers TDHconnect Service Pack 4 TMHP released TDHconnect 3.0 Service Pack 4 on August 20, 2004. Providers who use TDHconnect 3.0 are encouraged to download and install Service Pack 4, as it resolves several of the current issues with the software. The service pack can be downloaded from the TMHP website to the user s computer and installed. Service Pack Download To download the service pack, do the following: 1. Connect to TMHP at www.tmhp.com. 2. Click the Find Software/Service Packs link located in the I would like to list on the right side of the page. The TMHP File Library main page opens. 3. Scroll down to locate the File Library links. 4. Click the TDHconnect link. The TMHP File Library/TDHconnect web page opens. 5. Scroll down to locate the File Library links. 6. Click the TDHconnect Updates link. The TMHP File Library/TDHconnect/TDHconnect Updates web page opens. 7. Scroll down to locate the File Library links. 8. Select the most recent Service Pack, such as TDHconnect 3.0 Updates Service Pack 4. Service Pack Installation To install the service pack, do the following: 1. Double-click the TDHconnect 3.0 Updates Service Pack 4.zip icon. This icon was added to the desktop during the file download. LAN to share with other TDHconnect 3.0 users. 2. A dialog opens with the following message: This will install TDHconnect 3.0 Service Pack 4. Do you want to continue? Click Yes to install the TDHconnect 3.0 Service Pack. 3. After the TDHconnect Service Update Installation Utility window opens and the TDHconnect 3.0 Service Pack wizard opens, several informational messages will open. Read each message and click Next to advance to the next screen. 4. A dialog opens with the following message: Do you wish to backup your databases? This will overwrite databases that are in the Backup folder. Choose one of the following options: Click Yes to backup your databases before installing any database updates (this is the recommended choice). Click No to continue with the installation without making backups. Note: Several additional informational messages open. This process may take several minutes as database updates are made. 5. Installation of the TDHconnect 3.0 Service Pack is complete. To view the readme file, check the View readme check box and click Finish. The readme document opens. 6. Read the document, close it, uncheck the View readme check box, and click Finish. 7. When prompted to restart the computer, select Yes, I want to restart my computer now, and then click Finish. The next time TDHconnect is opened, the version of the Service Pack is listed along with the name TDHconnect 3.4.0. For problems with the download, contact the TMHP EDI Help Desk at 1-888-863-3638. TIP: The file can be moved to a location on a Texas Medicaid Bulletin, No. 182 4 September/October 2004
Ambulatory Surgical Center/Hospital Ambulatory Surgical Center (ASC/HASC) Providers ASC/HASC HCPCS Update The following procedure codes were inadvertently omitted from the HCPCS 2004 Special Bulletin. These codes are payable to ASC/HASC facilities for dates of service on or after July 1, 2004: Procedure Code Description 36555 Insert Non Tunneled CV Cath F=GP 1 36556 Insert Non Tunneled CV Cath F=GP 1 36557 Insert Tunneled CV Cath F=GP 3 36558 Insert Tunneled CV Cath F=GP 3 36560 Insert Tunneled CV Cath F=GP 3 36561 Insert Tunneled CV Cath F=GP 3 36563 Insert Tunneled CV Cath F=GP 3 36565 Insert Tunneled CV Cath F=GP 3 36566 Insert Tunneled CV Cath F=GP 1 36568 Insert Tunneled CV Cath F=GP 1 36569 Insert Tunneled CV Cath F=GP 1 36570 Insert Tunneled CV Cath F=GP 3 36571 Insert Tunneled CV Cath F=GP 3 36575 Repair Tunneled CV Cath F=GP 2 36576 Repair Tunneled CV Cath F=GP 2 36578 Replace Tunneled CV Cath F=GP 2 36580 Replace Tunneled CV Cath F=GP 1 36581 Replace Tunneled CV Cath F=GP 2 36582 Replace Tunneled CV Cath F=GP 2 36583 Replace Tunneled CV Cath F=GP 2 36585 Replace Tunneled CV Cath F=GP 2 36589 Removal Tunneled CV Cath F=GP 2 36590 Removal Tunneled CV Cath F=GP 2 For more information, call the TMHP Contact Center at 1-800-925-9126. ASC/HASC Group Rate Revisions The article titled ASC/HASC Group Rate Revisions on page 13 of the 2004 HCPCS Special Bulletin, No. 180, was printed in error. Note: There are no changes to the ASC/HASC group rates as a result of the changes adopted by Medicare effective October 1, 2003. Disregard the article. September/October 2004 5 Texas Medicaid Bulletin, No. 182
