Inpatient and Outpatient Hospital Services Handbook

 

1 General Information

The information in this handbook is intended for Texas Medicaid hospital (medical and surgical acute care facility) providers and covers services that take place only in an inpatient or outpatient hospital setting. The handbook provides information about Texas Medicaid’s benefits, policies, and procedures applicable to acute care hospitals, including military hospitals.

Important:All providers are required to read and comply with “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information). In addition to 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.

Refer to:  The Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for information about services offered in settings such as rural health clinics (RHCs), Federally Qualified Health Centers (FQHCs), dialysis centers, and other similar facilities.

1.1National Drug Codes (NDC)

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

1.2Medicaid Managed Care Services

This handbook contains information about Texas Medicaid fee-for-service benefits. For information about managed care benefits, refer to the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

Managed care carve-out services are administered as fee-for-service benefits. A list of all carve-out services is available in section 8, “Carve-Out Services” in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

2 Enrollment

To be eligible to participate in Texas Medicaid, a hospital must be certified by Medicare, have a valid provider agreement with the Health and Human Services Commission (HHSC), and have completed the Texas Medicaid & Healthcare Partnership (TMHP) enrollment process.

2.1Hospital Eligibility Through Change of Ownership

Under procedures set forth by the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS), a change in ownership of a hospital does not terminate Medicare eligibility; therefore, Medicaid participation may be continued subject to the following requirements:

The provider must obtain recertification as a Title XVIII (Medicare) hospital.

 The hospital under new ownership must submit a new signed and dated HHSC Medicaid Provider Agreement between the hospital and HHSC.

Providers can download the HHSC Medicaid Provider Agreement from the TMHP website at www.tmhp.com.

Refer to:  Subsection 1.4, “Provider Reenrollment” in “Section 1: Provider Enrollment and Responsi­bilities” (Vol. 1, General Information).

2.1.1Hospital-based Ambulatory Surgical Center (HASC) Enrollment

All hospitals enrolling in Texas Medicaid (except psychiatric and rehabilitation hospitals) are issued an HASC provider number at the time of enrollment.

2.2Hospital-based Rural Health Clinic Enrollment

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 the Clinical Laboratory Improvement Amendments (CLIA). Providers who do not comply with CLIA are not reimbursed for laboratory services.

Refer to:  Subsection 8.2, “Services, Benefits, Limitations, and Prior Authorization” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for RHC benefit and limitation information.

Subsection 1.1, “Provider Enrollment and Reenrollment” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about enrollment procedures, including information on Changes of Ownership.

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

3 Inpatient Hospital (Medical/Surgical Acute Care Inpatient Facility)

This section contains benefit, limitation, authorization, and claims filing information for inpatient hospital facility accommodation and ancillary services.

Refer to:  “Section 6: Claims Filing” (Vol. 1, General Information) for more comprehensive infor­mation about claims filing and appeals.

“Section 7: Appeals” (Vol. 1, General Information) for more comprehensive information about claims filing and appeals.

Hospital providers are encouraged to review the other handbooks for applicable information, prior authorization requirements, and for specific requirements for special programs.

3.1General Information

Inpatient hospital services include medically necessary items and services ordinarily furnished by a Texas Medicaid hospital or by an approved out-of-state hospital under the direction of a physician for the care and treatment of patients. Services must be medically necessary and are subject to Texas Medicaid’s utilization review requirements. Claims submitted to TMHP must comply with the appli­cable Texas Medicaid policies and procedures.

3.1.1Reimbursement Limitations

For clients who are 21 years of age and older, Texas Medicaid reimbursement for acute care inpatient hospital services is limited to $200,000 per client, per benefit year (November 1 through October 31). Claims are reviewed retrospectively, and payments that exceed $200,000 are recouped.

This $200,000 limitation does not apply to the following:

Services related to certain organ transplants.

Services rendered to Texas Health Steps (THSteps) clients when provided through the Compre­hensive Care Program (CCP).

For clients who are 20 years of age and younger, dollar limitations do not apply.

3.1.2Spell of Illness

Reimbursement to hospitals for inpatient services is limited to the Medicaid spell of illness. The spell of illness is defined as 30 days of inpatient hospital care, which may accrue intermittently or consecutively.

After 30 days of inpatient care is provided, reimbursement for additional inpatient care is not considered until the client has been out of an acute care facility for 60 consecutive days.

Exceptions to the spell of illness are as follows:

A prior-approved solid organ transplant. The 30-day spell of illness for transplants begins on the date of the transplant, allowing additional time for the inpatient stay.

THSteps-eligible clients who are 20 years of age and younger when a medically necessary condition exists.

Texas Medicaid will conduct a quarterly utilization review of inpatient claims to determine whether the claims were paid outside of the spell-of-illness limitation.

The first of these utilization reviews were for claims with dates of service from April 27, 2010, through January 6, 2012.

3.1.3Take-Home Drugs, Self-Administered Drug, or Personal Comfort Items

Take-home drugs and comfort items that are provided by the hospital during an inpatient hospital stay are included in the hospital reimbursement and are not reimbursed separately.

Take-home drugs and supplies may be a benefit through the Vendor Drug Program (VDP) when supplied by prescription.

Self-administered drugs are defined as drugs that the client administers themselves at home and may include, but are not limited to, prescription drugs, vitamins, and supplements. Self-administered drugs provided by the hospital during an inpatient hospital stay are included in the hospital reimbursement and are not reimbursed separately.

The client cannot be billed for take home drugs, comfort supplies or self-administered drugs that are provided by the hospital during an inpatient hospital stay.

3.1.4Services Included in the Inpatient Stay

The following services are included in the inpatient stay and are not separately reimbursed:

Whole blood and packed red blood cells. Inpatient services include whole blood and packed red blood cells that are reasonable and necessary for treatment of illness or injury. Whole blood and packed red blood cells that are available without cost are not reimbursed by Texas Medicaid.

Laboratory, radiology, and pathology services. Inpatient services include all medically necessary services and supplies ordered by a physician to include laboratory, radiology, and pathology services.

Note:Ultrasound interpretations in the inpatient hospital setting will be denied if they are billed by the attending physician. Services that are billed by the attending physician are included in the facility fee and are not reimbursed separately.

Note:All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendments (CLIA). Providers not complying with CLIA will not be reimbursed for laboratory 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.

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

The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

3.2Services, Benefits, Limitations, and Prior Authorization - Acute Care

Inpatient hospital services include the following:

Bed and board

Whole blood and packed red blood cells

All medically necessary services ordered by a physician to include laboratory, radiology, and pathology

All medically necessary supplies ordered by a physician

Medically necessary emergency and non-emergency ambulance transports during the inpatient stay

Maternity care

Newborn care

Inpatient surgery and rehabilitation

Organ and tissue transplant services

Colorectal cancer screening services

3.2.1Bed and Board

Inpatient bed and board include semiprivate accommodations or accommodations in an intensive care or coronary care unit. The accommodations include:

Meals

Special diets

General nursing services

Private accommodations including meals, special diets, and general nursing services may be reimbursed up to the hospital’s charge for its most prevalent semiprivate accommodations. Bed and board in private accommodations may be reimbursed in full if required for medical reasons as certified by the physician. The hospital must document the medical necessity for a private room (i.e., the existence of a critical or contagious illness, a condition that could result in disturbance to other patients). The medical necessity for the private accommodations must be included in Block 80 of the UB-04 CMS-1450 paper claim form or added as an attachment to the claim submission.

3.2.2Hysterectomy Services

Hysterectomy services are considered for reimbursement when the claim is filed with a signed Hyster­ectomy Acknowledgment Form or submitted documentation indicates that the Hysterectomy Acknowledgment Form could not be obtained.

Claims for services related to the hysterectomy cannot be reimbursed unless the signed Hysterectomy Acknowledgement Form is on file; consequently, to avoid claim denials, each individual provider is encouraged to submit a copy of the valid Hysterectomy Acknowledgement Form and not rely on another provider to do so.

Refer to:  Subsection 6.14.1, “Hysterectomy Acknowledgment” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for additional information.

Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information on the TMHP website at www.tmhp.com.

3.2.3Maternity Care

Inpatient maternity care includes usual and customary care for all female clients.

3.2.3.1Emergency Coverage

For women with a family income at or below 185 percent of the Federal Poverty Level (FPL), hospital facility charges are paid through Emergency Medicaid. A client must be determined eligible for Emergency Medicaid by HHSC for a claim to be paid to a Medicaid provider. Claims are sent to Texas Medicaid & Healthcare Partnership (TMHP) for processing.

3.2.3.2Mother and Newborn Hospital Stay

Circumstances that require the mother and newborn to remain in the hospital longer than two days for a routine vaginal delivery or four days for a cesarean section must be documented in the clients’ medical records.

Continuation of hospitalization is a benefit for the infant when the mother is required to remain hospi­talized for medical reasons. The reason for the continuation of hospitalization must be documented in the client’s medical record.

3.2.3.3Children’s Health Insurance Program (CHIP) Perinatal Coverage

For clients who are eligible for CHIP perinatal services as determined by HHSC, CHIP perinatal services include newborn services and inpatient hospital charges related to the delivery of the newborn. Preterm or false labor that does not result in a birth are not CHIP perinatal services.

Inpatient services limited to labor with delivery for women with income between 186 and 200 percent of FPL will be covered under CHIP perinatal. Newborn services will also be covered under CHIP perinatal.

For CHIP perinatal newborns with a family income at or below 185 percent of the federal poverty level, TMHP will process newborn transfer hospital claims even if the claim from the initial hospital stay has not been received. The hospital transfer must have occurred within 24 hours of the discharge date from the initial delivery hospital stay.

Transfer claims must be filed to TMHP using the admission type 1, 2, 3, or 5 in block 14; source of admission code 4 or 6 in block 15; and the actual date and time the client was admitted in block 12 of the UB-04 CMS-1450 paper claim form.

Refer to:  Subsection 6.19.1, “CHIP Perinatal Newborn Transfer Hospital Claims” in “Section 6: Claims Filing” (Vol. 1, General Information).

3.2.4Newborn Care

Newborn care includes routine newborn care, routine screenings, and specialized nursery care for newborns with specific problems.

Hospital providers must provide all state-mandated newborn screenings and vaccinations.

Refer to:  Subsection 5.3.11.2.3, “* Hearing Screening” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Subsection 5.3.9, “* Newborn Examination” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

3.2.4.1Newborn Eligibility

A child is deemed eligible for Texas Medicaid through 12 months of age if the mother is receiving Medicaid at the time of the child’s birth, the child continues to live with the mother, and the mother continues to be eligible for Medicaid or would be eligible for Medicaid if she were pregnant. Therefore, it is not acceptable for a hospital to require a deposit for newborn care from a Medicaid client. The child’s eligibility ends if the mother relinquishes her parental rights or if it is determined that the child is no longer part of the mother’s household.

Hospitals must complete Hospital Report (Newborn Child or Children) (Form 7484) on the TMHP website at www.tmhp.com to provide information about each child born to a mother who is eligible for Medicaid. If the newborn’s name is known, the name must be on the form.

Important:If the newborn’s name is not known, the name may be left blank. The use of “Baby Boy” or “Baby Girl” delays the assignment of a number.

The form must be completed by the hospital no later than five days after the child’s birth and sent to HHSC at the address identified on the form. The form should not be completed for stillbirths. Hospitals should duplicate the form as needed, because they are not supplied by HHSC, the Department of Aging and Disability Services (DADS), or TMHP.

Hospitals that submit the birth certificate information using the Department of State Health Services (DSHS), 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 involved in newborn care including pharmacies that provide outpatient prescription benefits for medically-needy newborns.

For additional information about obtaining a newborn Medicaid identification number, providers may call 1-888-963-7111, Ext. 7368 or 1-512-458-7368.

After receiving a completed form, HHSC verifies the mother’s eligibility. Within 10 days of receiving the completed form, HHSC sends notices to the hospital, mother, caseworker, and attending physician, if identified. The notice includes the child’s Medicaid client number and the effective date of coverage. After the child has been added to the eligibility file, HHSC issues a Medicaid Identification (Form H3087).

Claims submitted for services provided to a newborn child who is eligible for Medicaid must be filed using the newborn child’s Medicaid client number.

Newborns who are from families with an income at or below 185 percent of the FPL and who receive CHIP perinatal benefits are assigned a client number for Texas Medicaid. This number is only assigned for reimbursement of the newborn’s hospital facility charges (on a UB-04 CMS-1450 paper claim form) for the initial hospital stay after delivery. Claims for the newborn’s hospital facility charges should be sent to TMHP.

3.2.5Organ and Tissue Transplant Services

3.2.5.1Transplant Facilities

A facility that renders organ transplants must be a designated children’s hospital or a facility in continuous compliance with the criteria set forth by the following:

Organ Procurement and Transportation Network (OPTN)

United Network for Organ Sharing (UNOS)

National Marrow Donor Program (NMDP)

Facilities whose status of “good standing” has been suspended for any reason by the national creden­tialing bodies will not be reimbursed by Texas Medicaid for transplant services until the status of “good standing” is restored.

If a Medicaid client receives a transplant in an in-state or out-of-state facility that is not approved by Texas Medicaid, the client must be discharged from the facility to be considered to receive other medical and hospital benefits under Texas Medicaid. Coverage for other services needed as a result of complica­tions of the transplant may be considered when medically necessary, reasonable, and federally allowable.

Texas Medicaid will not pay for routine post-transplant services for transplant patients in facilities that are not approved by Texas Medicaid.

3.2.5.1.1Out-of-state Transplant Facilities

Out-of-state facilities may be reimbursed for transplants rendered to Texas Medicaid clients under certain conditions. In order for Texas Medicaid to reimburse for an out-of-state transplant, the out-of-state facility and professional providers must enroll as Texas Medicaid providers. The out-of state trans­plant facilities must submit proof of transplant facility UNOS or NMDP certification as required by the Texas HHSC.

Physicians who are licensed by the state of Texas may request prior authorization for transplant services to be performed at out-of-state facilities when all of the following criteria are met:

The required organ transplant is not available in Texas

The facility is nationally recognized as a Center of Excellence

The services are medically necessary, reasonable, and federally allowable

The client is enrolled in Texas Medicaid

The pretransplant evaluation must be performed by a Texas facility. If it is medically necessary that the pretransplant evaluation be performed at the out-of-state facility as well, the prior authorization request for the out-of-state pretransplant evaluation must be submitted with a copy of the evaluation that was performed by the Texas facility. The documentation must support the need for an out-of-state pretrans­plant evaluation.

Important:Texas Medicaid does not cover transplant services provided out-of-state that are available in Texas.

3.2.5.2Transplant Benefits and Limitations

If a transplant has been authorized as medically necessary by HHSC or its designee because of an emergent, life-threatening situation, a maximum of 30 days of inpatient hospital services during Title XIX spell of illness may be a benefit, beginning with the actual first day of the transplant. This benefit is in addition to covered inpatient hospital days provided before the actual first day of the transplant. This 30-day period is considered a separate inpatient hospital admission for reimbursement purposes, but is included under one hospital stay.

Refer to:  Subsection 3.1.2, “Spell of Illness” in this handbook for additional information about the 30-day spell of illness period.

Reimbursement for transplant is limited to an initial transplant as a lifetime benefit and one subsequent re-transplant because of rejection. Expenses incurred by a living donor will not be reimbursed.

All transplants require prior authorization. If a solid organ transplant is not prior authorized, services that are directly related to the transplant within the three-day pre-operative and six-week postoperative period will be denied, regardless of who provides the services. Services unrelated to the transplant surgery will be paid separately.

If the organ is rejected, the re-transplant requires its own prior authorization. If the re-transplant is not prior authorized, services that are directly related to the re-transplant within the three-day pre-operative and six-week postoperative period will be denied, regardless of who provides the services. Services unrelated to the re-transplant surgery will be paid separately.

Note:The re-transplant is not included in the prior authorization for the initial transplant. The subsequent re-transplant must be prior authorized separately.

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

3.2.5.3Prior Authorization for Organ and Transplant Services

All solid organ transplant services provided by facilities and professionals must be prior authorized. If a solid organ transplant is not prior authorized, services directly related to the transplant within the three day pre-operative and six-week postoperative period also will be denied, regardless of who provides the service, (e.g., laboratory services, status-post visits, and radiology services). Services unrelated to the transplant surgery will be paid separately.

A transplant request signed by a physician associated with transplant facilities is considered for prior authorization after the client has been evaluated and meets the guidelines of the institution’s transplant protocol.

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

3.2.5.4Transplants for Medicare-Eligible Clients

Transplants are also a benefit under the Medicare program; therefore, for clients eligible for Medicare and Medicaid, Texas Medicaid will pay only the deductible or coinsurance portion as applicable according to current payment guidelines. Prior authorization must be obtained for Medicaid-only clients; authorization will not be given for Medicare/Medicaid-eligible clients. Texas Medicaid will not pay for a transplant service denied by Medicare for a Medicare-eligible client.

3.2.5.5Experimental or Investigational Services

Benefits are not available for any experimental or investigational services (including xenotransplan­tation and artificial/bioartificial liver transplants), supplies, or procedures.

3.2.5.6Reimbursement for Transplant Services

The hospital diagnosis related group (DRG) payment for the transplant includes procurement of the organ and services associated with the organ procurement. The Omnibus Budget Reconciliation Act of 1986 (OBRA 86) Public Law 99-509 added Section 1138 of the Social Security Act, which defines condi­tions of participation for institutions in the organ procurement program. Organ procurement costs are not reimbursed to a hospital that fails to meet the conditions of participation. The specific guidelines may be found in the appropriate areas of the Code of Federal Regulations (CFR) Title 42, Parts 405, 413, 441, 482, and 485. Documentation of organ procurement must be maintained in the hospital’s medical record.

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.

3.2.5.7Nonsolid Organ Transplants

Under current Texas Medicaid policy, procedures are considered to be medically necessary and reasonable based on safety and efficacy, as demonstrated by scientific evidence and controlled by clinical studies.

Nonsolid organ transplants that are benefits of Texas Medicaid include:

Allogeneic and autologous stem cell transplantation

Allogeneic and autologous bone marrow transplantation

Autologous islet cell transplantation

All nonsolid organ transplants require prior authorization and must be performed in a Texas facility that is a designated Children’s Hospital or a facility in compliance with the criteria set forth by the Organ Procurement and Transportation Network (OPTN), the United Network for Organ Sharing (UNOS), or the National Marrow Donor Program (NMDP).

Experimental or investigational services, supplies, or procedures are not a benefit of Texas Medicaid.

3.2.5.7.1Inpatient Hospitalization

For a nonsolid organ transplant that has been prior authorized for clients who are 21 years of age and older, a maximum of 30 days of inpatient hospital services during a Title XIX spell of illness is covered beginning with the actual first day of the transplant. This coverage is in addition to covered inpatient hospital days provided before the actual first day of the transplant. This 30-day period is considered a separate inpatient hospital admission for reimbursement purposes but is included under one DRG payment.

Autologous harvesting of stem cells (single or multiple sessions) are reimbursed to the facility when prior authorized by HHSC or its designee and performed in the outpatient facility setting. Harvesting of stem cells performed in a hospital inpatient setting is included in the DRG and is not reimbursed separately.

Refer to:  Subsection 9.2.47.9, “Nonsolid Organ Transplants” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

3.3Services, Benefits, Limitations, and Prior Authorization - Inpatient Rehabilitation Services

Inpatient rehabilitation services are a benefit of Texas Medicaid when provided as part of a general acute care inpatient admission, or with prior authorization for clients who are 20 years of age and younger in a freestanding rehabilitation facility.

Inpatient rehabilitation services in an acute care setting are included in the hospital DRG payment. All rehabilitation services are subject to Medicaid benefit limitations including the spell of illness. Excep­tions to those limitations may be offered under CCP.

Refer to:  Subsection 1.6.15, “Physical, Occupational, and Speech Therapy Providers” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Subsection 2.17, “Inpatient Rehabilitation Facility (Freestanding) (CCP)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

3.4Services, Benefits, Limitations, and Prior Authorization - Inpatient Psychiatric Services

3.4.1Enrollment

Acute care hospitals and state psychiatric facilities must be certified by Medicare, have a valid provider agreement with the HHSC, and have completed the TMHP enrollment process.

Refer to:  Subsection 5.1, “Enrollment” in this handbook for more information about acute care hospital enrollment.

Freestanding psychiatric facilities must be licensed by DSHS or by the appropriate state board where services are rendered. The provider must be approved by The Joint Commission (TJC).

Providers cannot be enrolled if their licenses are due to expire within 30 days.

To be eligible to participate in the Comprehensive Care Inpatient Psychiatric (CCIP) Program to render services to Texas Health Steps (THSteps) clients, a freestanding or state psychiatric facility must be accredited by TJC, have a valid provider agreement with HHSC, and have completed the TMHP enrollment process. Facilities certified by Medicare must also meet TJC accreditation requirements.

Note:Acute care hospitals cannot enroll as CCIP facilities.

