Pub. No. 07 12276 CSHCN Services Program No. 77 PROVIDER BULLETIN Children with Special Health Care Needs Services Program February 2011 IN THIS EDITION General Interest 1 Vendor Drug Program (VDP) Website Revised 1 Administrative 2 Additional Demographic Information Required on Online Provider Lookup (OPL) 2 Additional TMHP Medically Needy Program Spend Down Processing Information 2 Electronic Data Interchange Version ANSI X12 5010 Implementation 2 Scheduled System Maintenance 3 MSRP Required for Unbundled Services that are Prior Authorized and for Manually-Priced 3 Electronic Data Interchange 835 File Changes 3 Paper Appeals Required for Total Billed Amount Changes 3 PEP and OPL Enhancements 4 TMHP Provider Relations Representatives 5 Coding and Reimbursement 6 Benefit Changes for Drug, Laboratory, and Medical 6 Benefit Changes for Some Expendable Medical Supplies 8 Benefit Criteria Changes for Cleft/Craniofacial Services 8 Benefit Criteria Changes for Doctor of Dentistry Services as a Limited Physician 9 Benefit Criteria Changes for Medical Nutritional Counseling Services 11 Claims Reprocessing for Stem Cell Transplant Procedure Code 12 Correction to Modifier 25 Information in the 2010 CSHCN Services Program Provider Manual.......... 12 Correction and Update to the Global Surgical Periods to Change for the CSHCN Services Program Article 12 Correction to September 2010 CSHCN Services Program Procedure Code Review Updates for 78804 and 91030 14 Outpatient Observation Changes 15 Vendor Drug Program (VDP) Website Revised The Vendor Drug Program (VDP) website at www.txvendordrug.com has been revised so that it is easier to navigate. Users who have previously bookmarked pages on the VDP website may need to update their favorites or bookmarks to point to the new pages. Some of the new links include: Preferred Drug List Online Drug and Prior Authorization Status Search Prescription Drug Prior Authorization Call Center Online Pharmacy Search For more information, e-mail the Health and Human Services Commission (HHSC) at contact@hhsc.state.tx.us. continued on next page 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 2010 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 Regula tion System/Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright 2010 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply.
Administrative Additional Demographic Information Required on Online Provider Lookup (OPL) Effective October 29, 2010, all providers are required to update in the OPL certain demographic information that was previously not required. These demographic updates are required so that clients and providers who refer clients can identify providers that can best meet the client s care needs. Providers should update the demographic information for all of the provider numbers that are marked with Review Required in their provider administrator account. The demographic information in the following fields must be updated: Office Phone Number (Address Section) E-mail Address (Address Section) Counties Served (County and Office Hours) Currently required Office hours (County and Office Hours) Currently required Traditional Medicaid (Additional Limitations) Patient Gender Limitations (Additional Limitations) Patient Age Limitations (Additional Limitations) Additional TMHP Medically Needy Program Spend Down Processing Information The Medically Needy Program (MNP) provides access to Medicaid benefits for pregnant women and children 18 years of age or younger. Prospective MNP clients who do not qualify for Medicaid must participate in the Spend Down program which is based on income and health-care expenses. Spend Down Program participants are responsible for paying a portion of their health-care bills and submitting those bills or completed claim forms, also referred to as invoices, to the Medically Needy Clearinghouse (MNC). The Spend Down amount and duration of Medicaid coverage is determined by HHSC. The MNC uses the invoices submitted by Spend Down Program participants to determine remaining Spend Down amounts. Once the client has met the total Spend Down amount and becomes eligible for Medicaid, the MNC will return the invoices to the client, and the client will receive a Medicaid Identification form. Spend Down Program participants are required to notify their providers once their Medicaid eligibility has been established. Providers are expected to submit claims to Medicaid for those clients after that time. On November 1, 2010, the MNC began mailing notification letters to providers who IN THIS EDITION continued from page 1 Payable Provider Type Added for Hearing Services Procedure Code V5266 15 Provider Type and Place of Service Changes 15 97002 and 97004 No Longer Require Prior Authorization 16 Reimbursement Rate Changes for Some Medical Services 16 Reimbursement Rate Changes for Some Physical Therapy, Occupational Therapy, and Speech-Language Therapy Services 17 Reimbursement Rate Changes for Some Radiology, Laboratory, and Radiation Therapy Services 17 Reimbursement Rate Changes for Some Surgical Services 17 Reimbursement Rates Pricing Change for Powered Air Flotation Bed 17 Reimbursement Rate Changes to Manual Pricing for Some DME 17 Reimbursement Rate Changes for Some Home Health Procedure, Eyeglass, and Genetic Services 18 September 2010 CSHCN Services Program Procedure Code Review Updates 19 Third Quarter 2010 HCPCS Updates Now Available 31 2011 ICD-9-CM Updates Now Available 31 CSHCN Services Program Contact Information 38 Forms 39 had not yet submitted claims for clients who had become eligible for Medicaid by meeting their Spend Down amount. For more detailed information about the Medically Needy Program and spend down processing, providers can refer to the 2010 CSHCN Services Program Provider Manual, section 3.6.1, Medically Needy Program (MNP). Electronic Data Interchange Version ANSI X12 5010 Implementation HHSC and the Texas Medicaid & Healthcare Partnership (TMHP) will soon initiate the implementation of Electronic Data Interchange (EDI) ANSI X12 version 5010 in accordance with Title 45 Code of Federal Regulations (CFR) Part 162 and the final rules published in an article titled Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA) Electronic Transaction Standards, which was published on January 16, 2009, in volume 74 of the Federal Register, on page 3296. HIPAA rules mandate the implementation of EDI ANSI X12 version 5010 beginning January 1, 2012. TMHP will support a dual-strategy approach to the implementation of EDI ANSI X12 version 5010. Trading partners can submit ANSI X12 version 4010 files and ANSI X12 version 5010 files between July 1, 2011, and December 31, No. 77, February 2011 2 CSHCN Services Program Provider Bulletin
Administrative 2011. Trading partners will not be able to submit a single file that includes claims in both ANSI X12 4010 and ANSI X12 5010 versions. EDI trading partners that pass EDI ANSI X12 version 5010 testing and certification requirements may elect to send ANSI X12 version 5010 transactions during the dualstrategy period. Trading partner outreach will begin in March 2011, and trading partner testing is scheduled to begin July 1, 2011. Additional information about specific changes that will be made with the implementation of EDI ANSI X12 version 5010 will be communicated through banner messages, website articles, bulletin articles, and EDI Companion Guide Updates. For more information, direct all questions and support requests to the EDI ANSI X12 version 5010 Implementation e-mail address at EDI5010Support@tmhp.com. MSRP Required for Unbundled Services that are Prior Authorized and for Manually- Priced This is an update to the 2010 CSHCN Services Program Provider Manual section 5.8.4, Manual Pricing, on page 5-42. The following information applies: Certain procedure codes do not have an established fee and must be priced manually by the TMHP-CSHCN Services Program medical staff. The medical staff determines the reimbursement amount by comparing the services to other services that require a similar amount of skill and resources. If an item requires manual pricing, providers must submit with the prior authorization request or the claim the appropriate procedure codes and documentation of one of the following, as applicable: The manufacturer s suggested retail price (MSRP) or average wholesale price (AWP) The provider s documented invoice cost if a published MSRP or AWP is not available Note: The AWP is for nutritional products only. For appropriate processing and payment, providers should bill the applicable MSRP or AWP rate instead of the calculated manual pricing rate. The calculated rate or the Pay Price that is indicated on the authorization letter for prior authorized services should not be billed on the claim. For prior authorization guidelines and manual pricing information for specific services, providers may refer to the appropriate sections of the 2010 CSHCN Services Program Provider Manual. Electronic Data Interchange 835 File Changes On November 5, 2010, TMHP implemented system modifications to EDI ANSI X12 4010 835 files. The 835 files display the appropriate Claims Adjustment Reason Code (CARC), Claims Adjustment Group Code (CAGC), and Remittance Advice Remarks Code (RARC) explanation codes that are associated with Explanation of Benefits (EOB) denials. The 835 file includes the CARC, CAGC, and RARC explanation codes that are associated with the highest priority detail EOB to provide a clearer explanation for the denial. The CARC, CAGC, and RARC explanation codes that are associated with EOB 01147 (Please refer to other EOB messages assigned to this claim for payment/denial information) are no longer displayed. Paper Appeals Required for Total Billed Amount Changes Providers must submit appeals on paper if the total billed amount is changed. If this kind of appeal is filed electronically, it will be denied for untimely filing if it is submitted more than 95 days after the original date of service. If providers want to resubmit a claim with a new total billed amount, they can submit the claims electronically as new day claims as long as the claim is still within 95 days of the filing deadline. If a claim is submitted after the 95-day filing deadline, it will be denied for untimely filing. Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled for: Sunday, February 13, 2011, 4:00 p.m. to 11:59 p.m. Sunday, March 13, 2010, 4:00 p.m. to 11:59 p.m. Sunday, April 10, 2010, 4:00 p.m. to 11:59 p.m. During system maintenance, some applications related to the claims engine will be unavailable. Specific details about the affected applications are posted on the TMHP website at www.tmhp.com. CSHCN Services Program Provider Bulletin 3 No. 77, February 2011
Administrative PEP and OPL Enhancements Enhancements to Provider Enrollment on the Portal (PEP) and the Online Provider Lookup (OPL) were implemented on October 29, 2010. If a provider chooses to enroll as a provider type other than a children s hospital, the Provider Enrollment screen in PEP asks if the provider has a children s unit. OPL Enhancements The OPL search page has been updated to allow clients to search for hospitals that include children s units. PEP Enhancements PEP has been updated to allow hospital providers and account administrators to: Self-declare during the enrollment process that the hospital has children s units. Declare within the Provider Information Management System (PIMS) that the hospital has designated children s units. Enrolling as a Children s Hospital Providers can enroll as a children s hospital by selecting the Children s checkbox in the Hospital Providers Only section. The Do you have children s unit(s)? question is disabled if the provider indicates that it is a children s hospital. Designated Children s Hospital and Children s Units in the OPL If a hospital enrolls as a children s hospital or indicates that it has children s units, the OPL search page is updated to show that the hospital has children s units. No. 77, February 2011 4 CSHCN Services Program Provider Bulletin
Administrative TMHP Provider Relations Representatives TMHP Provider Relations representatives offer a variety of services that inform and educate the provider community about the CSHCN Services Program s policies and claims filing procedures. Technical support and training are also provided for TexMedConnect. Provider Relations representatives assist providers through telephone contact, onsite visits, and scheduled workshops. The map at right and the table below indicate the TMHP Provider Relations representatives and the areas they serve. Additional information, including a regional listing by county and workshop information, is available on the TMHP website at www.tmhp.com. (Click on the Provider Support Services link, then click on the Provider Relations Reps link, and then choose your region.) Territory Regional Area Representative Telephone Number 1 Amarillo, Childress, and Lubbock Stephanie Hill 1 512 506 6217 2 Midland, Odessa, and San Angelo Mindy Wiggins 1 512 506 3423 3 Alpine, El Paso, and Van Horn Alma Gonzales 1 512 506 3530 4 Del Rio, Eagle Pass, and Laredo Christina Salinas 1 512 506 7271 5 Brownsville, Harlingen, and McAllen Cynthia Gonzales 1 512 506 7991 6 Abilene, Brownwood, and Wichita Falls Cynthia Rowlett 1 512 506 7095 7 Brady, North Austin,* Round Rock, and Waco Rhonda Williams 1 512 506 7600 8 South Austin,* Bastrop, Buda, Guadalupe, and San Marcos Kimberly Gauquier 1 512 506 3526 9 Kerrville and San Antonio* Kathe Barrett 1 512 506 3422 10 Corpus Christi, San Antonio,* and Victoria Alan Brown 1 512 506 3554 11 Cleburne, Denton, and Fort Worth Tamara House 1 512 506 7990 12 Corsicana, Dallas,* and Groesbeck Sandra Peterson 1 512 506 3552 13 Dallas,* Paris, and Whitesboro Demekia Merritt 1 512 506 3578 14 Texarkana and Tyler Trilby Foster 1 512 506 7053 15 Beaumont and Lufkin Gene Allred 1 512 506 3425 16 Bryan/College Station, Conroe, and Houston* Linda Wood 1 512 506 7682 17 Houston,* Ft. Bend Stephen Hirschfelder 1 512 506 3446 18 Chambers, Galveston, Brazoria, Houston,* Wharton, and Matagorda Michael Duffee 1 512 506 3586 Out of State Provider Representative Joann Kunde 1 512 506 7858 *Austin, Dallas, Houston, and San Antonio territories are shared by two or more provider representatives. These territories are divided by ZIP Codes. Refer to the TMHP website at www.tmhp.com for the assigned representative to contact in each ZIP Code. For more information, contact the TMHP CSHCN Contact Center at 1 800 568 2413. CSHCN Services Program Provider Bulletin 5 No. 77, February 2011
