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Physician
29.1 Enrollment 29-4
29.1.1 Independent Practices 29-4
29.1.2 Group Practices 29-4
29.1.3 Referrals to Other Providers 29-5
29.1.4 Substitute Physician 29-5
29.2 Benefits, Limitations, and Authorization Requirements 29-5
29.2.1 Authorization and Prior Authorization Requirements 29-5
29.2.2 Aerosol Treatments/Inhalation Therapy 29-6
29.2.3 Allergy Services 29-6
29.2.4 Anesthesia Services 29-7
29.2.4.1 Medical Direction 29-7
29.2.4.2 Monitored Anesthesia Care 29-8
29.2.4.3 Anesthesia Modifiers 29-8
29.2.4.4 Dental General Anesthesia 29-10
29.2.4.5 Services Incidental to Surgery or Anesthesia 29-10
29.2.4.6 Services Not Considered Incidental to Surgery or Anesthesia 29-10
29.2.4.7 Reimbursement 29-11
29.2.4.8 Conversion Factor 29-11
29.2.4.9 Time-Based Fees 29-11
29.2.5 Anterior Temporal Lobectomy 29-12
29.2.6 Audiometry/Hearing Services 29-12
29.2.7 Augmentative Communication Devices (ACDs) 29-12
29.2.8 Blood Factor Products 29-12
29.2.9 Bone Growth Stimulators 29-13
29.2.9.1 Internal Electromagnetic Bone Growth Stimulator 29-13
29.2.9.2 Electrical Stimulation (Noninvasive) 29-14
29.2.9.3 External Low-Intensity Ultrasound Stimulation 29-14
29.2.9.4 Prior Authorization Requirements for Bone Growth Stimulators 29-14
29.2.11 Chemotherapy 29-16
29.2.12 Clinician-Directed Care Coordination Services 29-17
29.2.12.1 Face-to-Face Clinician-Directed Care Coordination Services 29-17
29.2.12.2 Non-Face-to-Face Clinician-Directed Care Coordination Services 29-18
29.2.13 Cochlear Implants 29-22
29.2.14 Colorectal Cancer Screening 29-22
29.2.15 Critical Care Services 29-23
29.2.15.1 Pediatric Critical Care 29-25
29.2.15.2 Neonatal Critical Care 29-26
29.2.15.3 Intensive Care (Noncritical) Services 29-27
29.2.15.4 Newborn Resuscitation 29-28
29.2.16 Echoencephalography 29-28
29.2.16.1 Intraoperative Echography 29-28
29.2.16.2 Ambulatory Electroencephalogram 29-41
29.2.17 Electrodiagnostic Testing 29-42
29.2.17.1 Authorization and Prior Authorization Requirements 29-49
29.2.18 Evaluation and Management (E/M) Services 29-51
29.2.18.1 New or Established Patient Visits 29-51
29.2.18.2 Inpatient Professional Services 29-51
29.2.18.3 Emergency Services 29-52
29.2.18.4 Consultations 29-53
29.2.18.5 Services Outside of Business Hours 29-54
29.2.18.6 Prolonged Physician Services 29-54
29.2.18.7 Observation Room Services 29-54
29.2.18.8 Preventive Care Services 29-56
29.2.18.9 Dental Screening and Intermediate Oral Evaluation with
Fluoride Varnish Application in the Medical Home 29-56
29.2.18.10 Teaching Physicians 29-57
29.2.19 Extracorporeal Shock Wave Lithotripsy (ESWL) 29-57
29.2.20 Gastrostomy Devices 29-57
29.2.21 Genetics 29-57
29.2.22 Hyperbaric Oxygen Therapy (HBOT) 29-58
29.2.23 Immunizations (Vaccines and Toxoids) 29-72
29.2.23.1 Texas Vaccines for Children (TVFC) Program 29-72
29.2.23.4 Vaccine Information Statement 29-72