3.4.2General Information

Inpatient admissions to acute care hospitals, freestanding psychiatric facilities, and state psychiatric facilities for psychiatric conditions may be a benefit of Texas Medicaid as outlined in the following table:

Hospital Type

CCIP Clients 0-20 Years of Age

Medicaid Clients of Any Age

Acute care hospital

No

Yes

Freestanding psychiatric facility (IMD)

Yes

Yes (clients 65 years of age and older)

No (clients 21 through 64 years of age)

State psychiatric facility (IMD)

Yes

Yes (clients 65 years of age and older)

No (clients 21 through 64 years of age)

(IMD) Institution for Mental Diseases.

When a client requires admission, or once the client becomes Medicaid eligible while in the facility, a certification of need must be completed and placed in the client’s record within 14 days of the admission.

Inpatient psychiatric treatment is a benefit of Texas Medicaid if all of the following are met:

The client has a psychiatric condition that requires inpatient treatment.

The inpatient treatment is directed by a psychiatrist.

The inpatient treatment is provided in a nationally accredited facility or hospital.

The provider is enrolled in Texas Medicaid.

Client services must be provided in the most appropriate setting and in a timely manner to meet the mental health needs of the client.

Inpatient admissions to acute care hospitals, freestanding, and state psychiatric facilities are subject to the Texas Medicaid retrospective utilization review (UR) requirements. The UR requirements are appli­cable, regardless of the hospital’s designation as a psychiatric unit versus a medical or surgical unit.

3.4.2.1Professional Services Rendered in the Inpatient Setting

Services rendered in the inpatient hospital setting may be reimbursed to the professional that provides the service.

Refer to:  Subsection 6, “Psychiatric Services for Hospitals” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) for benefit and limitation information about services that are rendered by psychiatrists, psychologists, LPAs, APNs, and PAs in the inpatient setting.

3.4.2.2Documentation Requirements

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

Documentation of medical necessity for inpatient psychiatric care must specifically address the following issues:

Why the ambulatory care resources in the community cannot meet the treatment needs of the client.

Why inpatient psychiatric treatment under the care of a psychiatrist is required to treat the acute episode of the client.

How the services can reasonably be expected to improve the condition or prevent further regression of the client’s condition in a proximate time period.

Supporting documentation (certification of need) must be documented in the individual client’s record. This documentation must be maintained by each facility as applicable to state and federal guidelines and be readily available for review whenever requested by the HHSC or its designee.

Psychological or neuropsychological testing, when performed in an acute care hospital or in a freestanding or state psychiatric facility does not require prior authorization; however, these facilities must maintain documentation that supports medical necessity for the testing and the testing results of any psychological or neuropsychological testing services performed while the client is an inpatient.

3.4.2.3Noncovered Services

Inpatient admissions including, but not limited to, the following are not benefits of Texas Medicaid without an accompanying medical complication or condition:

Single diagnosis of chemical dependency or abuse (such as alcohol, opioids, barbiturates, and amphetamines).

Chronic diagnoses (such as intellectual or developmental disability [IDD], organic brain syndrome, or chemical dependency or abuse).

3.4.2.4CLIA Certification for Laboratory Services

All providers of laboratory services must comply with the rules and regulations of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Providers that do not comply with CLIA are not reimbursed for laboratory services.

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

Refer to:  The CMS website at www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Catego­rization_of_Tests.html for information about procedure code and modifier QW requirements.

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

3.4.3Acute Care Hospital Psychiatric Services

Acute care hospital psychiatric services are those services that are rendered to Texas Medicaid clients of any age who are admitted as an inpatient to an acute care hospital for treatment of a psychiatric condition.

Admissions to acute care hospitals must be medically necessary.

Refer to:  Subsection 3.2, “Services, Benefits, Limitations, and Prior Authorization - Acute Care” in this handbook for additional information about acute care benefits and limitations.

3.4.3.1Prior Authorization Requirements

Prior authorization is not required for fee-for-service clients admitted to psychiatric units in acute care hospitals.

3.4.4Freestanding and State Psychiatric Facilities

Psychiatric facility services are those services that are rendered in an Institutions for Mental Diseases (IMD). Freestanding and state psychiatric facilities are enrolled in Texas Medicaid as IMDs. According to TAC Rule §419.453 and based on 42 CFR §435.1009, an IMD is a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of individuals with mental illness, including medical attention, nursing care, and related services.

3.4.4.1CCIP Services

Inpatient psychiatric treatment in a nationally accredited freestanding psychiatric facility or a nationally-accredited state psychiatric hospital is a benefit of Texas Medicaid for clients who are 20 years of age and younger, and who are eligible for THSteps benefits at the time of the service request and service delivery.

Admissions to freestanding and state psychiatric facilities must be medically necessary, unless they are court-ordered services for mental health commitments or they are a condition of probation.

Revenue code 124 must be used for inpatient psychiatric services that are rendered to children and adolescents in freestanding and state psychiatric facilities.

Note:Outpatient services for hospital-based psychiatric day treatment programs or psychiatric facilities are not a benefit of Texas Medicaid.

3.4.4.1.1Prior Authorization Requirements for Children and Adolescents

Prior authorization is not required for initial admission to freestanding psychiatric facilities or state psychiatric hospitals for clients who are 20 years of age and younger for a maximum of five days based on Medicaid eligibility and documentation of medical necessity. Extended stay requests beyond the initial 5 days require prior authorization.

Extended stay prior authorization requests for fee-for-service clients may be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. The supervising psychiatrist may sign prior authorization forms and supporting documentation using electronic or wet signatures.

Refer to:  Subsection 5.5.1.2, “Document Requirements and Retention” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for additional information about electronic signatures.

To facilitate a determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including accurate documentation of medical necessity for the services requested.

Authorization procedures and approved providers may be different for managed care clients. Contact the client’s specific health plan for details.

The prior authorization requests will be reviewed as follows:

Providers must submit a Psychiatric Inpatient Extended Stay Request Form to the TMHP CCIP unit requesting prior authorization for an extended stay. Requests for an extension of stay must be received on or before the fifth day of an initial admission and/or on or before the last day authorized or denied for subsequent stay requests. If an extended stay is requested and the fifth day of the initial admission or the last date authorized or denied of the previous stay falls on a holiday or a weekend, the request for an extended stay is due by 5 p.m. of the next business day. The provider is notified of the decision in writing by the CCIP unit.

All psychiatric admission extended stay requests for clients who are 11 years of age or younger will be reviewed by a psychiatrist.

Psychiatric admission extended stay requests for clients who are 12 through 20 years of age will be reviewed by a mental health professional. Any requests for psychiatric extended stays that do not meet the medical necessity criteria for extended stays will be referred to a psychiatrist for final determination.

The Psychiatric Inpatient Extended Stay Request Form must reflect the need for extended stay in relation to the original need for admission. Any change in the client’s diagnosis must be noted on the request. Additional documentation or information supporting the need for extended stay may be attached to the form. Up to seven days may be authorized for an extension request.

Medicaid Clinical Criteria for the Initial Inpatient Psychiatric Stay

The client must have a valid diagnosis as listed in the current version of the DSM as the principal admitting diagnosis and one of the following:

Outpatient therapy or partial hospitalization has been attempted and failed

A psychiatrist has documented reasons why an inpatient level of care is required.

The client must meet at least one of the following criteria:

The client is presently a danger to self, demonstrated by at least one of the following:

Recent suicide attempt or active suicidal threats with a deadly plan, and there is an absence of appropriate supervision or structure to prevent suicide.

Recent self-mutilative behavior or active threats of same with likelihood of acting on the threat, and there is an absence of appropriate supervision or structure to prevent self-mutilation (e.g., intentionally cutting/burning self).

Active hallucinations or delusions directing or likely to lead to serious self-harm or debili­tating psychomotor agitation or impairment resulting in a significant inability to care for self.

Significant inability to comply with prescribed medical health regimens due to concurrent psychiatric illness and such failure to comply is potentially hazardous to the life of the client. The medical diagnosis must be treatable in a psychiatric setting.

The client is a danger to others. This behavior must be attributable to the client’s specific diagnosis as listed in the current version of the DSM, and can be adequately treated only in a hospital setting. This danger is demonstrated by one of the following:

Recent life-threatening action or active homicidal threats of same with a deadly plan, avail­ability of means to accomplish the plan, and with likelihood of acting on the threat.

Recent serious assaultive or sadistic behavior or active threats of same with likelihood of acting on the threat, and there is an absence of appropriate supervision or structure to prevent assaultive behavior.

Active hallucinations or delusions directing or likely to lead to serious harm of others.

The client exhibits acute onset of psychosis or severe thought disorganization, or there is significant clinical deterioration in the condition of someone with a chronic psychosis, rendering the client unmanageable and unable to cooperate in treatment, and the client is in need of assessment and treatment in a safe and therapeutic setting.

The client has a severe eating or substance use disorder that requires 24-hour-a-day medical obser­vation, supervision, and intervention.

The client exhibits severe disorientation to person, place, or time.

The client’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors and other behaviors, which may also include physical, psycho­logical, or sexual abuse.

The client requires medication therapy or complex diagnostic evaluation where the client’s level of functioning precludes cooperation with the treatment regimen.

The client is involved in the legal system, manifests psychiatric symptoms, and is ordered by a court to undergo a comprehensive assessment in a hospital setting to clarify diagnosis and treatment needs.

The proposed treatment or therapy requires 24-hour-a-day medical observation, supervision, and intervention and must include all of the following:

Active supervision by a psychiatrist with the appropriate credentials as determined by the Texas Medical Board (TMB) and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment/therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.

Implementation of an individualized treatment plan.

Provision of services that can reasonably be expected to improve the client’s condition or prevent further regression so that a lesser level of care can be implemented.

Documentation that proper treatment of the client’s psychiatric condition requires services on an inpatient basis under the direction of a psychiatrist and is being provided in the least restrictive environment available, and ambulatory care resources available in the community do not meet the client’s needs.

Medicaid Clinical Criteria for Extended Stays

Extended stays are considered for THSteps clients in freestanding and state psychiatric hospitals when the client meets at least one of the criteria from above and have a treatment or therapy regimen, which must include all of the following:

Active supervision by a psychiatrist with the appropriate credentials as determined by the Texas Medical Board (TMB) and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment/therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.

Treatment/therapy requires an inpatient level of care.

Initial discharge plans have been formulated and actions have been taken toward implementation, including documented contact with a local mental health provider.

Extended stays are also considered for children and adolescents whose discharge plan does not include returning to their natural home. If the party responsible for placement has provided the inpatient provider with three documented placement options for which the child meets admission criteria, but cannot accept the child, up to five days may be authorized, per request, to allow alternative placement to be located. Up to three 5-day extensions may be authorized.

Court-Ordered Services

A request for prior authorization of court-ordered services must be submitted no later than seven calendar days after the date on which the services began.

Court-ordered services are not subject to the five-day admission limitation or the seven-day extended stay limitation. Court-ordered services include:

Mental health commitments

Condition of probation (COP)

For court-ordered admissions, a copy of the doctor’s certificate and all court-ordered commitment papers signed by the judge must be submitted with the Psychiatric Inpatient Extended Stay Request Form.

Prior Authorization Appeals

All prior authorization requests not submitted or received by the TMHP CCIP unit in accordance with established policies are denied through the submission date, and claim payment is not made for the dates of service denied.

All denials may be appealed. The TMHP CCIP unit must receive these appeals within 15 days of the TMHP CCIP unit denial notice.

Appeals of a denial for an extended stay, must be accompanied by the documentation supporting medical necessity that the provider believes warrants reconsideration.

Appeals of a denial for late submission of information, must be accompanied by documentation that the provider believes supports the compliance with HHSC claims submission guidelines.

Appeals are reviewed first by an experienced psychiatric licensed clinical social worker (LCSW) or a registered nurse (RN) to determine if the required criteria is documented and then forwarded to a psychiatrist for final determination. The TMHP CCIP unit will notify the provider of all denial determi­nations in writing.

3.4.4.2Psychiatric Services for Clients 65 Years of Age and Older

IMD services for clients who are 65 years of age and older must be medically necessary and do not require prior authorization.

3.4.4.3Reimbursement for Services Rendered in an IMD

The following services will not be reimbursed during an inpatient stay when they are rendered to clients who are admitted as inpatients to an IMD:

Ambulance

Case management

Acute care hospital

Mental health rehabilitation

School Health and Related Services (SHARS)

IMD providers may be reimbursed only for services that are rendered to clients who are 20 years of age and younger or 65 years of age and older. IMD services and services rendered at an IMD to clients who are 21 years of age through 64 years of age are not eligible for reimbursement.

Services that are rendered in an IMD facility must be identified in the client’s plan of care. Services that are not included in the client’s plan of care are subject to recoupment.

If the client has not been discharged from the IMD, the IMD provider is responsible for acute care services that are rendered to the client in an acute care facility, and claims that are submitted for these services will be denied as a duplicate service that has been paid to another provider.

Services that are rendered on the date of admission to the IMD and the date of discharge from the IMD may be reimbursed.

Important:Claims for professional services rendered during an inpatient stay in an Institution for Mental Disease (IMD) must include the IMD facility’s ten-digit National Provider Identifier (NPI). Claims that do not include the IMD Facility’s NPI will be denied.

3.4.4.3.1Medicare Coinsurance and Deductible Reimbursement

Freestanding psychiatric hospitals that are enrolled in Medicare may also receive Medicaid payment for the Medicare coinsurance or deductible according to current Medicaid guidelines.

Exception: IMD services for clients who are 21 through 64 years of age are not benefits of Texas Medicaid. Medicaid will not reimburse coinsurance and deductible payments for psychiatric services that are rendered to these clients in an IMD.

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

3.4.4.4Providing IMD Client Information to TMHP

IMD providers are requested to inform TMHP of the Medicaid clients who are residing in their facilities before submitting inpatient claims for those clients.

IMD providers can use the TMHP secure web page to enter client information and the admission and discharge dates by going to My Account and choosing the Manage IMD Clients Segment link in the Acute Care Online Portal field.

IMD providers can search for Medicaid client records that are associated with their provider identifiers.

Providers will be asked to submit the client’s identification number and admission date. After the client is discharged, providers will be requested to enter the discharge date on the same Manage IMD Clients Segment screen.

Providers will not be able to change previously reported client information except for the To Date of Service information.

Providers that submit inaccurate information can call the Electronic Data Interchange (EDI) Help Desk at 1-888-863-3638 to have that client segment inactivated if the request is made within 24 hours of submission. After the erroneous client segment has been inactivated by TMHP, providers may submit a new client segment to replace it. After 24 hours have elapsed, providers must contact HHSC to request a correction to the information. This change must include the appropriate documentation of the client’s patient control number (PCN) and the admission and discharge dates.

The change request and appropriate documentation must be submitted in writing to the following address:

Texas Health and Human Services Commission
Mail Code 91X PO Box 204077
Austin, Texas 78720-4077

3.4.5Medicaid Clinical Criteria for Inpatient Psychiatric Care for Clients

The client must have a valid AXIS I, DSM diagnosis as the principle admitting diagnosis and outpatient therapy or partial hospitalization has been attempted and failed, or a psychiatrist has documented reasons why an inpatient level of care is required. The client’s Axis II diagnosis must also be included on the request for inpatient psychiatric treatment.

The client must meet at least one of the following criteria:

The client is presently a danger to self, demonstrated by at least one of the following:

Recent suicide attempt or active suicidal threats with a deadly plan and an absence of appropriate supervision or structure to prevent suicide.

Recent self-mutilative behavior or active threats of same with likelihood of acting on the threat and an absence of appropriate supervision or structure to prevent self-mutilation (i.e., inten­tionally cutting or burning self).

Active hallucinations or delusions directing or likely to lead to serious self-harm or debilitating psychomotor agitation or intellectual disability resulting in a significant inability to care for self.

Significant inability to comply with prescribed medical health regimens due to concurrent Axis I psychiatric illness and such failure to comply is potentially hazardous to the life of the client. The medical (AXIS III) diagnosis must be treatable in a psychiatric setting.

The client is a danger to others. This behavior should be attributable to the client’s specific AXIS I or DSM diagnosis and can be adequately treated only in a hospital setting. This danger is demon­strated by one of the following:

Recent life-threatening action or active homicidal threats of same with a deadly plan and avail­ability of means to accomplish the plan with likelihood of acting on the threat.

Recent serious assaultive or sadistic behavior or active threats of same with likelihood of acting on the threat and an absence of appropriate supervision or structure to prevent assaultive behavior.

Active hallucinations or delusions directing or likely to lead to serious harm of others.

The client exhibits acute onset of psychosis or severe thought disorganization, or there is significant clinical deterioration in the condition of someone with a chronic psychosis, rendering the client unmanageable and unable to cooperate in treatment, and the client is in need of assessment and treatment in a safe and therapeutic setting.

The client has a severe eating or substance abuse disorder which requires 24-hour-a-day medical observation, supervision, and intervention.

The client exhibits severe disorientation to person, place, or time.

The client’s evaluation and treatment cannot be carried out safely or effectively in other settings due to severely disruptive behaviors and other behaviors which may also include physical, psychological, or sexual abuse.

The client requires medication therapy or complex diagnostic evaluation where the client’s level of functioning precludes cooperation with the treatment regimen.

The client is involved in the legal system, manifests psychiatric symptoms, and is ordered by court to undergo a comprehensive assessment in a hospital setting to clarify the diagnosis and treatment needs.

The proposed treatment or therapy requires 24-hour-a-day medical observation, supervision, and inter­vention and must include all of the following:

Active supervision by a psychiatrist with the appropriate credentials as determined by the Texas Medical Board (TMB) and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment or therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.

Implementation of an individualized treatment plan.

Provision of services which can reasonably be expected to improve the client’s condition or prevent further regression so that a lesser level of care can be implemented.

Proper treatment of the client’s psychiatric condition requires services on an inpatient basis under the direction of a psychiatrist and is being provided in the least restrictive environment available, and ambulatory care resources available in the community do not meet the client’s needs.

3.4.6Extended Stays

Extended stays are considered when the client meets at least one of the criteria from above and has a treatment or therapy regimen that includes all of the following:

Active supervision by a psychiatrist with the appropriate credentials as determined by the TMB and with documented specialized training, supervised experience, and demonstrated competence in the care and treatment of children and adolescents. Treatment or therapy plans must be guided by the standards of treatment specified by the Texas Society of Child and Adolescent Psychiatry.

Treatment or therapy requires an inpatient level of care.

Initial discharge plans have been formulated and actions have been taken toward implementation, including documented contact with a local mental health provider.

Extended stays are considered for children and adolescents whose discharge plan does not include returning to their natural home. If the party responsible for placement has provided the provider with three documented placement options for which the child meets admission criteria, but which cannot accept the child, up to five days may be authorized, per request, to allow alternative placement to be located. Up to three five-day extensions may be authorized.

3.4.7Court-Ordered Services

A request for prior authorization of court-ordered services must be submitted no later than seven calendar days after the date on which the services began.

Court-ordered services are not subject to the 12-hour system limitation per provider, per day when billed with modifier H9.

Court-ordered services are not subject to the five day admission limitation or the seven day extended stay limitation. Court-ordered services include:

Mental health commitments

Condition of probation (COP)

For court-ordered admissions, a copy of the doctor’s certificate and all court-ordered commitment papers signed by the judge must be submitted with the Psychiatric Inpatient Extended Stay Request Form.

Specific court-ordered services for evaluations, psychological or neuropsychological testing, or treatment may be prior authorized as mandated by the court. A copy of the court document signed by the judge must accompany prior authorization requests. If the requested services differ from the court order, the additional services will be reviewed for medical necessity. Requested services beyond those court-ordered are subject to medical necessity review.

3.4.8Denials

All prior authorization requests not submitted or received by the TMHP CCIP Unit in accordance with established policies are denied through the submission date, and claim payment is not made for the dates of service denied.

All denials may be appealed. The TMHP CCIP Unit must receive these appeals within 15 days of the TMHP CCIP Unit denial notice.

Appeals of a denial for an extended stay must be accompanied by the documentation supporting medical necessity that the provider believes warrants reconsideration.

Appeals of a denial for late submission of information must be accompanied by documentation which the provider believes supports the compliance with HHSC claims submission guidelines.

Appeals are reviewed first by an experienced psychiatric LCSW (Licensed Clinical Social Worker) or an RN to determine if the required criteria is documented and then forwarded to a psychiatrist for final determination. The TMHP CCIP Unit will notify the provider of all denial determinations in writing by fax.

3.5Inpatient Utilization Review

UR activities of all Medicaid services provided by hospitals reimbursed under the DRG prospective payment system or the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 are required by Title XIX of the Social Security Act, Sections 1902 and 1903. The review activities are accomplished through a series of monitoring systems developed to ensure services are appropriate to need of optimum quality and quantity, and rendered in the most cost-effective mode. Clients and providers are subject to UR monitoring. The monitoring focuses on the appropriate screening activities, medical necessity of all services, and quality of care as reflected by the choice of services provided, type of provider involved, and settings in which the care was delivered. This monitoring ensures the efficient and cost-effective admin­istration of Texas Medicaid.

The HHSC Office of Inspector General (OIG) UR Unit is responsible for retrospective review of inpatient DRG and TEFRA admissions. These reviews are accomplished through onsite visits, electronic access, or mail-in.

