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SHARS Benefits to Change for Texas Medicaid October 1, 2022

Last updated on 10/12/2022

This article has been updated. To view the updated information, click here.

Effective for dates of service on or after October 1, 2022, School Health and Related Services (SHARS) benefits will change for Texas Medicaid.

Overview of Benefit Changes

Major changes to this medical benefit include the following:

Clarification relating to parental consent
Audiology benefits for students under a Section 504 plan
New psychotherapy benefits
Updated information for telehealth services, including the addition of telemedicine services
Updates to procedure code limitations
Clarification for other SHARS services

Clarification Relating to Parental Consent

In accordance with 34 Code of Federal Regulations (CFR) §300.154, 1 Texas Administrative Code (TAC) §354.1342, and the federal Family Educational Rights and Privacy Act (FERPA), local education agencies (LEAs) are required to obtain parental consent prior to disclosing personally identifiable student information maintained in a student’s education record; LEAs are also required to obtain parental consent for Medicaid-enrolled students prior to billing Medicaid for SHARS services prescribed in the Medicaid-enrolled student’s individualized education program or Section 504 Plan.

Audiology Services Provided Under Section 504 Plans

Note: Implementation is pending the Centers for Medicare & Medicaid Services (CMS) approval. The Texas Health and Human Services Commission (HHSC) is requesting an October 1, 2022, effective date. In the event of delayed CMS approval, HHSC will issue an updated notice to SHARS providers with additional information.

As approved by CMS, SHARS may include audiology evaluation and management services provided to eligible students under Section 504 of the Rehabilitation Act of 1973.

Medicaid-enrolled students must meet all eligibility requirements listed in the current Texas Medicaid Provider Procedures Manual (TMPPM), School Health and Related Services (SHARS) Handbook, and have one of the following:

A written Section 504 plan, documenting disability and medical necessity
A referral for audiology evaluation and management services

A Section 504 plan is mandated by 29 United States Code (U.S.C.) Section 794, regulated by 34 CFR §104, and developed by the school, in conjunction with the parents or guardians, teachers, and school administration. The plan must include evaluation data along with placement information regarding the type of services the student needs.

Evaluation under a Section 504 plan may be conducted using the same process to evaluate the needs of students under the Individuals with Disabilities Education Act (IDEA). If school districts choose to adopt a separate process for evaluating students under a Section 504 plan, 34 CFR §104.35 must be followed.

Refer to the current TMPPM, School Health and Related Services (SHARS) Handbook, subsection 2.4, “Documentation Requirements,” for additional information about service log documentation requirements for services prescribed in the student’s Section 504 Plan.

The SHARS program will not reimburse providers for services under a Section 504 plan beyond audiology evaluation and management services.

Modifiers

The following modifiers must be used when submitting claims for audiology evaluation and management services:

TM – To be used for audiology evaluation and management services provided to students with an Individualized Education Program (IEP)
U4 – To be used for audiology evaluation and management services provided to students with a Section 504 plan

Psychotherapy Benefits

Individual psychotherapy is therapy that focuses on a single person.

The following individual psychotherapy services, which will be limited to two per day for the same provider, will be a SHARS benefit:

Procedure Code	Unit of Service	Provider Type
90832 with modifier AH	30 minutes	Licensed psychiatrist, licensed psychologist, licensed specialist in school psychology (LSSP)
90832 with modifier UB	30 minutes	Licensed professional counselor (LPC), licensed clinical social worker (LCSW), licensed marriage and family therapist (LMFT)
90834 with modifier AH	45 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90834 with modifier UB	45 minutes	LPC, LCSW, LMFT
90837 with modifier AH	60 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90837 with modifier UB	60 minutes	LPC, LCSW, LMFT

Only one procedure code (either 90832, 90834, or 90837) may be reimbursed per day.

Group psychotherapy is a type of psychotherapy that involves one or more therapists working with several persons at the same time.

The following group psychotherapy services, which will be limited to one per day for the same provider, will be a SHARS benefit:

Procedure Code	Unit of Service	Provider Type
90853 with modifier AH	Untimed	Licensed psychiatrist, licensed psychologist, LSSP
90853 with modifier UB	Untimed	LPC, LCSW, LMFT

Procedure codes 90832, 90834, and 90837 will be denied if submitted on the same day as procedure code 90853.

