www.tmhp.comTexas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for the Texas Medicaid Program
under contract with the Texas Health and Human Services Commission (HHSC)
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•B i m o n t h l y u p d a t e t o t h e Te x a s M e d i c a i d P r o v i d e r P r o c e d u r e s M a n u a l
Texas MedicaidWarm Up to the Articles in This Bulletin:• 2004 ICD-9-CM Implementation Postponed. See page 2.• LMSW-ACP to LCSW? See page 2.• SHARS Rates SFY04. See page 3.• Hydrophilic Intermittent Urinary Catheters article. See page 4.
2004 ICD-9-CM Implementation Postponed ........................................................................... 2TMHP Electronic Funds Transfer (EFT) Information ................................................................. 2Licensed Clinical Social Worker (LCSW) ................................................................................ 2Influenza Coding Changes .................................................................................................... 2Medically Needy Spend Down Program Available to Adult Pregnant Women .............................. 2Preferred Drug List (PDL) ..................................................................................................... 2SHARS Rates SFY04 ........................................................................................................... 3Revised Influenza Vaccine Recommendations ........................................................................ 4
TMHP Electronic Funds Transfer (EFT) Information ............................................................... 11TMHP Electronic Funds Transfer (EFT) Authorization Agreement ............................................. 12Provider Information Change Form ...................................................................................... 13
Implementation of the annual 2004 International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) diagnoses, procedures and diagnosis-related groups (DRGs) has been postponed until 2004. As a result, the implemen-tation of Grouper 21 has also been postponed. Providers will be notified of the actual effective date and affected policies at a future date. Continue to use 2003 ICD-9-CM and Grouper 20 information for claims and authorizations until further notice. ■
Influenza Coding Changes
There is a change in coding related to the influenza vaccine and its administration. See the table below for appropriate codes for claims submission for this vaccine and its administration. To determine the appropriate code(s) for submission, the provider determines the type of service, age of the client receiving the vaccine, and whether or not the influenza vaccine is provided by the Texas Vaccines for Children (TVFC) program. If a claim related to the influenza vaccine or its adminis-tration has been denied since September 1, 2003, submit an appeal of the claim using the appropriate codes:
Licensed Clinical Social Worker (LCSW)
The Texas Medicaid Program has been informed of a recent change of licensure designation for licensed master social worker-advanced clinical practitioner (LMSW-ACP). The Texas State Board of Social Worker Examiners announced that effective September 1, 2003, LMSW-ACPs are now designated as licensed clinical social workers (LCSW).
The Social Work Licensing Board indicates that they understand that there will be a transition period for all licensees. Reportedly, many licensees have stated that, in order to avoid confusion, they will not begin using the new credentials until they are in receipt of the new license. All licensees must begin using the new titles by September 1, 2004.
At the direction of HHSC, the LMSW-ACP designation will not change until the 2005 manual revision cycle. ■
Medically Needy Spend Down Program Available to Adult Pregnant Women
The Medically Needy Spend Program is again available to adult pregnant women who are not otherwise eligible for Medicaid because of income. The effective date of the restoration is retroactive to September 1, 2003, when the program was discontinued for all adults. Only pregnant women are now allowed this coverage, no other adult applicants. Resume referring pregnant women to this program. ■
Preferred Drug List (PDL)
Early next year, the Texas Health and Human Services Commission (HHSC) will begin implementing the Preferred Drug List (PDL) for the Medicaid and Children's Health Insurance Program (CHIP) programs. In February 2004, HHSC will establish the PDL for the 15 drug classes reviewed by the Pharmaceutical and Therapeutics (P&T) Committee at its December meeting. HHSC will later expand the list to include additional drug classes.
