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2012 Texas Medicaid Provider Procedures Manual

Clinics and Other Outpatient Facility Services Handbook : 7. Rural Health Clinic : 7.2 Services, Benefits, Limitations, and Prior Authorization : 7.2.1 Freestanding and Hospital-Based RHC Services : Freestanding Rural Health Clinic Services
The services listed below cannot be reimbursed to freestanding RHCs using only the RHC provider identifier. Use of the RHC provider identifier for billing these services causes claims to be processed as informational only. Services in any of these categories must be billed using the professional (non-RHC) provider identifier and the appropriate benefit code:
These services must be billed with an AM, SA, or U7 modifier.
Physician supplies are not a benefit of Texas Medicaid. Costs of supplies are included in the reimbursement for office visits. Outpatient hospital services (including emergency room services) and inpatient hospital services provided outside the RHC setting are to be billed using the individual or group physician provider identifier.
Freestanding RHCs submit an all-inclusive encounter for services provided. All services provided that are incidental to the encounter, including developmental screening, must be included in the total charge for the encounter. A claim for these services may not be submitted as a separate encounter.
If immunizations are given outside of a THSteps medical checkup, procedure codes given in the THSteps section of this manual should be identified on the claim. These procedure codes are informational only, and are not payable.
All services provided during a freestanding RHC encounter must be submitted using procedure code T1015. The total submitted amount should be the combined charges for all services provided during that encounter.
One of the following modifiers must be reported with procedure code T1015 to designate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE, or U7. If the encounter is for antepartum or postpartum care, use modifier TH in addition to the modifier required to designate the health-care professional providing the service.
The primary initial contact is defined as “the health-care professional who spends the greatest amount of time with the client during that encounter.”
If more than one health-care professional is seen during the encounter, the modifier (if appropriate) must indicate the primary contact. For example, if an NP or a PA performs an antepartum exam, modifiers SA or U7, and TH, must be entered. A maximum of two modifiers may be reported with each encounter.

Texas Medicaid & Healthcare Partnership
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