3.6Utilization Review Process

The inpatient UR process for admissions reimbursed under the DRG prospective payment system consists of sampling medical records of paid Medicaid claims. The review process consists of three major components:

Admission review. Determination of the medical necessity of the admission. For purposes of the Texas Medical Review Program (TMRP), TEFRA, and facility-specific per diem methodology reviews, medical necessity means the client has a condition requiring treatment that can be safely provided only in the inpatient setting.

Quality review. Assessment of the quality of care provided to determine if it meets generally accepted standards of medical and hospital care practices or puts the client at risk of unnecessary injury or death. Quality of care review includes the use of discharge screens and generic quality screens.

DRG validation. Determination that the critical elements necessary to assign a DRG are present in the medical record and the diagnosis and procedures are sequenced correctly. The critical elements are age, sex, admission date, discharge date, patient discharge status, principal diagnosis, secondary diagnoses (complications or comorbidities), and principal and secondary procedures.

The HHSC OIG UR Unit staff reviews the complete medical record to make decisions about the medical necessity of the admission, validity of the DRG, including the present on admission (POA) indicator, and quality of care. The medical record must reflect that any services reimbursed by Texas Medicaid were ordered by a physician or non-physician provider.

When an admission denial or a denial of extended stay is issued, or when a technical denial becomes final, all money is recouped from the hospital for the admission or days of stay that are denied. When a DRG is reassigned as a result of UR, the payment to the hospital is adjusted.

Refer to:  Subsection 3.6.3, “Technical Denials (DRG Prospective Payment)” in this handbook.

If an inpatient admission is denied, but a physician’s order is present documenting the client originally was placed in observation, the UR unit may authorize the resubmission of services rendered during the first 48 hours on an outpatient claim.

Compliance with the DRG prospective payment system and aspects of the review as stated above are evaluated quarterly. Identified problems may result in an educational visit or action, such as recoupment or referral to the HHSC OIG Medicaid Program Integrity (MPI) or Sanctions Unit.

3.6.1Admission Review

All services, supplies, or items submitted as certified on claim submission, must be medically necessary for the client’s diagnosis or treatment. Review personnel assess the medical necessity of an admission by comparing documentation present in the medical record using recognized evidence-based guidelines for inpatient screening criteria. The evidence-based guidelines are Milliman Care Guidelines, which replace the physician developed and physician-approved Medicaid hospital screening criteria addressed through a rule revision effective August 1, 2006. Non-physician reviewers use the criteria as guidelines for the initial approval or for the referral of inpatient reviews for medical necessity decisions. Cases that do not meet initial approval are referred to a physician consultant to determine the medical necessity of the inpatient admission. If the criteria are met but the medical necessity of the admission is still questionable, the case is referred to a physician consultant for a determination. If a physician consultant determines the admission is not medically necessary, a denial is issued.

Review personnel assess the medical necessity of admissions prior to September 1, 2006, by comparing documentation present in the medical record with elements in the TMRP Hospitalization Screening Criteria.

3.6.1.1Readmission Review

If a hospital admission or readmission occurs within 30 days of a discharge from the same or a different hospital for the same or closely related diagnosis, or for a condition identified during the previous admission, it may be reviewed for medical necessity, quality, and DRG validation including POA indicators.

Transfers from one facility to another and readmissions are also subject to review.

3.6.1.2Hospital-Based Ambulatory (HASC) Surgical Procedures

Inpatient admissions for surgical procedures listed as ambulatory surgical codes in the current fee schedule are denied if documentation does not support the need for the inpatient admission.

3.6.1.3Quality Review

Each Medicaid case is evaluated for quality of client care, adequacy of discharge planning, and medical stability of the client at discharge. Quality of care review includes the use of discharge screens and generic quality screens. Potential quality of care issues are identified by the physician. HHSC contracts with physician consultants to review medical records for quality of care. Physician consultants, of the specialty related to the care rendered, may make clinical recommendations or determine corrective actions when deemed appropriate. Child and adolescent psychiatrists may make recommendations based on review of inpatient psychiatric services provided to Medicaid clients younger than 21 years of age. Failure to verify completion of any corrective action recommendation within the specified time frame may result in referral of the case to the HHSC OIG MPI or Sanctions Unit.

3.6.1.4Diagnosis-Related Group Validation

Each medical record is reviewed to validate the elements critical to the DRG assignment. These elements are the client’s age, sex, admission date, patient discharge date, patient discharge status, principal diagnosis, secondary diagnoses (complications or co-morbidities), POA indicators, and principal and secondary procedures. Documentation of these critical DRG elements in the medical record is evaluated for the correlation to the information provided on the claim form.

The principal diagnosis is the diagnosis (condition) established after study to be chiefly responsible for causing the admission of the client to the hospital for care. The condition must be treated or evaluated during this admission to the hospital.

The secondary diagnoses are conditions that affect client care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care and monitoring, or have clinically significant implications for future health-care needs.

The coding of diagnoses that have clinically significant implications for future health-care needs applies only to newborns and must be identified by the physician. Normal newborn conditions or routine procedures are not to be considered as complications or co-morbidities for DRG assignment.

Refer to:  Subsection 1.11, “Texas Medicaid Limitations and Exclusions” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

The POA review will validate the POA indicator assigned to the principal and secondary diagnoses codes reported on claim forms. If it is determined that the principal and/or secondary diagnoses were not present at the time the order for inpatient admission occurs, the Commission will revise the POA indicator for the diagnosis code. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery are considered POA.

If the principal diagnosis, secondary diagnoses (complications or co-morbidities), or procedures are not substantiated in the medical record; sequenced correctly; have an incorrect POA indicator; or have been omitted, codes may be deleted, changed, or added. All diagnosis or procedure coding changes potentially resulting in a DRG change are referred to a physician consultant. When it is determined that the diagnoses and procedures are substantiated and sequenced correctly, the information will be entered into the applicable version of the Grouper software for a DRG determination. The CMS-approved DRG software considers each diagnosis and procedure and the combination of all codes and elements to make a determination of the final DRG assignment. When the DRG is reassigned, the payment to the provider is adjusted.

3.6.2Recommendations to Enhance Compliance with Texas Medicaid Fee-for-Service Hospital Claims Submission

The following information highlights an area for physician and hospital providers where collaboration in client care delivery exists but can improve. Texas Medicaid, through its hospital UR activities, has identified this area for both compliance with provider responsibilities and the reduction of the submission of inappropriate inpatient hospital claims.

To enhance compliance with Texas Medicaid fee-for-service hospital claims submission and decrease the submission of inappropriate inpatient hospital claims, providers should adhere to the following:

For admissions on or after September 1, 2006, physicians and hospital staff should become familiar with the Milliman Care Guidelines for medical necessity for inpatient admission.

The hospital may admit clients in observation status if the physician has the reasonable expectation that the client will be discharged within 48 hours. If an inpatient claim was denied per retrospective UR, the hospital may resubmit the claim for the first 48 hours as an outpatient claim if the client was initially admitted in observation status (per physician order) and the stay was more than 48 hours.

When a client is admitted to the hospital as an inpatient and is discharged in less than 48 hours, the hospital may request that the physician change the admission order from inpatient status to outpa­tient observation status. This practice is acceptable when the physician makes changes to the admitting order before the hospital submits the claim for payment.

The correction in admission status, when the above criteria are met avoids errors in claims submission and the potential need for a more lengthy appeal process.

If the physician admitting orders do not accurately reflect the services provided, the hospital inpatient claim may be denied and the inappropriate payment recovered from both the hospital and the admitting physician.

3.6.3Technical Denials (DRG Prospective Payment)

3.6.3.1On-Site Reviews

The following information describes on-site reviews:

If the complete medical record is not made available during the on site review, a preliminary technical denial is issued on site. The hospital is allowed 60 calendar days from the date of the exit conference to provide the complete medical record to HHSC. If the complete medical record is not received by HHSC within this specified time frame, a final technical denial is issued and payment is recouped.

If a complete medical record is made available on site, but a copy is required for further review, and the copy is not received by HHSC within the specified time frame, a preliminary technical denial is issued by certified mail or fax. The hospital has 60 calendar days from the date of receipt of the notice to submit the complete medical record. If the complete medical record is not received by HHSC within this specified time frame, a final technical denial is issued and payment is recouped.

Note:A notarized business record affidavit in the format approved by HHSC is required for paper and electronic copies of requested medical records. A provider failing to provide this documentation must resubmit the requested records with the affidavit.

Refer to:  Subsection 1.6.3, “Retention of Records and Access to Records and Premises” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

3.6.3.2Mail-In Reviews

If the complete medical record is not received by HHSC within the specified time frame, a preliminary technical denial is issued by certified mail or fax. The hospital has 60 calendar days from the date of receipt of the notice to submit the complete medical record. If the complete medical record is not received by HHSC within this specified time frame, a final technical denial is issued and payment is recouped.

Hospital inpatient claim payments that have been recouped because of a technical denial may not be resubmitted on an outpatient claim.

Note:A notarized business record affidavit in the format approved by HHSC is required for paper and electronic copies of requested medical records. A provider who fails to provide this documentation must resubmit the requested records with the affidavit.

Refer to:  Subsection 1.6.3, “Retention of Records and Access to Records and Premises” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

3.6.4Acknowledgment of Penalty Notice

Hospitals must have on file a signed acknowledgment from the physician stating that the physician received the following notice:

Notice to Physicians: Medicaid payment to hospitals is based, in part, on each client’s principal and secondary diagnoses and the major procedures performed on the client, as attested to by the client’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of federal or state funds, may be subject to fine, imprisonment, or civil penalty under applicable federal and state laws.

The acknowledgment of penalty notice must be specific to Texas Medicaid. Medicare penalty notices are not accepted.

3.6.5Sanctions

Compliance with the DRG prospective payment system and aspects of the review as stated above are evaluated quarterly. Identified problems may result in an educational visit or action such as recoupment or referral to HHSC OIG MPI or Sanctions Unit.

3.6.6Utilization Review Appeals

Hospital providers may appeal adverse decisions by HHSC OIG UR Unit to the HHSC UR Medical Appeals Unit. A UR Medical Appeals decision is the final administrative decision of HHSC. Neither HHSC OIG UR Unit nor TMHP are responsible for Medical UR appeals.

Refer to:  Subsection 7.3.3, “Utilization Review Appeals” in “Section 7: Appeals” (Vol. 1, General Information).

3.7Claims Filing and Reimbursement

3.7.1Medicaid Relationship to Medicare

Texas Medicaid may make deductible or coinsurance payments according to current Medicaid payment guidelines on valid, assigned Part A (hospital) and Part B (medical) Medicare claims.

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

Texas Medicaid provides reimbursement for 30 inpatient benefit days per spell of illness. When the 30 days coincide with the first 30 days of the Medicare benefit period and the client is eligible for both Medicare and Medicaid, Texas Medicaid pays the:

Inpatient hospital deductible under Medicare Part A.

Medicare Part A deductible for the first three pints of whole blood or packed red cells.

When the client only has Medicare Part B coverage, the hospital must follow these guidelines:

Submit to Medicare the charges for certain inpatient ancillary services on a Medicare Claim Form 1483 for payment under the client’s Part B coverage. The ancillary charges include the following:

Diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests

X-ray, radium, and radioactive isotope therapy, including materials and services of technicians

Surgical dressings, splints, casts, and other devices used for reduction of fractures and dislocations

Prosthetic devices (other than dental) that replace all or part of an internal body organ or member (including contiguous tissue) or all or part of the function of a permanently inoperative or malfunctioning internal body organ or member including replacement or repairs of such devices (e.g., cardiac pacemakers, breast prostheses, maxillofacial devices, colostomy bags, and prosthetic lenses)

Leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements and adjustments (if required) because of a change in the client’s physical condition

Physical therapy (PT) services

Speech pathology services

Dialysis treatments

Submit to TMHP the remaining Part A charges on a UB-04 CMS-1450 paper claim form (or its electronic equivalent) indicating in Block 80 that the client is eligible for Medicare Part B benefits only. The client’s health insurance claim (HIC) number must appear on the Medicaid claim in Block 80. TMHP must receive these charges within 95 days of the last date of service on the claim.

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

3.7.2Inpatient Claims Information

Medicaid present on admission (POA) reporting is required for all inpatient hospital claims.

All hospital providers are required to submit a POA value for each diagnosis on the claim form, and no hospital is exempt from this POA requirement. Medicare crossover hospital claims must also comply with the Medicaid requirement to include the POA values.

POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient visit, including emergency department, observation, or outpatient surgery, are considered POA.

The following table shows the POA values:

POA Value

Description

Payment

Y

Diagnosis was present at the time of admission

Payment will be made by Medicare when a hospital-acquired condition (HAC) is present

N

Diagnosis was not present at the time of admission

No payment will be made by Medicare when an HAC is present

U

Documentation was insufficient

No payment will be made by Medicaid when an HAC is present

W

Clinically undetermined

Payment will be made by Medicaid when an HAC is present:

(blank)

Exempt from POA reporting

Exempt from POA reporting

Note: Texas Medicaid follows Medicare guidelines for payments referenced in this table.

Note:If a diagnosis code is exempt from POA reporting, providers should leave the POA indicator field blank on the claim.

TMHP will not recalculate the DRG based on POA indicator values for Medicare crossover claims or MCOs.

Depending on the POA indicator value, the DRG may be recalculated, resulting in a lower payment to the hospital facility provider. If the number of days on an authorization is higher than the number of days allowed as a result of a POA DRG recalculation, the lesser of the number of days will be reimbursed.

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

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

A complete list of POA exempt diagnosis codes can be found on the CMS website at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1019OTN.pdf 

Claims for inpatient hospital services must be submitted to TMHP in an approved electronic format or on the 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 attachments. Superbills, or itemized statements, are not accepted as claim supplements.

In Block 44 of the UB-04 CMS-1450, enter the accommodation rate per day. Match the appropriate diagnoses listed in Blocks 67A through 67Q corresponding to each procedure. If a procedure corre­sponds to more than one diagnosis, enter the primary diagnosis. Each service and supply must be itemized on the claim.

Hospitals may submit information only claims to TMHP when one of the following situations exists. Hospitals must use TOB 110 to file these claims:

Inpatient 30-day spell of illness benefit is exhausted.

Payment made by a third party resource or other insurance exceeds the Medicaid allowed amount.

Additional claims information can be found within individual topic areas in this section.

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

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

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

3.7.3Inpatient Reimbursement

3.7.3.1Prospective Payment Methodology

Inpatient hospital stays except state-owned teaching hospitals, and psychiatric facilities (CCP) are reimbursed according to a prospective payment methodology based on diagnosis-related groups (DRGs). The reimbursement method itself does not affect inpatient benefits and limitations. Inpatient admissions must be medically necessary and are subject to Texas Medicaid’s UR requirements.

The DRG reimbursement includes all facility charges (e.g., laboratory, radiology, and pathology). Hospital-based laboratories and laboratory providers who deliver referred services outside the hospital setting must obtain reimbursement for the technical portion from the hospital. The technical portion includes the handling of specimens and he automated or technician-generated reading and reporting of results. The technical services are not billable to Texas Medicaid clients.

Texas Medicaid does not distinguish types of beds or units within the same acute care facility for the same inpatient stay (e.g., psychiatric or rehabilitation). Because all Medicaid inpatient hospitalizations are included in the DRG database that determines the DRG payment schedule, psychiatric and rehabil­itation admissions are not excluded from the DRG payment methodology. To ensure accurate payment, Texas Medicaid requires that only one claim be submitted for each inpatient stay with appropriate diagnosis and procedure code sequencing. The discharge and admission hours (military time) are required on the UB-04 CMS-1450 paper claim form, to be considered for payment.

The number of days of care charged to a beneficiary for inpatient hospital or skilled nursing facility (SNF) care services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for reporting purposes even if the hospital or SNF uses a different definition of day for statistical or other purposes.

A part of a day, including the day of admission and day on which a patient returns from leave of absence, counts as a full day. However, the day of discharge, death, or a day on which a patient begins a leave of absence is not counted as a day unless discharge or death occur on the day of admission.

If admission and discharge or death occur on the same day, the day is considered a day of admission and counts as one inpatient day.

Reimbursement to acute care hospitals for inpatient services is limited to $200,000 per client, per benefit year (November 1 through October 31). Claims may be subject to retrospective review, which may result in recoupment. This limitation does not apply to services related to certain organ transplants or services to THSteps clients when provided through CCP.

Effective September 1, 2013, a hospital that is either located in a county with 60,000 or fewer persons, is a Medicare-designated rural referral center (RRC) or sole community hospital (SCH) that is not located in a metropolitan statistical area (MSA) as defined by the U.S. Office of Management and Budget, or is a Medicare-designated CAH, will be reimbursed the greater of the prospective payment system rate or a cost-reimbursement methodology authorized by DRG using the most recent data.

A new provider is given a reimbursement inpatient interim rate of 50 percent until a cost audit has been performed. A default standard dollar amount (SDA) rate is assigned for newly enrolled providers or newly constructed facilities.

Payment is calculated by multiplying the SDA for the hospital’s payment division indicator times the relative weight associated with the DRG assigned by Grouper.

Hospital reimbursement is made in accordance with the following TAC rules:

1 TAC §355.761 - Reimbursement Methodology for Institutions of Mental Diseases (IMD)

1 TAC §355.8052 - Inpatient Hospital Reimbursement

1 TAC §355.8056 - State-Owned Teaching Hospital Reimbursement Methodology

1 TAC §355.8058 - Inpatient Direct Graduate Medical Education (GME) Reimbursement

1 TAC §355.8060 - Reimbursement Methodology for Freestanding Psychiatric Facilities

1 TAC §355.8061 - Outpatient Hospital Reimbursement

1 TAC §355.8065 - Disproportionate Share Hospital Reimbursement Methodology

1 TAC §355.8066 - Hospital-Specific Limit Methodology

Medicaid providers that are cost-reimbursed are subject to cost reporting, cost reconciliation, and cost settlement processes, as defined in the following TAC rules:

1 TAC §355.8061 (a)(2) - Outpatient Hospital Remibursement

1 TAC §355.8052 (i)(i) - Inpatient Hospital Reimbursement

1 TAC §355.8056 - State-Owned Teaching Hospital Reimbursement Methodology

3.7.3.2Client Transfers

3.7.3.2.1Admission Dates

To ensure correct payor identification, providers that receive transfer patients from another hospital must enter the actual date on which the client was admitted into each facility in Block 12 on the UB-04 CMS-1450.

3.7.3.2.2Continuous Stays – Client Transfers and Readmissions

Client transfers within the same facility are considered one continuous stay and receive only one DRG payment. Texas Medicaid does not recognize specialty units within the same hospital as separate entities; therefore, these transfers must be submitted as one admission under the provider identifier. Readmis­sions to the same facility within 24 hours of a previous acute hospital or facility discharge are also considered one continuous stay and receive only one DRG payment.

Readmissions are considered a continuous stay regardless of the original or readmission diagnosis. Admissions submitted inappropriately are identified and denied during the UR process and may result in intensified review.

When more than one hospital provides care for the same client, the hospital providing the most signif­icant amount of care receives consideration for a full DRG payment. The other hospitals are paid a per diem rate based on the lesser of either the mean length of stay for the DRG or the eligible days in the facility. The DRG modifier, PT, on the R&S Report indicated per diem pricing related to a client transfer. Services must be medically necessary and are subject to Texas Medicaid’s UR requirements.

HHSC performs a postpayment review to determine if the hospital providing the most significant amount of care received the full DRG. If the review reveals that the hospital providing the most signif­icant amount of care did not receive the full DRG, an adjustment is initiated.

To ensure correct payor identification, providers that receive transfer patients from another hospital must enter the actual date that the client was admitted into each facility in Block 12 on the UB-04 CMS-1450. Inpatient authorization requirements are based on the requirements that are specified by the program in which the client is enrolled on the date of the original admission. Providers must adhere to the authorization requirements for claims to be considered for reimbursement. Providers are reimbursed at the rate in effect on the date of discharge.

3.7.3.3Observation Status to Inpatient Admission

The dates of the inpatient admission must be reported as follows:

Date of inpatient admission: The date of admission must reflect the date that the client was admitted to the hospital as an inpatient.

Dates of service: The from date of service (FDOS) must reflect the date that the client first presented at the hospital for services including, but not limited to, emergency room (ER), observation, labor and delivery, or inpatient services.

If services that are rendered before the inpatient admission must be submitted on the inpatient claim, the number of preadmission days that are related to the inpatient admission cannot exceed the days of allowed for the rendered services:

Services

Days Allowed

Units

Emergency room (ER) services

One day (24 hours) before the inpatient admission

Submitted per day

Observation services

Up to two days (48 hours) before the inpatient admission

Submitted in hours

Labor and Delivery

Up to three days before the inpatient admission

Submitted per day

Diagnosis-Related Group (DRG) hospital claims allow for a total of three days of pre-admit services. Non-DRG hospital claims are allowed one day of pre-admit services, and a second day if additional observation hours occurred.

Note:If the client is admitted as an inpatient more than 24 hours after presenting in the ER without being placed in observation status or more than 48 hours after being placed in observation status, the ER and observation services may be reimbursed separately as outpatient services and must not be included on the inpatient claim.

3.7.3.4Outliers

TMHP makes outlier payment adjustments to DRG hospitals for admissions that meet the criteria for exceptionally high costs or exceptionally long lengths of stay for clients who are 20 years of age and younger as of the date of the inpatient admission. If a client’s admission qualifies for both a day and a cost outlier, the outlier resulting in the higher payment to the hospital is paid.

