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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 : 4.2.18 Radiation Therapy Services : 4.2.18.1 Radiopharmaceuticals

4.2.18.1
Radiopharmaceuticals may be considered for separate reimbursement when used for therapeutic treatment.
The following procedure codes are payable to outpatient hospitals
Procedure codes A9542, A9543. and A9545 require prior authorization. Only one of these agents may be considered per lifetime by any provider. Procedure codes A9542, A9543, A9545 must be submitted with diagnosis code 20280.
Procedure code A9600 is limited to diagnosis 1985 and to one service per day by the same provider with a total of 10 mci intravenously injected every 90 days, by any provider.
Procedure code A9563 is limited to the following diagnosis codes:
Procedure code A9564 is limited to diagnosis 1972 or 1976. Modifier 76 must be used when submitting a claim for a radiopharmaceutical procedure code more than once per day by the same provider.
Refer to:
Subsection 8.2.64, “Radiation Therapy,” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Prior Authorization for Therapeutic Radiopharmaceuticals
Prior authorization is required for A9542, A9543, and A9545, which will be considered with documentation of all of the following:
Prior authorization must be requested through the SMPA department with appropriate documentation. Requests can be mailed or faxed to:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: (512) 514-4213
Requests for prior authorization can be submitted online through the TMHP website at www.tmhp.com.

Texas Medicaid & Healthcare Partnership
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