Children’s Services
Handbook

 

1 General Information

The information in this handbook is intended for dentists, school districts, physicians, physician assis­tants (PAs), rural health clinics (RHCs), federally qualified health centers (FQHCs), advanced practice registered nurses (APRNs), home health agencies (HHAs), durable medical equipment (DME) suppliers, hospitals, and clinics. The handbook provides information about Texas Medicaid’s benefits, policies, and procedures applicable to these providers.

Important:All providers are required to read and comply with “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information). In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 Texas Administrative Code (TAC) §371.1659. Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

All providers are required to report suspected child abuse or neglect as outlined in subsection 1.6, “Provider Responsibilities” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

1.1Medical Transportation Program

The Medical Transportation Program (MTP) is funded with federal and state dollars to arrange nonemergency transportation to medical or dental appointments for eligible clients and their attendants.

The Health and Human Services Commission (HHSC) administrative rules govern parental accompa­niment of children who receive Medicaid screenings, treatments, and MTP services.

Titles 1 Texas Administrative Code (TAC), Part 15, §380.207 allows parents or guardians to authorize one adult and one alternate adult to accompany their children on MTP rides when the parent or guardian is unable to do so. The parent or guardian is required to designate the other adult on a form prescribed by HHSC in accordance with section §380.207(4).

An adult who is authorized by a parent or guardian may not be a provider or an employee or affiliate of a provider that submits claims for services.

Refer to:  The Medical Transportation Program Handbook (Vol. 2, Provider Handbooks) for more information.

1.2Rates Reduction

Texas Medicaid implemented mandated rate reductions for certain services. The Online Fee Lookup (OFL) and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the Texas Medicaid & Healthcare Partnership (TMHP) website at www.tmhp.com/pages/topics/rates.aspx.

1.3NP, CNS, PA, and CNM Claims Submitted by a Physician

Physicians will be reimbursed 92 percent of the established reimbursement rate for services provided by an NP, CNS, PA, or CNM if the physician does not make a decision regarding the client’s care or treatment on the same date of service as the billable medical visit. Physicians who submit a claim using the physician’s own provider identifier for the services that were provided by the NP, CNS, PA, or CNM must submit one of the following modifiers on each claim detail:

SA—Services were provided by an NP or CNS

U7—Services were provided by a PA

SB—Services were provided by a CNM

Exception:The 92 percent reimbursement rate does not apply to laboratory services, radiology services, or injections provided by an NP, CNS, PA, or CNM.

1.4Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission

According to the three-day and one-day payment window reimbursement guidelines, most professional and outpatient diagnostic and nondiagnostic services that are rendered within the designated time frame of an inpatient hospital stay and are related to the inpatient hospital admission will not be reimbursed separately from the inpatient hospital stay if the services are rendered by the hospital or an entity that is wholly owned or operated by the hospital.

These reimbursement guidelines do not apply in the following circumstances:

Services are rendered at a federally qualified health center (FQHC) or rural health clinic (RHC).

Services are for a THSteps medical checkup.

Professional services are rendered in the inpatient hospital setting.

The hospital and the physician office or other entity are both owned by a third party, such as a health system.

The hospital is not the sole or 100-percent owner of the entity.

These reimbursement guidelines do not apply for FQHC, RHC, THSteps, and professional services that are rendered in the inpatient hospital setting.

Refer to:  Subsection 3.7.3.8, “Payment Window Reimbursement Guidelines” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for additional infor­mation about the payment window reimbursement guidelines.

2 Medicaid Children’s Services Comprehensive Care Program (CCP)

2.1CCP Overview

CCP is an expansion of the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) service as mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989, which requires all states to provide all medically necessary treatment for correction of physical or mental problems to Texas Health Steps (THSteps)-eligible clients when federal financial participation (FFP) is available, even if the services are not covered under the state’s Medicaid plan.

Under the Early Periodic Screening, Diagnostic, and Treatment (EPSDT) regulation, known in Texas as Texas Health Steps (THSteps), Section 1905(r) of the Social Security Act mandates that all Medicaid-eligible beneficiaries who are birth through 20 years of age receive medically necessary services to treat, correct and ameliorate illnesses and conditions identified if the service is covered in the state’s Medicaid plan or is an optional Medicaid service. It is the responsibility of the state to determine medical necessity on a case specific basis. No arbitrary limitations on services are allowed (e.g., one pair of eyeglasses or 10 therapy sessions per year) if determined to be medically necessary.

Services not covered under this section include:

Experimental or investigational treatment.

Services or items not generally accepted as effective and/or not within the normal course and duration of treatment.

Services for the caregiver or provider convenience.

All EPSDT requirements must be adhered to for beneficiaries who receive services under managed care arrangements.

The following CCP provider sections describe the specific requirements of each area of responsibility:

Subsection 2.5, “Clinician-Directed Care Coordination Services (CCP)” in this handbook.

Subsection 2.10, “Medical Nutrition Counseling Services (CCP)” in this handbook.

Subsection 2.8, “Early Childhood Intervention (ECI) Services” in this handbook.

Subsection 2.11, “Personal Care Services (PCS) (CCP)” in this handbook.

Subsection 2.16, “Inpatient Psychiatric Hospital or Facility (Freestanding) (CCP)” in this handbook.

Subsection 2.17, “Inpatient Rehabilitation Facility (Freestanding) (CCP)” in this handbook.

Refer to:  The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for information about comprehensive outpatient rehabilitation facilities (CORFs) and outpatient rehabilitation facilities (ORFs).

The Home Health Nursing and Private Duty Nursing Services Handbook (Vol. 2, Provider Handbooks) for more information about private duty nursing (PDN) services.

The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for more information about CCP therapy services.

The Certified Respiratory Care Practitioner (CRCP) Services Handbook (Vol. 2, Provider Handbooks) for more information about CRCP CCP services.

2.1.1Client Eligibility

The client must be birth through 20 years of age and eligible for THSteps on the date of service. If the client’s Your Texas Benefits Medicaid card states “Emergency,” “PE,” or “QMB,” the client is not eligible for CCP benefits.

Clients are ineligible for CCP services beginning the day of their 21st birthday.

2.1.2Enrollment

Refer to:  Subsection 1.6.16, “Children’s Services Comprehensive Care Program (CCP)” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for enrollment information.

2.1.3Services, Benefits, and Limitations

Payment is considered for any health-care service that is medically necessary and for which FFP is available. CCP benefits are allowable services not currently covered under Texas Medicaid (e.g., speech-language pathology [SLP] services for nonacute conditions, PDN, prosthetics, orthotics, apnea monitors and some DME, some specific medical nutritional products, medical nutrition services, inpatient rehabilitation, travel strollers, and special needs car seats). CCP benefits also include expanded coverage of current Texas Medicaid services where services are subject to limitations (e.g., diagnosis restrictions for total parenteral nutrition [TPN] or diagnosis restrictions for attendant care services).

Requests for services that require a prior authorization must be submitted to TMHP. Prior authorization is a condition for reimbursement, not a guarantee of payment. For information about specific benefits, providers can refer to provider-specific sections of this manual.

Payment cannot be made for any service, supply, or equipment for which FFP is not available. The following are some examples:

Vehicle modification, mechanical, or structural (such as wheelchair lifts).

Structural changes to homes, domiciles, or other living arrangements.

Environmental equipment, supplies, or services, such as room dehumidifiers, air conditioners, filters, space heaters, fans, water purification systems, vacuum cleaners, and treatments for dust mites, rodents, and insects.

Ancillary power sources and other types of standby equipment (except for technology-dependent clients such as those who are ventilator-dependent for more than six hours per day).

Educational programs, supplies, or equipment (such as a personal computer or software).

Equine or hippotherapy.

Exercise equipment, home spas or gyms, toys, therapeutic balls, or tricycles.

Tennis shoes.

Respite care (relief to caregivers).

Aids for daily living (toothbrushes, spoons, reachers, and foot stools).

Take-home drugs from hospitals (Eligible hospitals may enroll in and bill Vendor Drug Program (VDP). Pharmacies that want to enroll should call 1-512-491-1429.

Therapy involving any breed of animal.

2.1.4Prior Authorization and Documentation Requirements

Prior authorization is a condition for reimbursement; it is not a guarantee of payment. A prior authori­zation number (PAN) is a TMHP-assigned number establishing that a service or supply has been determined to be medically necessary and for which FFP is available. It is each provider’s responsibility to verify the client’s eligibility at the time each service is provided. Any service provided while the client is not eligible cannot be reimbursed by TMHP. The responsibility for payment of services is determined by private arrangements made between the provider and client.

Prior authorization of CCP services may be requested in writing by completing the appropriate request form, attaching any necessary supportive documentation, and submitting them by mail, fax, or the electronic portal to the TMHP-CCP department. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures.

Providers who fax new prior authorization requests, resubmitted requests, or additional information to complete a request must include:

A working fax number on the prior authorization form, so that they can receive faxed responses and correspondence from TMHP.

The last four digits of the client’s Medicaid identification number on the fax coversheet.

Prior authorization may also be requested through the TMHP website. (Providers can refer to Subsection 5.5.1, “Prior Authorization Requests Through the TMHP Website” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for additional information to include mandatory documentation and retention requirements). All requested information on the form must be completed, or the request is returned to the provider. Incomplete forms are not accepted. If prior authorization is granted, the potential service provider (such as the DME supplier, pharmacy, registered nurse (RN), or physical therapist) receives a letter that includes the PAN, the procedures prior authorized, and the length of the authorization. Providers are notified in writing when additional infor­mation is needed to process the request for services.

Providers must submit a CCP Prior Authorization Request Form and documentation to support medical necessity to the CCP department before providing services. Providers must submit the CCP Prior Authorization Request Form when requesting a medically necessary service if the service is not addressed in the Texas Medicaid Provider Procedures Manual and the client is 20 years of age or younger.

Important:Documentation to support medical necessity of the service, equipment, or supply (such as a prescription, letter, or medical records) must be current, signed, and dated by a physician (M.D. or D.O.) before services are performed. Providers must keep the information on file.

Refer to:  CCP provider-specific sections for prior authorization requirements of specific services, including the appropriate prior authorization request forms.

2.1.4.1Incomplete Prior Authorization Requests

Providers must respond to an incomplete prior authorization request within 14 business days of the request receipt date. Incomplete prior authorization requests are requests that are received by TMHP with missing, incomplete, or illegible information.

Prior to denying an incomplete request, TMHP’s Prior Authorization department will attempt to get the the correct information from the requesting provider. The Prior Authorization department will make a minimum of three attempts to contact the requesting provider before sending a letter to the client about the status of the request and the need for additional information.

If the necessary information to make a prior authorization determination is not received within 14 business days of the request receipt date, the request will be denied as “incomplete.” To ensure timely processing, providers should respond to requests for missing or incomplete information as quickly as possible.

For fee-for-service (FFS) Medicaid requests that require a physician review before a final determination can be made, TMHP’s Physician Reviewer will complete the review within three business days of receipt of the completed prior authorization request. An additional three business days will be allowed for requests that require a peer-to-peer review with the client’s prescribing physician.

2.1.4.2Diagnosis Coding

All providers must obtain the client’s medical diagnosis from the physician. This information must be reflected on each claim submitted to TMHP.

2.1.4.3Drug and Medical Device Approval

Manufacturers may request to have drug or medical device products added as a CCP benefit by sending the information in writing to the following address:

HHSC
1100 West 49th Street
Austin, TX 78756-3179

HHSC reviews the information. Requests for consideration must not be sent to TMHP.

2.1.4.4Physician Signature

The dated signature of the physician (M.D. or D.O.) on a prescription or CCP Authorization Request Form must be current to the service date(s) of the request, i.e., the signature must always be on or before the service start date and no older than three months before the current date(s) of service requested. Physician signatures dated after the service start date on initial requests cannot be accepted as documen­tation supporting medical necessity for dates of service prior to the signature date. A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or supply. If services begin as a result of a verbal order before the physician’s dated signature, proof of the verbal order must be submitted with the request.

Stamped signatures and dates are not accepted on CCP Authorization Request Forms or prescriptions for CCP prior authorized services, supplies, or equipment. Verbal orders must be cosigned and dated by a physician (M.D. or D.O.) within two weeks, per provider policy. Signatures of chiropractors or doctors of philosophy (PhDs) are not accepted on CCP Authorization Request Forms or prescriptions for CCP prior authorized services.

Certified nurse midwife (CNM), clinical nurse specialist (CNS), nurse practitioner (NP), and PA providers may sign on behalf of the physician for private duty nursing, physical, occupational and speech therapy services when the physician delegates this authority.

Physician prescriptions must be specific to the type of service requested.

2.2Managed Care Organization (MCO) Clients Who Transition to Medicaid Fee-For-Service (FFS)

When clients transition from an MCO to FFS, providers can request that previously approved authori­zations for Comprehensive Care Program (CCP) services, occupational therapy (OT), physical therapy (PT), private duty nursing (PDN), and speech therapy (ST) be transferred from the MCO to FFS.

2.2.1Submission Guidelines

TMHP will consider the reimbursement of claims for services that were rendered on or after the MCO’s disenrollment date only when the provider submits a request to TMHP to transfer the previously approved authorization for CCP services.

The request to TMHP must be received on or before the end date of the previously approved MCO authorization. Any requests submitted after the MCO’s authorization end date will have to meet the regular submission guidelines for the specific service type.

2.2.2Documentation Requirements

All of the requests to transfer the authorizations from the MCO to FFS must include:

A copy of the previously approved authorization letter.

All of the documentation that was sent in the original authorization request, including any physician orders that were used to determine the start of care. TMHP will accept the physician orders as the required documentation for the requested services.

The completed CCP Prior Authorization Request form, Special Medical Prior Authorization (SMPA) form, Home Health Plan of Care, or Texas Medicaid Physical, Occupational, or Speech Therapy (PT, OT, ST) Prior Authorization Form, whichever is applicable for the requested service. The form must include the dates of service and quantities that are being requested from TMHP, which must match the dates of service and quantities that were approved in the original authorization.

Note:It is not necessary to obtain signatures or dates on the forms listed above when submitted to TMHP for the purpose of transferring an authorization from an MCO to FFS Medicaid.

Authorizations for services transferred from an MCO to FFS Medicaid are subject to retrospective review.

TMHP will verify the client’s eligibility, the dates of service, and the quantities requested.

TMHP will process reimbursement claims as follows:

Claims for services that were rendered before the date on which the transfer request was received will be denied as a late submission, and the provider will be notified of their administrative appeal rights through the Health and Human Services Commission (HHSC).

Claims for services that were rendered on or after the date of receipt use the required information from the transferred authorization and will be processed as if the request was received in a timely manner.

If a request to transfer an MCO authorization is submitted after the end date of the MCO authorization or the provider does not have an authorization letter from the MCO, TMHP will process the request to transfer the authorization based on established TMHP authorization submission guidelines for CCP services, PDN, OT, PT, and ST.

All new requests for rendered services must meet the documentation requirements.

2.2.3New Services and Extension of Services

For new services that occur after the client’s MCO disenrollment change date, the provider is responsible for submitting all TMHP required paperwork and meeting all established submission guidelines for prior authorization.

Requests for the extension of services that occur after the MCO disenrollment change date must include all of the paperwork that is required by TMHP and meet all established submission guidelines for prior authorization.

2.2.4Loss of Eligibility

If an MCO disenrolled a client and the client also loses Medicaid eligibility, providers must anticipate, if and when Medicaid eligibility is restored, that the client will initially be considered a Medicaid FFS client and will have a retroactive eligibility period.

All requests for services that require prior authorization and that occur during the client’s retroactive eligibility period, must be submitted to TMHP following the process that is outlined in subsection 5.1.1, “Prior Authorization Requests for Clients with Retroactive Eligibility” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information).

If a client is retroactively disenrolled by an MCO, all of the services that are rendered by the provider during this retroactive disenrollment period (specifically from the date on which the client was eligible for FFS to the date of the client’s MCO eligibility change) will be denied by TMHP, and the provider will be notified of their administrative appeal rights.

TMHP may consider services for the MCO transition beginning on the date of the client’s MCO eligi­bility change date and going forward. TMHP uses the MCO transition process for the submission of paperwork and the processing of provider requests.

2.3Breastfeeding Support Services

Refer to:  Section 3, “Breastfeeding Support Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for information about breastfeeding support services.

2.4Certified Respiratory Care Practitioner Services (CCP)

Refer to:  The Certified Respiratory Care Practitioner (CRCP) Services Handbook (Vol. 2, Provider Handbooks) for information about CRCP (CCP) services.

2.5Clinician-Directed Care Coordination Services (CCP)

2.5.1Services, Benefits, and Limitations

Clinician-directed (physician, NP, CNS, and PA) care coordination services are a benefit of CCP for eligible clients who are birth through 20 years of age and have special health needs. These services are payable only to the clinician (primary care, specialist, or sub-specialist) who provides the medical home for the client.

To provide a medical home for the client, the primary care clinician directs care coordination together with the client and family. Care coordination consists of managing services and resources for clients with special health needs and their families to maximize the clients’ potential and provide them with optimal health care.

Clinician-directed care coordination services (face-to-face and non-face-to-face) must include the following components:

A written care plan (either a formal document or documentation contained in the client’s progress notes) developed and revised by the medical home clinician, in partnership with the client, family, and other agreed-upon contributors. This plan is shared with other providers, agencies, and organi­zations involved with the care of the client, including educational and other community organizations with permission of the client or family. The care plan must be maintained by the medical home clinician and reviewed every six months or more frequently as necessary for the client’s needs.

Care among multiple providers that are coordinated through the clinician.

A central record or database maintained by the medical home clinician containing all pertinent medical information, including hospitalizations and specialty care.

Assistance for the client or family in communicating clinical issues when a client is referred for a consultation or additional care, such as evaluation, interpretation, implementation, and management of the consultant recommendations for the client or family in partnership and collab­oration with other providers, the client, or family.

Clinician-directed care coordination services must also include the supervision of the development and revision of the client’s emergency medical plan in partnership with the client, the family, and other providers for use by emergency medical services (EMS) personnel, utility service companies, schools, other community agencies, and caregivers.

Face-to-face care coordination services are encompassed within the various levels of evaluation and management (E/M) encounters and prolonged services.

Non-face-to-face clinician-directed care coordination services include:

Prolonged services (procedure codes 99358 and 99359).

Medical team conference (procedure code 99367).

Care plan oversight and supervision, including telephone consultations with a specialist or subspe­cialist (procedure codes 99339, 99340, 99374, 99375, 99377, 99378, 99379, and 99380).

Specialist or subspecialist telephone consultations (procedure code 99499 with modifier U9).

Non-face-to-face clinician-directed care coordination services are not considered case management by Texas Medicaid.

Specifically, non-face-to-face medical home clinician oversight and supervision of the development or revision of a client’s care plan may include the following activities, which do not have to be contiguous:

Review of charts, reports, treatment plans, and lab or study results, except for the initial interpre­tation or review of lab or study results ordered during, or associated with, a face-to-face encounter.

Telephone calls with other Medicaid-enrolled health-care professionals (not employed in the same practice) involved in the care of the client.

Telephone or face-to-face discussions with a pharmacist about pharmacological therapies (not just ordering a prescription).

Medical decision-making.

Activities to coordinate services, if the coordination activities require the skill of a clinician.

Documenting the services provided, which includes writing a note in the client’s chart describing the services provided, decision-making performed, and the amount of time spent performing the countable services, including the start and stop times and time spent by the physician working on the care plan after the nurse has conveyed pertinent information from agencies and facilities to the physician.

The following activities are not covered as non-face-to-face clinician supervision of the development or revision of the client’s care plan (care plan oversight services):

Time that the staff spends getting or filing charts, calling home health agencies or clients, and similar administrative actions.

Clinician telephone calls to client or family, except when necessary to discuss changes in client’s care plan.

Clinician time spent telephoning prescriptions to a pharmacist (does not require clinician work and does not require a clinician to perform).

Clinician time getting or filing the chart, dialing the telephone, or time on hold (does not require clinician work and does not meaningfully contribute to the treatment of the illness or injury).

Travel time.

Time spent preparing claims and for claims processing.

Initial interpretation or review of lab or study results that were ordered during, or associated with, a face-to-face encounter.

Services included as part of other E/M services.

Consultations with health professionals not involved in the client’s case.

2.5.1.1Non-Face-to-Face Services

2.5.1.1.1Non-Face-to-Face Medical Conferences

Procedure code 99367 must be used when billing for medical team conferences.

2.5.1.1.2Non-Face-to-Face Clinician Supervision of a Home Health Client

Procedure code 99374 or 99375 must be used when billing for services requiring interaction with a home health agency.

2.5.1.1.3Non-Face-to-Face Clinician Supervision of a Hospice Client

Procedure code 99377 or 99378 must be used when billing for services requiring interaction with a hospice.

2.5.1.1.4Non-Face-to-Face Clinician Supervision of a Nursing Facility Client

Procedure code 99379 or 99380 must be used when billing for services requiring interaction with a nursing facility.

2.5.1.1.5Other Non-Face-to-Face Supervision

Procedure code 99339 or 99340 must be used when billing for services requiring interaction with an independently-enrolled nurse or other provider (e.g., not a home health agency, nursing facility, or hospice provider).

2.5.1.1.6Non-Face-to-Face Prolonged Services

Procedure code 99358 or 99359 must be used when billing for prolonged services without face-to-face contact. This service is to be reported in addition to other clinician services, including E/M services at any level, or health-care professionals outside of a home health agency, hospice, or nursing facility.

Non-face-to-face prolonged services are limited to a maximum of 90 minutes once per client by the same provider unless one of the following significant changes in the client’s clinical condition occurs:

The client will soon be, or has recently been, discharged from a prolonged and complicated hospi­talization that required coordination of complex care with multiple providers in order for the client to be adequately cared for in the home.

The client has experienced recent trauma resulting in new medical complications that require complex interdisciplinary care.

The client has a new diagnosis of a medically complex condition requiring additional interdisci­plinary care with additional specialists.

Procedure code 99359 must be billed on the same date of service as procedure code 99358. Additional prolonged non-face-to-face services may be authorized if the provider submits supporting documen­tation for authorization.

Procedure code 99358 must be used to report the first hour of prolonged services and must be billed with the appropriate physician E/M procedure code listed in the following table. Prolonged services of less than 30 minutes are considered part of the physician’s E/M service being provided.

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99221

99222

99223

99231

99232

99233

99241

99242

99243

99244

99245

99251

99252

99253

99254

99255

99304

99305

99306

99307

99308

99309

99310

99318

99324

99325

99326

99327

99328

99334

99335

99336

99337

99341

99342

99343

99344

99345

99347

99348

99349

99350

Procedure code 99359 is used to report an additional 15 to 30 minutes of prolonged non-face-to-face services beyond the first hour. Prolonged services of less than 15 minutes beyond the first hour are considered part of the first hour.

Non-face-to-face prolonged services procedure codes 99358 and 99359 may be used when billing for completion of paperwork required by a judge to determine guardianship of a client. Required paperwork may include a certified medical examination form for clients who are birth through 20 years of age that are eligible for the Texas Health Steps program on the date of service.

2.5.1.1.7Non-Face-to-Face Specialist or Subspecialist Telephone Consultation

Telephone consultations are limited to two every six months to the same provider and will not be reimbursed to the clinician providing the medical home.

The clinician providing the medical home must have an authorization on file for one of the following procedure codes before the specialist or subspecialist can be reimbursed:

Procedure Codes

99339

99340

99358

99374

99375

99377

99378

99379

99380

Because the specialist or sub-specialists cannot be reimbursed without the medical home clinician’s current prior authorization information, the clinician providing the medical home should provide their information to the specialist or subspecialist.

The specialist or subspecialist will not be separately reimbursed for the telephone consultation if he or she is the medical home clinician because care plan oversight by the medical home provider includes telephone consultations. The referring provider identifier and prior authorization number must be submitted on the claim.

2.5.1.1.8General Requirements for Non-Face-to-Face Clinician-Directed Care Coordi­nation Services

These services may be reimbursed for the medical home clinician time involved in this coordination. The clinician billing the services must personally perform the services. Care coordination services delegated to, or performed by others, do not count towards care coordination reimbursement. Care coordination provided during post-surgical care is a benefit if the care is unrelated to the surgery.

2.5.1.1.9Non-Face-to-Face Care Plan Oversight

The medical home clinician who bills for the care plan oversight must be the clinician who signed the plan of care (POC) in the home or domiciliary (procedure codes 99339 and 99340), home health agency (procedure codes 99374 and 99375), hospice (procedure codes 99377 and 99378), or nursing facility (procedure codes 99379 and 99380).

Procedure code 99339 is denied when billed on the same date of service by the same provider as procedure code 99340.

Procedure code 99374 is denied when billed on the same date of service by the same provider as procedure code 99375.

Procedure code 99377 is denied when billed on the same date of service by the same provider as procedure code 99378.

Procedure code 99379 is denied when billed on the same date of service by the same provider as procedure code 99380.

Care plan oversight services may be reimbursed for the clinician time involved in this coordination. The clinician billing the services must personally perform the services. Care coordination services delegated to or performed by others do not count towards care coordination reimbursement.

Only one clinician-directed care plan oversight service (procedure codes 99339, 99340, 99374, 99375, 99377, 99378, 99379 or 99380) will be reimbursed per client, per calendar month to any provider.

The medical home clinician may not have a significant financial or contractual relationship with the home health agency as defined in 42 Code of Federal Regulations (CFR) §424.

The medical home clinician may not be the medical director or employee of the hospice and may not furnish services under arrangements with the hospice, including volunteering.

2.5.1.1.10Medical Team Conference

One medical team conference (procedure code 99367) may be reimbursed once every six months when the medical home coordinating clinician attests that they are providing the medical home for the client. The coordinating clinician may be the client’s primary care provider or a specialist.

Additional medical team conferences may be considered with documentation of a change in the client’s medical home.

The medical team conference time must be documented in the client’s record.

2.5.1.2Face-to-Face Services

2.5.1.2.1General Requirements for Face-to-Face Clinician-Directed Care Coordination Services

Providers must use the most appropriate face-to-face E/M procedure codes to bill for care coordination services.

When counseling or care coordination requires more than 50 percent of the client or family encounter (face-to-face time in the office or other outpatient setting, or floor/unit time in the hospital), then time may be considered the key or controlling factor to qualifying for a particular level of E/M service.

Counseling is a discussion with the client or family concerning diagnostic studies or results, prognosis, risks and benefits, management options, importance of adhering to the treatment regimen, and client and family education.

Modifiers must be used as appropriate for billing.

Any face-to-face inpatient or outpatient E/M procedure code that is a benefit of Texas Medicaid may be billed on the same day as the following non-face-to-face clinician-directed care coordination procedure codes when the procedure requires significant, separately-identifiable E/M services by the same physician on the same day.

Procedure Codes

99339

99340

99358

99359

99367

99374

99375

99377

99378

99379

99380

2.5.2Prior Authorization and Documentation Requirements

Non-face-to-face clinician-directed care coordination services provided by the medical home require prior authorization. Providers must submit a request for prior authorization within seven business days of the date of service. Prior authorization is limited to a maximum of six months. Prior authorization is required to recertify the client for additional six-month periods and requires submission of a new request with documentation supporting medical necessity for ongoing services.

Prior authorization for initial non-face-to-face clinician-directed care coordination requires documen­tation of at least one covered face-to-face inpatient or outpatient E/M visit by the medical home clinician directing the care coordination during the six months preceding the provision of the first non-face-to-face care coordination service.

Prior authorization for subsequent non-face-to-face clinician-directed care coordination services requires at least one covered face-to-face inpatient or outpatient E/M visit by the medical home clinician directing the care coordination during the previous 12 months or more frequently as indicated by the client’s condition.

Prior authorization of CCP services may be requested in writing by completing a CCP Prior Authori­zation Request Form, attaching the necessary supportive documentation as detailed below, and mailing or faxing it to the TMHP-CCP department:

Texas Medicaid & Healthcare Partnership
Comprehensive Care Program
PO Box 200735
Austin, TX 78720-0735
Fax: 1-512-514-4212

For prior authorization to be considered, clients must require complex and multidisciplinary care modalities involving regular clinician development or revision of care plans, review of subsequent reports of client status, and review of related laboratory and other studies:

Medically complex. The health care needed by a Medicaid client achieves the designation of medically complex when the approved POC necessitates a clinical professional practicing within the scope of his or her license and in the context of a medical home to coordinate ongoing treatment to ensure its safe and effective delivery. The diagnosis must be covered under Texas Medicaid and be characterized by one of the following:

Significant and interrelated disease processes that involve more than one organ system (including behavioral health diagnoses) and require the services of two or more licensed clinical professionals, specialists, or subspecialists.

Significant physical or functional limitations that require the services of two or more therapeutic or ancillary disciplines, including, but not limited to, nursing, nutrition, OT, PT, ST, orthotics, and prosthetics.

Significant physical, developmental, or behavioral impairment that requires the integration of two or more medical or community-based providers, including, but not limited to, educational, social, and developmental professionals, that impact the care of the client.

Multidisciplinary Care. Care is multidisciplinary when the medically necessary covered services of an approved POC include the need to coordinate the assessment, treatment, or services of a Medicaid-enrolled clinical provider with two or more additional medical, educational, social, devel­opmental, or other professionals impacting the health care of the client.

Prior authorization is effective for care coordination services provided over a period of six months. Medical home clinicians must submit a revised care plan for subsequent periods of prior authorization.

Documentation of the following components must be submitted with the prior authorization form to obtain an initial authorization or renewal:

A current medical summary, encompassing all disciplines and all aspects of the client’s care, and containing key information about the client’s health, including conditions, complexity, medica­tions, allergies, past surgical procedures, and so on.

A current list of the main concerns, issues, and problems as well as key strengths and assets and the related current clinical information including a list of all diagnosis codes.

Planned action steps and interventions to address the concerns and to sustain and build strengths, with the expected outcomes.

Disciplines involved with the client’s care and how the multiple disciplines will work or are working together to meet the client’s need. Providers must explain how the multidisciplinary approach will or do benefit the client’s needs.

Short-term and long-term goals with timeframes.

The supporting documentation can be any of the following:

A formal written care plan

Progress note detailing the care coordination planning

A letter of medical necessity detailing the care plan oversight and care coordination

Clinician-directed care coordination services must be documented in the client’s medical record. Documentation must support the services being billed and must include a record of the medical home clinician’s time spent performing specific care coordination activities, including start and stop times. The documentation must also include a formal care plan and an emergency services plan. The supporting documentation maintained in the client’s medical records must be dated and include the following components and requirements:

Problem list

Interventions

Short-term and long-term goals

Responsible parties

Client medical records are subject to retrospective review.

Documentation for care coordination provided during post-surgical care must clearly indicate the care coordination is unrelated to the surgery.

2.5.2.1Documentation Requirements for the Medical Home Clinician for a Telephone Consult with a Specialist

The clinician providing the medical home must maintain the following documentation in the client’s medical record:

Start and stop times showing that the consultation was at least 15 minutes

The reason for the call

The specialist’s or subspecialist’s medical opinion

The recommended treatment or laboratory services

The name of the specialist or subspecialist

2.5.2.2Documentation Requirements for the Specialist or Subspecialist for a Telephone Consult with the Medical Home Clinician

Specialists or subspecialists must complete and retain the Specialist or Subspecialist Telephone Consul­tation Form for Non-Face-to-Face Clinician Directed Care Coordination Services-CCP. These records are subject to retrospective review. The supporting documentation must include, but is not limited to the following:

The client’s name, date of birth, and Medicaid identification number

Start and stop times indicating the consultation lasted at least15 minutes

The reason for the call

The specialist’s or subspecialist’s medical opinion

The recommended treatment or laboratory services

The name and telephone number of the clinician providing the medical home

Provider information for the specialist’s or subspecialist’s and the clinician providing the medical home

2.5.3Claims Information

Claims for clinician-care coordination services must be submitted to TMHP in an approved electronic claims format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

“Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for instructions on completing paper claims.

2.5.4Reimbursement

Clinician-directed care coordination services are reimbursed in accordance with 1 TAC §355.8441.

2.6Comprehensive Outpatient Rehabilitation Facilities (CORFs) and Outpatient Rehabilitation Facilities (ORFs)

Refer to:  The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for more information about CCP therapy services.

2.7Durable Medical Equipment (DME) Supplier (CCP)

2.7.1Enrollment

To be eligible to participate in CCP, providers of DME (including customized or non-basic medical equipment) and expendable medical supplies must be enrolled in Medicare.

Home health agencies that provide DME and supplies should refer to subsection 2.1, “Enrollment” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks).

2.7.1.1Pharmacies (CCP)

Pharmacy providers are eligible to participate in CCP. To be enrolled in CCP, the pharmacy must also be enrolled in VDP.

This enrollment allows pharmacy providers to bill for those medications and supplies payable by Medicaid for clients who are birth through 20 years of age but not covered by VDP (e.g., some over-the-counter drugs, some nutritional products, diapers, and disposable or expendable medical supplies). Pharmacy providers must continue to bill HHSC for drugs covered under VDP.

To locate a pharmacy CCP provider, use the Online Provider Lookup (OPL) at http://opl.tmhp.com/ProviderManager/AdvSearch.aspx.

Refer to:  Subsection 2.1.2, “Enrollment” in this handbook for more information about CCP enrollment procedures.

“Appendix B: Vendor Drug Program” (Vol. 1, General Information)

Section 2, “Texas Medicaid (Title XIX) Home Health Services” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for details about coverage through Texas Medicaid (Title XIX) Home Health Services.

2.7.2Services, Benefits, and Limitations

DME is defined as medical equipment that is manufactured to withstand repeated use, ordered by a physician for use in the home, and required to correct or ameliorate the client’s disability, condition, or illness.

Because there is no single authority (such as a federal agency) that confers the official status of “DME” on any device or product, HHSC retains the right to make such determinations with regard to DME covered by Texas Medicaid. DME covered by Texas Medicaid must either have a well-established history of efficacy or, in the case of novel or unique equipment, valid peer-reviewed evidence that the equipment serves a medical purpose, can withstand repeated use, and is appropriate and safe for use in the home.

Requested DME may be a benefit of Texas Medicaid when it meets the Medicaid definition of DME.

The majority of DME and expendable medical supplies are covered through Texas Medicaid (Title XIX) Home Health Services.

If a service cannot be provided through Texas Medicaid (Title XIX) Home Health Services, the service may be covered through CCP if it is determined to be medically necessary for the client and if FFP is available.

If a DME provider is unable to deliver a piece of equipment, the provider must allow the client the option of obtaining the DME or expendable medical supplies from another provider.

Periodic rental payments are made only for the lesser of the following:

The period of time the equipment is medically necessary

The total monthly rental payments equal the reasonable purchase cost for the DME

DME will be purchased when a purchase is determined to be medically necessary and more cost effective than leasing the device with supplies. Only new, unused equipment will be purchased. When a provider is replacing a piece of rental DME with purchased DME, the provider must supply a new piece of DME to the client.

Purchase is justified when the estimated duration of need multiplied by the rental payments would exceed the reasonable purchase cost of the equipment or it is otherwise more practical to purchase the equipment.

DME repair will be considered based on the age of the item and cost to repair it. A request for repair of DME must include an itemized estimated cost list from the vendor or DME provider who will make the repairs.

Rental equipment may be provided to replace purchased medical equipment for the period of time it will take to make necessary repairs to purchased medical equipment.

All adjustments and modifications that are made within the first six months after delivery are considered part of the purchase price. However, DME that has been delivered to the client’s home and then found to be inappropriate for the client’s condition will not be eligible for an upgrade within the first six months following purchase unless there had been a significant change in the client’s condition, as documented by the physician familiar with the client.

Rental reimbursement to the same provider cannot exceed the purchase price, except as addressed in specific policies.

All DME purchased for a client becomes the Medicaid client’s property upon receipt of the item. Delivered equipment will become the Medicaid client’s property in the following instances even though it will not be prior authorized or reimbursed:

Equipment delivered to the client before the physician signature date on the CCP Prior Authori­zation Request Form or prescription.

Equipment delivered more than three business days before obtaining prior authorization from TMHP that meets the criteria for purchase.

As long as the client is eligible for CCP services on the date the custom equipment is ordered from the manufacturer, the provider must use the order date as the date of service since custom equipment is client specific and cannot be used for another client.

To establish medical necessity of the equipment for the client, the provider must have on file in the client’s records current documentation that is signed by a physician (e.g., a signed and dated prescription) showing the following:

A diagnosis relative to each item requested.

The specific type of supply needed.

The length of time needed.

2.7.2.1Purchase Versus Equipment Rental

When providing equipment not prior authorized under Texas Medicaid (Title XIX) Home Health Services for CCP clients with long-term or chronic conditions, it is more cost-effective, in many cases, to purchase the equipment rather than rent it. The client’s condition and length of time the equipment will be used must be carefully assessed before prior authorization for rental or purchase is requested. CCP nurses determine whether the equipment will be rented, purchased, repaired, or modified based on the client’s needs, the duration of use, and the age of the equipment.

CCP does not pay for the purchase of certain types of equipment; consequently, long-term rental may be considered. Most other equipment is rented for only four months initially. During this time, the provider must assess whether the equipment should be purchased before the rental lapses. Rentals and purchases must be prior authorized.

After prior authorization is obtained for purchase, new equipment must be provided and the rental discontinued. CCP does not purchase used equipment.

Providers of customized or nonbasic medical equipment also must be enrolled as Medicare DME providers.

2.7.3Prior Authorization and Documentation Requirements

Providers can request prior authorization for most DME through the TMHP website. Providers that make written requests for prior authorization must complete the CCP Prior Authorization Request Form on the TMHP website at www.tmhp.com, and they must attach the documentation necessary to support the request. The documentation must include a current prescription that has been signed and dated by a physician (M.D. or D.O.), and it must be mailed or faxed to TMHP with the prior authori­zation request. For specific policy information not contained in this manual related to the purchase of DME, providers can call TMHP-CCP Customer Service at 1-800-846-7470.

A completed CCP Prior Authorization Request Form prescribing the DME or medical supplies must be signed and dated by the prescribing physician familiar with the client before requesting prior authori­zation. The completed CCP Prior Authorization Request Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept in the physician’s medical record for the client.

To complete the prior authorization process by paper, the DME provider must fax or mail the completed CCP Prior Authorization Request Form to the CCP prior authorization unit and retain a copy of the signed and dated CCP form in the client’s medical record at the provider’s place of business.

To complete the prior authorization process electronically, the DME provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated CCP Prior Authorization Request form in the client’s medical record at the provider’s place of business.

To avoid unnecessary denials, the physician must provide correct and complete information, including accurate documentation of the medical necessity for the equipment and services requested. The physician must maintain documentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request.

Retrospective review may be performed to ensure documentation supports the medical necessity of the requested equipment or supplies.

A determination as to whether the equipment will be rented, purchased, repaired, or modified will be made by HHSC or its designee based on the client’s needs, duration of use, and age of the equipment.

Equipment that has been purchased may be considered for replacement when loss or irreparable damage has occurred outside the warranty terms, conditions, and limitations. A copy of the police or fire report, when appropriate, and the measures to be taken to prevent reoccurrence must be submitted with the prior authorization request.

A request for prior authorization must include documentation from the provider to support the medical necessity of the service, equipment, or expendable medical supply. Physician prescriptions must be specific to the item requested. For example, if the provider is requesting a customized wheelchair, the prescription must request a customized wheelchair, not just a wheelchair. Providers must submit a CCP Prior Authorization Request Form and documentation to support medical necessity to the CCP department before providing services. Providers must obtain prior authorization within three business days of the requested date of service.

Refer to:  Section 2.2.29, “Procedure Codes That Do Not Require Prior Authorization” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for details about specific procedure codes that do not require prior authori­zation through Texas Medicaid (Title XIX) Home Health Services.

2.7.3.1Equipment Accessories

CCP may consider prior authorization of equipment accessories, such as ventilator and oxygen trays and positioning inserts, when supporting documentation takes into account all the client’s needs, capabil­ities, and physical or mental status.

2.7.3.2Equipment Modifications

A modification is the replacement of a component due to changes in the client’s condition, not the replacement of a component that is no longer functioning.

DME that has been delivered to the client’s home and then found to be inappropriate for the client’s condition will not be eligible for an upgrade within the first six months following purchase. All modifi­cations that are made within the first six months after delivery are considered part of the purchase price.

However, CCP may consider prior authorization of modifications to custom equipment if a change occurs in the client’s needs, capabilities, or physical or mental status that cannot be anticipated. Documentation must include:

All projected changes in the client’s needs.

The age of the current equipment, and the cost of purchasing new equipment versus modifying current equipment.

2.7.3.3Equipment Adjustments

Adjustments do not require supplies.

Labor for adjustments within the first six months after delivery are not prior authorized because these are considered part of the purchase price.

Up to one hour of labor for adjustments may be considered for reimbursement with prior authorization through CCP as needed after the first six months. Providers must use procedure code K0739 for adjustments.

2.7.3.4Repair to Client-Owned Equipment

Repairs to client-owned equipment may be prior authorized as needed with documentation of medical necessity. Technician fees are considered part of the cost of the repair.

HHSC or its designee reserves the right to request additional documentation about the need for repairs when there is evidence of abuse or neglect to equipment by the client, client’s family, or caregiver. When there is documented proof of abuse or neglect, requests for repairs will not be prior authorized.

Providers are responsible for maintaining documentation in the client’s medical record that specifies the repairs and supporting medical necessity.

Documentation must include all of the following:

The date of purchase

The serial number of the current equipment (as applicable)

The cause of the damage or need for repairs

What steps the client or caregiver will take to prevent further damage if repairs are due to an accident

When requested, the cost of purchasing new equipment as opposed to repairing current equipment

Temporary replacement of client-owned respiratory equipment during the repair may be considered for prior authorization for one month using procedure code K0462.

Labor for repair of client-owned respiratory equipment may be considered for prior authorization using procedure code K0739 up to a maximum of two hours per day (maximum quantity of eight units).

Routine maintenance of rental equipment is the provider’s responsibility.

2.7.3.5DME Certification and Receipt Form

The DME Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME delivered to a client. The certification form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver.

The DME provider must maintain the signed and dated form in the client’s medical record.

DME claims and appeals that meet or exceed a billed amount of $2,500 for the same date of service will suspend for verification of client receipt of the DME item(s). The DME Certification and Receipt Form must be faxed to 1-512-506-6615. If the claim is submitted without the form or if receipt of the DME item(s) cannot be verified, the DME item(s) on the claim will be denied. TMHP may contact the client that received the product for verification of services rendered.

Refer to:  DME Certification and Receipt Form on the TMHP website at www.tmhp.com.

2.7.3.6Documentation of Supply Delivery

Providers must retain individual delivery slips or corresponding invoices for each date of service to document the date of delivery for all supplies provided to a client. Providers must disclose this documen­tation to HHSC or its designee upon request. These records and claims must be retained for a minimum of five years from the date of service (DOS) or until all audit questions, appeals, hearings, investigations, or court cases are resolved. The DOS is the date on which supplies are delivered to the client or shipped by a carrier to the client as evidenced by the dated tracking document attached to the corresponding invoice for that date.

Documentation of delivery must include one of the following:

Delivery slip or invoice signed and dated by the client or caregiver.

A dated carrier tracking document that includes the shipping date and delivery date must be printed from the carrier’s website as confirmation that the supplies were shipped and delivered. The dated carrier tracking document must be attached to the delivery slip or corresponding invoice.

The dated delivery slip or invoice must include the client’s full name and address to where supplies were delivered, and an itemized list of goods that includes the descriptions and numerical quantities of the supplies delivered to the client, and the corresponding tracking number from the carrier. This document could also include prices, shipping weights, shipping charges, and any other description.

All claims submitted for DME supplies must include the same quantities or units that are documented on the delivery slip or corresponding invoice and on the CCP Prior Authorization Request form. They must reflect the number of units by which each product is measured. For example, diapers are measured as individual units. If one package of 300 diapers is delivered, the delivery slip or invoice and the claim must reflect that 300 diapers were delivered and not that one package was delivered. Diaper wipes are measured as boxes or packages. If one box of 200 wipes is delivered, the delivery slip or invoice and the claim must reflect that one box was delivered and not that 200 individual wipes were delivered. There must be one dated delivery slip or invoice for each claim submitted for each patient. All claims submitted for DME supplies must reflect the same date as the delivery slip or corresponding invoice and the same timeframe covered by the CCP Prior Authorization Request form. The DME Certification and Receipt Form is still required for all equipment delivered.

2.7.3.7Specific CCP Policies

Most DME and expendable medical supplies are available under Texas Medicaid (Title XIX) Home Health Services. If the service is not available under Texas Medicaid (Title XIX) Home Health Services, CCP may cover the requested service, if the client is CCP-eligible and the service is medically necessary, requested by a physician, and for which FFP is available.

Refer to:  DME Certification and Receipt Form on the TMHP website at www.tmhp.com.

The Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for DME services.

2.8Early Childhood Intervention (ECI) Services

The Texas Health and Human Services (HHS) ECI program is available statewide to all children who have been determined to be eligible for ECI services by ECI contractors. To be eligible for ECI services, children must be 35 months of age and younger (i.e., before their third birthday) and have disabilities or developmental delays as defined by ECI criteria. Texas Medicaid covers the ECI claims for children who are Medicaid clients.

All health-care professionals are required by federal and state regulations to refer children who are 35 months of age and younger (i.e., before their third birthday) to the Texas HHS ECI program as soon as possible, but no longer than 7 days after identifying a disability or suspected delay in development. Referrals can be based on professional judgment or a family’s concern. A medical diagnosis or a confirmed developmental delay is not required for referrals.

To refer families for services, providers can call their local ECI program, or they can call the HHS Inquiry Line at 1-877-787-8999. For additional ECI information, providers can visit the Early Childhood Inter­vention Services page of the HHS website at https://hhs.texas.gov. Persons who are hearing-impaired can call the TDD/TTY line at 1-866-581-9328.

2.8.1Enrollment

The Texas HHS ECI program contracts with local non-profit entities to take referrals, determine clients’ eligibility, and provide services to ECI-eligible children and their families. The non-profit entities must contract with the Texas HHS ECI program and must comply with all of the applicable federal and state laws and regulations that govern the Texas HHS ECI program.

ECI contractors are eligible to enroll as Texas Medicaid ECI providers to render services to eligible Medicaid clients. After providers meet the criteria of the Texas HHS ECI program, they must complete a Medicaid application.

To participate in Texas Medicaid, an ECI contractor must submit a copy of the current contract award from the Texas HHS ECI program.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about the procedures for enrolling as a Medicaid provider.

2.8.2Services, Benefits, and Limitations

Prior authorization is not required for evaluations, re-evaluations, seating assessments, therapy services, SST, and TCM. The IFSP Services Pages identify the amount, duration, and scope for the provision of SRS treatment services and serves as the prior authorization for ECI services. The IFSP is retained in the client's record and is subject to retrospective review.

ECI services include targeted case management (TCM) and specialized rehabilitative services (SRS), which includes occupational therapy (OT), physical therapy (PT), speech therapy (ST), and specialized skills training (SST).

ECI SRS services may be provided in the following places of service (POS): office/facility (POS 1), home (POS 2), outpatient (POS 5 applicable only to ECI services rendered in a Prescribed Pediatric Extended Care Center [PPECC]), and other locations (POS 9). In addition to these places of service, TCM may be provided in inpatient hospital (POS 3) and outpatient hospital (POS 5).

ECI services of OT, PT, ST, SST and TCM are provided to Medicaid-eligible clients who are birth through 35 months of age and have a documented developmental delay or a medically diagnosed condition as established by HHSC (40 TAC, Part 2, Chapter 108), or an auditory or visual impairment as defined by the Texas Education Agency (19 TAC §89.1040).

To the maximum extent appropriate, ECI services are delivered in the client’s natural environment, as defined in 40 TAC, Part 2, Chapter 108, and are family-centered.

The interdisciplinary team must document ECI eligibility decisions in accordance with 40 TAC, Part 2, Chapter 108. The eligibility statement must be in the child’s record and updated when eligibility changes or is re-determined.

All documentation of ECI services, including the plan of care specified in the Individualized Family Service Plan (IFSP) must be retained in the client’s record and available upon request. The IFSP is a written plan of care for providing early childhood intervention services and other medical, health, and social services to an eligible child and the child’s family when necessary to enhance the child’s development.

ECI service providers are employees and subcontractors of non-profit entities that have contracts with the State of Texas for the provision of Individuals with Disabilities Education Act (IDEA) Part C Early Childhood Intervention services.

Medically necessary services may be provided by other Medicaid-enrolled providers in addition to the services provided by the ECI contractor. For example, the family may choose to receive speech therapy from the ECI contractor and physical therapy from a home health provider. Or, outpatient clinic personnel may have expertise that will enhance the services of the ECI provider resulting in ECI providers and other Medicaid-enrolled providers providing services within the same discipline.

Only the services provided to ECI enrolled children by ECI contracted entities must comply with the Medicaid medical guidelines for ECI services.

Services provided by other Medicaid-enrolled providers, including other providers of physical, occupa­tional, and speech therapy, must comply with Medicaid medical guidelines that apply to those provider types (e.g., outpatient rehabilitation facility, home health agency).

2.8.2.1Physical, Occupational, and Speech Therapies and Specialized Skills Training (PT, OT, ST, and SST)

ECI services use techniques by which the ECI service provider engages the family or caregiver in activ­ities to meet the developmental needs of the child.

ECI services are performed in accordance with 40 TAC, Part 2, Chapter 108.

To the maximum extent possible, ECI services are provided in the client’s natural environment, as defined in 34 CFR Part 303, unless the IFSP team determines the identified outcomes cannot be achieved in a natural environment. Natural environments are defined as settings that are natural or typical for the same-aged infant or toddler without a disability, and may include the home and community settings such as daycare, playgrounds, stores, and restaurants.

Justification for providing services in other settings (e.g., office, clinic, Prescribed Pediatric Extended Care Center (PPECC)) must be documented in the client’s record.

