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Hospital (Medical/Surgical Acute Care Facility)
25.1 General Information 25-3
25.1.1 Introduction 25-3
25.1.2 Provider Cost and Reporting 25-3
25.1.3 Third Party Liability Reporting 25-3
25.1.4 Medicaid Relationship to Medicare 25-4
25.1.5 Nursing Facility Admission 25-4
25.1.6 Authorizations 25-4
25.2 Inpatient 25-4
25.2.1 Enrollment 25-4
25.2.1.1 Hospital Eligibility Through Change of Ownership 25-5
25.2.1.2 Psychiatric Hospital/Facility (THSteps-CCP) 25-5
25.2.1.3 Hospital Ambulance 25-5
25.2.1.4 Certified Registered Nurse Anesthetist (CRNA) Services 25-5
25.2.1.5 Medicaid Managed Care Enrollment 25-5
25.2.1.6 Hospital Transplant Centers 25-5
25.2.2 Reimbursement 25-5
25.2.2.1 Prospective Payment Methodology 25-5
25.2.2.2 Client Transfers 25-6
25.2.2.3 Observation Status to Inpatient Admission 25-6
25.2.2.5 Children's Hospitals 25-7
25.2.2.6 Hospital Transplant Center Approval 25-7
25.2.3 Benefits and Limitations 25-8
25.2.3.1 Hysterectomy Services 25-8
25.2.3.2 Newborn Services 25-9
25.2.3.3 Psychiatric Services 25-10
25.2.3.4 Rehabilitation Services 25-10
25.2.3.5 Organ/Tissue Transplant Services 25-10
25.2.4 Utilization Review 25-13
25.2.4.1 Responsibilities 25-14
25.2.4.2 Utilization Review Process 25-14
25.2.4.3 Recommendations to Enhance Compliance with the Texas
Medicaid Program Fee-for-Service Hospital Billing 25-15
25.2.4.4 Hospitals Reimbursed Under TEFRA 25-16
25.2.4.5 Technical Denials (DRG Prospective Payment and TEFRA) 25-16
25.2.4.6 Acknowledgment of Penalty Notice 25-16
25.2.4.8 Utilization Review Appeals 25-16
25.2.5 Claims Information 25-16
25.2.5.1 Claim Filing Resources 25-17
25.3 Outpatient 25-17
25.3.1 Enrollment 25-17
25.3.1.1 Hospital Ambulatory Surgical Center 25-17
25.3.1.2 Hospital Ambulance 25-17
25.3.1.3 Certified Registered Nurse Anesthetist 25-17
25.3.1.4 Medicaid Managed Care Enrollment 25-17
25.3.2 Reimbursement 25-17
25.3.2.1 Day Surgery 25-18
25.3.2.2 Revenue Codes (Outpatient Hospital) 25-20
25.3.3 Benefits and Limitations 25-26
25.3.3.1 Emergency Department Services 25-27
25.3.3.2 Hospital Outpatient Observation Room Services 25-27
25.3.3.3 Outpatient Total Parenteral Nutrition/Hyperalimentation 25-28
25.3.3.4 Aerosol Treatment 25-28
25.3.3.5 Pentamidine Aerosol 25-29
25.3.3.6 Fluocinolone Acetonide 25-29
25.3.3.7 Pulmonary Function Studies 25-29
25.3.3.8 Chemotherapy Administration 25-29
25.3.3.9 Bacillus Calmette-Guérin (BCG) Vaccine 25-30
25.3.3.10 Tetanus Injections, Acute Care 25-30
25.3.3.11 Deep Brain Stimulators 25-30
25.3.3.12 Neurostimulators 25-30
25.3.3.13 Hospital Laboratory Services 25-30
25.3.3.14 Helicobacter Pylori (H. Pylori) 25-32
25.3.3.15 Colorectal Cancer Screening 25-32
25.3.3.17 Fetal Nonstress Testing and Contraction Stress Test 25-32
25.3.3.18 Hospital Radiology Services 25-33
25.3.3.19 Computed Tomography 25-36
25.3.3.20 Strontium-89 Chloride 25-36
25.3.3.21 Technetium TC 99M Tetrofosmin 25-36
25.3.3.22 Low Osmolar (Nonionic) Contrast Material (LOCM) 25-36
25.3.3.23 Cardiac Blood Pool Imaging 25-36
25.3.3.24 Gamma Knife Radiosurgery 25-36
25.3.3.25 Hospital Radiation Therapy Services 25-37
25.3.3.26 Hyperbaric Oxygen Therapy (HBO) 25-37
25.3.3.27 Implantable Contraceptive Capsules 25-39
25.3.3.28 Occupational and Physical Therapy Services 25-40
25.3.3.29 Osteopathic Manipulation Treatments (OMT) 25-40
25.3.3.30 Psychiatric Services 25-40
25.3.3.31 Psychological and Neuropsychological Testing 25-41
25.3.3.32 Sterilization Services 25-41
25.3.4 Utilization Review 25-42
25.3.4.1 Responsibilities 25-42
25.3.5 Claims Information 25-42
25.3.5.1 Claim Filing Resources 25-43
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