CSHCN Provider Bulletin The Children with Special Health Care Needs Program February 2005 IN THIS EDITION General Interest Emergency Care Plans for Children with Special Health Care Needs ...... 1 Donate Life! .............................................................................................. 3 2-1-1 Service Now Available Statewide ..................................................... 3 Fetal Alcohol Syndrome Guidelines Available .......................................... 4 Promoting Independence ...........................................................................5 Children’s Policy Council Makes Recommendations to State Leaders .....5 Upcoming Events ...................................................................................... 6 Administrative 2004 Fee Schedules Available Online ....................................................... 6 Revisiting the Physician/Dentist Assessment Form (PAF) ....................... 6 Only Billing TPIs Receive R&S Reports...................................................7 New CSHCN Website Address .................................................................7 Requests for Additional Copies of the Paper R&S ....................................7 TDHconnect 3.0 Service Pack 5 Release .................................................. 8 TMHP Provider Relations Representatives .............................................. 9 Coding and Reimbursement ICD-9-CM Implementation Date Change ............................................ 10 2004 HCPCS Special Bulletin Correction ............................................. 10 2005 HCPCS Code Changes ................................................................. 10 RSV-IgIM (Palivisumab) Reimbursement ............................................. 10 Cataract and Vitrectomy Combined Services......................................... 10 Radiology Procedure Code Update ......................................................... 11 Fee Adjustment for Darbepoetin Alfa...................................................... 11 Contrast Material Procedure Code Update ............................................. 11 TDHconnect Comments/Narrative Field Restrictions ........................... 11 Medication Management Visits ............................................................... 11 Medical Nutritional Products Reimbursement ...................................... 12 ASC/HASC Billing Update.................................................................... 12 Supernumerary Tooth IDs ...................................................................... 12 New Service Benefits ............................................................................... 13 Updated Custom DME Manufacturers Listing ......................................14 Forms Emergency Information Form for Children with Special Needs ............ 15 Physician/Dentist Assessment Form (PAF) ............................................. 17 Provider Information Change Form ........................................................19 No. 53 Emergency Care Plans for Children with Special Health Care Needs In the event of an emergency, everyone needs to know how to respond quickly and meet the needs of a child with special health care needs. Some children are assisted by technology, and others have complex medical needs that may or may not be apparent. In an emergency situation, these issues can impact treatments and outcomes. is article shares the concept of an emergency care plan and its use for children with special health care needs. e purpose of the emergency care plan is to provide a written reference guide that everyone who is in contact with the child can rapidly access. Many children with special health care needs lead active lives in their communities. While parents or primary caregivers may know their children’s needs best, the children are frequently under the supervision of others. Teachers, school nurses, daycare workers, bus drivers, and neighbors may not know the details of a child’s condition or the emergency contact information. ese people may need help to assess if the child’s (continued on page 2) CPT and CDT codes, descriptions, and other data are copyright 2004 American Medical Association (AMA) and copyright 2002 American Dental Association (ADA) (or such other date of publication of CPT or CDT). All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. The AMA and ADA assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.
Transcript
CSHCN Provider BulletinThe Children with Special Health Care Needs Program
February 2005
IN THIS EDITIONGeneral Interest
Emergency Care Plans for Children with Special Health Care Needs ......1Donate Life! .............................................................................................. 32-1-1 Service Now Available Statewide ..................................................... 3Fetal Alcohol Syndrome Guidelines Available .......................................... 4Promoting Independence ...........................................................................5Children’s Policy Council Makes Recommendations to State Leaders .....5Upcoming Events ...................................................................................... 6
Administrative2004 Fee Schedules Available Online ....................................................... 6Revisiting the Physician/Dentist Assessment Form (PAF) ....................... 6Only Billing TPIs Receive R&S Reports ...................................................7New CSHCN Website Address .................................................................7Requests for Additional Copies of the Paper R&S ....................................7TDHconnect 3.0 Service Pack 5 Release .................................................. 8TMHP Provider Relations Representatives .............................................. 9
Coding and ReimbursementICD-9-CM Implementation Date Change ............................................ 102004 HCPCS Special Bulletin Correction ............................................. 102005 HCPCS Code Changes ................................................................. 10RSV-IgIM (Palivisumab) Reimbursement ............................................. 10Cataract and Vitrectomy Combined Services ......................................... 10Radiology Procedure Code Update .........................................................11Fee Adjustment for Darbepoetin Alfa ......................................................11Contrast Material Procedure Code Update .............................................11TDHconnect Comments/Narrative Field Restrictions ...........................11Medication Management Visits ...............................................................11Medical Nutritional Products Reimbursement ...................................... 12ASC/HASC Billing Update .................................................................... 12Supernumerary Tooth IDs ...................................................................... 12New Service Benefits ............................................................................... 13Updated Custom DME Manufacturers Listing ......................................14
FormsEmergency Information Form for Children with Special Needs ............15Physician/Dentist Assessment Form (PAF) .............................................17Provider Information Change Form ........................................................19
No. 53
Emergency Care Plans for Children with Special Health Care Needs
In the event of an emergency, everyone needs to know how to respond quickly and meet the needs of a child with special health care needs. Some children are assisted by technology, and others have complex medical needs that may or may not be apparent. In an emergency situation, these issues can impact treatments and outcomes. This article shares the concept of an emergency care plan and its use for children with special health care needs.
The purpose of the emergency care plan is to provide a written reference guide that everyone who is in contact with the child can rapidly access. Many children with special health care needs lead active lives in their communities. While parents or primary caregivers may know their children’s needs best, the children are frequently under the supervision of others. Teachers, school nurses, daycare workers, bus drivers, and neighbors may not know the details of a child’s condition or the emergency contact information. These people may need help to assess if the child’s
(continued on page 2)
CPT and CDT codes, descriptions, and other data are copyright 2004 American Medical Association (AMA) and copyright 2002 American Dental Association (ADA) (or such other date of publication of CPT or CDT). All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. The AMA and ADA assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.
condition is worsening. Sometimes, a passerby or emergency worker may respond to a situation, such as a vehicle accident, with no background knowledge. The emergency care plan provides critical information every step of the way, from the first responder to the emergency department.