CPW Providers/Home Health Providers CPW Claim Submissions All claims for Case Management for Children and Pregnant Women (CPW) services must include appropriate procedure codes and modifiers, as well as the prior authorization number. Claims without correct modifiers are denied. CPW Billable Service Procedure Code Required Modifiers Comprehensive Visit G9012 U2 and U5 Face-to-face follow-up visit G9012 TS and U5 Telephone follow-up visit G9012 TS For descriptions of procedure codes and modifiers, see Section 12, CPW, of the Texas Medicaid Provider Procedures Manual. Home Health Providers Humidification Units Humidification units for nonmechanically ventilated clients may be purchased when a purchase is determined to be more cost effective than leasing the device with supplies. Humidification units for nonmechanically ventilated clients are purchased using procedure code J-E1399, Durable medical equipment, with a maximum fee of $1,230 or the manufacturer s suggested retail price less 18 percent, whichever is lower. Supplies for use with client-owned humidification units are considered for purchase using the appropriate HCPCS code for each item requested. Documentation of medical necessity must be included with submission of the request. Texas Medicaid Bulletin, No. 182 6 September/October 2004
THSteps Dental Providers Orthodontic Procedures With the implementation of HIPAA code standardization, certain local orthodontia codes were deleted and mapped to a new national procedure code. Effective October 16, 2003, national procedure code D8080, Comprehensive orthodontic treatment of the adolescent dentition, replaced the three orthodontic local procedure codes Z2009, Diagnostic workup approved, Z2011, Orthodontic appliance, upper braces, and Z2012, Orthodontic appliances, lower braces. Many providers noted the national procedure code did not allow for work-in-progress or partial billing (separating out the three orthodontic components). As a result, providers have billed in various ways, affecting their Medicaid payments Effective immediately, when billing for theses services, the local codes must be submitted as remarks codes along with the national procedure code D8080. Local codes (Z2009, Z2011 or Z2012) are placed in the remarks code field on electronic claims or Block 35 on paper claims. Note: If the remarks code and procedure code D8080 are not submitted, the claim denies. Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum payment of $775. D8080 must be billed on three separate details, with the appropriate remarks code, even if billing for the workup and full banding. Billing only one detail for a total of $775 is no longer accepted. General Billing Examples Example One: A client is approved for full banding, but after the initial workup, discontinues treatment. This provider would bill the national code D8080 and place, in the remarks/comment field, the local code Z2009, Diagnostic workup approved. The claim would pay $175. Example Two: A client is approved for full banding. The provider continues treatment and places the maxillary bands. The provider would bill the national procedure code D8080 and place, in the remarks/ comment field, the local code Z2009, Diagnostic workup approved, and Z2011, Maxillary bands. The claim would pay $475. Important: All electronic claims for D8080 must have the appropriate remarks code associated with the procedure code. Electronic Claims Submission Providers must adhere to the following guidelines for electronic claim submission (other than TDHconnect, see next page) so that TMHP can accurately apply the correct remarks code to the appropriate claim detail. A Diagnostic Procedure Code (DPC) remarks code must be submitted only once, in the first three bytes of the NTE02 at the 2400 loop. Electronic Claims Submission Examples For a claim with one detail, submitted with procedure code D8080 and remarks code Z2009, enter the information as follows: DPCZ2009. The total billed would be $175. For a claim with two details, submitted with procedure code D8080 and remarks codes Z2009 and Z2011, enter the information as follows: DPCZ2009Z2011. The total billed would be $475. For a claim with three details, where all three details are submitted separately with procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPCZ2009Z2011Z2012. The total billed would be $775. This method ensures accurate and appropriate payment for services rendered and addresses the need for partial billing. September/October 2004 7 Texas Medicaid Bulletin, No. 182
