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Physician
24.1 Enrollment 24-4
24.1.1 Independent Practices 24-4
24.1.2 Group Practices 24-4
24.1.3 Specialty Team/Center 24-4
24.1.4 Personal Supervision Versus Direct Supervision 24-5
24.1.5 Exception for E/M Services Furnished in Certain Primary Care Centers 24-5
24.1.6 Clinical Laboratory Improvement Amendments (CLIA) Requirements 24-5
24.2 Reimbursement 24-6
24.2.1 General Medical Record Documentation Requirements 24-6
24.3 Benefits and Limitations 24-7
24.3.1 Aerosol Treatments/Inhalation Therapy 24-7
24.3.1.1 Pentamidine Aerosol Treatment 24-7
24.3.2 Allergy Services 24-7
24.3.3 Anesthesiology 24-8
24.3.3.3 Services Incidental to Surgery and/or Anesthesia 24-9
24.3.3.4 Reimbursement 24-9
24.3.4 Anesthesia, Regional (Epidural, Nerve Block, Spinal) 24-10
24.3.5 Audiometry/Hearing Services 24-10
24.3.6 Augmentative Communication Devices (ACDs) 24-12
24.3.7 Colorectal Cancer Screening 24-12
24.3.8 Chemotherapy 24-13
24.3.9 Cochlear Implants 24-14
24.3.9.1 Authorization Requirements 24-15
24.3.9.2 Sound Processor Replacement Guidelines 24-15
24.3.9.3 Claims Filing and Reimbursement 24-15
24.3.10 Echoencephalography 24-15
24.3.10.1 Intraoperative Echography 24-15
24.3.11 Ambulatory Electroencephalogram 24-28
24.3.12 Evaluation and Management (E/M) Services 24-29
24.3.12.1 New or Established Patient Visits 24-29
24.3.12.2 Office and Outpatient Services 24-29
24.3.12.3 Inpatient Professional Services 24-29
24.3.12.4 Critical Care Services 24-30
24.3.12.5 Emergency Services 24-33
24.3.12.6 Consultations 24-34
24.3.12.7 Services Outside of Business Hours 24-35
24.3.12.8 Prolonged Physician Services 24-35
24.3.12.9 Observation Room Services 24-35
24.3.12.10 Preventive Care Services 24-36
24.3.13 Gastrostomy Devices 24-37
24.3.14 Genetics 24-37
24.3.15 Hyperbaric Oxygen Therapy (HBOT) 24-37
24.3.16 Injection Administration Billed by a Physician 24-39
24.3.17 Injections and Oral Medications 24-39
24.3.17.1 Botulinum Toxin (Type A and Type B) 24-39
24.3.17.3 Clofarabine (Clorar) 24-42
24.3.17.4 Denileukin Diftitox 24-42
24.3.17.6 Epirubicin Hydrochloride 24-44
24.3.17.7 Epoprostenol 24-44
24.3.17.8 Erythropoietin Alfa (EPO) and Darbepoietin 24-44
24.3.17.9 Fluocinolone Acetonide (Retisert) 24-47
24.3.17.10 Granisetron Hydrochloride 24-47
24.3.17.11 Ibutilide Fumarate 24-48
24.3.17.12 Immune Globulins 24-48
24.3.17.16 Porfimer Sodium 24-51
24.3.17.18 Sumatriptan Succinate 24-51
24.3.18 Blood Factor Products 24-52
24.3.19 Clinician-Directed Care Coordination Services 24-53
24.3.19.1 Authorization 24-55
24.3.19.2 Reimbursement 24-56
24.3.20 Immunizations 24-58
24.3.20.1 Immunizations-Texas Vaccines for Children (TVFC) 24-58
24.3.20.2 Vaccines/Toxoids 24-58
24.3.20.3 Administration Procedure Codes for Vaccines/Toxoids 24-59
24.3.20.4 Authorization Requirements for Immunizations (Vaccines/Toxoids) 24-59
24.3.20.5 Reimbursement for Immunizations (Vaccines/Toxoids) 24-59
24.3.20.6 Human Papillomavirus (HPV) Vaccine 24-60
24.3.20.7 Rotavirus Vaccine and Tdap Vaccine 24-60
24.3.20.8 Respiratory Syncytial Virus (RSV) Prophylaxis 24-61
24.3.20.9 Intracranial Pressure Monitoring 24-65
24.3.21 Laboratory Services 24-65
24.3.21.1 Cytopathology Studies (Gynecological, Pap Smears) 24-66
24.3.21.2 Cytogenetics Testing 24-66
24.3.21.3 Helicobacter Pylori (H. Pylori) 24-66
24.3.22 Ophthalmological Services 24-67
24.3.22.1 Intraocular Lenses (IOL) 24-67
24.3.22.2 Vitrasert Ganciclovir Implant 24-67
24.3.22.3 Fluocinolone Acetonide Intravitreal Implant (Retisert) 24-67
24.3.23 Osteopathic Manipulative Treatment (OMT) 24-67
24.3.24 Physical Medicine and Physical Therapy (PT) Services 24-67
24.3.25 Podiatry 24-68
24.3.25.1 Nerve Conduction Studies 24-68
24.3.26 Polysomnography 24-68
24.3.27 Psychological Testing 24-69
24.3.28 Radiology Services 24-69
24.3.29 Radiation Therapy 24-69
24.3.30 Referrals to Other Providers 24-69
24.3.31 Sign Language Interpreting Services 24-69
24.3.32.1 Anesthesia Administered by Surgeon 24-70
24.3.32.2 Primary Surgeon 24-70
24.3.32.3 Assistant Surgeons 24-70
24.3.32.5 Bilateral Procedures 24-71
24.3.32.6 Bone Growth Stimulators 24-72
24.3.32.7 Noninvasive Bone Growth Stimulators 24-72
24.3.32.9 Circumcision 24-74
24.3.32.10 Extracorporeal Shock Wave Lithotripsy (ESWL) 24-74
24.3.32.12 Multiple Surgeries 24-74
24.3.32.13 Office Procedures 24-75
24.3.32.14 Second Opinions 24-75
24.3.32.16 Therapeutic Apheresis 24-79
24.3.32.17 Tonsillectomies, Adenoidectomies, and Myringotomies 24-83
24.3.32.18 Unlisted Surgical Procedure Code Considerations 24-83
24.4 Authorization and Team/Center Requirements 24-83
24.4.1 Stem Cell Transplant Facility Requirements 24-84
24.4.2 Cleft/Craniofacial Specialty Team Requirements 24-84
24.4.3 Services Requiring Physician Prior Authorization 24-84
24.4.3.1 Anterior Temporal Lobectomy for Complex Partial Seizures 24-85
24.4.3.2 Bone Marrow/Stem Cell Transplants 24-85
24.4.3.3 Cleft/Craniofacial and Oral Surgery Procedures 24-90
24.4.3.4 Reduction Mammoplasty 24-91
24.4.3.5 Renal Transplants 24-91
24.5 Telemedicine Services 24-93
24.5.1 Benefit/Limitations 24-93
24.5.2 Authorization Requirements 24-93
24.5.3 Reimbursement 24-93
24.6 Claims Information 24-94
24.6.1 Claims Submission 24-94
24.6.2 Claims Submission 24-94
24.7 TMHP-CSHCN Services Program Contact Center 24-94
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