CSHCN Services Program PrOvIDEr BullETIN - TMHP.com

IN THIS EDITION

For more information on any article in this bulletin, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.

Copyright AcknowledgementsUse of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2009 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply.”

The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply.”

General Interest 1

Online Resources to Help Communicate With Clients . . . . . 1

United Healthcare Children’s Foundation . . . . . . . . . 2

Agencies Replace the R-Word . . . . . . . . . . . . . 3

CSHCN Services Program Rates Available in Online Fee Lookup . . 3

PEP and OPL Enhancements . . . . . . . . . . . . . 3

Administrative 4

2010 ICD-9-CM Updates Now Available . . . . . . . . . . 4

Scheduled System Maintenance . . . . . . . . . . . . 7

CSHCN Services Program Medical Policy Updates . . . . . . 8

Revised Provider Enrollment Applications Now Available . . . . 9

Correction to CSHCN Services Program Provider Manual, Section 29 .2 .8, “Blood Factor Products” . . . . . . . . . 9

Peramivir EAU Authorized by FDA October 23, 2009 . . . . 10

Third Quarter 2009 HCPCS Updates Now Available . . . . . 10

Copy of IEP No Longer Required for Physical, Occupational, and Speech Therapy . . . . . . . . . . . . . . 10

Correction to Online Fee Lookup and Static Fee Schedule Note Codes . . . . . . . . . . . . . 10

TMHP Provider Relations Representatives . . . . . . . . 11

Coding and Reimbursement 12

Benefit Changes for Diabetic Equipment and Supplies . . . . 12

Reprocessing of Immunization Procedure Codes . . . . . 12

Procedure Codes D0150 and D0180 Not Limited to Once Per Lifetime . . . . . . . . . . . . . . . . 12

Benefit Changes for Outpatient Behavioral Health Services . . 13

Correction to “DME New Benefit Procedure Code Reimbursement Rate” . . . . . . . . . . . . . 15

Claims Reprocessing for Fecal Pancreatic Elastase, Qualitative or Semi-Qualitative . . . . . . . . . . 19

Age Restrictions Change for Menstruation Diagnosis Codes . . 19

Online Resources to Help Communicate With ClientsThere are many resources available online to help you when communication with clients is an issue. Here are just a few that can help when clients have limited health literacy or limited English proficiency.

Limited English ProficiencyThe Health Care Interpreter Network has a free video about how clinical staff can best work with an interpreter on its website at www.hcin.org/Resources/TrainingDVDforClinicalStaff /tabid/168/Default.aspx. You can view the 19-minute video online or order the free DVD for a $5 shipping charge. This is an excellent video that outlines the best practices and shows examples of how the various modes of interpretation occur in the clinical setting.

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PrOvIDEr BullETINChildren with Special Health Care Needs Services Program

CSHCN Services Program No. 73

Pub. No. e07-12276

February 2010

IN THIS EDITIONcontinued from page 1

The Agency for Healthcare Research and Quality (AHRQ) has new materials available for Spanish-speaking consumers.

“Consejos de Salud Para Tí,” (Health Advice for You) is a monthly online health advice column in Spanish. The column provides evidence-based tips on preventive health, safe and appropriate use of medications and medical therapies, ways to get better health care, and other key health-care issues.

The column is part of AHRQ’s Información en español website (www.ahrq.gov/consumer/espanoix.htm), which has been enhanced and now includes audio and video in Spanish on a wide range of health-care issues. The website includes more than 35 consumer guides on health-care quality, surgery, health conditions and diseases, quitting smoking, safe use of medicines, understanding health insurance options and prevention and wellness. The 30- and 60-second audio spots on the website focus on comparisons of pills for type 2 diabetes, pain medicines for osteoarthritis, tips for preventing blood clots, safe and effective use of blood thinner pills, tips for quitting smoking, preventive health and more. The website also features “Superhéroes,” a national public service campaign developed in partnership with the Advertising Council to encourage Hispanics to become more involved in their health care.

Sign up for Información en español (Spanish) e-mail updates from AHRQ at www.ahrq.gov/consumer/espanoix.htm.

Limited Health LiteracyThe National Library of Medicine added audio to its tutorial “Understanding Medical Words” at www.nlm.nih.gov/medlineplus/medicalwords.html. The tutorial has several sections, including word roots, beginnings and endings, and abbreviations. It is useful for helping clients learn and comprehend medical terminology the way that they are spoken as well as written.

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Coding and Reimbursement continued

Benefit Changes for Preventive Dental Services . . . . . . 20

Reimbursement for H1N1 Vaccination Administration . . . . 20

Reimbursement Rate Changes for Blood Factor Products . . . 21

Correction to “Preventive Care Medical Checkup Benefits to Change for the CSHCN Services Program” . . . . . . 21

Tamiflu and Relenza are Benefits of the CSHCN Services Program . . . . . . . . . . . . . . . 22

Root Canals Not Limited to Four Per Lifetime . . . . . . . 22

Reimbursement Rate Change for Visit for Drug Monitoring . . 22

Pharmacist and Pharmacy Enrollment to Administer Vaccinations . . . . . . . . . . . . . . . . 22

Reimbursement Rate Changes for Some Medical and Laboratory Procedure Codes . . . . . . . . . . . 23

Reprocessing of Claims for Hydration Intravenous (IV) Infusion . . 30

Reinstated Components for Some Radiology and Laboratory Procedure Codes . . . . . . . . . . . 32

Claims Reprocessing for End-Stage Renal Disease Dialysis Services . . . . . . . . . . . . . . . 33

Diagnosis Codes for Procedure Code J3488 (Reclast) . . . . . 33

Reimbursement Rate Change for Cochlear Implants . . . . 33

CSHCN Services Program Contact Information . . . . . . 34

Forms 35

Provider Information Change Form . . . . . . . . . . 35

Electronic Funds Transfer (EFT) Authorization Agreement . . . 37

Prior Authorization Request for External Insulin Pump . . . . 39

Authorization Request for Initial Outpatient Therapy (TP1) . . . 41

Authorization Request for Extension of Outpatient Therapy (TP2) . . . . . . . . . . . . . . . . 44

United Healthcare Children’s Foundation The United Healthcare Children’s Foundation (UHCCF) is accepting grant applications for families who have children with critical health-care treatment, services, or equipment not covered or not fully covered by their parents’ health benefit plans. Deadline for application is open.

No. 73, February 2010 2 CSHCN Services Program Provider Bulletin

General Interest

CPT only copyright 2008 American Medical Association. All rights reserved.

Agencies Replace the R-WordMany health and human service agencies and organizations in Texas and around the country are replacing the word

“retarded” or “retardation” with the term “intellectual disabil-ities.” In fact, the American Association on Mental Retarda-tion changed its name in 2007 to the American Association on Intellectual and Developmental Disabilities. The R-Word Campaign of Special Olympics Texas to eliminate the word’s use was developed over two years by representatives from organizations including the following:

Arc of Texas

Down Syndrome Association of Central Texas

Private Providers Association of Texas

Texas Council of Administrators of Special Education

Texas Council of Community MHMR Centers

Texas Health and Human Services Commission

More information is available at www.aamr.org/content_100.cfm?navID=21# and www.sotx.org/news-events/rword/.

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CSHCN Services Program Rates Available in Online Fee LookupThe online fee lookup (OFL) function on the Texas Medicaid & Healthcare Partnership (TMHP) website at www.tmhp.com contains reimbursement rates for the Children with Special Health Care Needs (CSHCN) Services Program and replaces any previously published fee schedules. Providers should disregard references to fee schedules and Medicaid-allowed amounts that are listed in the 2009 CSHCN Services Program Provider Manual and use instead the OFL function to locate reimbursement rates.OFL was created to provide reimbursement rates for both the CSHCN Services Program and Texas Medicaid. The static fee schedules contain reimbursement rates for Texas Medicaid only.A list of frequently asked questions (FAQs) and a computer-based training (CBT) module for the OFL function is available on the TMHP website at www.tmhp.com.

PEP and OPL EnhancementsBeginning December 14, 2009, Provider Enrollment on the Portal (PEP) and Online Provider Lookup (OPL) were enhanced to improve overall functionality. These enhancements have been accompanied by changes to the paper enrollment applications for each of the state health-care programs.The OPL is used primarily by clients to search for service providers. With the enhancements, clients are able to search for CSHCN Services Program providers in addition to Texas Medicaid providers. Prior to December, clients could not use OPL to search for CSHCN Services Program providers.The following enhancements were made to the OPL:

Clients are able to search for providers in up to five counties in a single search.

Doing business as (DBA) names appear for providers or provider groups.