Benefit Changes for Drug, Laboratory, and Medical Effective for dates of service on or after September 1, 2010, benefit criteria have changed for certain drug, laboratory, and medical procedure codes for services rendered to CSHCN Services Program clients. The procedure codes affected by this change are: 83026 88371 88372 93268 93271 93278 99001 J0130 J1327 J1630 J1825 J2792 J2950 J3400 J3535 J7197 J7198 J7599 J7799 P9031 P9032 P9033 P9034 P9035 P9036 P9037 P9038 P9039 P9040 P9041 P9043 P9044 Q3025 Q3026 The following procedure codes may be reimbursed for services that are rendered to CSHCN Services Program clients for the indicated provider types and places of service: Type of Service Place of Service Provider Type(s) I 83026, 88371, 88372 Inpatient hospital, outpatient hospital 5 88371, 88372 Office, outpatient hospital, independent laboratory Physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty) Physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty) 5 93268, 93271 Office Advanced practice registered nurse (APRN), physician (D.O.), physician (M.D.), physician group (D.O.s only), physician Group (M.D.s only and multispecialty), portable X-ray supplier 5 93268 Outpatient hospital Long-term, limited, specialized care, private full care and emergency hospitals 5 93271 Independent laboratory Long-term, limited, specialized care, private full care and emergency hospitals 1 J1327, J1825, J2950, J3400, J3535, J7599, J7799 1 J1327, J1825, J2950, J3400, J3535, J7599, J7799 Office Outpatient hospital Advanced practice registered nurse (APRN), physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty) Long-term, limited, specialized care, private full care and emergency hospitals 1 J1630 Home Advanced practice registered nurse (APRN), physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty), dentist (D.D.S., D.M.D.), dentistry group 1 J2792 Office, home Advanced practice registered nurse (APRN), physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty) 1 J7799 Home Medical supplier 0 P9031, P9032, P9033, P9034, P9035, P9036, Office Advanced practice registered nurse (APRN), physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty) No. 77, February 2011 6 CSHCN Services Program Provider Bulletin
Type of Service Place of Service Provider Type(s) 0 P9037, P9038, P9039, P9040, P9041, P9043, P9044, Q3025, Q3026 0 P9031, P9032, P9033, P9034, P9035, P9036, P9037, P9038, P9039, P9040, P9041, P9043, P9044, Q3025, Q3026 Office Outpatient hospital Advanced practice registered nurse (APRN), physician (D.O.), physician (M.D.), physician group (D.O.s only), physician group (M.D.s only and multispecialty) Long-term, limited, specialized care, private full care and emergency hospitals Effective September 1, 2010, the following procedure codes are no longer a benefit of the CSHCN Services Program: Type of Service Procedure Code Place of Service 5 93271 Independent laboratory T 93271 Office, home, inpatient hospital, nursing home (skilled nursing facility [SNF]/intermediate care facility [ICF]), outpatient hospital, nursing home (extended care facility [ECF]) 5 93278 Office, inpatient hospital, outpatient hospital, independent laboratory I 93278 Office, home, inpatient hospital, nursing home (SNF/ICF), outpatient hospital, independent laboratory, birthing center, nursing home (ECF) The following procedure codes are no longer reimbursed to nephrology and renal dialysis providers: Type of Service Procedure Code Place of Service I 83026, 88371 Inpatient hospital, outpatient hospital 5 88371, 88372 Office, inpatient hospital, outpatient hospital, independent laboratory I 88372 Inpatient hospital, outpatient hospital 5 93268 Office, inpatient hospital 5 93271 Office 1 J1327 Office, inpatient hospital 1 J1825 Office 1 J2792 Office, home 1 J3400 Office, outpatient hospital 1 J3535 Office, outpatient hospital 1 J7599 Office 1 J7799 Office, home, outpatient hospital 0 P9031, P9032, P9033, P9034, P9035, P9036, P9037, P9038, P9039, P9040, P9041, P9043, P9044 Office 1 Q3025, Q3026 Office CSHCN Services Program Provider Bulletin 7 No. 77, February 2011
Procedure codes J1825, J2950, J3400, J3535, and J7599 are no longer reimbursed in the home setting. Procedure code J0130 is no longer reimbursed in the inpatient hospital setting. Procedure code J7799 is no longer reimbursed in the nursing home SNF/ICF setting. Procedure code 99001 is no longer reimbursed in the birthing center setting. Procedure codes J1630, J1825, J2792, J7197, J2950, J3400, J3535, J7198, J7599, J7799, Q3025, and Q3026 are no longer reimbursed in the nursing home ECF setting. Benefit Changes for Some Expendable Medical Supplies Effective for dates of service on or after October 1, 2010, the limitations for the following expendable medical supplies changed for the CSHCN Services Program: Limitation A4351, A4352, and A4353 Combined total of 150 per calendar month A4326 and A4349 A5120 Combined total of 40 per month 50 per month B4034, T4537, and T4540 Quantity necessary to accomplish the service being provided A4554, T4541, and T4542 Combined total of 150 per calendar month B4087 and B4088 Two per rolling year Diagnosis codes 33371 and 33379 do not require authorization for diapers, pull-ups, briefs, and liners. Diagnosis code 7527 is no longer reimbursed for diapers, pull-ups, briefs, and liners. Benefit Criteria Changes for Cleft/Craniofacial Services Effective for dates of services on or after November 1, 2010, the benefit criteria for cleft/craniofacial (C/C) services changed for the CSHCN Services Program. Providers must be individually enrolled in the CSHCN Services Program, but are no longer required to be enrolled as a C/C team. The CSHCN Services Program recognizes the standard of care needed to appropriately address the repair of C/C anomalies, as outlined in the guidelines prepared by the American Cleft Palate-Craniofacial Association (www. acpa-cpf.org). A comprehensive, multidisciplinary approach is medically necessary to meet all of the needs of clients who have complex medical conditions that require treatment by a broad range of medical specialists. The standard of care for the comprehensive repair or reconstruction of craniofacial anomalies for CSHCN Services Program clients requires a team approach by either a C/C team or an equivalent coordinated multidisciplinary team. The following exceptions to this requirement may be considered: A C/C or equivalent multidisciplinary team is not available in the area and the client is unable to travel. Medical record documentation must explain the reasons for which the client is unable to travel. A C/C or equivalent multidisciplinary team is not available in the area and the team approach cannot be coordinated over multiple locations. Medical record documentation must describe the attempts that were made to coordinate a team approach. A C/C or equivalent multidisciplinary team is available but the client or the client s parent or guardian refuses care from the team. Medical record documentation must include the reason that the client or the client s parent or guardian gave for refusing care from the team. The C/C or equivalent coordinated multidisciplinary team must have surgical and medical specialists including, but not limited to, the following: Operating surgeon Orthodontist Speech-language pathologist At least one of the following specialists: Otolaryngologist Audiologist Pediatrician Geneticist Social worker Psychologist General pediatric or prosthetic dentist Each C/C or equivalent coordinated multidisciplinary team must identify the following: An administrator who is responsible for coordinating and maintaining C/C team records and ensuring that the C/C team adheres to CSHCN Services Program rules and regulations No. 77, February 2011 8 CSHCN Services Program Provider Bulletin
A team care coordinator to ensure that the focus of the service is client and family-oriented, and that the client, family, and C/C team jointly develop a comprehensive treatment plan for the client The comprehensive treatment plan must be maintained in the client s medical record and must be provided to the client and family, the referring physician, other collaborating providers, and the Department of State Health Services (DSHS) regional social worker upon request. The plan will include the specific services that the members of the C/C team will provide, action steps, persons responsible, and time-frame objectives for meeting treatment outcomes. Documentation of medical necessity must be kept in the client s medical record if the requested surgical procedure is being performed because of injury or other trauma that is not associated with the repair or reconstruction of cleft lip, cleft palate, or craniofacial anomalies. Prior Authorization The following C/C procedure codes require prior authorization: 30540 30545 30560 61550 61552 61556 61557 61558 61559 62115 62116 62117 Documentation of medical necessity must be submitted with the prior authorization request if the requested surgical procedure is being performed for reasons not related to the repair or reconstruction of cleft lip, cleft palate, or craniofacial anomalies. Prior authorization is also required for orthodontic services that are performed in conjunction with C/C services. Septoplasty (procedure code 30520) for nonrelated repair or reconstruction of cleft lip, cleft palate, or craniofacial anomalies may be prior authorized with documentation that supports medical necessity. Benefit Criteria Changes for Doctor of Dentistry Services as a Limited Physician Effective for dates of service on or after November 1, 2010, the benefit criteria for doctor of dentistry services as a limited physician changed for the CSHCN Services Program. Note: For the purposes of this article, advanced practice registered nurse (APRN) includes nurse practitioner (NP) and clinical nurse specialist (CNS) providers only. New Benefits The following surgical procedure codes are a benefit when performed by a physician or dentist in the office, inpatient hospital, or outpatient hospital setting: 11200 11201 11305 11306 11307 11308 11310 11311 11312 11313 30300 30310 Procedure codes 30300 and 30310 are also a benefit when performed by an APRN in the office setting. Provider Type and Place of Service Changes The following procedure codes are no longer a benefit for dentists: 10021 10022 11000 11001 17000 17003 17004 17106 17107 17108 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284 17286 20200 20205 20220 20240 20520 20550 20650 21015 21034 21044 21045 21501 21550 21555 21556 30400 30410 30420 30430 30435 30450 30465 30520 31030 31032 31225 31230 31600 41130 41135 41140 41145 41150 41153 41155 42425 42426 42815 42842 42844 42845 61575 61576 61580 61581 61584 61586 61590 61592 64600 64612 90284 J0120 J0170 J0280 J0360 J0475 J0670 J0780 J0945 J1165 J1562 J1568 J1569 J1572 J1630 J1730 J1790 J1800 J1840 J1990 J2060 J2175 J2180 J2360 J2370 J2410 J2515 J2550 J2690 J2765 J2800 J2810 J3010 J3310 J3320 J3360 J3410 J3485 Injections The following procedure codes are a benefit only when they are performed by an APRN, physician, or dentist in the office setting, or by a hospital in the outpatient setting: J0290 J0295 J0330 J0530 J0540 J0550 J0560 J0570 J0580 J0690 CSHCN Services Program Provider Bulletin 9 No. 77, February 2011
J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1020 J1030 J1040 J1094 J1100 J1170 J1200 J1364 J1580 J1700 J1710 J1720 J1850 J1885 J1890 J1940 J2010 J2400 J2460 J2510 J2540 J2560 J2650 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3430 J3480 J3490 J3520 J0280 Procedure codes J1631, J1790, and S0021 are a benefit for hospitals when they are performed in the outpatient setting and are no longer a benefit when they are performed by a physician or dentist in the inpatient or outpatient hospital setting. Surgical Procedures The following procedure codes are a benefit for APRNs when they are performed in the office setting: 10060 10061 11040 11420 11421 11422 11426 11440 11441 11442 11443 11444 11446 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11900 11901 12011 12013 12020 12021 15788 15789 15850 15851 15852 20000 20551 20552 20600 20605 21310 21315 21320 30901 30905 30906 41899 Procedure code 11040 is also a benefit for APRNs when it is performed in the inpatient or outpatient hospital setting. Procedure codes 15241 and 64738 are a benefit for physicians when they are performed in the office setting. Procedure codes 15780, 15788, and 15789 are a benefit for physicians when they are performed in the office or outpatient hospital setting. The following procedure codes are a benefit only when they are performed by a physician or dentist in the inpatient or outpatient hospital setting: 14061 20910 20912 20920 20922 20926 20955 20956 20970 21089 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 21147 21150 21151 21154 21155 21159 21160 21172 21175 21179 21180 21181 21182 21183 21184 21188 21193 21194 21195 21196 21198 21199 21206 21208 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21261 21263 21267 21268 21270 21275 21280 21282 21295 21296 21299 21337 21338 21339 21340 21343 21344 21346 21347 21348 21355 21356 21360 21365 21366 21385 21386 21387 21390 21395 21406 21407 21408 21423 21431 21432 21433 21435 21436 21445 21453 21454 21461 21462 21465 21470 21490 21495 21497 21499 21685 30125 30150 30160 31080 31081 31084 31085 31086 31087 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220 42225 42226 42227 42235 42260 42299 42409 42410 42415 42420 42440 42505 42699 42725 42890 42892 42894 42950 42962 67900 The following procedure codes are a benefit only when they are performed by a physician or dentist in the office, inpatient, or outpatient hospital setting: 15260 15781 15786 15820 15821 20100 21079 21080 21081 21082 21083 21085 21087 21088 30620 40490 40500 40510 40520 40527 40530 40650 40652 40654 40700 40701 40702 40720 40761 40800 40801 40804 40805 40806 40808 40810 40812 40814 40816 40819 40820 40830 40831 41006 41115 No. 77, February 2011 10 CSHCN Services Program Provider Bulletin
