Banner Message for the 01/30/06 ER&S and the 02/03/06 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 (29) 1 (2/03/06 through 3/03/06) *****Attention All Medicaid Providers***** Effective for dates of service on or after May 13, 2005, the criteria for authorization of lung, liver, and heart transplants changed. The details of these changes were published in the July/August 2005 Texas Medicaid Bulletin, No. 189, in the article titled Changes to Organ Transplant Authorization. The information is also available on the TMHP website at www.tmhp.com. This information updates the information published in the 2006 Texas Medicaid Provider Procedures Manual, Sections 36.4.29.2 "Heart Transplants," 36.4.29.4 "Liver Transplants," and 36.4.29.5 "Lung Transplants." For more information, call the TMHP Contact Center at 1-800-925-9126. 1 of 8
2 (2/03/06 through 3/03/06) *****Attention All Medicaid Providers***** Effective for dates of admission on or after March 6, 2006, admission code 5 (Trauma Center) will be added as a new option for the Type of Admission field on the UB-92 claim form or the equivalent electronic form. Admission code 5 is required for a trauma center admission to an inpatient or outpatient facility. 3 (1/27/06 through 2/24/06) *****Attention All Medicaid Providers***** On July 22, 2005, TMHP implemented an increase for School Health Related Services (SHARS) reimbursement rates effective for dates of service on or after September 1, 2005, for the following procedure codes: 92506, 92506-GN, 92507, 92507-GN, 96100, 97001, 97003, 97110, 97530, 99499, H0004, H0004- AH, T1002, and T2003. Claims submitted from September 1, 2005, through March 13, 2006, that include these procedure codes will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. A future banner message will notify providers when the reprocessing is complete and when additional payments will be reflected on providers Remittance and Status (R&S) report. Claims submitted on or after March 13, 2006, will be reimbursed with the new rates. Details of these changes are available on the website at www.tmhp.com. 4 (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. 5 (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. 2 of 8
6 (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. 7 (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. 8 (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. 9 (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. 10 (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. 3 of 8
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. 11 (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. 12 (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. 13 (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. 14 (2/03/06 through 3/03/06) *****Attention All Behavioral Health Providers***** The following information is an update to the article titled "Outpatient Behavioral Health Services" located on page 5 of the May/June 2005 Texas Medicaid Bulletin, No. 187. and is intended to clarify processing guidelines for these services. Outpatient behavioral health services are limited to 30 encounters per calendar year, per client, regardless of provider, unless prior authorized. TMHP conducts a retrospective review to determine and ensure that claims are processed appropriately according to dates of service. This review may result in the reprocessing of a claim that originally dispositioned based on the date of receipt because the system processes claims continuously. 4 of 8
Clinicians should plan therapy with the 30-encounters limitation in mind and should request extension authorizations before the client's twenty-fifth visit. The current policies and guidelines require that authorizations be obtained before rendering service. TMHP does not grant retro authorization. 15 (2/03/06 through 3/03/06) *****Attention All PCCM Providers***** Effective for dates of service on or after March 10, 2006, procedure code 54150 will no longer require precertification when provided by freestanding or hospital-based ambulatory surgical centers in order to be considered for reimbursement by the Primary Care Case Management (PCCM) Program. No action on the part of the provider is necessary. 16 (2/03/06 through 3/03/06) *****Attention All SHARS Providers***** The following is a clarification of the formula used by TMHP to calculate the State/Local Funds Expended column of the quarterly Certification of Funds Letters. Section 41.3.3 Verifying the Amounts in the Letters, on page 41-3 of the 2006 Texas Medicaid Provider Procedures Manual (TMPPM) lists the following formula: (Figure in the Total Amount Paid for Previous Quarter column/federal Matching Share percentage) x State Share percentage = State/Local Funds Expended column. The correct formula should read as follows: (Total Paid Claim Amount/Federal Matching Share percentage) x State Share percentage = State/Local Funds Expended. The calculation is completed per claim at each detail level and based on the federal matching share effective on the date of service and not the "Total Amount Paid for Previous Quarter." Multiple federal matching share percentages are possible during each quarter. The total listed in the State/Local Funds Expended column of the Certification of Funds letter is calculated by totaling the amounts for each claim. This calculation is applied to paid claims only. Adjustments and cash refunds are not included in this calculation. A future banner message will notify providers of changes to federal matching share percentages. 17 (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. 18 (11/25/05 through 01/27/06)*****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. 5 of 8
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. 19 (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. 20 (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. 21 (2/03/06 through 3/03/06) *****Attention All Medicaid and CSHCN Providers***** The Texas Medicaid Provider Enrollment Application has been revised. Effective immediately, providers are to begin completing the new application, which is available on the TMHP website at www.tmhp.com. Effective February 10, 2006, TMHP will return all applications not submitted on the new enrollment application. 22 (1/27/06 through 2/24/06) *****Attention All Medicaid and CSHCN Providers***** This is an update to a banner message that appeared on providers December 10, 2004, Remittance and Status (R&S) report. When submitting procedure code 5-80197, the correct diagnosis code to submit is V42.7 and not V24.7. Following is the complete article with the correct diagnosis code. Effective November 15, 2004, procedure code 5-80197 submitted with diagnosis code V42.7 (Monitoring post liver transplant status) is payable for the Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Programs. Claims submitted for dates of service on or after November 15, 2004, that include procedure code 5-80197 with diagnosis code V42.7 will be processed, and payments made accordingly. No action on the part of the provider is necessary. 6 of 8
23 (1/27/06 through 2/24/06) *****Attention All Medicaid and CSHCN Providers***** TMHP has identified an issue related to type of service (TOS) assignments impacting electronic claims submitted for processing between January 13, 2006, and January 16, 2006. Claims submitted during this time period that received rejections or denials because of an invalid TOS will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary. 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 (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 27 (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 7 of 8
28 (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 29 (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. 8 of 8