• Names and contact information for parents, guardians, and physicians.
• A brief medical history and list of medications.• Allergy information.• Immunizations.• Special baseline information and management
suggestions for certain problems.
For many years ACEP and AAP have encouraged all families of children with special health care needs to have a plan for emergencies in place.
What can providers do to promote emergency health care plans for children with special health care needs? First, they can meet with the child, family members, and other caregivers to complete or assist with completion of the initial form. Then, they can review and update the form at each annual well-child exam and after any significant change in status, such as a hospitalization. Finally, they can encourage the child’s caregiver to distribute the plan to key people and places in the child’s life and have extra copies available to give to EMS personnel should the need arise. Caregivers should make sure there is a copy of the plan wherever the child is: near the phone or on
the refrigerator at the home, at school, with the child (on a wheelchair or in a backpack), and in the car. The extra time and effort taken to develop and maintain a plan can have a huge impact on—or even help save—a child’s life.
(continued from page 1)
Emergency workers may respond to an emergency with no background knowledge on the patient. The emergency care plan provides first responders and emergency departments with this critical information.
References
U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau, National Association of Children’s Hospitals and Related Institutions, Recommendations for Emergency Care Plans for Children with Special Health Care Needs, Emergency Medical Services for Children (EMSC) Clearinghouse, Vienna, VA, 2001.
EMSC National Resource Center, Emergency Care Plans for Children with Special Health Care Needs (Fact Sheet), 1998, www.ems-c.org/rehab/framerehab.htm, accessed on November 1, 2004.
American Academy of Pediatrics (AAP), Emergency Preparedness for Children with Special Health Care Needs, www.aap.org/advocacy/emergprep.htm, accessed on October 14, 2004.
CSHCN Bulletin, No. 53 2 February 2005
General Interest
2-1-1 Service Now Available Statewide
2-1-1 Texas, which has been available in parts of the state for more than two years, is now available throughout Texas. The launch of the El Paso Area Information Center in the fall of 2004 completed the statewide rollout.
Texas now serves more than 32 percent of the total 2-1-1 population in the nation. Last year, 2-1-1 Texas received more than 1.5 million calls—more than any other state in the nation—and the number is expected to climb this year.
2-1-1 is an abbreviated dialing code for free information and referrals about health and human services. The service is operated in a public-private partnership between the Texas Health and Human Services Commission (HHSC), local government, and community groups. Assistance is available in English, Spanish, and other languages. Texans who are deaf or hard of hearing can access 2-1-1 through Relay Texas and through teletype (TTY) writer lines connected
Donate Life!
More than 87,000 people in the United States are currently awaiting a life-saving organ transplant—5,800 of those waiting are Texans. For the first time in history, the number of patients awaiting a kidney transplant has topped 60,000. Every day, 115 individuals are added to the nation’s organ transplant waiting list—one person every 13 minutes.
Unfortunately, organ and tissue donations have not kept up with the need. One donor can help save the lives of more than 50 people, with gifts of organs, tissue, and corneas.
The most important step in deciding to become an organ donor is to share that decision with a family member. Families are consulted before the donation process can take place, even when a person has signed a donor card or indicated his or her wishes to be an organ donor on a
driver’s license. During such a traumatic time, it makes it much easier on the family if they know their loved one’s wishes in advance.
Last November, the Department of State Health Services (DSHS) rolled out its first Organ Donor Awareness Campaign to its 11,600 employees. The effort included informational emails that encouraged
people to discuss the issue with their families.
In January, officials spread the word to the 47,000 employees in the Texas Health
and Human Services system, and in April, officials hope to contact all 134,000 state workers with a procla-mation from Govenor Rick Perry endorsing organ donation.
The DSHS Anatomical Gift Educational Program (AGEP) was established to educate
Texans about organ, eye, and tissue donation. To learn more about giving the gift of life, visit the website at www.dshs.state.tx.us/agep, or call Susan Ristine at 1-800-222-3986.
directly to the network.
When callers dial 2-1-1, they are directed to an area information center, which is run by a community group and staffed with certified information and referral specialists. Each center has a database of services available in the area, including state services, food pantries, career services, after-school programs, counseling services, and many other nonprofit resources. The centers are constantly expanding their databases.
To reach 2-1-1 Texas, dial 2-1-1 or visit www.helpintexas.com for a list of area information centers and other ways to find services, hotlines, and more. Callers using a cell phone may need to call an area information center directly. The local phone numbers are available on the Internet site. Some area information centers also have toll free numbers. In the future, new technology will allow all cell phone users to access 2-1-1 directly.
February 2005 3 CSHCN Bulletin, No. 53
General Interest
Fetal Alcohol Syndrome Guidelines Available
The Centers for Disease Control and Prevention (CDC) National Task Force on Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effect (FAE) has announced the availability of newly-adopted diagnostic guidelines. They are available to download from www.cdc.gov/ncbddd/fas/default.htm. This report is the culmination of more than two years of work and study to provide guidance to health and human services agencies and providers about how to uniformly diagnose this disorder.
In the fiscal year 2002 appropriations legislation, the U.S. Congress mandated that CDC, in concert with advocacy and other organizations, develop guidelines for the diagnosis of FAS and other negative birth outcomes resulting from prenatal exposure to alcohol. Additionally, the legislation also mandated that the guidelines be incorporated into medical and allied health curricula and that the curricula be disseminated to, and training provided for, medical and allied health students and practitioners.