41120 41870 41872 41874 42280 42281 42800 42802 42804 42806 42808 42809 67916 67917 67923 67924 67950 67961 Procedure codes 42961, 61501, 61559, and 62147 are a benefit only when they are performed by a physician or dentist in the inpatient hospital setting. The following procedure codes are no longer a benefit when performed in the office setting: 20900 20902 20957 20962 20969 20972 20973 20999 29999 30460 30462 The following procedure codes are no longer a benefit when they are performed, as indicated, in the inpatient or outpatient hospital settings: When Performed by an APRN 10121 12001 12002 12004 12005 12006 15004 15005 15241 15780 15788 15789 64400 64402 When Performed by a Hospital 15365 15366 15420 15421 15175 15176 15320 15320 15321 15335 15336 When Performed by an APRN or Hospital 15115 15116 15120 15135 15136 15156 15157 Procedure code 41899 is no longer a benefit when it is performed in the home, skilled nursing facility, birthing center, or nursing home settings. Procedure code 10120 is longer a benefit when it is performed by a registered nurse/nurse midwife in the office setting, by an APRN or registered nurse/nurse midwife in the inpatient or outpatient hospital setting, or by any provider in the skilled nursing facility setting. Procedure codes 21076, 21100, 21110, 21116, and 21120 are no longer a benefit when performed by an orthodontist or an oral maxillofacial surgeon. Procedure codes 20670 and 20680 are no longer a benefit when performed by an APRN. Radiology Procedures The technical component for the following procedure codes is a benefit only when performed by a physician, dentist, portable X-ray supplier, radiological lab, or physiological lab in the office setting: 70100 70110 70120 70140 70150 70160 70190 70200 70250 70260 70300 70310 70320 70328 70332 70336 70350 70355 70370 70371 70380 70390 73100 The total component for the following procedure codes is a benefit only when performed by a physician, dentist, portable X-ray supplier, radiological lab, or physiological lab in the office setting or by a hospital in the outpatient setting: 70100 70110 70120 70140 70150 70160 70190 70200 70250 70260 70300 70310 70320 70328 70332 70336 70350 70355 70370 70371 70380 70390 73100 Benefit Criteria Changes for Medical Nutritional Counseling Services Effective for dates of service on or after November 1, 2010, the benefit criteria for medical nutritional counseling services changed for the CSHCN Services Program. The new benefit limitations for medical nutrition therapy (procedure code 97803) and nutrition counseling (procedure code S9470) are: The limitation for procedure code 97803 increased from 4 units per rolling year to 12 units per rolling year. The limitation for procedure code S9470 increased from 2 visits per rolling year to 4 visits per rolling year. Note: Providers are expected to continue to obtain prior authorization for services that exceed the benefit limitation. The qualifying conditions for medical nutrition therapy and medical nutrition counseling services include, but are not limited to, the following: Abnormal weight gain Cardiovascular disease CSHCN Services Program Provider Bulletin 11 No. 77, February 2011
Diabetes or alterations in blood glucose Eating disorders Gastrointestinal disorders Gastrostomy or other artificial opening of gastrointestinal tract Hypertension Inherited metabolic disorders Kidney disease Lack of normal weight gain Nutritional deficiencies Nutrition intervention for chronic fatigue syndrome, attention-deficit hyperactivity disorder (ADHD), idiopathic environmental intolerances, and multiple food and chemical sensitivities is considered experimental and investigational and is not a benefit of the CSHCN Services Program. Forms The CSHCN Services Program Prior Authorization Request for Additional Nutritional Assessment, Counseling, and Products form has been updated; the form name has changed, and the units have been updated on the forms. The revised form is now named the CSHCN Services Program Prior Authorization Request for Additional Medical Nutritional Services form. The revised form is available in the Forms section of the TMHP website at www.tmhp.com. Claims Reprocessing for Stem Cell Transplant Procedure Code Effective September 8, 2010, for dates of service on or after February 1, 2010, procedure code 38241 is no longer a benefit of the CSHCN Services Program for assistant surgery. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Correction to Modifier 25 Information in the 2010 CSHCN Services Program Provider Manual This is a correction to information about modifier 25 that is referenced in the 2010 CSHCN Services Program Provider Manual, Section 30.2.11, Chemotherapy, on page 30-19; and Section 30.2.18.1, New or Established Patient Visits, on page 30-53. The manual incorrectly states that providers must provide documentation to TMHP that substantiates the use of modifier 25 for it to be considered for reimbursement. Modifier 25 may be used to identify a significant, separatelyidentifiable evaluation and management (E/M) service that is rendered by the same physician on the same day as the procedure code or other service. When billing with modifier 25, the documentation that supports the provision of a significant, separately-identifiable E/M service must be maintained in the client s medical record and made available to the CSHCN Services Program upon request. Correction and Update to the Global Surgical Periods to Change for the CSHCN Services Program Article This is a correction and an update to an article titled Global Surgical Periods to Change for the CSHCN Services Program, which was published on the TMHP website at www.tmhp.com on March 5, 2010, and in the May 2010 CSHCN Services Program Provider Bulletin, No.74. The article indicated some incorrect updates for global surgical periods. In addition, information for return trips to the operating room and postoperative care services has been revised. The following are corrections to the article: Preoperative Services The article incorrectly stated that: Reimbursement will be considered when the evaluation and management (E/M) services are performed for distinct reasons that are unrelated to the procedure. E/M services that meet the definition of a significant, separately identifiable service may be billed with modifier 25 if they are provided on the same day by the same provider as the surgical procedure. Modifier 25 is not used to report an E/M service that results in a decision to perform a surgical procedure. Medical record documentation must substantiate the use of modifier 25. The correct information is: Reimbursement will be considered when the evaluation and management (E/M) services are performed for distinct reasons that are unrelated to the procedure. E/M services that meet the definition of a significant, separately identifiable service may be billed with modifier 25 if they are provided on the same day by the same provider as the surgical procedure. Modifier 25 is not used to report an No. 77, February 2011 12 CSHCN Services Program Provider Bulletin
E/M service that results in a decision to perform a surgical procedure. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client s medical record and made available to the CSHCN Services Program upon request. Intraoperative Services The article incorrectly stated that: Physicians who performed a surgical procedure with a 10- or 90-day global period but do not render postoperative services must bill the surgical procedure code with the modifier 54. Modifier 54 indicates that the surgeon is relinquishing all of the postoperative care to a physician outside of the same group. The correct information is: Physicians who performed a surgical procedure with a 10- or 90-day global period but do not render postoperative services must bill the surgical procedure code with the modifier 54. Modifier 54 indicates that the surgeon provided the surgical care only. The article incorrectly stated that: Co-surgeons may be reimbursed for surgical procedures that are billed with modifier 62 if the Texas Medicaid fee schedule indicates that the procedure allows for co-surgeons. Claims will be suspended for manual review of the documentation of medical necessity. The correct information is: Co-surgeons may be reimbursed for surgical procedures that are billed with modifier 62 if the Online Fee Lookup (OFL) indicates that the procedure allows for co-surgeons. Claims will not suspend for a manual review of the documentation of medical necessity. Postoperative Services The article incorrectly stated: E/M services that are provided by the same provider for reasons that are unrelated to the operative surgical procedure may be considered for reimbursement if they are billed with modifier 24. The submitted documentation must substantiate the reasons for providing E/M services. Modifier 24 must be billed with modifier 25 if a significant, separately identifiable E/M service that was performed on the day of a procedure falls within the postoperative period of another unrelated procedure. The postoperative modifier should always be billed before any other modifiers. Modifier 24 must be billed with modifier 57 if an E/M service that was performed within the postoperative period of another unrelated procedure results in the decision to perform major surgery. The correct information is: Modifier 24 may be billed with modifier 25 if a significant, separately-identifiable E/M service that was performed on the day of a procedure falls within the postoperative period of another unrelated procedure. The postoperative modifier should always be billed before any other modifiers. Modifier 24 may be billed with modifier 57 if an E/M service that was performed within the postoperative period of another unrelated procedure results in the decision to perform major surgery. The article incorrectly stated that: Staged or related surgical procedures or services that are performed during the postoperative period may be reimbursed when they are billed with modifier 58. A postoperative period will be assigned to the subsequent procedure. Documentation must indicate that the subsequent procedure or service was not the result of a complication or any of the following: It was planned at the time of the initial surgical procedure. Is more extensive than the initial surgical procedure. It is for therapy following an invasive diagnostic surgical procedure. The correct information is: Documentation must indicate that the subsequent procedure or services were not the result of a complication and any of the following: It was planned at the time of the initial surgical procedure. Is more extensive than the initial surgical procedure. It is for therapy following an invasive diagnostic surgical procedure. The following are updates to the article: Return Trips to the Operating Room The article stated that: Return trips to the operating room for surgical procedures that are related to the initial surgery (i.e., complications) may be considered for reimbursement when they are billed with modifier 78 by the same provider. When a surgical procedure has a 000 global period, the full value of the surgical procedure will be paid since these codes have no preoperative, postoperative, or intraoperative values. CSHCN Services Program Provider Bulletin 13 No. 77, February 2011
When an unlisted procedure is billed because no code exists to describe the treatment for the complications, reimbursement is a maximum of 50 percent of the value of the intraoperative services that were originally performed. Note: Only the intraoperative portion of the global surgical fee for the subsequent procedure will be reimbursed. The updated language is: Return trips to the operating room for surgical procedures that are related to the initial surgery (i.e., complications) may be considered for reimbursement when they are billed with modifier 78 by the same provider. When a surgical procedure has a 0-day global period, the full value of the surgical procedure will be reimbursed; when the procedure has a 10- or 90-day global period only the intraoperative portion will be reimbursed. When an unlisted procedure is billed because no code exists to describe the treatment for the complications, reimbursement is a maximum of 50 percent of the value of the intraoperative services that were originally performed. Preoperative, Intraoperative, and Postoperative Periods The article stated that: For postoperative care that is rendered by physicians other than the surgeon for procedures that have a 10- or 90- day global period the following conditions apply: When transfer occurs immediately after surgery, the physician who assumes in-hospital postoperative care must bill subsequent care code 99231, 99232, or 99233. Physicians who provide post-discharge care must bill the appropriate surgical code with modifier 55. Reimbursement will be limited to a percentage of the Medicaid fee for the surgical procedure. Documentation in the medical record must include all of the following: A copy of the written transfer agreement. The dates the care was assumed and relinquished. The claim must indicate in the comments field of the claim form the dates on which care was assumed and relinquished, and the units field must reflect the total number of postoperative care days provided. Claims that are submitted on the CMS-1500 paper claim form must include the date of surgery in Block 14 and the dates on which care was assumed and relinquished in Block 19. The updated language is: When a transfer of care occurs for postoperative care for procedures with a 10- or 90-day global period, the following conditions apply: When the transfer of care occurs immediately after surgery, the surgeon or other provider assuming in-hospital postoperative care must bill subsequent care procedure code 99231, 99232, or 99233. When the transfer of care occurs after hospital discharge, the surgeon or other provider who provides postdischarge care must bill the appropriate surgical code with modifier 55. Reimbursement will be limited to a percentage of the Medicaid fee for the procedure. Documentation in the medical record must include all of the following: A copy of the written transfer agreement. The dates the care was assumed and relinquished. The claim must indicate in the comments field of the claim form the dates on which care was assumed and relinquished, and the units field must reflect the total number of postoperative care days provided. Claims that are submitted on the CMS-1500 paper claim form must include the date of surgery in Block 14 and the dates on which care was assumed and relinquished in Block 19. Correction to September 2010 CSHCN Services Program Procedure Code Review Updates for Procedure Codes 78804 and 91030 This is a correction to an article titled, Radiology, Laboratory, and Radiation Therapy Services Provider Type and POS Changes, an article titled, Radiology, Laboratory, and Radiation Therapy Services Age and Gender Changes, and an article titled, Additional Medical, Surgical, Radiology, and Laboratory Provider Type and POS Changes. These articles were posted on the TMHP website at www.tmhp.com on July 23, 2010, on the Code Updates CSHCN Services Program Procedure Code Review web page. The articles incorrectly indicated that benefit changes would be applied to the radiation therapy component of procedure code 78804, and that benefit changes would be applied to the laboratory component of procedure code 91030. No. 77, February 2011 14 CSHCN Services Program Provider Bulletin
