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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4. Outpatient Hospital (Medical/Surgical Acute Care Outpatient Facility) : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.15 Lung Volume Reduction Surgery (LVRS)

Lung Volume Reduction Surgery (LVRS)
LVRS surgery must be performed at a facility certified under the Disease Specific Care Certification Program for LVRS by the Joint Commission of Health Care Organization and identified by the National Heart, Lung, and Blood Institute, and at sites that have been approved by Medicare as lung transplant facilities.
LVRS surgery must be preceded and followed by a program of diagnostic and therapeutic services consistent with those provided in the National Emphysema Treatment Trial (NETT) and designed to maximize the potential to successfully undergo and recover from surgery. The program must be arranged, monitored, and performed under the coordination of the facility where the surgery takes place, and must include all of the following:
It must be consistent with the plan of care developed by the treating physician following performance of a comprehensive evaluation of the client's medical, psychosocial, and nutritional needs.
Prior authorization is required for the LVRS procedure.; however, prior authorization is not required for the pre-operative and post-discharge pulmonary services.
An outpatient facility must submit claims that include revenue code 469 and one of the pre-operative rehabilitation service procedure codes for preparation for LVRS (procedure code G0302, G0303, or G0304) or for the post-discharge surgery services after LVRS (procedure code G0305). These services are restricted to diagnosis code 4928.
Procedure codes G0302, G0303, and G0304 are limited to once per rolling year per client for any provider. Only one pre-operative pulmonary rehabilitation service will be reimbursed per client. Post-discharge pulmonary surgery services after LVRS (procedure code G0305) are limited to once per rolling year per client for any provider and only if a claim for procedure code 32491 has been submitted in the past 12 months. Procedure code G0305 may be considered on appeal with documentation of LVRS surgery performed in the previous 12 months.

Texas Medicaid & Healthcare Partnership
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