The following general diagnostic criteria were developed over the two-year work period and are discussed more completely in the guidelines:
• Facial dysmorphia, including smooth philtrum, thin vermillion, and small palpegral fissures
• Growth problems confirmed by prenatal or postnatal height or weight, or both, at or below the tenth percentile
• Structural, neurological, and functional central nervous system abnormalities
• Maternal alcohol exposure
The required criteria for a FAS diagnosis are documen-tation of all three facial abnormalities, growth deficits, and central nervous system abnormalities.
The guidelines seek to standardize diagnostic criteria for FAS in order to establish consistency among clinicians, scientists, and service providers. The criteria are based on recent research, clinical expertise, family input, and a consideration of other diagnostic systems in use. They are designed to provide balance between conser-vative and overly-inclusive diagnostic systems, and
they emphasize differential diagnosis from other genetic, teratological, and behavioral disorders.
Prevention of FAS and related disorders is an important public health issue. The guidelines also review current research and recommen-dations for identifying and intervening with women at risk for an alcohol-exposed pregnancy.
The report concludes by recognizing the need to continue research and refinement of science-based information concerning FAS and related disorders to help families affected by FAS receive services that enable them to achieve healthy lives and reach their maximum potentials.
A state resource for information about prevention of FAS disorders is the Texas Office for Prevention of Developmental Disabilities (TOPDD). It was formed in 1989 to coordinate activity within the health and human services enterprise to prevent developmental disabilities. Their mission is to minimize the economic and human losses caused by preventable developmental disabilities. They specifically focus on FAS disorders and head injuries among youth. Their web address is www.topdd.state.tx.us.
Reference
National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Department of Health and Human Services in coordination with the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect, Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis, July, 2004, www.cdc.gov/ncbddd/fas/documents/FAS_guidelines_accessible.pdf, accessed on December 28, 2004.
CSHCN Bulletin, No. 53 4 February 2005
General Interest
Texas established the Promoting Independence Advisory Board, now referred to as the Promoting Independence Advisory Committee (PIAC), to assist HHSC in developing and implementing the Texas Promoting Independence Plan and Initiative as a
response to the U.S. Supreme Court ruling in Olmstead v. L.C. (June 1999). This effort was launched through an executive order by former Governor George W. Bush and has been reinforced by an executive order from Governor Rick Perry and Texas legislation.
The PIAC is charged with providing guidance to the health and human service agencies in making recommendations for a plan that evaluates and implements a system of services and supports for people of all ages with disabilities to ensure access to alternatives to institutional care when community care is preferable.
Promoting IndependenceSupporting People with Disabilities in Their Homes
The Texas Promoting Independence Plan goes beyond just addressing the state’s response to the Olmstead decision. It makes recommendations to improve the entire long term care service system and improve the quality and capacity of community-based services.
As required by Senate Bill 367 (SB367), 77th Legislative Session, the Texas Promoting Independence Plan is submitted to the Governor and the Legislature in December of each even-numbered year. The original Texas Promoting Independence Plan was completed in January 2001, was revised in December 2002, and was revised again in December 2004.
SB367 further requires the PIAC advocate and consumer stakeholders to submit, every year, a report to HHSC. This report recommends actions that address the barriers to transitioning people from institutions to the community. Their most recent report, Promoting Independence Makes Good Cents, was submitted in September 2004.
Copies of the Revised (2004) Promoting Independence Plan and the Promoting Independence Advisory Committee Stakeholder Report for 2004 are available for download on the HHSC website at: www.hhsc.state.tx.us/about_hhsc/reports/search/search_LTC.asp. Printed copies can be obtained by contacting Terry Childress at the Department of Aging and Disability Services (DADS) at 1-512-438-2260.
Children’s Policy Council Makes Recommendations to State Leaders
The Children’s Policy Council (CPC) is an advisory group established by the Texas Legislature. The majority of the CPC are family members of children who receive long term care or health services. The CPC works to assist Texas in developing systems that help families care for their children with disabilities, allow children to grow up in families, and use state resources effectively. The CPC’s main job is to make recommen-dations to Texas leaders for improving care for children with disabilities or special health care needs.
The CPC has prepared a report entitled, Making Children a Priority: Recommendations for Improving Services for Children with Disabilities in Texas. The
report contains 20 recommendations for changing state policies and programs to better serve all children with special health care needs and disabilities.
Additionally, the report provides good background information on many issues affecting children with special health care needs.
The report is available on the Internet, at: www.hhsc.state.tx.us/pubs/090104_CPC_HB1478.html. Printed copies are available through Terry Beattie at 1-512-424-6528, by email to [email protected], or by mail to HHSC, 4900 N. Lamar, 4th Floor, Austin, TX 78751
February 2005 5 CSHCN Bulletin, No. 53
General Interest
2004 Fee Schedules Available Online
The 2004 Provider Fee Schedules were posted to the TMHP website at www.tmhp.com on September 30, 2004. The schedules can be downloaded in an Excel format. Providers may request a copy of a fee schedule free of charge by calling the TMHP Contact Center at 1-800-568-2413.
Revisiting the Physician/Dentist Assessment Form (PAF)
The May 2004 CSHCN Provider Bulletin, No. 50, and the August 2004 CSHCN Provider Bulletin, No. 51, both contained articles about the newly-implemented Physician/Dentist Assessment Form (PAF). The information provided for CSHCN clients in this form is vital to obtaining and retaining eligibility for and access to program health care benefits. A copy of the form can be found on pages 17 and 18 of this bulletin.
Providers’ assistance is needed in communicating the importance of this information to CSHCN clients. Complete instructions are included with the form as a part of the client application booklet, or the form and instructions may be downloaded from the CSHCN website, www.dshs.state.tx.us/cshcn.
