CSHCN 2008 > Physician > Reimbursement

24.2 Reimbursement

Physicians may be reimbursed for most physician services according to the Texas Medicaid Reimbursement Methodology (TMRM). For information about anesthesia services that may be reimbursed according to relative value units (RVUs), refer to Section 24.3.3, "Anesthesiology," on page 24-8.

The CSHCN Services Program limits reimbursement for those physician's services provided in hospital outpatient settings that are ordinarily provided in physicians' offices. The CSHCN Services Program determines the limit for each service by establishing a charge base for each professional service and multiplying by a factor of 0.60. The charge base for a service is the TMRM fee for similar routine services provided by family practitioners in the office.

This provision applies to those procedures performed in the outpatient department of the hospital (e.g., clinics and emergency situations). If an eligible client is seen in the outpatient department of the hospital in an emergency situation, the condition that created the emergency must be documented on the claim form. The following is a list of those services excluded from this limitation:

•Surgical services that are covered ambulatory surgical center (ASC) services.

•Anesthesiology and radiology services.

•Emergency services provided in a hospital emergency room after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention must reasonably be expected to result in one of the following outcomes:

•Placing the client's health in serious jeopardy.

•Serious impairment to bodily functions.

•Serious dysfunction of any bodily organ or part.