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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook
Table of Contents
1 General Information 13
1.1 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 13
2 Chiropractic Manipulative Treatment (CMT) 14
2.1 Enrollment 14
2.2 Services, Benefits, Limitations, and Prior Authorization 14
2.2.1 Prior Authorization 15
2.3 Documentation Requirements 15
2.4 Claims Filing and Reimbursement 15
2.4.1 Claims Information 15
2.4.2 Reimbursement 15
3 Certified Nurse Midwife (CNM) 16
3.1 Provider Enrollment 16
3.1.1 Enrollment in Texas Health Steps (THSteps) 17
3.2 Services, Benefits, Limitations, and Prior Authorization 17
3.2.1 Deliveries 17
3.2.2 Newborn Services 17
3.2.3 Prenatal and Postpartum Services 17
3.2.4 Laboratory and Radiology Services 17
3.2.5 Prior Authorization 17
3.2.6 Documentation Requirements 18
3.2.7 Claims Filing and Reimbursement 18
4 Certified Registered Nurse Anesthetist (CRNA) 19
4.1 Enrollment 19
4.2 Services, Benefits, Limitations, and Prior Authorization 19
4.2.1 Prior Authorization 20
4.3 Documentation Requirements 20
4.4 Claims Filing and Reimbursement 20
4.4.1 Claims Information 20
4.4.1.1 Interpreting the R&S Report 20
4.4.2 Reimbursement 20
5 Geneticists 21
5.1 Enrollment 21
5.1.1 Geneticists 21
5.2 Services, Benefits, Limitations, and Prior Authorization 22
5.2.1 Family History 22
5.2.2 Genetic Tests 22
5.2.3 Laboratory Practices 23
5.2.4 Genetic Counselors 23
5.2.5 Genetic Evaluation and Counseling by a Geneticist 23
5.2.6 Prior Authorization 24
5.3 Documentation Requirements 24
5.4 Claims Filing and Reimbursement 24
5.4.1 Claims Information 24
5.4.2 Reimbursement 24
6 Licensed Midwife (LM) 25
6.1 Provider Enrollment 25
6.2 Services, Benefits, Limitations, and Prior Authorization 25
6.2.1 Deliveries 25
6.2.2 Newborn Services 25
6.2.3 Prenatal Services 25
6.2.4 Prior Authorization 26
6.2.5 Documentation Requirements 26
6.2.6 Claims Filing and Reimbursement 26
7 Maternity Service Clinics (MSC) 26
7.1 Provider Enrollment 26
7.1.1 Physician Responsibility 27
7.1.2 Case Management Services to High-Risk Individuals 27
7.2 Services, Benefits, Limitations, and Prior Authorization 27
7.2.1 Initial Prenatal Care Visit Components 28
7.2.1.1 History 28
7.2.1.2 Physical Examination 28
7.2.1.3 Laboratory Tests 28
7.2.1.4 Assessment 29
7.2.1.5 Plan 29
7.2.1.6 Education and Counseling 29
7.2.2 Subsequent Prenatal Care Visits 29
7.2.2.1 Physical Examination 30
7.2.2.2 Laboratory Tests 30
7.2.3 Postpartum Care Visit 30
7.2.4 Prior Authorization 30
7.3 Documentation Requirements 30
7.4 Claims Filing and Reimbursement 30
8 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) 31
8.1 Enrollment 31
8.1.1 Enrollment in Texas Health Steps (THSteps) 31
8.2 Services, Benefits, Limitations, and Prior Authorization 32
8.2.1 Prior Authorization 32
8.3 Documentation Requirements 32
8.4 Claims Filing and Reimbursement 32
8.4.1 Claims Information 32
8.4.2 Reimbursement 33
9 Physician 33
9.1 Enrollment 33
9.1.1 Physicians and Doctors 33
