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Physician
36.1 Enrollment 36-8
36.1.1 Physicians and Doctors 36-8
36.1.2 Comprehensive Health Center (CHC) 36-8
36.2 Reimbursement 36-8
36.2.1 Supplies, Trays, and Drugs 36-9
36.2.2 Prior Authorization 36-9
36.3 Benefits and Limitations 36-9
36.3.1 Supervision 36-9
36.3.1.1 Teaching Attending Physician and Resident Physician 36-9
36.3.2 Substitute Physician 36-11
36.3.3 Physician Assistants (PAs) 36-11
36.4 Procedures and Services 36-11
36.4.1 Aerosol Treatment 36-11
36.4.2 Allergy Services 36-12
36.4.2.1 Allergy Immunotherapy 36-12
36.4.2.2 Allergy Testing 36-13
36.4.3 Anesthesia 36-13
36.4.3.1 Anesthesia for Sterilization 36-13
36.4.3.2 Anesthesia for Labor and Delivery 36-13
36.4.3.3 Anesthesia Provided by the Surgeon (Other than
Labor and Delivery) 36-14
36.4.3.4 Claim Filing 36-15
36.4.3.5 Complicated Anesthesia 36-15
36.4.3.6 Pain Management 36-15
36.4.3.7 Multiple Procedures 36-15
36.4.3.8 Services Incidental to Surgery and/or Anesthesia 36-16
36.4.3.9 Anesthesia Reimbursement 36-16
36.4.3.10 Anesthesia Modifiers 36-18
36.4.3.11 Anesthesia (General) for THSteps Dental 36-19
36.4.4 Assessment of Higher Cerebral Function Testing 36-19
36.4.5 Bariatric Surgery 36-19
36.4.5.1 Prior Authorization Requirements 36-20
36.4.6 Cancer 36-21
36.4.6.1 Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of
Bladder Cancer 36-21
36.4.6.2 Breast Cancer Screening 36-21
36.4.6.3 Chemotherapy 36-23
36.4.6.4 Colorectal Cancer Screening 36-24
36.4.6.5 Genetic Testing for Colorectal Cancer Screening 36-25
36.4.7 Casting, Splinting, and Strapping 36-26
36.4.8 Cardiopulmonary Resuscitation (CPR) 36-26
36.4.9 Cochlear Implants 36-27
36.4.9.1 Speech Therapy Post Cochlear Implant 36-27
36.4.9.2 Auditory Brainstem Implant (ABI) 36-27
36.4.9.3 Authorization Requirements 36-27
36.4.9.4 Sound Processor Replacement Guidelines 36-27
36.4.9.5 Equipment and Nonrechargeable Batteries 36-27
36.4.10 Continuous Glucose Monitoring (CGM) 36-28
36.4.10.1 Prior Authorization Requirements 36-28
36.4.11 Diagnostic Tests 36-28
36.4.11.1 Ambulatory Blood Pressure Monitoring 36-28
36.4.11.2 Ambulatory Electroencephalogram (A/EEG) 36-28
36.4.11.3 Bone Marrow Aspiration, Biopsy 36-29
36.4.11.4 Computed Tomography (CT) Scan 36-29
36.4.11.5 Cytopathology Studies-Other Than Gynecological 36-29
36.4.11.6 Echoencephalography 36-29
36.4.11.7 Electrocardiogram (EKG) 36-30
36.4.11.8 Esophageal pH Probe Monitoring 36-31
36.4.11.9 Electrodiagnostic (EDX) Testing 36-32
36.4.11.10 Helicobacter Pylori (H. Pylori) 36-34
36.4.11.11 Myocardial Perfusion Imaging 36-35
36.4.11.12 Pediatric Pneumogram 36-35
36.4.12 Doppler Studies 36-36
36.4.13 Endoscopies 36-37
36.4.14 Extracorporeal Membrane Oxygenation (ECMO) 36-37
36.4.15 Family Planning 36-38
36.4.15.1 Family Planning Annual Examinations 36-38
36.4.15.2 Other Family Planning Office or Outpatient Visits 36-38
36.4.15.3 Contraceptives 36-39
36.4.15.4 Elective Sterilization Services 36-39
36.4.15.5 Hysteroscopic Sterilization 36-40
36.4.16 Gynecological Health Services 36-40
36.4.16.1 Assays for the Diagnosis of Vaginitis 36-40
36.4.16.2 Diagnostic Hysteroscopy 36-41
36.4.16.3 Elective Abortions 36-41
36.4.16.4 Examination Under Anesthesia 36-41
36.4.16.5 Hysterectomy Services 36-42
36.4.16.6 Pap Smear (Cytopathology Studies) 36-43