The correct information is: Effective for dates of service on or after September 1, 2010, procedure code 78804 may be reimbursed as a radiology service and not as a radiation therapy service. The following changes were applied to procedure code 78804: The total radiology component may be reimbursed to radiation treatment center and hospital providers for services rendered in the office or outpatient hospital setting. Procedure code 78804 may be reimbursed for services rendered to male or female clients of any age. Effective for dates of service on or after September 1, 2010, procedure code 91030 may be reimbursed as a surgical service and not as a laboratory service. The following changes were applied to procedure code 91030: Procedure code 91030 may be reimbursed for services rendered to male or female clients of any age. The surgical component may be reimbursed to physician, radiological laboratory, and physiological laboratory providers for services rendered in the office setting, to physician providers for services rendered in the inpatient hospital setting, and to physician and hospital providers for services rendered in the outpatient hospital setting. Note: The professional interpretation and technical components are benefits for procedure codes 78804 and 91030 and may continue to be reimbursed. For more information about September 2010 updates, providers may refer to the Code Updates CSHCN Services Program Procedure Code Review web page. Outpatient Observation Changes Effective for dates of service on or after December 1, 2010, the hospital outpatient observation time period changed from less than 24 hours to 48 hours for the CSHCN Services Program. Services that are provided during the first 48 hours of an outpatient observation period will be considered for reimbursement based on the facility s reimbursement rate and the medical necessity of the service. Time units that are billed using revenue code 760, 762, or 769 will be used to determine the total number of hours that were submitted for outpatient observation. Claims that are submitted with more than 48 hours of observation room units will be denied. Revenue codes 450, 456, 459, and 761 will be denied if they are submitted for the same date of service by the same provider as revenue code 760, 762, or 769. Revenue code 762 will no longer be denied if it is submitted for the same date of service by the same provider as revenue code 451. Payable Provider Type Added for Hearing Services Procedure Code V5266 Effective for dates of service on or after September 1, 2010, hearing services procedure code V5266 may be reimbursed to hearing aid providers for services rendered to CSHCN Services Program clients in the office, home, and other locations setting. Provider Type and Place of Service Changes Effective for dates of services on or after November 1, 2010, the payable provider types and places of service changed for some injection and surgery procedure codes for the CSHCN Services Program. Note: For the purposes of this article, advanced practice registered nurse (APRN) includes nurse practitioner (NP) and clinical nurse specialist (CNS) providers only. New Benefits Surgical procedure codes 15838, 17110, and 17111 are a benefit when they are performed by a physician in the office, inpatient hospital, or outpatient hospital setting. Provider Type and Place of Service Changes The following procedure codes are a benefit for podiatrists when they are provided in the office setting: J0120 J0290 J0295 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1200 J1364 J1459 J1580 J1885 J1890 J2010 J2400 J2460 J2510 J2540 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3490 The following procedure codes are a benefit for podiatrists when they are provided in the inpatient or outpatient hospital setting: 15135 20200 20205 20240 20520 20900 20902 20957 20962 20969 CSHCN Services Program Provider Bulletin 15 No. 77, February 2011
20972 20973 20999 29999 The following procedure codes are a benefit for podiatrists when they are provided in the office, inpatient, or outpatient hospital setting: 10060 10061 10140 10160 10180 11000 11001 11010 11040 11041 11042 11043 11044 11100 11101 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 12007 12020 12021 13131 13132 13133 15115 15116 15120 15121 15155 15156 15157 15175 15176 15240 15241 15320 15321 15335 15336 15574 15620 15770 20000 20005 20550 20551 20552 20600 20605 20615 20690 20692 20693 20694 The following procedure codes are a benefit only when they are performed by an APRN or physician in the office setting or by a hospital in the outpatient setting: 90284 J0120* J0360 J0475 J0670 J0780 J0945 J1165 J1562 J1566 J1568 J1569 J1572 J1800 J1840 J1990 J2060 J2175 J2180 J2360 J2370 J2410 J2515 J2550 J2690 J2765 J2800 J2810 J3310 J3320 J3360 J3410 J3485 *Procedure code J0120 is also a benefit for podiatrists, as previously noted in this article. Procedure code 20550 is a benefit for APRNs when it is performed in the office setting. Procedure code J3010 is a benefit only when it is performed by a physician in the office setting or by a hospital in the outpatient setting. The following procedure codes are a benefit only when they are performed by a physician in the following settings: Office, Inpatient, and Outpatient Hospital 10022 41130 41140 41145 41155 64600 Inpatient and Outpatient Hospital 20650 21015 21044 21045 21556 31030 31032 31225 31230 42425 42426 42815 42842 42844 42845 Procedure codes J1630 and J1730 are a benefit for hospitals when they are performed in the outpatient setting, but they are no longer a benefit when performed by a physician in the inpatient or outpatient hospital setting. The following procedure codes are no longer a benefit when they are performed in the office setting: 20200 20205 20240 20520 21034 30400 30420 30430 30435 30450 30465 30520 97002 and 97004 No Longer Require Prior Authorization TMHP has identified an issue that affects CSHCN Services Program claims that were submitted with dates of service on or after September 1, 2009, and procedure code 97002 or 97004. These claims may have been incorrectly denied for prior authorization requirements. Effective for dates of service on or after September 1, 2009, prior authorization is not required for procedure codes 97002 and 97004. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Reimbursement Rate Changes for Some Medical Services Effective for dates of services on or after December 1, 2010, the reimbursement rates for some medical services changed for the CSHCN Services Program. Providers may refer to the article titled CSHCN Services Program Reimbursement Rates Will Change December 2010 for Some Medical Services, that was posted on the TMHP CSHCN web page on October 8, 2010, for the updated rates. Providers can also review reimbursement rates using the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. No. 77, February 2011 16 CSHCN Services Program Provider Bulletin
Reimbursement Rate Changes for Some Physical Therapy, Occupational Therapy, and Speech- Language Therapy Services Effective for dates of service on or after December 1, 2010, the reimbursement rates for some physical therapy (PT), occupational therapy (OT), and speech-language therapy (SLT) services changed for the CSHCN Services Program. Providers can review reimbursement rates using the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. Reimbursement Rate Changes for Some Radiology, Laboratory, and Radiation Therapy Services Effective for dates of services on or after December 1, 2010, the reimbursement rates for some radiology, laboratory, and radiation therapy services changed for the CSHCN Services Program. Providers may refer to the article titled CSHCN Services Program Reimbursement Rates Will Change December 2010 for Some Medical Services, that was posted on the TMHP CSHCN web page on October 8, 2010, for the updated rates. Providers can also review reimbursement rates using the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. Reimbursement Rate Changes for Some Surgical Services Effective for dates of service on or after December 1, 2010, the reimbursement rates for some surgical services changed for the CSHCN Services Program. Providers may refer to the article titled CSHCN Services Program Reimbursement Rates Will Change December 2010 for Some Medical Services, that was posted on the TMHP CSHCN web page on October 8, 2010, for the updated rates. Providers can also review reimbursement rates using the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. Reimbursement Rates Pricing Change for Powered Air Flotation Bed TMHP has identified an issue that affects CSHCN Services Program claims that were submitted with dates of service on or after September 1, 2009, and durable medical equipment (DME) procedure code E0193. Effective for dates of service on or after September 1, 2009, the reimbursement rate for procedure code E0193 is $817.63 for rental and $8176.30 for purchase. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Reimbursement Rate Changes to Manual Pricing for Some DME TMHP has identified an issue with CSHCN Services Program claims that were submitted with dates of service from September 1, 2009, through September 8, 2010, and some DME procedure codes. The claims may have been reimbursed incorrectly. Claims submitted with dates of service from September 1, 2009, through September 8, 2010, and any of the DME procedure codes in the following table may have been incorrectly reimbursed at a maximum fee of $5.01. Effective September 8, 2010, for dates of service on or after September 1, 2009, the following procedure codes will be manually priced: TOS 9 A4256 9 A4615 9 A4617 9 A4628 L J L J L L L L Procedure Code A4628 E0669 E0669 E0855 E0855 E1810 E1815 E1825 9 L8485 TOS) Type of service. (TOS 9) Other/DME purchase. (TOS J) DME purchase of new (equipment. (TOS L) DME rental CSHCN Services Program Provider Bulletin 17 No. 77, February 2011
TOS 9 L8499 9 L8610 9 L8613 9 L8630 9 L8641 9 L8642 9 L8658 9 L8670 9 L8699 Procedure Code TOS) Type of service. (TOS 9) Other/DME purchase. (TOS J) DME purchase of new (equipment. (TOS L) DME rental Claims submitted with dates of service from September 1, 2009, through September 8, 2010, and any of the DME procedure codes in the following table may have been incorrectly manually priced. Effective September 8, 2010, for dates of service on or after September 1, 2009, the following procedure codes may be reimbursed at the indicated maximum fee: TOS Procedure Code Reimbursement Rate J E1815 $1,130.90 J E1825 $1,127.60 J E1830 $1,127.60 L E1830 $1,127.60 (TOS) Type of service. (TOS 9) Other/DME purchase. (TOS J) DME purchase of new equipment. (TOS L) DME monthly rental. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Reimbursement Rate Changes for Some Home Health Procedure, Eyeglass, and Genetic Services The reimbursement rates for the following home health procedure, eyeglass, and genetic services are effective for dates of service on or after December 1, 2010, for the CSHCN Services Program: Home Health Procedures: Type of Service (TOS) C Procedure Code Age Range Current Fee G0151 All ages $29.09 $11.64 G0152 All ages $29.66 $11.86 G0153 All ages $35.00 $11.64 G0154 All ages $25.24 $11.28 G0154 All ages $25.24 $11.28 G0155 All ages $26.93 $11.64 G0156 All ages $11.76 $2.87 G0156 All ages $11.76 $2.87 Eyeglass: TOS E Procedure Code Age Range Current RVU Current CF Current Fee New RVU New CF 92326 All ages 1.71 $27.276 $46.64 0.94 $28.640 $26.92 92002 All ages 1.87 $28.640 $53.56 1.96 $28.640 $56.13 (RVU) Relative value unit. (CF) Conversion factor New Fee Effective for DOS on or after 12/1/10 New Fee Effective for DOS on or after 12/1/10 No. 77, February 2011 18 CSHCN Services Program Provider Bulletin
Procedure Code Age Range Current RVU Current CF Current Fee New RVU New CF 92004 All ages 3.30 $28.640 $94.51 3.67 $28.640 $105.11 92012 All ages 1.62 $28.640 $46.40 2.07 $28.640 $59.28 92014 All ages 2.44 $28.640 $69.88 3.02 $28.640 $86.49 (RVU) Relative value unit. (CF) Conversion factor Genetics: TOS G Procedure Code Age Range Current RVU Current CF Current Fee New RVU New CF 96040 All ages 0.98 $27.276 $26.73 1.12 $28.640 $32.08 (RVU) Relative value unit. (CF) Conversion factor New Fee Effective for DOS on or after 12/1/10 New Fee Effective for DOS on or after 12/1/10 September 2010 CSHCN Services Program Procedure Code Review Updates Effective for dates of service on or after September 1, 2010, provider type and place-of-service (POS) limitations will change for some CSHCN Services Program services. Click on the title to view the details. Note: For the purposes of this article, advanced practice registered nurse (APRN) providers includes nurse practitioners (NP) and clinical nurse specialists (CNS) only. Allergy Testing and Desensitization The following benefit changes will be applied to the indicated procedure codes: Changes 86003 Total laboratory component: Services rendered in the office setting will no longer be reimbursed to independent laboratory and hospital providers. Services rendered in the inpatient hospital setting will no longer be reimbursed. Services rendered in the outpatient hospital setting will no longer be reimbursed to independent laboratory providers. Services rendered in the independent laboratory setting will no longer be reimbursed to hospital providers. 95010, 95015, 95180 Medical service component: Services rendered in the outpatient hospital setting may be reimbursed to hospitals. The following procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed as indicated: Procedure Code Reimbursement Information 86005 Total laboratory component: Services rendered in the office setting may be reimbursed to APRN and physician providers. Services rendered in the outpatient hospital setting may be reimbursed to hospitals. Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers. One service per day up to four services per rolling year may be reimbursed when billed by the same provider. CSHCN Services Program Provider Bulletin 19 No. 77, February 2011
