Bimonthly update to the Texas Medicaid Provider Procedures ManualT exas Medicaid BulletinBimonthly update to the Texas Medicaid Provider Procedures ManualT exas Medicaid Bulletin
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Mailing of Provider Bulletins to be EliminatedBeginning in July, TMHP will produce only electronic versions of its provider bulletins and discontinue printing and mailing of paper versions. These publications will be available for viewing and download on the TMHP website at www.tmhp.com.The last issue dates for paper publication of the affected bulletins are the July/August 2010 Texas Medicaid Bulletin, No. 230, August 2010 CSHCN Services Program Provider Bulletin, No. 75, and the August 2010 Long Term Care Provider Bulletin, No. 43.This cost containment initiative will eliminate the printing and mailing costs of the paper bulletins, reduce paper usage, and allow providers to access the bulletins sooner on the TMHP website.
Copyright AcknowledgmentsUse 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 2009 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.”
The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes:
Contact InformationFor additional information about Texas Medicaid, call the TMHP Contact Center at 1‑800‑925‑9126.
For additional information about Primary Care Case Management (PCCM) articles in this bulletin, call the PCCM Provider Helpline at 1‑888‑834‑7226.
For additional information about articles pertaining to the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP‑CSHCN Contact Center at 1‑800‑568‑2413.
2010 Texas Medicaid Provider Procedures Manual Available in MayThe 2010 Texas Medicaid Provider Procedures Manual was mailed to providers and is available on the TMHP website at www.tmhp.com. The manual has been redesigned to help providers access information more easily. Volume 1 of the manual contains general information that applies to all health‑care providers who are enrolled in Texas Medicaid and provide services to Texas Medicaid clients. The sections in Volume 1 include information about enrolling in Texas Medicaid, receiving appropriate reimbursement, and claim submissions and appeals for services provided. Volume 2 includes 11 services‑specific handbooks that cover Medicaid policies, procedures, and claims filing requirements for specific products or services. Volume 2 includes the following handbooks:
Ambulance Services Handbook
Behavioral Health, Rehabilitation, and Case Management Services Handbook
Children’s Services Handbook
Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook
Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook
Hospital Services Handbook
Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
Nursing and Therapy Services Handbook
Outpatient Services Handbook
Radiology, Laboratory, and Physiological Lab Services Handbook
Vision and Hearing Services Handbook
The 2010 Texas Medicaid Provider Procedures Manual was mailed to providers in compact disc (CD) format.
CPT only copyright 2009 American Medical Association. All rights reserved.
New Benefit Limitations for Obstetric UltrasoundsEffective for dates of service on or after July 1, 2010, benefit criteria for obstetric ultrasounds will change. As stated in the article posted on the TMHP website at www.tmhp.com on April 9, 2010, titled “New Benefit Limitations and Authorization Requirements for Obstetric Ultrasounds,” Medicaid fee‑for‑service and Primary Care Case Management (PCCM) clients will be limited to three obstetric ultrasounds per pregnancy. If it is medically necessary to perform more than three obstetrical ultrasounds on a client during one pregnancy, the provider must request prior authorization. The limitation also applies to clients who are pregnant on July 1, 2010, and any obstetric ultrasounds that were performed on these clients before July 1, 2010, will count toward the limit of three ultrasounds. To clarify, claims for dates of service prior to July 1, 2010, will not be impacted by this limitation, but will be counted when processing claims for dates of service on or after July 1, 2010. This limitation does not apply to obstetric ultrasound procedures that are rendered in the emergency room, outpatient observation, or inpatient hospital setting.
Authorization Requirements for Obstetric ultrasoundsTMHP will begin accepting prior authorization requests on July 1, 2010.A new Obstetric Ultrasound Prior Authorization Request Form has been created, and providers must use this form to request prior authorization for this service.The Obstetric Ultrasound Prior Authorization Request Form is available on page 75 of this bulletin. Requests for additional obstetric ultrasounds may be considered when the requests are submitted with documentation of medical necessity on the new Obstetric Ultrasound Prior Authorization Request Form. Texas Medicaid follows the American Congress of Obstetricians and Gynecologists (ACOG) indications for sonography.First trimester ultrasounds may be medically necessary for, but are not limited to, the following reasons:
To confirm the presence of an intrauterine pregnancy
To evaluate a suspected ectopic pregnancy
To evaluate vaginal bleeding
To evaluate pelvic pain
To estimate gestational age
To diagnose or evaluate multiple gestation
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To confirm cardiac activity
As an adjunct to chorionic villus sampling or localization and removal of an intrauterine device
To assess certain fetal anomalies, such as anencephaly, in clients at high risk
To evaluate maternal pelvic or adnexal masses or uterine abnormalities
To screen for fetal aneuploidy
To evaluate a suspected hydatidiform mole
Second and third trimester ultrasounds may be medically necessary for, but are not limited to, the following reasons:
To estimate fetal age
To evaluate fetal growth
To evaluate vaginal bleeding
To evaluate cervical insufficiency
To evaluate abdominal pelvic pain
To determine fetal presentation
As an adjunct to amniocentesis or other procedure
To evaluate suspected multiple gestation
To evaluate a significant discrepancy between uterine size and clinical dates
To evaluate a pelvic mass
To evaluate a suspected hydatidiform mole
As an adjunct to cervical cerclage placement
To evaluate a suspected ectopic pregnancy
To evaluate suspected fetal death
To evaluate suspected uterine abnormality
To evaluate fetal well‑being
To evaluate suspected amniotic fluid abnormalities
To evaluate suspected placental abruption
As an adjunct to external cephalic version
To evaluate premature rupture of membranes or premature labor
To evaluate abnormal biochemical markers
As a follow‑up evaluation of a fetal anomaly
As a follow‑up evaluation of placental location for suspected placenta previa
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Texas Medicaid Bulletin, No. 2303July/August 2010
All Providers
CPT only copyright 2009 American Medical Association. All rights reserved.
To evaluate clients with a history of previous congenital anomaly
To evaluate fetal condition in late registrants for prenatal care
To assess findings that may increase the risk of aneuploidy
To screen for fetal anomalies
Providers can submit requests for prior authorization or retroactive authorization by calling the Inpatient/Outpatient Prior Authorization line at 1‑888‑302‑6167, by fax at 1‑512‑302‑5039, online at www.tmhp.com, or by mailing to:
When requesting retroactive authorization, providers must submit the request no later than 14 calendar days beginning the day after the study is completed. The Obstetric Ultrasound Prior Authorization Request Form must be completed, signed, dated, and maintained in the client’s medical record by the provider ordering the test. The form must include information related to medical necessity of the test including all of the following:
Procedure code requested (CPT code) and quantity requested
The trimesters during which the requested ultrasounds will be performed
The date range during which the procedures will be performed
Client’s estimated date of confinement (EDC) at the time the request is submitted
Diagnosis
Additional documentation to support medical necessity may include any of the following:
Treatment history
Treatment plan
Medications
Previous imaging results
The Obstetric Ultrasound Prior Authorization Request Form must be completed, signed, and dated by the ordering provider when requesting prior authorization for obstetric ultrasounds regardless of the method of request
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for authorization. A physician, nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM), or physician assistant (PA) may sign the Obstetric Ultrasound Prior Authorization Request Form.The provider’s signature must be current, unaltered, original, and handwritten. A computerized or stamped signature or date will not be accepted.Residents may order obstetric ultrasounds; however, the attending physician must sign the authorization form and provide the group or supervising provider’s provider identifier.
Claims Filing and Reimbursement for Obstetric ultrasounds The following obstetric ultrasound procedure codes will require prior authorization when billed as an interpretation, technical, or total component and performed in the office or outpatient setting:
Obstetric ultrasound procedures, other than those listed above are not subject to the three per pregnancy limitation.Note: Add-on procedure codes (76802, 76810, 76812, and 76814) when billed with the primary procedure code for obstetric ultrasounds do not count toward the three per pregnancy limitation.Obstetric ultrasounds provided in the emergency department or during a hospital observation stay must be submitted with modifier U6 when submitted on the professional claim form in order to be considered for payment. Obstetric ultrasounds provided in the emergency department must be submitted with the appropriate corresponding emergency services revenue code in order to be considered for payment. Reimbursement for obstetric ultrasounds may be considered on appeal when submitted with documentation that indicates any one of the following:
Ultrasound was performed for a different pregnancy.
The provider was unable to obtain the previous ultrasound records from a different provider.
The provider was new to treating the client and was not aware the client had already had three obstetric ultrasounds.
CPT only copyright 2009 American Medical Association. All rights reserved.
Only one appeal will be considered per client for the same provider. Providers must obtain prior authorization for any additional obstetric ultrasound performed after the appealed service. The initial three claims paid for obstetric ultrasounds do not require prior authorization. Any obstetric ultrasound claims submitted with or without prior authorization for the initial three will count toward the three‑per‑pregnancy limit.As a reminder, radiology interpretations in any place of service and ultrasound interpretations in the inpatient hospital setting billed by the attending physician are denied if the attending physician’s specialty is any of the following:
Family Practice
Gynecology (D.O.)
OB/GYN (D.O.)
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CDC Recommends Temporary Suspension of Rotavirus Vaccine
The Centers for Disease Control and Prevention (CDC) has recommended temporarily suspending the usage of the GlaxoSmithKline rotavirus vaccine, Rotarix. The Texas Vaccines for Children (TVFC) program is not currently offering this product. Providers that have existing inventories of Rotarix from TVFC or elsewhere should adhere to the CDC recommendations and temporarily suspend the use of Rotarix. The US Food and Drug Administration (FDA) has learned that DNA from porcine circovirus type 1 (PCV1) is present in the Rotarix vaccine. GlaxoSmithKline reported this finding to the FDA on March 15, 2010, based on work that was originally performed by an academic research team using a novel technique to look for viruses. There is no evidence at this time that this finding indicates a safety risk.While the FDA is learning more about the vaccine, the FDA recommends that providers temporarily suspend the use of Rotarix. The recommenda‑tion applies to all lots of Rotarix. Providers may keep their stock of Rotarix until additional recommendations are made by the FDA.The Merck rotavirus vaccine RotaTeq is available for rotavirus immunization during this period. For clients who have already received one dose of Rotarix, the CDC advises providers to complete the series using RotaTeq for the two remaining doses.Since RotaTeq was licensed in 2006 and Rotarix in 2008, most of the clients who have been vaccinated in the United States received RotaTeq.Providers who suspect adverse events following a Rotarix vaccination are asked to report them to the Vaccine Adverse Event Reporting System (VAERS) at 1‑800‑822‑7967 or online at http://vaers.hhs.gov.The FDA will provide frequent updates to patients, providers, and the general public as its information about Rotarix improves. The FDA is convening a committee to investigate this issue and will provide further recommendations on the use of the vaccine.Additional information about Rotarix is available at www.fda.gov.
First Quarter 2010 HCPCS Procedure Code AdditionsThe first quarter 2010 Healthcare Common Procedure Coding System (HCPCS) additions and changes are now available. Effective April 1, 2010, for dates of service on or after January 1, 2010, the following procedure codes were added and do not replace existing procedure codes:
Procedure Code
Medicaid Allowable
CSHCN Services Program Allowable
G0428 NC NCG0429 NC NC(NC) Not covered.
Modifier ChangesEffective April 1, 2010, for dates of service on or after April 1, 2010, the following changes apply to modifiers:
Modifier GX was added.
The descriptions for modifiers GA, RA, and RB have been revised. Providers can refer to the appropriate copyright holder for the revised descriptions.
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Texas Medicaid Bulletin, No. 2305July/August 2010
All Providers
CPT only copyright 2009 American Medical Association. All rights reserved.
Navigation on the TMHP Secure Portal Pages Has ChangedEffective June 11, 2010, the web pages on the secure portal portion of the TMHP website at www.tmhp.com no longer have navigation links to specific web pages on the public portion of the website. To return to the home page of the website from the secure portal, providers must click the TMHP.com link on the left side of the page. The navigation on the secure portal portion of the TMHP website is similar to navigation in the TexMedConnect application. The following screen shot shows the location of the new link to the home page of the TMHP website.
In May 2010, TMHP mailed letters to inpatient diagnosis‑related group (DRG) hospital providers. Each letter contains the preliminary full payment division standard dollar amounts (PDSDA). The preliminary PDSDA is used to determine the final PDSDA that will be effective for admissions on or after September 1, 2010. The preliminary PDSDA will be reduced to comply with the 2010-2011 General Appropriations Act (Article II, Health and Human Services Commission, Rider 68, S.B. 1, 81st Legislature, Regular Session, 2009).
This legislation requires HHSC to update the PDSDA amounts so that they are proportionate to the available state funds, as well as recompute the DRG statistics used to reimburse acute care hospitals.The letters also contain information about the proposed changes to the PDSDA and DRG statistics for state fiscal year 2011. TMHP sent the letters to the attention of the administrator or chief financial officer at the mailing address on file.
Initial Standard Dollar Amount Letters Mailed May 2010
CPT only copyright 2009 American Medical Association. All rights reserved.
June 2010 Texas Medicaid Procedure Code UpdatesEffective for dates of service on or after June 1, 2010, provider type and place‑of‑service (POS) limitations have changed for the following Texas Medicaid services: ambulatory electroencephalogram, blepharoplasty procedures, injections—iron, rhinoplasty, and male genital, female genital, and auditory procedures.
Ambulatory ElectroencephalogramBenefit changes apply to the following ambulatory electroencephalogram procedure codes:
Procedure Codes Changes95950, 95956
Total component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers.Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.Services rendered in the office setting are no longer reimbursed to portable X‑ray supplier and radiological and physiological laboratory providers. Professional interpretation component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers.
95951, 95953
Total component: Services rendered in the office or inpatient hospital setting are no longer reimbursed to independent laboratory, CNM, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray, radiological and physiological laboratory, and hospital‑based rural health clinic (RHC) providers.Services rendered in the outpatient hospital setting are no longer reimbursed to independent laboratory, CNM, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, and hospital‑based RHC providers.
Procedure Codes Changes(continued) 95951, 95953
(continued)Services rendered in the independent laboratory setting are no longer reimbursed.Professional interpretation component: Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM, portable X‑ray supplier, and radiological and physiological laboratory providers.Services rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers.Technical component: Services rendered in the office setting are no longer reimbursed to CNM and radiation treatment center providers.Services rendered in the home, skilled nursing facility (SNF), intermediate care facility (ICF), independent laboratory, or extended care facility (ECF) setting are no longer reimbursed.
Blepharoplasty ProceduresBenefit changes apply to the following blepharoplasty procedure codes:
Procedure Codes Changes15820, 15821
Surgical component: Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.
Surgical component: Services rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers.Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers.
67916, 67923
Surgical component: Services rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to dentist providers.
Texas Medicaid Bulletin, No. 2307July/August 2010
All Providers
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Codes Changes67917, 67924, 67961
Surgical component: Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to dentist providers.
67973, 67974
Surgical component: Services rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers.Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, and PA providers.Assistant surgery component: The assistant surgery component is now a benefit, and services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, PA, and physician providers.
Providers may refer to the 2009 Texas Medicaid Provider Procedures Manual section 36.4.31.2, “Blepharoplasty Procedures,” on page 36‑82, for more information.
Injections—IronBenefit changes apply to the following iron injection procedure codes:
Procedure Codes ChangesJ1750 Services rendered in the outpatient
hospital setting may be reimbursed to nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers.
J1756, J2916
Services rendered in the office setting are no longer reimbursed to CNM providers. Services rendered in the office setting may be reimbursed to nephrology (hemodialysis, renal dialysis) providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.
RhinoplastyBenefit changes apply to the following rhinoplasty procedure codes:
Procedure Codes New Settings to Be Reimbursed30400, 30420, 30435, 30465
Surgical component: Services rendered in the office setting may be reimbursed to NP, CNS, PA, physician, and dentist providers.
