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Physician
36.1 Enrollment 36-7
36.1.1 Physicians and Doctors 36-7
36.1.2 Medicaid Managed Care Enrollment 36-7
36.1.3 Comprehensive Health Center (CHC) 36-7
36.2 Reimbursement 36-7
36.2.1 Supplies, Trays, and Drugs 36-8
36.2.2 Prior Authorization 36-8
36.3 Benefits and Limitations 36-8
36.3.1 Supervision 36-8
36.3.1.1 Teaching Attending Physician and Resident Physician 36-9
36.3.2 Substitute Physician 36-10
36.3.3 Physician Assistants (PAs) 36-11
36.3.4 Physician Evaluation and Management Services 36-11
36.3.4.1 Office or Other Outpatient Services 36-11
36.3.4.2 Inpatient Services 36-14
36.3.4.3 Prolonged Physician Services 36-16
36.3.5 Hospital Visits 36-16
36.3.5.1 Nonintensive Care 36-16
36.3.5.2 Critical Care 36-16
36.3.5.3 Neonatal Critical Care 36-18
36.3.6 Physician Services in a Long Term Care (LTC) Nursing Facility 36-19
36.3.7 Telemedicine Services 36-20
36.3.7.1 Hub Site Provider 36-21
36.3.7.2 Remote Site Provider 36-21
36.3.8 Orthognathic Surgery 36-22
36.4 Procedures and Services 36-22
36.4.1 Aerosol Treatment 36-22
36.4.2 Allergy Services 36-23
36.4.2.1 Allergy Injections, Vials and Extracts 36-23
36.4.2.2 Allergy Testing 36-24
36.4.3 Anesthesia 36-24
36.4.3.1 Anesthesia for Abortion 36-24
36.4.3.2 Anesthesia for Sterilization 36-24
36.4.3.3 Anesthesia for Labor and Delivery 36-25
36.4.3.4 Anesthesia Provided by the Surgeon (Other than Labor and Delivery) 36-25
36.4.3.5 Base Units 36-26
36.4.3.6 Central Lines 36-26
36.4.3.7 Claim Filing 36-26
36.4.3.8 Complicated Anesthesia 36-26
36.4.3.9 Pain Management 36-26
36.4.3.10 Multiple Procedures 36-27
36.4.3.11 Reimbursement Methodology 36-27
36.4.3.12 Services Incidental to Surgery and/or Anesthesia 36-27
36.4.3.13 Supervision of Concurrent Anesthesia Procedures 36-28
36.4.3.14 Supervision of CRNA 36-28
36.4.3.15 Anesthesia (General) for THSteps Dental Restoration 36-29
36.4.4 Assessment of Higher Cerebral Function Testing 36-29
36.4.5 Cancer 36-29
36.4.5.1 Colorectal Cancer Screening 36-29
36.4.5.2 Chemotherapy 36-30
36.4.5.3 Bacillus Calmette-Guérin (BCG) Intravesical for
Treatment of Bladder Cancer 36-31
36.4.6 Casting, Splinting, and Strapping 36-31
36.4.7 Neurostimulators 36-32
36.4.7.1 Central Nervous System Stimulators 36-32
36.4.7.2 Deep Brain Stimulators 36-33
36.4.7.3 Percutaneous/Transcutaneous Nerve Stimulators 36-33
36.4.7.4 Sacral Nerve Stimulators 36-33
36.4.7.5 Vagal Nerve Stimulators 36-34
36.4.8 Cochlear Implants 36-34
36.4.8.1 Speech Therapy Post Cochlear Implant 36-34
36.4.8.2 Auditory Brainstem Implant (ABI) 36-35
36.4.8.3 Authorization Requirements 36-35
36.4.8.4 Sound Processor Replacement Guidelines 36-35
36.4.8.5 Equipment and Non-Rechargeable Batteries 36-35
36.4.9 Diagnostic Tests 36-35
36.4.9.1 Ambulatory Blood Pressure Monitoring 36-35
36.4.9.2 Ambulatory Electroencephalogram (A/EEG) 36-35
36.4.9.3 Bone Marrow Aspiration, Biopsy 36-35
36.4.9.4 Computed Tomography (CT) Scan 36-36
36.4.9.5 Cytopathology Studies-Gynecological, Pap Smears 36-36
36.4.9.6 Cytopathology Studies-Other Than Gynecological 36-36
36.4.9.7 Echoencephalography 36-37
36.4.9.8 Electrocardiogram (EKG) 36-38
36.4.9.9 Esophageal pH Probe Monitoring 36-39