Procedure Code Reimbursement Information 86486 Total laboratory component: Services rendered in the office setting may be reimbursed to APRN and physician providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers. Q3031 Total laboratory component: Services rendered in the office setting may be reimbursed to APRN providers and physicians. Services rendered in the outpatient hospital setting may be reimbursed to hospitals. Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers. 95027 Medical service component: Services rendered in the office setting may be reimbursed to APRN and physician providers. Services rendered in the outpatient hospital setting may be reimbursed to hospitals. 95199 Medical service component: Services rendered in the office setting may be reimbursed to APRN and physician providers. Services rendered in the outpatient hospital setting may be reimbursed to hospitals. Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers. Prior authorization is required. The following procedure codes will be denied if they are billed with the same date of service as procedure code 95027: 95024 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99291 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99356 99460 99461 99462 99463 99464 99465 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 Collagen Skin Tests Collagen skin tests (procedure code Q3031) are administered to detect a hypersensitivity to bovine collagen. This skin test is given four weeks prior to any type of surgical procedure which utilizes collagen. Collagen injections or implants used for cosmetic surgery are not a benefit of the CSHCN Services Program. Surgeries performed on abnormal structures of the body are generally performed to improve function. Collagen injections or implants performed on abnormal structures of the body caused by any of the following may be reimbursed: Congenital defects Developmental abnormalities Trauma Infection Tumors Disease No. 77, February 2011 20 CSHCN Services Program Provider Bulletin
Unlisted Procedure Code 95199 Every effort should be made to use the most appropriate procedure code that describes the procedure that is to be performed. For procedures that are rarely used, unusual, or new, and for which there is no specific procedure code, unlisted procedure code 95199 may be used with prior authorization. The prior authorization request must be submitted with the following documentation: The client s diagnosis Medical records indicating prior treatment for this diagnosis and the medical necessity of the requested procedure The physician s intended fee for this procedure Behavioral Health The following benefit changes will be applied to the procedure codes as indicated: Procedure Code(s) Changes 90804, 90806, 90808 Services rendered in the inpatient hospital setting will no longer be reimbursed. 90805, 90807, 90809, 90813, 90815 Services rendered in the home or other location setting may be reimbursed to APRN and physician providers. 90810, 90812, 90814 Services rendered in the home or other location setting may be reimbursed to APRN, physician, and psychologist providers. 90847, 90853 Services rendered in the inpatient hospital setting will no longer be reimbursed to licensed professional counselor, Comprehensive Care Program (CCP) social worker, and durable medical equipment (DME) medical supplier providers. 90862 Services rendered in the skilled nursing facility (SNF), intermediate care facility (ICF), birthing center, or extended care facility (ECF) setting will no longer be reimbursed. 96101 Services rendered in the inpatient hospital setting may be reimbursed to hospital providers. Services rendered in the other location setting may be reimbursed to physician and psychologist providers. 96118 Services rendered in the other location setting may be reimbursed to physician and psychologist providers. The following procedure code will be made a benefit of the CSHCN Services Program and may be reimbursed as indicated: Procedure Code(s) Reimbursement Information 96116 Services rendered in the office, inpatient hospital, outpatient hospital, or other location setting may be reimbursed to physician and psychologist providers. Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. Procedure codes 96110 and 96111 will be denied if billed with the same date of service by the same provider as procedure code 96116. Neurobehavioral status exam procedure code 96116, psychological testing procedure code 96101, and neuropsychological testing procedure code 96118 are limited to a total of four hours per day and eight hours per calendar year, per client, for any provider. Claims submitted for an amount greater than four hours per day or eight hours per year must be submitted with documentation of medical necessity. Time spent interpreting test results and documenting the results in the client s medical record is included in the reimbursement for procedure codes 96101, 96118, and 96116 and will not be reimbursed separately. Psychological testing procedure code 96101, neuropsychological testing procedure code 96118, and neurobehavioral status exam procedure code 96116 are not reimbursed to APRN providers. Behavioral health testing and neurobehavioral status exams performed by an APRN during an assessment is not reimbursed separately. The most appropriate office encounter code must be used. Psychological testing procedure code 96101, neuropsychological testing procedure code 96118 and neurobehavioral status exam procedure code 96116 may be reimbursed when billed with the same date of service as initial psychiatric diagnostic interview procedure code 90801 or interactive psychiatric diagnostic interview examination procedure code 90802. Procedure code 96116 is subject to the 12-hour per day limitation for behavioral health services regardless of client. CSHCN Services Program Provider Bulletin 21 No. 77, February 2011
Chemotherapy Note: This article includes the changes indicated the article titled Correction to September 2010 CSHCN Services Program Procedure Code Review Updates, which was published on July 13, 2010, on the TMHP website at www.tmhp.com on the Code Updates CSHCN Services Program Procedure Code Review web page. The changes apply to procedure codes 95991, 96450, 96420, 96521, 96522, 96523, 96422, 96423, and 96425. The following benefit changes will be applied to the procedure codes as indicated: Procedure Code(s) Changes 95991 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. Services rendered in the home setting may be reimbursed to physician providers. The following information was not included in the original article and is also effective for dates of service on or after September 1, 2010: Services rendered in the office or outpatient hospital setting may be reimbursed to radiation treatment center providers. 96440 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. 96445 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. Services rendered in the office setting will no longer be reimbursed. 96450 Services rendered in the inpatient hospital or outpatient hospital may be reimbursed to hospital providers. Services rendered in the office setting will no longer be reimbursed. Note: The original article incorrectly indicated that services rendered in the inpatient hospital or outpatient hospital setting would be reimbursed to APRN providers. The correct information is that APRN providers will not be reimbursed for services provided in the inpatient hospital or outpatient hospital settings. 96542 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to APRN providers. 96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422, 96423, 96425 Services rendered in the inpatient and outpatient hospital setting may be reimbursed to hospital providers. Services rendered in the office, home, inpatient hospital, or outpatient hospital setting may be reimbursed to APRN providers. Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. Note: The original article incorrectly indicated that for procedure code 96420, services rendered in the inpatient hospital or outpatient hospital setting would be reimbursed to APRN providers; and for procedure codes 96422, 96423, and 96425, services rendered in the office or home setting would be reimbursed to APRN providers. The correct information is that APRN providers will not be reimbursed for services provided in the office, home, inpatient hospital, or outpatient hospital setting. 96521 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. The original article incorrectly indicated that effective for dates of service on or after September 1, 2010, services rendered in the office, home, inpatient hospital, or outpatient hospital may be reimbursed to APRN providers. The following is the correct information: Services rendered in the office setting may be reimbursed to APRN providers effective for dates of service on or after April 1, 2008, and services rendered in the outpatient hospital setting may be reimbursed to APRN providers effective for dates of service on or after December 1, 2009. No. 77, February 2011 22 CSHCN Services Program Provider Bulletin
Procedure Code(s) Changes 96521 (cont.) Services rendered in the home or inpatient hospital setting may be reimbursed to APRN providers effective for dates of service on or after September 1, 2010. The following information was not included in the original article and is also effective for dates of service on or after September 1, 2010: Services rendered in the office or outpatient hospital setting may be reimbursed to radiation treatment center providers. Services rendered in the home setting may be reimbursed to physician providers. Services rendered in the inpatient hospital setting may be reimbursed to APRN and physician providers. 96522 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. The original article incorrectly indicated that effective for dates of service on or after September 1, 2010, services rendered in the office, home, inpatient hospital, or outpatient hospital may be reimbursed to APRN providers. The following is the correct information: Services rendered in the office setting may be reimbursed to APRN providers effective for dates of service on or after April 1, 2008, and services rendered in the outpatient hospital setting may be reimbursed to APRN providers effective for dates of service on or after December 1, 2009. Services rendered in the home or inpatient hospital setting may be reimbursed to APRN providers effective for dates of service on or after September 1, 2010. The following information was not included in the original article and is also effective for dates of service on or after September 1, 2010: Services rendered in the office or outpatient hospital setting may be reimbursed to radiation treatment center providers. Services rendered in the home or inpatient hospital setting may be reimbursed to physician providers. 96523 Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. The original article incorrectly indicated that effective for dates of service on or after September 1, 2010, services rendered in the office, home, inpatient hospital, or outpatient hospital may be reimbursed to APRN providers. The following is the correct information: Services rendered in the office or outpatient hospital setting may be reimbursed to APRN providers effective for dates of service on or after December 1, 2009. Services rendered in the home or inpatient hospital setting may be reimbursed to APRN providers effective for dates of service on or after September 1, 2010. The following information was not included in the original article and is also effective for dates of service on or after September 1, 2010: Services rendered in the office or outpatient hospital setting may be reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), and renal dialysis facility providers. Services rendered in the home or inpatient hospital setting may be reimbursed to physician providers. 96549 Services rendered in the office or home setting may be reimbursed to APRN providers. Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to hospital providers. Omalizumab The following benefit changes will be applied to the procedure codes as indicated: Procedure Code(s) J2357 Changes Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center and nephrology (hemodialysis, renal dialysis) providers. CSHCN Services Program Provider Bulletin 23 No. 77, February 2011
Procedure Code(s) J2357 (cont.) Changes Services rendered in the home setting will no longer be reimbursed. Omalizumab is an injectable drug that is approved by the Food and Drug Administration (FDA) for the treatment of clients who are 12 years of age or older and who have severe and persistent asthma. Omalizumab has unique clinical indications and mechanisms of action and has no generic or therapeutic alternative. Omalizumab may be reimbursed by the CSHCN Service Program when medically necessary and must be prior authorized. Prior authorization requests for clients who are 11 years of age or younger or with other exceptions may be considered on an individual basis. The CSHCN Services Program Prior Authorization Request for Omalizumab Form must be used to submit prior authorization requests for CSHCN Services Program clients. The form and all necessary documentation must be submitted to the TMHP-CSHCN Services Program Authorization Department at: Texas Medicaid & Healthcare Partnership TMHP-CSHCN Services Program Authorization Department 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727 Fax: 1-512-514-4222 If lapses in treatment occur, prior authorization will be considered on an individual basis with provider documentation. When requesting prior authorization, the exact dosage must be included with the request. Doses are determined by the client s body weight and frequency is determined by clinical severity. Medical Necessity Criteria Authorization requests for omalizumab may be granted for clients who are 12 years of age or older with documentation of the following medical necessity criteria: Diagnosis of asthma. A radioabsorbent assay test (RAST) to a perennial (not seasonal) aeroallergen within the past 36 months or a positive skin test. Total IgE level greater than 30 IU/ml but less than 700 IU/ml within the past 12 months is documented. Note: Total IgE level is required only for the initial prior authorization request and is not required for subsequent prior authorization requests. The client has been compliant with an inhaled steroid regimen. Clinical evidence of inadequate asthma control including the following: Dependence on daily systemic steroid, maximal inhaled steroid regimen with frequent systemic steroid pulses; or frequent hospitalizations for severe asthma exacerbations in the face of adequate maximal standard therapy. Daily therapy for persistent asthma for at least one year with frequent use of beta agonist. Persistence of significantly decreased pulmonary function testing (spirometry) demonstrating refractory lower airways obstruction and hyper-reactivity, overtime, despite the rigorous medical regimen delineated above. Pulmonary function tests have been performed within a three-month period. The client is not currently smoking. Prior authorizations may be granted for intervals of six months. Clients must be fully compliant with their omalizumab regimen in order to qualify for any additional authorizations. The provider must submit a statement documenting full compliance with the requests for each renewal in order to qualify for any additional authorizations. After 12 continuous months of authorizations, the provider must submit documentation of satisfactory clinical response to omalizumab in order to qualify for additional authorizations. No. 77, February 2011 24 CSHCN Services Program Provider Bulletin