The State of Texas Access Reform (STAR) Health program was added as a searchable health plan.

The default ZIP code radius for provider search was increased from five miles to ten miles.

Providers are encouraged to log onto the TMHP portal and verify that their information listed in the OPL is accurate and up-to-date. Most information can be updated through the portal.PEP is used by providers to enroll in state and federal health-care programs. With the enhancements, psychiatric hospitals and facilities are now able to enroll in the CSHCN Services Program using an electronic application.The following enhancements were made to PEP:

Updated on-screen instructions to make the online application process more efficient and user-friendly.

Providers now have the option to complete a survey at the end of the online application process to describe their reason for applying with the Texas state health-care programs.

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General Interest

CSHCN Services Program Provider Bulletin 3 No. 73, February 2010CPT only copyright 2008 American Medical Association. All rights reserved.

2010 ICD-9-CM Updates Now AvailableOn October 1, 2009, Texas Medicaid & Healthcare Partnership (TMHP) applied the annual 2010 International Classifica-tion of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) additions, changes, and deletions, which are effective for dates of service on or after October 1, 2009.This article addresses ICD-9-CM updates for the Children with Special Health Care Needs (CSHCN) Services Program and is intended to notify providers of program and coding changes made during the 2009 ICD-9-CM updates.

New Diagnosis CodesThe following table lists the new ICD-9-CM diagnosis codes:

Diagnosis Code Description35979 Other inflammatory and immune myo-

pathies, NEC37206 Acute chemical conjunctivitis4162 Chronic pulmonary embolism43813 Late effects of cerebrovascular disease, dys-

arthria43814 Late effects of cerebrovascular disease,

fluency disorder45350 Chronic venous embolism and thrombosis of

unspecified deep vessels of lower extremity45351 Chronic venous embolism and thrombosis of

deep vessels of proximal lower extremity45352 Chronic venous embolism and thrombosis of

deep vessels of distal lower extremity4536 Venous embolism and thrombosis of super-

ficial vessels of lower extremity45371 Chronic venous embolism and thrombosis of

superficial veins of upper extremity45372 Chronic venous embolism and thrombosis of

deep veins of upper extremity45373 Chronic venous embolism and thrombosis of

upper extremity, unspecified45374 Chronic venous embolism and thrombosis of

axillary veins45375 Chronic venous embolism and thrombosis of

subclavian veins45376 Chronic venous embolism and thrombosis of

internal jugular veins45377 Chronic venous embolism and thrombosis of

other thoracic veins45379 Chronic venous embolism and thrombosis of

other specified veins45381 Acute venous embolism and thrombosis of

superficial veins of upper extremity45382 Acute venous embolism and thrombosis of

deep veins of upper extremity45383 Acute venous embolism and thrombosis of

upper extremity, unspecified

Diagnosis Code Description20931 Merkel cell carcinoma of the face20932 Merkel cell carcinoma of the scalp and neck20933 Merkel cell carcinoma of the upper limb20934 Merkel cell carcinoma of the lower limb20935 Merkel cell carcinoma of the trunk20936 Merkel cell carcinoma of other sites20970 Secondary neuroendocrine tumor, unspeci-

fied site20971 Secondary neuroendocrine tumor of distant

lymph nodes20972 Secondary neuroendocrine tumor of liver20973 Secondary neuroendocrine tumor of bone20974 Secondary neuroendocrine tumor of peri-

toneum20975 Secondary Merkel cell carcinoma20979 Secondary neuroendocrine tumor of other

sites23981 Neoplasms of unspecified nature, retina and

choroid23989 Neoplasms of unspecified nature, other

specified sites27400 Gouty arthropathy, unspecified27401 Acute gouty arthropathy27402 Chronic gouty arthropathy without mention

of tophus (tophi)27403 Chronic gouty arthropathy with tophus

(tophi)27788 Tumor lysis syndrome27941 Autoimmune lymphoproliferative syndrome27949 Autoimmune disease, not elsewhere classified2853 Antineoplastic chemotherapy induced

anemia34881 Temporal sclerosis34889 Other conditions of brain35971 Inclusion body myositis


Administrative


Diagnosis Code Description45384 Acute venous embolism and thrombosis of

axillary veins45385 Acute venous embolism and thrombosis of

subclavian veins45386 Acute venous embolism and thrombosis of

internal jugular veins45387 Acute venous embolism and thrombosis of

other thoracic veins45389 Acute venous embolism and thrombosis of

other specified veins4880 Influenza due to identified avian influenza

virus4881 Influenza due to identified novel H1N1

influenza virus56971 Pouchitis

56979 Other complications of intestinal pouch

56987 Vomiting of fecal matter

62134 Benign endometrial hyperplasia

62135 Endometrial intraepithelial neoplasia (EIN)

67010 Puerperal endometritis, unspecified as to episode of care or not applicable

67012 Puerperal endometritis, delivered, with mention of postpartum complication

67014 Puerperal endometritis, postpartum condition or complication

67020 Puerperal sepsis, unspecified as to episode of care or not applicable

67022 Puerperal sepsis, delivered, with mention of postpartum complication

67024 Puerperal sepsis, postpartum condition or complication

67030 Puerperal septic thrombophlebitis, unspeci-fied as to episode of care or not applicable

67032 Puerperal septic thrombophlebitis, delivered, with mention of postpartum complication

67034 Puerperal septic thrombophlebitis, postpartum condition or complication

67080 Other major puerperal infection, unspecified as to episode of care or not applicable

67082 Other major puerperal infection, delivered, with mention of postpartum complication

67084 Other major puerperal infection, postpartum condition or complication

75672 Omphalocele

75673 Gastroschisis

76870 Hypoxic-ischemic encephalopathy, unspeci-fied

Diagnosis Code Description76871 Mild hypoxic-ischemic encephalopathy76872 Moderate hypoxic-ischemic encephalopathy76873 Severe hypoxic-ischemic encephalopathy77931 Feeding problems in newborn77932 Bilious vomiting in newborn77933 Other vomiting in newborn77934 Failure to thrive in newborn78442 Dysphonia78443 Hypernasality78444 Hyponasality78451 Dysarthria78459 Other speech disturbance78704 Bilious emesis7897 Colic79382 Inconclusive mammogram79921 Nervousness79922 Irritability79923 Impulsiveness79924 Emotional lability79925 Demoralization and apathy79929 Other signs and symptoms involving

emotional state79982 Apparent life-threatening event in infant81346 Torus fracture of ulna (alone)81347 Torus fracture of radius and ulna8322 Nursemaid’s elbow96900 Poisoning by antidepressant, unspecified96901 Poisoning by monoamine oxidase inhibitors96902 Poisoning by selective serotonin and norepi-

nephrine reuptake inhibitors96903 Poisoning by selective serotonin reuptake

inhibitors96904 Poisoning by tetracyclic antidepressants96905 Poisoning by tricyclic antidepressants96909 Poisoning by other antidepressants96970 Poisoning by psychostimulant, unspecified96971 Poisoning by caffeine96972 Poisoning by amphetamines96973 Poisoning by methylphenidate96979 Poisoning by other psychostimulants99524 Failed moderate sedation during procedureV1090 Personal history of unspecified malignant

neoplasm

Administrative


Diagnosis Code DescriptionV1091 Personal history of malignant neuroendo-

crine tumorV1552 Personal history of traumatic brain injuryV1580 Personal history of failed moderate sedationV1583 Personal history of underimmunization

statusV2031 Health supervision for newborn under 8 daysV2032 Health supervision for newborn 8 to 28 days

oldV2642 Encounter for fertility preservation

counselingV2682 Encounter for fertility preservation procedureV5350 Fitting and adjustment of intestinal appliance

and deviceV5351 Fitting and adjustment of gastric lap bandV5359 Fitting and adjustment of other gastrointes-

tinal appliance and deviceV6081 Foster care (status)V6089 Other specified housing or economic circum-

stancesV6107 Family disruption due to death of family

memberV6108 Family disruption due to other extended

absence of family memberV6123 Counseling for parent-biological child

problemV6124 Counseling for parent-adopted child problemV6125 Counseling for parent (guardian)-foster child

problemV6142 Substance abuse in familyV7260 Laboratory examination, unspecifiedV7261 Antibody response examinationV7262 Laboratory examination ordered as part of a

routine general medical examinationV7263 Pre-procedural laboratory examinationV7269 Other laboratory examinationV8001 Special screening for traumatic brain injuryV8009 Special screening for other neurological

conditionsV8732 Contact with and (suspected) exposure to

algae bloomV8743 Personal history of estrogen therapyV8744 Personal history of inhaled steroid therapyV8745 Personal history of systemic steroid therapyV8746 Personal history of immunosuppressive

therapy

Discontinued Diagnosis CodesThe following table lists discontinued diagnosis codes:

Diagnosis Code Description2398 Neoplasm of unspecified nature of other

specified sites2740 Gouty arthropathy

2794 Autoimmune disease, not elsewhere classified

3488 Other conditions of brain

4538 Other venous embolism and thrombosis of other specified veins

488 Influenza due to identified avian influenza virus

7687 Hypoxic-ischemic encephalopathy (HIE)

7793 Feeding problems in newborn

7845 Other speech disturbance

7992 Nervousness

9690 Poisoning by antidepressants

9697 Poisoning by psychostimulants

V109 Unspecified personal history of malignant neoplasm

V535 Fitting and adjustment of other intestinal appliance

V608 Other specified housing or economic circum-stances

V726 Laboratory examination

V800 Special screening for neurological conditions

Revised Diagnosis CodesThe following table lists diagnosis codes that have been revised:

Diagnosis Code New Description00865 Enteritis due to calicivirus

0413 Klebsiella pneumoniae

04186 Helicobacter pylori [H. pylori]

4532 Other venous embolism and thrombosis of inferior vena cava

45340 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity

45341 Acute venous embolism and thrombosis of deep vessels of proximal lower extremity

45342 Acute venous embolism and thrombosis of deep vessels of distal lower extremity

5722 Hepatic encephalopathy

5845 Acute kidney failure with lesion of tubular necrosis


Administrative


Scheduled System MaintenanceSystem maintenance to the TMHP claims processing system is scheduled for:

Sunday, February 14, 2010, 6:00 p.m. to 11:59 p.m.

Sunday, March 14, 2010, 6:00 p.m. to 11:59 p.m.

Sunday, April 11, 2010, 6:00 p.m. to 11:59 p.m

During system maintenance, some of the applications related to the claims engine will be unavailable. Specific details about the affected applications will be posted on the TMHP website at www.tmhp.com.

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Diagnosis Code New Description5846 Acute kidney failure with lesion of renal

cortical necrosis5847 Acute kidney failure with lesion of renal

medullary [papillary] necrosis5848 Acute kidney failure with other specified

pathological lesion in kidney5849 Acute kidney failure, unspecified6393 Kidney failure following abortion and

ectopic and molar pregnancies66930 Acute kidney failure following labor and

delivery, unspecified as to episode of care or not applicable

66932 Acute kidney failure following labor and delivery, delivered, with mention of postpartum complication

66934 Acute kidney failure following labor and delivery, postpartum condition or complica-tion

67000 Major puerperal infection, unspecified, unspecified as to episode of care or not appli-cable

67002 Major puerperal infection, unspecified, delivered, with mention of postpartum complication

67004 Major puerperal infection, unspecified, postpartum condition or complication

7576 Specified congenital anomalies of breast7720 Fetal blood loss affecting newborn7769 Unspecified hematological disorder specific

to newborn78440 Voice and resonance disorder, unspecified78449 Other voice and resonance disorders7930 Nonspecific (abnormal) findings on radio-

logical and other examination of skull and head7931 Nonspecific (abnormal) findings on radio-

logical and other examination of lung field

Diagnosis Code New Description7932 Nonspecific (abnormal) findings on radio-

logical and other examination of other intra-thoracic organs

7933 Nonspecific (abnormal) findings on radio-logical and other examination of biliary tract

7934 Nonspecific (abnormal) findings on radio-logical and other examination of gastro- intestinal tract

7935 Nonspecific (abnormal) findings on radio-logical and other examination of genito-urinary organs

7936 Nonspecific (abnormal) findings on radio-logical and other examination of abdominal area, including retroperitoneum

7937 Nonspecific (abnormal) findings on radio-logical and other examination of musculo-skeletal system

79389 Other (abnormal) findings on radiological examination of breast

79399 Other nonspecific (abnormal) findings on radiological and other examination of body structure

81345 Torus fracture of radius (alone)

99643 Broken prosthetic joint implant

V1506 Allergy to insects and arachnids

V1584 Personal history of contact with and (suspected) exposure to asbestos

V1585 Personal history of contact with and (suspected) exposure to potentially hazardous body fluids

V1586 Personal history of contact with and (suspected) exposure to lead

V573 Care involving speech-language therapy

V6129 Other parent-child problems

V6511 Pediatric pre-birth visit for expectant parent(s)

Administrative


CSHCN Services Program Medical Policy UpdatesThe following table indicates the added, revised, or discontinued diagnosis limitations for specific CSHCN Services Program procedure codes:

Procedure Code(s)Added Diagnosis Codes

Revised* Diagnosis Codes

Discontinued Diagnosis Codes

Blood Pressure Monitoring DevicesFor more information, refer to the 2009 CSHCN Services Program Provider Manual, section 11.2.1, “Blood Pressure Devices,” on page 11-2.

A4660, A4670, E1399 4162 5845, 5846, 5847, 5848, 5849 N/A

Bone-Anchored Hearing DevicesFor more information, refer to the 2009 CSHCN Services Program Provider Manual, section 19.2.4, “Bone-Anchored Hearing Aid (BAHA),” on page 19-5.

L8690, L8691, 69714, 69715, 69717, 69718

20931, 20932 N/A N/A

Electrodiagnostic Testing (Electromyography and Nerve Conduction Studies)For more information, refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.17, “Electrodiagnostic Testing,” on page 29-42.

51784, 51785, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95873, 95874, 95875, 95900, 95903, 95904, 95930, 95933, 95934, 95936, 95937

35971, 35979, 78451, 78459 78449 N/A

Electroencephalogram (Ambulatory)For more information, refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.16.2, “Ambulatory Electroencephalogram,” on page 29-41.

95950, 95951, 95953, 95956 34881, 34889, V1090, V1091

N/A N/A

Helicobacter pylori TestingFor more information, refer to the 2009 CSHCN Services Program Provider Manual, section 23.2.10, “Helicobacter pylori (H. pylori),” on page 23-23.

78267, 78268, 83013, 83014, 87338 N/A 04186 N/A

Hematopoietic InjectionsFor more information, refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.24.10, “Erythropoietin Alfa (EPO) and Darbepoetin,” on page 29-84.

J0881, J0885 2853 N/A N/A

Immune GlobulinsFor more information, refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.24.13, “Immune Globulins,” on page 29-87.

90281, 90283, 90284, J1459, J1460, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1560, J1561, J1562, J1566, J1568, J1569, J1572

27941, 27949 N/A 2794

Renal DialysisFor more information, refer to the 2009 CSHCN Services Program Provider Manual, section 31.3, “Benefits, Limitations, and Authorization Requirements” on page 31-2.

Outpatient Renal Dialysis Services N/A 5845, 5846, 5847, 5848, 5849 N/A

Respiratory Equipment and SuppliesFor more information, providers should refer to the 2009 CSHCN Services Program Provider Manual, section 32.2.8, “Nebulizers,” on page 32-9.

A7003, A7004, A7005, A7006, E0565, E0572

4880, 4881 N/A 488

* Refer to the Revised Diagnosis Descriptions section of this article for description changes.


Administrative


Accordingly, as part of the revised application proce-dures, current providers and those applying to participate in state health-care programs must have screened all employees and contractors and confirmed that none are excluded from participation in federally funded health-care programs. Providers are required to certify that this screening has been completed, and that it will be performed on an ongoing basis as a condition of the provider’s enrollment or reenrollment into state health-care programs.

Provider must screen their employees and contractors by checking both the federal List of Excluded Individuals and Entities (LEIE) and the state database of excluded persons and entities. The federal LEIE may be accessed at www.exclusions.oig.hhs.gov. The state database of excluded persons and entities may be accessed at the following internet address: www.oig.hhsc.state.tx.us/Exclusions/Search.aspx.

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Procedure Code(s)Added Diagnosis Codes

Revised* Diagnosis Codes

Discontinued Diagnosis Codes

Sleep StudiesFor more information, providers should refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.34.3, “Pediatric Pneumogram,” on page 29-100.

94772 79982 N/A N/A

Stem Cell TransplantsFor more information, providers should refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.38.2, “Stem Cell Transplant,” on page 29-120.

Allogenic stem cell transplants 27941 N/A N/A

Total Parenteral NutritionFor more information, providers should refer to the 2009 CSHCN Services Program Provider Manual, section 24.5.2, “Benefits, Limitations and Authorization Requirements,” on page 24-13.

B4185, S9364, S9365, S9366, S9367, S9368

20931, 20932, 20933, 20934, 20935, 20936, 20970, 20971, 20972, 20973, 20974, 20975, 20979, 27788

N/A N/A

* Refer to the Revised Diagnosis Descriptions section of this article for description changes.

