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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
1. General Information MD-15
2. Chiropractic Manipulative Treatment (CMT) MD-16
2.1 Enrollment MD-16
2.2 Services, Benefits, Limitations, and Prior Authorization MD-16
2.2.1 Prior Authorization MD-16
2.3 Documentation Requirements MD-17
2.4 Claims Filing and Reimbursement MD-17
2.4.1 Claims Information MD-17
2.4.2 Reimbursement MD-17
3. Certified Nurse Midwife (CNM) MD-18
3.1 Provider Enrollment MD-18
3.1.1 Enrollment in Texas Health Steps (THSteps) MD-18
3.2 Services, Benefits, Limitations, and Prior Authorization MD-18
3.2.1 Deliveries MD-19
3.2.2 Newborn Services MD-19
3.2.3 Prenatal and Postpartum Services MD-19
3.2.4 Laboratory and Radiology Services MD-19
3.2.5 Prior Authorization MD-19
3.2.6 Documentation Requirements MD-19
3.2.7 Claims Filing and Reimbursement MD-20
4. Certified Registered Nurse Anesthetist (CRNA) MD-20
4.1 Enrollment MD-20
4.2 Services, Benefits, Limitations, and Prior Authorization MD-21
4.2.1 Prior Authorization MD-21
4.3 Documentation Requirements MD-21
4.4 Claims Filing and Reimbursement MD-21
4.4.1 Claims Information MD-21
4.4.1.1 Interpreting the R&S Report MD-22
4.4.2 Reimbursement MD-22
5. Geneticists MD-22
5.1 Enrollment MD-22
5.1.1 Geneticists MD-22
5.2 Services, Benefits, Limitations, and Prior Authorization MD-23
5.2.1 Family History MD-23
5.2.2 Genetic Tests MD-24
5.2.3 Laboratory Practices MD-24
5.2.4 Genetic Counselors MD-24
5.2.5 Genetic Evaluation and Counseling by a Geneticist MD-24
5.2.6 Prior Authorization MD-25
5.3 Documentation Requirements MD-25
5.4 Claims Filing and Reimbursement MD-25
5.4.1 Claims Information MD-25
5.4.2 Reimbursement MD-26
6. Maternity Service Clinics (MSC) MD-26
6.1 Provider Enrollment MD-26
6.1.1 Physician Responsibility MD-26
6.1.2 Case Management Services to High-Risk Individuals MD-27
6.2 Services, Benefits, Limitations, and Prior Authorization MD-27
6.2.1 Initial Prenatal Care Visit Components MD-28
6.2.1.1 History MD-28
6.2.1.2 Physical Examination MD-28
6.2.1.3 Laboratory Tests MD-28
6.2.1.4 Assessment MD-29
6.2.1.5 Plan MD-29
6.2.1.6 Education and Counseling MD-29
6.2.2 Subsequent Prenatal Care Visits MD-29
6.2.2.1 Physical Examination MD-29
6.2.2.2 Laboratory Tests MD-29
6.2.3 Postpartum Care Visit MD-30
6.2.4 Prior Authorization MD-30
6.3 Documentation Requirements MD-30
6.4 Claims Filing and Reimbursement MD-30
7. Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) MD-31
7.1 Enrollment MD-31
7.1.1 Enrollment in Texas Health Steps (THSteps) MD-31
7.2 Services, Benefits, Limitations, and Prior Authorization MD-31
7.2.1 Prior Authorization MD-32
7.3 Documentation Requirements MD-32
7.4 Claims Filing and Reimbursement MD-32
7.4.1 Claims Information MD-32
7.4.2 Reimbursement MD-32
8. Physician MD-33
8.1 Enrollment MD-33
8.1.1 Physicians and Doctors MD-33