Reimbursement Physicians will be reimbursed at the lower of the billed amount or the amount allowed by Texas Medicaid. Advanced practice registered nurse providers will be reimbursed at the lower of the billed amount or 92 percent of the amount allowed by Texas Medicaid for physicians for the same service. Hospitals are reimbursed at 80 percent of the rate allowed by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, which is equivalent to the hospital s interim Medicaid rate. Providers may not bill for an office visit if the only reason for the visit is an omalizumab injection. Positron Emission Tomography (PET) The following benefit changes will be applied to the procedure codes as indicated: Procedure Code(s) Changes 78608 Total radiology component: The total radiology component will be made a benefit and may be reimbursed as follows: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting will no longer be reimbursed to APRN, radiological laboratory, or physiological laboratory providers. Technical component: The technical component will be made a benefit and may be reimbursed to physician, radiological laboratory, and physiological laboratory providers for services rendered in the office setting. Diagnosis restrictions: Procedure code 78608 may be reimbursed when it is billed with diagnosis code 34540, 34541, or 78039. 78811 Total radiology component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, and radiation treatment center providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, radiological laboratory, or physiological laboratory providers. Professional interpretation component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, radiation treatment center, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to physician providers. Services rendered in the inpatient hospital setting will no longer be reimbursed to APRN, independent laboratory, radiation treatment center, hospital, radiological laboratory, or physiological laboratory providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, hospital, radiological laboratory, and physiological laboratory providers. Technical component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, and radiation treatment center providers. Services rendered in the independent laboratory setting will no longer be reimbursed. 78812 Total radiology component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, and radiation treatment center providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, radiological laboratory, or physiological laboratory providers. Professional interpretation component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, radiation treatment center, radiological laboratory, and physiological laboratory providers. CSHCN Services Program Provider Bulletin 25 No. 77, February 2011
Procedure Code(s) Changes 78812 (cont.) Services rendered in the outpatient hospital setting may be reimbursed to physician providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, hospital, radiological laboratory, and physiological laboratory providers. Services rendered in the inpatient hospital setting will no longer be reimbursed to APRN, independent laboratory, radiation treatment center, radiological laboratory, or physiological laboratory setting. Technical component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, and radiation treatment center providers. Services rendered in the independent laboratory setting will no longer be reimbursed. 78813 Total radiology component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, and radiation treatment center providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, radiological laboratory, or physiological laboratory providers. Professional interpretation component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, radiation treatment center, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to physician providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, hospital, radiological laboratory, and physiological laboratory providers. Services rendered in the inpatient hospital setting will no longer be reimbursed to APRN, independent laboratory, radiation treatment center, radiological laboratory, or physiological laboratory providers. Technical component: Services rendered in the office setting will no longer be reimbursed to APRN, independent laboratory, and radiation treatment center providers. Services rendered in the independent laboratory setting will no longer be reimbursed. The following procedure codes will be made a benefit of the CSHCN Services Program and may be reimbursed as follows: Procedure Code(s) Reimbursement Information 78814, 78815, 78816 Total radiology component: Services rendered in the office setting may be reimbursed to physician providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Procedure codes 78814, 78815, and 78816 may be reimbursed when billed with one of the following diagnosis codes: Diagnosis Codes 1720 1721 1722 1723 1724 1725 1726 1727 1728 1729 1860 1869 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 No. 77, February 2011 26 CSHCN Services Program Provider Bulletin
The procedure codes in Column A will be denied when they are billed with the same date of service by the same provider as the procedure codes in Column B: Column A (Denied) 36000, 36005, 36410, 70450, 70480, 70486, 70490, 71250, 72125, 72128, 72131, 72192, 73200, 73700, 74150, 76376, 76377, 78811, 78812, 78813, 96360, 96365, 96372, 96374, 96375, 96376 Column B 78814, 78815, 78816 Radiology X-Ray and Ultrasound Radiology services include, but are not limited to, diagnostic imaging and interventional radiological procedures. Diagnostic Imaging Diagnostic imaging is any visual display of structural or functional patterns of organs or tissues for diagnostic evaluation. The following procedure codes for diagnostic imaging will be made benefits of the CSHCN Services Program and may be reimbursed with prior authorization: Procedure Code Reimbursement Information 58340 Surgical component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. 93980 Total radiology component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Procedure code 58340 may be reimbursed for services rendered to female clients only and must be prior authorized. The following documentation must be included with the prior authorization request for procedure code 58340: Evidence that the client has unexplained vaginal bleeding, suspected uterine fibroids, intrauterine adhesions, or endometrial polyps. Procedure code 93980 may be reimbursed for services rendered to male clients only and must be prior authorized. The following documentation must be included with the prior authorization request for procedure code 93980: An occurrence of trauma. Signs and symptoms that a vascular occlusion which include, but not limited to, pain, discoloration or abnormal visualization of penile area. Evaluation success of surgical treatment of Peyronie s disease. Note: Infertility and obstetrical services are not a benefit of the CSCHN Service Program. The following radiology procedure codes for diagnostic imaging will be made benefits of the CSHCN Services Program and may be reimbursed as indicated: Procedure Code Reimbursement Information 70030 Total radiology component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. CSHCN Services Program Provider Bulletin 27 No. 77, February 2011
Procedure Code Reimbursement Information 70030 (cont.) Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. 76831 Total radiology component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Procedure code 76831 may be reimbursed for services rendered to female clients only and must be billed in conjunction with procedure code 58340. Contrast material is a substance that, when administered, allows the provider to examine the organ or tissue as it fills. The following contrast material procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed as indicated when used during an echocardiography: Procedure Code Reimbursement Information Q9956, Q9957 Services rendered in the office or outpatient hospital setting may be reimbursed to physicians. Procedure code Q9956 or Q9957 must be billed in conjunction with echocardiography procedure code 93306. Interventional Radiological Procedures Interventional radiological procedures employ image guidance methods to gain access to deep soft tissue and organs. The following interventional radiological procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed as indicated: Procedure Code Reimbursement Information 74235 Total radiology component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. 75956 Professional interpretation component: Services rendered in the inpatient hospital setting may be reimbursed to physician providers. Procedure code 75956 must be billed with procedure code 33880. No. 77, February 2011 28 CSHCN Services Program Provider Bulletin
Procedure Code Reimbursement Information 75957 Professional interpretation component: Services rendered in the inpatient hospital setting may be reimbursed to physician providers. Procedure code 75956 must be billed with procedure code 33881. 75958 Professional interpretation component: Services rendered in the inpatient hospital setting may be reimbursed to physician providers. Procedure code 75956 must be billed with procedure codes 33883 and 33884. 75959 Professional interpretation component: Services rendered in the inpatient hospital setting may be reimbursed to physician providers. Procedure code 75956 must be billed with procedure code 33886. 76937 Total radiology component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Procedure code 76937 must be billed with one of the following procedure codes: 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36575, 36576, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 36589, 36590, 36591, 36593, 36595, 36596, 36597, 36598 The following changes will be applied to interventional radiological procedure code 76930: Procedure Code Changes 76930 Total radiology component: Services rendered in the office setting will no longer be reimbursed to APRN, certified nurse midwife (CNM), radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based rural health clinic (RHC) providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, radiological laboratory, physiological laboratory, and hospital-based RHC providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting will no longer be reimbursed to APRN, CNM, radiological laboratory, and physiological laboratory providers. Technical component: Services rendered in the office setting will no longer be reimbursed to APRN, CNM, and radiation treatment center providers. Services rendered in the home, SNF, ICF, or ECF setting will no longer be reimbursed. Additional Changes for Radiology Procedures The following benefit changes will be applied to the procedure codes indicated: Procedure Code(s) Changes 74000, 74010 Total radiology component: Services rendered in the office setting will no longer be reimbursed to APRN, CNM, radiation treatment center, federally qualified health center (FQHC), hospital, family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. CSHCN Services Program Provider Bulletin 29 No. 77, February 2011
Procedure Code(s) Changes 74000, 74010 (cont.) Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, FQHC, nephrology (hemodialysis, renal dialysis), renal dialysis facility, radiological laboratory, physiological laboratory, and hospital-based RHC providers. Professional interpretation component: Services rendered in the home, SNF, ICF, or ECF setting will no longer be reimbursed. Services rendered in the office, inpatient hospital, or outpatient hospital setting will no longer be reimbursed to APRN, CNM, radiological laboratory, and physiological laboratory providers. 74000, 74010 (cont.) Technical component: Services rendered in the office setting will no longer be reimbursed to CNM and radiation treatment center providers. Services rendered in the home, SNF, ICF, independent laboratory, or ECF setting will no longer be reimbursed. 74020 Total radiology component: Services rendered in the office setting will no longer be reimbursed to APRN, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, and hospital-based RHC providers. Services rendered in the outpatient hospital setting will no longer be reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, radiological laboratory, physiological laboratory, and hospital-based RHC providers. Professional interpretation component: Services rendered in the home, SNF, ICF, or ECF setting will no longer be reimbursed. Services rendered in the office, inpatient hospital, or outpatient hospital setting will no longer be reimbursed to APRN, CNM, radiological laboratory, and physiological laboratory providers. Technical component: Services rendered in the office setting will no longer be reimbursed to CNM and radiation treatment center providers. Services rendered in the home, SNF, ICF, independent laboratory, or ECF setting will no longer be reimbursed. Reimbursement for abdominal flat plate (AFP) and kidney, ureter, and bladder (KUB) procedure codes 74000, 74010, and 74020 is included in the reimbursement for more complicated X-rays and will not be reimbursed separately if they are billed with a more complicated X-ray. Procedure codes 74000, 74010, and 74020 may be reimbursed separately from a more complicated X-ray if the results of the AFP or KUB procedure indicate that a more complicated X-ray is required. The claim must include documentation that indicates that the results of the AFP or KUB procedure required more complicated x-rays. The procedure codes in Column A of the following table will be denied if they are billed with the same date of service by the same provider as the procedure codes in Column B: Column A (Denied) 01916, 36005, 76000, 76001, 75605, 76125, 77002, 96375, 01924, 36410, 75893, 76350, 96360, 96376, 01926, 36500, 75960, 76942, 96365, 36000, 75600, 76120, 76998, 96372 01916, 01924, 01926, 36000, 36005, 36410, 36500, 75600, 75605, 75893, 75958, 75959, 75960, 76000, 76001, 76120, 76125, 76350, 76942, 76998, 77002, 96360, 96365, 96372, 96375, 96376 00952, 36000, 36400, 36405, 36406, 36410, 36420, 36425, 36430, 36440, 36600, 36640, 37202, 51701, 51702, 51703, 57410, 62310, 62311, 62318, 62319, 64400, 64402, 64405, 64408, 64410, 64412, 64413, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64444, 64445, 64446, Column B 75958, 75959 75956, 75957 58340 No. 77, February 2011 30 CSHCN Services Program Provider Bulletin
