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Updates to the CSHCN Services Program Provider Manual Effective August 1, 2020

Last updated on 7/3/2020

Information posted July 3, 2020

Effective for dates of service on or after August 1, 2020, the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual will be updated to align with claims system limitations.

The chapters and their updates are listed below.

Chapter 16 Diagnostic Radiology Services

16.2.10.2 Interventional Radiological Procedures

Procedure code 33884 must be billed in conjunction with procedure code 33883 on the same day, by the same provider.

Procedure code 76937 is an add-on code and must be billed in conjunction with the appropriate primary procedure, on the same day, by the same provider.

The procedure code table for procedure codes that must be reimbursed when it is billed in conjunction with procedure code 76937 will be removed.

Chapter 20 Hearing Services

20.2.3.5 Limitations

Procedure code 92547 is an add-on code, and must be billed with the primary procedure code (92541, 92542, 92544, 92545, 92546, or 92540) on the same day by the same provider to be considered for reimbursement.

Procedure code 92621 is an add-on code, and must be billed with the primary procedure code 92620, on the same day, by the same provider to be considered for reimbursement.

20.3.2.2 Auditory Rehabilitation

Procedure code 92627 is an add-on procedure code and must be billed with the primary procedure code (92626) on the same day, by the same provider to be considered for reimbursement.

Chapter 25 Laboratory Services

25.2.6 Cytopathology of Vaginal, Cervical, and Uterine Sites

Procedure code 88154 is not a benefit and will be removed.

25.2.14 Urinalysis and Chemistry

Procedure code 82952 will be updated to an add-on code.

Chapter 31 Physician

31.2.12 Chemotherapy

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. Procedure code 96411 must be billed with 96401, 96402, 96409, 96413, or 96416.

Procedure code 96415 must be used for each additional hour beyond the initial hour, it must be used in conjunction with 96409, 96413, or 96416.

Procedure code 96417 must be used per subsequent infusion up to one hour and must be used in conjunction with 96409, 96413, or 96416 on the same day, by the same provider. Procedure code 96415 must be used for each additional hour.

31.2.19.2.2 Nerve Conduction Studies (NCS)

Procedure codes 95885, 95886, and 95887 must be billed with one of the primary procedure codes 95907, 95908, 95909, 95910, 95911, 95912, or 95913 on the same day, by the same provider.

31.2.19.3.1 Intraoperative Neurophysiology Monitoring

Procedure code 95940 and 95941 must be billed in conjunction with the appropriate procedure code, on the same day, by the same provider, or the service will be denied.

31.2.25.7 Botulinum Toxin (Type A and Type B)

Procedure code 64612 requires prior authorization. All other chemodenervation and nerve destruction by neurolytic agent procedure codes do not require prior authorization. Add-on procedure codes 95873 and 95874 will be reimbursed only when billed with the appropriate primary procedure code, on the same day, by the same provider.

31.2.25.12 Immune Globulins

Procedure code 96370 is an add-on code and must be billed with the appropriate primary procedure code, on the same date of service, by the same provider or it will be denied.

31.2.28 Magnetoencephalography (MEG)

Procedure codes 95965, 95966, and 95967 may be reimbursed for MEG services that are provided in the office, inpatient hospital, and outpatient hospital settings. Procedure code 95967 must be submitted along with primary procedure code 95966, on the same day, by the same provider.

Section 31.2.34 Psychological Testing

Psychological testing (procedure codes 96130, 96131+, 96136, 96137), neurobehavioral status exams (procedure codes 96116, 96121+), and neuropsychological testing (procedure codes 96132, 96133+, 96136, 96137+) are limited to a total for four hours per day and eight hours per calendar year, per client, for any provider. Add-on procedure codes (96121+, 96131+, 96133+ and 96137+) must be billed with their corresponding primary procedure codes (96116, 96130, 96132, or 96136) on the same day, by the same provider.

31.2.39.1.1 Diagnostic Breast Procedures

The following procedure codes are add-on codes and must be billed with the appropriate primary procedure code, on the same day, by the same provider:

Add-on Procedure Codes

19001

19082

19084

19086

19126

19282

19284

19286

19288

 

 

 

31.2.39.2.4 Breast Reconstruction

The following statement will be removed:

Procedure code 15777 is an add-on code, and must be used with the appropriate procedure codes.

31.2.39.6 Reconstructive and Corrective Procedures (Not Related to Breast Therapies)

Procedure code 15777 will be added to the table for procedure codes that may be reimbursed for corrective procedures.

The following procedure codes are add-on codes and must be billed with the appropriate primary procedure code, on the same day, by the same provider:

Add-on Procedure Codes

11201

15777

15787

15847

17003

17312

17314

17315

 

 

 

 

Chapter 34 Radiation Therapy Services

Section 34.2.2 Clinical Brachytherapy

The following statement will be added under the table for surgical procedure codes for brachytherapy:

Add-on procedure codes 10036, 19297, 49327, 49412, and 92974 must be billed with the appropriate primary procedure code, on the same day, by the same provider.

34.2.3 Clinical Treatment Planning

The following statement will be added:

Procedure code 77293 will be denied if not billed on the same date of service by the same provider as either procedure code 77295 or 77301.

34.2.8 Stereotactic Radiosurgery

The following statement will be added:

Add-on procedure codes 61781, 61782, 61783, 61797, 61799, 61800, and 63621 must be billed with the appropriate primary procedure code, on the same day, by the same provider.

The following will be removed from the benefits and limitations table:

  • Procedure code 61797 must be billed with procedure code 61796 or 61798.
  • Procedure code 61799 must be billed with procedure code 61798.
  • Procedure code 61800 must be billed with procedure code 61796 or 61798.
  • Procedure code 63621 must be billed with procedure code 63620.

Chapter 38 Telecommunications Services

38.2.2.1 Distant Site

The note in the procedure codes table will be updated with the following statement:

Procedure codes 90833, 90836, 90838, 99354, 99355, 99356, 99357, and 99358 are add-on codes and must be billed with the primary evaluation and management (E/M) procedure code to be reimbursed.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.