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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5. THSteps Medical : 5.4 Documentation Requirements : 5.4.0.1 Separate Identifiable Acute Care Evaluation and Management Visit

5.4.0.1
If an acute or chronic condition that requires E/M beyond the required components for a medical checkup is discovered, a separate E/M procedure code may be considered for reimbursement for the same date of service as a checkup or the client can be referred for further diagnosis and treatment.
The client's medical record must contain documentation that the separate identifiable service(s) were medically necessary and include a diagnosis other than V202 (routine infant or child health check) and treatment. Documentation must be made available to Texas Medicaid upon request.
An insignificant or trivial problem/abnormality that is encountered in the process of performing a checkup and does not require additional work and performance of the key components of a problem-oriented E/M service cannot be considered a separate established patient E/M acute care visit.
Modifier 25 may be used to identify a significant, separately identifiable E/M service rendered by the same provider on the same day of the procedure or other service. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record.

Texas Medicaid & Healthcare Partnership
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