Providers can view their day and cost outlier payment information for inpatient hospital claims on the Electronic Remittance and Status (ER&S) Report. The R&S Report reflects the outlier reimbursement payment and defines the type of outlier paid. To view the day and cost outlier payment information, providers, facilities, and third party vendors may need to update their 835 electronic file format. For information about how to update the 835 electronic file format, refer to the revised electronic data inter­change (EDI) companion guide (ANSI ASC X12N 835 Healthcare Claim Payment/Advice-Acute Care Companion Guide) on the TMHP website at www.tmhp.com.

3.7.3.4.1Day Outliers

The following criteria must be met to qualify for a day outlier payment:

Inpatient days must exceed the DRG day threshold for the specific DRG.

Additional payment is based on inpatient days that exceed the DRG day threshold multiplied by 60 percent of the per diem amount of a full DRG payment.

The per diem amount is established by dividing the full DRG payment amount by the arithmetic mean length of stay for the DRG.

In compliance with 1 TAC §355.8052, all DRG inpatient hospital day outlier payments must not exceed the allowed cost for the service. All hospitals except in-state children’s hospitals, both day and cost outlier payments have been reduced by 10 percent.

TMHP calculates payments as follows:

1)Calculate the day outlier.

Calculate the allowed cost for the service (i.e., the cap amount) by taking the difference between the Tax Equity and Fiscal Responsibility Act (TEFRA) and DRG-payable amounts.

Take the lesser of the day outlier or the cap amount.

Reduce the day outlier by 10 percent for all hospitals except in-state children’s hospitals.

2)Calculate the cost outlier:

Reduce the cost outlier by 10 percent for all hospitals except in-state children’s hospitals.

Reimbursement is made for day or cost outliers on claims that qualify. If a client’s admission qualifies for both a day and a cost outlier, the outlier resulting in the higher payment to the hospital is paid.

Example

Calculations

Example amount

Day Outlier Calculation:

([SDA x DRG relative weight / Mean Length of Stay] x Outlier Days) x 0.6 = day outlier amount

$500.00

Apply Cap and Reduce by 10 Percent

Calculate the allowed cost for the service (i.e., the cap amount) by taking the difference between the TEFRA and DRG payable amounts (in this example, $600.00).

Take the lesser of the day outlier or the cap amount (in this example it would be the day outlier of $500.00).

Reduce by 10 percent.

$450.00

Calculation1: Cost Threshold

11.14 x Universal Mean ($6,505.52) = <amount A>

11.14 x SDA = <amount B>

1.5 x DRG Relative Weight x SDA = <amount C>

 

Cost threshold = The greater of <amount C> compared with (the lesser of <amount A> and <amount B>)

$550.00

Calculation2: Cost Outlier

Allowed amount x reimbursement rate = TEFRA amount

TEFRA amount - cost threshold x 0.6 percent = cost outlier amount

Reduce by 10 percent.

$495.00

The calculations in this example would result in one of the following payments:

If the claim qualifies for the day outlier payment only, payment will be made up to $450.00.

If the claim qualifies for the cost outlier payment only, payment will be made up to $495.00.

If the claim qualifies for both the day outlier and cost outlier payment, the payment will be made up to $495.00, which is the greater of the day outlier or the cost outlier payment.

3.7.3.5Children’s Hospitals

Children’s hospitals are reimbursed using the prospective payment methodology based on APR-DRG methodology.

With the exception of designated children’s hospitals, hospitals that are reimbursed by APR-DRG payment methodology receive one SDA rate.

Designated children’s hospitals receive two SDA rates:

One rate for obstetric delivery services rendered to clients who are 18 years of age and older.

One rate for all other services rendered to clients who are 18 years of age and older and all services rendered to clients who are 17 years of age and younger, including obstetric delivery services.

3.7.3.6Potentially Preventable Complications (PPC) and Potentially Preventable
Readmissions (PPR)

Potentially Preventable Complications (PPCs)

By definition, potentially preventable complications (PPCs) are harmful events or negative outcomes that develop after hospital admission and may result from processes of care and treatment rather than from the natural progression of the underlying illness. A PPC is an inpatient hospital complication that was potentially preventable based on criteria such as hospital characteristics, reason for admission, procedures, and the interrelationships between underlying medical conditions.

S.B. 7, Chapter 526, the 82nd Texas Legislature, 2011, establishes the authority of HHSC to identify PPCs in the Medicaid population. HHSC must confidentially report the results to each hospital that serves Texas Medicaid clients, and each of those hospitals must distribute the information to its care providers.

HHSC also produces a public version of the report, which does not specifically identify any of the hospitals. A statewide average PPC rate is calculated for all hospitals within Texas. Each hospital has an individual rate. Hospitals are able to compare their rate of PPC to the statewide average.

The PPC analysis is performed in accordance with TAC, §354.1446 Potentially Preventable Complications.

Potentially Preventable Re-admission (PPRs)

By definition, potentially preventable re-admissions (PPRs) are return hospitalizations of a person within a period specified by HHSC that results from deficiencies in the care or treatment provided to the person during a previous hospital stay or from deficiencies in post-hospital discharge follow-up.

Texas Medicaid uses a 15 day re-admission interval.

Section 531.913, House Bill (H.B.) 1218, 81st Legislature, 2009, requires the HHSC to identify PPRs in the Medicaid population. HHSC must confidentially report the results to each hospital that serves Texas Medicaid clients, and each of those hospitals must distribute the information to its care providers.

HHSC delivers an annual, confidential report of the results to each hospital that is enrolled in Texas Medicaid, and each of those hospitals must distribute the information to their care providers. HHSC also produces a public version of the report, which does not specifically identify any of the hospitals. Patients are never identified in the reports.

PPR Analysis

The PPR analysis is performed in accordance with TAC, §354.1446 Potentially Preventable Readmissions.

3.7.3.7State-owned Teaching Hospitals

Inpatient hospital stays in designated state-owned teaching hospitals are reimbursed according to the payment methodology.

State-owned teaching hospitals are defined specifically in 1 TAC §355.8052 as the following hospitals: University of Texas Medical Branch (UTMB); University of Texas Health Center Tyler; and M.D. Anderson Hospital.

3.7.3.8Payment Window Reimbursement Guidelines

3.7.3.8.1Guidelines for Services Preceding an Inpatient Admission

The following payment window reimbursement guidelines apply to services that are rendered by the hospital or an entity that is wholly owned or operated by the hospital. The three-day (or one-day) payment window does not apply if:

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.

Texas Medicaid inpatient hospital providers must submit, as part of the client’s inpatient hospital claim, all related professional and outpatient services that were rendered on the date of the client’s inpatient admission or one of the following dates immediately before admission:

Within three calendar days before the client’s inpatient admission for hospitals that receive DRG reimbursement, with the exception of children’s hospitals.

Within one calendar day before the client’s inpatient admission for hospitals that receive reimbursement other than DRG.

Within one calendar day before the client’s inpatient admission for children’s hospitals.

Professional and outpatient services that must be submitted as part of the inpatient hospital claim include the following services if they are rendered by the hospital or an entity that is wholly owned or operated by the hospital:

Diagnostic services. Diagnostic services include outpatient laboratory and radiology services that are related to the inpatient admission and submitted by physician and outpatient hospital providers. Affected services will include the total and technical components. The professional interpretation component will not be included in the payment windows identified above.

Non-diagnostic services. Non-diagnostic services include surgeries and other non-diagnostic procedures and services that are related to the inpatient admission and submitted by physician, outpatient hospital, or other providers.

Important:Related professional and outpatient services that were rendered within the specified time frames must be submitted on the inpatient hospital claim and not on an outpatient hospital claim. An outpatient hospital claim for these services will be denied as part of the payment for the inpatient hospital stay.

3.7.3.8.2Exceptions

The following services are excluded from the payment window and may be submitted and reimbursed separately from the inpatient admission:

Services rendered by federally qualified health center (FQHC) providers

Services rendered by rural health clinic (RHC) providers

Professional services that are rendered in the inpatient hospital setting (place of service 3)

Non-emergency and emergency ambulance services

The outpatient emergency and maintenance renal dialysis procedure codes in the tables below are also exceptions to the one-day payment window reimbursement guidelines:

Procedure Codes

G0257

ESRD Physician Services

90951

90952

90953

90954

90955

90956

90957

90958

90959

90960

90961

90962

90963

90964

90965

90966

90967

90968

90969

90970

Physician Services for Hemodialysis or Other Dialysis Procedures

71010

71020

78300

78305

78306

80069

81050

82040

82310

82374

82435

82565

83615

83735

84075

84100

84132

84155

84295

84450

84520

85004

85007

85008

85014

85018

85025

85027

85041

85345

85347

85610

87340

90935

90937

90945

90947

93005

Equipment and Supplies

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

3.7.3.8.3Professional and Outpatient Claims for Services Related to the Inpatient Admission

Professional and outpatient services that are rendered on the date of admission, or within one of the one-day or three-day timeframes indicated above by the hospital or an entity that is wholly owned or operated by the hospital, are considered part of the inpatient stay. Professional and outpatient claims submitted for services that are related to the inpatient admission will be denied or recouped if they are submitted with the specified payment window.

When modifier PD is appended to a professional or outpatient service, the modifier indicates that the service is related to the inpatient admission. The total and technical components for professional and outpatient services that are related to the inpatient admission will be denied when submitted with modifier PD.

Note:The professional interpretation component for professional and outpatient services that are related to the inpatient stay may be reimbursed separately even if accompanied by PD modifier.

3.7.3.8.4Professional and Outpatient Claims for Services Unrelated to the Inpatient Admission

Professional and outpatient services that are rendered within the specified timeframe by the hospital or an entity that is wholly owned or operated by the hospital may be reimbursed if they are identified as unrelated to the inpatient admission as follows:

Professional and outpatient claims for diagnostic services that are unrelated to the inpatient admission must be submitted with modifier U4, which indicates the service is unrelated to the inpatient admission.

Professional claims for non-diagnostic services that are unrelated to the inpatient admission will be identified by comparing the referenced diagnosis code that is on the professional claim to the principal inpatient diagnosis. Professional services must be submitted with modifier U4 if the services are unrelated and up to six digits of the referenced professional diagnosis code match the principle inpatient diagnosis code.

Outpatient claims for non-diagnostic services that are unrelated to the inpatient admission will be identified by comparing the referenced diagnosis code that is on the outpatient claim to the principal inpatient diagnosis. The outpatient services must be submitted with condition code 51 if the services are unrelated and up to six digits of the referenced outpatient diagnosis code match the principle inpatient diagnosis code.

Unrelated services that are denied as part of the inpatient admission can be appealed with modifier U4 or condition code 51, which indicates that the service is unrelated to the inpatient admission.

Note:Claims that are submitted with modifier U4 or condition code 51 will be subject to retro­spective review and may be recouped if there is not sufficient documentation to indicate the service was unrelated to the inpatient admission.

These benefit changes do not impact services rendered by providers that are not wholly owned or operated by the hospital.

3.7.3.9Potentially Preventable Readmissions (PPR)

H.B. 1218, 81st Legislature, Regular Session 2009, requires that HHSC identify potentially preventable readmissions (PPRs) in the Medicaid population and report results confidentially to each hospital. The law also requires each hospital to distribute the information to its care providers.

Refer to:  TMHP Hospital Initiatives web page at www.tmhp.com/Pages/Medicaid/Hospi­tal_PPR.aspx for the new state fiscal year confidential Hospital Specific PPR Report, which includes frequently asked questions (FAQs) that help providers interpret their confidential reports.

3.7.4Provider Cost and Reporting

The method of determining reasonable cost is similar to that used by Title XVIII (Medicare). Hospitals must include inpatient and outpatient costs in the cost reports submitted annually. The provider must prepare one copy of the applicable CMS Cost Report Form along with the required PCCM supplemental worksheets. The PCCM supplemental worksheets include the Inpatient PCCM D-4 worksheet, available from CMS, and the Outpatient PCCM D, Part V worksheet. A sample of the Outpatient PCCM D, Part V is available on the TMHP website at www.tmhp.com.

Refer to:  Subsection 2.2.2, “Cost Reimbursement” in “Section 2: Texas Medicaid Fee-for-Service Reimbursement” (Vol. 1, General Information).

If a change of ownership or provider termination occurs, the cost report is due within five months after the date of the change in ownership or termination. Any request for an extension of time to file must be made on or before the cost report due date and sent to TMHP Medicaid Audit at the address indicated under “Written Communication With TMHP” in the “Appendix A: State, Federal, and TMHP Contact Information” (Vol. 1, General Information). For questions or assistance, call TMHP Medicaid Audit at 1-512-514-3648.

Annual cost reports must be filed as follows:

Submit one copy of the cost report to TMHP Medicaid Audit within five months of the end of the hospital’s fiscal year along with any amount due to Texas Medicaid.

TMHP Medicaid Audit performs a desk review of the cost report and makes a tentative settlement with the hospital. A tentative settlement letter requests payment for any balance due to Texas Medicaid or instructs TMHP to pay the amount due to the provider. Interim payment rates are changed at this time based on the cost report.

Field audits are conducted when necessary.

Medicaid final settlement is made after a copy of all the following information is received from the provider or the Medicare intermediary. The provider must send TMHP a copy of one of the following:

Audited or settled without audit Medicare Cost Report

Medicare Notice of Amount of Program Reimbursement

Medicare Audit Adjustment Report, if applicable

Medicaid hospitals may request copies of their claim summaries for their cost reporting fiscal year. The summaries for tentative settlements include three additional months of claim payments for the fiscal year. The summaries for final settlements include ten months of claim payments for the fiscal year. TMHP Medicaid Audit uses this data to determine the tentative and final settlements and interim rates.

The Medicaid claim summary data are only generated once each month, and the logs are received by the 15th of the following month. Requests for tentative settlement logs are submitted within 30 days after the fiscal year-end. Final settlement log requests are submitted within nine months after the fiscal year-end.

The Medicaid logs can be requested through the provider’s administrator account on the TMHP website at www.tmhp.com. Medicaid logs can also be requested by calling 1-512-506-6117 or by sending a written request to the following address:

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

Allow 45 days for receipt of these logs.

3.7.5Third Party Liability

Refer to:  “Section 8: Third Party Liability (TPL)” (Vol. 1, General Information).

Other Insurance Form on the TMHP website at www.tmhp.com.

Tort Response Form on the TMHP website at www.tmhp.com.

4 Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility)

This section contains benefit, limitation, authorization, and claims filing information for outpatient hospital facility emergency, observation, and other services.

Refer to:  “Section 6: Claims Filing” (Vol. 1, General Information) for more comprehensive infor­mation about claims filing and appeals.

“Section 7: Appeals” (Vol. 1, General Information) for more comprehensive information about claims filing and appeals.

Hospital providers are encouraged to review the other handbooks for applicable information, prior authorization requirements, and for specific requirements for special programs.

4.1General Information

Outpatient diagnostic, therapeutic, and surgical services that are rendered in an acute care hospital setting are services that are provided to clients by or under the direction of a physician.

Outpatient hospital services include those services that are rendered:

In the emergency room (ER)

As day surgery

In the observation room

By ancillary departments such as the laboratory, radiology, physical or occupational therapy, cardiac rehabilitation, hyperbaric chamber, infusion services, and other areas able to provide services in the outpatient setting.

4.1.1Drugs and Supplies

4.1.1.1Self-Administered Drugs

Self-administered drugs are defined as drugs that the client administers themselves at home and may include, but are not limited to, prescription drugs, vitamins, and supplements.

These drugs that are provided by the hospital during an outpatient hospital visit are included in the hospital reimbursement and are not reimbursed separately. The client cannot be billed for self-admin­istered drugs that are provided by the hospital during an outpatient hospital stay.

4.1.1.2Take-Home Drugs and Supplies

Benefits do not include drugs and biologicals provided by the hospital and taken home by the client. Supplies provided by a hospital for use in physicians’ offices are not reimbursable.

Take-home drugs and supplies are a benefit for services rendered to clients in the outpatient setting when supplied by prescription through the VDP.

4.1.2Outpatient Services Provided Without Charge

Texas Medicaid pays the clinic registration fee in lieu of other benefits when a hospital provides outpa­tient services without charge, and if the registration fee is less than the allowed Medicaid payment.

Refer to:  TAC Rule §354.1073 for information about authorized outpatient hospital services.

Subsection 1.11, “Texas Medicaid Limitations and Exclusions” in “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information) in Section 1, “Provider Enrollment and Responsibilities” (Vol. 1, General Information) for more information about noncovered items or services.

4.1.3Payment 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.

Refer to:  Subsection 3.7.3.8, “Payment Window Reimbursement Guidelines” in this handbook for additional information about the payment window reimbursement guidelines.

4.2Services, Benefits, Limitations, and Prior Authorization

4.2.1Prior Authorization Requirements

The hospital is responsible for requesting prior authorization for the non-emergency transport to the client’s home or to a nursing home after a non-scheduled outpatient visit.

Refer to:  Non-emergency Ambulance Prior Authorization Request on the TMHP website at www.tmhp.com.

4.2.2Emergency Department Services

An emergency department is defined as an organized hospital-based facility for the provision of unscheduled episodic services to clients who present for immediate medical attention. The facility must be available 24 hours a day, 7 days a week.

Hospital-based emergency departments are reimbursed for services based on a reasonable cost, based on the hospital’s most recent tentative Medicaid cost report settlement. The reasonable cost is reduced by a percentage determined by the state.

All claims that are submitted by outpatient hospital providers must include a procedure code with each revenue code for services that are rendered to Texas Medicaid clients. This procedure code must be listed on the same claim detail line as the emergency department revenue code.

The procedure code billed may include, but is not limited to, E/M, surgical or other procedure, or any other service rendered to the client in the emergency room. The procedure code must accurately reflect the services rendered in the hospital’s emergency department.

Emergency department reimbursement may include room changes and ancillary changes. Emergency department room charges may be submitted using the following revenue codes:

Revenue Code   

Description

450

Emergency room

451

Emergency room-EMTALA emergency medical screening

456

Emergency room, urgent care

459

Emergency room, other

Emergency department ancillary services include, but are not limited to, the following:

Laboratory services

Radiology services

Respiratory therapy services

Diagnostic studies (including, but not limited to, ECGs, computed tomography (CT) scans, and supplies)

The administration of an injection may be reimbursed to the provider who administers the injection. The administration of the injection will not be reimbursed to outpatient hospital providers. An injection or infusion administered by a nurse is included in the emergency room charge and is not reimbursed separately to the outpatient facility.

Ancillary services must be submitted on the UB-04 CMS-1450 paper claim form using the appropriate procedure codes or revenue codes for rendered services.

If a client visits the emergency room more than once in one day, the times must be given for each visit.

If the client ultimately is admitted as an inpatient within 48 hours of treatment in the ER or clinic, the ER or clinic charges must be submitted on the inpatient hospital claim form as an ancillary charge. The date of inpatient admission is the date the client initially was seen in the ER or clinic.

According to the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, if any individual presents at the hospital’s emergency department requesting an examination or treatment, the hospital must provide an appropriate medical screening examination and stabilization services within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether an emergency medical condition exists.

EMTALA medical screening code (451) may be considered for reimbursement when submitted as a stand-alone service and provided by a qualified medical professional as designated by the facility. Ancillary, professional, or facility services will not be considered for separate reimbursement. Services beyond screening (451) can be submitted with the appropriate corresponding emergency services code (450).

Medicaid claims administrators are prohibited from requiring prior authorization or primary care provider notification for emergency services including those needed to evaluate or stabilize an emergency medical condition or emergency behavioral health condition.

Texas Medicaid provides that certain undocumented aliens and legalized aliens who require treatment of an emergency medical condition or emergency behavioral health condition are eligible to receive that treatment. After the emergency condition requiring care is stabilized and is no longer an emergency, the coverage ends. If the alien continues to receive ongoing treatment after the emergency ceases, the ongoing treatment is not a benefit.

Texas Medicaid provides for medical services for eligible clients while out-of-state. The attending physician or other provider must document that the client was treated for an emergency condition. Out-of-state emergency services are also a benefit when the client’s health would be in danger if he or she were required to travel back to Texas.

Emergency department services are subject to retrospective review.

In instances of sudden illness or injury, the client may receive treatment in the ER and be discharged, placed on observation status, or admitted as an inpatient.

4.2.2.1Emergency Department Payment Reductions

Nonemergent and nonurgent evaluation and management (E/M) services rendered in the emergency room may be reimbursed at 125 percent of the adult, physician office visit fee for procedure code 99202. Reimbursement is based on the E/M procedure code submitted on the same line item as the emergency room revenue code.

Imaging services rendered by outpatient hospital providers are reimbursed at the flat fee that is based on the procedure code submitted on the same line item as the imaging revenue code.

Note:Evaluation and management services that are rendered in the emergency room for critically ill or critically injured Texas Medicaid clients of any age, are not subject to reduction in payment.

Exception:Rural hospitals, nonemergent and nonurgent E/M services rendered in the emergency room may be reimbursed at 65 percent of the allowed rate.

