Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook

 

1 General Information

The information in this handbook is intended for Texas chiropractors, nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), certified registered nurse anesthetists (CRNA), podiatrists, geneticists, maternity service clinics, physicians, and physician assistants. The handbook provides information about Texas Medicaid’s benefits, policies, and procedures.

Important:All providers are required to read and comply with “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information). In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide healthcare 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 may also be subject to Texas Medicaid sanctions for failure, at all times, to deliver healthcare 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:  “Section 1: Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Subsection 2.2, “Provider Enrollment and Responsibilities” in the Medicaid Managed Care Handbook (Vol. 2, Provider Handbooks).

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

For information on Advanced Practice Registered Nurses (APRNs), refer to:

Section 3, “Certified Nurse Midwife (CNM)” in this handbook.

Subsection 4.1, “Enrollment” in this handbook for information about CRNAs.

Subsection 5.2, “Services, Benefits, Limitations, and Prior Authorization” in this handbook for information about geneticists.

Subsection 8.1, “Enrollment” in this handbook for information about NPs and CNSs

Section 9, “Physician” in this handbook.

1.1Payment Window Reimbursement Guidelines for Services Preceding an Inpatient Admission

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

These reimbursement guidelines do not apply in the following circumstances:

The professional services are rendered in the inpatient hospital setting.

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

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

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

2 Chiropractic Manipulative Treatment (CMT)

2.1Enrollment

To enroll in Texas Medicaid, a doctor of chiropractic medicine (DC) must be licensed by the Texas Board of Chiropractic Examiners and enrolled as a Medicare provider.

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

2.2Services, Benefits, Limitations, and Prior Authorization

CMT performed by a chiropractor licensed by the Texas State Board of Chiropractic Examiners is a benefit of Texas Medicaid.

CMT is limited to an acute condition or an acute exacerbation of a chronic condition for a maximum of 12 visits in a consecutive 12-month period, and a maximum of one visit per day. The 12-month period consists of 12 consecutive months, beginning with the date the client receives the first treatment.

If the condition persists more than 180 days from the start of therapy, the condition is considered chronic, and treatment is no longer considered acute.

CMT is not a benefit of Texas Medicaid for maintenance therapy when:

Further clinical improvement cannot reasonably be expected from continuous ongoing care.

The chiropractic treatment becomes supportive rather than corrective in nature.

CMT may be reimbursed when billed using procedure codes 98940, 98941, or 98942.

Procedure codes 98940, 98941, and 98942 must be submitted with the AT modifier. The AT modifier is used to identify treatment provided for an acute condition or an exacerbation of a chronic condition that persists for 180 days or less from the start date of treatment. Providers may file an appeal for a claim denied beyond the 180 days of treatment with documentation supporting that further clinical improvement can be reasonably expected, maximal improvement has not been reached, and further improvement has not ceased.

Procedure code 98940 will be denied as part of another service when billed for the same date of service as 98941 or 98942 by any provider.

Procedure code 98941 will be denied as part of another service when billed for the same date of service as 98942 by any provider.

Texas Medicaid does not reimburse chiropractors for X-ray services, office visits, injections, supplies, appliances, spinalator treatments, laboratory services, physical therapy, or other adjunctive services furnished by themselves or by others under their orders or directions. Additionally, braces or supports, even though ordered by a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) and supplied by a chiropractor are not reimbursable items.

CMT is reimbursed only for a diagnosis of subluxation of the spine. The level of subluxation must be indicated by the appropriate diagnosis codes listed below:

Diagnosis Codes

M9900

M9901

M9902

M9903

M9904

M9905

M9908

2.2.1Prior Authorization

Prior authorization is not required for CMT services.

2.3Documentation Requirements

Manipulations must be provided in accordance with an ongoing, written treatment plan that supports medical necessity of an acute condition or an acute exacerbation of a chronic condition.

Documentation that supports medical necessity for the treatment plan includes all of the following:

Diagnosis

Region(s) treated

Degree of severity

Impairment characteristics

Physical examination findings, X-ray, or other pertinent findings

Specific statements of short- and long-term goals

A reasonable estimate of when the goals will be reached (estimated duration of treatment)

Frequency of treatment (number of times per week)

Equipment and/or the techniques utilized

The treatment plan must be updated as the client’s condition changes. Treatment plans must be maintained in the medical records and are subject to retrospective review.

2.4Claims Filing and Reimbursement

2.4.1Claims Information

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

When completing a CMS-1500 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

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

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

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

2.4.2Reimbursement

The Medicaid rates for chiropractic manipulative treatment (CMT) are reimbursed in accordance with 1 TAC §355.8081 and 355.8085. See the online fee lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

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

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

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 Certified Nurse Midwife (CNM)

3.1Provider Enrollment

To enroll in Texas Medicaid, a CNM must be licensed as a registered nurse and as an advanced practice registered nurse (APRN) by the Texas Board of Nursing (BON), and be authorized to practice as a nurse-midwife. A registered nurse under the multistate licensure compact may be licensed in another state but certified as an APRN for the state of Texas by the Texas BON. Texas Medicaid accepts a signed letter of certification from the Texas BON as documentation of appropriate licensure and certification for enrollment.

Refer to:  The HHSC website at www.healthytexaswomen.org for information about family planning and the locations of family planning clinics that receive funding from the HHSC Family Planning Program.

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

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

All APRNs (including CNMs, CRNAs, CNSs, and NPs) are enrolled within the categories of practice as determined by the Texas BON. CNSs and NPs must enroll as an APRN; CNMs and CRNAs may enroll using their specific titles.

A CNM must identify the licensed physician or group of physicians with whom there is an arrangement for referral and consultation if medical complications arise. Upon initial enrollment and upon re-enrollment, the CNM must complete and submit to TMHP, along with the Texas Medicaid Provider Enrollment Application, the Physician’s Letter of Agreement form that affirms the CNM’s referring or consulting physician arrangement. A separate letter of agreement must be submitted for each physician or group of physicians with whom an arrangement is made. This agreement must be signed by the CNM and the physician. The collaborating physician does not have to be a participating provider in Texas Medicaid. According to TAC, §354.1252 (3), if the collaborating physician or group is not a participating provider in Texas Medicaid, the CNM must inform clients of their potential financial responsibility. If the arrangement is changed or canceled, the CNM must notify TMHP Provider Enrollment in writing and a new letter of agreement must be completed and submitted to TMHP within 10 business days of the change or cancellation.

CNMs are encouraged to participate in or make referrals to family planning agencies.

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

Subsection 5.2, “Enrollment” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information about enrollment in the THSteps Program.

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

3.1.1Enrollment in Texas Health Steps (THSteps)

CNMs may enroll as providers of THSteps medical checkups for newborns and adolescent females.

3.2Services, Benefits, Limitations, and Prior Authorization

CNM providers may be reimbursed for family planning, obstetrical, neonatal, and primary care services.

3.2.1Deliveries

CNM providers may be reimbursed for procedure code 59409, 59410, 59612, or 59614 for delivery services.

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

3.2.2Newborn Services

Routine newborn care may be reimbursed to CNM providers.

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

Subsection 9.2.44, “Newborn Services” in this handbook for additional guidelines and limitations.

3.2.3Prenatal and Postpartum Services

CNM and physician providers are limited to a combined total of 20 outpatient prenatal care visits and 1 postpartum care visit per pregnancy. Normal pregnancies are anticipated to require around 11 visits per pregnancy and high-risk pregnancies are anticipated to require around 20 visits per pregnancy. If more than 20 visits are medically necessary, the provider can appeal with documentation supporting pregnancy complications. The high-risk client’s medical record documentation should reflect the need for increased visits and is subject to retrospective review.

When billing for prenatal services, use modifier TH with the appropriate evaluation and management procedure code to the highest level of specificity.

Postpartum care provided after discharge must be billed using procedure code 59430. Only one postpartum visit is allowed per pregnancy.

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

3.2.4Laboratory and Radiology Services

Laboratory (including pregnancy tests) and radiology services that are rendered during pregnancy must be billed separately from prenatal care visits.

3.2.5Prior Authorization

Prior authorization is not required for any of these services except delivery in the home. For prior autho­rization of a home delivery and the related supplies (procedure code S8415), the CNM must submit a written request for prior authorization during the client’s third trimester of pregnancy. The CNM must include a statement signed by a licensed physician who has examined the client during the third trimester and determined at that time that she is not at high risk and is suitable for a home delivery. Documentation must also include a plan for access to emergency transport for mother and neonate, if needed. Requests for home delivery prior authorizations must be submitted to the TMHP Medical Director at the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
Fax: 1-512-514-4213

Claims submitted for home deliveries performed by a CNM without prior authorization will be denied.

3.2.6Documentation Requirements

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

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

3.2.7Claims Filing and Reimbursement

CNMs must bill maternity services in one of two ways: itemizing each service individually on one claim form and filing at the time of delivery (the filing deadline is applied to the date of delivery) or itemizing each service individually and submitting claims as the services are rendered (the filing deadline is applied to each individual date of service).

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

When completing a CMS-1500 claim form all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

According to 1 TAC §355.8161(a), the Medicaid rate for CNMs is 92 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections.

Note:CNM providers who are enrolled in Texas Medicaid as THSteps providers also receive 92 percent of the rate paid to a physician for THSteps services when a claim is submitted with their THSteps provider identifier as the billing provider.

Physicians who submit a claim using the physician’s own provider identifier for services provided by a CNM must submit modifier SB on each claim detail if the physician does not make a decision regarding the client’s care or treatment on the same date of service as the billable medical visit.

Physicians may be reimbursed 92 percent of the established reimbursement rate for services provided by a CNM if the physician does not make a decision regarding the client’s care or treatment on the same date of service as the billable medical visit. This 92 percent reimbursement rate does not apply to laboratory services, X-ray services, and injections provided by a CNM.

Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

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

Refer to:  Subsection 4.1, “General Medicaid Eligibility” in “Section 4: Client Eligibility” (Vol. 1, General Information) for information about crossover payments.

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

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

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

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.

4 Certified Registered Nurse Anesthetist (CRNA)

4.1Enrollment

To enroll in Texas Medicaid, a CRNA must be licensed as a registered nurse (RN) and as an APRN by the Texas BON and must be currently certified by the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists. An RN under the multistate licensure compact may be licensed in another state but certified as an APRN for the state of Texas by the Texas BON. Texas Medicaid accepts a signed letter of certification from the Texas BON as acceptable documentation of appropriate licensure and certification for enrollment.

Medicare enrollment is a prerequisite for enrollment as a Medicaid provider. A current copy of the provider’s Council on Certification of Nurse Anesthetists or Recertification of Nurse Anesthetists Certificate must be submitted with the Medicaid provider enrollment application.

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

4.2Services, Benefits, Limitations, and Prior Authorization

Medically necessary services that are performed by a CRNA are benefits if the services are within the scope of the CRNA’s practice as defined by state law; are prescribed, supervised by, and provided under the direction of a supervising physician (MD or DO), dentist, or podiatrist licensed in the state in which they practice and to the extent allowed by state law; and are provided under one of the following conditions:

There is no physician anesthesiologist on the medical staff of the facility where the services are provided (e.g., rural settings).

There is no physician anesthesiologist available to provide the services, as determined by the policies of the facility in which the services are provided.

The physician, dentist, or podiatrist who performs the procedure that requires the services specifi­cally requests the services of a CRNA.

The eligible client who requires the services specifically requests the services of a CRNA.

The CRNA is scheduled or assigned to provide the services according to the policies of the facility in which the services are provided.

The services are provided by the CRNA in connection with a medical emergency.

Texas Medicaid does not reimburse the CRNA for equipment, drugs, or supplies.

Refer to:  Subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for information about drugs, equipment and supplies.

4.2.1Prior Authorization

Services performed by a CRNA are subject to the same prior authorization guidelines as services performed by other provider types.

4.3Documentation Requirements

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

4.4Claims Filing and Reimbursement

4.4.1Claims Information

All CRNA services must be billed with a CRNA individual provider identifier or a CRNA group provider identifier. No payment for CRNA services will be made under a hospital or physician provider identifier.

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

When completing a CMS-1500 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

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

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

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

Subsection 9.2.6.9.3, “CRNA and AA Services” in this handbook for more information on billing for CRNA services.

4.4.1.1Interpreting the R&S Report

The Billed Qty field on the Remittance and Status (R&S) Report reflects only the number of time units TMHP processes. The Relative Value Units (RVUs) assigned for the procedure code are not shown in the Billed Qty field.

4.4.2Reimbursement

A CRNA is reimbursed the lesser of either the CRNA’s billed charges or 92 percent of the reimbursement for the same service paid to a physician (M.D. or D.O.) other than an anesthesiologist in accordance with 1 TAC §355.8221. A CRNA under the supervision of an anesthesiologist is reimbursed the lesser of the billed charges or 50 percent of the calculated payment for a supervised anesthesia service.

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

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

Refer to:  Subsection 9.2.6.8, “Reimbursement Methodology” in this handbook for more information about flat fees and time based fees.

5 Geneticists

5.1Enrollment

5.1.1Geneticists

Geneticists may enroll in Texas Medicaid as both a physician or physician group and as a geneticist. Enrollment as a geneticist allows enhanced reimbursement for specific procedure codes when a claim is submitted using the geneticist provider identifier.

A provider of genetic services that wishes to enroll in Texas Medicaid as a geneticist must complete the required Medicaid provider enrollment application forms and enter into a written agreement with HHSC. Texas Medicaid provider enrollment forms are available from TMHP, and may be downloaded on the TMHP website at www.tmhp.com. Completed applications are submitted to:

Texas Medicaid & Healthcare Partnership
Provider Enrollment
PO Box 200795
Austin, TX 78720

Prior to enrollment, applicant qualifications for the provision of genetic services are verified and approved by DSHS. Verification and approval are administered through the Newborn Screening Unit. Basic contract requirements are as follows:

The provider must be a clinical geneticist (MD or DO) who is board eligible or board certified by the American Board of Medical Geneticists (ABMG).

Note:Board eligible providers are required to provide documentation reflecting completion of education requirements in a residency program in genetics.

The provider must use a team of professionals to provide genetic evaluative, diagnostic, and counseling services. The team rendering the services must consist of professional staff including the clinical geneticist and at least one of the following: nurse, social worker, medical geneticist, or genetic counselor.

Upon DSHS approval, TMHP issues a provider identifier and a performing provider identifier for the provision of genetic services.

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

5.2Services, Benefits, Limitations, and Prior Authorization

Genetic services may be used to diagnose a condition, optimize disease treatment, predict future disease risk, and prevent adverse drug response. Genetic services may be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist and typically include one or more of the following:

Comprehensive physical exams

Diagnosis, management, and treatment for clients with genetically-related health problems

Evaluation of family histories for the client and the client’s family members

Genetic risk assessment

Genetic laboratory tests

Interpretation and evaluation of laboratory test results

Education and counseling of clients, their families, and other medical professionals on the causes of genetic disorders

Consultation with other medical professionals to provide treatment

Pharmacogenetics encompasses the use of information encoded in DNA to help predict responses to medicines and thereby enhance the effectiveness and safety of medicines for individual clients.

Refer to:  Subsection 9.2.40, “Pharmacogenetics” in this handbook for additional information about pharmacogenetics services.

5.2.1Family History

It is important for primary care providers to recognize potential genetic risk factors in a client so that they can make appropriate referrals to a genetic specialist.

Obtaining an accurate family history is an important part of clinical evaluations, even when genetic abnormalities are not suspected. Knowing the family history may help health-care providers identify single-gene disorders or chromosomal abnormalities that occur in multiple family members or through multiple generations. Some genetic disorders that can be traced through an accurate family history include diabetes, hypertension, certain forms of cancer, and cystic fibrosis. Early identification of the client’s risk for one of these diseases can lead to early intervention and preventive measures that can delay onset or improve health conditions.

Using a genetics-specific questionnaire helps to obtain the information needed to identify possible genetic patterns or disorders. The most commonly used questionnaires are provided by the American Medical Association and include the Prenatal Screening Questionnaire, the Pediatric Clinical Genetics Questionnaire, and the Adult History Form.

5.2.2Genetic Tests

Diagnostic tests to check for genetic abnormalities must be performed only if the test results will affect treatment decisions or provide prognostic information. Tests for conditions that are treated symptom­atically are not appropriate since the treatment would not change. Providers who are uncertain whether a test is appropriate are encouraged to contact a geneticist or other specialist to discuss the client’s needs.

Any genetic testing and screening procedure must be accompanied by appropriate non-directive counseling, both before and after the procedure. Information must be provided to the client and family (if appropriate) about the possible risks and purpose and nature of the tests being performed.

The interpretation of certain tests, such as nuchal translucency, requires additional education and experience. Texas Medicaid supports national certification standards when available.

5.2.3Laboratory Practices

For many heritable diseases and conditions, test performance and interpretation of test results require information about client race/ethnicity, family history, and other pertinent clinical and laboratory infor­mation. To facilitate test requests and ensure prompt initiation of appropriate testing procedures and accurate interpretation of test results, the requesting provider must be aware of the specific client infor­mation needed by the laboratory before tests are ordered.

To help providers make appropriate test selections and requests, handle and submit specimens, and provide clinical care, laboratories that perform molecular genetic testing for heritable diseases and conditions must educate providers that request services about the molecular genetic tests the laboratory performs. For each molecular genetic test, the laboratory must provide the following information:

Indications for testing

Relevant clinical and laboratory information

Client race and ethnicity

Family history

Pedigree

Testing performed on a client to provide genetic information for a family member, and testing performed on a non-Medicaid client to provide genetic information for a Medicaid client are not benefits of Texas Medicaid.

5.2.4Genetic Counselors

Genetic counselor services may be billed by a physician when the genetic counselor is under physician supervision and is an employee of the physician. Services provided by independent genetic counselors are not a benefit of Texas Medicaid.

5.2.5Genetic Evaluation and Counseling by a Geneticist

A provider enrolled in Texas Medicaid as a geneticist may bill the following evaluation and management codes and receive an enhanced reimbursement. All other procedure codes must be billed under the geneticist’s individual, group, or laboratory provider identifier.

Procedure Code

Limitations

96040

None

99213

None

99214

None

99215

One per year, any provider

99244

One every three years, per provider

99245

One every three years, per provider

99254

One every three years, per provider

99255

One every three years, per provider

99402

One per pregnancy, per provider*

99404

One every three years, per provider

* Exception: Additional services are allowed when documentation of medical necessity to repeat a procedure accompanies a claim.

One office consultation, performed by a geneticist, (procedure code 99244 or 99245) may be considered for reimbursement if procedure code 99244, 99245, 99254, or 99255 has not been submitted by and reimbursed to that geneticist in the previous three years.

Inpatient consultations, performed by a geneticist, (procedure codes 99254 and 99255) may be considered for reimbursement once every three years even if an office consultation has been reimbursed in the previous three years.

5.2.6Prior Authorization

Prior authorization is not required for services billed by a geneticist.

5.3Documentation Requirements

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

5.4Claims Filing and Reimbursement

5.4.1Claims Information

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

When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

TMHP representatives are available for provider questions about genetic services, such as reimbursement rates and procedures. For more information, call the TMHP Contact Center at 1-800-925-9126.

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

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

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

5.4.2Reimbursement

Genetic services providers are reimbursed according to the established allowable maximum fee schedule. Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

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

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.

6 Licensed Midwife (LM)

6.1Provider Enrollment

To enroll in Texas Medicaid, an LM must be licensed as a midwife by the Texas Midwifery Board.

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

An LM must identify the licensed physician or group of physicians with whom there is an arrangement for referral and consultation if medical complications arise. Upon initial enrollment and upon re-enrollment, the LM must complete and submit to TMHP, along with the Texas Medicaid Provider Enrollment Application, the Physician’s Letter of Agreement form that affirms the LM’s referring or consulting physician arrangement. A separate letter of agreement must be submitted for each physician or group of physicians with whom an arrangement is made. This agreement must be signed by the LM and the physician.

If the arrangement is changed or canceled, the LM must notify TMHP Provider Enrollment in writing and a new letter of agreement must be completed and submitted to TMHP within 10 business days after the change or cancellation.

The referral physician or group does not have to be a participating provider in Texas Medicaid. According to TAC, §354.1253(c), if the referral physician or group is not a participating provider in Texas Medicaid, the LM must inform clients of their potential financial responsibility.

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

6.2Services, Benefits, Limitations, and Prior Authorization

LM providers may be reimbursed for obstetrical and newborn care services provided in a freestanding birthing center that is also enrolled as a Texas Medicaid provider.

6.2.1Deliveries

LM providers may be reimbursed for procedure code 59409 for delivery services.

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

6.2.2Newborn Services

Newborn care procedure codes 99460 and 99463 may be reimbursed to LM providers.

Refer to:  Subsection 9.2.44, “Newborn Services” in this handbook for additional guidelines and limitations.

6.2.3Prenatal Services

LM providers must include modifier TH with the appropriate evaluation and management procedure code (99201, 99202, 99211, or 99212) for prenatal services.

LM providers are limited to a total of 20 outpatient prenatal care visits, performed in a birthing center, per pregnancy. Normal pregnancies are anticipated to require around 11 visits per pregnancy and high-risk pregnancies are anticipated to require around 20 visits per pregnancy. If more than 20 visits are medically necessary, the provider can appeal with documentation supporting pregnancy complications. The high-risk client’s medical record documentation should reflect the need for increased visits and is subject to retrospective review.

If a client is discharged before delivery, LM providers may submit procedure code 99218, 99219, or 99220 for labor services only. Clinical documentation that clearly demonstrates the level of medical decision-making (i.e., moderate or complex) must be included in the client’s medical record. All medical documentation is subject to retrospective review. Services that are not supported by the medical documentation are subject to recoupment.

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

6.2.4Prior Authorization

Prior authorization is not required for services billed by an LM.

6.2.5Documentation Requirements

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

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

6.2.6Claims Filing and Reimbursement

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

When completing a CMS-1500 claim form all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

According to 1 TAC §355.8161 (b), the Medicaid rate for LMs is 70 percent of the rate paid to a physician (doctor of medicine [MD] or doctor of osteopathy [DO]) for the same service.

Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

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

7 Maternity Service Clinics (MSC)

7.1Provider Enrollment

To enroll in Texas Medicaid, MSCs must submit a complete application and meet the following requirements:

Must be a facility that is not an administrative, organizational, or financial part of a hospital.

Must be organized and operated to provide maternity clinic services to outpatients.

Must comply with all applicable federal, state, and local laws and regulations.

Must employ or have a contractual agreement or formal arrangement with a licensed MD or DO who assumes professional responsibility for the services provided to the clinic’s patients.

Must adhere to the Bureau of Maternal and Child Health Maternity Guidelines, dated June 20, 1988, and subsequent revisions issued by the Texas Department of Health, unless otherwise specified by the department or its designee.

Must ensure that services provided to each patient are commensurate with the patient’s risk assessment and are documented in the patient’s medical record.

The supervising physician’s license information must be provided. Providers cannot be enrolled in Texas Medicaid if their licenses are due to expire within 30 days.

Medicare certification is not a prerequisite for MSC enrollment.

7.1.1Physician Responsibility

To meet the requirement to assume professional responsibility for the services provided to the clinic’s clients, the supervising physician must do the following:

See the client at least once

Prescribe the type of care to be provided or approve the client’s plan of care (POC)

Periodically review the need for continued care (if the services are not limited by the prescription)

The physician must base the POC on a risk assessment completed by the physician or by licensed, professional clinic staff. The assessment must be based on findings obtained through a health history, laboratory or screening services, and a physical examination.

7.1.2Case Management Services to High-Risk Individuals

An MSC that wants to bill and receive reimbursement for case management services to high-risk individuals including infants, pregnant adolescents, and women must meet the eligibility criteria for case management services. To be considered for reimbursement for case management for these clients, the MSC must enroll as a group in Case Management for Children and Pregnant Women, and each eligible case manager must enroll as a performing provider.

Refer to:  Section 3, “Case Management for Children and Pregnant Women” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) for case management services provider eligibility criteria.

7.2Services, Benefits, Limitations, and Prior Authorization

Services billed by an MSC are those provided by a physician or by licensed, professional clinic staff and are determined to be reasonable and medically necessary for the care of a pregnant adolescent or woman during the prenatal period and subsequent 60-day postpartum period. MSC benefits do not include deliveries.

MSCs are limited to 20 prenatal care visits and 1 postpartum care visit per pregnancy. Normal pregnancies are anticipated to require around 11 visits per pregnancy and high-risk pregnancies are anticipated to require around 20 visits per pregnancy. If more than 20 visits are medically necessary, the provider can appeal with documentation supporting pregnancy complications. The high-risk client’s medical record documentation must reflect the need for increased visits and is subject to retrospective review.

Procedure codes in the following table are for prenatal and postpartum care visits:

Procedure Codes

59430*

99201-TH

99202-TH

99203-TH

99204-TH

99205-TH

99211-TH

99212-TH

99213-TH

99214-TH

99215-TH

* Procedure code 59430 is not submitted with modifier TH

Note: The prenatal visits must be billed with modifier TH

Providers must bill the most appropriate new or established prenatal visit code or postpartum visit code. New patient codes may be used when the client has not received any professional services from the provider, or another provider of the same specialty who belongs to the same group practice, within the past three years (36 months).

An MSC may be reimbursed for prenatal and postpartum care visits only. Hemoglobin, hematocrit, and urinalysis procedures are included in the charge for prenatal care and not separately reimbursed. Services other than prenatal and postpartum care visits will be denied. MSCs that are enrolled in Case Management for Children and Pregnant Women as a group may be reimbursed for these services under the group provider identifier assigned to their facility.

Medical services must be furnished on an outpatient basis by the physician or by licensed, professional clinic staff under the direction of the physician and must be within the staff’s scope of practice or licensure as defined by state law. Although the physician does not necessarily have to be present at the clinic when services are provided, the physician must assume professional responsibility for the medical services provided at the clinic and ensure through approval of the POC that the services are medically appropriate. The physician must spend as much time in the clinic as is necessary to ensure that clients are receiving medical services in a safe and efficient manner in accordance with accepted standards of medical practice.

MSCs must follow the procedures outlined throughout this manual. All service, frequency, and documentation requirements are applicable.

Providers submitting charges for high-risk prenatal care must document the high-risk diagnosis on the claim form and document the condition in the client’s medical record.

7.2.1Initial Prenatal Care Visit Components

The following initial prenatal care visit components should be completed as early as possible in the client’s pregnancy.

7.2.1.1History

History includes OB-GYN, present pregnancy, medical and surgical, substance use, environmental, nutritional, psychosocial (including violence), and family support system.

7.2.1.2Physical Examination

Physical examination includes height, weight, blood pressure; head, neck, lymph, breasts, heart, lungs, back, abdomen, pelvis, rectum, extremities, and skin; and uterine size, fetal heart rate, and location.

7.2.1.3Laboratory Tests

The initial hematocrit or hemoglobin and each subsequent hematocrit or hemoglobin is included in the visit fee and is not separately reimbursable to MSCs.

The laboratory services listed may not be billed using the MSC provider identifier. These services may be ordered by MSC personnel and provided by a reference laboratory.

MSCs must supply the client’s Medicaid number and the MSC provider identifier to the reference laboratory when laboratory services are requested.

The laboratory services requested by an MSC may include, but are not limited to, the following:

Hemoglobin, hematocrit, or complete blood count (CBC)

Urinalysis

Blood type and Rh

Antibody screen

Rubella antibody titer

Serology for syphilis

Hepatitis B surface antigen

Cervical cytology

Other laboratory tests

The following tests may be performed at the initial prenatal care visit, as indicated:

Pregnancy test

Gonorrhea test

Urine culture

Sickle cell test

Tuberculosis (TB) test

Chlamydia test

As stated in the Health and Safety Code §81.090, screening for Hepatitis B virus infection, HIV, and Syphilis must be performed at the initial prenatal care visit. In addition, HIV testing must be performed in the third trimester. HBV and Syphilis must be performed at labor and delivery.

Multiple marker screens for neural tube defects must be offered if the client initiates care between 16 and 20 weeks.

7.2.1.4Assessment

Assessment includes pregnancy, general health, medical, and psychosocial.

7.2.1.5Plan

Plan includes pregnancy, preventive health, medical, and referral as indicated.

7.2.1.6Education and Counseling

Education and counseling includes pregnancy, delivery, nutrition, breast-feeding, family planning, and preventive health. The education and counseling should also include the need for a medical home and information about THSteps medical and dental checkups for the client.

The complete physical examination may be completed at the second visit if the MSC’s routine involves a two-stage initial evaluation.

7.2.2Subsequent Prenatal Care Visits

The following is a recommended guide for the frequency of subsequent prenatal visits for a regular pregnancy:

One visit every 4 weeks for the first 28 weeks of pregnancy.

One visit every 2 to 3 weeks from 28 to 36 weeks of pregnancy.

One visit per week from 36 weeks to delivery.

More frequent visits may be medically necessary. Physicians, CNMs, and MSCs are limited to 20 prenatal care visits per pregnancy and 1 postpartum care visit per pregnancy after discharge from the hospital, without documentation of a complication of pregnancy.

Each subsequent visit must include the following:

Interim History

Problems

Maternal status

Fetal status

7.2.2.1Physical Examination

The physical examination must include the following:

Weight and blood pressure

Fundal height, fetal position and size, and fetal heart rate

Extremities

7.2.2.2Laboratory Tests

Required laboratory tests include the following:

Urinalysis for protein and glucose every visit

Note:The urinalysis for protein and glucose, hemoglobin, and hematocrit is included in the visit fee and is not separately reimbursable to MSCs.

Hematocrit or hemoglobin repeated once a trimester and at 32 to 36 weeks of pregnancy

Multiple marker screen for fetal abnormalities offered at 16 to 20 weeks of pregnancy

Repeated antibody screen for Rh negative women at 28 weeks (followed by Rho immune globulin administration if indicated)

Gestational diabetes screen at 24 to 28 weeks of pregnancy, one hour post 50 gram glucose load

Blood sample for HBsAg screening at the first examination and visit followed by a second blood sample for HBsAg screening on admission for delivery

Other laboratory tests as indicated by the medical condition of the client

7.2.3Postpartum Care Visit

Postpartum care provided by MSCs must be billed using procedure code 59430. A maximum of 1 postpartum visit is allowed per pregnancy.