PT, OT, ST, and SST are benefits for clients with an acute or a chronic condition when documented on the IFSP. Documentation on the IFSP is evidence that services are developed and recommended by the child’s interdisciplinary team, including the parents and a licensed practitioner of the healing arts (as defined in 40 TAC, Part 2, Chapter 108).

PT, OT, ST, and SST must be performed and delivered as identified in the IFSP.

Missed visits may be rescheduled within the authorization period as long as the total number of visits or units provided does not exceed the amount authorized in the client's IFSP. The ECI contractor must document the reason for visits outside of the weekly or monthly frequency in the client’s record.

A single identified need and treatment goal (outcome on the IFSP) may be addressed by more than one discipline.

More than one discipline can evaluate a child at the same time to facilitate compliance with the federal requirement for multidisciplinary evaluation (34 CFR, Part 303).

A client may receive a combination of PT, OT, ST, or SST with any other IFSP service when the IFSP indicates necessity for co-visits or co-treatment (i.e., two or more services to be provided at the same time).

PT, OT, ST, and SST may be delivered to a client individually or in a group setting according to 40 TAC, Part 2, Chapter 108 and when documented in the IFSP.

Documentation of each PT, OT, ST, and SST contact must be entered into the child’s record in accor­dance with 40 TAC, Part 2, Chapter 108.

2.8.2.2Physical, Occupational, and Speech Therapy (PT, OT, and ST)

Physical and occupational therapy treatment services require orders from a referring provider once a year.

Speech therapy treatment services do not require an order from a referring provider.

Therapy goals for acute or chronic conditions include, but are not limited to the following:

Improving function

Maintaining function

Slowing the deterioration of function

2.8.2.2.1Physical Therapy (PT)

PT includes services that address the promotion of sensory and motor function through enhancement of musculoskeletal status, neurobehavioral organization, perceptual and motor development, cardiopul­monary status, and effective environmental adaptation.

All services must be performed in accordance with 42 CFR 440.110.

A PT evaluation, re-evaluation, or seating assessment may be performed without an order from a referring provider as allowed by 22 TAC Part 16, Chapter 322, §322.1(a)(2)(A).

PT services must be provided by one of the following:

A licensed physical therapist who meets the requirements of 42 CFR 440.110(a)

A licensed physical therapy assistant (PTA) when the assistant is acting under the direction of a licensed physical therapist in accordance with 42 CFR 440.110 and all other applicable state and federal law

2.8.2.2.2Occupational Therapy (OT)

OT includes services that address the functional needs of a child related to adaptive development, adaptive behavior and play, and sensory, motor, and postural development. These services are designed to improve the client’s functional ability to perform tasks in the home and community settings.

All services must be performed in accordance with 42 CFR 440.110.

An OT evaluation, re-evaluation, or seating assessment may be performed without an order from a referring provider as allowed by §454.213 of the Texas Occupations Code.

OT services must be provided by one of the following:

A licensed occupational therapist who meets the requirements of 42 CFR 440.110(b)

A licensed or licensed and certified occupational therapist assistant (OTA) when the assistant is acting under the direction of a licensed occupational therapist in accordance with 42 CFR 440.110 and all other applicable state and federal law

2.8.2.2.3Speech Therapy (ST)

Speech and language therapy includes services designed to promote rehabilitation and remediation of delays or disabilities in language-related symbolic behaviors, communication, language, speech, emergent literacy, or feeding and swallowing behavior.

All services must be delivered in accordance with 42 CFR 440.110 and §401.001(6) of the Texas Occupa­tions Code.

A ST evaluation, re-evaluation, and treatment service may be performed without a physician order as allowed by Chapter 401 of the Texas Occupations Code.

ST services must be provided by one of the following:

A licensed speech-language pathologist (SLP) who meets the requirements of 42 CFR 440.110(c) and all other applicable state and federal law

A licensed assistant in SLP when the assistant is acting under the direction of a licensed SLP in accor­dance with 42 CFR 440.110

A licensed intern when the intern is acting under the direction of a licensed SLP in accordance with 42 CFR 440.110 and all other applicable state and federal law

2.8.2.3Physical Therapy, Occupational Therapy, and Speech Therapy Procedure Codes

Clients who are eligible for ongoing PT, OT, and ST through the ECI program may request additional therapy under the Early & Periodic Screening, Diagnosis, & Treatment (EPSDT) benefit of Medicaid (also known as Texas Health Steps) when medically necessary.

Refer to:  Section 5, “Children’s Therapy Services Clients birth through 20 years of age” in the Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for information about physical, occupational, and speech therapy procedure codes outside of the ECI benefit that are not defined in this section.

2.8.2.3.1Evaluation and Re-evaluation Procedure Codes

The following encounter-based evaluation and re-evaluation procedure codes for PT, OT, and ST are benefits of Texas Medicaid:

Procedure Codes

Description

97165, 97166, or 97167

OT Evaluation

97168

OT Re-evaluation

97161, 97162, or 97163

PT Evaluation

97164

PT Re-Evaluation

92521, 92522, 92523, or 92524

ST Evaluation

S9152

ST Re-Evaluation

92610

ST Evaluation swallowing function

2.8.2.3.2Time-Based Procedure Codes

The following time-based PT and OT treatment procedure codes may be a benefit of Texas Medicaid and must be billed in 15-minute increments (units).

Procedure Codes

97032

97033

97034

97035

97036

97110

97112

97113

97116

97124

97140

97530

97535

97542

97750

97760

97761

97762

2.8.2.3.3Untimed PT and OT Procedure Codes

The following untimed PT and OT treatment procedure codes representing supervised modalities are limited to one encounter each, per date of service per discipline, must be delivered on the same day as one or more time-based codes listed above, and are subject to the CMS NCCI relationships.

Procedure Codes

97012

97014

97016

97018

97022

97024

97026

97028

The following PT and OT group therapy code may be reimbursed as an untimed procedure code, payable per encounter, and reimbursed once per date of service per discipline.

Procedure Codes

97150

2.8.2.3.4Encounter-Based Speech Therapy Procedure Codes

The following speech therapy individual treatment codes must be billed per encounter and are limited to once per day per provider. Only one ST treatment procedure code 92507 or 92526 may be reimbursed per date of service.

Procedure Codes

92507

92526

The following ST group treatment code may be reimbursed as an untimed procedure code, payable per encounter, and reimbursed once per date of service.

Procedure Codes

92508

2.8.2.3.5Modifier Requirements for PT, OT, or ST Services

The following modifiers must be submitted for PT, OT, and ST treatment services:

Modifier

Description

GO

Services delivered under an outpatient occupational therapy plan of care

GP

Services delivered under an outpatient physical therapy plan of care

GN

Services delivered under an outpatient speech therapy plan of care

UB

Services delivered by a therapy assistant under supervision of a licensed therapist

U5

Services delivered by a licensed therapist or a physician

Modifier UB or U5 is required on all claims for therapy treatment procedure codes to designate whether treatment was provided by a licensed therapist or a licensed assistant.

Modifier U3 is not used by an ECI contractor for co-visits or co-treatment services.

Modifier

Description

U3

Not used by an ECI contractor

2.8.2.3.6Seating Assessments

Seating assessments are reimbursed in 15-minute increments (units) and must be billed with the following procedure code:

Procedure Codes

97542

The PT completing the assessment must submit procedure code 97542 with modifiers GP and UC in order to bill for the seating assessment.

Modifier

Description

GP

Services delivered under an outpatient physical therapy plan of care

UC

Assessment performed by an OT or PT

The OT completing the assessment must submit procedure code 97542 with modifiers GO and UC in order to bill for the seating assessment:

Modifier

Description

GO

Services delivered under an outpatient occupational therapy plan of care

UC

Assessment performed by an OT or PT

2.8.2.3.7Specialized Skills Training (SST) Services

SST services are rehabilitative services to promote age-appropriate development by providing skills training to correct deficits and teach compensatory skills for deficits that directly result from medical, developmental, or other health-related conditions.

Services must include all the following:

Be designed to create learning environments and activities that promote the client’s acquisition of skills in one or more of the following developmental areas: physical or motor, communication, adaptive, cognitive, and social or emotional.

Skills training and anticipatory guidance for family members, or other significant caregivers, to ensure effective treatment and to enhance the client’s development.

SST services do not require an order from a referring provider. The ECI contractor ensures that SST services are provided by a certified early intervention specialist. SST services must be provided by an early intervention specialist who meets the criteria established in 40 TAC Part 2, Chapter 108.

SST services must be submitted with the following procedure codes and modifiers, and they must be billed in 15-minute increments:

Procedure Code

Description

Modifier

T1027

Individual setting

U1

T1027

Group setting

 

2.8.2.3.8Reimbursement Guidelines for PT, OT, ST, and SST

Claims may be submitted to Medicaid when the interaction is directly with the client and the client’s parent(s) as defined in 20 U.S.C. §1401, or the client and the routine caregiver(s) as defined in 40 TAC, Part 2, Chapter 108.

ECI services must be billed under the ECI contractor’s Texas Provider Identifier, National Provider Identifier, and benefit code of EC1 as the insured’s policy group when submitting claims.

Refer to:  “Section 6: Claims Filing” (Vol. 1, General Information) for more information about benefit codes.

Physical therapy, occupational therapy, and speech-language pathology evaluations are performed for the purposes of initial determination of need for rehabilitative services and annually to verify the child’s ongoing need for rehabilitative services. To ensure there are no gaps in rehabilitative services, the annual evaluation should occur prior to the child’s annual IFSP meeting.

Physical, occupational, and speech therapy evaluation and re-evaluation services are benefits through the ECI Medicaid benefit and do not require an order from a referring provider.

Physical therapy, occupational therapy, and speech-language pathology re-evaluations may be performed periodically during the child’s annual enrollment in ECI services, and without a physician’s order, to determine if changes to the IFSP are necessary.

Evaluations, re-evaluations, and seating assessments are not required to be listed on the IFSP Service Pages. A physical or occupational therapist may provide a seating assessment that is required to order a wheeled mobility system. A seating assessment does not require an order from a referring provider.

Refer to:  Subsection 2.2.16, “Mobility Aids” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for information about mobility aids.

Reimbursement is available to two or more of the ECI contractor’s service providers when the client receives a combination of any Medicaid-covered service identified on the IFSP and the IFSP indicates necessity for co-visits or co-treatments (i.e., two or more services to be provided at the same time). For example, the child may receive both PT and ST at the same time. Another example, the child may receive counseling and SST at the same time.

Reimbursement is available to two or more of the ECI contractor’s service providers when they are conducting an evaluation at the same time.

When an evaluation and treatment service within the same discipline occur on the same day, only the evaluation will pay.

When a re-evaluation and treatment service within the same discipline occur the same day, only the treatment will pay.

PT, OT, and ST equipment and supplies used during therapy visits are not reimbursed separately.

Reimbursement under Medicaid benefit guidelines applies to only the services provided to ECI enrolled children by ECI contracted entities.

Reimbursement for services provided to ECI enrolled children by other Medicaid-enrolled providers (e.g., home health, CORF) is available under the Medicaid medical policies that apply to those provider types.

2.8.2.4Targeted Case Management (TCM)

TCM services are provided to assist an eligible client and his or her family in gaining access to the rights and procedural safeguards under Part C of IDEA, and to needed medical, social, educational, develop­mental, and other appropriate services.

TCM services are performed in accordance with the ECI Medicaid benefit guidelines and 40 TAC, Part 2, Chapter 108.

TCM services do not require an order from a referring provider, but must be delivered by a qualified ECI contractor. The ECI contractor ensures that TCM services are provided by the assigned Service Coordi­nator who meets the criteria established in 40 TAC Part 2, Chapter 108.

TCM is provided in the natural environment (including office, home, daycare, and other community locations), outpatient, PPECC, and inpatient hospital setting.

The documentation for each TCM contact must be in accordance with 40 TAC, Part 2, Chapter 108. The place of service is the location of the service coordinator at the time of service delivery.

TCM services must be submitted with the following procedure codes and modifiers, and they must be billed in 15-minute increments:

Procedure Code

Description

Modifier

T1017

Face-to-face interaction

U1

T1017

Telephone interaction

 

TCM services may be delivered face-to-face or by telephone.

2.8.2.4.1Guidelines for TCM Services

Claims may be submitted to Texas Medicaid when the interaction is directly with the client or the client’s parent(s) as defined in 20 United States Code (U.S.C.) §1401), or other routine caregiver(s) as defined in 40 TAC, Part 2, Chapter 108.

Contacts may be made with other individuals when directly related to identifying the eligible client’s needs, helping the eligible client access services, identifying needs and support to assist the eligible client in obtaining services, providing the service coordinator with useful feedback, and alerting the service coordinator to changes in the eligible client’s needs. These contacts must be documented in the client’s record, but are not submitted as claims to Medicaid if they took place outside of the presence of the client or the client's parent or routine caregivers.

2.8.2.5Guidelines for ECI Services Performed in a Prescribed Pediatric Extended Care Center (PPECC)

When ECI services are rendered in a PPECC, the place of service will be outpatient hospital (used for a PPECC). The PPECC’s NPI must appear on the claim, in addition to the ECI contractor’s NPI. The ECI contractor and PPECC must have a written agreement for the provision of ECI services at the PPECC. The written agreement must address responsibilities of both parties, and how the parties will coordinate related to the client’s IFSP or plan of care, which includes documentation of coordination with the PPECC. The written agreement must be maintained in the client’s record.

2.8.3Claims Filing and Reimbursement

2.8.3.1Claims Information

Claims for SST and TCM services that have been rendered by an ECI contractor must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Contractors may purchase CMS-1500 paper claim forms from the vendor of their choice; TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills or itemized state­ments are not accepted as claim supplements.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

Subsection 6.1, “Claims Information” in “Section 6: Claims Filing” (Vol. 1, General Infor­mation) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) to find the instructions for completing paper claims.

Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more infor­mation about reimbursement.

2.8.3.1.1Billing Units Based on 15 Minutes

All claims for reimbursement are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units should be rounded to the nearest quarter hour.

The following table shows the time intervals for 1 through 8 units:

Units

Number of Minutes

0 units

0 minutes through 7 minutes

1 unit

8 minutes through 22 minutes

2 units

23 minutes through 37 minutes

3 units

38 minutes through 52 minutes

4 units

53 minutes through 67 minutes

5 units

68 minutes through 82 minutes

6 units

83 minutes through 97 minutes

7 units

98 minutes through 112 minutes

8 units

113 minutes through 127 minutes

2.8.3.1.2Managed Care Clients

If the child is enrolled in a Medicaid managed care organization (MCO), claims for PT, OT, and ST are submitted to the MCO.

TCM services are carved-out of Medicaid managed care and must be billed to TMHP for payment consideration.

SST services are carved-out of Medicaid managed care and claims must be billed to TMHP for payment consideration.

2.8.3.2Reimbursement

ECI therapy, SST, and TCM services are reimbursed according to a maximum allowable fee established by HHSC. See the applicable fee schedule on the TMHP website at www.tmhp.com.

ECI therapy services are reimbursed in accordance with 1 TAC §355.8441.

SST services are reimbursed in accordance with 1 TAC §355.8422.

TCM services are reimbursed in accordance with 1 TAC §355.8421.

2.9Health and Behavior Assessment and Intervention

2.9.1Services, Benefits, and Limitations

Health and Behavior Assessment and Intervention (HBAI) services are a benefit of Texas Medicaid for clients who are 20 years of age and younger when the services are provided by a licensed practitioner of the healing arts (LPHA) who is co-located in the same office or building complex as the physician, PA, NP, or CNS who is treating the client.

In many cases, the treating physician, PA, NP, or CNS will be the client’s primary care provider; however, a specialist seeing a client regularly may function in a similar role to a primary care provider and may also make HBAI referrals to a co-located LPHA.

These services are designed to identify the psychological, behavioral, emotional, cognitive and social factors important to prevention, treatment or management of physical health symptoms.

HBAI services are a benefit when the client meets all of the following criteria:

The client has an underlying physical illness or injury.

There are indications that biopsychosocial factors may be significantly affecting the treatment or medical management of an illness or an injury.

The client is alert, oriented, and, depending on the client’s age, has the capacity to understand and to respond meaningfully during the in-person evaluation.

The client has a documented need for psychological evaluation or intervention to successfully manage his or her physical illness, and activities of daily living.

The assessment is not duplicative of other provider assessments.

HBAI services that include the client’s family are a benefit when the family member directly participates in the overall care of the client.

Family is defined as a responsible adult. This adult individual has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to, biological parents, adoptive parents, foster parents, guardians, court-appointed managing conservators, and other family members by birth or marriage.

HBAI services may be reimbursed when billed with the following procedure codes:

Procedure Codes

96150

96151

96152

96153

96154

96155

These services may be rendered by physician, nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), licensed professional counselor (LPC), licensed clinical social worker (LCSW), licensed marriage family therapist (LMFT), Comprehensive Care Program (CCP) LCSW, or psychol­ogist provider in the office or outpatient setting.

LMFTs must bill with state defined modifier U8 to identify services billed.

For services that are rendered by physician, NP, CNS, or PA providers, claims must be submitted with the appropriate evaluation and management (E/M) procedure codes (99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, or 99215). The physician, NP, CNS, or PA may bill the HBAI procedure codes for an LPHA that is in the medical practice.

HBAI services are limited to four 15-minute units (one hour) per day, any procedure, any provider. A unit is defined as 15 minutes of in-person evaluation time. An in-person evaluation is defined as a patient evaluation conducted by a provider who is at the same physical location as the client. These services are considered acute per rolling 180 days from the initiation of services and are limited as shown in the following table:

Procedure Codes

Limitations

96150

Limited to a maximum of four 15-minute units (one hour) per client, per rolling 180 days, any provider

96151

Limited to a maximum of four 15-minute units (one hour) per client, per rolling 180 days, any provider

96152, 96153, 96154, 96155

Limited to a maximum of sixteen 15-minute units (four hours), per client, per rolling 180 days, any provider

Rural Health Clinics and Federally Qualified Health Centers may be reimbursed for client in-person evaluation visits based on encounter rates.

For re-assessment (procedure code 96151), providers must maintain documentation in the client’s medical record that details the change in the mental or medical status warranting reassessment of the client’s capacity to understand and cooperate with the medical interventions that are necessary to the client’s health and well-being.

Clients must be referred for psychiatric evaluation or psychotherapy as soon as the need is identified. Providers cannot use all 16 units if the need for psychiatric or psychological intervention is identified earlier.

After the initial HBAI assessment (procedure code 96150), if the client is receiving behavioral health services from another health-care provider, the HBAI provider should coordinate with the external behavioral health provider and establish the most appropriate course of treatment for the client.

Refer to:  Section 4, “Outpatient Mental Health Services” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) for more information about behavioral health services beyond the acute care limitations outlined in this section.

The initial clinical interview, reassessment, psychophysiological monitoring, observation, and inter­vention do not include the following:

Conversations about educating the family or caregivers outside of the in-person evaluation sessions

Psychotherapy

After the initial 180 days of HBAI services, the client may receive another episode of HBAI with the same medical diagnosis if there is a newly identified behavioral health issue. The client may have two episodes of HBAI per rolling year.

HBAI services are adjunct to other services and are to be used as a non-intensive means to identify specific needs. As appropriate, the client should be referred for those additional services that would meet the client’s biopsychosocial needs.

2.9.2Prior Authorization and Documentation Requirements

Prior authorization is not required for HBAI services.

Documentation is required for HBAI services to support the medical necessity of the initial assessment, reassessment, and intervention.

For the initial assessment, documentation must support the medical necessity of the assessment and must include the following information:

The date of initial diagnosis of physical illness

A clear rationale for assessment

Outcome of assessment, which includes mental status and the client’s or caregiver’s ability to under­stand and respond meaningfully

Goals and expected duration of specifically recommended psychological intervention(s).

For reassessment, documentation must support the reassessment is necessary and include the following information:

The date of change in mental or physical status

Rationale for re-assessment with a clear indication of precipitating events.

For the intervention, documentation must support the necessity of the intervention and include the following information:

Evidence that the client or caregiver has the capacity to understand and respond meaningfully,

Clear outline of planned psychological intervention    

Goals of the psychological intervention identifying expected improvement in compliance with the medical treatment plan

The client’s response to the intervention

Rationale for frequency and duration of acute care services

All documentation must include the amount of time spent in the HBAI assessment or intervention and must be documented in the client’s medical record.

All services are subject to retrospective review to ensure that the documentation in the client’s medical record supports the medical necessity of the services provided.

2.9.3Claims Information

Claims for HBAI services must be submitted to TMHP in an approved electronic claims format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

“Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for instructions on completing paper claims.

2.9.4Reimbursement

Providers may refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com for reimbursement rates.

2.10Medical Nutrition Counseling Services (CCP)

2.10.1Enrollment

Independently practicing licensed dietitians may enroll in Texas Medicaid to provide services to CCP-eligible clients. Dieticians who provide nutrition assessments and counseling must be currently licensed by the Texas State Board of Examiners of Dietitians in accordance with the Licensed Dietitians Act, Chapter 701, Texas Occupations Code.

Refer to:  Subsection 2.1.2, “Enrollment” in this handbook for more information about CCP enrollment procedures.

2.10.2Services, Benefits, and Limitations

Medical nutrition therapy (assessment, re-assessment, and intervention) and medical nutrition counseling may be beneficial for treating, preventing, or minimizing the effects of illness, injuries, or other impairments. A case manager, school counselor, or school nurse may refer a client for medical nutrition counseling services.

Medical nutrition counseling services are a benefit when all of the following criteria are met:

The client is 20 years of age or younger

The client is eligible for CCP

The services are prescribed by a physician

The services are performed by a Medicaid-enrolled licensed dietitian

Clinical documentation supports medical necessity and medical appropriateness

FFP is available

Medical nutrition therapy and nutrition counseling may be considered beneficial for disease states for which dietary adjustment has a therapeutic role. Such disease states include, but are not limited to, the following conditions:

Abnormal weight gain

Cardiovascular disease

Diabetes or alterations in blood glucose

Eating disorders

Gastrointestinal disorders

Gastrostomy or other artificial opening of gastrointestinal tract

Hypertension

Inherited metabolic disorders

Kidney disease

Lack of normal weight gain

Multiple food allergies

Nutritional deficiencies

Nutrition intervention for the following conditions is considered experimental and investigational and is not a benefit:

Attention-deficit hyperactivity disorder

Chemical sensitivities

Chronic fatigue syndrome

Idiopathic environmental intolerance

Medical nutrition counseling services for the diagnosis of obesity without a comorbid condition is not a benefit.

Medical nutrition therapy (procedure code 97802) is a more comprehensive service than medical nutrition counseling and is provided to individual clients for assessment and intervention. Procedure code 97802 is limited to one session per day and four units per rolling year.

Medical nutrition therapy (procedure code 97803) is provided to individual clients for a reassessment and intervention, after the initial assessment and intervention. Procedure code 97803 may be used for direct therapy sessions with clients. These sessions are limited to 1 session per day and 12 units per rolling year.

Nutrition assessments and re-assessments are in-depth evaluations of both objective and subjective data related to an individual’s food and nutrient intake, lifestyle, and medical history. Nutrition assessments and re-assessments are performed as part of medical nutrition therapy. Nutrition assessments and re-assessments may be required as a result of a medical diagnosis and may be performed in conjunction with other therapies for treatment or as a goal to help clients make and maintain dietary changes. Documentation must include the following:

Objective and subjective date obtained

Height, weight, body mass index (BMI), and correlating percentiles on the growth curves

Estimated caloric needs

Nutritional diagnosis

Intervention and plan

Evaluation

Medical nutrition counseling (procedure code S9470) is provided to individual clients after an initial assessment and is less comprehensive than medical nutrition therapy. Nutritional counseling may be used to discuss the plan of care or intervention and to determine whether modifications are needed. Procedure code S9470 is limited to one visit per day and four visits per rolling year.

Medical nutrition group therapy (procedure code 97804) is not a benefit in the home setting, and does not include an individual nutrition assessment. Medical nutrition group therapy is limited to eight units per rolling year.

Medical nutrition group therapy may be provided to a group of clients with the same condition. While medical nutrition group therapy must be led by a Medicaid-enrolled dietitian licensed by the Texas State Board of Examiners of Dietitians, other health-care providers may participate in the group sessions. The focus of the therapy is on nutrition and health for chronic conditions such as the following:

Acquired acanthosis nigricans

Diabetes

Dysmetabolic syndrome X

Eating disorder

Hyperlipidemia

Other specified hypoglycemia

Pure hypercholesterolemia

Pure hyperglyceridemia

Medical nutrition group therapy sessions must last at least 30 minutes, have a minimum of two clients and a maximum of ten clients, and must include the following:

An age-appropriate presentation on nutrition issues related to the chronic condition. (The presen­tation may include information about prevention of disease exacerbation or complications and living with chronic illness. The presentation may also offer suggestions for making healthy food choices or changing ideas about food.)

A question-and-answer period.

Client participation in medical nutrition group therapy is optional. Providers must obtain an informed consent from a client’s parent or guardian before rendering services. The medical documentation maintained in a client’s medical record must include the following:

Physician prescription

Referral, if applicable

Location where the services were provided

Services that were provided during medical nutrition group therapy

Goals or objectives for the group therapy

Client participation

Beginning and ending time of the group therapy session

In the following table, the procedure codes in Column A will be denied as part of another service if they are submitted by any provider for the same date of service as the corresponding procedure codes in Column B:

Column A: Procedure Codes Denied When Submitted With…

Column B: Procedure Codes

S9470

97802, 97803, or 97804

Claims for medical nutrition therapy and counseling services should be submitted as follows:

Procedure Code

Time Unit

Limitation

97802

Initial assessment

15 minutes

4 units per rolling year

97803

Reassessment

15 minutes

12 units per rolling year

97804

Group

30 minutes

8 units per rolling year

S9470

Dietitian visit

Per visit

1 visit per day/ 4 visits per rolling year

2.10.3Prior Authorization and Documentation Requirements

Prior authorization is required for services that exceed the limitations for medical nutrition therapy (assessment, re-assessment, and intervention), medical nutrition group therapy, and nutrition counseling visits.

Prior authorization is also required for consideration of other health conditions that are not addressed.

The following documentation must be submitted to the CCP Prior Authorization Unit for prior authorization:

Completed CCP Prior Authorization Request Form

Treatment plan

Diagnosis of a condition for which there is medical necessity for the service

Obstacles for not meeting goals

Interventions planned to meet goals

The prescribing physician and provider must maintain documentation of medical necessity, including the completed CCP Prior Authorization Request Form, in a client’s medical record. The physician must maintain the original signed copy of the CCP Prior Authorization Request Form. The completed CCP Prior Authorization Request Form is valid for a period of up to six months from the date of the physician’s signature.

2.10.4Claims Information

Providers must submit services provided by licensed dietitians in an approved electronic claims format or on a CMS-1500 paper claim form from the vendor of their choice. TMHP does not supply the forms.

Claims for services that have been prior authorized must reflect the PAN in Block 23 of the CMS-1500 paper claim form or its equivalent.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

“Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for instructions on completing paper claims.

Medical Nutrition Counseling (CCP Only) on the TMHP website at www.tmhp.com for a claim form example.

2.10.5Reimbursement

Dietitian services are reimbursed in accordance with 1 TAC §355.8441.

2.11Personal Care Services (PCS) (CCP)

2.11.1Enrollment

CCP providers that want to participate in the delivery of PCS to Medicaid clients must be enrolled with TMHP and have the appropriate Texas Department of Aging and Disability Services (DADS) licensure or certification.

All PCS providers must have a TPI and a National Provider Identifier (NPI).

Providers that are currently contracted with DADS to administer consumer-directed services (CDS) or provide PCS through the service responsibility option (SRO), including providers currently enrolled in Texas Medicaid, are required to enroll or re-enroll separately as a CDS or SRO provider. Texas Medicaid enrolls only new providers that are currently contracted with DADS to provide PCS through CDS and SRO.

Providers (other than those discussed above) that want to provide PCS to Medicaid clients must enroll through TMHP. Texas Medicaid enrollment rules for PCS participation require providers to have one of the following categories of DADS licensure prior to enrollment:

Personal Assistance Services (PAS)

Licensed Home Health Services (LHHS)

Licensed and Certified Home Health Services (LCHHS)

LCHH and LHH agencies that are currently enrolled through TMHP do not need to enroll as CCP-PCS providers to provide PCS. Providers must have a TPI in one of the following enrollment categories: LHHS agency, LCHHS agency, or PCS provider.

Providers that are enrolled as any entity other than an LHHS agency or LCHHS agency are required to meet the provider enrollment rules in order to participate in the delivery of PCS through Texas Medicaid.

Refer to:  Subsection 2.1.2, “Enrollment” in this handbook for more information about CCP enrollment procedures.

2.11.2Services, Benefits, and Limitations

PCS is a benefit of CCP for Texas Medicaid clients who are birth through 20 years of age. PCS may not be authorized in hospitals, nursing facilities, or intermediate care facilities for individuals with intel­lectual or developmental disabilities (ICF-IID). PCS will be denied when billed on the same date of service as an inpatient stay service. The provider may appeal the denied claim with documentation supporting that PCS was performed while the client was not in a hospital setting. PCS are support services provided to clients who meet the definition of medical necessity and require assistance with the performance of ADLs, instrumental activities of daily living (IADLs), and health maintenance activities (HMAs) due to a physical, cognitive, or behavioral limitation related to a client’s disability or chronic health condition. PCS are provided by someone other than the responsible adult of the client who is a minor child or the legal spouse of the client.

A responsible adult is an individual, 18 years of age or older, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to, biological parents, adoptive parents, step parents, foster parents, legal guardians, court-appointed managing conservators, and the primary adult who is acting in the role of parent.

PCS are those services that assist eligible clients in performing ADLs, IADLs, and HMAs. The scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Typically, developing children gradually and sequentially acquire the ability to perform these ADLs, IADLs, and HMAs for themselves. If a typically developing child of the same chronological age could not safely and independently perform an ADL, IADL, or HMAs without adult supervision, then the client’s responsible adult ensures that the client’s needs for the ADLs, IADLs, and HMAs are met.

PCS include direct intervention (assisting the client in performing a task) or indirect intervention (cueing or redirecting the client to perform a task). ADLs, IADLs, and HMAs include, but are not limited to, the following:

ADLs

IADLs

Bathing

Escort or Assistance with Transportation Services

Dressing

Grocery or Household Shopping

Eating

Laundry

Locomotion or Mobility

Light housework

Personal Hygiene

Meal preparation

Positioning

Medication Assistance

Toileting

Money management

Transferring

Telephone Use or Other Communication

* Escort or Assistance with Transportation Services includes the coordination of transportation to medical appointments and accompaniment to appointments to assist with needed ADLs. PCS does not include the payment for transportation or transportation vehicles since these services are available through MTP.

 

Note:Health maintenance activities (HMAs) and nurse-delegated tasks that fall within the scope of the task listed above are allowable in PCS.

Note:Exercise and range of motion are not available through PCS, but are services that could be provided through PT, PDN, or home health SN.

PCS does not include the following:

ADLs, IADLs, or HMAs that a typically developing child of the same chronological age could not safely and independently perform without adult supervision

Services that provide direct intervention when the client has the physical, behavioral, and cognitive abilities to perform an ADL, IADL, or health-related function without adult supervision

Services used for or intended to provide respite care, child care, or restraint of a client

Stand-by supervision related to safety

Potty training

Grocery shopping for members of the client’s family or household

Cleaning for members of the client’s family or household (exception: light housework is approved if the client shares a room with a person)

Cleaning the entire house (exception: a need for clean environment is approved if related to the client’s diagnosis or condition [e.g., asthma, allergies, or autoimmune deficiencies])

Note:Cleaning an area or equipment that is used to complete a task may be included in the light housework IADL, as appropriate.

Laundry services for members of the client’s family or household (exception: laundry is approved when related to the client’s diagnosis or condition that results in soiled bedding or clothing for the client beyond the norm [e.g., incontinence, feeding tube, trachea, an ostomy, diapers, or skin condition])

Waiting time for the laundry machine to complete a cycle in the home setting (exception: the time an attendant is at a laundromat completing the laundry task for the client is covered for PCS)

Meal preparation for members of the client’s family or household

Time of a PCS attendant while acting as the responsible adult for the receipt of medical care or providing medical transportation

An escort is approved if it is related to the client’s diagnosis or condition, such as using the toilet at the appointment or assistance carrying equipment (e.g., feeding pump, oxygen tank).

An escort is approved if it is related to the client’s diagnosis or condition and the responsible adult is occupied during the transport. For example, a child’s condition might include behaviors that create an unsafe situation for the child during transport, such as removing a seatbelt, attempting to open the car door while the car is in motion, or elopement.

PCS does cover the entire time that an attendant is away from the home performing this task.

PCS is considered for reimbursement when providers use procedure code T1019 in conjunction with the appropriate modifier listed in the following table. PCS provided by a home health agency or PCS-only provider, including PCS being provided under the SRO defined in 40 TAC Part 1, Chapter 41, must be billed in 15-minute increments. PCS provided by a financial management services agency (FMSA) under the CDS option defined in 40 TAC Part 1, Chapter 41, must submit the attendant fee in 15-minute increments. FMSAs must bill the administration fee once per calendar month per client for any month in which the client receives PCS under the CDS option and regardless of the number of PCS units of service the client receives under the CDS option during the month. PCS claims are considered for reimbursement only when TMHP has issued a valid PAN to a PCS provider.

PCS Procedure Codes

All PCS Providers* (except FMSA)

Procedure Code

T1019

Modifier

U6 (PCS each 15 minutes)

UA (Behavioral health condition, each 15 minutes)

FMSA Under CDS Option*

Procedure Code

T1019

Modifier

U7 (Attendant fee each 15 minutes)

U8 (Administration fee once a month)

UB (Behavior health condition, each 15 minutes)

* 40 TAC Part 1, Chapter 41

Home health agencies and Personal Care Services (PCS) providers that provide PCS and Community First Choice (CFC) Services in the home setting may be reimbursed for nurse evaluation and supervision using procedure code G0162.

The following limitations apply for procedure code G0162:

For a registered nurse (RN) assessment, procedure code G0162 (without modifier) is limited to three hours per day (12 to 15 minute increments) and two occurrences per rolling year for any provider.

For training and supervision of the attendant, procedure code G0162 must be billed with modifier U1 and is limited to three hours (12 to 15 minute increments) per 30 days for any provider.

Note:Training and supervision and an RN assessment may be billed on the same day.

Prior authorization is not required for procedure code G0162.

2.11.2.1Place of Services

PCS may be provided in the following settings if medically necessary:

The client’s home

The client’s school

The client’s daycare facility

Other community setting in which the client is located

Note:For claims filing purposes, the PCS provider must bill POS 2 (home) when submitting claims to TMHP.

Texas Medicaid does not reimburse providers for PCS that duplicate services that are the legal respon­sibility of school districts. The school district, through the School Health and Related Services (SHARS) program, is required to meet the client’s personal care needs while the client is at school. If those needs cannot be met by SHARS or the school district, the school district must submit documentation to the Texas Department of State Health Services (DSHS) case manager indicating the school district is unable to provide all medically necessary services. When clients are receiving both PCS and PDN services from an individual person over the same span of time, the combined total number of hours for PCS and PDN are reimbursed according to the maximum allowable rate.

2.11.2.2Client Eligibility

The PCS benefit is available to Texas Medicaid clients who:

Are birth through 20 years of age.

Are enrolled with Texas Medicaid.

Are eligible for CCP.

Have physical, cognitive, or behavioral limitations related to a disability or chronic health condition that inhibits the client’s ability to accomplish ADLs, IADLs, or HMAs.

Whether the client has a physical, cognitive, or behavioral limitation related to a disability or chronic health condition that inhibits the client’s ability to accomplish ADLs, IADLs, or HMAs, the following needs and conditions of the responsible adult will be considered:

The responsible adult’s need to sleep, work, attend school, and meet their own medical obligations

The responsible adult’s legal obligation to care for, support, and meet the medical, educational, and psychosocial needs of other dependents

Whether requiring the responsible adult to perform the PCS will put the client’s health or safety in jeopardy

The time periods during which the PCS tasks are required by the client, as they occur over the course of a 24-hour day and a seven-day week.

Whether or not the need to help the family perform PCS on behalf of the client is related to a medical, cognitive, or behavioral condition that results in a level of functional ability that is below that expected of a typically developing child of the same chronological age

Whether services are needed based on:

The Practitioner Statement of Need (PSON)

The client’s personal care assessment form (PCAF)

Clients who are enrolled in a DADS waiver program may also receive PCS if they are eligible for it, as long as the services that are provided through the waiver program and PCS are not duplicated. Clients who are enrolled in the following DADS waiver programs may access the PCS benefits if they meet the PCS eligibility requirements:

Community Living Assistance and Support Services (CLASS)

Deaf/Blind Multiple Disabilities (DBMD)

Community-Based Alternatives (CBA)

Consolidated Waiver Program (CWP)

Medically Dependent Children Program (MDCP)

Texas Home Living Waiver (TxHmL)

Home and Community Services (HCS)

Note:Clients who receive HCS Residential Support Services, Supervised Living Services, or Foster/Companion Care Services are not eligible to receive attendant care services through PCS.

Clients must choose the program through which they receive attendant care, if they meet the eligibility requirements of both programs. Clients will be given the following options for the delivery of attendant care services:

A client can receive all attendant care services through PCS.

A client can decline PCS and receive all attendant care service through a waiver program, if the waiver program offers attendant care.

Clients who participate in the CDS option for PCS and for a waiver program are required to choose one FMSA to provide services through both programs. FMSAs will only be permitted to file the financial management services (FMS) fee, also known as the monthly administrative fee, through one program. The FMSA must file the FMS claim through the program that provides the highest reimbursement rate.

2.11.2.2.1Accessing the PCS Benefit

Clients must be referred to DSHS before receiving the PCS benefit. A referral can be made by any person who recognizes a client may have a need for PCS, including, but not limited to, the following:

The client, a parent, a guardian, or a responsible adult

A primary practitioner, primary care provider, or medical home

A licensed health professional who has a therapeutic relationship with the client and ongoing clinical knowledge of the client

A family member

Home health, personal assistance, or FMSA providers

Referrals to DSHS can be made to the appropriate DSHS Health Service Region, based on the client’s place of residence in the state. Clients, parents, or guardians may also call the TMHP PCS Client Line at 1-888-276-0702 for more information on PCS. PCS providers must provide contact information for the client or responsible adult to DSHS or the TMHP PCS Client Contact Line when making a referral.

Upon receiving a referral, DSHS assigns the client a case manager, who then conducts an assessment in the client’s home with the input and assistance of the client or responsible adult. Based on the assessment, the case manager identifies whether the client has a need for PCS. If the case manager identifies a need for PCS, the client or responsible adult is asked to select a Medicaid-enrolled PCS provider in their area.

Once a provider is selected, the DSHS case manager prior authorizes a quantity of PCS based on the assessment and requests TMHP to issue a PAN to the selected PCS provider. The PCS provider uses the PAN to submit claims to TMHP for the services provided.

2.11.2.2.2The Primary Practitioner’s Role in the PCS Benefit

A client who is assessed for the PCS benefit must have a primary practitioner (a licensed physician, APRN, or PA) or a primary care provider who has personally examined the client within the last 12 months and reviewed all of the appropriate medical records. The primary practitioner or primary care provider must have established a diagnosis for the client and must provide continuing care and medical supervision of the client. Prior to authorizing PCS, HHSC requires the completion of an HHSC-approved Practitioner Statement of Need (PSON) by a primary practitioner. The PSON must be on file with HHSC prior to the initiation of PCS and will only accept the PSON from an individual who is a physician, APRN, or PA.

The PSON certifies that the client is 20 years of age or younger and has a physical, cognitive, or behav­ioral limitation related to a disability or chronic health condition. The primary practitioner or primary care provider must mail or fax the completed PSON to the appropriate DSHS Health Services Region. DSHS keeps the signed and dated PSON and the client’s PCAF in the client’s case management record for the duration of the client’s participation in the benefit.

When a behavioral health condition exists, the primary practitioner may be a behavioral health provider.

If the client’s medical record does not include the primary practitioner’s documentation and a PSON that certifies that the client has a physical, cognitive or behavioral health condition that impacts the client’s ability to perform an ADL or IADL, then PCS payments may be recouped.

Note:If a client is entering or is already in the conservatorship of the state, PCS may be provisionally initiated for up to 60 days once eligibility has been established through the assessment.

HHSC requires the reassessment of the client’s need for PCS every 12 months or when requested due to a change in the client’s health or living condition. A new PSON will be required at each annual reassessment and when there is a change in the client’s medical condition that may increase the need for services.

2.11.2.3PCS Provided in Group Settings

PCS may be provided in a provider to client ratio other than one-to-one. Settings in which providers can provide PCS in a provider to client ratio other than one-to-one include homes with more than one client needing PCS, foster homes, and independent living arrangements.

A PCS provider may provide PCS to more than one client over the span of the day as long as:

Each client’s care is based on an individualized service plan.

Each client’s needs and service plan do not overlap with another client’s needs and service plan.

Example:If the prior authorized PCS hours for Client A is four hours, Client B is six hours, and the actual time spent with both clients is eight hours, the provider must bill for the actual one-on-one time spent with each client, not to exceed the client’s prior authorized hours or total hours worked. It would be acceptable to bill four hours for Client A and four hours for Client B, or three hours for Client A and five hours for Client B. It would not be acceptable to bill five hours for Client A and three hours for Client B. It would be acceptable to bill ten hours if the individual person actually spent ten hours onsite providing prior authorized PCS split as four hours for Client A and six hours for Client B. A total of ten hours cannot be billed if the individual person worked only eight hours.

PCS may be delivered in a client-to-provider ratio other than one-on-one as long as each client’s care is based on an individualized POC and each client’s needs are being met. Only the time spent on authorized PCS tasks for each client is eligible for reimbursement. Total PCS billed for all clients cannot exceed an individual attendant’s total number of hours at the place of service.

When there is more than one client within the same household receiving PCS, the DSHS case manager will synchronize authorizations within the households for all eligible clients. The DSHS case manager will assess all eligible clients in the home and submit authorizations for all eligible clients in the household for the same authorization period. DSHS case managers will communicate with the provider the actions that are being taken using the existing Communication Tool.

Note:There should be no lapse in services to the client.

2.11.3Prior Authorization and Documentation Requirements

Prior authorization is required before services are provided. All PCS must be prior authorized by a DSHS case manager based upon client need, as determined by the client assessment. DSHS prior authorizes PCS for eligible clients. The DSHS case manager notifies TMHP of the authorized quantity of PCS. TMHP sends a notification letter with the PAN to the client or responsible adult and the selected PCS provider if PCS is approved or modified. Only the client or responsible adult receives a notification letter with an explanation of denied services. PCS is prior authorized for periods of up to twelve months. PCS providers must provide services from the start of care date agreed to by the client or responsible adult, the case manager, and the PCS provider.

PCS may be authorized in the same day as PPECC, if medically necessary. However, they must be rendered in a home setting, before or after PPECC services.

A PCS provider may obtain prior authorization to provide enhanced PCS to clients with a behavioral health condition when the following criteria are met:

The DSHS case manager completes the Personal Care Assessment Form (PCAF) and identifies the behavioral health condition.

The PCAF indicates that the identified behavioral health condition impacts the client’s ability to perform an ADL or IADL.

The PCAF indicates which ADL(s) or IADL(s) cannot be performed by the client without assistance.

The DSHS case manager submits the appropriate modifier on the authorization request.

When a client experiences a change in condition, the client or responsible adult must notify the DSHS Health Service Office in the client’s region. A new assessment is required when a client’s physician orders services in a PPECC. A DSHS case manager must perform a new assessment and prior authorize any revisions in the quantity of PCS based on the new assessment. TMHP issues a revised authorization and notifications are sent to the client or responsible adult and the selected PCS provider. If the change is made during a current prior authorization period, the new prior authorization will maintain the same end date as the original prior authorization period. The revised authorization period will begin on the SOC date stated in the new assessment.

For continuing and ongoing PCS needs beyond the initial prior authorization period of up to twelve months, a DSHS case manager must conduct a new assessment and submit a new authorization request to TMHP. TMHP sends a notification letter updating the prior authorization to the client, responsible adults, and the selected PCS provider.

HHSC or its designee may suspend an authorization for PCS when either:

The client or the client’s family creates an unsafe environment for the attendant’s health and safety.

The provider requests suspension for the reasons outlined in 40 TAC Part 1, Chapter 41.

Providers can call a toll-free PCS Provider Inquiry Line at 1-888-648-1517 for assistance with inquiries about the status of a PCS prior authorization. Providers should direct inquiries about other Medicaid services to the TMHP Contact Center at 1-800-925-9126. PCS providers should encourage the client or responsible adult to contact the appropriate DSHS Health Service Region with inquiries or concerns about the PCS assessment.

Note:Any organization that employs attendants who provide PCS, and any organization serving as an FMSA, must comply with all documentation requirements as specified by the PCS program.

2.11.3.1PCS Provider Responsibilities

PCS providers must comply with all applicable federal, state, and local laws and regulations.

All PCS providers must maintain written policies and procedures for obtaining consent for medical treatment in the absence of the responsible adult. The procedure and policy must meet the standards of the Texas Family Code, Chapter 32.

Providers must accept clients only when there is a reasonable expectation and evidence that the client’s needs can be adequately met in the POS. The POS must be able to support the client’s health and safety needs and adequately support the use, maintenance, and cleaning of all required medical devices, equipment, and supplies. Necessary primary and backup utility, communication, and fire safety systems must be available in the POS.

The PCS provider is responsible for the supervision of the PCS attendant as required by the PCS provider’s licensure requirements.

2.11.3.2Documentation of Services Provided and Retrospective Review

Documentation elements are routinely assessed for compliance in retrospective review of client records, including the following:

All entries are legible to people other than the author, dated (month, day, year, time), and signed by the author.

Each page of the record documents the client’s name and Medicaid identification number.

All attendants’ arrival and departure times are documented with signature and time.

Documentation of services correlates with, and reflects medical necessity for, the services provided on any given day.

Client’s arrival or departure from the home setting is documented with the time of arrival, departure, mode of transportation, and who accompanied the client.

2.11.4Coordination with PPECC Provider

When a DSHS case manager is notified by the client, client’s responsible adult, or client’s physician that PPECC services have been initiated, revised, or recertified, the DSHS case manager must conduct a PCS reassessment, and submit all documentation required for a revision, modification, or denial of the original PCS authorization request, including a Physician’s Statement of Need if there is a change in client condition. The new authorization request must be submitted within ten (10) business days of notification.

DSHS case managers must provide documentation to support medical necessity if PCS service hours do not decrease when PPECC services are initiated.

DSHS case managers must also document coordination with the PPECC provider, maintaining documentation that the client or the client’s responsible adult has participated in the development of the plan of care.

When a client receives both PCS and PPECC in a single day, and decides to receive fewer hours of service in a PPECC (i.e., shifts more services to the home setting), or terminates PPECC services, the PCS case manager must conduct a reassessment, and submit all documentation required for a revision, modifi­cation, or denial of the original PCS authorization request, including a Physician’s Statement of Need if there is a change in condition within ten (10) business days of notification by the client, client’s respon­sible adult, or client’s physician.

Similarly, if the client decides to receive fewer hours of PCS services in the home, and increase PPECC hours, the DSHS case manager must conduct a reassessment, and submit all documentation required for an modification of the authorization request, within ten (10) business days of notification by the client, client’s responsible adult, or client’s physician.

Note:Coordination requirements may be different in a Medicaid managed care environment.

PCS services rendered in a client’s home may be billed before or after PPECC services on the same day, but not at the same time as PPECC services. PCS services required while a client is in a PPECC are considered part of the PPECC billable rate.

2.11.5Claims Information

TMHP processes PCS claims. PCS providers must submit claims for services in an approved electronic claims format or on the appropriate claim form based on their provider type. PCS providers, other than home health agencies, that are enrolled as PAS-only providers, FMSAs, or SRO providers must file PCS claims using a CMS-1500 paper claim form. Home health agencies, including those enrolled as an FMSA, or an SRO provider, must file PCS claims using the UB-04 CMS-1450 paper claim form. TMHP does not supply the forms.

Home health agencies and consumer-directed agencies that bill for PCS using procedure code T1019 must include the prior authorization number on claims submitted for reimbursement. Additionally, providers utilizing paper, TexMedConnect, or billing through EDI must include the prior authorization number with all claims submissions.

2.11.5.1Managed Care Clients

PCS services are carved-out of the Medicaid Managed Care Program for State of Texas Access Reform (STAR) clients and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid Managed Care clients but are administered by TMHP and not the client’s MCO. Claims for STAR Health, STAR Kids, and STAR+PLUS are not carved out and must be submitted to the client’s MCO for payment consideration.

2.11.5.2PCS for STAR Health Clients

PCS for eligible STAR Health clients are authorized and processed by Superior HealthPlan.

Medicaid providers that want to provide PCS services to clients in the STAR Health program should contact Superior HealthPlan for information regarding the contracting and credentialing process at:

Superior HealthPlan - Network Development
Telephone: 1-866-615-9399 Ext. 22534
Email: shp-networkdevelopment@centene.com

2.11.6Reimbursement

Providers of PCS are reimbursed in accordance with 1 TAC §355.8441.

2.12Community First Choice (CFC) Services

2.12.1Enrollment

CFC providers, including providers offering the Service Responsibility Option (SRO), must be licensed and enrolled in Texas Medicaid and comply with all applicable federal, state, and local laws and regula­tions. When CFC is provided through the Consumer Directed Services (CDS) option by a Financial Management Services Agency (FMSA), the FMSA must be certified and enrolled in Texas Medicaid as a FMSA and must comply with all applicable federal, state, and local laws and regulations.

Note:CDS, FMSA, and SRO are defined in the Title 40 Texas Administrative Code (TAC), Part 1, Chapter 41. Licensure requirements for FMSA and SRO providers are defined in the Title 40 TAC, Part 1, Chapter 49.