8.2 Services, Benefits, Limitations, and Prior Authorization MD-33
8.2.1 Teaching Physician and Resident Physician MD-34
8.2.1.1 Teaching Physician Prerequisites MD-34
8.2.2 Substitute Physician MD-35
8.2.3 Aerosol Treatment MD-36
8.2.4 Allergy Services MD-37
8.2.4.1 Allergy Immunotherapy MD-37
8.2.4.1.1 Prior Authorization for Allergy Immunotherapy MD-37
8.2.4.1.2 Limitations of Allergy Immunotherapy MD-37
8.2.4.2 Allergy Testing MD-38
8.2.4.2.1 RAST/MAST Tests MD-40
8.2.4.2.2 Collagen Skin Test MD-40
8.2.4.2.3 Prior Authorization for Collagen Skin Tests MD-40
8.2.5 Ambulance Transport Services - Nonemergency MD-40
8.2.6 Anesthesia MD-41
8.2.6.1 Medical Direction by an Anesthesiologist MD-41
8.2.6.2 Anesthesia for Sterilization MD-42
8.2.6.3 Anesthesia for Labor and Delivery MD-42
8.2.6.4 Anesthesia Provided by the Surgeon (Other Than Labor and Delivery) MD-43
8.2.6.5 Complicated Anesthesia MD-43
8.2.6.6 Multiple Procedures MD-43
8.2.6.7 Monitored Anesthesia Care MD-43
8.2.6.8 Reimbursement Methodology MD-43
8.2.6.9 Anesthesia Modifiers MD-45
8.2.6.9.1 State-Defined Modifiers MD-45
8.2.6.9.2 Modifier Combinations MD-45
8.2.6.9.3 CRNA Services MD-46
8.2.6.10 Prior Authorization for Anesthesia MD-46
8.2.6.11 Claims Filing MD-46
8.2.6.12 Anesthesia (General) for THSteps Dental MD-46
8.2.7 Abdominal Aortic Aneurysm Screening MD-46
8.2.8 Bariatric Surgery MD-47
8.2.8.1 Prior Authorization for Bariatric Surgery MD-47
8.2.9 Bacillus Calmette‑Guérin (BCG) Intravesical for Treatment of Bladder Cancer MD-49
8.2.10 Behavioral Health Services MD-50
8.2.11 Biopsy MD-50
8.2.12 Biofeedback Services MD-50
8.2.12.1 Biofeedback Certification MD-50
8.2.12.2 Prior Authorization for Biofeedback Services MD-51
8.2.13 Blepharoplasty Procedures MD-52
8.2.14 BRCA Testing MD-52
8.2.14.1 Prior Authorization for Gene Mutation Analysis MD-53
8.2.14.2 Retroactive Authorization MD-54
8.2.15 Mammography (Screening and Diagnostic Studies of the Breast) MD-55
8.2.16 Prognostic Breast and Gynecological Cancer Studies MD-55
8.2.16.1 Colorectal Cancer Screening MD-56
8.2.16.2 Prior Authorization for Colorectal Cancer Screening MD-58
8.2.16.3 Genetic Testing for Colorectal Cancer MD-58
8.2.16.3.1 Testing for Familial Adenomatous Polyposis MD-58
8.2.16.3.2 Hereditary Nonpolyposis Colorectal Cancer (HNPCC) MD-59
8.2.16.3.3 Prior Authorization for Genetic Testing for Colorectal Cancer MD-59
8.2.17 Capsulotomy MD-59
8.2.18 Cardiac Rehabilitation MD-59
8.2.18.1 Prior Authorization for Cardiac Rehabilitation MD-61
8.2.18.2 Reimbursement MD-61
8.2.19 Casting, Splinting, and Strapping MD-62
8.2.20 Cardiopulmonary Resuscitation (CPR) MD-63
8.2.21 Chemotherapy MD-64
8.2.21.1 Chemotherapy Procedure Codes MD-64
8.2.22 Circumcisions MD-65
8.2.23 Closure of Wounds MD-65
8.2.24 Cochlear Implants MD-66
8.2.25 Continuous Glucose Monitoring (CGM) MD-67
8.2.25.1 Prior Authorization for Continuous Glucose Monitoring MD-67