Correction to CSHCN Services Program Provider Manual, Section 29.2.8, “Blood Factor Products”This is a correction to the 2009 CSHCN Services Program Provider Manual, Section 29.2.8, “Blood Factor Products,” on page 29-12. Procedure codes J7190, J7191, J7192, J7198, and J7199 must be billed with diagnosis code 2860, 2861, 2862, 2863, or 2865.

Revised Provider Enrollment Applications Now AvailableRevised enrollment applications for each of the state health-care programs are available to providers on the TMHP website at www.tmhp.com. The revisions to the applications reflect enhancements were made to the Provider Enrollment Portal (PEP).The following changes were made to the enrollment applications:

Providers are required to list their 9-digit federal tax identification number instead of their Texas Comptroller Number on the line labeled “EIN.”Providers are required to submit a Principal Information Form (PIF-2) for any subcontractors with whom they have a relationship.Title 1, Section 371.1677 of the Texas Administrative Code (TAC) states that a provider is subject to sanction for billing Texas Medicaid or any other federally funded health-care program for items or services provided by or under the direction of a person or entity that is excluded from federal health-care program participation. The resulting sanctions may include the recoupment of all of the funds paid for the items or services, the imposition of penalties, and the exclusion of the provider from participa-tion in federally funded health-care programs.

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Administrative


Copy of IEP No Longer Required for Physical, Occupational, and Speech TherapyYou asked; we listened….Authorization requests for therapy services including physical therapy, occupational therapy, and speech-language pathology services just got easier.

The CSHCN Services Program will no longer require a copy of the client’s Individual Education Plan (IEP) or a statement from the client’s school stating that the client is not eligible for therapy services from the school district as a requirement for authorization. This change in authorization requirements was effective December 1, 2009.

The CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1) and the CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2) forms found in the 2009 CSHCN Services Program Provider Manual have been revised to remove the IEP requirement. The revised forms are available in the Provider Forms section of the TMHP website at www.tmhp.com and in the Forms section of this bulletin.

Correction to Online Fee Lookup and Static Fee Schedule Note CodesTMHP has identified an issue with note codes 15 and 16 that appear in the OFL and static fee schedules on the TMHP website at www.tmhp.com. Note codes 15 and 16 displayed incorrect note messages.

The following are the correct note messages: Note code 15: “Displayed fee reflects reimbursement for the service rendered in a non-facility location.” Note code 16: “Displayed fee reflects reimbursement for the service rendered in a facility location.”

The note messages have been corrected in both the OFL and the static fee schedules.

The presidential proclamation that declared the H1N1 influenza a national emergency was delivered on October 24, 2009. The full text of the presidential proclamation is available at www.whitehouse.gov/the-press-office /declaration-a-national-emergency-with-respect-2009

-h1n1-influenza-pandemic-0.For more information, see www.cdc.gov/h1n1flu/eua/ or call 1-800-CDC-INFO (1-800-232-4636).

Third Quarter 2009 HCPCS Updates Now AvailableThe third quarter 2009 Healthcare Common Procedure Coding System (HCPCS) additions, changes, and deletions that are effective for dates of service on or after October 1, 2009, are now available. Deleted procedure codes are no longer benefits of the CSHCN Services Program. The following table lists new procedure codes that do not replace existing procedure codes; however, these codes are not a benefit of the CSHCN Services Program:

Procedure Code AllowableQ2024 Not a benefitS3713 Not a benefit

Description ChangesThe description for procedure code S0605 has changed. Providers must contact the appropriate copyright holder to obtain procedure code descriptions.

Discontinued Procedure CodesProcedure code S0162 has been discontinued.

Peramivir Authorized by FDA October 23, 2009On October 23, 2009, the U.S. Food and Drug Administration (FDA) announced that it issued an emergency use authorization (EUA) for the investigational antiviral drug Peramivir IV in certain adult and pediatric patients who are admitted to a hospital with confirmed or suspected 2009 H1N1 influenza infection. This is in response to a request from the U.S. Centers for Disease Control and Prevention (CDC).Peramivir is the only intravenously administered influenza treatment currently authorized for use under EUA for 2009 H1N1 infections. There are no FDA-approved intravenously administered antivirals for the treatment of influenza.Intravenous Peramivir is authorized only for hospitalized adult and pediatric patients for whom therapy with an IV drug is clini-cally appropriate, based on one or more of the following reasons:

The patient is not responding to either oral or inhaled antiviral therapy.Drug delivery by a route other than an IV—e.g., oral or inhaled—is not expected to be dependable or feasible.The clinician judges IV therapy is appropriate due to other circumstances (for adults only).

The EUA authority allows the FDA, based on the evalua-tion of available data, to authorize the use of unapproved or uncleared medical products or to authorize unapproved or uncleared uses of approved or cleared medical products following a determination and declaration of emergency, provided certain criteria are met. The FDA has reviewed the available scientific data and has concluded that the criteria for authorizing the emergency use of Peramivir have been met. The authorization will end when the declaration of emergency is terminated or the authorization is revoked by the agency.

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Administrative


TMHP Provider Relations RepresentativesTMHP Provider Relations representatives offer

a variety of services that inform and educate the

provider community about the CSHCN

Services Program’s policies and claims filing

procedures. Technical support and training

are also provided for TexMedConnect. Provider

Relations representatives assist providers

through telephone contact, onsite visits, and

scheduled workshops. The map at right and the

table below indicate the TMHP Provider Relations

representatives and the areas they serve. Additional

information, including a regional listing by county

and workshop information, is available on the

TMHP website at www.tmhp.com/Providers.

(Click on the Regional Support link, and then

choose the region.)

Territory Regional Area Representative Telephone Number1 Amarillo, Childress, and Lubbock Miles Vaner 1-512-506-62172 Midland, Odessa, and San Angelo Mindy Wiggins 1-512-506-34233 Alpine, El Paso, and Van Horn Alma Gonzales 1-512-506-35304 Del Rio, Eagle Pass, and Laredo Christina Salinas 1-512-506-72715 Brownsville, Harlingen, and McAllen Cynthia Gonzales 1-512-506-79916 Abilene, Brownwood, and Wichita Falls Cynthia Rowlett 1-512-506-70957 Brady, North Austin,* Round Rock, and Waco Rhonda Williams 1-512-506-76008 South Austin,* Bastrop, Buda, Guadalupe,

and San MarcosYvonne Olivo 1-512-506-3526

9 Kerrville and San Antonio* Kathe Barrett 1-512-506-342210 Corpus Christi, San Antonio,* and Victoria Alan Brown 1-512-506-355411 Cleburne, Denton, and Fort Worth Tamara House 1-512-506-799012 Corsicana, Dallas,* and Groesbeck Sandra Peterson 1-512-506-355213 Dallas,* Paris, and Whitesboro Demekia Merritt 1-512-506-357814 Texarkana and Tyler Trilby Foster 1-512-506-705315 Beaumont and Lufkin Gene Allred 1-512-506-342516 Bryan/College Station, Conroe, and Houston* Linda Wood 1-512-506-768217 Houston,* Ft. Bend Stephen Hirschfelder 1-512-506-344718 Chambers, Galveston, Brazoria, Houston,*

Wharton, and MatagordaMichael Duffee 1-512-506-3586

Out-of-State Provider Representative Joann Kunde 1-512-506-7858

*Austin, Dallas, Houston, and San Antonio territories are shared by two or more provider representatives. These territories are divided by ZIP Codes. Refer to the TMHP website at www.tmhp.com for the assigned representative to contact in each ZIP Code.

For more information, contact the TMHP-CSHCN Contact Center at 1-800-568-2413. ■

Administrative


Benefit Changes for Diabetic Equipment and SuppliesEffective for dates of service on or after November 1, 2009, diabetic equipment and supplies services criteria changed for the CSHCN Services Program. To qualify for the external insulin pump and supplies, the client must have the following:

The cognitive and physical abilities to use the recommended insulin pump

An understanding of cause and effect and the awareness of client’s condition

Family or caregiver(s) willing to support the client in the use of the external insulin pump

The CSHCN Services Program Prior Authorization Request for External Insulin Pump form has been updated to include the information listed above and can be found on pages 39-40 of this bulletin and in the Provider Forms section of the TMHP website at www.tmhp.com.

Replacement leg bags (procedure code A9900) and glucose tabs/gel (procedure code A9150) must be prior authorized with documentation that supports medical necessity.The purchase of a blood glucose monitor (procedure codes E0607, E2100, or E2101) and external insulin pump (procedure code E0784) is limited to once every 3 years.The diabetic equipment and supplies procedure codes in Table A are limited to the diagnosis codes in Table B.