Note:Any organization that employs attendants who provide CFC, and any organization serving as an FMSA, must comply with all documentation requirements as specified in CFC program policy.

All CFC providers must maintain written policies and procedures for obtaining consent for medical treatment for clients in the absence of a responsible adult that meet the standards of the Texas Family Code, Chapter 32.

Providers must only accept clients when there is a reasonable expectation and evidence that the client’s CFC needs can be adequately met in the place of service.

The CFC provider is responsible for supervising the CFC attendant in accordance with the provider’s licensure requirements.

Note:For CFC services delivered through a Department of Aging and Disability Services (DADS) 1915(c) waiver or through a managed care organization (MCO), providers must refer to DADS or the MCO for information about benefits, limitations, prior authorization, reimbursement, and specific claim processing procedures.

2.12.2Services, Benefits, and Limitations

CFC services may be rendered by a Home Health Agency, PCS-only provider, Financial Management Services Agency (FMSA) under the CDS option, or by a Service Responsibility Option (SRO) Provider.

CFC is a benefit for Texas Medicaid fee-for-service clients who are birth through 20 years of age and who are:

Eligible for medical assistance under the state plan

Need help with activities of daily living; and

Need an institutional level of care (to include hospital, nursing facility, intermediate care facility for clients with intellectual disabilities or institution of mental disease)

Services included are CFC personal assistance services, CFC habilitation, and CFC support management. CFC personal assistance services is the assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision, and/or cueing. CFC habilitation services are the acquisition, maintenance, and enhancement of skills necessary for the client to accomplish ADLs, IADLs, and health maintenance activities (HMAs). CFC support management is voluntary training on how to select, manage, and dismiss attendants.

CFC includes assistance with ADLs, IADLs and HMAs through hands-on assistance, supervision, or cueing. CFC also includes training on the acquisition, maintenance, and enhancement of skills necessary for the client to accomplish ADLs, IADLs, and HMAs.

ADLs are activities that include:

Bathing—Assisting the client with any or all parts of bathing; selecting appropriate water temperature and flow speed, turning water on and off; laying out and putting away supplies; trans­ferring in and out of bathtub or shower; washing and drying hair and body; clean up after task is completed.

Dressing—Assisting the client with any or all parts of getting dressed; putting on, fastening, and taking off all items of clothing; donning and removing shoes or prostheses; choosing and laying out weather-appropriate clothing.

Eating—Assisting the client with some or all parts of eating and drinking; feeding the client; assis­tance with utensils or special or adaptive eating devices; clean up after task is completed.

Personal hygiene: Assisting the client with some or all parts of personal hygiene; routine hair care; oral care; ear care; shaving; applying makeup; managing feminine hygiene; washing and drying face, hands, perineum; basic nail care; applying deodorant; routine skin care; clean up after task is completed.

Toileting—Assisting the client with some or all parts of toileting; using commode, bedpan, urinal, toilet chair; transferring on and off; cleansing; changing diapers, pad, incontinence supplies; adjusting clothing; clean up after task is completed.

Locomotion or mobility—Assisting the client with moving between locations; assisting the client with walking or using wheelchair, walker, or other mobility equipment.

Positioning—Assisting the client with positioning their body while in a chair, bed, or other piece of furniture or equipment; changing and adjusting positions; moving to or from a sitting position; turning side-to-side; assisting the client to sit upright.

Transferring—Assisting the client with moving from one surface to another with or without a sliding board; moving from bed, chair, wheelchair, or vehicle to a new surface; moving to or from a standing or sitting position; moving the client with lift devices.

IADLs are activities that include:

Telephone use or other communication—Assisting the client in making or receiving telephone calls; managing and setting up communication devices; making and receiving the call for the client.

Grocery or household shopping—Shopping for or assisting clients in shopping for grocery and household items; preparing a shopping list; putting food and household items away; picking up medication and supplies.

Light housework—Performing or assisting the client in performing light housework such as: Cleaning and putting away dishes; wiping countertops; dusting; sweeping, vacuuming or mopping; changing linens and making bed; cleaning bathroom; taking out trash.

Laundry—Assisting the client with doing laundry; gathering, sorting, washing, drying, folding, and putting away personal laundry, bedding, and towels; removing bedding to be washed and remaking the bed; using a laundry facility.

Meal preparation—Assisting clients in preparing meals and snacks; cooking; assembling ingre­dients; cutting, chopping, grinding, or pureeing food; setting out food and utensils; serving food; preparing and pouring a predetermined amount of liquid nutrition; cleaning the feeding tube; cleaning area after meal; washing dishes.

Money management—Assisting the client with managing their day-to-day finances; paying bills; balancing checkbook; making deposits or withdrawals; assisting in preparing and adhering to a budget.

Medication assistance or administration—Assisting the client with oral medications that are normally self-administered, including administration through a permanently placed feeding tube with irrigation.

Escort or assistance with transportation services—Assisting the client in making transportation arrangements for medical and other appointments; accompanying the client to a health care appointment to assist with needed ADLs.

HMAs include tasks that may be exempt from delegation based on the Registered Nurse (RN) assessment that enables the client to remain in an independent living environment and go beyond ADLs because of the higher skill level in which they are required to perform. HMAs will be limited to those within the scope of CFC that include:

Administering oral medications that are normally self-administered, including administration through a permanently placed feeding tube with irrigation.

Topically applied medications.

Insulin or other injectable medications prescribed in the treatment of diabetes mellitus adminis­tered subcutaneously, nasally, or via an insulin pump.

Unit dose medication administration by way of metered dose inhaler (MDIs) including medications administered as nebulizer treatments for prophylaxis or maintenance.

Routine administration of a prescribed dose of oxygen.

Noninvasive ventilation (NIV) such as continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) therapy.

The administering of a bowel and bladder program, including suppositories, enemas, manual evacuation, intermittent catheterization, digital stimulation associated with a bowel program, tasks related to external stoma care including but not limited to pouch changes, measuring intake and output, and skin care surrounding the stoma area.

Routine preventive skin care and care of Stage 1 pressure ulcers.

Feeding and irrigation through a permanently placed feeding tube inserted in a surgically created orifice or stoma.

Those tasks that an RN may reasonably conclude as safe to exempt from delegation based on an assessment consistent with 22 Texas Administrative Code (TAC) §225.6 of this title (relating to the RN Assessment of the client).

Reporting as to the client’s condition, including changes to the client’s condition or needs and completing appropriate record.

Skin care: Maintenance of the hygienic state of the client’s skin under optimal conditions of clean­liness and comfort.

Use of durable medical equipment (DME).

Such other tasks as the Board of Nursing may designate.

Whether the client has a physical, cognitive, or behavioral limitation related to a disability or chronic health condition that inhibits the client’s ability to accomplish ADLs, IADLs, or HMAs, the following needs and conditions of the responsible adult will be considered in the determination of hours for CFC personal assistance services:

The responsible adult’s need to sleep, work, attend school, and meet their own medical obligations

The responsible adult’s legal obligation to care for, support, and meet the medical, educational, and psychosocial needs of other dependents

Whether requiring the responsible adult to perform the CFC personal assistance services will put the client’s health or safety in jeopardy

The time periods during which the CFC personal assistance services tasks are required by the client, as they occur over the course of a 24-hour day and a seven-day week.

Whether or not the need to help the family perform CFC personal assistance services on behalf of the client is related to a medical, cognitive, or behavioral condition that results in a level of functional ability that is below that expected of a typically developing child of the same chrono­logical age

CFC also includes training on the acquisition, maintenance, and enhancement of the following additional habilitation needs:

Community integration—Client may need assistance finding, participating in and accessing community activities or community services such as free meal programs, churches, parks or self-advocacy training or events.

Use of adaptive equipment—Client may need assistance operating, learning to use, or accessing adaptive equipment.

Personal decision-making—Client may need assistance making decisions for him or herself, including assistance in assessing what is important to that client, pros and cons, as well as consequences.

Reduce challenging behaviors to allow clients to accomplish ADLs, IADLs, and HMAs—Client may need assistance in increasing positive social encounters and engagement in preferred activities. Client may have challenging behaviors that can be reduced through behavior support plans, prompting, rewards, or redirection among others.

Socialization/relationship development—Client may need assistance with development and maintenance of relationships or appropriate social behaviors.

Accessing leisure and recreational activities—Client may need assistance identifying, finding, or accessing activities they would like to participate in during leisure time.

CFC does not include the following:

Direct intervention to perform a task the client has the physical, behavioral, and cognitive abilities to perform;

Skilled nursing services, or the supervision of delegated nursing tasks as described in the Texas Nurse Practice Act, the Act’s implementing regulations, the Texas Medicaid Provider Procedures Manual sections for Private Duty Nursing (PDN) Services - THSteps - Comprehensive Care Program (CCP) and Home Health Skilled Nursing and Home Health Aide Services;

Costs associated with purchasing products for ADLs or IADLs;

Services used for or intended to provide respite care, child care, or restraint of a client;

Duplication of services provided by another program;

Tasks that a typically developing child of the same chronological age could not safely and independently perform without adult supervision;

Services provided in an institutional setting including hospitals, nursing facilities, psychiatric hospitals, or intermediate care facilities for clients with intellectual or developmental disabilities.

CFC is considered for reimbursement when billed with procedure code T1019 in conjunction with the appropriate modifier listed in the following table. CFC provided by a home health agency or PCS-only provider, including CFC being provided under the SRO defined in 40 TAC Part 1, Chapter 41, must be billed in 15-minute increments. CFC provided by a FMSA under the CDS option defined in 40 TAC Part 1, Chapter 41, must submit the attendant fee in 15-minute increments.

CFC Procedure Codes

All CFC Providers (except FMSA)

Procedure Code

T1019

Modifier

UD (CFC —client needs attendant care only, each 15 minutes)

U9 (CFC—client needs habilitation only, or attendant and habilitation, each 15 minutes)

Procedure Code

T1019

Modifier

U3 (CFC attendant care for PCS - CDS Option, each 15 minutes)

Note:This modifier will be used for individuals receiving attendant care only.

U4 (CFC Habilitation for PCS - CDS Option, each 15 minutes)

Note:This modifier will be used for individuals receiving attendant care and habilitation.

U5 (CFC CDS, per month)

Note:This modifier is used for the administrative fee for CFC provider under the CDS option.

FMSAs must bill the administration fee once per calendar month per client for any month in which the client receives CFC under the CDS option and regardless of the number of CFC units of service the client receives under the CDS option during the month. CFC claims are considered for reimbursement only when TMHP has issued a valid PAN to a CFC provider.

Home health agencies and Personal Care Services (PCS) providers that provide PCS and Community First Choice (CFC) Services in the home setting may be reimbursed for nurse evaluation and supervision using procedure code G0162.

The following limitations apply for procedure code G0162:

For a registered nurse (RN) assessment, procedure code G0162 (without modifier) is limited to three hours per day (12 to 15 minute increments) and two occurrences per rolling year for any provider.

For training and supervision of the attendant, procedure code G0162 must be billed with modifier U1 and is limited to three hours (12 to 15 minute increments) per 30 days for any provider.

Note:Training and supervision and an RN assessment may be billed on the same day.

Prior authorization is not required for procedure code G0162.

2.12.2.1Place of Service

CFC may be provided in the following settings:

Client’s home;

Client’s school;

Client’s daycare facility; or

Other community setting in which the client is located.

Note:For claims filing purposes, the CFC provider must bill POS 2 (home) when submitting claims to TMHP.

Texas Medicaid does not reimburse providers for CFC services that duplicate services that are the legal responsibility of school districts. The school district, through the School Health and Related Services (SHARS) program, is required to meet the client’s personal care needs while the client is at school. If those needs cannot be met by SHARS or the school district, the school district must submit documen­tation to the DSHS case manager indicating the school district is unable to provide all medically necessary services.

2.12.3CFC Attendant and Habilitation Services in Group Settings

CFC may be provided in a provider to client ratio other than one-to-one. Settings in which providers can provide CFC in a provider to client ratio other than one-to-one include homes with more than one client needing CFC, foster homes, and independent living arrangements. A CFC provider may provide CFC to more than one client over the span of the day as long as:

Each client’s care is based on an individualized service plan.

Each client’s needs and service plan do not overlap with another client’s needs and service plan.

Only the time spent on authorized CFC tasks for each client is eligible for reimbursement. Total CFC billed for all clients cannot exceed an individual attendant’s total number of hours at the place of service.

When there is more than one client within the same household receiving CFC, the Department of State Health Services (DSHS) case manager will synchronize authorizations within the households for all eligible clients. The DSHS case manager will assess all eligible clients in the home and submit authoriza­tions for all eligible clients in the household for the same authorization period. DSHS case managers will communicate with the provider the actions that are being taken using the existing Communication Tool.

2.12.4Prior Authorization

Prior authorization is required before services are provided. All CFC must be prior authorized by a DSHS case manager based upon client need, as determined by the client assessment. DSHS prior autho­rizes CFC for eligible clients. The DSHS case manager notifies TMHP of the authorized quantity of CFC. TMHP sends a notification letter with the prior authorization number (PAN) to the client or responsible adult and the selected CFC provider if CFC is approved or modified. Only the client or responsible adult receives a notification letter with an explanation of denied services. CFC is prior authorized for periods of up to twelve months. CFC providers must provide services from the start of care date agreed to by the client or responsible adult, the case manager, and the CFC provider.

When DSHS has approved CFC services, DSHS will send the client’s selected CFC provider: A CFC Communication tool, specifying the approved hours and CFC tasks and a copy of the Personal Care Assessment Form (PCAF) CFC Addendum, which documents that client’s goals and preferences for the delivery of CFC services. The CFC provider may receive a Practitioner’s Statement of Need (PSON) for the client, but this form is not required documentation for CFC and is intended merely for informational purposes.

When a client experiences a change in condition, the client or responsible adult must notify the DSHS Health Service Office in the client’s region. A DSHS case manager must perform a new assessment and prior authorize any revisions in the quantity of CFC based on the new assessment. TMHP issues a revised authorization and notifications are sent to the client or responsible adult and the selected CFC provider. If the change is made during a current prior authorization period, the new prior authorization will maintain the same end date as the original prior authorization period. The revised authorization period will begin on the start of care date stated in the new assessment.

For ongoing CFC needs beyond the initial prior authorization period of up to twelve months, a DSHS case manager must conduct a new assessment and submit a new authorization request to TMHP. A new in-home assessment must be conducted every twelve months with the client. TMHP will send a notifi­cation letter updating the prior authorization to the client, responsible adults, and the selected CFC provider. HHSC or its designee may suspend an authorization for CFC when either:

The client or the client’s family creates an unsafe environment for the attendant’s health and safety; or

The provider requests suspension for the reasons outlined in 40 TAC Part 1, Chapter 41.

Providers can call a toll-free Provider Inquiry Line at 1-888-648-1517 for assistance with inquiries about the status of a CFC prior authorization. Providers should direct inquiries about other Medicaid services to the TMHP Contact Center at 1-800-925-9126. CFC providers should encourage the client or respon­sible adult to contact the appropriate DSHS Health Service Region with inquiries or concerns about the CFC assessment.

2.12.4.1CFC Provider Responsibilities

CFC providers must comply with all applicable federal, state, and local laws and regulations. All CFC providers must maintain written policies and procedures for obtaining consent for medical treatment in the absence of the responsible adult. The procedure and policy must meet the standards of the Texas Family Code, Chapter 32. Providers must accept clients only when there is a reasonable expectation and evidence that the client’s needs may be adequately met in the place of service (POS). The POS must be able to support the client’s health and safety needs and adequately support the use, maintenance, and cleaning of all required medical devices, equipment, and supplies. Necessary primary and backup utility, communication, and fire safety systems must be available in the POS. The CFC provider is responsible for the supervision of the CFC attendant as required by the CFC provider’s licensure requirements.

2.12.4.2Documentation Requirements

Documentation elements are routinely assessed for compliance in retrospective review of client records, including the following:

All entries are legible to people other than the author, dated (month, day, year, time), and signed by the author.

Each page of the record documents the client’s name and Medicaid identification number.

All attendants’ arrival and departure times are documented with signature and time.

Documentation of services correlates with, and reflects medical necessity for, the services provided on any given day.

Client’s arrival or departure from the home setting is documented with the time of arrival, departure, mode of transportation, and who accompanied the client.

2.12.5Claims Information

TMHP processes CFC claims. CFC providers must submit claims for services in an approved electronic claims format or on the appropriate claim form based on their provider type. CFC providers, other than home health agencies, that are enrolled as PAS-only providers, FMSAs, or SRO providers must file CFC claims using a CMS-1500 paper claim form. Home health agencies, including those enrolled as an FMSA, or an SRO provider, must file PCS claims using the UB-04 CMS-1450 paper claim form.

TMHP does not supply the forms. Home health agencies and consumer-directed agencies that bill for CFC using procedure code T1019 must include the prior authorization number on claims submitted for reimbursement. Additionally, providers utilizing paper, TexMedConnect, or billing through EDI must include the prior authorization number with all claims submissions.

2.12.5.1Managed Care Clients

CFC services are carved-out of the Medicaid Managed Care Program for State of Texas Access Reform (STAR) clients and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid Managed Care clients but are administered by TMHP and not the client’s MCO. Claims for STAR Health and STAR+PLUS are not carved out and must be submitted to the client’s MCO for payment consideration.

2.13Private Duty Nursing (PDN)(CCP)

Refer to:  The Home Health Nursing and Private Duty Nursing Services Handbook (Vol. 2, Provider Handbooks) for information about private duty nursing (PDN) (CCP) services.

2.14Prescribed Pediatric Extended Care Centers (PPECC) (CCP)

PPECC services may be a benefit of the Texas Health Steps (THSteps) Comprehensive Care Program (CCP) for Medicaid clients who are:

20 years of age and younger;

THSteps - CCP eligible;

Medically or technologically dependent;

Note:The term “medically dependent or technologically dependent client” does not include a minor or occasional medical condition that does not require continuous nursing care, including asthma or diabetes, or a condition that requires an epinephrine injection.

Have an acute or chronic condition;

Require ongoing skilled nursing care beyond the level of Skilling Nursing (SN) visits normally authorized under Texas Medicaid Home Health Skilled Nursing (HHSN) and Home Health Aide (HHA) Services;

Meet the medical necessity criteria for admission to a PPECC detailed in the authorization and medical necessity requirements, including a prescription from the client’s ordering physician, and;

Have chosen to receive PPECC services.

A PPECC does not provide emergency services. PPECCs must follow the safety provisions in state PPECC licensure requirements, including the adoption and enforcement of policies and procedures for a client’s medical emergency. PPECCs must call for emergency transport to the nearest hospital when emergency services are needed by a PPECC client.

2.14.1Services, Benefits, and Limitations

PPECC services are provided in a non-residential facility licensed by the Texas Department of Aging and Disability Services (DADS). PPECCs serve four or more medically dependent or technologically dependent clients who are 20 years of age or younger and who require ongoing skilled nursing prescribed by the client’s physician to avert death or further disability or require the routine use of a medical device to compensate for a deficit in life-sustaining body function.

Services must be included in a PPECC plan of care (POC) and are limited to no more than 12 hours in a 24-hour period. PPECC services may not be provided overnight. PPECC services are intended as an alternative to private duty nursing (PDN). When the services duplicate, PPECC services must be a one-to-one replacement of private duty nursing (PDN) hours, unless additional hours are medically necessary.

PPECCs must comply with:

Medicaid program rules, as well as PPECC licensing statute and rules;

Mandatory reporting of suspected abuse and neglect of children;

Texas Medicaid provider participation requirements; and

The requirements of the TMPPM.

Clients who receive PPECC services through THSteps-CCP require ongoing medical supervision by the ordering physician who has a therapeutic relationship with and ongoing clinical knowledge of the client. A face-to-face evaluation must be performed each year by the ordering physician for each client. A physician order is required for each authorization period including initial, revisions, and recertification. A physician in a relationship with a PPECC (employed by or contracted with a PPECC) cannot provide the physician’s order, unless the physician is the client’s treating physician and has examined the client outside of the PPECC setting.

The following services may be rendered at a PPECC, but are not considered part of the PPECC services covered by Texas Medicaid, and must be billed separately by Medicaid-enrolled service providers:

Speech, physical, and occupational therapies

Certified respiratory care practitioner services

Early intervention services provided through the Early Childhood Intervention (ECI) program, which are subject to ECI policies.

When the client’s plan of care indicates that therapy services are required while the client is at the PPECC, clients must be provided a choice in speech, occupational, and physical therapy providers, as well as certified respiratory care providers. PPECC providers must coordinate care with the therapy providers to ensure the client receives therapy services as required in the PPECC setting.

Clients from birth through 36 months of age must be given the option of receiving ECI services in addition to their PPECC services. The PPECC providers must coordinate care with the client’s ECI service coordinator.

ECI services rendered in a PPECC are provided by entities that are contracted with the state to provide early intervention services.

When therapy services (occupational, speech, and/or physical therapy), or certified respiratory care services are rendered in a PPECC, they may be provided by:

Medicaid-enrolled providers contracted with or employed by the PPECC or Medicaid-enrolled providers not employed by or contracted with the PPECC.

Independent therapists

Home health therapists

Certified respiratory care providers

Refer to:  The Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for additional information about CCP therapy services.

Refer to:  The Certified Respiratory Care Practitioner (CRCP) Services Handbook (Vol. 2, Provider Handbooks) for information about CRCP (CCP) services.

An admission authorized under this section is not intended to supplant the right of a client to access private duty nursing (PDN), personal care services (PCS), home health skilled nursing (HHSN), home health aide (HHA), and therapies (PT, OT, ST), as well as certified respiratory care practitioner services and early childhood intervention (ECI) services rendered in the client’s residence when medically necessary.

PPECC providers must collaborate and coordinate care with the client’s existing service providers, including physicians, therapists, certified respiratory care practitioners, and home health agencies rendering services such as private duty nursing and/or home health skilled nursing, home health aide services, personal care services, hospice, and other providers who render medically necessary services. The PPECC must ensure the provision of the following basic services:

The development, implementation, and monitoring of a comprehensive POC in collaboration with the client or the client’s responsible adult that addresses the client’s medical, nursing, psychosocial, therapeutic, and developmental services, including the following prescribed services:

Skilled nursing

Personal care services to assist with activities of daily living or instrumental activities of daily living while in the PPECC

Functional developmental services

Nutritional and dietary services, including nutritional counseling

Note:Nutritional services must comply with standards in DADS licensure rules related to nutri­tional counseling and dietary services.

Occupational, physical and speech therapy

Respiratory care

Psychosocial services

Physician’s oversight of services

The POC must also include the following, as applicable:

Training for the client’s responsible adult associated with caring for a medically or technologi­cally dependent client.

Transportation services needed by a client to access PPECC services.

Transportation must be provided by a PPECC when a client has a stated need or a prescription for transportation to the PPECC.

When a PPECC provides transportation to a PPECC client, Registered Nurse (RN) or Licensed Vocational Nurse (LVN) employed by the PPECC must be on board the transport vehicle.

The client does not need to be accompanied by the client’s responsible adult when a PPECC provides transportation.

When a client has a stated need or prescription for transportation, the client must be able to utilize transportation services offered by the PPECC with the assistance of a PPECC nurse to and from the PPECC, rather than a non-emergency ambulance.

A non-emergency ambulance may not be utilized for transport to and from a PPECC.

Note:A client may decline a PPECC’s transportation, and choose to be transported by other means, including his or her responsible adult.

Direct care staff, defined in licensure regulations, provides assistance with personal care services.

PPECC services must be:

Individualized, specific, and consistent with symptoms or confirmed diagnosis of the condition, illness or injury under treatment, not in excess of the client’s needs;

Consistent with generally accepted professional medical standards as determined by the Medicaid program and may not be experimental or investigational;

Reflective of the level of service that can be safely and effectively furnished;

Furnished in a manner not primarily intended for the convenience of the client, the client’s responsible adult, or the provider.

Note:The fact that a client’s ordering physician has prescribed, recommended, or approved medical care, goods or services does not, in itself, make such care or services medically necessary or a covered service.

2.14.1.1Prior Authorization and Documentation Requirements

Prior authorization is required for PPECC services, excluding PPECC transportation. All requests for PPECC services must be based on the client’s current medical needs. Texas Medicaid defines medically necessary THSteps services as health care, diagnostic services, treatments, and other measures necessary to correct or ameliorate any disability, physical or mental illness, or chronic conditions.

Documentation of medical necessity is required for PPECC services. PPECC services are considered medically necessary when a client meets all of the following admission criteria:

Eligible for THSteps-CCP;

20 years of age or younger;

Requires ongoing skilled nursing care and supervision, skillful observations, judgments and thera­peutic interventions all or part of the day to correct or ameliorate health status;

Considered to be a medically dependent or technologically dependent client in accordance with Texas Health and Safety Code chapter 248A;

Stable for outpatient medical services, and does not present significant risk to other clients or personnel at the PPECC;

Requires ongoing and frequent skilled interventions to maintain or ameliorate health status, and delayed skilled intervention is expected to result in:

Deterioration of a chronic condition;

Loss of function;

Imminent risk to health status due to medical fragility; or

Risk of death.

Has a prescription for PPECC services signed and dated by an ordering physician who has personally examined the client within 30 calendar days prior to admission and reviewed all appro­priate medical records;

Has consent for the client’s admission to the PPECC signed and dated by the client or the client’s responsible adult. Admission must be voluntary and based on the preference for PPECC services in place of PDN by the client or client’s responsible adult in both managed care and non-managed care service delivery systems.

Resides with the responsible adult and does not reside in any 24-hour inpatient facility, including the following:

General acute hospital

Skilled nursing facility

Intermediate care facility

Special care facility, including sub-acute units or facilities for the treatment of AIDS.

The PPECC will hold interdisciplinary conferences when PPECC services are initiated, recer­tified, or revised, and at least every 90 calendar days. Interdisciplinary conferences should include the client’s responsible adult and the following, as applicable:

The client’s Department of Family and Protective Services case worker.

The client’s therapy provider(s) and

Hospice provider.

Note:For clients who receive their PPECC services through a Medicaid managed care organization, the MCO service coordinator and/or service manager should be included in interdisciplinary conferences.

When the sole purpose of PPECC services is to train and educate the client’s responsible adult or the client (e.g., how to administer total parenteral nutrition (TPN) or how to manage a chronic condition), PPECC services will not be approved.

Training in a home setting for certain services such as how to administer TPN may be considered through intermittent home health skilled nursing visits.

Refer to:  The Home Health Nursing and Private Duty Nursing Services Handbook (Vol. 2, Provider Handbooks) for more details on training and education for the client or the client’s respon­sible adult on TPN administration in a home setting.

2.14.1.1.1Initial Authorization Requests

Initial requests may be prior authorized for a maximum of 90 calendar days. Requests for the prior authorization, including all required documentation, must be submitted to the Texas Medicaid Claims Administrator by electronic portal, fax, or mail no later than three (3) business days following the start of care (SOC). Requests received after the three (3) business day period allowed will be denied for dates of service (DOS) that occurred before the date the request is received.

When PPECC services are authorized, the authorized period begins on the day of the week that prior authorization starts. For example, if services hours are authorized on a weekly basis, the period would begin from the day of the week the prior authorization period begins and continue for seven (7) calendar days. PPECC services may be authorized on a daily, weekly, or hourly basis.

Consistent with PPECC licensure requirements, an initial nursing assessment must be completed, signed and dated by the PPECC Registered Nurse (RN) no earlier than three (3) business days before the SOC at the PPECC. The initial nursing assessment must be performed by a PPECC RN and cannot be delegated. The initial nursing assessment is used to establish the POC and must support medical necessity for the client to receive on-going skilled nursing care. The assessment must include, but is not limited to the following:

Complexity and intensity of the client’s care;

Stability and predictability of the client’s condition;

Frequency of the client’s need for skilled nursing services;

Identified medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, educational, and developmental needs and goals, and any training needs for the client or the client’s responsible adult;

Description of wounds, if present;

The client’s equipment needs and whether the setting can support the health and safety needs of the client and is adequate to accommodate the use, maintenance, and cleaning of all medical devices, equipment, and supplies required by the client;

The comprehension level of the client’s responsible adult; and

Receptivity to training and ability level of the responsible adult.

Note:The PPECC provider may be asked to submit additional documentation to support medical necessity as defined in this section.

Initial prior authorization requests for PPECC services must include the following documentation:

A completed CCP Prior Authorization Request form signed and dated by the ordering physician.

A completed Prescribed Pediatric Extended Care Center (PPECC) Plan of Care (POC) form signed and dated by the ordering physician, the PPECC RN completing the POC, and client or client’s responsible adult. A PPECC may also submit the POC on their own form, but the POC must contain the elements listed in this section. A written or verbal physician approval of the POC from the ordering physician must be in place by the SOC. If the PPECC has a verbal approval of the POC at the time the prior authorization request is submitted, the dated documentation of this POC verbal approval must be submitted with the POC, followed by the physician-signed and dated POC within fourteen (14) calendar days from receipt by the Texas Medicaid Claims Administrator.

A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the ordering physician, RN completing the assessment, and client or client’s responsible adult. This completed form must include:

Updated problem list

Updated rationale and summary page

A contingency plan

A 24-hour daily care flow sheet

Physician and client acknowledgment

A written or verbal order for PPECC services from the ordering physician. A physician’s order (written or verbal) must be in place by the SOC. If the PPECC has a verbal order at the time the prior authorization request is submitted, dated documentation of this verbal order must be submitted separately, or it must be included on the POC.

Per PPECC licensure requirements, the physician order must include:

Client’s name, date of birth, gender, and Medicaid ID number

Provider name, address, phone number, TPI number, and NPI number

Date the client was last seen by the physician

Description of current medical diagnosis or condition

Nursing services

Medication administration, if applicable

Dietary needs, if applicable

Permitted activities, if applicable

Therapies, if applicable

Transportation authorization, if applicable

Other services, if applicable

Approval of the client’s admission to the PPECC.

Note:For authorization purposes, a physician signature on the PPECC plan of care serves as the physician order. However, the physician order as outlined above must be maintained in the client’s medical records.

Signed and dated consent of the client or client’s responsible adult documenting his/her choice of PPECC services. The signed consent must include an acknowledgement by the client or the client’s responsible adult that he/she has been informed that their private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the client’s personal health information with the client’s other providers to ensure coordination of care must also be obtained.

A client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form meets the client consent requirements.

The POC must be developed by a PPECC RN, in collaboration with an interdisciplinary team, in compliance with PPECC licensure requirements. The POC, using either the Prescribed Pediatric Extended Care (PPECC) POC form or a PPECC-developed form, must include the following components:

The client’s name, date of birth and Medicaid number;

The PPECC’s name, TPI, NPI, and hours of operation, as well as address, phone, and fax numbers

The ordering physician’s name, phone number, TPI and NPI

Date the PPECC nursing assessment was completed and name, title, and credentials of the RN who completed the POC and his/her dated signature

Name, title and credentials of the team member who completed the POC and his/her dated signature

Date the client was last seen by the ordering physician

The requested SOC date for PPECC services

All pertinent diagnoses and known allergies

Nursing services to be provided, including amount, duration, and frequency

The client’s prognosis

The client’s mental status

Rehabilitation potential

The equipment and/or supplies required

Therapies (occupational, physical, speech, and respiratory care), including how those therapies are accessed, amount, duration, and frequency. Therapies provided in the PPECC, as well as outside the PPECC (e.g., school based), must be documented.

Other prescribed services, including amount, duration, and frequency

Nutritional requirements, including type, method of administration, and frequency

Medications, including the dose, route, frequency and any medication-related allergies if known

Treatments, including amount and frequency

Wound care orders and measurements

Safety measures to protect against injury

Functional developmental services and psychosocial services, including amount, duration and frequency

Name, phone number and signature of responsible adult when the client is a minor child

Client emergency contact name and phone number

Confirmation that a signed contingency plan is in place in circumstances when PPECC services are not available (e.g., fire, flood, windstorm, or electrical malfunctions), and for emergencies that occur while the client is in the care of the PPECC

List of services the client receives in the home and school settings. (e.g., ECI, therapies, school-based services (SHARS), PCS, PDN, therapies, skilled home health, case management services, hospice, and Medicaid waiver programs such as Medically Dependent Children’s Program (MDCP), Home and Community-Based Services (HCS), Deaf-Blind Multiples Disabilities (DBMD), Texas Home Living (Uxmal), and Community Living Assistance and Support Services (CLASS)).

Note:Services provided under these programs will not prevent a client from obtaining medically necessary services.

Client-specific measure able goals, including, if receiving PDN, the goal of ensuring coordi­nation of ongoing skilled nursing services with the PDN provider, if receiving PDN

Responsible adult training needs

Prior and current functional or medical limitations

Permitted activities

Client’s scheduled days and hours of attendance

Confirmation of a discharge plan, including instructions for timely discharge or referral

Emergency contact information

Method of transportation

Private Duty Nursing provider name, TPI, NPI, phone, address and fax number, if known

Ordering physician signature and date of signature

The ordering physician, PPECC RN and client or client responsible adult signatures must be current. Current is defined as signed and dated within the 30 calendar day period before the SOC. To be current, the ordering physician’s dated signature must be within the fourteen (14) calendar day period following the receipt of the authorization request by the Texas Medicaid claims administrator, when services are initiated by verbal order. All the following documentation requires the ordering physician’s signature with date, the CCP Prior Authorization Request form, the Prescribed Pediatric Extended Care Center (PPECC) Plan of Care, and the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form.

If documentation is submitted solely with the ordering physician’s verbal order, it must be resubmitted with the ordering physician’s dated signature within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator.

If the request is not received with a dated physician signature within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator, the prior authori­zation will be considered incomplete and will be denied.

When there is documentation of a verbal order, if all required documentation is not signed and dated by the ordering physician and received by the Texas Medicaid Claims Administrator within fourteen (14) calendar days of the receipt of the authorization request, claims with dates of services prior to the receipt of the signed and dated documentation will be denied.

Requests for authorizations of PPECC services should always be commensurate with the client’s medical needs.

The length of the authorization is determined on an individual basis and is based on the goals and timelines identified by the physician, provider, and client or responsible adult. PPECC services will not be authorized for more than 90 calendar days from the SOC for an initial authorization.

Note:Clients enrolled in a Medicaid managed care health plan may receive services from a PPECC. Authorization must be received from the health plan.

2.14.1.1.2Revisions to the Plan of Care

The PPECC provider may request a revision to the plan of care at any time during an authorization period. Requests for changes in the service hours during a current authorization period should be submitted if there is a change in the client’s condition, or the authorized services are not commensurate with the client’s medical needs and additional authorized hours are medically necessary.

Note:Schedule changes that do not affect overall authorized ongoing skilled nursing hours do not require a revision authorization request, but must be documented in the client’s medical record.

Requests for revisions must be submitted to the Texas Medicaid Claims Administrator as soon as the PPECC identifies the need for a revision. Revision requests may be submitted by electronic portal, fax, or mail.

Requests for revisions must be submitted within three (3) business days of the revised SOC date. Requests received after the three (3) business days will be denied for dates of service that occurred before the request is received.

When a client’s condition changes during the course of the authorization period that impacts the amount or duration of services, a reassessment performed by a PPECC RN is required. A reassessment is not necessary if there is not a change in the client’s condition.

The PPECC provider must notify the Texas Medicaid Claims Administrator and the client’s ordering physician at any time during an authorization period if the client’s condition changes, the authorized services are not commensurate with the client’s medical needs, and the client requires additional hours of ongoing skilled nursing services. Submission of a revision authorization request, with physician signatures on required documentation, meets the notification requirement.

Revisions require all the following documentation:

A completed CCP Prior Authorization Request form signed and dated by the ordering physician.

An updated Prescribed Pediatric Extended Care Center (PPECC) Plan of Care form signed and dated by the ordering physician, the PPECC RN completing the POC, and client or client’s respon­sible adult. A PPECC may also submit the POC on its own form, but the POC must contain all required elements listed under Initial Authorizations in this section. A written or verbal physician approval of the POC from the ordering physician must be in place by the revised SOC. If the PPECC has a verbal approval of the POC at the time the prior authorization request is submitted, the dated documentation of this POC verbal approval must be submitted with the POC, followed by the physician signed and dated POC within fourteen (14) calendar days from the receipt of the autho­rization request by the Texas Medicaid Claims Administrator.

A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the ordering physician, RN completing the assessment, and client or client’s responsible adult. This completed form must include:

Updated problem list

Updated rationale and summary page

A contingency plan

A 24-hour daily care flow sheet

Physician and client acknowledgment

A written or verbal order for PPECC services from the ordering physician. A physician’s order (written or verbal) must be in place by the revised SOC. If the PPECC has a verbal order at the time the prior authorization request is submitted, dated documentation of this verbal order must be submitted separately or it must be included on the POC. The signed, dated order must be received within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator.

Note:For authorization purposes, a physician signature on the PPECC plan of care serves as the physician order. However, the physician order, as detailed in “Initial Authorizations,” must be maintained in the client’s medical records.

Signed and dated consent of the client or client’s responsible adult documenting his/her choice of PPECC services. The signed consent must include an acknowledgment by the client or the client’s responsible adult that he/she has been informed that their private duty nursing might be reduced as a result of accepting PPECC services. Consent to share the client’s personal health information with the client’s other providers to ensure coordination of care must also be obtained.

Note:A client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form meets the client consent requirements.

The ordering physician, PPECC RN, and client or client responsible adult signatures must be current. Current is defined as signed and dated within the 30 calendar day period before the SOC. To be current, the ordering physician dated signature may be submitted within the fourteen (14) calendar day period following the receipt of the authorization request by the Texas Medicaid Claims Administrator, when services are initiated by verbal order. All the following revision documentation requires the ordering physician’s dated signature: the CCP Prior Authorization Request Form, the Prescribed Pediatric Extended Care Center (PPECC) Plan of Care form, and the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form.

Revisions during a current authorization period must fall within that authorization period. If the revision is requested beyond the existing authorization period, the provider must request a recerti­fication authorization and submit all required documentation for a recertification.

When there is a revision request, and documentation is submitted solely with the ordering physician’s verbal order, it must be resubmitted with the ordering physician’s signature and date within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Adminis­trator. If the request is not received with a dated physician signature within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator, the prior autho­rization will be considered incomplete and will be denied.

When there is documentation of a verbal order and all of the required documentation is not signed and dated by the ordering physician and received by TMHP within fourteen (14) calendar days of the receipt of the authorization request by the Texas Medicaid Claims Administrator, claims with dates of services prior to receipt of the signed and dated documentation will be denied.

2.14.1.1.3PPECC Provider Change During an Existing Authorization Period

If a provider or client discontinues PPECC services during an existing prior authorized period and the client requests services through a new PPECC provider, the new PPECC provider must follow all of the processes and submit documentation required for an initial request, as well as the following:

A change of provider letter signed and dated by the client or the client’s responsible adult documenting the date the client ended PPECC services (effective date of the change) with the previous provider, the names of the previous and new providers, and an explanation of why providers were changed.

When the new provider submits an authorization request, including all required documentation for an initial request, it will be authorized for no more than 90 calendar days. Regardless of the number of provider changes, clients may not receive PPECC services beyond the limitations outlined in this section.

2.14.1.1.4Recertification

A recertification is a new authorization period that may be approved for up to a maximum of 180 calendar days when the client meets medical necessity criteria. Revision requests may be submitted by electronic portal, fax, or mail. The client or the client’s responsible adult, physician, and PPECC provider must agree in writing that the recertification is appropriate each certification period.

An updated nursing assessment must be performed by the PPECC RN no more than 30 calendar days before the current authorization period expires. If there is no change in the client’s condition, the POC must document medical necessity to support continued PPECC services.

A recertification request must be submitted no more than 30 calendar days and no fewer than seven (7) calendar days before a current authorization period will expire. Requests received after the current authorization expires will be denied for dates of service that occurred before the date the request is received. The following documentation is required for a recertification request:

A completed CCP Prior Authorization Request form signed and dated by the ordering physician within 30 calendar days prior to the SOC date.

A completed Prescribed Pediatric Extended Care Center (PPECC) Plan of Care form, signed and dated by the ordering physician, the PPECC RN completing the POC, and client or client’s respon­sible adult within 30 calendar days prior to the SOC date. A PPECC may also submit the POC on their own form, but the POC must contain the elements listed under “Initial Authorization Request” requirements in this section.

The PPECC provider is responsible for ensuring that the ordering physician reviews and signs the POC within 30 calendar days of the expiration of the authorization period and this documen­tation must be maintained in the client’s record.

A completed Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form signed and dated by the ordering physician, RN completing the assessment, and client or client’s responsible adult within 30 calendar days prior to the SOC date. The addendum must include an updated 24-hour nursing services flow sheet and if there are changes, an updated problem list, and updated rationale summary page, a contingency plan, and a signed physician and client acknowledgment.

A written order for PPECC services signed and dated by the client’s ordering physician. A physician’s order must be in place by the SOC.

Note:For authorization purposes, a physician signature on the PPECC plan of care serves as the physician order. However, the physician order, with elements outlined in “Initial Authori­zation Requests,” must be maintained in the client’s medical record.

Signed, dated consent of the client or client’s responsible adult documenting their choice of PPECC services. The signed consent must include an acknowledgment by the client or the client’s respon­sible adult that he/she has been informed that other services such as private duty nursing might be reduced as a result of accepting PPECC services. Signed and dated consent to share the client’s personal health information with the client’s other providers, as needed to ensure coordination of care, must also be obtained.

Note:A client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers form meets the client consent requirements.

The provider may request a revision of a recertification at any time during the recertification period. Revisions must follow the instructions outlined under Revisions in this section. The provider must notify the claims administrator at any time during a recertification period if the client’s condition changes and the authorized services are not commensurate with the client’s medical needs.

All authorization timelines apply to recertification.

2.14.1.1.5Termination of Authorizations

Authorization for PPECC services will be terminated when:

The client is no longer eligible for THSteps-CCP.

The client no longer meets the medical necessity criteria for PPECC services.

The place of service cannot ensure the health and safety of the client.

The client or the client’s responsible adult refuses to comply with the service plan and compliance is necessary to assure the health and safety of the client.

The client changes providers, and the change of notification is submitted to the claims administrator in writing with a PA request from the new provider.

After receiving PPECC services, the client opts to decline PPECC services and receive his or her services at home. The home health agency or independent provider offering ongoing skilled nursing (e.g., PDN) must submit or update all required authorization documentation to the claims administrator.

2.14.1.1.6Appeal of Authorization Decisions

Providers may appeal denials or modifications of requested PPECC services with documentation to support the medical necessity of the requested PPECC services.

Appeals must be submitted to the Medicaid Claims Administrator’s CCP department with complete documentation and any additional information within two weeks of the date on the decision letter. If changes are made to the authorization based on this documentation, CCP claims administrators will go back no more than three (3) business days for initial, or revision requests; and no more than seven calendar days for recertification requests when additional documentation is submitted.

The client or the client’s responsible adult will be notified of any denial or modification of requested services and will be given information about how to appeal the claims administrator’s decision or request a fair hearing.

PPECC services may be denied when:

The client does not meet medical necessity criteria for admission.

The client does not have an ordering physician.

The client is not 20 years of age or younger.

The client’s needs are not beyond the scope of services available through Medicaid Title XIX Home Health SN and/or HHA Services because the needs can be met on a part-time or intermittent basis through a visiting nurse.

The services are primarily intended to provide respite care or child care.

The services are provided for the sole purpose of responsible adult training.

The signed and dated POC is not received by the claims administrator within fourteen business days from the SOC.

The request is incomplete.

The information in the request is inconsistent.

The requested services are not ongoing skilled nursing services.

There is a duplication of services.

Prior authorization requests must be submitted for processing to the Texas Medicaid Claims Adminis­trator Prior Authorization Department (fee-for-service clients).

Note:Clients enrolled in a managed care health plan may receive services from a PPECC. Prior authorization requests for these clients must be submitted solely to the client’s managed care organization.

2.14.1.1.7Documentation Requirements

In addition to documentation requirements outlined in the “Authorization Requirements” section, the following documentation requirements apply. Services not supported by documentation are subject to recoupment.

All services outlined in this section are subject to retrospective review to ensure that the documentation in the client’s medical record supports the medical necessity of the service(s) provided.

PPECCs must maintain documentation in the client’s medical record, including but not limited to the following:

Evidence that the client’s condition will allow safe delivery of PPECC services as described in the POC.

The PPECC nursing assessment.

The client’s individualized PPECC plan of care and documentation of medical necessity.

The physician’s specific, written, signed and dated orders for PPECC services. Documentation of verbal orders must also be maintained.

All prior authorization request forms for Medicaid.

The signed, dated consent of the client or the client’s responsible adult.

The PPECC must provide documentation that the client or the client’s responsible adult has been informed about how care will be coordinated between the client’s providers (e.g., client signature on the Nursing Addendum to Plan of Care for Private Duty Nursing and/or Prescribed Pediatric Extended Care Centers).

The PPECC must maintain evidence in the medical record that client or the client’s responsible adult has been involved in the development of the POC. (e.g., client signature on the Prescribed Pediatric Extended Care Center [PPECC] Plan of Care).

Evidence of PDN provider notification when a child receives PDN, and the date notification was provided.

Notes from interdisciplinary team meetings.

Documentation of all discrepancies between the weekly service hours scheduled and the service hours provided. Examples include but are not limited to, doctor’s appointments; the PPECC was closed one day for unforeseen reasons; the child was hospitalized; or the client’s responsible adult was ill and could not provide services that he or she would normally provide.

For each day that PPECC services are provided, the client’s medical record must identify:

The names of the specific person (e.g. nursing, direct care staff, therapist) providing services,

Date of service,

Type of services performed, and

The start and end times of services performed.

The PPECC must be able to calculate the cost by practitioner and type of service provided as requested by HHSC.

To complete a prior authorization process by paper, the provider must complete and submit the prior authorization documentation through fax or mail and must maintain a copy of the prior authorization request and all submitted documentation in the client’s medical record at the PPECC’s place of business.

To complete a prior authorization process electronically, the provider must complete and submit the prior authorization documentation through any approved electronic method, and must maintain a copy of the prior authorization request and all submitted documentation in the client’s medical record at the PPECC’s place of business.

The ordering physician must also maintain a copy of the signed and dated physician order and signed and dated POC in the client’s medical record.

PPECC service providers must provide written notice to clients of their intent to voluntarily terminate PPECC services at least fifteen (15) calendar days prior to terminating services, except in situations of a potential threat to the provider’s personal safety.

The PPECC must sign, date, and indicate the time the client is boarded on PPECC transportation, and the time when the client arrives at the PPECC. The PPECC must also sign, date, and indicate the time when the client is boarded for a return trip from PPECC services, as well as the arrival time at the client’s destination. The PPECC provider may use any reliable method to record times, dates, and signatures provided that it is accurate and allows for an auditable review of the records, including electronic census, time-stamp, scanning, and signature records.

For any Medicaid client that is in transport for longer than one hour, the PPECC must document the reason for the extended time in transport.

A responsible adult must sign and confirm the time that the client is boarded on PPECC transportation, as well as when a client returns from the PPECC. If a responsible adult provides the transportation, the responsible adult must sign and indicate the date and time that the client is dropped off and picked up from a PPECC. The PPECC provider must keep these records in case of an audit or monitoring.

A responsible adult must be provided daily a written, one-page summary of services provided to the client for each day that the client is in the PPECC’s care.

The PPECC must maintain documentation in the client’s medical record of the notification provided to the client and/or the client’s responsible adult of an intent to transfer or discharge the client as follows:

A copy of the written notification provided,

Personal contact with the client and/or the client’s responsible adult, and

The client’s ordering physician was notified of the date of transfer or discharge.

The PPECC and the therapy provider must have a written agreement for each client regarding the provision of therapy services when therapy services (occupational, speech, physical, and respiratory care) are provided at the PPECC. The written agreement must address responsibilities of both parties, and how the parties will coordinate related to the client’s plan of care. The written agreement must be kept in the client’s medical record.

The PPECC and hospice provider must have a written agreement for each client regarding the provision of hospice services when hospice is provided at the PPECC. The written agreement must address respon­sibilities of both parties, and how the parties will coordinate related to the client’s plan of care. The written agreement must be kept in the client’s medical record.

2.14.1.1.8Exclusions

The services that are not covered by the PPECC benefit include the following:

Baby food or formula.

PPECC services to clients related to the PPECC owner by blood, marriage or adoption.

Services that are intended to provide mainly respite care or child care and do not directly relate to the client’s medical needs or disability.

PPECC services rendered to a client who does not meet the definition of a medically or technolog­ically dependent minor.

Services covered separately by Texas Medicaid, such as:

Speech, occupational, physical, respiratory therapy services, and early childhood intervention services.

Durable medical equipment (DME), medical supplies, nutritional products provided to the client by Medicaid’s DME and medical supply service providers.

Private duty nursing, skilled nursing and home health aid services provided in the home setting when medically needed in addition to the PPECC services authorized.

Services that are the legal responsibility of a local school district.

Individualized comprehensive case management beyond required service coordination.

2.14.1.1.9Claims Filing and Reimbursement

PPECC services may be reimbursed when billed with procedure codes T1025, T1026, or T2002.

Services begin when the PPECC assumes responsibility for the care of the client (i.e., the point the client boards the PPECC transportation, or when the client is brought to the PPECC by a responsible adult) and ends when the care is relinquished to the client’s responsible adult.

Providers must use appropriate procedure codes for the PPECC services performed. Procedure codes T1025 and T2002 are limited to once per day.

The PPECC per diem code (T1025) and hourly procedure code (T1026) may not be billed on the same day.

Procedure code T1026 is allowed on an hourly basis, up to four hours. Services beyond four hours must be billed using T1025. At a minimum, four hours and fifteen minutes of services must be provided before T1025 may be billed.

Procedure code T2002 is not allowed without a PPECC service on the same day, same provider.