4.2.3Day Surgery

Inpatients may occasionally require a surgery that has been designated as an outpatient procedure. The physician must document the need for this surgery as an inpatient procedure before the procedure is performed. These claims are subject to retrospective review.

These procedures are for clients who are scheduled for a day surgery procedure and are not inpatient at the time the day surgery is performed.

4.2.3.1Inpatient Admissions for Day Surgeries

If a client is admitted for a day surgery procedure—whether scheduled or emergency—one of the following classifications may be considered an inpatient procedure.

ASA Classification of Physical Status of III (P3), IV (P4), or V (P5)

Classification of Heart Disease IV

The day surgery services must be submitted on an inpatient claim (TOB 111) using the hospital’s provider identifier. The reason for the surgery (principal diagnosis), any additional substantiated condi­tions, and the procedure must be included on one inpatient claim.

Refer to:  The Texas Medicaid Hospital Screening Criteria at www.hhs.state.tx.us/OIG/screen/SC_TOC.shtml#asa, for a description of the ASA classes of physical status.

The descriptions for ASA classes of physical status are as follows:

Class I. A normal healthy patient, without organic, physiological, or psychiatric disturbance.

Example:Healthy patient with good exercise tolerance.

Class II. A patient with mild systemic disease, controlled medical conditions without significant systemic effects.

Example:Controlled hypertension or diabetes mellitus without system effects, cigarette smoking without evidence of chronic obstructive pulmonary disease (COPD), anemia, mild obesity, age less than 1 or greater than 70 years, or pregnancy.

Class III. A patient exhibiting severe systemic disturbance that may or may not be associated with the surgical complaint and that seriously interferes with the patient’s activities.

Example:Severely limiting organic heart disease, severe diabetes with vascular complications; moderate to severe degrees of pulmonary insufficiency; angina pectoris or healed myocardial infarction.

Class IV. A patient exhibiting extreme systemic disturbance that may or may not be associated with the surgical complaint, that interferes with the patient’s regular activities, and that has already become life-threatening.

Example:Organic heart disease with marked signs of cardiac insufficiency present (for example, cardiac decompensation); persistent anginal syndrome, or active myocarditis; advanced degrees of pulmonary, hepatic, renal, or endocrine insufficiency present.

Class V. The rare person who is moribund (in a dying state) before operation, whose pre-operative condition is such that he or she is expected to die within 24 hours even if not subjected to the additional strain of operation.

Example:Burst abdominal aneurysm with profound shock; major cerebral trauma with rapidly increasing intracranial pressure; massive embolus.

The Classification of Heart Disease consists of four classes:

Class I. No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

Class II. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

Class III. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

Class IV. Unable to carry on any physical activity without discomfort. Symptoms of cardiac insuffi­ciency, or of the anginal syndrome, may be present even at rest. If any physical activity is undertaken, discomfort occurs.

4.2.3.2Complications Following Elective or Scheduled Day Surgeries

If a condition of the scheduled day surgery requires additional care beyond the recovery period, the client may be placed in outpatient observation (stay less than 48 hours). The observation period must be submitted on an outpatient claim (TOB 131) using the hospital’s provider identifier. If the client requires inpatient admission following the observation stay, the admission date for the inpatient claim is the date the client was placed in observation. All charges for services provided from the time of observation placement (excluding the surgical procedure) must be included on the inpatient claim (TOB 111) using the hospital’s provider identifier. The principal diagnosis to be used on the inpatient claim is the compli­cation of the surgery that necessitated the extended stay. The day surgery procedure must still be submitted as an outpatient procedure under the HASC provider identifier.

4.2.3.3Inpatient Admissions After Day Surgery

If a complication occurs for which the client requires inpatient admission immediately following the day surgery (no observation period), the day surgery must be submitted as an outpatient procedure (TOB 131), using the appropriate hospital or HASC provider identifier. The inpatient admission is to be submitted as an inpatient claim (TOB 111), using the hospital’s provider identifier. The principal diagnosis to be used on the inpatient claim is the complication of the surgery that necessitated the extended stay. The day surgery procedure must not be included on the inpatient claim. The inpatient admission must be medically necessary and is subject to retrospective review.

4.2.3.4Emergency or Unscheduled Day Surgeries

These procedures are for clients who require an unscheduled (emergency) day surgery procedure and are not inpatient at the time the day surgery is performed.

If a client is first treated in the ER and then requires emergency surgery as an outpatient, claims for emergency, unscheduled outpatient surgical procedures must be filed itemizing each service, such as room charge, laboratory, radiology, anesthesia, and supplies. Providers must submit claims for unscheduled day surgery procedures and emergency services as outpatient procedures using the hospital provider identifier. If a condition of the unscheduled day surgery requires additional care beyond the recovery period, the client may be placed on outpatient observation status. The observation period must be submitted on the same outpatient claim.

Providers must submit claims for the unscheduled day surgery procedures and emergency services as outpatient procedures (TOB 131) using the hospital’s provider identifier. If a condition of the unscheduled day surgery requires additional care beyond the recovery period, the client may be placed on outpatient observation status (stay less than 48 hours). The observation period must be submitted on the same outpatient claim (TOB 131) using the hospital’s provider identifier.

4.2.3.5Complications Following Emergency or Unscheduled Day Surgery

If the client requires inpatient admission following the observation stay, the admission date for the inpatient claim is the date the client was placed in observation. All charges for services provided from the time of observation status (excluding surgical procedures and emergency services) must be included on the inpatient claim (TOB 111) using the hospital’s provider identifier. The principal diagnosis to be used on the inpatient claim is the complication of the surgery that necessitated the extended stay. The day surgery and emergency services must not be included on the inpatient claim since they are to be submitted using TOB 131 as outpatient procedures under the hospital’s provider identifier.

4.2.3.6Incomplete Day Surgeries

Facilities must use either one of the following diagnosis codes or one of the following modifiers to indicate that a surgical procedure (type of service F) was not completed:

Diagnosis Codes

Z5309

Procedure and treatment not carried out because of other contraindication

Z5329

Procedure and treatment not carried out because of patient’s decision for other reasons

Z538

Procedure and treatment not carried out for other reasons

Modifier

Description

73

Discontinued outpatient procedure prior to anesthesia administration

74

Discontinued outpatient procedure after anesthesia administration

Providers must submit the following documentation with the claim:

The operative report

The anesthesia report

The reason that the operation was not complete

Reimbursement to HASC facilities for canceled or incomplete surgeries because of patient complica­tions, is made according to the following criteria, depending on the extent to which the anesthesia or surgery proceeded:

Reimburse at 0 percent of HASC group payment schedule for a procedure that is terminated for nonmedical or medical reasons before the facility has expended substantial resources.

Reimburse at 33 percent of HASC group payment schedule up to the administration of anesthesia.

Reimburse at 67 percent of HASC group payment schedule after the administration of anesthesia but before incision.

Reimburse at 100 percent of HASC group payment schedule after incision.

Surgeries canceled because of incomplete pre-operative procedures are not reimbursed.

4.2.4Outpatient Observation Room Services

Observation care is defined by the CMS as “a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether clients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.”

Outpatient observation services are usually ordered for clients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision about their admission or discharge. The decision whether to discharge a client from the hospital following resolution of the reason for the observation care or to admit the client as an inpatient can be made in less than 48 hours, usually in less than 24 hours.

Outpatient observation services require the use of a hospital bed and periodic monitoring by the hospital’s nursing or other ancillary staff to evaluate the client’s condition and to determine the need for an inpatient admission. Outpatient observation services can be provided anywhere in the hospital. The level of care, not the physical location of the bed, dictates the observation status.

Outpatient observation services (revenue codes 760, 761, 762, and 769) are a benefit only when medically necessary and when provided under a practitioner’s order or under the order of another person who is authorized by state licensure law and hospital bylaws to admit clients to the hospital and to order outpa­tient services.

Outpatient observation services are considered medically necessary if the following conditions are met (this list is not all-inclusive):

The client is clinically unstable for discharge and one of the following additional conditions apply:

Laboratory, radiology, or other testing is necessary to assess the client’s need for an inpatient admission.

The treatment plan is not established or, based on the client’s condition, is anticipated to be completed within a period not to exceed 48 hours.

The client had a significant adverse response to therapeutic services, invasive diagnostic testing, or outpatient surgery and requires short-term monitoring or evaluation.

The medical necessity for inpatient treatment is unclear, that is:

The client’s medical condition requires careful monitoring and evaluation, or treatment to confirm or refute a diagnosis in order to determine whether an inpatient admission is necessary

There is a delayed or slow progression of the client’s signs and symptoms that makes diagnosis difficult and the monitoring or treatment does not meet the criteria for an inpatient level of care.

The client is undergoing treatment for a diagnosed condition, and continued monitoring of clinical response to therapy may prevent an inpatient admission.

The admitting practitioner anticipates that the client will require observation care for a minimum of eight hours.

Medically necessary services that do not meet the definition of observation care should be submitted separately or included as part of the emergency department or clinic visit, and are not reimbursed as observation care.

Outpatient observation services are not a substitute for a medically appropriate inpatient admission. If a client meets the medical necessity criteria for an inpatient admission and an inpatient admission is ordered by the practitioner, an inpatient admission is a benefit regardless of the length of stay. Claims for observation services may be denied in their entirety if the services should have initially been inpatient admissions or if a reason for an inpatient admission developed, but the observation stay was not converted to inpatient.

The determination of an inpatient or outpatient status for any given client is specifically reserved to the admitting practitioner. The decision must be based on the practitioner’s expectation of the care that the client will require.

4.2.4.1Direct Outpatient Observation Admission

A client may be directly admitted to outpatient observation from the evaluating practitioner’s office without being seen in the emergency room by a hospital-based practitioner. The practitioner’s order should clearly specify that the practitioner wants the client to be admitted to outpatient observation status. An order for “direct admission” will be considered an inpatient admission unless otherwise specified by the practitioner’s orders.

Brief observation periods following an office visit or at the direction of an off-site practitioner that involve a simple procedure (e.g., a breathing treatment) would be more appropriately coded as a treatment room visit.

4.2.4.2Observation Following Emergency Room

A client may be admitted to outpatient observation through the emergency room if the client presents to the facility with an unstable medical condition and the evaluating practitioner determines that outpa­tient observation is medically necessary to determine a definitive treatment plan. An unstable medical condition is defined as one of the following:

A variance in laboratory values from what is considered the generally accepted, safe values for the individual client.

Clinical signs and symptoms that are above or below those of normal range and that require extended monitoring and further evaluation.

Changes in the client’s medical condition are anticipated, and further evaluation is necessary.

If a client is admitted to observation status from the emergency room, the hospital is reimbursed only for the observation room charges. The emergency room charges are not reimbursed separately, but must be submitted on a separate detail on the same claim as the observation room charges.

Brief observation periods following an emergency room evaluation will not be reimbursed if the service would normally have been provided within the time frames and facilities of an emergency room visit.

4.2.4.3Observation Following Outpatient Day Surgery

If a medical condition or complication of a scheduled day surgery requires additional care beyond the routine recovery period, the client may be placed in outpatient observation. The observation period should be submitted as an outpatient claim.

Reimbursement for outpatient observation after a scheduled day surgery is limited to situations in which the client exhibits an unusual reaction to the surgical procedure and requires monitoring or treatment beyond what is normally provided in the immediate post-operative period. Examples include, but are not limited to:

Difficulty in awakening from anesthesia.

A drug reaction.

Other post-surgical complications.

4.2.4.4Observation Following Outpatient Diagnostic Testing or Therapeutic Services

A client may be admitted to outpatient observation if the client develops a significant adverse reaction to a scheduled outpatient diagnostic test or to a therapeutic service, such as chemotherapy, that requires further monitoring. Observation services begin when the reaction occurred and end when the practi­tioner determines that the client is stable for discharge, or that an inpatient admission is appropriate.

4.2.4.5Documentation Requirements for Outpatient Observation

Documentation that supports the medical necessity of the outpatient observation services must be maintained by the facility in the client’s medical record. Documentation must include:

The order of the ordering practitioner for admission to observation care, which must be dated and timed.

The practitioner’s admission and progress notes, which must be dated and timed, confirm the need for observation care, and outline the client’s condition, treatment, and response to treatment.

Nurse’s notes, which must be dated and timed, reflect the time at which the client was admitted to the observation bed, and the reason for the observation stay.

All supporting diagnostic and ancillary testing reports, including orders for the testing or any pread­mission testing.

Procedure notes and operative notes that address any complication that would support admission to observation status and must be dated and timed.

Anesthesia and recovery room/post anesthesia care unit notes from the practitioner and the nurse, which must be dated and timed and detail orders and any complications that require admission to observation status.

Documentation related to an outpatient clinic visit or critical care service that was provided on the same date of service as the observation service. The documentation must address any need for observation services and be dated and timed.

All of the client education that was provided during the observation stay.

The order for discharge from observation care, which must be signed, dated, and timed.

The discharge notes, including nurse’s notes that reflect the date and time at which the client was discharged from observation.

The client must be in the care of a practitioner during the period of observation, as documented in the medical record by admission, discharge, and other appropriate progress notes that are dated, timed, written, and signed by the practitioner.

Claims submitted for outpatient procedures in which the original intention was to keep the client for an extended period of time, such as overnight or for a 48-hour period, will be denied unless significant medical necessity is documented.

Retrospective review may be performed to ensure that the documentation supports the medical necessity of the outpatient observation services. Medical records will be evaluated to determine whether the practitioner’s order (practitioner intent) and the services that were actually provided were consistent.

The medical records must clearly support the medical necessity of the outpatient observation services and must include a timed order for observation services that will support the number of hours that the client was under observation care and the hours that were submitted for payment.

4.2.4.6Reporting Hours of Observation

Providers must submit the number of observation hours the client was under observation care.

Observation time begins at the clock time documented in the client’s medical record. This time should coincide with the time that the client is placed in a bed for the purpose of initiating observation care in accordance with the practitioner’s order.

Observation time ends when all medically necessary services related to observation care are completed. The end time of observation services may coincide with the time the client is actually discharged from the hospital or is admitted as an inpatient.

Hospitals should round clock times for the beginning and end of observation to the nearest hour and submit the total number of hours for the observation stay on the claim. For the purposes of submitting claims for observation services, one unit equals one hour. Partial units or hours should be rounded up or down to the nearest hour. Claims submitted with observation room units exceeding 48 hours will be denied.

Any service that was ordered within the observation period may be included on the outpatient claim if a practitioner’s order for the service was made within the observation period time frame but hospital scheduling limitations prevented the service from being performed before the 48 hours expired. Any services ordered after 48 hours must not be included on the outpatient claim nor billed to the client. If a period of observation spans more than one calendar day (i.e., extends past midnight), all of the hours for the entire period of observation must be included on a single line, and the date of service for that line is the date on which the observation care began.

Observation time may include medically necessary services and follow-up care that is provided after the time the practitioner writes the discharge order, but before the client is discharged. Reported obser­vation time does not include the time the client remains in the observation area after treatment is completed for reasons such as waiting for transportation home.

Observation services must not be submitted concurrently with diagnostic or therapeutic services for which active monitoring is part of the procedure. In situations where a diagnostic or therapeutic procedure interrupts the observation stay, hospitals should record for each period of observation services the beginning and ending times of the observation period and add the lengths of time for the periods of observation services together to reach the total number of units reported on the claim.

Recovery room hours that are associated with an outpatient procedure must not be submitted simulta­neously with hours of observation time.

Revenue code 761 will be denied if it is submitted for the same date of service by the same provider as revenue code 760, 762, or 769.

4.2.4.7Client Status Change

When a client’s status changes from outpatient observation to inpatient admission within the allowed 48-hour observation period, both the outpatient observation service and the inpatient admission must be submitted as separate details on the same inpatient claim.

The inpatient claim must include:

The provider must submit the correct FDOS and Date of Admission (DOA) on the claim header.

Charges for the observation room on the inpatient claim claim may be coded using the appropriate revenue code (760, 761, 762, or 769).

The observation services are considered part of the facility’s DRG payment, and are not separately reimbursed.

The practitioner’s order for a change in client status from outpatient observation to inpatient admission must be written, dated, and timed before the outpatient observation claim is submitted for reimbursement.

4.2.4.8Inpatient Admission to Outpatient Observation

When a client is admitted to the hospital as an inpatient and a subsequent internal utilization review (UR) determines that the services did not meet inpatient criteria, the hospital may change the client’s status from inpatient to outpatient observation. The order to change from an inpatient to outpatient observation admission is effective for the same date and time as the inpatient order. This practice is acceptable under Texas Medicaid if all of the following conditions are met:

The change in client status is made before the claim is submitted.

The hospital has not submitted a claim for the inpatient admission.

The practitioner responsible for the care of the client concurs with the hospital UR determination to change to outpatient status.

The practitioner’s concurrence with the UR decision is documented in the client’s medical record.

Note:When the hospital has determined that it may submit an outpatient claim according to the conditions described above, the entire episode of care should be billed as an outpatient episode of care.

Reimbursement for emergency room (ER) and observation services are considered part of the inpatient DRG payment and must be submitted as separate details on the inpatient claim when the client is admitted as an inpatient under one or both of the following circumstances:

The client has spent fewer than 24 hours after presenting in the ER without being placed in obser­vation status.

The client has spent fewer than 48 hours in observation status after presenting in the ER.

The date of admission on the inpatient claim must reflect the date the client presents at the hospital.

If the client is admitted as an inpatient more than 24 hours after presenting in the ER without being placed in observation status or more than 48 hours after being placed in observation status, the ER and observation services may be reimbursed separately as outpatient services.

Examples

The following examples indicate the appropriate dates of admission and claim submissions for different scenarios:

Scenario 1

In scenario 1, the ER and outpatient observation services must be submitted on the inpatient hospital claim, because the ER services are within 24 hours of the observation services, and the observation services are within 48 hours of the inpatient admission, and the client was not discharged and sent home before being admitted as an inpatient.

The inpatient admission date reflects the date the patient presented at the ER.

Date and Time

Patient Services

5/1/12 (11:50 p.m.)

Patient presents in the ER

5/2/12 (12:30 a.m.)

40 minutes later, patient is placed in observation status

5/3/12 (12:00 a.m.)

23.5 hours later, after placement is in observation status, patient is admitted as an inpatient

Claims submissions are as follows:

ER visit: Submitted on the inpatient claim as a separate detail (part of the DRG payment)

Observation services: Submitted on the inpatient claim as a separate detail (part of the DRG payment)

Date of inpatient admission: May 1, 2012

Scenario 2

In scenario 2, the ER service was more than 24 hours before the observation period began and must be submitted on an outpatient hospital claim. The observation service must be billed on the inpatient hospital claim because the service was within 48 hours of the inpatient admission, and the client was not discharged and sent home before being admitted as an inpatient.

The inpatient admission date reflects the date the patient was placed in observation status.

Date and Time

Patient Services

5/1/12 (11:50 p.m.)

Patient presents in the ER

5/2/12 (11:55 p.m.)

24 + hours later, patient is placed in observation status

5/3/12 (4:00 a.m.)

4 hours later, patient admitted as an inpatient

Claims submissions are as follows:

ER visit: Submitted on an outpatient claim and reimbursed separately from the observation and inpatient services

Observation services: Submitted on the inpatient claim as a separate detail (part of the DRG payment)

Date of inpatient admission: May 2, 2012

Scenario 3

In scenario 3, the ER service must be submitted on an outpatient claim as part of the observation service because the ER service was within 24 hours of the observation service. The observation service may be reimbursed separately from the inpatient admission because the observation service was more than 48 hours before the inpatient admission, and the client was not discharged and sent home before being admitted as an inpatient.

The inpatient admission date reflects the date the patient was admitted as an inpatient.

Date and Time

Patient Services

5/1/12 (11:50 p.m.)

Patient presents in the ER

5/2/12 (12:30 a.m.)

40 minutes later, patient placed in observation status

5/4/12 (12:45 a.m.)

48 + hours later patient admitted as an inpatient

Claims submissions are as follows:

ER visit: Submitted on an outpatient claim and reimbursed as part of the outpatient observation services

Observation services: Submitted on the outpatient claim and reimbursed separately from the inpatient services

Date of inpatient admission: May 4, 2012

Scenario 4

In scenario 4, the ER service may be reimbursed separately because it was more than 24 hours before the client was placed in observation status. The observation service may be reimbursed separately because it was more than 48 hours before the client was admitted as an inpatient.

The inpatient admission date reflects the date the patient was admitted as an inpatient.

Date and Time

Patient Services

5/1/12 (11:50 p.m.)

Patient presents in the ER

5/2/12 (11:55 p.m.)

24 + hours later, patient is placed in observation status

5/4/12 (12:00 p.m.)

48 + hours later, patient admitted as an inpatient

Claims submissions are as follows:

ER visit: Submitted on an outpatient claim and reimbursed separately from the observation and inpatient services.

Observation services: Submitted on an outpatient claim and reimbursed separately from the inpatient services.

Date of inpatient admission: May 4, 2012

Scenario 5

In scenario 5, the ER service must be submitted on an outpatient claim as part of the observation service because the ER service was within 24 hours of the observation service. The observation service may be reimbursed separately from the inpatient admission because the client was discharged and sent home without being admitted as an inpatient.

The inpatient admission date reflects the date the patient presented at the ER after being discharged and sent home 14 hours earlier.