9.2 Services, Benefits, Limitations, and Prior Authorization 34
9.2.1 Teaching Physician and Resident Physician 34
9.2.1.1 Teaching Physician Prerequisites 35
9.2.2 Substitute Physician 36
9.2.3 Aerosol Treatment 37
9.2.3.1 Diagnostic Testing 37
9.2.4 Allergy Services 38
9.2.4.1 Allergy Immunotherapy 38
9.2.4.1.1 Prior Authorization for Allergy Immunotherapy 40
9.2.4.1.2 Limitations of Allergy Immunotherapy 40
9.2.4.2 Allergy Testing 41
9.2.4.2.1 Allergy Blood Tests 42
9.2.4.2.2 Collagen Skin Test 42
9.2.4.2.3 Prior Authorization for Collagen Skin Tests 43
9.2.4.2.4 Ingestion Challenge Test 43
9.2.5 Ambulance Transport Services - Nonemergency 43
9.2.6 Anesthesia 43
9.2.6.1 Medical Direction by an Anesthesiologist 43
9.2.6.2 Anesthesia for Sterilization 45
9.2.6.3 Anesthesia for Labor and Delivery 45
9.2.6.4 Anesthesia Provided by the Surgeon (Other Than Labor and Delivery) 46
9.2.6.5 Complicated Anesthesia 46
9.2.6.6 Multiple Procedures 46
9.2.6.7 Monitored Anesthesia Care 46
9.2.6.8 Reimbursement Methodology 46
9.2.6.9 Anesthesia Modifiers 47
9.2.6.9.1 State-Defined Modifiers 48
9.2.6.9.2 Modifier Combinations 48
9.2.6.9.3 CRNA and AA Services 49
9.2.6.10 Prior Authorization for Anesthesia 49
9.2.6.10.1 Anesthesia for Medical Services 49
9.2.6.11 Claims Filing 49
9.2.6.12 Anesthesia (General) for THSteps Dental 49
9.2.7 Abdominal Aortic Aneurysm Screening 49
9.2.8 Bariatric Surgery 49
9.2.8.1 Prior Authorization for Bariatric Surgery 50
9.2.9 Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer 52
9.2.10 Behavioral Health Services 53
9.2.11 Biopsy 53
9.2.12 Biofeedback Services 53
9.2.12.1 Biofeedback Certification 53
9.2.12.2 Prior Authorization for Biofeedback Services 54
9.2.13 Blepharoplasty Procedures 55
9.2.14 Bone Growth Stimulation 56
9.2.14.1 Invasive Bone Growth Stimulation 56
9.2.14.2 Non-invasive Bone Growth Stimulation 56
9.2.14.3 Ultrasound Bone Growth Stimulation 57
9.2.14.4 Reimbursement 57
9.2.15 Cancer Screening and Testing 57
9.2.15.1 BRCA Testing 57
9.2.15.2 Colorectal Cancer Screening 58
9.2.15.2.1 Prior Authorization for Colorectal Cancer Screening 59
9.2.15.3 Genetic Testing for Colorectal Cancer 59
9.2.15.3.1 Testing for Familial Adenomatous Polyposis 60
9.2.15.3.2 Hereditary Nonpolyposis Colorectal Cancer (HNPCC) 61
9.2.15.3.3 Prior Authorization for Genetic Testing for Colorectal Cancer 61
9.2.15.4 Mammography (Screening and Diagnostic Studies of the Breast) 62
9.2.15.5 Prognostic Breast and Gynecological Cancer Studies 63
9.2.16 Capsulotomy 64
9.2.17 Cardiac Rehabilitation 64
9.2.17.1 Prior Authorization for Cardiac Rehabilitation 65
9.2.17.2 Reimbursement 66
9.2.18 Casting, Splinting, and Strapping 66
9.2.19 Cardiopulmonary Resuscitation (CPR) 68
9.2.20 Chemotherapy 68
9.2.20.1 Chemotherapy Procedure Codes 68
9.2.21 Circumcisions 69
9.2.22 Closure of Wounds 69
9.2.23 Cochlear Implants 71
9.2.24 Continuous Glucose Monitoring (CGM) 71
9.2.24.1 Prior Authorization for Continuous Glucose Monitoring 71
9.2.25 Developmental and Neurological Assessment and Testing 71
