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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook
Table of Contents
1 General Information 5
1.1 Family Planning Overview 5
1.1.1 Guidelines for Family Planning Providers 6
1.2 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 6
2 Medicaid Title XIX Family Planning Services 7
2.1 Title XIX Provider Enrollment 7
2.2 Services, Benefits, Limitations, and Prior Authorization 7
2.2.1 Family Planning Annual Exams 8
2.2.1.1 FQHC Reimbursement for Family Planning Annual Exams 9
2.2.2 Other Family Planning Office or Outpatient Visits 9
2.2.2.1 FQHC Reimbursement for Other Family Planning Office or Outpatient Visits 10
2.2.2.2 * RHC Reimbursement for Other Family Planning Office or Outpatient Visits 11
2.2.3 Laboratory Procedures 11
2.2.3.1 Clinical Laboratory Improvement Amendments (CLIA) Requirement 11
2.2.3.2 Medical Record Documentation 11
2.2.3.3 Lab Specimen Handling and Testing 11
2.2.3.4 Providing Information to the Reference Laboratory 11
2.2.4 Radiology Services 11
2.2.5 Contraceptive Devices and Related Procedures 11
2.2.5.1 External Contraceptives 11
2.2.5.2 Intrauterine Device 12
2.2.5.2.1 Insertion of the IUD 12
2.2.5.2.2 Removal of the IUD 12
2.2.5.3 Contraceptive Capsules 12
2.2.5.4 Immediate Postpartum Insertion of IUDs and Implantable Contraceptive Capsules 13
2.2.6 Drugs and Supplies 13
2.2.6.1 Prescriptions and Dispensing Medication 13
2.2.6.2 Long-Acting Reversible Contraception Products 14
2.2.6.3 Medroxyprogesterone Acetate (Depo-Provera) 14
2.2.6.4 Injection Administration 14
2.2.7 Medical Counseling and Education 14
2.2.8 Sterilization and Sterilization-Related Procedures 14
2.2.8.1 Sterilization Consent 15
2.2.8.2 Anesthesia for Sterilization 15
2.2.8.3 Occlusive Sterilization Device 15
2.2.8.4 Tubal Ligation 15
2.2.8.5 Vasectomy 15
2.2.8.6 Facility Fees for Sterilization 15
2.2.9 Prior Authorization 15
2.2.10 Non-covered Services 16
2.2.10.1 Family Planning Services for Undocumented Aliens 16
2.3 Documentation Requirements 16
2.4 Claims Filing and Reimbursement 16
2.4.1 Claims Information 16
2.4.1.1 Family Planning and Third Party Liability 17
2.4.2 Billing Procedures for Non-Family-Planning Services Provided During a Family Planning Visit (Title XIX Only) 17
2.4.3 National Drug Code 17
2.4.4 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines 18
3 Obstetric Services 18
3.1 *Services, Benefits, Limitations, and Prior Authorization 18
3.1.1 Antepartum and Fetal Invasive Procedures 19
3.1.2 Vaginal and Cesarean Deliveries 21
3.1.2.1 Home Deliveries 22
3.1.3 Elective Deliveries Prior to 39 Weeks 22
3.1.4 Other Vaginal and Cesarean Delivery Procedures 22
3.1.5 Abortion 22
3.1.6 Other Maternity Care and Delivery Services 24
3.1.7 Obstetric Ultrasound 24
3.1.8 Diagnostic Ultrasound and Ultrasonic Guidance 27
3.1.9 Doppler Studies 28
3.1.10 Echocardiography 28
3.1.11 Hydroxyprogesterone Caproate 29
3.1.12 Fetal Surgery 29
3.1.13 Antenatal and Postnatal Care Visits 30
3.1.13.1 Maternity Service Clinic (MSC) 31
3.1.14 Birthing Centers—Professional Services 31
3.1.15 Birthing Centers—Facility Services 32
3.1.16 Tobacco Use Cessation 32
4 Noninvasive Prenatal Testing (NIPT) 32
4.1 Screening for Fetal Sex Chromosome Aneuploidy 33
4.1.1 Screening Criteria 33
4.2 Genetic Counseling Requirement 34
4.3 Prior Authorization 34
4.3.1 Additional Documentation Requirements 35
4.4 NIPT Limitations 35
4.5 Non-Covered Services 35
5 Gynecological Health Services 36
5.1 Services, Benefits, Limitations, and Prior Authorization 36
5.2 Surgical and Laparoscopic Treatment of Ectopic Pregnancy 36
5.3 Laparoscopic Procedures 36
5.4 Endometrial Cryoablation 36
5.5 Uterine Suspension 36
5.6 Vulvectomy 36
5.6.1 Prior Authorization for Vulvectomy 36
5.7 Salpingostomy 36
5.7.1 Prior Authorization for Salpingostomy 37
5.8 Ovarian Wedge Resection 37
5.8.1 Prior Authorization for Ovarian Wedge Resection 37
5.9 Assays for the Diagnosis of Vaginitis 37
5.10 Hysteroscopy 38
5.11 Abortions 38
5.11.1 Services Related to Abortion Procedures 39
5.12 Examination Under Anesthesia 39
5.13 Laminaria Insertion 39
5.14 Hysterectomy Services 39
5.14.1 Hysterectomy Acknowledgment 40
5.15 Pap Smear (Cytopathology Studies) 41
5.16 Clitoroplasty and Vaginoplasty 42
5.17 Documentation Requirements 42
5.18 Claims Filing and Reimbursement 42
5.18.1 NCCI and MUE Guidelines 42
5.19 National Drug Code 43
6 Claims Resources 43
7 Contact TMHP 43
8 Forms 43
9 Claim Form Examples 44
 

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