Clinics and Other Outpatient Facility Services Handbook

 

1 General Information

This information is intended for Federally Qualified Health Centers (FQHCs) renal dialysis facilities, Rural Health Clinics (RHCs) and tuberculosis (TB) clinics. This handbook provides information about Texas Medicaid’s benefits, policies, and procedures applicable to these providers. This handbook contains information about Texas Medicaid fee-for-service benefits. For information about managed care benefits, refer to the Texas Medicaid Managed Care Handbook. Managed care carve-out services are administered as fee-for-service benefits. A list of all carve-out services is available in Subsection 17, “Carve-Out Services” in the Texas Medicaid Managed Care Handbook.

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 Title 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.

1.1National Drug Codes (NDC)

Refer to:  Subsection 6.3.4, “National Drug Code (NDC)” in “Section 6: Claims Filing” (Vol. 1, General Information).

1.2Revenue Codes for UB-04 Submissions

Claims that are submitted on the CMS-1450 UB-04 paper claim form or electronic equivalent by non-hospital facility or other non-hospital providers must be submitted with a revenue code for correct processing.

If the non-hospital provider is required to submit a procedure code for reimbursement, the provider must include the procedure code and an appropriate corresponding revenue code on the same detail, even if the chosen revenue code does not require a procedure code for claims processing.

Refer to:  Subsection 4.5.5, “Outpatient Hospital Revenue Codes” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for a list of revenue codes that do and do not require procedure codes.

1.3Payment 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 timeframe 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:

The services were FQHC, RHC, THSteps, or some renal dialysis services.

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.

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 Birthing Center

2.1Provider Enrollment

A birthing center is a place, facility, or institution where a woman is scheduled to give birth following a normal, uncomplicated (low-risk) pregnancy. This term does not include a hospital, an ambulatory surgical center, or the residence of the woman giving birth.

A birthing center must be licensed as a birthing center by the Department of State Health Services (DSHS) and meet the minimum standards as required by the Texas Health and Safety Code, Chapter 244.010. To enroll in Texas Medicaid, a birthing center must be licensed to provide a level of service commensurate with the professional services of a doctor of medicine (MD), doctor of osteopathy (DO), certified nurse-midwife (CNM), or licensed midwife (LM) who acts as birth attendant. Texas Medicaid may reimburse birthing center providers only for those services that the attending physician or CNM determines to be reasonable and necessary for the care of the mother or newborn child.

Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted.

Birthing centers are encouraged to refer clients for Texas Health Steps (THSteps) services.

Refer to:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures.

Section 2, “Medicaid Title XIX Family Planning Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for infor­mation on setting up referral procedures for family planning services.

The HHSC website at www.healthytexaswomen.org for information about family planning and the locations of family planning clinics receiving HHSC Family Planning Program funding from HHSC.

Subsection 7.2.1.3, “Laboratory Tests” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about required human immunodeficiency virus (HIV) testing for pregnant women.

2.2Services, Benefits, Limitations, and Prior Authorization

Birthing centers may only be reimbursed by Texas Medicaid for their facility labor and delivery services using the following procedure codes:

Service

Procedure Code

Delivery

59409

Labor only

S4005

Note:Deliveries at a facility licensed as a birthing center by DSHS must be billed with procedure code 59409.

If the client is discharged prior to delivery, procedure code S4005 may be billed by the facility for labor services only.

Refer to:  Subsection 9.2.34, “Immunization Guidelines and Administration” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for additional information about immunization administration.

2.2.1Newborn Hearing Screening

The Texas Health and Safety Code, Chapter 47, requires birthing centers to offer all newborns a hearing screening as a part of the obstetrical care at delivery.

Refer to:  Subsection 5.3.9, “* Newborn Examination” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about the newborn hearing screening.

Subsection 2.2.2.3, “Abnormal Hearing Screening Results” in the Vision and Hearing Services Handbook (Vol. 2, Provider Handbooks) for more information about abnormal hearing screens.

2.2.2Newborn Eligibility Process

If the mother of the newborn is eligible for Medicaid, the newborn may be assigned his or her own Medicaid number. The birthing center must complete form GN.4, “Birthing Center Report (Newborn Child or Children) (Form 7484)” to provide information about each child born to a mother who is eligible for Medicaid.

Refer to:  Hospital Report (Newborn Child or Children) (Form 7484) on the TMHP website at www.tmhp.com.

If the newborn’s name is known, the name must be on the form. The use of “Baby Boy” or “Baby Girl” delays the assignment of a number.

The form must be completed by the birthing center no later than five days after the child’s birth. Birthing centers that submit the birth certificate information using the HHSC, Vital Statistics Unit (VSU) Texas Electronic Registrar for Birth software and the HHSC Form 7484 receive a rapid and efficient assignment of a newborn Medicaid identification number. This process expedites reimbursement to hospitals and other providers that are involved in the care of the newborn.

Additional information about obtaining a newborn Medicaid identification number can be found on the agency website at www.hhsc.state.tx.us/medicaid/mc/proj/newid/newid.html. Providers may also call 1-888-963-7111, Ext. 7368 or 1-512-458-7368 for additional information or comments about this process.

Upon receipt of a completed 7484 form, DSHS verifies the mother’s eligibility and, within ten days of the receipt, sends notification letters to the hospital or birthing center, attending physician (if identified), mother, and caseworker. The notice includes the child’s Medicaid identification number and the effective date of coverage. After the child has been added to the eligibility file, HHSC issues a Medicaid Identification card (Your Texas Benefits Medicaid card) to the client.

The attending physician’s notification letter is sent to the address on file (by license number) at the Texas Medical Board. This address must be kept current to ensure timely notification. Physicians must submit address changes to the following address:

Texas Medical Board
Customer Information, MC-240
PO Box 2018
Austin, TX 78767-2018

2.2.3Prior Authorization

Prior authorization is not required for services rendered in birthing centers.

2.2.4Services Rendered in the Birthing Center Setting

Maternity clinic, physician, CNM, LM, nurse practitioner (NP), clinical nurse specialist (CNS), and physician assistant (PA) providers who render prenatal or family planning services in the birthing center setting must submit separate claims.

Refer to:  Section 4, “Obstetric Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for information about birthing center providers.

2.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered.

Birthing center services are subject to retrospective review and recoupment if documentation does not support the service billed.

2.4Claims Filing and Reimbursement

2.4.1Claims Information

Claims for birthing center services must be submitted to Texas Medicaid & Healthcare Partnership (TMHP) in an approved electronic format or on the 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.

When completing a CMS-1500 paper claim form, providers must include all required information on the claim, as TMHP does not key any information from 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.

“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. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

2.4.2Reimbursement

Birthing centers are reimbursed in accordance with 1 TAC §355.8181. See the applicable fee schedule on the TMHP website at www.tmhp.com. Texas Medicaid implemented mandated rate reductions for certain services.

Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

2.4.2.1National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines

The Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes included in the Texas Medicaid Provider Procedures Manual are subject to National Correct Coding Initiative (NCCI) relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. The Centers for Medicare & Medicaid Services (CMS) NCCI and medically unlikely edits (MUE) guidelines can be found in the NCCI Policy and Medicaid Claims Processing manuals, which are available on the CMS NCCI web page. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

3 Comprehensive Health Center (CHC)

CHCs or physician-operated clinics are funded by federal grants. To apply for participation in Texas Medicaid, they must be certified and participate as health centers under Medicare (Title XVIII).

CHC claims are paid according to each center’s encounter rates as established by CMS. Medicaid payments to CHCs are limited to Medicare deductible or coinsurance according to current guidelines. CHC providers that supply laboratory services in an office setting must comply with the rules and regulations for the Clinical Laboratory Improvement Amendments (CLIA). Providers that do not comply with CLIA are not reimbursed for laboratory services.

Refer to:  Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

“Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Section 4, “Federally Qualified Health Center (FQHC)” in this handbook.

Section 7, “Rural Health Clinic” in this handbook.

4 Federally Qualified Health Center (FQHC)

4.1Enrollment

To enroll in Texas Medicaid, an FQHC must be receiving a grant under Section 329, 330, or 340 of the Public Health Service Act or designated by the U.S. Department of Health and Human Services (HHS) to have met the requirements to receive this grant. FQHCs and their satellites are required to enroll in Medicare to be eligible for Medicaid enrollment. The CMS has granted a waiver for the Medicare prereq­uisite at the time of initial enrollment of FQHC parents and satellites. FQHC look-alikes are not required to enroll in Medicare but may elect to do so to receive reimbursement for crossovers.

Refer to:  Subsection 4.4.2.1, “Medicare Crossover Claims Pricing” in this handbook.

A copy of the Public Health Service’s Notice of Grant Award reflecting the project period and the current budget period must be submitted with the enrollment application. A current notice of grant award must be submitted to TMHP Provider Enrollment annually.

FQHCs are required to notify TMHP of all satellite centers that are affiliated with the parent FQHC and their actual physical addresses. All FQHC satellite centers billing Texas Medicaid for FQHC services must also be approved by the United States Department of Health and Human Services Health Resources and Services Administration (HRSA). For accounting purposes, centers may elect to enroll the HRSA-approved satellites using a Federally Qualified Satellite (FQS) provider identifier that ties back to the parent FQHC provider identifier and tax ID number (TIN). This procedure allows for the parent FQHC to have one provider agreement and one cost report that combines all costs from all approved satellites and the parent FQHC. If an approved satellite chooses to submit claims to Texas Medicaid directly, the center must have a provider identifier separate from the parent FQHC and will be required to file a separate cost report.