36.4.9.10 Electromyography (EMG) 36-39
36.4.9.11 Helicobacter Pylori (H. Pylori) 36-40
36.4.9.12 Screening and Diagnostic Studies of the Breast 36-40
36.4.9.13 Breast Cancer (BRCA) 36-41
36.4.9.14 Myocardial Perfusion Imaging 36-42
36.4.9.15 Nerve Conduction Studies 36-42
36.4.9.16 Pediatric Pneumogram 36-43
36.4.10 Doppler Studies 36-43
36.4.10.1 Noninvasive Diagnostic Studies 36-43
36.4.11 Elective Sterilization Services 36-45
36.4.12 Endoscopies 36-46
36.4.13 Epidural/Subarachnoid Infusion for Chronic Spasticity 36-46
36.4.14 Extracorporeal Membrane Oxygenation (ECMO) 36-46
36.4.15 Gamma Knife Radiosurgery 36-47
36.4.16 Genetic Services 36-47
36.4.17 Gynecological and Reproductive Health Services 36-47
36.4.17.1 Assays for the Diagnosis of Vaginitis 36-47
36.4.17.2 Diagnostic Hysteroscopy 36-47
36.4.17.3 Elective Abortions 36-47
36.4.17.4 Examination Under Anesthesia 36-48
36.4.17.5 Family Planning 36-48
36.4.17.6 Faxing Forms 36-50
36.4.17.7 Hysterectomy Services 36-50
36.4.17.8 Hysteroscopic Sterilization 36-51
36.4.17.10 Surgery For Masculinized Females 36-51
36.4.18 Ilizarov Device/Procedure 36-51
36.4.19 Hyperbaric Oxygen Therapy (HBOT) 36-51
36.4.20 Injections 36-53
36.4.20.1 Abatacept (Orencia) 36-54
36.4.20.2 Alatrofloxacin Mesylate (Trovan) 36-54
36.4.20.3 Alglucosidase Alfa (Myozyme) 36-55
36.4.20.5 Antihemophilic Factor 36-55
36.4.20.7 Programmable Pumps for Epidural or Intrathecal Infusion 36-56
36.4.20.8 Botulinum Toxin Type A 36-57
36.4.20.9 Chelating Agents 36-58
36.4.20.11 Cladribine (Leustatin) 36-58
36.4.20.13 Liposomal Encapsulated Daunorubicin (DaunoXome) 36-58
36.4.20.14 Denileukin Diftitox (Ontak) 36-58
36.4.20.16 Dolasetron Mesylate (Anzemet) 36-59
36.4.20.17 Hematopoietic Agents 36-59
36.4.20.18 Fluocinolone Acetonide (Retisert) 36-60
36.4.20.20 Gamma Globulin/Immune Globulin 36-60
36.4.20.21 Gemcitabine HCI (Gemzar) 36-61
36.4.20.22 Granisetron Hydrochloride 36-61
36.4.21 Immunizations 36-61
36.4.21.1 Vaccine Coverage through the Texas Vaccines for
Children (TVFC) Program 36-61
36.4.21.2 Hepatitis A Vaccine 36-61
36.4.21.3 Hepatitis B Vaccine 36-61
36.4.21.4 Human Papillomavirus (HPV) 36-62
36.4.21.5 Influenza Vaccine 36-62
36.4.21.6 Pneumococcal Polysaccharide Vaccine 36-62
36.4.21.7 Pneumococcal 7 Valent Conjugate Vaccine 36-63
36.4.21.8 Hormone Injections 36-63
36.4.21.9 Ibutilide Fumarate 36-64
36.4.21.10 Idarubicin/Idamycin PFS Injection 36-64
36.4.21.11 Idursulfase (Elaprase) 36-64
36.4.21.13 Immunosuppressive Drugs 36-64
36.4.21.14 Infliximab (Remicade) 36-64
36.4.21.15 Interferon Injections 36-64
36.4.21.16 Intralesional Injection(s) 36-65
36.4.21.18 Iron Injections 36-66
36.4.21.19 Joint Injections and Trigger Point Injections 36-67
36.4.21.20 Leuprolide Acetate (Lupron Depot) 36-67
36.4.21.22 Melphalan Hydrochloride 36-67
36.4.21.26 Porfimer (Photofrin) 36-68
36.4.21.27 Rho(D) Immune Globulin 36-68
36.4.21.29 Filgrastim, Pegfilgrastim (G-CSF), and Sargramostim (GM-CSF) 36-69
36.4.21.30 Strontium-89 Chloride 36-70
36.4.21.31 Tetanus Injections, Acute Care 36-71
36.4.21.32 Anti-thymocyte Globulin (Rabbit) (Thymoglobulin) 36-76
36.4.21.33 Thyrotropin Alpha for Injection (Thyrogen) 36-76