Procedure Codes New Settings to Be Reimbursed(continued) 30400, 30420, 30435, 30465
(continued) Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.
30410, 30430, 30450
Surgical component: Services rendered in the office setting may be reimbursed to NP, CNS, PA, physician, and dentist providers.Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.Assistant surgery component: The assistant surgery component is now a benefit, and services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, PA, physician, and dentist providers.
30460, 30462
Surgical component: Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to dentist providers.Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM providers.Services rendered in the office setting are no longer reimbursed.Assistant surgery component: The assistant surgery component is now a benefit, and services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to NP, CNS, PA, physician, and dentist providers.
In the following table, the procedure codes in Column A will be denied if billed with the same date of service by the same provider as procedure codes in Column B:
CPT only copyright 2009 American Medical Association. All rights reserved.
The following reimbursement rates apply to the new assistant surgery benefits:
Procedure Code Age Rate30410 Birth through 20 years of age $141.2030410 21 years of age or older $134.4730430 Birth through 20 years of age $103.6830430 21 years of age or older $98.7430450 Birth through 20 years of age $182.7230450 21 years of age or older $174.0230460 Birth through 20 years of age $88.5030460 21 years of age or older $84.2830462 Birth through 20 years of age $179.0030462 21 years of age or older $170.48
Male genital, Female genital, and Auditory Procedure Code updatesThe assistant surgery component of the following procedure codes are now benefits and may be reimbursed to NP, CNS, PA, and physician providers for services rendered in the inpatient hospital or outpatient hospital setting:
Procedure Codes Ages Rate54110 Birth through 20 years of age $81.9154110 21 years of age or older $78.0154111 Birth through 20 years of age $105.4054111 21 years of age or older $100.3854112 Birth through 20 years of age $123.7254112 21 years of age or older $117.8354115 Birth through 20 years of age $55.2854115 21 years of age or older $52.6454205 Birth through 20 years of age $70.1754205 21 years of age or older $66.8354360 Birth through 20 years of age $95.6654360 21 years of age or older $91.1054440 Birth through 20 years of age $240.0054440 21 years of age or older $240.0054522 Birth through 20 years of age $75.9054522 21 years of age or older $72.2854680 Birth through 20 years of age $102.2454680 21 years of age or older $97.3855400 Birth through 20 years of age $65.87
* Family planning clinic providers reimbursement
Procedure Codes Ages Rate55400 21 years of age or older $62.7355520 Birth through 20 years of age $53.2755520 21 years of age or older $50.7355650 Birth through 20 years of age $93.6555650 21 years of age or older $89.1955720 Birth through 20 years of age $59.2855720 21 years of age or older $56.4656700 Birth through 20 years of age $22.9156700 21 years of age or older $21.8256800 Birth through 20 years of age $30.0756800 21 years of age or older $28.6456810 Birth through 20 years of age $32.3656810 21 years of age or older $30.8257200 Birth through 20 years of age $36.6657200 21 years of age or older $34.9157267 Birth through 20 years of age $32.9457267 21 years of age or older $31.3757289 Birth through 20 years of age $93.0857289 21 years of age or older $88.6557291 Birth through 20 years of age $67.0257291 21 years of age or older $63.8357545 Birth through 20 years of age $101.9657545 21 years of age or older $97.1057720 Birth through 20 years of age $37.8057720 21 years of age or older $36.0058660 Birth through 20 years of age $83.3458660 21 years of age or older $79.3758660* All ages $78.6458662 Birth through 20 years of age $87.6458662 21 years of age or older $83.4658662* All ages $80.0058820 Birth through 20 years of age $38.6658820 21 years of age or older $36.8269320 Birth through 20 years of age $184.4469320 21 years of age or older $175.6669530 Birth through 20 years of age $200.1969530 21 years of age or older $190.6669550 Birth through 20 years of age $124.8769550 21 years of age or older $118.9269605 Birth through 20 years of age $188.74
* Family planning clinic providers reimbursement
Texas Medicaid Bulletin, No. 2309July/August 2010
All Providers
CPT only copyright 2009 American Medical Association. All rights reserved.
Scheduled System Maintenance
System maintenance for the TMHP claims processing system is scheduled as follows:
Sunday, July 16, 2010, from 6:00 p.m. until midnight.
Sunday, August 13, 2010, from 6:00 p.m. until midnight.
During scheduled system maintenance, some applications related to the claims engine will be unavailable. Details about the affected applications are available on the TMHP website at www.tmhp.com.
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Procedure Codes Ages Rate69605 21 years of age or older $179.7569670 Birth through 20 years of age $113.7069670 21 years of age or older $108.2969725 Birth through 20 years of age $230.5569725 21 years of age or older $219.5769802 Birth through 20 years of age $126.0269802 21 years of age or older $120.0169805 Birth through 20 years of age $128.3169805 21 years of age or older $122.2069820 Birth through 20 years of age $103.9669820 21 years of age or older $99.0169840 Birth through 20 years of age $108.5569840 21 years of age or older $103.38
* Family planning clinic providers reimbursement
Procedure code 55400 may also be reimbursed to NP, CNS, PA, and physician providers for services rendered in the office setting.
Maximum Number of Units on Claim DetailsProviders who submit a claim with more than 9,999 units must bill 9,999 units on the first detail of the claim and any additional units on separate details. For example, 20,000 units would require three claim details—two of the details would indicate 9,999 units, and the third detail would indicate the remaining 2 units.
Medicaid Fee-For-Service Prior Authorization Requirements ChangeEffective for dates of service on or after June 1, 2010, the following procedure codes no longer require prior authorization for Medicaid fee‑for‑service clients:
CPT only copyright 2009 American Medical Association. All rights reserved.
February 2010 Drug Procedure Code UpdatesEffective for dates of service on or after February 1, 2010, some provider type and place‑of‑service changes were applied to some drug procedure codes. The following changes were applied to the procedure codes indicated:
Procedure Code ChangesJ0128, J0180, J1457, J1931
Services rendered in the office setting are no longer reimbursed to CNM or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.
J0130, J0395
Services rendered in the office setting may be reimbursed to physician providers. Services rendered in the inpatient hospital setting are no longer reimbursed.Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.
The following changes apply to the procedure codes in Table A:
Services rendered in the office setting are no longer reimbursed to certified registered nurse‑anesthetist (CRNA), case management, Comprehensive Care Program (CCP) social worker, optometrist, chiropractor, psychologist, podiatrist, CNM, physical therapist, occupational therapist, audiologist, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
Services rendered in the home setting are no longer reimbursed.
Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, ASC, medical supply company, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
The following changes were applied to the procedure codes indicated:
Procedure Code ChangesJ0133 Services rendered in the office setting
are no longer reimbursed to CRNA, case management, CCP social worker, optometrist, chiropractor, psychologist, podiatrist, physical therapist, occupational therapist, audiologist, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, ASC, medical supply company, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J0150, J1245, J1250
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ0152 Services rendered in the office setting
may be reimbursed to NP, CNS, and PA providers.Services rendered in the inpatient hospital setting are no longer reimbursed.Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.
The following changes apply to the procedure codes in Table B:
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
Services rendered in the ECF setting are no longer reimbursed.
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting may be reimbursed to hospitals.Services rendered in the ECF setting are no longer reimbursed.
J0278 Services rendered in the office setting are no longer reimbursed to CRNA, case management, CCP social worker, optometrist, chiropractor, psychologist, physical therapist, occupational therapist, audiologist, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code Changes(continued)J0278
(continued) Services rendered in the home setting are no longer reimbursed. Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, ASC, medical supply company, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J0282 Services rendered in the office setting are no longer reimbursed to CNM, hospital, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
J0287, J0288, J0289
Services rendered in the office setting are no longer reimbursed to CNM providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, or CNM providers.Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.
J0348, J0594, J0894, J1324, J2248, J2315, J9261
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, federally qualified health center (FQHC), family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, FQHC, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J0364 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
The following change applies to the procedure codes in Table C:Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
The following changes were applied to the procedure codes indicated:Procedure Code ChangesJ0456 Services rendered in the office setting are
no longer reimbursed to podiatrist, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.
J0476 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the inpatient hospital, skilled nursing facility (SNF), intermediate care facility (ICF), or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J0583, J1335, J2185, J3411
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
(continued) Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the SNF, ICF, or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting may be reimbursed to hospitals.
J0587 Services rendered in the office setting are no longer reimbursed to hospital or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J0592, J0637
Services rendered in the office setting are no longer reimbursed to CNM providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, or CNM providers.Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.
J0595 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
Procedure Code Changes(continued)J0595
(continued) Services rendered in the SNF, ICF, or ECF setting are no longer reimbursed. Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), or renal dialysis facility providers.
J0636 Services rendered in the office setting are no longer reimbursed to CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J0706 Services rendered in the office setting are no longer reimbursed to CNM, hospital, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, CNM, or hospital‑based RHC providers.
J0713 Services rendered in the office setting are no longer reimbursed to DME medical supplier, radiation treatment center, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the office setting are no longer reimbursed to dentist providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
Services rendered in the office setting are no longer reimbursed to CNM, hospital, or hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
J0795 Services rendered in the office setting are no longer reimbursed to CNM or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
J0835, J1327, J1620, J9310
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J0878 Services rendered in the office setting are no longer reimbursed to chiropractor, hospital, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, chiropractor, or hospital‑based RHC providers.
J1000, J2675
Services rendered in the office setting are no longer reimbursed to hospital or hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
Procedure Code ChangesJ1051 Services rendered in the office setting may
be reimbursed to CNM providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
J1055 Services rendered in the office setting are no longer reimbursed to DME medical supplier, FQHC, or hospital providers.Services rendered in the inpatient hospital setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to FQHC or hospital‑based RHC providers.
J1120, J3070
Services rendered in the office setting are no longer reimbursed to dentist, podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, dentist, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J1270 Services rendered in the office setting are no longer reimbursed to podiatrist providers.Services rendered in the outpatient hospital setting are no longer reimbursed to nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ1438, J2780
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J1458 Services rendered in the inpatient hospital setting are no longer reimbursed.
J1590 Services rendered in the office setting are no longer reimbursed to CNM providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
J1645, J1650, J1652
Services rendered in the home or extended care facility (ECF) setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, or physician providers.
J1740 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, family planning clinic, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.
Procedure Code Changes(continued)J1740
(continued)Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, FQHC, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J1745 Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J1950, J9217
Services rendered in the office setting are no longer reimbursed to CNM, radiation treatment center, FQHC, hospital, or RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, FQHC, or RHC providers.
J1956, J2321, J2322
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ2210 Services rendered in the office setting are
no longer reimbursed to podiatrist, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J2260 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
Procedure Code ChangesJ2270, J2275, J2795
Services rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J2278, J2503, J2504
Services rendered in the office setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, or hospital‑based RHC providers.
J2320 Services rendered in the office setting are no longer reimbursed to dentist, podiatrist, CNM, durable medical equipment (DME) medical supplier, radiation treatment center, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, dentist, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to dentist, radiation treatment center, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ2325 Services rendered in the office setting
are no longer reimbursed to podiatrist or CNM providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, or CNM providers.Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.Services rendered in the ECF setting are no longer reimbursed.
J2353, J2354
Services rendered in the office setting are no longer reimbursed to radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J2469 Services rendered in the office setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the office setting are no longer reimbursed to NP, CNS, or PA providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), or hospital‑based RHC providers.
J2501 Services rendered in the office setting are no longer reimbursed to podiatrist or CNM providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
Procedure Code ChangesJ2680, J2794
Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, and physician providers.
J2724 Services rendered in the office setting may be reimbursed to physician providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based rural health clinic (RHC) providers.
J2788, J3315, J3487
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, or radiation treatment center providers.Services rendered in the outpatient hospital setting are no longer reimbursed to nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J2993, J2997, J3364
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.
J3030 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ3110 Services rendered in the office setting are
no longer reimbursed to CNM or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center providers.
J3243 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, FQHC, family planning clinic, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, FQHC, or hospital‑based RHC providers.
J3246, J9041, J9055, J9305
Services rendered in the office setting are no longer reimbursed to CNM or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J3365 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers. Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J3396 Services rendered in the office setting are no longer reimbursed to CNM or hospital‑based RHC providers.
Procedure Code ChangesJ3473 Services rendered in the office setting
are no longer reimbursed to podiatrist or CNM providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J7311 Services rendered in the office setting may be reimbursed to NP, CNS, PA, and physician providers. Services rendered in the inpatient hospital setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to ambulatory surgical center (ASC) providers.
J7611, J7612, J7613, J7614
Services rendered in the office setting are no longer reimbursed to radiation treatment center providers.Services rendered in the home or ECF setting are no longer reimbursed. Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J7674 Services rendered in the office setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ7699, J7799
Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers. Services rendered in the SNF, ICF, or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
J9001 Services rendered in the office setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.
J9025 Services rendered in the office setting are no longer reimbursed to hospital‑based RHC, optometrist, chiropractor, podiatrist, psychologist, or physical therapy providers.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, or hospital‑based RHC providers.
Procedure Code ChangesJ9035 Services rendered in the office setting are
no longer reimbursed to hospital‑based RHC providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.
J9160, J9178
Services rendered in the office setting are no longer reimbursed to hospital or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.
J9201 Services rendered in the office setting are no longer reimbursed to CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting may be reimbursed to hospitals.Services rendered in the ECF setting are no longer reimbursed.
J9218 Services rendered in the office setting are no longer reimbursed to CNM, radiation treatment center, FQHC, or RHC providers.Services rendered in the outpatient hospital setting may be reimbursed to hospitals.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code ChangesJ9219 Services rendered in the office setting
are no longer reimbursed to radiation treatment center, FQHC, hospital, or RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center, FQHC, or RHC providers.
J9265 Services rendered in the office setting are no longer reimbursed to radiation treatment center, hospital, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to radiation treatment center or hospital‑based RHC providers.
J9355 Services rendered in the office setting are no longer reimbursed to CNM, hospital, renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home or ECF setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.
J9357 Services rendered in the office setting are no longer reimbursed to podiatrist, DME medical supplier, hospital, or hospital‑based RHC providers.Services rendered in the office setting may be reimbursed to NP, CNS, and PA providers.Services rendered in the home setting are no longer reimbursed to physician, podiatrist, hospital, or hospital‑based RHC providers.Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
Procedure Code ChangesJ9600 Services rendered in the office setting
are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the home setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers. Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, DME medical supplier, radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the ECF setting are no longer reimbursed.
J9999 Services rendered in the office setting are no longer reimbursed to podiatrist, CNM, DME medical supplier, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.Services rendered in the inpatient hospital setting are no longer reimbursed.Services rendered in the outpatient hospital setting are no longer reimbursed to NP, CNS, PA, physician, podiatrist, CNM, DME medical supplier, radiation treatment center, nephrology (hemodialysis, renal dialysis), renal dialysis facility, or hospital‑based RHC providers.
CPT only copyright 2009 American Medical Association. All rights reserved.
Changes to Reimbursement Rates for Clinical Laboratory Procedure CodesEffective for dates of service on or after April 1, 2010, the reimbursement rates for clinical laboratory procedure codes changed. The following procedure codes are effective for dates of service on or after April 1, 2010:
CPT only copyright 2009 American Medical Association. All rights reserved.
The Texas Health and Human Services Commission (HHSC) Office of
e‑Health Coordination invites providers to learn about several new Medicaid Health
Information Technology (HIT) initiatives: The Medicaid Eligibility and Health Information System (EHIS).
Health Information Exchange (HIE) pilots.
Electronic prescribing.
Electronic Health Record (EHR) incentive payments to providers.