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 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.

FQHC providers do not need to apply for a separate physician or agency number to provide family planning services.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures.

FQHCs must identify and attest to all contractual agreements for those medical services in which the FQHC is receiving Prospective Payment System (PPS) reimbursement. This is a mandate from the 2012 to 2013 General Appropriations Act, H.B. 1, 82nd Legislature, Regular Session, 2011 (Article II, Health and Human Services Commission, Rider 78).

The attestation shall be made using the Federally Qualified Health Center Affiliation Affidavit, which is available on the TMHP website at www.tmhp.com.

4.1.1Initial Cost Reporting

New FQHCs must file a projected cost report within 90 days of their designation as an FQHC to establish an initial payment rate. The cost report will contain the FQHC’s reasonable costs anticipated to be incurred during the FQHC’s initial fiscal year. The FQHC must file a cost report within five months of the end of the FQHC’s initial fiscal year. The cost settlement must be completed within 11 months of the receipt of a cost report. The cost per visit rate established by the cost settlement process will be the base rate. Any subsequent increases will be calculated as provided herein.

FQHC providers are required to submit a copy of their Medicare-audited cost report for the provider’s fiscal year within 30 days of receipt from Medicare to:

Texas Medicaid & Healthcare Partnership
Medicaid Audit
PO Box 200345
Austin, TX 78720-0345

A new FQHC location established by an existing FQHC participating in Texas Medicaid will receive the same effective rate as the FQHC establishing the new location. An FQHC establishing a new location may request an adjustment to its effective rate as provided herein if its costs have increased as a result of establishing a new location.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures.

4.2Services, Benefits, Limitations, and Prior Authorization

The services listed in the following tables may be reimbursed using the FQHC’s National Provider Identifier (NPI). Any additional physician services must be submitted for reimbursement using the physician’s Medicaid provider identifier. Hospital services are not considered for reimbursement to FQHC providers, and cannot be billed using the facility provider number assigned to the FQHC.

General Medical Services

T1015

General medical services must be submitted using one of the appropriate modifiers AH, AJ, AM, SA, TD, TE, TH, or U7.

FQHC Encounter Services

G0466

G0467

G0468

G0469

G0470

Adult Preventative Care

99385

99386

99387

99395

99396

99397

Adult preventative care must be submitted with diagnosis codes Z0000, Z0001, Z01411, and Z01419.

Case Management

G9012

Comprehensive visit must be submitted using modifiers U2 and U5.

Follow-up face-to-face visit must be submitted using modifiers TS and U5.

Follow-up telephone visit must be submitted using modifier TS.

Family Planning Services

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

J7297

J7298

J7300

J7301

J7307

Annual family planning examination must be submitted with modifier FP.

Mental Health Services

90791

90792

90832

90833*

90834

90836*

90837

90838*

90846

90847

90853

90899

96101

96118

* Procedures cannot be performed by Psychologist. Mental health services must be submitted using one of the appropriate modifiers AH, AJ, AM, U1, or U2.

THSteps Dental Services

D0120

D0140

D0145

D0150

D0160

D0170

D0180

D0330

D0340

D0350

D0367

D0470

D1110

D1120

D1208

D1351

D1352

D1510

D1515

D1520

D1525

D1555

D1575

D2140

D2150

D2160

D2161

D2330

D2331

D2332

D2335

D2390

D2391

D2392

D2393

D2394

D2750

D2751

D2791

D2792

D2930

D2931

D2932

D2933

D2934

D2940

D2950

D2954

D2971

D3220

D3230

D3240

D3310

D3320

D3330

D3346

D3347

D3348

D3351

D3352

D3353

D4277

D4278

D4283

D4285

D4341

D4355

D5211

D5212

D5281

D5610

D5630

D5640

D5650

D5660

D5670

D5671

D5720

D5721

D5740

D5741

D5760

D5761

D5992

D5993

D6549

D7140

D7210

D7220

D7230

D7250

D7270

D7286

D7510

D7550

D7910

D7970

D7971

D7997

D7999

D8050

D8060

D8080

D8210

D8220

D8660

D8670

D8680

D8690

D9110

D9211

D9212

D9223

D9230

D9243

D9248

D9930

D9974

D9999

Procedure codes D8210, D8220, and D8080 must be submitted with Diagnostic Procedure Code (DPC) remarks codes for correct claims processing.

THSteps Medical Services

99211

99381

99382

99383

99384

99385

99391

99392

99393

99394

99395

96160

96161

THSteps medical services must be submitted using modifier EP in addition to one of the appropriate modifiers AM, SA, or U7.

Note:Procedure codes 96160 and 96161 are a benefit for Texas Medicaid clients who are 12 through 18 years of age and is limited to once per lifetime.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.

Vision Care Services

92002

92004

92012

92014

92015

92020

92025

92060

92065

92081

92082

92083

92100

92225

92226

92230

92235

92240

92242

92250

92260

92265

92270

92275

92285

92286

92287

95060

95930

95933

S0620

S0621

Copayments

CP001

CP002

CP003

CP004

CP005

CP006

CP007

CP008

Refer to:  Subsection 6.3.5, “Modifiers” in “Section 6: Claims Filing” (Vol. 1, General Information) for a definition of modifiers.

Section 4, “Texas Health Steps (THSteps) Dental” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Section 5, “THSteps Medical” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Section 2, “Healthy Texas Women (HTW) Program Overview” in the Women’s Health Services Handbook (Vol. 2, Provider Handbooks).

Section 3, “Health and Human Services Commission (HHSC) Family Planning Program Services” in the Women’s Health Services Handbook (Vol. 2, Provider Handbooks).

Section 4, “Vision Care Professionals” in the Vision and Hearing Services Handbook (Vol. 2, Provider Handbooks).

Section 4, “Outpatient Mental Health Services” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks).

Subsection 9.2.56.1.2, “Preventive Care Visits” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Subsection 8.8.2.2, “HMO Copayments” in “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information) for information about HMO copayments.

Medicaid coverage is limited to FQHC services that are covered by Texas Medicaid and are reasonable and medically necessary. When furnished to a client of the FQHC, medically necessary services include the following:

CNM services

Clinical psychologist services

Clinical social worker services; other mental health services

Dental services

NP services

Other ambulatory services included in Medicaid such as family planning, THSteps, and maternity service clinic (MSC)

PA services

Physician services

Services and supplies necessary for services that would be covered otherwise, if furnished by a physician or a physician service

Vision care services

Visiting nurse services to a homebound individual, in the case of those FQHCs located in areas with a shortage of home health agencies

Types of FQHC visits are defined in 1 TAC §355.8261. A visit is a face-to-face encounter between an FQHC client and a physician, PA, NP, CNM, visiting nurse, qualified clinical psychologist, clinical social worker, other health-care professional for mental health services, dentist, dental hygienist, or optome­trist. Encounters that take place on the same day at a single location with more than one health-care professional or multiple encounters with the same health-care professional constitute a single visit, except where one of the following conditions exists:

After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment.

The FQHC client has a medical visit and an other health visit such as a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a THSteps medical checkup.

All services provided that are incidental to the encounter, including developmental screening, must be included in the total charge for the encounter. They are not billable as a separate encounter.

Registered nurses may not be the sole provider of a medical checkup in an FQHC. If immunizations are given outside of a THSteps medical checkup, procedure codes given in the THSteps section of this manual should be used. These procedure codes are informational only, and are not payable.

To be reimbursed for Case Management for Children and Pregnant Women, an FQHC must be approved as a case management services provider by the DSHS Case Management Branch.

An annual family planning examination is allowed once per state fiscal year (September 1 through August 31), per client, per provider. An FQHC may be reimbursed for up to three family planning encounters per client, per year, regardless of the reason for the encounter. The three encounters may include any combination of general family planning encounters, an annual family planning examination, or intrauterine devices.

Family planning services must be submitted with the most appropriate evaluation and management (E/M) procedure code and one of the following family planning diagnosis codes:

Family Planning Diagnosis Codes

Z30011

Z30013

Z30014

Z30018

Z3002

Z3009

Z302

Z3040

Z3041

Z3042

Z30430

Z30431

Z30432

Z30433

Z3049

Z308

Z309

Z9851

Z9852

Procedure code 58300 must be submitted on the same claim as J7297, J7298, J7300, and J7301. Procedure code 58300 will process as informational only. Only the annual family planning examination requires modifier FP. All other family planning visits do not require the FP modifier. Claims filed incorrectly may be denied.

Laboratory and radiology services or the services of a licensed vocational nurse (LVN), registered nurse (RN), nutritionist, or dietitian are not considered an encounter, because they are incidental to an encounter with one of the previously-mentioned payable health-care professionals. Providers should continue to include the cost associated with these services on their cost report (they are allowable but do not constitute an encounter).

Per federal regulations, the provider cannot submit claims to Medicaid or bill the client for vaccines obtained from the Texas Vaccine for Children (TVFC) Program.

Refer to:  Section 5, “THSteps Medical” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

4.2.1After-Hours Care

After-hours care for FQHCs is defined as care provided on weekends, on federal holidays, or before 8 a.m. and after 5 p.m., Monday through Friday. After-hours care provided by FQHCs does not require a referral.

4.2.2Prior Authorization

Prior authorization or authorization may be required for FQHC services. Refer to the individual sections referenced in subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization” in this handbook.

4.2.3Referral Requirements

Texas Medicaid fee-for-service limited clients, are allowed to choose any enrolled family planning provider.