36.4.16.7 Surgery for Masculinized Females 36-43
36.4.17 Hospital Visits 36-43
36.4.18 Hyperbaric Oxygen Therapy (HBOT) 36-43
36.4.19 Ilizarov Device/Procedure 36-45
36.4.20 Immunizations 36-45
36.4.20.1 Vaccine Coverage through the Texas Vaccines for Children
(TVFC) Program 36-45
36.4.20.2 Hepatitis Prophylaxis and Vaccination 36-45
36.4.20.3 Human Papillomavirus (HPV) 36-46
36.4.20.4 Human Rabies Vaccine Supply Information 36-46
36.4.20.5 Influenza Vaccine 36-47
36.4.20.6 Measles, Mumps, and Rubella (MMR) Vaccine 36-47
36.4.20.7 Pneumococcal Polysaccharide Vaccine 36-47
36.4.20.8 Pneumococcal Seven-Valent Conjugate Vaccine 36-47
36.4.20.9 Tetanus Injections, Acute Care 36-47
36.4.21 Injections 36-48
36.4.21.1 Reimbursement 36-48
36.4.21.2 Injection Administration 36-48
36.4.21.3 Oral Medications 36-48
36.4.21.4 Abatacept (Orencia) 36-48
36.4.21.6 Alatrofloxacin Mesylate (Trovan) 36-49
36.4.21.7 Alglucosidase Alfa (Myozyme) 36-49
36.4.21.9 Antibiotics and Steroids 36-50
36.4.21.10 Antihemophilic Factor 36-51
36.4.21.12 Botulinum Toxin Type A 36-51
36.4.21.13 Chelating Agents 36-51
36.4.21.15 Cladribine (Leustatin) 36-52
36.4.21.17 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and
Sargramostim) 36-52
36.4.21.18 Liposomal Encapsulated Daunorubicin (DaunoXome) 36-54
36.4.21.19 Denileukin Diftitox (Ontak) 36-54
36.4.21.21 Dolasetron Mesylate (Anzemet) 36-54
36.4.21.22 Hematopoietic Agents 36-54
36.4.21.23 Fluocinolone Acetonide (Retisert) 36-55
36.4.21.25 Gamma Globulin/Immune Globulin 36-55
36.4.21.26 Gemcitabine HCI (Gemzar) 36-56
36.4.21.27 Granisetron Hydrochloride 36-56
36.4.21.28 Hormone Injections 36-56
36.4.21.29 Ibutilide Fumarate 36-57
36.4.21.30 Idarubicin/Idamycin PFS Injection 36-57
36.4.21.31 Idursulfase (Elaprase) 36-57
36.4.21.33 Immunosuppressive Drugs 36-57
36.4.21.34 Infliximab (Remicade) 36-57
36.4.21.36 Intralesional Injections 36-58
36.4.21.38 Iron Injections 36-58
36.4.21.39 Joint Injections and Trigger Point Injections 36-59
36.4.21.40 Leuprolide Acetate (Lupron Depot) 36-59
36.4.21.42 Melphalan Hydrochloride 36-59
36.4.21.46 Porfimer (Photofrin) 36-60
36.4.21.47 Implantable Infusion Pumps 36-60
36.4.21.48 Rho(D) Immune Globulin 36-61
36.4.21.50 Strontium-89 Chloride 36-62
36.4.21.51 Thyrotropin Alpha for Injection (Thyrogen) 36-62
36.4.21.54 Valrubicin Sterile Solution for Intravesical Instillation (Valstar) 36-62
36.4.21.55 Vitamin B12 (Cyanocobalamin) 36-62
36.4.22 Laboratory Services 36-63
36.4.22.1 Laboratory Handling Fee 36-63
36.4.22.2 Blood Counts 36-64
36.4.22.3 Clinical Lab Panel Implementation 36-64
36.4.22.4 Clinical Pathology Consultations 36-64
36.4.22.5 Cytogenetics Testing 36-64
36.4.22.6 Maternal Serum Alpha-Fetoprotein (MSAFP) 36-66
36.4.23 Lung Volume Reduction Surgery (LVRS) 36-66
36.4.24 Mastectomy and Breast Reconstruction 36-68
36.4.25 Neurostimulators 36-69
36.4.25.1 Prior Authorization 36-69
36.4.25.2 Neuromuscular Electrical Stimulation (NMES) 36-70
36.4.25.3 Transcutaneous Electrical Nerve Stimulators (TENS) 36-71
36.4.25.4 NMES/TENS Garments 36-71
36.4.25.5 NMES and TENS Supplies 36-71
36.4.25.6 Dorsal Column Neurostimulator (DCN) 36-72
36.4.25.7 Intracranial Neurostimulators 36-72
36.4.25.8 Percutaneous Electrical Nerve Stimulators (PENS) 36-72
36.4.25.9 Sacral Nerve Stimulators (SNS) 36-73
36.4.25.10 Vagal Nerve Stimulators (VNS) 36-73
36.4.25.11 Neurostimulator Devices 36-73
