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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 : 9.2.60 Radiation Therapy

9.2.60
Radiation treatment management may be reimbursed by Texas Medicaid as defined in the Current Procedure Terminology (CPT) manual under the “Radiation Treatment Management” section.
The following radiation therapy services are limited to once per day unless documentation submitted with an appeal supports the need for the service to be provided more frequently:
Laboratory and diagnostic radiological services provided in the office setting may be reimbursed to physicians as a total component. Radiation treatment centers may also be reimbursed for the total component for these services in the outpatient hospital setting. Injectable medications given during the course of therapy in any setting may be reimbursed separately.
Routine follow-up care by the same physician on the day of any therapeutic radiology service will be denied. Medical services within program limitations may be reimbursed on appeal when documentation supports the medical necessity of the visit due to services unrelated to the radiation treatment or radiation treatment complication.
The professional component and the technical component will be denied when billed with the total component. The total component includes the professional and the technical components.
The professional component may be reimbursed for services rendered in the inpatient hospital setting, radiation treatment center setting, or outpatient hospital setting. Physicians billing client services rendered in the office setting or in a facility recognized by Medicaid as a radiation treatment center may be reimbursed for total components.

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