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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 : 9.2.28 Evoked Response Tests and Neuromuscular Procedures : 9.2.28.1 Autonomic Function Tests

9.2.28.1
AFTs are a benefit of Texas Medicaid when submitted with procedure codes 95921, 95922, 95923, 95924, and 95943.
Procedure codes 95921, 95922, 95923, 95924, and 95943 are limited to once per date of service, by the same provider.
Autonomic disorders may be congenital or acquired (primary or secondary). Some of the conditions under which autonomic function testing may be appropriate include, but are not limited to, the following:
The reason for the referral, the specific autonomic function being tested, and a clear diagnostic impression must be documented in the client’s medical record for each AFT performed.
The client’s medical records must clearly document the medical necessity for the AFT. The medical record documentation must reflect the actual results of specific tests (such as latency and amplitude).
Medical necessity for reevaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client’s medical record. Supporting documentation includes, but is not limited to, the following:
The client’s medical records are subject to retrospective review. Wave form recordings obtained during the testing will aid documentation requirements in cases where a review becomes necessary.

Texas Medicaid & Healthcare Partnership
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