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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.60 Physician Evaluation and Management (E/M) Services : 8.2.60.1 Office or Other Outpatient Hospital Services

8.2.60.1
Office or Other Outpatient Hospital Services
8.2.60.1.1 New and Established Patient Services
A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider.
An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility.
When a new patient checkup is billed for the same date of service as a new patient acute care visit, both new patient services may be reimbursed when billed by the same provider or provider group if no other acute care visits or preventive care medical checkups have been billed in the past three years.
Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same day as another procedure or service. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client’s medical record and made available to Texas Medicaid upon request. The documentation must clearly indicate what the significant problem/abnormality was, including the important, distinct correlation with signs and symptoms to demonstrate a distinctly different problem that required additional work and must support that the requirements for the level of service billed were met or exceeded.
The date and time of both services performed must be outlined in the medical record and the time of the second service must be different than the time of the first service, although a different diagnosis is not required.
An established patient visit that is billed with the same date of service as a new patient visit by the same provider will be denied as part of another procedure except when the established patient visit is billed with a new THSteps medical checkup.
Office visits (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) provided on the same date of service as a planned procedure (minor or extensive) are included in the cost of the procedure and are not separately reimbursed.
Office visit procedure code 99211, 99212, 99213, 99214, or 99215 must be billed by the same provider with the same date of service as a group clinical visit.
Refer to:
Procedures that are included in the E/M service (e.g., binocular microscopy, noninvasive ear or pulse oximetry for oxygen saturation, etc.) are denied as part of another procedure when billed by the same provider with the same date of service as one of the following office or outpatient consultation visit procedure codes:
Emergency department‑based physicians or emergency department‑based groups may not bill charges for inconvenience or after hours services (procedure code 99050, 99056, or 99060).
8.2.60.1.2 Preventive Care Visits
Preventive care services are comprehensive visits that may include counseling, anticipatory guidance, and risk-factor-reduction interventions. Documentation must indicate the anticipatory guidance rendered.
Preventive health visits for clients who are birth through 20 years of age are available through THSteps medical checkups.
Refer to:
Section 5, “THSteps Medical” in Children’s Services Handbook (Vol. 2, Provider Handbooks).
Subsection 5.3.9.2.3, “Hearing Screening,” in Children’s Services Handbook (Vol. 2, Provider Handbooks) for additional information about hearing screenings.
Adult preventive services (procedure codes 99385, 99386, 99387, 99395, 99396, and 99397) are a benefit of Texas Medicaid for clients who are 21 years of age and older. Procedure codes 99385 and 99395 are restricted to clients who are 21 through 39 years of age. Adult preventive services are limited to one service per rolling year, any provider, and must be billed with diagnosis code V700.
Adult preventive services must be provided in accordance with the U.S. Preventive Services Task Force (USPSTF) recommendations with grades A or B. USPSTF recommendations, with specific age and frequency guidelines, are located on the Agency for Healthcare Research and Quality website at www.ahrq.gov/clinic/uspstfix.htm.
Laboratory, immunization, and diagnostic procedures recommended by USPSTF are covered benefits and may be billed separately, as clinically indicated, using the most appropriate diagnosis code that represents the client’s condition.
The following USPSTF recommendations are not reimbursed separately but must be provided, when applicable, as part of the routine preventive exam:
The following USPSTF recommendations are not a benefit of Texas Medicaid:
The following screenings are covered benefits in addition to USPSTF recommendations:
Services that exceed USPSTF recommendations are not considered part of a screening and require medical documentation to justify medical necessity of the services performed.
For clients who are 21 years of age and older, breast exams and Pap smears are available through programs related to women’s health, including Texas Medicaid family planning services and Women’s Health Program.
Refer to:
Section 2, “Medicaid Title XIX family planning services” in Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks).
Section 3, “Women’s Health Program (Title XIX Family Planning)” in Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks).
8.2.60.1.3 Consultation Services
A consultation is an E/M service provided at the request of another provider for the evaluation of a specific condition or illness. The consultation must meet the following requirement:
During a consultation, the consulting provider may initiate diagnostic and therapeutic services if necessary.
The visit is not considered a consultation if any of the following applies:
If diagnostic or therapeutic treatment is initiated during a consultation and the patient returns for follow‑up care, the follow‑up visit is considered an established patient visit, and must be billed as an established patient visit.
The medical records maintained by both the referring and consulting providers must identify the other provider and the reason for consultation.
Providers must use procedure code 99241, 99242, 99243, 99244, or 99245 when billing new or established patient consultations in the office, or in an outpatient or other ambulatory facility.
Office or outpatient consultations are limited to one consultation every six months by the same provider for the same diagnosis. Subsequent office or outpatient consultation visits during this six-month period will be denied.
8.2.60.1.4 Services Outside of Business Hours
Texas Medicaid limits reimbursement for after‑hours charges (procedure codes 99050, 99056, and 99060) to office‑based providers rendering services after routine office hours.
An office‑based provider may bill an after‑hours charge in addition to a visit when providing medically necessary services for the care of a client with an emergent condition after the provider’s posted, routine office hours. Office‑based physicians may be reimbursed an inconvenience charge when either of the following exists and the reason is documented in the client’s medical record:
8.2.60.1.5 Observation Services
Hospital observation (procedure codes 99217, 99218, 99219, and 99220) are professional services provided for a period of more than 6 hours but fewer than 24 hours regardless of the hour of the initial contact, even if the client remains under physician care past midnight. Subsequent observation care, per day (procedure codes 99224, 99225, and 99226) is also a benefit of Texas Medicaid.
Inpatient hospital observation services must be submitted using the procedure code 99234, 99235, or 99236.
Observation care discharge day management procedure code 99217 must be billed to report services provided to a client upon discharge from observation status if the discharge is on a date other than the initial date of admission. The following procedure codes are denied if submitted with the same date of service as procedure codes 99217, 99234, 99235, and 99236:
If an E/M service is billed by the same provider with the same date of service as a physician observation visit, the E/M service is denied if provided in any place of service other than inpatient hospital.
If a physician observation visit (procedure code 99217, 99218, 99219, 99220, 99234, 99235, or 99236) is billed by the same provider with the same date of service as prolonged services (procedure code 99354, 99355, 99356, or 99357), the prolonged services will be denied as part of another procedure on the same day.
If dialysis treatment and a physician observation visit are billed by the same provider (and same specialty other than an internist or nephrologist) with the same date of service, the dialysis treatment may be reimbursed and the physician observation visit will be denied.

Texas Medicaid & Healthcare Partnership
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