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December 2016 Texas Medicaid Provider Procedures Manual

Radiology and Laboratory Services Handbook

Radiology and Laboratory Services Handbook
Table of Contents
1 General Information 4
1.1 Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission 4
2 Independent Laboratory 4
2.1 Enrollment 4
2.1.1 Clinical Laboratory Improvement Amendments (CLIA) 5
2.1.2 CLIA Requirements 5
2.2 Services, Benefits, Limitations, and Prior Authorization 5
2.2.1 CLIA Certificates 6
2.2.2 Laboratory Handling Fees and Reference Laboratories 6
2.2.2.1 Independent Laboratory Providers 6
2.2.2.2 Physician Providers 6
2.2.2.3 Outpatient Hospital Providers 6
2.2.2.4 Family Planning Laboratory Tests 6
2.2.3 Nonclinical Laboratory Procedures 7
2.2.4 Clinical Laboratory Procedures 7
2.2.4.1 Repeat Procedures 7
2.2.5 Automated Laboratory Tests and Laboratory Paneling 7
2.2.5.1 Fee Calculations for Automated Tests and Laboratory Panels 7
2.2.6 Breast Cancer Gene 1 and 2 (BRCA) Testing 9
2.2.6.1 Genetic Counseling 10
2.2.6.2 Documentation 10
2.2.6.3 Prior Authorization for BRCA Testing 11
2.2.7 Complete Blood Count (CBC) 13
2.2.8 Drug Testing and Therapeutic Drug Assays 13
2.2.9 Evocative and Suppression Testing 15
2.2.10 Genetic Testing for Colorectal Cancer 15
2.2.10.1 Documentation Requirements 15
2.2.10.2 Authorization Requirements 15
2.2.11 Hematology and Coagulation 17
2.2.12 Human Immunodeficiency Virus (HIV) Drug Resistance Testing 17
2.2.13 Microbiology 18
2.2.14 Organ or Disease-Oriented Panels 19
2.2.15 * Urinalysis and Chemistry 20
2.2.16 Additional Laboratory Services 22
2.2.16.1 Colorectal Cancer Screening 22
2.2.16.2 Cytopathology Studies 22
2.2.16.3 Helicobacter pylori Testing 22
2.2.16.4 Laboratory Services for Clients on Dialysis 22
2.2.16.5 Prognostic Breast and Gynecological Cancer Studies 22
2.2.16.6 THSteps Outpatient Laboratory Services 22
2.2.16.7 Authorization Requirements 22
2.3 Documentation Requirements 22
2.4 Claims Filing and Reimbursement 23
2.4.1 Claims Information 23
2.4.1.1 Electronic Filing for Laboratory Providers 23
2.4.2 Reimbursement 23
2.4.2.1 National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines 24
3 Radiological and physiological laboratory services 24
3.1 Enrollment 24
3.1.1 Enrollment Criteria for Mammography Providers 24
3.2 Services, Benefits, Limitations, and Prior Authorization 25
3.2.1 Cardiac Nuclear Imaging 25
3.2.1.1 Authorization Requirements 25
3.2.2 Computed Tomography and Magnetic Resonance Imaging 26
3.2.2.1 Functional MRI (fMRI) 26
3.2.2.2 Intraoperative MRI (iMRI) 27
3.2.2.3 Authorization Requirements and Flexibility 27
3.2.3 Positron Emission Tomography (PET) Scan Imaging 28
3.2.3.1 Authorization Requirements 28
3.2.4 Radiology/Diagnostic Imaging Policy 29
3.2.4.1 Authorization Requirements 29
3.2.5 Physician-Performed Radiology Services 29
3.2.6 Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services 29
3.2.6.1 Retroactive Authorization 31
3.2.6.2 Request Form and Documentation 32
3.2.6.3 Methods of Submission 33
3.2.7 Additional Radiology and Physiological Laboratory Services 33
3.2.7.1 Ambulatory Electroencephalogram 33
3.2.7.2 Brachytherapy 33
3.2.7.3 * Diagnostic Doppler Sonography 33
3.2.7.4 Electrocardiograms 33
3.2.7.5 Electromyography (EMG) and Nerve Conduction Studies (NCS) 34
3.2.7.6 Esophageal pH Probe Monitoring 34
3.2.7.7 Mammography Services 34
3.2.7.8 Nonsurgical Vision Services 34
3.2.7.9 Obstetric Services 34
3.2.7.10 Radiation Therapy Services 34
3.2.7.11 Screening and Diagnostic Studies of the Breast 34
3.2.7.12 Sleep Studies 34
3.3 Documentation Requirements 34
3.4 Claims Filing and Reimbursement 35
3.4.1 Claims Information 35
3.4.1.1 Diagnosis Requirements 35
3.4.1.2 Modifier Requirements for Type of Service Assignment 36
3.4.2 Reimbursement 36
3.4.2.1 NCCI and MUE Guidelines 36
4 Claims Resources 37
5 Contact TMHP 37
6 Forms 37
7 Claim Form Examples 37
 

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