It is especially important to emphasize that a provider (a physician or dentist*) who has seen the client at least once within the past 12 months must complete the PAF at least annually. If the client’s condition changes, a PAF may be submitted at any time. The PAF becomes a part of an official record, and an original physician’s or dentist’s signature and current date are required.
*Note: A dentist should complete the form only when most of the client’s care is related to cleft-craniofacial defects or other dental problems.
CSHCN appreciates all that providers do on behalf of children with special health care needs in Texas. Contact CSHCN at 1-800-252-8023 for additional information or answers to questions.
Upcoming Events
“Building Blocks of Exceptional Education—Workshop on Estate Planning for Families who have Children with Disabilities” will be presented by Steve Rhatigan on February 8, 2005, at 7:00 p.m. at the Graceview Baptist Church, North Campus, in Tomball, Texas. The workshop is free of charge, but registration is required. Send registration by email to Michelle [email protected].
“Inclusion Works 2005—The State Conference on Including Children with Disabilities in the Classroom” will be held February 9–12, 2005, at the Renaissance Austin Hotel in Austin, Texas. The target audience for this conference is teachers, administrators, and parents. Information is available at www.familytofamilynetwork.org, or call 1-713-466-6304.
“Sensory Integration for Those with Developmental, Learning Disorders, Autism Spectrum Disorders, and Dyspraxia” will be held February 10-13, 2005, in Baytown, Texas. Information is available at www.eritherapyseminars.com, or call 1-800-487-6530.
The Attention Defecit Disorder Association Southern Region 17th Annual Conference, “ADDing Up to Success,” will be held February 25-26, 2005, in Houston, Texas, at the Sheraton North Houston, George Bush Intercontinental Airport. The keynote speaker is Jay Geidd, M.D. Information is available at www.adda-sr.org, or call 1-281-897-0982.
The “Texas Association for Behavior Analysis Annual Conference Promoting Speech and Language in Children with Autism: Integrating ABA and Speech-Language Pathology” will be presented by Joanne Gerenser, PhD, CCC-SLP, BCBA in Houston, Texas, March 4-5, 2005. Information is available at www.unt.edu/behv/txaba/.
The “Autism/Asperger’s Conference” will be held April 7–8, 2005, in South Padre Island, Texas. Dr. Temple Grandin will be the presenter. Additional information is available at www.FutureHorizons-Autism.com, by email to [email protected], or by calling 1-800-489-0727.
General Interest/Administrative
CSHCN Bulletin, No. 53 6 February 2005
New CSHCN Website Address
CSHCN has a new web address and a new look to its website. All of the “old” information is still available, and CSHCN adds new information all the time.
Within the website, there are pages for clients, contractors, and providers. Th ere are forms, newsletters, and manuals, links to other resources, and much more. Visit the website at www.dshs.state.tx.us/cshcn and bookmark the new address. CSHCN hopes providers fi nd the information helpful and appreciates feedback and suggestions. Send comments or suggestions via email to [email protected].
Only Billing TPIs Receive R&S Reports
As a reminder, only billing Texas Provider Identifi ers (TPIs)/provider numbers receive Remittance and Status (R&S) reports. It is essential that providers who are part of a group plan use the group provider number and not the performing provider number.
Providers may download the R&S report, available on the TMHP website (www.tmhp.com), using the billing TPI/provider number or group number but not the performing provider number. TMHP has received numerous requests to include performing providers (number) in this option; however, these requests are not being processed and must be resubmitted with the correct TPI/provider number associated with the provider’s actual reimbursement.
Providers may verify their billing TPI/provider number using a previous R&S report and completing an online request using the number found in the R&S header. For further clarifi cation or to answer questions about a previously-submitted request, contact the EDI Help Desk at 1-888-863-3638.
Requests for Additional Copies of the Paper R&S
Additional copies of paper R&S reports will be charged to the provider if requested more than 30 days after the original R&S was issued. Th ere is an initial charge of $9.75 for the request (additional hours = $9.75), with a charge of $0.32 per page and applicable taxes of 8.25 percent.
Example: Th e total charge for a 60 page report is $31.34: the labor fee is $9.75, the per-page fee total is $19.20 (60 pages x $.32), and the taxes are $2.39 (8.25 percent).
Providers have the option to obtain their R&S reports electronically or they may also view them on the TMHP website (www.tmhp.com). Providers who choose to receive electronic R&S reports no longer receive paper copies.
Note: Providers must retain their R&S reports for a minimum of fi ve years.
For more information, call the CSHCN Contact Center at 1-800-568-2413.
Administrative
February 2005 7 CSHCN Bulletin, No. 53
TDHconnect 3.0 Service Pack 5 Release
Texas Medicaid & Healthcare Partnership (TMHP) is releasing TDHconnect 3.0 Service Pack 5 on February 4, 2005. Providers who use TDHconnect 3.0 are encouraged to download
and install Service Pack 5 from the TMHP website at www.tmhp.com. In addition to resolving several existing issues, Service Pack 5 adds new functionality that allows providers to transmit electronic files using a broadband connection. Service Pack 5 will continue to support a dial-up connection.
With the release of Service Pack 5, TMHP is discon-tinuing support for the Windows 95 operating system. TMHP will continue to provide support for TDHconnect users with Windows 98, 2000, ME, NT, and XP. While Service Pack 5 will work with Windows 95, future updates to TDHconnect may not provide all current functionality on Windows 95 systems.
Service Pack Download
To download the service pack, follow these steps:
1) Connect to TMHP at www.tmhp.com.2) Click the Find Software/Service Packs link located in
the I would like to… list on the right side of the page. The TMHP File Library main page opens.
3) Scroll down to locate the File Library links.4) Click the TDHconnect link. The TMHP File
Library/TDHconnect webpage opens.5) Scroll down to locate the File Library links.6) Click the TDHconnect Updates link. The TMHP
7) Scroll down to locate the File Library links.8) Select the most recent service pack, such as
TDHconnect 3.0 Updates Service Pack 5.