4.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered. All services provided are subject to retrospective review and recoupment if documentation does not support the service that was submitted for reimbursement.

4.4Claims Filing and Reimbursement

4.4.1Claims Information

All services provided that are incidental to the encounter must be included in the total charge for the encounter and are not billable as a separate encounter. For example, if an office visit was provided at a charge of $30 and a lab test for $15, the center would submit a claim to TMHP for procedure code T1015 for $45 and would be reimbursed at the center’s encounter rate. All services (except for family planning, THSteps medical, THSteps dental, copayments, vision, mental health services, and case management for high-risk pregnant women and infants) provided during an encounter must be submitted for reimbursement using procedure code T1015.

All providers of laboratory services must comply with the rules and regulations of CLIA. Providers who do not comply with CLIA are not reimbursed for laboratory services.

Refer to:  Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

To obtain the encounter rate when submitting claims for family planning services that are provided under Title XIX or HTW, FQHCs must use the most appropriate E/M procedure code, or procedure code J7297, J7298, J7300, and J7301, or J7307 with a family planning diagnosis code. Providers must use procedure code J7297, J7298, J7300, or J7307 if the visit is for the insertion of an intrauterine device (IUD) or implantable contraceptive capsule. These procedure codes must be submitted in conjunction with the most appropriate informational procedure codes for services that were rendered. Procedure codes J7297, J7298, J7300, J7301, and J7307 may be reimbursed in addition to the FQHC encounter payment. When seeking reimbursement for an IUD or implantable contraceptive capsule, providers must submit on the same claim the procedure code for the family planning service provided and the procedure code for the contraceptive device. The contraceptive device is not subject to FQHC limita­tions. Providers must use modifier U8 when submitting claims for a contraceptive device purchased through the 340B Drug Pricing Program. Providers must use modifier FP only to submit claims for the annual family planning examination.

If an employed physician of an FQHC provides a service in the hospital (e.g., a delivery), the service may be billed using the physician provider number if the terms of the FQHC and physician agreement indicate this occurrence. Physicians must be enrolled in Medicaid separately from the FQHC facility). Physicians are not allowed to bill through their FQHC group number for hospital services. The services will be reimbursed at the physician fee-for-service (FFS) fee schedule rate. The costs that are associated with these physician services must be excluded from the FQHC’s cost report and will not be considered during the FQHC cost settlement or encounter rate setting process.

Services rendered in the (inpatient or outpatient) hospital setting are not considered a reimbursable FQHC encounter and are not payable to the FQHC. FQHC services for clients who have only Medicaid must be submitted to TMHP in approved electronic format or on a UB-04 CMS-1450, CMS-1500, or 2017 paper claim form. Providers may purchase UB-04 CMS-1450 or CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a UB-04 CMS-1450 or 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.

The ADA Dental Claim Form can be downloaded at www.ada.org/7119.aspx. 

The 2017 Claim Form can be found in the Forms section of this manual.

Refer to:  2017 Claim Form on the TMHP website at www.tmhp.com.

“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.

Section 11, “Forms” in this handbook.

Claims must be filed as follows:

Services

Claim Form

THSteps medical services

UB-04 CMS-1450 or CMS-1500 paper claim form or approved electronic format

Family planning claims filed by FQHC providers who have contracted with HHSC

2017 Claim Form or approved electronic format

Family planning claims filed by FQHC providers not contracted with HHSC

UB-04 CMS-1450 or 2017 paper claim form or approved electronic format

THSteps dental services

American Dental Association (ADA) Dental Claim Form or approved electronic format

Case Management for Children and Pregnant Women services

UB-04 CMS-1450 or CMS-1500 paper claim form or approved electronic format

When filing for a client who has Medicare and Medicaid coverage, providers must file on the same claim form that was filed with Medicare.

Services provided by a health-care professional require one of the following modifiers with procedure code T1015, to designate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE, or U7.

If more than one health-care professional is seen during the encounter, the modifier must indicate the primary contact. The primary contact is defined as the health-care professional who spends the greatest amount of time with the client during that encounter.

If the encounter is for antepartum care or postpartum care, the modifier TH must be indicated on the claim in addition to any other appropriate modifier.

If the antepartum or postpartum care is provided by a CNM, the modifier SA must be indicated on the claim in addition to any other appropriate modifiers.

Use modifier TD or TE for home health services provided in areas with a shortage of home health agencies.

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.

The Claim Form Examples page of the TMHP website at www.tmhp.com.

The Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks).

The Women’s Health Services Handbook (Vol. 2, Provider Handbooks).

4.4.2Reimbursement

FQHCs are reimbursed provider-specific prospective payment system encounter rates in accordance with 1 TAC §355.8261.

FQHCs are exempt from the mandated rate reductions except for HHSC Family Planning services.

Texas Medicaid implemented mandated rate reductions for certain services. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

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 about reimbursement.

Subsection 2.3, “Reimbursement Reductions” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for more information about reimbursement.

4.4.2.1Medicare Crossover Claims Pricing

For Medicare Part B cost sharing obligations, all deductible obligations will be reimbursed at 100 percent of the deductible amount owed, even if the cost sharing comparison results in a lower payment. For all other cost sharing obligations (including Medicare Part A, B, and C), the cost sharing comparison is performed according to current guidelines.

For FQHC Medicare crossover claims, Texas Medicaid will reimburse the lesser of the following:

The coinsurance and full deductible payment.

The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service. If this amount is less than the deductible, then the full deductible is reimbursed instead.

If the Medicare payment is equal to, or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid will not make a payment for coinsurance.

The client has no liability for any balance or Medicare coinsurance and deductible related to Medicaid-covered services.

Refer to:  Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

4.4.2.2NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

5 Maternity Service Clinic (MSC)

MSCs are limited provider clinics that are unrelated to a hospital and that only provide maternity services. An MSC will be reimbursed for antepartum and/or postpartum care visits only. Hemoglobin, hematocrit and urinalysis procedures are included in the charge for antepartum care and not separately reimbursed. Services other than antepartum and postpartum care visits will be denied.

Refer to:  Section 7, “Maternity Service Clinics (MSC)” in the Medical and Nursing Specialists, Physi­cians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

6 Renal Dialysis Facility

6.1Enrollment

To enroll in Texas Medicaid, a renal dialysis facility must be Medicare-certified in the state where it is located. Facilities must also adhere to the appropriate rules, licensing, and regulations of the state where they operate.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information.

6.2Services, Benefits, Limitations, and Prior Authorization

Renal dialysis is a benefit of Texas Medicaid for the following acute renal failure or end stage renal disease (ESRD) diagnosis codes:

Diagnosis Codes

N170

N171

N172

N178

N179

N181

N182

N183

N184

N185

N186

N189

All of the services, except for ultrafiltration (revenue code B-881), are diagnosis-restricted to the diagnoses in the above table.

Refer to:  Subsection 9.2.47, “Organ/Tissue Transplants” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Subsection 3.2.5, “Organ and Tissue Transplant Services” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for information on organ trans­plant and facility services.

Dialysis treatments are a benefit for clients in an inpatient or outpatient hospital or a renal dialysis facility according to the guidelines for outpatient maintenance dialysis approved through CMS. Dialysis treatments may also be a benefit in the client’s home. Outpatient dialysis includes:

Staff-assisted dialysis performed by the staff of the center or facility.

Self-dialysis performed by a client with little or no professional assistance (the client must have completed an appropriate course of training).

Home dialysis performed by an appropriately trained client (and the client’s caregiver) at home.

Dialysis furnished in a facility on an outpatient basis at an approved renal dialysis facility.

6.2.1Physician Supervision

Physician reimbursement for supervision of ESRD clients on dialysis is based on a monthly capitation payment (MCP) that is calculated by Medicare. The MCP is a comprehensive payment that covers all of the physician services that are associated with the continuing medical management of a maintenance dialysis client for treatments received in the facility. An original onset date of dialysis treatment must be included on claims for all renal dialysis procedures in all places of service except inpatient hospital.

Physician supervision of outpatient ESRD dialysis includes services that are rendered by the attending physician in the course of office visits during which any of the following occur:

The routine monitoring of dialysis

The treatment or follow-up of complications of dialysis, including:

The evaluation of related diagnostic tests and procedures

Services that are involved in the prescription of therapy for illnesses that are unrelated to renal disease, if the treatment occurs without increasing the number of physician-client contacts

The following physician services are a benefit for physician supervision of outpatient ESRD dialysis services:

Procedure Codes

90951

90952

90953

90954

90955

90956

90957

90958

90959

90960

90961

90962

90963

90964

90965

90966

90967

90968

90969

90970

Procedure codes 90935, 90937, 90945, and 90947 are a benefit for:

ESRD or non-ERSD services in the inpatient setting when the physician is present during dialysis treatment. The physician must be physically present and involved during the course of dialysis. These codes are not payable for a cursory visit by the physician. Hospital visit procedure codes must be used for a cursory visit.

Non-ERSD services when provided by a physician, nurse practitioner, clinical nurse specialist, or physician assistant in an office or outpatient setting.

Only one of the following procedure codes 90935, 90937, 90945, or 90947 may be reimbursed per day by any provider.

If the physician sees the client only when the client is not dialyzing, the physician must submit the appro­priate hospital visit procedure code. The inpatient dialysis procedure code must not be submitted for payment.

Providers must use one of the following procedure codes to submit claims for services when the client:

Is not on home dialysis.

Has had a complete assessment visit during the calendar month.