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

7.2.4Prior Authorization

Prior authorization is not required for services rendered in MSCs.

7.3Documentation Requirements

Each client must have a complete and accepted standard medical record with documentation for the initial visit with procedures, as well as each subsequent visit with procedures. Such records must be made available when requested by HHSC or TMHP for utilization and quality assurance reviews as required by federal regulations. The documentation record or a true copy or narrative abstract must be sent to the hospital of delivery by the client’s 35th week of pregnancy. The record must be made available to the client if the client transfers care to another institution. Records completed by licensed professional clinic staff under the direction of a physician must be signed by the supervising physician.

7.4Claims Filing and Reimbursement

MSC services must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

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

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

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

MSCs are reimbursed in accordance with 1 TAC §355.8081. Providers can refer to the OFL or the appli­cable fee schedule on the TMHP website at www.tmhp.com.

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

Note:Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.

8 Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS)

For other APRNs, see Section 4, “Certified Registered Nurse Anesthetist (CRNA)” in this handbook for information regarding CRNAs, and Section 3, “Certified Nurse Midwife (CNM)” in this handbook for information about certified nurse midwives (CNMs).

8.1Enrollment

To enroll in Texas Medicaid, an NP or CNS must be licensed as a registered nurse and as an APRN by the Texas BON. A registered nurse under the multistate licensure compact may be licensed in another state but certified as an APRN for the state of Texas by the Texas BON. Texas Medicaid accepts a signed letter of certification from the Texas BON as documentation of appropriate licensure and certification for enrollment.

Providers cannot be enrolled if their license is due to expire within 30 days.

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

All APRNs (including CNMs, CRNAs, CNSs, and NPs) are enrolled within the categories of practice as determined by the Texas BON. CNSs and NPs must enroll as an APRN; CNMs and CRNAs may enroll using their specific titles.

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

Section 3, “Certified Nurse Midwife (CNM)” in this handbook for more information on CNM enrollment.

Section 4, “Certified Registered Nurse Anesthetist (CRNA)” in this handbook for more information on CRNA enrollment.

8.1.1Enrollment in Texas Health Steps (THSteps)

APRNs, including NPs, and CNSs, who are recognized by the Texas BON can enroll as THSteps providers and provide checkup services within their scope of practice. Specific information is found in the Children’s Services Handbook.

Refer to:  subsection 5.2, “Enrollment” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information on enrollment procedures.

8.2Services, Benefits, Limitations, and Prior Authorization

Services performed by NPs and CNSs are benefits if the services meet the following criteria:

Are within the scope of practice for NPs and CNSs, as defined by Texas state law.

Are consistent with rules and regulations promulgated by the Texas BON or other appropriate state licensing authority.

Are covered by Texas Medicaid when provided by a licensed physician (MD or DO).

Are reasonable and medically necessary as determined by HHSC or its designee.

NPs and CNSs who are employed or remunerated by a physician, hospital, facility, or other provider must not bill Texas Medicaid for their services if the billing results in duplicate payment for the same services.

Physicians who submit a claim using the physician’s own provider identifier for services provided by an NP or CNS must submit modifier SA on each claim detail if the physician does not make a decision regarding the client’s care or treatment on the same date of service as the billable medical visit.

Benefit limitation information for services can be found in Section 9, “Physician” in this handbook, the Children’s Services Handbook (Vol. 2, Provider Handbooks), and the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks).

Payment for supplies is not a benefit of Texas Medicaid. Costs of supplies are included in the reimbursement for office visits.

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

Section 9, “Physician” in this handbook.

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

8.2.1Prior Authorization

Services performed by an NP or CNS are subject to the same prior authorization guidelines as services performed by other provider types.

8.3Documentation Requirements

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

8.4Claims Filing and Reimbursement

8.4.1Claims Information

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

When completing a CMS-1500 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements.

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

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

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

8.4.2Reimbursement

According to 1 TAC §355.8281, the Medicaid rate for NPs and CNSs is 92 percent of the rate paid to a physician (MD or DO) for the same professional service and 100 percent of the rate paid to physicians for laboratory services, X-ray services, and injections. When NPs or CNSs bill Medicaid directly for services they performed, they must use their individual provider identifier. If the services are performed by the NP or CNS but billed by a physician or physician group, the billing provider is the physician or physician group. Physicians may be reimbursed 92 percent of the established reimbursement rate for services provided by an NP or CNS if the physician does not make a decision regarding the client’s care or treatment on the same date of service as the billable medical visit. This 92 percent reimbursement rate does not apply to laboratory services, X-ray services, and injections provided by an NP or CNS.

Note:NP and CNS providers who are enrolled in Texas Medicaid as THSteps providers also receive 92 percent of the rate paid to a physician for THSteps services when a claim is submitted with their THSteps provider identifier as the billing provider.

Providers can refer to the OFL or the applicable fee schedule on the TMHP website at www.tmhp.com.

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

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

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.

9 Physician

9.1Enrollment

9.1.1Physicians and Doctors

To enroll in Texas Medicaid to provide medical services, physicians (MD or DO), doctors of dental surgery [DDS], and doctors of podiatric medicine (DPM) must be authorized by the licensing authority of their profession to practice in the state where the services are performed at the time they are provided.

Providers cannot be enrolled in Texas Medicaid if their licenses are due to expire within 30 days. A current Texas license must be submitted.

Important:The Centers for Medicare & Medicaid Services (CMS) guidelines mandate that physicians who provide durable medical equipment (DME) products such as spacers or nebulizers are required to enroll as Texas Medicaid DME providers.

All physicians except gynecologists, pediatricians, pediatric subspecialists, pediatric psychiatrists, and providers performing only Texas Health Steps (THSteps) medical or dental checkups must be enrolled in Medicare before enrolling in Medicaid. TMHP may waive the Medicare enrollment prerequisite for pediatricians or physicians whose type of practice and service may never be billed to Medicare.

9.2Services, Benefits, Limitations, and Prior Authorization

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the use of national coding and transaction standards. HIPAA requires that the American Medical Association’s (AMA) Current Procedural Terminology (CPT) system be used to report professional services, including physician services. Correct use of CPT coding requires using the most specific code that matches the services provided, based on the code’s description. Providers must pay special attention to the standard CPT descriptions for the evaluation and management (E/M) services. The medical record must document the specific elements necessary to satisfy the criteria for the level of services as described in CPT. Reimbursement may be recouped when the medical record documents a different level of service from what is submitted on the claim. The level of service provided and documented must be medically necessary, based on the clinical situation and needs of the client.

To receive reimbursement, providers must document the following information in the client’s medical record:

The service

The date rendered

Pertinent information about the client’s condition supporting the need for the service

The care given

Physician services include those reasonable and medically necessary services ordered and performed by physicians or under physician supervision that are within the scope of practice of their profession as defined by state law.

9.2.1Teaching Physician and Resident Physician

The roles of the teaching physician and resident physician occur in the context of an accredited graduate medical education (GME) training program.

The teaching physician is the Medicaid-enrolled physician who is professionally responsible for the particular services that were provided and are being submitted for reimbursement; the physician must be affiliated and in good standing with an accredited GME program and must possess all appropriate licensure.

Physician services must be performed personally by the teaching physician or by the person to whom the physician has delegated the responsibility. The level of supervision required may be direct or personal.

In all cases, the client’s medical record must clearly document that the teaching physician provided identifiable supervision of the resident. As defined below, the supervision must be direct or personal depending on the setting and the clinical circumstances:

Direct supervision means that the teaching physician must be in the same office, building, or facility when and where the service is provided and must be immediately available to furnish assistance and direction.

Personal supervision means that the teaching physician must be physically present in the room when and where the service is being provided.

Personal supervision by the teaching physician is required during the key portions of all major surgeries and the key portions of all other physician services billed to Texas Medicaid if the immediate super­vision, participation, or intervention of the supervising physician is medically prudent in order to assure the health and safety of the client. Physician services that require personal supervision may include invasive procedures and evaluation and management services that require complex medical decision making. Situations that require personal supervision include those in which:

The clinical condition of the client is unstable or will likely become unstable during, or as a result of, the planned medical intervention.

The planned medical intervention, even under optimal conditions will result in a medically reasonable risk for significant morbidity or death following the procedure.

Deviation from the expected technique at the time the procedure or service is performed presents a medically reasonable, causally-related, foreseeable risk to the patient’s life or health.

This criterion applies regardless of the place of service.

The teaching physician must provide medically appropriate, identifiable direct supervision for all other services that do not require personal supervision.

The following prerequisites apply when the teaching physician submits claims for services performed, in whole or in part, by the resident physician in the inpatient hospital setting, the outpatient hospital setting, and surgical services and procedures.

Note:When requesting services for prior authorization at patient discharge, the signature of the resident on the actual prescription is permitted as long as the Medicaid enrolled attending/supervising physician’s signature appears on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form and on any letters or documentation provided to support medical necessity. The resident’s order and the Title XIX Form signed by the attending/supervising physician must be for the same service.

9.2.1.1Teaching Physician Prerequisites

Services provided in an outpatient setting.

For services provided in an outpatient setting, a face-to-face encounter between the teaching physician providing direct supervision and the client is not required in the context of a GME program. All other requirements for personal or direct supervision in this division must be met for the services to qualify for reimbursement. The following tasks must be performed by the teaching physician and their completion must be documented in the patient’s medical record before the claims are submitted for consideration of reimbursement:

Review the patient’s history and physical examination.

Confirm or revise the patient’s diagnosis.

Determine the course of treatment to be followed.

Assure that any necessary supervision of interns or residents was provided.

Confirm that documentation in the medical record supports the level of service provided.

Exception:Exception for E/M services furnished in certain primary care centers. Teaching physicians that meet the primary care exception under Medicare are allowed to bill for low-level and mid-level E/M services furnished by residents in the absence of a teaching physician. Facilities that meet the primary care exception under Medicare may bill Texas Medicaid, Family Planning, or the Children with Special Health Care Needs (CSHCN) Services Program for new patient services (procedure codes 99201, 99202, and 99203) and established patient services (procedure codes 99211, 99212, and 99213).

Note:All services provided in an outpatient setting that do not qualify for the exception above require that the teaching physician examine the patient.

Services provided in an inpatient setting.

For services provided in an inpatient setting, the teaching physician must demonstrate that medically appropriate supervision was provided. The following tasks must be performed and their completion must be documented in the patient’s medical record before the claims are submitted for consideration of reimbursement. The documentation must be made in the same manner as required by federal regula­tions under Medicare:

Review the patient’s history, review the resident’s physical examination, and examine the patient no later than 36 hours after the patient’s admission and before the patient’s discharge.

Confirm or revise the patient’s diagnosis.

Determine the course of treatment to be followed.

Document the teaching physician’s presence and participation in the major surgical or other complex and dangerous procedure or situation.

Confirm that documentation in the medical record supports the level of service provided.

A face-to-face encounter with the client on the same day as any services provided by the resident physician.

Surgical services and procedures.

The teaching surgeon is responsible for the patient’s preoperative, operative, and postoperative care. The teaching physician must demonstrate that medically appropriate supervision was provided. The following tasks must be performed and their completion must be documented in the patient’s medical record before the claims are submitted for consideration of reimbursement. The documentation must be made in the same manner as required by federal regulations under Medicare:

Review the patient’s history, review the resident’s physical examination, and examine the patient within a reasonable period of time after the patient’s admission and before the patient’s discharge.

Confirm or revise the client’s diagnosis.

Determine the course of treatment to be followed.

Document the teaching physician’s presence and participation in the major surgical or other complex and dangerous procedure or situation.

Important:Reimbursement may be reduced, denied, or recouped if the prerequisites are not documented in the medical record. The documentation must be made in the same manner as required by federal regulations under Medicare.

9.2.2Substitute Physician

Physicians may bill for the service of a substitute physician who sees clients in the billing physician’s practice under either a reciprocal or locum tenens arrangement.

A reciprocal arrangement is one in which a substitute physician covers for the billing physician on an occasional basis when the billing physician is unavailable to provide services. Reciprocal arrangements are limited to a continuous period no longer than 14 days and do not have to be in writing.

A locum tenens arrangement is one in which a substitute physician assumes the practice of a billing physician for a temporary period no longer than 90 days when the billing physician is absent for reasons such as illness, pregnancy, vacation, continuing medical education, or active duty in the armed forces. The locum tenens arrangement may be extended for a continuous period of longer than 90 days if the billing physician’s absence is due to being called or ordered to active duty as a member of a reserve component of the armed forces. Locum tenens arrangements must be in writing.

The substitute physician must be enrolled in Texas Medicaid and must not be on the Texas Medicaid or HHSC Family Planning Program provider exclusion list. The billing provider’s name, address, and national provider identifier must appear in Block 33 of the claim form. The name and office or mailing address of the substitute physician must be documented on the claim in Block 19, not Block 33.

When a physician bills for a substitute physician, modifier Q5 or Q6 must follow the procedure code in Block 24D for services provided by the substitute physician. The Q5 modifier is used to indicate a recip­rocal arrangement and the Q6 modifier is used to indicate a locum tenens arrangement.

When physicians in a group practice bill substitute physician services, the performing provider identifier of the physician for whom the substitute provided services must be in Block 24J.

Physicians must familiarize themselves with these requirements and document accordingly. Those services not supported by the required documentation as detailed above will be subject to recoupment.

9.2.3Aerosol Treatment

Nebulized aerosol treatments (procedure codes 94640, 94644, and 94645) with short-acting beta-agonists are a benefit of Texas Medicaid and considered medically necessary when breathing is compro­mised by certain acute medical conditions. Documentation to support an aerosol treatment for the worsening of an acute or chronic condition must be maintained in the client’s medical record and is subject to retrospective review.

Procedure code 94645 is only a benefit in the outpatient setting, specifically in a hospital emergency department or an urgent care clinic.

Pulse oximetry and evaluation of the client’s use of an aerosol generator, nebulizer, or metered-dose inhaler are considered part of an evaluation and management (E/M) visit and will not be reimbursed separately.

Hypertonic saline used in aerosol therapy will be denied if billed separately.

Refer to:  Subsection 4.2.20.1, “Aerosol Treatment” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks).

9.2.3.1Diagnostic Testing

Nitric oxide expired gas determination (FeNO) measurement (procedure code 95012) is a benefit for Texas Medicaid.

FeNO measurement provided in the physician’s office 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 client who has asthma to anti-inflammatory therapy. FeNO measurement may be reimbursed by Texas Medicaid when the test is used as follows:

To assist in assessing the etiology of respiratory symptoms.

To help identify the eosinophilic asthma phenotype.

To assess potential response or failure to respond to anti-inflammatory agents, particularly inhaled corticosteroids (ICS).

To establish a baseline FeNO during non-exacerbations for subsequent monitoring of chronic persistent asthma.

To guide changes in dosing of anti-inflammatory medications, i.e., step-down dosing, step-up dosing, or discontinuation of anti-inflammatory medications.

To assist in the evaluation of adherence to anti-inflammatory medications.

To assess whether airway inflammation is contributing to respiratory symptoms.

The technical and interpretation components of procedure code 95012 will not be reimbursed separately, as the instrument produces an exhaled nitric oxide (NO) measurement that requires little interpretation. Procedure code 95012 will be limited to once per day and must be submitted with procedure code 94010 or 94060.

If FeNO is measured during an office visit where additional E/M components are fulfilled, a separate E/M procedure code may be reimbursed if it is submitted with modifier 25.

9.2.4Allergy Services

Texas Medicaid uses the following guidelines for reimbursement of allergy services.

9.2.4.1Allergy Immunotherapy

Allergen immunotherapy consists of the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.

Preparation of the allergy vial or extracts is a benefit of Texas Medicaid when preparations are made in accordance with the American Academy of Allergy, Asthma, and Immunology. Claims for preparations should be submitted using the following procedure codes:

Procedure Codes for Preparation of Allergy Vial or Extract

95145

95146

95147

95148

95149

95165

95170

Administration of the allergy extract may be reimbursed using procedure codes 95115 and 95117.

Rapid desensitization may be reimbursed using procedure code 95180 when submitted with diagnosis code Z516.

Allergen immunotherapy is a benefit for clients who have allergy conditions when the following criteria are met:

A diagnosed hypersensitivity to an allergen can be indicated by one of the valid diagnosis codes listed below.

Hypersensitivity cannot be managed by avoidance or pharmacologic therapy to control allergic symptoms, or the client has unacceptable side effects with pharmacologic therapy.

The pharmacologic treatment is refused by the client or leads to significant side effects.

The allergen content is based on appropriate skin testing, and the allergens are prepared for the client individually.

The preparation of the allergy vial or extract and the administration of an injection may be reimbursed for the following diagnosis codes:

Diagnosis Codes

H1045

H6501

H6502

H6503

H6504

H6505

H6506

H65111

H65112

H65113

H65114

H65115

H65116

H65191

H65192

H65193

H65194

H65195

H65196

H6521

H6522

H6523

H65491

H65492

H65493

J301

J302

J305

J3081

J3089

J309

J441

J449

J4520

J4521

J4522

J4530

J4531

J4532

J4540

J4541

J4542

J4550

J4551

J4552

J45901

J45902

J45909

J45998

L500

M041

M042

M048

M049

T531X4A

T531X4D

T531X4S

T532X4A

T532X4D

T532X4S

T533X4A

T533X4D

T533X4S

T534X4A

T534X4D

T534X4S

T536X4A

T536X4D

T536X4S

T59812A

T59812D

T59812S

T63001A

T63001D

T63001S

T63002A

T63002D

T63002S

T63003A

T63003D

T63003S

T63004A

T63004D

T63004S

T63011A

T63011D

T63011S

T63012A

T63012D

T63012S

T63013A

T63013D

T63013S

T63014A

T63014D

T63014S

T63021A

T63021D

T63021S

T63022A

T63022D

T63022S

T63023A

T63023D

T63023S

T63024A

T63024D

T63024S

T63031A

T63031D

T63031S

T63032A

T63032D

T63032S

T63033A

T63033D

T63033S

T63034A

T63034D

T63034S

T63041A

T63041D

T63041S

T63042A

T63042D

T63042S

T63043A

T63043D

T63043S

T63044A

T63044D

T63044S

T63061A

T63061D

T63061S

T63062A

T63062D

T63062S

T63063A

T63063D

T63063S

T63064A

T63064D

T63064S

T63071A

T63071D

T63072A

T63073A

T63073D

T63073S

T63074A

T63074D

T63074S

T63081A

T63081D

T63081S

T63082A

T63082D

T63082S

T63083A

T63083D

T63083S

T63084A

T63084D

T63084S

T63091A

T63091D

T63091S

T63092A

T63092D

T63092S

T63093A

T63093D

T63093S

T63094A

T63094D

T63094S

T63111A

T63111D

T63111S

T63112A

T63112D

T63112S

T63113A

T63113D

T63113S

T63114A

T63114D

T63114S

T63121A

T63121D

T63121S

T63122A

T63122D

T63122S

T63123A

T63123D

T63123S

T63124A

T63124D

T63124S

T63191A

T63191D

T63191S

T63192A

T63192D

T63192S

T63193A

T63193D

T63193S

T63194A

T63194D

T63194S

T632X1A

T632X1D

T632X1S

T632X2A

T632X2D

T632X2S

T632X3A

T632X3D

T632X3S

T632X4A

T632X4D

T632X4S

T63301A

T63301D

T63301S

T63302A

T63302D

T63302S

T63303A

T63303D

T63303S

T63304A

T63304D

T63304S

T63311A

T63311D

T63311S

T63312A

T63312D

T63312S

T63313A

T63313D

T63313S

T63314A

T63314D

T63314S

T63321A

T63321D

T63321S

T63322A

T63322D

T63322S

T63323A

T63323D

T63323S

T63324A

T63324D

T63324S

T63331A

T63331D

T63331S

T63332A

T63332D

T63332S

T63333A

T63333D

T63333S

T63334A

T63334D

T63334S

T63391A

T63391D

T63391S

T63392A

T63392D

T63392S

T63393A

T63393D

T63393S

T63394A

T63394D

T63394S

T63411A

T63411D

T63411S

T63412A

T63412D

T63412S

T63413A

T63413D

T63413S

T63414A

T63414D

T63414S

T63421A

T63421D

T63421S

T63422A

T63422D

T63422S

T63423A

T63423D

T63423S

T63424A

T63424D

T63424S

T63431A

T63431D

T63431S

T63432A

T63432D

T63432S

T63433A

T63433D

T63433S

T63434A

T63434D

T63434S

T63441A

T63441D

T63441S

T63442A

T63442D

T63442S

T63443A

T63443D

T63443S

T63444A

T63444D

T63444S

T63451A

T63451D

T63451S

T63452A

T63452D

T63452S

T63453A

T63453D

T63453S

T63454A

T63454D

T63454S

T63461A

T63461D

T63461S

T63462A

T63462D

T63462S

T63463A

T63463D

T63463S

T63464A

T63464D

T63464S

T63481A

T63481D

T63481S

T63482A

T63482D

T63482S

T63483A

T63483D

T63483S

T63484A

T63484D

T63484S

T63511A

T63511D

T63511S

T63512A

T63512D

T63512S

T63513A

T63513D

T63513S

T63514A

T63514D

T63514S

T63591A

T63591D

T63591S

T63592A

T63592D

T63592S

T63593A

T63593D

T63593S

T63594A

T63594D

T63594S

T63611A

T63611D

T63611S

T63612A

T63612D

T63612S

T63613A

T63613D

T63613S

T63614A

T63614D

T63614S

T63621A

T63621D

T63621S

T63622A

T63622D

T63622S

T63623A

T63623D

T63623S

T63624A

T63624D

T63624S

T63631A

T63631D

T63631S

T63632A

T63632D

T63632S

T63633A

T63633D

T63633S

T63634A

T63634D

T63634S

T63691A

T63691D

T63691S

T63692A

T63692D

T63692S

T63693A

T63693D

T63693S

T63694A

T63694D

T63694S

T63711A

T63711D

T63711S

T63712A

T63712D

T63712S

T63713A

T63713D

T63713S

T63714A

T63714D

T63714S

T63791A

T63791D

T63791S

T63792A

T63792D

T63792S

T63793A

T63793D

T63793S

T63794A

T63794D

T63794S

T63811A

T63811D

T63811S

T63812A

T63812D

T63812S

T63813A

T63813D

T63813S

T63814A

T63814D

T63814S

T63821A

T63821D

T63821S

T63822A

T63822D

T63822S

T63823A

T63823D

T63823S

T63824A

T63824D

T63824S

T63831A

T63831D

T63831S

T63832A

T63832D

T63832S

T63833A

T63833D

T63833S

T63834A

T63834D

T63834S

T63891A

T63891D

T63891S

T63892A

T63892D

T63892S

T63893A

T63893D

T63893S

T63894A

T63894D

T63894S

T6391XA

T6391XD

T6391xS

T6392XA

T6392xD

T6392xS

T6393XA

T6393xD

T6393xS

T6394XA

T6394xD

T6394xS

T65824A

T65824D

T65824S

9.2.4.1.1Prior Authorization for Allergy Immunotherapy

Authorization is not required for immunotherapy services; however, requests for services beyond the established limits of 160 doses per one-year period for procedure code 95165 may be considered for prior authorization with documentation of medical necessity. Documentation must be submitted to the Special Medical Prior Authorization Department and include the following information:

Copy of the allergen testing results

Severity and periodicity of symptoms

Physical limitations created by the symptoms

Concurrent drug treatment

Explanation of how efficacy has not been achieved with prior treatment and the objectives of the new anticipated treatment program

9.2.4.1.2Limitations of Allergy Immunotherapy

The quantity billed for the allergy extract preparation procedure must represent the total number of doses to be administered from the vial. If the number of doses is not stated on the claim, a quantity of one is allowed.

Note:A “dose” is defined as the amount of antigen(s) administered in a single injection from a multidose vial.

Procedure code 95165 is limited to a total of 160 doses per one-year period, which begins the date the immunotherapy is initiated. Additional doses may be considered for reimbursement through prior authorization with documentation of medical necessity. Procedure code 95165 is limited to no more than ten doses per vial.

When an injection is given from a vial, providers should use an administration-only procedure code (95115 or 95117). Reimbursement for the administration is limited to one per day.

An office visit, clinic visit, or observation room visit is not considered for reimbursement in addition to the fee for the preparation or the administration of the allergy vial or extract unless the additional visit results in a non-allergy-related diagnosis or a re-evaluation of the client’s condition. The following E/M procedure codes may be submitted with modifier 25:

Procedure Codes

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99217

99218

99219

99220

Allergen immunotherapy that is considered experimental, investigational, or unproven is not a benefit of Texas Medicaid.

Single dose vials (procedure code 95144) are not a benefit of Texas Medicaid.

9.2.4.2Allergy Testing

Texas Medicaid benefits include allergy testing for clients with clinically significant allergic symptoms. Allergy testing is focused on determining the allergens that cause a particular reaction and the degree of the reaction. Allergy testing also provides justification for recommendations of particular medicines, of immunotherapy, or of specific avoidance measures in the environment.

An initial evaluation of a new patient is considered for reimbursement in addition to allergy testing on the same day.

Established patient visits are not considered for reimbursement in addition to allergy testing on the same day. The allergy testing is considered for reimbursement and the visit is denied as part of another procedure on the same day.

The following allergy tests are benefits of Texas Medicaid:

Percutaneous and intracutaneous skin test. The skin test for IgE-mediated disease with allergenic extracts is used in the assessment of allergy-prone clients. The test involves the introduction of small quantities of test allergens below the epidermis. Procedure codes 95004, 95017, 95018, 95024, 95027, and/or 95028 should be used to submit skin tests for consideration of reimbursement.

Patch or application tests. Patch testing (procedure code 95044) is used for diagnosing contact allergic dermatitis.

Photo or photo patch skin test. Procedure codes 95052 and 95056 may be used for diagnosing contact allergic dermatitis.

Ophthalmic mucous membrane or direct nasal mucous membrane tests. Nasal or ophthalmic mucous membrane tests (procedure codes 95060 and 95065) are used for the diagnosis of either food or inhalant allergies and involve the direct administration of the allergen to the mucosa.

Inhalation bronchial challenge testing (not including necessary pulmonary function tests). Bronchial challenge testing with methacholine, histamine, or allergens (procedure codes 95070 and 95071) is used for defining asthma or airway hyperactivity when skin testing results are not consistent with the client’s medical history. Results of these tests are evaluated by objective measures of pulmonary function.

Procedure code 95199 may be used for an unlisted allergy or clinical immunologic service or procedure if there is not a specific procedure code that describes the service performed. Prior authorization is required for unlisted procedure codes. Every effort must be used to bill with the appropriate CPT code that describes the procedure being performed. If a code does not exist to describe the service performed, prior authorization may be requested using unlisted procedure code 95199 and must be submitted with documentation to assist in determining coverage. The documentation submitted must include all of the following:

The client’s diagnosis

Medical records indicating prior treatment for this diagnosis and the medical necessity of the requested procedure

A clear, concise description of the procedure to be performed

Reason for recommending this particular procedure

A CPT or HCPCS procedure code that is comparable to the procedure being requested

Documentation that this procedure is not investigational or experimental

Place of service (POS) the procedure is to be performed

The physician’s intended fee for this procedure

Prior authorization requests for Texas Medicaid fee-for-service clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department.

The number of allergy tests performed must be indicated on the claim. When the number of tests is not specified, a quantity of one is allowed.

9.2.4.2.1Allergy Blood Tests

Allergy blood testing procedure codes 86001, 86003, and 86005 are a benefit when the test is performed for a reason that includes, but is not limited to, the following:

The client is unable to discontinue medications

An allergy skin test is inappropriate for the client for the following reasons:

The client is pediatric

The client is disabled

The client suffers from a skin condition such as dermatitis

Radioallergosorbent tests (RAST) and multiple antigen simultaneous tests (MAST) are benefits of Texas Medicaid. RAST testing is used to detect specific allergens. RAST testing is usually performed by an independent lab; however, there are physicians who have the capability of performing these tests in their offices. Physicians who submit RAST/MAST tests performed in the office setting must use modifier SU to be considered for reimbursement. Without the use of the SU modifier, RAST/MAST testing submitted with POS 1 (office) is denied with the message, “Lab performed outside of office must be billed by the performing facility.”

RAST/MAST tests must be submitted using procedure codes 86003 and 86005.

Procedure code 86001 is limited to 20 allergens per rolling year, any provider.

Procedure code 86003 is limited to 30 allergens per rolling year, any provider.

Procedure code 86005 is limited to 4 multiallergen tests per rolling year, same provider.

9.2.4.2.2Collagen Skin Test

Collagen skin tests are a benefit of Texas Medicaid using procedure code Q3031. Collagen skin tests are administered to detect a hypersensitivity to bovine collagen. This skin test is given four weeks prior to any type of surgical procedure that utilizes collagen.

Collagen injections that are used for cosmetic surgery are not considered medically necessary and are not a benefit of Texas Medicaid.

9.2.4.2.3Prior Authorization for Collagen Skin Tests

Prior authorization is required for collagen skin test procedure code Q3031.

Prior authorization requests for Texas Medicaid fee-for-service clients must be submitted by the physician to the Special Medical Prior Authorization (SMPA) department.

Prior authorization is not required for other allergy testing procedure codes unless the limits are exceeded. The following medical documentation must be submitted to the SMPA Department with the prior authorization request for additional procedures:

Results of any previous treatment

Documentation that explains why the client’s treatment could not be completed within the policy limits for the requested procedures

Client diagnosis and conditions that support the medical necessity for the additional procedures requested

Client outcomes that the requested procedures will achieve

9.2.4.2.4Ingestion Challenge Test

Ingestion challenge tests are a benefit of Texas Medicaid using procedure code 95076. Ingestion challenge tests are used to confirm an allergy to a food or food additive.

Procedure code 95076 is limited to one service per day, any provider.

9.2.5Ambulance Transport Services - Nonemergency

Nonemergency ambulance services require prior authorization in circumstances not involving an emergency. Facilities and other providers must request and obtain prior authorization before contacting the ambulance provider for nonemergency ambulance services.

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

subsection 2.2.2, “Nonemergency Ambulance Transport Services” in the Ambulance Services Handbook (Vol. 2, Provider Handbooks) for more information about ambulance services.

Subsection 5.1.8, “Prior Authorization for Nonemergency Ambulance Transport” in “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for more information about nonemergency ambulance transport prior authorization.