Service Pack Installation
To install the service pack, do the following:
1) Double-click the TDHconnect 3.0 Updates Service Pack 5.msi icon. This icon was added to the desktop during the file download.
2) A dialog opens with the following message: This will install TDHconnect 3.0 Service Pack 4. Do you want to continue? Click Yes to install the TDHconnect 3.0 Service Pack.
3) After the TDHconnect Service Update Installation Utility window opens and the TDHconnect 3.0 Service Pack wizard opens, several informational messages will open. Read each message and click Next to advance to the next screen.
4) A dialog opens with the following message: Do you wish to backup your databases? This will overwrite databases that are in the Backup folder. Choose one of the following options:a) Click Yes to backup your databases before
installing any database updates (this is the recommended choice).
b) Click No to continue with the installation without making backups.
Note: Several additional informational messages open. This process may take several minutes as database updates are made.
5) Installation of the TDHconnect 3.0 Service Pack is complete. To view the readme file, check the View readme check box and click Finish. The readme document opens.
6) Read the document, close it, uncheck the View readme check box, and click Finish.
7) When prompted to restart the computer, select Yes, I want to restart my computer now, and then click Finish.
The next time TDHconnect is opened, the version of the Service Pack is listed along with the name TDHconnect 3.5.0.
For help with problems with the download, contact the TMHP EDI Help Desk at 1-888-863-3638.
CSHCN Bulletin, No. 53 8 February 2005
Administrative
TMHP Provider Relations Representatives
TMHP provider relations representatives offer a variety of services designed to inform and educate the provider community about the Texas Medicaid and CSHCN programs’ policies and claims filing procedures. Technical support and training are also provided for TDHconnect software users. 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/Providers/default.aspx. (Click on the Regional Support link, then choose your region.)
Territory Regional Area Provider Representative Telephone Number
1 Amarillo and Lubbock Elizabeth Ramirez 1-512-506-6217
2 Abilene, Midland, Odessa, and San Angelo Diane Molina 1-512-506-3423
3 El Paso Isaac Romero 1-512-506-3530
4 Del Rio, Kerrville, and N. San Antonio Sue Lamb 1-512-506-3422
5 Brownsville, Falfurrias, and Laredo Cynthia Gonzales 1-512-506-7991
6 Corpus Christi and S. San Antonio Will McGowan 1-512-506-3554
7 Galveston, Harris County, and Wharton Rachelle Moore 1-512-506-3447
8 Harris County Linda Dickson 1-512-506-3446
9 Conroe and Harris County Linda Wood 1-512-506-7682
10 Beaumont and Lufkin Gene Allred 1-512-506-3425
11 Dallas, Tyler, and Waxahachie Sandra Peterson 1-512-506-3552
12 Dallas and Texarkana Olga Fletcher 1-512-506-3578
13 Eastland, Fort Worth, and Wichita Falls Rita Martinez 1-512-506-7990
14Austin, Bryan, College Station, Marble Falls, and Waco
Andrea Daniell 1-512-506-7600
February 2005 9 CSHCN Bulletin, No. 53
Administrative
ICD-9-CM Implementation Date Change
Each year the Centers for Medicare and Medicaid Services (CMS) issues changes that result in new, revised, or invalid diagnosis codes, procedure codes, diagnosis related groups (DRGs), and major diagnostic categories (MDCs), published annually as revisions to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The new ICD-9-CM codes are valid for dates of service on or after October 1, 2004.
This updates information published in the November 2004, CSHCN Provider Bulletin, No. 52, which incorrectly stated that the new codes would be valid for dates of service on or after November 1, 2004. Refer to the November/December Texas Medicaid Bulletin, No. 183, for a complete listing of ICD-9-CM updates. Bulletins are available on the TMHP website, www.tmhp.com, under the Find Publications/File Libraries link located in the “I would like to…” list on the right side of the webpage.
2004 HCPCS Special Bulletin Correction
The article entitled, “ASC/HASC Group Rate Revisions,” on page 13 of the 2004 HCPCS Special Bulletin, No. 180, was printed in error. There were no changes to the ASC/HASC group rates as a result of the changes adopted by Medicare effective October 1, 2003. Providers should disregard the article.
2005 HCPCS Code Changes
Each year the Centers for Medicare & Medicaid Services (CMS) issues its changes to HCFA Common Procedure Coding System (HCPCS) procedure codes and modifiers. Changes reflect codes that have been added, discontinued, or the description has been revised. These changes are posted in the 2005 HCPCS Special Bulletin that is available on the website, www.tmhp.com, and will be mailed to providers in February 2005.
RSV-IgIM (Palivisumab) Reimbursement
CSHCN reimburses for RSV-IgIM (Palivisumab), using procedure codes 90378 or J1565. Providers must indicate the name of the medication and the dosage. RSV prophylaxis is reimbursed the lower of the billed amount or the amount allowed by the Texas Medicaid Program.
Effective for dates of service on or after October 1, 2004, the reimbursment for procedure code 1-90378, Rsv ig, im, 50 mg, was increased from $11.96/mg to $13.26/mg.
Claims submitted for dates of service from October 1, 2004, through December 16, 2004, that included procedure code 1-90378 will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. A future banner message will notify providers when the additional payment will be reflected on the Remittance and Status report.
Authorization is required for any diagnoses not included in the list found on page 18 of the November 2004 CSHCN Provider Bulletin, No. 52. The authorization request must provide documentation of medical necessity and include the client’s diagnosis, age, and the specific indication or justification for RSV prophylaxis.
For more information, call the CSHCN Contact Center at 1-800-568-2413.