HHSC is developing a state health information technology plan using federal stimulus funding approved by the Centers for Medicare and Medicaid Services (CMS). The final plan will be a blueprint for
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the Texas Medicaid health information network that will encompass all health information technology initiatives and involve providers throughout Texas.Visit the HHSC website at www.hhsc.state.tx.us for an overview of the initiatives and information about the Health Information Exchange Advisory Committee. From the side bar on the home page, click these headings: About HHSC/Advisory Committees/Health Information Exchange System. This is the first in a series of articles about the HIT initiatives. Future updates will include more specifics about each project, including status reports and links to useful information. Providers are welcome to submit questions or comments about HIT by e‑mail. Visit www.tmhp.com. Scroll to E‑mail the Contact Center on the menu on the right side of the screen.
Invitation to Learn About Health Information Technology Initiatives
HIT
Initiatives
Age Increase for HPV for MalesEffective for dates of service on or after April 1, 2010, the Human Papillomavirus (HPV) vaccine procedure code 90649 is a benefit of Texas Medicaid for males 9 through 26 years of age.The HPV vaccine is available now through the Texas Vaccines for Children (TVFC) Program for clients 9 through 18 years of age. For clients who are 9 through 18 years of age, providers may be reimbursed the administration fee for the HPV vaccine by billing the appropriate administration procedure code. Procedure code 90649, which is processed as informational, and must be included on the claim to receive reimbursement for the administration.For clients who are 19 through 26 years of age, the provider may be reimbursed for the vaccine, procedure code 90649 and the administration fee.
Prior Authorization Required for Procedure Code 77421Reminder: Procedure code 77421 requires prior authorization. For more information about prior authorization for radiation therapy procedures, providers can refer to the 2009 Texas Medicaid Provider Procedures Manual, section 36.4.45.8, “Stereotactic Radiosurgery,” on page 36‑122.
Personal Care Services BenefitReminder: Personal Care Services (PCS) are a benefit
of the CCP for Texas Medicaid clients who are birth through 20 years of age and who are not inpatients or residents of a hospital that is in a nursing facility, an
intermediate care facility for persons with mental retardation (ICF‑MR), or an institution for
mental disease. Providers cannot submit PCS claims for dates of service that occur during a client’s stay in the hospital. PCS claims will be eligible for recoupment if the date of service
CPT only copyright 2009 American Medical Association. All rights reserved.
Benefit Changes for Texas Medicaid Mastectomy and Breast Reconstruction ServicesEffective for dates of service on or after June 1, 2010, some benefits will change for Texas Medicaid mastectomy and breast reconstruction services including the addition of prophylactic mastectomy benefits, new procedure codes for breast reconstruction and breast prostheses, and authorization requirements. Mastectomy and breast reconstruction procedures are benefits of Texas Medicaid for male or female clients. These procedures are to be individualized, specific, and not in excess of the client’s needs.Mastectomy and breast reconstruction procedures may be reimbursed when the procedures are consistent with confirmed diagnosis of illness or injury under treatment or with appropriate personal history. Mastectomy and breast reconstruction procedures may be reimbursed without prior authorization for services rendered to clients who are 18 years of age or older when the procedures meet the criteria outlined below and are billed with the following diagnosis codes:
*Diagnosis codes V103, V163, V4571, and V8401 may be billed only with breast reconstruction procedures and simple, subcuta‑neous, radical, and modified radical mastectomy procedures.
The physician must maintain documentation of medical necessity in the client’s medical record. Services are subject to retrospective review.Mastectomy and breast reconstruction procedure codes will no longer be reimbursed when submitted with diagnosis codes 61183, 6120, or 6121.Important: Prior authorization is required for mastectomy and prophylactic mastectomy services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.
MastectomyPartial mastectomy procedure codes 19301 and 19302 may be reimbursed by Texas Medicaid for services rendered to male or female clients of any age when the services are billed with an appropriate diagnosis code.
For clients with a diagnosis of cancer, procedure codes 19301 and 19302 may be reimbursed for more than 2 services rendered per lifetime.The following simple, subcutaneous, radical, and modified radical mastectomy procedure codes may be reimbursed by Texas Medicaid:
Procedure Codes
19303 19304 19305 19306 19307
Procedure codes 19303, 19304, 19305, 19306, and 19307 may be reimbursed for services rendered to male or female clients who are 18 years of age or older when the services are billed with an appropriate diagnosis code. Prior authorization is required for services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.Procedure codes 19303, 19304, 19305, 19306, and 19307 may be reimbursed for 2 services rendered per lifetime.
Prophylactic MastectomyProphylactic mastectomy is the removal of the breast to prevent the development of cancer. This procedure is a benefit of Texas Medicaid for clients who are 18 years of age or older and who are at moderate‑to‑high risk for the development of breast cancer. Prior authorization is required for services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.Moderate‑risk to high‑risk clients are those who meet one or more of the following criteria:
Presence of a breast cancer 1 (BRCA1) or a breast cancer 2 (BRCA2) genetic mutation
Presence of lesions associated with an increased risk of cancer, such as atypical hyperplasia or lobular carcinoma in situ (LCIS)
Diagnosis of breast cancer in one breast
Documentation that supports medical necessity for the procedure must be maintained in the client’s medical record and must include the following:
Documentation that the client is moderate‑to‑high risk.
CPT only copyright 2009 American Medical Association. All rights reserved.
Documentation that, as a candidate for prophylactic mastectomy, the client has undergone counseling regarding cancer risks. Counseling must include assessment of all of the following:
The client’s ability to understand the risks and long‑term implications of the surgical procedure.
The client’s informed choice to proceed with the surgical procedure.
All documentation is subject to retrospective review.
Breast ReconstructionBreast reconstruction includes the following:
Creation of a new mound.
Reconstruction of the nipple or areola, which is accomplished with small flaps for the nipple and either tattooing or a skin graft for the areola. Nipple‑areola pigmentation, commonly known as medical tattooing, is the final stage of breast reconstruction surgery.
Breast reconstruction may also include the following, in order to establish symmetry with the contralateral breast:
Reduction mammaplasty
Mastopexy
Augmentation
Breast implants, tissue flaps, or both are surgically placed in the area where natural tissue has been removed.Breast reconstruction is performed in order to correct or repair abnormal structures of the breast caused by any of the following:
Tumor or disease (e.g. following a primary mastectomy procedure in order to establish symmetry with a contralateral breast or following bilateral mastectomy)
Congenital defect
Developmental abnormality
Infection
Trauma to the chest wall
Breast reconstruction may be based on the type of treatment a client receives or on the extent of surgery performed. The reconstructive surgery may be performed in a single stage or several stages and may occur during or after the initial surgical procedure.Breast reconstruction following a medically necessary mastectomy is a benefit of Texas Medicaid when all of the following criteria are met:
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The client is eligible for Texas Medicaid at the time of the breast reconstruction.
The client has a documented history of a mastectomy performed while eligible for Texas Medicaid and has one of the diagnoses listed previously. Note: Prior authorization is required for breast recon-struction service rendered to clients that do not have an established history of mastectomy procedures reimbursed by Texas Medicaid for the client.
The client meets age and sex criteria for the requested procedure as outlined above.
The physician has documented a plan in the client’s chart that addresses the recommended breast reconstruction.
The following breast reconstruction procedure codes may be reimbursed for services rendered to clients who are 18 years of age or older:
Procedure Codes
11920 11921 11922 19316* 19324*19325* 19340* 19342* 19350 1935519357* 19361 19364 19366 1936719368 19369 19396* S2068* Procedure codes 19316, 19324, 19325, 19340, 19342, 19357, and 19396 may be reimbursed for services rendered to female clients only. Prior authorization is required for services rendered to male clients.
Prior authorization is required for services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.For clients with a diagnosis of cancer, the following procedure codes may be reimbursed for more than two services rendered per lifetime:
The following procedure codes may be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed for the client by Texas Medicaid:
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Prior authorization is required for breast reconstruction service rendered to clients that do not have an established history of mastectomy procedures reimbursed by Texas Medicaid for the client.The following procedure codes are benefits of Texas Medicaid:
The surgical component may be reimbursed to physician providers for services rendered in the office, inpatient hospital, or outpatient hospital setting. Two services rendered per lifetime may be reimbursed.May be reimbursed if a breast reconstruction (procedure code 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, or S2068) has been reimbursed by Texas Medicaid within the 12 months. Prior authorization is required for service rendered to clients that do not have an established history of breast reconstruction procedures reimbursed by Texas Medicaid for the client.Procedure code 11922 must be billed with procedure code 11920 or 11921.
19316, 19396
The surgical and assistant surgery components may be reimbursed to physicians for services rendered in the inpatient hospital setting and to ambulatory surgical centers for services rendered in the outpatient hospital setting.May be reimbursed for services rendered to female clients only. Prior authorization is required for services rendered to male clients.May be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed by Texas Medicaid within the client’s lifetime.
19324, 19325, 19355
The surgical component may be reimbursed to physician providers for services rendered in the inpatient hospital setting and to ASC providers for services rendered in the outpatient hospital setting.
(continued)Procedure codes 19324 and 19325 may be reimbursed for services rendered to female clients only. Prior authorization is required for services rendered to male clients.May be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed by Texas Medicaid within the client’s lifetime. Prior authorization is required for service rendered to clients that do not have an established history of mastectomy procedures reimbursed by Texas Medicaid for the client.
Reimbursement Rates for New BenefitsThe following rates apply to the new mastectomy and breast reconstruction procedure codes:
Type of Service
Procedure Code Reimbursement Rate
2 11920 $82.372 11921 $97.102 11922 $22.092 19316 $552.078 19316 $88.37F 19316 Group 92 19324 $343.68F 19324 Group 92 19325 $457.69F 19325 Group 92 19355 $406.69F 19355 Group 92 19396 $96.288 19396 $15.27F 19396 Group 9
Tattooing to Correct Color Defects of the SkinTattooing to correct color defects of the skin (procedure codes 11920, 11921, and 11922) is limited to clients with a documented history of a breast reconstruction performed within the past 12 months. The breast reconstruction must have been performed while the client was eligible for Texas Medicaid. Prior authorization is required for tattooing services for clients that do not have an established history.
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Treatment for Complications of Breast ReconstructionThe treatment of complications related to breast reconstruction may be reimbursed using procedure codes 19370, 19371, and 19380 when all of the following criteria are met:
The client is eligible for the Texas Medicaid breast reconstruction benefit when the complications occur.
The client is 18 years of age or older at the time the services are rendered.
A breast reconstruction (procedure code 19316, 19324, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, or S2068) has been reimbursed for the client by Texas Medicaid.
Procedure codes 19370 and 19371 may be reimbursed for services rendered to female clients only.Prior authorization is required for services rendered to clients who do not have an established history of related services reimbursed for the client by Texas Medicaid or for clients who do not meet the age and gender criteria indicated in this article.
External Breast ProsthesesExternal breast prostheses are benefits when provided by a licensed prosthetist or orthotist to clients with a history of a medically necessary mastectomy procedure. The following procedure codes may be reimbursed for external breast prostheses services rendered to female clients of any age:
Procedure codes L8001, L8010, L8020, L8030, L8031, and L8032 must be submitted with modifier LT or RT indicating the location for the breast prosthesis.The external breast prosthesis procedure codes are limited as follows:
Procedure Code limitationL8000 4 per rolling year
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Procedure Code limitationL8001 4 per rolling year
Note: If more than 4 unilateral mastectomy bras are required per rolling year, prior authorization may be requested for the additional items. If a second mastectomy is performed within the same year, the bilateral procedure code must be used for the necessary mastectomy bra.
L8002 4 per rolling yearL8010 8 total per rolling year (regardless
of modifier)L8015 2 per lifetimeL8020 1 total per 6 rolling months (regardless
of modifier)L8030 1 total per 2 rolling years (regardless
of modifier)L8031 1 total per 2 rolling years (regardless
of modifier)L8032 8 total per rolling yearL8035 Prior authorization requiredL8039 Prior authorization required
The following procedure codes may be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed for the client by Texas Medicaid:
Prior authorization is required for the initial prosthesis for clients who do not have an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.Prior authorization is required for the replacement of external breast prosthesis as follows:
If the external breast prosthesis is lost or irreparably damaged, prosthesis of the same type may be prior authorized at any time.
If the external breast prosthesis is needed due to a change in the client’s medical condition, prosthesis of a different type may be prior authorized at any time.
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Noncovered ServicesThe following services are not benefits of Texas Medicaid:
Mastectomy for a diagnosis of fibrocystic disease in the absence of documented risk factors.
Cosmetic services performed primarily to improve appearance, except as outlined in this article.
Commercial or “decorative” tattooing.
Replacement of external breast prostheses beyond the limitations outlined in this policy, when the replacement is due to ordinary wear and tear.
Authorization RequirementsPrior authorization is not required when all of the following criteria are met:
The procedure is a mastectomy.
The procedure is a breast reconstruction and the client has an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.
The client is 18 years of age or older.
The diagnosis code is listed in diagnosis code table (page 36).
The client meets gender criterion.
The request is within the limitations outlined in this article for external breast prosthesis procedure code L8000, L8001, L8002, L8010, L8015, L8020, or L8030.
Prior authorization is required when any of the following criteria is met:
The client is 17 years of age or younger. Exception: Partial mastectomy procedure codes 19301 and 19302 may be reimbursed for clients of any age and do not require prior authorization.
The diagnosis code is not listed in diagnosis code table (page 36). Note: If it becomes medically necessary to submit a noncovered diagnosis code that differs from the noncovered diagnosis code approved in the prior authorization, the authorization may be updated before claim submission.
The client does not meet the gender criterion for the requested procedure.
The client does not have an established history of related services while Medicaid‑eligible as follows:
For breast reconstruction procedures, the client does not have an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.
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For complications related to breast reconstruction, the client does not have an established history of breast reconstruction procedures reimbursed for the client by Texas Medicaid.
For external breast prostheses, the client does not have an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.
The request is for external breast prosthesis procedure code L8035 or L8039. The request must include documentation of medical necessity for the requested device.
The request is for new or replacement external breast prostheses outside of the limitations outlined above.
Prior authorization requests for fee‑for‑service Medicaid clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department by approved electronic method using the “Special Medical Prior Authorization (SMPA) Request Form.” Documentation that supports medical necessity for the requested procedure must be included with the request. When required, the requests must include the physician’s original signature and the date signed. Stamped or computerized signatures and dates are not accepted. Without this information, requests will be considered incomplete.Prior authorization requests for PCCM clients must be submitted by the physician to PCCM Prior Authorization department by telephone or by approved electronic method using the “Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form.” Documentation that supports medical necessity for the requested procedure must be included with the request.
limitationsIn the following table, the procedure codes in Column B will be denied when billed with the same date of service by the same provider as the corresponding procedure codes in Column A:
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Texas Medicaid Claims Reprocessingwill be reprocessed, and payments will be adjusted accordingly. Providers that did not bill an encounter with procedure codes 55250 or 58600 must submit a new claim to TMHP for the encounter. These claims will receive special handling to override filing or appeal deadlines that were missed because of the error.
Provider Types and Places of Service Reinstated for Debridement and Biopsy Procedure CodesTMHP has identified an issue that affects claims submitted with the following procedure codes:
Effective April 21, 2010, some benefits have been reinstated and affected claims will be reprocessed. For dates of service on or after April 1, 2009, debridement procedure codes 11008, 16020, 16025, 16030, 21627, 21750, 28289, 69220, or 69222 may be reimbursed to nurse practitioner, clinical nurse specialist, and physician assistant providers for services rendered in the inpatient hospital or outpatient hospital setting. Affected claims that were submitted with dates of service from April 1, 2009, through April 20, 2010, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.Effective for dates of service on or after July 1, 2009, procedure code 31717 may be reimbursed to physician providers for services rendered in the office, inpatient hospital, or outpatient hospital setting.