Has received a full month of ESRD related services

Procedure Codes

90951

90952

90953

90954

90955

90956

90957

90958

90959

90960

90961

90962

.

When a full calendar month of ESRD-related services are submitted for clients on home dialysis, providers must use procedure code 90963, 90964, 90965, or 90966.

Providers must submit claims with procedure code 90967, 90968, 90969, or 90970 if ESRD-related services are provided for less than a full month, per day, under the following conditions:

Partial month during which a client who is not on home dialysis received one or more face-to-face visits but did not receive a complete assessment.

A client who is on home dialysis received less than a full month of services.

Transient client.

Client was hospitalized during a month of services before a complete assessment could be performed.

Dialysis was stopped due to recovery or death of a client.

Client received a kidney transplant.

Procedure codes 90967, 90968, 90969, and 90970 are limited to one per day by any provider. When submitting claims for these procedure codes, providers must indicate the dates of service on which supervision was provided.

Procedure codes 90967, 90968, 90969, and 90970 will be denied if they are submitted with dates of service in the same calendar month by any provider as the following procedure codes:

Procedure Codes

90951

90952

90953

90954

90955

90956

90957

90958

90959

90960

90961

90962

90963

90964

90965

90966

Only one of the procedure codes in the previous table will be reimbursed per calendar month by any provider.

The following services may be provided in conjunction with physician supervision of outpatient ESRD dialysis but are considered nonroutine and may be submitted for reimbursement separately.

Declotting of shunts when performed by the physician.

Physician services to inpatients.

If one of the following occurs:

A client is hospitalized during a calendar month of ESRD-related services before a complete assessment is performed.

The client receives one or more face-to-face assessments, but the timing of inpatient admission prevents the client from receiving a complete assessment.

Then the physician must submit both of the following:

Procedure code 90967, 90968, 90969, or 90970 for each date of outpatient supervision.

The appropriate hospital evaluation and management code for individual services provided on the days during which the client was hospitalized.

If a client has a complete assessment in the month during which the client is hospitalized, one of the following procedure codes must be submitted for the month of supervision:

Procedure Codes

90951

90952

90953

90954

90955

90956

90957

90958

90959

90960

90961

90962

The appropriate inpatient evaluation and management codes must be reported for procedures provided during the hospitalization.

Dialysis at an outpatient facility other than the usual dialysis setting for a client of a physician who bills the MCP. The physician must submit procedure code 90967, 90968, 90969, or 90970 for each date on which supervision is provided. The physician may not submit claims for days that the client dialyzed elsewhere.

Physician services beyond those that are related to the treatment of the client’s renal condition that cause the number of physician-client contacts to increase. Physicians may submit claims on a fee-for-service basis if they supply documentation on the claim that the illness is not related to the renal condition and that additional visits are required.

Inpatient services that are provided to a hospitalized client for whom the physician has agreed to submit monthly claims, may be reimbursed in one of the following ways:

The physician may elect to continue monthly billing, in which case the physician may not bill for individual services that were provided to the hospitalized client.

The physician may reduce the monthly amount submitted by 1/30th for each day of hospitalization and may charge fees for individual services that were provided on the hospitalized days.

The physician may submit a claim for inpatient dialysis services using the inpatient dialysis procedure codes. The physician must be present and involved with the client during the course of the dialysis.

Clients may receive dialysis at an outpatient facility other than the client’s usual dialysis setting, even if their physician bills for monthly dialysis coordination. The physician must reduce the monthly amount submitted for reimbursement by 1/30th for each day the client is dialyzed elsewhere.

Physician services beyond those related to the treatment of the client’s renal condition may be reimbursed on a fee-for-service basis. The physician must provide medical documentation with the claim that identifies how the illness is not related to the renal condition and added visits are required.

Payment is made for physician training services in addition to the MCP for physician supervision rendered to maintenance facility clients.

6.2.1.1Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility

For some medical situations in which ESRD clients cannot obtain their regularly scheduled dialysis treatment at a certified ESRD facility, Texas Medicaid will allow for non-routine dialysis treatments furnished in the outpatient department of a hospital that does not have a certified dialysis facility.

Unscheduled dialysis for clients may be a benefit for one of the following reasons:

Dialysis was performed following, or in connection with, a vascular access procedure.

Dialysis was performed following treatment for an unrelated medical emergency (e.g., a client goes to the emergency room and, as a result, misses a regularly scheduled dialysis treatment that cannot be rescheduled).

Emergency dialysis was performed for clients who would otherwise have to be admitted as inpatient in order for the hospital to receive payment.

Providers must submit claims using procedure code G0257 with revenue code 880 in order to receive payment for unscheduled outpatient dialysis.

Procedure code G0257 is only reimbursed to clients with ESRD and must be billed with revenue code 880 on the same claim. If procedure code G0257 is not on the same claim as revenue code 880, it will be denied.

Procedure code G0257 is limited to diagnosis codes N185 and N186 and is limited to one service per day, any provider.

Erythropoietin (procedure code Q4081) may be billed separately and must be billed with revenue code 634 or 635 on the same claim.

Texas Medicaid will provide a single payment to reimburse unscheduled or emergency dialysis treat­ments furnished to ESRD clients in the outpatient department of a hospital that does not have a certified ESRD facility.

Reimbursement for procedure code G0257 is limited to the same services included in the Method 1 composite. Providers will not be reimbursed for individual services related to dialysis.

Repeated billing of this service by the same provider for the same clients may indicate routine dialysis treatments are being performed and providers will be subject to recoupment upon medical record review.

Reimbursement of other outpatient hospital services are only reimbursed if they are not related to the dialysis services and are determined to be medically necessary with supporting documentation.

6.2.2Renal Dialysis Facilities-Method I Composite Rate

The composite rate includes all necessary equipment, supplies, and services for the client receiving dialysis whether in the home or in a facility. The facility’s charge must not include the charge for the physician’s routine supervision. Examples of services included in the composite rate include, but are not limited to:

Cardiac monitoring—procedure code 93040 or 93041.

Catheter changes—procedure code 36000 or 49421.

Crash cart usage for cardiac arrest.

Declotting of shunt (procedure code 36593) and any supplies used to declot shunts performed by facility staff in the dialysis unit.

Dialysate—procedure code A4720, A4722, A4723, A4724, A4725, A4726, or A4765.

Oxygen—procedure code E0424, E0431, E0434, E0439, E0441, E0442, E0443, or E0444.

Routine laboratory services for dialysis.

Note:When one of these laboratory services is required more frequently, renal dialysis facility providers must submit the appropriate procedure code with modifier 91 for separate reimbursement.

Staff time to administer blood, separately billable drugs, and blood collection for
laboratory—procedure code 36430 or 36591.

Suture removal or dressing changes.

Certain drugs such as those to elevate or decrease blood pressure, antiarrythmics, blood thinners or expanders, antihistamines or antibiotics to treat infections or peritonitis related to peritoneal dialysis are included in the composite rate. Examples include, but are not limited to:

Hydralazine—procedure code J0360

Diphenenhydramine—procedure code J1200

Heparin—procedure code J1642 or J1644

Dopamine—procedure code J1265

Glucose

Propranolol—procedure code J1800

Insulin

Digoxin—procedure code J1160

Norepinephrine bitartrate

Mannitol—procedure code J2150

Procaine

Protamine—procedure code J2720

Saline—procedure code A4216 or A4217

Hydrocortisone sodium succinate—procedure code J1720

Verapamil

Medically necessary drugs that are not included in the composite rate may be separately reimbursed when provided by and administered in the dialysis facility by facility staff. Staff time and supplies used to administer the drugs are included in the composite rate. Examples include, but are not limited to, the following:

Antibiotics, except when prescribed for clients to treat infections or peritonitis related to peritoneal dialysis

Hematinics

Anabolics

Muscle relaxants

Analgesics

Sedatives

Tranquilizers

Erythropoietin

Thrombolytics used to declot central venous catheters

Intravenous levocarnitine (procedure code J1955), for ESRD clients who have been on dialysis for a minimum of three months with one of the following indications (All other indications for levocar­nitine are not covered.):

Carnitine deficiency, defined as a plasma free carnitine level less than 40 micromoles per liter.

Signs and symptoms of erythropoietin-resistant anemia that has not responded to standard erythropoietin with iron replacement, and for which other causes have been investigated and adequately treated.

Hypotension on hemodialysis that interferes with delivery of the intended dialysis despite appli­cation of usual measures deemed appropriate (e.g., fluid management) (such episodes of hypotension must have occurred during at least two dialysis treatments in a 30-day period).

Note:Continued use of levocarnitine is not covered if improvement has not been demonstrated within six months of the initiation of treatment.

The ordering physician must maintain documentation in the client’s medical record to support medical necessity.

6.2.3Method II Dealing Direct-Support Services

With Method II, the client selects and works with a single supplier to obtain supplies and equipment to dialyze at home. The selected supplier cannot be a dialysis facility, although the supplier must maintain a written agreement with a support dialysis facility to provide backup and support services. Method II support services are reimbursed under revenue codes 845 and 855.

Support services reimbursed monthly under Method II are limited to clients who are 20 years of age and younger, and include, but are not limited to:

Periodic monitoring of a client’s adaptation to home dialysis and performance of dialysis, including provisions for visits to the home or the facility.

Visits by trained personnel for the client with a qualified social worker and a qualified dietitian, made in accordance with a plan prepared and periodically reviewed by a professional team, which includes the physician.

Individual unscheduled visits to a facility made on an as-needed basis; (e.g., assistance with difficult access situations).