Cataract and Vitrectomy Combined Services
Effective for dates of service on and after January 1, 2005, when cataract extraction (procedure codes 66850 and 66984) and vitrectomy (procedure codes 67005, 67010, and 67036) are performed on the same eye, the vitrectomy will pay at 100 percent and the cataract extraction will pay at 50 percent per multiple surgical procedure payment guidelines for clients 8 years of age and younger. This has been updated from the previous age limit of 3 years and younger.
CSHCN Bulletin, No. 53 10 February 2005
Coding and Reimbursement
Contrast Material Procedure Code Update
Effective for dates of service on or after October 16, 2003, contrast material procedure codes A4641, A4642, A4643, A4644, A4645, A4646, A4647, and 78990 are no longer payable. This change occurred as a result of the Health Insurance Portability and Accountability Act (HIPPA).
Claims submitted with dates of service on or after October 16, 2003, that included these procedure codes were reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.
TDHconnect Comments/Narrative Field Restrictions
An issue has been identified that impacts ambulance, dental, and medical nutritional products providers using the Comments/Narrative field in TDHconnect. The use of special characters such as the asterisk (*), colon (:), and tilde (~) results in delineation in the electronic file and in an electronic rejection that prevents the claim from being considered for payment. Therefore, providers must discontinue use of special characters until further notice. Also note that ambulance providers indicating a time segment must use military time.
For more information, visit the TMHP website at www.tmhp.com or call the CSHCN Contact Center at 1-800-568-2413.
Medication Management Visits
The May 2004 CSHCN Provider Bulletin, No. 50, page 7, incorrectly instructed physicians to enroll and bill TMHP-CSHCN for medication management visits (M0064 and 90862). Physicians must continue to enroll and bill DSHS-CSHCN for these services.
For more information, call the CSHCN Contact Center at 1-800-568-2413.
Fee Adjustment for Darbepoetin Alfa
Effective for dates of service on or after July 1, 2004, the CSHCN fee for procedure code Q0137, Darbepoetin alfa, non-esrd, was adjusted from $4.54 to $4.24 to correct a pricing data entry error. Paid claims submitted with dates of service from July 1, 2004, through July 14, 2004, that included procedure code Q0137 were reprocessed and the recoupments appeared on provider’s R&S reports. No action on the part of the provider is necessary.
For more information, visit the TMHP website at www.tmhp.com or call the CSHCN Contact Center at 1-800-568-2413.
Radiology Procedure Code Update
Effective September 17, 2004, radiology procedure codes 76012 and 76013 are no longer reimbursable by the CSHCN Program when billed with TOS 4 (Radiology total component). These procedure codes must be billed with TOS I (Interpretation) in POS 1 (Office) and POS 5 (Outpatient hospital) to be considered for reimbursement.
February 2005 11 CSHCN Bulletin, No. 53
Coding and Reimbursement
Medical Nutritional Products Reimbursement
CSHCN reimburses for medical nutritional products, defined as those nutritional products that serve as a therapeutic agent for life and health that are part of a treatment regimen. The CSHCN Program does not cover nutritional products for individuals who can be sustained on an age-appropriate diet. Nutritional
products are not provided to infants younger than 12 months of age unless medical necessity is documented.
CSHCN reimburses for medical nutritional products according to the lower of the billed amount or the average wholesale price (AWP) per can/volume according to the prices in the current edition of the Drug Topics Red Book, published by Medical Economics Company, Inc., Montvale, New Jersey 07645-1742. For products not listed in the current edition of the Drug Topics Red Book, reimbursement is based on the same methodology using the AWP supplied by the manufacturer of the product.
Providers should use modifier BO, orally administered nutrition—not by feeding tube, when appropriate to differentiate enteral versus oral administration.
Authorization and prior authorization is no longer required for medical nutritional products listed in the 2004 CSHCN Provider Manual Medical Nutritional Products Formulary. Only products not listed in the CSHCN Medical Nutritional Products Formulary require prior authorization approved by the CSHCN Medical Director at DSHS.
ASC/HASC Billing Update
The following correction applies to the 2004 HCPCS Special Bulletin “Corrections” article that appears on page 14 of the November 2004 CSHCN Provider Bulletin, No. 52. The article contains an incorrect rate for Ambulatory Surgical Center/Hospital Ambulatory Surgical Center (ASC/HASC) providers for procedure code F-36566, Insert tunneled cv cath. The incorrect rate was published as group GP 1: the correct rate is GP 3.
No claims require reprocessing. This was a publication error and not a systems error. No action on the part of the provider is necessary.
For more information, visit the TMHP website at www.tmhp.com or call the CSHCN Contact Center at 1-800-568-2413.
Supernumerary Tooth IDs
Effective January 1, 2005, TMHP implemented the revised supernumerary tooth identification system designed by the American Dental Association (ADA). Each identified permanent tooth and each identified primary tooth has its own identifiable supernumerary number. This developed system can be found in the Current Dental Terminology (CDT) 2005 published by the ADA.
The Tooth Identifiers (TID) for each identified supernumerary tooth will be used for paper and electronic claims and can only be billed with the following codes:
• For primary supernumerary teeth only: D7111.
• For both primary and permanent teeth, the following codes are billable: D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7285, D7286, D7510.
For tooth numbers and the corresponding supernu-merary codes, please refer to the 2005 HCPCS Special Bulletin, or the 2005 CDT.
CSHCN Bulletin, No. 53 12 February 2005
Coding and Reimbursement
New Service Benefi ts
Procedure Code 68530
Eff ective for dates of service on and after November 17, 2004, procedure code 2-68530, Clearance of tear duct, is a benefi t of the CSHCN Program. It is paid at the conversion factor of 27.276 multiplied by the RVU of $6.98 (a total of $190.39).