9.2.25.1 Assessment of Aphasia 72
9.2.25.2 Developmental Screening 72
9.2.25.3 Developmental Testing 72
9.2.25.4 Neurobehavioral Testing 73
9.2.25.5 12-Hour Limitation for Procedure Codes 96110, 96111, and 96116 78
9.2.26 Diagnostic Tests 79
9.2.26.1 Ambulatory Blood Pressure Monitoring 79
9.2.26.2 Ambulatory Electroencephalogram (Ambulatory EEG) 80
9.2.26.3 Bone Marrow Aspiration, Biopsy 80
9.2.26.4 Cytopathology Studies—Other Than Gynecological 80
9.2.26.5 Echoencephalography 80
9.2.26.6 Electrocardiogram (ECG) 83
9.2.26.6.1 Prior Authorization for ECG 84
9.2.26.7 Esophageal pH Probe Monitoring 85
9.2.26.7.1 Prior Authorization 85
9.2.26.8 Helicobacter Pylori (H. pylori) 85
9.2.26.9 Myocardial Perfusion Imaging 86
9.2.26.10 Pediatric Pneumogram 86
9.2.27 Diagnostic Doppler Sonography 87
9.2.28 Evoked Response Tests and Neuromuscular Procedures 101
9.2.28.1 Autonomic Function Tests 101
9.2.28.2 Electromyography and Nerve Conduction Studies 102
9.2.28.2.1 EMG 107
9.2.28.2.2 NCS 107
9.2.28.3 Evoked Potential Testing 109
9.2.28.3.1 Visual Evoked Potentials 110
9.2.28.4 Motion Analysis Studies 110
9.2.29 Extracorporeal Membrane Oxygenation (ECMO) 111
9.2.30 Family Planning 112
9.2.31 Gynecological Health Services 112
9.2.32 Hospital Visits 112
9.2.33 Hyperbaric Oxygen Therapy (HBOT) 112
9.2.33.1 Prior Authorization for HBOT 113
9.2.34 Ilizarov Device and Procedure 116
9.2.35 Immunization Guidelines and Administration 116
9.2.35.1 Administration Fee 116
9.2.35.2 Documentation 118
9.2.35.3 Vaccine Adverse Event Reporting System (VAERS) 119
9.2.36 Immunizations for Clients Birth through 20 Years of Age 119
9.2.36.1 Vaccine Coverage Through the TVFC Program 119
9.2.36.2 Vaccine and Toxoid Procedure Codes 120
9.2.37 Immunizations for Clients Who Are 21 Years of Age and Older 122
9.2.38 Postexposure Prophylaxis for Rabies 123
9.2.38.1 Prior Authorization for Postexposure Rabies Vaccine 124
9.2.38.2 Limitations for Postexposure Rabies Vaccine 124
9.2.38.2.1 Obtaining Rabies Vaccine and HRIG from DSHS for PEP Use 124
9.2.39 Clinician-Administered Drugs 125
9.2.39.1 Reimbursement 125
9.2.39.2 Injectable Medications as a Pharmacy Benefit 126
9.2.39.3 National Drug Code (NDC) 126
9.2.39.4 Calculating Billable HCPCS and NDC Units 126
9.2.39.5 Single-Dose Vials Calculation Examples 127
9.2.39.6 Multi-Dose Vials Calculation Examples 127
9.2.39.7 Single and Multi-Use Vials 128
9.2.39.8 Nonspecific, Unlisted or Miscellaneous Procedure Codes 128
9.2.39.9 Abatacept (Orencia) 132
9.2.39.9.1 Prior Authorization for Abatacept (Orencia) 132
9.2.39.10 Ado-trastuzumab entansine (Kadcyla) 133
9.2.39.11 Alglucosidase Alfa (Myozyme) 134
9.2.39.12 Antibiotics and Steroids 134
9.2.39.13 Azacitidine (Vidaza) 135
9.2.39.14 Blood Factor Products 135
9.2.39.15 Botulinum Toxin Type A and Type B 136
9.2.39.16 Chelating Agents 139
9.2.39.16.1 Dimercaprol 139
9.2.39.16.2 Edetate calcium disodium 139
9.2.39.16.3 Deferoxamine mesylate (Desferal) 139
9.2.39.16.4 Edetate disodium 140
9.2.39.17 Clofarabine 140