36.4.25.12 Supplies for Neurostimulators 36-73
36.4.25.13 Electronic Analysis for Neurostimulators 36-73
36.4.25.14 Revision or Removal of Neurostimulator Devices 36-73
36.4.25.15 Noncovered Neurostimulator Services 36-73
36.4.26 Newborn Services 36-73
36.4.26.1 Attendance at Delivery and Physician Standby 36-74
36.4.26.2 Circumcisions 36-74
36.4.26.3 Claims Filing Instructions, Eligibility Requirements 36-74
36.4.26.4 Critical Care 36-75
36.4.26.5 Hospital Visits 36-75
36.4.26.6 Newborn Hearing Screening 36-76
36.4.26.7 Newborn Resuscitation 36-76
36.4.26.8 Potential SSI/Medicaid Eligibility for Premature Infants 36-76
36.4.26.9 Routine Care 36-77
36.4.27 Noncoronary Percutaneous Transluminal Angioplasty (PTA) 36-77
36.4.28 Nuclear Medicine 36-78
36.4.29 Obstetrics and Prenatal Care 36-78
36.4.29.1 Ultrasound of the Pregnant Uterus 36-79
36.4.29.2 External Cephalic Version 36-79
36.4.29.3 Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion
(FIUT) and Ultrasonic Guidance for Cordocentesis 36-79
36.4.29.4 Fetal Fibronectin 36-80
36.4.29.5 Nonstress Testing, Contraction Stress Testing 36-80
36.4.29.6 Required Screening of Pregnant Women for Syphilis,
HIV, and Hepatitis B 36-81
36.4.30 Occupational Therapy 36-81
36.4.31 Ophthalmology 36-81
36.4.31.1 Complete Eye Exams 36-82
36.4.31.2 Blepharoplasty Procedures 36-82
36.4.31.3 Corneal Topography 36-83
36.4.31.4 Corneal Transplants 36-83
36.4.31.5 Echography Ophthalmic, A & B Scan 36-83
36.4.31.6 Echography Scan, Ophthalmic 36-84
36.4.31.7 Eye Surgery by Laser 36-84
36.4.31.8 Eye Surgery by Incision 36-86
36.4.31.9 Intraocular Lens (IOL) 36-87
36.4.31.10 Intravitreal Drug Delivery System 36-87
36.4.31.11 Iridectomy/Iridotomy/Trabeculectomy 36-87
36.4.31.12 Ophthalmic Ultrasound Foreign Body Localization 36-87
36.4.31.13 Ophthalmological Services Billed with a Diagnosis of Cataract 36-87
36.4.32 Organ/Tissue Transplants 36-87
36.4.32.1 Pancreas Transplant/Simultaneous Kidney-Pancreas Transplant 36-88
36.4.32.2 Stem Cell Transplants 36-89
36.4.32.3 Heart Transplants 36-91
36.4.32.4 Intestinal Transplants 36-92
36.4.32.5 Kidney Transplants 36-92
36.4.32.6 Liver Transplants 36-92
36.4.32.7 Lung Transplants 36-93
36.4.32.8 Organ Procurement 36-93
36.4.32.9 Prior Authorization 36-93
36.4.33 Orthognathic Surgery 36-94
36.4.34 Osteogenic Stimulation 36-94
36.4.35 Osteopathic Manipulative Treatment (OMT) 36-95
36.4.36 Pentamadine, Aerosol 36-95
36.4.37 Percutaneous Transluminal Coronary Interventions 36-95
36.4.38 Physical Therapy (PT) Services 36-95
36.4.38.2 Nursing Facility 36-96
36.4.39 Physician Evaluation and Management Services 36-96
36.4.39.1 Domiciliary, Rest Home, or Custodial Care Services 36-96
36.4.39.2 E/M Emergency Department Services 36-96
36.4.39.3 Group Clinical Visits 36-98
36.4.39.4 Home Services 36-98
36.4.39.5 Inpatient Hospital Services 36-99
36.4.39.6 Office or Other Outpatient Hospital Services 36-102
36.4.39.7 Prolonged Physician Services 36-104
36.4.40 Physician Services in a Long Term Care (LTC) Nursing Facility 36-105
36.4.41 Podiatrist Services 36-106
36.4.41.1 Clubfoot Casting 36-106
36.4.41.2 Echography/Ultrasound of Extremity 36-106
36.4.41.3 Flat Foot Treatment 36-106
36.4.41.4 Nursing Facility 36-106
36.4.41.5 Routine Foot Care 36-106
36.4.41.6 Vascular Studies Performed by Podiatrist 36-106
