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Physician
30.1.1 Independent Practices 30-4
30.1.2 Group Practices 30-4
30.1.3 Changes in Provider Enrollment 30-5
30.1.4 Referrals to Other Providers 30-5
30.1.5 Substitute Physician 30-5
30.2 Benefits, Limitations, and Authorization Requirements 30-5
30.2.1 Authorization and Prior Authorization Requirements 30-6
30.2.2 Aerosol Treatments/Inhalation Therapy 30-6
30.2.3 Allergy Services 30-9
30.2.4 Anesthesia Services 30-9
30.2.4.1 Medical Direction 30-9
30.2.4.2 Monitored Anesthesia Care 30-10
30.2.4.3 Anesthesia Modifiers 30-11
30.2.4.4 Dental General Anesthesia 30-12
30.2.4.5 Services Incidental to Surgery or Anesthesia 30-12
30.2.4.6 Services Not Considered Incidental to Surgery or Anesthesia 30-13
30.2.4.7 Reimbursement 30-13
30.2.4.8 Conversion Factor 30-13
30.2.4.9 Time-Based Fees 30-14
30.2.5 Anterior Temporal Lobectomy 30-14
30.2.6 Audiometry/Hearing Services 30-14
30.2.7 Augmentative Communication Devices (ACDs) 30-14
30.2.8 Blood Factor Products 30-14
30.2.9 Bone Growth Stimulators 30-15
30.2.9.1 Internal Electromagnetic Bone Growth Stimulator 30-16
30.2.9.2 Electrical Stimulation (Noninvasive) 30-16
30.2.9.3 External Low-Intensity Ultrasound Stimulation 30-16
30.2.9.4 Prior Authorization Requirements for Bone Growth Stimulators 30-16
30.2.11 Chemotherapy 30-18
30.2.12 Clinician-Directed Care Coordination Services 30-19
30.2.12.1 Face-to-Face Clinician-Directed Care Coordination Services 30-20
30.2.12.2 Non-Face-to-Face Clinician-Directed Care Coordination Services 30-20
30.2.13 Cochlear Implants 30-24
30.2.14 Colorectal Cancer Screening 30-24
30.2.15 Critical Care Services 30-25
30.2.15.1 Pediatric Critical Care 30-27
30.2.15.2 Neonatal Critical Care 30-28
30.2.15.3 Intensive Care (Noncritical) Services 30-29
30.2.15.4 Newborn Resuscitation 30-30
30.2.16 Echoencephalography 30-31
30.2.16.1 Intraoperative Echography 30-31
30.2.16.2 Ambulatory Electroencephalogram 30-43
30.2.17 Electrodiagnostic Testing 30-44
30.2.17.1 Authorization and Prior Authorization Requirements 30-52
30.2.18 Evaluation and Management (E/M) Services 30-53
30.2.18.1 New or Established Patient Visits 30-53
30.2.18.2 Inpatient Professional Services 30-54
30.2.18.3 Emergency Services 30-55
30.2.18.4 Consultations 30-56
30.2.18.5 Services Outside of Business Hours 30-56
30.2.18.6 Prolonged Physician Services 30-56
30.2.18.7 Observation Room Services 30-57
30.2.18.8 Preventive Care Services 30-58
30.2.18.9 Preventive Care Medical Checkups and Developmental Testing 30-58
30.2.18.10 Dental Screening and Intermediate Oral Evaluation with Fluoride
Varnish Application in the Medical Home 30-60
30.2.18.11 Teaching Physicians 30-60
30.2.19 Extracorporeal Shock Wave Lithotripsy (ESWL) 30-61
30.2.20 Gastrostomy Devices 30-61
30.2.21 Genetics 30-61
30.2.22 Hyperbaric Oxygen Therapy (HBOT) 30-62
30.2.23 Immunizations (Vaccines and Toxoids) 30-76
