Note: This article applies only to claims submitted to TMHP for processing. Refer to the Medicaid managed care organizations (MCOs) for information about MCO benefits, limitations, prior authorization, reimbursement, and MCO specific claim processing procedures.
Effective for dates of service on or after February 1, 2016, benefit criteria for aerosol treatments will change for Texas Medicaid.
The following codes will no longer be diagnosis-restricted:
Nebulized aerosol treatments (procedure codes 94640, 94644, and 94645) with short-acting beta-agonists provided in the outpatient setting are 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 will only be a benefit in the outpatient setting, specifically in a hospital emergency department or an urgent care clinic.
Outpatient facilities must submit claims for aerosol treatments using revenue code 412. The beta-agonist that was used must be identified on the claim form.
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.
For more information, call the TMHP Contact Center at 1-800-925-9126.