36.4.21.36 Valrubicin Sterile Solution for Intravesical Instillation (Valstar) 36-76
36.4.21.37 Vitamin B12 (Cyanocobalamin) 36-76
36.4.22 Laboratory Services 36-77
36.4.22.1 Blood Counts 36-78
36.4.22.2 Clinical Lab Panel Implementation 36-78
36.4.22.3 Clinical Pathology Consultations 36-79
36.4.22.4 Cytogenetics Testing for Leukemia and Lymphoma 36-79
36.4.22.5 Maternal Serum Alpha-Fetoprotein (MSAFP) 36-81
36.4.23 Mastectomy and Breast Reconstruction 36-81
36.4.24 Obstetrics/Prenatal Care 36-82
36.4.24.1 Ultrasound of the Pregnant Uterus 36-83
36.4.24.2 External Cephalic Version 36-83
36.4.24.3 Amniocentesis, Cordocentesis, Fetal Intrauterine Transfusion
(FIUT) and Ultrasonic Guidance for Cordocentesis 36-83
36.4.24.4 Fetal Fibronectin 36-84
36.4.24.5 Certified Nurse-Midwife (CNM) 36-84
36.4.24.6 Nonstress Testing, Contraction Stress Testing 36-84
36.4.24.7 Screening of Pregnant Women for Syphilis, HIV,
and Hepatitis B Required 36-85
36.4.25 Newborn Services 36-86
36.4.25.1 Apnea Monitors 36-86
36.4.25.2 Circumcisions 36-86
36.4.25.3 Claims Filing Instructions, Eligibility Requirements 36-86
36.4.25.4 THSteps Newborn Examination 36-87
36.4.25.5 Newborn Screening 36-87
36.4.25.6 Newborn Hearing Screening 36-88
36.4.25.7 Critical Care 36-88
36.4.25.8 Newborn Resuscitation 36-88
36.4.25.9 Potential SSI/Medicaid Eligibility for Premature Infants 36-88
36.4.26 Noncoronary Percutaneous Transluminal Angioplasty (PTA) 36-89
36.4.27 Nuclear Medicine 36-89
36.4.28 Occupational Therapy 36-89
36.4.29 Ophthalmology 36-91
36.4.29.1 Complete Eye Exams 36-91
36.4.29.2 Blepharoplasty Procedures 36-93
36.4.29.3 Corneal Topography 36-94
36.4.29.4 Corneal Transplants 36-94
36.4.29.5 Echography Ophthalmic, A & B Scan 36-94
36.4.29.6 Echography Ophthalmic Biometry, A-Mode 36-95
36.4.29.7 Echography Scan, Ophthalmic 36-95
36.4.29.8 Eye Surgery by Laser 36-95
36.4.29.9 The Anterior Segment of the Eye-The Lens 36-95
36.4.29.10 Eye Surgery by Incision 36-97
36.4.29.11 Intraocular Lens (IOL) 36-98
36.4.29.12 Intravitreal Drug Delivery System 36-98
36.4.29.13 Iridectomy/Iridotomy/Trabeculectomy 36-98
36.4.29.14 Ophthalmic Ultrasound Foreign Body Localization 36-98
36.4.29.15 Ophthalmological Services Billed with a Diagnosis of Cataract 36-98
36.4.30 Organ/Tissue Transplants 36-98
36.4.30.1 Pancreas Transplant/Simultaneous Kidney-Pancreas Transplant 36-99
36.4.30.2 Stem Cell Transplants 36-100
36.4.30.3 Heart Transplants 36-102
36.4.30.4 Intestinal Transplants 36-103
36.4.30.5 Liver Transplants 36-103
36.4.30.6 Lung Transplants 36-103
36.4.30.7 Prior Authorization 36-104
36.4.31 Osteopathic Manipulative Treatment (OMT) Services 36-104
36.4.32 Pentamadine, Aerosol 36-105
36.4.33 Percutaneous Transluminal Coronary Interventions 36-105
36.4.34 Physical Therapy Services 36-105
36.4.34.1 Limitations 36-105
36.4.34.2 Nursing Facility 36-106
36.4.35 Podiatrist Services 36-106
36.4.35.1 Clubfoot Casting 36-106
36.4.35.2 Echography/Ultrasound of Extremity 36-106
36.4.35.3 Flat Foot Treatment 36-106
36.4.35.4 Nerve Conduction Studies Performed by Podiatrist 36-106
36.4.35.5 Nursing Facility 36-107
36.4.35.6 Routine Foot Care 36-107
36.4.35.7 Vascular Studies Performed by Podiatrist 36-107