Table A: Diabetic Equipment and Supplies Procedure CodesA4230 A4231 A4232 A4233 A4234 A4235 A4236 A4250 A4252 A4253

A4256 A4258 A4259 A9275 E0607

Table B: Diagnosis Codes24900 24901 24910 24911 24920 24921 24930 24931 24940 2494124950 24951 24960 24961 24970 24971 24980 24981 24990 2499125000 25001 25002 25003 25010 25011 25012 25013 25020 2502125022 25023 25030 25031 25032 25033 25040 25041 25042 2504325050 25051 25052 25053 25060 25061 25062 25063 25070 2507125072 25073 25080 25081 25082 25083 25090 25091 25092 250932512* 2711* 2777* 27785* 64800 64801 64802 64803 64804 6488064881 64882 64883 64884 7751 79029* 7915*

*New diagnosis codes effective November 1, 2009

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Reprocessing of Immunization Procedure CodesTMHP has identified an issue with claims that were submitted with dates of service on or after October 1, 2009, and influenza or pneumonia immunization procedure codes. These claims might have been denied incorrectly for diagnosis. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Procedure Codes D0150 and D0180 Not Limited to Once Per Lifetime Effective for dates of service on or after April 1, 2009, procedure codes D0150 and D0180 are not limited to once per lifetime by the same provider. Claims with dates of service on or after April 1, 2009, billed with procedure code D0150 or D0180 that were denied with explanation of benefits (EOB), “Procedure not a benefit more than once in a lifetime” will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary.


Coding and Reimbursement


Benefit Changes for Outpatient Behavioral Health ServicesEffective for dates of service on or after January 1, 2010, benefit criteria for outpatient behavioral health services changed for the CSHCN Services Program. The CSHCN Services Program does not provide outpatient behavioral health services for clients who are also enrolled in Texas Medicaid, Texas Health Steps-Comprehensive Care Program (THSteps-CCP), or Children’s Health Insurance Program (CHIP). Outpatient behavioral health services are limited to no more than 30 encounters by all practitioners per client, per calendar year. Benefits include, but are not limited to, psychological and neuropsychological testing, psychotherapy, psychoanal-ysis, counseling, and narcosynthesis.Laboratory and radiology services do not count toward the 30 outpatient encounters per client, per calendar year limitation. Pharmacological regimen oversight (procedure code M0064) and pharmacological management (procedure code 90862) also do not count toward the 30 encounters per client, per calendar year limitation.Pharmacological regimen oversight refers to a brief, face-to-face office encounter for the sole purpose of evaluating, monitoring, or changing drug prescriptions or making simple drug dosage adjustments. Pharmacological regimen oversight is a lesser level of drug monitoring than pharmacological management.Pharmacological management refers to the in-depth manage-ment of psychopharmacological agents, which are medica-tions with potentially significant side effects. Pharmacological management represents a skilled aspect of client care and is intended for use by clients who are being managed primarily by psychotropics, antidepressants, or other types of psychophar-macologic medications as well as by electroconvulsive therapy (ECT). Procedure code 90862 cannot be billed when only a brief office encounter to evaluate the client’s state is provided.The focus of a pharmacological management encounter is the use of medication for relief of a client’s signs and symptoms of mental illness. When the client continues to experience signs and symptoms of mental illness, which necessitates a discussion beyond minimal psychotherapy or counseling in a given day, the focus of the service is broader and is considered outpatient psychotherapy or counseling rather than pharma-cological management.Pharmacological management must be provided during a face-to-face encounter with the client. A pharmacological manage-ment encounter may not include more than 20 minutes of outpatient psychotherapy or counseling.Pharmacological management visits are billed as regular physician visits, not as behavioral health visits. Pharmacolog-ical management visits should be conducted on the basis of medical necessity.

Authorization Requirements Authorization is not required for outpatient behavioral health services. The CSHCN Services Program may reimburse a maximum of 30 outpatient behavioral health services encounters by any practitioner per client, per calendar year.

Documentation RequirementsServices that are not supported by documentation in the client’s medical record are subject to recoupment. All entries in the client’s medical record must be clear and concise, legible to individuals other than the author, dated (month/date/year), and signed by the performing provider. Documentation must include all of the following:

Beginning and ending times for each counseling session or test administered

Diagnosis

Support for the medical necessity of the chosen treatment

All pertinent information about the client’s condition that substantiates the need for services, including, but not limited to, the following:

Reason for referral and/or presenting problemPrior history, including prior treatmentOther pertinent medical, social, and family historyClinical observations and mental status examinationsThe name of the test(s) administered (e.g., WAIS-R, Rorschach, MMPI) The scoring of the testNarrative descriptions of the test findingsAn explanation to substantiate the necessity of retesting, if testing is repeated Background, symptoms, impressionNarrative description of the assessmentBehavioral observations during the sessionNarrative description of the counseling sessionTreatment plan and recommendations, including expected long-term and short-term benefits

For the interactive psychiatric diagnostic interview (procedure code 90802), the medical record must indicate the adaptations used in the session and the rationale for employing these interactive techniques.The original testing material must be maintained by the provider and readily available for retrospective review by the Department of State Health Services (DSHS) or its designee.

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Pharmacological Management Services DocumentationDocumentation for pharmacological management services must include the following:

Complete diagnosis Medication historyCurrent symptoms and problems (including the presenting mental status and/or physical symptoms) that indicate the client requires a medication adjustmentProblems, reactions, and side effects (if any) to medica-tions and/or ECTDescription of optional minimal psychotherapeutic intervention (less than 20 minutes), if anyReasons for medication adjustments, changes, or continuationDesired therapeutic drug levels, if applicableCurrent laboratory values, if applicableAnticipated physical and behavioral outcomes

Pharmacological Regimen Oversight DocumentationDocumentation for pharmacological regimen oversight (procedure code M0064) must address all of the following information in the client’s medical record:

A description of the client’s condition, described as one of the following:

The client has been evaluated and determined to be stable but continues to have a psychiatric diagnosis that needs close monitoring of therapeutic drug levels.

The client requires evaluation for prescription renewal, a new psychiatric medication, or a minor medication dosage adjustment.

Documentation of the medication history with current signs and symptoms, and new medication modifications with anticipated outcomes.

Reimbursement The 12-Hour System Limitation The following provider types are limited in the CSHCN Services Program claims processing system to a maximum reimbursement of a combined total of 12 hours per provider, per day for inpatient and outpatient behavioral health services:

Psychologist Advance practice registered nurse (APRN)Licensed clinical social worker (LCSW) Licensed marriage and family therapist (LMFT) Licensed professional counselor (LPC)

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Doctors of medicine (MDs) and doctors of osteopathy (DOs) are not subject to the12-hour system limitation because they can delegate services and as a result may submit claims in excess of 12 hours per day. All providers, including MDs, DOs, and each provider to whom they delegate, are subject to retrospective review and recoupment.

Procedure Codes Included in the 12-Hour System Limitation The following table lists the outpatient behavioral health procedure codes included in the system limitation. The table also includes the time increments the system applies based on the billed procedure code. The system uses the “time applied” time increments to determine whether the 12-hour-per-day system limitation has been exceeded.

Procedure Code

Time Assigned by Procedure Code Description

Time Applied

90801 N/A 60 minutes


90804 20-30 minutes 30 minutes













96101 60 minutes 60 minutes

96118 60 minutes 60 minutes

N/A = Not Applicable

LCSWs or LPCs may use only the following procedure codes when filing claims: 90804, 90806, 90808, 90847, and 90853.LMFTs may use only the following procedure codes and modifier U8 when filing claims: 90804, 90806, 90808, 90847, and 90853.Note: Procedure code 90853 is not included in the 12-hour system limitation, so it is not shown in the table.

The CSHCN Services Program will now be referencing nurse practitioner (NP) and certified nurse specialist (CNS) as advance practice registered nurse (APRN).




Psychological and Neuropsychological TestingPsychological (procedure code 96101) or neuropsycholog-ical (procedure code 96118) testing is limited to a total of 4 hours per day and 8 hours per calendar year, per client, for any provider. Claims submitted for an amount greater than 4 hours per day and 8 hours per calendar year must be submitted with documentation of medical necessity.Interpretation and documentation time, including time to document test results in the client’s medical record, is not reimbursed separately and is included in the procedure codes for psychological and neuropsychological testing.Providers must bill the units of each half hour of testing and indicate that number of units on the claim form.Behavioral health testing may be performed during an assess-ment by an APRN but will not be reimbursed separately. The most appropriate office encounter code must be billed. Psychological or neuropsychological testing may be reimbursed on the same date of service as an initial psychi-atric diagnostic interview (procedure code 90801) or interac-tive psychiatric diagnostic interview examination (procedure code 90802). Psychological testing (procedure code 96101) done on the same date of service as neuropsychological testing (procedure code 96118) will be denied as part of another service.