8.2.26 Developmental and Neurological Assessment and Testing MD-67
8.2.26.1 Assessment of Aphasia MD-68
8.2.26.2 Developmental Screening MD-68
8.2.26.3 Developmental Testing MD-69
8.2.26.4 Neurobehavioral Testing MD-69
8.2.26.5 12-Hour Limitation for Procedure Codes 96110, 96111, and 96116 MD-72
8.2.27 Diagnostic Tests MD-72
8.2.27.1 Ambulatory Blood Pressure Monitoring MD-72
8.2.27.2 Ambulatory Electroencephalogram (Ambulatory EEG) MD-73
8.2.27.3 Bone Marrow Aspiration, Biopsy MD-73
8.2.27.4 Cytopathology Studies—Other Than Gynecological MD-73
8.2.27.5 Echoencephalography MD-74
8.2.27.6 Electrocardiogram (ECG) MD-75
8.2.27.6.1 Prior Authorization for ECG MD-75
8.2.27.7 Electrodiagnostic (EDX) Testing MD-76
8.2.27.7.1 Electromyography (EMG) MD-77
8.2.27.7.2 Nerve Conduction Studies (NCS) MD-78
8.2.27.7.3 Documentation Requirements for EDX Testing MD-79
8.2.27.7.4 Prior and Retrospective Authorization for EDX Testing MD-80
8.2.27.8 Esophageal pH Probe Monitoring MD-81
8.2.27.8.1 Prior Authorization MD-81
8.2.27.9 Helicobacter Pylori (H. pylori) MD-81
8.2.27.10 Myocardial Perfusion Imaging MD-83
8.2.27.11 Pediatric Pneumogram MD-83
8.2.28 Diagnostic Doppler Sonography MD-83
8.2.29 Extracorporeal Membrane Oxygenation (ECMO) MD-88
8.2.30 Family Planning MD-89
8.2.31 Gynecological Health Services MD-89
8.2.32 Hospital Visits MD-89
8.2.33 Hyperbaric Oxygen Therapy (HBOT) MD-89
8.2.34 Ilizarov Device and Procedure MD-91
8.2.35 Immunization Guidelines and Administration MD-91
8.2.35.1 Administration Fee MD-91
8.2.35.2 Documentation MD-94
8.2.35.3 Vaccine Adverse Event Reporting System (VAERS) MD-94
8.2.36 Immunizations for Clients Birth through 20 Years of Age MD-94
8.2.36.1 Vaccine Coverage Through the TVFC Program MD-95
8.2.36.2 Vaccine and Toxoid Procedure Codes MD-96
8.2.37 Immunizations for Clients Who Are 21 Years of Age and Older MD-98
8.2.38 Postexposure Prophylaxis for Rabies MD-100
8.2.38.1 Prior Authorization for Postexposure Rabies Vaccine MD-101
8.2.38.2 Limitations for Postexposure Rabies Vaccine MD-101
8.2.38.2.1 Obtaining Rabies Vaccine and HRIG from DSHS for PEP Use MD-101
8.2.39 Medications - Injectable MD-101
8.2.39.1 Abatacept (Orencia) MD-104
8.2.39.1.1 Prior Authorization for Abatacept (Orencia) MD-104
8.2.39.2 Alatrofloxacin Mesylate (Trovan) MD-104
8.2.39.3 Alglucosidase Alfa (Myozyme) MD-105
8.2.39.3.1 Prior Authorization for Alglucosidase Alfa (Myozyme) MD-105
8.2.39.4 17-Alpha Hydroxyprogesterone Caproate MD-105
8.2.39.4.1 Compounded 17P-alpha hydroxyprogesterone caproate MD-105
8.2.39.4.2 Prior Authorization for Trademarked 17P-alpha hydroxyprogesterone
caproate (Makena) MD-105
8.2.39.5 Amifostine MD-106
8.2.39.6 Antibiotics and Steroids MD-107
8.2.39.7 Antihemophilic Factor MD-108
8.2.39.8 Botulinum Toxin Type A MD-108
8.2.39.9 Chelating Agents MD-109
8.2.39.9.1 Dimercaprol MD-109
8.2.39.9.2 Edetate calcium disodium MD-109
8.2.39.9.3 Deferoxamine mesylate (Desferal) MD-109