Speech/language Therapy Claims ReprocessingTMHP has identified two issues that impact claims submitted by comprehensive outpatient rehabilitation facilities (CORFs) and outpatient rehabilitation facilities (ORFs). The impacted claims include those submitted by CORFs or ORFs with dates of service from January 1, 2006, to August 30, 2009, and procedure code 92507 or 92508, and claims submitted with dates of service from January 1, 2006, to February 11, 2010, and procedure code 92630 or 92633. These claims may have been denied or cut back in error with an explanation of benefits (EOB) message that indicated the services exceeded the allowed benefit limitations.
The following claims issues have been identified. All affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.
ASC/HASC Claims ReprocessingTMHP has identified an issue that affects claims that were submitted by ASC and hospital ambulatory surgical center (HASC) providers. Claims for some procedure codes may have been denied in error because of an incorrect type‑of‑service assignment by the claims system. Affected claims that are still available for reprocessing will be reprocessed, and payments will be adjusted accordingly.
Audiology Procedure Code Claims ReprocessingTMHP has identified an issue that impacts claims submitted with procedure code 92572 or 92576 and dates of service on or after July 1, 2009. Procedure codes 92572 and 92573 may have been reimbursed incorrectly to audiologists for services rendered in the outpatient hospital setting and may have been incorrectly denied for services rendered by audiologists in the office setting. The following is the correct information:Effective March 25, 2010, for dates of service on or after July 1, 2009, procedure codes 92572 and 92576 may be reimbursed to audiologists for services rendered in the office setting; however, procedure codes 92572 and 92576 will not be reimbursed to audiologists for services rendered in the outpatient hospital setting.
Reclast Injection Procedure Code Claims ReprocessingTMHP has identified an issue that affects claims submitted by physicians and hospitals with dates of service from January 1, 2008, through November 30, 2009, diagnosis code 73301, 73302, 73303, 73309, or 73390, and procedure code J3488. These claims may have been denied in error.
FQHCs Billing Procedure Code 58600 and 55260 Claims ReprocessingTMHP has identified an issue that impacts claims that were submitted with dates of service on or after January 1, 2006, and procedure code 55250 or 58600. Federally qualified health center (FQHC) providers may have been reimbursed a fee for these procedure codes; however, procedure codes 55250 and 58600 should have been processed as informational only. Affected claims
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Updates to Previously Published Information“To calculate the sole‑community hospital rate for clinical laboratories, multiply the access‑based or max fee by 103.35 percent.”
laboratory Services Procedure Codes limitation Changes Did Not Implement April 6, 2010This is a follow‑up to “Update to Limitations Change for Some Laboratory Services Procedure Codes,” which was published on the TMHP website on April 1, 2010. The changes described in the article are not effective for dates of service on or after April 6, 2010. Providers will be notified in a future article of the date on which the changes will become effective.
Obstetric Services Benefits to Change CorrectionThis is a correction to an article titled “Obstetric Services Benefits to Change” with the subheading “Fetal Fibronectin,” which was published in the January/February 2009 Texas Medicaid Bulletin, No. 220 and on September 8, 2008, on the TMHP website.The article incorrectly indicated that diagnosis code V2882 is allowable for procedure code 82731. The only allowable diagnosis codes for procedure code 82731 are 64400 and 64403.
Correction to “Texas Medicaid Professional Services and DME Reimbursement Rate Change”This is a correction to “Texas Medicaid Professional Services and DME Reimbursement Rate Change,” which was published in the November/December 2009 Texas Medicaid Bulletin, No. 226, and on the TMHP website on August 21, 2009. The article indicated that the revised reimbursement rates would apply to claims that were submitted with dates of service on or after July 1, 2009; however, these reimbursement rates did not become effective until January 1, 2010. Reimbursement rates that were effective on June 30, 2009, remained in effect through December 31, 2009. Claims for dates of service from July 1, 2009, through December 31, 2009, that were submitted with any of these procedure codes will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required. Reimbursement rates for procedure code S9445, which was discontinued on February 1, 2010, were not changed, so claims for procedure code S9445 will be reprocessed for dates of service from July 1, 2009, through January 31, 2010.
The following are updates and corrections to articles that were published in previous bulletins or on the TMHP website at www.tmhp.com as either banner messages or web articles.
update to “Adult Preventive Care Benefits to Change”This is an update to an article titled “Adult Preventive Care Benefits to Change” that was published on the TMHP website on January 8, 2010. Additional updates were made for rural health clinics (RHC) and managed care claims.
RHC providers may use encounter procedure code T1015 with diagnosis code V700 to bill adult preventive care services.PCCM clients may receive adult preventive care services from any PCCM provider. Clients do not need to be referred by their primary care providers.Claims for adult preventive care services that were submitted with dates of service on or after January 1, 2010, by RHC or PCCM providers may have been denied incorrectly. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required.
Correction to “TMHP to update the Field Description on the Static Fee Schedule”The following information is a correction to an article that was published in the May/June Texas Medicaid Bulletin No.229. Effective July 12, 2010, TMHP will update the field description for the “Access‑Based or Max Fee” on all static fee schedules. The Medicare‑payable rate description was updated to say “To calculate the Medicare payable rate for clinical laboratories, multiply the access‑based or max fee by 104.17 percent.” The sole‑community hospital rate description was updated to say
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The following table shows the reimbursement rates that were included in the original article.
Type of Service
Procedure Code Age Range/ Provider Type
Reimbursement Rate Effective July 1, 2009
Reimbursement Rate Effective January 1, 2010
Medical Services1 S0620 Birth through 20 years of age $45.83 $65.001 S0620 21 years of age or older $43.65 $65.001 S0621 Birth through 20 years of age $41.25 $68.001 S0621 21 years of age or older $39.29 $68.001 S8990 All ages $7.37 $140.001 S9445 21 years of age or older $7.00 Unchanged until
discontinued February 1, 2010
1 S9445 All ages Family Planning
$7.00
1 S9445 Birth through 20 years of age $31.971 S9470 Birth through 20 years of age $31.97 $49.00
Surgery and Assistant Surgery2 S2053 All ages $12,180.00 $7,042.008 S2053 All ages $1,948.80 $1,126.722 S2068 All ages $7,750.00 $15,582.678 S2068 All ages $1,240.00 $2,493.232 S2079 All ages $523.15 $950.852 S2095 All ages $696.08 $445.922 S2117 All ages $591.34 $602.872 S2225 All ages $110.20 $86.782 S2230 All ages $712.18 $753.232 S2235 All ages $712.18 $827.982 S2325 All ages $579.62 $667.318 S2325 All ages $92.74 $106.772 S8030 All ages $1,249.18 $1,091.47
Durable Medical Equipment9 S0515 All ages Manual Review Manual Review9 S1015 All ages $10.50 $10.509 S1040 All ages $2,418.18 $2,418.189 S8101 All ages $37.00 $37.00J S8185 All ages $40.92 $40.92J S8270 All ages $64.31 $64.31J S8999 All ages $58.26 $58.26
* Type of service1 = Medical2 = Surgery8 = Assistant Surgery9 and J = DME
CPT only copyright 2009 American Medical Association. All rights reserved.
Correction to “Benefits to Change for Regional Anesthesia Services”This is a correction to an article that was published in the May/June 2009 Texas Medicaid Bulletin, No. 223, titled,
“Benefits to Change for Regional Anesthesia Services.” The article incorrectly indicated that effective for dates of service on or after April 1, 2009, procedure codes 64450, 64505, and 64510 will no longer be reimbursed to APRN, PA, and RN/CNM providers. The correct information is as follows: Effective for dates of service on or after April 1, 2009, procedure codes 64450, 64505, and 64510 are not reimbursed to CNM providers. Procedure codes 64450, 64505, and 64510 may be reimbursed to APRN providers including NP, CNS, and PA providers.Some of the procedure codes that were included in the article were displayed incorrectly in the Online Fee Lookup (OFL) and the “Nurse Practitioner, Clinical Nurse Specialist, and Physician Assistant” static fee schedule.The following procedure codes now display correctly on the OFL and were updated on the static fee schedule in April 2010:
Procedure Codes Date updated
64470, 64472, 64475, 64476 Corrected February 15, 2010
64479, 64480, 64483, 64484 Corrected February 11, 2010
Note: Procedure codes 64450, 64505, and 64510 displayed correctly and have not been changed.
Correction to Computed Tomography Procedure CodesThis is a correction to the January 2010 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin, No. 2. The bulletin incorrectly indicates that effective for dates of service on or after January 1, 2010, computed tomography (CT) colonography procedure codes 74261, 74262, and 74263 require prior authorization. Following is the correct information:CT colonography procedure codes 74261, 74262, and 74263 do not require prior authorization for up to four
medically necessary services per rolling year, effective for dates of service from January 1, 2010, through January 31, 2010. Providers must maintain in the client’s medical record documentation of the medical necessity of the procedures. Retrospective review may be performed to ensure that the documentation supports the medical necessity of the CT procedures.Effective for dates of service on or after February 1, 2010, procedure codes 74261, 74262, and 74263 require prior authorization that must be obtained through MedSolutions.Providers may refer to the January 2010 HCPCS Special Bulletin, No. 2, for more information about 2010 HCPCS additions, changes, and deletions. Providers may refer to the March/April 2010 Texas Medicaid Bulletin, No. 228, for more information about authorization requests for positron emission tomography (PET) and cardiac nuclear imaging services.
update and Correction to “April Procedure Code Review updates Now Available”This is an update to an article titled “April Procedure Code Review Updates Now Available” that was published on February 19, 2010, on the Code Updates–Procedure Code Review web page of the TMHP website. The benefits have been revised for penile and testicular prostheses and pulmonary function studies.
Penile and Testicular ProsthesisThe following changes will be applied to penile and testicular prosthesis procedure codes:
Procedure code 64470 will be denied if it is billed with the same date of service by the same provider as procedure code 54406 or 54415. Procedure code 54470, which was included in the original table, is not a valid procedure code. The correct procedure code is 64470.
Procedure codes 54406, 54415, and 54660 may be reimbursed to ASC providers when the services are rendered in the outpatient hospital setting.
Pulmonary Function StudiesProcedure codes 94452 and 94453 do not require prior authorization.The professional interpretation component of procedure code 94010 may be reimbursed to NP, CNS, PA, and physician providers for services that are rendered in the office setting. Services that are rendered in the inpatient hospital or outpatient hospital setting will no longer be reimbursed to CNM, portable X‑ray supplier, or radiological and physiological laboratory providers.
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Services that are rendered in the inpatient hospital or outpatient hospital setting will continue to be reimbursed to physician providers.No changes were made to the technical component of the following procedure codes:
The professional interpretation component of the following procedure codes may be reimbursed to NP, CNS, and PA providers for services rendered in the office setting, and will no longer be reimbursed to NP, CNS, and PA providers for services rendered in the inpatient hospital or outpatient hospital setting.
The technical component for procedure code 94621 will continue to be reimbursed to physician providers for services rendered in the office setting.
Orthognathic SurgeryThe article indicated that effective for dates of service on or after April 1, 2010, the assistant surgery component for procedure code 29804 would be reimbursed to podiatrist providers for services rendered in the inpatient hospital or outpatient hospital setting. The correct information is that effective for dates of service on or after April 1, 2010, the assistant surgery component for procedure code 29804 will not be reimbursed to podiatrist providers for services rendered in the inpatient hospital or outpatient hospital setting.The following corrected information applies to procedure code 29804:
Surgery component: Services rendered in the office setting may be reimbursed to physician and dentistry group providers.
Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to NP, CNS, PA, and CNM providers.
Assistant surgery component: Services rendered in the inpatient hospital or outpatient hospital setting
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is a benefit and may be reimbursed to NP, CNS, PA, physician, and dentist providers.
The following rates were applied to the assistant surgery component of procedure code 29804:
Procedure Codes Clients Age Reimbursement Rate29804 Birth through
20 years of ageAssistant surgery
component: $81.0529804 21 years of age
or olderAssistant surgery
component: $77.19
update to “April Procedure Code Review updates for IV Therapy and urinalysis Services”This is an update to “April Procedure Code Review Updates for IV Therapy and Urinalysis Services,” which was published on February 22, 2010, on the TMHP website on the Code Updates – Procedure Code Review web page. The following applies to procedure code 81007:Effective for dates of service on or after April 1, 2010, the total radiology component for procedure code 81007 is a benefit and may be reimbursed as follows: To physician and family planning clinic providers for services rendered in the office setting; to hospital providers for services rendered in the outpatient hospital setting; and to independent laboratory providers for services rendered in the independent laboratory setting. The reimbursement rate for the professional interpretation component is $3.53.Additionally, the article incorrectly indicated that procedure code A4221 may be reimbursed by Texas Medicaid. The correct information is that procedure code A4221 is not reimbursed by Texas Medicaid.
Correction and update to “May 2010 Procedure Code updates”This is a correction and an update to an article titled “May 2010 Procedure Code Updates” that was published on March 5, 2010, on the Code Updates–Procedure Code Review web page of the TMHP website. The following corrections apply to continuous glucose monitoring procedure code 82948, complete blood count procedure code 84009, and antihemophilic factor service procedure code J7189:
Complete blood count procedure code 84009 is an invalid procedure code. The correct procedure code is 85049.
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Total laboratory component services that are rendered in the office setting for continuous glucose monitoring procedure code 82948 may also be reimbursed to CNM providers.
The article incorrectly indicated that effective for dates of service on or after May 1, 2010, antihemophilic factor service procedure code J7189 is no longer reimbursed to psychologist providers when rendered in the office setting. This change has already taken place and was made effective for dates of service on or after September 1, 2009. For more information, providers can refer to the article titled, “Procedure Codes That Are No Longer Reimbursable to Psychologists,” which was published in the January/February 2010 Texas Medicaid Bulletin, No. 227.
The following correction applies to physician inpatient and outpatient observation ventilator management procedure codes 94002 and 94003:
The changes indicated in the article for physician inpatient and outpatient observation ventilator management procedure codes 94002 and 94003 were implemented on April 1, 2010, instead of May 1, 2010. Providers may refer to “April Procedure Code Review Updates Now Available,” which was published on February 19, 2010, for the information about procedure codes 94002 and 94003.
The following updates apply to stereotactic radiosurgery procedure code 77399:
Effective for dates of service on or after May 1, 2010, procedure code 77399 requires prior authorization. The prior authorization request must include diagnosis, documentation of medical necessity, a specific description of the procedure to be performed, and an explanation that indicates that a specific procedure code is not available for the requested procedure.
Procedure code 77399 may be reimbursed to physician and radiation treatment center providers for services rendered in the office setting and to hospital providers for services rendered in the outpatient hospital setting.
The following corrections apply to prognostic breast and gynecological cancer studies procedure codes 88342, 88360, and 88361:
Procedure Code 88342 ChangesCorrection: The professional interpretation and the technical components will not be reimbursed to NP, CNS, and PA providers for services rendered in the office setting. The following is the complete, corrected information:
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Total laboratory component: Services rendered in the inpatient hospital setting are no longer reimbursed. Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.Professional interpretation component: Services rendered in the office setting may be reimbursed to physician providers. Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM, portable X‑ray supplier, or radiological and physiological laboratory providers.Technical component: Is a benefit of Texas Medicaid and may be reimbursed as follows:
Services rendered in the office setting may be reimbursed to physician providers.
Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers.
Services rendered may be reimbursed at $45.25.