Procedure Code 90655
Eff ective July 1, 2004, procedure code 90655, Flu vaccine, 6-35 mo, IM, is payable for the CSHCN Program with an allowable fee of $4.01. Providers giving this vaccine as part of a medical checkup or with vaccines obtained from the Texas Vaccines for Children (TVFC) Program should use procedure code 90749 (unlisted) with administration code 90471 or 90472. Claims for dates of service from July 1, 2004, through October 15, 2004, that included this procedure code were reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.
Procedure Codes G0104, G0105, G0106, and G120
Eff ective for dates of service on and after February 11, 2005, diagnosis range 5583–55830 is payable for the CSHCN Program for the following procedure codes:
• G0104, CA screen;fl exi sigmoidscope• G0105, Colerectal scrn; hi risk ind• G0106, Colon CA screen;barium
enema• G0120, Colon CA scrn; barium
enema
Procedure Code J0152
Procedure code J0152, Adenosine injection, became eff ective December 21, 2004, with
a retroactive date of service of July 1, 2004. Th e reimbursement rate is $46.43 per 30mg. Claims submitted with dates of service from July 1, 2004, through December 21, 2004, that include procedure code J0152 will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.
Procedure Codes J2353 and J2354
Eff ective for dates of service on or after January 1, 2005, procedure codes J2353, Octreotide injection, depot and J2354, Octreotide non-depot, are payable for the CSHCN Program with allowable fees of $85.98 per 1 mg and $4.07 per 25 mcg, respectively. Claims submitted with dates of service on or after January 1, 2005, that include procedure codes J2353 and J2354 will be processed and payments adjusted accordingly. No action on the part of the provider is necessary.
Procedure Code J9178
Eff ective July 1, 2004, procedure code J9178, Inj, epirubicin hcl, 2 mg, is payable for the CSHCN Program with an allowable fee of $23.49. Claims submitted with dates of service from July 1, 2004, through October 31, 2004, that included this procedure code were reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.
Procedure Code S0163
Eff ective for dates of service on or after November 17, 2004, procedure code S0163
is a benefi t of the CSHCN Program with an allowable fee of $124.23 for 12.5 mg. Th is drug is payable in place of service
(POS) 1 (offi ce) or POS 5 (outpatient hospital) and is only payable for diagnosis
codes 29500 through 29595.
For more information, call the CSHCN Contact Center at 1-800-568-2413.
November 17, 2004, procedure code 2-68530, Clearance of tear duct, is a benefi t of the CSHCN Program. It is paid at the conversion factor of 27.276
Claims for dates of service from July 1, 2004,
payments adjusted accordingly. No action on
code J0152 will be reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.
Procedure Codes J2353 and J2354
Eff ective for dates of service on or after January 1, 2005Octreotide injection, depot and J2354, Octreotide non-depot, are payable for the CSHCN Program with allowable fees of $85.98 per 1 mg and $4.07 per 25 mcg, respectively. Claims submitted with dates of service on or after January 1, 2005, that include procedure codes J2353 and J2354 will be processed and payments adjusted accordingly. No action on the part of the provider is necessary.
Procedure Code J9178
Eff ective July 1, 2004, procedure code J9178, Inj, epirubicin hcl, 2 mg, is payable for the CSHCN Program with an allowable fee of $23.49. Claims submitted with dates of service from July 1, 2004, through that included this procedure code were reprocessed and payments adjusted accordingly. No action on the part of the provider is No action on the part of the provider is necessary.
Procedure Code S0163
Eff ective for dates of service on or after
codes 29500 through 29595.
For more information, call the CSHCN Contact Center at 1-800-568-2413.
February 2005 13 CSHCN Bulletin, No. 53
Coding and Reimbursement
Updated Custom DME Manufacturers Listing
The list of manufacturers approved to provide custom durable medical equipment (DME) products has been updated since publication of the list in the November 2004 CSHCN Provider Bulletin, No. 52. Authorization, prior authorization, and/or claims submission will be considered for custom DME products produced by the manufac-turers appearing in the following list. Requests to add manufacturers will be accepted only when an approved manufacturer cannot meet the client’s need.
• Activeaid
• Adaptive Engineering Lab
• Adaptive Equipment Systems (AES) (Recently acquired by Sunrise Medical)
• Alimed Tempered Foam Cushions Medical
• Altimate Medical
• Anthros Medical
• Bodypoint Designs
• Britax
• Cascade Designs, Inc.
• Colours in Motion, Inc.
• Columbia Medical Manufacturing
• Convaid, Inc.
• Crown Therapeutics (Roho)
• Danmar Products, Inc.
• Embracing Concepts, Inc.
• Etac®
• Everest and Jennings (a.k.a. G F Health Products, Inc., d.b.a. Graham Fields)
• EZ-Access Modular Ramp Systems
• EZ International
• E-Z-On Products, Inc.
• Freedom Designs, Inc.
• Guardian Products (Sunrise Medical)
• Gunnell, Inc.
• Handi-Ramp
• Hoyer Lifts
• Invacare
• Jay Products
• Kaye Products, Inc.
• Kees Goebel Temper Foam®
• Kuschall® (Everest & Jennings)
• Lumex® (a.k.a. GF Health Products, Inc., d.b.a. Graham Fields)
• Matrix Seating (Invacare)
• MEYRA Wilhelm Meyer GmbH & Co Kg
• Mobility Plus
• Motion Concepts (Invacare)
• Mulholland Positions Systems
• Optiway Technology, Inc.
• Otto Bock®
• Permobile, Inc.
• Prairie Seating Corporation
• Prairie View Industries, Inc.
• Pride Mobility Products Corp.
• Prime Engineering, Inc.
• Quantum (Pride Mobility Products Corp.)
• RehabiliTech (Recently aquired by Sunrise Medical)
• Rifton Equipment
• Roho Cushions (Floatation)
• Sammons Preston Rolyan
• Snug Seat, Inc.