8.2.39.9.4 Edetate disodium MD-109
8.2.39.10 Clofarabine MD-110
8.2.39.10.1 Prior Authorization for Clofarabine MD-110
8.2.39.11 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and
Sargramostim) MD-110
8.2.39.12 Hematopoietic Injections MD-112
8.2.39.12.1 Epoetin Alfa (EPO) MD-113
8.2.39.12.2 Darbepoetin Alfa MD-113
8.2.39.13 Fluocinolone Acetonide (Retisert) MD-114
8.2.39.14 Gamma Globulin/Immune Globulin MD-114
8.2.39.15 Medroxyprogesterone Acetate (Depo Provera) MD-115
8.2.39.16 Immunosuppressive Drugs MD-115
8.2.39.17 Interferon MD-117
8.2.39.18 Joint Injections and Trigger Point Injections MD-118
8.2.39.19 Leuprolide Acetate (Lupron Depot) MD-118
8.2.39.20 Omalizumab MD-119
8.2.39.20.1 Prior Authorization for Omalizumab MD-119
8.2.39.21 Paclitaxel MD-120
8.2.39.22 Implantable Infusion Pumps MD-120
8.2.39.22.1 Prior Authorization for Implantable Infusion Pumps MD-121
8.2.39.22.2 Implantation of Catheters, Reservoirs, and Pumps MD-125
8.2.39.23 Trastuzumab MD-126
8.2.39.24 Vitamin B12 (Cyanocobalamin) Injections MD-126
8.2.39.25 Injection Administration MD-127
8.2.39.26 Billing for Injectable Medications MD-127
8.2.39.27 Unit Calculations for Billing Drugs MD-128
8.2.40 Medications - Oral MD-128
8.2.41 Laboratory Services MD-128
8.2.41.1 THSteps Laboratory Services MD-129
8.2.41.2 Laboratory Handling Charge MD-129
8.2.41.3 Blood Counts MD-129
8.2.41.4 Clinical Lab Panel Implementation MD-130
8.2.41.5 Clinical Pathology Consultations MD-130
8.2.41.6 Cytogenetics Testing MD-130
8.2.41.7 Maternal Serum Alpha‑Fetoprotein (MSAFP) MD-133
8.2.42 Lung Volume Reduction Surgery (LVRS) MD-133
8.2.42.1 Prior Authorization for Lung Volume Reduction Surgery MD-134
8.2.42.1.1 Noncovered Conditions MD-135
8.2.43 Mastectomy and Breast Reconstruction MD-136
8.2.43.1 Mastectomies MD-136
8.2.43.2 Prophylactic Mastectomies MD-137
8.2.43.3 Breast Reconstruction MD-137
8.2.43.4 Tattooing to Correct Color Defects of the Skin MD-139
8.2.43.5 Treatment for Complications of Breast Reconstruction MD-139
8.2.43.6 External Breast Prostheses MD-139
8.2.43.7 Prior Authorization Requirements for Mastectomy and Breast
Reconstruction MD-140
8.2.43.8 Limitations for Mastectomy and Breast Reconstruction MD-141
8.2.44 Neurostimulators MD-142
8.2.44.1 Prior Authorization for Neurostimulators MD-143
8.2.44.2 Neuromuscular Electrical Stimulation (NMES) MD-143
8.2.44.2.1 NMES Rental MD-143
8.2.44.2.2 NMES Purchase MD-144
8.2.44.2.3 NMES for Muscle Atrophy MD-144
8.2.44.2.4 NMES for Walking in Clients with Spinal Cord Injury (SCI) MD-144
8.2.44.3 Transcutaneous Electrical Nerve Stimulation (TENS) MD-145
8.2.44.3.1 TENS Rental MD-145
8.2.44.3.2 TENS Purchase MD-145
8.2.44.4 NMES and TENS Garments MD-145
8.2.44.5 NMES and TENS Supplies MD-146
8.2.44.6 Dorsal Column Neurostimulator (DCN) MD-146
8.2.44.6.1 Prior Authorization for Dorsal Column Neurostimulators MD-146