9.2.39.17.1 Prior Authorization for Clofarabine 140
9.2.39.18 Denileukin diftitox (Ontak) 141
9.2.39.19 Fluocinolone Acetonide (Retisert) 141
9.2.39.20 Hematopoietic Injections 141
9.2.39.20.1 Epoetin Alfa (EPO) 141
9.2.39.20.2 Darbepoetin Alfa 142
9.2.39.21 Immune Globulin 143
9.2.39.22 Immunosuppressive Drugs 143
9.2.39.23 Infliximab (Remicade) 144
9.2.39.24 Interferon 145
9.2.39.25 Iron Injections 146
9.2.39.26 Joint Injections and Trigger Point Injections 147
9.2.39.27 Leuprolide Acetate (Lupron Depot) 147
9.2.39.28 Melphalan 148
9.2.39.29 Natalizumab 148
9.2.39.30 * Monoclonal Antibodies—Asthma and Chronic Idiopathic Urticaria 148
9.2.39.30.1 * Omalizumab 148
9.2.39.30.2 * Mepolizumab 148
9.2.39.30.3 * Prior Authorization for Omalizumab and Mepolizumab 149
9.2.39.30.4 * Prior Authorization Criteria for Chronic Idiopathic Urticaria 149
9.2.39.30.5 * Prior Authorization Criteria for Asthma: Moderate to Severe (Omalizumab) and Severe (Mepolizumab) 149
9.2.39.30.6 * Requirements for Continuation of Therapy 150
9.2.39.31 Sumatriptan succinate (Imitrex) 151
9.2.39.32 Trastuzumab 151
9.2.39.33 Valrubicin sterile solution for intravesical instillation (Valstar) 151
9.2.39.34 Vitamin B12 (Cyanocobalamin) Injections 151
9.2.39.35 Adalimumab 152
9.2.39.36 Amifostine 153
9.2.39.37 Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim) 157
9.2.39.38 Implantable Infusion Pumps 160
9.2.39.38.1 Prior Authorization for Implantable Infusion Pumps 161
9.2.39.38.2 IIP for Administration of Anti-spasmodic Drug to Treat Severe Refractory Spasticity 161
9.2.39.39 IIP for Administration of Analgesic (Opioid or Nonopioid) Drug for Treatment of Severe Intractable Pain 162
9.2.39.40 IIP for Administration of Intrahepatic Chemotherapy in Primary Liver Cancer or Colorectal Cancer with Liver Metastases 164
9.2.39.41 IIP for Administration of Intra-Arterial Chemotherapy in Head and Neck Cancers 164
9.2.39.42 Replacement of an IIP 165
9.2.39.43 Implantation of Catheters, Reservoirs, and Pumps 165
9.2.39.44 Drug Monitoring Services 166
9.2.40 Laboratory Services 167
9.2.40.1 THSteps Laboratory Services 167
9.2.40.2 Laboratory Handling Charge 168
9.2.40.3 Blood Counts 168
9.2.40.4 Clinical Lab Panel Implementation 168
9.2.40.5 Clinical Pathology Consultations 168
9.2.40.6 Cytogenetics Testing 169
9.2.40.7 Maternal Serum Alpha-Fetoprotein (MSAFP) 172
9.2.41 Lung Volume Reduction Surgery (LVRS) 173
9.2.41.1 Prior Authorization for Lung Volume Reduction Surgery 174
9.2.41.1.1 Noncovered Conditions 174
9.2.42 Diagnostic and Therapeutic Breast Procedures 175
9.2.42.1 Diagnostic Procedures 176
9.2.42.2 Therapeutic Procedures 176
9.2.42.2.1 Mastectomy Procedures 176
9.2.42.2.2 Prophylactic Mastectomy 177
9.2.42.2.3 Mastectomy for Pubertal Gynecomastia 177
9.2.42.3 Breast Reconstruction 178
9.2.42.3.1 Tattooing to Correct Color Defects of the Skin 180
9.2.42.3.2 Treatment for Complications of Breast Reconstruction 180
9.2.42.3.3 External Breast Prostheses 180
9.2.42.4 Prior Authorization Requirements for Diagnostic and Therapeutic Breast Procedures 181
