Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 6 Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers : 6.3 The 12-Hour System Limitation

6.3
The following provider types are limited in the Medicaid claims processing system to reimburse for a maximum combined total of 12-hours per day, per provider system limitation for inpatient and outpatient behavioral health services:
Because MDs and DOs can delegate and may submit claims in excess of 12 hours per day, they are not subject to the 12-hour system limitation.
Providers who perform group therapy may possibly submit claims in excess of 12 hours in a given day due to the manner in which group therapy is billed.
Because a psychologist can delegate to multiple LPAs and PLPs and may submit claims for LPA services in excess of 12 hours per day, LPAs and PLPs are not subject to the 12-hour system limitation.
All providers, including MDs and DOs and each provider to whom they delegate, are subject to retrospective review as outlined below, including the following:
Court-ordered and DFPS services are not subject to the 12-hour system limitation per provider, per day when billed with modifier H9.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.