Telehealth and Telemedicine Services

Telemedicine and telehealth services have the meaning assigned by Texas Occupations Code §111.001 and must be provided in compliance with standards established by the respective licensing or certifying board of the professional providing the service.

Schools that participate in the SHARS program may be reimbursed for telehealth or telemedicine physical therapy (PT), occupational therapy (OT), speech therapy (ST), counseling, psychological, or physician services delivered to children in school-based settings or while receiving remote instruction. Remote instruction is defined according to requirements set forth by the Texas Education Agency (TEA) and includes technology-based learning in home or community-based settings.

Services Provided Through Synchronous Audiovisual Technology

PT, OT, ST, counseling, psychological, or physician services provided by school districts through SHARS, using telehealth or telemedicine, can be delivered during school hours with synchronous audiovisual technologies. Synchronous audiovisual technology is an interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA).

The following procedure codes may be provided as telehealth or telemedicine services via synchronous audiovisual technology to clients eligible through SHARS, if clinically appropriate (as determined by the treating provider), safe, and agreed to by the client receiving services:

Procedure Code	Individual or Group	Unit of Service	Provider Type
90832 with modifier AH	Individual	30 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90832 with modifier UB	Individual	30 minutes	LPC, LCSW, LMFT
90834 with modifier AH	Individual	45 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90834 with modifier UB	Individual	45 minutes	LPC, LCSW, LMFT
90837 with modifier AH	Individual	60 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90837 with modifier UB	Individual	60 minutes	LPC, LCSW, LMFT
90853 with modifier AH	Group	Untimed	Licensed psychiatrist, licensed psychologist, LSSP
90853 with modifier UB	Group	Untimed	LPC, LCSW, LMFT
92507 with modifier GN and U1	Individual	Untimed	Licensed speech assistant
92507 with modifier GN and U8	Individual	Untimed	Licensed speech therapist
92508 with modifier GN and U1	Group	Untimed	Licensed speech assistant
92508 with modifier GN and U8	Group	Untimed	Licensed speech therapist
96158 with modifier AH	Individual	30 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96158 with modifier UB	Individual	30 minutes	LPC, LCSW, LMFT
96159 with modifier AH	Individual	15 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96159 with modifier UB	Individual	15 minutes	LPC, LCSW, LMFT
96164 with modifier AH	Group	30 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96164 with modifier UB	Group	30 minutes	LPC, LCSW, LMFT
96165 with modifier AH	Group	15 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96165 with modifier UB	Group	15 minutes	LPC, LCSW, LMFT
97110 with modifier GP	Individual	15 minutes	Licensed physical therapist
97110 with modifier GP and U1	Individual	15 minutes	Licensed physical therapy assistant
97530 with modifier GO	Individual	15 minutes	Licensed occupational therapist
97530 with modifier GO and U1	Individual	15 minutes	Licensed occupational therapy assistant

Procedure Code	Individual or Group	Provider Type
92521, 92522, 92523, or 92524 with modifier GN	Individual	Licensed speech therapist
97150 with modifier GO	Group	Licensed occupational therapist
97150 with modifier GO and U1	Group	Licensed occupational therapy assistant
97150 with modifier GP	Group	Licensed physical therapist
97150 with modifier GP and U1	Group	Licensed physical therapy assistant
97161 (low), 97162 (medium), and 97163 (high)	Individual	Licensed physical therapist
97165 (low), 97166 (medium), and 97167 (high)	Individual	Licensed occupational therapist
99499	Individual	Physician

Services provided through synchronous audiovisual technology must be billed with modifier 95.

Services Provided Through Synchronous Audio-Only Technology

Counseling or psychological services provided by school districts through SHARS, using telehealth or telemedicine, can also be delivered during school hours via synchronous telephone (audio-only) technologies. Synchronous telephone (audio-only) technology is an interactive, two-way audio telecommunications platform, including the use of telephonic communication that uses only sound and meets the privacy requirements of HIPAA.

