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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.25 Developmental and Neurological Assessment and Testing : 12-Hour Limitation for Procedure Codes 96110, 96111, and 96116
APRNs, PAs, and psychologists are limited to a maximum, combined total of 12 hours per day for developmental screening and testing, neurobehavioral testing, and inpatient and outpatient behavioral health services.
Because physicians (M.D. and D.O.) can delegate and may submit claims for services in excess of 12 hours per day, they are not subject to the 12-hour system limitation.
Developmental screening, developmental testing, and neurobehavioral testing are included in the 12-hour per day, per provider, system limitation. The following table lists the procedure codes that are included in the 12-hour per day system limitation, along with the time increments the system will apply based on the billed procedure code. The time increments applied will be used to calculate the 12-hour per day system limitation.
Refer to:
Subsection 6.3, “The 12-Hour System Limitation,” in the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks) for more information about procedure codes included in the 12-hour system limitation.
All providers, including physicians and all providers to whom they delegate services, are subject to retrospective review. HHSC and TMHP routinely perform retrospective reviews of all providers. All providers are subject to retrospective review for the total hours of services performed and billed in excess of 12 hours per day. Retrospective review may include:
All E/M procedure codes, including those listed in the Evaluation and Management Section of the CPT Manual, billed with a diagnosis listed in the diagnosis table above under Neurobehavioral Testing
Developmental and neurological assessment and testing procedure codes and behavioral health procedure codes are included in the review. If a provider provides developmental and neurological assessment and testing at more than one location, any of these services may be retrospectively reviewed.

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