8.2.44.7 Intracranial Neurostimulators MD-147
8.2.44.7.1 Prior Authorization for Intracranial Neurostimulators MD-147
8.2.44.8 Percutaneous Electrical Nerve Stimulation (PENS) MD-148
8.2.44.8.1 Prior Authorization for PENS MD-148
8.2.44.9 Sacral Nerve Stimulators (SNS) MD-148
8.2.44.9.1 Prior Authorization for SNS MD-148
8.2.44.10 Vagal Nerve Stimulators (VNS) MD-148
8.2.44.10.1 Prior Authorization for VNS MD-148
8.2.44.11 Prior Authorization of Neurostimulator Devices Procedure Codes MD-149
8.2.44.12 Supplies for Neurostimulators MD-149
8.2.44.13 Electronic Analysis for Neurostimulators MD-149
8.2.44.14 Revision or Removal of Neurostimulator Devices MD-149
8.2.44.15 Noncovered Neurostimulator Services MD-149
8.2.45 Newborn Services MD-149
8.2.45.1 Circumcisions for Newborns MD-150
8.2.45.2 Hospital Visits and Routine Care MD-150
8.2.45.3 Newborn Hearing Screening MD-153
8.2.46 Obstetrics and Prenatal Care MD-153
8.2.46.1 Amniocentesis, Cordocentesis, and Ultra­sonic Guidance MD-155
8.2.46.2 Deliveries MD-155
8.2.46.3 External Cephalic Version MD-155
8.2.46.4 Fetal Fibronectin MD-156
8.2.46.5 Fetal Intrauterine Transfusion (FIUT) MD-156
8.2.46.6 Doppler Studies MD-156
8.2.46.7 Fetal Echocardiography MD-156
8.2.46.8 Obstetric Ultrasound MD-157
8.2.46.9 Prenatal Surveillance MD-160
8.2.46.10 Tobacco Use Cessation Counseling MD-161
8.2.46.11 Documentation Requirements for Diagnostic Studies MD-161
8.2.46.12 Required Screening of Pregnant Women for Syphilis, HIV, and
Hepatitis B MD-162
8.2.46.12.1 HIV Testing MD-162
8.2.46.12.2 Hepatitis B and Syphilis Screening MD-162
8.2.47 Occupational Therapy (OT) Services MD-162
8.2.48 Ophthalmology MD-162
8.2.48.1 Corneal Transplants MD-162
8.2.48.2 Eye Surgery by Laser MD-163
8.2.48.2.1 Other Eye Surgery Procedures MD-163
8.2.48.3 Eye Surgery by Incision MD-164
8.2.48.4 Intraocular Lens (IOL) MD-165
8.2.48.5 Intravitreal Drug Delivery System MD-165
8.2.48.6 Other Eye Surgery Limitations MD-165
8.2.49 Organ/Tissue Transplants MD-166
8.2.49.1 Heart Transplants MD-166
8.2.49.1.1 Prior Authorization for Heart Transplants MD-166
8.2.49.1.2 Guidelines for Coverage of a Heart Transplant MD-166
8.2.49.2 Intestinal Transplants MD-167
8.2.49.2.1 Prior Authorization for Intestinal Transplants MD-167
8.2.49.2.2 Guidelines for Coverage of an Intestinal Transplant MD-167
8.2.49.2.3 Other Limitations for Intestinal Transplants MD-168
8.2.49.3 Kidney Transplants MD-168
8.2.49.3.1 Prior Authorization for Kidney Transplants MD-168
8.2.49.3.2 Guidelines for Coverage of a Kidney Transplant MD-168
8.2.49.3.3 Other Limitations for Kidney Transplants MD-169
8.2.49.3.4 Cytogam MD-169
8.2.49.4 Liver Transplants MD-169
8.2.49.4.1 Prior Authorization for Liver Transplants MD-169
8.2.49.4.2 Guidelines for Coverage MD-170
8.2.49.5 Lung Transplants MD-170
8.2.49.5.1 Prior Authorization for Lung Transplants MD-170
8.2.49.5.2 Guidelines for Coverage of a Lung Transplant MD-171
