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Benefit Criteria to Change for CSHCN Expendable Medical Supplies

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Effective for dates of service on or after January 1, 2021, benefit criteria will change for the Children with Special Health Care Needs (CSHCN) Services Program.

Procedure code B9998 with modifiers U1, U2, U3, U4, and U5 will be a benefit for CSHCN expendable medical supplies.

Prior Authorization

Four gastrostomy tubes will be allowed per client, per rolling year, without prior authorization only when prescribed by a physician.

Prior authorization is required when more than four gastrostomy/jejunostomy tubes are requested in a rolling year. This will allow for two gastrostomy/jejunostomy tubes and two for back up.

When requesting prior authorization, providers must submit documentation supporting medical necessity that includes, but is not limited to:

  • A failure of the tube
  • An infection at gastrostomy site
  • The need for an extra tube to have on hand in case of dislodgement

Appropriate limitations for miscellaneous procedure codes B9998 and T1999 and procedure code A9273 will be determined on a case-by-case basis through prior authorization.

Note: Products that are a form of nutritional intake requested using procedure code B9998 will be considered with medical nutritional products.

Reimbursement

Procedure code A4300 may be reimbursed to home health durable medical equipment (DME), medical supplier and medical supply company providers for services rendered in office and home settings.

Reimbursement for miscellaneous procedure codes B9998 and T1999 will be determined by prior authorization based on one of the following:

  • The average wholesale price (AWP) less 10.5 percent, or the manufacturer’s suggested retail price (MSRP) less 18 percent, whichever is applicable
  • The provider’s documented invoice cost

The AWP, MSRP, or the documented invoice cost must be submitted with the appropriate procedure code to be considered for reimbursement.

The following procedure codes do not require prior authorization when requested within the stated limitations:

Procedure Code

Maximum Limitation

A4217

10 per month

A4244

4 per month

A4246

4 per month

A4247

6 per month

A4320

15 per month

A4322

30 per month

A4452

100 per month

A4456

60 per month

A6258

30 per month

A9273

As needed (prior authorization required)

B4034

31 per month

B4036

31 per month

B4087

4 per rolling year, any combination of B4087, B4088, B9998 with U2 modifier, B9998 with U4 modifier

B4088

4 per rolling year, any combination of B4087, B4088, B9998 with U2 modifier, B9998 with U4 modifier

B9998

As needed (prior authorization required)

B9998 with U1 modifier

4 per month

B9998 with U2 modifier

4 per rolling year, any combination of B4087, B4088, B9998 with U2 modifier, B9998 with U4 modifier

B9998 with U3 modifier

4 per month, any combination of B4087, B4088, B9998 with U2 modifier, B9998 with U4 modifier

B9998 with U4 modifier

4 per rolling year, any combination of B4087, B4088, B9998 with U2 modifier, B9998 with U4 modifier

B9998 with U5 modifier

4 per month, any combination of B9998 with U3 modifier, B9998 with U5 modifier

T1999

As needed (prior authorization required)

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