Procedure Code 88360 ChangesCorrection: The total, professional interpretation, and technical components will not be reimbursed to NP, CNS, and PA providers for services rendered in the office setting. The following is the complete, corrected information:Total laboratory component: Services rendered in the inpatient hospital setting are no longer reimbursed. Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based rural health clinic (RHC) providers.Professional interpretation component: Services rendered in the office setting may be reimbursed to physician providers. Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to CNM, hospital, portable X‑ray supplier, or radiological and physiological laboratory providers.Technical component: The technical component is a benefit of Texas Medicaid and may be reimbursed as follows:
Services rendered in the office setting may be reimbursed to physician providers.
Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers.
CPT only copyright 2009 American Medical Association. All rights reserved.
Procedure Code 88361 ChangesCorrections: The total, professional interpretation, and technical components will not be reimbursed to NP, CNS, and PA providers for services rendered in the office setting. The professional interpretation component will continue to be reimbursed to independent laboratory providers for services rendered in the independent laboratory setting. The technical component may be reimbursed to physician providers for services rendered in the office setting and not to portable X-ray supplier, radiological laboratory, and physiological laboratory providers. The following is the complete, corrected information:Total laboratory component: Services rendered in the inpatient hospital setting are no longer reimbursed. Services rendered in the outpatient hospital setting are no longer reimbursed to hospital‑based RHC providers.Professional interpretation component: Services rendered in the office setting are no longer reimbursed to independent laboratory, podiatrist, CNM, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, or hospital‑based RHC providers. Services rendered in the inpatient hospital or outpatient hospital setting are no longer reimbursed to independent laboratory, radiation treatment center, hospital, nephrology (hemodialysis, renal dialysis), renal dialysis facility, portable X‑ray supplier, radiological and physiological laboratory, or hospital‑based RHC providers. Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to physician providers.Technical component: Is a benefit of Texas Medicaid and may be reimbursed as follows:
Services rendered in the office setting may be reimbursed to physician providers.
Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers.
Services rendered may be reimbursed at $66.01.
Providers can refer to the “May 2010 Procedure Code Updates” article on the TMHP website to read the updates for procedure code 85049 and the additional updates for procedure code 82948.
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Reimbursement update for Some Procedure CodesEffective February 26, 2010, updates were made to procedure codes 74340, 91030, 91052, 91065, and 93288 as follows.
Procedure Codes 74340, 91030, 91052, and 91065Effective for dates of service on or after March 1, 2010, the technical component may be reimbursed for procedure codes 74340, 91030, 91052, and 91065. Services rendered in the office setting may be reimbursed to NP, CNS, PA, physician, portable X‑ray, and radiological and physiological laboratory providers.
Procedure Code 93288Effective for dates of service on or after January 1, 2009, the professional interpretation component for procedure code 93288 may be reimbursed to NP, CNS, PA, and physician providers for services rendered in the office setting and to physician providers for services rendered in the inpatient hospital or outpatient hospital setting. The technical component for procedure code 93288 may be reimbursed to NP, CNS, PA, physician, portable X‑ray supplier, and radiological and physiological laboratory providers for services rendered in the office setting. The professional interpretation component may be reimbursed at $19.93, and the technical component may be reimbursed at $14.44. Affected claims with dates of service from January 1, 2009, through February 26, 2010, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required.
Technical Component of Procedure Code 93306 ClarifiedEffective for dates of service on or after January 1, 2009, the technical component of procedure code 93306 is payable to physicians (provider type 19, 20, 21, and 22) in the office setting (place of service [POS] 1). Affected claims that were submitted with dates of service on or after January 1, 2009, will be reprocessed, and payments will be adjusted accordingly. No action by the provider is required.
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Family Planning Providers
New Filing Deadline for Family Planning Titles V and XX New Day ClaimsEffective June 25, 2010, TMHP changed the claims filing system to enforce the 95-day filing deadline for New Day claims submitted for Titles V and XX. This change aligns with the family planning claim submission policy of the Department of State Health Services (DSHS), as stated in the DSHS Fiscal Year 2010 Policy and Procedure Manual for Title V, Title X, and Title XX Family Planning Services, which was published in November of 2009. The filing deadline for claim appeals will remain 120 days from the disposition date on the Remittance and Status (R&S) Report on which the claim reaches a finalized status. Towards the end of a contract period, filing and appeals deadlines are further constrained. Providers must submit all claims and appeals within 60 days of the date on which a contract period ends to have those claims considered for reimbursement.
Obstetrics Services are Not a Benefit of Family PlanningReminder: Obstetrics services and any associated professional services are not a benefit of Texas Medicaid for family planning clients. Evaluation and management procedure codes that are billed with the TH modifier are not a benefit for Family Planning Title V and XX clients.
Revised Sterilization Consent Form and InstructionsThe Sterilization Consent Form Instructions and the English and Spanish versions of the Sterilization Consent Form have been updated.
The Sterilization Consent Form Instructions have been updated to include the following information for premature delivery: “There must be at least 72 hours between the date of consent and the date of surgery. The informed consent must have been given at least 30 days before the expected date of delivery.” The English and Spanish versions of the Sterilization Consent Form have been updated to include check boxes in front of the options for premature delivery
and emergency abdominal surgery. The revised Sterilization Consent Form Instructions and the English and Spanish versions of the Sterilization Consent Form are available starting on page 71 of this bulletin. Providers may refer to the Code of Federal Regulations (CFR) Title 42 Part 50 Section 50.203 and to the article titled, “Family Planning Procedures Performed for the Purpose of Sterilization,” on page 51 of the January/February 2010 Texas Medicaid Bulletin, No. 227, for more information about the Sterilization Consent Form and instructions.
This is a correction to an article titled “Benefit Changes for Family Planning Titles V and XX Services” that was published in the March/April 2010 Texas Medicaid Bulletin, No. 228 and the TMHP website at www.tmhp.com on December 11, 2009. The article stated incorrectly that procedure code 99000 must be submitted with a family
planning diagnosis code. Procedure code 99000 requires a family planning diagnosis code only if the claims are submitted by family planning Title XIX providers. Title V or XX providers are not required to include a family planning diagnosis code when they submit procedure code 99000.
Correction to “Benefit Changes for Family Planning Titles V and XX Services”
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Home HealtH Providers
Home Health Services Benefit Changes for Manual and Automated Blood Pressure DevicesThis is an update to an article titled “THSteps‑CCP Blood Pressure Device Benefits to Change,” that was published on January 15, 2010, on the TMHP website at www.tmhp.com. The article included changes to the blood pressure device benefits for the Texas Health Steps Comprehensive Care Program (THSteps‑CCP). The benefit changes for procedure codes A4660 and A4670 (manual and automated blood pressure devices) also apply to Texas Medicaid (Title XIX) home health services. The information in this article updates the 2009 Texas Medicaid Provider Procedures Manual section 24.4.18,
“Blood Pressure Devices,” on page 24‑37.Manual and automated blood pressure devices may be reimbursed as follows:
DeviceProcedure Code
Authorization Requirements and limitations
Manual A4660 Prior authorization is not required for the purchase of 1 per year when billed with one of the diagnosis codes in the table below.
Automated* A4670
Replacement or repair of components
A4660 Prior authorization is required for the replacement or repair of components.
Procedure codes A4660 and A4670 do not require prior authorization if they are billed with one of the following diagnosis codes:
Manual and automated blood pressure devices should last at least one year and may be considered for replacement after one year has passed. If it is medically necessary to replace nonfunctional and irreparable equipment before one year has passed, providers can submit prior authorization requests with documentation of medical necessity that explains the need for the replacement. Prior authorization is required in the following situations:
Another blood pressure device is medically necessary within the same year. Replacement of equipment within the same year as the purchase requires prior authorization. If equipment must be replaced before the end of the anticipated lifespan, the provider must submit a copy of the police or fire report, when appropriate, and the measures that will be taken to prevent reoccurrence.
The diagnosis code is not in the table above. If the diagnosis code is not one of those listed in the table above, providers must submit a request for the prior authorization of the initial or replacement device and must include all of the documentation necessary to support the medical necessity of the blood pressure device.
Authorization Requirements Providers can refer to the 2009 Texas Medicaid Provider Procedures Manual section 24.2.2, “Prior Authorization,” on page 24‑5, for more information about prior authorization requirements.
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managed Care Providers
PCCM Prior Authorization Requirements to Change for Some Procedure CodesEffective for dates of service on or after June 1, 2010, the following procedure codes no longer require prior authorization for Primary Care Case Management (PCCM) clients:
Translation Services Available for PCCM Clients and ProvidersReminder: PCCM clients who need interpretive and translation services to effectively communicate with providers about treatment and medical history can call the PCCM Nurse Helpline toll‑free at 1‑800‑304‑5468. If providers or their staffs need additional translation services to meet requirements on limited English proficiency, they can call Language Line Services at 1‑800‑752‑6096. Language Line Services charges a fee for service to providers.
PCCM Nurse Helpline: 1-800-304-5468The PCCM Nurse Helpline is a free service for PCCM clients that is available 24 hours a day, 7 days a week, including holidays. The PCCM Nurse Helpline is staffed by registered nurses who provide the following services to PCCM clients:
Triage, assistance, and reassurance.
Direction to the most appropriate care setting.
Coordination of the interpretive language services that are necessary to ensure effective communication about treatment, medical history, and health education.
Answers to questions such as:
What to do if a child wakes in the night vomiting, or has a fever.
What to do if a baby is sick or will not stop crying.
When to go the hospital.
language line Services: 1-800-752-6096If providers or their staffs need additional translation services to meet requirements for limited English proficiency, they can call Language Line Services 24 hours a day, 7 days a week. Language Line Services provides over‑the‑telephone interpretation, video interpreting, document translation, interpreter testing and training, and other language products.Language Line Services charges a fee to providers. Language Line Services bills in one‑minute increments, and charges begin when the interpreter is connected to the call. The electronic bill that is sent to the provider will include the date, time, and duration of the call, the language, the interpreter number, the personal code of the person placing the call, and a Language Line Services internal reference number.
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tHstePs dental Providers
Dental Services Change for Medicaid-Eligible Residents of ICF-MR Who Are 21 Years of Age or Older
Avoiding Mismatched Authorizations on Hospital Claims for STAR+PLUS, STAR SSI, and PCCM ClientsHospital providers that submit claims for clients of STAR+PLUS, STAR Supplemental Security Income (SSI), and PCCM will have difficulty with reimbursement if the claims have mismatched authorizations. Mismatched authorizations can occur when a hospital that submits claims for these clients does not update the diagnosis codes on an existing authorization. Mismatched authorizations will cause claims to be denied if the authorizations are not updated before the claims are submitted. If an existing authorization must be changed, providers must verify and update the following:
Diagnosis codes (e.g., primary, secondary)
Procedure codes
Discharge date
Diagnosis related group (DRG) code for DRG facilities (This only applies to claims submitted for services rendered to PCCM clients.)
Authorization updates for PCCM, STAR+PLUS, and STAR SSI clients are each handled differently:
If a hospital provider submits a claim to TMHP for a PCCM client who is admitted to an inpatient facility for behavioral health services but is discharged
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from that stay with an acute‑care principle diagnosis, then the hospital provider must obtain an updated authorization from PCCM before submitting the claim to TMHP.
If a hospital provider obtains a prior authorization for acute‑care services from a health maintenance organization (HMO) for a STAR+PLUS member and, following admission, it is determined that the principle diagnosis is behavioral health, the hospital provider must obtain an updated authorization from the HMO for the behavioral health inpatient stay. The hospital provider must then submit the claim to the HMO upon discharging the client.
If a hospital provider obtains a pre‑authorization for behavioral health services from an HMO for a STAR SSI member and, following admission, it is determined that the principle diagnosis is acute care, then the hospital provider must obtain an updated authorization from the HMO for the acute care services. The hospital provider must then submit the claim to THMP.
Claims are adjudicated based on the principal diagnosis and authorization that are in effect when the claim is received, so it is too late to update an authorization once the claim has been submitted.
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Effective April 8, 2010, dental services for residents of intermediate care facilities for persons with mental retardation (ICF‑MR) who are eligible for Medicaid and 21 years of age or older are not limited to the Texas Health Steps (THSteps) Periodicity Schedule, which allows for preventive dental care services once every six months. Because of the medical conditions and medications
taken by these clients, these clients may receive preventive dental care services as needed. Dental providers must document that any procedures they perform are medically necessary and appropriate. Residents of ICF‑MR facilities who are 20 years of age or younger receive dental services through the THSteps Dental program.
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tHstePs mediCal Providers
Changes in the Timeliness of THSteps Medical CheckupsEffective for dates of service on or after September 1, 2010, the timeliness of Texas Health Steps (THSteps) medical checkups will change for Texas Medicaid.
Existing Medicaid ClientsThe definition of “timeliness” will change for THSteps medical checkups for clients who are three years of age or older. Children under three years will continue to be due for medical checkups more frequently.Currently a THSteps medical checkup is considered timely when it occurs within 60 days of the client’s birthday. Effective for dates of service on or after September 1, 2010, the timeframe for a timely THSteps checkup will be extended to one year from the child’s birthday. This means if the child gets a THSteps checkup anytime the child is a particular age, that checkup will be considered timely. With this change, clients who are three years of age or older will still be considered “due” for a THSteps medical checkup on their birthday and will still be encouraged to have a yearly checkup as soon as they become due. A THSteps checkup should occur on or as soon after a child’s birthday as practical but will not be considered late unless the child does not have the checkup prior to their next birthday.
How does this change affect providers?Providers and families will have more flexibility in scheduling a client’s yearly THSteps medical checkup requirements.
Families with more than one child will be able to more easily schedule checkups at the same time.
Providers and family can more easily avoid scheduling a checkup during flu season.
Migrant workers can schedule a checkup prior to or after returning to their home communities.
Exception‑to‑periodicity checkups will still be allowable when it has been less than one year since the last medical checkup if medically necessary, state‑mandated (such as entry into foster care or adoption), or for general anesthesia prior to dental surgery.
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What does not change?Unless there is a specific reason to delay the checkup, all clients should be given the first available appointment. This will help ensure the family still has Medicaid coverage at the time the appointment is scheduled.
The Medicaid ID cards will still show that the client is due for a checkup when they have a birthday until a checkup is completed and a claim submitted.
Exception to periodicity checkups still exist when medically necessary, state‑mandated (such as entry into foster care or adoption), or for general anesthesia prior to dental surgery and it has been less than one year since the last medical checkup. The increased flexibility may require fewer claims to be submitted as exceptions to periodicity if it has been a year since the child’s last checkup.
While the change in the definition of timeliness only applies to children 3 years of age or older, a claim for a medical checkup can be submitted based on the total number of checkups that can be provided in each age range below. This allows a provider to perform one THSteps checkup per year for a child three years or older and submit a claim and still receive reimbursement, even for a checkup performed prior to the birth date/due date.
Age RangeNumber of Visits Allowed
Birth through 11 months (does not include 12 months)
7
1 through 4 years of age 75 through 11 years of age 712 through 17 years of age 618 through 20 years of age 3
New Medicaid ClientsChildren who are new Medicaid clients in PCCM or to an HMO should receive a THSteps checkup within 90 days of receiving their Medicaid eligibility. Children should receive subsequent THSteps checkups per the periodicity schedule. An allowance can be made to the 90‑day requirement if there is documentation that the child previously received a THSteps medical checkup through a different provider and that the next checkup is not due.