9.2.6Anesthesia

Anesthesia services are a benefit of Texas Medicaid with specific benefits and limitations to reimbursement.

Medicaid may reimburse anesthesiologists, certified registered nurse anesthetists (CRNAs), and anesthesiologist assistants (AAs) for administering anesthesia as defined within their individual scope of practice.

9.2.6.1Medical Direction by an Anesthesiologist

Medical direction by an anesthesiologist of an anesthesia practitioner (CRNA, AA, or other qualified professional) is a benefit of Texas Medicaid if the following criteria are met:

No more than four anesthesia procedures are being performed concurrently.

The anesthesiologist is physically present in the operating suite.

Exception:Anesthesiologists may be considered for reimbursement when they medically direct more than four anesthesia services or simultaneously supervise a combination of more than four CRNAs, AAs, or other qualified professionals under emergency circumstances only.

Medical direction provided by an anesthesiologist is a benefit of Texas Medicaid if the following criteria are met:

The anesthesiologist performs a preanesthetic examination and evaluation.

The anesthesiologist prescribes the anesthesia plan.

The anesthesiologist personally participates in the critical portions of the anesthesia plan, including induction and emergence.

The anesthesiologist ensures that a qualified professional can perform the procedures in the anesthesia plan that the anesthesiologist does not perform personally.

The anesthesiologist monitors the course of anesthesia administration at intervals.

The anesthesiologist provides direct supervision when medically directing an anesthesia procedure. Direct supervision means the anesthesiologist must be immediately available to furnish assistance and direction.

The anesthesiologist provides postanesthesia care.

The anesthesiologist does not perform any other services (except as noted below) during the same time period. The anesthesiologist who directs the administration of no more than four anesthesia procedures may provide the following without affecting the eligibility of the medical direction services:

Address an emergency of short duration in the immediate area

Administer an epidural or caudal anesthetic to ease labor pain

Provide periodic, rather than continuous, monitoring of an obstetrical patient

Receive clients entering the operating suite for the next surgery

Check or discharge clients in the recovery room

Handle scheduling matters

As noted above, an anesthesiologist may concurrently medically direct up to four anesthesia procedures. Concurrency is defined as the maximum number of procedures that the anesthesiologist is medically directing within the context of a single procedure and whether those other procedures overlap each other. Concurrency is not dependent on each of the cases involving a Medicaid client. For example, if three procedures are medically directed but only two involve Medicaid clients, the Medicaid claims must be billed as concurrent medical direction of three procedures.

For medical direction, the anesthesiologist must document in the client’s medical record that he or she did the following:

Performed the pre-anesthetic exam and evaluation.

Provided indicated post-anesthesia care.

Was present during the critical and key portions of the anesthesia procedure, including, if appli­cable, induction and emergence.

Was present during the anesthesia procedure to monitor the client’s status.

The following information must be available to state agencies upon request and is subject to retro­spective review:

The name of each CRNA, AA, or other qualified professional that was concurrently medically directed or supervised and a description of the procedure that was performed must be documented and maintained.

Signatures of the anesthesiologist, CRNA, AA, or other qualified professional involved in adminis­tering anesthesia services must be documented in the client’s medical record.

9.2.6.2Anesthesia for Sterilization

Refer to:  Subsection 2.2, “Services, Benefits, Limitations, and Prior Authorization” in the Gyneco­logical, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for the complete list of family planning diagnosis codes.

Subsection 2.2.8, “Sterilization and Sterilization-Related Procedures” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks).

Section 4, “Federally Qualified Health Center (FQHC)” in the Clinics and Other Outpatient Facility Services Handbook (Vol. 2, Provider Handbooks) for more information about FQHCs and billing the annual family planning examination for Title XIX clients.

9.2.6.3Anesthesia for Labor and Delivery

Providers must bill the most appropriate procedure code for the service provided. Other time-based procedure codes cannot be submitted if either 01960 or 01967 is the most appropriate procedure code.

The following procedure codes must be used for obstetrical anesthesia:

Procedure Codes

01960

01961

01963

01967

01968

01969

Procedure codes 01960 and 01967 are limited to once every 210 days when billed by any provider and are reimbursed a flat fee. The time reported must be in minutes. Providers should refer to the definition of time in the CPT manual in the “Anesthesia Guidelines—Time Reporting” section.

Procedure code 01968 or 01969 may be considered for reimbursement when submitted with procedure code 01967. For a Cesarean delivery following a planned vaginal delivery, the anesthesia administered during labor must be billed with procedure code 01967 and must indicate the time in minutes that represents the time between the start and stop times for the procedure. The additional anesthesia services administered during the operative session for a Cesarean delivery must be submitted using procedure code 01968 or 01969 and must indicate the time spent administering the epidural and the actual face-to-face time spent with the client. The insertion and injection of the epidural are not considered separately for reimbursement.

All time must be documented in block 24D of the claim form or the appropriate field of the chosen electronic format.

For continuous epidural analgesia procedure codes (other than procedure codes 01960 and 01967), Texas Medicaid reimburses providers for the time when the physician is physically present and monitors the continuous epidural. Reimbursable time refers to the period between the catheter insertion and when the delivery commences.

Texas Medicaid reimburses the epidural anesthesia services and the delivery at full allowance when they are provided by the delivering obstetrician.

9.2.6.4Anesthesia Provided by the Surgeon (Other Than Labor and Delivery)

Local, regional, or general anesthesia provided by the operating surgeon is not reimbursed separately from the surgery. A surgeon billing for a surgery will not be reimbursed for the anesthesia when billing for the surgery, even when using the CPT modifier 47. The anesthesia service is included in the global surgical fee.

9.2.6.5Complicated Anesthesia

The following procedure codes may be reimbursed in addition to an anesthesia procedure or service: 99100, 99116, 99135, and 99140. Documentation supporting the medical necessity for use of the procedure codes may be subject to retrospective review.

Procedure code 99140 is not reimbursed for diagnosis code O80 or O82 when one of these diagnoses is documented as the referenced diagnosis on the claim. The referenced diagnosis must indicate the complicating condition. An emergency is defined as existing when delay in treatment of the client would lead to a significant increase in the threat to life or body part.

9.2.6.6Multiple Procedures

When billing for anesthesia and other services on the same claim, the anesthesia charge must appear in the first detail line for correct reimbursement. Any other services billed on the same day must be billed as subsequent line items.

When billing for multiple anesthesia services performed on the same day or during the same operative session, use the procedure code with the higher RVU. For accurate reimbursement, apply the total minutes and dollars for all anesthesia services rendered on the higher RVU code. Multiple services reimbursement guidelines apply.

9.2.6.7Monitored Anesthesia Care

Monitored anesthesia care may include any of the following:

Intraoperative monitoring by an anesthesiologist or qualified professional under the medical direction of an anesthesiologist

Monitoring of the client’s vital physiological signs in anticipation of the need for general anesthesia

Monitoring of the client’s development of an adverse physiological reaction to a surgical procedure

Anesthesiologists, CRNAs, AAs, or other qualified professionals may use modifier QS to report monitored anesthesia care.

The QS modifier is an informational modifier.

9.2.6.8Reimbursement Methodology

There are two types of reimbursement for anesthesia procedure codes.

Flat fee

Time-based fees, which require documentation of the exact amount of face-to-face time with the client

Anesthesiologists directing one or multiple CRNAs and/or AAs during medical procedures will be reimbursed at 50 percent of the established reimbursement rate.

An AA under the supervision of an anesthesiologist is reimbursed the lesser of the billed charges or 50 percent of the calculated payment for a supervised anesthesia service.

If multiple CRNAs, anesthesiologists, or anesthesiologist assistants under anesthesiologist supervision are providing anesthesia services for a client, only one CRNA or AA and one anesthesiologist may be reimbursed.

Both the flat-fee and time-based-fee procedure codes must be submitted with modifiers and are subject to medical direction/supervision reimbursement adjustments.

Flat Fees

Both OB related anesthesia procedure codes 01960 and 01967 are considered for reimbursement with a flat-fee rate.

Flat fees are subject to medically-directed modifier combination adjustments based on the modifier submitted with the anesthesia procedure code.

The time-based add-on procedure code 01968 must be billed in addition to the flat fee when anesthesia for Cesarean delivery following neuraxial labor analgesia/anesthesia has occurred.

For flat-fee anesthesiology codes, anesthesia time begins when the anesthesia practitioner begins to prepare the client for the induction of anesthesia in the operating room or the equivalent area and ends when the anesthesia practitioner is no longer in personal attendance, that is, when the client may be safely placed under postoperative supervision.

Time-Based Fees

For time-based anesthesiology procedure codes, anesthesia time is the time during which an anesthesia practitioner is present with the client. Anesthesia time begins when the anesthesia practitioner begins to prepare the client for the induction of anesthesia in the operating room or the equivalent area and ends when the anesthesia practitioner is no longer in personal attendance (e.g., when the client may be safely placed under postoperative supervision).

For time-based anesthesiology codes, anesthesia practitioners must document interruptions in anesthesia time in the client’s medical record.

The documented time must be the same in the records or claims of the anesthesiologist and other anesthesia practitioners who were medically directed by the anesthesiologist.

One time unit is equal to 15 minutes of anesthesia. Providers must submit the total anesthesia time in minutes on the claim. The claims administrator will convert total minutes to time units.

Reimbursement of time-based anesthesia services is derived by adding the RVUs (e.g., base units) for the procedures performed (when multiple procedures are performed use the procedure with the highest RVUs) to the total face-to-face anesthesia time in minutes divided by 15 minutes, multiplied by the appropriate conversion factor:

[RVUs + (Minutes / 15] x Conversion Factor = Anesthesia Reimbursement

Provider Type Description - Physician Pricing Example

Time: 120 minutes

=

120/15

=

8 (quantity billed)

Procedure code: 00851

=

(6 RVUs) 6.00 + 8

=

14.00

Conversion factor: $19.58

=

14.00 x 19.58

=

$274.12 (physician reimbursement)

Conversion Factor

A conversion factor is the multiplier that transforms relative values into payment amounts. There is a standard conversion factor for anesthesia services.

9.2.6.9Anesthesia Modifiers

Each anesthesia procedure code must be submitted with the appropriate anesthesia modifier combi­nation whether billing as the sole provider or for the medical direction of CRNAs, AAs, or other qualified professionals.

When an anesthesia procedure is billed without the appropriate reimbursement modifiers or is billed with modifier combinations other than those listed below in the Modifier Combinations section, the claim will be denied.

A procedure billed with a modifier indicating that the anesthesia was personally performed by an anesthesiologist (modifier AA) will be denied if another claim has been paid indicating the service was personally performed by, and reimbursed to, a CRNA (modifier QZ) for the same client, date of service, and procedure code. The opposite is also true—a CRNA-administered procedure will be denied if a previous claim was paid to an anesthesiologist for the same client, date of service, and procedure code. Denied claims may be appealed with supporting documentation of any unusual circumstances.

9.2.6.9.1* State-Defined Modifiers

Modifiers U1 (indicating one Medicaid claim billed by an anesthesia practitioner and U2 (indicating two Medicaid claims) are state-defined modifiers that must be billed by an anesthesiologist, CRNA, AA, or other qualified professional.

Modifier U1, indicating that only one Medicaid claim will be submitted, cannot be billed by two providers for the same procedure, client, and date of service. Modifier U2, indicating that two Medicaid claims will be submitted, can only be billed by two providers for the same procedure, client, and date of service if one of the providers was medically directed by the other. Denied claims may be appealed with supporting documentation of any unusual circumstances.

Anesthesia providers must submit modifier U1 or U2 in combination with an appropriate pricing modifier (AA, GC, QY, QK, AD, QZ, QX) when billing for any payable anesthesia procedure codes.

9.2.6.9.2* Modifier Combinations

When a single claim per client is billed by the anesthesiologist for personally performing the anesthesia service, the AA and U1 modifier combination must be billed together.

Anesthesiologists may be reimbursed for medical direction of CRNAs, AAs, or other qualified profes­sional by using one of the following modifier combinations:

Modifier Combination Submitted by Anesthesiologist

When is it used?

Who will submit claims?

Anesthesiologist Directing Other Qualified Professionals

QY and U1

When a single claim per client is billed by the anesthesiologist for medically directing anesthesia services of an anesthesia procedure provided by one CRNA, AA, or other qualified professional.

Only the anesthesiologist

AA, U1, and GC

When a single claim per client is billed by the anesthesiologist for medically directing anesthesia services of an anesthesia procedure provided by one resident physician.

Note:For procedure code 01967 medical supervision of resident physicians rather than medical direction is required, however, modifiers AA-U1-GC must still be noted on the claim.

Only the anesthesiologist

QK and U1

When a single claim per client is billed by the anesthesiologist for medically directing anesthesia services of two, three, or four concurrent anesthesia procedures provided by CRNAs, AAs, or other qualified professionals.

Only the anesthesiologist

AD and U1 (Emergency circum­stances only)

When a single claim per client is billed by the anesthesiologist for medical super­vision of anesthesia services for more than four concurrent anesthesia proce­dures provided by CRNAs, AAs, or other qualified professionals. Used in emergency circumstances only and limited to 6 units (90 minutes) per case for each occurrence requiring five or more concurrent procedures.

Only the anesthesiologist

Anesthesiologist Directing CRNAs or AAs

QY and U2

When two claims per client are billed, one by the medically directing anesthesi­ologist and one by the CRNA, AA, or other qualified professional.

Both the anesthesiologist and CRNA, AA, or other qualified professional

QK and U2

When two claims per client are billed for medically directed anesthesia services of two, three, or four concurrent anesthesia procedures provided by CRNAs, AAs, or other qualified professionals.

Both the anesthesiologist and CRNA, AA, or other qualified professional

AD and U2 (Emergency circum­stances only)

When two claims per client are billed for the medical supervision of more than four concurrent anesthesia procedures provided by CRNAs, AAs, or other qualified professionals. Used in emergency circumstances only and limited to 6 units (90 minutes) per case for each occurrence requiring five or more concurrent procedures.

Both the anesthesiologist and CRNA, AA, or other qualified professional

9.2.6.9.3CRNA and AA Services

Modifiers QZ and U1 must be submitted when a CRNA or AA has personally performed the anesthesia services, is not medically directed by the anesthesiologist, and is directed by the physician.

Modifiers QX and U2 must be submitted by a CRNA, AA, or other qualified professional who provided services under the medical direction of an anesthesiologist.

9.2.6.10Prior Authorization for Anesthesia

9.2.6.10.1Anesthesia for Medical Services

Anesthesia services provided in combination with most medical surgical procedures do not require prior authorization. However, some medical surgical procedures may require prior authorization. Anesthesia may be reimbursed if prior authorization for the surgical procedure was not obtained, but services provided by the facility, surgeon, and assistant surgeon will be denied.

9.2.6.11Claims Filing

Texas Medicaid reimburses anesthesiologists based on the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982. Anesthesiologists must identify the following information on their claims:

Procedure performed (CPT anesthesia code in Block 24 of the CMS-1500 paper claim form).

Person (physician, CRNA, or AA) administering anesthesia (modifiers must be used to designate this provider type).

Time in minutes.

Any other appropriate modifier (refer to subsection 6.3.5, “Modifiers” in “Section 6: Claims Filing” (Vol. 1, General Information) for a list of the most common modifiers).

9.2.6.12Anesthesia (General) for THSteps Dental

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

9.2.7Bariatric Surgery

Bariatric surgery is considered medically necessary when used as a means to treat covered medical conditions that are caused or significantly worsened by the client’s obesity in cases where those comorbid conditions cannot be adequately treated by standard measures unless significant weight reduction takes place. The pathophysiology of the covered comorbid conditions must be sufficiently severe that the expected benefits of weight loss subsequent to this surgery significantly outweigh the risks associated with bariatric surgery.

The following procedure codes may be reimbursed for medically necessary bariatric surgery services with prior authorization: 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, and 43888.

Bariatric surgery is not a benefit when the primary purpose of the surgery is any of the following:

For weight loss for its own sake

For cosmetic purposes

For reasons of psychological dissatisfaction with personal body image

For the client’s or provider’s convenience or preference

9.2.7.1Prior Authorization for Bariatric Surgery

All clients must meet the criteria outlined below.

The same contraindications exist for bariatric surgery as for any other elective abdominal surgery. Documentation provided for prior authorization must attest that none of the following additional contraindications exist:

Endocrine cause for obesity, inflammatory bowel disease, chronic pancreatitis, cirrhosis, portal hypertension, or abnormalities of the gastrointestinal tract

Chronic, long-term steroid treatment

Pregnant, or plans to become pregnant within 18 months

Noncompliance with medical treatment

Significant psychological disorders that would be exacerbated or interfere with the long-term management of the client after the operation

Active malignancy

All clients must undergo preoperative psychological evaluation by a behavioral health provider and have clearance for surgery if any of the following conditions exist:

They have a history of psychiatric or psychological disorders.

They are currently under the care of a psychologist or psychiatrist.

They are on psychotropic medications.

The client’s medical record must include documentation of the evaluation.

Clients without a history of psychiatric or psychological disorder must also undergo a preoperative psychological evaluation by a behavioral health provider and have clearance for surgery. The client’s medical record must include documentation that the client is psychologically mature and able to cope with the postsurgical changes of the surgery.

Documentation must be submitted with the prior authorization request that is signed by the surgeon and attests that the services are provided by a facility in Texas that is one of the following:

Accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

A children’s hospital that has a bariatric surgery program and provides access to an experienced surgeon who employs a team that is capable of long-term follow-up of the metabolic and psycho­social needs of the client and family.

Bariatric surgery for clients who are 20 years of age and younger may be prior authorized when the client meets all of the following criteria:

The client has reached a Tanner Scale stage IV or V plus 95 percent of adult height based on bone age.

The client has a body mass index (BMI) of greater than or equal to 40 kg/m2.

The client has one or more comorbid conditions that are exacerbated by or attributable to obesity.

Female clients must be at least 13 years of age and menstruating.

Male clients must be at least 15 years of age.

Bariatric surgery for clients who are 21 years of age and older may be prior authorized when the client meets all of the following criteria:

The client has a BMI of greater than or equal to 35 kg/m2.

The client has one or more of the following comorbid conditions that are exacerbated by or attrib­utable to obesity:

Obesity-associated hypoventilation

Moderate to severe sleep apnea (defined as apnea/hypoapnea index of 16 or more events per hour)

Congestive heart failure

Obesity-induced cardiomyopathy

Refractory hypertension resistant to pharmacotherapy (defined as blood pressure greater than 140mmHg systolic or greater than 90mmHg diastolic, despite maximally tolerated doses of at least three different classes of antihypertensive medications)

Pseudotumor cerebri (documented idiopathic intracerebral hypertension)

Adult onset (Type II) diabetes (with or without complications) with Hgb A1c greater than 9 percent, regardless of therapy, or 7 to 9 percent on maximal medical therapy (defined as taking insulin or maximally tolerated doses of at least two different classes of oral hypoglycemic medications)

Cardiovascular or peripheral vascular disease

Refractory hyperlipidemia (defined as triglycerides greater than 250 mg/dl, cholesterol greater than 220/mg/dl, HDL less than 35 mg/dl, or LDL greater than 200 mg/dl, despite maximally tolerated doses of at least two different classes of lipid-lowering medications)

Recurrent or chronic skin ulcerations with infection

Pulmonary hypertension

Chronic joint disease, deterioration of the joint cartilage, and the formation of new bone (bone spurs) at the margins of the joints, with symptoms that severely affect work or leisure activities, on maximal medical therapy (defined as maximally tolerated dose of a non-steroidal anti-inflammatory drug (NSAID) or COX-II inhibitor or acetaminophen and the completion of at least one physical-therapist-supervised exercise program)

Hepatic steatosis without evidence of active inflammation

Documentation must include a summary of the treatment provided for the client’s comorbid conditions, including descriptions of how the client’s response to standard treatment measures are unsatisfactory and why the bariatric surgery is medically necessary in the context of current treatment and medically-reasonable alternatives that are available.

Referral for bariatric surgery to the bariatric surgeon is required from the practitioner who is treating the comorbid condition(s). The bariatric surgeon will determine the client’s eligibility for bariatric surgery. Documentation of the referral must be submitted with the prior authorization request.

The client must have had previous unsuccessful medical treatment for obesity, as documented in the medical record. All of the following minimal requirements must be met:

The client has made a diligent effort to achieve healthy body weight with such efforts described in the medical record and certified by the operating surgeon.

The client has failed to maintain a healthy weight despite a minimum of 6 months documented regular participation in a structured dietary program overseen by a physician (M.D. or D.O.) within 12 months of the request date.

Documentation that is submitted for prior authorization must also include all of the following:

The process by which the client will receive postoperative surgical, nutritional, and psychological services.

Affirmation that the client and the parent/guardian (if applicable) understand and will support the changes in eating habits that must accompany the surgery and the extensive postoperative follow-up.

Repeat bariatric surgery may be considered medically necessary in either of the following circumstances:

To correct complications from bariatric surgery such as band malfunction, obstruction, or stricture

To convert to a Roux-en-Y gastroenterostomy or to correct pouch failure in an otherwise compliant client when the initial bariatric surgery met medical necessity criteria

Note:Conversion to a Roux-en-Y gastroenterostomy may be considered medically necessary for clients who have not had adequate success (defined as a loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure, and the client has been compliant with a prescribed nutrition and exercise program following the procedure.

All documentation required for prior authorization is to be maintained in the client’s medical record and is subject to retrospective review. This includes medical records from both the practitioner treating the comorbid condition(s) and the bariatric surgeon.

Providers may fax or mail prior authorization requests for bariatric surgery services for clients who are 20 years of age and younger to the TMHP Comprehensive Care Program (CCP) Prior Authorization Department. Prior authorization requests for clients who are 21 years of age and older may be faxed or mailed to the TMHP Special Medical Prior Authorization Department.

Clients may be eligible under Texas Medicaid or CCP for separate reimbursement for nutritional and psychological assessment and counseling associated with bariatric surgery.

Behavioral health services provided as part of the preoperative or postoperative phase of bariatric surgery are subject to behavioral health guidelines, and are not considered part of the bariatric surgery.

Refer to:  Subsection 6, “Psychiatric Services for Hospitals” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) for information about behavioral health services.

9.2.8Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer

Live BCG for intravesical (procedure code 90586) or transvesical (procedure code J9031) are benefits of Texas Medicaid for the following diagnosis codes:

Diagnosis Codes

C670

C671

C672

C673

C674

C675

C676

C677

C678

C679

C7911

D090

Procedure code 90585 is a benefit of Texas Medicaid for diagnosis code Z23. Authorization is not required for the BCG vaccine.

Bladder instillation of anticarcinogenic agent (procedure code 51720) may be reimbursed separately when billed with BCG instillation (procedure code 90586 or J9031).

9.2.9Behavioral Health Services

Refer to:  The Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks).

9.2.10Biopsy

A biopsy refers to the surgical excision of tissue for pathological examination.

If a surgeon bills separate charges for a surgical procedure and a biopsy on the same organ or structure on the same day, the charges are reviewed and reimbursed only for the service with the higher of the allowed amounts.

9.2.11Biofeedback Services

Biofeedback services are a benefit of Texas Medicaid for clients who are 4 years of age and older with the following conditions:

Urinary incontinence

Fecal incontinence

Migraine and tension headache

Biofeedback services may be reimbursed using procedure codes 90901 and 90911.

Biofeedback services are limited to a maximum of 18 sessions rendered by any provider for the lifetime of each client for each condition.

Biofeedback services that are not a benefit of Texas Medicaid are the following:

Biofeedback performed in the home setting

Neurofeedback (such as, but not limited to, electroencephalography [EEG])

Treatment for muscle tension, except tension headache

Psychological, psychophysiological, and behavioral health therapy and psychosomatic conditions

Investigational or experimental biofeedback services and procedures

Procedure code 90901 or 90911 are limited to one service per day. The reimbursement for procedure codes 90901 and 90911 include all modalities of the biofeedback training performed on the same day, regardless of the time increments or the number of modalities performed.

Any device used during a biofeedback session is considered part of the procedure and will not be reimbursed separately.

9.2.11.1Biofeedback Certification

A staff member who is certified by Biofeedback Certification International Alliance (BCIA) must perform biofeedback services.

The certification types accepted by Texas Medicaid are the following:

General biofeedback certification (BCB)

Pelvic muscle dysfunction biofeedback certification (BCB-PMD)

Providers must maintain documentation in the client’s medical record to support the medical necessity of the biofeedback service provided. Documentation must include the name of the staff person who provided the biofeedback and the prescribing physician must maintain in the office a record of the current certification of the staff member(s) who perform biofeedback. Documentation is subject to retrospective review.

9.2.11.2Prior Authorization for Biofeedback Services

Prior authorization is required for biofeedback services.

Any combination of procedure codes 90901 and 90911 are a benefit for biofeedback sessions for urinary or fecal incontinence conditions in clients who are 4 years of age and older.

Procedure code 90901 is a benefit for biofeedback sessions for migraine or tension headache conditions.

The initial request may include up to 12 visits and not exceed a total duration of 12 weeks. Documen­tation of the following must be submitted for consideration of prior authorization:

Conventional treatments that were given but were not successful, including, but not limited to, pharmacotherapy, exercise, rest, and heating and cooling modalities.

Statements from the prescribing physician that the client is capable of understanding the require­ments and agrees actively to participate in the biofeedback sessions.

Name and certification information for the person performing the training.

In addition, documentation must be submitted to support the specific type of biofeedback requested.

Urinary and Fecal Incontinence

Diagnosis of fecal or urinary stress, urge, overflow, or a mix of stress and urge incontinence in a client who is 4 years of age or older.

Exclusion by the physician of any underlying medical conditions that could be causing the problem.

Failed pelvic floor muscle exercise (PME) training for clients who are 21 years of age and older.

Note:Failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of an ordered plan of PME exercises.

Migraine and tension headache

A diagnosis of migraine, tension headache, or mixed migraine and tension headache.

Symptoms that occur with a duration of at least 4 hours for at least 15 days a month over at least 3 months.

Failure of first-line approaches, including avoidance of precipitating stimuli and pharmacological prophylaxis.

Prior authorization requests must be submitted by the physician to the Special Medical Prior Authori­zation (SMPA) Department. The request must be submitted with documentation that supports medical necessity. Providers may submit prior authorization requests online through the TMHP website at www.tmhp.com, by fax to 1-512-514-4213, or by mail to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway
Austin, TX 78727

After the client completes the initial biofeedback treatment course, prior authorization may be considered for a total of six follow-up sessions not to exceed three sessions per week and total duration not to exceed eight weeks. Providers must submit prior authorization documentation for the same condition as the original request, and must include each original symptom and how it has objectively improved. Documentation may include, but is not limited to, the following:

For treatment of urinary incontinence, improvement in continence scores, vitality, health, a decrease in high-grade stress incontinence, nocturnal enuresis, and urine loss with activity. In clients who are 21 years of age and older, evidence of increased pelvic floor contraction strength and the ability to hold the contractions longer and to perform more repetitions.

For treatment of fecal incontinence, improvement in continence scores, squeeze and anal pressures, squeeze duration, vitality, and health. In clients who are 21 years of age and older, evidence of increased pelvic floor contraction strength and the ability to hold the contractions longer and to perform more repetitions.

For migraine and tension headaches, diminished intensity, frequency, and duration of the headache activity.

9.2.12Blepharoplasty Procedures

Procedure codes 15820, 15821, 67911, 67961, 67966, 67971, 67973, 67974, and 67975 are not diagnosis-restricted.

Procedure codes 67901, 67902, 67903, 67904, 67906, 67908, and 67909 may be reimbursed for clients who are 20 years of age and younger without prior authorization when performed for one of the following diagnosis codes:

Diagnosis Codes

Q100

Q101

Q102

Q103

Procedure codes 67901, 67902, 67903, 67904, 67906, and 67908 do not require prior authorization for clients who are 21 years of age and older when billed for the following diagnosis codes:

Diagnosis Codes

H0231

H0232

H0234

H0235

H02411

H02412

H02413

H02421

H02422

H02423

H02431

H02432

H02433

Blepharoplasty for clients who are 21 years of age and older requires mandatory prior authorization. The following information from the physician is required at the time of the request for blepharoplasty for procedure codes 15820, 15821, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911:

A brief history and physical evaluation

Photographs of the eyelid problem

Visual field measurements

Diagnosis code

The following blepharoplasty and eyelid repair procedures do not require prior authorization:

Procedure Codes

67916

67917

67923

67924

67961

67966

67971

67973

67974

67975

All supporting documentation must be included with the request for authorization. Send requests and documentation to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
Fax: 1-512-514-4213

Retroactive authorization may be granted on an appeal basis when submitted with the appropriate documentation.

9.2.13Bone Growth Stimulation

Professional services for bone growth stimulation (procedure codes 20974, 20975, and 20979) are a benefit of Texas Medicaid.

Prior authorization is required for a bone growth stimulator device (procedure codes E0747, E0748, E0749, and E0760).

Refer to:  Subsection 2.2.7, “Bone Growth Stimulators” in the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook (Vol. 2, Provider Handbooks) for prior autho­rization criteria.

9.2.13.1Invasive Bone Growth Stimulation

Invasive bone growth stimulation (procedure code 20975) is indicated for the following conditions:

Nonunion of long bone fractures (i.e., clavicle, humerus, radius, ulna, femur, tibia, fibula, and metacarpal, metatarsal, carpal, and tarsal bones). Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for three or more months prior to starting treatment with the bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. Each set of radio­graphs must include multiple views of the fracture site.

Failed fusion of a joint other than the spine when a minimum of three months has elapsed since the joint fusion was performed.

Congenital pseudoarthrosis.

An adjunct to spinal fusion surgery for patients at high risk for pseudoarthrosis due to previously failed spinal fusion at the same site.

An adjunct to multiple-level fusion, which involves three or more vertebrae (e.g., L3-L5, L4-S1, etc.).

9.2.13.2Non-invasive Bone Growth Stimulation

Non-invasive bone growth stimulation (procedure code 20974) is indicated for the following conditions:

Nonunions, failed fusions, and congenital pseudarthrosis where there is no evidence of progression of healing for three or more months despite appropriate fracture care.

Delayed unions of fractures of failed arthrodesis at high risk sites (e.g., open or segmental tibial fractures, carpal navicular fractures).