For procedure code T1026, a minimum of 15 minutes of service is required to round up to a full hour after the first hour.

Therapy services are billed separately by Medicaid-enrolled licensed therapists, including ECI providers, and are subject to prior authorization and policies governing Physical, Occupational, and Speech Therapy - Children (Acute and Chronic), or ECI services, as applicable.

If hospice services are rendered in a PPECC setting, they must be billed separately by Medicaid-enrolled hospice providers, and are subject to prior authorization and policies governing hospice reimbursement.

The following services may be billed on the same day as PPECC services, but they may not be billed simultaneously with PPECC services. These services may be billed before or after PPECC services:

Private Duty Nursing

Home Health Skilled Nursing

Home Health Aide services

PCS services provided in a PPECC are considered part of the PPECC billable rate. PCS services rendered in a client’s home may be billed before or after PPECC services on the same day.

PPECC services may be reimbursed only to a licensed PPECC.

Note:Texas Medicaid will not reimburse PPECC services that duplicate services that are the legal responsibility of the school districts. The school district, through the SHARS program, is required to meet the client’s skilled nursing needs while the client is at school. However, if those needs cannot be met by SHARS or the school district, documentation supporting medical necessity may be submitted to the Texas Medicaid Claims Administrator.

Parental accompaniment is not required for PPECC reimbursement.

Non-emergency ambulance service providers will not be reimbursed for transportation to and from a PPECC.

PPECC services are subject to retrospective review and possible recoupment when the medical record does not document the provision of PPECC services is medically necessary based on the client’s situation and needs. The PPECC provider must explain all discrepancies between the service hours approved and the service hours provided. For example: The parents withdrew their client from a PPECC and released the provider from all responsibility for the service hours; the PPECC was closed one day for unforeseen reasons; the client was hospitalized; or the responsible adult was ill and could not provide services that he or she would normally provide.

Payment will not be rendered for services that are not prior authorized.

2.15Therapy Services (CCP)

Refer to:  Section 5, “Children’s Therapy Services Clients birth through 20 years of age” in the Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook (Vol. 2, Provider Handbooks) for information about CCP therapy services.

2.16Inpatient Psychiatric Hospital or Facility (Freestanding) (CCP)

Inpatient psychiatric treatment in a nationally accredited freestanding psychiatric facility or a nationally accredited state psychiatric hospital is a benefit of Texas Medicaid for clients who are birth through 20 years of age at the time of the service request and service delivery, if the client meets certain conditions.

Refer to:  Subsection 3.4, “Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychi­atric Services” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks).

2.17Inpatient Rehabilitation Facility (Freestanding) (CCP)

2.17.1Enrollment

Note:Rehabilitation provided at an acute care facility is covered through Texas Medicaid fee-for-service.

To be eligible to participate in CCP, a freestanding inpatient rehabilitation facility must be certified by Medicare, have a valid provider agreement with HHSC, and have completed the TMHP enrollment process. Texas Medicaid enrolls and reimburses freestanding inpatient rehabilitation facilities for CCP services and Medicare deductibles or coinsurance according to current payment guidelines. The infor­mation in this section is applicable to CCP services only.

Refer to:  Subsection 2.1.2, “Enrollment” in this handbook for more information about CCP enrollment procedures.

2.17.1.1Continuity of Hospital Eligibility Through Change of Ownership

Under procedures set forth by the CMS and HHSC, a change in ownership of a hospital does not terminate Medicare eligibility; therefore, Medicaid participation may be continued subject to the following requirements:

The provider must obtain recertification as a Title XVIII (Medicare) hospital.

The hospital under new ownership must submit a new signed and dated HHSC Medicaid Provider Agreement between the hospital and HHSC.

Providers can download the HHSC Medicaid Provider Agreement from the TMHP website at www.tmhp.com.

2.17.2Services, Benefits, and Limitations

Inpatient rehabilitation services include medically necessary items and services ordinarily furnished by a Medicaid hospital or by an approved out-of-state hospital under the direction of a physician for the care and treatment of inpatient clients. Inpatient rehabilitation services will be considered for an acute problem or an acute exacerbation of a chronic problem resulting in a significant decrease in functional ability that will benefit from inpatient rehabilitation services. A condition is considered to be acute or an acute exacerbation of a chronic condition only during the six months from the onset date of the acute condition or the acute exacerbation of the chronic condition.

When a client is admitted to an inpatient facility for acute care physical, occupational, or speech therapy services, the therapy services are reimbursed as part of the inpatient hospital reimbursement method­ology (Diagnosis- Related Group [DRG] or Tax Equity and Fiscal Responsibility Act [TEFRA]) and not reimbursed separately to the individual therapist. The hospital must include the physician’s written treatment plan that supports the medical necessity of the hospitalization and services.

2.17.2.1Comprehensive Treatment

The intensity of necessary rehabilitative service cannot be provided in the outpatient setting.

Comprehensive rehabilitation treatment must be under the leadership of a physician. Comprehensive rehabilitation treatment must be an active interdisciplinary team, defined as at least two types of therapies.

Comprehensive treatment must consist of at least two appropriate physical modalities designed to resolve or improve the client’s condition (OT, PT, and ST), and must be provided for a minimum of three hours per day for five days per week.

2.17.3Prior Authorization and Documentation Requirements

All inpatient rehabilitation services provided to clients who are birth through 20 years of age in a freestanding inpatient rehabilitation facility require prior authorization.

Prior authorization will be considered when the client has met all of the following criteria:

The client has an acute problem or an acute exacerbation of a chronic problem resulting in a signif­icant decrease in functional ability that will benefit from inpatient rehabilitation services.

The intensity of necessary rehabilitative service cannot be provided in the outpatient setting.

The client requires and will receive multidisciplinary team care defined as at least two therapies (OT, PT, or ST).

This therapy will be provided for a minimum of three hours per day, five days per week.

The physician and the provider must maintain all documentation in the client’s medical record.

Inpatient rehabilitation may be prior authorized for up to two months when the attending physician submits documentation of medical necessity. The treatment plan must indicate that the client is expected to improve within a 60-day period and be restored to a more functional lifestyle for an acute condition or the previous level of function for an acute exacerbation of a chronic condition.

Requests for subsequent services for increments up to 60 days may be prior authorized based on medical necessity. Requests for prior authorization of subsequent services must be received before the end-date of the preceding prior authorization.

A prior authorization request for an additional 60 days of therapy will be considered with documen­tation supporting medical necessity.

Supporting documentation for an initial request must include the following:

The request for inpatient rehabilitation and the treatment plan must be signed and dated by the physician. The physician’s signature is valid for no more than 60 days prior to the requested start of care date.

A CCP Prior Authorization Request Form signed and dated by the physician.

A current therapy evaluation with the documented age of the client at the time of evaluation.

Therapy goals related to the client’s individual needs; goals may include improving or maintaining function, or slowing of deterioration of function.

An updated written comprehensive treatment plan established by the attending physician or by the therapist to be followed during the inpatient rehabilitation admission that:

Is under the leadership of a physician and includes a description of the specific therapy being prescribed, diagnosis, treatment goals related to the client’s individual needs, and duration and frequency of therapy.

Includes the date of onset of the illness or injury requiring the freestanding inpatient rehabili­tation facility admission.

Includes the requested dates of service.

Incorporates an active interdisciplinary team.

Consists of at least two appropriate physical modalities (OT, PT, and ST) designed to resolve or improve the client’s condition.

Includes a minimum of three hours of team interaction with the client every day, five days per week.

In addition to the documentation for an initial request, supporting documentation for a request for subsequent services must include the following:

A brief synopsis of the outcomes of the previous treatment relative to the debilitating condition.

The expected results to be achieved by an extension of the active treatment plan, and the time interval at which this extension outcome should be achieved.

Discussion why the initial two months of inpatient rehabilitation has not met the client’s needs and why the client cannot be treated in an outpatient setting.

After receiving the documentation establishing the medical necessity and plan of medical care by the treating physician, prior authorization is considered by CCP for the initial service and an extension of service as applicable. A request for prior authorization must include documentation from the provider to support the medical necessity of the service.

2.17.4Claims Information

Providers must submit inpatient rehabilitation services to TMHP in an approved electronic claims format or on a UB-04 CMS-1450 paper claim form. Providers must purchase the UB-04 CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

For OT, PT, and ST services, freestanding inpatient rehabilitation facilities and acute care hospitals can use revenue codes 128, 420, 424, 430, 434, 440, and 444.

TMHP must receive claims for payment consideration according to filing deadlines for inpatient claims. Claims for services that have been prior authorized must reflect the PAN in Block 63 of the UB-04 CMS-1450 paper claim form or its electronic equivalent.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

“Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.6, “UB-04 CMS-1450 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for paper claims completion instructions.

Inpatient Rehabilitation Facility (Freestanding) (CCP Only) on the TMHP website at www.tmhp.com for a claim form example.

2.17.5Reimbursement

Reimbursement for care provided in the freestanding inpatient rehabilitation facility is made under the Texas Diagnosis-Related Group (DRG) Payment System.

A new provider is given a reimbursement interim rate of 50 percent until a cost audit has been performed. Payment is calculated by multiplying the standard dollar amount (SDA) for the hospital’s payment division indicator times the relative weight associated with the DRG assigned by Grouper.

Important:Outpatient services are not reimbursed.

The DRG payment may be enhanced by an adjusted day or cost outlier payment, if applicable. For example, the limit per spell-of-illness under Texas Medicaid guidelines is waived for clients who are birth through 20 years of age. An outlier payment may be made to compensate for unusual resource utilization or a lengthy stay.

The following criteria must be met to qualify for a day outlier payment. Inpatient days must exceed the DRG day threshold for the specific DRG. Additional payment is based on inpatient days that exceed the DRG day threshold multiplied by 70 percent of the per diem amount of a full DRG payment. The per diem amount is established by dividing the full DRG payment amount by the arithmetic mean length of stay for the DRG.

To establish a cost outlier, TMHP determines the outlier threshold by using the greater of the full DRG payment amount multiplied by 1.5 or an amount determined by selecting the lesser of the universe mean of the current base year data multiplied by 11.14 or the hospital’s SDA multiplied by 11.14.

The calculation that yields the greater amount is used in calculating the actual cost outlier payment. The outlier threshold is subtracted from the amount of reimbursement for the admission established under the TEFRA principles and the remainder multiplied by 70 percent to determine the actual amount of the cost outlier payment.

If an admission qualifies for both a day and a cost outlier, the outlier resulting in the highest payment to the hospital is paid.

The Remittance and Status (R&S) Report reflects the outlier reimbursement payment and defines the type of outlier paid, day or cost.

Providers should call the TMHP provider relations representative for their area with questions about the outlier payment.

2.17.5.1Client Transfers

When more than one hospital provides care for the same case, the hospital furnishing the most signif­icant amount of care receives consideration for a full DRG payment.

The other hospital(s) is/are paid a per diem rate based on the lesser of the mean length of stay for the DRG or eligible days in the facility. The DRG modifier PT on the R&S Report indicates per diem pricing related to a client transfer.

Client transfers within the same facility are considered one continuous stay and receive only one DRG payment. The facility must bill only one claim.

After all hospital claims have been submitted, HHSC performs a post-payment review to determine whether the hospital furnishing the most significant amount of care received the full DRG. If the review reveals that the hospital furnishing the most significant amount of care did not receive the full DRG, an adjustment is initiated.

3 School Health and Related Services (SHARS)

3.1Overview

Medicaid services provided by school districts in Texas to Medicaid-eligible students are known as SHARS. The oversight of SHARS is a cooperative effort between the Texas Education Agency (TEA) and HHSC. SHARS allows local school districts, including public charter schools, to obtain Medicaid reimbursement for certain health-related services provided to students in special education under IDEA that are documented in a student’s Individualized Education Program (IEP).

Important:CMS requires school districts to be enrolled as a SHARS Medicaid provider, participate in the Random Moment Time Study (RMTS), claim on an interim basis, and submit an annual SHARS Cost Report.

SHARS reimbursement is provided for students who meet all of the following requirements:

Are 20 years of age and younger and eligible for Medicaid

Meet eligibility requirements for special education described in IDEA

Have IEPs that prescribe the needed services

Services covered by SHARS includes:

Audiology services

Counseling

Nursing services

Occupational therapy (OT)

Personal care services (PCS)

Physical therapy (PT)

Physician services

Psychological services, including assessments

Speech therapy (ST)

Transportation in a school setting

These services must be provided by qualified personnel who are under contract with or employed by the school district.

3.1.1Random Moment Time Study (RMTS)

CMS requires SHARS providers to participate in the RMTS to be eligible to submit claims and receive reimbursement for SHARS services. SHARS providers must comply with the Texas Time Study Guide, which includes, but is not limited to, Mandatory Annual RMTS Contact training certification of RMTS participants for all three annual RMTS quarters, and compliance with participation requirements for selected sampled moments. The three annual RMTS quarters are October through December, January through March, and April through June. A July through September RMTS is not conducted.

An existing school district can only become a SHARS provider effective October 1, each year and they must participate in all three RMTS quarters for that annual period. SHARS providers that do not partic­ipate in all three required RMTS quarters, or are RMTS non-compliant, cannot be a SHARS provider for that entire annual period (October 1 through September 30) and will be required to return any Medicaid payments received for SHARS services delivered during that annual cost report period. The school district can return to participating in the SHARS program the following federal fiscal year beginning on October 1.

A new school district (i.e., a newly formed district that began operations after October 1) can become a SHARS provider effective with the first day of the federal quarter in which it participates in the RMTS. New SHARS providers may not submit claims or be reimbursed for SHARS services provided prior to the RMTS quarter in which they begin to participate and they must participate in all remaining RMTS quarters for that annual period.

School districts can access the Texas Time Study Guide, on the HHSC website at www.hhsc.state.tx.us/rad/time-study/ts-isd.shtml and refer to the link titled Guides/Manuals.

SHARS providers can contact the HHSC Time Study Unit by email at TimeStudy@hhsc.state.tx.us or by telephone at 1-512-491-1715.

3.1.2Eligibility Verification

The following are means to verify Medicaid eligibility of students:

Verify electronically through third party software or TexMedConnect.

School districts may inquire about the eligibility of a student by submitting the student’s Medicaid number or two of the following: name, date of birth, or Social Security number (SSN). A search can be narrowed further by entering the county code or sex of the student. Verifications may be submitted in batches without limitations on the number of students.

Contact AIS at 1-800-925-9126.

3.2Enrollment

3.2.1SHARS Enrollment

To enroll in Texas Medicaid as a SHARS provider, school districts, including public charter schools, must employ or contract with individuals or entities that meet certification and licensing requirements in accordance with the Texas Medicaid State Plan for SHARS to provide program services. Since public school districts are government entities, they should select “public entity” on the enrollment application.

SHARS providers are required to notify parents or guardians of their rights to a “freedom of choice of providers” (42 CFR §431.51) under Texas Medicaid. Most SHARS providers currently provide this notification during the initial Admission, Review, and Dismissal (ARD) process. If a parent requests that someone other than the employees or currently contracted staff of the SHARS provider (school district) provide a required service listed in the student’s IEP, the SHARS provider must make a good faith effort to comply with the parent’s request. The SHARS provider can negotiate with the requested provider to provide the services under contract. The requested provider must meet, comply with, and provide all of the employment criteria and documentation that the SHARS provider normally requires of its employees and currently contracted staff. The SHARS provider can negotiate the contracted fee with the requested provider and is not required to pay the same fee that the requested provider might receive from Medicaid for similar services.

Refer to:  Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information.

3.2.2Private School Enrollment

A private school may not participate in the SHARS program as a SHARS provider.

3.3Services, Benefits, Limitations, and Prior Authorization

All of the SHARS procedures listed in the following sections require a valid diagnosis code. SHARS includes audiology services, counseling, physician services, nursing services, psychological services, OT, PT, or ST services, personal care services, and transportation.

Reminder:SHARS are the services determined by the ARD committee to be medically necessary and reasonable to ensure that children with disabilities who are eligible for Medicaid and who are 20 years of age and younger receive the benefits accorded to them by federal and state law in order to participate in the educational program.

3.3.1Audiology

Audiology evaluation services include:

Identification of children with hearing loss

Determination of the range, nature, and degree of hearing loss, including the referral for medical or other professional attention for the habilitation of hearing

Determination of the child’s need for group and individual amplification

Audiology therapy services include the provision of habilitation activities, such as language habilitation, auditory training, audiological maintenance, speech reading (lip reading), and speech conversation.

Audiology services must be provided by a professional who holds a valid state license as an audiologist or by an audiology assistant who is licensed by the state when the assistant is acting under the super­vision of a qualified audiologist. State licensure requirements are equal to American Speech-Language-Hearing Association (ASHA) certification requirements.

Audiology evaluation is billable on an individual (procedure code 92620) basis only. Audiology evalu­ation (procedure code 92620) is limited to a combined maximum total of twelve units in a 30-day period.

Audiology therapy is billable on an individual (procedure code 92507) and group (procedure code 92508) basis.

Only the time spent with the student present is billable; time spent without the student present is not billable.

Session notes for evaluations are not required; however, documentation must include the billable start time, billable stop time, and total billable minutes with a notation of the activity performed (e.g., audiology evaluation).

Session notes are required for therapy. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

3.3.1.1Audiology Billing Table

POS*

Procedure Code

Individual or Group

Therapist or Assistant

1, 2, or 9

92507 with modifier U9

Individual

Licensed audiologist

1, 2, or 9

92507 with modifier U1

Individual

Licensed assistant

1, 2, or 9

92508 with modifier U9

Group

Licensed audiologist

1, 2, or 9

92508 with modifier U1

Group

Licensed assistant

1, 2, or 9

92620

Individual

Licensed audiologist

*Place of Service: 1=office; 2=home; 9=other locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time for audiology evaluation is three hours, which may be billed over several days. The recommended maximum billable time for direct audiology therapy (individual or group) is one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.2Counseling Services

Counseling services are provided to help a child with a disability benefit from special education and must be listed in the IEP. Counseling services include, but are not limited to, the following:

Assisting the child or parents in understanding the nature of the child’s disability

Assisting the child or parents in understanding the special needs of the child

Assisting the child or parents in understanding the child’s development

Health and behavior interventions to identify the psychological, behavioral, emotional, cognitive, and social factors that are important to the prevention, treatment, or management of physical health problems

Assessing the need for specific counseling services

Counseling services must be provided by a professional who has one of the following certifications or licensures: a licensed professional counselor (LPC), a licensed clinical social worker (LCSW), or a licensed marriage and family therapist (LMFT).

Counseling services are billable on an individual (procedure code 96152) or group (procedure code 96153) basis. Session notes are required and documentation must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

School districts may receive reimbursement for emergency counseling services as long as the student’s IEP includes a behavior improvement plan that documents the need for emergency services.

3.3.2.1Counseling Services Billing Table

POS*

Procedure Code

Individual or Group

1, 2, or 9

96152 with modifier UB

Individual

1, 2, or 9

96153 with modifier UB

Group

*Place of Service: 1 = Office; 2 = Home; 9 = Other Locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time (individual or group) is one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.3Psychological Testing and Services

3.3.3.1Psychological Testing

Evaluations or assessments include activities related to the evaluation of the functioning of a student for the purpose of determining eligibility, the needs for specific SHARS services, and the development or revision of IEP goals and objectives. An evaluation or assessment is billable if it leads to the creation of an IEP for a student with disabilities who is eligible for Medicaid and who is 20 years of age or younger, whether or not the IEP includes SHARS.

Evaluations or assessments (procedure code 96101) must be provided by a professional who is a licensed specialist in school psychology (LSSP), a licensed psychologist, or a licensed psychiatrist in accordance with 19 TAC §89.1040(b)(1) and 34 CFR §300.136(a)(1).

Evaluation or assessment billable time includes the following:

Psychological, educational, or intellectual testing time spent with the student present

Necessary observation of the student associated with testing

A parent/teacher consultation with the student present that is required during the assessment because a student is unable to communicate or perform certain activities

Time spent without the student present for the interpretation of testing results

Report writing

Time spent gathering information without the student present or observing a student is not billable evaluation or assessment time.

Session notes are not required; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note which assessment activity was performed (e.g., testing, interpretation, or report writing).

3.3.3.1.1Evaluation or Assessment Billing Table

POS*

Procedure Code

Individual/Group

Unit of Service

1, 2, or 9

96101

Individual

1 hour

*Place of Service: 1=office; 2=home; 9=other locations

Important:One unit (1.0) is equivalent to one hour or 60 minutes. Providers may bill in partial hours, expressed as 1/10th of an hour (six-minute segments). For example, express 30 minutes as a billed quantity of 0.5.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

When billing, minutes of Evaluations or Assessments are not accumulated over multiple days. Minutes of Evaluations or Assessments can only be billed per calendar day.

The recommended maximum billable time for psychological testing is eight hours (8.0 units) over a 30-day period. Time spent for the interpretation of testing results without the student present is billable time. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.3.2Psychological Services

Psychological services are counseling services provided to help a child with a disability benefit from special education and must be listed in the IEP.

Psychological services must be provided by a licensed psychiatrist, a licensed psychologist, or an LSSP. Nothing in this rule prohibits public schools from contracting with licensed psychologists, licensed psychological associates, and provisionally licensed psychologists who are not LSSPs to provide psycho­logical services, other than school psychology, in their areas of competency. School districts may contract for specific types of psychological services, such as clinical psychology, counseling psychology, neuropsychology, and family therapy, that are not readily available from the LSSP who is employed by the school district. Such contracting must be on a short-term or part-time basis and cannot involve the broad range of school psychological services listed in 22 TAC §465.38(1)(B).

All psychological services are billable on an individual (procedure code 96152) or group (procedure code 96153) basis.

Session notes are required. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

School districts may receive reimbursement for emergency psychological services as long as the student’s IEP includes a behavior improvement plan that documents the need for the emergency services.

3.3.3.2.1Psychological Services Billing Table

POS*

Procedure Code

Individual or Group

1, 2, or 9

96152 with modifier AH

Individual

1, 2, or 9

96153 with modifier AH

Group

*Place of Service: 1=office; 2=home; 9=other locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time for direct psychological therapy (individual or group) is a total of one hour per day for nonemergency situations. Providers must maintain documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.4Nursing Services

Nursing services are SN tasks, as defined by the Texas BON, that are included in the student’s IEP. Nursing services may be direct nursing care or medication administration. Examples of reimbursable nursing services include, but are not limited to, the following:

Inhalation therapy

Ventilator monitoring

Nonroutine medication administration

Tracheostomy care

Gastrostomy care

Ileostomy care

Catheterization

Tube feeding

Suctioning

Client training

Assessment of a student’s nursing and personal care services needs

Direct nursing care services are billed in 15-minute increments and medication administration is reimbursed on a per-visit increment. The RN or APRN determines whether these services must be billed as direct nursing care or medication administration.

Nursing services must be provided by an RN, an APRN (including NPs and CNSs), LVN, LPN, or a school health aide or other trained, unlicensed assistive person delegated by an RN or APRN.

Nursing services are billable on an individual or group basis. Only the time spent with the student present is billable. Time spent without the student present is not billable. Session notes are not required for nursing services; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the type of nursing service that was performed.

3.3.4.1Nursing Services Billing Table

POS*

Procedure Code

Individual
or Group

Unit of Service

1, 2, or 9

T1002 with modifier TD

Individual

15 minutes

1, 2, or 9

T1002 with modifier TD and UD

Group

15 minutes

1, 2, or 9

T1502 with modifier TD

 

Medication administration, per visit

1, 2, or 9

T1002 with modifier U7

Delegation, Individual

15 minutes

1, 2, or 9

T1002 with modifier U7 and UD

Delegation, group

15 minutes

1, 2, or 9

T1502 with modifier U7

 

Delegation, medication admin­istration, per visit

1, 2, or 9

T1003 with modifier TE

Individual

15 minutes

1, 2, or 9

T1003 with modifier TE and UD

Group

15 minutes

1, 2, or 9

T1502 with modifier TE

 

Medication, administration per visit

*Place of Service: 1=office; 2=home; 9=other locations

Modifier TD = nursing services provided by an RN or APRN

Modifier U7 = nursing services delivered through delegation

Modifier TE = nursing services delivered by an LVN/LPN

Modifier UD = nursing services delivered on a group basis

The Medicaid-allowable fee is determined based on 15-minute increments. Providers must use a 15-minute unit of service for billing.

All of the nursing services minutes that are delivered to a student during a calendar day must be added together before they are converted to units of service. Do not convert minutes of nursing services separately for each nursing task that was performed.

Minutes of nursing services cannot be accumulated over multiple days. Minutes of nursing services can only be billed per calendar day. If the total number of minutes of nursing services is less than eight minutes for a calendar day, then no unit of service can be billed for that day, and that day’s minutes cannot be added to minutes of nursing services from any previous or subsequent days for billing purposes.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time for direct nursing services is four hours per day. The recom­mended maximum billable units for procedure code T1502 with modifier TD, T1502 with modifier U7, or T1502 with modifier TE is a total of four medication administration visits per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.5Occupational Therapy (OT)

3.3.5.1Referral

In order for a student to receive OT through SHARS, the name and complete address or the provider identifier of the licensed physician who prescribed the OT must be provided.

3.3.5.2Description of Services

OT evaluation services include determining what services, assistive technology, and environmental modifications a student requires for participation in the special education program.

OT includes:

Improving, developing, maintaining, or restoring functions impaired or lost through illness, injury, or deprivation.

Improving the ability to perform tasks for independent functioning when functions are impaired or lost.

Preventing, through early intervention, initial or further impairment or loss of function.

OT must be provided by a professional who is licensed by the Texas Board of Occupational Therapy Examiners or an occupational therapy assistant (OTA) acting under the supervision of a qualified occupational therapist.

OT evaluation is billable on an individual (procedure code 97165, 97166, or 97167) basis only. Procedure codes 97165, 97166, and 97167 may be submitted for initial evaluations and reevaluations. OT is billable on an individual (procedure code 97530) or group (procedure code 97150) basis.

If an evaluation is performed over several days, the provider must submit the same evaluation procedure code for each evaluation session. The procedure code submitted must reflect the complexity level of the entire evaluation.

The therapist who performs the evaluation should use professional clinical judgment to decide which evaluation code to use. The selection of low (procedure code 97165), moderate (procedure code 97166), or high complexity (procedure code 97167) evaluation codes must be based on professional clinical judgment and may not be made by staff other than the rendering therapist.

The occupational therapist or COTA can only bill for time spent with the student present, including time spent assisting the student with learning to use adaptive equipment and assistive technology.

Time spent without the student present, such as training teachers or aides to work with the student (unless the student is present during the training time), report writing, and time spent manipulating or modifying the adaptive equipment is not billable.

Session notes are not required for procedure codes 97165, 97166, and 97167; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the activity that was performed (e.g., OT evaluation).

Session notes are required for procedure codes 97530 and 97150. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student obser­vation, and the related IEP objective.

3.3.5.3Occupational Therapy Billing Table

POS*

Procedure Code

Individual
or Group

Therapist or Assistant

1, 2, or 9

97165, 97166, and 97167

Individual

Licensed therapist

1, 2, or 9

97150 with modifier GO

Group

Licensed therapist

1, 2, or 9

97150 with modifier GO and U1

Group

Licensed therapy assistant

1, 2, or 9

97530 with modifier GO

Individual

Licensed therapist

1, 2, or 9

97530 with modifier GO and U1

Individual

Licensed therapy assistant

*Place of Service: 1=office; 2=home; 9=other locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time for OT evaluation is three hours, which may be billed over several days within a 30 day period. The recommended maximum billable time for direct therapy (individual or group) is a total of one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.6Personal Care Services

Personal care services are provided to help a child with a disability or chronic condition benefit from special education. Personal care services include a range of human assistance provided to persons with disabilities or chronic conditions which enables them to accomplish tasks that they would normally do for themselves if they did not have a disability. An individual may be physically capable of performing ADLs and IADLs but may have limitations in performing these activities because of a functional, cognitive, or behavioral impairment.

Refer to:  Subsection 2.11, “Personal Care Services (PCS) (CCP)” in this handbook for a list of ADLs and IADLs.

For personal care services to be billable, they must be listed in the student’s IEP. Personal care services are billable on an individual (procedure code T1019 with modifier U5 or U6) or group (procedure code T1019 with modifier U5 and UD or U6 and UD) basis.

Session notes are not required for procedure codes T1019 with modifier U5 or T1019 with modifier U5 and UD; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the type of personal care service that was performed.

Procedure codes T1019 with modifier U6 and T1019 with modifier U6 and UD are billed using a one-way trip unit of service.

3.3.6.1Personal Care Services Billing Table

POS*

Procedure Code

Individual
or Group

Unit of Service

1, 2, or 9

T1019 with modifier U5

Individual, school

15 minutes

1, 2, or 9

T1019 with modifier U5 and UD

Group, school

15 minutes

1, 2, or 9

T1019 with modifier U6

Individual, bus

Per one-way trip

1, 2, or 9

T1019 with modifier U6 and UD

Group, bus

Per one-way trip

*Place of Service: 1=office; 2=home; 9=other locations

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable units for T1019 with modifier U6 or T1019 with modifier U6 and UD is a total of four one-way trips per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended units of service are billed.

3.3.7Physical Therapy (PT)

3.3.7.1Referral

In order for a student to receive PT through SHARS, the name and complete address or the provider identifier of the licensed physician who prescribes the PT must be provided.

3.3.7.2Description of Services

PT evaluation includes evaluating the student’s ability to move throughout the school and to participate in classroom activities and the identification of movement dysfunction and related functional problems.

PT is provided for the purpose of preventing or alleviating movement dysfunction and related functional problems.

PT must be provided by a professional who is licensed by the Texas Board of Physical Therapy Examiners or a licensed physical therapist assistant (LPTA) acting under the supervision of a qualified physical therapist.

PT evaluation is billable on an individual (procedure code 97161, 97162, or 97163) basis only. Procedure codes 97161, 97162, and 97163 may be submitted for initial evaluations and reevaluations. PT is billable on an individual (procedure code 97110) or group (procedure code 97150) basis.

If an evaluation is performed over several days, the provider must submit the same evaluation procedure code for each evaluation session. The procedure code submitted must reflect the complexity level of the entire evaluation.

The therapist who performs the evaluation should use professional clinical judgment to decide which evaluation code to use. The selection of low (procedure code 97161), moderate (procedure code 97162), or high complexity (procedure code 97163) evaluation codes must be based on professional clinical judgment and may not be made by staff other than the rendering therapist.

The physical therapist can only bill time spent with the student present, including time spent helping the student to use adaptive equipment and assistive technology.

Time spent without the student present, such as training teachers or aides to work with the student (unless the student is present during the training time) and report writing, is not billable.

Session notes are not required for procedure codes 97161, 97162, and 97163; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the activity that was performed (e.g., PT evaluation). Session notes are required for procedure codes 97110 and 97150.

Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

3.3.7.3Physical Therapy Billing Table

POS*

Procedure Code

Individual
or Group

Therapist or Assistant

1, 2, or 9

97161, 97162, and 97163

Individual

Licensed therapist

1, 2, or 9

97110 with modifier GP

Individual

Licensed therapist

1, 2, or 9

97110 with modifier GP and U1

Individual

Licensed therapy assistant

1, 2, or 9

97150 with modifier GP

Group

Licensed therapist

1, 2, or 9

97150 with modifier GP and U1

Group

Licensed therapy assistant

*Place of Service: 1=office; 2=home; 9=other locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time for PT evaluation is three hours, which may be billed over several days within a 30 day period. The recommended maximum billable time for direct therapy (individual or group) is a total of one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.8Physician Services

Diagnostic and evaluation services are reimbursable under SHARS physician services. Physician services must be provided by a licensed physician (M.D. or D.O.). A physician prescription is required before PT or OT services may be reimbursed under SHARS. ST services require either a physician prescription or a referral from a licensed SLP before the ST services may be reimbursed under the SHARS program. The school district must maintain the prescription or referral. The prescription or referral must relate directly to specific services listed in the IEP. If a change is made to a service on the IEP that requires a prescription or referral, the prescription or referral must be revised accordingly.

The expiration date for the physician prescription is the earlier of either the physician’s designated expiration date on the prescription or three years, in accordance with the IDEA three-year re-evaluation requirement.

SHARS physician services are billable only when they are provided on an individual basis. The determi­nation as to whether or not the provider needs to see the student while reviewing the student’s records is left up to the professional judgment of the provider. Therefore, billable time includes the following:

The diagnosis or evaluation time spent with the student present

The time spent without the student present reviewing the student’s records for the purpose of writing a prescription or referral for specific SHARS services

The diagnosis or evaluation time spent with the student present, or the time spent without the student present reviewing the student’s records for the evaluation of the sufficiency of an ongoing SHARS service to see whether any changes are needed in the current prescription or referral for that service

Session notes are not required for procedure code 99499; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the medical activity that was performed.

3.3.8.1Physician Services Billing Table

POS*

Procedure Code

1, 2, or 9

99499

*Place of Service: 1 = Office; 2 = Home; 9 = Other Locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time is one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.9Speech Therapy (ST)

3.3.9.1Referral

The name and complete address or the provider identifier or license number of the referring licensed physician or licensed SLP is required before ST services can be billed under SHARS. A licensed SLP’s evaluation and recommendation for the frequency, location, and duration of ST serves as the speech referral.

3.3.9.2Description of Services

ST evaluation services include the identification of children with speech or language disorders and the diagnosis and appraisal of specific speech and language disorders. ST services include the provision of speech and language services for the habilitation or prevention of communicative disorders.

ST evaluation is billable on an individual (procedure codes 92521, 92522, 92523, and 92524) basis only. ST is billable on an individual (procedure code 92507) or group (procedure code 92508) basis.

Procedure codes 92521, 92522, 92523, and 92524 are limited to a total of 12 units and may be reimbursed for each client per provider in a 30-day period.

Procedure code 92522 will be denied if it is submitted with the same date of service as procedure code 92523.

Procedure code 92523 will be denied if it is submitted with the same date of service as procedure code 92522.

Providers can only bill time spent with the student present, including assisting the student with learning to use adaptive equipment and assistive technology.

Time spent without the student present, such as report writing and training teachers or aides to work with the student (unless the student is present during training), is not billable. Session notes are not required for procedure codes 92521, 92522, 92523, and 92524; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the activity that was performed (e.g., speech evaluation).

Session notes are required for procedure codes 92507 and 92508. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student obser­vation, and the related IEP objective.

3.3.9.3Provider and Supervision Requirements

ST services are eligible for reimbursement when they are provided by a qualified SLP, who holds a Texas license or an ASHA-equivalent SLP (has a master’s degree in the field of speech-language pathology and a Texas license). ST services are also eligible for reimbursement when provided by an SLP with a state education agency certification, a licensed SLP intern, a grandfathered SLP when acting under the super­vision or direction of an SLP, or a licensed assistant in speech-language pathology acting under the supervision or direction of an SLP.

The supervision must meet the following provisions:

The supervising SLP must provide supervision that is sufficient to ensure the appropriate completion of the responsibilities that were assigned.

The direct involvement of the supervising SLP in overseeing the services that were provided must be documented.

The SLP who provides the direction must ensure that the personnel who carry out the directives meet the minimum qualifications set forth in the rules of the State Board of Examiners for Speech-Language Pathology and Audiology which relate to Licensed Interns or Assistants in Speech-Language Pathology.

CMS interprets “under the direction of a speech-language pathologist,” as an SLP who:

Is directly involved with the individual under his direction.

Accepts professional responsibility for the actions of the personnel he agrees to direct.

Sees each student at least once.

Has input about the type of care provided.

Reviews the student’s speech records after the therapy begins.

Assumes professional responsibility for the services provided.

3.3.9.4Speech Therapy Billing Table

POS*

Procedure Code

Individual
or Group

Therapist or Assistant

1, 2, or 9

92521, 92522, 92523, or 92524 with modifier GN

Individual

Licensed therapist

1, 2, or 9

92507 with modifier GN and U8

Individual

Licensed therapist

1, 2, or 9

92507 with modifier GN and U1

Individual

Licensed assistant

1, 2, or 9

92508 with modifier GN and U8

Group

Licensed therapist

1, 2, or 9

92508 with modifier GN and U1

Group

Licensed assistant

*Place of Service: 1=office; 2=home; 9=other locations

Providers must use a 15-minute unit of service for billing.

Refer to:  Subsection 3.5.1.2, “Billing Units Based on 15 Minutes” in this handbook.

The recommended maximum billable time for evaluation is three hours, which may be billed over several days. The recommended maximum billable time for direct therapy (individual or group) is a total of one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

3.3.10Transportation Services in a School Setting

Transportation services in a school setting may be reimbursed when they are provided on a specially adapted vehicle and if the following criteria are met:

Provided to or from a Medicaid-covered service on the day for which the claim is made

A child requires transportation in a specially adapted vehicle to serve the needs of the disabled

A child resides in an area that does not have school bus transportation, such as those in close proximity to a school

The Medicaid services covered by SHARS are included in the student’s IEP

The special transportation service is included in the student’s IEP

A specially adapted vehicle is one that has been physically modified (e.g., addition of a wheelchair lift, addition of seatbelts or harnesses, addition of child protective seating, or addition of air conditioning). A bus monitor or other personnel accompanying children on the bus is not considered an allowable special adaptive enhancement for Medicaid reimbursement under SHARS specialized transportation. Specialized transportation services reimbursable under SHARS requires the Medicaid-eligible special education student has the following documented in his or her IEP:

The student requires a specific physical adaptation or adaptations of a vehicle in order to be transported

The reason the student needs the specialized transportation

Children with special education needs who ride the regular school bus to school with other nondisabled children are not required to have the transportation services in a school setting listed in their IEP. Also, the cost of the regular school bus ride cannot be billed to SHARS. Therefore, the fact that a child may receive a service through SHARS does not necessarily mean that the transportation services in a school setting may be reimbursed for them.

Reimbursement for covered transportation services is on a student one-way trip basis. If the student receives a billable SHARS service (including personal care services on the bus) and is transported on the school’s specially adapted vehicle, the following one-way trips may be billed:

From the student’s residence to school

From the school to the student’s residence

From the student’s residence to a provider’s office that is contracted with the district

From a provider’s office that is contracted with the district to the student’s residence

From the school to a provider’s office that is contracted with the district

From a provider’s office that is contracted with the district to the student’s school

From the school to another campus to receive a billable SHARS service

From the campus where the student received a billable SHARS service back to the student’s school

Covered transportation services from a child’s residence to school and return are not reimbursable if, on the day the child is transported, the child does not receive Medicaid services covered by SHARS (other than transportation). Documentation of each one-way trip provided must be maintained by the school district (e.g., trip log). This service must not be billed by default simply because the student is trans­ported on a specially adapted bus.

3.3.10.1Transportation Services in a School Setting Billing Table

POS*

Procedure Code

Unit of Service

1, 2, or 9

T2003

Per one-way trip

*Place of Service: 1=office; 2=home; 9=other locations

The recommended maximum billable units for procedure code T2003 is a total of four one-way trips per day.

3.3.11Prior Authorization

Prior authorization is not required for SHARS services.

3.4Documentation Requirements

3.4.1Record Retention

Student-specific records that are required for SHARS become part of the student’s educational records and must be maintained for seven years. All records that are pertinent to SHARS billings must be maintained by the school district until all audit questions, appeal hearings, investigations, or court cases are resolved. Records must be stored in a readily accessible location and format and must be available for state or federal audits.

The following is a checklist of the minimum documents to collect and maintain:

Signed consent to bill Medicaid by parent or guardian

IEP

Current provider qualifications (licenses)

Attendance records

Prescriptions and referrals

Medical necessity documentation (e.g., diagnoses and history of chronic conditions or disability)

Session notes or service logs, including provider signatures

Supervision logs

Special transportation logs

Claims submittal and payment histories

All services require documentation to support the medical necessity of the service rendered, including SHARS services. SHARS services are subject to retrospective review and recoupment if documentation does not support the service billed.

3.5* Claims Filing and Reimbursement

During the cost report period, school districts participating in SHARS are reimbursed on an interim claiming basis using SHARS interim rates. It is important that SHARS providers understand that SHARS interim payments are provisional in nature. The total allowable costs for providing services for SHARS must be documented by submitting the required annual cost report.

3.5.1Claims Information

Claims for SHARS must be submitted to TMHP in an approved electronic claims format or on a CMS-1500 claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

Claims must be submitted within 365 days from the date of service, or no later than 95 days after the end of the Federal Fiscal Year (i.e., January 3), whichever comes first.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

“Section 6: Claims Filing” (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for instructions on completing paper claims.

3.5.1.1Appealing Denied SHARS Claims

SHARS providers that appeal claims denied for exceeding benefit limitations must submit documen­tation of medical necessity with the appeal. Documentation submitted with an appeal must include the pages from the IEP and ARD documents that show the authorization of the services, including the specified frequency and duration and the details of the need for additional time or the reasons for exceeding the benefit limitations.

Each page of the documentation must have the client’s name and Medicaid number.

3.5.1.2Billing Units Based on 15 Minutes

All claims for reimbursement are based on the actual amount of billable time associated with the SHARS service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour.

Reminder:Enter the number of billing units in Block 24G of the CMS-1500 paper claim form. Claims without this information may be reimbursed as a unit of 1.

To calculate billing units, count the total number of billable minutes for the calendar day for the SHARS student, and divide by 15 to convert to billable units of service. If the total billable minutes are not divisible by 15, the minutes are converted to one unit of service if they are greater than seven and converted to 0 units of service if they are seven or fewer minutes.

For example, 68 total billable minutes/15 = 4 units + 8 minutes. Since the 8 minutes are more than 7 minutes, those 8 minutes are converted to one unit. Therefore, 68 total billable minutes = 5 units of service.

Examples:

Minutes

Units

0 min–7 mins

0 units

8 mins–22 mins

1 unit

23 mins–37 mins

2 units

38 mins–52 mins

3 units

53 mins–67 mins

4 units

68 mins–82 mins

5 units

3.5.1.3Billing Units Based on an Hour

All claims for reimbursement are based on the actual amount of billable time associated with the SHARS service. For those services for which the unit of service is an hour (1 unit = 60 minutes = one hour), partial units must be billed in tenths of an hour and rounded up or down to the nearest six-minute increment.

Enter the number of billing units in Block 24G of the CMS-1500 paper claim form. Claims without this information may be reimbursed as a unit of 1.

To calculate billing units, count the total number of billable minutes for the calendar day for the SHARS student and divide by 60 to convert to billable units of service. If the total billable minutes are not divisible by 60, the minutes are converted to partial units of service as follows:

Minutes

Units

0 mins–3 mins

0 units

4 mins–9 mins

0.1 unit

10 mins–15 mins

0.2 unit

16 mins–21 mins

0.3 unit

22 mins–27 mins

0.4 unit

28 mins–33 mins

0.5 unit

34 mins–39 mins

0.6 unit

40 mins–45 mins

0.7 unit

46 mins–51 mins

0.8 unit

52 mins–57 mins

0.9 unit

Other examples:

Minutes

Units

58 mins–63 mins

1 unit

64 mins–69 mins

1.1 units

70 mins–75 mins

1.2 units

76 mins–81 mins

1.3 units

82 mins–87 mins

1.4 units

88 mins–93 mins

1.5 units

3.5.2Managed Care Clients

SHARS services are carved-out of the Medicaid Managed Care Program and must be billed to TMHP for payment consideration. Carved-out services are those that are rendered to Medicaid Managed Care clients, but are administered by TMHP and not the client’s MCO.

3.5.3Reimbursement

Providers are reimbursed for medical and transportation services provided under the SHARS Program on a cost basis using federally mandated allocation methodologies in accordance with 1 TAC §355.8443.

In order to accommodate participating SHARS districts that require interim cash flow to offset the financial burden of providing for students, an interim fee-for-service claiming system still exists for SHARS. The interim claims are based on SHARS interim rates but are provisional in nature.

The provider’s final reimbursement amount is arrived at by a cost report, cost reconciliation, and cost settlement process. The provider’s total costs for both direct medical and transportation services as reported in the cost report are adjusted using the federally mandated allocation methodologies.

If a provider’s interim payments exceed 99 percent of the provider’s federal portion of the total certified Medicaid allowable costs, the provider must repay the over payments or HHSC will offset all of the provider’s future claims payments until the amount is recovered.

If 99 percent of the provider’s federal portion of the total certified Medicaid allowable costs exceeds the interim Medicaid payments, HHSC will pay the difference to the provider in accordance with the final actual certification agreement.

Submittal of a SHARS cost report is mandatory for each provider that requests and receives interim payments. Failure to file a SHARS cost report will result in sanctions, which includes recoupment of all interim payments for the cost report period in which the default occurs.

School districts can access SHARS interim rates and published cost report guidance documents, on the HHSC website at https://rad.hhs.texas.gov/acute-care/school-health-and-related-services-shars.

For additional information SHARS providers can contact a SHARS Rate Analyst by email at ra_shars@hhsc.state.tx.us or by telephone at 1-512-730-4300.

Refer to:  Subsection 2.2, “Fee-for-Service Reimbursement Methodology” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information.

Subsection 2.9, “Federal Medical Assistance Percentage (FMAP)” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

3.5.3.1Quarterly Certification of Funds

SHARS providers are required to certify on a quarterly basis the amount reimbursed during the previous federal fiscal quarter. TMHP Provider Enrollment mails the quarterly Certification of Funds statement to SHARS providers after the end of each quarter of the federal fiscal year (October 1 through September 30). The purpose of the statement is to verify that the school district incurred costs on the dates of service that were funded from state or local funds in an amount equal to, or greater than, the combined total of its interim rates times the paid units of service. While the payments were received the previous federal fiscal quarter, the actual dates of service could have been many months prior. Therefore, the certification of public expenditures is for the date of service and not the date of payment.

In order to balance amounts in the Certification of Funds, providers will receive, or have access to, the Certification of Funds Claims Information Report. For help balancing the amounts in the statement, providers can contact the TMHP Contact Center at 1-800-925-9126.

Refer to:  Subsection A.12.4, “TMHP Provider Relations” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)” for more information about provider relations representatives.

The Certification of Funds statement must be:

Signed by the business officer or other financial representative who is responsible for signing other documents that are subject to audit.

Notarized.

Returned to TMHP within 25 calendar days of the date printed on the letter.

Failure to do so may result in recoupment of funds or the placement of a vendor hold on the provider’s payments until the signed Certification of Funds statement is received by TMHP. Providers must contact the TMHP Contact Center at 1-800-925-9126 if they do not receive their Certification of Funds statement.

On an annual basis, SHARS providers are required to certify through their cost reports their total, actual, incurred costs, including the federal share and the nonfederal share. Refer to subsection 3.6, “* Cost Reporting, Cost Reconciliation, and Cost Settlement” in this handbook for additional information about cost reporting.

3.6* Cost Reporting, Cost Reconciliation, and Cost Settlement

CMS requires annual cost reporting, cost reconciliation, and cost settlement processes for all Medicaid SHARS services delivered by school districts. CMS requires that school districts, as public entities, not be paid in excess of their Medicaid-allowable costs and that any overpayments be recouped through the cost reconciliation and cost settlement processes. In an effort to minimize any potential recoupments, HHSC has assigned SHARS interim rates that are as close as possible to each district’s Medicaid-allowable costs for providing each SHARS service.

3.6.1Cost Reporting

Each SHARS provider is required to complete an annual cost report for all SHARS that were delivered during the previous federal fiscal year (October 1 through September 30). The cost report is due on or before April 1 of the year following the reporting period.

School districts can access published cost report guidance documents, on the HHSC website at www.hhsc.state.tx.us/rad/acute-care/shars/index.shtml.

The following certification forms must be submitted and received by HHSC for the cost report. The annual cost report includes two certification forms which must be completed to certify the provider’s incurred actual costs:

Cost report certification

Claimed expenditures

The certification forms received by HHSC for the cost report must be:

The original certification pages.

Signed by the business officer or other financial representative who is responsible for legally binding the district.

Notarized.

The primary purpose of the cost report is to document the provider’s costs for delivering SHARS, including direct costs and indirect costs, and to reconcile the provider’s interim payments for SHARS with its actual total Medicaid-allowable costs. All annual SHARS cost reports that are filed are subject to desk review by HHSC or its designee.

For additional information, SHARS providers can contact a SHARS Rate Analyst by email at ra_shars@hhsc.state.tx.us or by telephone at 1-512-730-7400.

3.6.2Cost Reconciliation and Cost Settlement

The cost reconciliation process must be completed within 24 months of the end of the reporting period covered by the annual SHARS cost report. The total Medicaid-allowable costs are compared to the provider’s interim payments for SHARS delivered during the reporting period, which results in a cost reconciliation.

If a provider has not complied with all cost report requirements or a provider’s interim payments exceed the actual certified Medicaid-allowable costs of the provider for SHARS to Medicaid clients, HHSC will recoup the federal share of the overpayment by one of the following methods:

Offset all future claims payments to the provider until the amount of the federal share of the overpayment is recovered

Recoup an agreed-upon percentage from future claims payments to the provider to ensure recovery of the overpayments within one year

Recoup an agreed-upon dollar amount from future claims payments to ensure recovery of the overpayment within one year

If the actual certified Medicaid-allowable costs of a provider for SHARS exceed the provider’s interim payments, HHSC will pay the federal share of the difference to the provider in accordance with the final, actual certification agreement and submit claims to CMS for reimbursement of that payment in the federal fiscal quarter following payment to the provider.

HHSC issues a notice of settlement that denotes the amount due to or from the provider.

3.6.3Informal Review of Cost Reports Settlement

An ISD or the Superintendent, Chief Financial Officer, Business Officer, or other ISD Official with legal authority who disagrees with the adjustments made during the cost reconciliation process has the right to request an informal review of the adjustments. Requests for informal reviews must be sent by certified mail and received by HHSC within the time frame designated on the settlement notice. Furthermore, the request for informal review must include a concise statement of the specific actions or determinations the district disputes, the ISD’s recommended resolution, and any supporting documentation deemed relevant to the dispute. Failure to follow these instructions will result in the denial of the request for an informal review.