ESRD-related laboratory tests covered under the composite rate.

Providing, installing, repairing, testing, and maintaining home dialysis equipment, including appropriate water testing and treatment.

Ordering of supplies on an ongoing basis.

A record keeping system that assures continuity of care.

Support services specifically applicable to chronic ambulatory peritoneal dialysis (CAPD) also include, but are not limited to:

Changing the connecting tube and administration set.

Monitoring the client’s performance of CAPD, assuring that it is done correctly, and reviewing proper techniques with the client or informing the client of modifications to apparatus or technique.

Documenting whether the client has or has had peritonitis that requires physician intervention or hospitalization (unless there is evidence of peritonitis, a culture for peritonitis is not necessary).

Inspecting the catheter site.

Routine laboratory services are included in the support services and are not reimbursed separately.

Equipment and supplies are:

Reimbursed under Method II to only one provider per month who must agree to submit claims once per month for only one month’s quantity per claim.

Limited to clients who are 20 years of age and younger.

Reimbursed separately up to the total monthly allowable as determined by HHSC.

The following equipment, supply, and services procedure codes are benefits of Texas Medicaid under Method II:

Procedure Codes

 

36000

36430

36591

36593

49421

93040

93041

A4216

A4217

A4651

A4652

A4657

A4660

A4663

A4670

A4680

A4690

A4706

A4707

A4708

A4709

A4714

A4719

A4720

A4721

A4722

A4723

A4724

A4725

A4726

A4730

A4736

A4737

A4740

A4750

A4755

A4760

A4765

A4766

A4772

A4773

A4774

A4802

A4860

A4911

A4913

A4918

A4927

A4928

A4929

A4930

A4931

A4932

E0424

E0431

E0434

E0439

E0441

E0442

E0443

E0444

E1510

E1520

E1530

E1540

E1550

E1560

E1570

E1575

E1580

E1590

E1592

E1594

E1600

E1620

E1630

E1632

E1635

E1637

E1639

E1699

J0360

J1160

J1200

J1265

J1642

J1644

J1720

J1800

J1955

J2150

J2720

Installation and repair of home hemodialysis machines are not a benefit of Texas Medicaid. Home modifications for use of medical equipment are not a benefit of Texas Medicaid.

A Medicaid client may receive CAPD and continuous cycle peritoneal dialysis (CCPD) support services furnished by the facility on a monthly basis. Charges for support services in excess of this frequency must include documentation of medical necessity.

Clients may have a one month reserve of supplies available for use. Renal dialysis services beyond these limitations may be considered for clients who are 20 years of age and younger through the Compre­hensive Care Program (CCP) with prior authorization.

6.2.4Facility Revenue Codes

The following services are a benefit for renal dialysis centers billing under reimbursement methodology I composite rate or II dealing direct.

Service

Revenue Code

Description

Maintenance

821

Hemodialysis (outpatient/home)–composite or other rate

831

Peritoneal Dialysis (outpatient/home)–composite or other rate

841

CAPD (outpatient/home)–composite or other rate

851

CCPD (outpatient/home)–composite or other rate

Training

829

Hemodialysis (outpatient/home)–other

839

Peritoneal Dialysis (outpatient/home)–other

849

CAPD (outpatient/home)–other

859

CCPD (outpatient/home)–other

Support

845

CAPD (outpatient/home)–support services

855

CCPD (outpatient/home)–support services

Miscellaneous

881

Miscellaneous dialysis–ultrafiltration

Method II is limited to clients who are 20 years of age or younger.

The facility charge must not include the charge for the physician’s routine supervision.

6.2.5Training for Hemodialysis, Intermittent Peritoneal Dialysis (IPD), Continuous Cycle Peritoneal Dialysis (CCPD), and Chronic Ambulatory Peritoneal Dialysis (CAPD)

Most self-dialysis training for hemodialysis, IPD, CCPD, and CAPD is provided in an outpatient setting. Dialysis training provided in an inpatient setting will be reimbursed at the same rate as the facility’s outpatient training rate.

Reimbursement for hemodialysis, IPD, CCPD, and CAPD training services and supplies provided by the dialysis facility includes personnel services, parenteral items routinely used in dialysis, training manuals and materials, and routine dialysis laboratory tests.

No frequency limitation is applied to routine laboratory tests during the training period because these tests commonly are given during each day of training. Nonroutine laboratory tests performed during the training period may be reimbursed when documentation of medical necessity is submitted with the claim.

It may be necessary to supplement the patient’s dialysis during CAPD training with intermittent peritoneal dialysis or hemodialysis because the client has not mastered the CAPD technique.

Training is limited to once per day. The composite rate will be denied as part of dialysis training when submitted for the same date of service.

6.2.6Maintenance Hemodialysis

The facility composite rate applies when a chronic renal dialysis client receives hemodialysis in an approved renal dialysis facility. Reimbursement is based on the facility’s per-treatment composite rate, as calculated by Medicare. Services included in the facility’s charge are routine laboratory tests, personnel services, equipment, supplies, and other services associated with the treatment.

For hospitals to be reimbursed for maintenance hemodialysis, they must be enrolled as an approved dialysis facility with the appropriate provider identifier. When a client is admitted for hospitalization for no reason other than to receive maintenance renal dialysis, the dialysis services are considered outpa­tient services and are covered if the hospital has been designated as a CMS certified renal dialysis center.

6.2.7Maintenance IPD

Maintenance IPD is usually performed in sessions of 10 to 12 hours duration, three times per week. It may also be performed in fewer sessions that are longer in duration. If more than three sessions occur in one week, the provider must supply documentation of medical necessity with the claim.

6.2.8Maintenance CAPD and CCPD

Support services for maintenance furnished to clients receiving CAPD or CCPD in the home may be reimbursed to dialysis facilities. Home dialysis support services must be furnished by the facility in either the home or the facility. CAPD and CCPD support services are limited to once per day.

6.2.9Laboratory and Radiology Services

All providers of laboratory services must comply with the rules and regulations of CLIA. Providers who do not comply with CLIA will not be reimbursed for laboratory services.

Refer to:  Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

6.2.9.1* In-Facility Dialysis—Routine Laboratory

Laboratory testing may be obtained and processed in the renal dialysis facility or by an outside laboratory. Charges for routine laboratory tests performed according to the established frequencies in the following tables are included in the facility’s composite rate submitted to Texas Medicaid regardless of where tests were processed. If the routine laboratory testing is processed by an outside laboratory, the outside laboratory will bill the renal dialysis facility. The renal dialysis facility will then submit a claim to Texas Medicaid unless the test results are inclusive tests.

If additional in-facility laboratory testing is medically necessary beyond the following routine frequencies, providers must bill with modifier 91 to indicate the billed laboratory procedure is medically necessary. The billing provider must also submit documentation supporting the medical necessity with the claim and maintain the documentation in the client’s medical record.

Modifier 91 is used to indicate that a test was performed more than once on the same day for the same client only when it is necessary to obtain multiple results in the course of the treatment. This modifier may not be used to indicate any of the following:

When tests are rerun to confirm initial results

Testing problems with specimens or equipment

When a normal one-time, reportable result is all that is required

When there are standard Healthcare Common Procedure Coding System (HCPCS) codes available that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.).

Modifier 91 may only be used for laboratory tests paid under the clinical diagnostic laboratory fee schedule.

Per Dialysis

Procedure Codes

85014^

85018^

85345

85347

^ QW modifier is required.

Per Week

Procedure Codes

82565^

84520^

85610^

^ QW modifier is required.

Per Month

Procedure Codes

82040^

82310^

82374^

82435^

83615

84075^

84100

84132^

84155^

84450^

85025

85027

^ QW modifier is required.

The routine tests listed in the previous tables are frequently performed as an automated battery of tests such as the sequential multi-channel analysis with computer (SMAC)-12 (chemistry panels). These tests are considered routine and are included in the charge for dialysis, unless there is an additional diagnosis to document medical necessity for performing the tests in excess of the recommended frequencies.

6.2.9.2In-Facility Dialysis—Nonroutine Laboratory

The following procedure codes are considered necessary, nonroutine tests. They must be submitted separately from the dialysis charge when performed in the renal dialysis facility or by an outside laboratory that bills the facility for laboratory services. All nonroutine laboratory and radiology tests beyond the following recommended frequencies must be medically necessary.

If additional in-facility laboratory testing is medically necessary beyond the following nonroutine frequencies, providers must submit the claim with modifier 91 to indicate the billed laboratory procedure is medically necessary. The billing provider must also submit documentation supporting the medical necessity with the claim and maintain the documentation in the client’s medical record.

Once a Month

Procedure Codes

87340

Every 3 Months

Procedure Codes

93005

Every 6 Months

Procedure Codes

71010

71020

95907

95908

95909

95910

95911

95912

95913

Annually

Procedure Codes

78300

78305

78306

A handling fee (procedure code 99001) for nonroutine laboratory services may be submitted to Texas Medicaid only if the specimen is obtained by venipuncture or catheterization and sent to an outside lab. The claim form must document that the handling fee is for nonroutine laboratory services.

6.2.9.3* CAPD Laboratory

The following laboratory tests are routine for home maintenance CAPD clients when performed according to the indicated frequency. These laboratory tests may be reimbursed separately when the client is dialyzing in the home and is not undergoing IPD or hemodialysis in the facility. The provider must indicate the client’s diagnosis and the type of dialysis on the claim form. Tests in excess of this frequency or tests not listed in the tables require documentation of medical necessity for payment to be made.