36.4.35.8 X-Ray Procedures by Podiatrist 36-107
36.4.36 Polysomnography 36-107
36.4.37 Prostate Surgeries 36-108
36.4.38 Psychiatric Pharmacological Management Services 36-108
36.4.39 Psychiatric Services 36-110
36.4.39.1 Documentation Required 36-117
36.4.39.2 Psychological and Neuropsychological Testing 36-117
36.4.40 Radiation Therapy 36-119
36.4.40.1 Clinical Treatment Planning 36-119
36.4.40.2 Clinical Treatment Management 36-119
36.4.40.3 Medical Radiation Physics, Dosimetry, Treatment Devices,
Special Services, and Proton Beam Treatment Delivery 36-120
36.4.40.4 Clinical Brachytherapy 36-120
36.4.40.5 Radiation Treatment Delivery/Port Films 36-120
36.4.40.6 Freestanding Radiation Therapy Facilities/Outpatient Facilities 36-120
36.4.41 Radiology Services 36-121
36.4.41.1 Cardiac Blood Pool Imaging 36-122
36.4.41.2 Chest X-Rays 36-122
36.4.41.3 Diagnosis Requirements 36-124
36.4.41.4 Contrast Materials/Radiopharmaceuticals 36-124
36.4.41.5 Magnetic Resonance Angiography (MRA) 36-125
36.4.41.6 Magnetic Resonance Imaging (MRI) 36-125
36.4.41.7 Technetium TC 99M-Tetrofosmin 36-125
36.4.42 Reduction Mammoplasties 36-125
36.4.43 Renal Disease 36-126
36.4.43.2 Dialysis Patients 36-126
36.4.43.3 Epoetin Alfa (Erythropoietin; EPO) 36-127
36.4.43.4 Laboratory Services for Dialysis Patients 36-127
36.4.43.5 Self-Dialysis Patients 36-127
36.4.44 Sign Language Interpreting Services 36-128
36.4.45 Skin Therapy 36-128
36.4.46 Speech-Language Therapy 36-130
36.4.46.1 Speech Therapy and Aural Rehabilitation Post Cochlear Implant 36-130
36.4.47 Surgeons and Surgery 36-131
36.4.47.1 Primary Surgery 36-131
36.4.47.2 Anesthesia Administered by Surgeon 36-131
36.4.47.3 Assistant Surgeon 36-131
36.4.47.4 Bilateral Procedures 36-131
36.4.47.6 Capsulotomy 36-132
36.4.47.8 Global Fees 36-132
36.4.47.9 Global Surgery Concurrent Care 36-133
36.4.47.10 Multiple Surgeries 36-133
36.4.47.11 Office Procedures 36-133
36.4.47.12 Orthopedic Hardware 36-134
36.4.47.13 Second Opinions 36-134
36.4.48 Suture of Wounds 36-134
36.4.49 Therapeutic Apheresis 36-134
36.4.50 Therapeutic Phlebotomy 36-135
36.4.51 Ventilation Assist and Management for the Inpatient 36-136
36.5 Doctor of Dentistry Practicing as a Limited Physician 36-136
36.5.1 Medicaid Managed Care Enrollment 36-136
36.5.1.1 Mandatory Prior Authorization Due to Life-Threatening
Medical Condition 36-136
36.5.2 Guidelines for Requesting Mandatory Prior Authorization 36-137
36.5.3 Reimbursement for Doctor of Dentistry Practicing as a Limited Physician 36-137
36.5.3.1 Benefits and Limitations 36-137
36.5.3.2 Diagnosis Codes 36-137
36.5.3.3 Evaluation and Management Procedure Codes 36-138
36.5.3.4 CPT Procedure Codes 36-138
36.5.3.5 CPT Codes Requiring Mandatory Prior Authorization 36-139
36.5.3.6 Radiographs by a Doctor of Dentistry Practicing as a Limited
Physician 36-140
36.5.3.7 Dental Anesthesia by a Doctor of Dentistry Practicing
as a Limited Physician 36-140
36.5.4 Claims Information for Doctor of Dentistry Practicing as a Limited Physician 36-140
36.6 Procedure Codes Requiring Prior Authorization 36-140
36.7 Claims Information 36-142
36.7.1 Claim Filing Resources 36-142
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