Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service beginning May 1, 2022, for the School Health and Related Services (SHARS) program, the Texas Health and Human Services Commission (HHSC) will implement interim guidance in alignment with House Bill (H.B.) 4 (87th Legislature, Regular Session, 2021).
HHSC is working to update the Texas Medicaid Provider Procedures Manual (TMPPM). This notice will serve as interim guidance for reimbursement of SHARS physical therapy (PT), occupational therapy (OT), and speech therapy (ST), audiology, physician services, and counseling and psychological services delivered by synchronous audio-visual or telephone (audio-only) technology as outlined below until TMPPM updates are finalized. The draft benefit language will be posted for public comment before it is finalized and made effective.
For all SHARS PT, OT, ST, audiology, physician services, and counseling and psychological services listed below, per standards of care, the service modality must be clinically appropriate, safe, and consented to by the student, the student’s parent, or the student’s legal guardian prior to services being rendered. Telehealth or telemedicine may require the participation of a parent or caregiver to assist with the treatment.
Synchronous Audio-visual PT, OT, ST, and Audiology Evaluation and Treatment
Effective for dates of service beginning May 1, 2022, HHSC authorizes SHARS providers to submit interim claims for reimbursement of the following evaluation and treatment service procedure codes delivered by synchronous audio-visual technology:
|
Description of Services |
Procedure Codes |
|---|---|
|
Physical Therapy Evaluation – Low, Moderate, and High Complexity |
97161, 97162, 97163 |
|
Occupational Therapy Evaluation – Low, Moderate, and High Complexity |
97165, 97166, 97167 |
|
Physical Therapy – Individual |
97110 |
|
Occupational Therapy – Individual |
97530 |
|
Physical or Occupational Therapy – Group |
97150 |
|
Speech Therapy Evaluation |
92521, 92522, 92523, 92524 |
|
Audiology Evaluation |
92620, 92621 |
|
Pure Tone Audiometry |
92553 |
|
Speech Audiometry Threshold |
92556 |
|
Comprehensive Audiometry |
92557 |
|
Speech or Audiology Therapy – Individual |
92507 |
|
Speech or Audiology Therapy – Group |
92508 |
Note: Further analysis of the clinical appropriateness for telehealth delivery of audiology services as specified in the Vision and Hearing Services Handbook of the TMPPM is currently underway, and any additional guidance regarding codes 92553, 92556, 92557, 92620, and 92621 will be outlined in future guidance.
Important: Services may be reimbursed when delivered by telehealth using synchronous audio-visual technology as deemed clinically appropriate by the rendering therapist and in compliance with each discipline’s rules. Texas Medicaid does not reimburse for SHARS PT, OT, ST, or audiology services delivered by telephone (audio-only).
Texas licensure rules for physical therapy, occupational therapy, and speech-language pathology address the provision of telehealth by two-way audiovisual platforms. Telehealth therapy services must be delivered within the provision of current licensure requirements found on the Physical Therapy Rules, Occupational Therapy Rules, and Speech-Language Pathologists and Audiologists Administrative Rules webpages.
Therapy assistants may provide telehealth and receive supervision within limits outlined in each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline.
Synchronous Audio-visual Physician Services
Effective for dates of service beginning May 1, 2022, HHSC authorizes SHARS providers to submit interim claims for reimbursement of the following services delivered by synchronous audio-visual technology:
|
Description of Services |
Procedure Codes |
|---|---|
|
Physician Services |
99499 |
Important: Texas Medicaid does not reimburse for SHARS physician services delivered by telephone (audio-only).
Synchronous Audio-visual and Telephone (Audio-only) Counseling and Psychological Services
Effective May 1, 2022, HHSC authorizes SHARS providers to submit interim claims for reimbursement of the following services delivered by synchronous audio-visual technology or telephone (audio-only):
|
Description of Services |
Procedure Codes |
|---|---|
|
Counseling Services Delivered by Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT), or Licensed Clinical Social Worker (LCSW) |
96158, 96159, 96164, 96165 |
|
Psychological Services Delivered by Licensed Psychiatrist, Licensed Psychologist, or Licensed Specialist in School Psychology (LSSP) |
96158, 96159, 96164, 96165 |
Whenever possible, HHSC encourages face-to-face interaction, such as in-person visits or synchronous audio-visual technology, over telephone audio-only technology for telemedicine and telehealth services.
Providers can refer to the Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook for additional information about the Texas Medicaid telemedicine and telehealth benefits and the School Health and Related Services (SHARS) Handbook for more information about current SHARS benefits.
Note: To indicate remote delivery, providers must continue to use modifier 95 for telehealth or telemedicine services.
For more information, call the TMHP Contact Center at 800-925-9126.