8.2.49.6 Pancreas Transplant and Simultaneous Kidney‑Pancreas Transplant MD-171
8.2.49.6.1 Prior Authorization for Pancreas Transplant/Simultaneous
Kidney-Pancreas Transplant MD-171
8.2.49.6.2 Guidelines for Coverage of a Pancreas/Simultaneous Kidney‑Pancreas
Transplant MD-171
8.2.49.6.3 Pancreas Transplant Alone MD-172
8.2.49.6.4 Simultaneous Kidney-Pancreas Transplant MD-172
8.2.49.7 Nonsolid Organ Transplants MD-173
8.2.49.7.1 Allogeneic and Autologous Bone Marrow and Stem Cell
Transplantation MD-173
8.2.49.7.2 Autologous Islet Cell Transplantation MD-174
8.2.49.7.3 Prior Authorization for Nonsolid Organ Transplants MD-175
8.2.49.8 Organ Procurement MD-175
8.2.49.9 Prior Authorization for All Transplants MD-175
8.2.50 Orthognathic Surgery MD-176
8.2.50.1 Prior Authorization for Orthognathic Surgery MD-177
8.2.51 Osteogenic Stimulation MD-177
8.2.52 Osteopathic Manipulative Treatment (OMT) MD-177
8.2.53 Pain Management MD-179
8.2.53.1 Epidural and Subarachnoid Infusion (Not Including Labor and Delivery) MD-179
8.2.54 Palivizumab Injections MD-180
8.2.54.1 Benefits and Limitations MD-180
8.2.54.2 Prior Authorization Requirements MD-180
8.2.54.3 Obtaining Palivizumab MD-182
8.2.55 Panniculectomy and Abdominoplasty MD-183
8.2.55.1 Panniculectomy MD-183
8.2.55.2 Abdominoplasty MD-185
8.2.56 Penile and Testicular Prostheses MD-186
8.2.57 Pentamidine Aerosol MD-186
8.2.58 Percutaneous Transluminal Coronary Interventions MD-186
8.2.59 Physical Therapy (PT) Services MD-187
8.2.60 Physician Evaluation and Management (E/M) Services MD-187
8.2.60.1 Office or Other Outpatient Hospital Services MD-187
8.2.60.1.1 New and Established Patient Services MD-187
8.2.60.1.2 Preventive Care Visits MD-188
8.2.60.1.3 Consultation Services MD-189
8.2.60.1.4 Services Outside of Business Hours MD-190
8.2.60.1.5 Observation Services MD-190
8.2.60.2 Domiciliary, Rest Home, or Custodial Care Services MD-191
8.2.60.3 Physician Services Provided in the Emergency Department MD-191
8.2.60.4 Group Clinical Visits MD-192
8.2.60.4.1 Group Clinical Visits for Diabetes MD-192
8.2.60.4.2 Group Clinical Visits for Asthma MD-193
8.2.60.4.3 Group Clinical Visits for Pregnancy MD-193
8.2.60.5 Home Services MD-195
8.2.60.6 Inpatient Hospital Services MD-195
8.2.60.6.1 Hospital Admissions, Initial Visits, and Subsequent Visits MD-195
8.2.60.6.2 Concurrent Care MD-196
8.2.60.6.3 Consultations MD-196
8.2.60.6.4 Critical Care MD-197
8.2.60.6.5 Hospital Discharge MD-199
8.2.60.6.6 Nursing Facility Services MD-200
8.2.60.6.7 Observation MD-200
8.2.60.7 Prolonged Physician Services MD-201
8.2.60.8 Referrals MD-201
8.2.60.8.1 Referral Requirements for Children with Disabilities MD-201
8.2.61 Physician Services in a Long Term Care (LTC) Nursing Facility MD-202
8.2.62 Podiatry and Related Services MD-202
8.2.62.1 Clubfoot Casting MD-202
8.2.62.2 Flat Foot Treatment MD-202
8.2.62.3 Routine Foot Care MD-202