Psychotherapy and CounselingReimbursement for outpatient psychotherapy or counseling is limited to no more than 4 hours per client, per day.When more than one type of session (individual, group, or family outpatient psychotherapy or counseling) is provided by any provider on the same date of service, each session type will be reimbursed individually.Psychiatrists may bill for services performed by individ-uals under their supervision; however, psychologist, LMFT, LCSW, and LPC providers may bill only for behavioral health services they actually perform.Interpretation and documentation time is not reimbursed separately and is included in the procedure codes for psycho-therapy or counseling.

Psychotherapy and counseling are billed in 15-minute units. Providers must indicate the number of 15-minute units on the claim form. Evaluation and management (E/M) services will be denied if they are billed on the same date of service by the same provider as a diagnostic interview examination (procedure code 90801 or 90802).E/M services will be denied as part of psychotherapy services when performed on the same date of service by the same provider.Professional services are reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. Hospitals are reimbursed at 80 percent the rate allowed by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, which is equivalent to the hospital’s Medicaid interim rate.

Pharmacological Regimen Oversight and Pharmacological ManagementProcedure codes 90862 and M0064 describe a physician service and cannot be delegated to a non-physician or incident to a physician’s service. APRNs whose scope of license permits them to prescribe may also use these codes. The service must only be billed by the physician or APRN who actually performs the service. If procedure codes 90862 and M0064 are billed for the same date of service by any provider, procedure code M0064 will be denied as part of procedure code 90862.E/M services include pharmacological management. Procedure codes M0064 and 90862 will be denied as part of any E/M service billed for the same date of service by the same provider. If the primary reason for the office visit is psychotherapy, the specific psychotherapy procedure code should be billed. Procedure codes M0064 and 90862 will be denied as part of any psychotherapy service billed on the same date of service by the same provider. Procedure codes 90862 and M0064 are limited to one service per day, per client by any provider in any setting. Procedure code M0064 is limited to the office setting.

Correction to “DME New Benefit Procedure Code Reimbursement Rate”

This is a correction to an article that was posted on the TMHP website at www.tmhp.com on June 26, 2009, and published in the November 2009 CSHCN Services Program Provider Bulletin, No. 72, titled “DME New Benefit Procedure Code Reimbursement Rate.” The article listed an incorrect reimbursement rate for procedure code K0739.

The following is the correct information: Effective for dates of service on or after July 1, 2009, the reimbursement rate for benefit procedure code K0739 is $13.41. This procedure code is a benefit of the CSHCN Services Program for clients of all ages.

Procedure code K0739 may be billed with prior authorization for non-warranty repairs of durable medical equipment (DME) and may be reimbursed to home health DME suppliers and medical DME suppliers in the home setting. Procedure code K0739 will be denied if it is billed with the same date of service as procedure code E1340 by any provider.



National Correct Coding Initiative (NCCI) LimitationsThe HCPCS/Current Procedural Terminology (CPT) code(s) included in this article are subject to NCCI relationships as indicated in the table below. Any exceptions to NCCI code relationships are specifically noted. Providers may refer to NCCI for correct coding guidelines and specific applicable code combinations. In the following table, the procedure codes in column A will be denied when they are billed with the same date of service by the same provider as the corresponding procedure codes in column B:

Column A (Denied When)

Column B (Billed on Same Day as)

M0064, 90802, 90862, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, or 99357

90801

M0064, 90801, 90862, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90802

M0064, 36640, 90801, 90802, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802, or 97803

90804

M0064, 36640, 90801, 90802, 90804, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90821, 90822, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, or 99357

90805

M0064, 36640, 90801, 90802, 90804, 90805, 90813, 90814, 90816, 90817, 90818, 90819, 90821, 90822, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802, or 97803

90806

M0064, 36640, 90801, 90802, 90804, 90805, 90806, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90826, 90827, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90807

M0064, 36640, 90801, 90802, 90804, 90805, 90806, 90807, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90828, 90829, 90862, 90865, 97802, or 97803

90808

M0064, 36640, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90815, 90821, 90822, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90809

M0064, 36640, 90801, 90802, 90805, 90806, 90807, 90808, 90809, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802 or 97803

90810

For more information on any article in this bulletin, call the TMHP-CSHCN Services Program Contact Center at 1‑800‑568‑2413.






M0064, 36640, 90801, 90802, 90806, 90807, 90808, 90809, 90810, 90814, 90815, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90811

M0064, 36640, 90801, 90802, 90806, 90807, 90808, 90809, 90811, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90862, 90865, 97802, or 97803

90812

M0064, 36640, 90801, 90802, 90808, 90809, 90811, 90812, 90814, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90813

M0064, 36640, 90801, 90802, 90809, 90812, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90862, 90865, 97802, or 97803

90814

M0064, 36640, 90801, 90802, 90806, 90812, 90813, 90814, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90815

M0064, 36640, 90801, 90802, 90809, 90811, 90812, 90813, 90814, 90815, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802, or 97803

90816

M0064, 36640, 90801, 90802, 90809, 90812, 90813, 90814, 90815, 90816, 90824, 90826, 90827, 90828, 90829, 90845, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90817

M0064, 36640, 90801, 90802, 90809, 90813, 90814, 90815, 90816, 90817, 90826, 90827, 90828, 90829, 90862, 90865, 97802, or 97803

90818

M0064, 36640, 90801, 90802, 90804, 90805, 90809, 90814, 90815, 90816, 90817, 90818, 90827, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90819

M0064, 36640, 90801, 90802, 90815, 90816, 90817, 90818, 90819, 90828, 90829, 90862, 90865, 97802, or 97803

90821

M0064, 36640, 90801, 90802, 90816, 90817, 90818, 90819, 90821, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90822





M0064, 36640, 90801, 90802, 90805, 90806, 90807, 90808, 90809, 90817, 90818, 90819, 90821, 90822, 90827, 90828, 90829, 90845, 90862, 90865, 97802, or 97803

90823

M0064, 36640, 90801, 90802, 90807, 90808, 90809, 90818, 90819, 90821, 90822, 90823, 90828, 90829, 90845, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99456, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90824

M0064, 36640, 90801, 90802, 90808, 90809, 90819, 90821, 90822, 90823, 90824, 90829, 90862, 90865, 97802, or 97803

90826

M0064, 36640, 90801, 90802, 90808, 90809, 90821, 90822, 90824, 90826, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90827

M0064, 36640, 90801, 90802, 90822, 90826, 90862, 90865, 97802, or 97803 90828M0064, 36640, 90801, 90802, 90828, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, 99357, 99465, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, or 99480

90829

M0064, 36640, 90801, 90802, 90807, 90808, 90809, 90812, 90813, 90814, 90815, 90818, 90819, 90821, 90822, 90826, 90827, 90828, 90829, 90847, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99341, 99342, 99343, 99344, 99345, 99347, 99340, 99354, 99355, 99356, or 99357

90845

M0064, 36640, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, or 99357

90847

M0064, 36640, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90847, 90849, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, or 99357

90853







M0064, 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90845, 90847, 90849, 90853, 90862, 90865, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, or 99357

90857

97802 or 97803 90862M0064, 90801, 90802, 90862, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99282, 99283, 99284, 99285, 99291, 99292, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99356, and 99357

90865

M0064, 90801, 90802, or 90862 90804, 90810, 90816, 90823, 90845, or 90865

Additional benefit changes include:Procedure codes 90804 and 90808 may be reimbursed in the office, home, outpatient hospital, and other locations to the following provider types: LPC, LCSW, and CCP social worker.

Procedure code 96118 may be reimbursed in the office setting to physicians, physician groups, psychologists, and psycholo-gist groups.

Procedure code 96101 may be reimbursed in the office setting to psychologist groups.

Procedure code 96101 may be reimbursed in the outpatient hospital setting to hospitals.

Procedure code 96118 may no longer be reimbursed in the home, inpatient hospital, and outpatient hospital setting to an APRN.

Procedure code 96101 may no longer be reimbursed in the office, home, inpatient hospital, or outpatient hospital setting to an APRN .

Procedure code 96118 may no longer be reimbursed in the home and inpatient hospital setting to hospitals.

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Claims Reprocessing for Fecal Pancreatic Elastase, Qualitative or Semi-QualitativeTMHP has identified an issue that affects outpatient claims submitted for laboratory services with dates of service from May 1, 2005, through September 8, 2009 and procedure code 82656. These claims may have been denied in error.