With the implementation of the PDL, HHSC will establish a prior authorization function that will allow prescribers to obtain prior authorization for nonpreferred drugs. Nonpreferred drugs are drugs that have been reviewed by the P&T Committee, but that were not selected by HHSC to be on the PDL. Prior authorization will not be required for drugs and drug classes
Type of service
THSteps(During a THSteps medical check-up)
Acute Care/Medical (Outside of THSteps medical check-up)
Acute Care/Medical(Outside of THSteps medical checkup)
Client age and vaccine source
Less than 19 years andReceiving vaccine from TVFC
Less 19 yearsand Receiving vaccine from TVFC
19 years or older or All age groups if not receiving vaccine from TVFC
that have not been reviewed by the P&T Committee. Policies and procedures for requesting prior authorizations will be posted on the Vendor Drug Program @eb site (www.hhsc.state.tx.us/HCF/vdp/vdpstart.html) 30 days before program implementation. ■
SHARS Rates SFY04
This article contains an updated table of School Health and Related Services (SHARS) state fiscal year 2004 (SFY04) local and SFY04 national code pricing changes effective during SFY04. The following table includes the local codes and pricing effective September 1, 2003, through October 15, 2003, and the national codes and pricing effective October 16, 2003, through August 31, 2004:
H0004 Behavioral health counseling and therapy, per 15 minutes $17.45 per 15 minutes
7009X Occupational therapy, each 15 minutes
$16.02 per 15 minutes
97003or97530
Occupational therapy evaluation orTherapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), 15 minutes each
$16.02 per 15 minutes
7010X Physical therapy, each 15 minutes
$16.65 per 15 minutes
97001or97110
Physical therapy evaluation orTherapeutic procedure, one or more areas, 15 minutes each, therapeutic exercises to develop strength and endurance, range of motion, flexibility
$16.65 per 15 minutes
7011X Psychological services, each 15 minutes
$18.84 per 15 minutes
H0004 with modifier AH
Behavioral health counseling and therapy, per 15 minutes with clinical psychologist
Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual with services delivered under and outpatient speech-language pathology plan or care
$15.13 per 15 minutes
7013X Medical services, each 15 minutes
$47.61 per 15 minutes
99499 Unlisted evaluation and management service $47.61 per 15 minutes
7014X School health services, each 15 minutes
$13.89 per 15 minutes
T1002 RN services, up to 15 minutes $13.89 per 15 minutes
7015X Assessment, each 15 minutes
$17.35 per 15 minutes
96100 Psychological testing (includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, for example, WAIS-R, Rorschach, MMPI) with interpretation and report, per hour
$69.40 per hour, with partial units billable in 6-minute increments
4738Z SHARS special transportation, per student round trip
$19.76 per student round trip
T2003 Nonemergency transportation; encounter/trip $19.76 per student round trip ■
The Centers for Disease Control and Prevention (CDC) has announced an expansion of the routine recommendations for influenza vaccine during the 2003-2004 influenza season. All children eligible for the TVFC should be vaccinated in accor-dance with the revised Advisory Committee on Immunization Practices (ACIP) and the Federal Vaccines for Children (VFC) Program resolution. (A copy of the resolution can be downloaded from www.cdc.gov/mmwr/PDF/rr/rr5208.pdf.) Eligible groups are identified as:
• Children age 6 months through 23 months
• Children and adolescents age 6 months through 18 years with chronic disorders of the pulmonary or cardiovascular systems, including asthma
• Children and adolescents age 6 months through 18 years who have required regular medical follow-up or hospital-ization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglolbinopathies, or immunosuppression (including immunosuppression caused by medications)
• Children and adolescents age 6 months through 18 years who are receiving long-term aspirin therapy and may therefore be at risk for developing Reye syndrome after influenza
• Children and adolescents age 2 years through 18 years who are household contacts of people in high-risk groups (e.g., people age 65 years or older, transplant recipients, people with AIDS, and children younger than age 2 years)
• Children and adolescents age 6 months through 18 years who are residents of nursing facilities and other chronic-care facilities that house people at any age who have chronic medical conditions
• Adolescent females less than age 19 years who will be in the second or third trimester of pregnancy during influenza season
Influenza vaccine orders for Medicaid children and all TVFC-eligible children should be placed following the TVFC vaccine ordering procedures currently in place for routine childhood vaccines.
Contact the nearest Public Health region (PHR) Immunization Program Manager with questions regarding influenza vaccine recommendations. For influenza vaccine ordering information, contact Lisa Davis at 800-252-9152 or 512-458-7284. ■
TMHP Electronic Funds Transfer (EFT) Information
Providers currently participating in electronic funds transfer (EFT) with NHIC are not required to resubmit or change their current EFT agreements. All current agreements will transfer to TMHP. Only providers who do not currently have an existing agreement or newly enrolled providers will need to complete the revised EFT application.