9.2.42.4.1 Unlisted Breast Procedure 181
9.2.42.4.2 Documentation Requirements 182
9.2.43 Neurostimulators 182
9.2.43.1 Prior Authorization for Neurostimulators 182
9.2.43.2 Neuromuscular Electrical Stimulation (NMES) 183
9.2.43.2.1 NMES Rental 183
9.2.43.2.2 NMES Purchase 183
9.2.43.2.3 NMES for Muscle Atrophy 183
9.2.43.2.4 NMES for Walking in Clients with Spinal Cord Injury (SCI) 183
9.2.43.3 Transcutaneous Electrical Nerve Stimulation (TENS) 184
9.2.43.3.1 TENS Rental 184
9.2.43.3.2 TENS Purchase 185
9.2.43.4 NMES and TENS Garments 185
9.2.43.5 NMES and TENS Supplies 185
9.2.43.6 Diaphragm-Pacing Neuromuscular Stimulation 186
9.2.43.6.1 Prior Authorization for Diaphragm-Pacing Neuromuscular Stimulation 186
9.2.43.7 Dorsal Column Neurostimulator (DCN) 186
9.2.43.7.1 Prior Authorization for Dorsal Column Neurostimulators 187
9.2.43.8 Gastric Electrical Stimulation (GES) 187
9.2.43.8.1 Prior Authorization for GES 187
9.2.43.9 Intracranial Neurostimulators 188
9.2.43.9.1 Prior Authorization for Intracranial Neurostimulators 188
9.2.43.10 Pelvic Floor Stimulation 188
9.2.43.10.1 Prior Authorization for Pelvic Floor Stimulation 188
9.2.43.11 Percutaneous Electrical Nerve Stimulation (PENS) 189
9.2.43.11.1 Prior Authorization for PENS 189
9.2.43.12 Sacral Nerve Stimulators (SNS) 189
9.2.43.12.1 Prior Authorization for SNS 189
9.2.43.13 Vagal Nerve Stimulators (VNS) 189
9.2.43.13.1 Prior Authorization for VNS 190
9.2.43.14 Prior Authorization of Neurostimulator Devices Procedure Codes 190
9.2.43.15 Supplies for Neurostimulators 190
9.2.43.16 Electronic Analysis for Neurostimulators 190
9.2.43.17 Revision or Removal of Neurostimulator Devices 191
9.2.43.18 Noncovered Neurostimulator Services 191
9.2.44 Newborn Services 191
9.2.44.1 Circumcisions for Newborns 191
9.2.44.2 Hospital Visits and Routine Care 191
9.2.44.3 Newborn Hearing Screening 194
9.2.45 Occupational Therapy (OT) Services 194
9.2.46 Ophthalmology 194
9.2.46.1 Corneal Transplants 194
9.2.46.2 Eye Surgery by Laser 194
9.2.46.2.1 Other Eye Surgery Procedures 195
9.2.46.3 Eye Surgery by Incision 196
9.2.46.4 Intraocular Lens (IOL) 197
9.2.46.5 Intravitreal Drug Delivery System 197
9.2.46.6 Other Eye Surgery Limitations 197
9.2.47 Organ/Tissue Transplants 197
9.2.47.1 General Prior Authorization Requirements 199
9.2.47.2 Heart Transplants 199
9.2.47.2.1 Prior Authorization for Heart Transplants 199
9.2.47.3 Intestinal Transplants 200
9.2.47.4 Kidney Transplants 201
9.2.47.4.1 Prior Authorization for Kidney Transplants 201
9.2.47.4.2 Cytogam 201
9.2.47.5 Liver Transplants 201
9.2.47.5.1 Prior Authorization for Liver Transplants 201
9.2.47.6 Lung Transplants 202
9.2.47.6.1 Prior Authorization for Lung Transplants 202
9.2.47.7 Pancreas Transplant 202
9.2.47.7.1 Prior Authorization for Pancreas Transplant 202
9.2.47.8 Multi-Organ Transplants 203
9.2.47.9 Nonsolid Organ Transplants 203
9.2.47.9.1 Allogeneic and Autologous Bone Marrow and Stem Cell Transplantation 203
9.2.47.9.2 Autologous Islet Cell Transplantation 204
