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December 2016 Texas Medicaid Provider Procedures Manual

Certified Respiratory Care Practitioner (CRCP) Services Handbook : 7 Claims Filing and Reimbursement : 7.2 Reimbursement

7.2
Respiratory therapy services provided by a participating CRCP are reimbursed the lesser of the provider’s billed charges or the rate calculated in accordance with 1 TAC §355.8089.
Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.
Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.
Refer to:
Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in Section 2, “Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.
Providers will not be reimbursed for procedure codes 99503 and 99504 on the same date of service, any provider.
The professional service may be billed by the CRCP for services provided in the client’s home (procedure code 99504). The professional service will be allowed once per day up to a limit of 24 visits per year. The recommended frequency for CRCP services is as follows: 7 visits during the first week, a total of 6 visits during the second through fourth weeks, and 11 monthly visits for the second through the 12th month.
Disposable respiratory supplies and respiratory equipment rental or purchase are a home health services benefit and are not reimbursed to the certified respiratory therapist.
Refer to:
Subsection 2.2, “Services, Benefits, Limitations and Prior Authorization” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for more information about DME or medical supplies prior authorization information.
Retrospective review may be performed to ensure documentation supports the medical necessity of the service when claims are submitted for the procedure codes listed within this handbook.
The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in this policy are subject to National Correct Coding Initiative (NCCI) relationships. Any exceptions to NCCI code relationships are specifically noted in the policy. Providers should refer to NCCI for correct coding guidelines and specific applicable code combinations.
 

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