TMPPM 2008 > Texas Medicaid Services > Physician > Reimbursement

36.2 Reimbursement

The Texas Medicaid Program rates for physicians and certain other practitioners are calculated in accordance with TAC §355.8085. The current physician fee schedule is available on the TMHP website at www.tmhp.com/file library/file ibrary/fee schedules.

Refer to: "Physician Services in Outpatient Hospital Setting" .

Section 104 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 requires that Medicare/Medicaid limit reimbursement for those physician services furnished in outpatient hospital settings (e.g., clinics and emergency situations) that are ordinarily furnished in physician offices. The limit is 60 percent of the Texas Medicaid Program rate for the service furnished in physician offices. The following table identifies the services applicable to the 60 percent limitation when furnished in outpatient hospital settings:

These procedures are designated with note code "1" in the current physician fee schedule, which is available at www.tmhp.com. The following list shows the services excluded from the 60 percent limitation:

•Services furnished in rural health clinics (RHCs).

•Surgical services that are covered ambulatory surgical center (ASC)/hospital-based ambulatory surgical center (HASC) services.

•Anesthesiology and radiology services.

•Emergency services provided in a hospital emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention could reasonably be expected to result in one of the following:

•Serious jeopardy to the client's health.

•Serious impairment to bodily functions.

•Serious dysfunction of any bodily organ or part.

Because of TEFRA, Texas Medicaid Program reimbursement for a payable nonemergency office service performed in the outpatient department of a hospital is limited to 60 percent of the Texas Medicaid Program rate for that service. If the condition qualifies as an emergency, the 60 percent professional service reimbursement limit does not apply.

Note: STAR, STAR+PLUS, and NorthSTAR programs may follow a different reimbursement methodology. Providers should check each plan's reimbursement policies.

Refer to: "Reimbursement" for more information.

"Anesthesia" for information on anesthesia services that are reimbursed according to relative value units (RVUs).

"TMHP Website" for more information on obtaining fee schedules.

Fee schedules for services in this chapter are available on the TMHP website at www.tmhp.com/file library/file library/fee schedules.