Documentation must also indicate all of the following:

Serial radiographs have confirmed that no progressive signs of healing have occurred.

The fractured gap is 1 cm or less.

The individual can be adequately immobilized and is likely to comply with non-weight-bearing restrictions.

Non-invasive bone growth stimulation for spinal application is indicated for the following conditions:

One or more failed fusions.

Grade II or worse spondylolisthesis.

A multiple-level fusion with extensive bone grafting is required.

Other risk factors for fusion failure are present, including gross obesity, degenerative osteoarthritis, severe spondylolisthesis, current smoking, previous fusion surgery, previous disc surgery, or gross instability.

9.2.13.3Ultrasound Bone Growth Stimulation

Ultrasound bone growth stimulation (procedure code 20979) is indicated for nonunion of a fracture, other than the skull or vertebrae, in a skeletally mature person, which is documented by a minimum of two sets of radiographs that were:

Obtained prior to starting treatment with the osteogenesis stimulator.

Separated by a minimum of 90 days.

Taken with multiple views of the fracture site.

Accompanied by a written interpretation by a physician who states that there has been no clinically significant evidence of fracture healing between the two set of radiographs.

Documentation must also indicate evidence of all of the following:

The fracture is not tumor-related.

The fracture is not fresh (less than 7 days), closed or grade I open, tibial diaphyseal fractures, or closed fractures of the distal radius (Colles fracture).

9.2.13.4Reimbursement

Professional claims that are submitted for bone growth stimulation (procedure codes 20974, 20975, and 20979) may be reimbursed if the claim includes documentation of one of the following:

Documentation of medical necessity as outlined for each type of bone growth stimulation.

The corresponding bone growth stimulator device was submitted within 95 days of the date the bone growth stimulation procedure was performed.

The appropriate evaluation and management (E/M) procedure code must be billed for monitoring the effectiveness of bone growth stimulation treatment.

Procedure codes 20974, 20975, and 20979 are limited to one per six months. During the six-month limitation period, a subsequent fracture that meets the criteria for a bone growth stimulator may be reimbursed after the submission of an appeal with documentation of medical necessity that demon­strates the criteria have been met.

9.2.14Cancer Screening and Testing

9.2.14.1BRCA Testing

Refer to:  Subsection 2.2.6, “Breast Cancer Gene 1 and 2 (BRCA) Testing” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

9.2.14.2* Colorectal Cancer Screening

Fecal occult blood tests, barium enemas, screening colonoscopies, and sigmoidoscopies are benefits of Texas Medicaid. Screening refers to the testing of asymptomatic persons in order to assess their risk for the development of colorectal cancer. Screening has been shown to decrease mortality due to this cancer by detecting cancers at earlier stages and allowing the removal of adenomas, thus preventing the subse­quent development of cancer.

The American Cancer Society (ACS) and U.S. Preventive Services Task Force (USPSTF) both recommend screening people at average risk for colorectal cancer beginning at 50 years of age by any of the following methods:

A fecal occult blood test (FOBT)* or fecal immunochemical test (FIT) every year

Flexible sigmoidoscopy every five years

A FOBT* or FIT every year plus flexible sigmoidoscopy every five years, or (of these three options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every five years is preferable)

Double-contrast barium enema every five years

Colonoscopy every ten years

Note:For FOBT, the take-home multiple sample method should be used.

The ACS and USPSTF recommends screening for people at high-risk for colorectal cancer once every two years.

Indications/characteristics of a high-risk individual:

A close relative (sibling, parent or child) has had colorectal cancer or an adenomatous polyp.

There is a family history of familial adenomatous polyposis.

There is a family history of hereditary nonpolyposis colorectal cancer.

There is a personal history of adenomatous polyps.

There is a personal history of colorectal cancer.

There is a personal history of colonic polyps.

There is a personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.

Colorectal screening services are considered for reimbursement when submitted using procedure codes G0328 (with modifier QW), G0104, G0105, G0106, G0120, G0121, and G0122 by associated risk category based on the ACS and USPSTF frequency recommendations. Reimbursement for these procedure codes is considered when medical necessity is documented in the client’s record.

Fecal Occult Blood Tests

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

Barium Enemas

Procedure code G0122 is considered for reimbursement once every 5 years for clients who are 50 years of age and older.

Sigmoidoscopies

Procedure codes G0104 and G0106 are considered for reimbursement once every five years when submitted with diagnosis code Z0000, Z0001, Z1210, Z1211, Z1213, Z859, or Z86010, as recommended by the ACS and USPSTF. Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but not more frequently than recommended by the USPSTF.

A screening barium enema may be substituted for a screening flexible sigmoidoscopy if the effectiveness has been established by the physician for substitution. Procedure code G0106 may be used as an alter­native to procedure code G0104 respectively.

If during the course of screening flexible sigmoidoscopy, a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a flexible sigmoid­oscopy with biopsy or removal must be reported rather than procedure code G0104 or G0106.

Colonoscopies: Average Risk

Procedure code G0121 is considered for reimbursement once every ten years when submitted with diagnosis code Z0000, Z0001, Z1210, Z1211, Z1213, or Z86010, as recommended by the ACS and USPSTF for clients who do not meet the criteria for high-risk. Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but not more frequently than recommended by the USPSTF.

If during the screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the procedure code for a colonoscopy with biopsy or removal of lesion should be reported rather than procedure code G0121.

Colonoscopies: High-Risk

Procedure codes G0105 and G0120 are considered for reimbursement once every two years for clients who meet the definition of high-risk. Procedure codes G0105 and 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

A screening barium enema may be substituted for a screening colonoscopy if the effectiveness has been established by the physician for substitution. Procedure code G0120 may be used as an alternative to procedure code G0105 respectively.

If during the screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the procedure code for a colonoscopy with biopsy or removal of lesion should be reported rather than procedure code G0105 or G0120.

9.2.14.2.1Prior Authorization for Colorectal Cancer Screening

Prior authorization is not required for colorectal screening.

9.2.14.3Genetic Testing for Colorectal Cancer

Genetic testing for colorectal cancer may be considered for reimbursement to independent laboratories with prior authorization.

Genetic testing may be provided to clients who have a known predisposition (i.e., having a first- or second-degree relative) for colorectal cancer. Results of the testing may indicate whether the client has an increased risk of developing colorectal cancer. A first-degree relative is defined as a sibling, parent, or offspring. A second-degree relative is defined as an uncle, aunt, grandparent, nephew, niece, or half-sibling.

Genetic test results, when informative, may influence clinical management decisions. Documentation in the medical record must reflect that the client or family members have been given information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions before the genetic testing.

Genetic testing for colorectal cancer may be considered for reimbursement with the following procedure codes:

Procedure Codes

81201

81202

81203

81210

81275

81288

81292

81293

81294

81295

81296

81297

81298

81299

81300

81301

81317

81318

81319

81327

Diagnosis code Z800 is acceptable as a diagnosis for the procedure codes in the table above. Prior autho­rization is still required and must be obtained for these services. Interpretation of gene mutation analysis results is not reimbursed separately. Interpretation is part of the physician E/M service.

The following procedure codes are limited to once per lifetime for any procedure code by any provider. Testing is limited to once per lifetime for any procedure code by any provider, regardless of whether additional services are authorized.

Procedure Codes

81201

81202

81203

81210

81275

81288

81292

81293

81294

81295

81296

81297

81298

81299

81300

81301

81317

81318

81319

81327

Providers must maintain the following documentation in the client’s medical record for genetic testing for colorectal cancer:

Documentation of formal pre-test counseling, including assessment of the client’s ability to under­stand the risks and limitations of the test.

The client’s informed choice to proceed with the genetic testing for colorectal cancer.

The provider must order the most appropriate test based on familial medical history and the availability of previous family testing results.

The medical record is subject to retrospective review.

9.2.14.3.1Testing for Familial Adenomatous Polyposis

Testing for familial adenomatous polyposis (procedure codes 81201, 81202, and 81203) may be offered to clients who have well-defined hereditary cancer syndromes and for whom a positive or negative result will change medical care. Testing for familial adenomatous polyposis may be considered for reimbursement with documentation of at least one of the following:

The client has more than 20 polyps.

The client has a first-degree relative with familial adenomatous polyposis and a documented mutation.

For clients who are 7 years of age and younger, testing must be medically necessary and supported by documentation with a clear rationale for testing, which must be retained in the client’s medical record.

9.2.14.3.2Hereditary Nonpolyposis Colorectal Cancer (HNPCC)

Testing for HNPCC (procedure codes 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, and 81319) is used to determine whether a client has an increased risk of colorectal cancer or other HNPCC-associated cancers, including Lynch Syndrome. Results of the test may influence clinical management decisions. Testing for HNPCC may be considered for reimbursement with documentation of at least one of the following:

The client has three or more family members, one of whom is a first-degree relative, with colorectal cancer; two successive generations are affected; one or more of the colorectal cancers was diagnosed before the family member was 50 years of age; and familial adenomatous polyposis has been ruled out for the client.

The client has had two previous HNPCCs.

The client has colorectal cancer and a first-degree relative who has one of the following:

Colorectal cancer or HNPCC extracolonic cancer at 50 years of age and younger

Colorectal adenoma at 40 years of age and younger

The client has had colorectal cancer or endometrial cancer at 50 years of age and younger.

The client has had right-sided colorectal cancer with an undifferentiated pattern of histology at 50 years of age and younger.

The client has had signet-cell type colorectal cancer at 50 years of age and younger.

The client has had a colorectal adenoma at 40 years of age and younger.

The client is asymptomatic and has a first- or second-degree relative who has a documented HPNCC mutation.

The client has a family history of malignant neoplasm in the gastrointestinal tract.

For clients who are 20 years of age and younger, testing must be medically necessary and supported by documentation with a clear rationale for testing, which must be retained in the client’s medical record.

9.2.14.3.3Prior Authorization for Genetic Testing for Colorectal Cancer

Prior authorization is required for genetic testing for colorectal cancer. A written authorization request that is signed and dated by the referring provider must be submitted. A provider’s signature, including the prescribing provider’s, on a submitted document indicates that the provider certifies, to the best of the provider’s knowledge, the information in the document is true, accurate, and complete.

Medical documentation that is submitted by the physician must verify the client’s diagnosis or family history. Requisition forms from the laboratory are not sufficient for verification of the personal and family history.

To complete the prior authorization process, the provider must mail or fax the request to the TMHP Special Medical Prior Authorization Unit and include documentation of medical necessity. The form may be faxed to 1-512-514-4213 or mailed to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization Department
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727

A request for retroactive authorization must be submitted no later than 7 calendar days after the lab draw is performed. To facilitate a determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including the accurate medical necessity of the services requested.

9.2.14.4Mammography (Screening and Diagnostic Studies of the Breast)

The following breast imaging studies are benefits of Texas Medicaid:

Screening mammogram

Diagnostic mammogram

Diagnostic breast ultrasound

The American Cancer Society recommends that women discuss when to start breast cancer screening mammography with their provider beginning at 40 years of age.

By the age of 45 all women should begin annual breast cancer mammography screening.

By the age of 55 women may transition to screening with mammography every other year, or in some cases may continue annual screenings in consultation with their healthcare provider.

A screening mammogram may be billed using procedure code 77067 or G0202. Procedure code 77067 will be denied when billed if it is submitted for the same date of service as procedure code G0202 by any provider.

A diagnostic mammogram may be billed using procedure code 77065, 77066, G0204, or G0206.

Procedure code 77065 will be denied if it is submitted for the same date of service as procedure code 77066, G0204, or G0206 by any provider.

Procedure code 77066 will be denied if it is submitted for the same date of service as procedure code G0204 by any provider.

Procedure code G0206 will be denied if it is submitted for the same date of service as procedure code 77065 or G0204 by any provider.

Screening mammograms may be reimbursed for the same date of service as a diagnostic mammogram if the diagnostic mammography procedure codes are submitted with a GG modifier.

A mammogram may be indicated for a male client based on medical necessity due to existing signs and symptoms. In such rare circumstances, procedure codes 77065, 77066, G0204, and G0206 may be considered for reimbursement.

Other breast diagnostic radiology procedures may be medically necessary based on existing signs and symptoms. When indicated, such procedures may be considered for reimbursement using procedure code 76098, 77053, or 77054. Procedure code 77053 will be denied if it is submitted for the same date of service as procedure code 77054 by any provider. Procedure code 76098 may be reimbursed for both male and female clients.

Breast ultrasound may be considered for reimbursement using procedure code 76641 or 76642.

Authorization is not required for these services.

The prescribing physician must maintain documentation of medical necessity in the client’s medical record. The radiologist or interpreting physician at the testing facility may determine and document that, because of the abnormal result of the diagnostic test performed, additional studies are medically necessary. The radiologist or interpreting physician ordering the additional studies must provide documentation to the prescribing physician.

9.2.14.5Prognostic Breast and Gynecological Cancer Studies

Prognostic breast and gynecological cancer studies are benefits of Texas Medicaid when ordered by a physician for the purpose of determining the best course of treatment for a patient with breast/gyneco­logical cancers.

Prognostic breast and gynecological cancer studies are divided into three categories: Receptor assays, Her-2/neu, and gene expression profiling.

Receptor Assays (procedure codes 84233 and 84234) - The estrogen receptor assay (ERA) and the progesterone receptor assay (PRA) are tests in which a tissue sample is exposed to radioactively tagged estrogen or progesterone. The presence of these receptors can have prognostic significance in breast and endometrial cancer.

Her-2/neu (procedure codes 83950, 88237, 88239, 88271, 88274, 88291, 88341, 88342, 88344, 88360, 88361, 88364, 88365, 88366, 88367, 88368, 88369, 88373, 88374, and 88377) - Human epidermal growth factor receptor 2 (Her-2/neu) is responsible for the production of a protein that signals cell growth. The overexpression of Her-2/neu in breast cancer is associated with decreased overall survival and response to some therapies. Each procedure used in the analysis should be coded separately.

Gene expression profiling (procedure code 81519) - Gene expression profiling using the Oncotype DX® Breast Cancer Assay analyzes the expression of a panel of 21 genes to predict the likelihood of breast cancer recurrence in clients with newly diagnosed early stage invasive breast cancer.

Reimbursement for procedure codes 88360 and 88361 is limited to claims with a diagnosis of breast or uterine cancer as listed in the following table:

Diagnosis Codes

C50011

C50012

C50021

C50022

C50111

C50112

C50121

C50122

C50211

C50212

C50221

C50222

C50311

C50312

C50321

C50322

C50411

C50412

C50421

C50422

C50511

C50512

C50521

C50522

C50611

C50612

C50621

C50622

C50811

C50812

C50821

C50822

C50921

C50922

C540

C541

C542

C543

C548

C792

C7981

D0501

D0502

D0511

D0512

D0581

D0582

Testing for other diagnoses will be denied.

Interpretation of receptor assays, and Her-2/neu results is not considered separately for reimbursement. Interpretation is part of the physician’s E/M service.

Gene expression profiling (procedure code 81519) is a benefit when all of the following criteria are met:

The test is ordered by an oncologist.

The client is a female, with newly diagnosed breast cancer. (“Newly diagnosed” means that not more than six months have elapsed since the initial diagnosis.)

The clinical stage of the breast cancer is I or II.

Axillary node biopsy is negative for tumor, and there is no evidence of metastatic breast cancer.

The primary tumor is estrogen receptor-positive, and Her-2/neu receptor negative, or the primary tumor is Her-2/neu receptor positive and less than 1 cm in diameter.

The client is a candidate for adjuvant chemotherapy.

The outcome of the test will guide decision-making regarding adjuvant chemotherapy.

The client has one of the following diagnosis codes:

Diagnosis Codes

C50011

C50012

C50111

C50112

C50211

C50212

C50311

C50312

C50411

C50412

C50511

C50512

C50611

C50612

C50811

C50812

D0501

D0502

D0511

D0512

D0581

D0582

Gene expression profiling is limited to once per lifetime, but may be considered for reimbursement more than once per lifetime for the same client on appeal. The provider must submit documentation that demonstrates that the client has a new, second, primary breast cancer diagnosis that meets the criteria described above.

The provider must maintain documentation of medical necessity in the client’s medical record. Retro­spective review may be performed to ensure that the documentation supports the medical necessity of the service.

Gene expression profiling is not covered for the following:

Repeat testing or testing of multiple tumor sites in the same client.

Use in predicting the likelihood of distant recurrence in male breast cancer.

Tests for gene expression profiling other than Oncotype DX® are considered experimental and investi­gational, and are not benefits of Texas Medicaid.

9.2.15Capsulotomy

A capsulotomy is a benefit when not performed with a joint surgery.

9.2.16Cardiac Rehabilitation

Cardiac rehabilitation is a physician-supervised program that furnishes physician-prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Cardiac rehabili­tation programs must include all of the following:

Physician-prescribed exercise for each day on which cardiac rehabilitation items and services are furnished

Cardiac risk factor modification, including education, counseling, and behavioral intervention, tailored to a client’s individual needs

Psychosocial assessment

Outcomes assessment

An individual treatment plan that specifies how components are used for a client and that is reviewed and signed by the prescribing physician every 30 days

Cardiac rehabilitation procedure codes 93797 and 93798 are benefits of Texas Medicaid.

The appropriate procedure code must be billed with 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 for whom there is documentation of any of the following conditions within the 12 months immediately preceding the beginning of the 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 (ECGs) to a remote site is not a benefit of Texas Medicaid.

Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (e.g., oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use.

Cardiac rehabilitation is limited to 2 one-hour sessions per day for 18 weeks per rolling year and can not exceed 36 sessions.

Cardiac rehabilitation may be considered medically necessary beyond 36 sessions if the client has another documented cardiac event or if the prescribing physician documents that a continuation of cardiac rehabilitation is medically necessary. To confirm that a continuation of cardiac rehabilitation is at the request of or is coordinated with the prescribing physician, the medical record must include evidence of communication between the cardiac rehabilitation staff and the prescribing physician. If the physician responsible for such follow-up is the medical director, then the physician’s notes must be evident in each client’s chart.

Additional cardiac rehabilitation sessions must be prior authorized and must not exceed a total of 36 sessions for 52 weeks from the date of authorization of additional sessions.

If no clinically-significant arrhythmia is documented during the first three weeks of the program, the physician may give the order for the client to complete the remaining portion of the cardiac rehabili­tation without telemetry monitoring.

Although cardiac rehabilitation may be considered a form of physical therapy, it is a specialized program that is conducted by personnel who are not physicians but are trained in both basic and advanced cardiac life support techniques and exercise therapy for coronary disease and who 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.

9.2.16.1Prior Authorization for Cardiac Rehabilitation

Prior authorization is not required for the initial 36 sessions of cardiac rehabilitation.

Cardiac rehabilitation may be considered medically necessary beyond 36 sessions in the following circumstances:

The medical record must support the client has had another cardiac event; or

The prescribing physician documents that a continuation of cardiac rehabilitation is medically necessary. Documentation must include the following:

Progress made from the beginning of 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.

Requests for prior authorization for additional sessions that exceed a total of 36 sessions in 52 weeks will not be granted. Prior authorization must be obtained through the TMHP Special Medical Prior Autho­rization (SMPA) Department.

9.2.16.2Reimbursement

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 billed with modifier 25 appended to the E/M code when a separately identifiable E/M service was provided on the same day by the provider that rendered cardiac rehabilitation. Documen­tation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client’s medical record and made available to Texas Medicaid upon request.

Physical and occupational therapy will not be reimbursed when furnished in addition to cardiac rehabil­itation exercise program services unless there is also a diagnosis of a non-cardiac condition that requires such therapy, e.g., a client who is recuperating from an acute phase of heart disease and may have had a stroke that requires physical and/or occupational therapy.

Client education services, such as formal lectures and counseling on diet, nutrition, and sexual activity, that help a client adjust living habits because of the cardiac condition; will not be separately reimbursed when the services are provided as part of the cardiac rehabilitation program.

9.2.17Casting, Splinting, and Strapping

Casting, splinting, and strapping supplies are considered part of the procedure and are not reimbursed separately. The following procedure codes for casting, splinting, and strapping are a benefit of Texas Medicaid:

Procedure Codes

29000

29010

29015

29035

29040

29044

29046

29049

29055

29058

29065

29075

29085

29086

29105

29125

29126

29130

29131

29200

29220

29240

29260

29280

29305

29325

29345

29355

29358

29365

29405

29425

29435

29440

29445

29450

29505

29515

29520

29530

29540

29550

29580

When a claim for casting, splinting, or strapping is submitted with the same date of service as a surgery, the surgery may be reimbursed and the procedure codes listed in the table above will be denied as part of another procedure.

The replacement of a cast, splint, or strapping is not included in the original surgical fee and may be reimbursed separately. Reimbursement for cast removal, windowing, wedging, or repair will be denied if submitted for reimbursement within six weeks of the initial cast application, splinting, or strapping by the same provider.

Procedure Codes

29700

29705

29710

29720

29730

29740

The following procedure codes for cast removal, windowing, wedging, or repair may be reimbursed to a provider other than the provider who applied the initial cast, splint, or strap:

Procedure Codes

29700

29705

29710

29720

29730

29740

29750

29799

Authorization is not required for casting, splinting, or strapping services.

The following table includes the procedure codes that will be denied when submitted for reimbursement with other casting, splinting, and strapping procedure codes:

Procedure Codes That Will Be Denied

When Submitted With Any of These Procedure Codes

36000, 36410, 37202, 51701, 51702, 51703, 64415, 64416, 64417, 64450, 96360, 96365, 96372, 96374, or 96375

29000, 29010, 29015, 29035, 29040, 29044, 29046, 29049, 29055, 29058, 29065, 29075, 29085, 29086, 29105, 29125, 29126, 29130, 29131, 29200, 29220, 29240, 29260, 29280, 29305, 29325, 29345, 29355, 29358, 29365, 29405, 29425, 29435, 29440, 29445, 29450, 29505, 29515, 29520, 29530, 29540, 29550, 29580, 29700, 29705, 29710, 29720, 29730, 29740, 29750, or 29799

29035

29040, 29044, or 29046

29044

29046

29075

29065, 29105, or 29425

29085, 29125, 29126, or 29705

29065 or 29075

29105

29065

11055, 11056, 11057, or 29125

29425

12001, 12002, 12035, 29125, or 29705

29105

12001, 28190, 28192, 28193, 29130, 29131, 29260, or 29700

29075

29705

29435

12002

29125, 29530, or 29580

12001, 12032, 12042, 12044, 13121, 13132, 29130, or 29260

29125

29305

29325

29365 or 29425

29345

29405

29345, 29425, or 29740

29345, 29365, 29405, or 29425

29355

29440, 29580, 29700, or 29705

29405 or 29425

29580

29515 or 29705

29730

29405

29540

29425, 29505, 29515, or 29580

29730 or 29740

29445

29515

29505

11055, 11056, or 29550

29515

11900, 12004, or 29550

29540

12004, 15852, 29550, or 29700

29580

G0127, 11719, or 11900

29550

15852

29705

9.2.18Cardiopulmonary Resuscitation (CPR)

CPR (procedure code 92950) is a benefit of Texas Medicaid and may be reimbursed when medical necessity is documented in the client’s medical record. Only the primary provider performing CPR may be reimbursed for procedure code 92950. CPR billed as an ambulance service by an ambulance provider will be denied.

CPR may be billed with the same date of service as critical care when reported as a separately identifiable procedure. The time spent performing CPR must not be included in the time reported as critical care.

9.2.19Chemotherapy

Chemotherapy infusion procedure codes listed in the following table are comprehensive codes that include all supplies, catheters, and solutions necessary to safely administer the necessary chemothera­peutic agents either by or under the supervision of the physician, but do not include the provision of the chemotherapeutic agents:

Procedure Codes

96401

96402

96405

96406

96409

96411

96413

96415

96416

96417

96420

96422

96423

96425

96440

96446

96450

96521

96522

96523

96542

96549

G0498

The appropriate E/M procedure code must be billed by a physician for a face-to-face visit with the patient to review chemotherapy options.

9.2.19.1Chemotherapy Procedure Codes

Procedure code 51720 should be used for intravesical instillation of anti carcinogenic agents into the bladder including retention time.

The chemotherapy administration procedure codes 96440, 96446, and 96450 include payment for the surgical procedure; separate reimbursement for the surgical codes will not be allowed. These procedure codes may be paid in addition to E/M procedure codes billed on the same day, regardless of the place of service billed.

Chemotherapeutic drugs and other injections given in the course of chemotherapy may be billed separately and reimbursed using the appropriate procedure codes.

For the first 15 minutes, up to the first hour of chemotherapy infusion, procedure code 96409 or 96413 must be used for a single or initial chemotherapeutic medication. Procedure code 96411 must be used for each additional chemotherapeutic medication given and must be billed with procedure code 96409 or 96413.

Procedure code 96415 must be used for each additional hour beyond the initial hour and must be used in conjunction with procedure code 96413.

Procedure code 96416 will be denied if billed with procedure code G0498 on the same date of service, any provider.

Procedure code 96417 must be used for one additional hour per subsequent infusion and must be used in conjunction with procedure code 96413. Procedure code 96415 may be used for each additional hour.

Procedure code 96425 must be used when initiating an infusion that will take more than eight hours and requires using an implanted pump or a portable pump.

Procedure code 96422 must be used for the first hour of intra-arterial push administration. Procedure code 96423 must be used for each additional hour in conjunction with procedure code 96422.

Chemotherapy administration by push technique (procedure codes 96409 and 96420) and by infusion technique (procedure codes 96413 and 96422) are reimbursed when billed for the same date of service.

Only one intravenous push administration (procedure code 96409) and only one intra-arterial push administration (procedure code 96420) will be allowed per day, regardless of whether separate drugs are given.

Evaluation and management (E/M) services related to other services and procedures being performed may be billed with modifier 25 appended to the E/M code. Documentation that supports the provision of that significant, separately identifiable E/M service must be maintained in the client’s medical record and made available to Texas Medicaid upon request. Modifier 25 use is subject to retrospective review.

Prolonged infusion of chemotherapeutic agents is reimbursed using procedure codes 95991, 96413, 96415, 96416, 96417, 96422, 96423, and 96425.

Inpatient and outpatient hospitals must use revenue code 636 for the reimbursement of the technical component. The appropriate chemotherapy procedure code must be listed on the claim.

9.2.20Circumcisions

Texas Medicaid may provide reimbursement for circumcisions billed with procedure code 54150 or procedure code 54161. Circumcisions performed on clients who are 1 year of age and older must be documented with medical necessity.

Refer to:  Subsection 9.2.44.1, “Circumcisions for Newborns” in this handbook for additional benefit information.

9.2.21Closure of Wounds

The repair of wounds is defined as simple, intermediate, or complex. Simple repair involves the dermis and subcutaneous tissue and requires a one-layer closure. Intermediate repair requires some layered closure of deeper layers of subcutaneous tissue and superficial fascia. Complex repair involves more layered closure, debridement, extensive undermining, stints, or retention sutures.

Wound closures may use sutures, staples, or tissue adhesives. Wounds closed with adhesive strips must not be reported using wound closure procedure codes. When adhesive strips are the only wound closure material used, providers must report the most appropriate E/M visit procedure code on their claim.

Simple exploration of nerves, blood vessels, or tendons exposed in an open wound is considered inclusive to the wound closure and will not be reimbursed separately.

The lengths of multiple closures of wounds must be added together and billed as one procedure code if they meet at least one of the following criteria:

The closures have the same CPT classification (see “Repair [Closure]” in the CPT manual).

The closures are in anatomic sites that are grouped together in the same procedure code descriptor.

Providers must submit the procedure code that represents the total length of the repairs. Lengths of repairs from different CPT classifications or groupings of anatomic sites must be billed as separate procedure codes.

Wound closures must be billed using the following procedure codes:

Procedure Codes

Repair Simple

12001

12002

12004

12005

12006

12007

12011

12013

12014

12015

12016

12017

12018

12020

12021

Repair Intermediate

12031

12032

12034

12035

12036

12037

12041

12042

12044

12045

12046

12047

12051

12052

12053

12054

12055

12056

12057

Repair Complex

13100

13101

13102

13120

13121

13122

13131

13132

13133

13151

13152

13153

13160

Multiple wounds on the same day will be paid the full allowed amount for the major (largest total length of the repair at the same anatomic site) wound and one-half the allowed amount for each additional laceration (total length of the repair at the same anatomic site).

No separate payment will be made for incision closures billed in addition to a surgical procedure when the closure is part of that surgical procedure.

No separate payment will be made for supplies in the office.

When the debridement is carried out separately without immediate primary closure, when gross contamination requires prolonged cleansing, or when large amounts of devitalized or contaminated tissue are removed, debridement may be reimbursed separately. Debridement rendered during the same surgical session as wound closure is considered inclusive to the closure and is not reimbursed separately.

Refer to:  Subsection 9.2.69.11, “Supplies, Trays, and Drugs” in this handbook for the hospital-based emergency department.

Wound suture and wound closure are considered part of any surgical procedure performed on the same area, except for excision of benign or malignant lesion procedure codes that require more than simple closure. Providers may be reimbursed for the appropriate intermediate or complex closure procedure code. Multiple surgery guidelines apply.

The exceptions listed above apply to the following excision and closure procedure codes:

Excision of Benign Lesion Procedure Code

11400

11401

11402

11403

11404

11406

11420

11421

11422

11423

11424

11426

11440

11441

11442

11443

11444

11446

Excision of Malignant Lesion Procedure Codes

11600

11601

11602

11603

11604

11606

11620

11621

11622

11623

11624

11626

11640

11641

11642

11643

11644

11646

Intermediate Closure Procedure Codes

12031

12032

12034

12035

12036

12037

12041

12042

12044

12045

12046

12047

12051

12052

12053

12054

12055

12056

12057

Complex Closure Procedure Codes

13100

13101

131022

13120

13121

13122

13131

13132

13133

13151

13152

13153

13160

9.2.22Cochlear Implants

Cochlear implants, when medically indicated, are benefits of Texas Medicaid with prior authorization. A cochlear implant device (procedure code 69930) is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn externally to capture and amplify sound. These devices are available in single and multichannel models. Cochlear implants are used to provide awareness and identification of sound and to facilitate communication for persons who are profoundly hearing impaired.

Refer to:  Subsection 3.2.1, “Cochlear Implants” in the Vision and Hearing Services Handbook (Vol. 2, Provider Handbooks) for additional information on benefit and authorization require­ments for cochlear implants.

