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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 : 6.3.1 Retrospective Review of Behavioral Health Services Billed in Excess of 12 Hours per Day

No single behavioral health services provider may be reimbursed for more than 12 hours of behavioral health services per day. HHSC and TMHP routinely perform retrospective review of all providers. In addition, all provider types including MDs and DOs and each provider to whom they delegate are subject to retrospective review for the total hours of services performed and billed in excess of 12 hours per day.
Retrospective review of any behavioral health provider may include:
All evaluation and management (E/M) procedure codes, including those listed in the E/M section of the Current Procedural Terminology (CPT), billed with a psychiatric diagnosis
Documentation requirements for all services billed are listed for each individual specialty in this handbook. All documentation is subject to retrospective review. If inappropriate payments are identified on retrospective review for any provider type, the reimbursement will be recouped.
Behavioral health services subject to the 12-hour system limitation and retrospective review will be based on the provider’s TPI base (the first seven digits of the TPI). The location where the services occurred will not be a basis for exclusion of hours. If a provider practices at multiple locations and has a different suffix for the various locations, but has the same TPI base, all services identified for restriction to the provider 12-hour limit will be counted regardless of whether they were performed at different locations.

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