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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.2 Clinician-Directed Care Coordination Services (CCP) : 2.2.1 Services, Benefits, and Limitations : 2.2.1.1 Non-Face-to-Face Services

2.2.1.1
2.2.1.1.1 Non-Face-to-Face Medical Conferences
Procedure code 99367 must be used when billing for medical team conferences.
2.2.1.1.2 Non-Face-to-Face Clinician Supervision of a Home Health Client
Procedure code 99374 or 99375 must be used when billing for services requiring interaction with a home health agency.
2.2.1.1.3 Non-Face-to-Face Clinician Supervision of a Hospice Client
Procedure code 99377 or 99378 must be used when billing for services requiring interaction with a hospice.
2.2.1.1.4 Non-Face-to-Face Clinician Supervision of a Nursing Facility Client
Procedure code 99379 or 99380 must be used when billing for services requiring interaction with a nursing facility.
2.2.1.1.5 Other Non-Face-to-Face Supervision
Procedure code 99339 or 99340 must be used when billing for services requiring interaction with an independently-enrolled nurse or other provider (e.g., not a home health agency, nursing facility, or hospice provider).
2.2.1.1.6 Non-Face-to-Face Prolonged Services
Procedure code 99358 or 99359 must be used when billing for prolonged services without face-to-face contact. This service is to be reported in addition to other clinician services, including E/M services at any level, or health-care professionals outside of a home health agency, hospice, or nursing facility.
Non-face-to-face prolonged services are limited to a maximum of 90 minutes once per client by the same provider unless one of the following significant changes in the client’s clinical condition occurs:
The client will soon be, or has recently been, discharged from a prolonged and complicated hospitalization that required coordination of complex care with multiple providers in order for the client to be adequately cared for in the home.
Procedure code 99359 must be billed on the same date of service as procedure code 99358. Additional prolonged non-face-to-face services may be authorized if the provider submits supporting documentation for authorization.
Procedure code 99358 must be used to report the first hour of prolonged services and must be billed with the appropriate physician E/M procedure code listed in the table below. Prolonged services of less than 30 minutes are considered part of the physician’s E/M service being provided.
Procedure code 99359 is used to report an additional 15 to 30 minutes of prolonged non-face-to-face services beyond the first hour. Prolonged services of less than 15 minutes beyond the first hour are considered part of the first hour.
2.2.1.1.7 Non-Face-to-Face Specialist or Subspecialist Telephone Consultation
Telephone consultations are limited to two every six months to the same provider and will not be reimbursed to the clinician providing the medical home.
The clinician providing the medical home must have an authorization on file for one of the following procedure codes before the specialist or subspecialist can be reimbursed:
Because the specialist or sub-specialists cannot be reimbursed without the medical home clinician's current prior authorization information, the clinician providing the medical home should provide their information to the specialist or subspecialist.
The specialist or subspecialist will not be separately reimbursed for the telephone consultation if he or she is the medical home clinician because care plan oversight by the medical home provider includes telephone consultations. The referring provider identifier and prior authorization number must be submitted on the claim.
2.2.1.1.8 General Requirements for Non-Face-to-Face Clinician-Directed Care Coordination Services
These services may be reimbursed for the medical home clinician time involved in this coordination. The clinician billing the services must personally perform the services. Care coordination services delegated to or performed by others do not count towards care coordination reimbursement. Care coordination provided during post-surgical care is a benefit if the care is unrelated to the surgery.
2.2.1.1.9 Non-Face-to-Face Care Plan Oversight
The medical home clinician who bills for the care plan oversight must be the clinician who signed the plan of care (POC) in the home or domiciliary (procedure codes 99339 and 99340), home health agency (procedure codes 99374 and 99375), hospice (procedure codes 99377 and 99378), or nursing facility (procedure codes 99379 and 99380).
Procedure code 99339 is denied when billed on the same date of service by the same provider as procedure code 99340.
Procedure code 99374 is denied when billed on the same date of service by the same provider as procedure code 99375.
Procedure code 99377 is denied when billed on the same date of service by the same provider as procedure code 99378.
Procedure code 99379 is denied when billed on the same date of service by the same provider as procedure code 99380.
Care plan oversight services may be reimbursed for the clinician time involved in this coordination. The clinician billing the services must personally perform the services. Care coordination services delegated to or performed by others do not count towards care coordination reimbursement.
Only two clinician-directed care plan oversight services (procedure codes 99339 or 99340, 99374 or 99375, 99377 or 99378, and 99379 or 99380) are reimbursed every six months.
Payment is made only to one clinician per client per calendar month for procedure code 99374 or 99375.
The medical home clinician may not have a significant financial or contractual relationship with the home health agency as defined in 42 Code of Federal Regulations (CFR) §424.
The medical home clinician may not be the medical director or employee of the hospice and may not furnish services under arrangements with the hospice, including volunteering.
2.2.1.1.10 Medical Team Conference
One medical team conference (procedure code 99367) may be reimbursed once every six months when the medical home coordinating clinician attests that they are providing the medical home for the client. The coordinating clinician may be the client’s primary care provider or a specialist.
Additional medical team conferences may be considered with documentation of a change in the client’s medical home.
The medical team conference time must be documented in the client’s record.

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