8.2.63 Prostate Surgery MD-202
8.2.64 Radiation Therapy MD-203
8.2.64.1 Brachytherapy MD-204
8.2.64.1.1 Prior Authorization for Brachytherapy MD-204
8.2.64.1.2 Other Limitations on Brachytherapy MD-204
8.2.64.2 Procedure Code Limitations MD-205
8.2.64.3 Stereotactic Radiosurgery MD-207
8.2.64.3.1 Prior Authorization for Stereotactic Radiosurgery MD-207
8.2.64.3.2 Other Limitations on Stereotactic Radiosurgery MD-208
8.2.65 Radiology Services MD-208
8.2.65.1 Diagnosis Requirements MD-209
8.2.65.2 Cardiac Blood Pool Imaging MD-210
8.2.65.3 Chest X‑Rays MD-210
8.2.65.4 Magnetic Resonance Angiography (MRA) MD-212
8.2.65.5 Magnetic Resonance Imaging (MRI) MD-212
8.2.65.6 Technetium TC 99M MD-213
8.2.66 Reduction Mammaplasties MD-213
8.2.66.1 Prior Authorization for Reduction Mammaplasty MD-213
8.2.67 Renal Disease MD-214
8.2.67.1 Dialysis Patients MD-214
8.2.67.1.1 Physician Supervision of Dialysis Patients MD-214
8.2.67.2 Laboratory Services for Dialysis Patients MD-216
8.2.67.3 Self‑Dialysis Patients MD-216
8.2.67.3.1 Physician Supervision MD-217
8.2.67.3.2 Initial Training MD-217
8.2.67.3.3 Subsequent Training MD-217
8.2.68 Sign Language Interpreting Services MD-217
8.2.69 Skin Therapy MD-218
8.2.70 Sleep Studies MD-220
8.2.70.1 Actigraphy MD-221
8.2.70.2 Pneumocardiograms MD-222
8.2.70.3 Polysomnography MD-222
8.2.70.4 Multiple Sleep Latency Test (MSLT) MD-223
8.2.70.5 Sleep Facility Restrictions for Polysomnography and Multiple Sleep
Latency Testing MD-224
8.2.71 Speech Therapy (ST) Services MD-225
8.2.72 Surgery Billing Guidelines MD-225
8.2.72.1 Primary Surgeon MD-225
8.2.72.2 Anesthesia Administered by Surgeon MD-225
8.2.72.3 Assistant Surgeon MD-226
8.2.72.4 Bilateral Procedures MD-226
8.2.72.5 Cosurgery MD-227
8.2.72.6 Global Fees MD-227
8.2.72.7 Multiple Surgeries MD-231
8.2.72.8 Office Procedures MD-231
8.2.72.9 Orthopedic Hardware MD-232
8.2.72.10 Second Opinions MD-232
8.2.72.11 Services Incidental to Surgery and/or Anesthesia MD-232
8.2.72.12 Supplies, Trays, and Drugs MD-234
8.2.73 Telemedicine Services MD-234
8.2.73.1 Distant Site MD-234
8.2.73.2 Patient Site MD-235
8.2.74 Therapeutic Apheresis MD-236
8.2.75 Therapeutic Phlebotomy MD-237
8.2.76 Therapeutic Radiopharmaceuticals MD-237
8.2.76.1 Prior Authorization for Therapeutic Radiopharmaceuticals MD-238
8.2.76.2 Other Limitations on Therapeutic Radiopharmaceuticals MD-238
8.2.77 Urethral Dilation MD-238
8.2.78 Ventilation Assist and Management for the Inpatient MD-239
8.2.79 Wearable Cardiac Defibrillator (WCD) MD-239
8.2.79.1 Prior Authorization for WCD MD-239
8.2.80 Wound Care Management MD-242
8.2.80.1 First-Line Wound Care Therapy MD-243
8.2.80.1.1 Cleansing, Antibiotics, and Pressure Off-loading MD-243
8.2.80.1.2 Compression MD-243
8.2.80.1.3 Debridement MD-243
8.2.80.1.4 Dressings and Metabolically Active Skin Equivalents MD-245
8.2.80.1.5 Whirlpool for Burns MD-245