Every Month

Procedure Codes

82040^

82310^

82374^

82565^

83615

83735

84075^

84100

84132^

84155^

84295^

84450^

84520^

85018^

^ QW modifier is required.

Every 3 Months

Procedure Codes

85004

85007

85008

85014^

85027

85041

^ QW modifier is required.

Every 6 Months

Procedure Codes

71010

71020

78300

78305

78306

80069^

81050

95907

95908

95909

95910

95911

95912

95913

^ QW modifier is required.

6.2.9.4Hematopoietic Injections

Medicaid reimbursement is allowed for hematopoietic injections that are administered to clients who have anemia that is associated with chronic renal failure.

Providers must submit the client’s most recent dated hemoglobin or hematocrit levels in the comments section of the claim form when billing with procedure code Q4081. Frequency and quantity limitations apply.

Refer to:  Subsection 9.2.38.21, “Hematopoietic Injections” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information about benefit and limitation criteria.

6.2.9.5Blood Transfusions

Whole blood transfusions may be reimbursed separately to dialysis facilities when medically indicated for a Medicaid eligible client.

6.2.10Prior Authorization

Prior authorization is not required for renal dialysis services. Prior authorization must be obtained for transplant-related services provided to clients who are not eligible for Medicare and are eligible only for Medicaid.

6.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including renal dialysis services. Renal dialysis services are subject to retrospective review and recoupment if documentation does not support the service submitted for reimbursement. All physicians’, renal dialysis centers’, and medical suppliers’ supporting documentation is subject to retrospective review.

6.4Claims Filing and Reimbursement

6.4.1Claims Information

Renal dialysis facility services must be submitted to TMHP in an approved electronic claims format or on a UB-04 CMS-1450 paper claim form. Providers may purchase UB-04 CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply them.

When completing a UB-04 CMS-1450 paper claim form, all required information must be included on the claim, as information is not keyed from 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.

“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 instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Reminder:The original onset date must be included on the claim form to prevent claim denial. The original onset date must be the same date entered on Form CMS-2728 sent to the Social Security office.

6.4.2Reimbursement

Renal dialysis facilities are reimbursed according to composite rates, which are based on the CMS-specified calculations and the Texas Medicaid Reimbursement Methodology (TMRM). Texas Medicaid may reimburse for dialysis services through either Method I or Method II as defined by CMS.

The hemodialysis, IPD, CAPD and CCPD laboratory and radiology services and the physician super­vision of dialysis clients limitations pertain to both Method I and Method II reimbursement.

Texas Medicaid implemented mandated rate reductions for certain services. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

Refer to:  Section 2.3, “Reimbursement Methodology” (Vol. 1, General Information) for more infor­mation about reimbursement.

6.4.2.1NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

6.5Medicare and Medicaid

Medicaid coverage of a renal dialysis client who may be eligible for Medicare coverage begins with the original onset date of the dialysis treatments and may continue for a period of three months. During this period, Medicare eligibility is reviewed through the Health and Human Services Commission (HHSC). If HHSC determines that the client is Medicare-eligible, Medicaid coverage begins with the original onset date and continues until Medicare coverage begins.

If HHSC determines that the client is not eligible for Medicare, Medicaid coverage of eligible clients begins with the original onset date and continues as long as the dialysis treatments are medically necessary and the client is eligible for Medicaid. The date of onset is the date of the first dialysis treatment and does not change even if the client sees another provider.

Medicare eligibility usually begins after a three-month waiting period has been served. Medicare eligi­bility begins before the waiting period has expired if the individual receives a transplant or participates in a self-dialysis training program during the waiting period.

6.5.1Facility Providers

Texas Medicaid pays the Medicare coinsurance less 5 percent and full Medicare deductible for Medicare crossover claims that are submitted by nephrology (hemodialysis, renal dialysis) and renal dialysis facility providers.

6.5.2Physician Providers

The five percent reduction does not apply to physician-billed services. Nephrologists that are enrolled in Texas Medicaid as physician providers may be reimbursed according to the current payment guidelines.

Refer to:  Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information) for additional information about Medicare coinsurance and deductible reimbursement for professional and outpa­tient services.

7 Rural Health Clinic

7.1Enrollment

To enroll in Texas Medicaid and qualify for participation as a Title XIX RHC, RHCs must be enrolled in Medicare. A nine-digit provider identifier is issued to the RHC after a certification letter from Medicare is received, stating that the clinic qualifies for Medicaid participation. An RHC can also apply for enrollment as a family planning agency.

All providers of laboratory services must comply with the rules and regulations of CLIA. Providers who do not comply with CLIA are not reimbursed for laboratory services.

7.1.1Initial Cost Reporting

New RHCs must file a projected cost report within 90 days of their designation as an RHC to establish an initial payment rate. The cost report will contain the RHC’s reasonable costs anticipated to be incurred during the RHC’s first full fiscal year. The projected cost report must contain a minimum of six months of information. The RHC must file a cost report within five months of the end of the RHC’s initial fiscal year. The cost settlement must be completed within six months of the receipt of a cost report. The cost per visit rate established by the cost settlement process shall be the base rate. Any subsequent increases or decreases shall be calculated as provided herein. A new RHC location established by an existing RHC participating in Texas Medicaid will receive the same effective rate as the RHC establishing the new location. An RHC establishing a new location may request an adjustment to its effective rate as provided herein if its costs have increased as a result of establishing a new location.

Providers must submit initial cost reports to the following address:

Texas Medicaid & Healthcare Partnership
Medicaid Audit
PO Box 200345
Austin, TX 78720-0345

Providers can refer to 1 TAC §355.8101 for more information about reimbursement.

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information.

Subsection 2.1.1, “Clinical Laboratory Improvement Amendments (CLIA)” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

7.2Services, Benefits, Limitations, and Prior Authorization

7.2.1Services Rendered by the RHC Facility Provider

General services and copayments are billed using the RHC’s National Provider Identifier (NPI). All other services billed using the RHC’s NPI are processed as informational only.

Important:If an RHC facility provider submits a claim for THSteps and Family Planning services, the services will process as informational only and will not be reimbursed.

The following services are benefits of Texas Medicaid when provided in an RHC:

Physician services

Services and supplies furnished as incidental to physician services

Services provided by an NP, a CNM, a clinical social worker, or a PA’s services

Services and supplies furnished as incidental to the NP’s or PA’s services

Visiting nurse services on a part-time or intermittent basis to homebound clients in areas deter­mined to have a shortage of home health agencies (A homebound client is someone who is permanently or temporarily confined to his place of residence, not including a hospital or skilled nursing facility (SNF), because of a medical condition.)

When an RHC bills for visiting nurse services, the written plan of treatment to be used for the visiting nurse must be developed by the RHC supervising physician. It must be approved and ordered by the client’s treating physician if different from the supervising physician. The plan of treatment must be reviewed and approved by the supervising physician of the clinic at least every 60 days.

A visit is a face-to-face encounter between an RHC client and a physician, PA, NP, CNM, visiting nurse, or clinical NP. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one or the other of the following conditions exists:

After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment.

The RHC client has a medical visit and an other health visit.

An other health visit includes, but is not limited to, a face-to-face encounter between an RHC client and a clinical social worker.

For freestanding RHCs, all laboratory services provided in the RHC’s laboratory are included in the encounter. This includes the basic laboratory tests as well as any other laboratory tests provided in the RHC laboratory. Consequently, there is no separate billing for laboratory services. However, if the RHC laboratory becomes a certified Medicare laboratory with its own supplier number, and enrolls in Medicaid as an independent laboratory, all laboratory tests (except the basic laboratory tests) performed for RHC and non-RHC clients can be billed to Medicaid. The claim must be filed under their independent laboratory Medicaid provider identifier and using the appropriate HCPCS codes.

Refer to:  The Medicare website at www.cms.gov for more information about Medicare RHC laboratory requirements.

7.2.1.1Encounter Rates

An encounter rate may be reimbursed to the RHC facility only for the following services:

General Medical Services (encounter may be reimbursed to the RHC facility only)

T1015

General medical services must be submitted using one of the appropriate modifiers AJ, AM, SA, TD, TE, or U7. Adult preventative care must be submitted with diagnosis codes Z0000, Z0001, Z01411, and Z01419.

Note:If the encounter is for antepartum or postpartum care, use modifier TH in addition to the modifier required to clarify the service that was performed.

7.2.1.2Medicaid Fee-for-Service Reimbursement Rates

The following copayments may be reimbursed to RHC providers billing under their own NPI, and are reimbursed at the Medicaid fee-for-service rate.

Copayments

CP001

CP002

CP005

CP006

7.2.1.3Freestanding Rural Health Clinic Services

The following services cannot be reimbursed to freestanding RHCs using only the RHC provider identifier. Use of the RHC provider identifier for billing these services causes claims to be processed as informational only. Services in any of these categories must be billed using the professional (non-RHC) provider identifier and the appropriate benefit code:

THSteps medical checkups, which includes immunizations

Family planning services (including implantable contraceptive capsules provision, insertion, or removal)

These services must be billed with an AM, SA, or U7 modifier.

Physician supplies are not a benefit of Texas Medicaid. Costs of supplies are included in the reimbursement for office visits. Outpatient hospital services (including emergency room services) and inpatient hospital services provided outside the RHC setting are to be billed using the individual or group physician provider identifier.

Exception:If later in the same day the client suffers an additional illness or injury requiring diagnosis or treatment, the clinic may submit a claim for a second visit.