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Texas Health Steps – Lead Screening and TestingIn accordance with current federal regulations, THSteps requires clients to be screened for lead exposure through blood tests or parent questionnaires at 6, 9, 12, 15, 18, and 24 months of age and annually until 6 years of age. Blood lead analyses are mandatory at the 12‑ and 24‑month THSteps medical checkups. At other THSteps medical checkups (6, 9, 15, and 18 months of age and 3, 4, 5, and 6 years of age), the “Form Pb‑110: Risk Assessment for Lead Exposure: Parent Questionnaire” must be administered to the parent or guardian, and if the parent answers “Yes” or “I don’t know” to any of the questions, a blood lead analysis must be performed. Providers may download the “Pb‑110: Risk Assessment for Lead Exposure: Parent Questionnaire”, which is provided in both English and Spanish, from the Department of State Health Services (DSHS) website at www.dshs.state.tx.us or in the Children’s Services Handbook of the 2010 Texas Medicaid Provider Procedures Manual.If a client has an abnormal test or unsatisfactory test result, and cannot be located for follow‑up testing, providers can contact the MAXIMUS Special Services Unit (SSU) at 1‑877‑847‑8377, 8 a.m. to 8 p.m., Central Time. Providers can also complete the “THSteps Missed Appointment Referral Form,” which is available on the THSteps website at www.dshs.state.tx.us/thsteps/forms.shtm, and fax it to 1‑512‑533‑3867 ATTN: Special Services Unit. After receiving the referral, MAXIMUS SSU staff will attempt to contact the family to encourage them to contact their provider and to assist in making the follow‑up appointment. MAXIMUS will inform providers of the referral’s results.
This is a clarification of an article about H1N1 vaccine administration fee reimbursement that was published in the January/February, 2010 Texas Medicaid Bulletin, No. 227, and on the TMHP website at www.tmhp.com on October 16, 2009. The article indicated that the administration of the H1N1 flu vaccine is reimbursed separately from a
THSteps visit. Although THSteps providers may not bill for vaccine administration (procedure
codes 90465, 90466, 90471, or 90472) using their THSteps provider numbers,
they may file separate claims for vaccine administration using their Medicaid
provider identifier.
Women’s HealtH Program Providers
Women’s Health Program Providers and Performance of Elective AbortionsEffective September 1, 2005, Texas Human Resources Code, Section 32.048(h), prohibits the payment of Women’s Health Program (WHP) funds to providers who perform elective abortions. Beginning June 28, 2010, providers will be able to use this website to disclose whether they have performed elective abortions in the past calendar year. After completing the online portion of the certifi‑cation, providers must submit a completed copy of the Women’s Health Program (WHP) Certification form, including an original, handwritten signature, to complete the certification process.Beginning June 28, 2010, providers who have not completed the WHP certification form will have their claims for WHP services denied for payment with explanation of benefits (EOB) code 001163, “provider not certified to provide WHP services.” Claims that are submitted for services rendered to other Medicaid clients will not be impacted.If the Texas Health and Human Services Commission (HHSC) determines that WHP funds were paid to a provider who has performed elective abortions, HHSC may direct TMHP to recoup those funds. A list of frequently asked questions about the WHP certification is available on the HHSC website at www.hhsc.state.tx.us/WomensHealth/WHP
_CertificationFAQs.doc.
Filing THSteps Provider Claims for H1N1 Vaccine Administration
THSteps Medical Providers/Women’s Health Program Providers
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Benefit Changes for Mastectomy and Breast Reconstruction ServicesEffective for dates of service on or after June 1, 2010, some benefits have changed for Texas Medicaid mastectomy and breast reconstruction services including the addition of prophylactic mastectomy benefits, new procedure codes for breast reconstruction and breast prostheses, and authorization requirements. Mastectomy and breast reconstruction procedures are benefits of Texas Medicaid for male or female clients. These procedures are to be individualized, specific, and not in excess of the client’s needs.Mastectomy and breast reconstruction procedures may be reimbursed when the procedures are consistent with confirmed diagnosis of illness or injury under treatment or with appropriate personal history. Mastectomy and breast reconstruction procedures may be reimbursed without prior authorization for services rendered to clients who are 18 years of age or older when the procedures meet the criteria outlined below and are billed with the following diagnosis codes:
Diagnosis Codes
1740 1741 1742 1743 17441745 1746 1748 1749 17501759 19881 2330 V103* V163*V4571* V8401** Diagnosis codes V103, V163, V4571, and V8401 may be billed only with breast reconstruction procedures and simple, subcutaneous, radical, and modified radical mastectomy procedures.
The physician must maintain documentation of medical necessity in the client’s medical record. Services are subject to retrospective review.Mastectomy and breast reconstruction procedure codes are no longer reimbursed when submitted with diagnosis codes 61183, 6120, or 6121.Important: Prior authorization is required for mastectomy and prophylactic mastectomy services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.
MastectomyPartial mastectomy (procedure codes 19301 and 19302) is a benefit of Texas Medicaid. Procedure codes 19301 and 19302 may be reimbursed for services rendered to male or female clients of any age when the services are billed with an appropriate diagnosis code.
For clients with a diagnosis of cancer, procedure codes 19301 and 19302 may be reimbursed for more than 2 services rendered per lifetime.Subcutaneous, radical, and modified radical mastectomy (procedure codes 19303, 19304, 19305, 19306, and 19307) are benefits of Texas Medicaid.Procedure codes 19303, 19304, 19305, 19306, and 19307 may be reimbursed for services rendered to male or female clients who are 18 years of age or older when the services are billed with an appropriate diagnosis code. Prior authorization is required for services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.Procedure codes 19303, 19304, 19305, 19306, and 19307 may be reimbursed for 2 services rendered per lifetime.
Prophylactic MastectomyProphylactic mastectomy is the removal of the breast to prevent the development of cancer. This procedure is a benefit of Texas Medicaid for clients who are 18 years of age or older and who are at moderate‑to‑high risk for the development of breast cancer. Prior authorization is required for services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.Moderate‑risk to high‑risk clients are those who meet one or more of the following criteria:
Presence of a breast cancer 1 (BRCA1) or a breast cancer 2 (BRCA2) genetic mutation
Presence of lesions associated with an increased risk of cancer, such as atypical hyperplasia or lobular carcinoma in situ (LCIS)
Diagnosis of breast cancer in one breast
Documentation that supports medical necessity for the procedure must be maintained in the client’s medical record and must include the following:
Documentation that the client is moderate‑to‑high risk.
Documentation that, as a candidate for prophylactic mastectomy, the client has undergone counseling regarding cancer risks. Counseling must include assessment of all of the following:
The client’s ability to understand the risks and long‑term implications of the surgical procedure.
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The client’s informed choice to proceed with the surgical procedure.
All documentation is subject to retrospective review.
Breast ReconstructionBreast reconstruction includes the following:
Creation of a new mound.
Reconstruction of the nipple or areola, which is accomplished with small flaps for the nipple and either tattooing or a skin graft for the areola. Nipple‑areola pigmentation, commonly known as medical tattooing, is the final stage of breast reconstruction surgery.
Breast reconstruction may also include the following, in order to establish symmetry with the contralateral breast:
Reduction mammaplasty
Mastopexy
Augmentation
Breast implants, tissue flaps, or both are surgically placed in the area where natural tissue has been removed.Breast reconstruction is performed in order to correct or repair abnormal structures of the breast caused by any of the following:
Tumor or disease (e.g. following a primary mastectomy procedure in order to establish symmetry with a contralateral breast or following bilateral mastectomy)
Congenital defect
Developmental abnormality
Infection
Trauma to the chest wall
Breast reconstruction may be based on the type of treatment a client receives or on the extent of surgery performed. The reconstructive surgery may be performed in a single stage or several stages and may occur during or after the initial surgical procedure.Breast reconstruction following a medically necessary mastectomy is a benefit of Texas Medicaid when all of the following criteria are met:
The client is eligible for Texas Medicaid at the time of the breast reconstruction.
The client has a documented history of a mastectomy performed while eligible for Texas Medicaid and has one of the diagnoses listed above. Note: Prior authorization is required for breast recon-
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struction service rendered to clients that do not have an established history of mastectomy procedures reimbursed by Texas Medicaid for the client.
The client meets age and sex criteria for the requested procedure as outlined above.
The physician has documented a plan in the client’s chart that addresses the recommended breast reconstruction.
The following breast reconstruction procedure codes may be reimbursed for services rendered to clients who are 18 years of age or older:
Procedure Codes
11920 11921 11922 19316* 19324*19325* 19340* 19342* 19350 1935519357* 19361 19364 19366 1936719368 19369 19396* S2068* Procedure codes 19316, 19324, 19325, 19340, 19342, 19357, and 19396 may be reimbursed for services rendered to female clients only. Prior authorization is required for services rendered to male clients.
Prior authorization is required for services rendered to clients who are 17 years of age or younger. Providers may refer to the Authorization Requirements section of this article for more information.For clients with a diagnosis of cancer, the following procedure codes may be reimbursed for more than 2 services rendered per lifetime:
The following procedure codes may be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed for the client by Texas Medicaid:
Prior authorization is required for breast reconstruction service rendered to clients that do not have an established history of mastectomy procedures reimbursed by Texas Medicaid for the client.
The surgical component may be reimbursed to physician providers for services rendered in the office, inpatient hospital, or outpatient hospital setting. Two services rendered per lifetime may be reimbursed.May be reimbursed if a breast reconstruction (procedure code 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, or S2068) has been reimbursed by Texas Medicaid within 12 months. Prior authorization is required for services rendered to clients that do not have an established history of breast reconstruction procedures reimbursed by Texas Medicaid for the client.Procedure code 11922 must be billed with procedure code 11920 or 11921.
19324, 19325, 19355
The surgical component may be reimbursed to physician providers for services rendered in the inpatient hospital setting and to ambulatory surgical center (ASC) providers for services rendered in the outpatient hospital setting.Procedure codes 19324 and 19325 may be reimbursed for services rendered to female clients only. Prior authorization is required for services rendered to male clients.May be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed by Texas Medicaid within the client’s lifetime. Prior authorization is required for services rendered to clients that do not have an established history of mastectomy procedures reimbursed by Texas Medicaid for the client.
19316, 19396
The surgical and assistant surgery components may be reimbursed to physicians for services rendered in the inpatient hospital setting and to ambulatory surgical centers for services rendered in the outpatient hospital setting.
(continued) May be reimbursed for services rendered to female clients only. Prior authorization is required for services rendered to male clients.May be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed by Texas Medicaid within the client’s lifetime.
Reimbursement Rates for New BenefitsThe following rates apply to the new mastectomy and breast reconstruction procedure codes:
TOS Procedure Code Fee
2 11920 $82.372 11921 $97.102 11922 $22.092 19316 $552.078 19316 $88.37F 19316 Group 92 19324 $343.68F 19324 Group 92 19325 $457.69F 19325 Group 92 19355 $406.69F 19355 Group 92 19396 $96.288 19396 $15.27F 19396 Group 9(TOS) Type of service.
Tattooing to Correct Color Defects of the SkinTattooing to correct color defects of the skin (procedure codes 11920, 11921, and 11922) is limited to clients with a documented history of a breast reconstruction performed within the past 12 months. The breast reconstruction must have been performed while the client was eligible for Texas Medicaid. Prior authorization is required for tattooing services for clients that do not have an established history.
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Treatment for Complications of Breast ReconstructionThe treatment of complications related to breast recon‑struction may be reimbursed using procedure codes 19370, 19371, and 19380 when all of the following criteria are met:
The client is eligible for the Texas Medicaid breast reconstruction benefit when the complications occur.
The client is 18 years of age or older at the time the services are rendered.
A breast reconstruction (procedure code 19316, 19324, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, or S2068) has been reimbursed for the client by Texas Medicaid.
Procedure codes 19370 and 19371 may be reimbursed for services rendered to female clients only.Prior authorization is required for services rendered to clients who do not have an established history of related services reimbursed for the client by Texas Medicaid or for clients who do not meet the age and gender criteria indicated in this article.
External Breast ProsthesesExternal breast prostheses are benefits when provided by a licensed prosthetist or orthotist to clients with a history of a medically necessary mastectomy procedure. The following procedure codes may be reimbursed for external breast prostheses services rendered to female clients of any age:
Procedure codes L8001, L8010, L8020, L8030, L8031, and L8032 must be submitted with modifier LT or RT indicating the location for the breast prosthesis.The external breast prosthesis procedure codes are limited as follows:
Procedure Code limitationL8000 4 per rolling year
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Procedure Code limitationL8001 4 per rolling year
Note: If more than 4 unilateral mastectomy bras are required per rolling year, prior authorization may be requested for the ad-ditional items. If a second mastectomy is per-formed within the same year, the bilateral procedure code must be used for the necessary mastectomy bra.
L8002 4 per rolling yearL8010 8 total per rolling year (regardless of
modifier)L8015 2 per lifetimeL8020 1 total per 6 rolling months (regardless of
modifier)L8030 1 total per 2 rolling years (regardless of
modifier)L8031 1 total per 2 rolling years (regardless of
modifier)L8032 8 total per rolling yearL8035 Prior authorization requiredL8039 Prior authorization required
The following procedure codes may be reimbursed if a mastectomy (procedure code 19303, 19304, 19305, 19306, or 19307) has been reimbursed for the client by Texas Medicaid:
Prior authorization is required for the initial prosthesis for clients who do not have an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.Prior authorization is required for the replacement of external breast prosthesis as follows:
If the external breast prosthesis is lost or irreparably damaged, prosthesis of the same type may be prior authorized at any time.
If the external breast prosthesis is needed due to a change in the client’s medical condition, prosthesis of a different type may be prior authorized at any time.
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Women's Health Program Providers
Noncovered ServicesThe following services are not benefits of Texas Medicaid:
Mastectomy for a diagnosis of fibrocystic disease in the absence of documented risk factors.
Cosmetic services performed primarily to improve appearance, except as outlined in this article.
Commercial or “decorative” tattooing.
Replacement of external breast prostheses beyond the limitations outlined in this policy, when the replacement is due to ordinary wear and tear.
Authorization RequirementsPrior authorization is not required when all of the following criteria are met:
The procedure is a mastectomy.
The procedure is a breast reconstruction and the client has an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.
The client is 18 years of age or older.
The diagnosis code is listed in the diagnosis code table above.
The client meets gender criterion.
The request is within the limitations outlined in this article for external breast prosthesis procedure code L8000, L8001, L8002, L8010, L8015, L8020, or L8030.
Prior authorization is required when any of the following criteria is met:
The client is 17 years of age or younger. Exception: Partial mastectomy procedure codes 19301 and 19302 may be reimbursed for clients of any age and do not require prior authorization.
The diagnosis code is not listed in the diagnosis code table above. Note: If it becomes medically necessary to submit a noncovered diagnosis code that differs from the noncovered diagnosis code approved in the prior authorization, the authorization may be updated before claim submission.
The client does not meet the gender criterion for the requested procedure.
The client does not have an established history of related services while Medicaid‑eligible as follows:
For breast reconstruction procedures, the client does not have an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.
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For complications related to breast reconstruction, the client does not have an established history of breast reconstruction procedures reimbursed for the client by Texas Medicaid.
For external breast prostheses, the client does not have an established history of mastectomy procedures reimbursed for the client by Texas Medicaid.
The request is for external breast prosthesis procedure code L8035 or L8039. The request must include docu‑mentation of medical necessity for the requested device.
The request is for new or replacement external breast prostheses outside of the limitations outlined above. Prior authorization requests for fee‑for‑service Medicaid clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department by approved electronic method using the Special Medical Prior Authorization (SMPA) Request Form. Documentation that supports medical necessity for the requested procedure must be included with the request. When required, the requests must include the physician’s original signature and the date signed. Stamped or computerized signatures and dates are not accepted. Without this information, requests will be considered incomplete.Prior authorization requests for Primary Care Case Management (PCCM) clients must be submitted by the physician to PCCM Prior Authorization department by telephone or by approved electronic method using the Primary Care Case Management (PCCM) Inpatient/Outpatient Authorization Form. Documentation that supports medical necessity for the requested procedure must be included with the request.
limitationsIn the following table, the procedure codes in Column B will be denied when billed with the same date of service by the same provider as the corresponding procedure codes in Column A:
CPT only copyright 2009 American Medical Association. All rights reserved.
