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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 : 6.3.3 Formula Applied

Formula Applied
For client L on the table below, 80 billed minutes are applied, but the provider only has 40 available minutes before reaching the 12-hour daily limit (720 minutes); therefore, only 40 minutes are considered for reimbursement. The 40 allowed minutes are divided into the 80 applied minutes to get an allowed unit of 0.5 for payment.
Amount Applied*
760 billed minutes for 1 day
720 paid minutes for 1 day
The procedure codes listed above have time ranges built in, so the quantity billed should be reflected in quantities of one, versus the actual amount of time spent with the client, i.e., procedure code 90804 is for 20 to 30 minutes of time spent with the client. The provider would bill a quantity of one when submitting a claim.
If a claim is adjusted and causes additional minutes to be available to the provider for that day, the system does not automatically reprocess any previously denied or cutback claims that would now be payable. It is up to the provider to request reprocessing of the denied or cutback claims.
Claims submitted for psychological evaluation or testing performed by a qualified provider at the request of the DFPS, or by a court order, are not counted against the benefit limitations. These claims must be submitted with the following information:
If psychological services are court ordered, the claim must include a copy of the court order for outpatient treatment signed by the judge, and documentation of medical necessity.
If psychological services are directed by DFPS, the claim must include the name and telephone number of the DFPS employee who provided the direction, the reason for the DFPS request, and documentation of medical necessity.
Texas Medicaid does not cover treatment for chronic diagnoses such as intellectual disability and organic brain syndrome. Psychiatric daycare is not a covered service.
Refer to:
Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement methodologies.
Form BH. 3, “Outpatient Psychotherapy/Counseling Request Form” in this handbook.
Section 4, “Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC)” in this handbook.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.