• Stealth Products, Inc.
• Sunrise Medical
• Supracor
• TherAdept Products, Inc.
• TiLite
• Tumbleform2® (Sammons Preston Rolyan)
• Varilite Manufacturer
• Whitmyer Biomechanix (Recently acquired by Sunrise Medical)
CSHCN Bulletin, No. 53 14 February 2005
Coding and Reimbursement
Emergency Information Form for Children With Special Needs
CSHCN Physician/Dentist Assessment Form (For Application to CSHCN)Please complete and sign this form for the person applying for the Children with Special Health Care Needs Program (CSHCN). If you need more copies or have questions, please refer to the instruction sheet or call 1-800-252-8023. Send the completed form to the parent/guardian or to the client’s local CSHCN office.
Name of Client/Applicant (Last, First, Middle): CSHCN Case No. (if known): Date of Birth:
Address (Street, City, State, Zip):
Parent/Guardian Name: Telephone No.: ( )
1) DIAGNOSIS AND EVALUATION SERVICES (screening exam): Is this a request for Diagnosis and Evaluation Services to determine whether the client/applicant has a chronic physical or developmental condition? (Please check the box.) � Yes Please indicate the appropriate V-Code: and go to the “Physician/Dentist Data” section
on the reverse side. (Only CSHCN-enrolled providers will be reimbursed for Diagnosis and Evaluation Services.)
� No Please complete the remainder of this form.
2) MEDICAL CERTIFICATION DEFINITION: The client/applicant must be either: 2a) A person younger than 21 years of age who has a chronic physical or developmental condition that:
• Will last or is expected to last for at least 12 months; and • Results or, if not treated, may result in limits to one or more major life activities; and • Requires health and related services of a type or amount beyond those required by children generally; and • Has a physical (body, bodily tissue or organ) manifestation; and • May exist with accompanying developmental, mental, behavioral, or emotional conditions; but • Is not solely a delay in intellectual development or solely a mental, behavioral, and/or emotional condition. OR
2b) A person of any age who has cystic fibrosis.
I certify that the client/applicant meets the above definition. � Yes � No
3) QUESTIONS FOR INITIAL APPLICATION TO CSHCN: (If renewing, go to the next section) Is the applicant’s condition a result of a traumatic injury or accident? � Yes � No If yes, date of trauma or accident? If hospitalized, date of discharge home? Date of admission to rehab. facility?
For applicants less than 1 year old: Was the child born before 36 weeks gestation? � Yes � No If yes, date of discharge home after birth? Has the child spent 14 consecutive days out of the hospital? � Yes � No
NOT VALID WITHOUT THE SIGNATURE OF A PHYSICIAN OR DENTIST ON PAGE 2
4) DETERMINATION OF URGENT NEED FOR SERVICES: 4a) Would an inability to get healthcare services cause a permanent increase in disability, intense pain or suffering, or
death? Please base your answer on what would happen if the applicant had no resources to pay for health care.� Yes � NoIf Yes, explanation required:
4b) Is the family or client/applicant actively planning to move the client/applicant to a nursing home, group home, or similar institution in the next 6 months?� Yes � No
If Yes, explanation required:
4c) If there is additional information related to the complexity or severity of the client’s/applicant’s condition or need for care that the CSHCN Program should know, please indicate below or attach additional narrative.
6) SERVICES NEEDED: Check all blocks that apply for services the client/applicant may require. Data is for CSHCN Program planning purposes and does not affect eligibility.
� bone marrow transplant � case management � dental services � drugs � durable medical equipment � expendable medical supplies� family support services � growth hormone
� help with drug co-payments� hemophilia blood factor products � home health/nursing services � inpatient hospital� Insurance Premium Payment Assistance � mental health services � outpatient services (including PT, OT & SLP) � physician services
� pulmozyme� renal dialysis/renal transplant � inhaled tobramycin � total parenteral nutrition� transportation/meals/lodging � vision services � other
7) PHYSICIAN/DENTIST DATA – Must Be Completed for All Applications Name of Physician/Dentist: (type or print) TPI#: Tax ID#: Specialty:
Complete this form and submit to update your provider files. Mail or fax the completed form or mail to the appropriate entity. PLEASE PRINT OR TYPE THE INFORMATION SUBMITTED ON THIS FORM.
Important: Must be signed and dated or changes cannot be completed.
Date:Nine-Character
Texas Provider Identifier (TPI):
If you have more than one TPI that will also use this same information, list the other TPIs:
Physical AddressCannot be a PO Box
Accounting/Mailing AddressW–9 Form Required
Secondary AddressPlan Use Only
Telephone Telephone Telephone
Fax Fax Fax
Type of Change: (please check the appropriate box below
� 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 (i.e., termination from plan, moved out of area, specialist, etc.). Please Explain:
� Other (i.e., panel closing, capacity changes, age acceptance, etc.)
Tax Information—IRS ID Number:Attach W–9
List the exact name reported to theIRS for the above Tax ID number:
PO Box 200795Austin, TX 78720-0795FAX: 1-512-514-4214
Office UseTMHP Representative: Date:
TO THE INDIVIDUAL FILLING THIS OUT:You have the right to ask us about this form. You also have the right to review the information you give us on the form. (There are a few exceptions). If the information is wrong, you can ask us to correct it. The Health and Human Services Commission has a method for asking for corrections. You can find it in Title 1 of the Texas Administrative Code, section §351.17 through §351.23. To talk to someone about this form or ask for corrections, please contact the Texas Medicaid & Healthcare Partnership Helpline at 1-800-925-9126.
February 2005 19 CSHCN Bulletin, No. 53
Forms
PLACE POSTAGE HERE
CSHCN Provider BulletinThe Children with Special Health Care Needs Program