School districts can access published cost report guidance documents, on the HHSC website at www.hhsc.state.tx.us/rad/acute-care/shars/index.shtml. For additional information, SHARS providers can contact a SHARS Rate Analyst by email at ra_shars@hhsc.state.tx.us or by telephone at 1-512-730-7400.

4 Texas Health Steps (THSteps) Dental

Medicaid dental services rules are described under Title 25 Texas Administrative Code (TAC) Part 1, Chapter 33. The online version of TAC is available at the Secretary of State’s website at www.sos.state.tx.us/tac/index.shtml. All dental providers must comply with the rules and regulations of the Texas State Board of Dental Examiners (TSBDE), including standards for documentation and record maintenance as stated in 22 TAC §108.7, Minimum Standard of Care, General, and §108.8, Records of the Dentist.

Note:THSteps dental benefits are administered as Children’s Medicaid Dental Services by dental managed care organizations for most Medicaid fee-for-service and managed care clients who are 20 years of age and younger.

Refer to:  The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) or to the HHSC website at www.hhsc.state.tx.us/medicaid/managed-care/mmc.shtml, for additional infor­mation about children’s Medicaid dental Services.

Under the Early Periodic Screening Diagnostic, and Treatment (EPSDT) regulation, known in Texas as Texas Health Steps (THSteps), Section 1905(r) of the Social Security Act mandates that all Medicaid eligible beneficiaries who are birth through 20 years of age receive medically necessary services to treat, correct, and ameliorate illnesses and conditions identified if the service is covered in the state’s Medicaid plan or is an optional Medicaid service. It is the responsibility of the state to determine medical necessity on a case-specific basis. No arbitrary limitations on services are allowed (e.g., one pair of eyeglasses or 10 therapy sessions per year) if determined to be medically necessary.

Services not covered under this section include:

Experimental or investigational treatment.

Services or items not generally accepted as effective and/or not within the normal course and duration of treatment.

Services for the caregiver or provider convenience.

All EPSDT requirements must be adhered to for beneficiaries who receive services under managed care arrangements.

4.1Enrollment

To become a provider of THSteps or intermediate care facility for persons with intellectual disability (ICF-IID) dental services, a dentist must:

Practice within the scope of the provider’s professional licensure.

Complete the Dental Provider Enrollment Application and return it to TMHP.

Dental providers are required to maintain an active license status with the TSBDE. TMHP receives a monthly automated board feed from TSBDE to update licensure information. If licensure cannot be verified with the automated board feed, it is the providers’ responsibility to provide a copy of the active TSBDE license to TMHP. If TSBDE has a delay in processing license applications and renewals, the provider must request a letter from TSBDE for their individual provider information and send the letter of verification of current licensure to TMHP. The letter must contain the provider’s specific identifi­cation information, license number, and licensure period.

If TMHP cannot verify a valid license at the time of enrollment, it is the providers’ responsibility to provide a copy of the active TSBDE license to TMHP.

A dental provider cannot be enrolled if his or her dental license is due to expire within 30 days; a current license must be submitted. Dental licensure for owners of a dental practice is a requirement of the Occupations Code, Vernon’s Texas Codes Annotated (VTCA), Subtitle D, Chapters 251-267 (the Texas Dental Practice Act).

Providers can download and print dental provider enrollment application forms from the TMHP website at www.tmhp.com or call the TMHP Contact Center at 1-800-925-9126 to request them.

All owners of a dental practice must maintain an active license status with the TSBDE to receive reimbursement from Texas Medicaid. Any change in ownership or licensure status for any enrolled dentist must be immediately reported in writing to TMHP Provider Enrollment and will affect reimbursement by Texas Medicaid.

A dentist must complete the Dental Provider Enrollment Application for each separate practice location and will receive a unique provider identifier for each practice location if the application is approved.

The application form includes a written agreement with HHSC.

Dental providers may enroll in the THSteps Dental program and ICF-IID Dental Programs or as a Doctor of Dentistry Practicing as a Limited Physician, or both. The enrollment requirements are different with respect to the category of enrollment.

All dental providers must declare one or more of the following categories:

General practice

Pediatric dentist

Periodontist

Endodontist

Oral and maxillofacial surgeon

Orthodontist

Other (prosthodontist, public health, and others)

Dentists (D.D.S., D.M.D.) who want to provide orthodontic services must be enrolled as a dentist or orthodontist provider for THSteps and must have at least one of the following qualifications.

THSteps dental providers may perform and be reimbursed for orthodontic services if they have attested to at least one of the following requirements:

Completion of a dental pediatric specialty residency

Completion of a minimum of 200 hours of continuing education in orthodontics within the last 10 years (8 hours can be online or self instruction) (Proof of the completion of continuing education hours is not required to be submitted with a request for prior authorization of orthodontic services; however, documentation must be produced by the dentist during retrospective review.)

Orthodontist providers are eligible to provide orthodontic services. In order to comply with the TSBDE rules and regulations, this designation can only be associated with dentists who are board-eligible or board-certified by an American Dental Association (ADA) recognized orthodontic specialty board.

Refer to:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information)

Dental residents may provide dental services in a teaching facility under the guidance of the attending staff/faculty member(s) as long as the facility’s dental staff by-laws and standards by the Commission on Dental Accreditation (CODA) are met, and the attending dentist/faculty member has determined the resident to be competent to perform the dental services. THSteps does not require the supervising dentist to examine the client as long as these conditions are met.

In a clinic, an attending dentist/faculty member must be present in the dental clinic for consultation, supervision, and active teaching when residents are treating patients in scheduled clinic sessions. This does not preclude occasional situations where a faculty member cannot be available. A dentist must assume responsibility for the clinic’s operation.

4.1.1THSteps Dental Eligibility

The client must be Medicaid- and THSteps-eligible (birth through 20 years of age) at the time of the service request and service delivery. However, Medicaid-approved orthodontic services already in progress may be continued even after the client loses Medicaid eligibility if the orthodontic treatment:

Began before the loss of Medicaid eligibility.

Began before the day of the client’s 21st birthday.

Was completed within 36 months of the beginning date.

The client is not eligible for a THSteps medical checkup or THSteps dental benefits if the client’s Your Texas Benefits Medicaid card or Medicaid Eligibility Verification Form (Forms H1027 and H1027-A-C) states any of the following:

Emergency

Presumptive eligibility (PE)

Qualified Medicare beneficiary (QMB)

Healthy Texas Women (HTW) program

4.1.2THSteps Dental and ICF-IID Dental Services

A provider may enroll as an individual dentist, a group practice, or both. Regardless of the category of practice designation under THSteps Dental, providers can only submit claims for THSteps and ICF-IID Dental Services.

Refer to:  Subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization” in this handbook.

4.1.3THSteps Dental Checkup and Treatment Facilities

All THSteps dental checkup and treatment policies apply to examinations and treatment completed in a dentist’s office, a health department, clinic setting, hospital operating room, or in a mobile/satellite unit. Enrollment of a mobile/satellite unit must be under a dentist or clinic name. Mobile units can be a van or any temporary site away from the primary office and are considered extensions of that office and are not separate entities. The physical setting must be appropriate so that all elements of the checkup or treatment can be completed. The checkup must meet the requirements detailed in subsection D.5, “Parental Accompaniment” in this handbook. The provider with a mobile unit or who uses portable dental equipment must obtain a permit for the mobile unit from the TSBDE.

4.1.4Doctor of Dentistry Practicing as a Limited Physician

Dentists who serve clients and submit claims using medical (CPT) procedure codes, such as oral-maxil­lofacial surgeons, may enroll as a doctor of dentistry practicing as a limited physician. Providers may enroll as an individual dentist or as a dental group. To enroll as a doctor of dentistry practicing as a limited physician, a dentist must:

Be currently licensed by the TSBDE or currently licensed in the state where the service was performed.

Have a Medicare provider identification number before applying for a Medicaid provider identifier.

Enroll as a Medicaid provider with a limited physician provider identifier.

4.1.5Client Rights

Dental providers enrolled in Texas Medicaid enter into a written contract with HHSC to uphold the following rights of the Medicaid client:

To receive dental services that meet or exceed the standards of care established by the laws relating to the practice of dentistry and the rules and regulations of the TSBDE.

To receive information following a dental examination about the dental diagnosis; scope of proposed treatment, including alternatives and risks; anticipated results; and the need and risks for administration of sedation or anesthesia.

To have full participation in the development of the treatment plan and the process of giving informed consent.

To have freedom from physical, mental, emotional, sexual, or verbal abuse, or harm from the provider or staff.

To have freedom from overly aggressive treatment in excess of that required to address documented medical necessity.

A provider’s failure to ensure any of the client rights may result in termination of the provider agreement or contract and other civil or criminal remedies.

4.1.6Complaints and Resolution

Complaints about dental services are typically received through the TMHP Contact Center, although a complaint is accepted from any source. A complaint is researched by TMHP and resolved or escalated as appropriate. Examples of complaints from clients about providers include:

The provider did not consult with the client, explain what services were necessary, or obtain parent or guardian informed consent.

The treating provider refused to make the child’s record available to the new provider.

The provider did not give the child the appropriate local anesthesia or pain medication.

The provider did not use sterile procedures; the facility or equipment were not clean.

The provider or his staff were verbally abusive.

The client did not receive a service, but the provider submitted a claim to Texas Medicaid.

The provider charged a Medicaid client for benefits covered by Medicaid.

4.2Services, Benefits, Limitations, and Prior Authorization

4.2.1THSteps Dental Services

THSteps is the Texas version of the Medicaid program known as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).

THSteps dental services are mandated by Medicaid to provide for the early detection and treatment of dental health problems for Medicaid-eligible clients who are birth through 20 years of age. THSteps dental service standards are designed to meet federal regulations and incorporate the recommendations of representatives of national and state dental professional organizations.

THSteps’ designated staff (DSHS, DADS, or contractor), through outreach and informing, encourage eligible children to use THSteps dental checkups and services when children first become eligible for Medicaid, and each time children are periodically due for their next dental checkup.

Children within Medicaid have free choice of Medicaid-enrolled providers and are given names of enrolled providers. A list of THSteps dental providers in a specific area can be obtained using the Online Provider Lookup on the TMHP website at www.tmhp.com, or by calling 1-877-847-8377.

Upon a provider’s request, DSHS (or its contractor) will assist eligible children with the scheduling of free transportation to their dental appointment or clients can call the Medical Transportation Program at 1-877-633-8747.

Refer to:  The Medical Transportation Program Handbook (Vol. 2, Provider Handbooks) for infor­mation about transportation arrangements.

4.2.1.1Eligibility for THSteps Dental Services

A client is eligible for THSteps dental services from birth through 20 years of age. The eligibility period is determined by the client’s age on the first of the month. If a client’s birthday is not on the first of a month, the new eligibility period begins on the first day of the following month. When the client turns 21 years of age during a month, the client is eligible for THSteps dental non-CCP services through the end of that month.

A client is eligible for Comprehensive Care Program (CCP) dental services until their 21st birthday. The eligibility period ends on their 21st birthday and does not continue through the end of the month in which the birthday falls.

4.2.1.2Parental Accompaniment

Children who are 14 years of age and younger must be accompanied to THSteps dental appointments by a parent, legal guardian, or another adult who is authorized by the parent or guardian unless the services are provided by an exempt entity as defined by the Human Resources Code. For additional information and exceptions, see Subsection D.5, “Parental Accompaniment” in this handbook.

4.2.2* Substitute Dentist

In accordance with TAC §§354.1121 and 354.1221, related to Medicaid billing for the services of substitute dentists, dentists who are temporarily absent from their practice are allowed to submit claims for reimbursement of Medicaid services rendered to their Medicaid clients by a substitute dentist.

Dentists may bill for the services of a substitute dentist pursuant to 42 CFR §447.10.   

The following are conditions for reimbursement of services rendered by a substitute dentist:

Dentists who take a leave of absence for no more than 90 days may bill for the services of a substitute dentist who renders services on an occasional basis when the primary dentist is unavailable to provide services. Services must be rendered at the practice location of the dentist who has taken the leave of absence. A locum tenens arrangement is not allowed for dentists.

This arrangement is limited to no more than 90 consecutive days. Under this temporary basis, the primary dentist (who is the billing agent dentist) may not submit a claim for services furnished by a substitute dentist to address long-term vacancies in a dental practice. The billing agent dentist may submit claims for the services of a substitute dentist for longer than 90 consecutive days if the dentist has been called or ordered to active duty as a member of a reserve component of the Armed Forces. Medicaid and CSHCN accepts claims from the billing agent dentist for services provided by the substitute dentist for the duration of the billing agent dentist's active duty as a member of a reserve component of the Armed Forces.

Providers billing for services provided by a substitute dentist must bill with modifier U5 in Block 19 of the American Dental Association (ADA) claim form.

The billing agent dentist may recover no more than the actual administrative cost of submitting the claim on behalf of the substitute dentist. This cost is not reimbursable by Medicaid or CSHCN.

The billing agent dentist must bill substitute dentist services on a different claim form from his or her own services. The billing agent dentist services cannot be billed on the same claim form as substitute dentist services.

The substitute dentist must be licensed to practice in the state of Texas, must be enrolled in Texas Medicaid, and must not be on the Texas Medicaid provider exclusion list.

The dentist who is temporarily absent from the practice must be indicated on the claim as the billing agent dentist, and his or her name, address, and National Provider Identifier (NPI) must appear in Blocks 53, 54, and 56 of the ADA claim form.

The substitute dentist's NPI number must be documented in Block 35 of the ADA claim form. Electronic submissions do not require a provider signature.

Dentists must familiarize themselves with these requirements and document accordingly. Those services not supported by the required documentation, as detailed above, will be subject to recoupment.

4.2.2.1* Diagnostic Services

Diagnostic services should be performed for all clients, starting within the first six months of the eruption of the first primary tooth, but no later than one year of age.

Procedure Code

Limitations

Clinical Oral Evaluations

Procedure codes D0140, D0160, D0170, and D0180 are limited dental codes and may be paid in addition to a comprehensive oral exam (procedure code D0150) or periodic oral exam (procedure code D0120), when submitted within a six-month period. When submitting a claim for procedure code D0140, D0160, D0170, or D0180, the provider must indicate documentation of medical necessity on the claim. These claims are subject to retrospective review. If no comments are indicated on the claim form, the payment may be recouped.

D0120*

A Birth–20. Limited to one every six months by the same provider. Denied when submitted for the same DOS as D0145 by any provider.

D0140*

Used for problem-focused examination of a specific tooth or area of the mouth. Limited to one service per day by the same provider or to two services per day by different providers. Denied when submitted for the same DOS as D0160 by the same provider. A Birth–20, N

D0145*

Limited to one service per day and ten times a lifetime, with a minimum of 60 days between dates of service. Providers must be certified by DSHS Oral Health Program staff to perform this procedure. Procedure codes D0120, D0150, D0160, D0170, D0180, D1120, D1206, D1208, or D8660 will be denied when submitted by any provider for the same DOS. A 6–35 months

D0150*

Used for a comprehensive oral evaluation. Limited to one service every three years by the same provider. Denied when submitted for the same DOS as D0145 by any provider. A Birth–20

D0160*

Used for a problem focused, detailed and extensive oral evaluation. Limited to one service per day by the same provider. Not payable for routine postoperative follow-up. Denied when submitted for the same DOS as D0145 by any provider. A 1–20, N, CCP

D0170*

Limited to one service per day by the same provider. When used for emergency claims, refer to General Information. Denied when submitted for the same DOS as procedure code D0140 or D0160 by the same provider. Denied when submitted for the same DOS as D0145 by any provider. A Birth–20

D0180*

Used for periodontal evaluation. Denied when submitted for the same DOS as D0120, D0140, D0145, D0150, D0160 or D0170 by the same provider. A 13–20

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

The provider must document medical necessity and the specific tooth or area of the mouth on the claim for procedure codes D0140, D0160, and D0170.

Documentation supporting medical necessity for procedure codes D0140, D0160, and D0170 must also be maintained by the provider in the client’s medical record and must include the following:

The client’s complaint supporting medical necessity for the examination

The specific area of the mouth that was examined or the tooth involved

A description of what was done during the visit

Supporting documentation of medical necessity which may include, but is not limited to, radio­graphs or photographs

Documentation supporting medical necessity for procedure code D0180 must be maintained by the provider in the client’s medical record and must include the following:

The client’s complaint supporting medical necessity for the examination

A description of what was done during the treatment

Supporting documentation of medical necessity which may include, but is not limited to, radio­graphs or photographs

A caries risk assessment procedure code (D0601, D0602, or D0603) is required on the same claim when dental examination procedure code D0120, D0145, or D0150 is submitted for reimbursement. Procedure codes D0601, D0602, and D0603 are informational only, and are not payable. Information-only procedure codes must be billed in the amount of at least $0.01 in the cost column on the claim form.

The client’s dental condition(s) that justifies the risk assessment classification submitted with the claim must be maintained by the provider in the client’s medical record, and it must be clearly documented using a caries risk assessment tool or in narrative charting. The client’s medical record is subject to retro­spective review.

Professionally developed caries risk assessment tools are available at:

American Dental Association (ADA)

American Academy of Pediatric Dentistry (AAPD)

Department of State Health Services (DSHS), Oral Health Program

Procedure Code

Limitations

Radiographs/Diagnostic Imaging (Including Interpretation)

Number of films required is dependent on the age of the client. A minimum of eight films is required to be considered a full-mouth series. Adults and children who are 12 years of age and older require
12–20 films, as is appropriate. The Panorex radiographic image (D0330) with four bitewing radio­graphic images (D0274) may be considered equivalent to the complete or full-mouth series of radiographic images (D0210), and the submitted amount for either combination is equivalent to the maximum fee.

D0210

Limited to one service every three years by the same provider. Will be denied when submitted on an emergency claim. A 2–20

D0220

Limited to one service per day by the same provider. A 1–20

D0230

The total cost of periapicals and other radiographs cannot exceed the payment for a complete intraoral series. A 1–20

D0240

Limited to two services per day by the same provider. Periapical films taken at an occlusal angle must be submitted as periapical radiograph, procedure code D0230. May be submitted as an emergency service. A Birth–20

D0250

Limited to one service per day by the same provider. A 1–20, N, CCP

D0270

Limited to one service per day by the same provider. A 1–20

D0272

Limited to one service per day by the same provider. Denied when submitted for the same DOS as D0210 by any provider. A 1–20

D0273

Limited to one service per day by the same provider. Denied when submitted for the same DOS as D0210 by any provider. A 1–20

D0274

Limited to one service per day by the same provider. Denied when submitted for the same DOS as D0210 by any provider. A 2–20

D0277

Limited to one service per day by the same provider. Not to be submitted within 36 months of D0210 or D0330. Denied when submitted for the same DOS as D0330 by the same provider. Denied when submitted for the same DOS as D0210 by any provider. A 2–20

D0310

A 1–20, N, CCP

D0320

A 1–20, N, CCP

D0321

A 1–20, N, CCP

D0322

A 1–20, N, CCP

D0330*

Limited to one service per day, any provider, and to one service every three years by the same provider. Not allowed on emergency claims unless third molars or a traumatic condition is involved. For clients who are 2 years of age and younger, must document the necessity of a panoramic film. The Panorex radiographic image (D0330) with four bitewing radiographic images (D0274) may be considered equivalent to the complete or full-mouth series of radiographic images (D0210), and the submitted amount for either combination is equivalent to the maximum fee. A 3–20

D0340*

Limited to one service per day by the same provider. Not reimbursable separately when a comprehensive orthodontic or crossbite therapy workup is performed. A 1–20, N, CCP

D0350*

Limited to one service per day by the same provider. Not reimbursable separately when a comprehensive orthodontic or crossbite therapy workup is performed. A Birth–20

D0367

Prior authorization is required. Limited to a combined maximum of three services per year, any provider. Additional services may be considered with documen­tation of medical necessity. A Birth-20

Note:Radiograph codes do not include the exam. If an exam is also performed, providers must submit the appropriate ADA procedure code.

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

Procedure code D0350 must be used to submit claims for photographs, and will be accepted only when diagnostic-quality radiographs cannot be taken. Supporting documentation and photographs must be maintained in the client’s medical record when medical necessity is not evident on radiographs for dental caries or the following procedure codes. Medical necessity must be documented on the electronic or paper claim.

Procedure Codes

D4210

D4211

D4240

D4241

D4245

D4266

D4267

D4270

D4273

D4275

D4276

D4277

D4278

D4283

D4285

D4355

D4910

Procedure Code

Limitations

Tests and Examinations

D0415

A 1–20, N, CCP

D0425

Not reimbursable separately. Considered part of another dental procedure.

D0460

Limited to one service per day by the same provider. Not payable for primary teeth. Will deny when submitted for the same DOS as any endodontic procedure. A 1-20, N, CCP

Tests and Examinations continued

D0470*

Not reimbursable separately when crown, fixed prosthodontics, diagnostic workup, or crossbite therapy workup is performed.
A 1-20, N, CCP

Oral Pathology Laboratory

D0472

By pathology laboratories only. (refer to CPT codes)

D0473

By pathology laboratories only. (refer to CPT codes)

D0474

By pathology laboratories only. (refer to CPT codes)

D0480

By pathology laboratories only. (refer to CPT codes)

D0502

A 1–20, N, CCP

D0999

A 1–20, N, CCP

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.2.2* Preventive Services

Procedure Code

Limitations

Dental Prophylaxis

D1110*

Limited to one prophylaxis per client, any provider, per six-month period (includes oral health instructions). If submitted on emergency claim, procedure code will be denied. Denied when submitted for the same DOS as any D4000 series periodontal procedure code. A 13–20

D1120*

Limited to one prophylaxis per client, any provider, per six-month period (includes oral health instructions). If submitted on emergency claim, procedure code will be denied. Denied when submitted for the same DOS as any D4000 series periodontal procedure code, or with procedure code D0145. A 6 months–12 years

Topical Fluoride Treatment (Office Procedure)

D1206

Includes oral health instructions. If submitted on emergency claim, procedure code will be denied. Denied when submitted for the same DOS as any D4000 series periodontal procedure code or with procedure code D0145. A 6 months–20 years, N, CCP

D1208

Includes oral health instructions. Denied when submitted for the same DOS as any D4000 series periodontal procedure code or with procedure code D0145. A 6 months–20 years, N, CCP

Other Preventive Services

D1310

Denied as part of all preventative, therapeutic and diagnostic dental procedures. A client requiring more involved nutrition counseling may be referred to a THSteps primary care physician.

D1320

A client requiring tobacco counseling may be referred to a THSteps primary care provider.

D1330

Requires documentation of the type of instructions, number of appointments, and content of instructions. This procedure refers to services above and beyond routine brushing and flossing instruction and requires that additional time and expertise have been directed toward the client’s care.

Denied when billed for the same DOS as dental prophylaxis (D1110 or D1120) or topical fluoride treatments (D1206 or D1208) by any provider. Limited to once per client, per year, by any provider. A 1–20, N, CCP

D1351*

Sealants may be applied to the occlusal, buccal, and lingual pits and fissures of any tooth that is at risk for dental decay and is free of proximal caries and free of resto­rations on the surface to be sealed. Sealants are a benefit when applied to deciduous (baby or primary) teeth or permanent teeth. Indicate the tooth numbers and surfaces on the claim form. Reimbursement will be considered on a per-tooth basis, regardless of the number of surfaces sealed. Denied when billed for the same DOS as any D4000 series periodontal procedure code. Sealants and replacement sealants are limited to one every 3 years per tooth by the same provider or provider group. Dental sealants performed more frequently than once every three years by a different provider are also a benefit if the different provider is not associated with the provider or provider group that initially placed the sealant on the tooth. If submitted on emergency claim, procedure code will be denied. A Birth–20

D1352

Denied if a caries risk assessment (procedure code D0602 or D0603) has not been submitted, by any provider, within 180 days prior. Denied when submitted for the same DOS as any D4000 series periodontal procedure code. A 5–20

Space Maintenance (Passive Appliances)

Space maintainers are a benefit of Texas Medicaid after premature loss of primary or secondary molars (TID A, B, I, J, K, L, S, and T for clients who are 1 through 12 years of age, and after loss of permanent molars (TID 3, 14, 19, and 30) for clients who are 3 through 20 years of age. Limited to 1 space maintainer per TID, per lifetime, per client.

When procedure code D1510 or D1515 have been previously reimbursed, the recementation of space maintainers (procedure code D1550) may be considered for reimbursement to either the same or different THSteps dental provider. Replacement space maintainers may be considered upon appeal with documentation supporting medical necessity. Removal of a fixed space maintainer is not payable to the provider or dental group practice that originally placed the device.

D1510*

A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID

Space Maintenance (Passive Appliances) continued

D1515*

A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID

D1520*

A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID

D1525*

A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID

D1550

A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID

D1555*

A 1–20 (TIDs #A, B, I, J, K, L, S, T), MTID
A 1–20 (TIDs #3, 14, 19, 30), MTID

D1575

A 3-7 (TIDs #A, J, K, T), MTID

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.2.3* Therapeutic Services

Medicaid reimbursement is contingent on compliance with the following limitations:

Documentation requirements

Refer to:  Subsection 4.3, “Documentation Requirements” in this handbook.

The total reimbursement for restorative services of a primary tooth over a 6-month period cannot exceed the fee for a stainless steel crown (with the exception of D2335 and D2933), when provided by the same dentists within a dental group. An exception will be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity of the retreatment dental services during pre-payment review.

Restoration of a primary tooth through the use of a stainless steel crown is considered to be a once-in-a-lifetime restoration. An exception will be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity of the replacement of the stainless steel crown during pre-payment review.

All fees for tooth restorations include local anesthesia and pulp protective media, where indicated, without additional charges. These services are considered part of the restoration.

More than one restoration on a single surface is considered a single restoration.

Multiple surface restorations must show definite crossing of the plane of each surface listed for each primary and permanent tooth completed.

A multiple surface restoration cannot be submitted as two or more separate one-surface restorations.

Restorations and therapeutic care are provided as a Medicaid service based on medical necessity and reimbursed only for therapeutic reasons and not preventive purposes (refer to CDT).

All dental restorations and prosthetic appliances that require lab fabrication may be submitted for reimbursement using the date the final impression was made as the DOS. If the client did not return for final seating of the restoration or appliance, a narrative must be included on the claim form and in the client’s chart in lieu of a postoperative radiograph. The 95-day filing deadline is in effect from the date of the final impression. If the client returns to the office after the claim has been filed, the dentist is obligated to attempt to seat the restoration or appliance at no cost to the client or Texas Medicaid. For records retention requirements, refer to subsection 4.3, “Documentation Requirements” in this handbook.

Direct pulp caps may be reimbursed separately from any final tooth restoration performed on the same tooth (as noted by the TID) on the same DOS by the same provider.

4.2.3Comprehensive Care Program (CCP)

The Omnibus Budget Reconciliation Act (OBRA) of 1989 mandated the expansion of the federal EPSDT program to include any service that is medically necessary and for which federal financial participation (FFP) is available, regardless of the limitations of Texas Medicaid. This expansion is referred to as the Comprehensive Care Program (CCP).

CCP services are provided only for those clients who are birth through 20 years of age who are eligible to receive THSteps services. When the client becomes 21 years of age, all CCP benefits stop. Dental services that are a benefit through CCP are designated in the Limitations column of the tables with the notation “CCP” beginning in subsection 4.2.2.1, “* Diagnostic Services” in this handbook.

4.2.4Children’s Medicaid Dental Plan Choices

Children’s Medicaid dental services benefits are administered by two dental managed care organizations (i.e., dental plans) across the state of Texas.

Medicaid Managed Care Dental Plan Dental Plan Provider Services

DentaQuest

1-800-685-9971

MCNA Dental

1-855-776-6262

Note:Services provided to Medicaid managed care clients must be provided by their main dentist.

4.2.5Authorization Transfers for Medicaid Managed Care Dental Ortho­dontic Services

If a client transitions to a managed care dental plan after their orthodontic services were initially autho­rized by TMHP, the claims for the orthodontic services will be processed and reimbursed by the managed care dental plan. Providers should check client eligibility to identify the managed care dental plan to which the client transitions.

Claims for orthodontic services remain the responsibility of the dental managed care plan until the authorized services are completed, even if the client loses dental managed care or Medicaid eligibility.

4.2.6ICF-IID Dental Services

ICF-IID dental services are mandated by Medicaid. Reimbursement is provided for treatment of dental problems for Medicaid-eligible residents of ICF-IID facilities who are 21 years of age and older. Residents of ICF-IID facilities who are 20 years of age and younger receive services through the regular THSteps Program. Eligibility for ICF-IID services is determined by DADS.

Procedure codes that do not have a CCP designation in the Limitations column of the dental fee schedule may be submitted in a routine manner for ICF-IID clients. These procedures must be documented as medically necessary and appropriate. ICF-IID clients are not subject to periodicity for preventive care. For procedure codes that have a CCP designation, a provider may request authorization with documen­tation or provide documentation on the submitted claim.

Refer to:  Subsection 4.2.13, “Medicaid Dental Benefits, Limitations, and Fee Schedule” in this handbook.

4.2.6.1THSteps and ICF-IID Provision of Dental Services

All THSteps and ICF-IID dental services must be performed by the Medicaid-enrolled dental provider except for permissible work that is delegated to a licensed dental hygienist, dental assistant, or dental technician in a dental laboratory on the premises where the dentist practices, or in a commercial laboratory registered with the TSBDE. The Texas Dental Practice Act and the rules and regulations of the TSBDE (22 TAC, Part 5) define the scope of work that dental auxiliary personnel may perform. Any deviations from these practice limitations shall be reported to the TSBDE and HHSC, and could result in sanctions or other actions imposed against the provider.

THSteps and ICF-IID clients must receive:

Dental services specified in the treatment plan that meet the standards of care established by the laws relating to the practice of dentistry and the rules and regulations of the TSBDE.

Dental services free from abuse or harm from the provider or the provider’s staff.

Only the treatment required to address documented medical necessity that meets professionally recognized standards of health care.

4.2.6.2Children in Foster Care

Clients in foster care receive services from Superior HealthPlan’s dental contractor. Providers may contact DentaQuest at 1-888-308-9345 for more information.

Paper claims and requests for prior authorization must be mailed to:

DentaQuest
12121 North Corporate Parkway
Mequon, WI 53092
Fax: 1-262-241-7150 or 1-888-313-2883

4.2.7Written Informed Consent and Standards of Care

As outlined in 22 TAC §108.7, the dental provider must maintain written informed consent signed by the patient, or a parent or legal guardian of the patient if the patient is a minor, or a legal guardian of the patient if the patient has been adjudicated incompetent to manage the patient’s personal affairs.

Additionally, as required in 25 TAC §33.6 and §33.20, THSteps providers must obtain legally effective, written informed consent before providing THSteps dental checkups and treatment services. Such consent is required for all oral evaluations; dental diagnostic, preventative, and therapeutic services; and treatment plans. The written informed consent must identify the tooth and surface IDs associated with the proposed treatment and should disclose risks or hazards that could influence a reasonable person in making a decision to give or withhold consent.

THSteps clients or their parents or legal guardians who can give written informed consent must receive information following a dental examination about the dental diagnosis, scope of proposed treatment, including alternatives and risks, anticipated results, and need for and risks of the administration of sedation or anesthesia. Additionally, they must receive a full explanation of the treatment plan and give written informed consent before treatment is initiated. The parent or guardian being present at the time of the dental visit facilitates the provider obtaining written informed consent. Dentists must comply with TSBDE Rule 22 TAC §108.2, “Fair Dealing.”

4.2.8First Dental Home

Based on the American Academy of Pediatric Dentistry’s (AAPD) definition, Texas Medicaid defines a dental home as the dental provider who supports an ongoing relationship with the client that includes all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a client’s dental home begins no later than 6 months of age and includes referrals to dental specialists when appropriate.

In providing a dental home for a client, the dental provider enhances the ability to assist clients and their parents in obtaining optimum oral health care. The first dental home visit can be initiated as early as 6 months of age and must include, but is not limited to, the following:

Comprehensive oral examination

Oral hygiene instruction with primary caregiver

Dental prophylaxis, if appropriate

Topical fluoride varnish application when teeth are present

Caries risk assessment

Dental anticipatory guidance

Clients who are from 6 through 35 months of age may be seen for dental checkups by a certified First Dental Home provider.

First Dental Home services are submitted using procedure code D0145. The dental home provider must retain supporting documentation for procedure code D0145 in the client’s record. The supporting documentation must include, but is not limited to, the following:

Oral and physical health history review

Dental history review

Primary caregiver’s oral health

Oral evaluation

Caries risk assessment

Dental prophylaxis, which may include a toothbrush prophylaxis

Oral hygiene instruction with parent or caregiver

Fluoride varnish application

An appropriate preventive oral health regimen (recall schedule)

Anticipatory guidance communicated to the client’s parent, legal guardian, or primary caregiver to include the following:

Oral health and home care

Oral health of primary caregiver/other family members

Development of mouth and teeth

Oral habits

Diet, nutrition, and food choices

Fluoride needs

Injury prevention

Medications and oral health

Any referrals, including dental specialist’s name

Procedure code D0145 is limited to individual dentists certified by the DSHS Oral Health Program to perform this service. Training for certification as a First Dental Home provider is available as a free continuing education course on the THSteps website at www.txhealthsteps.com.

Procedure codes D0120, D0150, D0160, D0170, D0180, D1120, D1206, D1208, and D8660 are denied if procedure code D0145 is submitted for the same DOS by any provider. A First Dental Home examination is limited to ten services per client lifetime with at least 60 days between visits by any provider to prevent denials of the service.

4.2.9Dental Referrals by THSteps Primary Care Providers

Dental providers may receive referrals for clients who are 6 months of age and older from THSteps primary care providers. The primary care provider must provide information about the initiation of routine dental services with the recommendation to the client’s parent or guardian that an appointment be scheduled with a dental provider in order to establish a dental home. If a THSteps dental checkup reveals a dental health condition that requires follow-up diagnosis or treatment, the provider performing the dental checkup should assist the client in planning follow-up care within their practice or in making a referral to another qualified dental provider.

Note:For clients who are 20 years of age and younger, the client’s guardian may refer the client for dental services or a client of legal age may refer themselves for dental services.

4.2.10Change of Provider

A provider may refer a client to another dental provider for treatment for any of the following reasons:

Treatment by a dental specialist such as a pediatric dentist, periodontist, oral surgeon, endodontist, or orthodontist is indicated and is in the best interests of the THSteps client.

The services needed are outside the skills or scope of practice of the initial provider.

A provider may discontinue treatment if there is documented failure to keep appointments by the client, noncompliance with the treatment plan, or conflicts with the client or other family members. In any such action to discontinue treatment, providers must comply with 22 TAC §108.5, “Patient Abandonment.”

The client also may select another provider, if desired. HHSC may refer the client to another provider as a result of adverse information obtained during a utilization review or resolution of a complaint from either provider or client.

4.2.10.1Interrupted or Incomplete Orthodontic Treatment Plans

Authorizations for orthodontic or extensive restorative treatment plans that have been prior authorized for a provider are not transferable to another provider. If a client’s treatment plan is interrupted and the services are not completed, the original or new provider must request a new prior authorization to complete the interrupted, incomplete, and prior authorized treatment plan.

To complete the treatment plan, the client must be eligible for Medicaid. It is the provider’s responsi­bility to verify the client’s eligibility through www.yourtexasbenefitscard.com, TexMedConnect, or the TMHP Contact Center.

If the client does not return for the completion of services and there is a documented failure to keep appointments by the client, the dental provider who initiated the services may submit a claim for reimbursement in compliance with the 95-day filing deadline.

Refer to:  Subsection 4.2.25.4, “Premature Termination of Comprehensive Orthodontic Treatment” in this section.

4.2.11Periodicity for THSteps Dental Services

For clients who are 6 months through 20 years of age, dental checkups may occur at 6-month (181-day) intervals. Texas Medicaid has adopted the AAPD’s “Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children” to serve as a guide and reference for dentists when scheduling and providing services to THSteps clients.

In November 2004, the ADA, in conjunction with the FDA, established “Guidelines for Prescribing Dental Radiographs.” The guidelines include type of encounters relevant to the client’s age and dental developmental stage. Texas Medicaid has adopted the ADA guidelines to serve as a guide and reference for dentists who treat THSteps clients.

Refer to:  “Appendix G. American Academy of Pediatric Dentistry Periodicity Guidelines”  in this handbook.

THSteps dental providers may provide any medically necessary dental services such as emergency, diagnostic, preventive, therapeutic, and orthodontic services that are within the Texas Medicaid guide­lines and limitations specified for each area as long as the client’s Medicaid eligibility is current for the date that dental services are being provided.

4.2.11.1Exceptions to Periodicity

If a periodic dental checkup has been conducted within the last six months, the client still may be able to receive another periodic dental checkup in the same six-month period by any provider. For THSteps clients, exceptions to the six-month periodicity schedule for dental checkup services may be approved for one of the following reasons:

Medically necessary service, based on risk factors and health needs (includes clients who are birth through 6 months of age).

Required to meet federal or state exam requirements for Head Start, daycare, foster care, preadoption, or to provide a checkup prior to the next periodically-due checkup if the client will not be available when due. This includes clients whose parents are migrant or seasonal workers.

Clients’ choice to request a second opinion or change service providers (not applicable to referrals).

Subsequent therapeutic services necessary to complete a case for clients who are 5 months of age and younger when initiated as emergency services, for trauma, or early childhood caries.

Medical checkup prior to a dental procedure requiring general anesthesia.

A First Dental Home client can be seen up to ten times within the age of 6 through 35 months.

It is the provider’s responsibility to verify that the client is eligible for the date that dental services are to be provided. Eligibility may be verified through www.yourtexasbenefitscard.com, TexMedConnect, or the TMHP Contact Center.

When the need for an exception to periodicity is established, a narrative explaining the reason for the exception to periodicity limitations must be documented in the client’s file and on the claim submission. For claims filed electronically, check “yes” when prompted. For claims filed on paper, place comments in Block 35.

For ICF-IID clients who are 21 years of age and older, the periodicity schedule for preventive dental procedures (exams, prophylaxis, fluoride, and radiographs) does not apply.

4.2.12Tooth Identification (TID) and Surface Identification (SID) Systems

Claims are denied if the procedure code is not compatible with TID or SID. Use the alpha characters to describe tooth surfaces or any combination of surfaces. For SID designation on anterior teeth, use facial (F) and incisal (I). For SID purposes, use buccal (B) and occlusal (O) designations for posterior teeth.

Tooth_ID-Dental.jpg

4.2.12.1Supernumerary Tooth Identification

Each identified permanent tooth and each identified primary tooth has its own identifiable supernu­merary number. This developed system can be found in the Current Dental Terminology (CDT) published by the ADA.

The TID for each identified supernumerary tooth will be used for paper and electronic claims and can only be submitted for payment with the following procedure codes:

For primary teeth only: D7111.

For both primary and permanent teeth the following codes can be submitted: D7140, D7210, D7220, D7230, D7240, D7241, D7250, D7285, D7286, and D7510.

Permanent Teeth Upper Arch

Tooth #

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Super #

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

Permanent Teeth Lower Arch

Tooth #

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

Super #

82

81

80

79

78

77

76

75

74

73

72

71

70

69

68

67

Primary Teeth Upper Arch

Tooth #

A

B

C

D

E

F

G

H

I

J

Super #

AS

BS

CS

DS

ES

FS

GS

HS

IS

JS

Primary Teeth Lower Arch

Tooth #

T

S

R

Q

P

O

N

M

L

K

Super #

TS

SS

RS

QS

PS

OS

NS

MS

LS

KS

4.2.13Medicaid Dental Benefits, Limitations, and Fee Schedule

For THSteps clients, dental procedure limitations may be waived when all the following have been met. The dental procedure is:

Medically necessary and FFP is available for it.

Prior authorized by the TMHP Dental Director.

Properly documented in the client’s record.

Refer to:  Subsection 4.3, “Documentation Requirements” in this handbook.

For ICF-IID clients, services designated as CCP-type are available. In the Limitations column of the fee schedule, abbreviations indicate the age range limitations and documentation requirements. The following abbreviations also appear in a table at the bottom of each page of the fee schedule:

Acronym

Description

A

Age range limitations

CCP

Payable under CCP for clients who are 20 years of age and younger when THSteps benefits or limits are exceeded

DOS

Date of service

FMX

Intraoral radiographs—complete series

MTID

Missing tooth ID(s)

N

Narrative of medical necessity for the procedure must be retained in the client’s record

NC

Not reimbursed by Medicaid. Services may not be charged to the client.

PATH

Pathology report must accompany the claim and must be retained in the client’s record

PC

Periodontal charting must be retained in the client’s record

PHO

Preoperative and postoperative photographs required and must be maintained in the client’s medical record

PPXR

Preoperative and postoperative radiographs are required when the procedure is performed and must be retained in the client’s record; do not send with initial claims

PXR

Preoperative radiographs are required when the procedure is performed and must be retained in the client’s record; do not send with initial claims

4.2.14Restorative Services

Procedure Code

Limitations

Amalgam Restorations (Including Polishing)

D2140*

A Birth–20, PXR

D2150*

A Birth–20, PXR

D2160*

A 1–20, PXR

D2161*

A 1–20, PXR

Resin-Based Composite Restorations—Direct

Resin restoration includes composites or glass ionomer.

D2330*

TID #C–H, M–R, 6–11, 22–27. A Birth–20, PXR

D2331*

TID #C–H, M–R, 6–11, 22–27. A Birth–20, PXR

D2332*

TID #C–H, M–R, 6–11, 22–27. A 1–20, PXR

D2335*

TID #C–H, M–R, 6–11, 22–27. A 1–20, PXR

D2390*

A Birth–20, PXR

D2391*

A Birth–20, PXR

D2392*

A Birth–20, PXR

D2393*

A 1–20, PXR

D2394*

A 1–20, PXR

Inlay/Onlay Restorations (Permanent Teeth only)

For procedure codes D2510 through D2664, inlay/onlay (permanent teeth only), porcelain is allowed on all teeth. Prior authorization is required for all inlays/onlays or permanent crowns. Procedure codes D2543, D2544, D2650 through DD2652 and D2662 through D2664 are payable once per client, per tooth every ten years.

D2510

A 13–20, N, PPXR, CCP

D2520

A 13–20, N, PPXR, CCP

D2530

A 13–20, N, PPXR, CCP

D2542

Same as D2520. A 13–20, N, PPXR, CCP

D2543

All materials accepted. A 13–20, N, PPXR, CCP

D2544

All materials accepted. A 13–20, N, PPXR, CCP

D2650

All materials accepted. A 13–20, N, PPXR, CCP

D2651

All materials accepted. A 13–20, N, PPXR, CCP

D2652

All materials accepted. A 13–20, N, PPXR, CCP

D2662

All materials accepted. A 13–20, N, PPXR, CCP

D2663

All materials accepted. A 13–20, N, PPXR, CCP

D2664

All materials accepted. A 13–20, N, PPXR, CCP

Crowns—Single Restorations Only

For procedure codes D2710 through D2794, single crown restorations (permanent teeth only), the following limitations apply:

Prior authorization is required for codes D2710 through D2794.

Reimbursement for crowns and onlay restorations require submission of post-operative bitewing radiograph(s) (for posterior teeth); post-operative periapical radiograph(s) (for anterior teeth) will need to be submitted with the claim to verify that the restoration meets the standard of care.

Radiographs are reviewed to verify that the restoration meets both medical necessity and standard of care to approve reimbursement.

Reimbursement for crowns and onlay restorations are payable once per client, per tooth every ten years.

Stainless steel crowns and permanent all-metal cast crowns are not reimbursed on anterior permanent teeth (6–11, 22–27).

D2710

All materials accepted. A 13–20, N, PPXR, CCP

D2720

All materials accepted. A 13–20, N, PPXR, CCP

D2721

All materials accepted. A 13–20, N, PPXR, CCP

D2722

All materials accepted. A 13–20, N, PPXR, CCP

D2740

All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.

D2750*

All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.

D2751*

All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.

D2752

All materials accepted. A 13–20, N, PPXR, CCP
Limited to TID #4–13 and 20–29 only.

D2780

A 13–20, N, PPXR, CCP

D2781

A 13–20, N, PPXR, CCP

D2782

A 13–20, N, PPXR, CCP

D2783

Anterior teeth only (#6–11 and 22–27). A 13–20, N, PPXR, CCP

D2790

Posterior teeth only (#1–5, 12–21, and 28–32). All materials accepted. A 13–20, N, PPXR, CCP

D2791*

Posterior teeth only (#1–5, 12–21, and 28–32). All materials accepted. A 13–20, N, PPXR

D2792*

Posterior teeth only (#1–5, 12–21, and 28–32). All materials accepted. A 13–20, N, PPXR, CCP

D2794

A 13–20, N, PPXR, CCP

Other Restorative Services

D2910

A 13–20, PXR

D2915

A 4–20

D2920

A 1–20, PXR

D2930*

A Birth–20, PXR

D2931*

A 1–20, PXR

D2932*

A 1–20, PXR (primary tooth)

D2933*

Limited to anterior primary teeth only (TID #C–H, M–R).
A Birth–20, N, CCP, PXR

D2934*

Limited to anterior primary teeth only (TID #C–H, M–R).
A Birth–20, N, CCP, PXR

D2940*

Not allowed on the same date as permanent restoration.
A Birth–20, PXR

D2950*

Provider payments received in excess of $45.00 for restorative work performed within six months of a crown procedure on the same tooth will be deducted from the subsequent crown procedure reimbursement. Not allowed on primary teeth. A 4–20, N, CCP, PXR

D2951

Not allowed on primary teeth.
A 4–20, PXR

D2952

Not payable with D2950. Not allowed on primary teeth.
A 13–20, CCP, PXR

D2953

Must be used with D2952. Not allowed on primary teeth.
A 13–20

D2954*

Not payable with D2952 or D3950 on the same TID by the same provider. Not allowed on primary teeth. A 13–20, N, CCP, PXR

D2955

For removal of posts (for example, fractured posts) not to be used in conjunction with endodontic retreatment (D3346, D3347, D3348). Not allowed on primary teeth. A 4–20, CCP, PXR

D2957

Must be used with D2954. Not allowed on primary teeth.
A 13–20, PXR, CCP

D2960

A 13–20, N, PPXR, CCP

D2961

A 13–20, N, PPXR, CCP

D2962

A 13–20, N, PPXR, CCP

D2971*

May be reimbursed up to four services per lifetime for each tooth. Payable to any THSteps dental provider who performed the original cementation of the crown. A 13–20

D2980

A 1–20, PXR (permanent teeth only)

D2999

A 1–20, N, CCP, PXR

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

 

4.2.15Endodontics Services

Therapeutic pulpotomy (procedure code D3220) and apexification and recalcification procedures (procedure codes D3351, D3352, and D3353) are considered part of the root canal (procedure codes D3310, D3320, and D3330) or retreatment of a previous root canal (procedure codes D3346, D3347, and D3348). When therapeutic pulpotomy or apexification and recalcification procedures are submitted with root canal codes, the reimbursement rate is adjusted to ensure that the total amount reimbursed does not exceed the total dollar amount allowed for the root canal procedure.

Reimbursement for a root canal includes all appointments necessary to complete the treatment. Pulpotomy and radiographs performed pre, intra, and postoperatively are included in the root canal reimbursement.

Root canal therapy that has only been initiated, or taken to some degree of completion, but not carried to completion with a final filling, may not be submitted as a root canal therapy code. It must be submitted using code D3999 with a narrative description of what procedures were completed in the root canal therapy.

Documentation supporting medical necessity must be kept in the client’s record and include the following: the medical necessity as documented through periapical radiographs of tooth treated showing pre-treatment, during treatment, and post-treatment status; the final size of the file to which the canal was enlarged; and the type of filling material used. Any reason that the root canal may appear radio­graphically unacceptable must be documented in the client’s record.

If the client is pregnant and does not want radiographs, use alternative treatment (temporary) until after delivery.

Procedure Code

Limitations

Pulp Capping

Procedure codes D3110 and D3120 will not be reimbursed when submitted with the following procedure codes for the same tooth, for the same DOS, by the same provider: D2952, D2953, D2954, D2955, D2957, D2980, D2999, D3220, D3230, D3240, D3310, D3320, or D3330.

D3110

A 1–20, N, PXR, CCP

D3120

A 1–20, N, PXR, CCP

Pulpotomy

D3220*

Denied when performed within six months of D3230, D3240, D3310, D3320, or D3330 for the same primary TID, same provider. Denied when performed within six months of D3310, D3320, or D3330 on the same permanent TID, same provider. A Birth–20, PXR.

Limited to once per lifetime, per primary tooth (TIDs A-T). Re-treatment claims for an incomplete pulpotomy performed by a dentist not associated with the original treating dentist or dental group will be considered for reimbursement upon appeal. Documentation of medical necessity and the incomplete initial pulpotomy must be submitted with the appeal. The appeal must include a written narrative and pre- and post-treatment X-rays, which will be reviewed by a Texas licensed dentist.

Note:The identified, original treating dentist or dental group will not be considered for reimbursement.

