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Guidelines for Evaluation and Management Services to Be Updated in the TMPPM

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

On June 1, 2024, the Texas Medicaid & Healthcare Partnership (TMHP) will update language in the Texas Medicaid Provider Procedures Manual (TMPPM) about choosing the appropriate procedure code to bill for evaluation and management services. When selecting the level of service provided, providers must follow guidelines established in the Current Procedural Terminology (CPT) Manual.

The following sections in the TMPPM will be updated to reflect this information:

  • Section 1: “Provider Enrollment and Responsibilities,” subsection 1.7.12, “General Medical Record Documentation Requirements”
  • Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.59, “Physician Evaluation and Management (E/M) Services”

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