Date and Time

Patient Services

5/1/12 (11:50 p.m.)

Patient presents in the ER

5/2/12 (12:30 a.m.)

40 minutes later, patient is placed in observation status.

5/2/12 (10:00 a.m.)

9.5 hours later, patient is discharged and sent home

5/3/12 (12:05 a.m.)

14 hours later, patient presents at the ER again and is admitted as an inpatient

Claims submissions are as follows:

ER visit: Submitted on an outpatient claim and reimbursed as part of the observation services

Observation services: Submitted on the outpatient claim and reimbursed separately from the inpatient services

Date of inpatient admission: May 3, 2012

When the hospital has determined that it may submit an outpatient claim according to the conditions described above, the entire episode of care should be submitted as an outpatient episode of care.

4.2.4.9Observation Services that are not a benefit

Outpatient observation services that are not medically necessary or appropriate are not benefits of Texas Medicaid, including, but not limited to, services provided under the following circumstances:

As a substitute for an inpatient admission.

Without a practitioner’s order, including services ordered as inpatient services by the ordering practitioner, but submitted as outpatient by the billing office.

For clients awaiting transfer to another facility, such as for nursing home placement.

For clients with lack of or delay in transportation.

As a convenience to the client, client’s family, the practitioner, hospital, or hospital staff.

For routine preparation before, or recovery after, outpatient diagnostic or surgical services.

When an overnight stay is planned before diagnostic testing.

To medically stable clients who need diagnostic testing or outpatient procedures that are routinely provided in an outpatient setting.

Following an uncomplicated treatment or procedure.

As standing orders for observation following outpatient surgery.

For postoperative monitoring during a standard recovery period of four to six hours, which is considered part of the recovery room service.

For outpatient blood or chemotherapy administration and concurrent services.

For services that would normally require an inpatient admission.

Beyond 48 hours from the time of the observation admission.

For a medical examination for clients who do not require skilled support.

4.2.5Hospital-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 services listed below must be submitted using the RHC provider identifier 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

These services must be submitted with an AM, SA, or U7 modifier if performed in an RHC setting. Claims are paid under the Prospective Payment System (PPS) reimbursement methodology.

When submitting a claim on the CMS-1500 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.

Note:A visit is a face-to-face encounter between an RHC client and a physician, PA, nurse practi­tioner (NP), certified nurse-midwife (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.

4.2.6Cardiac Rehabilitation

Cardiac rehabilitation is a physician-supervised program that furnishes physician-prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment.

Outpatient cardiac rehabilitation is considered reasonable and necessary for clients who have had one of the following within 12 months of beginning the cardiac rehabilitation program:

Acute myocardial infarction

Coronary artery bypass surgery (CABG)

Percutaneous transluminal coronary angioplasty or coronary stenting

Heart valve repair or replacement

Major pulmonary surgery

Sustained ventricular tachycardia or fibrillation

Class III or class IV congestive heart failure

Chronic stable angina

Note:A cardiac rehabilitation program in which the cardiac monitoring is done using telephoni­cally transmitted electrocardiograms to a remote site is not covered by Texas Medicaid.

Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (i.e. oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use. If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the client complete the remaining portion without telemetry monitoring by the physician’s order.

Although cardiac rehabilitation may be considered a form of physical therapy, it is a specialized program conducted by non-physician personnel who are trained in both basic and advanced cardiac life support techniques and exercise therapy for coronary disease, and provide the services under the direct super­vision of a physician.

Direct supervision of a physician means that a physician must be immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under cardiac rehabilitation programs. Outpatient cardiac rehabilitation begins after the client has been discharged from the hospital. A physician’s prescription is required after the acute convalescent period and after it has been determined that the client’s clinical status and capacity will allow for safe partici­pation in an individualized progressive exercise program. Outpatient cardiac rehabilitation requires close monitoring and direct supervision by a physician and includes:

Medical evaluation performed by the physician responsible for prescribing the client’s rehabilitation program and includes a clinical examination, a medical history, and an initial plan or goal.

An education and counseling program to modify risk factors (nutritional counseling, stress reduction, smoking cessation, weight loss, etc.).

Prescribed exercise concurrent with and without electrocardiogram (ECG) monitoring.

Services performed in an approved facility by trained professionals.

Note:Direct supervision is met when the services are performed on hospital premises or within 250 yards of the hospital.

Cardiac rehabilitation will be limited to a maximum of 2 one-hour sessions per day and 36 sessions over 18 weeks per rolling year.

Providers must obtain prior authorization for additional cardiac rehabilitation sessions, which will be limited to a maximum of 36 sessions in an extended period of time in a 52-week period from the date of authorization of additional sessions.

To confirm that a continuation of cardiac rehabilitation is at the request of, and coordinated with the attending physician, the medical record must include evidence of communication between the cardiac rehabilitation staff and either the medical director or the referring physician. If the physician responsible for such follow-up is the medical director, then his or her notes must be evident in each client’s medical record.

Cardiac rehabilitation may be considered medically necessary beyond 36 sessions if the medical record contains documentation that the client has had another cardiac event, or if the prescribing physician documents that a continuation of cardiac rehabilitation is medically necessary. Medical necessity documentation must include the following:

Progress made from the beginning of the cardiac rehabilitation period to the current service request date, including progress towards previous goals

Information that supports the client’s capability of continued measurable progress

A proposed treatment plan for the requested extension dates with specific goals related to the client’s individual needs

Prior authorization must be obtained through the TMHP Special Medical Prior Authorization (SMPA) Department. Providers must send prior authorization requests, along with documentation to support medical necessity, to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213

Requests for prior authorization can also be submitted online through the TMHP website at www.tmhp.com.

The evaluation provided by the cardiac rehabilitation team at the beginning of each cardiac rehabili­tation session is not considered a separate service and will be included in the reimbursement for the cardiac rehabilitation session. Evaluation and management (E/M) services unrelated to cardiac rehabil­itation may be submitted with modifier 25 appended to the E/M code when supporting documentation in the medical record demonstrates a separately identifiable E/M service was provided on the same day by the same provider who renders the cardiac rehabilitation.

Physical and occupational therapy will not be reimbursed separately when furnished in addition to cardiac rehabilitation exercise program services unless there is also a diagnosis of a non-cardiac condition requiring such therapy.

Example:If a client is recuperating from an acute phase of heart disease and has had a stroke that requires physical or occupational therapy, the physical or occupational therapy for the stroke may be reimbursed separately from the cardiac rehabilitation services for the acute phase of heart disease.

When provided as part of the cardiac rehabilitation program, client education services, such as formal lectures and counseling on diet, nutrition, and sexual activity to assist the client in adjusting living habits because of the cardiac condition, will not be separately reimbursed.

Procedure code S9472 (cardiac rehabilitation program nonphysician provider per diem) is used for hospitals submitting claims for cardiac rehabilitation, and it must be submitted with revenue code 943 (other therapeutic services-cardiac rehabilitation) and one of the following diagnosis codes:

Diagnosis Codes

I110

I160

I161

I169

I201

I208

I209

I2101

I2102

I2109

I2111

I2119

I2121

I2129

I213

I214

I219

I21A1

I21A9

I220

I221

I222

I228

I229

I2720

I2721

I2722

I2723

I2724

I2729

I2783

I501

I5020

I5021

I5022

I5023

I5030

I5031

I5032

I5033

I5040

I5041

I5042

I5043

I50810

I50811

I50812

I50813

I50814

I5082

I5083

I5084

I5089

I509

Z941

Z943

Z951

Z952

Z953

Z954

Z955

Z9861

Z98890

Coverage of cardiac rehabilitation programs is considered reasonable and necessary only for clients who have documentation of acute myocardial infarction, coronary artery bypass surgery (CABG), percuta­neous transluminal coronary angioplasty or coronary stenting heart valve repair/replacement, major pulmonary surgery, sustained ventrical tachycardia or fibrillation, class III or class IV congestive heart failure, or chronic stable angina within the past twelve (12) months prior to the beginning of the program.

4.2.7Chemotherapy Administration

Hospitals must submit outpatient charges using the appropriate revenue codes for room charges, supplies, IV equipment, and pharmacy.

Revenue code 636 may be reimbursed for the technical component of prolonged infusion of chemother­apeutic agents. The most appropriate chemotherapy procedure code must be billed with revenue code 636.

Refer to:  Subsection 9.2.19, “Chemotherapy” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.8Colorectal Cancer Screening

Fecal occult blood tests, barium enemas, screening colonoscopies, and sigmoidoscopies are a benefit of Texas Medicaid.

4.2.8.1* Fecal Occult Blood Tests

Procedure code G0328 may be reimbursed once per year with QW modifier for services rendered to clients who are 50 years of age and older.

4.2.8.2Barium Enemas

Procedure code G0122 may be reimbursed once every 5 years for services rendered to clients who are 50 years of age and older.

4.2.8.3Sigmoidoscopies

Procedure code G0106 may be reimbursed once every 5 years and is limited to one of the following diagnosis codes:

Diagnosis Codes

Z0000*

Z0001*

Z1210

Z1211

Z1213

Z859

Z86010

*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more frequently than recommended by the U.S. Preventive Services Task Force (USPSTF).

4.2.8.4Colonoscopies

Procedure code G0120 may be reimbursed once every two years for clients who meet the definition of high-risk. Procedure code G0120 must be submitted with one of the following diagnosis codes:

Diagnosis Codes

K5000

K50011

K50012

K50013

K50014

K50018

K5010

K50111

K50112

K50113

K50114

K50118

K5080

K50811

K50812

K50813

K50814

K50818

K5090

K50911

K50912

K50913

K50914

K50918

K50919

K5120

K51211

K51212

K51213

K51214

K51218

K5130

K51311

K51312

K51313

K51314

K51318

K5180

K51811

K51812

K51813

K51814

K51818

K5190

K51911

K51912

K51913

K51914

K51918

K51919

K523

K5281

K5282

K52831

K52832

K52838

K52839

K5289

K529

Z800

Z8371

Z85038

Z85048

Z859

Z86010

Refer to:  Subsection 9.2.14.2, “* Colorectal Cancer Screening” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.9Computed Tomography and Magnetic Resonance Imaging

Prior authorization is required for all outpatient nonemergent (i.e., those that are scheduled) CT, computed tomography angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) studies before services are rendered. Authorization is not required for the emergency department or inpatient hospital radiology services. Retroactive authorization may be required for some outpatient emergent studies.

Reimbursement for procedures with descriptions that specify “with contrast” include payment for contrast materials. Some diagnostic radiopharmaceuticals are benefits of Texas Medicaid. Outpatient hospitals may submit the total component of the following procedure codes:

Procedure Codes

77371

77372

77373

77422

77423

77520

77525

G0339

Procedure code 77399 may be submitted as either the total component or the technical component.

Providers can refer to the OFL or the applicable fee schedules on the TMHP website at www.tmhp.com to review the diagnostic radiopharmaceuticals that are reimbursed by Texas Medicaid. OFL and static fee schedules available on the TMHP website display fees after applicable rate reductions have been applied. Previously, the OFL and static fee schedules did not reflect all rate reductions, and providers were required to calculate the 1- and 2-percent reductions implemented.

Refer to:  Subsection 4.2.9, “Computed Tomography and Magnetic Resonance Imaging” in this handbook for additional information about prior authorization requirements.

Subsection 3.2.6, “Authorization Requirements for CT, CTA, MRI, fMRI, MRA, PET, and Cardiac Nuclear Imaging Services” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks) for additional information about emergency outpatient imaging services.

4.2.10Electrodiagnostic (EDX) Testing

Electromyography (EMG) and nerve conduction studies (NCS), collectively known as EDX testing, must be medically indicated and may be reimbursed to outpatient hospitals. Testing must be performed using EDX equipment that provides assessment of all parameters of the recorded signals. Studies performed with devices designed only for screening purposes rather than diagnoses are not a benefit of Texas Medicaid.

NCS and EMG studies are diagnosis restricted and may require prior authorization.

Refer to:  Subsection 9.2.25.7, “Esophageal pH Probe Monitoring” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.11Fluocinolone Acetonide

The fluocinolone acetonide intravitreal implant may be reimbursed for services rendered to clients who are 12 years of age and older. Procedure code J7311 is only payable with a posterior uveitis diagnosis of more than six months duration and the condition has been unresponsive to oral or systemic medication treatment.

4.2.11.1Prior Authorization for Fluocinolone Acetonide

To request prior authorization, providers must submit requests by fax or mail to the SMPA Department at:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213

Requests for prior authorization can be submitted online through the TMHP website at www.tmhp.com.

4.2.12Fetal Nonstress Testing and Contraction Stress Test

Claims for nonstress and contraction stress testing conducted in the outpatient setting must be submitted with revenue code 729. Services during an inpatient hospital stay are reimbursed under the hospital’s DRG.

Refer to:  Section 4.1.1, “Antepartum and Fetal Invasive Procedures” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks).

4.2.13Hyperbaric Oxygen Therapy (HBOT)

HBOT is a type of therapy that increases the environmental oxygen pressure to promote the movement of oxygen from the environment into the client’s body tissues. Such treatment may be a benefit of Texas Medicaid when it is performed in specially constructed hyperbaric chambers, pressurized to 1.4 atmosphere absolute (atm abs) or higher, which may hold one or more clients (sea-level pressure is equal to 1 atm.abs). Although oxygen may be administered by mask, cannula, or tube in addition to the hyper­baric treatment, this use of oxygen is not considered hyperbaric oxygen treatment in itself.

HBOT procedure codes 99183 and G0277 require prior authorization before the date that service is initiated.

The number of billable units of procedure code G0277 is based upon the time that the client receives treatment with hyperbaric oxygen.

In calculating how many 30-minute intervals to report, hospitals should take into consideration the time spent under pressure during descent, air breaks, and ascent, (in minutes), as follows:

The first unit is for the time spent in the chamber receiving hyperbaric oxygen and must be for a minimum of 16 minutes.

To bill for a second (or subsequent unit), all previous units of time must have been for the full thirty minutes, and the last unit must be fore 16-30 minutes.

Procedure code 99183 equates to one total treatment (one professional session).

Procedure code G0277 must be billed with revenue code B-413 on the same claim. If procedure code G0277 is not on the same claim as revenue code B-413, the claim will be denied.

Refer to:  Subsection 9.2.32, “Hyperbaric Oxygen Therapy (HBOT)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for more information.

4.2.14Laboratory Services

Routine laboratory services, directly related to the surgical procedure being performed, are not reimbursed separately. Claims for nonroutine laboratory services provided with emergency conditions may be submitted separately with documentation that the complicating condition arose after the initi­ation of the surgery. Outpatient claims for laboratory services must reflect only tests actually performed by the hospital laboratory.

Exception:Hospital laboratories may submit claims for all the tests performed on a specimen if some but not all the tests are done by another laboratory on referral from the hospital submitting the claim.

The billing hospital must enter the name and provider identifier of the performing laboratory in Block 80 of the UB-04 CMS-1450 paper claim form and must enter the performing laboratory’s provider identifier next to the service provided by the performing laboratory.

Hospitals may submit claims for a handling fee (procedure code 99001) for collecting and forwarding a specimen to a referral laboratory when the laboratory handling fee is not being billed through other methods. Only one handling fee may be charged per day, per client, unless specimens are sent to two or more different laboratories; this must be documented on the claim.

Refer to:  The Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

4.2.14.1Clinical Laboratory Improvement Amendments (CLIA)

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

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

The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

4.2.15Lung Volume Reduction Surgery (LVRS)

LVRS surgery must be performed in a facility that meets at least one of the following requirements:

Certified under the Disease Specific Care Certification Program for LVRS by the Joint Commission on Accreditation of Health Care Organization (JCAHO)

Approved by Medicare as a lung or heart-lung transplant facility

The surgery must be both preceded and followed by a program of diagnostic and therapeutic services that are consistent with those provided in the National Emphysema Treatment Trial (NETT) and designed to maximize the client’s potential to successfully undergo and recover from surgery. The program must meet all of the following requirements:

Include a 6-to 10-week series of at least 16, and no more than 20, pre-operative sessions, each lasting a minimum of 2 hours

Include at least 6, and no more than 10, post-operative sessions, each lasting a minimum of 2 hours, within 8 to 9 weeks after the LVRS

Be consistent with the care plan that was developed by the treating physician following the perfor­mance of a comprehensive evaluation of the client’s medical, psychosocial, and nutritional needs

Be arranged, monitored, and performed under the coordination of the facility where the surgery takes placePrior authorization is required for the LVRS procedure. However; prior authorization is not required for the pre-operative and post-discharge pulmonary services

LVRS must be prior authorized and is limited to clients who have severe emphysema, disabling dyspnea, and evidence of severe air trapping. Prior authorization is not required for the associated preoperative pulmonary surgery services for preparation of LVRS (procedure codes G0302, G0303, and G0304) or the associated postdischarge pulmonary surgery services after LVRS (procedure code G0305).

LVRS and post-discharge LVRS are restricted to the following eemphysema diagnosis codes:

Diangosis Codes

J430

J431

J432

J438

J983

Procedure codes 32491, G0302, G0303, G0304 and G0305 are limited to one per rolling year per client any provider.

Procedure code G0305 may be reimbursed only if a claim for LVRS (procedure code 32491) has been submitted within the past 12 months.

Refer to:  Subsection 9.2.41, “Lung Volume Reduction Surgery (LVRS)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.16Magnetoencephalography (MEG) Services

Inpatient and outpatient hospitals must use revenue code 860 or 861 for reimbursement of magnetoen­cephalography (MEG) services. The appropriate MEG procedure code must be listed on the claim.

Note:Reimbursement to an outpatient hospital will be based on the the submitted procedure code.

Refer to:  Subsection 9.2.62, “Magnetoencephalography (MEG)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.17Neurostimulators

Neurostimulators may be a benefit in the outpatient hospital setting when medically necessary. All procedures require prior authorizations.

Refer to:  Subsection 9.2.43, “Neurostimulators” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Subsection 4.2.17.1, “Prior Authorization for Neurostimulators” in this handbook.

4.2.17.1Prior Authorization for Neurostimulators

All devices and related procedures for the initial application or surgical implantation of the stimulator device require prior authorization. Requests for prior authorization must be submitted to the SMPA Department.

Refer to:  Subsection 9.2.43.14, “Prior Authorization of Neurostimulator Devices Procedure Codes” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.18Occupational and Physical Therapy Services

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

4.2.19Radiation Therapy Services

Take-home drugs given during the course of therapy can be reimbursed separately through the VDP.

Hospitals use revenue code 333, Radiation therapy, on the UB-04 CMS-1450 paper claim form when submitting charges for these services.

The following radiation therapy services provided in an outpatient setting are allowed only once per day unless documentation of medical necessity supports the need for repeated services:

Therapeutic radiation treatment planning

Therapeutic radiology simulation-aided field setting

Teletherapy

Brachytherapy isodose calculation

Treatment devices

Proton beam delivery/treatment

Intracavity radiation source application

Interstitial radiation source application

Remote afterloading high intensity brachytherapy

Radiation treatment delivery

Localization, and radioisotope therapy

4.2.19.1Radiopharmaceuticals

Radiopharmaceuticals may be considered for separate reimbursement when used for therapeutic treatment.

The following procedure codes are payable to outpatient hospitals:

Procedure Codes

79403*

A9542

A9543

A9563

A9564

A9600

A9699

*Total or technical component

Procedure codes A9542 and A9543 require prior authorization. Ibritumomab tiuxetan will be considered when submitted with one of the following diagnosis codes:

Diagnosis Codes

C8259

C8399

C8499

C84A9

C84Z9

C8519

C8529

C8589

C8599

Strontium-89 chloride may be billed using procedure code A9600 and will be limited to a total of 10 mci intravenously injected every 90 days, any provider.

Strontium-89 chloride is reimbursed as one service per day for the same provider on the same claim.

Strontium-89 chloride will be considered when submitted with diagnosis code C7951 or C7952.

Sodium phosphate p-32, therapeutic, will be considered when submitted with one of the following diagnoses:

Diagnosis Codes

C7951

C7952

C9110

C9112

C9192

C91Z2

C9292

C92Z2

C9512

C9592

D45

Chromic phosphate p-32 suspension will considered when submitted with diagnosis code C782 (secondary malignant neoplasm of the pleura) and diagnosis code C786 (secondary malignant neoplasm of the retroperitoneum and peritoneum).

Refer to:  Subsection 9.2.60, “Radiation Therapy” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Prior Authorization for Therapeutic Radiopharmaceuticals

Prior authorization is required for procedure codes A9542 and A9543, which will be considered with documentation of all of the following:

A diagnosis of either a low-grade follicular or transformed B-cell non-Hodgkin’s lymphoma.

Client has failed, relapsed, or become refractory to conventional chemotherapy.

Marrow involvement is less than 26 percent.

Platelet count is 100,000 cell/mm3 or greater.

Neutrophil count is 1,500 cells/mm3 or greater.

Client has failed a trial of rituximab.

Prior authorization must be requested through the SMPA department with appropriate documentation. Requests can be mailed or faxed to:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213

Requests for prior authorization can be submitted online through the TMHP website at www.tmhp.com.