Freestanding RHCs submit an all-inclusive encounter for services provided. All services provided that are incidental to the encounter, including developmental screening, must be included in the total charge for the encounter. A claim for these services may not be submitted as a separate encounter.

If immunizations are given outside of a THSteps medical checkup, procedure codes given in the THSteps section of this manual should be identified on the claim. These procedure codes are informa­tional only, and are not payable.

All services provided during a freestanding RHC encounter must be submitted using procedure code T1015. The total submitted amount should be the combined charges for all services provided during that encounter.

One of the following modifiers must be reported with procedure code T1015 to designate the health-care professional providing the services: AH, AJ, AM, SA, TD, TE, or U7. If the encounter is for antepartum or postpartum care, use modifier TH in addition to the modifier required to designate the health-care professional providing the service.

Reminder:The primary initial contact is defined as “the health-care professional who spends the greatest amount of time with the client during that encounter.”

If more than one health-care professional is seen during the encounter, the modifier (if appropriate) must indicate the primary contact. For example, if an NP or a PA performs an antepartum exam, modifiers SA or U7, and TH, must be entered. A maximum of two modifiers may be reported with each encounter.

Providers who render services in an RHC setting for THSteps Medical services or Family Planning services may be reimbursed an encounter rate.

THSteps Medical Services

RHC facility providers may be reimbursed for THSteps medical services using their RHC NPI with the appropriate benefit code.

If the appropriate benefit code is not included, the service will process as informational only and will not be reimbursed.

THSteps Medical Services

99381

99382

99383

99384

99385

99391

99392

99393

99394

99395

THSteps medical services must be billed using one of the following modifiers: AM, SA, or U7.

7.2.1.4Family Planning Services

RHC facility providers may be reimbursed for family planning services using their RHC NPI with the appropriate benefit code.

If the appropriate benefit code is not included, the service will process as informational only and will not be reimbursed.

Family planning services must be submitted with the most appropriate evaluation and management (E/M) procedure code and the most appropriate family planning diagnosis code:

Family Planning Services*

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

J7297

J7298

J7300

J7301

J7307

* Family planning services performed in the RHC setting must be billed with the appropriate modifier: AM, SA, or U7.

RHC providers may receive an encounter rate when submitting claims with procedure code T1015, in addition to a flat “add on” fee for the Long-Acting Reversible Contraception (LARC) procedure codes listed above.

Refer to:  Subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization” in this handbook for the list of family planning diagnosis codes.

Subsection 6.3.5, “Modifiers” in “Section 6: Claims Filing” (Vol. 1, General Information) for a definition of modifiers.

Section 9, “Physician” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Section 5, “THSteps Medical” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Section 2, “Medicaid Title XIX Family Planning Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks).

Subsection 8.8.2.2, “HMO Copayments” in “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information) for information about HMO copayments.

Subsection 9.2.56.1.2, “Preventive Care Visits” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

7.2.2Services Rendered by Non-RHC Providers In An RHC Setting

Non-RHC providers (i.e., physicians and non-physician practitioners) submitting claims for THSteps and Family Planning services in the RHC setting must use their own NPI and the appropriate benefit code.

The following services, when rendered in an RHC setting by a non-RHC provider, will process as an encounter and will be reimbursed to the non-RHC provider as an encounter rate equivalent to the host facility:

THSteps medical services

Family planning services

Non-RHC providers rendering services in an RHC setting must use the appropriate national place of service (72) in order for claims to process as encounters.

7.2.3Hospital-Based Rural Health Clinic Services

Hospital-based RHCs must use the encounter code T1015. A hospital-based RHC is paid based on an all-inclusive encounter rate. One of the following modifiers must be submitted for general medical services: AH, AJ, AM, SA, TD, TE, or U7.

The following services must be submitted using the physician’s Texas Provider Identifier (TPI) and the appropriate benefit code:

THSteps medical checkups

Family planning services (including implantable contraceptive capsules provision, insertion, or removal)

Immunizations provided in hospital-based RHCs

Note:Refer to the tables in the above sections for procedure codes.

These services must be submitted with an AM, SA, or U7 modifier if performed in an RHC setting. Claims are paid under the PPS reimbursement methodology. When submitting a claim on the CMS-1450 paper claim form, providers must use the appropriate national POS (72) for an RHC setting.

Outpatient hospital services (including emergency room services) and inpatient hospital services provided outside the RHC setting are to be submitted using the individual or group physician provider identifier. Hospital-based RHCs must submit claims for pneumococcal and influenza vaccines as non-RHC services, under their hospital provider identifier.

7.2.3.1After-Hours Care

After-hours care for RHCs is defined as care provided on weekends, federal holidays, or before 8 a.m. and after 5 p.m., Monday through Friday.

7.3Prior Authorization

Prior authorization or authorization is not required for RHC services.

7.4Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including RHC services. RHC services are subject to retrospective review and recoupment if documentation does not support the service billed.

7.4.1Record Retention

Freestanding RHCs must retain their records for a minimum of six years. Hospital-based RHCs must retain their records for a minimum of ten years.

7.5Claims Filing and Reimbursement

7.5.1Claims Information

General services and copayments are billed using the RHC’s NPI. For all other services, providers must submit claims using their NPI and the appropriate benefit code.

Refer to:  Subsection 8.2, “Services, Benefits, Limitations, and Prior Authorization” in this handbook.

Place of service 72 must be used on all claims when billing for services other than general medical. Benefit code EP1 must be used on claims for THSteps medical services.

Freestanding and hospital-based RHC services must be submitted to TMHP in an approved electronic format or on a UB-04 CMS-1450 paper claim form. Providers may purchase UB-04 CMS-1450 paper claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a UB-04 CMS-1450 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.

7.5.2Reimbursement

Freestanding and hospital-based RHCs are reimbursed provider-specific per visit rates calculated in accordance with 1 TAC §355.8101. Texas Medicaid implemented mandated rate reductions for certain services. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx.

7.5.2.1Medicare Crossover Claims Pricing

For Medicare Part B cost sharing obligations, all deductible obligations will be reimbursed at 100 percent of the deductible amount owed, even if the cost sharing comparison results in a lower payment. For all other cost sharing obligations (including Medicare Part A, B, and C), the cost sharing comparison is performed according to current guidelines.

For RHC Medicare crossover claims, Texas Medicaid will reimburse the lesser of the following:

The coinsurance and full deductible payment.

The amount remaining after the Medicare payment amount is subtracted from the allowed Medicaid fee or encounter rate for the service. If this amount is less than the deductible, then the full deductible is reimbursed instead.

If the Medicare payment is equal to, or exceeds the Medicaid allowed amount or encounter payment for the service, Texas Medicaid will not make a payment for coinsurance.

The client has no liability for any balance or Medicare coinsurance and deductible related to Medicaid-covered services.

Refer to:  Subsection 2.7, “Medicare Crossover Claim Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

7.5.2.2NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

8 Tuberculosis Services

TB clinics must be enrolled in Texas Medicaid and provide services in accordance with 1 TAC, §354.1371.

8.1Enrollment

To enroll in Texas Medicaid, a TB clinic must be either:

A public entity operating under an HHSC tax identification number (TB regional clinic)

A public entity operating under a non-HHSC tax identification number (city/county/local clinic)

A non-hospital-based entity for private providers

Providers of TB-related clinic services must complete a provider application from the TB Services Branch within DSHS. Per Texas DSHS policy, TB clinics must develop and operate under a set of written policies and procedures that specify the criteria for licensed and non-licensed staff to provide services. The policies and procedures must include the following:

The personnel file requirements for staff who provide directly observed therapy (DOT).

The training and supervision that are required for outreach workers to be considered qualified to perform the assigned services.

The written delegation protocol for services that are not performed by a physician, advanced practice registered nurse (APRN), or PA.

The documentation that is required for all client encounters.

Upon written notice of approval by TB Services Branch, Medicaid enrollment applications from TMHP Provider Enrollment are sent to HHSC-approved providers of TB-related clinic services.

TMHP is responsible for issuing a group or individual a nine-digit provider identifier. Providers that list additional (satellite) clinics in the TB Services Branch provider application will receive nine-digit performing provider identifiers for each off-site clinic. TB off-site clinics operating under the juris­diction of the applying provider must use the assigned group provider identifier and their nine-digit performing provider identifier.

Enrollment as a Medicaid provider is not complete until the TMHP enrollment packet has been finalized and a nine-digit provider identifier number is issued to the provider.

The effective date for participation is the date an approved provider application with the TB Services Branch is established.

To receive a TB Services Branch provider application form or provider supplement, send a request to the following address:

Texas Department of State Health Services
TB/HIV/STD/Viral Hepatitis Unit
Tuberculosis Services Branch
Mail Code 1939
1100 West 49th Street
PO Box 149347
Austin, TX 78714-9347

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures related to the TMHP Medicaid enrollment applications.

8.1.1Managed Care Program Enrollment

TB clinics do not need to enroll with the Medicaid managed care health plans. All services provided by TB clinics are submitted to TMHP for all Medicaid clients, including Medicaid managed care clients.

8.2Services, Benefits, Limitations, and Prior Authorization

The level of service provided varies depending on whether the services are delivered by a nonphysician or physician and if medications are prescribed.

8.2.1TB-Related Clinic Services

The following services may be performed by a physician, APRN, or PA in the TB clinic:

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

A physician’s presence is not required to perform procedure code 99211; however, the physician must provide direct supervision by being present in the clinic and immediately available to furnish assistance and direction at the time service is provided.

