Skip to main content

Update to “TMPPM Update for Initial Hospital Care Visit” Web Article

Last updated on

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.

There is an update to the article titled “TMPPM Update for Initial Hospital Care Visit” that was posted on this website on April 15, 2022.

The “same diagnosis” language will not be removed from the following statement in the Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, section 9.2.58.5.1, “Hospital Admissions, Initial Visits, and Subsequent Visits”:

“Only one initial hospital care visit may be reimbursed to the same provider within a 30-day period for the same diagnosis. Additional initial hospital visits with the same diagnosis within a 30-day period will be denied.”

Consultations

On September 1, 2022, the Texas Medicaid & Healthcare Partnership (TMHP) will update reimbursement language for initial patient consultation in the Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physicians Assistants Handbook, section 9.2.58.5.3, “Consultations.”

“Same diagnosis” language will be added to the following statement:

“One initial inpatient consultation (procedure code 99251, 99252, 99253, 99354, or 99255) is allowed for each hospitalization within a 30-day period for the same diagnosis. Subsequent consultations billed as initial consultations during this time will be denied.”

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