Endodontic Therapy on Primary Teeth

D3230*

Anterior primary incisors and cuspids.
TIDs #C–H, M–R. A 1–20, PXR

D3240*

Posterior first and second molars.
TIDs #A, B, I, J, K, L, S, T. A 1–20, PXR

Endodontic Therapy (including Treatment Plan, Clinical Procedures, and Follow-up Care)

D3310*

A 6–20, PPXR

D3320*

A 6–20, PPXR

D3330*

A 6–20, PPXR

Endodontic Retreatment

D3346*

A 6–20, PPXR

D3347*

A 6–20, PPXR

D3348*

A 6–20, PPXR

Apexification/Recalcification Procedures

D3351*

A 6–20, N, PXR, CCP

D3352*

A 6–20, N, PXR, CCP

D3353*

A 6–20, PPXR, CCP

Apicoectomy/Periradicular Services

D3410

A 6–20, N, PPXR, CCP

D3421

A 6–20, N, PPXR, CCP

D3425

A 6–20, N, PPXR, CCP

D3426

A 6–20, N, PPXR, CCP

D3430

A 6–20, N, PPXR, CCP

D3450

A 6–20, N, PXR, CCP

D3460

Prior authorization required. Submit request with periapical radiographs, for each tooth involved. A 16–20, N, PPXR, CCP

D3470

A 6–20, N, PXR, CCP

Other Endodontic Procedures

D3910

A 1–20, N, CCP

D3920

A 6–20, N, PXR, CCP

D3950

A 6–20, N, PXR, CCP

D3999

A 1–20, N, PXR, CCP

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.16Periodontal Services

Procedure codes D4210 and D4211, when submitted for clients who are 12 years of age and younger, will be initially denied, but may be appealed with documentation of medical necessity. Preoperative and postoperative photographs are required for the following procedure codes: D4210, D4211, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4355, and D4910.

Procedure codes D4283 and D4285 are limited to three teeth per site, same day same provider. Procedure code D4283 must be billed along with procedure code D4273 and procedure code D4285 must be billed along with procedure code D4275.

Preoperative and postoperative photographs are required when medical necessity is not evident on radiographs for the following procedure codes: D4240, D4241, D4245, D4266, and D4267. Documen­tation is required when medical necessity is not evident on radiographs for the following procedure codes: D4210, D4211, D4240, D4241, D4245, D4266, D4267, D4270, D4273, D4275, D4276, D4277, D4278, D4283, D4285, D4355, and D4910.

Procedure code D4278 must be billed on the same date of service as procedure code D4277 or the service will be denied.

Full mouth debridement (procedure code D4355) will be denied when submitted for the same date of service as the following procedure codes by any provider:

Procedure Codes

D4210

D4211

D4230

D4231

D4240

D4241

D4245

D4249

D4260

D4261

D4266

D4267

D4270

D4273

D4274

D4275

D4276

D4277

D4278

D4283

D4285

D4320

D4321

D4381

D4910

D4920

D4999

Claims for preventive dental procedure codes D1110, D1120, D1206, D1208, D1351, and D1352 will be denied when submitted for the same DOS as any D4000 series periodontal procedure codes.

Procedure codes D4266 and D4267 may be appealed with documentation of medical necessity. Medical necessity for third molar sites are:

Medical or dental history documenting need due to inadequate healing of bone following third molar extraction, including the date of third molar extraction.

Secondary procedure several months postextraction.

Position of the third molar preoperatively.

Postextraction probing depth to document continuing bony defect.

Postextraction radiographs documenting continuing bony defect.

Bone graft and barrier material used.

Medical necessity for other than third molar sites are:

Medical or dental history documenting comorbid condition (e.g., juvenile diabetes, cleft palate, avulsed tooth or teeth, traumatic oral injuries).

Intra- or extra-oral radiographs of treatment site(s).

If not radiographically evident, intraoral photographs are optional unless requested preoperatively by HHSC or its agent.

Periodontal probing depths.

Number of intact walls associated with an angular bony defect.

Bone graft and barrier material used.

Procedure Code

Limitations

Surgical Services (Including Usual Postoperative Care)

D4210

A 13–20, N, PPXR, PHO, CCP

D4211

A 13–20, N, PHO, CCP

D4230

A 13–20, N, PHO, PXR, CCP

D4231

A 13–20, N, PHO, PXR, CCP

D4240

A 13–20, N, FMX, PXR, PHO when medical necessity is not evident on radio­graphs, PC, CCP

D4241

Limited to once per year. A 13–20, N, FMX, PXR, PHO when medical necessity is not evident on radiographs, PC

D4245

Per quadrant. A 13–20, N, PXR, PHO when medical necessity is not evident on radiographs, CCP

D4249

A six- to eight-week healing period following crown lengthening before final tooth preparation, impression making, and fabrication of a final restoration is required for claims submission of this code. A 13–20, N, PPXR, CCP

D4260

A 13–20, N, FMX, PXR, PC, CCP

D4261

Limited to once per year. A 13–20, N, FMX, PXR, PC

D4266

A 13–20, N, PXR, PHO when medical necessity is not evident on radiographs, CCP

D4267

A 13–20, N, PXR, PHO when medical necessity is not evident on radiographs, CCP

D4270

A 13–20, N, PXR, PHO, CCP

D4273

This procedure is performed to create or augment gingiva, to obtain root coverage or to eliminate frenum pull, or to extend the vestibular fornix. A 13–20, N, PXR, PHO, CCP

D4274

This procedure is performed in an edentulous area adjacent to a periodontally involved tooth. Gingival incisions are used to allow removal of a tissue wedge to gain access and correct the underlying osseous defect and to permit close flap adaptation.
A 13–20, N, PXR, CCP

D4275

Limited to once per day. A 13–20, PXR, PHO

D4276

Prior authorization is required. Not payable in addition to D4273 or D4275 for the same DOS. A 13–20, PXR, PHO

D4277

A 13-20, N, PXR, PHO, CCP

D4278

A 13-20, N, PXR, PHO, CCP

D4283

A 13-20, N, PHO

D4285

A 13-20, N, PHO

Nonsurgical Periodontal Services

D4320

A 1–20, PXR

D4321

A 1–20, PXR

D4341*

Prior authorization is required. Denied when submitted on the same date of service as D4355. Denied when submitted for the same DOS as other D4000 series codes or with D1110, D1120, D1206, D1208, D1351, D1510, D1515, D1520, or D1525.
A 13–20, FMX, PC, N, CCP

D4342

Prior authorization is required. Denied when submitted on the same date of service as D4355. Denied when submitted for the same DOS as other D4000 series codes or with D1110, D1120, D1206, D1208, D1351, D1510, D1515, D1520, or D1525.
A 13–20, PC, FMX, N

D4355*

Denied when submitted for the same DOS as other D4000 series codes or with D1110, D1120, D1206, D1208, D1351, D1510, D1515, D1520, or D1525.
A 13–20, N, PXR, PHO, CCP

D4381

This procedure does not replace conventional or surgical therapy required for debridement, respective procedures, or regenerative therapy. The use of controlled-release chemotherapeutic agents is an adjunctive therapy or for cases in which systemic disease or other factors preclude conventional or surgical therapy.
A 13–20, N, PXR, CCP

Other Periodontal Services

D4910

Payable only following active periodontal therapy by any provider as evidenced either by a submitted claim for procedure code D4240, D4241, D4260, or D4261 or by evidence through client records of periodontal therapy while not Medicaid-eligible. Not payable within 90 days after D4355, not payable for the same DOS as any other evaluation procedure. Limited to once per 12 calendar months by the same provider.
A 13–20, N, PXR, PHO, CCP

D4920

A 13–20, N, PXR, CCP

D4999

A 13–20, N, PXR, CCP

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC= No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.17Prosthodontic (Removable) Services

Procedure Code

Limitations

Complete Dentures (Including Routine Post Delivery Care)

D5110

A 3–20, PXR

D5120

A 3–20, PXR

D5130

A 13–20, N, PXR, CCP

D5140

A 13–20, N, PXR, CCP

Partial Dentures (Including Routine Post Delivery Care)

D5211*

A 6–20, PXR, MTID

D5212*

A 6–20, PXR, MTID

D5213

A 9–20, N, PXR, MTID, CCP

D5214

A 9–20, N, PXR, MTID, CCP

D5281*

A 9–20, N, PXR, MTID, CCP

Adjustments to Dentures

D5410

A 3–20, PXR

D5411

A 3–20, PXR

D5421

A 6–20, PXR

D5422

A 6–20, PXR

Repairs to Complete Dentures

D5510

Cost of repairs cannot exceed replacement costs. A 3–20, PXR

D5520

Cost of repairs cannot exceed replacement costs. A 3–20, PXR

Repairs to Partial Dentures

Cost of repairs cannot exceed replacement costs. The laboratory portion of the claim, not to exceed $137.50, must be submitted.

D5610*

A 3–20, PXR

D5620

A 6–20, PXR

D5630*

A 6–20, PXR

D5640*

A 6–20, PXR

D5650*

A 6–20, PXR

D5660*

A 6–20, PXR

D5670*

Will be denied as part of procedure codes D5211, D5213, D5281, and D5640. A 6–20

D5671*

Will be denied as part of procedure codes D5212, D5214, D5281, and D5640. A 6–20

Denture Rebase Procedures

D5710

A 4–20, PXR

D5711

A 4–20, PXR

D5720*

A 7–20, PXR

D5721*

A 7–20, PXR

Denture Reline Procedures

Allowed whether or not the denture was obtained through THSteps or ICF-IID dental services if the reline makes the denture serviceable.

D5730

A 4–20, N, PXR, CCP

D5731

A 4–20, N, PXR, CCP

D5740*

A 7–20, N, PXR, CCP

D5741*

A 7–20, N, PXR, CCP

D5750

A 4–20, PXR

D5751

A 4–20, PXR

D5760*

A 7–20, PXR

D5761*

A 7–20, PXR

Interim Prosthesis

D5810

A 3–20, N, PXR, CCP

D5811

A 3–20, N, PXR, CCP

D5820

A 3–20, N, PXR, CCP

D5821

A 3–20, N, PXR, CCP

Other Removable Prosthetic Services

D5850

A 3–20, N, PXR, CCP

D5851

A 3–20, N, PXR, CCP

D5862

A 4–20, N, PXR, CCP

D5863

A 4-20, N, PXR, CCP

D5864

A 4-20, N, PXR, CCP

D5865

A 4-20, N, PXR, CCP

D5866

A 4-20, N, PXR, CCP

D5899

A 1–20, N, PXR, CCP

Maxillofacial Prosthetics

D5911

A 1–20, N, PXR, CCP

D5912

A 1–20, N, PXR, CCP

D5913

A 1–20, N, PXR, CCP

D5914

A 1–20, N, PXR, CCP

D5915

A 1–20, N, PXR, CCP

D5916

A 1–20, N, PXR, CCP

D5919

A 1–20, N, PXR, CCP

D5922

A 1–20, N, PXR, CCP

D5923

A 1–20, N, PXR, CCP

D5924

A 1–20, N, PXR, CCP

D5925

A 1–20, N, PXR, CCP

D5926

A 1–20, N, PXR, CCP

D5927

A 1–20, N, PXR, CCP

D5928

A 1–20, N, PXR, CCP

D5929

A 1–20, N, PXR, CCP

D5931

A 1–20, N, PXR, CCP

D5932

A 1–20, N, PXR, CCP

D5933

A 1–20, N, PXR, CCP

D5934

A 1–20, N, PXR, CCP

D5935

A 1–20, N, PXR, CCP

D5936

A 1–20, N, PXR, CCP

D5937

Not for temporo-mandibular dysfunction (TMD) treatment.
A 1–20, N, PXR, CCP

D5951

Prior authorization. A Birth–20, N, PXR

D5952

Prior authorization. A Birth–20, N, PXR

D5953

Prior authorization. A 13–20, N, PXR

D5954

Prior authorization. A Birth–20, N, PXR

D5955

Prior authorization. A Birth–20, N, PXR

D5958

Prior authorization. A Birth–20, N, PXR

D5959

Prior authorization. A Birth–20, N, PXR

D5960

Prior authorization. A Birth–20, N, PXR

D5982

A 1–20, N, PXR, CCP

D5983

A 1–20, N, PXR, CCP

D5984

A 1–20, N, PXR, CCP

D5985

A 1–20, N, PXR, CCP

D5986

A 1–20, N, PXR, CCP

D5987

A 1–20, N, PXR, CCP

D5988

A 1–20, N, PXR

D5992*

 

D5993*

 

D5999

A 1–20, N, PXR, CCP

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC= No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.18Implant Services

Implant services require prior authorization.

Refer to:  Subsection 4.2.30, “Mandatory Prior Authorization” in this handbook for documentation requirements.

Periapical radiographs are required for each tooth involved in the authorization request. The criteria used by the TMHP Dental Director are:

At least one abutment tooth requires a crown (based on traditional requirements of medical necessity and dental disease).

Space cannot be filled with removable partial denture.

The purpose is to prevent the drifting of teeth in all dimensions (anterior, posterior, lateral, and the opposing arch).

4.2.19Prosthodontic (Fixed) Services

Prosthodontic procedure codes require prior authorization.

Refer to:  Subsection 4.2.30, “Mandatory Prior Authorization” in this handbook for documentation requirements.

Periapical radiographs are required for each tooth involved in the authorization request. The criteria used by the TMHP Dental Director are:

At least one abutment tooth requires a crown (based on traditional requirements of medical necessity and dental disease).

The space cannot be filled with a removable partial denture.

The purpose is to prevent the drifting of teeth in all dimensions (anterior, posterior, lateral, and the opposing arch).

Each abutment or each pontic constitutes a unit in a bridge.

Porcelain is allowed on all teeth.

Procedure Code

Limitations

Fixed Partial Dental Pontics

D6210

A 16–20, PPXR, MTID, CCP

D6211

A 16–20, PPXR, MTID, CCP

D6212

A 16–20, PPXR, MTID, CCP

D6240

A 16–20, PPXR, MTID, CCP

D6241

A 16–20, PPXR, MTID, CCP

D6242

A 16–20, PPXR, MTID, CCP

D6245

A 16–20, PPXR, MTID, CCP

D6250

A 16–20, PPXR, MTID, CCP

D6251

A 16–20, PPXR, MTID, CCP

D6252

A 16–20, PPXR, MTID, CCP

Fixed Partial Dental Retainers—Inlays/Onlays

D6545

A 16–20, PPXR, CCP

D6548

A 16–20, PPXR, CCP

D6549

A 16-20, PPXR, CCP

Fixed Partial Dental Retainers—Crowns

D6720

A 16–20, PPXR, CCP

D6721

A 16–20, PPXR, CCP

D6722

A 16–20, PPXR, CCP

D6740

A 16–20, PPXR, CCP

D6750

A 16–20, PPXR, CCP

D6751

A 16–20, PPXR, CCP

D6752

A 16–20, PPXR, CCP

D6780

A 16–20, PPXR, CCP

D6781

A 16–20, PPXR, CCP

D6782

A 16–20, PPXR, CCP

D6783

A 16–20, PPXR, CCP

D6790

Permanent posterior teeth only. A 16–20, PPXR, CCP

D6791

Permanent posterior teeth only. A 16–20, PPXR, CCP

D6792

Permanent posterior teeth only. A 16–20, PPXR, CCP

Other Fixed Partial Dental

D6920

A 16–20, PXR, CCP

D6930

A 16–20, PXR, CCP

D6940

A 16–20, N, PXR, CCP

D6950

A 16–20, N, PXR, CCP

D6980

A 16–20, N, PXR, CCP

D6999

A 16–20, N, PXR, CCP

A=Age range limitations, N=Narrative required, FMX=Full–mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.20Oral and Maxillofacial Surgery Services

All oral surgery procedures include local anesthesia, suturing, if needed, and visits for routine postoper­ative care.

Procedure Code

Limitations

D7111

TIDs #A–T and AS–TS. A Birth–20

D7140*

Replaces procedure codes D7110, D7120, and D7130.
A Birth–20, PXR

Surgical Extractions

D7210*

Includes removal of the roots of a previously erupted tooth missing its clinical crown. A 1–20, PXR

D7220*

A 1–20, PXR

D7230*

A 1–20, PXR

D7240

A 1–20, PXR

D7241

Document unusual circumstance. A 1–20, N, PXR

D7250*

Involves tissue incision and removal of bone to remove a permanent or primary tooth root left in the bone from a previous extraction, caries, or trauma. Usually some degree of soft or hard tissue healing has occurred. A 1–20, N, PXR

Other Surgical Procedures

D7260

Requires prior authorization. A 1–20, N, PXR; TIDs #1–16 only.

D7261

May not be paid for the same DOS as D7260; TIDs #1–16 only.
A 1–20

D7270*

A 1–20, N, PXR, CCP

D7272

Requires prior authorization. A 1–20, N, PXR, CCP

D7280

A 1–20, N, PXR

D7282

Permanent TIDs #1–32 only; may not be paid for the same DOS as D7280. A 4–20

D7283

A 1–20

D7285

A 1–20, PXR, PATH, CCP

D7286*

A 1–20, PXR, PATH, CCP

D7290

A 1–20, N, PXR, CCP

D7291

A 4–20, N, PXR, CCP

Alveoloplasty—Surgical Preparation of Ridge for Dentures

D7310

A 1–20, N, PXR, CCP

D7320

A 1–20, N, PXR, CCP

Vestibuloplasty

D7340

A 1–20, N, PXR, CCP

D7350

A 1–20, N, PXR, CCP

Surgical Excision of Soft Tissue Lesions

D7410

A 1–20, PXR, PATH

D7411

A 1–20, PXR, PATH

D7413

The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

D7414

The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

Surgical Excision of Intraosseous Lesions

D7440

The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

D7441

The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

D7450

The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

D7451

The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

D7460

The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A Birth–20, N, PXR, PATH, CCP

D7461

The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A Birth–20, N, PXR, PATH, CCP

D7465

The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A 1–20, N, PXR, PATH, CCP

Excision of Bone Tissue

D7472

Prior authorization is required. A 1–20

Surgical Incision

D7510*

TID required. A 1–20, PXR

D7520

A 1–20, N, PXR, CCP

D7530

A 1–20, N, PXR

D7540

A 1–20, N, PXR

D7550*

A 1–20, N, PXR

D7560

A 1–20, N, PXR, CCP

D7670

A 1–20, N, PXR, CCP

Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions

D7820

A 1–20, N, PXR

D7880

A 1–20, N, PXR, CCP

D7899

A 1–20, N, PXR, CCP

Repair of Traumatic Wounds

D7910*

A 1–20, N, PXR, CCP

Complicated Suturing

D7911

A 1–20, N, PXR, CCP

D7912

A 1–20, N, PXR, CCP

Other Repair Procedures

D7955

A 1–20

D7960

A 1–20, N, PXR, CCP

D7970*

A 1–20, N, PXR, CCP

D7971*

A 1–20, N, PXR, CCP

D7972

TIDs #1, 16, 17, and 32 only; may not be paid in addition to D7971 for the same DOS. A 13–20

D7980

A 1–20, N, PXR, CCP

D7983

A 1–20, N, PXR, CCP

D7997*

Per arch, appliance removal (not by the dentist who placed the appliance). Includes removal of arch bar. Prior authorization is required. A 1–20, N, PXR, CCP

D7999*

A 1–20, N, PXR, CCP

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.21* Adjunctive General Services

Procedure Code

Limitations

Unclassified Treatment

D9110*

Refer to:  Subsection 4.2.21.1, “Benefit Limitations for Adjunctive General Services” in this handbook for benefit limitations.

Emergency service only. The type of treatment rendered and TID must be indicated. It must be a service other than a prescription or topical medication. The reason for emergency and a narrative of the procedure actually performed must be documented and the appropriate block for emergency must be checked. Refer to subsection 4.2.28, “Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger” in this handbook

D9120

 A 13-20, N, PXR

Anesthesia

Refer to:  Criteria for Dental Therapy Under General Anesthesia on the TMHP website at www.tmhp.com for general anesthesia criteria and additional information.

D9210

Claim form narrative must describe the situation if used as a diagnostic tool. Denied if submitted with D9248. A 1–20, N, CCP

D9211*

Denied if submitted with D9248. A 1–20, N, CCP

D9212*

Denied if submitted with D9248. A 1–20, N, CCP

D9223

Limited to three hours per day. Prior authorization is required. Denied if submitted with D9248. Dental anesthesiologists are reimbursed at an enhanced rate if the provider has a Level 4 permit, TSBDE portability permit, and proof of an anesthesiology residency recognized by the American Dental Board of Anesthesiology on file with TMHP. Providers who do not have the TSBDE porta­bility permit and proof of anesthesiology residency on file with TMHP will still be eligible for reimbursement. A 1–20

D9230*

May not be submitted more than one per client, per day. Denied if submitted with D9248. A 1–20.

D9243

May be considered for reimbursement for conscious sedation services. Limited to one and one-half hours per day. Denied if submitted with D9248. A 1–20

D9248*

May be submitted twice within a 12-month period. Must comply with all TSBDE rules and AAPD guidelines, including maintaining a current permit to provide non-intravenous (IV) conscious sedation. Denied if submitted with D9420, any provider. A 1–20

Professional Consultation

D9310

An oral evaluation by a specialist of any type who is also providing restorative or surgical services must be submitted as D0160.
A 1–20, N, CCP

Professional Visits

D9410

Narrative required on claim form. A 1–20, N

D9420

Limited to twice per rolling year, per client, any provider. Documentation supporting the medical necessity of a dental hospital call, including any medical, physical, (e.g.,traumatic event), mental or behavioral disability, and a description of the service performed that requires a hospital call must be retained in the client’s dental record and will be subject to retrospective review. Charts are subject to retrospective review. A 1–20, N

D9430

During regularly scheduled hours, no other services performed. Visits for routine postoperative care are included in all therapeutic and oral surgery fees. A 1–20, N

D9440

Visits for routine postoperative care are included in all therapeutic and oral surgery fees. A 1–20, N

Drugs

Procedure code D9630 is not payable for take home fluorides or drugs. Prescriptions should be given to clients to be filled by the pharmacy for these medications as the pharmacy is reimbursed by the Medicaid Vendor Drug Program. Procedure code D9630 is payable for medications (antibiotics, analgesics, etc.) administered to a client in the provider’s office. Documentation of dosage and route of administration must be provided in the Remarks section of the claim.

Refer to:   “Appendix B: Vendor Drug Program” (Vol. 1, General Information).

D9610

May not be submitted with code D9248. A 1–20, N

D9612

A 13-20, N, PXR

D9630

Includes, but is not limited to, oral antibiotics, oral analgesic, and oral sedatives administered in the office. May not be submitted with codes D9230, D9241, D9248, D9610, and D9920. A 1–20, N

Miscellaneous Services

D9910

Per whole mouth application, does not include fluoride. Not to be used for bases, liners, or adhesives under or with restorations. Limited to once per year. A 18–20, N, CCP

D9920

The provider must indicate the client’s medical diagnosis of intellectual disability described as mild, moderate, severe, profound, or unspecified by using the most appropriate diagnosis code in the diagnosis code field of the claim form, or the provider must indicate that the client is ICF-IID eligible in the Remarks field of the claim form.

Documentation supporting the medical necessity and appropriateness of dental behavior management must be retained in the client’s chart and available to state agencies upon request, and is subject to retrospective review. Documentation of medical necessity must include:

A current physician statement detailing the client’s the intellectual disability. The statement must be signed and dated within one year prior to the dental behavior management.

A description of the service performed (including the specific problem and the behavior management technique applied).

Personnel and supplies required to provide the behavioral management.

The duration of the behavior management (including session start and end times).

Dental behavior management is not reimbursed with an evaluation, prophylactic treatment, or radiographic procedure. Denied if submitted with D9248. A 1–20

D9930*

Prior authorization is required. A 1–20, N

D9940

A 13–20, N, CCP

D9950

A 13–20, N, CCP

D9951

Full mouth procedure. Limited to once per year, per client, any provider. A 13–20, N, CCP

D9952

Full mouth procedure. Payable once per lifetime, any provider. A 13–20, N, CCP

D9970

One service per day, any provider. A 13–20

D9974*

Claim must include documentation of medical necessity. A 13–20, CCP

D9999*

A 1–20, N, CCP, PPXR

A=Age range limitations, N=Narrative required, FMX=Full-mouth radiographs (nonpanoramic), MTID=Missing tooth ID(s), PPXR=Preoperative and postoperative radiographs required, PXR=Preoperative radiographs required, PHO=Preoperative and postoperative photographs required, PC=Periodontal charting required, PATH=Pathology report required and must be retained in the client’s record, CCP=Comprehensive Care Program, NC=No charge to Medicaid and may not bill the client, and *= Services payable to an FQHC for a client encounter

4.2.21.1Benefit Limitations for Adjunctive General Services

Procedure code D9110 is a benefit for the following:

Sedative or periodontal dressing

Starting root canal procedure; i.e., open and drain tooth or re-medication of previously opened tooth

Smoothing fractured tooth that is cutting lips or cheek

Debridement or curettage of wound

Excision of operculum over an erupting tooth

Limited gingivectomy

Suture removal by dentist other than the dentist who placed suture(s)

Placement of a temporary crown by other than the patient’s regular dentist and one who is not in the process, has not previously, or does not in the future intend to perform an acrylic, polycar­bonate, stainless steel or cast crown on this same tooth

Tissue conditioning of a full or partial denture

Removal of spontaneously or post-surgically sequested bone spicule

Spot or limited scaling and root planing

Procedures necessary to treat a dry socket

Procedures necessary to control bleeding

Non-surgical reduction of TMJ dislocation

Procedures necessary to relieve pain associated with pericoronitis, particularly third molars

Procedure code D9110 is not a benefit for the following:

A written prescription

Medication given or administered

Application of topical medication to teeth or gums

Occlusal adjustments

Oral hygiene instructions

4.2.22Dental Anesthesia

Dental providers must have the following information on file with TMHP to be eligible for reimbursement for dental anesthesia:

A current anesthesia permit level issued by the TSBDE.

A portability permit from the TSBDE (required to be reimbursed for anesthesia provided in a location other than the provider’s office or satellite office). If the provider does not have a permit, the services will be denied.

Providers must have a Level 4 permit, a TSBDE portability permit, and an anesthesiology residency recognized by the American Dental Board of Anesthesiology to bill the enhanced rate for procedure code D9223.

All dental providers must comply with the American Academy of Pediatric Dentistry (AAPD) guide­lines and TSBDE rules and regulations, including the standards for documentation and record maintenance for dental anesthesia.

4.2.22.1Anesthesia Permit Levels

The following table shows the levels of anesthesia permits that are issued by the TSBDE:

Permit Level

Description of Level

Permit Privileges

Nitrous oxide/oxygen inhalation conscious sedation

 

Stand-alone permit

Level 1

Minimal sedation

Stand-alone permit

Level 2

Moderate enteral

Automatically qualifies for Level 1 and Level 2 permit privileges

Level 3

Moderate parenteral

Automatically qualifies for Level 1, Level 2, and Level 3 permit privileges

Level 4

Deep sedation/general anesthesia

Automatically qualifies for Level 1, Level 2, Level 3, and Level 4 permit privileges

Providers will be reimbursed only for those procedure codes that are covered by their anesthesia permit level. The following table indicates the anesthesia procedure codes and the minimum anesthesia permit level to be reimbursed for the procedure codes:

 

Procedure Codes

Minimum Anesthesia Permit Level

D9211

Level 3

D9212

Level 3

D9223

Level 4

D9230

Stand-alone permit for nitrous oxide/oxygen inhalation conscious sedation or Level 1

D9243

Level 3

D9248

Level 2

Local anesthesia in conjunction with operative or surgical services (procedure code D9215) is all inclusive with any other dental service and is not reimbursed separately.

4.2.22.2Method for Counting Minutes for Timed Procedure Codes

All claims for reimbursement of procedure codes paid in 15-minute increments are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units should be rounded up or down to the nearest quarter hour.

Time intervals for 1 through 12 units are as follows:

Units

Number of Minutes

0 units

0 minutes through 7 minutes

1 unit

8 minutes through 22 minutes

2 units

23 minutes through 37 minutes

3 units

38 minutes through 52 minutes

4 units

53 minutes through 67 minutes

5 units

68 minutes through 82 minutes

6 units

83 minutes through 97 minutes

7 units

98 minutes through 112 minutes

8 units

113 minutes through 127 minutes

9 units

128 minutes through 142 minutes

10 units

143 minutes through 157 minutes

11 units

158 minutes through 172 minutes

12 units

173 minutes through 187 minutes

All levels of sedation must have clinical documentation and a narrative in the client’s dental record to support the necessity of the service. Documentation must include the sedation record that indicates sedation start and end times in accordance with the American Academy of Pediatric Dentistry (AAPD) guidelines. The client’s dental record must be available for review by representatives of HHSC or its designee.

4.2.23Dental Therapy Under General Anesthesia

Providers must comply with TSBDE Rules and Regulations, Title 22 TAC, Part 5, Chapter 110, §§110.6 –110.10. Any anesthesia type services are paid only to the provider. The dental provider is responsible for determining whether a client meets the minimum criteria necessary for receiving general anesthesia. A local anesthesia fee is not paid in addition to other restorative, operative, or surgical procedure fees.

For clients who are six years of age or younger, the following will apply:

All Level 4 sedation/general anesthesia services provided by a dentist (procedure code D9223), and any anesthesia services provided by an anesthesiologist (M.D./D.O.) or certified registered nurse anesthetist (CRNA) to be provided in conjunction with dental therapeutic services (procedure code 00170 with modifier EP) must be prior authorized.

The dentist performing the therapeutic dental procedure is responsible for obtaining prior authori­zation from TMHP and is responsible for providing the anesthesia prior authorization information to the anesthesiology provider.

Prior authorization for both dental services and Level 4 sedation/general anesthesia service is mandatory for the reimbursement of either service.

Dental general anesthesia using procedure code D9223 or 00170 with modifier EP is limited to once per six calendar months per client, by any provider.

Requests for prior authorization must include, but is not limited to, the following client-specific documents and information:

A completed Criteria for Dental Therapy Under General Anesthesia form

A completed THSteps Dental Mandatory Prior Authorization Request Form

The location of where the procedure(s) will be performed (office, inpatient hospital, or outpatient hospital)

A narrative unique to the client, detailing the reasons for the proposed level of anesthesia (indicate procedure code D9223 or 00170). The narrative must include a history of prior treatment, infor­mation about failed attempts at other levels of sedation, behavior in the dental chair, proposed restorative treatment (tooth ID and surfaces), urgent need to provide comprehensive dental treatment based on extent of diagnosed dental caries, and any relevant medical condition(s).

Diagnostic quality radiographs or photographs

Note:When appropriate radiographs or photographs cannot be taken prior to general anesthesia, the narrative must support the reasons for an inability to perform diagnostic services. For special cases that receive authorization, diagnostic quality radiographs or photographs will be required for payment and will be reviewed by the TMHP dental director.

The current process of scoring 22 points on the Criteria for Dental Therapy Under General Anesthesia form does not guarantee authorization or reimbursement for clients who are six years of age and younger.

Note:In cases of an emergency medical condition, accident, or trauma, prior authorization is not necessary. However, a narrative and appropriate pre- and post-treatment radiographs or photographs must be submitted with the claim, which will be reviewed by the TMHP dental director.

A copy of the Criteria for Dental Therapy Under General Anesthesia form must be maintained in the client’s dental record. The client’s dental record must be available for review by representatives of the Health and Human Services Commission (HHSC) or its designee.

Prior authorization is required for medically necessary dental general anesthesia that exceeds once per six months, per client, any provider. The dental provider is responsible for obtaining prior authorization for the services performed under general anesthesia. Hospitals, ASCs, and anesthesiologists must obtain the prior authorization number from the dental provider.

Refer to:  Criteria for Dental Therapy Under General Anesthesia on the TMHP website at www.tmhp.com. Dental rehabilitation or restoration services requiring general anesthesia may be performed in an office, inpatient, or outpatient facility.

Surgical services related to THSteps dental services requiring general anesthesia must be coded as follows:

Procedure code 00170 with modifier EP is for the anesthesiologist or certified registered nurse anesthetist (CRNA) to use on the claim form.

Procedure code 41899 with modifier EP is for the facility to use on the claim form. Procedure code 41899 does not require prior authorization for ASCs and Hospital-based Ambulatory Surgical Centers (HASCs).

An appropriate diagnosis code must be used on the claim form.

Modifier EP identifies that the service is associated with THSteps.

The claim forms used are the CMS-1500 or the UB-04 CMS-1450 paper claim forms. The examining physician, anesthesiologist, hospital, ASC, or HASC must submit claims to TMHP separately for the medical and facility components of their services.

Refer to:  THSteps Dental Mandatory Prior Authorization Request Form on the TMHP website at www.tmhp.com.

4.2.24Hospitalization and ASC/HASC

Dental services performed in an ASC, HASC, or a hospital (either as an inpatient or an outpatient) may be benefits of THSteps based on the medical or behavioral justification provided, or if one of the following conditions exist:

The procedures cannot be performed in the dental office.

The client is severely disabled.

To satisfy the preadmission history and physical examination requirements of the hospital, ASC, or HASC, a THSteps medical checkup for dental rehabilitation or restoration may be performed by the child’s primary care provider. Physicians who are not enrolled as THSteps medical providers must submit claims for the examination of a client before the procedure with the appropriate evaluation and management procedure code from the following table:

Procedure Code

Place of Service (POS)

99202

POS 1 (office)

99222

POS 3 (inpatient hospital)

99282

POS 5 (outpatient hospital)

Refer to:  Subsection 4.2.11.1, “Exceptions to Periodicity” in this handbook.

Note:The dental provider must submit claims to TMHP using the ADA Dental Claim Form to be considered for reimbursement through THSteps Dental Services.

The dental provider is responsible for obtaining prior authorization for the services performed under general anesthesia. Hospitals, ASC’s, and anesthesiologists must obtain the prior authorization number from the dental provider.

Contact the individual HMO for precertification requirements related to the hospital procedure. If services are precertified, the provider receives a precertification number effective for 90 days.

In those areas of the state with Medicaid managed care, the provider should contact the managed care plan for specific requirements or limitations. It is the dental provider’s responsibility to obtain precerti­fication from the client’s HMO or managed care plan for facility and general anesthesia services if precertification is required.

To be reimbursed by the HMO, the provider must use the HMO’s contracted facility and anesthesia provider. These services are included in the capitation rates paid to HMOs, and the facility or anesthe­siologist risk nonpayment from the HMO without such approval. Coordination of all specialty care is the responsibility of the client’s primary care provider. The primary care provider must be notified by the dentist or the HMO of the planned services.

Dentists providing sedation or anesthesia services must have the appropriate current permit from the TSBDE for the level of sedation or anesthesia provided.

The dental provider must be in compliance with the guidelines detailed in General Information.

Note:Post-treatment authorization will not be approved for codes that require mandatory prior authorization.

4.2.25Orthodontic Services (THSteps)

Orthodontic services are a benefit for THSteps clients who are 13 years of age and older who have either permanent dentition and a severe handicapping malocclusion or one of the following special medical conditions:

Cleft palate

Head-trauma injury involving the oral cavity

Skeletal anomalies involving the oral cavity

A severe handicapping malocclusion is defined by Texas Medicaid as dysfunctional masticatory (chewing) capacity as a result of the existing relationship between the maxillary (upper) and mandibular (lower) dental arches or teeth that without correction will result in damage to the temporomandibular joint (s) (TMJ) or other supporting oral structures (e.g., bone, tissues, intra- or extra-oral muscles, etc.).

Exception to the age restriction may be considered for clients who are 12 years of age and younger if medical necessity has been verified by the dental director for one of the following:

Interceptive orthodontic treatment services

Crossbite therapy

Limited orthodontic treatment and minor treatment to control harmful habits

Special medical conditions

Dental services that are not covered by THSteps Dental Services but are medically necessary and allowable may be a benefit under CCP according to federal Medicaid guidelines and TAC.

As required by the Texas Human Resources Code, if the client is 14 years of age and younger and services are not provided by an exempt entity, THSteps dental providers shall require the client to be accom­panied to THSteps dental appointments by a parent, guardian, or other adult who is authorized by the parent or guardian.

Exempt entities (school health clinics, Head Start program, or childcare facilities) that provide services must as a condition of reimbursement:

Obtain written, unrevoked consent for the services from the client’s parent or legal guardian within a one-year period before the date of service.

Encourage parental involvement in and management of the health care of the clients who receive services from the clinic, program, or facility.

The following definitions of dentition established by the ADA’s Current Dental Terminology (CDT) manual are recognized by Texas Medicaid:

Primary Dentition: Teeth developed and erupted first in order of time.

Transitional Dentition: The final phase of the transition from primary to adult teeth, in which the deciduous molars and canines are in the process of shedding and the permanent successors are emerging.

Adolescent Dentition: The dentition that is present after the normal loss of primary teeth and prior to cessation of growth that would affect orthodontic treatment.

Adult Dentition: The dentition that is present after the cessation of growth that would affect ortho­dontic treatment.

The American Association of Orthodontists classification of occlusion or malocclusion is as follows:

Class I: A Class I occlusion exists with the teeth in a normal relationship when the mesialbuccal cusp of the maxillary first permanent molar coincides with the buccal groove of the mandibular first molar.

Class II: A Class II malocclusion occurs when the mandibular teeth are distal or behind the normal relationship with the maxillary teeth. This can be due to a deficiency of the lower jaw or an excess of the upper jaw and therefore, presents two types:

Division I is when the mandibular arch is behind the upper jaw with a consequential protrusion of the upper front teeth.

Division II exists when the mandibular teeth are behind the upper teeth, with a retrusion of the maxillary front teeth. Both of these malocclusions have a tendency toward a deep bite because of the uncontrolled migration of the lower front teeth upwards.

Class III: A Class III malocclusion occurs when the lower dental arch is in front of (mesial to) the upper dental arch. People with this type of occlusion usually have a strong or protrusive chin, which can be due to either horizontal mandibular excess or horizontal maxillary deficiency. Commonly referred to as an underbite.

4.2.25.1Benefits and Limitations for Orthodontic Services

Comprehensive orthodontic services must be provided by a board-eligible or board-certified orthodontist.

Note:Exceptions to a board-eligible or board-certified orthodontist may be considered for clients in a rural or frontier area or where access to care is an issue.

The diagnostic workup is considered part of the pre-orthodontic treatment visit (procedure code D8660). The following procedure codes are used to submit claims for the diagnostic workup:

Diagnostic Workup Procedure Codes

D0330

D0340

D0350

D0470

Comprehensive orthodontic services include all of the following:

Diagnostic workups

Banding

Initial brackets

Replacement brackets

Monthly visits

Initial retainers

Special orthodontic treatment appliance(s)

The following procedure codes are used to submit claims for orthodontic services:

Orthodontic Services Procedure Codes

D8080

D8660

D8670

D8690

Full banding is allowed on permanent dentition only, and treatment should be accomplished in one stage and is limited to once per lifetime.

Exception: Cases of mixed dentition may be considered when the treatment plan includes extractions of remaining primary teeth or in the case of cleft palate.

4.2.25.2Crossbite Therapy

Crossbites (anterior and posterior) are defined by the American Academy of Pediatric Dentistry (AAPD) as malocclusions involving one or more teeth in which the maxillary teeth occlude lingually with the mandibular antagonistic (opposing) teeth. A crossbite can be of a dental or skeletal origin or a combination of both.

The intent of crossbite therapy is to prevent the need for comprehensive orthodontic treatment. This treatment may lessen the severity or future effects of a malformation, eliminate its cause, or may include localized tooth movement.

Crossbite therapy (limited orthodontics) is allowed for primary or transitional dentition. Crossbite therapy will not be considered for transitional dentition when there is a need for full banding of the adult teeth.

Crossbite therapy must be submitted with procedure code D8050 or D8060. Clients with special medical conditions may be considered for interceptive orthodontic services of the primary dentition if the services are medically necessary and submitted with procedure code D8050.

Crossbite therapy is an inclusive charge for treating the crossbite to completion. Adjustments, mainte­nance, diagnostic models, and diagnostic workup procedures are not reimbursed separately.

4.2.25.3Minor Treatment to Control Harmful Habits

Special orthodontic appliances are a benefit for minor treatment to control harmful habits.

Orthodontic appliances for minor treatment to control harmful habits must be submitted with procedure codes D8210, D8220, and D8670.

Monthly adjustments (procedure code D8670) for minor treatment to control harmful habits are limited up to 10 visits.

Claims for panoramic films (procedure code D0330), cephalometric films (procedure code D0340), oral/facial photographic images obtained intraorally or extraorally (procedure code D0350) and diagnostic models (procedure code D0470) will be denied when they are submitted with procedure code D8210 or D8220.

Each orthodontic appliance (procedure code D8210 and D8220) are limited to once per arch, per lifetime.

4.2.25.4Premature Termination of Comprehensive Orthodontic Treatment

Premature termination of comprehensive orthodontic treatment includes the following:

Removal of the brackets and arch wires

Removal of appliances with the fabrication of retainers

Delivery of orthodontic retainers

Documentation of one of the following must be retained for premature termination of comprehensive orthodontic treatment:

Documentation of a lack of cooperation from the client.

Documentation that the client requested premature removal and a release of liability form has been signed by the parent, guardian, or client if he or she is at least 18 years of age.

Premature termination of comprehensive orthodontic treatment must be submitted with procedure code D8680.

Removal of the appliance (procedure code D8680) will be denied if the claim is submitted by any provider on the same date of service as orthodontic treatment (procedure codes D8050, D8060, and D8080).

Providers must keep a copy of the release of liability form on file and are responsible for this documen­tation during a review process.

If premature removal of the appliances is requested before completion of treatment, future orthodontic services may not be considered. The provider must document why the premature removal was necessary.

4.2.25.5Other Orthodontic Services

Replacement brackets (procedure code D8690) are a benefit when the client transfers from one provider to another or when trauma is involved.

Providers are responsible for any replacement brackets that are required as part of the comprehensive orthodontic treatment. Additional reimbursement for replacement brackets (procedure code D8690) is limited to a combined total amount of $100.00, same provider.

Rebonding or recementing of fixed orthodontic appliances (procedure code D8693) may be reimbursed once per lifetime per orthodontic appliance.

Only one retainer per arch per lifetime (procedure code D8680) is allowed; however, each retainer may be replaced with prior authorization once per lifetime due to loss or breakage. Retainer adjustments are not reimbursed separately.

Appliances required as part of the cleft palate treatment plan may be reimbursed separately.

Special orthodontic appliances may be used with full banding and crossbite therapy when approved by the TMHP Dental Director or Associate Dental Director.

4.2.25.6Non-covered Services

Single arch comprehensive orthodontic treatment is not a benefit of Texas Medicaid.

Orthodontic services that are performed solely for cosmetic purposes are not a benefit of Texas Medicaid. Although aesthetics is an important part of self-esteem, services primarily for self-worth are not within the scope of this Texas Medicaid benefit.

Orthodontic services for a client who initiated orthodontic treatment through a private arrangement while Medicaid-eligible are not a benefit of Texas Medicaid.

An initial orthodontic or pre-orthodontic treatment visit (procedure code D8660) is considered part of the exam in an oral evaluation (procedure codes D0120 or D0150).

4.2.25.7Comprehensive Orthodontic Treatment

Comprehensive orthodontic services (procedure code D8080) are restricted to clients who are 13 years of age and older or clients who have exfoliated all primary dentition.

National procedure codes do not allow for any work-in-progress or partial submission of a claim by separating the three orthodontic components: diagnostic workup, orthodontic appliance (upper), or orthodontic appliance (lower).

When submitting claims for comprehensive orthodontic treatment procedure code D8080, three local codes must be submitted as remarks codes along with procedure code D8080. Local codes (procedure codes Z2009, Diagnostic workup approved; Z2011, Orthodontic appliance, upper; or Z2012, Ortho­dontic appliance, lower) must be placed in the Remarks Code field on electronic claims or Block 35 on paper claims.

Note:If the remarks code and procedure code D8080 are not submitted, the claim will be denied.

Each remarks code pays the correct reimbursement rate which, when combined, totals the maximum payment of $775. Procedure code D8080 must be submitted on three separate details, with the appro­priate remarks code, even if the claim submission is for the workup and full banding. Submission of only one detail for a total of $775 will not be accepted.

Example 1: A client is approved for full banding, but after the initial workup, the client discontinues treatment. This provider would submit the national procedure code D8080 and place the local code Z2009, Diagnostic workup approved, in the Remarks/comment field. The claim would pay $175.

Example 2: A client is approved for full banding. The provider continues treatment and places the maxillary bands. The provider would submit the national procedure code D8080 and place the local procedure code Z2009, Diagnostic workup approved, and Z2011, Maxillary bands, in the Remarks/comment field. The claim would pay $475.

All electronic claims for procedure code D8080 must have the appropriate remarks code associated with the procedure code.

Providers must adhere to the following guidelines for electronic claim submission so TMHP can accurately apply the correct remarks code to the appropriate claim detail.

A Diagnostic Procedure Code (DPC) remarks code must be submitted, only once, in the first three bytes of the NTE02 at the 2400 loop.

Example 1: For a claim with one detail, submitted with procedure code D8080 and remarks code Z2009, enter the information as follows: DPCZ2009. The total submitted would be $175.

Example 2: For a claim with two details, where details one and two are procedure code D8080 and the remarks codes are Z2009 and Z2011, enter the information as follows: DPCZ2009Z2011. The total submitted would be $475.

Example 3: For a claim with three details, where all three details are submitted separately with procedure code D8080, enter the remarks code based on the order of the claim detail as follows: DPCZ2009Z2011Z2012. The total submitted would be $775.

This method ensures accurate and appropriate payment for services rendered and addresses the need for submission of a partial claim.

4.2.25.8Orthodontic Procedure Codes and Fee Schedule

When submitting claims for orthodontic procedures, use the following procedure codes:

Procedure Code

Limitations

Orthodontic Services

D0330*, D0340*, D0350*, and D0470*

 

D7280

A 1-20

D7997*

Replaces Z2016. Not payable to the dentist who placed the appliance. Includes removal of arch bar and premature removal of braces. A 1-20

Interceptive Orthodontic Treatment

D8050*

Replaces Z2018 and 8110D. Limited to one per lifetime.

D8060*

Replaces Z2018 and 8120D. Limited to one per lifetime.

Comprehensive Orthodontic Treatment

D8080*

Replaces Z2009, Z2011, and Z2012. Limited to one per lifetime.

Minor Treatment to Control Harmful Habits

D8210*

Refer to subsection 4.2.26, “Special Orthodontic Appliances” in this handbook for associated remarks field code.

D8220*

Refer to subsection 4.2.26, “Special Orthodontic Appliances” in this handbook for associated remarks field code.

Other Orthodontic Services

D8660*

Replaces Z2008. Denied when submitted for the same DOS as D0145 by any provider. Denied when submitted for the same DOS as D0120 or D0150 by the same provider.

D8670*

Replaces Z2013.

D8680*

Replaces Z2014 and Z2015; one retainer per arch per lifetime; may be replaced once because of loss or breakage (prior authorization is required).

D8690*

Bracket replacement.

D8691

Not considered medically necessary.

D8692

Although procedure code D8692 is not a benefit of Texas Medicaid, providers can use procedure code D8680 to submit a claim for retainer(s). Providers must include local code Z2014 or Z2015 on the claim form to indicate upper or lower, as appropriate.

D8693

Limited to once per lifetime per orthodontic appliance.

D8999

 

* = Services payable to an FQHC for a client encounter.

4.2.26Special Orthodontic Appliances

All removable or fixed special orthodontic appliances must be prior authorized. The prior authorization request must include both the national code and remarks code. However, prior authorization requests may omit the DPC prefix to the eight-digit remarks code.

All removable or fixed special orthodontic appliances must be submitted with national procedure code D8210 or D8220. To ensure appropriate claims processing, the DPC remarks code (local procedure code) reflecting the specific service is also required. The appropriate remarks codes must be entered on the prior authorization request form. Failure to follow the following steps will cause the claims to deny. Failure to enter the DPC remarks code and the appropriate procedure code will not result in claim denial; however, manual intervention is required to process the claim, which may result in a delay of payment.

For paper claim submissions, providers must enter the local procedure code in Block 35 (Remarks) of the 2012 ADA claim form.

For electronic submissions, providers enter the DPC remarks code in the Comments field to ensure correct authorization, accurate records, and reimbursement.

For electronic submissions other than TexMedConnect submissions, providers must use the following instructions to ensure that TMHP accurately applies the correct local procedure code to the appropriate claim detail:

The DPC prefix must be submitted, only once, in the first three bytes of the NTE02 at the 2400 loop.

In bytes 4–8, providers must submit the remark code (local procedure code) based on the order of the claim detail. Do not enter any spaces or punctuation between remark codes, unless to designate the detail is not submitted with D8210 or D8220.

Example:For a claim with three details, where details one and three are submitted with procedure code D8210 and detail two is not, enter the following information in the NTE02 at the 2400 loop: DPC1014D 1046D. (The space shows that detail two needs no local code.) If all details require a local code, enter DPC, no spaces, and the appropriate local codes.

To submit using TexMedConnect, providers must enter the local code into the Remarks Code field, located under the details header. The Remarks Code field is the field directly after the Procedure Code field. TexMedConnect submitters are not required to manually enter the DPC prefix as it is placed in the appropriate field on the TexMedConnect electronic claim.