The following procedure codes may be provided as telehealth or telemedicine services via synchronous telephone (audio-only) technology to clients eligible through SHARS with whom the treating provider has an “established relationship,” if clinically appropriate (as determined by the treating provider), safe, and agreed to by the client receiving services:

Procedure Code	Individual or Group	Unit of Service	Provider Type
90832 with modifier AH	Individual	30 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90832 with modifier UB	Individual	30 minutes	LPC, LCSW, LMFT
90834 with modifier AH	Individual	45 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90834 with modifier UB	Individual	45 minutes	LPC, LCSW, LMFT
90837 with modifier AH	Individual	60 minutes	Licensed psychiatrist, licensed psychologist, LSSP
90837 with modifier UB	Individual	60 minutes	LPC, LCSW, LMFT
90853 with modifier AH	Group	Untimed	Licensed psychiatrist, licensed psychologist, LSSP
90853 with modifier UB	Group	Untimed	LPC, LCSW, LMFT
96158 with modifier AH	Individual	30 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96158 with modifier UB	Individual	30 minutes	LPC, LCSW, LMFT
96159 with modifier AH	Individual	15 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96159 with modifier UB	Individual	15 minutes	LPC, LCSW, LMFT
96164 with modifier AH	Group	30 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96164 with modifier UB	Group	30 minutes	LPC, LCSW, LMFT
96165 with modifier AH	Group	15 minutes	Licensed psychiatrist, licensed psychologist, LSSP
96165 with modifier UB	Group	15 minutes	LPC, LCSW, LMFT

Services provided through synchronous telephone (audio-only) technology must be billed with modifier 93.

Note: Information about policy restrictions for services delivered by synchronous telephone (audio-only) technologies will be published in the September 2022 Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook.

Whenever possible, HHSC encourages the use of synchronous audio-visual technology instead of telephone (audio-only) delivery of telehealth and telemedicine services. If services are delivered by synchronous telephone (audio-only) technology, providers must document in the client’s medical record the reasons why a synchronous audio-visual platform was not used.

Guidelines for Telehealth and Telemedicine Services

Reimbursement for providers is only available when the patient site is a school, home, or community-based setting, and the distant site is a school or office-based setting. A telehealth or telemedicine visit may not be conducted if the provider and student are both physically located at the same school at the time the services are rendered.

Providers must defer to the needs of the client receiving services, allowing the mode of service delivery (synchronous audiovisual, synchronous telephone [audio-only], or in-person) to be accessible. Providers should obtain informed consent for treatment from the client’s parent or legal guardian and the client before rendering a telehealth or telemedicine service. Verbal consent is permissible and should be documented in the client’s medical record.

Refer to the current Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook, for additional information about informed consent for telehealth and telemedicine services.

Services delivered by synchronous audiovisual or synchronous telephone (audio-only) technology may require the participation of a parent or caregiver to assist with the treatment.

All other reimbursement and billing guidelines that are applicable to in-person services will also apply when PT, OT, ST, counseling, psychological, or physician services are delivered as telehealth or telemedicine services.

Telehealth and telemedicine services must adhere to documentation, privacy, and security requirements as outlined in this article and the current Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook.

Note: During a declaration of a state of disaster, HHSC may issue direction to providers regarding the use of a telemedicine or telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described in this article to the extent permitted by Texas law. A declaration of a state of disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

Limitation Updates

Procedure codes 92507 and 92508 will be limited to one per day for the same provider.

Comprehensive audiometry (procedure code 92557) will be limited to one per day for the same provider. This service includes testing of both ears. Audiologists must use modifier 52, reduced services, if a test is applied to one ear instead of both.

Procedure codes 96158, 96159, 96164, and 96165 will be limited to a total of three units (one hour) per day for the same provider (cumulative between codes - initial code plus two additional 15 minutes).

Speech and Language Services

The following providers, who must be licensed in the state of Texas, may provide speech and language services:

Qualified speech-language pathologist (SLP)
Licensed SLP intern
Licensed assistant in speech-language pathology acting under the supervision and direction of a licensed SLP

Personal Care Services

Personal care services must be medically necessary and must not be delivered solely for the purpose of education with classes such as Reading, English, Language Arts, Writing, Mathematics, Science, Social Studies, Physical Education, Functional Curriculum, or Electives.

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