9.2.47.9.3 HPC Boost Infusion 204
9.2.47.9.4 Prior Authorization for Nonsolid Organ Transplants 204
9.2.47.10 Organ Procurement 205
9.2.48 Orthognathic Surgery 205
9.2.48.1 Prior Authorization for Orthognathic Surgery 205
9.2.49 Osteopathic Manipulative Treatment (OMT) 206
9.2.50 Pain Management 207
9.2.50.1 Epidural and Subarachnoid Infusion (Not Including Labor and Delivery) 208
9.2.51 Palivizumab Injections 208
9.2.52 Panniculectomy and Abdominoplasty 208
9.2.52.1 Panniculectomy 208
9.2.52.2 Abdominoplasty 210
9.2.53 Penile and Testicular Prostheses 211
9.2.54 Percutaneous Transluminal Coronary Interventions 211
9.2.55 Physical Therapy (PT) Services 211
9.2.56 Physician Evaluation and Management (E/M) Services 212
9.2.56.1 Office or Other Outpatient Hospital Services 212
9.2.56.1.1 New and Established Patient Services 212
9.2.56.1.2 Preventive Care Visits 213
9.2.56.1.3 Consultation Services 214
9.2.56.1.4 Services Outside of Business Hours 214
9.2.56.1.5 Observation Services 215
9.2.56.2 Domiciliary, Rest Home, or Custodial Care Services 215
9.2.56.3 Physician Services Provided in the Emergency Department 216
9.2.56.4 Group Clinical Visits 216
9.2.56.4.1 * Group Clinical Visits for Diabetes 217
9.2.56.4.2 * Group Clinical Visits for Asthma 219
9.2.56.4.3 Group Clinical Visits for Pregnancy 219
9.2.56.5 Home Services 220
9.2.56.6 Inpatient Hospital Services 220
9.2.56.6.1 Hospital Admissions, Initial Visits, and Subsequent Visits 221
9.2.56.6.2 Concurrent Care 221
9.2.56.6.3 Consultations 222
9.2.56.6.4 Critical Care 222
9.2.56.6.5 Hospital Discharge 224
9.2.56.6.6 Nursing Facility Services 224
9.2.56.6.7 Observation 225
9.2.56.7 Prolonged Physician Services 225
9.2.56.8 Referrals 225
9.2.56.8.1 Referral Requirements for Children with Disabilities 226
9.2.57 Physician Services in a Long Term Care (LTC) Nursing Facility 226
9.2.58 Podiatry and Related Services 226
9.2.58.1 Clubfoot Casting 226
9.2.58.2 Flat Foot Treatment 226
9.2.58.3 Routine Foot Care 226
9.2.59 Prostate Surgery 226
9.2.60 Radiation Therapy 227
9.2.60.1 Brachytherapy 227
9.2.60.1.1 Prior Authorization for Brachytherapy 227
9.2.60.1.2 Other Limitations on Brachytherapy 227
9.2.60.2 Stereotactic Radiosurgery 228
9.2.60.2.1 Prior Authorization for Stereotactic Radiosurgery 228
9.2.60.2.2 Other Limitations on Stereotactic Radiosurgery 229
9.2.61 Radiology Services 229
9.2.61.1 Diagnosis Requirements 230
9.2.61.2 Cardiac Blood Pool Imaging 230
9.2.61.3 Chest X-Rays 230
9.2.61.4 Magnetic Resonance Angiography (MRA) 230
9.2.61.5 Magnetic Resonance Imaging (MRI) 231
9.2.61.6 Technetium TC 99M 231
9.2.62 Magnetoencephalography (MEG) 231
9.2.62.1 Prior Authorization for MEG 231
9.2.62.2 Documentation Requirements 232
9.2.62.3 Noncovered Services 233
9.2.63 Reduction Mammaplasties 233
9.2.63.1 Prior Authorization for Reduction Mammaplasty 233
9.2.64 Renal Disease 234
9.2.64.1 Dialysis Patients 234
9.2.64.1.1 Physician Supervision of Dialysis Patients 234
9.2.64.2 Laboratory Services for Dialysis Patients 236
9.2.64.3 Self-Dialysis Patients 237