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

Age Restrictions Change for Menstruation Diagnosis CodesEffective for dates of service on or after November 1, 2009, diagnosis codes 6261, 6262, 6263, 6264, 6265, 6266, and 6268 no longer have an age restriction.



Benefit Changes for Preventive Dental ServicesEffective for dates of services on or after November 1, 2009, benefit criteria for preventive dental services changed for the CSHCN Services Program.Age restrictions for the following procedure codes changed:

Procedure Code Current Age Restriction New Age RestrictionD1120, D1203 1 year of age through 12 years of age 6 months of age through 12 years of ageD1110, D1204 13 years of age through 20 years of age 13 years of age or olderD1206 1 year of age or older No age limitD1351 1 year of age through 20 years of age 1 year of age or olderD1510, D1515, D1520, D1525 1 year of age through 12 years of age for

primary first or second molars;3 years of age through 20 years of age for permanent first molars

1 year of age through 12 years of age for primary first or second molars;

3 years of age or older for permanent first molars

D1550 3 years of age through 12 years of age 1 year of age or older

Oral hygiene instruction (procedure code D1330) will be denied when billed on the same date of service by the same provider as procedure code D1203 or D1204. Dental sealants (procedure code D1351) are a benefit when applied to primary or permanent teeth. Replacement sealants will be limited to one every 3 years, per tooth, for any provider.

Space MaintainersSpace maintainers are used after premature loss of a primary first or second molar, or permanent first molar. Premature loss is defined as the loss of a tooth before the expected or normal life of the tooth. For a primary molar, this occurs before eruption of the comparable bicuspid permanent tooth.The removal of a space maintainer (procedure code D1555) will not be payable to the provider or dental group practice that originally placed the device. The provider may be reimbursed for removal only if the space maintainer was placed by a different provider.

Reimbursement for H1N1 Vaccination AdministrationThe CSHCN Services Program will provide the H1N1 flu vaccine free of charge to registered providers. Informa-tion about registration with DSHS to receive the H1N1 vaccine is available on the agency’s website at www.dshs.state.tx.us/txflu/flu-vaccineprovider.shtm. The CSHCN Services Program reimburses for the admin-istration of the intranasal or injected H1N1 vaccine. The CSHCN Services Program will reimburse the admin-istration fee for up to two doses per client, any provider, when the doses are given on different dates following the Advisory Committee on Immunization Practices (ACIP) guidelines. (See www.cdc.gov/flu/professionals)In order to be reimbursed for the administration of the H1N1 flu vaccine, providers must submit a claim for the administration of the vaccine in one of the following ways:

For vaccine administration procedure codes 90465, 90466, 90471, or 90472, providers must include the H1N1 pandemic flu vaccine procedure code 90663, which will process as informational only.

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For vaccine administration procedure code 90470, which is specific to the administration of the H1N1 vaccine, providers do not need to include the procedure code for the vaccine.

Note: Claims will be processed faster when submitted with procedure code 90663 along with the appropriate administration code. Because of system constraints, claims submitted for procedure code 90470 may initially be denied with EOB 1086 on a Remittance & Status (R&S) Report. They will be reprocessed in the following week and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Providers must use only one method per administration of the vaccine. Both methods will reimburse the same amount to providers for administering the H1N1 vaccine.

Administration of the H1N1 flu vaccine will be reimbursed separately from an office visit.

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Reimbursement Rate Changes for Blood Factor ProductsEffective for dates of services on or after November 1, 2009, reimbursement rates for blood product procedure codes changed for the CSHCN Services Program. The following table includes the reimbursement rates for blood product procedure codes that are effective for dates of service on or after November 1, 2009, for the CSHCN Services Program:

Type of Service Procedure Code Reimbursement Rate

0 P9010 $230.40

0 P9011 $31.12

9 P9016 $188.92

9 P9017 $76.73

9 P9019 $73.25

9 P9020 $394.95

9 P9021 $136.82

9 P9022 $261.64

0 P9031 $111.67

0 P9032 $164.42

0 P9033 $128.19

0 P9034 $468.66

0 P9035 $514.82

0 P9036 $469.53

0 P9037 $653.50

0 P9038 $250.69

0 P9039 $341.43

0 P9040 $251.33

Type of Service Procedure Code Reimbursement Rate

0 P9041 $19.12

0 P9043 $15.62

0 P9044 $85.16

0 P9045 $70.02

0 P9046 $24.67

0 P9047 $69.22

0 P9048 $196.27

0 P9050 $1,669.99

0 P9051 $144.13

0 P9052 $711.89

0 P9053 $649.24

0 P9054 $101.68

0 P9055 $480.41

0 P9056 $226.31

0 P9057 $424.67

0 P9058 $301.43

0 P9059 $75.62

0 P9060 $64.25

Correction to “Preventive Care Medical Checkup Benefits to Change for the CSHCN Services Program” This is a correction to an article that was published in the November 2009 CSHCN Services Program Provider Bulletin, No. 72, titled “Preventive Care Medical Checkup Benefits to Change for the CSHCN Services Program.” The article incorrectly stated that a provider can bill a new patient preventive care medical checkup even if the provider has previously billed for a new patient acute care E/M visit.

A new patient preventive care medical checkup will only be allowed when the client has not received any professional services from the same provider or provider group in the past three years. The original article titled “Preventive Care Medical Checkup Benefits to Change for the CSHCN Services Program” published on the TMHP website at www.tmhp.com on July 17, 2009, was correct.



Pharmacist and Pharmacy Enrollment to Administer Vaccinations Effective October 1, 2009, pharmacies and pharmacists can begin enrolling in the CSHCN Services Program to admin-ister immunizations to CSHCN Services Program clients. To enroll in the CSHCN Services Program, a pharmacist must obtain and provide proof of Texas Board of Pharmacy certification to administer vaccinations. A criminal background check will be performed on all pharmacists who enroll as performing providers under a group. All providers who enroll in the CSHCN Services Program must first be enrolled in Texas Medicaid. A pharmacy with at least one performing provider (pharma-cist) who is certified to administer immunizations can enroll in the CSHCN Services Program as a group provider. Pharmacies that are currently enrolled as DME providers with either Texas Medicaid or the CSHCN Services Program can use a shortened enrollment application called the Texas State Health-Care Deeming Form to enroll as a pharmacy that administers vaccines.The CSHCN Services Program enrollment application and Texas State Health-Care Pharmacy Deeming Form are available on the TMHP website at www.tmhp.com. Providers enrolling with the CSHCN Services Program are not required to provide a copy of their license unless it is expiring within the next 30 days.Any pharmacy that is eligible for the shortened enrollment process will also receive a CSHCN Services Program Texas Provider Identifier (TPI) and a benefit code to be used in submitting claims. To retain an active CSHCN Services Program account, the pharmacy will be required to complete a CSHCN Services Program enrollment application within 6 months of the initial enrollment date.Pharmacists that are directly employed by a pharmacy currently enrolled as a DME provider with Texas Medicaid or the CSHCN Services Program can also enroll as performing providers using the Texas State Health-Care Deeming Form.Enrolled pharmacies and pharmacists can submit claims with dates of service on or after October 1, 2009. These claims may initially be processed as “Informational Only” or be denied as “procedure not covered for this provider type.” They will be reprocessed at a later date. Providers must still submit claims within the 95-day filing deadline. General information about provider enrollment is available on the TMHP website at www.tmhp.com. Providers can also refer to the 2009 CSHCN Services Program Provider Manual, section 29.2.23, “Immunizations (Vaccines and Toxoids),” on page 29-72 for additional information.

Tamiflu and Relenza are Benefits of the CSHCN Services ProgramEffective for dates of service on or after October 1, 2009, antiviral medications zanamivir inhalation powder (Relenza) and oseltamivir phosphate (Tamiflu) are benefits of the CSHCN Services Program for clients of all ages when provided by a physician, APRN, or physician assistant in the office setting.Relenza may be billed using procedure code G9018 for each 10 mg of powder. Tamiflu may be billed using procedure code G9019 for each 75 mg capsule. TMHP will process claims for physician-administered Relenza and Tamiflu only for the duration of the pandemic. Relenza is reimbursed at a fee of $5.48, and Tamiflu is reimbursed at a fee of $8.30. Administration procedure codes are not payable for procedure codes G9018 or G9019.These antiviral medications are currently available by prescrip-tion through the Texas Vendor Drug Program (VDP) for clients enrolled in the CSHCN Services Program. Pharma-cists may compound the Tamiflu capsule into a suspension.For additional information about seasonal influenza, providers can refer to articles on the influenza web page of the TMHP website at www.tmhp.com or to the state of Texas influenza website at www.texasflu.org.

