TMPPM 2008 > Texas Medicaid Services > Hospital (Medical/Surgical Acute Care Facility) > Outpatient

25.3.3 Benefits and Limitations

Outpatient hospital services are diagnostic, therapeutic, and rehabilitative services that are provided to clients by or under the direction of a physician in a licensed hospital setting.

Benefits do not include drugs and biologicals taken home by the client. Supplies provided by a hospital supply room for use in physicians' offices in the treatment of clients in the outpatient setting are not reimbursable.

Take-home drugs and supplies are a benefit in the outpatient setting for outpatients when supplied by prescription through the Vendor Drug Program.

Outpatient hospital services include those services performed in the ER, clinic, or observation room. In instances of sudden illness or injury, the client may receive treatment in the ER and be discharged, placed on observation status, or admitted as an inpatient. If a client goes from the ER to an observation room, the hospital is reimbursed only for the observation room charges: not the ER charges. If the client ultimately is admitted as an inpatient within 24 hours of treatment in the ER or clinic, the ER or clinic charges must be billed on the inpatient hospital claim form as an ancillary charge. The date of inpatient admission is the date the client initially was seen in the ER or clinic.

Outpatient hospital services must be itemized by date of service. Procedure repeated over a period of time should be billed for each separate date of service. Do not combine multiple dates of service on the same line detail.

The Texas Medicaid Program pays the clinic registration fee in lieu of other benefits when a hospital provides outpatient services without charge, and if the fee is less than what the Medicaid payment would be for the service.

Refer to: "Texas Medicaid Program Limitations and Exclusions" for more information about noncovered items/services.