Before TB treatment can be initiated, an initial screening (procedure code T1023) by an RN, LPN, or LVN, or a new patient physician E/M visit (procedure code 99201, 99202, 99203, 99204, or 99205) must be performed. If the treatment is initiated by a nursing screening, a new patient physician E/M visit must be completed within 90 days, or subsequent reimbursement for DOT (procedure code H0033) will be denied.

Following the initial new patient physician E/M visit, an established patient physician E/M visit (procedure code 99212, 99213, 99214, or 99215) must be billed every 90 days throughout the course of treatment, or subsequent reimbursement for DOT (procedure code H0033) will be denied.

Clients with latent TB infection, including those in a high-risk group (children who are 4 years of age and younger, those who are immunocompromised, and clients who are HIV-positive), and those with active TB disease, must be seen by a physician every 90 days throughout the course of treatment.

A physician must evaluate each client with active or latent TB disease prior to discharge from TB treatment.

Procedure codes H0033, T1002, T1003, and T1023 may be provided under established clinic protocols.

The initial TB screening (procedure code T1023), performed by an RN, LPN, or LVN includes, but is not limited to the following:

Brief mental and physical assessment

Exposure history

Referral for lab or X-ray per protocol

Referral for social or other medical services

Other assessment

Procedure code T1023 may be reimbursed prior to the client being seen by a physician, and no more often than once per 12 months. One RN or LVN/LPN (procedure codes T1023, T1002, and T1003) service may be reimbursed per day, per client, when physician services are not performed.

Subsequent nursing services (Procedure code T1002 and T1003) may be a benefit when not provided the same day as a physician E/M visit.

Reimbursement for DOT services (procedure code H0033) provided in the clinic or other places of service, excluding inpatient hospitals, SNFs, intermediate care facilities (ICFs), outpatient hospitals, independent laboratories, birthing centers, and extended care facilities will be limited to one per day, and a maximum of five per week, per client, throughout the course of treatment.

Procedure codes T1002 and T1003 are limited to a maximum of eight 15-minute units per day, per client.

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 per procedure code is less than 8 minutes for a calendar day, then no unit of service can be billed for that day. The minutes cannot be added to minutes of nursing services from any previous or subsequent days for billing purposes.

If more than 1 unit of service is billed, every unit except the last must be for the complete 15 minutes, with the last unit being no less than 8 minutes of nursing service.

Time spent in contact investigations in not reimbursable.

Reimbursement for new client examinations (procedure code 99201, 99202, 99203, 99204, and 99205) are limited to new clients who have not received services in the same clinic for a period of three years.

One physician E/M service may be reimbursed per day, per client.

8.2.2* Ancillary Services

The following ancillary TB services are a benefit of Texas Medicaid:

Procedure Codes

71010

71020

71021

71022

71030

71035

81025*

86580

86701^

86703

89220

96365

96366

96367

96368

96374

96375

99000

99001

J0278

J1840

J1956

J2020**

J2280**

J3000**

* CLIA waived test

^ Must be billed with QW modifier

** Must be billed with KX modifier when oral formulation is not appropriate for the client

Procedure code 99000 is limited to specimens transported from the office setting.

Procedure code 99001 is limited to specimens transported from any setting except the office.

Certain injectable TB medications (procedure codes J2020, J2280, and J3000), which also have an oral formulation, must be billed with modifier KX to indicate that the oral formulation is not appropriate for the client.

All drugs for which Medicaid is billed must have been purchased by the TB clinic. In the event that the clinic received the drug at no cost through DSHS or another source, it cannot be billed to Texas Medicaid. All medication claims are subject to retrospective review.

Handling or conveyance of a specimen from the patient in the clinic to a laboratory (procedure code 99000) will be reimbursed only when submitted with one of the following professional or nursing services performed on the same date of service. Prior authorization is not required for procedure code 99000 or 99001.

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

T1002

T1003*

T1023

* Reimbursed for individual or group TB clinics for services rendered in the home or other setting.

 

Texas Medicaid follows the Medicare categorization of tests for CLIA certificate holders.

Refer to:  The CMS website at www.cms.gov/CLIA/10_Categorization_of_Tests.asp for information about procedure code and modifier QW requirements.

For waived tests, providers must use modifier QW as indicated on the CMS website.

8.2.3Prior Authorization

Prior authorization is not required for TB-related services.

8.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including TB services. TB services are subject to retrospective review and recoupment if documentation does not support the service billed.

8.4Provider Responsibilities

If approved to submit claims as a TB clinic under Texas Medicaid, the provider must adhere to the following requirements:

Be a facility that is not an administrative, organizational, or financial part of a hospital, but is organized and operated to provide medical care to outpatients.

Comply with all applicable federal, state, and local laws and regulations.

Employ or have a contract or formal arrangement with a licensed physician (M.D. or D.O.) who is responsible for providing medical direction and supervision over all services provided to the clinic’s clients. To meet this requirement, a physician must see the client at least once every 90 days to prescribe the type of care provided and, if the services are not limited by the prescription, periodi­cally review the need for continued care.

Adhere to the guidelines issued by HHSC, under the authority of the Texas Health and Safety Code, and ensure that services are consistent with the recommendations of the American Thoracic Society and the Centers for Disease Control and Prevention (CDC). For more information, visit the website at www.cdc.gov/tb/default.htm.

Maintain complete and accurate medical records of each recipient’s care and treatment and accurately document all services provided and the medical necessity for the services.

Ensure that services provided to each client are commensurate with the client’s medical needs based on the client’s assessment or evaluation, diagnostic studies, plan of care, and physician direction. These services must be documented in the client’s medical records.

Be enrolled and approved for participation in Texas Medicaid.

Sign a written provider agreement with HHSC or its designee. By signing the agreement, the provider of TB-related clinic services agrees to comply with the terms of the agreement and all requirements of Texas Medicaid including regulations, rules, handbooks, standards, and guidelines published by HHSC or its designee.

Submit claims for services covered by Texas Medicaid in the manner and format prescribed by HHSC or its designee.

Be organized and operated to provide TB-related services, which include, but are not limited to, the covered services as indicated in subsection 8.2, “Services, Benefits, Limitations, and Prior Authori­zation” in this handbook.

Not provide services within an SNF, ICF, or intermediate care facility for persons with intellectual disability (ICF-ID)

Refer to:  Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information.

8.5Claims Filing and Reimbursement

8.5.1Claims Information

TB-related clinic services must use benefit code TB1 on all claims and authorization requests. All TB-related clinic services must be submitted to TMHP in an approved electronic claims format or on a CMS-1500 paper claim form from the vendor of their choice. TMHP does not supply them. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from 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.

“Section 6: Claims Filing” (Vol. 1, General Information).

Subsection 6.5, “CMS-1500 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

8.5.1.1Managed Care Clients

TB-related 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.

8.5.2Reimbursement

The Medicaid reimbursement rates for TB clinics are calculated in accordance with 1 TAC §355.8081.

X-ray services are reimbursed in accordance with 355.8081 and are listed in the current physician fee schedule on the TMHP website at www.tmhp.com. 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 TMHP website at www.tmhp.com/pages/topics/rates.aspx.

8.5.2.1NCCI and MUE Guidelines

The HCPCS and CPT codes included in the Texas Medicaid Provider Procedures Manual are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the Texas Medicaid Provider Procedures Manual. Providers should refer to the CMS NCCI web page for correct coding guidelines and specific applicable code combinations.

In instances when Texas Medicaid limitations are more restrictive than NCCI MUE guidance, Texas Medicaid limitations prevail.

9 Claims Resources

Refer to the following sections or forms when filing claims:

Resource

Location

Acronym Dictionary

“Appendix D: Acronym Dictionary” (Vol. 1, General Information)

American Dental Association (ADA) Dental Claim Filing Instructions

Subsection 6.7, “2012 American Dental Associ­ation (ADA) Dental Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information)

Automated Inquiry System (AIS)

Subsection A.10, “TMHP Telephone and Fax Communication” in “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

CMS-1500 Paper Claim Filing Instructions

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

State, federal, and TMHP contact information

“Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information)

TMHP electronic claims submission information

Subsection 6.2, “TMHP Electronic Claims Submission” in “Section 6: Claims Filing” (Vol. 1, General Information)

TMHP Electronic Data Interchange (EDI) information

“Section 3: TMHP Electronic Data Interchange (EDI)” (Vol. 1, General Information)

Tuberculosis Screening and Guidelines

Subsection A.5, “Tuberculosis Screening and Guidelines” in the Children’s Services Handbook (Vol. 2, Provider Handbooks)

UB-04 CMS-1450 Paper Claim Filing Instructions

Subsection 6.6, “UB-04 CMS-1450 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information)

10 Contact TMHP

The TMHP Contact Center at 1-800-925-9126 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time.

11 Forms

The following linked forms can also be found on the Forms page of the Provider section of the TMHP website at www.tmhp.com:

Forms

Federally Qualified Health Center Affiliation Affidavit

Hospital Report (Newborn Child or Children) (Form 7484)

12 Claim Form Examples

Claim Form Examples

Birthing Center

2017 Claim Form

Family Planning Services for Hospitals, FQHCs

FQHC Encounter (T1015)

FQHC Follow-Up

Renal Dialysis Facility CAPD Training

Renal Dialysis Facility CAPD/CCPD

Renal Dialysis CMS-1500 Example

Rural Health Clinic Freestanding

Rural Health Clinic Freestanding (Immunization)

Rural Health Clinic Hospital-Based

Tuberculosis