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December 2016 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 5 THSteps Medical : 5.3 Services, Benefits, Limitations, and Prior Authorization : 5.3.8 Medical Checkup Follow-up Visit

5.3.8
Use procedure code 99211 with the provider identifier and THSteps benefit code when billing for a follow-up visit.
Note:
Reimbursement for the follow-up visit includes all elements of the visit. Reimbursement may not be allowed for the follow-up visit when submitted with certain procedure codes. For example: In accordance with CMS NCCI requirements, modifier 25 guidelines do not apply for procedure code 99211 when billed with other procedure codes that are included in the visit as related elements, including, but not limited to, administration of immunizations.
Refer to:
Subsection 6.4.1, “National Correct Coding Initiative (NCCI) Guidelines” in Section 6: Claims Filing (Vol. 1, General Information) for additional information.
Medical Checkup Follow-up Visit with Immunization Administration on the TMHP website at www.tmhp.com for a claim form example.
Medical Checkup Follow-up Visit with TB Skin Test on the TMHP website at www.tmhp.com for a claim form example.
A follow-up visit may be required to complete necessary procedures related to a checkup or exception-to-periodicity checkup, such as:
Administering immunizations in cases where the client’s immunizations were not up-to-date, medically contraindicated, or unable to be given during the checkup.
A return visit to follow up on treatment initiated during a checkup or to make a referral is not a follow-up visit, but is considered an acute care visit under an appropriate E/M procedure code for an established client.
If the parent or guardian did not give consent for a component during the initial checkup, and supporting documentation is provided, no follow-up visit is necessary.

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