9.2.23Continuous Glucose Monitoring (CGM)

CGM (procedure codes 95250 and 95251) is a benefit of Texas Medicaid with prior authorization.

Procedure codes 95250 and 95251 are limited to once per 12 calendar months by any provider.

The rental or purchase of a continuous glucose monitoring system (CGMS) is considered part of the CGM and is not reimbursed separately.

9.2.23.1Prior Authorization for Continuous Glucose Monitoring

CGM requires prior authorization and must be prescribed by a physician performing the glucose monitoring.

CGM may be prior authorized for clients with Type I diabetes or diabetes during pregnancy, including gestational diabetes. The client must be compliant with his or her current medical regimen, use insulin injections three or more times per day or be on an insulin pump, and have documented self-blood glucose monitoring at least four times per day. At least one or more of the following conditions must also be present:

Frequent unexplained hypoglycemic episodes

Unexplained large fluctuations in daily, preprandial blood glucose

Episodes of ketoacidosis or hospitalization for uncontrolled glucose

Additional CGM services may be considered with documentation of medical necessity that indicates the client meets the criteria above and has a change in condition that would warrant a second procedure within 12 calendar months.

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

9.2.24Developmental Screening and Testing and Aphasia Assessment

The following types of developmental screening and testing and aphasia assessment are benefits of Texas Medicaid when medically necessary:

Developmental screening when performed outside of a Texas Health Steps (THSteps) medical checkup (procedure code 96110)

Developmental testing (procedure code 96111)

Assessment of aphasia (procedure code 96105)

Re-evaluations are a benefit of Texas Medicaid only to address a clinical need, to provide the documen­tation needed to measure a client’s status over time, and to direct the plan of care.

Procedure codes 96105, 96110, and 96111 are used to report medically necessary aphasia assessment, developmental screening, and testing.

Prior authorization is not required for developmental screening, developmental testing, and aphasia assessment.

9.2.24.1Developmental Screening

Developmental screening requiring the use of a standardized, validated screening tool (procedure code 96110) is a benefit of Texas Medicaid for clients who are birth through 6 years of age.

Developmental screening is limited to once per rolling year, any provider, outside of a THSteps medical checkup when medically necessary. This screening should only be completed for a diagnosis of suspected developmental delay or to evaluate a change in the client’s developmental status outside of a THSteps medical checkup.

Developmental screening should be used to identify clients who are birth through 6 years of age and who may need a more comprehensive evaluation. Results of developmental screening may guide or identify the need for further testing. Clients with abnormal screening results must be referred to an appropriate provider for further testing. Clients who are birth through 35 months of age who have suspected devel­opmental delay must be referred to Texas Early Childhood Intervention (ECI) within 7 days after the child has been identified.

Refer to:  Subsection 2.8, “Early Childhood Intervention (ECI) Services” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for additional information on the Texas ECI program.

Subsection 5.3.11.1.2, “Developmental Surveillance or Screening” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for additional information on developmental screening for THSteps checkups.

9.2.24.2Developmental Testing

Developmental testing (procedure code 96111) is a benefit of Texas Medicaid for clients who are birth through 20 years of age.

Developmental testing consists of an extended evaluation and requires the use of a standardized norm-referenced tool. Developmental testing is medically necessary when there is suspected developmental delay supported by clinical evidence. Developmental testing is only medically indicated when clinical evidence suggests the following:

Suspected developmental delay or atypical development when the diagnosis cannot be clearly identified through clinical interview or standardized screening tool alone.

Retesting of a client to evaluate a change in developmental status that results in a change of treatment plan.

Procedure code 96111 is limited to two services per rolling year, any provider.

Developmental testing performed when a development delay or a change in the client’s developmental status is not suspected is not a benefit of Texas Medicaid.

Developmental screening and testing is not a benefit when completed for the purposes of entering day care, Head Start, or a school setting.

Providers cannot bill the client for developmental testing that better fits the description of develop­mental screening.

The physician must maintain documentation of medical necessity in the client’s medical record. Retro­spective review may be performed to ensure that the documentation supports the medical necessity of the service. The following information is required at least every six months to establish medical necessity:

The physician’s prescription that includes a description of the specific service being prescribed

The treatment plan that includes a copy of the current evaluation and documented age of the child at the time of the evaluation

9.2.24.3Assessment of Aphasia

Aphasia assessment (procedure code 96105) is a benefit of Texas Medicaid when medically necessary and is limited to the following diagnosis codes:

Diagnosis codes

R4701

R4702

R471

R4781

R4789

Procedure code 96105 is limited to two services per rolling year, same provider.

9.2.24.412-Hour Limitation for Procedure Codes 96110 and 96111

APRNs, PAs, and psychologists are limited to a maximum, combined total of 12 hours per day for devel­opmental screening and testing, and inpatient and outpatient mental health services.

Because physicians (M.D. and D.O.) can delegate and may submit claims for services in excess of 12 hours per day, they are not subject to the 12-hour system limitation.

Developmental screening and testing are included in the 12-hour per day, per provider, system limitation. The following table lists the procedure codes that are included in the 12-hour per day system limitation, along with the time increments the system will apply based on the billed procedure code. The time increments applied will be used to calculate the 12-hour per day system limitation.

Procedure Code

Time Applied by System

96110

30 Minutes

96111

60 Minutes

Refer to:  Subsection 4.5, “Twelve Hour System Limitation” in the Behavioral Health and Case Management Services Handbook (Vol. 2, Provider Handbooks) for more information about procedure codes included in the 12-hour system limitation.

All providers, including physicians and all providers to whom they delegate services, are subject to retro­spective review. HHSC and TMHP routinely perform retrospective reviews of all providers. All providers are subject to retrospective review for the total hours of services performed and billed in excess of 12 hours per day. Retrospective review may include:

All E/M procedure codes, including those listed in the Evaluation and Management Section of the CPT Manual, billed with a diagnosis listed in the diagnosis table above under Neurobehavioral Testing

All developmental screening and testing procedure codes included in the 12-hour system limitation

Note:Developmental screening and testing procedure codes and mental health procedure codes are included in the review. If a provider provides developmental and neurological assessment and testing at more than one location, any of these services may be retrospectively reviewed.

9.2.25Diagnostic Tests

9.2.25.1Ambulatory Blood Pressure Monitoring

Ambulatory blood pressure monitoring is a benefit of Texas Medicaid when used as a diagnostic tool to assist a physician in diagnosing hypertension in individuals whose blood pressure is either elevated, or inconclusive when evaluated in the office alone.

Ambulatory blood pressure monitoring may also be used for the following:

Clients with established hypertension under treatment

Evaluating refractory or resistant blood pressure

Evaluating symptoms such as light-headedness corresponding with blood pressure changes

Evaluating nighttime blood pressure

Examining diurnal patterns of blood pressure

Ambulatory blood pressure monitoring is indicated for the evaluation of one of the following conditions:

White coat hypertension, which is defined as the following:

Blood pressure measurements taken in the clinic or office are greater than 140/90 mm Hg on at least three separate visits, with two separate measurements made at each visit.

At least two separately documented blood pressure measurements taken outside of the clinic or office that are less than 140/90 mm Hg.

There is no evidence of end-organ damage.

Resistant hypertension

Hypotensive symptoms as a response to hypertension medications

Nocturnal angina

Episodic hypertension

Syncope

Ambulatory blood pressure monitoring is for diagnostic purposes only.

Use procedure codes 93784, 93786, 93788, and/or 93790 to bill in 24-hour increments for ambulatory blood pressure monitoring. Ambulatory blood pressure monitoring is limited to two services per lifetime, any provider. Ambulatory blood pressure monitoring performed more than twice per lifetime may be considered when documentation of medical necessity is submitted with the claim.

9.2.25.2Ambulatory Electroencephalogram (Ambulatory EEG)

Ambulatory EEG monitoring or 24-hour ambulatory monitoring is a covered benefit for clients in whom a seizure diathesis is suspected but not defined by history, physical, and resting EEG.

Benefits are limited to 3 units (each unit 24 hours) for each physician for the same client per 6 months when medically necessary.

Use the following procedure codes to bill ambulatory EEG: 95950, 95951, 95953, and 95956.

Procedure codes 95950, 95951, 95953, and 95956 may be reimbursed when billed with the following diagnosis codes:

Diagnosis Codes

F05

F060

F068

G253

G3101

G3109

G3183

G40001

G40009

G40011

G40019

G40101

G40109

G40111

G40119

G40201

G40209

G40211

G40219

G40301

G40309

G40311

G40319

G40401

G40409

G40411

G40419

G40501

G40509

G40801

G40802

G40803

G40804

G40811

G40812

G40813

G40814

G4089

G40901

G40909

G40911

G40919

G40A11

G40A19

G40B01

G40B09

G40B11

G40B19

G912

O99351

O99352

O99353

O99354

O99355

P90

P912

R410

R4182

R5601

R561

R569

S060X1A

S060X1D

S060X1S

Z052

Other diagnosis codes may be considered on appeal with supporting medical documentation to the TMHP Medical Director.

9.2.25.3Bone Marrow Aspiration, Biopsy

Physicians may bill procedure code 85097 if interpretation is for smear interpretation, or procedure code 88305 if interpretation is for preparation and interpretation of cell block. If both procedure codes 85097 and 88305 are billed, procedure code 88305 is paid and procedure code 85097 is denied.

Physicians may bill procedure code 85097 or 88305 for preparation and interpretation of the specimen.

9.2.25.4Cytopathology Studies—Other Than Gynecological

Procurement and handling of the specimen for cytopathology of sites other than vaginal, cervical, or uterine is considered part of the client’s E/M and will not be reimbursed separately.

Procedure codes 88160, 88161, and 88162 are reimbursed according to the POS where the cytopathology smear is interpreted.

9.2.25.5Echoencephalography

Echoencephalography (procedure code 76506) is medically indicated for the following conditions or diagnosis codes:

Diagnosis Codes

A066

A170

A171

A1781

A1782

A1789

C410

C6961

C6962

C700

C710

C711

C712

C713

C714

C715

C716

C717

C718

C719

C7221

C7222

C7231

C7232

C7241

C7242

C7259

C729

C751

C752

C768

C7931

C7932

C7940

C7949

C7951

C7952

C7989

D075

D098

D164

D3161

D3162

D320

D329

D330

D331

D332

D333

D3500

D3501

D3502

D420

D421

D429

D432

D433

D434

D438

D439

D47Z1

D47Z2

D480

D487

D492

D496

D497

F0390

G060

G062

G07

G08

G132

G138

G232

G300

G301

G308

G309

G3101

G3109

G311

G312

G3183

G3184

G3185

G3189

G319

G910

G911

G912

G930

G932

G9340

G9341

G9349

G935

G936

G937

G9381

G9389

G939

G94

G988

G998

H35361

H4600

H4601

H4602

H4603

H4610

H4611

H4612

H4613

H462

H463

H468

H469

H47011

H47012

H47013

H47019

H47021

H47022

H47023

H47029

H47031

H47032

H47033

H47039

H47091

H47092

H47093

H47099

H4710

H4711

H4712

H4713

H47141

H47142

H47143

H47149

H4720

H47211

H47212

H47213

H47219

H4722

H47231

H47232

H47233

H47239

H47291

H47292

H47293

H47299

H47311

H47312

H47313

H47319

H47321

H47322

H47323

H47329

H47331

H47332

H47333

H47339

H47391

H47392

H47393

H47399

H4741

H4742

H4743

H4749

H47511

H47512

H47519

H47521

H47522

H47529

H47531

H47532

H47539

H47611

H47612

H47619

H47621

H47622

H47629

H47631

H47632

H47639

H47641

H47642

H47649

I6000

I6001

I6002

I6010

I6011

I6012

I602

I6030

I6031

I6032

I604

I6050

I6051

I6052

I606

I607

I608

I609

I610

I611

I612

I613

I614

I615

I616

I618

I619

I6200

I6201

I6202

I6203

I621

I629

I6330

I63311

I63312

I63319

I63321

I63322

I63323

I63333

I63329

I63331

I63332

I63339

I6339

I6340

I63411

I63412

I63419

I63421

I63422

I63429

I63431

I63432

I63439

I6349

I6350

I63511

I63512

I63513

I63519

I63521

I63522

I63523

I63529

I63531

I63532

I63533

I63539

I63543

I6601

I6602

I6603

I6609

I6611

I6612

I6613

I6619

I6621

I6622

I6623

I6629

I668

I669

I671

I6781

I6782

I6783

I6789

I680

I69098

I6921

I69210

I69211

I69212

I69213

I69214

I69215

I69218

I69219

I69220

I69221

I69222

I69223

I69269

I69290

I69291

I69292

I69293

I69298

O99411

O99412

O99413

O99419

O9942

O9943

P0700

P0701

P0702

P0703

P0710

P0714

P0715

P0716

P0717

P100

P101

P102

P103

P104

P108

P109

P112

P119

P120

P121

P122

P123

P124

P1281

P1289

P129

P150

P151

P152

P153

P154

P155

P156

P158

P352

P370

P371

P372

P373

P374

P378

P520

P521

P5221

P5222

P523

P524

P525

P526

P528

P529

P90

P912

P91811

P91819

P9188

Q010

Q011

Q012

Q018

Q02

Q030

Q031

Q038

Q040

Q041

Q042

Q045

Q046

Q048

Q050

Q051

Q052

Q054

Q0701

Q0702

Q0703

Q282

Q283

R220

R221

R5600

R569

S0190XA

S0190XD

S0190XS

S060X0A

S060X0D

S060X0S

S060X1A

S060X1D

S060X1S

S060X9A

S060X9D

S060X9S

S061X0A

S061X0D

S061X0S

S061X1A

S061X1D

S061X1S

S061X2A

S061X2D

S061X2S

S061X3A

S061X3D

S061X3S

S061X4A

S061X4D

S061X4S

S061X5A

S061X5D

S061X5S

S061X6A

S061X6D

S061X6S

S061X7A

S061X8A

S061X9A

S061X9D

S061X9S

S06305A

S06305D

S06305S

S06306A

S06306D

S06306S

S06307A

S06308A

S06310A

S06310D

S06310S

S06311A

S06311D

S06311S

S06312A

S06312D

S06312S

S06313A

S06313D

S06313S

S06314A

S06314D

S06314S

S06315A

S06315D

S06315S

S06316A

S06316D

S06316S

S06317A

S06318A

S06319A

S06319D

S06319S

S06320A

S06320D

S06320S

S06321A

S06321D

S06321S

S06322A

S06322D

S06322S

S06323A

S06323D

S06323S

S06324A

S06324D

S06324S

S06325A

S06325D

S06325S

S06326A

S06326D

S06326S

S06327A

S06328A

S06329A

S06329D

S06329S

S06330A

S06330D

S06330S

S06331A

S06331D

S06331S

S06332A

S06332D

S06332S

S06333A

S06333D

S06333S

S06334A

S06334D

S06334S

S06335A

S06335D

S06335S

S06336A

S06336D

S06336S

S06337A

S06338A

S06339A

S06339D

S06339S

S06340A

S06340D

S06340S

S06341A

S06341D

S06341S

S06342A

S06342D

S06342S

S06343A

S06343D

S06343S

S06344A

S06344D

S06344S

S06345A

S06345D

S06345S

S06346A

S06346D

S06346S

S06347A

S06348A

S06349A

S06349D

S06349S

S06350A

S06350D

S06350S

S06351A

S06351D

S06351S

S06352A

S06352D

S06352S

S06353A

S06353D

S06353S

S06354A

S06354D

S06354S

S06355A

S06355D

S06355S

S06356A

S06356D

S06356S

S06357A

S06358A

S06359A

S06359D

S06359S

S06360A

S06360D

S06360S

S06361A

S06361D

S06361S

S06362A

S06362D

S06362S

S06363A

S06363D

S06363S

S06364A

S06364D

S06364S

S06365A

S06365D

S06365S

S06366A

S06366D

S06366S

S06367A

S06368A

S06369A

S06369D

S06369S

S06370A

S06370D

S06370S

S06371A

S06371D

S06371S

S06372A

S06372D

S06372S

S06373A

S06373D

S06373S

S06374A

S06374D

S06374S

S06375A

S06375D

S06375S

S06376A

S06376D

S06376S

S06377A

S06378A

S06379A

S06379D

S06379S

S06380A

S06380D

S06380S

S06381A

S06381D

S06381S

S06382A

S06382D

S06382S

S06383A

S06383D

S06383S

S06384A

S06384D

S06384S

S06385A

S06385D

S06385S

S06386A

S06386D

S06386S

S06387A

S06388A

S06389A

S06389D

S06389S

S064X0A

S064X0D

S064X0S

S064X1A

S064X1D

S064X1S

S064X2A

S064X2D

S064X2S

S064X3A

S064X3D

S064X3S

S064X4A

S064X4D

S064X4S

S064X5A

S064X5D

S064X5S

S064X6A

S064X6D

S064X6S

S064X7A

S064X8A

S064X9A

S064X9D

S064X9S

S065X0A

S065X0D

S065X0S

S065X1A

S065X1D

S065X1S

S065X2A

S065X2D

S065X2S

S065X3A

S065X3D

S065X3S

S065X4A

S065X4D

S065X4S

S065X5A

S065X5D

S065X5S

S065X6A

S065X6D

S065X6S

S065X7A

S065X8A

S065X9A

S065X9D

S065X9S

S066X0A

S066X0D

S066X0S

S066X1A

S066X1D

S066X1S

S066X2A

S066X2D

S066X2S

S066X3A

S066X3D

S066X3S

S066X4A

S066X4D

S066X4S

S066X5A

S066X5D

S066X5S

S066X6A

S066X6D

S066X6S

S066X7A

S066X8A

S066X9A

S066X9D

S066X9S

S06890A

S06890D

S06890S

S06891A

S06891D

S06891S

S06892A

S06892D

S06892S

S06893A

S06893D

S06893S

S06894A

S06894D

S06894S

S06895A

S06895D

S06895S

S06896A

S06896D

S06896S

S06897A

S06898A

S06899A

S06899D

S06899S

S069X0A

S069X0D

S069X0S

S069X1A

S069X1D

S069X1S

S069X2A

S069X2D

S069X2S

S069X3A

S069X3D

S069X3S

S069X4A

S069X4D

S069X4S

S069X5A

S069X5D

S069X5S

S069X6A

S069X6D

S069X6S

S069X7A

S069X8A

S069X9A

S069X9D

S069X9S

S0990xA

S0990xD

S0990xS

9.2.25.6Electrocardiogram (ECG)

Electrocardiograms (ECG) are a benefit of Texas Medicaid when used for the evaluation and management (E/M) of a confirmed or suspected primary disease of the heart, pericardium, and coronary arteries or when necessary for management of diseases that are not primarily cardiac, but can affect the heart directly or indirectly.

ECGs are limited to six treatments for each client, by any provider per benefit period.

For ECGs, a benefit period is defined as 12 consecutive months, beginning with the month the client receives the first ECG.

The following procedure codes may be reimbursed for ECGs: 93000, 93005, 93010, 93040, 93041, and 93042.

Claims that are denied for exceeding the six-ECG limitation may be appealed with documentation supporting medical necessity. The documentation must include the following:

Diagnosis

Treatment history

Documentation of why additional ECGs are needed

The report of the professional component (the interpretation) for the ECG must be a complete written report that includes relevant findings and appropriate comparisons.

The interpretation may appear on the actual tracing.

When the ECG is performed in conjunction with the performance of an evaluation and management (E/M) service, the interpretation may appear with a progress note or other report of the E/M service; however, if the ECG is billed as a separate service from the E/M service, the interpretation should contain the same information as a report made upon the tracing itself.

A simple notation of “ECG/EKG normal” without an accompanying tracing will not suffice as documen­tation of a separately payable interpretation.

Appropriate documentation, which includes a copy of the ECG tracing, must be kept in the client’s medical record. Documentation must support the medical necessity of the ECG. Documentation may appear on the actual tracing or with a progress note or report. Documentation is subject to retrospective review.

Only an ECG interpretation that directly contributes to the diagnosis and treatment of a client may be considered for reimbursement. Services, such as routine admission ECGs performed without medical indications, that do not directly contribute to the diagnosis and treatment of an individual client are not considered medically necessary.

9.2.25.6.1Prior Authorization for ECG

Prior authorization is not required for ECGs performed in the emergency room or inpatient hospital setting.

Prior authorization is required for more than six ECGs in a rolling 12-month period.

Requests for additional ECGs must be submitted on the Special Medical Prior Authorization (SMPA) Request Form along with documentation of medical necessity.

Providers may request a prior authorization up to 12 months in advance. When requesting retroactive authorization, a provider must submit the request no later than 14 calendar days after the ECG is completed.

Before submitting a prior authorization request for an ECG, a provider must have a completed SMPA Request Form that has been signed and dated by a physician who is familiar with the client. The completed SMPA Request Form must include the procedure codes and numerical quantities for the services requested. The completed SMPA Request Form with the original dated signature must be maintained by the prescribing physician in the client’s medical record.

The SMPA Request Form must include all of the following information, which is related to medical necessity:

Procedure requested (CPT)

Diagnosis

Treatment history

Treatment plan

Prior authorization requests submitted by paper, must be faxed or mailed with the completed SMPA Request Form to the SMPA department and a copy of the signed and dated form must be retained in the client’s medical record at the provider’s place of business. Requests may be faxed or mailed 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.

9.2.25.7Esophageal pH Probe Monitoring

Esophageal pH monitoring uses an indwelling pH microelectrode positioned just above the esophageal sphincter. The pH electrode and skin reference electrode are connected to a battery-powered pH meter and transmitter worn as a shoulder harness. The esophageal pH is monitored continuously and a strip chart is used to record the pH determinations. The patient is usually monitored for a 24-hour period. Esophageal pH monitoring is a medically appropriate adjunct procedure to help establish the presence or absence of gastroesophageal reflux.

Esophageal pH probe monitoring should be coded with procedure codes 91034, 91035, and 78262.

Esophageal pH probe testing (procedure codes 78262, 91034, and 91035) are limited to two services per rolling year, same procedure, any provider.

Claims that are denied for exceeding two services per rolling year may be considered on appeal with documentation of one of the following:

The client is new and the provider has been unsuccessful in obtaining the client’s previous records from a different provider.

The provider is not aware that the client received previous esophageal testing.

Only one appeal will be considered per client, for the same provider. Providers must request prior autho­rization for any additional esophageal testing performed after the appealed service.

9.2.25.7.1Prior Authorization

Esophageal pH probe testing (procedure codes 78262, 91034, and 91035) require prior authorization for services that exceed two per rolling year.

Requests for additional testing may be considered when submitted with documentation of medical necessity that supports, but is not limited to, the following:

Adult’s unintentional weight loss is more than 5 percent of their normal body weight in a span of 12 months or less

Child’s weight loss is 3 to 5 percent of their body mass in less than 30 days

Symptoms of gastroesophageal reflux disease (GERD) that include heartburn and regurgitation that do not respond to treatment with medication

Atypical symptoms of GERD, such as chest pain, coughing, wheezing, hoarseness, and sore throat

Prior authorization requests must be submitted to the Special Medical Prior Authorization Department using the Special Medical Prior Authorization (SMPA) Request Form. The completed prior authori­zation request form must be maintained by the requesting provider and the prescribing physician. The original, signed copy must be kept by the physician in the client’s medical record.

9.2.25.8* Helicobacter Pylori (H. pylori)

Initial testing for H. pylori may be performed using the following tests:

Serology testing (procedure codes 83009 and 86677)

Stool testing (procedure code 87338 with modifier QW)

Breath testing (procedure codes 78267, 78268, 83013, and 83014)

Serology testing for H. pylori is a noninvasive diagnostic procedure that is preferred for initial diagnosis but is not indicated after a diagnosis has been made. Serology testing is not indicated or covered for monitoring a response to therapy.

Procedure codes 83009 and 86677 are allowed once per lifetime when submitted by any provider. A second test may be considered on appeal with documentation that indicates the original test result was negative for H. pylori.

Urea breath tests (UBTs) and fecal antigen tests provide reliable means of identifying active H. pylori infection before antibiotic therapy. UBTs are the most reliable non-endoscopic test to document eradi­cation of H. pylori infection.

H. pylori is accepted as an etiologic factor in duodenal ulcers, peptic ulcer disease, gastric carcinoma, and primary B cell gastric lymphoma. H. pylori testing may be indicated for symptomatic clients who have a documented history of chronic/recurrent duodenal ulcer, gastric ulcer, or chronic gastritis. The history must delineate the failed conservative treatment for the condition.

H. pylori testing is not indicated or covered for any of the following:

New onset uncomplicated dyspepsia.

New onset dyspepsia responsive to conservative treatment (e.g., withdrawal of nonsteroidal anti-inflammatory drugs [NSAID] and/or use of antisecretory agents). If the treatment does not prove successful in eliminating the symptoms, further testing may be indicated to determine the presence of H. pylori.

Screening for H. pylori in asymptomatic clients.

Dyspeptic clients requiring endoscopy and biopsy.

H. pylori testing is not indicated under the following circumstances:

There has been a negative endoscopy in the previous 90 days.

An endoscopy is planned.

H. pylori is of new onset and still being treated.

H. pylori testing will be denied if it is performed within 90 days of an upper gastrointestinal endoscopy. Procedure codes 87338 (with modifier QW), 78267, 78268, 83013, and 83014 may be reimbursed within the 90 days if the provider submits documentation that indicates the client was tested for eradication after treatment.

If a follow-up breath or stool test is used to document eradication of H. pylori, the medical record documentation must verify the history of the following previous complication(s):

The client remains symptomatic after a treatment regimen for H. pylori.

The client is asymptomatic after H. pylori eradication therapy but has a history of hemorrhage, perforation, or outlet obstruction from peptic ulcer disease.

The client has a history of ulcer on chronic NSAID or anticoagulant therapy.

Testing for H. pylori eradication after the completion of antibiotic therapy (procedure codes 87338 [with modifier QW], 78267, 78268, 83013, and 83014) will be denied if billed less than 35 days after the initial test.

Procedure code 87339 is not a benefit of Texas Medicaid.

9.2.25.9Myocardial Perfusion Imaging

Refer to:  Subsection 3.2.1, “Cardiac Nuclear Imaging” in the Radiology and Laboratory Services Handbook (Vol. 2, Provider Handbooks).

9.2.25.10Pediatric Pneumogram

A pediatric pneumogram (procedure code 94772) is a 12-hour to 24-hour recording of breathing effort, heart rate, oxygen level, and airflow to the lungs during sleep. The study is useful in identifying abnormal breathing patterns, with or without bradycardia, especially in premature infants.

The following diagnosis codes may be reimbursed for a pediatric pneumogram in infants from birth through 11 months of age:

Diagnosis Codes

K200

K208

K209

K210

K219

K220

P220

P228

P270

P271

P278

P282

P283

P284

P285

P2881

P2889

P84

R0600

R0609

R062

R063

R0681

R0682

R0683

R0689

R6813

A pediatric pneumogram is limited to two services without prior authorization when submitted with one of the diagnosis codes listed above. Additional studies may be considered under CCP with documentation of medical necessity, and will require prior authorization.

Refer to:  Section 2, “Medicaid Children’s Services Comprehensive Care Program (CCP)” in the Children’s Services Handbook (Vol. 2, Provider Handbooks).

EMGs, polysomnography, EEGs, and ECGs are denied when billed on the same day as a pediatric pneumogram.

Pediatric pneumograms are reimbursed on the same day as an apnea monitor (rented monthly) if documentation supports the medical necessity.

Pneumogram supplies are considered part of the technical component and are denied if billed separately.

9.2.26Diagnostic Doppler Sonography

Diagnostic Doppler sonography is a benefit of Texas Medicaid when treatment decisions depend on the results. Authorization is not required for diagnostic Doppler services.

A vascular diagnostic study may be personally performed by a physician or by a technologist. The accuracy of noninvasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and physician performing and interpreting the study. Consequently, the physician who performs and/or interprets the study must be able to document training through recent residency training or post-graduate continuing medical education and experience and must maintain that documentation for post-payment review.

If noninvasive vascular diagnostic studies are performed by a technologist, the technologist must have demonstrated competency in ultrasound by receiving one of the following credentials in vascular ultra­sound technology:

Registered Vascular Specialist (RVS) provided by Cardiovascular Credentialing International (CCI)

Registered Vascular Technologist (RVT) provided by the American Registry of Diagnostic Medical Sonographers (ARDMS)

Vascular Sonographer (VS) provided by the American Registry of Radiologic Technologists (ARRT), Sonography

Alternately, such studies must be performed in a facility or vascular laboratory accredited by one of the following nationally recognized accreditation organizations. If a vascular laboratory or facility is accredited, the technologists performing noninvasive cerebrovascular arterial studies in that laboratory are considered to have demonstrated competency in cerebrovascular ultrasound:

American College of Radiology (ACR) Vascular Ultrasound Accreditation Program

Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)

Cerebrovascular Doppler Studies

Cerebrovascular Doppler sonography includes both extracranial and transcranial (intracranial) studies. Cerebrovascular Doppler sonography should not be used when treatment decisions will not be affected by the findings.

Cerebrovascular Doppler studies for the diagnosis of migraine are considered experimental and are not a benefit of Texas Medicaid.

