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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 Nonemergency Ambulance Services 25-4
25.1.6.1 Nonemergency Ambulance Authorization 25-4
25.2 Inpatient 25-6
25.2.1 Enrollment 25-6
25.2.1.1 Hospital Eligibility Through Change of Ownership 25-6
25.2.1.2 Psychiatric Hospital/Facility (THSteps-CCP) 25-6
25.2.1.3 Certified Registered Nurse Anesthetist (CRNA) Services 25-6
25.2.1.4 Hospital Transplant Centers 25-6
25.2.2 Reimbursement 25-7
25.2.2.1 Prospective Payment Methodology 25-7
25.2.2.2 Client Transfers 25-7
25.2.2.3 Observation Status to Inpatient Admission 25-8
25.2.2.5 Children's Hospitals 25-8
25.2.2.6 State-owned Teaching Hospitals 25-9
25.2.3 Benefits and Limitations 25-9
25.2.3.1 Hysterectomy Services 25-10
25.2.3.2 Lung Volume Reduction Surgery (LVRS) 25-10
25.2.3.3 Maternity Care/Children's Health Insurance Program (CHIP)
Perinatal Coverage 25-10
25.2.3.4 Newborn Services 25-10
25.2.3.5 Psychiatric Services 25-11
25.2.3.6 Rehabilitation Services 25-12
25.2.3.7 Organ/Tissue Transplant Services 25-12
25.2.4 Utilization Review 25-16
25.2.4.1 Responsibilities 25-16
25.2.4.2 Utilization Review Process 25-16
25.2.4.3 Recommendations to Enhance Compliance with Texas Medicaid
Fee-for-Service Hospital Billing 25-17
25.2.4.4 Hospitals Reimbursed Under TEFRA 25-18
25.2.4.5 Technical Denials (DRG Prospective Payment and TEFRA) 25-18
25.2.4.6 Acknowledgment of Penalty Notice 25-18
25.2.4.8 Utilization Review Appeals 25-19
25.2.5 Claims Information 25-19
25.2.5.1 Claim Filing Resources 25-19
25.3 Outpatient 25-19
25.3.1 Enrollment 25-19
25.3.1.1 Certified Registered Nurse Anesthetist 25-19
25.3.2 Reimbursement 25-20
25.3.2.1 Day Surgery 25-20
25.3.2.2 Revenue Codes (Outpatient Hospital) 25-22
25.3.3 Benefits and Limitations 25-28
25.3.3.1 Aerosol Treatment 25-28
25.3.3.2 Bacillus Calmette-Guérin (BCG) Vaccine 25-29
25.3.3.3 Cardiac Blood Pool Imaging 25-29
25.3.3.4 Chemotherapy Administration 25-29
25.3.3.5 Cochlear Implants 25-29
25.3.3.6 Colorectal Cancer Screening 25-30
25.3.3.7 Emergency Department Services 25-30
25.3.3.8 Fetal Nonstress Testing and Contraction Stress Test 25-30
25.3.3.9 Fluocinolone Acetonide 25-31
25.3.3.10 Helicobacter Pylori (H. Pylori) 25-32
25.3.3.11 Hospital Laboratory Services 25-32
25.3.3.12 Hospital Outpatient Observation Room Services 25-33
25.3.3.13 Hospital Radiation Therapy Services 25-34
25.3.3.14 Hospital Radiology Services 25-35
25.3.3.15 Hyperbaric Oxygen Therapy (HBOT) 25-36
25.3.3.16 Implantable Infusion Pump 25-36
25.3.3.17 Myocardial Perfusion Imaging 25-36
25.3.3.18 Neurostimulators 25-36
25.3.3.19 Occupational and Physical Therapy Services 25-36
25.3.3.20 Osteopathic Manipulation Treatments (OMT) 25-36
25.3.3.21 Outpatient Total Parenteral Nutrition 25-37
25.3.3.22 Pap Smears (Cytopathology Studies) 25-37
25.3.3.23 Pentamidine Aerosol 25-37
25.3.3.24 Psychiatric Services 25-37
25.3.3.25 Psychological and Neuropsychological Testing 25-38
25.3.3.26 Pulmonary Function Studies 25-38
25.3.3.27 Sterilization Services 25-39
25.3.3.28 Tetanus Injections, Acute Care 25-39
25.3.4 Utilization Review 25-39
25.3.4.1 Responsibilities 25-39
25.3.5 Claims Information 25-40
25.3.5.1 National Drug Codes (NDC) 25-41
25.3.5.2 Claim Filing Resources 25-41
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