The following table identifies the appropriate DPC remarks codes to use when requesting prior autho­rization or submitting a claim for procedure code D8210 or D8220:

Procedure Code

Remarks Code

Remarks Code Description

Special Orthodontic Appliances

D8220*

DPC1000D

Appliance with horizontal projections

D8220*

DPC1001D

Appliance with recurved springs

D8220*

DPC1002D

Arch wires for crossbite correction (for total treatment)

D8220*

DPC1003D

Banded maxillary expansion appliance

D8210*

DPC1004D

Bite plate/bite plane

D8210*

DPC1005D

Bionator

D8210*

DPC1006D

Bite block

D8210*

DPC1007D

Bite-plate with push springs

D8220*

DPC1008D

Bonded expansion device

D8210*

DPC1010D

Chateau appliance (face mask, palatal exp and hawley)

D8210*

DPC1011D

Coffin spring appliance

D8220*

DPC1012D

Crib

D8210*

DPC1013D

Dental obturator, definitive (obturator)

D8210*

DPC1014D

Dental obturator, surgical (obturator, surgical stayplate, immediate temporary obturator)

D8220*

DPC1015D

Distalizing appliance with springs

D8220*

DPC1016D

Expansion device

D8210*

DPC1017D

Face mask (protraction mask)

D8220*

DPC1018D

Fixed expansion appliance

D8220*

DPC1019D

Fixed lingual arch

D8220*

DPC1020D

Fixed mandibular holding arch

D8220*

DPC1021D

Fixed rapid palatal expander

D8210*

DPC1022D

Frankel appliance

D8210*

DPC1023D

Functional appliance for reduction of anterior openbite and crossbite

D8210*

DPC1024D

Headgear (face bow)

D8220*

DPC1025D

Herbst appliance (fixed or removable)

D8220*

DPC1026D

Inter-occlusal cast cap surgical splints

D8210*

DPC1027D

Intrusion arch

D8220*

DPC1028D

Jasper jumpers

D8220*

DPC1029D

Lingual appliance with hooks

D8220*

DPC1030D

Mandibular anterior bridge

D8220*

DPC1031D

Mandibular bihelix (similar to a quad helix for mandibular expansion to attempt nonextraction treatment)

D8210*

DPC1032D

Mandibular lip bumper

D8220*

DPC1036D

Mandibular lingual 6x6 arch wire

D8210*

DPC1037D

Mandibular removable expander with bite plane (crozat)

D8210*

DPC1038D

Mandibular ricketts rest position splint

D8210*

DPC1039D

Mandibular splint

D8210*

DPC1040D

Maxillary anterior bridge

D8210*

DPC1041D

Maxillary bite-opening appliance with anterior springs

D8220*

DPC1042D

Maxillary lingual arch with spurs

D8220*

DPC1043D

Maxillary and mandibular distalizing appliance

D8220*

DPC1044D

Maxillary quad helix with finger springs

D8220*

DPC1045D

Maxillary and mandibular retainer with pontics

D8210*

DPC1046D

Maxillary Schwarz

D8210*

DPC1047D

Maxillary splint

D8210*

DPC1048D

Mobile intraoral Arch-Mia (similar to a Bihelix for nonextraction treatment)

D8220*

DPC1049D

Modified quad helix appliance

D8220*

DPC1050D

Modified quad helix appliance (with appliance)

D8220*

DPC1051D

Nance appliance

D8220*

DPC1052D

Nasal stent

D8210*

DPC1053D

Occlusal orthotic device

D8210*

DPC1054D

Orthopedic appliance

D8210*

DPC1055D

Other mandibular utilities

D8210*

DPC1056D

Other maxillary utilities

D8220*

DPC1057D

Palatal bar

D8210*

DPC1058D

Post-surgical retainer

D8220*

DPC1059D

Quad helix appliance held with transpalatal arch horizontal projections

D8220*

DPC1060D

Quad helix maintainer

D8220*

DPC1061D

Rapid palatal expander (RPE), such as quad Helix, Haas, or Menne

D8210*

DPC1062D

Removable bite plate

D8210*

DPC1063D

Removable mandibular retainer

D8210*

DPC1064D

Removable maxillary retainer

D8210*

DPC1065D

Removable prosthesis

D8210*

DPC1066D

Sagittal appliance 2 way

D8210*

DPC1067D

Sagittal appliance 3 way

D8220*

DPC1068D

Stapled palatal expansion appliance

D8210*

DPC1069D

Surgical arch wires

D8210*

DPC1070D

Surgical splints (surgical stent/wafer)

D8210*

DPC1071D

Surgical stabilizing appliance

D8220*

DPC1072D

Thumbsucking appliance, requires submission of models

D8210*

DPC1073D

Tongue thrust appliance, requires submission of models

D8210*

DPC1074D

Tooth positioner (full maxillary and mandibular)

D8210*

DPC1075D

Tooth positioner with arch

D8220*

DPC1076D

Transpalatal arch

D8220*

DPC1077D

Two bands with transpalatal arch and horizontal projections forward

D8220*

DPC1078D

Appliance

* = Services payable to an FQHC for a client encounter.

4.2.27Handicapping Labio-lingual Deviation (HLD) Index

The orthodontic provider must complete and sign the HLD Index (Angle classification).

The HLD index requires the use of an HLD score sheet and a Boley gauge for measuring.

Refer to:  The Texas Medicaid Handicapping Labio-Lingual Deviation (HLD) Index Score Sheet on the TMHP website at www.tmhp.com.

Providers should be conservative in scoring. The client must be considered severe handicapping maloc­clusion with dysfunctional masticatory (chewing) capacity as a result of the existing relationship between the maxillary (upper) and mandibular (lower) dental arches and/or teeth that, without correction, will result in damage to the temporomandibular joint(s) (TMJ) and/or other supporting oral structures (e.g., bone, tissues, intra and/or extra oral muscles, etc.) and have a minimum of 26 points on the HLD index to be considered for any orthodontic care other than crossbite correction. “Half-mouth” treatment cannot be approved.

With the client or models in the centric position, the HLD index is to be scored as follows. Record all measurements rounded-off to the nearest millimeter (mm). Enter a score of “0” if the condition is absent.

Cleft Palate

A cleft palate case request for mixed dentition will be considered only if narrative justification supports treatment before the client reaches full dentition.

Note:Intermittent treatment requests may exceed the allowable 26 reimbursable treatment visits.

Severe Traumatic Deviations

Refers to facial accidents only. Points cannot be awarded for congenital deformity. Severe traumatic deviations do not include traumatic occlusions for crossbites.

Overjet in Millimeters

Score the case exactly as measured. The measurement must be recorded from the most protrusive incisor, then subtract 2 mm (considered the norm), and enter the difference as the score.

Overbite in Millimeters

Score the case exactly as measured. The measurement must be recorded from the labio-incisal edge of the overlapped anterior tooth or teeth to the point of maximum coverage, then subtract 3 mm (considered the norm), and enter the difference as the score.

Mandibular Protrusion in Millimeters

Score the client exactly as measured. The measurement must be recorded from the “line of occlusion” of the permanent teeth, not from the ectopically erupted teeth in the anterior segment.

Open Bite in Millimeters

Score the case exactly as measured. Measurement must be recorded from the “line of occlusion” of the permanent teeth, not from the ectopically erupted teeth in the anterior segment. Caution is advised in undertaking treatment of open bites in older teenagers, because of the frequency of relapse.

Ectopic Eruption

An unusual pattern of eruption, such as high labial cuspids or teeth that are grossly out of the long axis of the alveolar ridge.

Ectopic eruption does not include teeth that are rotated or teeth that are leaning or slanted especially when the enamel-gingival junction is within the long axis of the alveolar ridge.

Note:Record the more serious condition. Do not include (score) teeth from an arch if that arch is to be counted in the category of Anterior Crowding. For each arch, either the ectopic eruption or anterior crowding may be scored, but not both.

Anterior Crowding

Arch length insufficiency must exceed 3.5 mm to be considered as crowding in either arch. Mild rotations that may react favorably to stripping or moderate expansion procedures are not to be scored as crowded.

Excessive Anterior Spacing in Millimeters

The score for this category must be the total, in millimeters, of the anterior spaces.

Providers should be conservative in scoring. Liberal scoring will not be helpful in the evaluation and approval of the case. The case must be considered dysfunctional and have a minimum of 26 points on the HLD index to qualify for any orthodontic care other than crossbite correction. Half-mouth cases cannot be approved.

The intent of the program is to provide orthodontic care to clients with handicapping malocclusion to improve function. Although aesthetics is an important part of self-esteem, services that are primarily for aesthetics are not within the scope of benefits of this program.

The proposals for treatment services should incorporate only the minimal number of appliances required to properly treat the case. Requests for multiple appliances to treat an individual arch will be reviewed for duplication of purpose.

If attaining a qualifying score of 26 points is uncertain, providers must include a brief narrative when submitting the case. The narrative may reduce the time necessary to gain final approval and reduce shipping costs incurred to resubmit records.

Providers must properly label and protect all records (especially plaster diagnostic models) when shipping. If plaster diagnostic models are requested by and shipped to TMHP, the provider should assure that the models are adequately protected from breakage during shipping. TMHP will return intact models to the provider.

4.2.28Emergency or Trauma Related Services for All THSteps Clients and Clients Who Are 5 Months of Age and Younger

THSteps clients who are birth through 5 months of age are not eligible for routine dental checkups; however:

They can be seen for emergency dental services by the dentist at any time for trauma, early childhood caries, or other oral health problems.

They may be referred to a dentist by their primary care provider when a medical checkup identifies the medical necessity for dental services.

Prior authorization is not required for emergency or trauma-related dental services. Claims for these dental services must be filed separately from nonemergency dental services. Only one emergency or trauma-related dental claim per client, per day, may be considered for reimbursement. Routine thera­peutic procedures are not considered emergency or trauma-related procedures.

When submitting a claim for emergency or trauma-related dental services, the provider must:

Enter the word “Emergency” or “Trauma” in the description field (Block 30) of the claim form (also enter a brief description of the CDT procedure code used). Claims are subject to retrospective review. If no comments are indicated on the claim form, the payment may be recouped.

If checking the Other Accident box, briefly describe in the Remarks field, Block 35 of the claim form, what caused the emergency or trauma.

Check the appropriate box in Block 45, Treatment Resulting From, of the claim form (the options to check are Occupational Illness/Injury, Auto Accident, or Other Accident).

Documentation to support the diagnosis and treatment of trauma must be retained in the client’s record.

Note:Indicating Trauma in the description field allows the provider to be reimbursed for treatment on an emergency, continuing, and long-term basis without regard to periodicity, subject to the client’s eligibility and program limitations. An exception to periodicity for THSteps dental services is granted automatically for immediate treatment and any future follow-up treatment, as long as each claim submitted for payment is marked “Trauma” in the Description field, Block 30, and the original date of treatment or incident is referenced in the Remarks field, Block 35.

Refer to:  Subsection 6.7, “2012 American Dental Association (ADA) Dental Claim Filing Instruc­tions” in “Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 4.1, “General Medicaid Eligibility” in “Section 4: Client Eligibility” (Vol. 1, General Information).

Subsection 9.3, “Doctor of Dentistry Practicing as a Limited Physician” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Subsection 4.2.13, “Medicaid Dental Benefits, Limitations, and Fee Schedule” in this handbook.

4.2.29Emergency Services for Medicaid Clients Who Are 21 Years of Age and Older

Limited dental services are available for clients who are 21 years of age and older (not residing in an ICF-IID facility) whose dental diagnosis is secondary to and causally related to a life-threatening medical condition.

Refer to:  Subsection 9.3, “Doctor of Dentistry Practicing as a Limited Physician” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for complete description and details.

4.2.29.1Long Term Care (LTC) Emergency Dental Services

DADS provides a limited range of dental services for Medicaid-eligible residents of LTC facilities. All claims for dental services provided to LTC residents are submitted to DADS. For information, providers should contact the appropriate LTC facility or DADS at 1-512-438-2633.

4.2.29.2Laboratory Requirements

Dental laboratories must be registered with TSBDE laboratories, and technicians must not be under restrictions imposed by TSBDE or a court.

4.2.30Mandatory Prior Authorization

Mandatory prior authorization is required for consideration of reimbursement to dental providers who render the following services:

Orthodontia

Implants

Fixed prosthetic services

Removable prosthodontics

Dental general anesthesia

All inlays/onlays or permanent crowns

Procedure code D4276

Procedure code D7272

Procedure code D7472

Limited dental services for clients who are 21 years of age and older (not residing in an ICF-IID facility) whose dental diagnosis is secondary to and causally related to a life-threatening medical condition

Cone beam imaging

Approved orthodontic treatment plans must be initiated before the client’s loss of Medicaid eligibility and before the 21st birthday, and must be completed within 36 months of the authorization date. Autho­rization for other procedures is valid for up to 90 days.

To obtain prior authorization for crowns, onlays, implants, and fixed prosthodontics, a prior authori­zation form together with documentation supporting medical necessity and appropriateness must be submitted. Required documentation includes, but is not limited to:

The THSteps Dental Mandatory Prior Authorization Request Form.

Current, dated, pre-operative periapical radiographs completely showing the apex of the tooth to be treated.

Current, dated, pre-operative full arch radiographs are required for fixed prosthodontics.

Documentation supporting that the mouth is free of disease; no untreated periodontal or endodontic disease, or rampant caries.

Documentation supporting only one virgin abutment tooth; at least one tooth must require a crown unless a Maryland Bridge is being considered.

Provider documentation supporting the medical necessity and appropriateness of the recom­mended treatment.

Tooth Identification (TID) System noting only permanent teeth.

Documentation supporting that a removable partial is not a viable option to fill the space between the teeth.

Prior authorization will not be given when films show two abutment teeth (virgin teeth do not require a crown, except for Maryland Bridge) or there is untreated periodontal or endodontic disease, or rampant caries which would contraindicate the treatment.

Refer to:  Subsection 9.3, “Doctor of Dentistry Practicing as a Limited Physician” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Removable prosthodontics (procedure codes D5951, D5952, D5953, D5954, D5955, D5958, D5959, and D5960) for clients with cleft lip or cleft palate requires prior authorization with a completed THSteps Dental Mandatory Prior Authorization Request Form and narrative documenting the medical need for these appliances. Additional information may be requested by the TMHP Dental Director if necessary before making a determination.

The prior authorization number is required on claims for processing. If the client is not eligible for Medicaid on the DOS or the claim is incomplete, it will affect reimbursement. Prior authorization is a condition for reimbursement; it is not a guarantee of payment.

Note:Post-treatment authorization will not be approved for codes that require mandatory prior authorization.

Refer to:  THSteps Dental Mandatory Prior Authorization Request Form on the TMHP website at www.tmhp.com.

4.2.30.1Cone Beam Imaging

Prior authorization is required for procedure code D0367.

Cone beam imaging is used to determine the best course of treatment for cleft palate repair, skeletal anomalies, post-trauma care, implanted or fixed prosthodontics, and orthodontic or orthognathic procedures. Cone beam imaging is limited to initial treatment planning, surgery, and postsurgical follow up.

To obtain prior authorization, a THSteps Dental Mandatory Prior Authorization Request Form must be submitted with documentation supporting medical necessity and appropriateness. Required documen­tation includes, but is not limited to, the following:

Presenting conditions

Medical necessity

Status of the client’s treatment

4.2.30.2General Anesthesia for Dental Treatment

Prior authorization is required for the use of general anesthesia while rendering treatment (to include the dental service fee, the anesthesia fee, and facility fee) regardless of place of service. A client must meet the minimum requirement of 22 total points on the Criteria for Dental Therapy Under General Anesthesia form.

Refer to:  Criteria for Dental Therapy Under General Anesthesia on the TMHP website at www.tmhp.com.

In those areas of the state with Medicaid Managed Care, precertification or approval is required from the client’s health maintenance organization (HMO) for anesthesia and facility charges. It is the dental provider’s responsibility to obtain precertification from the client’s HMO or managed care plan for facility and general anesthesia services. A medical checkup prior to a dental procedure requiring general anesthesia is considered an exception to THSteps periodicity. A referral to the client’s primary care physician is not required. Prior authorization is available for exceptions to periodicity. Providers must include all appropriate supporting documentation with the submittal. The criteria for general anesthesia applies only to treatment of clients who are 20 years of age and younger or ICF-IID program clients.

4.2.30.3Orthodontic Services

Prior authorization is required for all orthodontic services except for rebonding or recementing of fixed retainers (procedure code D8693). Providers must maintain documentation of medical necessity in the client’s dental record for rebonding or recementing of fixed retainers.

Orthodontic services do not include any related services outside those listed in this section (e.g., extractions or surgeries); however, all services must be included in the orthodontic treatment plan.

Approved orthodontic treatment plans must be initiated before clients lose Medicaid eligibility or reach 21 years of age, and all active orthodontic treatments must be completed within 36 months of the autho­rization date. Services cannot be added or approved after eligibility has expired.

Note:If a client reaches 21 years of age or loses Medicaid eligibility before the authorized ortho­dontic services are completed, reimbursement is provided to complete the orthodontic treatment plan that was authorized and initiated while the client was 20 years of age or younger and eligible for Texas Medicaid as long as the orthodontic treatment plan is completed within the appropriate time frames.

Any non-orthodontic service that is included as part of the treatment plan (extractions or surgeries) must be completed before the client loses eligibility or reaches 21 years of age in order to be reimbursed through Texas Medicaid. Services cannot be added or approved after Texas Medicaid eligibility has expired.

Once prior authorization is obtained, the provider is obligated to advise the client that he or she is able to receive the approved orthodontic service (including monthly orthodontic adjustment visits and retainers) even if the client loses eligibility or reaches his or her 21st birthday.

All requests must be reviewed by the TMHP Dental Director or other state dental contractor’s board-eligible or board-certified orthodontist employee or consultant who is licensed in Texas.

To avoid unnecessary denials, providers must submit correct and complete information, including documentation for medical necessity for the services requested. Providers must maintain documen­tation of medical necessity in the client’s medical record. Requesting providers may be asked for additional information to clarify or complete a request.

A completed Texas Health Steps (THSteps) Dental Mandatory Prior Authorization Request Form must be signed and dated by the performing dental provider. The completed authorization form must include the procedure codes for all services requested along with a written statement of medical necessity for the proposed orthodontic treatment.

All prior authorization requests for orthodontic services must be accompanied by an attestation from the requesting provider that the provider is either a pediatric dentist or orthodontist.

General dentists who are requesting prior authorization for orthodontic services must attest and maintain documentation of a minimum of 200 hours of continuing dental education specifically in orthodontics within the last 10 years; 8 hours can be online or self-instruction.

Proof of the completion of continuing education hours is not required to be submitted with a request for prior authorization of orthodontic services; however, documentation must be produced by the dentist during retrospective review. All attestations are subject to compliance review and orthodontic services may be subject to recoupment.

4.2.30.3.1Initial Orthodontic Services Request

The prior authorization form must include all of the procedures that are required to complete the requested treatment including, but not limited to, the following:

Diagnostic workup

Medically necessary extractions (Tooth ID must be included)

Orthognathic surgery

Upper and lower appliance

Monthly adjustments

Special orthodontic treatment appliances

Placement of banding and brackets

Replacement of brackets

Removal of the brackets and arch wires

Other special orthodontic appliances

Fabrication of special orthodontic appliances

Delivery of orthodontic retainers

Appliance removal (if indicated)

A completed and scored Handicapping Labio-Lingual Deviations (HLD) Index with a diagnosis of Angle class (a minimum of 26 points are required for approval of non-cleft palate cases). If attaining a qualifying score of 26 points is uncertain, a brief narrative should be provided.

Note:A score of a minimum 26 points on the HLD index does not indicate an automatic approval for comprehensive orthodontics. Approval will be based on the diagnostic workup supporting the HLD index. Documentation provided must be reviewed by a qualified board eligible or board certified orthodontist.

When requesting prior authorization, providers must include diagnostic models, radiographs (X-rays), cephalometic X-ray with tracings, photographs, and other supporting documentation with the THSteps Dental Mandatory Prior Authorization Request Form.

All required documents must be submitted together in one package per prior authorization request. Prior authorization requests that are not submitted in one package per request will be considered incomplete.

Note:All documentation submitted with an incomplete request will be sent back to the provider with a letter that indicates the prior authorization request was incomplete. Providers must resubmit prior authorization requests with all the required documentation within 14 business days of the request receipt date, or the request will be denied as “incomplete.”

4.2.30.3.2Diagnostic Tools

Prior authorization requests must include the date of service the diagnostic tools were obtained (the date of service the dental records were produced). All diagnostic tools must be properly labeled and protected when shipped by the provider. If any diagnostic tool is damaged during shipment, the provider may be required to reproduce the documentation for consideration of the case for prior authorization.

Note:If medical necessity cannot be determined from the diagnostic tools that are submitted with the request, the prior authorization request may be denied.

TMHP will be responsible for retaining an image of each diagnostic tool that is submitted for every complete orthodontic prior authorization request.

Copies of diagnostic models, X-rays, and any other paper diagnostic tools will be accepted and are preferred. Copies will not be returned, but providers will be required to maintain the dental records for retrospective review. Originals will be returned to the submitting provider only when the document is clearly marked “original.”

Diagnostic models in the form of plaster casts are preferred; however, providers may choose the positions in which the casts are made. E-models must be in the centric occlusion position.

Radiographs that are submitted must include, but are not limited to, the following:

Panoramic or a full mouth series

Cephalometric with tracings

Photographic images must be submitted with the request and must be in a 1:1 ratio format (actual size), including, but not limited to, the following:

Full face, smiling

Left and right profiles

Full maxillary arch (open mouth view)

Full mandibular arch (open mouth view)

Right side occluded in centric occlusion

Left side occluded in centric occlusion

Anterior occluded in centric occlusion

X-rays must be of diagnostic quality and do not have to be submitted on photographic quality paper.

Submitting providers must attest that radiographs, photographs, and other documentation are unaltered.

4.2.30.3.3Authorization Extensions

Extensions on allowed time frames may be considered no sooner than 60 days before the authorization expires. Extra monthly adjustments (procedure code D8670) will not be prior authorized, but the time frame may be considered for extension not to exceed 36 months of actual treatment. Providers must submit the following:

Diagnostic workup.

Note:Photographs may be substituted for models.

The reason the treatment was not completed in the original time frame.

An explanation of the treatment plan status.

4.2.30.3.4Crossbite Therapy

Requests for crossbite therapy (procedure codes D8050 or D8060) require the submission of diagnostic models to receive authorization. An HLD score sheet is not required for crossbite therapy.

Providers that submit requests for crossbite therapy must maintain documentation in the client’s record that demonstrates the following criteria:

Posterior teeth—Are not end-to-end, but the buccal cusp of the upper teeth is lingual to the buccal cusp of the lower teeth.

Anterior teeth—The incisal edge of the upper teeth are lingual to the incisal edge of the opposing arch.

4.2.30.3.5Minor Treatment to Control Harmful Habits

A THSteps Dental Mandatory Prior Authorization Form must be completed when requesting prior authorization for orthodontic appliances for minor treatment to control harmful habits. Documentation must support medical necessity of any appliance requested.

Providers must submit diagnostic models when requesting prior authorization for a removable appliance or fixed appliance.

Procedure codes D8210 or D8220 may only be approved for control of harmful habits including, but not limited to, thumb sucking or tongue thrusting and may not be prior authorized for services that are related to comprehensive orthodontic services.

4.2.30.3.6Premature Termination of Orthodontic Services

Prior authorization for the premature termination of orthodontic services (procedure code D8680) is required.

Premature termination of orthodontic services includes all of the following:

Removal of the brackets and arch wires.

Other special orthodontic appliances.

Fabrication of special orthodontic appliances.

Delivery of orthodontic retainers.

The prior authorization must include all of the following for consideration:

Panoramic radiograph (copies are preferred).

Cephalometric radiograph with tracing (copies are preferred).

Six intra-oral photographs (copies are preferred).

Three extra-oral photographs (copies are preferred).

A narrative documenting why the provider is terminating the orthodontic services early.

Documentation that the parent, legal guardian, or the client, if he or she is 18 years of age or older or an emancipated minor, understands that the provider is terminating the orthodontic services, and the client is no longer eligible for orthodontic services by Texas Medicaid/THSteps.

In addition to the final record, the provider requesting premature termination of orthodontic services must submit a copy of the signed release form that includes the following:

A signature by one of the following:

The parent

Legal guardian

The client, if he or she is 18 years of age or older or an emancipated minor

One of the following statements:

The client is uncooperative or non-compliant with the treating dentist’s directions and does not intend to complete orthodontic treatment.

The client requested the premature removal of orthodontic appliances and does not intend to complete orthodontic treatment.

Note:A client for whom removal of an appliance has occurred due to the client’s request, or is uncooperative or non-compliant will not be eligible for any additional Medicaid orthodontic services.

The client has requested the premature removal of orthodontic appliances due to extenuating circumstances including, but not limited to, the following:

Incarceration.

Mental health complications with a recommendation from the treating physician.

Foster care placement.

Child of a migrant farm worker. With the intent to complete orthodontic treatment at a later date if Medicaid eligibility for orthodontic services continues.

Special medical conditions.

Note:If comprehensive orthodontic services are terminated due to extenuating circumstances, clients will be eligible for completion of their Medicaid orthodontic services if the services are re-initiated while the client is eligible for Medicaid.

The requesting provider will be responsible for removal of the orthodontic appliances, final records, and fabrication and delivery of orthodontic retainers at the time of premature removal or at any future time should the client present to the treating provider’s office.

4.2.30.3.7Transfer of Services

Prior authorization that is issued to a provider for orthodontic services is not transferable to another provider. The new provider must request a new prior authorization to complete the orthodontic treatment that was initiated by the original provider. The original prior authorization will be end-dated when services are transferred to another provider.

The new provider must obtain his or her own records, and the new request for orthodontic services must include the date of service on which the documentation was obtained (the date of service on which the records were produced) and the following supporting documentation:

All of the documentation that is required for the original request

Note:Photographs may be substituted for models.

The reason the client left the previous provider

An explanation of the treatment status

The authorization request for clients who are undergoing orthodontic treatment services and subse­quently become eligible for Medicaid are subject to the same requirements.

4.2.30.3.8Orthodontic Cases Initiated Through a Private Arrangement

Authorization may be given for continuation of orthodontic cases for clients who initiated orthodontic treatment through a private arrangement before becoming eligible for Medicaid.

Authorization will not be given for continuation of orthodontic cases for clients who initiated ortho­dontic treatment through a private arrangement and were eligible for Medicaid at the start of service.

4.2.31THSteps and ICF-IID Dental Prior Authorization

Submit claims, dental correspondence, and THSteps and ICF-IID prior authorization requests to the appropriate address listed in the following table:

Correspondence

Address

ADA dental claim forms

Texas Medicaid & Healthcare Partnership

PO Box 200555

Austin, TX 78720-0555

All dental correspondence

Prior authorization requests

Texas Medicaid & Healthcare Partnership

Fee-for-Service and ICF-IID Dental Authorizations

PO Box 204206

Austin, TX 78720-4206

4.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including dental services. Dental services are subject to retrospective review and recoupment if documentation does not support the service submitted for payment.

The provider must educate all staff members, including dentists, about the following documentation requirements and charting procedures:

For THSteps and ICF-IID dental claims, providers are not required to submit preoperative and postoperative radiographs unless these are specifically requested by HHSC, the TMHP Dental Director, or are needed for prior authorization or pre-payment review.

Documentation of all restorative, operative, crown and bridge, and fixed and removable prostho­dontics procedures must support the services that were performed and must demonstrate medical necessity that meets the professional standards of health care that are recognized by TSBDE. Documentation must include appropriate pretreatment, precementation and postcementation radiographs, study models and working casts, laboratory prescriptions, and invoices. Documen­tation must include the correct DOS. A panoramic radiograph without additional bitewing radiographs is considered inadequate as a diagnostic tool for caries detection. OIG may retrospec­tively recoup payment if the documentation does not support the services submitted for payment.

All documentation must be maintained in the client’s record for a period of five years to support the medical necessity at the time of any post-payment utilization review. All documentation, including radiographs, must be of diagnostic and appropriate quality.

In any situation where radiographs are required but cannot be obtained, intraoral photographs must be in the chart.

Any complications, unusual circumstances encountered, morbidity, and mortality must be entered as a complete narrative in the client’s record.

A provider must maintain a minimum standard of care through appropriate and adequate records, including a current history, limited physical examination, diagnosis, treatment plan, and written informed consent as a reasonable and prudent dentist would maintain. These records, as well as the actual treatment, must be in compliance with all state statutes, the Dental Practice Act, and the TSBDE Rules.

Documentation for endodontic therapy must include the following: the medical necessity, pretreatment, during treatment, and post-treatment periapical radiographs, the final size of the file to which the canal was enlarged, and the type of filling material used. Any reason that the root canal may appear radiographically unacceptable must be entered in the chart. Endodontic therapy must be in compliance with the American Association of Endodontists quality assurance guidelines.

Documentation for most periodontal services requires a six-point per tooth depth of pocket charting, a complete mouth series of periapical and bitewing radiographs, and any other narratives or supporting documentation consistent with the nationally accepted standards of care of the specialty of periodontics, and which conform to the minimum standard of care for periodontal treatment required of Texas dentists. A panoramic radiograph without additional bitewing or periapical radiographs is considered inadequate for diagnosis of periodontal problems.

Documentation for surgical procedures requiring a definitive diagnosis for submitting a claim for a specific CDT code necessitates that a pathology report and a written record of clinical observations be present in the chart, together with any appropriate radiographs, operative reports, and appro­priate supporting documentation. All impactions, surgical extractions, and residual tooth root extractions require appropriate preoperative periapical or panoramic radiographs (subject to limitations) be present in the chart.

Any documentation requirements or limitations not mentioned in this manual that are present in the CDT are applicable. The written documentation requirements or limitations in this manual supercede those in the CDT.

4.3.1General Anesthesia

When proceeding with Level 4 sedation/general anesthesia the dental provider is required to maintain the following documentation in the client’s dental record:

The medical evaluation justifying the need for anesthesia

Description of relevant behavior and reference scale

Other relevant narratives justifying the need for general anesthesia

client’s demographics, including date of birth

Relevant dental and medical history

Dental radiographs, intraoral/perioral photography, or diagram of dental pathology

Proposed dental plan of care

Consent signed by parent or guardian giving permission for the proposed dental treatment and acknowledging that the reason for the use of IV sedation or general anesthesia for dental care has been explained

Completed Criteria for Dental Therapy Under General Anesthesia form

The parent or guardian dated signature on the Criteria for Dental Therapy Under General Anesthesia form attesting that they understand and agree with the dentist’s assessment of their child’s behavior

Dentist’s attestation statement and signature, which may be put on the bottom of the Criteria for Dental Therapy Under General Anesthesia form or included in the client’s dental record as a stand alone form

4.3.2Orthodontic Services

Requests for orthodontic services must be accompanied by all of the following documentation:

An orthodontic treatment plan. The treatment plan must include all procedures required to complete full treatment (e.g., extractions, orthognathic surgery, upper and lower appliance, monthly adjustments, anticipated bracket replacements, appliance removal if indicated, special orthodontic appliances). The treatment plan should incorporate only the minimal number of appli­ances required to properly treat the case. Requests for multiple appliances to treat an individual arch are reviewed for duplication of purpose.

Diagnostic models.

Cephalometric radiograph with tracings.

Completed and scored HLD sheet with diagnosis of Angle class (a minimum of 26 points is required for consideration of approval of non cleft palate cases).

Facial photographs.

Full series of radiographs or a panoramic radiograph; diagnostic-quality films are required (copies are preferred and will not be returned to the provider).

Any additional pertinent information as determined by the dentist or requested by TMHP’s Dental Director. Requests for crossbite therapy require the submission of diagnostic models to receive authorization. Providers must maintain documentation in the client’s record that demonstrates the following criteria:

Posterior teeth. Not end-to-end, but buccal cusp of upper teeth should be lingual to buccal cusp of lower teeth.

Anterior teeth. The incisal edge of upper should be lingual to the incisal of the opposing arch.

The dentist should be certain that radiographs, photographs, and other information are properly packaged to avoid damage. TMHP is not responsible for lost or damaged materials.

Refer to:  THSteps Dental Mandatory Prior Authorization Request Form on the TMHP website at www.tmhp.com.

4.4Utilization Review

HHSC or a designated entity may conduct utilization reviews through automated analysis of a provider’s pattern(s) of practice, including peer group analysis. Such analysis may result in a subsequent on-site utilization review. HHSC or its claims processing contractor may conduct utilization reviews at the direction of the Office of Inspector General (OIG), according to HHSC rules.

DSHS may also conduct dental utilization reviews of randomly selected THSteps dental providers. These reviews compare Medicaid dental services that have been reimbursed to a dental provider to the results of an oral examination of the client as conducted by DSHS regional dentists.

Refer to:  25 TAC, §33.72 for more information about utilization review.

4.5Claims Filing and Reimbursement

4.5.1Reimbursement

The Medicaid rates for dentists are calculated as access-based fees in accordance with 1 TAC §§355.455(b), 355.8081, 355.8085, and 355.8441(11). Providers can refer to the online fee lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

Texas Medicaid implemented mandated rate reductions for certain services. The OFL and static fee schedules include a column titled “Adjusted Fee” to display the individual fees with all mandated percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

4.5.2Claim Submission After Loss of Eligibility

The Texas Medicaid 95-day filing deadline applies to all THSteps and ICF-IID dental services. If a client has lost Medicaid eligibility or turned 21 years of age, continue to file claims for services provided on the DOS the client was eligible. Indicate the actual DOS on the claim form, and enter the authorization number in the appropriate block on each claim filed.

Refer to:  Subsection 6.1.4, “* Claims Filing Deadlines” in “Section 6: Claims Filing” (Vol. 1, General Information).

4.5.3Third Party Liability

Refer to:  “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information).

4.5.4Claims Information

Dental services must be submitted to TMHP in an approved electronic format or on the ADA Dental Claim Form. Providers may purchase ADA Dental claim forms from the vendor of their choice. TMHP does not supply the forms. A sample of the ADA Dental Claim form can be found on the ADA website at www.ada.org.

When completing an ADA Dental claim form, all required information must be included on the claim, as TMHP does not key information from attachments. Superbills or itemized statements are not accepted as claim supplements.

All THSteps and ICF-IID claims must be received by TMHP within 95 days from each DOS and submitted to the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200555
Austin, TX 78720-0555

Claims for emergency, orthodontic, or routine dental services must each be filed on separate forms. A claim submitted for either emergency or orthodontic services must be identified as such in Block 35 (Remarks) of the claim form.

A THSteps and ICF-IID dental provider cannot submit claims to Texas Medicaid under his individual performing provider identifier for the services provided by one or more associate dentists practicing in his office as employees or independent contractors with specific employer-employee or contractual relationships. All dentists providing services to Medicaid clients must enroll as THSteps dental providers regardless of employer relationships. The individual provider submitting claims may be reimbursed into a single accounting office to maintain these described relationships.

Claims submitted by newly-enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the DOS.

Providers should submit claims to Texas Medicaid for their usual and customary fees.

Claims for dental services provided to children in foster care must be filed with DentaQuest, the dental claims processor for Superior HealthPlan.

Refer to:  Subsection 4.2.6.2, “Children in Foster Care” in this handbook.

Claims must not be submitted to Texas Medicaid for appointments missed by clients. A client with Medicaid cannot be billed for failure to keep an appointment. Only claims for actual services rendered are considered for payment.

Refer to:  “Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information) for information on electronic claims submissions.

“Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 1.6.9, “Billing Clients” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

4.5.5Claim Appeals

A claim denied because of age restrictions or other limitations listed in the Medicaid dental fee schedule may be considered for reimbursement on appeal when client medical necessity is provided to the TMHP Dental Director.

All denied claim appeals must be submitted to TMHP with the exception of a request to waive late filing deadlines. TMHP does not have the authority to waive state or federal mandates regarding claim filing deadlines.

If, after all appeal processes at TMHP have been exhausted, the provider remains dissatisfied with TMHP’s decision concerning the appeal, the provider may file a complaint with the HHSC Claims Administrator Operations Management Unit.

Refer to:  Subsection 7.1.4, “Paper Appeals” in “Section 7: Appeals” (Vol. 1, General Information).

Subsection 7.3.1, “Administrative Claim Appeals” in “Section 7: Appeals” (Vol. 1, General Information).

Note:Providers must exhaust the appeals process with TMHP before filing a complaint to the HHSC Claims Administrator Operations Management Unit.

Providers may use one of three methods to appeal Medicaid claims to TMHP: telephone (AIS), paper, or electronic.

All appeals of denied claims or requests for adjustments on paid claims must be received by TMHP within 120 days of the date of disposition of the R&S Report on which the claim appears. If the 120-day appeal deadline falls on a weekend or TMHP-recognized holiday, the deadline will be extended to the next business day.

Certain claims must be appealed on paper; they cannot be appealed either electronically or by telephone.

Refer to:  Subsection 7.1.4, “Paper Appeals” in “Section 7: Appeals” (Vol. 1, General Information) for information about appeals that may not be appealed electronically and claims that may not be appealed through AIS.

To appeal in writing:

If a claim cannot be appealed electronically or by telephone, appeal the claim on paper by completing the following steps:

1)Provide a copy of the R&S Report page where the claim is reported.

2)Circle one claim per R&S Report page.

3)Identify the information that was incorrectly provided and note the correct information that should be used to appeal the claim. If necessary, specify the reason for appealing the claim.

4)Attach radiographs or other necessary supporting documentation.

5)If available, attach a copy of the original claim. Claim copies are helpful when the appeal involves dental policy or procedure coding issues.

6)Do not copy supporting documentation on the opposite side of the R&S Report.

7)It is strongly recommended that providers submitting paper appeals retain a copy of the documen­tation being sent. It is also recommended that paper documentation be sent by certified mail with a return receipt requested to establish TMHP’s receipt of the claim and the date the claim was received. The provider is urged to retain copies of multiple claim submissions if the Medicaid provider identifier is pending.

Note:Claims submitted by newly-enrolled providers must be received within 95 days of the date the new provider identifier is issued, and within 365 days of the DOS.

8)Submit the paper appeal with supporting documentation and any radiographs and adjustment requests to the following address:

Texas Medicaid & Healthcare Partnership
Inquiry Control Unit
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727

To appeal by telephone:

1)Contact the Dental Line at 1-800-568-2460.

2)For each claim in question, have the R&S Report listing the claim and any supporting documents readily available.

3)Identify the claim submitted for appeal. The internal control number (ICN) will be requested.

4)Supply the information necessary to correct the claim, such as the missing tooth number or letter, the corrected procedure code, surface ID, or Medicaid number.

The appeal will appear as finalized or pending on the following week’s R&S Report.

Providers may also appeal electronically.

Electronic appeal submission is a method of submitting Texas Medicaid appeals using a personal computer. The electronic appeals feature can be accessed directly through the TMHP EDl Gateway or by using TexMedConnect. For additional information, contact the TMHP EDI Help Desk at 1-888-863-3638.

Electronic appeals can increase accuracy of claims processing, resulting in a more efficient case flow to the provider:

Download and printout capabilities help maintain audit trails for the provider.

Appeal submission windows can be automatically filled in with electronic R&S Report information, thereby reducing data entry time.

4.5.6Frequently Asked Questions About Dental Claims

Q   Why is routine dental treatment not a benefit when performed at the same visit as an emergency visit?

A   The following are reasons routine dental treatment is not a benefit when performed at the same visit as an emergency visit:

The purpose of an emergency claim is to allow the provider to treat a true emergency without the concern that routine dental procedures may be denied.

Medicaid program policy guidelines do not allow payment for both emergency and routine services to the same provider at the same visit. True emergency claims process through the audit system correctly when “emergency” is checked on either the paper or electronic claim and the Remarks or Narrative section of the claim form describes the nature of the emergency.

Q   Why are some claims for oral exams and emergency exams on the same date for the same client denied?

A   Medicaid program policy does not allow claims for an initial oral exam and an emergency exam to be submitted for the same DOS for the same client. An emergency exam performed by the same provider in the same six-month time period as an initial exam may be considered for reimbursement only when the claim for the emergency exam indicates it is an emergency and the emergency block is marked and the Remarks or Narrative section is completed. If the claim is not marked as an emergency, the claim will be denied.

Q   How are orthodontic bracket replacements reimbursed? Can the client be charged for bracket replacements?

A   The provider must use orthodontic procedure code D8690 to claim reimbursement for bracket replacement. Medical necessity must be documented in the client record. Payment is subject to retrospective review. The client with current Medicaid eligibility must not be charged for bracket replacement. If the provider charges the client erroneously, the provider must refund any amount paid by the client.

Q   Why could an appeal of a denied claim take a long time?

A   An appeal can take a long time if TMHP is required to research the denied claim and determine the reason the claim did not go through the system. For faster results, providers should submit appeals as soon as possible and not use the entire 120 days allowed to submit the appeal.
The following are guidelines on filing claims efficiently:

Use R&S Report dates to track filed claims.

File claims electronically through TMHP EDI. Electronic claims submission does not allow a claim with an incorrect date to be accepted and processed, which saves time for the provider submitting claims and TMHP in processing claims. Call 1-888-863-3638, for more information about TMHP EDI.

File claims with the correct information included. Most denied claims result from the omission of dates, signature, or narrative, or incorrect ID numbers such as client Medicaid numbers or provider identifiers.

Q   Why are only ten appeals allowed per call?

A   There is a limit on appeals per call to allow all providers equal access.

Q   Why do reimbursement checks sometimes take a long time to arrive?

A   Reimbursement may be delayed if a provider fails to submit claims in a timely manner.

Q   Does electronic claims submission result in delayed payment?

A   No. Providers who submit claims electronically report faster results than when submitting claims on paper. Providers are encouraged to use TMHP EDI for claims submission.

The following are helpful hints to a more efficiently processed claim:

Ensure the provider identifier is on all claims.

Include the performing provider’s signature on all paper claims.

Verify client eligibility for procedures.

Verify if the procedure code requires a narrative on the claim; the narrative is for medical necessity.

Include the required client information, including name, birth date, and client number.

Dental auxiliary staff (i.e., the hygienist or the chairside assistant) cannot enroll in Texas Medicaid; therefore, they cannot submit claims to Texas Medicaid. Any procedure performed by the auxiliary must be submitted by the supervising dentist, using the dentist’s provider identifier.

Claim Submission Reminders:

Procedure code D8660 is allowed at different age levels, per provider. If a claim for procedure code D8660 is submitted within six months of procedure code D8080, procedure code D8080 will be reduced by the amount that was paid for procedure code D8660.

Prior authorization is required with documentation of medical necessity when replacing lost or broken orthodontic retainers (procedure code D8680). Clients may not be billed for covered services.

Prior authorization of orthodontic services is nontransferable. If a client changes an orthodontic provider for any reason, or a provider ceases to be a Medicaid provider, the new orthodontic services provider must submit a separate request for prior authorization. The provider requesting and receiving authorization for the service also must perform the service and submit the claim. Codes listed on the authorization letters are the only codes considered for payment. All other codes submitted for payment are denied. Providing the authorization number on the submitted claim results in more efficient claims processing.

General anesthesia (provided in the dentist office, ambulatory service clinic, and inpatient/outpa­tient hospital settings) does not require prior authorization, unless the client does not meet the minimum required points for general anesthesia in Criteria for Dental Therapy Under General Anesthesia on the TMHP website at www.tmhp.com. All THSteps dental charts for dental general anesthesia are subject to retrospective, random review for compliance with the Criteria for Dental Therapy Under General Anesthesia and requirements for chart documentation.

Providers must not bill a client unless a formal denial for the requested item or service has been issued by TMHP stating the service is not a benefit of Texas Medicaid and the client has signed the Client Acknowledgment Statement in advance of the service being provided for that specific item or service. A provider must not bill Medicaid clients if the provided service is a benefit of Texas Medicaid.

Refer to:  Subsection 1.6.9.1, “Client Acknowledgment Statement” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

THSteps clients must receive:

Dental services specified in the treatment plan that meet the standards of care established by the laws relating to the practice of dentistry and the rules and regulations of the TSBDE.

Dental services that are free from abuse or harm from the provider or the provider’s staff.

Only the treatment required to address documented medical necessity that meets professionally recognized standards of health care.

5 THSteps Medical

5.1THSteps Medical and Dental Administrative Information

5.1.1Overview

This section describes the administrative requirements for THSteps, including provider requirements, client eligibility requirements, and billing and claims processing information. Providers that need additional information may call 1-800-757-5691 or refer to “Appendix F. Texas Health Steps Quick Reference Guide”  in this handbook for a more specific list of resources and telephone numbers. Providers may also contact the Texas Department of State Health Services (DSHS) THSteps Provider Relations staff located in DSHS regional offices by calling the appropriate regional office as listed in“Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information). THSteps Provider Relations contact information is also available on the DSHS website at www.dshs.texas.gov/thsteps/regions.shtm.

In addition, THSteps has developed online educational modules to provide additional information about the program, components of the medical checkup, and other information. These modules provide free continuing education hours for a variety of providers. Providers do not have to be enrolled in THSteps. These courses may be accessed at www.txhealthsteps.com.

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service is Medicaid’s compre­hensive preventive child health service for clients who are birth through 20 years of age. In Texas, EPSDT is known as THSteps and includes periodic screening, vision, hearing, and dental preventive and treatment services. EPSDT was created by the 1967 amendments to the federal Social Security Act and defined by the Omnibus Budget Reconciliation Act (OBRA) of 1989. The periodic screening for a checkup consists of five federally required components as noted on the THSteps Periodicity Schedule. In addition, Section 1905(r)(5) of the Social Security Act (SSA) requires that any medically necessary health-care service listed in the Act be provided to EPSDT clients even if the service is not available under the state’s Medicaid plan to the rest of the Medicaid population. A service is medically necessary when it corrects or ameliorates the client’s disability, physical or mental illness, or chronic condition. These additional services are available through CCP. For questions about coverage, providers can call CCP at 1-800-846-7470.

5.1.2Statutory Requirements

Several specific legislative requirements affect THSteps and the providers participating in the program. These include, but are not limited to, the following:

Newborn Screening, Health and Safety Code, Chapter 33, Section §33.011 Newborn Screening Test Requirement.

Subsection D.5, “Parental Accompaniment” in this handbook.

Requirements for Reporting Abuse or Neglect, as outlined in subsection 1.6.1, “Compliance with Texas Family Code” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Early Childhood Intervention (ECI), 34 Code of Federal Regulations (CFR) Part 303; Chapter 73, Texas Human Resources Code, and Title 40 TAC, Chapter 108.

Newborn Hearing Screening, Health and Safety Code, Chapter 47.

Teen Confidentiality Issues. There are many state statutes that may affect consent to medical care for a minor, depending on the facts of the situation. Among the relevant statutes are Chapters 32, 33, 153, and 266 of the Texas Family Code. Providers may want to consult an attorney, their licensing board, or professional organization if guidance is needed or questions arise on matters of medical consent.

Refer to:  “Appendix D. Texas Health Steps Statutory State Requirements”  in this handbook for more information.

5.1.3Texas Vaccines for Children (TVFC) Program

The TVFC program provides vaccines at no cost to the provider. The vaccines are recommended according to the Recommended Childhood and Adolescent Immunization Schedule (Advisory Committee on Immunization Practices [ACIP], AAP, and the American Academy of Family Physicians [AAFP]). Medicaid does not reimburse for vaccines/toxoids that are available from TVFC. THSteps providers are strongly encouraged to enroll in TVFC at DSHS and must do so in order to obtain free vaccines for clients who are birth through 18 years of age. Local and public health departments that are not otherwise enrolled as a provider that is authorized to receive reimbursement for vaccine adminis­tration fees should enroll as a Comprehensive Care Program (CCP) provider. Providers may not charge Texas Medicaid for the cost of the vaccines obtained from TVFC; however the administration fee, not to exceed $14.85, is considered for reimbursement.

When single antigen vaccine(s)/toxoid(s) or comparable antigen vaccine(s)/toxoid(s) are available for distribution through TVFC, but the provider chooses to use an ACIP-recommended product that is not distributed through TVFC, the vaccine/toxoid will not be covered; however, the administration fee will be considered.

Note:Administered vaccines/toxoids must be reported to DSHS. DSHS submits all vaccines/toxoids reported with parental consent to a centralized repository of immunization histories for clients younger than 18 years of age. This repository is known in Texas as ImmTrac.

For additional information about immunizations, providers can refer to the THSteps online educational module “Immunization” at www.txhealthsteps.com.

Refer to:  “Appendix B. Immunizations”  in this handbook.

5.1.4Vaccine Adverse Event Reporting System (VAERS)

The National Childhood Vaccine Injury Act (NCVIA) of 1986 requires health-care providers to report:

Any reaction listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine.

Any reaction listed in the Reportable Events Table that occurs within the specified time period after vaccination.

NCVIA requires health-care providers to report certain adverse events that occur following vaccination. As a result, VAERS was established by CDC and FDA in 1990. VAERS provides a mechanism for the collection and analysis of adverse events (side effects) associated with vaccines currently licensed in the United States. Adverse events are defined as health effects that occur after immunization that may or may not be related to the vaccine. VAERS data are monitored continually to detect unknown adverse events or increases in known side effects.

A copy of the Reportable Events Table can be obtained by calling VAERS at 1-800-822-7967 or by downloading it from www.dshs.texas.gov/immunize/forms/vaers_table.pdf.

Clinically significant adverse events should be reported even if it is unclear whether a vaccine caused the event. For additional information about NCVIA, providers can refer to www.dshs.texas.gov/immunize/forms/11-11246.

5.1.5Referrals for Medicaid-Covered Services

When a provider performing a checkup determines that a referral for diagnosis or treatment is necessary for a condition found during the medical checkup, that information must be discussed with the parents or guardians. A referral must be made to a provider who is qualified to perform the necessary diagnosis or treatment services. If the performing provider is competent to treat the condition found, a referral elsewhere is not necessary, unless it is to the primary care provider to assure continuity of care.

Providers that need assistance finding a specialist who accepts clients with Medicaid coverage can call the THSteps toll-free helpline at 1-877-847-8377, or they can find one using the Online Provider Lookup on the TMHP website at www.tmhp.com.

Continuity of care is an important aspect of providing services and follow-up. Efforts should be made to determine that the appointment was kept and that the provider who received the referral has provided a diagnosis and recommendations for further care to the referring provider.

In addition to referrals for conditions discovered during a checkup or for specialized care, the following referrals may be used:

Case Management for Children and Pregnant Women. Case Management for Children and Pregnant Women provides health-related case management services to eligible children and pregnant women. Case Management for Children and Pregnant Women services include assessing the needs of eligible clients, formulating a service plan, making referrals, problem-solving, advocacy, and follow-up regarding family and client needs. For more information about eligibility and client referral, see subsection 3.1.1, “Eligibility” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) or subsection 3.1.2, “Referral Process” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks).

Hearing Services referrals. If the hearing screening returns abnormal results, clients who are birth through 20 years of age must be referred to a Texas Medicaid provider who is an audiologist or physician who is experienced with the pediatric population and who offers auditory services.