Extracranial arterial Doppler (procedure codes 93880 and 93882) are limited to the following diagnosis codes:

Diagnosis Codes

D446

D447

D7801

D7802

D7811

D7812

D7821

D7822

D7831

D7832

D7833

D7834

E3601

E3602

E3611

E3612

G450

G453

G454

G458

G459

G8100

G8101

G8102

G8103

G8104

G8110

G8111

G8112

G8113

G8114

G8190

G8191

G8192

G8193

G8194

G9731

G9732

G9748

G9749

G9751

G9752

G9761

G9762

G9763

G9764

H3401

H3402

H3403

H3411

H3412

H3413

H34211

H34212

H34213

H34231

H34232

H34233

H348110

H348111

H348112

H348120

H348121

H348122

H348130

H348131

H348132

H348190

H348191

H348192

H34821

H34822

H34823

H348310

H348311

H348312

H348320

H348321

H348322

H348330

H348331

H348332

H348390

H348391

H348392

H349

H3582

H5310

H53121

H53122

H53123

H53131

H53132

H53133

H532

H5340

H53411

H53412

H53413

H53421

H53422

H53423

H53431

H53432

H53433

H53451

H53452

H53453

H53461

H53462

H5347

H53481

H53482

H53483

H59111

H59112

H59113

H59119

H59121

H59122

H59123

H59129

H59211

H59212

H59213

H59219

H59221

H59222

H59223

H59229

H59311

H59312

H59313

H59319

H59321

H59322

H59323

H59329

H59331

H59332

H59333

H59339

H59341

H59342

H59343

H59349

H59351

H59352

H59353

H59359

H59361

H59362

H59363

H59369

H93A1

H93A2

H93A3

H93A9

H9521

H9522

H9531

H9532

H9541

H9542

H9551

H9552

H9553

H9554

I610

I611

I612

I613

I614

I615

I616

I618

I619

I6300

I63011

I63012

I63013

I6302

I63031

I63032

I63033

I6309

I6310

I63111

I63112

I63113

I6312

I63131

I63132

I63133

I6319

I6320

I63213

I63233

I6329

I63311

I63312

I63313

I63321

I63322

I63323

I63331

I63332

I63333

I63343

I63411

I63412

I63413

I63421

I63422

I63423

I63431

I63432

I63433

I63443

I63511

I63512

I63513

I63521

I63522

I63523

I63531

I63532

I63533

I63543

I6359

I638

I6501

I6502

I6503

I651

I6521

I6522

I6523

I658

I659

I6601

I6602

I6603

I6609

I6611

I6612

I6613

I6619

I6621

I6622

I6623

I663

I669

I671

I672

I677

I6781

I6782

I67848

I6789

I679

I680

I682

I6990

I69920

I69921

I69922

I69923

I69961

I69962

I69963

I69964

I69965

I69969

I69990

I69991

I69992

I69993

I7100

I720

I725

I726

I728

I770

I771

I772

I773

I776

I7770

I7775

I7776

I7777

I7789

I779

I97410

I97411

I97418

I9742

I9751

I9752

I97610

I97611

I97618

I97620

I97621

I97622

I97630

I97631

I97638

I97640

I97641

I97648

J9561

J9562

J9571

J9572

J95830

J95831

J95860

J95861

J95862

J95863

K9161

K9162

K9171

K9172

K91840

K91841

K91870

K91871

K91872

K91873

L7601

L7602

L7611

L7612

L7621

L7622

L7631

L7632

L7633

L7634

M300

M303

M310

M311

M312

M3130

M3131

M314

M315

M316

M96810

M96811

M96820

M96821

M96830

M96831

M96840

M96841

M96842

M96843

N9961

N9962

N9971

N9972

N99820

N99821

N99840

N99841

N99842

N99843

R0989***

R200

R201

R202

R203

R208

R209

R220**

R221**

R260

R261

R2681

R2689

R269

R270

R278

R279

R295

R29700

R29701

R29702

R29703

R29704

R29705

R29706

R29707

R29708

R29709

R29710

R29711

R29712

R29713

R29714

R29715

R29716

R29717

R29718

R29719

R29720

R29721

R29722

R29723

R29724

R29725

R29726

R29727

R29728

R29729

R29730

R29731

R29732

R29733

R29734

R29735

R29736

R29737

R29738

R29739

R29740

R29741

R29742

R4701

R4702

R471

R4781

R4789

R5084

R55*

R561

S090XXA

S090XXD

S090XXS

S15001A

S15001D

S15001S

S15002A

S15002D

S15002S

S15009A

S15009D

S15009S

S15011A

S15011D

S15011S

S15012A

S15012D

S15012S

S15021A

S15021D

S15021S

S15022A

S15022D

S15022S

S15091A

S15091D

S15091S

S15092A

S15092D

S15092S

S15211A

S15211D

S15211S

S15212A

S15212D

S15212S

S15221A

S15221D

S15221S

S15222A

S15222D

S15222S

S15291A

S15291D

S15291S

S15292A

S15292D

S15292S

S15311A

S15311D

S15311S

S15312A

S15312D

S15312S

S15321A

S15321D

S15321S

S15322A

S15322D

S15322S

S15391A

S15391D

S15391S

S15392A

S15392D

S15392S

S158XXA

S158XXD

S158XXS

S159XXA

S159XXD

S159XXS

S178XXA

S178XXD

S178XXS

S25111A

S25111D

S25111S

S25112A

S25112D

S25112S

S25121A

S25121D

S25121S

S25122A

S25122D

S25122S

S25191A

S25191D

S25191S

S25192A

S25192D

S25192S

T794XXA

T794XXD

T794XXS

T8030XA

T8030XD

T8030XS

T80310A

T80310D

T80310S

T80311A

T80311D

T80311S

T80319A

T80319D

T80319S

T8039XA

T8039XD

T8039XS

T8040XA

T8040XD

T8040XS

T80410A

T80410D

T80410S

T80411A

T80411D

T80411S

T80419A

T80419D

T80419S

T8049XA

T8049XD

T8049XS

T80910A

T80910D

T80910S

T80911A

T80911D

T80911S

T80919A

T80919D

T80919S

T80A0XA

T80A0XD

T80A0XS

T80A10A

T80A10D

T80A10S

T80A11A

T80A11D

T80A11S

T80A19A

T80A19D

T80A19S

T80A9XA

T80A9XD

T80A9XS

T8130XA

T8130XD

T8130XS

T8131XA

T8131XD

T8131XS

T8132XA

T8132XD

T8132XS

T8133XA

T8133XD

T8133XS

T81500A

T81500D

T81500S

T81501A

T81501D

T81501S

T81502A

T81502D

T81502S

T81503A

T81503D

T81503S

T81504A

T81504D

T81504S

T81505A

T81505D

T81505S

T81506A

T81506D

T81506S

T81507A

T81507D

T81507S

T81508A

T81508D

T81508S

T81509A

T81509D

T81509S

T81510A

T81510D

T81510S

T81511A

T81511D

T81511S

T81512A

T81512D

T81512S

T81513A

T81513D

T81513S

T81514A

T81514D

T81514S

T81515A

T81515D

T81515S

T81516A

T81516D

T81516S

T81517A

T81517D

T81517S

T81518A

T81518D

T81518S

T81519A

T81519D

T81519S

T81520A

T81520D

T81520S

T81521A

T81521D

T81521S

T81522A

T81522D

T81522S

T81523A

T81523D

T81523S

T81524A

T81524D

T81524S

T81525A

T81525D

T81525S

T81526A

T81526D

T81526S

T81527A

T81527D

T81527S

T81528A

T81528D

T81528S

T81529A

T81529D

T81529S

T81530A

T81530D

T81530S

T81531A

T81531D

T81531S

T81532A

T81532D

T81532S

T81533A

T81533D

T81533S

T81534A

T81534D

T81534S

T81535A

T81535D

T81535S

T81536A

T81536D

T81536S

T81537A

T81537D

T81537S

T81538A

T81538D

T81538S

T81539A

T81539D

T81539S

T81590A

T81590D

T81590S

T81591A

T81591D

T81591S

T81592A

T81592D

T81592S

T81593A

T81593D

T81593S

T81594A

T81594D

T81594S

T81595A

T81595D

T81595S

T81596A

T81596D

T81596S

T81597A

T81597D

T81597S

T81598A

T81598D

T81598S

T81599A

T81599D

T81599S

T8160XA

T8160XD

T8160XS

T8161XA

T8161XD

T8161XS

T8169XA

T8169XD

T8169XS

T8183XA

T8183XD

T8183XS

T82390A

T82390D

T82390S

T82391A

T82391D

T82391S

T82392A

T82392D

T82392S

T8249XA

T8249XD

T8249XS

T82590A

T82590D

T82590S

T82591A

T82591D

T82591S

T82593A

T82593D

T82593S

T82595A

T82595D

T82595S

T82598A

T82598D

T82598S

T82855A

T82855S

T82856A

T82856S

T85810A

T85810S

T85818A

T85818S

T85820A

T85820S

T85828A

T85828S

T85830A

T85830S

T85838A

T85838S

T85840A

T85840S

T85848A

T85848S

T85850A

T85850S

T85860A

T85860S

T85868A

T85868S

T85890A

T85890S

T85898A

T85898S

T888XXA

T888XXD

T888XXS

Z09

Z95820

Z95828

Z978

Z983

Z9862

Z98890

Z98891

* Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency

** Use R220 or R221 to report pulsatile neck mass

*** Use R0989 to report carotid bruit

Transcranial Doppler (procedure codes 93886, 93888, 93890, 93892, and 93893) are limited to the following diagnosis codes:

Diagnosis Codes

D7801

D7802

D7811

D7812

D7821

D7822

D7831

D7832

D7833

D7834

E3601

E3602

E3611

E3612

G450

G453

G454

G458

G459

G8100

G8101

G8102

G8103

G8104

G8110

G8111

G8112

G8113

G8114

G8190

G8191

G8192

G8193

G8194

G8220

G8221

G8222

G8250

G8251

G8252

G8253

G8254

G830

G8310

G8311

G8312

G8313

G8314

G8320

G8321

G8322

G8323

G8324

G8330

G8331

G8332

G8333

G8334

G839

G9381

G9382

G9389*

G9731

G9732

G9748

G9749

G9751

G9752

G9761

G9762

G9763

G9764

H3401

H3402

H3403

H3411

H3412

H3413

H34211

H34212

H34213

H34231

H34232

H34233

H348110

H348111

H348112

H348120

H348121

H348122

H348130

H348131

H348132

H348190

H348191

H348192

H34821

H34822

H34823

H348310

H348311

H348312

H348320

H348321

H348322

H348330

H348331

H348332

H348390

H348391

H348392

H349

H3582

H4901

H4902

H4903

H4911

H4912

H4913

H4921

H4922

H4923

H4931

H4932

H4933

H4941

H4942

H4943

H499

H52511

H52512

H52513

H5310

H53121

H53122

H53123

H53131

H53132

H53133

H532

H5340

H53411

H53412

H53413

H53421

H53422

H53423

H53431

H53432

H53433

H53451

H53452

H53453

H53461

H53462

H5347

H53481

H53482

H53483

H59111

H59112

H59113

H59119

H59121

H59122

H59123

H59129

H59211

H59212

H59213

H59219

H59221

H59222

H59223

H59229

H59311

H59312

H59313

H59319

H59321

H59322

H59323

H59329

H59331

H59332

H59333

H59339

H59341

H59342

H59343

H59349

H59351

H59352

H59353

H59359

H59361

H59362

H59363

H59369

H9521

H9522

H9531

H9532

H9541

H9542

H9551

H9552

H9553

H9554

I6000

I6001

I6002

I6010

I6011

I6012

I602

I6030

I6031

I6032

I604

I6050

I6051

I6052

I606

I607

I608

I609

I610

I611

I612

I613

I614

I615

I616

I618

I619

I6300

I63011

I63012

I63013

I6302

I63031

I63032

I63033

I6309

I6310

I63111

I63112

I63113

I6312

I63131

I63132

I63133

I6319

I6320

I63213

I63233

I6329

I63311

I63312

I63313

I63321

I63322

I63323

I63331

I63332

I63333

I63343

I63411

I63412

I63413

I63421

I63422

I63423

I63431

I63432

I63433

I63443

I63511

I63512

I63513

I63521

I63522

I63523

I63531

I63532

I63533

I63543

I638

I6501

I6502

I6503

I651

I6521

I6522

I6523

I658

I659

I6601

I6602

I6603

I6609

I6611

I6612

I6613

I6619

I6621

I6622

I6623

I663

I669

I671

I672

I675

I677

I6781

I6782

I67848

I6789

I679

I680

I682

I69098

I6990

I69920

I69921

I69922

I69923

I69961

I69962

I69963

I69964

I69965

I69969

I69990

I69991

I69992

I69993

I7090

I7091

I720

I725

I726

I728

I749**

I770

I771

I772

I773

I776

I7770

I7775

I7776

I7777

I7789

I779

I97410

I97411

I97418

I9742

I9751

I9752

I97610

I97611

I97618

I97620

I97621

I97622

I97630

I97631

I97638

I97640

I97641

I97648

J9561

J9562

J9571

J9572

J95830

J95831

J95860

J95861

J95862

J95863

K9161

K9162

K9171

K9172

K91840

K91841

K91870

K91871

K91872

K91873

L7601

L7602

L7611

L7612

L7621

L7622

L7631

L7632

L7633

L7634

M300

M303

M310

M311

M312

M3130

M3131

M314

M315

M316

M96810

M96811

M96820

M96821

M96830

M96831

M96840

M96841

M96842

M96843

N9961

N9962

N9971

N9972

N99820

N99821

N99840

N99841

N99842

N99843

Q282

Q283

R0989****

R200

R201

R202

R203

R208

R209

R260

R261

R2681

R2689

R269

R270

R278

R279

R295

R29700

R29701

R29702

R29703

R29704

R29705

R29706

R29707

R29708

R29709

R29710

R29711

R29712

R29713

R29714

R29715

R29716

R29717

R29718

R29719

R29720

R29721

R29722

R29723

R29724

R29725

R29726

R29727

R29728

R29729

R29730

R29731

R29732

R29733

R29734

R29735

R29736

R29737

R29738

R29739

R29740

R29741

R29742

R42

R4701

R471

R5084

R55***

R561

R683

S090XXA

S090XXD

S090XXS

S15001A

S15001D

S15001S

S15002A

S15002D

S15002S

S15009A

S15009D

S15009S

S15011A

S15011D

S15011S

S15012A

S15012D

S15012S

S15021A

S15021D

S15021S

S15022A

S15022D

S15022S

S15091A

S15091D

S15091S

S15092A

S15092D

S15092S

S15211A

S15211D

S15211S

S15212A

S15212D

S15212S

S15221A

S15221D

S15221S

S15222A

S15222D

S15222S

S15291A

S15291D

S15291S

S15292A

S15292D

S15292S

S15311A

S15311D

S15311S

S15312A

S15312D

S15312S

S15321A

S15321D

S15321S

S15322A

S15322D

S15322S

S15391A

S15391D

S15391S

S15392A

S15392D

S15392S

S158XXA

S158XXD

S158XXS

S159XXA

S159XXD

S159XXS

S178XXA

S178XXD

S178XXS

S25111A

S25111D

S25111S

S25112A

S25112D

S25112S

S25121A

S25121D

S25121S

S25122A

S25122D

S25122S

S25191A

S25191D

S25191S

S25192A

S25192D

S25192S

T794XXA

T794XXD

T794XXS

T8030XA

T8030XD

T8030XS

T80310A

T80310D

T80310S

T80311A

T80311D

T80311S

T80319A

T80319D

T80319S

T8039XA

T8039XD

T8039XS

T8040XA

T8040XD

T8040XS

T80410A

T80410D

T80410S

T80411A

T80411D

T80411S

T80419A

T80419D

T80419S

T8049XA

T8049XD

T8049XS

T80910A

T80910D

T80910S

T80911A

T80911D

T80911S

T80919A

T80919D

T80919S

T80A0XA

T80A0XD

T80A0XS

T80A10A

T80A10D

T80A10S

T80A11A

T80A11D

T80A11S

T80A19A

T80A19D

T80A19S

T80A9XA

T80A9XD

T80A9XS

T8130XA

T8130XD

T8130XS

T8131XA

T8131XD

T8131XS

T8132XA

T8132XD

T8132XS

T8133XA

T8133XD

T8133XS

T81500A

T81500D

T81500S

T81501A

T81501D

T81501S

T81502A

T81502D

T81502S

T81503A

T81503D

T81503S

T81504A

T81504D

T81504S

T81505A

T81505D

T81505S

T81506A

T81506D

T81506S

T81507A

T81507D

T81507S

T81508A

T81508D

T81508S

T81509A

T81509D

T81509S

T81510A

T81510D

T81510S

T81511A

T81511D

T81511S

T81512A

T81512D

T81512S

T81513A

T81513D

T81513S

T81514A

T81514D

T81514S

T81515A

T81515D

T81515S

T81516A

T81516D

T81516S

T81517A

T81517D

T81517S

T81518A

T81518D

T81518S

T81519A

T81519D

T81519S

T81520A

T81520D

T81520S

T81521A

T81521D

T81521S

T81522A

T81522D

T81522S

T81523A

T81523D

T81523S

T81524A

T81524D

T81524S

T81525A

T81525D

T81525S

T81526A

T81526D

T81526S

T81527A

T81527D

T81527S

T81528A

T81528D

T81528S

T81529A

T81529D

T81529S

T81530A

T81530D

T81530S

T81531A

T81531D

T81531S

T81532A

T81532D

T81532S

T81533A

T81533D

T81533S

T81534A

T81534D

T81534S

T81535A

T81535D

T81535S

T81536A

T81536D

T81536S

T81537A

T81537D

T81537S

T81538A

T81538D

T81538S

T81539A

T81539D

T81539S

T81590A

T81590D

T81590S

T81591A

T81591D

T81591S

T81592A

T81592D

T81592S

T81593A

T81593D

T81593S

T81594A

T81594D

T81594S

T81595A

T81595D

T81595S

T81596A

T81596D

T81596S

T81597A

T81597D

T81597S

T81598A

T81598D

T81598S

T81599A

T81599D

T81599S

T8160XA

T8160XD

T8160XS

T8161XA

T8161XD

T8161XS

T8169XA

T8169XD

T8169XS

T8183XA

T8183XD

T8183XS

T82390A

T82390D

T82390S

T82391A

T82391D

T82391S

T82392A

T82392D

T82392S

T8249XA

T8249XD

T8249XS

T82590A

T82590D

T82590S

T82591A

T82591D

T82591S

T82593A

T82593D

T82593S

T82595A

T82595D

T82595S

T82598A

T82598D

T82598S

T888XXA

T888XXD

T888XXS

Z09

Z95820

Z95828

Z9862

 

 

 

 

* Use G9389 to identify assessment of suspected brain death

** Use I749 to report paradoxical cerebral embolism

*** Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency

**** Use R0989 to report carotid bruit

In addition to the diagnosis codes listed in the table above, procedure codes 93886 and 93888 are benefits for clients who are 2 through 16 years of age with sickle cell disease to evaluate the risk of stroke when submitted with the following diagnosis codes:

Diagnosis Codes

D5700

D5702

D571

D5720

D57212

D57219

D5780

D57812

D57819

Peripheral Arterial Doppler Studies

Peripheral arterial Doppler (procedure codes 93922, 93923, 93924, 93925, 93926, 93930, and 93931) are limited to the following diagnosis codes (unless otherwise indicated):

Diagnosis Codes

D7801

D7802

D7811

D7812

D7821

D7822

D7831

D7832

D7833

D7834

E1051

E1052

E1059

E1151

E1159

E1165

E1351

E1359

E3601

E3602

E3611

E3612

G540

G9731

G9732

G9748

G9749

G9751

G9752

G9761

G9762

G9763

G9764

H59111

H59112

H59113

H59119

H59121

H59122

H59123

H59129

H59211

H59212

H59213

H59219

H59221

H59222

H59223

H59229

H59311

H59312

H59313

H59319

H59321

H59322

H59323

H59329

H59331

H59332

H59333

H59339

H59341

H59342

H59343

H59349

H59351

H59352

H59353

H59359

H59361

H59362

H59363

H59369

H9521

H9522

H9531

H9532

H9541

H9542

H9551

H9552

H9553

H9554

I200

I201

I208

I209

I2101

I2102

I2109

I2111

I2119

I2129

I214

I240

I241

I248

I249

I2510

I25110

I25111

I25118

I25119

I252

I253

I2541

I2542

I25700

I25701

I25708

I25709

I25710

I25711

I25718

I25719

I25730

I25731

I25738

I25739

I25750

I25751

I25758

I25759

I25760

I25761

I25768

I25769

I25790

I25791

I25798

I25799

I25810

I25811

I25812

I2589

I2602

I2692

I700

I70201

I70202

I70203

I70211

I70212

I70213

I70221

I70222

I70223

I70231

I70232

I70233

I70234

I70238

I70241

I70242

I70243

I70244

I70248

I70261

I70262

I70263

I70301

I70302

I70303

I70308

I70309

I70311

I70312

I70313

I70318

I70319

I70321

I70322

I70323

I70328

I70329

I7035

I70368

I70369

I70391

I70392

I70393

I70411

I70412

I70413

I70421

I70422

I70423

I70501

I70502

I70503

I70508

I70509

I70511

I70512

I70513

I70518

I70519

I70521

I70522

I70523

I70528

I70529

I70538

I70539

I70548

I70549

I70561

I70562

I70563

I70568

I70569

I70591

I70592

I70593

I70598

I70599

I70601

I70602

I70603

I70608

I70609

I70611

I70612

I70613

I70618

I70619

I70621

I70622

I70623

I70628

I70629

I70639

I70649

I7065

I70668

I70669

I70691

I70692

I70693

I70698

I70699

I70701

I70702

I70703

I70708

I70709

I70711

I70712

I70713

I70718

I70719

I70721

I70722

I70723

I70728

I70729

I70738

I70739

I70748

I70749

I7075

I70761

I70762

I70763

I70768

I70769

I70791

I70792

I70793

I70798

I70799

I7092

I7100

I7101

I7102

I7103

I711

I712

I713

I714

I715

I716

I718

I723

I725

I726

I728

I7300

I731

I7381

I7389

I739

I7401

I7409

I7411

I745

I748

I749

I7581

I7589

I76

I770

I771

I772

I773

I775

I776

I7770

I7771

I7772

I7773

I7774

I7775

I7779

I7789

I779

I798

I96

I97410

I97411

I97418

I9742

I9751

I9752

I97610

I97611

I97618

I97620

I97621

I97622

I97630

I97631

I97638

I97640

I97641

I97648

J9561

J9562

J9571

J9572

J95830

J95831

J95860

J95861

J95862

J95863

K9161

K9162

K9171

K9172

K91840

K91841

K91870

K91871

K91872

K91873

L7601

L7602

L7611

L7612

L7621

L7622

L7631

L7632

L7633

L7634

L98411

L98412

L98413

L98414

L98419

L98421

L98422

L98423

L98424

L98429

L98491

L98492

L98493

L98494

L98499

M25551

M25552

M314

M315

M316

M340

M341

M342

M3489

M349

M79601

M79602

M79604

M79605

M79621

M79622

M79631

M79632

M79641

M79642

M79651

M79652

M79661

M79662

M79671

M79672

M96810

M96811

M96820

M96821

M96830

M96831

M96840

M96841

M96842

M96843

N183

N184

N185

N186

N9961

N9962

N9971

N9972

N99820

N99821

N99840

N99841

N99842

N99843

Q279

R1900

R1901

R1902

R1903

R1904

R1905

R1906

R1907

R5084

R561

S2590XA

S2590XD

S2590XS

S358X9A

S358X9D

S358X9S

S45091A

S45091D

S45091S

S45092A

S45092D

S45092S

S45111A

S45111D

S45111S

S45112A

S45112D

S45112S

S45191A

S45191D

S45191S

S45192A

S45192D

S45192S

S45211A

S45211D

S45211S

S45212A

S45212D

S45212S

S45291A

S45291D

S45291S

S45292A

S45292D

S45292S

S45811A

S45811D

S45811S

S45812A

S45812D

S45812S

S45891A

S45891D

S45891S

S45892A

S45892D

S45892S

S55011A

S55011D

S55011S

S55012A

S55012D

S55012S

S55091A

S55091D

S55091S

S55092A

S55092D

S55092S

S55111A

S55111D

S55111S

S55112A

S55112D

S55112S

S55191A

S55191D

S55191S

S55192A

S55192D

S55192S

S65011A

S65011D

S65011S

S65012A

S65012D

S65012S

S65091A

S65091D

S65091S

S65092A

S65092D

S65092S

S65111A

S65111D

S65111S

S65112A

S65112D

S65112S

S65191A

S65191D

S65191S

S65192A

S65211D

S65211S

S65212A

S65212D

S65212S

S65291A

S65291D

S65291S

S65292A

S65292D

S65292S

S65311A

S65311D

S65312A

S65312D

S65391A

S65391D

S65391S

S65392A

S65392D

S65392S

S65411A

S65411D

S65411S

S65412A

S65412D

S65412S

S65419A

S65419D

S65419S

S65491A

S65491D

S65491S

S65492A

S65492D

S65492S

S65499A

S65499D

S65499S

S65510A

S65510D

S65510S

S65511A

S65511D

S65511S

S65512A

S65512D

S65512S

S65513A

S65513D

S65513S

S65514A

S65514D

S65514S

S65515A

S65515D

S65515S

S65516A

S65516D

S65516S

S65517A

S65517D

S65517S

S65518A

S65518D

S65518S

S65590A

S65590D

S65590S

S65591A

S65591D

S65591S

S65592A

S65592D

S65592S

S65593A

S65593D

S65593S

S65594A

S65594D

S65594S

S65595A

S65595D

S65595S

S65596A

S65596D

S65596S

S65597A

S65597D

S65597S

S65598A

S65598D

S65598S

S65599A

S65599D

S65599S

S75011A

S75011D

S75011S

S75012A

S75012D

S75012S

S75021A

S75021D

S75021S

S75022A

S75022D

S75022S

S75091A

S75091D

S75091S

S75092A

S75092D

S75092S

S75111A

S75111D

S75111S

S75112A

S75112D

S75112S

S75121A

S75121D

S75121S

S75122A

S75122D

S75122S

S75191A

S75191D

S75191S

S75192A

S75192D

S75192S

S75211A

S75211D

S75211S

S75212A

S75212D

S75212S

S75221A

S75221D

S75221S

S75222A

S75222D

S75222S

S75291A

S75291D

S75291S

S75292A

S75292D

S75292S

S85001A

S85001D

S85001S

S85002A

S85002D

S85002S

S85011A

S85011D

S85011S

S85012A

S85012D

S85012S

S85091A

S85091D

S85091S

S85092A

S85092D

S85092S

S85101A

S85101D

S85101S

S85102A

S85102D

S85102S

S85109A

S85109D

S85109S

S85131A

S85131D

S85131S

S85132A

S85132D

S85132S

S85141A

S85141D

S85141S

S85142A

S85142D

S85142S

S85151A

S85151D

S85151S

S85152A

S85152D

S85152S

S85171A

S85171D

S85171S

S85172A

S85172D

S85172S

S85181A

S85181D

S85181S

S85182A

S85182D

S85182S

S85311A

S85311D

S85311S

S85312A

S85312D

S85312S

S85391A

S85391D

S85391S

S85392A

S85392D

S85392S

S85411A

S85411D

S85411S

S85412A

S85412D

S85412S

S85491A

S85491D

S85491S

S85492A

S85492D

S85492S

S85501A

S85501D

S85501S

S85502A

S85502D

S85502S

S85511A

S85511D

S85511S

S85512A

S85512D

S85512S

S85591A

S85591D

S85591S

S85592A

S85592D

S85592S

S85811A

S85811D

S85811S

S85812A

S85812D

S85812S

S85891A

S85891D

S85891S

S85892A

S85892D

S85892S

S95111A

S95111D

S95111S

S95112A

S95112D

S95112S

S95191A

S95191D

S95191S

S95192A

S95192D

S95192S

T8030XA

T8030XD

T8030XS

T80310A

T80310D

T80310S

T80311A

T80311D

T80311S

T80319A

T80319D

T80319S

T8039XA

T8039XD

T8039XS

T8040XA

T8040XD

T8040XS

T80410A

T80410D

T80410S

T80411A

T80411D

T80411S

T80419A

T80419D

T80419S

T8049XA

T8049XD

T8049XS

T80910A

T80910D

T80910S

T80911A

T80911D

T80911S

T80919A

T80919D

T80919S

T80A0XA

T80A0XD

T80A0XS

T80A10A

T80A10D

T80A10S

T80A11A

T80A11D

T80A11S

T80A19A

T80A19D

T80A19S

T80A9XA

T80A9XD

T80A9XS

T8131XA

T8131XD

T8131XS

T8132XA

T8132XD

T8132XS

T81718A

T81718D

T81718S

T81719A

T81719D

T81719S

T8172XA

T8172XD

T8172XS

T82390A

T82390D

T82390S

T82391A

T82391D

T82391S

T82392A

T82392D

T82392S

T8249XA

T8249XD

T8249XS

T82590A

T82590D

T82590S

T82591A

T82591D

T82591S

T82593A

T82593D

T82593S

T82595A

T82595D

T82595S

T82598A

T82598D

T82598S

T827XXA

T827XXD

T827XXS

T82817A

T82817D

T82817S

T82818A

T82818D

T82818S

T82827A

T82827D

T82827S

T82828A

T82828D

T82828S

T82837A

T82837D

T82837S

T82838A

T82838D

T82838S

T82847A

T82847D

T82847S

T82848A

T82848D

T82848S

T82855A

T82855D

T82855S

T82856A

T82856D

T82856S

T82857A

T82857D

T82857S

T82858A

T82858D

T82858S

T82867A

T82867D

T82867S

T82868A

T82868D

T82868S

T82897A

T82897D

T82897S

T82898A

T82898D

T82898S

T829XXA

T829XXD

T829XXS

T83598A

T83598D

T83598S

T8369XA

T8369XD

T8369XS

T8381XA

T8381XD

T8381XS

T8382XA

T8382XD

T8382XS

T8383XA

T8383XD

T8383XS

T8384XA

T8384XD

T8384XS

T8385XA

T8385XD

T8385XS

T8386XA

T8386XD

T8386XS

T8389XA

T8389XD

T8389XS

T839XXA

T839XXD

T839XXS

T8481XA

T8481XD

T8481XS

T8482XA

T8482XD

T8482XS

T8483XA

T8483XD

T8483XS

T8484XA

T8484XD

T8484XS

T8485XA

T8485XD

T8485XS

T8486XA

T8486XD

T8486XS

T8489XA

T8489XD

T8489XS

T849XXA

T849XXD

T849XXS

T85615A

T85615D

T85615S

T85625A

T85625D

T85625S

T85635A

T85635D

T85635S

T85695A

T85695D

T85695S

T85738A

T85738D

T85738S

T85810A

T85810D

T85810S

T85818A

T85818D

T85818S

T85820A

T85820D

T85820S

T85828A

T85828D

T85828S

T85830A

T85830D

T85830S

T85838A

T85838D

T85838S

T85840A

T85840D

T85840S

T85848A

T85848D

T85848S

T85850A

T85850D

T85850S

T85858A

T85858D

T85858S

T85860A

T85860D

T85860S

T85868A

T85868D

T85868S

T85890A

T85890D

T85890S

T85898A

T85898D

T85898S

T859XXA

T859XXD

T859XXS

T8600

T8601

T8602

T8603

T8609

T8610

T8611

T8612

T8613

T8619

T8620

T8621

T8622

T8623

T86290

T86298

T8640

T8641

T8642

T8643

T8649

T86810

T86811

T86812

T86818

T86819

T86850

T86851

T86852

T86858

T86859

T86890

T86891

T86892

T86898

T86899

T8690

T8691

T8692

T8693

T8699

T871X1

T871X2

T888XXA

T888XXD

T888XXS

Z01810

Z01818

Z09

Z4803

Z48812

Z86711

Z951

Z955

Z95820

Z95828

Z9861

Z9862

Diagnosis Codes for Upper Extremity Conditions

I742

I75011

I75012

I75013

I7776

M79A11

M79A12

Q2731

S45311A

S45311D

S45311S

S45312A

S45312D

S45312S

S45391A

S45391D

S45391S

S45392A

S45392D

S45392S

S45811A

S45811D

S45811S

S45812A

S45812D

S45812S

S45891A

S45891D

S45891S

S45892A

S45892D

S45892S

S45899A

S45899D

S45899S

S45911A

S45911D

S45911S

S45912A

S45912D

S45912S

S45991A

S45991D

S45991S

S45992A

S45992D

S45992S

S55211A

S55211D

S55211S

S55212A

S55212D

S55212S

S55291A

S55291D

S55291S

S55292A

S55292D

S55292S

S55811A

S55811D

S55811S

S55812A

S55812D

S55812S

S55891A

S55891D

S55891S

S55892A

S55892D

S55892S

S55911A

S55911D

S55911S

S55912A

S55912D

S55912S

S55991A

S55991D

S55991S

S55992A

S55992D

S55992S

S65811A

S65811D

S65811S

S65812A

S65812D

S65812S

S65891A

S65891D

S65891S

S65892A

S65892D

S65892S

S65911A

S65911D

S65911S

S65912A

S65912D

S65912S

S65991A

S65991D

S65991S

S65992A

S65992D

S65992S

T870X1

T870X2

T870X9

Diagnosis Codes for Lower Extremity Conditions

I7777

L89500

L89501

L89502

L89503

L89504

L89509

L89510

L89511

L89512

L89513

L89514

L89519

L89520

L89521

L89522

L89523

L89524

L89529

L97111

L97112

L97113

L97114

L97115

L97116

L97118

L97119

L97121

L97122

L97123

L97124

L97125

L97126

L97128

L97129

L97211

L97212

L97213

L97214

L97215

L97216

L97218

L97219

L97221

L97222

L97223

L97224

L97225

L97226

L97228

L97229

L97311

L97312

L97313

L97314

L97315

L97316

L97318

L97319

L97321

L97322

L97323

L97324

L97325

L97326

L97328

L97329

L97401

L97411

L97412

L97413

L97414

L97415

L97416

L97418

L97419

L97421

L97422

L97423

L97424

L97425

L97426

L97428

L97429

L97511

L97512

L97513

L97514

L97515

L97516

L97518

L97519

L97521

L97522

L97523

L97524

L97525

L97526

L97528

L97529

L97815

L97816

L97818

L97825

L97826

L97828

L97911

L97912

L97913

L97914

L97919

L97921

L97922

L97923

L97924

L97929

L98415

L98416

L98418

L98425

L98426

L98428

M79A21

M79A22

Q2732

S75811A

S75811D

S75811S

S75812A

S75812D

S75812S

S75819A

S75819D

S75819S

S75891A

S75891D

S75891S

S75892A

S75892D

S75892S

S75911A

S75911D

S75911S

S75912A

S75912D

S75912S

S75991A

S75991D

S75991S

S75992A

S75992D

S75992S

S85811A

S85811D

S85811S

S85812A

S85812D

S85812S

S85891A

S85891D

S85891S

S85892A

S85892D

S85892S

S85911A

S85911D

S85911S

S85912A

S85912D

S85912S

S85991A

S85991D

S85991S

S85992A

S85992D

S85992S

S95811A

S95811D

S95811S

S95812A

S95812D

S95812S

S95891A

S95891D

S95891S

S95892A

S95892D

S95892S

S95911A

S95911D

S95911S

S95912A

S95912D

S95912S

S95991A

S95991D

S95991S

S95992A

S95992D

S95992S

Peripheral Venous Doppler Studies

Peripheral venous Doppler (procedure codes 93970 and 93971) are limited to the following diagnosis codes:

Diagnosis Codes

D7811

D7812

E3611

E3612

G9748

G9749

H59211

H59212

H59213

H59219

H59221

H59222

H59223

H59229

H9531

H9532

I2602

I2690

I2692

I2699

I2782

I7401

I7409

I749

I8001

I8002

I8003

I8011

I8012

I8013

I80211

I80212

I80213

I80221

I80222

I80223

I80231

I80232

I80233

I80291

I80292

I80293

I803

I808

I809

I82220

I82221

I82290

I82291

I82401

I82402

I82403

I82411

I82412

I82413

I82421

I82422

I82423

I82431

I82432

I82433

I824Y1

I824Y2

I824Y3

I824Z1

I824Z2

I824Z3

I82501

I82502

I82503

I82511

I82512

I82513

I82521

I82522

I82523

I82531

I82532

I82533

I82541

I82542

I82543

I825Y1

I825Y2

I825Y3

I825Z1

I825Z2

I825Z3

I82601

I82602

I82603

I82611

I82612

I82613

I82621

I82622

I82623

I82701

I82702

I82703

I82711

I82712

I82713

I82721

I82722

I82723

I82811

I82812

I82813

I82890

I82891

I82A11

I82A12

I82A13

I82A21

I82A22

I82A23

I82B11

I82B12

I82B13

I82B21

I82B22

I82B23

I82C11

I82C12

I82C13

I82C21

I82C22

I82C23

I83011

I83012

I83013

I83014

I83015

I83018

I83019

I83021

I83022

I83023

I83024

I83025

I83028

I83029

I8311

I8312

I83204

I83211

I83212

I83213

I83214

I83215

I83218

I83219

I83221

I83222

I83223

I83224

I83225

I83228

I83229

I83811

I83812

I83813

I83891

I83892

I83893

I8390

I87001

I87002

I87003

I87011

I87012

I87013

I87021

I87022

I87023

I87031

I87032

I87033

I87091

I87092

I87093

I871

I87301

I87302

I87303

I87311

I87312

I87313

I87321

I87322

I87323

I87331

I87332

I87333

I87391

I87392

I87393

I9751

I9752

J9571

J9572

K9171

K9172

L7611

L7612

L89500

L89501

L89502

L89503

L89504

L89509

L89510

L89511

L89512

L89513

L89514

L89519

L89520

L89521

L89522

L89523

L89524

L89529

L97111

L97112

L97113

L97114

L97115

L97116

L97118

L97119

L97121

L97122

L97123

L97124

L97125

L97126

L97128

L97129

L97211

L97212

L97213

L97214

L97215

L97216

L97218

L97219

L97221

L97222

L97223

L97224

L97225

L97226

L97228

L97229

L97311

L97312

L97313

L97314

L97315

L97316

L97318

L97319

L97321

L97322

L97323

L97324

L97325

L97326

L97328

L97329

L97401

L97411

L97412

L97413

L97414

L97415

L97416

L97418

L97419

L97421

L97422

L97423

L97424

L97425

L97426

L97428

L97429

L97511

L97512

L97513

L97514

L97515

L97516

L97518

L97519

L97521

L97522

L97523

L97524

L97525

L97526

L97528

L97529

L97815

L97816

L97818

L97825

L97826

L97828

L97911

L97912

L97913

L97914

L97919

L97921

L97922

L97923

L97924

L97929

L98415

L98416

L98418

L98425

L98426

L98428

M7121

M7122

M79601

M79602

M79604

M79605

M79621

M79622

M79631

M79632

M79641

M79642

M79651

M79652

M79661

M79662

M79671

M79672

M79A11

M79A12

M79A21

M79A22

M96820

M96821

N9971

N9972

O2220

O2221

O2222

O2223

O2230

O2231

O2232

O2233

O2290

O2291

O2292

O2293

O870

O871

O879

O88211

O88212

O88213

O88219

O8822

O8823

Q2731

Q2732

Q278

Q279

R0603

R220

R221

R222

R2231

R2232

R2233

R2241

R2242

R2243

R5084

R561

R600

R601

R609

S2590XA

S2590XD

S2590XS

S358X9A

S358X9D

S358X9S

S45091A

S45091D

S45091S

S45092A

S45092D

S45092S

S45111A

S45111D

S45111S

S45112A

S45112D

S45112S

S45191A

S45191D

S45191S

S45192A

S45192D

S45192S

S45211A

S45211D

S45211S

S45212A

S45212D

S45212S

S45291A

S45291D

S45291S

S45292A

S45292D

S45292S

S45311A

S45311D

S45311S

S45312A

S45312D

S45312S

S45391A

S45391D

S45391S

S45392A

S45392D

S45392S

S45811A

S45811D

S45811S

S45812A

S45812D

S45812S

S45891A

S45891D

S45891S

S45892A

S45892D

S45892S

S45899A

S45899D

S45899S

S45911A

S45911D

S45911S

S45912A

S45912D

S45912S

S45991A

S45991D

S45991S

S45992A

S45992D

S45992S

S55011A

S55011D

S55011S

S55012A

S55012D

S55012S

S55091A

S55091D

S55091S

S55092A

S55092D

S55092S

S55111A

S55111D

S55111S

S55112A

S55112D

S55112S

S55191A

S55191D

S55191S

S55192A

S55192D

S55192S

S55211A

S55211D

S55211S

S55212A

S55212D

S55212S

S55291A

S55291D

S55291S

S55292A

S55292D

S55292S

S55811A

S55811D

S55811S

S55812A

S55812D

S55812S

S55891A

S55891D

S55891S

S55892A

S55892D

S55892S

S55911A

S55911D

S55911S

S55912A

S55912D

S55912S

S55991A

S55991D

S55991S

S55992A

S55992D

S55992S

S65011A

S65011D

S65011S

S65012A

S65012D

S65012S

S65091A

S65091D

S65091S

S65092A

S65092D

S65092S

S65111A

S65111D

S65111S

S65112A

S65112D

S65112S

S65191A

S65191D

S65191S

S65192A

S65211D

S65211S

S65212A

S65212D

S65212S

S65291A

S65291D

S65291S

S65292A

S65292D

S65292S

S65311A

S65311D

S65311S

S65312A

S65312D

S65312S

S65391A

S65391D

S65391S

S65392A

S65392D

S65392S

S65411A

S65411D

S65411S

S65412A

S65412D

S65412S

S65419A

S65419D

S65419S

S65491A

S65491D

S65491S

S65492A

S65492D

S65492S

S65499A

S65499D

S65499S

S65510A

S65510D

S65510S

S65511A

S65511D

S65511S

S65512A

S65512D

S65512S

S65513A

S65513D

S65513S

S65514A

S65514D

S65514S

S65515A

S65515D

S65515S

S65516A

S65516D

S65516S

S65517A

S65517D

S65517S

S65518A

S65518D

S65518S

S65590A

S65590D

S65590S

S65591A

S65591D

S65591S

S65592A

S65592D

S65592S

S65593A

S65593D

S65593S

S65594A

S65594D

S65594S

S65595A

S65595D

S65595S

S65596A

S65596D

S65596S

S65597A

S65597D

S65597S

S65598A

S65598D

S65598S

S65599A

S65599D

S65599S

S65811A

S65811D

S65811S

S65812A

S65812D

S65812S

S65891A

S65891D

S65891S

S65892A

S65892D

S65892S

S65911A

S65911D

S65911S

S65912A

S65912D

S65912S

S65991A

S65991D

S65991S

S65992A

S65992D

S65992S

S75011A

S75011D

S75011S

S75012A

S75012D

S75012S

S75021A

S75021D

S75021S

S75022A

S75022D

S75022S

S75091A

S75091D

S75091S

S75092A

S75092D

S75092S

S75111A

S75111D

S75111S

S75112A

S75112D

S75112S

S75121A

S75121D

S75121S

S75122A

S75122D

S75122S

S75191A

S75191D

S75191S

S75192A

S75192D

S75192S

S75211A

S75211D

S75211S

S75212A

S75212D

S75212S

S75221A

S75221D

S75221S

S75222A

S75222D

S75222S

S75291A

S75291D

S75291S

S75292A

S75292D

S75292S

S75811A

S75811D

S75811S

S75812A

S75812D

S75812S

S75819A

S75819D

S75819S

S75891A

S75891D

S75891S

S75892A

S75892D

S75892S

S75911A

S75911D

S75911S

S75912A

S75912D

S75912S

S75991A

S75991D

S75991S

S75992A

S75992D

S75992S

S85001A

S85001D

S85001S

S85002A

S85002D

S85002S

S85011A

S85011D

S85011S

S85012A

S85012D

S85012S

S85091A

S85091D

S85091S

S85092A

S85092D

S85092S

S85101A

S85101D

S85101S

S85102A

S85102D

S85102S

S85109A

S85109D

S85109S

S85131A

S85131D

S85131S

S85132A

S85132D

S85132S

S85141A

S85141D

S85141S

S85142A

S85142D

S85142S

S85151A

S85151D

S85151S

S85152A

S85152D

S85152S

S85171A

S85171D

S85171S

S85172A

S85172D

S85172S

S85181A

S85181D

S85181S

S85182A

S85182D

S85182S

S85311A

S85311D

S85311S

S85312A

S85312D

S85312S

S85391A

S85391D

S85391S

S85392A

S85392D

S85392S

S85411A

S85411D

S85411S

S85412A

S85412D

S85412S

S85491A

S85491D

S85491S

S85492A

S85492D

S85492S

S85501A

S85501D

S85501S

S85502A

S85502D

S85502S

S85511A

S85511D

S85511S

S85512A

S85512D

S85512S

S85591A

S85591D

S85591S

S85592A

S85592D

S85592S

S85811A

S85811D

S85811S

S85812A

S85812D

S85812S

S85891A

S85891D

S85891S

S85892A

S85892D

S85892S

S85911A

S85911D

S85911S

S85912A

S85912D

S85912S

S85991A

S85991D

S85991S

S85992A

S85992D

S85992S

S95111A

S95111D

S95111S

S95112A

S95112D

S95112S

S95191A

S95191D

S95191S

S95192A

S95192D

S95192S

S95811A

S95811D

S95811S

S95812A

S95812D

S95812S

S95891A

S95891D

S95891S

S95892A

S95892D

S95892S

S95911A

S95911D

S95911S

S95912A

S95912D

S95912S

S95991A

S95991D

S95991S

S95992A

S95992D

S95992S

T800XXA

T801XXA

T801XXD

T801XXS

T8030XA

T8030XD

T8030XS

T80310A

T80310D

T80310S

T80311A

T80311D

T80311S

T80319A

T80319D

T80319S

T8039XA

T8039XD

T8039XS

T8040XA

T8040XD

T8040XS

T80410A

T80410D

T80410S

T80411A

T80411D

T80411S

T80419A

T80419D

T80419S

T8049XA

T8049XD

T8049XS

T80910A

T80910D

T80910S

T80911A

T80911D

T80911S

T80919A

T80919D

T80919S

T80A0XA

T80A0XD

T80A0XS

T80A10A

T80A10D

T80A10S

T80A11A

T80A11D

T80A11S

T80A19A

T80A19D

T80A19S

T80A9XA

T80A9XD

T80A9XS

T81718A

T81718D

T81718S

T81719A

T81719D

T81719S

T8172XA

T8172XD

T8172XS

T82390A

T82390D

T82390S

T82391A

T82391D

T82391S

T82392A

T82392D

T82392S

T8249XA

T8249XD

T8249XS

T82590A

T82590D

T82590S

T82591A

T82591D

T82591S

T82593A

T82593D

T82593S

T82595A

T82595D

T82595S

T82598A

T82598D

T82598S

T82817A

T82818A

T82818D

T82818S

T82828A

T82828D

T82828S

T82838A

T82838D

T82838S

T82848A

T82848D

T82848S

T82855A

T82856A

T82858A

T82858D

T82858S

T82868A

T82868D

T82868S

T82898A

T82898D

T82898S

T85810A

T85818A

T85820A

T85828A

T85830A

T85838A

T85840A

T85848A

T85850A

T85858A

T85860A

T85868A

T85890A

T85898A

T888XXA

T888XXD

T888XXS

Z01818

Z86711

Z940

Z951

Doppler echocardiography color flow velocity mapping (procedure code 93325) must be billed with one of the corresponding procedure codes in column B to be considered for reimbursement:

Column A Procedure Code

Column B Procedure Codes

93325

76825, 76826, 76827, 76828, 93303,93304, 93307, 93308, 93312, 93314, 93315, 93317, 93320, 93321, or 93350

Limitations for Diagnostic Doppler Sonography

Documentation of medical necessity for the diagnostic Doppler study must be maintained by the ordering provider in the client’s medical record.

Procedure codes described as complete bilateral studies are inclusive codes, and right and left studies billed on the same day will be reimbursed at a quantity of one.

Diagnostic Doppler procedure codes are limited to one study per day, same provider.

When medically necessary, multiple Doppler procedures (e.g., studies of extracranial arteries and intra­cranial arteries) billed on the same day by the same provider will be reimbursed at full fee for the first study and one-half fee for each additional study, regardless of the number of services billed.

The use of transcranial Doppler studies performed for the assessment of stroke risk in clients who are 2 through 16 years of age who have sickle cell anemia should be limited to once every 6 months.

The use of a simple hand-held or other Doppler device that does not produce hard copy output or that does not permit analysis of bidirectional vascular flow is considered part of the physical examination of the vascular system and is not separately reported.

9.2.27Evoked Response Tests and Neuromuscular Procedures

The following services are a benefit of Texas Medicaid:

Autonomic function test (AFT)

Electromyography (EMG)

Nerve conduction studies (NCS)

Evoked potential (EP) testing

Motion analysis studies

9.2.27.1Autonomic Function Tests

AFTs are a benefit of Texas Medicaid when submitted with procedure codes 95921, 95922, 95923, 95924, and 95943.

Procedure codes 95921, 95922, 95923, 95924, and 95943 are limited to once per date of service, by the same provider.

Autonomic disorders may be congenital or acquired (primary or secondary). Some of the conditions under which autonomic function testing may be appropriate include, but are not limited to, the following:

Amyloid neuropathy

Diabetic autonomic neuropathy

Distal small fiber neuropathy

Excessive sweating

Gastrointestinal dysfunction

Idiopathic neuropathy

Irregular heart rate

Multiple system atrophy

Orthostatic symptoms

Pure autonomic failure

Reflex sympathetic dystrophy or causalgia (sympathetically maintained pain)

Sjogren’s syndrome

The reason for the referral, the specific autonomic function being tested, and a clear diagnostic impression must be documented in the client’s medical record for each AFT performed.

The client’s medical records must clearly document the medical necessity for the AFT. The medical record documentation must reflect the actual results of specific tests (such as latency and amplitude).

Medical necessity for reevaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client’s medical record. Supporting documentation includes, but is not limited to, the following:

The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis.

Evidence that the client’s condition is changing rapidly, supported by the following:

Diagnosis

Current clinical signs and symptoms

Prior clinical condition

Expected clinical disease course

Clinical benefit of additional studies.

The client’s medical records are subject to retrospective review. Wave form recordings obtained during the testing will aid documentation requirements in cases where a review becomes necessary.

9.2.27.2Electromyography and Nerve Conduction Studies

Electromyography (EMG) and nerve conduction studies (NCS), collectively known as electrodiagnostic (EDX) testing, must be medically indicated and may be reimbursed with the diagnosis codes listed below. 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.

Diagnosis Codes

C701

C720

C721

E0842

E0942

E1041

E1042

E10610

E1141

E1142

E1144

E11610

E1342

E5111

E5112

E512

E518

E519

E560

E568

E786

E851

E852

E853

E8581

E8582

E8589

E859

G120

G121

G1221

G1222

G1223

G1224

G1225

G1229

G128

G129

G130

G243

G2589

G26

G320

G360

G370

G375

G501

G510

G511

G512

G513

G514

G518

G519

G522

G523

G527

G528

G540

G541

G542

G543

G544

G545

G548

G549

G5601

G5602

G5603

G5611

G5612

G5613

G5621

G5622

G5623

G5631

G5632

G5633

G5641

G5642

G5643

G5681

G5682

G5683

G5691

G5692

G5693

G5701

G5702

G5703

G5711

G5712

G5713

G5721

G5722

G5723

G5731

G5732

G5733

G5741

G5742

G5743

G5751

G5752

G5753

G5761

G5762

G5763

G5771

G5772

G5773

G5781

G5782

G5783

G5791

G5792

G5793

G587

G588

G589

G59

G600

G601

G602

G603

G608

G609

G610

G6181

G6182

G6189

G619

G620

G621

G622

G6281

G6282

G629

G63

G650

G651

G652

G7000

G7001

G701

G702

G7081

G7089

G709

G710

G7111

G7112

G7113

G7114

G7119

G712

G713

G718

G719

G721

G722

G723

G7241

G7249

G7281

G7289

G729

G731

G733

G737

G800

G801

G802

G803

G804

G808

G809

G8311

G8312

G8313

G8314

G8321

G8322

G8323

G8324

G834

G8381

G8382

G8383

G8384

G8389

G839

G9009

G902

G904

G9050

G90511

G90512

G90513

G90519

G90521

G90522

G90523

G90529

G9059

G909

G950

G9511

G9519

G9520

G9529

G9581

G9589

G959

G990

G992

I776

I951

J3800

J3801

J3802

K5902

K5903

K5904

K5909

K592

K594

K624

K6289

M05411

M05412

M05421

M05422

M05431

M05432

M05441

M05442

M05451

M05452

M05461

M05462

M05471

M05472

M0549

M05511

M05512

M05521

M05522

M05531

M05532

M05541

M05542

M05551

M05552

M05561

M05562

M05571

M05572

M0559

M05711

M05712

M05721

M05722

M05731

M05732

M05741

M05742

M05751

M05752

M05761

M05762

M05769

M05771

M05772

M05779

M0579

M05811

M05812

M05821

M05822

M05831

M05832

M05841

M05842

M05851

M05852

M05861

M05862

M05871

M05872

M0589

M06011

M06012

M06021

M06022

M06031

M06032

M06041

M06042

M06051

M06052

M06061

M06062

M06071

M06072

M0608

M0609

M06811

M06812

M06821

M06822

M06831

M06832

M06841

M06842

M06852

M06861

M06862

M06871

M06872

M0688

M0689

M069

M21271

M21272

M21331

M21332

M21511

M21512

M216X1

M216X2

M21831

M21832

M21931

M21932

M320

M3210

M3211

M3212

M3213

M3214

M3215

M3219

M328

M329

M3300

M3301

M3302

M3309

M3310

M3311

M3312

M3319

M3320

M3321

M3322

M3329

M3390

M3391

M3392

M3399

M340

M341

M342

M3481

M3482

M3483

M3489

M358

M360

M4321

M4322

M4323

M4324

M4325

M4326

M4327

M4328

M436

M438X9

M4644

M4645

M4646

M4647

M4711

M4712

M4713

M4714

M4715

M4716

M4721

M4722

M4723

M4724

M4725

M4726

M4727

M4728

M47811

M47812

M47813

M47814

M47815

M47816

M47817

M47818

M47891

M47892

M47893

M47894

M47895

M47896

M47897

M47898

M4801

M4802

M4803

M4804

M4805

M48062

M4807

M4808

M5000

M5001

M50020

M50021

M50022

M50023

M5003

M5011

M50120

M50121

M50122

M50123

M5013

M5020

M5021

M50220

M50221

M50222

M50223

M5023

M5030

M5031

M50320

M50321

M50322

M50323

M5033

M5080

M5081

M50820

M50821

M50822

M50823

M5083

M5091

M50920

M50921

M50922

M50923

M5093

M5104

M5105

M5106

M5124

M5125

M5126

M5127

M5134

M5135

M5136

M5137

M5184

M5185

M5186

M5187

M5410

M5411

M5412

M5413

M5414

M5415

M5416

M5417

M5431

M5432

M545

M546

M5489

M60011

M60012

M60021

M60022

M60031

M60032

M60041

M60042

M60044

M60045

M60046

M60051

M60052

M60061

M60062

M60070

M60071

M60073

M60074

M60076

M60077

M6008

M6009

M60111

M60112

M60121

M60122

M60131

M60132

M60141

M60142

M60151

M60152

M60161

M60162

M60171

M60172

M6018

M6019

M609

M6250

M62511

M62512

M62519

M62521

M62522

M62529

M62531

M62532

M62539

M62541

M62542

M62549

M62551

M62552

M62559

M62561

M62562

M62569

M62571

M62572

M62579

M6258

M6259

M6281

M6284

M629

M791

M792

M79601

M79602

M79604

M79605

M79621

M79622

M79631

M79632

M79641

M79642

M79651

M79652

M79661

M79662

M79671

M79672

M797

M961

N393

N3941

N3942

N3943

N3944

N3945

N3946

N39490

N39491

N39492

N39498

N94819

R150

R151

R152

R159

R200

R201

R202

R203

R208

R209

R260

R261

R2681

R2689

R269

R290

R295

R29701

R29702

R29703

R29704

R29705

R29706

R29707

R29708

R29709

R29710

R29711

R29712

R29713

R29714

R29715

R29716

R29717

R29718

R29719

R29720

R29721

R29722

R29723

R29724

R29725

R29726

R29727

R29728

R29729

R29730

R29731

R29732

R29733

R29734

R29735

R29736

R29737

R29738

R29739

R29740

R29741

R29742

R32

R3914

R39191

R39192

R39198

R4702

R471

R4781

R4789

R498

R6884

S14101A

S14101D

S14101S

S14102A

S14102D

S14102S

S14103A

S14103D

S14103S

S14104A

S14104D

S14104S

S14105A

S14105D

S14105S

S14106A

S14106D

S14106S

S14107A

S14107D

S14107S

S14108A

S14108D

S14108S

S14109A

S14109D

S14109S

S14111A

S14111D

S14111S

S14112A

S14112D

S14112S

S14113A

S14113D

S14113S

S14114A

S14114D

S14114S

S14115A

S14115D

S14115S

S14116A

S14116D

S14116S

S14117A

S14117D

S14117S

S14118A

S14118D

S14118S

S14121A

S14121D

S14121S

S14122A

S14122D

S14122S

S14123A

S14123D

S14123S

S14124A

S14124D

S14124S

S14125A

S14125D

S14125S

S14126A

S14126D

S14126S

S14127A

S14127D

S14127S

S14128A

S14128D

S14128S

S14131A

S14131D

S14131S

S14132A

S14132D

S14132S

S14133A

S14133D

S14133S

S14134A

S14134D

S14134S

S14135A

S14135D

S14135S

S14136A

S14136D

S14136S

S14137A

S14137D

S14137S

S14138A

S14138D

S14138S

S14141A

S14141D

S14141S

S14142A

S14142D

S14142S

S14143A

S14143D

S14143S

S14144A

S14144D

S14144S

S14145A

S14145D

S14145S

S14146A

S14146D

S14146S

S14147A

S14147D

S14147S

S14148A

S14148D

S14148S

S14151A

S14151D

S14151S

S14152A

S14152D

S14152S

S14153A

S14153D

S14153S

S14154A

S14154D

S14154S

S14155A

S14155D

S14155S

S14156A

S14156D

S14156S

S14157A

S14157D

S14157S

S14158A

S14158D

S14158S

S142XXA

S142XXD

S142XXS

S143XXA

S143XXD

S143XXS

S144XXA

S144XXD

S144XXS

S145XXA

S145XXD

S145XXS

S148XXA

S148XXD

S148XXS

S149XXA

S149XXD

S149XXS

S24101A

S24101D

S24101S

S24102A

S24102D

S24102S

S24103A

S24103D

S24103S

S24104A

S24104D

S24104S

S24109A

S24109D

S24109S

S24111A

S24111D

S24111S

S24112A

S24112D

S24112S

S24113A

S24113D

S24113S

S24114A

S24114D

S24114S

S24131A

S24131D

S24131S

S24132A

S24132D

S24132S

S24133A

S24133D

S24133S

S24134A

S24134D

S24134S

S24141A

S24141D

S24141S

S24142A

S24142D

S24142S

S24143A

S24143D

S24143S

S24144A

S24144D

S24144S

S24151A

S24151D

S24151S

S24152A

S24152D

S24152S

S24153A

S24153D

S24153S

S24154A

S24154D

S24154S

S242XXA

S242XXD

S242XXS

S243XXA

S243XXD

S243XXS

S244XXA

S244XXD

S244XXS

S248XXA

S248XXD

S248XXS

S249XXA

S249XXD

S249XXS

S34109A

S34109D

S34109S

S34111A

S34111D

S34111S

S34112A

S34112D

S34112S

S34113A

S34113D

S34113S

S34114A

S34114D

S34114S

S34115A

S34115D

S34115S

S34121A

S34121D

S34121S

S34122A

S34122D

S34122S

S34123A

S34123D

S34123S

S34124A

S34124D

S34124S

S34125A

S34125D

S34125S

S34131A

S34131D

S34131S

S34132A

S34132D

S34132S

S34139A

S34139D

S34139S

S3421XA

S3421XD

S3421XS

S3422XA

S3422XD

S3422XS

S343XXA

S343XXD

S343XXS

S344XXA

S344XXD

S344XXS

S345XXA

S345XXD

S345XXS

S4400XA

S4400XD

S4400XS

S4401XA

S4401XD

S4401XS

S4402XA

S4402XD

S4402XS

S4410XA

S4410XD

S4410XS

S4411XA

S4411XD

S4411XS

S4412XA

S4412XD

S4412XS

S4420XA

S4420XD

S4420XS

S4421XA

S4421XD

S4421XS

S4422XA

S4422XD

S4422XS

S4430XA

S4430XD

S4430XS

S4431XA

S4431XD

S4431XS

S4432XA

S4432XD

S4432XS

S4440XA

S4440XD

S4440XS

S4441XA

S4441XD

S4441XS

S4442XA

S4442XD

S4442XS

S4450XA

S4450XD

S4450XS

S4451XA

S4451XD

S4451XS

S4452XA

S4452XD

S4452XS

S448X1A

S448X1D

S448X1S

S448X2A

S448X2D

S448X2S

S448X9A

S448X9D

S448X9S

S4491XA

S4491XD

S4491XS

S4492XA

S4492XD

S4492XS

S5400XA

S5400XD

S5400XS

S5401XA

S5401XD

S5401XS

S5402XA

S5402XD

S5402XS

S5410XA

S5410XD

S5410XS

S5411XA

S5411XD

S5411XS

S5412XA

S5412XD

S5412XS

S5420XA

S5420XD

S5420XS

S5421XA

S5421XD

S5421XS

S5422XA

S5422XD

S5422XS

S5430XA

S5430XD

S5430XS

S5431XA

S5431XD

S5431XS

S5432XA

S5432XD

S5432XS

S5490XA

S5490XD

S5490XS

S5491XA

S5491XD

S5491XS

S5492XA

S5492XD

S5492XS

S6400XA

S6400XD

S6400XS

S6401XA

S6401XD

S6401XS

S6402XA

S6402XD

S6402XS

S6410XA

S6410XD

S6410XS

S6411XA

S6411XD

S6411XS

S6412XA

S6412XD

S6412XS

S6420XA

S6420XD

S6420XS

S6421XA

S6421XD

S6421XS

S6422XA

S6422XD

S6422XS

S6430XA

S6430XD

S6430XS

S6431XA

S6431XD

S6431XS

S6432XA

S6432XD

S6432XS

S64490A

S64490D

S64490S

S64491A

S64491D

S64491S

S64492A

S64492D

S64492S

S64493A

S64493D

S64493S

S64494A

S64494D

S64494S

S64495A

S64495D

S64495S

S64496A

S64496D

S64496S

S64497A

S64497D

S64497S

S64498A

S64498D

S64498S

S648X1A

S648X1D

S648X1S

S648X2A

S648X2D

S648X2S

S648X9A

S648X9D

S648X9S

S6490XA

S6490XD

S6490XS

S6491XA

S6491XD

S6491XS

S6492XA

S6492XD

S6492XS

S7401XA

S7401XD

S7401XS

S7402XA

S7402XD

S7402XS

S7411XA

S7411XD

S7411XS

S7412XA

S7412XD

S7412XS

S7421XA

S7421XD

S7421XS

S7422XA

S7422XD

S7422XS

S748X1A

S748X1D

S748X1S

S748X2A

S748X2D

S748X2S

S7491XA

S7491XD

S7491XS

S7492XA

S7492XD

S7492XS

S8401XA

S8401XD

S8401XS

S8402XA

S8402XD

S8402XS

S8411XA

S8411XD

S8411XS

S8412XA

S8412XD

S8412XS

S8421XA

S8421XD

S8421XS

S8422XA

S8422XD

S8422XS

S84801A

S84801D

S84801S

S84802A

S84802D

S84802S

S8491XA

S8491XD

S8491XS

S8492XA

S8492XD

S8492XS

S9421XA

S9421XD

S9421XS

S9422XA

S9422XD

S9422XS

S9431XA

S9431XD

S9431XS

S9432XA

S9432XD

S9432XS

S948X1A

S948X1D

S948X1S

S948X2A

S948X2D

S948X2S

S948X9A

S948X9D

S948X9S

S9490XA

S9490XD

S9490XS

S9491XA

S9491XD

S9491XS

S9492XA

S9492XD

S9492XS

T85840A

T85840D

T85840S

Any EDX testing procedures may be reimbursed up to four different dates of service per calendar year, same provider. Any E/M service will be denied as part of another service when billed for the same date of service as EMG or NCS service by the same provider.