8.2.80.2 Second-Line Wound Care Therapy MD-246
8.2.80.2.1 Whirlpool MD-246
8.2.80.2.2 Pulsatile-Jet Irrigation MD-246
8.2.80.3 Documentation Requirements MD-246
8.3 Doctor of Dentistry Practicing as a Limited Physician MD-246
8.3.1 Prior Authorization for General Dental Services Due to Life‑Threatening
Medical Condition MD-247
8.3.1.1 Guidelines for Requesting Mandatory Prior Authorization MD-247
8.3.2 Benefits and Limitations MD-248
8.3.2.1 Diagnosis Codes MD-248
8.3.2.2 Evaluation and Management Procedure Codes MD-249
8.3.2.3 Additional Payable Procedure Codes MD-249
8.3.2.4 Immune Globulin by a Doctor of Dentistry as a Limited Physician MD-251
8.3.2.5 Radiographs by a Doctor of Dentistry Practicing as a Limited Physician MD-252
8.3.2.6 Dental Anesthesia by a Doctor of Dentistry Practicing as a
Limited Physician MD-252
8.4 Documentation Requirements MD-252
8.5 Claims Filing and Reimbursement MD-252
8.5.1 Claims Information MD-252
8.5.2 National Drug Codes (NDC) MD-253
8.5.3 Reimbursement MD-253
9. Physician Assistant MD-254
9.1 Enrollment MD-254
9.2 Services, Benefits, Limitations, and Prior Authorization MD-254
9.2.1 Prior Authorization MD-255
9.3 Documentation Requirements MD-255
9.4 Claims Filing and Reimbursement MD-255
9.4.1 Claims Information MD-255
9.4.2 Reimbursement MD-256
10. Claims Resources MD-256
11. Contact TMHP MD-257
12. Forms MD-258
MD.1 Abortion Certification Statements Form MD-259
MD.2 DME Certification and Receipt Form (3 pages) MD-260
MD.3 Hospital Report (Newborn Child or Children) (Form 7484) MD-263
MD.4 Hysterectomy Acknowledgment Form MD-264
MD.5 Medicaid Certificate of Medical Necessity for Reduction Mammaplasty MD-265
MD.6 Nonemergency Ambulance Prior Authorization Request Form (2 Pages) MD-266
MD.7 Obstetric Ultrasound Prior Authorization Request Instructions MD-268
MD.8 Obstetric Ultrasound Prior Authorization Request Form MD-269
MD.9 Special Medicaid Prior Authorization (SMPA) Request Form MD-270
MD.10 Sterilization Consent Form Instructions (2 pages) MD-271
MD.11 Sterilization Consent Form (English) MD-273
MD.12 Sterilization Consent Form (Spanish) MD-274
MD.13 Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form MD-275
MD.14 Texas Medicaid Vendor Drug Program for Outpatient Pharmacies Synagis
(Palivizumab) Prior Authorization Request & Prescription Form for 2011 MD-276
MD.15 THSteps Dental Mandatory Prior Authorization Request Form MD-277
MD.16 THSteps Dental Criteria for Dental Therapy Under General Anesthesia (2 pages) MD-278
13. Claim Form Examples MD-280
MD.17 Anesthesia MD-281
MD.18 Certified Nurse-Midwife (CNM) MD-282
MD.19 Certified Registered Nurse Anesthetist (CRNA) MD-283
MD.20 Chiropractic Services MD-284
MD.21 Dental (Doctor of Dentistry) MD-285
MD.22 Dialysis Training MD-286
MD.23 Genetics MD-287
MD.24 Radiation Therapy MD-288
MD.25 Surgery MD-289
Index MD-290

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