THSteps Dental Providers TDHconnect Claims Submission Follow the same guidelines for TDHconnect, with the exception of placing the remarks code into the Remarks Code field, next to the Procedure Code field, under the Details tab. Do not add DPC if using TDHconnect to file claims. TDHconnect Claim Examples For a claim with one detail, submitted with procedure code D8080 and remarks code Z2009, enter the information as follows: In the Procedure Code ID field, enter D8080. Place Z2009 into the Remarks Code field. The total billed would be $175. to the requesting provider. Because the received paper is not readable, TMHP is unable to identify the client for whom the provider is requesting the orthodontic prior authorization. 3) Ensure all submitted items, models, radiographs, and paper include complete client and provider information. 4) Include the client name and Program Case Number as well as the provider name and Texas Provider Identifier on all submitted items. For a claim with two details, submitted with procedure code D8080 and remarks codes Z2009 and Z2011, enter the information as follows: For the first detail, enter D8080 into the Procedure Code ID field. Place Z2009 into the Remarks Code field. The billed amount will be $175. In the second detail, enter D8080 into the Procedure Code ID field. Place Z2011 into the Remarks Code field. The billed amount will be $300. The total billed will be $475. For a claim with three details, enter the information as follows: For first detail, enter D8080 into the Procedure Code ID field. Place Z2009 into the Remarks Code field. The billed amount would be $175. In the second detail, enter D8080 into the Procedure Code ID field. Place Z2011 into the Remarks Code field. The billed amount would be $300. In the third detail, enter D8080 into the Procedure Code ID field. Place Z2012 into the Remarks Code field. The billed amount would be $300. The total billed would be $775. Tips for Orthodontic Prior Authorization Some tips for submitting orthodontic requests to TMHP: 1) Use black ink (blue, red, or other colors do not scan). 2) Write legibly. All paper received is scanned into the system and then reviewed. If the request received cannot be read, TMHP sends a letter Texas Medicaid Bulletin, No. 182 8 September/October 2004
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 the 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 are also denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client. Review the entire Exclusion List for Texas Medicaid at www.hhsc.state.tx.us/oie/exclusionlist/exclusion.asp. Report Medicaid providers who engage in fraud/abuse by calling 1-512-424-6519 or 1-888-752-4888, or by writing to the following address: Provider Ashlock, Ken A Barbay, Mary Louise Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity PO Box 13247 Austin 78711-3247 License Number Exclusion Date City State Provider Type Add Date 18-Jun-04 Tuscola 05-Jul-04 09-Jun-04 Groves Candruff, Frank B. 593942 10-Feb-04 Ft. Collins TN CO RN Cardenas, Kimberly M. 658184 31-Oct-03 Houston RN Cherry, Adam C. 2582 18-Mar-04 Coral Springs Cronk, John A. Evans, Patricia R. H7006 K2459 02-Apr-04 Quinlan 02-Apr-04 Ferguson, Karen M. 564512 10-Feb-04 Glasgow, Mark L. H5888 02-Apr-04 Kingman FL AZ OD Dallas RN Floyds Knobs IN Guillemaud, Andre 612001 20-Dec-03 Canada RN Hannah, Jamilee 15854 16-Apr-04 Coppell DDS Hughes, Donald D Kids Health Services, Inc. Lopez, Anthony R. Mancillas, Bianca B. McKinney, Eyerhonda Mills, Bryan D. E8575 13-May-04 Ft Worth 15-Jun-04 21-Jun-04 28-Jun-04 16-Jun-04 17-Jun-04 16-Jun-04 15-Jun-04 20-Apr-04 Coral Springs 28-Jun-04 14-Feb-02 Albuquerque 28-Jul-04 Levelland 20-Apr-04 Nguyen, Alan D. 18771 16-Apr-04 Nolte, Julie P. 653359 09-Mar-04 Pang, Shing Y. J1124 NM 28-Jul-04 Houston 05-Jul-04 18-Dec-03 Houston 30-Jun-04 Dallas Keithville 02-Apr-04 Arlington LA DDS RN 10-Jun-04 09-Jun-04 18-Jun-04 September/October 2004 9 Texas Medicaid Bulletin, No. 182
Excluded Providers Provider License Number Exclusion Date City State Provider Type Parks, Patrick H. 140457 20-Apr-04 Weatherford LVN Payne, Steven M. J0184 02-Apr-04 Pierre, Adam J 614801 19-Feb-04 Redding, Todd S. J2271 06-Feb-04 Houston Houston Bartlesville Rogers, Demetre L. 176833 26-Feb-04 Arlington Rose, Myrtle Scooters to Go, Inc. 08-Feb-01 Dallas 09-May-03 Dallas Spivey, Metha 099045 04-Jul-04 Abilene Stansill, Ashlea M. 687136 19-Feb-04 Spring Stoltz, James N. 591126 09-Mar-04 Clarksville Tamplen, Donald R. 11452 12-Feb-04 Venegas, Carlos L. K0566 20-Apr-04 Zimbelman, Deborah V. 677767 08-Jan-04 OK RN LVN Add Date 26-Jul-04 05-Jul-04 28-Jul-04 32 05-Jul-04 TN DME LVN RN RN Stafford DDS Irving Round Rock RN 13-Jul-04 05-Jul-04 25-Jun-04 16-Jun-04 10-Jun-04 15-Jun-04 16-Jun-04 Texas Medicaid Bulletin, No. 182 10 September/October 2004
Notes September/October 2004 11 Texas Medicaid Bulletin, No. 182
September/October 2004 No. 182 Texas Medicaid Bimonthly update to the Texas Medicaid Provider Procedures Manual PLACE POSTAGE HERE ATTENTION: BUSINESS OFFICE