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December 2016 Texas Medicaid Provider Procedures Manual

Section 6: Claims Filing : 6.1 Claims Information : 6.1.2 Claims Filing Instructions : Wrong Surgery Notification
Providers are required to notify TMHP when a wrong surgery or other invasive procedure is performed on a Texas Medicaid client. Notification is mandated by Senate Bill (SB) 203, Section 3, Regular Session, 81st Texas Legislature, which covers preventable adverse events (PAE) and reimbursement for services associated with PAE.
Professional, inpatient, and outpatient hospital claims that are submitted for the wrong surgery or invasive procedure will be denied. Any corresponding procedures that are rendered to the same client, on the same dates of service (for professional and outpatient hospital claims), or the same date of surgery (for inpatient hospital claims) will be denied. Claims that have already been reimbursed will be recouped.
The law requires providers that are submitting claims for services rendered to Texas Medicaid clients to indicate whether any of the following situations apply to the claim:
Providers must notify Texas Medicaid of a wrong surgery or invasive procedure by submitting one of the following nonspecific injury, poisoning and other consequences of external causes diagnosis codes or modifiers with the procedure code for the rendered service:
Professional or outpatient hospital
Professional or outpatient hospital claims must include a valid diagnosis with up to seven-digit specificity, the procedure code that identifies the service rendered, and the PA, PB, or PC modifier that describes the type of “wrong surgery” performed.
Inpatient hospital claims must be submitted with type of bill (TOB) 110 as an inpatient hospital-nonpayment claim when a “wrong surgery” is reported. If other services or procedures that are unrelated to the “wrong surgery” are provided during the same stay as the “wrong surgery,” the inpatient hospital must submit a claim for the “wrong surgery” and a separate claim or claims for the unrelated services rendered during the same stay as the “wrong surgery.”
The “wrong surgery” claim must include TOB 110, the appropriate diagnosis code, the surgical procedure code for the surgical service rendered, and the date of surgery. The “wrong surgery” claim will be denied.
The unrelated services rendered during the same stay as the “wrong surgery” must include TOB 111, 112, 113, 114, or 115 on a claim separate from the “wrong surgery” claim. The unrelated services that are benefits of Texas Medicaid may be reimbursed by Texas Medicaid.
A claim that is denied for wrong surgery will have one of the following EOB codes:

Texas Medicaid & Healthcare Partnership
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