29.2.23.5 Administration Fee 29-73
29.2.23.6 Benefits, Limitations, and Authorization Requirements 29-73
29.2.23.7 DTaP-IPV-Hib Vaccine (Pentacel) 29-75
29.2.23.8 Respiratory Syncytial Virus (RSV) Prophylaxis 29-75
29.2.24 Injections and Oral Medications 29-78
29.2.24.1 Injection Administration Billed by a Physician 29-79
29.2.24.2 Adalimumab Injection 29-79
29.2.24.3 Botulinum Toxin (Type A and Type B) 29-79
29.2.24.5 Clofarabine (Clorar) 29-82
29.2.24.6 Denileukin Diftitox 29-83
29.2.24.8 Epirubicin Hydrochloride 29-83
29.2.24.9 Epoprostenol 29-83
29.2.24.10 Erythropoietin Alfa (EPO) and Darbepoetin 29-84
29.2.24.11 Granisetron Hydrochloride 29-87
29.2.24.12 Ibutilide Fumarate 29-87
29.2.24.13 Immune Globulins 29-87
29.2.24.16 Natalizumab Injection 29-90
29.2.24.18 Porfimer Sodium 29-91
29.2.24.20 Sumatriptan Succinate 29-92
29.2.25 Intracranial Pressure Monitoring 29-93
29.2.26 Laboratory Services 29-93
29.2.26.1 Physician Laboratory Services 29-93
29.2.26.2 Laboratory Handling Fee 29-93
29.2.26.3 Claims Filing for Laboratory Tests 29-94
29.2.26.4 Clinical Pathology Services and Pathology Consultations 29-94
29.2.26.5 Reimbursement 29-94
29.2.26.6 Cytopathology Studies (Gynecological, Pap Smears) 29-94
29.2.26.7 Cytogenetics Testing 29-94
29.2.26.8 Helicobacter Pylori (H. Pylori) 29-95
29.2.26.9 CLIA Requirement 29-95
29.2.27 Neurostimulator Devices and Supplies 29-95
29.2.28 Ophthalmological Services 29-95
29.2.28.1 Intraocular Lenses (IOL) 29-95
29.2.28.2 Vitrasert Ganciclovir Implant 29-95
29.2.29 Osteopathic Manipulative Treatment (OMT) 29-95
29.2.30 Physical Medicine and Physical Therapy (PT) Services 29-96
29.2.31 Podiatry 29-96
29.2.32 Psychological Testing 29-96
29.2.33 Sign Language Interpreting Services 29-97
29.2.34 Sleep Studies 29-97
29.2.34.1 Polysomnography 29-97
29.2.34.2 Multiple Sleep Latency Test 29-99
29.2.34.3 Pediatric Pneumogram 29-100
29.2.35 Surgery 29-101
29.2.35.1 Anesthesia Administered by Surgeon 29-101
29.2.35.2 Primary Surgeons 29-101
29.2.35.3 Assistant Surgeons 29-101
29.2.35.5 Bilateral Procedures 29-103
29.2.35.6 Global Fees 29-103
29.2.35.7 Multiple Surgeries 29-103
29.2.35.8 Office Procedures 29-103
29.2.35.9 Second Opinions 29-104
29.2.35.10 Unlisted Surgical Procedure Code Considerations 29-104
29.2.35.12 Cleft/Craniofacial Procedures 29-104
29.2.35.13 Reconstructive and Cosmetic Procedures 29-106
29.2.36 Telemedicine Services 29-113
29.2.37 Therapeutic Apheresis 29-114
29.2.38 Transplants 29-119
29.2.38.1 Renal (Kidney) Transplant 29-119
29.2.38.2 Stem Cell Transplant 29-120
29.3 Claims Information 29-138
29.3.1 Substitute Physician 29-138
29.3.2 General Medical Record Documentation Requirements 29-138
29.4 Reimbursement 29-139
29.4.1 Physician Services in Outpatient Hospital Setting 29-139
29.5 TMHP-CSHCN Services Program Contact Center 29-140
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