Refer to: TMHP Electronic Funds Transfer (EFT) Information on page 11. ■
DME Providers
Hydrophilic Intermittent Urinary Catheters
Effective for dates of service on or after October 16, 2003, all hydrophilic intermittent urinary catheters (such as, Speed-iCath, Bard Interglide, and LoFric) may be considered for prior authorization and reimbursement using procedure code A9900, Miscellaneous DME supply, accessory, and/or service component of another HCPCS code, manually priced at manufacturer’s suggested retail price (MSRP) less 18 percent, with a maximum fee of $3.53. ■
THSteps Medical Providers
TDH Laboratory Billing of THSteps Medical Providers
All laboratory specimens, obtained as part of a THSteps medical checkup, must be submitted to the TDH Bureau of Labora-tories. There is no cost to the THSteps medical provider for laboratory supplies and services that are part of a THSteps medical checkup for THSteps-eligible clients. However, THSteps does reimburse the TDH Laboratory for the cost of these supplies and services.
THSteps must have information sufficient to verify that the client is Medicaid-eligible on the date of the medical checkup to reimburse the TDH Laboratory for the cost of these services. Without sufficient client information for a Medicaid eligibility verification, THSteps cannot reimburse the laboratory. Therefore, THSteps supports the TDH Laboratory billing to any
THSteps provider for any laboratory test conducted on a specimen that is not accompanied with client information sufficient to verify Medicaid eligibility. Sources: 2003 TMPPM-Texas Health Steps, page 22; 2004 TMPPM-Texas Health Steps, page 23.
THSteps laboratory specimens submitted to TDH must include the client’s name and Medicaid number as they appear on the Form 3087 on a THSteps Laboratory Request (Form NBS-3, G--1A, G-1B). Write PENDING in the Medicaid number space if a number is not currently available but is pending (such as, a newborn or a newly certified client patient verified by a Form 1027 as eligible for Medicaid).
Important: These services and supplies are limited to THSteps medical checkup and laboratory services provided in the course of a medical checkup to THSteps clients. Unauthorized use of services and supplies is in violation of federal regulations. The $70 reimbursement for the complete medical checkup includes specimen collection, shipping, and receiving test results from the TDH laboratory. Claims for tests listed in the following table submitted by a provider or an outside laboratory for the same date of service as a THSteps medical checkup are denied and subject to retrospective review:
Excluded ProvidersIn compliance with the Medicare and Medicaid Patient Protection Act of 1987, HHSC identifies providers or employees of providers who have been excluded from state and federal health care programs.
Providers excluded from the Medicaid and Title XX programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client.
Review the entire Exclusion List for Texas Medicaid at www.hhsc.state.tx.us/OIE/exclusionlist/exclusion.asp. Report Medicaid providers who engage in fraud/abuse by calling 512-424-6519 or 888-752-4888, or by writing to the following address:
Sharon E. Thompson, Director HHSC Office of Program Integrity
PO Box 13247Austin TX 78711-3247
Provider License No. Exclusion Date City State Provider Type Add Date
Abdullahi, Shadia 683211 12-Aug-03 New Orleans LA RN 04-Dec-03
Adams, Kathy Lynn 130145 10-Jun-03 Corpus Christi LVN 13-Oct-03
Adelman, Harold F H3965 6-Jun-03 De Soto TX MD 23-Oct-03
Amstutz, John F 90145 10-Jun-03 Seguin LVN 13-Oct-03
Anderson, Christy D F 217626 11-Feb-03 Arlington RN 8-Oct-03
Bache-Russell, Amanda B 532596 4-Oct-02 Dallas RN 6-Oct-03
Bailey, George A L0009 28-Mar-03 Houston DO 1-Oct-03
Baker, Michele A 132810 10-Jun-03 Abbott LVN 27-Oct-03
Baluch, Abdul F7693 15-Aug-03 Lubbock MD 25-Nov-03
Bauer, John 12539 1-Sep-03 Mansfield DDS 15-Oct-03
Bazazzadegan, Julia E 09-Sep-03 Elmo 04-Dec-03
Beals, Lee E 181229 10-Jun-03 Dallas LVN 29-Oct-03
Betros, Arnold 133522 10-Jun-03 Killeen LVN 23-Oct-03
Boling, Louis A 118339 4-Mar-03 Brownsville TX LVN 1-Oct-03
Brende, Marti A 583416 6-May-03 Bastrop TX RN 15-Oct-03
Broadnax, Terri L 158610 4-Mar-03 El Paso TX LVN 3-Oct-03