Excluded ProvidersAs required by the Medicare and Medicaid Patient Protection Act of 1987, the Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health‑care programs. Providers excluded from Texas Medicaid and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries, wages, or benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any client.Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by Texas Medicaid for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of the HHSC exclusion list. The HHSC‑Sanctions Department submits updates to the exclusion list periodically and the updates appear on the website weekly.Review the entire Texas Medicaid exclusion list at https://oig.hhsc.state.tx.us /Exclusions/Search.aspx.To report Medicaid providers who engage in fraud/abuse, call 1‑512‑424‑6519 or 1‑800‑436‑6184, or write to the following address:
Brian Klozik, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC‑1361
PO Box 85200 Austin TX 78708‑5200
Providerlicense Number Add Date
Type Provider City State Start Date
Abdallah, Mazen Y. 26‑Feb‑10 Owner Houston TX 19‑Nov‑09Akpan, Jude E. 12021 13‑Apr‑10 Tech Richmond TX 20‑Jul‑09Amazon Health Care Inc. 14‑Apr‑10 Houston TX 20‑Jan‑10Andradi, Anura 13‑Apr‑10 Owner Forney TX 12‑Apr‑10Andrus, Rita H. 10023757 13‑Apr‑10 Aide Palmetto LA 25‑Jul‑09Atchley, Katina A. 209865 26‑Feb‑10 LVN Pampa TX 08‑Sep‑09Atkinson, Abigail 118720 12‑Mar‑10 LVN San Benito TX 09‑Jun‑09Atlantic Ambulance Services 30‑Mar‑10 Huntsville TX 20‑Dec‑09Atlantic Mental Health Service 30‑Mar‑10 Huntsville TX 20‑Dec‑09Avery, Parnell N. D8849 26‑Mar‑10 MD Houston TX 06‑Nov‑10Awe, Oluwafemi 27853 29‑Mar‑10 Pharm Mansfield TX 11‑Aug‑09Bartschi, Carlin G. J0916 14‑Apr‑10 MD Gilbert AZ 06‑Oct‑09Bio Care Specialties, Inc. 24‑Mar‑10 DME Colleyville TX 20‑May‑08Blake, Lori D. 97633 12‑Mar‑10 LVN Waco TX 12‑May‑09Bram, Clint A. 106316 14‑Apr‑10 Tech Corpus Christi TX 20‑Jan‑10Burch, Debbie J. 167973 25‑Mar‑10 LVN Fort Morgan CO 18‑Aug‑09Chappell, Sandra R. 532922 15‑Apr‑10 RN Greenville TX 10‑Nov‑09Charleston, Kimberly R. 102465 13‑Apr‑10 Tech Atlanta TX 03‑Sep‑09Choy, Robert K. 12948 10‑Mar‑10 DDS Sugarland TX 05‑Jun‑09Cleaver, Denise D. 179243 14‑Apr‑10 LVN Eastland TX 20‑Jan‑10Coleman, Carleen B. 164428 14‑Apr‑10 LVN Hempstead TX 25‑Oct‑09
CPT only copyright 2009 American Medical Association. All rights reserved.
Providerlicense Number Add Date
Type Provider City State Start Date
Jenkins, Charles D. 208483 26‑Feb‑10 LVN Pflugerville TX 22‑Sep‑09Jennings, Michael L. 175616 01‑Mar‑10 LVN Amarillo TX 05‑Oct‑09Job, Georgio R. 14‑Apr‑10 Owner Richmond TX 20‑Dec‑09Johnson, Danette L. 670485 15‑Apr‑10 RN Chandler AZ 10‑Nov‑09Jones, Cloanna K. 637459 25‑Mar‑10 RN Sanger TX 19‑Aug‑09Klutts, Jimmy L. 631827 25‑Mar‑10 RN Newcastle OK 12‑Nov‑09Lancaster, Susan F. 173204 26‑Feb‑10 LVN Wichita Falls TX 09‑Sep‑09Lander, F. D. 622917 12‑Mar‑10 RN Brownsville TX 09‑Jun‑09LaPaloma Medical Supplies 26‑Feb‑10 DME Roma TX 15‑Dec‑09Leonard, Danyell M. 169646 14‑Apr‑10 LVN Marshall TX 10‑Nov‑09Logan, Marshall D. 80991 25‑Mar‑10 LVN Austin TX 18‑Aug‑09Looney, Sherri J. 8788 15‑Apr‑10 LVN N Richland
HillsTX 10‑Nov‑09
Lopez, Peter C. 8239 14‑Apr‑10 MD Boerne TX 25‑Jul‑09Luth, David W. 201612 14‑Apr‑10 LVN Ft Worth TX 20‑Jan‑10Lyon, Jennifer L. 178391 15‑Apr‑10 LVN Crowley TX 10‑Nov‑09Mann, Rockland D. 454212 12‑Mar‑10 RN Irving TX 09‑Jun‑09Mannino, Troy M. 15737 30‑Mar‑10 Dent Katy TX 19‑Mar‑09Marler, Brandon L. 200902 25‑Mar‑10 LVN Orange TX 18‑Aug‑09Martin, Ann N. 642604 15‑Apr‑10 RN El Paso TX 23‑Jun‑09Matta, Gloria J. 130176 30‑Mar‑10 Tech Richmond TX 28‑Mar‑09Mayes, Gayla B. 108597 15‑Mar‑10 LVN Gainesville TX 24‑Jun‑09McDade, Dana P. 112356 14‑Apr‑10 OT Detroit MI 19‑Jun‑09McNutt, Steven S. L0413 15‑Apr‑10 MD Dover OH 06‑Nov‑09McQueen‑Torres Spicola, Kelly 670656 15‑Apr‑10 RN Baytown TX 25‑Oct‑09McSchooler, Ashley 212935 25‑Mar‑10 BON Quitman TX 04‑Sep‑09Mouser, Lara L. 139484 14‑Apr‑10 LVN Houston TX 20‑Jan‑10Nele, Victoria L. 83534 15‑Apr‑10 LVN Beaumont TX 08‑Dec‑09Newberry, Betty F. 157901 26‑Feb‑10 LVN Springtown TX 17‑Sep‑09Nezat, Ronald S. 681179 25‑Mar‑10 RN Sunset LA 10‑Sep‑09Oliver, Katrice L. 14‑Apr‑10 Pasadena TX 02‑Apr‑10Pacheco, Elisabeth 658224 15‑Apr‑10 RN Cedar Park TX 08‑Dec‑09Peet, Angelia M. 123242 30‑Mar‑10 Tech Porter TX 10‑Feb‑09Plattenburg, John P. 28651 30‑Mar‑10 Pharm Houston TX 01‑Jul‑09Pounds, Nina M. 121458 26‑Mar‑10 Tech Fort Worth TX 10‑Feb‑09Pyatt, Ronald 15‑Apr‑10 Other Dallas TX 08‑Mar‑10Randall, Terrecita M. 209730 15‑Apr‑10 LVN Houston TX 08‑Dec‑09Rasko, Josephine K. 695428 15‑Apr‑10 RN Wewoka OK 03‑Dec‑09Reynolds, Melissa J. 753697 26‑Mar‑10 RN Sale City GA 09‑Sep‑09Rice, Melissa A. 578036 15‑Apr‑10 RN Newton TX 10‑Nov‑09Roberts, Dale T. 739447 25‑Mar‑10 RN Denton TX 12‑Nov‑09
CPT only copyright 2009 American Medical Association. All rights reserved.
Providerlicense Number Add Date
Type Provider City State Start Date
Robinson, Debra A. 573430 15‑Mar‑10 RN Van TX 09‑Jun‑09Salas, Jamie R. 172967 15‑Apr‑10 LVN Arlington TX 19‑Jun‑09Sanders, Walter Jr. L. 15‑Apr‑10 Owner Rowlett TX 22‑Jun‑09Schmidt, Deanne M. 698895 26‑Mar‑10 RN Montrose CO 10‑Aug‑09Schmitt, Georgieann L. 655678 26‑Mar‑10 RN Allen TX 18‑Aug‑09Shipp, Dwayne A. 137076 15‑Apr‑10 LVN Houston TX 08‑Dec‑09Smith, Dawn M. 113347 15‑Mar‑10 RN Albia IA 09‑Jun‑09Smith, Sondra N. 15‑Apr‑10 Other Lufkin TX 24‑Oct‑08Spires, Cynthia L. 194667 01‑Mar‑10 LVN Morgantown KY 14‑Oct‑09Star Medical Academy 30‑Mar‑10 Huntsville TX 20‑Dec‑09Stewart, Philip A. 568605 01‑Mar‑10 RN The Woodlands TX 30‑Sep‑09Tenorio, Eddie 188615 15‑Mar‑10 LVN Albuquerque NM 09‑Jun‑09Vanciel, Nancy E. 495969 14‑Apr‑10 RN Garland TX 20‑Dec‑09Waltco Medical Equipment & Supplies, Inc.
16‑Apr‑10 DME Mesquite TX 19‑Jun‑09
West, Katherine D. 15‑Apr‑10 Owner Houston TX 07‑Dec‑09Widener, Patricia G. 59676 15‑Mar‑10 LVN Fort Worth TX 11‑Jun‑09Windecker, Heather H. 752502 25‑Mar‑10 RN Hammond LA 18‑Aug‑09
CPT only copyright 2009 American Medical Association. All rights reserved.
Sterilization Consent Form (Fax Consent Form to 1-512-514-4229)
Client Medicaid or family planning number: Date Client Signed / / (month/day/year)
Notice: Your decision at any time not to be sterilized will not result in the withdrawal or withholding of any benefits provided by programs or projects receiving federal funds.Consent to Sterilization
I have asked for and received information about sterilization from __________________________________ (doctor or clinic). When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I understand that the sterilization must be considered permanent and not reversible. I have decided that I do not want to become pregnant, bear children or father children. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized.
I understand that I will be sterilized by an operation known as a ______________________________________. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least 30 days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years of age and was born on ____ (month), ____(day), ____ (year). I, ______________________________________, hereby consent of my own free will to be sterilized by __________________________________(doctor or clinic) by a method called ___________________________. My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. Client’s Signature: Date of Signature: / / (month/day/year) Notice: You are requested to supply the following information, but it is not required.
Race and Ethnicity Designation Not Hispanic or Latino Native Hawaiian or Other Pacific Islander Black or African American Ethnicity Hispanic or Latino Race (mark one or more) American Indian or Alaska Native Asian White
Interpreter’s Statement If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice and presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in the ______________________ language and explained its contents to him/her. To the best of my knowledge and belief, he/she has understood this explanation.
Interpreter Signature: Date of Signature: / / (month/day/year) Statement of Person Obtaining Consent
Before ____________________________________________ (client’s full name), signed the consent form, I explained to him/her the nature of the sterilization operation known as a _________________________________________, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure.
Signature of person obtaining consent: Date of Signature: / / (month/day/year)
Facility name: Facility address:
Physician’s Statement
Shortly before I performed a sterilization operation upon __________________________________ (name of individual to be sterilized), on______/______/______ at (date of sterilization), I explained to him/her the nature of the sterilization operation _____________________________(specify type of operation), the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.) (1) At least 30 days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested):
Premature delivery - Individual's expected date of delivery:________/________ /________ (month, day, year)
Emergency abdominal surgery (describe circumstances): ____________________________________________________________________________________________
Physician’s Signature: Date of Signature: / / (month/day/year)
Paperwork Reduction Act Statement A federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays the currently valid OMB control number. Public reporting burden for this collection of information will vary; however, we estimate an average of one hour per response, including for reviewing instructions, gathering and maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or any other aspect of this collection of information to the OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Respondents should be informed that the collection of information requested on this form is authorized by 42 CAR part 50, subpart B, relating to the sterilization of persons in federally assisted public health programs. The purpose of requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks, benefits and consequences, and to assure the voluntary and informed consent of all persons undergoing sterilization procedures in federally assisted public health programs. Although not required, respondents are requested to supply information on their race and ethnicity. Failure to provide the other information requested on this consent form, and to sign this consent form, may result in an inability to receive sterilization procedures funded through federally assisted public health programs. All information as to personal facts and circumstances obtained through this form will be held confidential, and not disclosed without the individual’s consent, pursuant to any applicable confidentiality regulations.
All Fields in This Box Required for Processing TPI: NPI: Taxonomy: Benefit Code: Provider/clinic telephone: Provider/Clinic fax number: Titled Billed (check one): V X XIX (Medicaid) XX
CPT only copyright 2009 American Medical Association. All rights reserved.
Sterilization Consent Form (Spanish) (Fax Consent Form to 1-512-514-4229)
Client Medicaid or family planning number: Date Client Signed / / (month/day/year) Nota: La decisión de no esterilizarse que usted puede tomar en cualquier momento, no causará el retiro o la retención de ningún beneficio que le sea proporcionado por programas o proyectos que reciben fondos federales.