4.2.20Respiratory Services

4.2.20.1Aerosol Treatment

Nebulized aerosol treatments with short-acting beta-agonists provided in the outpatient setting are considered medically necessary for certain acute medical problems when breathing is compromised. Authorization is not required for aerosol treatments.

Outpatient facilities must submit claims for aerosol treatments using revenue code 412 and the appro­priate beta-agonist procedure code.

4.2.20.2Pentamidine Aerosol

Aerosol pentamidine treatments are reimbursed using procedure code 94642. Providers may also be reimbursed for pentamidine medication using procedure code J2545.

Reimbursement for aerosol pentamidine treatment is limited to the following diagnosis codes:

Diagnosis Codes

A481

B20

B4481

B59

B9733

B9734

B9735

Aerosol pentamidine treatments are limited to one treatment every 28 days.

Oral trimethoprim-sulfamethoxazole is available from pharmacies for self administration at home. The use of oral trimethoprim-sulfamethoxazole is not a payable benefit of the insured portion of Texas Medicaid.

4.2.20.3Diagnostic Testing

Nitric oxide expired gas determination (FeNO) measurement provided in the physician’s office or outpatient hospital setting is considered medically necessary as an adjunct to the established clinical and laboratory assessments for diagnosing and assessing asthma, predicting exacerbations, and evaluating the response of a patient with asthma to anti-inflammatory therapy.

Claims for nitric oxide treatments may be submitted using procedure code 95012. Hospital providers must include the following when submitting claims for procedure code 95012:

Revenue code 419 must appear on the same line as procedure code 95012.

The claim must have a line item for either procedure code 94010 or 94060. This line item must also indicate revenue code 419.

Note:Procedure code 94010 or 94060, when submitted in conjunction with procedure code 95012, may only be reimbursed in an office or outpatient hospital setting, and is not reimbursed for critical care, emergency care, or anesthesiology.

4.2.20.4Pulmonary Function Studies

Pulmonary function studies considered for reimbursement to outpatient hospitals include, but are not limited to, the following procedures when submitted with the total component (TOS 5):

Procedure Codes

94010

94060

94070

94150

94200

94250

94375

94400

94450

94452

94453

94620

94621

94726

94727

94728

94729

95012

High Altitude Simulation Test (HAST) procedure codes 94452 and 94453 must be submitted with one of the following diagnosis codes:

Diagnosis Codes

E840*

E8411

E8419*

E848*

E849*

I270*

I271*

I2720

I2721

I2722

I2723

I2724

I2729

I2781*

I2783

I2789*

I279*

J410*

J411*

J418*

J42*

J430*

J431*

J432*

J438*

J439*

J440*

J441*

J449*

J471*

J479*

J60*

J700*

J701

J708*

J709*

J82*

J8401

J8402

J8403

J8409

J8410

J849

J9610

J9611

J9612

J982

P270*

P271*

P278*

Q332*

Q334

Q336

Note:When billing for HAST (procedure code 94452 or 94453) with one of the diagnosis codes indicated in the table with an asterisk (*), evidence of hypoxemia must be documented in the client’s medical record.

When multiple procedure codes are submitted, the most inclusive code of the related codes will be reimbursed and all other related codes will be denied.

When unrelated pulmonary function studies are submitted together, each will be considered for reimbursement.

4.2.21Screening, Brief Intervention, and Referral to Treatment (SBIRT)

Refer to:  Subsection 7, “Screening, Brief Intervention, and Referral to Treatment (SBIRT)” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks).

4.3Documentation Requirements

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

4.4Outpatient Utilization Review

UR activities of all Medicaid services provided by hospitals reimbursed under the DRG prospective payment system are required by Title XIX of the Social Security Act, Sections 1902 and 1903. The review activities are accomplished through a series of monitoring systems developed to ensure services are appropriate to need, of optimum quality and quantity, and rendered in the most cost-effective mode. Clients and providers are subject to UR monitoring. The monitoring focuses on the appropriate screening activities, medical necessity of all services, and quality of care as reflected by the choice of services provided, type of provider involved, and settings in which the care was delivered. This monitoring ensures the efficient and cost-effective administration of Texas Medicaid.

TMHP is responsible for a comprehensive integrated review process to identify misuse and inappro­priate claim submission patterns by outpatient hospitals and HASCs. All providers are subject to TMHP’s UR monitoring. Providers are selected for review based on a comparison of their individual resource utilization with a peer group of similar specialty and geographic locality. The main goal of the required utilization control is to identify those providers whose practice patterns are aberrant from their peers and provide the necessary educational actions to help the provider achieve Texas Medicaid compliance. An analysis of UR data is completed by a registered nurse analyst for review by the medical director and staff. If the analyst substantiates that a provider’s practice and claim submission patterns are inconsistent with the federal requirements and Texas Medicaid’s scope of benefits, a TMHP repre­sentative contacts the provider. The purpose of the contact is to discuss appropriate claim submission guidelines and to assist the provider in resolving the inappropriate claim submission patterns identified in the review.

TMHP uses the following criteria when reviewing all hospital outpatient medical records. Services must be:

Medically necessary.

Ordered by a physician, signed, and dated. Signature stamps are valid if initialed and dated by the physician.

Submitted in the quantities ordered and documented as provided.

Program benefits.

Specifically identified on the charge tickets or itemized statement submitted with the claim or by the HCPCS procedure code on the claim.

Indicated by the documentation in the medical record.

Submitted to Texas Medicaid only after other medical insurance resources have been exhausted.

Refer to:  Subsection 4.1.1, “Your Texas Benefits Medicaid Card” in “Section 4: Client Eligibility” (Vol. 1, General Information).

The determination of the TMHP UR process may result in the following:

Educational letters and visits

Mail-in of medical records for review

On-site medical record review (outpatient, HASC, or inpatient records not reviewed)

Referral of questionable claims to HHSC or HHSC OIG

Recoupment

Prepayment review

The intent of these actions is to ensure the most effective and appropriate use of available services and facilities and provide appropriate, cost-effective care to clients with Medicaid coverage.

4.5Claims Filing and Reimbursement

4.5.1Outpatient Claims Information

Claims for scheduled procedures that are performed in a HASC must be submitted using the HASC provider identifier with type of bill (TOB) 131. Claims for emergency or unscheduled procedures performed in a hospital when the client is an outpatient must be submitted using the hospital provider identifier and appropriate revenue and HCPCS code (if required) with TOB 131.

Claims for outpatient hospital services must be submitted to TMHP in an approved electronic format or on the UB-04 CMS-1450 paper claim form.

Freestanding ambulatory surgical centers must submit claims on the CMS-1500 claim form. The performing surgeon or referring physician name and number must be identified in Block 17. Identifi­cation of outpatient charges must be in Block 44 if submitting by HCPCS code. If appropriate, the revenue code must be indicated in Block 42. Texas Medicaid recommends the use of specific procedure codes for claim submission. Do not use the revenue code description in Block 43; the HCPCS narrative description must be identified in this block. For example, when submitting charges for physical therapy, do not use the description associated with revenue code 420. To receive reimbursement for physical therapy services, providers must identify the specific modality used (e.g., gait training).

Examples:

Emergency Room. Submit as “Emergency room” or “Emergency room charge per use.” If the client visits the emergency room more than once in one day, the time must be given for each visit. The time of the first visit must be identified in Block 13, using 00 to 23 hours military time (e.g., 1350 for 1:50 p.m.). Indicate other times on the same line as the procedure code. Claims for emergency CT, CTA, MRI, or MRA studies provided in the emergency department must have the appropriate corresponding emergency services revenue code (450, 451, 456, or 459) to be considered for payment.

Observation Room. Submit as “observation room.” (Revenue code 762).

Operating Room. Submit as “Operating Room.” (Revenue code 360, 361, or 369).

Recovery Room. Submit as “Recovery Room” or “Cast Room” as appropriate. (Revenue code 710 or 719).

Injections. Must have “Inj.-name of drug; route of administration; the dosage and quantity” or the injection code.

Drugs and Supplies. The drug description must include the name, strength, and quantity. Take-home drugs and supplies are not a benefit of Texas Medicaid:

Take-home drugs must be submitted with revenue code 253.

Take-home supplies must be submitted with revenue code 273.

Self-administered drugs must be submitted with revenue code 637.

Radiology. Facilities must submit claims using the most appropriate revenue and HCPCS code. The physician must submit claims for professional services by a physician separately. The license number of the ordering physician must be in Block 83. If the client receives the same radiology procedure more than once in one day, the time must be given for each visit. The time of the first visit must be identified in Block 13, using 00 to 23 hours military time (such as 1350 for 1:50 p.m.). Indicate other times on the same line as the procedure code.

Laboratory. Provide a complete description or use the procedure codes for the laboratory proce­dures. The physician must submit claims for professional services by a physician separately. Blocks 78–79 must have the license number of the ordering physician. If laboratory work is sent out, enter the name of the test and name and address or Medicaid number of the laboratory where the work was forwarded. If the client receives the same laboratory procedure more than once in one day, give the time for each visit. The time of the first visit must be identified in Block 13, using 00 to 23 hours military time (e.g., 1350 for 1:50 p.m.). Indicate other times on the same line as the procedure code.

Nuclear Medicine. Provide a complete description.

Day Surgery. Day surgery must be submitted as an inclusive charge using TOS F. Providers must not submit claims for separate services that were provided in conjunction with the surgery (e.g., lab, radiology, and anesthesia). File claims for unscheduled emergency outpatient surgical procedures with separate charges (e.g., lab, radiology, anesthesia, and emergency room) for all services using TOB 131 and the hospital’s provider identifier.

Claims for emergency or unscheduled procedures performed in a hospital when the client is an outpa­tient must be submitted using the hospital provider identifier and appropriate revenue and HCPCS code (if required) with TOB 131.

Refer to the ASC/HASC section for information on scheduled procedures.Additional claims infor­mation can be found within individual topic areas within this section.

Charges on claims must be itemized on the face of the UB-04 CMS-1450 paper claim form instead of submitting attachments or charge details. TMHP uses information attached to the claim for clarification purposes only.

If a claim contains more than 28 details, continue the claim on additional UB-04 CMS-1450 paper claim forms or electronic equivalent. Total each claim form as a stand-alone claim. If you do not total each page, your claim may be denied for being over the limitation, and must be resubmitted with 28 or less details.

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

Outpatient hospital services must be itemized by date of service. Procedures repeated over a period of time must be submitted for each separate date of service. Do not combine multiple dates of service on the same line detail.

4.5.2Outpatient Reimbursement

Outpatient services are reimbursed on a reasonable cost based on a percentage of the hospital’s most recent tentative Medicaid cost report settlement.

The reimbursement rate for non-high-volume hospitals is as follows with the application of the hospital specific interim rate:

Non-high-volume Provider

Current Allowable Rate

Children’s hospitals

72.27 percent of the allowable charges

Rural hospitals

100 percent of the allowable charges

State-owned teaching hospitals

72.27 percent of the allowable charges

Other hospitals

68.44 percent of the allowable charges

The reimbursement rate for high-volume hospitals is as follows with the application of the hospital specific interim rate:

High-volume Provider

Current Allowable Rate

Children’s hospitals

76.03 percent of the allowable charges

Rural hospitals

100 percent of the allowable charges

State-owned teaching hospitals

76.03 percent of the allowable charges

Other hospitals

72 percent of the allowable charges

ASCs/HASCs that qualify as high-volume providers

Additional 5.2 percent increase in payment rates

High-volume providers are eligible for additional payments on Texas Medicaid fee-for-service claims. A high-volume outpatient hospital provider is defined as one that was paid at least $200,000 during calendar year 2004.

All clinical laboratory services are reimbursed at a percentage of the prevailing charge. Hospitals that are identified by Medicare as sole community hospitals are reimbursed at a higher percentage of the prevailing charges for services that are provided to clients in the outpatient setting.

Clinical pathology consultations are also allowed for reimbursement.

Refer to:  The HHSC Rate Analysis web page at www.hhsc.state.tx.us/rad/hospital-svcs/index.shtml for additional information about hospital reimbursement.

Subsection 3.7.4, “Provider Cost and Reporting” in this handbook for more information about the calculation of the interim rate.

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

4.5.3Provider Cost and Reporting

Refer to:  Subsection 3.7.4, “Provider Cost and Reporting” in this handbook.

4.5.4National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) Guidelines

The HCPCS and 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. Providers should refer to the Centers for Medicare & Medicaid Services (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.

4.5.5Outpatient Hospital Revenue Codes

UB-04 CMS-1450 revenue codes must be used to submit claims for outpatient hospital facility services. In some instances, a HCPCS procedure code is required in addition to the revenue code for accurate claims processing:

Revenue Code

Description

Comments

Special Charges – Canceled Surgery

220

Special Charges

Procedure code required

Pharmacy

250

General classification

 

251

Generic drugs

 

252

Nongeneric drugs

 

253

Take-home drugs

Not a benefit

254

Drugs incident to other diagnostic services

 

255

Drugs incident to radiology

 

256

Experimental drugs

Not a benefit

257

Nonprescription drugs

 

258

IV solutions

 

259

Other pharmacy

 

260

General classification

 

261

Infusion pump

 

262

IV therapy/pharmacy services

 

263

IV therapy/drug/supply delivery

 

264

IV therapy/supplies

 

269

Other IV therapy

 

Medical/Surgical Supplies and Devices

270

General classification

 

271

Nonsterile supply

 

272

Sterile supply

 

273

Take-home supplies

Not a benefit

274      

Prosthetic/orthotic devices

Not a benefit

275   

Pacemaker

 

276

Intraocular lens

 

277

Oxygen take-home

Not a benefit

278

Medical/surgical supplies and devices- other implants

Procedure code required

279

Medical/surgical supplies and devices- other

Procedure code required

280

General Classification

 

289

Other oncology

 

300

Laboratory

Procedure code required

301

Laboratory- chemistry

Procedure code required

302

Laboratory- immunology

Procedure code required

303

Laboratory- renal patient (home)

Procedure code required

304

Laboratory- non-routine dialysis

Procedure code required

305

Laboratory- hematology

Procedure code required

306

Laboratory- bacteriology/microbiology

Procedure code required

307

Laboratory- urology

Procedure code required

309

Laboratory- other

Procedure code required

Laboratory – Pathological

310

Laboratory- pathological

Procedure code required

311

Laboratory- pathological cytology

Procedure code required

312

Laboratory- pathological histology

Procedure code required

314

Laboratory- pathological biopsy

Procedure code required

319

Laboratory- pathological other

Procedure code required

Radiology – Diagnostic

320

Radiology- diagnostic

Procedure code required

321

Radiology- diagnostic angiocardiography

Procedure code required

322

Radiology- diagnostic, arthrography

Procedure code required

323

Diagnostic, arteriography

Procedure code required

324

Chest X-ray

Procedure code required

329

Other diagnostic radiology

Procedure code required

Radiology – Therapeutic

330

General classification

Procedure code required

331

Chemotherapy-injected

Procedure code required

332

Chemotherapy-oral

Procedure code required

333

Chemotherapy-radiation therapy

Procedure code required

335

Chemotherapy-IV

Procedure code required

339

Other therapeutic radiology

Procedure code required

Nuclear Medicine

340

General classification

Procedure code required

341

Nuclear medicine- diagnostic

Procedure code required

342

Nuclear medicine- therapeutic

Procedure code required

349

Nuclear medicine- other

Procedure code required

Computed Tomography (CT) Scan

350

General classification

Procedure code required

351

CT scan- head scan

Procedure code required

352

CT scan- body scan

Procedure code required

359

CT scan- other CT scans

Procedure code required

Operating Room Services

360

Operating room services

 

361

Minor surgery

 

369

Other operating room services

 

Anesthesia

370

Anesthesia

 

371

Anesthesia incident to radiology

 

372

Anesthesia incident to other diagnostic services

 

374

Acupuncture

Not a benefit

379

Other anesthesia

 

380

Blood

Procedure code required

381

Blood- packed red cells

Procedure code required

382

Blood- whole blood

Procedure code required

383

Blood- plasma

Procedure code required

384

Blood- platelets

Procedure code required

385

Blood- leucocytes

Procedure code required

386

Blood- other components

Procedure code required

387

Blood- other derivatives (cryoprecipitates)

Procedure code required

389

Other blood

Procedure code required

Blood Storage and Processing

390

Blood storage and processing

 

391

Blood administration

Not a benefit

399

Other blood storage and processing

Not a benefit

Other Imaging Services

400

Other imaging services

Procedure code required

401

Other imaging services- diagnostic mammography

Procedure code required

402

Other imaging services- ultrasound

Procedure code required

403

Other imaging services- screening mammography

Procedure code required

404

Other imaging services- positron emission tomography

Procedure code required

409

Other imaging services- other

Procedure code required

Respiratory Services

410

Respiratory services

 

412

Inhalation services

 

413

Hyperbaric oxygen therapy

 

419

Other respiratory services

Procedure code required

Physical Therapy

420

Physical therapy

Procedure code required

421

Physical therapy- visit charge

Procedure code required

422

Physical therapy- hourly charge

Procedure code required

423

Physical therapy- group rate

Procedure code required

424

Physical therapy- evaluation/reevaluation

Procedure code required

429

Physical therapy- other

Procedure code required

Occupational Therapy

430

Occupational therapy

Procedure code required

431

Occupational therapy- visit charge

Procedure code required

432

Occupational therapy- hourly

Procedure code required

433

Occupational therapy- group rate

Procedure code required

434

Occupational therapy- evaluation/reevaluation

Procedure code required

439

Occupational therapy- other

Procedure code required

Speech-Language Pathology

440

Speech-language pathology

 

441

Speech-language pathology- visit charge

Procedure code required

442

Speech-language pathology- hourly charge

Procedure code required

443

Speech-language pathology- group rate

Procedure code required

444

Speech-language pathology- evaluation/reevaluation

Procedure code required

449

Speech-language pathology- other

Procedure code required

Emergency Room

450

Emergency room

Procedure code required

451

EMTALA emergency medical screening services

 

456

Urgent care

Procedure code required

459

Other

Procedure code required

460

Pulmonary function

Procedure code required

469

Pulmonary function- other

Procedure code required

Audiology

470

Audiology

Procedure code required

471

Audiology- diagnostic

Procedure code required

472

Audiology- treatment

Procedure code required

479

Audiology- other

Procedure code required

Cardiology

480

Cardiology

Procedure code required

481

Cardiology- cardiac cath lab

Procedure code required

482

Cardiology- stress test

Procedure code required

483

Unassigned procedure code

Procedure code required

489

Cardiology- other

Procedure code required

Clinic

510

Clinic

 

511

Chronic pain center

 

512

Dental clinic

 

513

Psychiatric clinic

 

514

Obstetrics-Gynecology (OB/GYN) clinic

 

515

Pediatric clinic

 

516

Urgent care clinic

 

517

Family practice clinic

 

519

Other clinic

 

Freestanding Clinic

520

Freestanding clinic

 

523

Family practice clinic

 

526

Urgent care clinic

 

529

Other freestanding clinic

 

Skilled Nursing (Home Health)

550

Skilled nursing

Procedure code required

551

Skilled nursing- visit charge

Procedure code required

552

Skilled nursing- hourly charge

Procedure code required

559

Skilled nursing- other

Procedure code required

Medical Social Services (Home Health)

560

Medical social services

Procedure code required

561

Medical social services- visit charge

Procedure code required

562

Medical social services- hourly charge

Procedure code required

569

Medical social services- other

Procedure code required

Home Health Aide (Home Health)

570

Home health aide

Procedure code required

571

Home health aide- visit charge

Procedure code required

572

Home health aide- hourly charge

Procedure code required

579

Home health aide- other

Procedure code required

Other Visits (Home Health)

580

Other visits (home health)

Procedure code required

581

Other visits (home health)- visit charge

Procedure code required

582

Other visits (home health)- hourly charge

Procedure code required

589

Other visits (home health)- other

Procedure code required

Magnetic Resonance Technology (MRT)

610

Magnetic resonance imaging- general classification

Procedure code required

611

Magnetic resonance imaging- brain (incl brain stem)

Procedure code required

612

Magnetic resonance imaging- spinal cord (incl spine)

Procedure code required

619

Magnetic resonance imaging- other MRI

Procedure code required

Drugs Requiring Specific Identification

630

Drugs requiring specific identification

 

631

Drugs requiring specific identification, single source drug

 

632

Drugs requiring specific identification, multiple source drug

 

633

Drugs requiring specific identification, restrictive prescription

 

634

Drugs requiring specific identification, erythro­poietin (EPO) less than 10,000 units

 

635

Drugs requiring specific identification, erythro­poietin (EPO) 10,000 or more units

 

636

Drugs requiring specific identification, drugs requiring detailed coding

 

Hospice Service

650

Hospice services

 

651

Routine home care

 

652

Continuous home care - 1/2 (at least 8 but less than 16 hrs care)

 

655

Inpatient respite care

 

656

General inpatient care/non-respite

 

657

Physician

 

659

Hospice services - other

 

Cast Room

700

General classification

 

709

Other cast room

 

Recovery Room

710

General classification

 

719

Other recovery room

 

Labor Room/Delivery

720

General classification

 

721

Labor

 

722

Delivery

 

723

Circumcision

 

724

Birthing center

 

729

Other labor room/delivery

 

Electrocardiogram (EKG/ECG)

730

General classification

Procedure code required

731

Holter monitor

Procedure code required

732

Telemetry

Procedure code required

739

Other EKG/ECG

Procedure code required

Electroencephalogram (EEG)

740

General classification

Procedure code required

741

Other EEG

Procedure code required

Gastrointestinal Services

750

General classification

 

759

Other gastrointestinal

 

Treatment or Observation Room

760

General classification

 

761

Treatment room

 

762

Observation room

 

769

Other treatment/observation room

 

Preventive Care Services

770

General classification

Procedure code required

771

Vaccine administration

Procedure code required

779

Other preventive care services

Procedure code required

Lithotripsy

790

General classification

Not a benefit

799

Other lithotripsy

Not a benefit

Miscellaneous Dialysis

880

Miscellaneous dialysis

Procedure code required

881

Ultrafiltration

 

Other Diagnostic Services

920

General classification

Procedure code required

921

Peripheral vascular lab

Procedure code required

922

Electromyelogram

Procedure code required

923

Pap smear

Procedure code required

924

Allergy test

Procedure code required

925

Pregnancy test

Procedure code required

929

Other diagnostic service

Procedure code required

943

Cardiac rehabilitation

Procedure code required

Refer to:  The National Uniform Billing Committee (NUBC) website at www.nubc.org for additonal information.