9.2.64.3.1 Physician Supervision 237
9.2.64.3.2 Initial Training 237
9.2.64.3.3 Subsequent Training 237
9.2.65 Sign Language Interpreting Services 238
9.2.66 Skin Therapy 238
9.2.67 Sleep Studies 246
9.2.67.1 Actigraphy 246
9.2.67.2 Pneumocardiograms 247
9.2.67.3 Polysomnography 247
9.2.67.4 Multiple Sleep Latency Test (MSLT) 249
9.2.67.5 Home Sleep Study Test 249
9.2.67.6 Sleep Facility Restrictions for Polysomnography and Multiple Sleep Latency Testing 250
9.2.68 Speech Therapy (ST) Services 251
9.2.69 Surgery Billing Guidelines 251
9.2.69.1 Primary Surgeon 251
9.2.69.2 Anesthesia Administered by Surgeon 251
9.2.69.3 Assistant Surgeon 251
9.2.69.4 Bilateral Procedures 252
9.2.69.5 Cosurgery 253
9.2.69.6 Global Fees 253
9.2.69.7 Multiple Surgeries 257
9.2.69.8 Office Procedures 257
9.2.69.9 Orthopedic Hardware 258
9.2.69.10 Second Opinions 258
9.2.69.11 Supplies, Trays, and Drugs 258
9.2.70 Telemedicine Services 259
9.2.71 Therapeutic Apheresis 259
9.2.72 Therapeutic Phlebotomy 261
9.2.73 Therapeutic Radiopharmaceuticals 261
9.2.73.1 Prior Authorization for Therapeutic Radiopharmaceuticals 261
9.2.73.2 Other Limitations on Therapeutic Radiopharmaceuticals 262
9.2.74 Urethral Dilation 262
9.2.75 Ventilation Assist and Management for the Inpatient 262
9.2.76 Wearable Cardiac Defibrillator (WCD) 263
9.2.76.1 Prior Authorization for WCD 263
9.2.77 Wound Care Management 265
9.2.77.1 First-Line Wound Care Therapy 266
9.2.77.1.1 Cleansing, Antibiotics, and Pressure Off-loading 267
9.2.77.1.2 Compression 267
9.2.77.1.3 Debridement 267
9.2.77.1.4 Dressings and Metabolically Active Skin Equivalents 268
9.2.77.1.5 Whirlpool for Burns 269
9.2.77.2 Second-Line Wound Care Therapy 269
9.2.77.2.1 Whirlpool 269
9.2.77.2.2 Pulsatile-Jet Irrigation 270
9.2.77.3 Documentation Requirements 270
9.3 Doctor of Dentistry Practicing as a Limited Physician 270
9.3.1 Prior Authorization for General Dental Services Due to Life-Threatening Medical Condition 270
9.3.1.1 Guidelines for Requesting Mandatory Prior Authorization 271
9.3.2 Benefits and Limitations 272
9.3.2.1 Additional Payable Procedure Codes 272
9.3.2.2 Immune Globulin by a Doctor of Dentistry as a Limited Physician 274
9.3.2.3 Radiographs by a Doctor of Dentistry Practicing as a Limited Physician 274
9.3.2.4 Dental Anesthesia by a Doctor of Dentistry Practicing as a Limited Physician 274
9.4 Documentation Requirements 275
9.5 Claims Filing and Reimbursement 275
9.5.1 Claims Information 275
9.5.2 National Drug Codes (NDC) 275
9.5.3 Reimbursement 275
9.5.3.1 Affordable Care Act of 2010 (ACA) Rate Increase for Primary Care Services 277
10 Physician Assistant 278
10.1 Enrollment 278
10.2 Services, Benefits, Limitations, and Prior Authorization 278
10.2.1 Prior Authorization 279
10.3 Documentation Requirements 279
10.4 Claims Filing and Reimbursement 279
10.4.1 Claims Information 279
10.4.2 Reimbursement 279
11 Claims Resources 280
12 Contact TMHP 280
13 Forms 280
14 Claim Form Examples 281
 

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