Consentimiento para Esterilización Yo he solicitado y he recibido información de __________________________________(médico o clínica) sobre la esterilización. Cuando inicialmente solicité esta información, me dijeron que la decisión de ser esterilizada/o es completamente mía. Me dijeron que yo podía decidir no ser esterilizada/o. Si decido no esterilizarme, mi decisión no afectará mi derecho a recibir tratamiento o cuidados médicos en el futuro. No perderé ninguna asistencia o beneficios de programas patrocinados con fondos federales, tales como A.F. D. C. o Medicaid, que recibo actualmente o para los cuales seré elegible. Entiendo que la esterilización se considera una operación permanente e irreversible. Yo he decidido que no quiero quedar embarazada, no quiero tener hijos o no quiero procrear hijos. Me informaron que me pueden proporcionar otros métodos de anticoncepción disponibles que son temporales y que permitirán que pueda tener o procrear hijos en el futuro. He rechazado estas opciones y he decidido ser esterilizada/o. Entiendo que seré esterilizada/o por medio de una operación conocida como ______________________________________. Me han explicado las molestias, los riesgos y los beneficios asociados con la operación. Han respondido satisfactoriamente a todas mis preguntas. Entiendo que la operación no se realizará hasta que hayan pasado 30 días, como mínimo, a partir de la fecha en la que firme esta Forma. Entiendo que puedo cambiar de opinión en cualquier momento y que mi decisión en cualquier momento de no ser esterilizada/o no resultará en la retención de beneficios o servicios médicos proporcionados a través de programas que reciben fondos federales. Tengo por lo menos 21 años y nací el ____ (mes), ____( día), ____ (año). Yo, ______________________________________, por medio de la presente doy mi consentimiento de mi libre voluntad para ser esterilizada/o por __________________________________ (médico o clínica) por el método llamado ___________________________. Mi consentimiento vence 180 días a partir de la fecha en la que firme este documento. También doy mi consentimiento para que se presente esta Forma y otros expediente médicos sobre la operación a: Representantes del Departamento de Salud y Servicios Sociales, o Empleados de programas o proyectos financiados por ese Departamento, pero sólo para que puedan determinar si se han cumplido las leyes federales. He recibido una copia de esta Forma. Firma: Fecha: / / (mes, día , año) Nota: Se ruega proporcione la siguiente información, aunque no es obligatorio hacerlo:
Definición de Raza y Origen Étnico No hispano o latino Natural de Hawaii u otras islas del Pacífico Negro o afroamericano Origen étnico Hispano o latino
Raza (marque según aplique) Indígena americano o indígena de Alaska Blanco Asiático
Declaración Del Intérprete Si se han proporcionado los servicios de un intérprete para asistir a la persona que será esterilizada: He traducido la información y los consejos que verbalmente se le han presentado a la persona que será esterilizada/o por el individuo que ha obtenido este consentimiento. También le he leído a él/ella la Forma de Consentimiento en idioma ______________________ y le he explicado el contenido de esta forma. A mi mejor saber y entender, ella/él ha entendido esta explicación. Firma: Fecha: / / (mes, día , año)
Declaración De La Persona Que Obtiene Consentimiento Antes de que ____________________________________________(nombre de persona) firmara la Forma de Consentimiento para la Esterilización, le he explicado a ella/él los detalles de la operación _________________________________________, para la esterilización, el hecho de que el resultado de este procedimiento es final e irreversible, y las molestias, los riesgos y los beneficios asociados con este procedimiento. He aconsejado a la persona que será esterilizada que hay disponibles otros métodos de anticoncepción que son temporales. Le he explicado que la esterilización es diferente porque es permanente. Le he explicado a la persona que será esterilizada que puede retirar su consentimiento en cualquier momento y que ella/él no perderá ningún servicio de salud o beneficio proporcionado con el patrocinio de fondos federales. A mi mejor saber y entender, la persona que será esterilizada tiene por lo menos 21 años de edad y parece ser mentalmente competente. Ella/él ha solicitado con conocimiento de causa y por libre voluntad ser esterilizada/o y parece entender la naturaleza del procedimiento y sus consecuencias.. Firma de la persona que obtiene el consentimiento: Fecha: /: /: (mes, día , año) Lugar: Dirección:
Declaración Del Médico Previamente a realizar la operación para la esterilización a __________________________________ (nombre de persona esterilizada/o), en ______/______/______ (fecha de esterilización: día, mes, año), le expliqué a él/ella los detalles de esta operación para la esterilización _____________________________(especifique tipo de operación), del hecho de que es un procedimiento con un resultado final e irreversible, y las molestias, los riesgos y los beneficios asociados con esta operación. Le aconsejé a la persona que sería esterilizada que hay disponibles otros métodos de anticoncepción que son temporales. Le expliqué que la esterilización es diferente porque es permanente. Le informé a la persona que sería esterilizada que podía retirar su consentimiento en cualquier momento y que ella/él no perdería ningún servicio de salud o ningún beneficio proporcionado con el patrocinio de fondos federales. A mi mejor saber y entender, la persona que será esterilizada tiene a lo menos 21 años de edad y parece ser mentalmente competente. Ella/él ha solicitado con conocimiento de causa y libre voluntad ser esterilizada/o y parece entender el procedimiento y las consecuencias de este procedimiento. (Instrucciones para uso alternativo de párrafos finales: Utilice el párrafo 1 que se presenta a continuación, excepto para casos de parto prematuro y cirugía abdominal de emergencia cuando se ha realizado la esterilización a menos de 30 días después de la fecha en la que la persona firmó la Forma de Consentimiento para la Esterilización. Para esos casos, utilice el párrafo 2 que se presenta más adelante. Tache con una X el párrafo que no se aplique). (1) Han transcurrido por lo menos 30 días entre la fecha en la que la persona firmó esta Forma de Consentimiento y la fecha en la que se realizó la esterilización. (2) La operación para la esterilización se realizó a menos de 30 días, pero a más de 72 horas, después de la fecha en la que la persona firmó la Forma de Consentimiento debido a las siguientes circunstancias (marque la casilla apropiada y escriba la información requerida):
Parto prematuro - Fecha prevista de parto ________/________ /________(mes, día , año) Cirugía abdominal de urgencia (Describa las circunstancias): __________________________________________________________________________________________
Firma del médico: Fecha: / / (mes, día , año) Declaración Sobre Ley De Reducción De Trámites
Una agencia federal no debe llevar a cabo o patrocinar la recolección de información, y el público no está obligado a responder a la misma o a facilitar la información, a no ser que dicha solicitud de información presente un número de control válido de la OMB. La carga horaria para el público que completa esta forma variará; sin embargo, se ha estimado un promedio de una hora por cada respuesta, cálculo que incluye el tiempo para revisar las instrucciones, buscar y presentar los datos exigidos y completar la forma. Para enviar sus comentarios sobre la carga horaria estimada o cualquier otro aspecto de la información requerida, escriba a OS Reports Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, S.W., Washington, D.C. 20201.Se debe informar al público que responde a esta forma que la recolección de información solicitada en la misma se autoriza en virtud de 42 CAR parte 50, subparte B, que tiene que ver con la esterilización de personas en programas de salud pública que son financiados por el gobierno federal. El propósito de la recolección de esta información es asegurar que las personas que solicitan la esterilización sean informadas sobre los riesgos, los beneficios y las consecuencias de esta operación, y para asegurar el consentimiento voluntario e informado de todas las personas que se someten al procedimiento de esterilización en programas de salud pública que reciben asistencia federal. Se pide a las personas que llenan la forma que incluyan datos sobre su raza y grupo étnico, aunque esta información no es requerida. Toda la demás información solicitada en esta forma de consentimiento es requerida. Si la persona que llena la forma no proporciona la información requerida o si no firma esta forma de consentimiento, podría resultar en que no recibiera el procedimiento de esterilización financiado por un programa de salud pública patrocinado con fondos federales.Toda la información de datos y circunstancias personales obtenidas por medio de esta Forma son confidenciales y no se divulgarán sin el consentimiento de la persona, en conformidad con todos los reglamentos aplicables de confidencialidad.
All Fields in This Box Required for Processing TPI: NPI: Taxonomy: Benefit Code: Provider/clinic telephone: Provider/Clinic fax number: Titled Billed (check one): V X XIX (Medicaid) XX
CPT only copyright 2009 American Medical Association. All rights reserved.
Sterilization Consent Form Instructions
Per Title 42 Code of Federal Regulations (CFR) 50, Subpart B, all sterilizations require a valid consent form regardless of the funding source. Ensure all required fields are completed for timely processing.
Fax or mail the Sterilization Consent Form five business days before submitting the associated claim(s) to expedite the processing of the Sterilization Consent Form and associated claim(s).
Fax fully completed Sterilization Consent Forms to Texas Medicaid & Healthcare Partnership (TMHP) at 1-512-514-4229. Claims and appeals are not accepted by fax. Only send family planning sterilization correspondence to this fax number.
Note: Hysterectomy Acknowledgment forms are not sterilization consents and should be faxed to 1-512-514-4218.
Clients must be at least 21 years of age when the consent form is signed. If the client was not 21 years of age when the consent form was signed, the consent will be denied. Changing signature dates is considered fraudulent and will be reported to the Office of the Inspector General (OIG).
There must be at least 30 days between the date the client signs the consent form and the date of surgery, with the following exceptions:
Exceptions: (1) Premature delivery - There must be at least 72 hours between the date of consent and the date of surgery. The informed consent must have been given at least 30 days before the expected date of delivery. (2) Emergency Abdominal Surgery -There must be at least 72 hours between the date of consent and the date of surgery. Operative reports detailing the need for emergency surgery are required.
Listed below are field descriptions for the Sterilization Consent Form. Completion of all sections is required to validate the consent form, with only two exceptions:
Exceptions: Race and Ethnicity Designation is requested but not required. The Interpreter’s Statement is not required as long as the consent form is written in the client's language, or the person obtaining the consent speaks the client's language. If this section is partially completed, the consent will be denied for incomplete information.
This Sterilization Consent Form may be copied for provider use. Providers are encouraged to frequently recopy the original form to ensure legible copies and to expedite consent validation.
Required Fields All of the fields must be legible in order for the consent form to be valid. Any illegible field will result in a denial of the submitted consent form. Resubmission of legible information must be indicated on the consent form itself. Resubmission with information indicated on a cover page or letter will not be accepted.
Consent to Sterilization • Name of Doctor or Clinic. • Name of the Sterilization Operation. • Client’s Date of Birth (month, day, year). • Client's Name (first and last names are required). • Name of Doctor or Clinic. • Name of the Sterilization Operation. • Client’s Signature. • Date of Client Signature - Client must be at least 21 years of age on this date. This date
CPT only copyright 2009 American Medical Association. All rights reserved.
Interpreter’s Statement (If applicable) • Name of Language Used by Interpreter. • Interpreter’s Signature. • Date of Interpreter’s Signature (month, day, year). Statement of Person Obtaining Consent • Client's Name (first and last names are required). • Name of the Sterilization Operation. • Signature of Person Obtaining Consent -The statement of person obtaining consent must be
completed by the person who explains the surgery and its implications and alternate methods of birth control. The signature of person obtaining consent must be completed at the time the consent is obtained. The signature must be an original signature, not a rubber stamp.
• Date of the Person Obtaining Consent’s Signature (month, day, year) - Must be the same date as the client's signature date.
• Facility Name - Clinic/office where the client received the sterilization information. • Facility Address - Clinic/office where the client received the sterilization information. Physician’s Statement • Client’s Name (first and last names are required). • Date of Sterilization Procedure (month, day, year) - Must be at least 30 days and no more
than 180 days from the date of the client’s consent except in cases of premature delivery or emergency abdominal surgery.
• Name of the Sterilization Operation. • Expected Date of Delivery (EDD) - Required when there are less than 30 days between the
date of the client consent and date of surgery. Client’s signature date must be at least 30 days prior to EDD.
• Circumstances of Emergency Surgery - Operative report(s) detailing the need for emergency abdominal surgery are required.
• Physician’s Signature - Stamped or computer-generated signatures are not acceptable. • Date of Physician’s Signature (month, day, year) - This date must be on or after the date of
surgery. Paperwork Reduction Act Statement This is a required statement and must be included on every Sterilization Consent Form submitted.
Additional Required Fields • Medicaid or Family Planning Number - Clients submitted as Titles V, X, and XX may not have
a Family Planning number. Please simply indicate the appropriate Title below. • Date Client Signed the Consent (month, day, year). • The following provider identifcation numbers will be required to expedite the processing of the
consent form: o TPI o NPI o Taxonomy o Benefit Code
• Provider/Clinic Phone Number. • Provider/Clinic Fax Number (If available). • Family Planning Title for Client - Indicate by circling V, X, XIX (Medicaid), or XX.
CPT only copyright 2009 American Medical Association. All rights reserved.
Effective Date_12012009/Revised Date_05032010
Obstetric Ultrasound Prior Authorization RequestTexas Medicaid Program
v
This form is to be used to obtain prior authorization for greater than three obstetric ultrasounds per pregnancy. Forms that are submitted without all of the required information will be returned for correction. Fax the completed form to 1-512-302-5039 or call 1-888-302-6167 for authorization.
Client Information
First Name: Last Name: Middle Initial:
DOB: Client Medicaid Number:
Requesting Provider Information
Name: Address:
City: State: Zip:
TPI: NPI: Taxonomy:
Telephone number: Fax number:
Performing/Facility Provider Information (if different from requesting provider)
Name: Address:
City: State: Zip:
TPI: NPI: Taxonomy:
Telephone number: Fax number:
Procedure(s) Requested: CPT Codes
CPTCode
Qty Trimester Performed
From Date To Date CPTCode
Qty Trimester Performed
From Date To Date
/ / / / / / / /
/ / / / / / / /
Client’s Estimated Date ofConfinement (EDC): / /
Gravidity: Parity: Diagnosis:
Clinical documentation supporting medical necessity for obstetric ultrasounds includes treatment history, treatment plan, medications, and previous imaging results:
If requesting serial ultrasounds, please provide intended frequency and clinical rationale.
Provider (Physician, CNM, NP, CNS, or PA) must complete and sign this form prior to requesting authorization.
Medicaid fee-for-service and Primary Care Case Management (PCCM) clients are limited to three obstetric ultrasounds per pregnancy. Obstetrical ultrasounds procedures performed in the emergency room, outpatient observation, or inpatient hospital setting are excluded from this limitation.
If it is medically necessary to perform more than three obstetrical ultrasounds on a client during a pregnancy, the provider must complete this form to request prior authorization. A request for retroactive authorization must be submitted no later than 14 calendar days beginning the day after the study is completed.
Use the guidelines below in filling out the Obstetric Ultrasound Prior Authorization Request form.
Client Information Client’s name Last name (required), first name (required), middle initial (optional) Date of birth Date of birth given by month, day and year (required) Medicaid number: Nine-digit number from client’s current Medicaid identification card. (required)
Requesting Provider InformationName Name of Provider (required)Address Agency address given by street, city, state and ZIP code (required) TPI Texas Provider Identifier number (10-digit) (optional) NPI National Provider Identifier number (10-digit) (required) Taxonomy Ten-character Taxonomy code showing service type, classification, and specialization of the medical
service provider (optional) Telephone Area code and telephone number (required) Fax Number Area code and fax number (required)
Performing / Facility Provider Information (complete only if different from requesting provider)
Name Name of Provider (required) Address Agency address given by street, city, state and ZIP code (required) TPI Texas Provider Identifier number (10-digit) (optional) NPI National Provider Identifier number (10-digit) (required) Taxonomy Ten-character Taxonomy code showing service type, classification, and specialization of the medical
service provider (optional) Telephone Area code and telephone number (required) Fax Number Area code and fax number (required)
Procedures Requested SectionCPT Codes The five digit code from the most recent edition of the Current Procedural Terminology manual
(required)Quantity The number of ultrasounds requested for that CPT code (required) Performed Trimester The trimester(s) during which the requested ultrasounds will be performed (required) Dates of Service (from and to) Indicate the date range during which the procedure(s) will be performed (required)
Note: If requesting more than one CPT code complete the additional linesClient’s Estimated Date of Confinement
Provide current estimated month, day, and year of delivery at the time the request is submitted (required)
Gravidity Total number of a woman’s pregnancies (optional) Parity Total number of viable pregnancies (optional) Diagnosis Codes Include all applicable ICD-9-CM diagnosis codes (required)
Clinical Documentation Section Treatment History Summary of previous treatment, if any for the clients condition (required, if applicable) Treatment Plan Proposed treatment plan related to obstetric ultrasounds and pregnancy (required, if applicable) Medications List of current medications, if any (required, if applicable) Previous Imaging Results List type of imaging, date(s) and results (required, if applicable) Serial Ultrasounds If requesting serial ultrasounds provide the intended frequency for the procedures and the clinical
rationale to support the need for serial ultrasounds
Provider Signature Section Requesting Provider signature, Date signed, Printed provider name, Provider license number
Requesting provider for OB ultrasounds must be a physician, certified nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). The provider’s signature, the date the form was signed by the provider, and the provider’s printed name are all required, and the provider’s license number is optional.
Provider Accounting Address Provider Phone Number ( ) Ext.
Bank Name ABA/Transit Number
Bank Phone Number Account Number
Bank Address Type Account (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 health insuring 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 Email Address (if applicable)
Contact Name Phone
Return this form to: Texas Medicaid & Healthcare Partnership
CPT only copyright 2009 American Medical Association. All rights reserved.
Electronic Funds Transfer (EFT) Information
— A STATE MEDICAID CONTRACTOR23
Effective Date_10152007/Revised Date_10152007
Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider’s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.
The following items are specific to EFT:
• Pre–notification to your bank takes place on the cycle following the application processing.
• 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, and API) and R&S number. • EFT funds are released by TMHP to depository financial institutions each Friday. • 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. Please 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 the agreement and either a voided check or a statement from your bank written on the bank’s letterhead to the TMHP address indicated on the form.
Call the TMHP Contact Center at 1–800–925–9126 for assistance.
CPT only copyright 2009 American Medical Association. All rights reserved.
Effective Date_09012009/Revised Date_08212009
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 : / /
National Provider Identifier (NPI): Primary Taxonomy Code:
Atypical Provider Identifier (API): Benefit Code:
List any additional TPIs that use the same provider information:
TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI:
Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid 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 Hearing Services for Children
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
CPT only copyright 2009 American Medical Association. All rights reserved.
Effective Date_09012009/Revised Date_08212009
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.