4.5.6Third Party Liability

Refer to:  Subsection 3.7.1, “Medicaid Relationship to Medicare” in this handbook.

“Section 8: Third Party Liability (TPL)” (Vol. 1, General Information).

Other Insurance Form on the TMHP website at www.tmhp.com.

Tort Response Form on the TMHP website at www.tmhp.com.

5 Ambulatory Surgical Center and Hospital Ambulatory Surgical Center

5.1Enrollment

To enroll in Texas Medicaid, an ASC must:

Meet and comply with applicable state and federal laws, rules, regulations, and provisions of the state plan under Title XIX of the Social Security Act.

Be enrolled in Medicare.

Meet and comply with state licensure requirements for ASCs.

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

All hospitals enrolling in Texas Medicaid (except psychiatric and rehabilitation hospitals) are issued an HASC provider number at the time of enrollment.

An out-of-state provider may enroll in Texas Medicaid if it is the customary or general practice for clients in a particular locality to use medical resources in another state. An out-of-state provider located within 50 miles of the Texas border is automatically considered to meet this criterion.

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.

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

The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

5.2Services, Benefits, Limitations, and Prior Authorization

ASCs, both freestanding and hospital-based, provide same day elective surgery for clients who do not require a hospital admission and who are not expected to require extensive postoperative care.

5.2.1Drugs and Supplies

Outpatient prescribed medications are a benefit to eligible clients when obtained through a pharmacy contracted with the Medicaid Vendor Drug Program. Prescribed take-home supplies are a benefit to eligible clients when obtained through Medicaid durable medical equipment (DME).

Refer to:  “Appendix B: Vendor Drug Program” (Vol. 1, General Information) for information about outpatient prescription drugs and the Medicaid Vendor Drug Program.

Subsection 2.2.3, “Medical Supplies” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks).

5.2.2Incomplete Surgical Procedures

Refer to:  Subsection 4.2.3.6, “Incomplete Day Surgeries” in this handbook for information about incomplete surgical procedures.

5.2.3Complications Following Day Surgery Requiring Outpatient Obser­vation or Inpatient Admission

If the client is placed in outpatient observation or inpatient status following an HASC day surgery, the day surgery procedure must still be submitted as an outpatient procedure under the HASC provider identifier.

Refer to:  Subsection 4.2.3.2, “Complications Following Elective or Scheduled Day Surgeries” in this handbook.

Subsection 4.2.3.4, “Emergency or Unscheduled Day Surgeries” in this handbook in this handbook.

5.2.4Planned Admission for Day Surgery

Inpatients may occasionally require a surgery that has been designated as an outpatient procedure. The physician must document the need for this surgery as an inpatient procedure before the procedure is performed. These claims are subject to retrospective review.

5.2.5Cochlear Implants

A cochlear implant is a benefit of Texas Medicaid when medically indicated. ASC and HASC providers may be reimbursed for the implantation procedure using procedure code 69930, and for the cochlear implant devices using procedure code L8614.

Refer to:   Subsection 9.2.22, “Cochlear Implants” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

5.2.6Colorectal Cancer Screening

Procedure codes G0104, G0105, and G0121 are a benefit of Texas Medicaid in the ASC or HASC setting.

5.2.6.1Sigmoidoscopies

Procedure code G0104 may be reimbursed once every 5 years and is limited to one of the following diagnosis codes:

Diagnosis Codes

Z0000*

Z0001*

Z1210

Z1211

Z1213

Z859

Z86010

*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more frequently than recommended by the USPSTF.

5.2.6.2Colonoscopies

Procedure code G0121 may be reimbursed once every ten years for clients who do not meet the criteria for high-risk as recommended by the American Cancer Society (ACS) and USPSTF. Procedure code G0121 must be submitted with one of the following diagnosis codes:

Diagnosis Codes

Z0000*

Z0001*

Z1210

Z1211

Z1213

Z86010

*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more frequently than recommended by the USPSTF.

Procedure code G0105 may be reimbursed once every two years for clients who meet the definition of high-risk. Procedure code G0105 must be submitted with one of the following diagnosis codes:

Diagnosis Codes

K5000

K50011

K50012

K50013

K50014

K50018

K5010

K50111

K50112

K50113

K50114

K50118

K5080

K50811

K50812

K50813

K50814

K50818

K5090

K50911

K50912

K50913

K50914

K50918

K50919

K5120

K51211

K51212

K51213

K51214

K51218

K5130

K51311

K51312

K51313

K51314

K51318

K5180

K51811

K51812

K51813

K51814

K51818

K5190

K51911

K51912

K51913

K51914

K51918

K51919

K523

K5281

K5282

K52831

K52832

K52838

K52839

K5289

K529

Z800

Z8371

Z85038

Z85048

Z859

Z86010

Refer to:  Subsection 9.2.14.2, “* Colorectal Cancer Screening” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

5.2.7Dental Therapy Under General Anesthesia

Facilities must use procedure code 41899 with modifier EP to submit claims for dental therapy under general anesthesia. Prior authorization is not required for ASCs and HASCs unless the client is enrolled in a Medicaid managed care organization.

Refer to:  Subsection 4.2.23, “Dental Therapy Under General Anesthesia” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

Subsection 4.2.24, “Hospitalization and ASC/HASC” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

5.2.8Fluocinolone Acetonide

Procedure code 67027 for implantation may be reimbursed to HASCs. This benefit is limited to clients who are 12 years of age and older and requires prior authorization.

Refer to:  Non-emergency Ambulance Prior Authorization Request on the TMHP website at www.tmhp.com.

Subsection 4.2.11, “Fluocinolone Acetonide” in this handbook.

5.2.9Implantable Infusion Pumps

Implantable infusion pumps are a benefit of Texas Medicaid. Implantable infusion pumps may be medically necessary in the following circumstances:

Administration of intrathecal or epidural antispasmodic drugs to treat refractory intractable spasticity

Administration of intrathecal, epidural, or central venous analgesic (opioid or non-opioid) drugs for treatment of severe chronic intractable pain

Administration of intrahepatic chemotherapy for primary liver cancer or metastatic cancer with metastases limited to the liver

An IIP is not a benefit for the following uses:

Continuous insulin infusion for diabetes

Continuous heparin infusion for recurrent thromboembolic disease

Continuous intralesional infusion for severe chronic intractable pain

Continuous intra-arterial infusion

Continuous intra-articular infusion for severe chronic intractable pain

Administration of antibiotics for osteomyelitis

All supplies associated with an IIP are included with the reimbursement for the surgery to implant the infusion pump and are not reimbursed separately.

Providers may be reimbursed for implantable infusion pumps using procedure codes E0782, E0783, and E0786.

If procedure codes E0782 and E0783 are billed with the same date of service, only one may be reimbursed.

Refer to:  Subsection 9.2.38.39, “Implantable Infusion Pumps” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

5.2.9.1Prior Authorization for Implantable Infusion Pump

Implantable infusion pumps (procedure codes E0782, E0783, and E0786) require prior authorization.

Prior authorization is not required for the physician services associated with the insertion, revision, removal, refilling, or maintenance of the IIP.

Providers must request prior authorization for the implantable infusion pump through the SMPA department with the supporting documentation for medical necessity. Send authorization requests to:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213

Requests for prior authorization can be submitted online through the TMHP website at www.tmhp.com.

Refer to:  Subsection 9.2.38.39.1, “Prior Authorization for Implantable Infusion Pumps” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

5.2.10Stereotactic Radiosurgery

Procedure code S8030 is payable to ASC and HASC facilities. Prior authorization is required.

Refer to:  Subsection 9.2.60.2, “Stereotactic Radiosurgery” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

5.2.11Brachytherapy

The following procedure codes are payable to ASC and HASC facilities:

Procedure Codes

19296

19297

19298

31643

55860

55862

55865

55875

57155

58346

92974

Prior authorization is not required for brachytherapy services.

Refer to:  Subsection 9.2.60, “Radiation Therapy” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

5.2.12Neurostimulators

Neurostimulators are a benefit of Texas Medicaid when medically necessary. All procedures require prior authorization.

Refer to:  Subsection 9.2.43, “Neurostimulators” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Neurostimulator devices may be reimbursed separately from the global fee.

Refer to:  The Texas Medicaid fee schedules on the TMHP website at www.tmhp.com for procedure codes that may be reimbursed to ASC providers.

5.2.13Prior Authorization

Some procedures require the performing provider to obtain prior authorization. When prior authori­zation is required, providers can mail or fax the request to:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4213

Requests for prior authorization can be submitted online through the TMHP website at www.tmhp.com.

5.2.14Gynecological and Reproductive Health and Family Planning Services

The following gynecological and reproductive health services and family planning services procedure codes may be reimbursed to ASC and HASC providers:

Procedure Codes

11976

11981

11982

11983

55250

56620

56805

57335

57410

58260

58262

58353

58356

58541

58545

58546

58550

58552

58555

58558

58559

58560

58561

58562

58563

58565

58600

58615

58670

58671

58673

58674

59150

59151

59840

59841

Refer to:  The Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for additional information about these procedure codes.

The Texas Medicaid fee schedules on the TMHP website at www.tmhp.com for additional information about procedure codes that may be reimbursed to ASC providers.

The online fee lookup (OFL) or the static fee schedules for on the TMHP website at www.tmhp.com for additional information about rate information for individual procedure codes.

5.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including ASC and HASC services. ASC and HASC services are subject to retrospective review and recoupment if documentation does not support the service submitted for reimbursement.

5.4Claims Filing and Reimbursement

5.4.1Claims Information

Freestanding ASC claims must be submitted to TMHP in an approved electronic claims format or on a CMS-1500 paper claim form. Hospital-based ASCs must submit claims to TMHP in an approved electronic claims format or on a UB-04 CMS-1450 paper claim form.

Claims must contain the billing provider’s complete name, address, and a provider identifier. When completing a UB-04 CMS-1450 or a CMS-1500 paper claim form, providers must include all required information on the claim; TMHP does not key any information from claim attachments. Providers must purchase UB-04 CMS-1450 and CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply them.

Scheduled procedures performed in a HASC must be submitted for reimbursement using the HASC provider identifier with TOB 131. Emergency or unscheduled procedures performed in a hospital when the client is an outpatient must be submitted for reimbursement using the hospital provider identifier with TOB 131.

To submit claims for services performed by certified registered nurse anesthetists (CRNAs), an ASC must enroll as a CRNA group provider and indicate the CRNA performing provider identifier on claims for those services.

Refer to:  Section 4, “Certified Registered Nurse Anesthetist (CRNA)” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for specific billing instructions for CRNA services.

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

Section 10, “Claim Form Examples” in this handbook.

5.4.2Reimbursement

Reimbursement of ASC and HASC procedures is based on the CMS-approved Ambulatory Surgical Code Groupings (1 through 9 per CMS and Group 10 per HHSC) payment schedule. Reimbursement is limited to the lesser of the amount reimbursed to an ASC for similar services, the hospital’s actual charge, or the allowable cost determined by HHSC. When multiple surgical procedures are performed on the same day, only the procedure with the highest surgical code grouping is reimbursed. A complete list of approved ASC and HASC procedure codes with the assigned payment group can be found on the TMHP website at www.tmhp.com. Click on Fee Schedules. This list can also be obtained by calling the TMHP Contact Center at 1-800-925-9126.

Claims for physician and CRNA services performed in an ASC or HASC must be submitted under the physician or CRNA provider identifier and are reimbursed separately.

5.4.2.1ASC and HASC Global Services

The ASC or HASC payment represents a global payment and includes room charges and supplies. Covered services provided are submitted as one inclusive charge. All facility services provided in conjunction with the surgery (e.g., laboratory, radiology, anesthesia supplies, medical supplies) are considered part of the global payment and cannot be itemized or submitted separately.

Routine X-ray and laboratory services directly related to the surgical procedure being performed are not reimbursed separately. All nonroutine laboratory and X-ray services provided with emergency condi­tions may be submitted separately with documentation that the complicating condition arose after the initiation of the surgery.

Medical and prosthetic devices such as intraocular lenses may be supplied by the ASC or HASC and implanted, inserted, or otherwise applied during a covered surgical procedure and is considered part of the global surgical fee.

Exception:Certain pieces of equipment, (e.g., cochlear implants, implantable infusion pumps, and neurostimulator devices) may be reimbursed separately from the ASC or HASC global rate.

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 4.2.3, “Day Surgery” in this handbook for information about HASCs.

5.4.2.2NCCI 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.

6 Military Hospitals

6.1Military Hospital Enrollment

To enroll in Texas Medicaid, a military hospital must be certified by Medicare, have a valid provider agreement with HHSC, and have completed the TMHP enrollment process. Veterans Administration (VA) hospitals are eligible to receive Texas Medicaid payment only on claims that have crossed over from Medicare.

Military hospital providers must comply with CLIA rules and regulations. Providers who do not comply with CLIA will not be reimbursed for laboratory services.

6.2Services, Benefits, Limitations and Prior Authorization

6.2.1Military Hospital Inpatient Services

Inpatient hospital services include medically necessary items and services ordinarily furnished by a Medicaid hospital or by an approved out-of-state hospital under the direction of a physician for the care and treatment of inpatient clients. Reimbursement to hospitals for inpatient services is limited to the Medicaid “spell of illness.” The spell of illness is defined as “30 days of inpatient hospital care, which may accrue intermittently or consecutively.”

After 30 days of inpatient care have been provided, reimbursement for additional inpatient care is not considered until the client has been out of an acute care facility for 60 consecutive days. Exceptions are made in the following instances:

THSteps-eligible clients do not have a 30-day spell of illness limitation, if medically necessary condi­tions exist (covered under THSteps-CCP).

Refer to:  The Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

Subsection 3.1.2, “Spell of Illness” in this handbook.

Hospitals may submit information only claims to TMHP when one of the following situations exists:

The inpatient 30-day spell of illness benefit is exhausted.

Payment that was made by a third party resource or other insurance exceeds the Medicaid allowed amount.

For clients who are 21 years of age and older, there is an inpatient expenditure cap of $200,000 per benefit year (November 1 through October 31). Claims are reviewed retrospectively, and payments exceeding $200,000 will be recouped.

It is appropriate to submit information only claims using TOB 110.

The following hospital services must be medically necessary and are subject to the utilization review requirements of Texas Medicaid. Medicaid reimbursement for services cannot exceed the limitations of Texas Medicaid.

Inpatient hospital services include the following items and services:

Bed and board in semiprivate accommodations or in an intensive care or coronary care unit, including meals, special diets, and general nursing services; or an allowance for bed and board in private accommodations, including meals, special diets, and general nursing services up to the hospital’s charge for its most prevalent semiprivate accommodations. Bed and board in private accommodations are provided in full if required for medical reasons, as certified by the physician. Additionally, the hospital must document the medical necessity for a private room, such as the existence of a critical or contagious illness or a condition that could result in disturbance to other patients. This type of information is included in Block 80 or attached to the claim.

Whole blood and packed red cells that are reasonable and necessary for treatment of illness or injury, provided they are not available without cost.

All medically necessary services or supplies ordered by a physician.

Medicaid benefits are not available for take-home or self-administered drugs or personal comfort items except when received by prescription through the VDP.

Only inpatient claims that have an emergency diagnosis on the claim are considered for reimbursement.

6.2.2Military Hospital Outpatient and Physician Services

Although Medicare reimburses for emergency outpatient and inpatient services, Medicaid does not reimburse for either outpatient or physician services. Military hospitals are not reimbursed for outpa­tient day surgery.

6.2.3Prior Authorization

Prior authorization is not required for services rendered in military hospitals.

6.3Documentation Requirements

All services require documentation to support the medical necessity of the service rendered, including military hospital services. Military hospital services are subject to retrospective review and recoupment if documentation does not support the service submitted for reimbursement.

6.3.1Documentation for Nursing Facility Admissions

The admission Minimum Data Set (MDS) must be used for admissions to a nursing facility. There are instances in which hospital social workers and discharge nurses might also complete the admission MDS, such as:

If the client is in a long-term care acute center.

If the potential receiving nursing facility wants a better clinical picture of the client, a paper copy of the admission MDS is completed by the hospital staff before the client is accepted for admission into the nursing facility.

Refer to:  The Long Term Care Program page on the TMHP website at www.tmhp.com for additional information, including instructions for all forms and assessments.

6.4Claims Filing and Reimbursement

6.4.1Military Hospital Claims Information

If TOB 110 is used to submit a claim, all charges must be noncovered and the claim will finalize with EOB 217, “Payment reduced through hospital action.”

It is appropriate to submit information only claims using TOB 110.

Military hospitals may submit total charges in one line with appropriate accommodation revenue codes. Emergency hospital services must be submitted to TMHP in an approved electronic format or on the UB-04 CMS-1450 paper claim form. Providers may purchase claim forms from the vendor of their choice. TMHP does not supply the forms.

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

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

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 claims supplements.

Refer to:  Subsection 6.6, “UB-04 CMS-1450 Paper Claim Filing Instructions” in “Section 6: Claims Filing” (Vol. 1, General Information) for paper claims completion instructions. Blocks that are not referenced are not required for processing by TMHP and may be left blank.

Military Hospital (Emergency Inpatient) on the TMHP website at www.tmhp.com for a claim form example.

6.4.2Military Hospital Reimbursement

Reimbursement is limited to claims submitted for emergency inpatient care only.

Allowed inpatient hospital stays are reimbursed according to a prospective payment methodology based on DRGs. The reimbursement method itself does not affect inpatient benefits and limitations. Texas Medicaid requires that one claim be submitted for each inpatient stay with appropriate diagnosis and procedure code sequencing. Providers must submit only one claim per inpatient stay to Medicaid, regardless of the diagnosis, to ensure accurate payment. The DRG reimbursement includes all facility services provided to the client while registered as an inpatient.

Reimbursement to hospitals for inpatient services is limited to $200,000 per client, per benefit year (November 1 through October 31). This limitation does not apply to services related to certain organ transplants or services to clients who are 20 years of age and younger and covered by the CCP.

Military hospitals should keep a Medicaid client as an inpatient for only the length of time necessary to stabilize the client. The Medicaid client, once stabilized, should be transferred to the nearest Medicaid acute care hospital facility for further treatment.

When more than one hospital provides care for the same client, the hospital that furnishes the most significant amount of care receives consideration for a full DRG payment.

The other hospital is paid a per diem rate based on the lesser of the mean length of stay for the DRG or eligible days in the facility.

Client transfers within the same facility or readmissions to the same facility within 24 hours of a previous acute hospital or facility discharge are considered one continuous stay. These readmissions are considered a continuous stay regardless of the original or readmission diagnosis. Texas Medicaid does not recognize specialty units within the same hospital as separate entities; therefore, these transfers must be included in one submission under the provider identifier. Admissions that were submitted inappro­priately are identified and denied during the utilization review process and may result in an intensified review.

After all hospital claims have been submitted, TMHP performs a post-payment review to determine if the hospital furnishing the most significant amount of care received the full DRG. If the review reveals that the hospital furnishing the most significant amount of care did not receive the full DRG, an adjustment is initiated.

The inpatient DRG reimbursement includes payment for all radiology and laboratory services, including those sent to referral laboratories.

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.

7 Claims Resources

Refer to the following sections and forms when filing claims:

Resource

Location

Acronym Dictionary

“Appendix D: Acronym Dictionary” (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)

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)

8 Contact TMHP

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

9 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

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

Texas Medicaid - Title XIX Acknowledgment of Hysterectomy Information

Non-emergency Ambulance Prior Authorization Request

Psychiatric Inpatient Extended Stay Request Form

Radiology Prior Authorization Request Form

Sterilization Consent Form Instructions

Sterilization Consent Form (English)

Sterilization Consent Form (Spanish)

10 Claim Form Examples

The following linked claim form examples can also be found on the Claim Form Examples page of the Provider section of the TMHP website at www.tmhp.com:

Claim Form Examples

Ambulatory Surgical Center

Hospital-Based ASC

Hospital Inpatient

Military Hospital (Emergency Inpatient)