36.4.41.7 X-Ray Procedures by Podiatrist 36-106
36.4.42 Polysomnography 36-106
36.4.43 Prostate Surgeries 36-107
36.4.44 Psychiatric Services 36-107
36.4.44.1 Documentation Required 36-111
36.4.44.2 Prior Authorization 36-111
36.4.44.3 Psychological and Neuropsychological Testing 36-113
36.4.44.4 Psychiatric Pharmacological Management 36-115
36.4.45 Radiation Therapy 36-117
36.4.45.1 Radiation Treatment Planning 36-118
36.4.45.2 Radiation Treatment Management 36-118
36.4.45.3 Medical Radiation Physics, Dosimetry, Treatment Devices,
Special Services, and Proton Beam Treatment Delivery 36-118
36.4.45.4 Brachytherapy 36-118
36.4.45.5 Radiation Treatment Delivery/Port Film 36-119
36.4.45.6 Procedure Code Limitations 36-120
36.4.45.7 Freestanding Radiation Therapy Facilities/Outpatient Facilities 36-122
36.4.45.8 Stereotactic Radiosurgery 36-122
36.4.46 Radiology Services 36-123
36.4.46.1 Cardiac Blood Pool Imaging 36-124
36.4.46.2 Chest X-Rays 36-124
36.4.46.3 Diagnosis Requirements 36-126
36.4.46.4 Therapeutic Radiopharmaceuticals 36-126
36.4.46.5 Magnetic Resonance Angiography (MRA) 36-127
36.4.46.6 Magnetic Resonance Imaging (MRI) 36-127
36.4.46.7 Technetium TC 99M 36-127
36.4.47 Reduction Mammaplasties 36-127
36.4.48 Renal Disease 36-128
36.4.48.2 Dialysis Patients 36-128
36.4.48.3 Epoetin Alfa (Erythropoietin; EPO) 36-129
36.4.48.4 Laboratory Services for Dialysis Patients 36-129
36.4.48.5 Self-Dialysis Patients 36-129
36.4.49 Sign Language Interpreting Services 36-130
36.4.50 Skin Therapy 36-130
36.4.51 Speech-Language Therapy 36-132
36.4.51.1 Speech Therapy and Aural Rehabilitation 36-132
36.4.52 Surgeons and Surgery 36-133
36.4.52.1 Primary Surgery 36-133
36.4.52.2 Anesthesia Administered by Surgeon 36-133
36.4.52.3 Assistant Surgeon 36-133
36.4.52.4 Bilateral Procedures 36-134
36.4.52.6 Capsulotomy 36-134
36.4.52.8 Global Fees 36-134
36.4.52.9 Global Surgery Concurrent Care 36-135
36.4.52.10 Multiple Surgeries 36-135
36.4.52.11 Office Procedures 36-135
36.4.52.12 Orthopedic Hardware 36-136
36.4.52.13 Second Opinions 36-136
36.4.53 Suture of Wounds 36-136
36.4.54 Telemedicine Services 36-137
36.4.54.1 Hub Site Provider 36-138
36.4.54.2 Remote Site Provider 36-138
36.4.55 Therapeutic Apheresis 36-138
36.4.56 Therapeutic Phlebotomy 36-139
36.4.57 Ventilation Assist and Management for the Inpatient 36-139
36.4.58 Wearable Cardiac Defibrillator (WCD) 36-140
36.5 Doctor of Dentistry Practicing as a Limited Physician 36-142
36.5.1 Medicaid Managed Care Enrollment 36-142
36.5.1.1 Mandatory Prior Authorization Due to Life-Threatening
Medical Condition 36-142
36.5.2 Guidelines for Requesting Mandatory Prior Authorization 36-142
36.5.3 Reimbursement 36-142
36.5.3.1 Benefits and Limitations 36-142
36.5.3.2 Diagnosis Codes 36-143
36.5.3.3 Evaluation and Management Procedure Codes 36-143
36.5.3.4 Procedure Codes 36-144
36.5.3.5 Procedure Codes Requiring Mandatory Prior Authorization 36-145
36.5.3.6 Radiographs by a Doctor of Dentistry Practicing as a
Limited Physician 36-146
36.5.3.7 Dental Anesthesia by a Doctor of Dentistry Practicing as a
Limited Physician 36-146
36.5.4 Claims Information for Doctor of Dentistry Practicing as a
Limited Physician 36-146
36.6 Claims Information 36-146
36.6.1 National Drug Codes (NDC) 36-146
36.6.2 Claim Filing Resources 36-147
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