Column A (Denied) 64448, 64449, 64450, 64479, 64483, 64505, 64508, 64510, 64517, 64520, 64530, 76942, 77002, 93000, 93005, 93040, 93041, 94002, 94200, 94250, 94680, 94681, 94690, 94770, 95812, 95813, 95816, 95819, 95822, 95829, 95955, 96360, 96365, 96372, 96374, 96375, 96376, J1644 Column B 58340 51701, 51702, 76830, 76998 76831 76000, 76001, 76942, 76998, 77002 76937 76000, 76001 74235 76998 93980 75957 75956 Third Quarter 2010 HCPCS Updates Now Available Effective for dates of service on or after October 1, 2010, TMHP implemented the third quarter 2010 Health Care Common Procedure Coding System (HCPCS) additions, revisions, and discontinued procedure codes. Discontinued procedure codes will not be reimbursed after September 30, 2010. Third Quarter 2010 HCPCS Procedure Code Additions The following procedure codes were added as noncovered procedure codes for the CSHCN Services Program: Q5010 S0148 S0169 C1749 C8931 C8932 C8933 C8934 C8935 C8936 C9269 C9270 C9271 C9272 C9273 Note: Noncovered procedure code S0148 is a direct replacement for discontinued procedure code S0146. Discontinued Procedure Code Noncovered procedure codes S0146, S0161, and S0196 have been discontinued by the Centers for Medicare & Medicaid Services (CMS) and will not be reimbursed by the CSHCN Services Program. Modifier Updates Modifier AY has been added. 2011 ICD-9-CM Updates Now Available Effective for dates of service on or after October 1, 2010, TMHP implemented the annual 2011 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) additions, changes, and deletions. This article addresses ICD-9-CM updates for the CSHCN Services Program and is intended to notify providers of program and coding changes made during the 2011 ICD-9-CM updates. New Diagnosis Codes The following diagnosis codes are new ICD-9-CM diagnosis codes: Diagnosis Code Description 23773 Schwannomatosis 23779 Other neurofibromatosis 27501 Hereditary hemochromatosis 27502 Hemochromatosis due to repeated red blood cell transfusions 27503 Other hemochromatosis 27509 Other disorders of iron metabolism 27661 Transfusion associated circulatory overload 27669 Other fluid overload 27803 Obesity hypoventilation syndrome * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. CSHCN Services Program Provider Bulletin 31 No. 77, February 2011
Diagnosis Code Description 28741 Posttransfusion purpura 28749 Other secondary thrombocytopenia 31535 Childhood onset fluency disorder 44770 Aortic ectasia, unspecified site 44771 Thoracic aortic ectasia 44772 Abdominal aortic ectasia 44773 Thoracoabdominal aortic ectasia 48801 Influenza due to identified avian influenza virus with pneumonia 48802 Influenza due to identified avian influenza virus with other respiratory manifestations 48809 Influenza due to identified avian influenza virus with other manifestations 48811 Influenza due to identified novel H1N1 influenza virus with pneumonia 48812 Influenza due to identified novel H1N1 influenza virus with other respiratory manifestations 48819 Influenza due to identified novel H1N1 influenza virus with other manifestations 56032 Fecal impaction 72403 Spinal stenosis, lumbar region, with neurogenic claudication 75231 Agenesis of uterus 75232 Hypoplasia of uterus 75233 Unicornuate uterus 75234 Bicornuate uterus 75235 Septate uterus 75236 Arcuate uterus 75239 Other anomalies of uterus 75243 Cervical agenesis 75244 Cervical duplication 75245 Vaginal agenesis 75246 Transverse vaginal septum 75247 Longitudinal vaginal septum 78033 Post traumatic seizures 78066 Febrile nonhemolytic transfusion reaction * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. Diagnosis Code Description 78452 Fluency disorder in conditions classified elsewhere 78492 Jaw pain 78630 Hemoptysis, unspecified 78631 Acute idiopathic pulmonary hemorrhage in infants [AIPHI] 78639 Other hemoptysis 78760 Full incontinence of feces 78761 Incomplete defecation 78762 Fecal smearing 78763 Fecal urgency 79950 Unspecified signs and symptoms involving cognition 79951 Attention or concentration deficit 79952 Cognitive communication deficit 79953 Visuospatial deficit 79954 Psychomotor deficit 79955 Frontal lobe and executive function deficit 79959 Other signs and symptoms involving cognition 97081 Poisoning by cocaine 97089 Poisoning by other central nervous system stimulants 99960 ABO incompatibility reaction, unspecified 99961 ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed 99962 ABO incompatibility with acute hemolytic transfusion reaction 99963 ABO incompatibility with delayed hemolytic transfusion reaction 99969 Other ABO incompatibility reaction 99970 Rh incompatibility reaction, unspecified 99971 Rh incompatibility with hemolytic transfusion reaction not specified as acute or delayed 99972 Rh incompatibility with acute hemolytic transfusion reaction 99973 Rh incompatibility with delayed hemolytic transfusion reaction * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. No. 77, February 2011 32 CSHCN Services Program Provider Bulletin
Diagnosis Code Description 99974 Other Rh incompatibility reaction 99975 Non-ABO incompatibility reaction, unspecified 99976 Non-ABO incompatibility with hemolytic transfusion reaction not specified as acute or delayed 99977 Non-ABO incompatibility with acute hemolytic transfusion reaction 99978 Non-ABO incompatibility with delayed hemolytic transfusion reaction 99979 Other non-abo incompatibility reaction 99980 Transfusion reaction, unspecified 99983 Hemolytic transfusion reaction, incompatibility unspecified 99984 Acute hemolytic transfusion reaction, incompatibilty unspecified 99985 Delayed hemolytic transfusion reaction, incompatibility unspecified V114 V1323 V1324 V1362 V1363 V1364 V1365 V1366 V1367 V1368 V1553 Personal history of combat and operational stress reaction Personal history of vaginal dysplasia Personal history of vulvar dysplasia Personal history of other (corrected) congenital malformations of genitourinary system Personal history of (corrected) congenital malformations of nervous system Personal history of (corrected) congenital malformations of eye, ear, face, and neck Personal history of (corrected) congenital malformations of heart and circulatory system Personal history of (corrected) congenital malformations of respiratory system Personal history of (corrected) congenital malformations of digestive system Personal history of (corrected) congenital malformations of integument, limbs, and musculoskeletal systems Personal history of retained foreign body fully removed * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. Diagnosis Code Description V2511* Encounter for insertion of intrauterine contraceptive device V2512 Encounter for removal of intrauterine contraceptive device V2513* Encounter for removal and reinsertion of intrauterine contraceptive device V4986 V4987 V6285 V8541 V8542 V8543 V8544 V8545 V8811 V8812 V9001 V9009 V9010 V9011 V9012 V902 V9031 V9032 V9033 V9039 V9081 V9083 V9089 V909 Do not resuscitate status Physical restraints status Homicidal ideation Body mass index 40.0-44.9, adult Body mass index 45.0-49.9, adult Body mass index 50.0-59.9, adult Body mass index 60.0-69.9, adult Body mass index 70 and over, adult Acquired total absence of pancreas Acquired partial absence of pancreas Retained depleted uranium fragments Other retained radioactive fragments Retained metal fragments, unspecified Retained magnetic metal fragments Retained nonmagnetic metal fragments Retained plastic fragments Retained animal quills or spines Retained tooth Retained wood fragments Other retained organic fragments Retained glass fragments Retained stone or crystalline fragments Other specified retained foreign body Retained foreign body, unspecified material V9100* Twin gestation, unspecified number of placenta, unspecified number of amniotic sacs V9101* Twin gestation, monochorionic/ monoamniotic (one placenta, one amniotic sac) V9102* Twin gestation, monochorionic/ diamniotic (one placenta, two amniotic sacs) * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. CSHCN Services Program Provider Bulletin 33 No. 77, February 2011
Diagnosis Code Description V9103* Twin gestation, dichorionic/diamniotic (two placentae, two amniotic sacs) V9109* Twin gestation, unable to determine number of placenta and number of amniotic sacs V9110* Triplet gestation, unspecified number of placenta and unspecified number of amniotic sacs V9111* Triplet gestation, with two or more monochorionic fetuses V9112* Triplet gestation, with two or more monoamniotic fetuses V9119* Triplet gestation, unable to determine number of placenta and number of amniotic sacs V9120* Quadruplet gestation, unspecified number of placenta and unspecified number of amniotic sacs V9121* Quadruplet gestation, with two or more monochorionic fetuses V9122* Quadruplet gestation, with two or more monoamniotic fetuses V9129* Quadruplet gestation, unable to determine number of placenta and number of amniotic sacs V9190* Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs V9191* Other specified multiple gestation, with two or more monochorionic fetuses * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. Diagnosis Code Description V9192* Other specified multiple gestation, with two or more monoamniotic fetuses V9199* Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. Discontinued Diagnosis Codes The following diagnosis codes have been discontinued: Diagnosis Code Description 2750 Disorders of iron metabolism 2766 Fluid overload 2874 Secondary thrombocytopenia 4880 Influenza due to identified avian influenza virus 4881 Influenza due to identified novel H1N1 influenza virus 7523 Other anomalies of uterus 7863 Hemoptysis 7876 Incontinence of feces 9708 Poisoning by other specified central nervous system stimulants 9996 ABO incompatibility reaction 9997 RH incompatibility reaction V251 V854 Encounter for insertion of intrauterine contraceptive device Body mass index 40 and over, adult Want to know more? You may be eligible for continuing education credits by participating in THSteps Online Provider Education training opportunities. To find out more, visit the THSteps Online Provider Education website at www.txhealthsteps.com. No. 77, February 2011 34 CSHCN Services Program Provider Bulletin
Revised Diagnosis Codes The following diagnosis codes have been revised: Diagnosis Code New Description Old Description 3070 Adult onset fluency disorder Stuttering 62981* Recurrent pregnancy loss without current pregnancy 64630* Recurrent pregnancy loss, unspecified as to episode of care or not applicable 64631* Recurrent pregnancy loss, delivered, with or without mention of antepartum condition 64633* Recurrent pregnancy loss, antepartum condition or complication 72402 Spinal stenosis, lumbar region, without neurogenic claudication Habitual aborter without current pregnancy Habitual aborter-unspecified as to episode of care or not applicable Habitual aborter-delivered, with or without mention of antepartum condition Habitual abort-antepartum condition or complication Spinal stenosis-lumbar 7818 Neurologic neglect syndrome Neurologic neglect syndrome V0751 Use of selective estrogen receptor modulators (SERMS) Prophylactic use of selective estrogen receptor modulators (SERMS) V0752 Use of aromatase inhibitors Prophylactic use of aromatase inhibitors V0759 V078 V079 Use of other agents affecting estrogen receptors and estrogen levels Other specified prophylactic or treatment measure Unspecified prophylactic or treatment measure Prophylactic use of other agents affecting estrogen receptors and estrogen levels Prophylactic measure NEC Prophylactic measure NOS V1361 Personal history of (corrected) hypospadias Hx-hypospadius V1369* Personal history of other (corrected) congenital malformations V2635* Encounter for testing of male partner of female with recurrent pregnancy loss Hx-congenital malformations other congenital malformations Encounter for testing of male partner of habitual aborter * Not covered by the CSHCN Services Program. Procedure codes that are referenced to a noncovered diagnosis code are not reimbursed by the CSHCN Services Program. CSHCN Services Program Medical Policy Updates Added Diagnosis Codes Revised Diagnosis Codes* Discontinued Diagnosis Codes Cytogenetics Testing Providers can refer to the 2010 CSHCN Services Program Provider Manual section 24.2.5.1, Cytogenetics Testing, on page 24-7, for more information. 88230, 88233, 88237, 88239, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291 23773, 27501, 44770, 44771, 44772, 44773, 75231, 75232, 75243, 75245 N/A 7523 CSHCN Services Program Provider Bulletin 35 No. 77, February 2011
Added Diagnosis Codes Revised Diagnosis Codes* Discontinued Diagnosis Codes Electrodiagnostic (EDX) Testing Providers can refer to the 2010 CSHCN Services Program Provider Manual section 30.2.17, Electrodiagnostic Testing, on page 30-44, for more information. 51784, 51785 56032, 78760, 78761, 78762, 78763 95860, 95861, 95863, 95864, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95875, 95900, 95903, 95904, 95905, 95934, 95936 95937 72403, 78492, 78760, 78761 N/A 7876 72403, 78492 72402 N/A 72402 7876 Electroencephalogram (Ambulatory) Providers can refer to the 2010 CSHCN Services Program Provider Manual section 30.2.16.2, Ambulatory Electroencephalogram, on page 30-43, for more information. 95950, 95951, 95953, 95956 78033, V1363 V1369 N/A Immune Globulins Providers can refer to the 2010 CSHCN Services Program Provider Manual section 30.2.24.8, Immune Globulins, on page 30-93, for more information. Providers can refer to article titled September 2010 CSHCN Services Program Procedure Code Review Updates for Immune Globulins, which was published on July 30, 2010, on the Code Updates CSHCN Services Program Procedure Code Review page of the TMHP website at www.tmhp.com. 90281, 90283, 90284, 90399, J1459, J1460, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1560, J1561, J1562, J1566, J1568, J1569, J1572 28741, 28749 N/A N/A 90386, J2791 28749 N/A N/A Neurostimulators Providers can refer to the 2010 CSHCN Services Program Provider Manual section 26.2.1, Dorsal Column Neurostimulation (DCN), on page 26-2, and section 26.2.2, Intracranial Neurostimulation (ICN), on page 26-3, for more information. 63650, 63655, 63685, 64555, 64590, E0740, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689 64561, 64581, 64590, E0740, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689 72403 72402 N/A 78760 N/A 7876 No. 77, February 2011 36 CSHCN Services Program Provider Bulletin