30.2.23.1 Texas Vaccines for Children (TVFC) Program 30-76
30.2.23.4 Vaccine Information Statement 30-76
30.2.23.5 Authorization Requirements 30-77
30.2.23.6 Immunizations During an Office Visit 30-77
30.2.23.7 Administration Fee 30-77
30.2.23.8 Vaccine and Toxoid Procedure Codes 30-77
30.2.23.9 Reimbursement for Vaccines and Toxoids 30-78
30.2.23.10 Respiratory Synctial Virus (RSV) Prophylaxis 30-78
30.2.24 Injections and Oral Medications 30-82
30.2.24.1 Injection Administration Billed by a Physician 30-82
30.2.24.2 Unit Calculations for Billing Drugs 30-83
30.2.24.3 Injection Procedure Codes 30-83
30.2.24.5 Botulinum Toxin (Type A and Type B) 30-86
30.2.24.6 Erythropoietin Alfa (EPO) and Darbepoetin 30-89
30.2.24.7 Growth Hormone 30-93
30.2.24.8 Immune Globulins 30-93
30.2.24.9 Leuprolide Acetate Injection 30-97
30.2.25 Intracranial Pressure Monitoring 30-98
30.2.26 Laboratory Services 30-98
30.2.26.1 Physician Laboratory Services 30-98
30.2.26.2 Laboratory Handling Fee 30-98
30.2.26.3 Claims Filing for Laboratory Tests 30-99
30.2.26.4 Clinical Pathology Services and Pathology Consultations 30-99
30.2.26.5 Reimbursement 30-99
30.2.26.6 Cytopathology Studies (Gynecological, Pap Smears) 30-99
30.2.26.7 Cytogenetics Testing 30-99
30.2.26.8 Helicobacter pylori (H. pylori) 30-100
30.2.26.9 CLIA Requirement 30-100
30.2.27 Neurostimulator Devices and Supplies 30-100
30.2.28 Ophthalmological Services 30-100
30.2.28.1 Intraocular Lenses (IOL) 30-100
30.2.28.2 Vitrasert Ganciclovir Implant 30-100
30.2.29 Osteopathic Manipulative Treatment (OMT) 30-100
30.2.30 Physical Medicine and Physical Therapy (PT) Services 30-101
30.2.31 Podiatry 30-101
30.2.32 Psychological Testing 30-101
30.2.33 Sign Language Interpreting Services 30-102
30.2.34 Sleep Studies 30-103
30.2.34.1 Polysomnography 30-103
30.2.34.2 Multiple Sleep Latency Test 30-105
30.2.34.3 Pediatric Pneumogram 30-105
30.2.35 Surgery 30-106
30.2.35.1 Anesthesia Administered by Surgeon 30-106
30.2.35.2 Primary Surgeons 30-106
30.2.35.3 Assistant Surgeons 30-107
30.2.35.5 Bilateral Procedures 30-108
30.2.35.6 Global Fees 30-108
30.2.35.7 Multiple Surgeries 30-108
30.2.35.8 Second Opinions 30-108
30.2.35.9 Unlisted Surgical Procedure Code Considerations 30-109
30.2.35.11 Cleft/Craniofacial Procedures 30-109
30.2.35.12 Reconstructive and Cosmetic Procedures 30-112
30.2.36 Telemedicine Services 30-119
30.2.36.1 Distant Site 30-119
30.2.36.2 Patient Site 30-120
30.2.37 Therapeutic Apheresis 30-120
30.2.38 Transplants 30-126
30.2.38.1 Renal (Kidney) Transplant 30-126
30.2.38.2 Stem Cell Transplant 30-127
30.3 Claims Information 30-145
30.3.1 General Medical Record Documentation Requirements 30-145
30.4 Reimbursement 30-146
30.4.1 Physician Services in Outpatient Hospital Setting 30-146
30.5 TMHP-CSHCN Services Program Contact Center 30-147
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