Claims for nerve conduction studies that are denied for exceeding the maximum number of studies allowed per day, may be appealed with supporting medical record documentation.

The reason for the referral, the specific site(s) tested, and a clear diagnostic impression must be documented in the client’s medical record for each NCS or EMG study performed.

The client’s medical records must clearly document the medical necessity for the NCS and EMG testing. The medical record documentation must reflect the actual results of specific tests (such as latency and amplitude).

Medical necessity for re-evaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client’s medical record. Supporting documentation includes, but is not limited to, the following:

The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis. Examples may include suspected:

Peripheral nerve entrapment syndromes

Other neuropathies (traumatic, metabolic, or demyelinating)

Neuromuscular junction disorders (myasthenia gravis, botulism)

Myopathies (dermatomyositis, congenital myopathies)

Unexplained symptoms suggestive of peripheral nerve, muscle or neuromuscular junction pathology, manifested by muscle weakness, muscle atrophy, loss of dexterity, spasticity, sensory deficits, swallowing dysfunction, diplopia, or dysarthria

The client’s diagnosis could not be confirmed on previous studies, although suspected.

Evidence exists that the client’s condition is changing rapidly, supported by the following:

Diagnosis

Current clinical signs and symptoms

Prior clinical condition

Expected clinical disease course

There is clinical benefit of additional electrodiagnostic studies.

The client’s medical records are subject to retrospective review. NCS hard copies of the wave form recordings obtained during the testing will aid documentation requirements in cases where a review becomes necessary.

9.2.27.2.1EMG

The following EMG procedure codes may be reimbursed for one service per day, each procedure, by the same provider:

Procedure Codes

51784

51785

95860

95861

95863

95864

95865

95867

95868

95869

95872

95875

Procedure code 95866 may be reimbursed up to two services per day, same provider. Procedure code 95870 may be reimbursed in multiple quantities if specific muscles are documented.

The needle EMG examination must be performed by a physician specially trained in electrodiagnostic medicine, as these tests are simultaneously performed and interpreted.

Surface or macro-EMG testing is considered experimental and is not a benefit of the Texas Medicaid.

9.2.27.2.2NCS

NCS are reimbursed by Texas Medicaid with documentation of medical necessity using the following procedure codes:

Procedure Codes

95885

95886

95887

95905

95907

95908

95909

95910

95911

95912

95913

95933

95937

NCS must be performed by one of the following:

A physician

A trained individual under the direct supervision of a physician. (Direct supervision means that the physician is in close physical proximity to the electrodiagnostic laboratory while testing is underway, immediately available to provide the trained individual with assistance and direction, and responsible for selecting the appropriate NCS to be performed.)

When the same studies are performed on unique sites by the same provider for the same date of service, studies for the first site must be billed without a modifier and studies for each additional site must be billed with modifier XE, XP, XS, or XU, indicating a distinct procedural service. Modifier 59 should be used when modifier XE, XP, XS, or XU is not appropriate.

Procedure codes 95907, 95908, 95909, 95910, 95911, 95912, and 95913 may be reimbursed only once when multiple sites on the same nerve are stimulated or recorded.

Prior authorization is required when the anticipated number of nerve conduction studies planned for an evaluation exceeds the following maximum number of studies:

Procedure Code

Limitation

95885, 95886

Reimbursed once per extremity up to 4 units, using any combination of procedure codes, per day, any provider.

95885, 95886, 95887

Must be billed with one of the primary procedure codes 95907, 95908, 95909, 95910, 95911, 95912, or 95913.

95937

Up to 3 studies per day, per procedure, same provider without prior authorization.

Requests for prior authorization must be submitted to the Special Medical Prior Authorization department (SMPA) using the Special Medical Prior Authorization (SMPA) Request Form.

Note:An advanced practice registered nurse (APRN) or a physician assistant (PA) may sign all documentation related to the provision of evoked response tests and neuromuscular proce­dures on behalf of the client’s physician when the physician delegates this authority to the APRN or PA. The APRN or PA provider’s signature and license number must appear on the forms where the physician signature and license number blocks are required.

Requests must include documentation supporting medical necessity for the number of studies requested, and they must be received on or before the requested DOS. Requests received after the services are performed will be denied for DOS that occurred before the date the request was received.

Medical record documentation must establish medical necessity for the additional studies, including one or more of the following:

Other diagnosis in the differential that require consideration should include provider notes about both of the following:

The additional diagnoses considered.

The clinical signs, symptoms, or electrodiagnostic findings that necessitated the inclusion.

If multiple diagnoses have been established by nerve conduction studies and the recommendations in the table above for a single diagnostic category do not apply, then the provider should document all diagnoses established as a result of EDX testing.

Testing of an asymptomatic contralateral limb to establish normative values for an individual client (particularly the elderly, diabetic, and clients with a history of ethyl alcohol [ETOH] usage).

Comorbid clinical conditions are identified. The clinical condition must be one that may cause sensory or motor symptoms, for example:

Underlying metabolic disease (such as thyroid condition or diabetes mellitus)

Nutritional deficiency (alcoholism)

Malignant disease

Inflammatory disorder (including but not limited to lupus, sarcoidosis or Sjögren’s syndrome)

9.2.27.3Evoked Potential Testing

Evoked potential (EP) tests are a benefit of Texas Medicaid when medically necessary. The most common EP tests are:

Brainstem auditory evoked potentials (BAEPs)

Motor evoked potentials (MEPs)

Somatosensory evoked potentials (SEPs)

Visual evoked potentials (VEPs)

Each EP test (procedure codes 92585, 92586, 95925, 95926, 95927, 95928, 95929, 95930, 95938, or 95939) is considered a bilateral procedure and is limited to once per date of service any provider regardless of modifiers that indicate multiple sites were tested.

EP tests may be reimbursed up to four services per rolling year, any combination of services by any provider. Claims that exceed the limitation of four services per rolling year may be considered for reimbursement on appeal with documentation that supports the medical necessity.

Intraoperative neurophysiology monitoring (procedure codes 95940 and 95941) is a benefit when performed in addition to each evoked potential test on the same day.

The documentation for the intraoperative neurophysiology monitoring must include the time for which each test is performed.

Procedure codes 95940 and 95941 are limited to a maximum of two hours per date of service, per client, same procedure, any provider.

Procedure codes 95940 and 95941 must be billed in conjunction with one of the following procedure codes or the service will be denied:

Procedure Codes

92585

95822

95860

95861

95863

95864

95865

95866

95867

95868

95870

95907

95908

95909

95910

95911

95912

95913

95925

95926

95927

95928

95929

95930

95933

95937

95938

95939

95969

Procedure codes 95940 and 95941 cannot be reported by the surgeon or anesthesiologist.

The reason for the referral, the specific nerve evoked potential being tested, and a clear diagnostic impression must be documented in the client’s medical record for each EP study performed.

The client’s medical records must clearly document the medical necessity for the EP testing. The medical record documentation must reflect the actual results of specific tests (such as latency and amplitude).

Medical necessity for re-evaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client’s medical record. Supporting documentation includes, but is not limited to, the following:

The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis.

Evidence exists that the client’s condition is changing rapidly, supported by the following:

Diagnosis

Current clinical signs and symptoms

Prior clinical condition

Expected clinical disease course

There is clinical benefit of additional studies.

The client’s medical records are subject to retrospective review. Wave form recordings obtained during the testing will aid documentation requirements in cases where a review becomes necessary.

9.2.27.3.1Visual Evoked Potentials

Some of the conditions under which VEP testing (procedure code 95930) may be appropriate include, but are not limited to, the following:

Identification of persons at increased risk for developing clinically definite multiple sclerosis.

Diagnosing, monitoring, and assessing treatment response in multiple sclerosis.

Localizing the cause of a visual field defect not explained by lesions seen on CT or MRI, or by metabolic disorders or infectious disease.

Evaluating the signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons, non-verbal persons).

Evaluating clients who experience double vision, blurred vision, loss of vision, eye injuries, head injuries, or weakness of the eyes, arms, or legs.

9.2.27.4Motion Analysis Studies

Motion analysis studies (procedure codes 96000, 96001, 96002, and 96003) are a benefit of Texas Medicaid for clients who are 3 through 20 years of age.

Procedure codes 96000, 96001, 96002, and 96003 are limited to one per date of service by the same provider and two per rolling year, any provider.

In the following table, the procedure codes in Column A will be denied when they are submitted on the same date of service by the same provider as the procedure codes in Column B:

Column A (Denied)

Column B

96000

96001

95860, 95861, 95863, 95864, 95865, 95866, 95869, 95870, 95872

96002 or 96003

Documentation must include the following information that indicates the client meets all the require­ments for motion analysis studies. The client must be:

Ambulatory for a minimum of ten consecutive steps, with or without assistive devices.

At least three years of age.

Physically able to tolerate up to three hours of testing.

The reason for the referral and a clear diagnostic impression must be documented in the client’s medical record for each motion analysis study performed.

The client’s medical records must clearly document the medical necessity for the motion analysis study. The medical record documentation must reflect the actual results of specific tests.

Medical necessity for re-evaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client’s medical record. Supporting documentation includes, but is not limited to, the following:

The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis.

Evidence exists that the client’s condition is changing rapidly, supported by the following:

Diagnosis

Current clinical signs and symptoms

Prior clinical condition

Expected clinical disease course

There is clinical benefit of additional studies.

The client’s medical records are subject to retrospective review.

9.2.28Extracorporeal Membrane Oxygenation (ECMO)

ECMO may be effective on a short-term basis for clients with life-threatening respiratory and/or cardiac insufficiency.

ECMO may be reimbursed for clients who have the following clinical indications (this is not an all-inclusive list):

Persistent pulmonary hypertension

Meconium aspiration syndrome

Respiratory distress syndrome

Adult respiratory distress syndrome

Congenital diaphragmatic hernia

Sepsis

Pneumonia

Preoperative and postoperative congenital heart disease or heart transplantation

Reversible causes of cardiac failure

Cardiomyopathy

Myocarditis

Aspiration pneumonia

Pulmonary contusion

Pulmonary embolism

The following procedure codes may be used when billing ECMO:

Procedure Codes

33946

33947

33948

33949

33951

33952

33953

33954

33955

33956

33957

33958

33959

33962

33963

33964

33965

33966

33969

33984

33985

33986

33987

33988

33989

Terminal disease with expectation of short survival, advanced multiple organ failure syndrome, irreversible central nervous system injury and severe immunosuppression are contraindications to ECMO. Claims for ECMO services may be recouped if the services are provided in the presence of these conditions.

The initial 24 hours of veno-venous (VV) ECMO should be submitted using procedure code 33946. Procedure code 33948 should be used for each additional 24 hours. Procedure code 33946 is denied as part of procedure code 33948 if submitted with the same date of service. Procedure codes 33946 and 33948 are limited to one per day when billed by any provider.

The initial 24 hours of veno-arterial (VA) ECMO should be submitted using procedure code 33947. Procedure code 33949 should be used for each additional 24 hours. Procedure code 33947 is denied as part of procedure code 33949 if submitted with the same date of service. Procedure codes 33947 and 33949 are limited to one per day when billed by any provider.

If insertion of VV cannula (procedure codes 33951, 33952, 33953, 33954, 33955, and 33956) for prolonged extracorporeal circulation for cardiopulmonary insufficiency is submitted by the same provider with the same date of service as procedure code 33946 or 33948, the insertion of the cannula is denied, and the ECMO (procedure code 33946 or 33948) is considered for reimbursement.

If insertion of VA cannula (procedure codes 33951, 33952, 33953, 33954, 33955, and 33956) for prolonged extracorporeal circulation for cardiopulmonary insufficiency is submitted by the same provider with the same date of service as procedure code 33947 or 33949, the insertion of the cannula is denied, and the ECMO (procedure code 33947 and 33949) is considered for reimbursement.

9.2.29Family Planning

Physicians, PAs, NPs, CNSs, and CNMs are encouraged to provide family planning services to Texas Medicaid clients, especially pregnant and postpartum clients. No separate enrollment is required. Providers are reimbursed for family planning services through Texas Medicaid (Title XIX) or through the DSHS Family Planning Program.

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

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

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

9.2.30Gynecological Health Services

Gynecological examinations, surgical procedures, and treatments are benefits of Texas Medicaid.

Refer to:  Section 6, “Gynecological Health Services” in the Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook (Vol. 2, Provider Handbooks) for information about contraception, sterilizations, and family planning annual examinations.

9.2.31Hospital Visits

Refer to:  Subsection 9.2.56, “Physician Evaluation and Management (E/M) Services” in this handbook.

9.2.32Hyperbaric Oxygen Therapy (HBOT)

Physicians who bill for the professional component of HBOT must use procedure code 99183. Hospital providers who bill for the chamber time must use procedure code G0277 with revenue code 413.

Note:Although oxygen may be administered by mask, cannula, or tube in addition to the hyper­baric treatment, the use of oxygen by mask, or other device, or applied topically is not considered hyperbaric treatment in itself.

Texas Medicaid recognizes the following indications for HBOT, as approved by the Undersea and Hyperbaric Medical Society (UHMS):

Air or gas embolism

Carbon monoxide poisoning

Central retinal artery occlusion

Compromised skin grafts and flaps

Crush injuries, compartment syndrome, and other acute traumatic ischemias

Decompression sickness

Delayed radiation injury (soft tissue and bony necrosis)

Diabetic foot ulcer

Severe anemia

Clostridial myositis and myonecrosis (gas gangrene)

Intracranial abscess

Necrotizing soft tissue infections

Refractory osteomyelitis

Acute thermal burn injuries

HBOT is not a replacement for other standard successful therapeutic measures.

Texas Medicaid considers HBOT experimental and investigational for any indications other than the ones approved by UHMS and outlined in this section. Non-covered indications include, but are not limited to, autism and traumatic brain injury.

Oxygen administered outside of a hyperbaric chamber, by any means, is not considered hyperbaric treatment.

The physician must be in constant attendance of hyperbaric oxygen therapy during compression and decompression of the chamber and may not delegate the rendering of the service. Both the facility’s medical record and the client’s medical record must contain documentation to support that there was a physician in attendance who provided direct supervision of the compression and decompression phases of the HBOT treatment. All documentation pertaining to HBOT is subject to retrospective review.

9.2.32.1Prior Authorization for HBOT

HBOT procedure codes 99183 and G0277 require prior authorization. Prior authorization requests submitted for procedure code G0277 must also include revenue code 413. When requesting prior autho­rization, providers should use the Special Medical Prior Authorization (SMPA) Request Form on the TMHP website at www.tmhp.com.

Refer to:  “Section 5: Fee-for-Service Prior Authorizations” (Vol. 1, General Information) for detailed information about prior authorization requirements.

The prior authorization request must include documentation that supports medical necessity and is specific to each appropriate covered indication as listed in the following table:

Covered Indication

Total
30-Minute Intervals Allowed for Procedure Code G0277

Total
Professional Sessions Allowed for Procedure Code 99183

Medical Necessity Documentation of the Following is Required

Air or gas embolism

6

2

Evidence that gas bubbles are detectable by ultrasound, Doppler or other diagnostics

Carbon monoxide poisoning - initial authorization

15

5

Persistent neurological dysfunction secondary to carbon monoxide inhalation

Carbon monoxide poisoning - one subse­quent authorization

9

3

Evidence of continuing improvement in cognitive functioning

Central retinal artery occlusion

36

6

Evidence of central retinal artery occlusion with treatment initiated within 24 hours of the occlusion

Compromised skin grafts and flaps - initial authorization

80

10

Evidence the flap or graft is failing because tissue is/has been compromised by irradiation or there is decreased perfusion or hypoxia

Compromised skin grafts and flaps - one subsequent authorization

40

5

Evidence of stabilization of graft or flap

Crush injury, compartment syndrome and other acute traumatic ischemias

36

12

Adjunct to standard medical and surgical interventions

Decompression sickness

28

1

Diagnosis based on signs and/or symptoms of decompression sickness after a dive or altitude exposure

Diabetic foot ulcer -initial authorization

60

30

After at least 30 days of standard medical wound therapy, with a wound pO2 less than 40 mmHg AND wound classified as Wagner grade 3 or higher. *

Diabetic foot ulcer - two subsequent authorizations

60

20

Evidence of continuing healing and wound pO2 less than 40 mmHg

Severe anemia

50

10

Hgb less than 6.0 sustained secondary to hemorrhage, hemolysis, or aplasia, when the client is unable to be cross matched or refuses transfusion because of religious beliefs

Clostridial myositis and myonecrosis (gas gangrene)

39

13

Evidence of unsuccessful medical and/or surgical wound treatment and positive Gram-stained smear of the wound fluid

Necrotizing soft tissue infections - initial authorization

36

12

Evidence of unsatisfactory response to standard medical and surgical treatment and advancement of dying tissue

Necrotizing soft tissue infections - two subse­quent authorizations

15

5

Evidence that advancement of dying tissue has slowed

Delayed radiation injury (soft tissue and bony necrosis) -initial authorization

40

10

Evidence of unsatisfactory clinical response to conventional treatment

Delayed radiation injury - one subsequent authorization

40

10

Evidence of improvement demonstrated by clinical response

Refractory osteomy­elitis - initial authorization

40

10

Evidence of unsatisfactory clinical response to conventional multidisciplinary treatment

Refractory osteomy­elitis - one subsequent authorization

15

5

Evidence of improvement demonstrated by clinical response

Acute thermal burn injury - initial authorization

45

15

Partial or full thickness burns covering greater than 20% of total body surface area OR with involvement of the hands, face, feet or perineum

Acute thermal burn injury - three subse­quent authorizations

30

10

Evidence of continuing improvement demon­strated by clinical response

Intracranial abscess - initial authorization

15

5

Adjunct to standard medical and surgical interventions when one or more of the following conditions exist:

Multiple abscesses

Abscesses in a deep or dominant location

Compromised host

Surgery contraindicated or client is a poor surgical risk

Intracranial abscess - one subsequent authorization

15

5

Evidence of improvement demonstrated by clinical response and radiological findings

Note: The following Wagner wound classification grades apply only to the diabetic foot ulcer indications:

Grade 1: Superficial diabetic ulcer

Grade 2: Ulcer extension - involves ligament, tendon, joint capsule or fascia (No abscess or osteomyelitis)

Grade 3: Deep ulcer with abscess or osteomyelitis

Grade 4: Gangrene to portion of forefoot

Grade 5: Extensive gangrene of foot

Procedure code 99183 is authorized according to the number of professional sessions (total HBOT treat­ments), and procedure code G0277 is authorized according to the number of 30-minute intervals of chamber time. The units in the columns for procedure codes 99183 and G0277 represent the maximum number of sessions and intervals that are allowed for that procedure code per authorization.

Limitations beyond those listed in the table above are considered experimental and investigational.

In emergency situations, the prior authorization request must be submitted no later than three business days after the date the service is rendered. Providers must not submit a claim until the prior authori­zation request has been approved. If the request has not been approved, the claim will be denied.

9.2.33Ilizarov Device and Procedure

Providers must use procedure codes 20692, 20693, 20694, and 20999 when submitting claims for the Ilizarov procedure. A global fee payment methodology is applied to the Ilizarov device procedure codes. Procedure codes 20692, 20693, 20694, and 20999 include the preconstruction, surgical application, adjustments to the device for up to 6 months, and the removal of the device.

Providers who bill for other external fixator devices, such as the Monticelli device, should continue to use procedure codes 20690 or 20692, where applicable, when billing for the surgical applications.

9.2.34Immunization Guidelines and Administration

Texas Medicaid reimburses immunizations (vaccines and toxoids) that the Advisory Committee on Immunization Practices (ACIP) recommends as routine.

Providers must follow the most current ACIP recommendations unless they conflict with guidelines from the Texas Vaccines for Children (TVFC) Program, in which case providers must follow TVFC guidelines. Providers must also provide the appropriate vaccine information statements (VISs) produced by the Centers for Disease Control and Prevention (CDC). VISs explain the benefits and risks of the vaccines and toxoids administered.

Note:Administered vaccines and toxoids must be reported to DSHS. After obtaining consent, DSHS submits all reported vaccines and toxoids to a centralized repository of immunization histories. This lifespan registry is known in Texas as ImmTrac.

9.2.34.1Administration Fee

An administration fee may be reimbursed for all covered vaccines and toxoids that are administered according to the ACIP. The following procedure codes may be reimbursed when billed for vaccine and toxoid administration:

Procedure Code

90460

90461

90471

90472

90473

90474

Procedure codes 90460 and 90461 are benefits for services rendered to clients who are birth through 18 years of age when counseling is provided for the immunization administered.

Procedure codes 90471, 90472, 90473, and 90474 are benefits when counseling is not provided for the immunization administered. Procedure codes 90471 and 90472 may be reimbursed for services rendered to clients of any age. Procedure codes 90473 and 90474 are restricted to clients who are 20 years of age and younger.

The administration fee may be reimbursed when the procedure code for the vaccine or toxoid adminis­tered (regardless of the source of the vaccine or toxoid) and the administration fee procedure code are billed on the same claim with the same date of service. Only one administration fee may be reimbursed to any provider for each vaccine or toxoid administered per day.

The following vaccines and toxoids procedure codes are a benefit of Texas Medicaid for clients who are 20 years of age and younger based on the number of recognized components as follows:

Procedure Code

Number of Recognized Components**

Procedure Code

Number of Recognized Components**

90620*

1

90621*

1

90630

1

90632

1

90633*

1

90636

2

90644

2

90647*

1

90648*

1

90649*

1

90650*

1

90651*

1

90654

1

90655*

1

90656*

1

90657*

1

90658*

1

90660*

1

90661

1

90670*

1

90672*

1

90673

1

90674

1

90680*

1

90681*

1

90682 (18+)

1

90685*

1

90686*

1

90687*

1

90688*

1

90696*

4

90698*

5

90700*

3

90702*

2

90707*

3

90710*

4

90713*

1

90714*

2

90715*

3

90716*

1

90723*

5

90732*

1

90733

1

90734*

1

90743

1

90744*

1

90746

1

90748*

2

90749

1

 

 

* TVFC-distributed vaccine/toxoid

** The number of components applies if counseling is provided and procedure codes 90460 and 90461 are submitted.

Each vaccine or toxoid and its administration must be submitted on the claim in the following sequence: the vaccine procedure code immediately followed by the applicable immunization administration procedure code(s). All of the immunization administration procedure codes that correspond to a single vaccine or toxoid procedure code must be submitted on the same claim as the vaccine or toxoid procedure code.

Each vaccine or toxoid procedure code must be submitted with the appropriate “administration with counseling” procedure code(s) (procedure codes 90460 and 90461) or the most appropriate “adminis­tration without counseling” procedure code (procedure code 90471, 90472, 90473, or 90474). If an “administration with counseling” procedure code is submitted with an “administration without counseling” procedure code for the same vaccine or toxoid, the second administration of the vaccine or toxoid will be denied.

Administration with Counseling

Providers must submit claims for immunization administration procedure codes 90460 or 90461 based on the number of components per vaccine. Providers must specify the number of components per vaccine by billing 90460 and 90461 as defined by the procedure code descriptions:

Procedure code 90460 is submitted for the administration of the first component.

Procedure code 90461 is submitted for the administration of each additional component identified in the vaccine.

Procedure code 90461 will be denied if procedure code 90460 has not been submitted on the same claim for the same vaccine or toxoid.

The necessary counseling that is conducted by a physician or other qualified health-care professional must be documented in the client’s medical record.

The following is an example of how to submit claims for immunization administration procedure codes when counseling is provided:

Procedure Code

Quantity Billed

Vaccine or toxoid procedure code with 1 component

1

90460 (1st component)

1

Vaccine or toxoid procedure code with 3 components

1

90460 (1st component)

1

90461 (2nd and 3rd components)

2

 

Note:The term “components” refers to the number of antigens that prevent disease(s) caused by one organism. Combination vaccines are those that contain multiple vaccine components.

Administration without Counseling

Procedure codes 90471, 90472, 90473, and 90474 may be reimbursed per vaccine based on the route of administration.

The following is an example of how to submit claims for injection administration procedure codes when counseling is not provided:

Procedure Code

Quantity Billed

Vaccine or toxoid procedure code

1

90471 (Injection administration)

1

Vaccine or toxoid procedure code

1

90472 (Injection administration)

1

Vaccine or toxoid procedure code

1

90472 (Injection administration)

1

 

9.2.34.2Documentation

Providers must document the following information in the client’s medical record, which is subject to retrospective review to determine appropriate utilization and reimbursement of this service:

The vaccine or toxoid given

The date of the vaccine or toxoid administration (day, month, year)

The name of the vaccine or toxoid manufacturer and the vaccine or toxoid lot number

The signature and title of the person administering the vaccine or toxoid

The organization’s name and address

The publication date of the VIS issued to the client, parent, or guardian

The site at which the vaccine was given (recommended)

9.2.34.3Vaccine Adverse Event Reporting System (VAERS)

VAERS encourages providers to report any adverse event that occurs after the administration of any vaccine in the United States, even if it’s unclear whether a vaccine caused it. The National Childhood Vaccine Injury Act (NCVIA) requires health-care providers to report:

Any adverse event listed by the vaccine manufacturer as a contraindication to subsequent doses of the vaccine.

Any reaction listed in the VAERS Reportable Events Table that occurs within the specified time period after vaccination.

Clinically significant adverse events should be reported even if it is unclear whether a vaccine caused the event.

Documentation of the injection site is recommended but not required.

A copy of the Reportable Events Table can be obtained by calling VAERS at 1-800-822-7967 or by downloading it from http://vaers.hhs.gov/resources/vaersmaterialspublications.

9.2.35Immunizations for Clients Birth through 20 Years of Age

Administration of vaccines and toxoids to clients who are birth through 20 years of age may be a benefit of THSteps when provided as part of a THSteps medical checkup. A THSteps provider who bills vaccines and toxoids with diagnosis or age restrictions is subject to those restrictions. In addition to the age appropriate diagnosis for the THSteps preventive care medical checkup, providers must bill the claim with the diagnosis code that indicates the condition that necessitates the vaccine or toxoid.

If an immunization is administered as part of the preventive care medical checkup, diagnosis code Z23 may also be included on the claim, in addition to the age-appropriate diagnosis.

If an immunization is the only service provided during an office visit, providers may submit only diagnosis code Z23 on the claim.

Administration of vaccines and toxoids to clients who are birth through 20 years of age may be a benefit of CCP when the vaccine or toxoid is provided as part of an acute medical visit outside of a THSteps medical checkup.

Refer to:  Section 5, “THSteps Medical” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) for more information on THSteps age related diagnosis codes.

9.2.35.1Vaccine Coverage Through the TVFC Program

Providers may refer to the TVFC web site at www.dshs.texas.gov/immunize/tvfc/default.shtm for infor­mation about the program and