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2012 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6. Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.3 The 12-Hour System Limitation

6.3
The 12-Hour System Limitation
The following provider types are limited in the Medicaid claims processing system to reimburse for a maximum combined total of 12-hours per day, per provider system limitation for inpatient and outpatient behavioral health services:
Because MDs and DOs can delegate and may submit claims in excess of 12 hours per day, they are not subject to the 12-hour system limitation.
Providers who perform group therapy may possibly submit claims in excess of 12 hours in a given day due to the manner in which group therapy is billed.
Because a psychologist can delegate to multiple LPAs and may submit claims for LPA services in excess of 12 hours per day, LPAs are not subject to the 12-hour system limitation.
All providers, including MDs and DOs and each provider to whom they delegate, are subject to retrospective review as outlined below, including the following:
Court-ordered and DFPS services are not subject to the 12-hour system limitation per provider, per day when billed with modifier H9.

Texas Medicaid & Healthcare Partnership
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