Added Diagnosis Codes Revised Diagnosis Codes* Discontinued Diagnosis Codes Respiratory Equipment and Supplies Providers can refer to the 2010 CSHCN Services Program Provider Manual section 33.2.8, Nebulizers, on page 33-9, for more information. A7003, A7004, A7005, A7006, E0570 48801, 48802, 48811, 48812 N/A 4880, 4881 Sleep Studies Providers can refer to the 2010 CSHCN Services Program Provider Manual section 30.2.34.2, Multiple Sleep Latency Test, on page 30-105, for more information. 95805, 95808, 95810, 95811 27803 N/A N/A Therapeutic Apheresis Providers can refer to the 2010 CSHCN Services Program Provider Manual section 30.2.37, Therapeutic Apheresis, on page 30-120, for more information. 36511, 36512, 36513, 36514 N/A N/A 2874 Note: Refer to the Revised Diagnosis Descriptions section of this article for description changes. CSHCN Services Program Provider Bulletin 37 No. 77, February 2011
CSHCN Services Program Contact Information CSHCN Services Program Telephone and Fax Communication Contact Telephone Number FAX Number TMHP-CSHCN Services Program Contact Center 1-800-568-2413 Prior Authorization and Authorization 1-512-514-4222 Provider Enrollment 1-800-568-2413 1-512-514-4214 DSHS-CSHCN Services Program Customer Service 1-800-252-8023 TMHP Electronic Data Interchange (EDI) Help Desk 1-888-863-3638 1-512-514-4228 Third-Party Resource (TPR) 1-800-846-7307 1-512-514-4225 Appeal Submission through AIS Line 1-800-568-2413 Written Communication with CSHCN Services Program Correspondence First-Time Claims and resubmissions of all zero allowed, zero paid claims and claims originally denied as an Incomplete Claim on an R&S Report Appeals and Adjustments Prior Authorization and Authorization Provider Enrollment Third-Party Resource (TPR) Electronic Claims and Rejected Reports (Past the 95-day filing deadline) Authorizations for Family Support Services Only Other Correspondence (Must be addressed and sent to a specific individual or department) Address TMHP-CSHCN Services Program PO Box 200855 Austin, Texas 78720-0855 TMHP Attn: CSHCN Services Program Appeals, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, Texas 78727 TMHP Attn: CSHCN Services Program Authorizations, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, Texas 78727 TMHP-CSHCN Services Program Provider Enrollment PO Box 200795 Austin, Texas 78720-0795 TMHP-TPR PO Box 202948 Austin, Texas 78720-2948 TMHP PO Box 200645 Austin, Texas 78720-0645 CSHCN Services Program Purchased Health Services Unit, MC1938 Texas Department of State Health Services PO Box 149347 Austin, Texas 78714-9347 TMHP-CSHCN Services Program Attn: (Individual or Department) 12357-B Riata Trace Parkway, Suite 150 Austin, Texas 78727 No. 77, February 2011 38 CSHCN Services Program Provider Bulletin
Forms Instructions for Completing the Provider Information Change Form Signatures The provider s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers. A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers. Address Performing providers (physicians performing services within a group) may not change accounting information. For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form. For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers. Tax Identification Number (TIN) TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN. Provider Demographic Information An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please visit the OPL at www.tmhp.com. Please review the existing information and add or modify any specific practice limitations accordingly. This will allow clients more detailed information about your practice. General TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Fax: 512-514-4214 Effective Date_01012009/Revised Date_12172008 CSHCN Services Program Provider Bulletin 39 No. 77, February 2011
Forms Provider Information Change Form Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page. Check the box to indicate a PCCM Provider Date : / / Nine-Digit Texas Provider Identifier (TPI): Provider Name: National Provider Identifier (NPI): Atypical Provider Identifier (API): List any additional TPIs that use the same provider information: Primary Taxonomy Code: Benefit Code: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: Physical Address The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Texas Medicaid fee-for-service who change their ZIP Code must submit a copy of the Medicare letter along with this form. Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Email: Accounting/Mailing Address All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form. Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Email: Secondary Address Street Address City State Zip Code Telephone: ( ) Fax Number: ( ) Email: Type of Change (check the appropriate box) Change of physical address, telephone, and/or fax number Change of billing/mailing address, telephone, and/or fax number Change/add secondary address, telephone, and/or fax number Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field Other (e.g., panel closing, capacity changes, and age acceptance) Comments: Tax Information Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS) Tax ID number: Effective Date: Exact name reported to the IRS for this Tax ID: Provider Demographic Information Note: This information can be updated on www.tmhp.com. Languages spoken other than English: Provider office hours by location: Accepting new clients by program (check one): Accepting new clients Current clients only No Patient age range accepted by provider: Additional services offered (check one): HIV High Risk OB Participation in the Woman s Health Program? Yes No Patient gender limitations: Female Male Both Signature and date are required or the form will not be processed. Provider signature: Date: / / Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Fax: 512-514-4214 Effective Date_01012009/Revised Date_12172008 No. 77, February 2011 40 CSHCN Services Program Provider Bulletin
Forms Electronic Funds Transfer (EFT) Notification Electronic Funds Transfer (EFT) is a payment method used to deposit funds directly into a provider s bank account. These funds can be credited to either checking or savings accounts, if the provider s bank accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks by ensuring funds are directly deposited into a specified account. The following items are specific to EFT: Pre-notification to your bank occurs on the weekly cycle following the completion of enrollment in EFT. Future deposits are received electronically after pre-notification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider s account during the weekly cycle. Specific deposits and associated R&S reports are cross-referenced by both the provider identifiers (i.e., NPI, TPI, API) and R&S number. EFT funds are released by TMHP to depository financial institutions each Thursday. The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received. TMHP must provide the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Contact your financial institution regarding posting time if funds are not available on the release date. However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution, who in turn should work out the best way to serve their customer s needs. In all cases, credits received should be posted to the customer s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date. To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or signed letter from your bank on bank letterhead with the agreement to the TMHP address indicated on the form. Call the TMHP Contact Center at 1-800-925-9126 if you need assistance. Rev. 0/22/09 Page EFT Authorization CSHCN Services Program Provider Bulletin 41 No. 77, February 2011
Forms Electronic Funds Transfer (EFT) Notification NOTE: Complete all sections below and attach a voided check or a signed letter from your bank on bank letterhead. Type of authorization: New Change Provider name: Billing TPI: (9-digit) National Provider Identifier (NPI)/Atypical Provider Identifier (API): Primary taxonomy code: List any additional TPIs that use the same provider information: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: Provider accounting address: Number Street Suite City State ZIP Provider phone number: Bank name: Bank phone number: ABA/Transit number: Account number: Bank address: Account type: (check one) Checking Savings I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period. I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws. I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations. Authorized signature: Date: Title: E-mail address: (if applicable) Contact name: Contact phone number: Return this form to: Texas Medicaid & Healthcare Partnership ATTN: Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Rev. 0/22/09 Page 2 EFT Authorization No. 77, February 2011 42 CSHCN Services Program Provider Bulletin
Forms CSHCN Services Program Prior Authorization Request for Additional Medical Nutritional Services Form and Instructions General Information Ensure the most recent version of the Prior Authorization Request for Additional Medical Nutritional Services form is submitted. The form is available on the TMHP website at www.tmhp.com. Complete all sections of this form. Incomplete prior authorization requests are denied. Requests are considered only when completed and received before the service is provided. Print or type all information. Contact the TMHP-CSHCN Services Program Contact Center at 1-512-514-3000, option 2, or 1-800-568-2413, Monday through Friday, from 7 a.m. to 7 p.m., Central Time, for assistance with this form. This form may be submitted by mail to the following address: TMHP-CSHCN Services Program Authorization Department 12357-B Riata Trace Parkway Ste #150 MC-A11 Austin, TX 78727 This form may be submitted by fax to 1-512-514-4222. Submit only the prior authorization form. Do not submit instruction pages. Refer to: Chapter 25, Medical Nutrition Services. Field Description First name Last name CSHCN Services Program number Date of birth Address/City/State/ZIP Diagnoses (ICD-9-CM) Client Information Guidelines Enter the client s first name as indicated on the CSHCN Services Program eligibility form Enter the client s last name as indicated on the CSHCN Services Program eligibility form Enter the client s ID number as indicated on the CSHCN Services Program eligibility form Enter the client s date of birth as indicated on the CSHCN Services Program eligibility form Enter the client s address, city, state, and ZIP Enter the diagnosis code relevant to the need for additional nutritional assessment, counseling, and products Nutritional Counseling and Assessment, Reassessments, and Intervention Information Field Description Guidelines More than 1 hour (4 units) of Check this item when requesting more than 1 hour (4 units) of nutrition nutrition assessments and assessments and interventions or more than 3 hours (12 units) of interventions or more than 3 reassessment and intervention per rolling year. hours (12 units) of reassessments and intervention per rolling year More than 4 nutritional counseling visits per rolling year Document medical necessity for additional nutritional assessments, or reassessments and intervention, and counseling below: Check this item when requesting more than four nutritional counseling visits per rolling year. Document medical necessity Field Description Name of product Size of can Number of cans Document medical necessity, including desired caloric intake Nutritional Products Guidelines Enter the name of the nutritional product that is listed on the product label Enter the size of can Indicate the number of cans Document medical necessity for nutritional products Page 1 of 3 Effective Date_11012010/Revised Date_09282010 CSHCN Services Program Provider Bulletin 43 No. 77, February 2011
Forms Field Description Dietician name CSHCN TPI NPI Taxonomy code Benefit code Telephone number Fax number Address/City/State/ZIP Signature Date Field Description Physician s name Telephone number Fax number Signature Date Dietician Information and Required Signature Guidelines Enter the dietician s name. Enter the dietician s CSHCN Texas provider identifier (TPI) Enter the dietician s national provider identifier (NPI) Enter the dietician s taxonomy code Enter CSN benefit code Enter the dietician s telephone number Enter the dietician s fax number Enter the dietician s address, city, state, and ZIP Dietician must sign in this field Enter the date the form is signed Prescribing Physician Information and Required Signature Guidelines Enter the name of the physician prescribing the nutritional counseling or product Enter the prescribing physician s telephone number Enter the prescribing physician s fax number Prescribing physician must sign in this field Enter the date the form is signed Additional Requirements Prior Authorization request for nutritional products: Providers must only request prior authorization when prescribing a product not listed in the CSHCN Services Program Medical Nutritional Formulary list. Page 2 of 3 Effective Date_11012010/Revised Date_09282010 No. 77, February 2011 44 CSHCN Services Program Provider Bulletin
Forms CSHCN Services Program Prior Authorization Request for Additional Medical Nutritional Services Client Information: First name: Last name: CSHCN Services Program number: 9- -00 Date of birth: Address/City/State/ZIP: Diagnoses (ICD-9-CM): Nutritional Counseling and Assessment, Reassessments, and Intervention Information: Check the appropriate box More than 1 hour (4 units) of nutrition assessments and interventions or more than 3 hours (12 units) of reassessments and intervention per rolling year Document medical necessity: More than 4 nutritional counseling visits per rolling year Nutritional Products Name of product: Size of can: Procedure code: Number of cans: Document medical necessity, including desired caloric intake: Dietician Information and Required Signature Dietician name: CSHCN TPI: Taxonomy code: Telephone number: NPI: Benefit code: CSN Fax number: Address/City/State/ZIP: Signature: Prescribing Physician Information and Required Signature: Prescribing physician name (printed or typed): Date: Contact name: Telephone number: Fax number: Prescribing physician signature: Date: Page 3 of 3 Effective Date_11012010/Revised Date_09282010 CSHCN Services Program Provider Bulletin 45 No. 77, February 2011