Routine Dental Referrals. The provider must refer clients to establish a dental home beginning at 6 months of age or earlier if trauma or early childhood caries are identified. For established clients after the 6-month medical checkup, the provider must confirm if a dental home has been established and is ongoing; if not, additional referrals must be made at subsequent medical checkups until the parent or caregiver confirms that a dental home has been established for the client. Clients who are birth through 5 months of age are not eligible for routine dental checkups but should be referred to a dentist if any dental issues are identified during a THSteps medical checkup or acute care visit. When possible, clients should be referred to a provider who has completed the required benefit education and is certified by the DSHS Oral Health Program to perform First Dental Home services. The First Dental Home provider may be located through the advanced search function in the Online Provider Look Up or by calling 1-877-847-8377.

Referrals for Dental Treatment. If a THSteps medical provider identifies the medical necessity of dental services, the provider must refer the client to a THSteps dental provider. The THSteps medical provider can accomplish this by providing the parent or guardian a listing of THSteps dentists from the Online Provider Lookup. The parent or guardian can receive assistance in locating a THSteps dentist and assistance with scheduling of dental appointments by contacting the THSteps toll-free helpline at 1-877-847-8377. Clients who are birth through 5 months of age also can be seen for emergency dental services by the dentist at any time for trauma, early childhood caries, or other oral health problems. Clients who are birth through 20 years of age may self-refer for dental care.

Emergency Dental Referrals. If a medical checkup provider identifies an emergency need for dental services, such as bleeding, infection, or excessive pain, the client may be referred directly to a partic­ipating dental provider. Emergency dental services are covered at any time for all Medicaid clients who are birth through 20 years of age.

Note:Assistance in coordinating dental referrals can be obtained from the THSteps toll-free helpline at 1-877-847-8377 or the DSHS Regional THSteps Coordinator for the respective region (lists are provided in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information). In cases of both emergency and nonemergency dental services, clients are able to make a choice when selecting a dental provider who is participating in the THSteps Dental Program.

Family Planning and Genetic Services Referrals. For clients eligible for Medicaid who need genetic services or family planning services, a referral should be made. Information about Medicaid-covered genetic services is available in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) and information about family planning services is available in Section 2, “Medicaid Title XIX Family Planning Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks). If a THSteps medical provider also provides family planning, the provider may inform clients that these services are available.

ECI Referrals. Federal and state law requires providers to refer children as soon as possible, but no longer than 7 days after identification of a suspected developmental delay or disability to the local ECI program for children who are birth through 35 months of age regardless if a referral was made to another qualified provider. The provider may call the local ECI program or the DARS Inquiries Line at 1-800-628-5115 to make referrals. Children who are 3 years of age and older with a suspected developmental delay or disability should be referred to the local school district.

WIC Referrals. Clients who are birth through 5 years of age or who are pregnant are eligible for WIC and should be referred to WIC for nutrition education and counseling, and food benefits.

Refer to:  Section 1, “* General Information” in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks) for more information about referrals.

5.1.6THSteps Medical Checkup Facilities

All THSteps medical checkup policies apply to checkups completed in a physician’s office, a health department, clinic setting, or in a mobile/satellite unit. Enrollment of a mobile/satellite unit must be under a physician or clinic name. Mobile units can be a van or any area away from the primary office and are considered extensions of that office and are not separate entities.

The physical setting must be appropriate so that all elements of the checkup can be completed.

Refer to:  Subsection 5.3.10, “THSteps Medical Checkups Periodicity Schedule” in this handbook on the THSteps Periodicity Schedule.

Subsection 5.3.11, “Mandated Components” in this handbook for additional information on checkup components.

5.1.7THSteps Dental Services

Access to THSteps dental services is mandated by Texas Medicaid and provides reimbursement for the early detection and treatment of dental health problems, including oral health preventive services, for Medicaid clients who are birth through 20 years of age. THSteps dental service standards are designed to meet federal regulations and to incorporate the recommendations of representatives of national and state dental professional groups.

OBRA 1989 mandated the expansion of the federal EPSDT program to include any service that is medically necessary and for which FFP is available, regardless of the limitations of Texas Medicaid. This expansion is referred to as CCP.

Refer to:  Section 2, “Medicaid Children’s Services Comprehensive Care Program (CCP)” in this handbook for more information.

THSteps-designated staff (HHSC, DSHS, or its designee), through outreach and education, encourage the parents or caregivers of eligible clients to use THSteps dental checkups and preventive care when clients first become eligible for Medicaid and each time clients are due for their next periodic dental checkup.

Upon request, THSteps-designated staff (HHSC, DSHS, or its designee) assist the parents or caregivers of eligible clients with scheduling appointments and transportation. Medicaid clients have freedom of choice of providers and are given names of enrolled providers. Call the THSteps toll-free helpline at 1-877-847-8377 for a list of THSteps dental providers in a specific area.

For additional information about dental health, providers can refer to the THSteps online educational modules “Oral Health For Primary Care Providers” and “Oral Health Examinations for Dental Profes­sionals” at www.txhealthsteps.com.

5.2Enrollment

5.2.1THSteps Medical Provider Enrollment

Providers cannot be enrolled if their professional license is due to expire within 30 days of application. Facility providers must submit a current copy of the supervising practitioner’s license. To provide Medicaid services, each NP or CNS must be licensed as an RN and be recognized as an APRN by Texas BON.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for information about enrollment procedures.

The following provider types may provide THSteps preventive services within his or her scope of practice and must also be enrolled in Texas Medicaid and as a THSteps provider:

A physician (doctor of medicine [M.D.] or doctor of osteopathy [D.O.]) or physician group

A physician assistant (PA)

A clinical nurse specialist (CNS)

A nurse practitioner (NP)

A certified nurse midwife (CNM)

A federal qualified health center (FQHC)

A rural health clinic (RHC)

A health-care provider or facility with physician supervision including, but not limited to:

Community-based hospital and clinic

Family planning clinic

Home health agency

Local or regional health department

Maternity clinic

Migrant health center

School-based health center

Medical Residents  Medical residents may provide medical checkups in a teaching facility under the guidance of the attending staff as long as the facility’s medical staff by-laws and requirements of the Graduate Medical Education (GME) Program are met, and the attending physician has determined the intern or resident to be competent to perform checkups. THSteps does not require the supervising physician to examine the client as long as these conditions are met.

Clinics – In a clinic, a physician is not required to be present at all times during the hours of operation unless otherwise required by federal regulations. A physician must assume responsibility for the clinic’s operation.

5.2.1.1Requirements for Registered Nurses Who Provide Medical Checkups

RNs without a CNS, NP, or CNM recognition as an APRN by the Texas BON may provide medical checkups only under direct physician supervision, meaning the physician is either on site during the checkup or immediately available to furnish assistance and direction to the RN during the checkup.

Required online education modules developed by THSteps must be completed prior to providing checkup services. All modules are approved for continuing education units (CEUs) for RN’s as well as other medical disciplines. Required THSteps online education modules are available on the RN Infor­mation page of the THSteps website. The RN or the RN’s employer must maintain documentation that the required modules were completed.

Online modules are updated regularly to include new content. RNs that have completed the required modules previously are encouraged, but not required to retake online modules.

Before a physician delegates a THSteps checkup to an RN, the physician must establish the RN’s compe­tency to perform the service as required by the physician’s scope of practice. The delegating physician is responsible for supervising the RN who performs the services. The delegating physician remains respon­sible for any service provided to a client.

Refer to:  Subsection 5.2.1, “THSteps Medical Provider Enrollment” in this handbook for more infor­mation about enrollment procedures.

5.3Services, Benefits, Limitations, and Prior Authorization

5.3.1Eligibility for THSteps Services and Checkup Due Dates

Through outreach, THSteps staff (DSHS, HHSC, or contractors) encourage clients to use THSteps preventive medical checkup services when they first become eligible for Medicaid and each time there­after when they are periodically due for their next medical checkup. THSteps will send clients a letter when they are due for a medical checkup.

A client is eligible for THSteps services, including medical checkups, from birth through 20 years of age.

Although the Medicaid Eligibility Verification Letter (Form H1027) identifies eligible clients when the client’s Your Texas Benefits Medicaid card is lost or has not yet been issued, Form H1027 does not indicate whether the client is due for medical checkup services. Providers can verify the client’s eligibility through www.yourtexasbenefitscard.com, TexMedConnect, or the TMHP Contact Center.

A client is due for a THSteps medical checkup based on his or her date of birth and the ages indicated on the periodicity schedule. Children younger than three years of age are due at frequent intervals. Children and youth three years of age and older are considered due for a checkup on their birthday and are encouraged to have a yearly checkup as soon as practical. In addition, for children enrolled in Medicaid managed care, a new member is due for a THSteps medical checkup as soon as practicable, but in no case later than 14 days of enrollment for newborns, and no later than 90 days of enrollment for all other eligible child members.

Managed care organizations are also required to assure existing members of their health plan eligibility requirements to receive timely medical checkups. A checkup for an existing member from birth through 35 months of age is timely if received within 60 days beyond the periodic due date based on the client’s birth date. For existing members 36 months of age and older, a checkup is due beginning on the child’s birthday and is considered timely if it occurs within 364 calendar days after the child’s birthday in a non-leap year or 365 days after the child’s birthday in a leap year. Checkups received before the periodic due date are not reportable as timely medical checkups. Providers should contact the appropriate MCO for further details.

Providers should schedule checkups based on the ages in the periodicity schedule, but circumstances may support the need for a checkup prior to the client’s birthday (for example, a 4-year checkup could be performed prior to the child’s 4th birthday if the child is a member of a migrant family that is leaving the area). THSteps fee-for-service policy creates this flexibility by allowing a total number of checkups at each age range.

Refer to:  Subsection 5.3.6, “THSteps Medical Checkups” in this handbook for additional details.

Providers are encouraged to notify the client when they are due for the next checkup according to the THSteps periodicity schedule.

A checkup that is necessary more frequently than indicated on the periodicity schedule is considered an exception-to-periodicity.

Refer to:  Subsection 5.3.7, “Exception-to-Periodicity Checkups” in this handbook for additional details about billing for a checkup performed as an exception-to-periodicity checkup.

5.3.2Prior Authorization

Prior authorization is not required for preventive care medical checkups.

5.3.3Additional Consent Requirements

Additional parental or guardian consent may be required if online or web-based screening tools are used that could result in client data being stored electronically in an outside database other than the provider’s electronic medical record system, or if the data is used for purposes other than THSteps screening. The provider should seek legal advice regarding the need for this consent.

5.3.4Verification of Medical Checkups

The first source of verification that a THSteps medical checkup has occurred is a paid claim or encounter. THSteps encourages providers to file a claim either electronically or on a CMS-1500 paper claim form as soon as possible after the date of service, as the paid claim updates client information. The provider may contact TMHP through the TMHP website at www.tmhp.com or AIS at 1-800-925-9126 to verify that the client is due for a checkup.

A second source of acceptable verification is a physician’s written statement that the checkup occurred. If the provider chooses to give the client written verification, it must include the client’s name, Medicaid ID number, date of the medical checkup, and a notation that a complete THSteps medical checkup was performed.

Note:Verification of medical checkups must not be sent to THSteps but must be maintained by the client to be provided as needed by an HHSC eligibility caseworker.

If neither the first nor the secondary source of verification is available, a THSteps outreach worker may contact the provider’s office for verification.

5.3.5Medical Home

HHSC and DSHS encourage the provision of the THSteps medical checkup as part of a medical home. Texas Medicaid defines a medical home as a model of delivering care that is accessible, continuous, comprehensive, family-centered, and coordinated. In providing a medical home for the client, the primary care clinician directs care coordination together with the client or youth and/or family.

Medical checkup providers with mobile units should encourage the families to establish a medical home for their child(ren) and obtain future checkups from their primary care provider.

When a checkup is provided in the home setting, mobile unit, or clinic other than the medical home, it should be in coordination with the medical home and the results must be provided to the medical home as soon as possible.

A mobile unit is an extension of the provider’s office and must be able to provide a complete checkup.

For additional information on the medical home, providers can refer to the “Introduction to the Medical Home” module provided by THSteps at www.txhealthsteps.com.

5.3.6THSteps Medical Checkups

THSteps medical checkups reflect the federal and state requirements for a preventive checkup. Preventive care medical checkups are a benefit of the THSteps program if they are provided by enrolled THSteps providers and all of the required components are completed. An incomplete preventive medical checkup is not a benefit. The THSteps periodicity schedule specifies screening procedures required at each stage of the client’s life to ensure that health screenings occur at age-appropriate points in a client’s life.

Components of a medical checkup that have an available CPT code are not reimbursed separately on the same day as a medical checkup, with the exception of initial point-of-care blood lead testing, once per lifetime mental health screening for adolescents, a tuberculin skin test (TST), developmental and autism screening, vaccine administration, and OEFV.

Note:Initial blood lead testing, other than point-of-care, must be sent to the DSHS Laboratory for testing.

Reminder:Incomplete medical checkups are subject to recoupment unless there is documentation supporting why a component was not completed.

Refer to:  Subsection 5.3.11.1.3, “Mental Health Screening” in this handbook for more information about required mental health screenings.

Sports physical examinations are not a benefit of Texas Medicaid. If the client is due for a THSteps medical checkup and a comprehensive medical checkup is completed, a THSteps medical checkup may be reimbursed and the provider may complete the documentation for the sports physical.

THSteps preventive medical checkups are not a benefit under telemedicine or telehealth.

Refer to:  The THSteps Medical Checkups Periodicity Schedule which may be found at www.dshs.texas.gov/thsteps/providers.shtm.

Checkups should be scheduled, to the extent possible, based on the ages on the periodicity schedule to accommodate the need for flexibility when scheduling checkup appointments.

The following table lists the number of visits allowed at each age range:

Age Range

Number of Visits

Birth through 11 months (does not include 12 month checkup)

6

1 through 4 years

7

5 through 11 years

7

12 through 17 years

6

18 through 20 years

3

All of the checkups listed on the periodicity schedule were developed according to the recommendations of the AAP and in consultation with recognized authorities in pediatric preventive health. In Texas, the THSteps periodicity schedule may differ from the AAP periodicity schedule based on the scheduling of laboratory or other tests in federal EPSDT or state regulations.

For more information about conducting a THSteps checkup, providers can refer to the THSteps online educational modules at www.txhealthsteps.com.

The following table includes the procedure codes for checkups and the referral and condition indicators. Condition indicators must be used to describe the results of a checkup. A condition indicator must be submitted on the claim with the periodic medical checkup procedure code. Indicators are required whether a referral was made or not. If a referral is made, then providers must use the Y referral indicator. If no referral is made, then providers must use the N referral indicator.

Procedure Codes

Referral Indicator

Condition Indication

99381, 99382, 99383, 99384, and 99385 (new client preventive visit)

 -or-

99391, 99392, 99393, 99394, and 99395 (Established client preventive visit)

N (no referral given)

NU (not used)

Y (yes THSteps or EPSDT referral was given to the client)

* The ST condition indicator should only be used when a referral is made to another provider or the client must be rescheduled for another appointment with the same provider. It does not include treatment initiated at the time of the checkup.

THSteps preventive care medical checkups for clients who are 18 through 20 years of age must be submitted with procedure codes 99385 or 99395 and diagnosis code Z0000 or Z0001.

Claims for procedure codes 99381, 99382, 99383, 99384, 99391, 99392, 99393, and 99394 must be submitted with the appropriate age related diagnosis code listed in the following table:

Client Age

Diagnosis Code

Birth through 7 days

Z00110

8 through 28 days

Z00111

29 days through 17 years

Z00121, Z00129

18 through 20 years

Z0000, Z0001

The age-appropriate diagnosis code for a preventive care medical checkup must be submitted on the claim. If an immunization is administered as part of the preventive care medical checkup, diagnosis code Z23 may also be included on the claim, in addition to the age-appropriate diagnosis.

If an immunization is the only service provided during an office visit, providers may submit only diagnosis code Z23 on the claim.

Note:Note: A THSteps preventive care medical checkup will not be reimbursed if the office visit is only for immunization.

Modifier AM, SA, TD, or U7 must be submitted with the THSteps medical checkups procedure code to indicate the practitioner who performed the unclothed physical examination during the medical checkup.

Modifier

Practitioner

AM

Physician, team member service

SA

Nurse practitioner rendering service in collaboration with a physician

TD

Registered nurse

U7

Physician assistant

THSteps medical checkups performed in an FQHC or RHC setting are paid an all-inclusive rate per encounter, which includes immunizations, developmental screening, autism screening, once per lifetime mental health screening for adolescents, TST, blood lead test, and oral evaluation and fluoride varnish. When submitting claims for THSteps checkups and services, RHC providers must use the national POS code 72, and FQHC providers must use modifier EP in addition to the modifiers used to identify who performed the medical checkup. In accordance with the federal rules for RHCs and FQHCs, an RN in an RHC or FQHC may not perform THSteps checkups independently of a physician’s interactions with the client.

Refer to:  Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information related to billing.

Section 7, “Rural Health Clinic” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information related to billing.

Checkups, exception-to-periodicity checkups, and follow-up visits are limited to once per day any provider.

A checkup and the associated follow-up visit may not be reimbursed on the same date of service. The follow-up visit will be denied.

An incomplete checkup is subject to recoupment unless there is documentation to support why the component was not completed as part of the checkup.

A new patient is one who has not received any professional services within the preceding three years from the provider or from another provider of the same specialty who belongs to the same group practice. As an exception, a new preventive care medical checkup (procedure code 99381, 99382, 99383, 99384, or 99385) may be billed when no prior checkups have been billed by the same provider or provider group, even if an acute care new patient E/M service was previously performed by the same provider.

An additional new checkup is allowed only when the client has not received any professional services in the preceding three years from the same provider or another provider who belongs to the same group practice, because subsequent acute care visits to the new patient THSteps checkup continues the estab­lished relationship with the provider.

If the provider that performs the medical checkup provides treatment for an identified condition on the same day, the provider may submit a separate claim for an acute care established-client office visit. The separate claim must include the established-client procedure code that is appropriate for the diagnosis and treatment of the identified problem. Treatment of minor illnesses or conditions (e.g., follow-up of a mild upper respiratory infection) during the THSteps medical checkup may not warrant additional billing.

Acute Care Visits

When a new patient checkup is billed for the same date of service as a new patient acute care visit, both new patient services may be reimbursed when billed by the same provider or provider group if no other acute care visits or preventive care medical checkups have been billed in the past three years.

Providers must use modifier 25 to describe circumstances in which an acute care E/M visit was provided at the same time as a checkup. Providers must submit modifier 25 with the E/M procedure code when the rendered services are distinct and provided for a different diagnosis. Providers must bill an appro­priate level E/M procedure code with the diagnosis that supports the acute care visit. The medical record must contain documentation that supports the medical necessity and the level of service of the E/M procedure code that is submitted for reimbursement.

An acute care E/M visit for an insignificant or trivial problem or abnormality billed on the same date of service as a checkup or exception-to-periodicity checkup is subject to recoupment.

Providers must bill an acute care visit with their provider identifier on a separate claim without benefit code EP1.

Refer to:  Acute Care Visit on the Same Day as a THSteps Preventive Visit Checkup on the TMHP website at www.tmhp.com.

THSteps Preventive Visit Checkup with Immunization and Vaccine Administration on the TMHP website at www.tmhp.com for a claim form example.

5.3.7Exception-to-Periodicity Checkups

Exception-to-periodicity checkups are complete medical checkups completed outside the timeframes listed in the THSteps Periodicity Schedule due to extenuating circumstances.

Exception-to-periodicity checkups are complete medical checkups, which are medically necessary and might cause the total number of checkups to exceed the number allowed for the client’s age range if the client were to have all regular scheduled checkups. An exception-to-periodicity checkup is allowed when:

Medically necessary, for example, for a client with developmental delay, suspected abuse, or other medical concerns or a client in a high-risk environment, such as living with a sibling with elevated blood lead.

Required to meet state or federal exam requirements for Head Start, day care, foster care, or preadoption.

When needed before a dental procedure requiring general anesthesia.

As noted in the Periodic Checkup Age Range table, the number of checkups is set for each age range. This may avoid an exception-to-periodicity checkup and allow flexibility for the provider and family to schedule a checkup including before the child’s birthday.

If a client is due for a medical checkup, a checkup outside of the regular THSteps schedule must be billed as a regular checkup rather than an exception to periodicity.

The checkup is considered complete when all the required components are documented in the client’s medical record or supporting documentation, which details the reason a component(s) was not completed. A plan to complete the component(s) if not due to reasons of conscious or parental concerns must be included in the documentation.

Note:A sports physical is not a reason for an exception-to-periodicity checkup.

When billing for an exception-to-periodicity visit, provider must also include the most appropriate exception-to-periodicity modifiers. Claims for periodic THSteps medical checkups exceeding period­icity that do not include one for these modifiers will be denied as exceeding periodicity.

Modifier

Description

SC

Medically necessary service or supply

23

Unusual Anesthesia: Occasionally, a procedure that usually requires either no anesthesia or local anesthesia must be done under general anesthesia because of unusual circumstances. This circumstance may be reported by adding the modifier “23” to the procedure code of the basic service.

32

Mandated Services: Services related to mandated consultation or related services (e.g., PRO, third party payer, governmental, legislative, or regulatory requirement) may be identified by adding the modifier “32” to the basic procedure.

THSteps medical exception-to-periodicity services must be billed with the same procedure codes, provider type, modifier, and condition indicators as a medical checkup. Additionally, providers must use modifiers 23, 32, and SC to indicate the exception.

5.3.8Medical Checkup Follow-up Visit

Use procedure code 99211 with the provider identifier and THSteps benefit code when billing for a follow-up visit.

Note:Reimbursement for the follow-up visit includes all elements of the visit. Reimbursement may not be allowed for the follow-up visit when submitted with certain procedure codes. For example: In accordance with CMS NCCI requirements, modifier 25 guidelines do not apply for procedure code 99211 when billed with other procedure codes that are included in the visit as related elements, including, but not limited to, administration of immunizations.

Refer to:  Subsection 6.4.1, “National Correct Coding Initiative (NCCI) Guidelines” in “Section 6: Claims Filing” (Vol. 1, General Information) for additional information.

Medical Checkup Follow-up Visit with Immunization Administration on the TMHP website at www.tmhp.com for a claim form example.

Medical Checkup Follow-up Visit with TB Skin Test on the TMHP website at www.tmhp.com for a claim form example.

A follow-up visit may be required to complete necessary procedures related to a checkup or exception-to-periodicity checkup, such as:

Reading the TST.

Administering immunizations in cases where the client’s immunizations were not up-to-date, medically contraindicated, or unable to be given during the checkup.

Collection of specimens for laboratory testing that were not obtained during the checkup or the original specimen could not be processed.

Completion of sensory or developmental screening that was not completed at the time of the checkup due to the client’s condition.

A return visit to follow up on treatment initiated during a checkup or to make a referral is not a follow-up visit, but is considered an acute care visit under an appropriate E/M procedure code for an established client.

If the parent or guardian did not give consent for a component during the initial checkup, and supporting documentation is provided, no follow-up visit is necessary.

5.3.9* Newborn Examination

Providers do not have to be enrolled as THSteps providers to bill newborn examination procedure codes 99460, 99461, or 99463.

Newborn examinations that are billed with procedure code 99460, 99461, or 99463 may qualify as a THSteps medical checkup when all required components are completed according to the THSteps Periodicity Schedule and documented in the medical record.

Providers must use their provider identifier without benefit code EP1 when billing newborn examination services.

Note:In Texas, the mandated newborn hearing screening and newborn screening test is included as part of the in-hospital newborn exam.

A newborn hearing screening is included in the reimbursement to the hospital for the newborn hospital stay and is not reimbursed separately. The screening is covered as part of the newborn delivery. A newborn hearing screening must be offered to each newborn by the facility where the birth occurs, through a program mandated by the Texas Legislature and certified by the Department of State Health Services (DSHS). If a facility is not required by legislative mandate to perform newborn hearing screenings, a referral must be made to a facility that offers the screening.

If an infant is not born in a birthing facility and is not admitted to a birthing facility, the infant must be referred to a facility that provides newborn hearing screening.

State-mandated newborn screening for critical congenital heart disease (CCHD) is offered by and performed in the birth facility in accordance with Health and Safety Code (HSC) § 33.011 and 25 TAC §§37.75–37.79.

Providers billing these newborn codes are not required to be THSteps providers, but they must be enrolled as Medicaid providers. TMHP encourages THSteps enrollment for all providers that offer a medical home for clients and provide them with medical checkups and immunizations. Physicians and hospital staff are encouraged to inform parents eligible for Medicaid that the next THSteps checkup on the periodicity schedule should be scheduled from discharge to five days of age and that regular checkups should be scheduled during the first year and after.

Refer to:  Subsection 9.2.44, “Newborn Services” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for additional infor­mation on inpatient newborn services.

The THSteps online education module “Newborn Hearing Screening” on the THSteps website at www.txhealthsteps.com for additional information about conducting a newborn hearing screen.

5.3.10THSteps Medical Checkups Periodicity Schedule

The client is periodically eligible for medical checkup services based on the THSteps Medical Checkups Periodicity Schedule. All the checkups listed on the periodicity schedule have been developed based on recommendations of the AAP and recognized authorities in pediatric preventive health. In Texas, THSteps has modified the AAP periodicity schedule based on the scheduling of a laboratory or other test in federal EPSDT or state regulations.

The THSteps Medical Checkups Periodicity Schedule is available on the DSHS website at www.dshs.texas.gov/thsteps/providers.shtm.

5.3.11Mandated Components

THSteps medical checkups must include regularly scheduled examinations and screenings of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth.

The following federal and state mandated components must be documented in the client’s medical record for the checkup to be considered complete:

Comprehensive health and developmental history, including physical and mental health development

Comprehensive unclothed physical examination

Immunizations appropriate for age and health history

Laboratory test appropriate to age and risk, including lead toxicity at specific federally-mandated ages

Health education including anticipatory guidance

Dental referral

The client’s medical record must include documentation to support the rationale a component was not completed, and a plan to complete the component(s) if not due to parent or caregiver concern or reasons of conscience, including religious beliefs. THSteps provides optional clinical records to assist the provider in the documentation of the required components.These forms may be found at www.dshs.texas.gov/thsteps/forms.shtm.

If the client has a condition that has been previously diagnosed and is currently receiving treatment, the associated standardized screening may be omitted with proper documentation.

Documented test or screening results obtained within the preceding 30 days for clients who are two years of age and younger, and the preceding 90 days for clients who are three years of age and older may be used to meet the testing or screening requirements. Results must include the dates of service and one of the following:

A clear reference to the previous visit by the same provider

Results obtained from another provider

5.3.11.1Comprehensive Health and Developmental History

5.3.11.1.1Nutritional Screening

Dietary practices must be evaluated at each checkup to identify and address nutritional issues or concerns.

5.3.11.1.2Developmental Surveillance or Screening

Developmental surveillance or screening is a required component of every checkup for clients who are birth through 6 years of age. Autism screening is required at 18 months of age and again at 24 months of age. If not completed at 24 months of age, or if there is a particular concern it should be completed at 30 months of age.

As THSteps medical services, developmental screening (procedure code 96110) and autism screening (procedure code 96110 with modifier U6) are limited to once per day, per client, by the same provider or provider group. This service will be denied unless a checkup, exception-to-periodicity checkup, or follow-up visit was reimbursed for the same date of service by the same provider.

Standardized developmental screening is required at the ages listed in the “Required Screening Ages and Recommended Tools” table. Providers must use one of the validated, standardized tools listed in the table when performing a developmental or autism screening. A standardized screen is not required at other checkups up to and including the 6-year checkup; however, developmental surveillance is required at these checkups and includes a review of milestones (gross and fine motor skills, communication skills, speech-language development, self-help/care skills, and social, emotional, and cognitive development) and mental health and is not considered a separate service.

Providers may be reimbursed separately when using one of the required screening tools listed in the following table in addition to the checkup visit at specific age visits. THSteps requires one of the following required standardized tools at the following ages for a checkup to be considered complete:

Required Screening Ages and Recommended Tools

Screening Ages

Developmental Screening Tools

Autism Screening Tools

9 months

Ages and Stages Questionnaire (ASQ) or Parents’ Evaluation of Development Status (PEDS)

N/A

18 months

ASQ or PEDS

Modified Checklist for Autism in Toddlers (M-CHAT) or M-CHAT Revised with Follow-Up (M-CHAT R/F)

24 months

ASQ or PEDS

M-CHAT or M-CHAT R/F

3 years

ASQ, Ages and Stages Questionnaire: Social-Emotional (ASQ:SE) or PEDS

N/A

4 years

ASQ, ASQ:SE or PEDS

N/A

If a developmental or autism screening that is required in the Required Screening Ages and Recom­mended Tools table is not completed during a checkup or if the client is being seen for the first time, standardized developmental screening must be completed through 6 years of age.

If a provider administers a standardized and validated developmental screening at additional checkups other than those listed in the Required Screening Ages and Recommended Tools table, the provider must document the rationale for the additional screening, which may be due to provider or parental concerns.

Developmental screening that is completed without the use of one of the required standardized screening tools is not a separately payable benefit, and the checkup will be considered incomplete.

Standardized developmental screening as part of a medical checkup and for ages other than required on the periodicity schedule is not covered when completed for the sole purpose of meeting day care, Head Start, or school program requirements.

Standardized developmental screening may be performed outside a THSteps medical checkup as part of development and neurological assessment testing.

Refer to:  Subsection 9.2.24, “Developmental Screening and Testing and Aphasia Assessment” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information related to developmental screening testing outside a THSteps medical checkup.

Referral for an in-depth developmental evaluation is determined by the criteria of the specific tool or at the provider’s discretion. Referral for in-depth evaluation of development should be provided when parents express concern about their child’s development, regardless of scoring on a standardized devel­opment screening tool. A medical diagnosis or a confirmed developmental delay is not required for referrals.

The ECI program serves clients who are birth through 35 months of age with disabilities or develop­mental delays. Under federal and state regulations, all health-care professionals are required to refer children to the Texas HHS ECI program as soon as possible, but no longer than 7 days after identifying a disability or a suspected delay in development, even if referred to an appropriate provider for further testing. If the client is 3 years of age or older, referral should be made to the local school district’s special education program.

5.3.11.1.3Mental Health Screening

Mental health screening for behavioral, social, and emotional development is required at each THSteps checkup.

Mental health screening using one of the following validated, standardized mental health screening tools recognized by THSteps is required once for all clients who are 12 through 18 years of age:

Pediatric Symptom Checklist (PSC-17)

Pediatric Symptom Checklist (PSC-35)

Pediatric Symptom Checklist for Youth (Y-PSC)

Patient Health Questionnaire (PHQ-9)

Car, Relax, Alone, Forget, Family, and Trouble Checklist (CRAFFT)

A mental health screening must be submitted with procedure code 96160 for a screening tool completed by the adolescent, or procedure code 96161 for a screening tool completed by the parent or caregiver on behalf of the adolescent. When claims with procedure code 96160 or 96161 are submitted for mental health screenings, one of the validated, standardized mental health screening tools recognized by THSteps must be used.

Mental health screening at other checkups does not require the use of a validated, standardized mental health screening tool.

Only one procedure code (96160 or 96161) may be reimbursed for the mental health screening per client per lifetime based on the description of the procedure code and the service rendered. Procedure codes 96160 and 96161 will not be reimbursed for the same client for any date of service.

Procedure code 96160 or 96161 must be submitted on the same date of service by the same provider as procedure code 99384, 99385, 99394, or 99395, and reimbursement is limited to once per lifetime.

The client’s medical record must include documentation identifying the tool that was used, the screening results, and any referrals that are made.

When the clinician conducting the mental health screen has the appropriate training and credentials to conduct the mental health evaluation and provide treatment, the clinician may choose to provide the mental health services or refer the client to an appropriate clinician. Clinicians who do not have these qualifications must refer clients to a qualified Medicaid-enrolled mental health specialist for such care.

For additional information about conducting a mental health screen, providers can refer to the THSteps online educational module “Mental Health Screening” at www.txhealthsteps.com.

5.3.11.1.4Tuberculosis (TB) Screening

Administer the TB risk screening tool annually beginning at 12 months of age and thereafter at other medical checkups.

The TB risk screening tool is available on the DSHS website at www.dshs.texas.gov/thsteps/forms.shtm.

A TST is to be administered when the screening tool indicates a risk for possible exposure. Providers must use procedure code 86580 when a TST is administered.

A TST may be reimbursed separately when performed as part of a THSteps medical checkup. TB screenings are part of the encounter rates for FQHCs and RHCs and are not reimbursed separately.

A follow-up visit (procedure code 99211) is required to read all TSTs. The provider may bill the follow-up visit with a provider identifier and THSteps benefit code.

If further evaluation is required to diagnose either latent TB infection or active TB disease, the provider may bill the appropriate E/M office visit code. Diagnosis and treatment are provided as a medical office visit. Providers can also call the TB program at 1-512-533-3000 for additional clinical information.

Refer to:  “TB Policies and Procedures” at www.dshs.texas.gov/idcu/disease/tb/ for guidance on skin testing children in various settings. Click TB Control Standards, and then look under “Texas TB Policies and Procedures.”

5.3.11.2Comprehensive Unclothed Physical Examination

An age-appropriate unclothed physical examination is required at each checkup.

Recording of measurements and percentiles as appropriate to age to document growth and development including:

Length or height and weight.

The World Health Organization (WHO) growth charts, which are recommended for clients from birth to 2 years of age.

The Centers for Disease Control and Prevention (CDC) growth charts, which are recommended for clients from 2 years of age and older.

Fronto-occipital circumference (FOC) through the first 24 months of age.

Body mass index (BMI) calculated beginning at 2 years of age.

Blood pressure beginning at 3 years of age.

5.3.11.2.1Oral Health Screening

Oral health screening is a part of the medical checkup physical examination.

5.3.11.2.2Sensory Screening

Documentation of test results from a school vision or hearing screening program may replace the required audiometric or visual acuity screening if conducted within 12 months prior to the checkup.

Clients who are birth through 35 months of age with suspected or confirmed hearing or visual impairment must be referred to ECI as soon as possible, but no longer than 7 days after identification.

5.3.11.2.3* Hearing Screening

State-mandated newborn hearing screening is offered by and performed in the birth facility in accor­dance with Health and Safety Code (HSC), Chapter 47, §§ 47.001–47.009 and 25 TAC §§ 37.501–37.507.

A newborn hearing screening must be completed at the birthing facility. Automated auditory brainstem response (AABR) or transient evoke or distortion product otoacoustic emissions (OAE) may be performed.

Screening Results

Birthing facilities must report all newborn hearing screening results to DSHS within five business days using the web-based Texas Early Hearing Detection and Intervention (TEHDI) Management Infor­mation System (MIS) if written parental consent is obtained. Documented written consent must be maintained in the infant's medical record.

Birthing facilities must provide written newborn hearing screening results to the parent or caregiver as well as the newborn's primary care provider (PCP) or medical home.

PCPs or medical homes (Texas Health Steps [THSteps] providers) must obtain a copy of the newborn hearing screening results within the TEHDI MIS if not provided by the birthing facility. The PCP or medical home must review all newborn hearing screening results with the parent or caregiver at the first checkup and determine if any additional follow-up is necessary.

Note:The PCP or medical home is responsible for managing and coordinating care for the child. Refer to the American Academy of Pediatrics Position Statement at http://pediatrics.aappublications.org/content/129/5/996.

Newborns who pass the newborn hearing screening must have their hearing monitored per the THSteps periodicity schedule. The PCP or medical home may opt to use the following tools to monitor develop­mental milestone benchmarks in newborns that pass their newborn hearing screening:

TEHDI: A Roadmap for Families (English)

Hearing Checklist for Parents (English)

Hearing Checklist for Parents (Spanish)

Newborns who do not pass the initial screen must be rescreened a second time in the birthing facility before discharge.

Outpatient Rescreening

Newborns who do not pass the second screen in the birthing facility must be referred to a Medicaid-enrolled provider for an outpatient follow-up rescreen. The rescreen provider must have access to AABR or OAE screening and must be experienced with the pediatric population under age three.

Newborns who do not receive a referral from the birthing facility, after not passing the second screen in the birthing facility, must be referred by their PCP or medical home to a Medicaid-enrolled provider for an outpatient follow-up rescreen, unless their PCP or medical home is adequately equipped to provide the service. The optimal time frame for the outpatient follow-up rescreen is when the infant is between 10 and 30 days old.

Outpatient follow-up rescreens must be completed by AABR or OAE screening. Results must be reported as soon as possible to the DSHS TEHDI MIS, as well as the infant's PCP or medical home.

Newborns who pass the outpatient rescreen must have their hearing monitored by their PCP or medical home per the THSteps periodicity schedule.

Diagnostic Audiological Evaluation

Newborns who do not pass the outpatient rescreen must be referred to a Medicaid-enrolled audiologist for a diagnostic audiological evaluation using the Texas Pediatric Protocol for Evaluation. Referrals should be made upon consultation with the PCP or medical home.

Note:Additional information about the Texas Pediatric Protocol for Evaluation is available at www.dshs.texas.gov/tehdi/Audiologic-Evaluation-Protocol.aspx.

Unless the newborn or infant has been hospitalized since birth, the diagnostic audiological evaluation must be completed no later than the third month after birth, or upon referral by the PCP or medical home.

Diagnostic audiological evaluations completed by audiologists using the Texas Pediatric Protocol for Evaluation must include a diagnostic auditory brainstem response (ABR) and, if not previously done, a diagnostic OAE to determine cochlear involvement.

Audiologists will use equipment norms for newborns, preferably ones they have collected on their equipment.

Protocols include air and bone conduction testing using tone burst ABR, as well as click ABR, so the amplification may be appropriate to fit the individual.

Note:Additional information about technologies that have been evaluated by an independent investigator and DSHS, and have been found to meet the requirements for conducting newborn hearing screening is available at www.dshs.texas.gov/tehdi/approved-screening-equipment.aspx.

Evaluation Results

Audiologists must report all diagnostic results to DSHS TEHDI MIS and provide written hearing screening results to the PCP or medical home.

The newborn or infant will be fitted for hearing aids by the audiologist when appropriate and should receive continued audiological assessments and monitoring as needed.

ECI Referrals

Newborns or infants not passing the outpatient rescreen must also be referred by the PCP or medical home to ECI for provision of services. The referral should be made within the TEHDI MIS.

Newborns or infants, as required by federal law under the Individuals with Disabilities in Education Act (IDEA), may be referred to ECI twice under the following circumstances:

Upon suspicion that the child is deaf or hard of hearing, for service coordination and possible confirmation of eligibility for ECI services

Upon confirmation that the child is deaf or hard of hearing, for a referral to other Local Education Agency for auditory impairment services

Late Onset Hearing Loss

When one or more risk factors for late onset hearing loss has been identified and the newborn or infant passed their hearing screen, the outcome will not be “normal hearing” but will be “in process.” Noting the infant as “in process” allows all health-care providers in the care of the infant to be aware of the presence of risk factors to determine the frequency of risk monitoring to identify audiological issues as soon as possible. This determination depends on the type and number of the following risks identified:

Craniofacial anomalies

Exchange transfusion for elevated bilirubin

Family history of deafness

NICU > 5 days

Apgar 0-4 at 1 minute

Apgar 0-6 at 5 minutes

Bacterial meningitis

Birth weight < 1500g

Congenital infection

Head injury

Neurodegenerative disorder

Other postnatal infection

Otitis media > 3 months (middle ear infection)

Ototoxic medications administered

Parental concern regarding hearing status

Persistent pulmonary hypertension of the newborn associated with mechanical ventilation

Syndrome

Note:Information about risk factors for late onset hearing loss and a risk monitoring periodicity schedule is available in Chapter 3, “Tracking, Reporting, & Follow-Up,” in The NCHAM E-Book on the National Center for Hearing Assessment and Management (NCHAM) website at http://infanthearing.org.

Hearing screening must be performed at each checkup for clients who are birth through 20 years of age. Audiometric screening must be performed at specific ages indicated on the periodicity schedule. Subjective screening through provider observation or informant report is required at the other checkups.

Clients at high risk or with abnormal screening results must be referred to an appropriate Medicaid-enrolled provider who specializes in pediatric audiology services. Clients who are birth through 20 years of age enrolled with Texas Medicaid for the date(s) of service are eligible for Texas Medicaid hearing services benefits.

5.3.11.2.4Vision Screening

Vision screening must be performed at each checkup. A visual acuity test must be performed at ages indicated on the periodicity schedule. Subjective screening through provider observation or informant report is done at the other checkups.

All clients must be screened for eye abnormalities by history, observation, and physical exam and referred to a Medicaid-enrolled optometrist or ophthalmologist experienced with the pediatric population if at high risk.

Clients with abnormal visual acuity screening results must be referred to a Medicaid-enrolled optome­trist or ophthalmologist experienced with the pediatric population.

5.3.11.3Immunizations

Providers must assess the immunization status at every medical checkup to ensure all age requirements have been met. The necessary vaccines and toxoids must be administered at the time of the checkup unless medically contraindicated or because of parent’s or caregiver’s reasons of conscience including religious beliefs. If an indicated vaccine or toxoid was not administered, the reason must be documented in the client’s medical record.

Vaccines and toxoids must be administered according to the current ACIP “Recommended Childhood and Adolescent Immunization Schedule - United States.” Providers must not refer clients to the local health department or other entity for immunization administration.

THSteps providers are strongly encouraged to obtain vaccines from TVFC for clients who are birth through 18 years of age. Vaccines that are identified as being distributed through TVFC are not reimbursed separately.

Vaccines and toxoids may be reimbursed through Texas Medicaid at a fee determined by HHSC when the vaccine is medically necessary for THSteps clients who are 19 through 20 years of age.

The specific diagnosis necessitating the vaccine and toxoid is required when billing with the following administration procedure codes in combination with an appropriate vaccine/toxoid procedure code:

Procedure Codes

90460

90461

90471

90472

90473

90474

The age-appropriate diagnosis code for a preventive care medical checkup must be submitted on the claim. If an immunization is administered as part of a preventive care medical checkup, diagnosis code Z23 may also be included on the claim, in addition to the age-appropriate diagnosis.

Providers may only submit diagnosis code Z23 on the claim if an immunization is the only service provided during an office visit.

Vaccine and toxoid administration must be billed with the following age appropriate diagnosis codes:

Client Age

Diagnosis Code

Birth through 7 days

Z00110

Eight through 28 days

Z00111

29 days through 17 years

Z00121, Z00129

18 years or older

Z0000, Z0001

Procedure codes 90460 and 90461 are benefits for services rendered to clients who are birth through 18 years of age when counseling is provided for the immunization administered.

Procedure codes 90471 and 90472 are benefits for services rendered to clients of any age when counseling is not provided for the immunization administered.

Procedure codes 90473 and 90474 are benefits for services rendered to clients who are birth through 20 years of age when counseling is not provided for the immunization administered.

The following vaccines and toxoids are a benefit of Texas Medicaid:

Procedure Code

Number of Components**

Procedure Code

Number of Components**

Procedure Code

Number of Components**

90620*

1

90621*

1

90630

1

90632

1

90633*

1

90636

2

90644

2

90647*

1

90648*

1

90649*

1

90650*

1

90651*

1

90654

1

90655*

1

90656*

1

90657*

1

90658*

1

90660*

1

90661

1

90670*

1

90672*

1

90673

1

90674

1

90680*

1

90681*

1

90682

1

90685*

1

90686*

1

90687*

1

90688*

1

90696*

4

90698*

5

90700*

3

90702*

2

90707*

3

90710*

4

90713*

1

90714*

2

90715*

3

90716*

1

90723*

5

90732*

1

90733

1

90734*

1

90743

1

90744*

1

90746

1

90748*

2

90749

1

* TVFC-distributed vaccine/toxoid

** The number of components applies if counseling is provided and procedure code 90460 and 90461 are submitted.

 

Procedure codes 90655, 90657, 90685, and 90687 are limited to clients who are 6 through 35 months of age.

Procedure codes 90656 and 90658 are limited to clients who are 3 years of age and older.

Procedure codes 90686 and 90688 are limited to clients who are 6 months of age and older.

Procedure code 90682 is limited to clients who are 18 years of age and older.

Providers may use the state-defined modifier U1 in addition to the associated administered vaccine procedure code for clients who are birth through 18 years of age and the vaccine was unavailable through TVFC.

Modifier

Description

U1

State-defined modifier: Vaccine(s)/toxoid(s) privately purchased by provider when TVFC vaccine/toxoid is unavailable

Note:“Unavailable” is defined as a new vaccine approved by ACIP that has not been negotiated or added to a TVFC contract, funding for new vaccine that has not been established by TVFC, or national supply or distribution issues. Providers will be informed if a vaccine meets the definition of ‘not available’ from TVFC and when the provider’s privately purchased vaccine may be billed with modifier U1.

Modifier U1 may not be used for failure to enroll in TVFC, maintain sufficient TVFC vaccine/toxoid inventory, or clients who are 19 through 20 years of age.

Each vaccine or toxoid and its administration must be submitted on the claim in the following sequence: the vaccine procedure code immediately followed by the applicable immunization administration procedure code(s). All of the immunization administration procedure codes that correspond to a single vaccine or toxoid procedure code must be submitted on the same claim as the vaccine or toxoid procedure code.

Each vaccine or toxoid procedure code must be submitted with the appropriate “administration with counseling” procedure code(s) (procedure codes 90460 and 90461) or the most appropriate “adminis­tration without counseling” procedure code (procedure code 90471, 90472, 90473, or 90474). If an “administration with counseling” procedure code is submitted with an “administration without counseling” procedure code for the same vaccine or toxoid, the administration of the vaccine or toxoid will be denied.

Administration With Counseling

Providers must submit claims for immunization administration procedure codes 90460 or 90461 based on the number of components per vaccine. Providers must specify the number of components per vaccine by billing 90460 and 90461 as defined by the procedure code descriptions:

Procedure code 90460 is submitted for the administration of the 1st component.

Procedure code 90461 is submitted for the administration of each additional component identified in the vaccine.

Procedure code 90461 will be denied if procedure code 90460 has not been submitted on the same claim for the same vaccine or toxoid.

The necessary counseling that is conducted by a physician or other qualified health-care professional must be documented in the client’s medical record.

The following is an example of how to submit claims for immunization administration procedure codes when counseling is provided:

Procedure Code

Quantity Billed

Vaccine or toxoid procedure code with 1 component

1

90460 (1st component)

1

Vaccine or toxoid procedure code with 3 components

1

90460 (1st component)

1

90461 (2nd and 3rd components)

2

Note:The term “components” refers to the number of antigens that prevent disease(s) caused by one organism. Combination vaccines are those that contain multiple vaccine components.

Administration Without Counseling

Procedure codes 90471, 90472, 90473, and 90474 may be reimbursed per vaccine based on the route of administration.

The following is an example of how to submit claims for injection administration procedure codes when counseling is not provided:

Procedure Code

Quantity Billed

Vaccine or toxoid procedure code

1

90471 (Injection administration)

1

Vaccine or toxoid procedure code

1

90472 (Injection administration)

1

Vaccine or toxoid procedure code

1

90472 (Injection administration)

1

Vaccine Administration and Preventive E/M Visits

For claims that are submitted with an immunization administration procedure code and a preventive E/M visit, providers may append modifier 25 to the preventive E/M visit procedure code to identify a significant, separately identifiable E/M service that was rendered by the same provider on the same day as the immunization administration. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client’s medical record and made available to Texas Medicaid upon request.

Refer to:  Acute Care Visit on the Same Day as a THSteps Preventive Visit Checkup on the TMHP website at www.tmhp.com.

THSteps Preventive Visit Checkup with Immunization and Vaccine Administration on the TMHP website at www.tmhp.com for a claim form example.

5.3.11.3.1Vaccine Information Statement (VIS)

A VIS is required by federal mandate to inform parents and vaccine recipients of the risks and benefits of the vaccine they are about to receive. Not only is it important to explain the risks and benefits before a vaccine is administered, it is also important that providers use the most current forms available. For more about immunizations, vaccine-preventable diseases, or literature and forms, providers can call the DSHS Immunization Branch at 1-800-252-9152 or review information at www.dshs.texas.gov/immunize.

Refer to:  “Appendix B. Immunizations”  in this handbook.

The DSHS website for TVFC provider enrollment information at www.dshs.texas.gov/immunize/tvfc/default.shtm.

The THSteps online education module “Immunizations,” located on the THSteps website at www.txhealthsteps.com, for more information about immunizations.

5.3.11.4Health Education and Anticipatory Guidance

Anticipatory guidance is a federally mandated component of the THSteps medical checkup and includes health education and counseling. Health education and counseling with parents or guardians and clients are required to assist parents in understanding what to expect in terms of the client’s development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. Written material may also be given but does not replace counseling. The optional THSteps clinical records include age-appropriate topics on the back of each form. These forms can be found at www.dshs.texas.gov/thsteps/forms.shtm.

5.3.11.5Dental Referral

Based on the AAPD definition of a dental home, Texas Medicaid defines a dental home as the dental provider who supports an ongoing relationship with the client that is inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. In Texas, establishment of a client’s dental home should begin at 6 months of age but no later than 12 months of age and includes referral to dental specialists when appropriate.

The physician must refer clients to establish a dental home beginning at 6 months of age or earlier if trauma or early childhood caries are identified. For established clients after the six-month medical checkup, the provider must confirm if a dental home has been established and is on-going; if not, additional referrals must be made at subsequent medical checkup visits until the parent or caregiver confirms that a dental home has been established for the client. The parent or caregiver of the client may self-refer for dental care at any age, including 12 months of age or younger.

5.3.11.6Laboratory Test

Age-appropriate and risk-based laboratory testing as noted on the periodicity schedule is considered part of the medical checkup. The DSHS Laboratory provides supplies for specimen collection and mailing and shipping; and reporting of test results to enrolled THSteps medical providers that submit specimens to the DSHS Laboratory. These services and supplies are limited to THSteps medical checkup laboratory services provided in the course of a medical checkup to THSteps clients. Unauthorized use of services and supplies is a violation of federal regulations.

DSHS Laborato