Effective for dates of service on or after May 1, 2007, new patient evaluation and management (E/M) procedure codes were limited to one new patient service every 3 years (36 months) instead of one service every 2 years. If a new patient procedure code has been reimbursed to the provider or a provider in the same group within the previous 3 years, the most appropriate established patient procedure code may be reimbursed.

Effective for dates of service on or after November 1, 2008, obstetric new patient E/M procedure codes were limited to one new patient service every 3 years (36 months) instead of one per pregnancy. If a new patient procedure code has been reimbursed to the provider or a provider in the same group within the previous 3 years, the most appropriate established patient procedure code may be reimbursed.

TMHP identified an issue that impacted the new patient E/M procedure codes and reprocessed affected claims from May 1, 2007, through June 30, 2009. The obstetric E/M procedure codes 99201, 99202, 99203, 99204, 99205, 99341, 99342, 99343, 99344, and 99345 billed with modifier TH were incorrectly reprocessed from May 1, 2007, through October 31, 2008. As a result, claims billed with dates of service from May 1, 2007, through October 31, 2008, and these procedure codes with modifier TH may have been denied incorrectly.

Affected claims will be reprocessed, and payments will be adjusted accordingly. No further action on the part of the provider is necessary.

Providers may refer to the article published in the September/October 2009 Texas Medicaid Bulletin, No. 225, titled, “Evaluation and Management Procedure Code Limitation Changes ,” and the article published in the November/December 2009 Texas Medicaid Bulletin, No. 226, titled, “Clarification of Obstetric Services Benefits to Change,” for more information about changes to these procedure codes.

For more information, call the TMHP Contact Center at 1-800-925-9126.