Root Canals Not Limited to Four Per LifetimeEffective for dates of service on or after October 1, 2008, root canal therapy is not limited to four per lifetime for the CSHCN Services Program. The procedure codes that are no longer subject to the four-per-lifetime limitation are D3310, D3320, D3330, D3346, D3347, D3348, D3351, D3352, and D3353. Claims submitted with dates of service on or after October 1, 2008, and any of these procedure codes might have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Reimbursement Rate Change for Drug MonitoringEffective for dates of service on or after November 1, 2009, procedure code M0064 has a reimbursement rate of $29.84 (1.12 relative value units [RVUs], $28.640 conversion factor) for the CSHCN Services Program.




Reimbursement Rate Changes for Some Medical and Laboratory Procedure Codes Effective for dates of service on or after November 1, 2009, reimbursement rates for some medical and laboratory procedure codes changed for the CSHCN Services Program.The following procedure code reimbursement rates are effective for dates of service on or after November 1, 2009.

Type of Service

Procedure Code Reimbursement Rate

Clinical Pathology

2 36600 $23.48 (0.82 RVU, $28.640 conversion factor)

3 80500 $17.19

3 80502 $50.98 (1.78 RVUs, $28.640 conversion factor)

5 81099 Manually priced


5/I 85060 $16.91 (1.24 RVUs, $27.276 conversion factor)



5/I 85999 Manually priced




5/I 86490 $5.18 (0.19 RVU, $27.276 conversion factor)


5 86580 $7.21

I 86580 $5.46 (0.20 RVU, $27.276 conversion factor)


5/I 86850 $16.99

5/I 86860 $29.71

5/I 86870 $16.98



5/I 86920 $14.06

5/I 86921 $16.00

5/I 86922 $34.02

Type of Service


5 86923 $15.62

5/I 86950 $61.70

5 86960 $25.52



5 88182 $100.99

I 88182 $35.35

T 88182 $65.64

T 88184 $6.82 (0.25 RVU , $27.276 conversion factor)

T 88185 $6.82 (0.25 RVU , $27.276 conversion factor)

I 88187 $50.98 (10.47 RVUs, $28.640 conversion factor)




5 89230 $3.97


5/I P9012 $30.00

5/I Q0091 $30.28 (1.11 RVUs, $27.276 conversion factor)

5 S3845 $355.25

Anatomic Pathology



T 88323 $42.55 (1.56 RVU, $27.276 conversion factor)


5 88104 $50.07

I 88104 $22.63



Type of Service


T 88104 $27.44



T 88106 $38.09 (1.33 RVUs, $28.640 conversion factor)

5 88107 $76.63

I 88107 $30.65

T 88107 $45.98

5 88108 $59.66

I 88108 $22.91

T 88108 $36.75

5 88112 $88.37

I 88112 $47.73

T 88112 $40.64

I 88141 $21.28 (Clients 21 years of age or older)

I 88141 $22.34 (Clients from birth through 20 years of age)

5 88160 $42.46

I 88160 $20.34

T 88160 $22.12

5 88161 $47.42

I 88161 $21.48

T 88161 $25.94

5 88162 $74.26

I 88162 $36.09

T 88162 $38.17

5 88172 $51.94

I 88172 $29.57

T 88172 $22.37





5 88300 $23.08

I 88300 $4.33

T 88300 $18.75

Type of Service


5 88302 $48.33

I 88302 $6.49

T 88302 $41.84

5 88304 $61.31

I 88304 $10.82

T 88304 $50.49

5 88305 $103.87

I 88305 $37.15

T 88305 $66.72

5 88307 $192.95

I 88307 $73.32

T 88307 $119.63




5 88311 $16.05

I 88311 $10.59

T 88311 $5.46




5 88313 $65.37

I 88313 $10.59

T 88313 $54.78

5 88314 $87.28

I 88314 $22.36

T 88314 $64.92




5 88319 $123.47

I 88319 $23.46

T 88319 $100.01




Type of Service























5 88348 $617.45

I 88348 $73.94

T 88348 $543.51

5 88349 $293.94

I 88349 $37.87

Type of Service


T 88349 $256.07

5 88355 $233.17

I 88355 $85.34

T 88355 $147.83

5 88356 $282.24

I 88356 $136.04

T 88356 $146.20

5 88358 $77.54

I 88358 $45.80

T 88358 $31.74

5 88360 $103.05

I 88360 $46.68


I 88361 $42.25

T 88361 $71.49

5 88362 $231.76

T 88362 $136.97


5 88367 $237.32

I 88367 $85.34

5 88368 $208.83

I 88368 $64.92

5 88384 $105.12




Electroencephalogram








Type of Service













5 95824 $117.38


T 95824 $89.56










5 95951 $1,367.09


Type of Service


T 95951 $1,141.52
















Gastroenterology












Type of Service


5 91030 $110.84

I 91030 $40.68

5 91052 $119.74

I 91052 $40.39

5 91065 $43.53

I 91065 $7.27

Audiology

5/I 92551 $15.75

5/I 92552 $17.18




5/I 92557 $39.52

I 92562 $20.33


5/I 92565 $12.32

5/I 92567 $16.91


5/I 92569 $12.88




5/I 92576 $16.90

5/I 92577 $22.91


5/I 92582 $32.36


5/I 92584 $78.76

5 92585 $100.00

I 92585 $25.72

T 92585 $74.28


Type of Service


5 92587 $46.11I 92587 $8.21T 92587 $37.905 92588 $63.58I 92588 $18.03T 92588 $45.55

Cardiovascular













5 93235 $117.29







5 93561 $35.43




Type of Service


T 93561 $17.43

5 93562 $16.56


T 93562 $10.83














5/I/T 93799 Manually priced


Pulmonology







Type of Service



5 94060 $57.71

I 94060 $14.43

T 94060 $43.28










5 94240 $38.95

I 94240 $12.26

T 94240 $26.69














Type of Service


























Type of Service



















I 94770 $5.46


5 94772 $334.48

I 94772 $59.48

T 94772 $275.00


Sleep Studies (conversion factor = $27.276)

5 95805 $318.86 (11.69 RVUs)

I 95805 $69.01 (2.53 RVUs)

T 95805 $249.85 (9.16 RVUs)



Type of Service


5 95808 $487.97 (17.89 RVUs)

I 95808 $97.10 (3.56 RVUs)

T 95808 $390.87 (14.33 RVUs)

5 95810 $580.43 (21.28 RVUs)

I 95810 $127.92 (4.69 RVUs)

T 95810 $452.51 (16.59 RVUs)

5 95811 $639.35 (23.44 RVUs)

I 95811 $137.47 (5.04 RVUs)

T 95811 $501.88 (18.40 RVU)

Electromyogram (conversion factor = $27.276)

5 95860 $60.83 (2.23 RVUs)

I 95860 $37.10 (1.36 RVUs)

T 95860 $23.73 (0.87 RVU)

5 95861 $88.37 (3.24 RVUs)

I 95861 $59.19 (2.17 RVUs)

T 95861 $29.19 (1.07 RVUs)

5 95863 $105.29 (3.86 RVUs)

I 95863 $70.92 (2.60 RVUs)

T 95863 $34.37 (1.26 RVUs)

5 95864 $121.11 (4.44 RVUs)

I 95864 $75.83 (2.78 RVUs)

T 95864 $45.28 (1.66 RVUs)

5 95865 $84.56 (3.10 RVUs)

I 95865 $61.10 (2.24 RVUs)

T 95865 $23.46 (0.86 RVU)

5 95866 $69.28 (2.54 RVUs)

I 95866 $48.55 (1.78 RVUs)

T 95866 $20.73 (0.76 RVU)

5 95867 $52.92 (1.94 RVUs)

I 95867 $30.00 (1.10 RVUs)

T 95867 $22.91 (0.84 RVU)

Type of Service


5 95868 $72.55 (2.66 RVUs)

I 95868 $44.73 (1.64 RVUs)

T 95868 $27.82 (1.02 RVUs)

5 95869 $33.82 (1.24 RVUs)

I 95869 $14.18 (0.52 RVU)

T 95869 $19.64 (0.72 RVU)

5 95870 $33.00 (1.21 RVUs)

I 95870 $14.18 (0.52 RVU)

T 95870 $18.82 (0.69 RVU)

5 95872 $124.11 (4.55 RVUs)

I 95872 $103.92 (3.81 RVUs)

T 95872 $20.18 (0.74 RVU)

5 95875 $69.55 (2.55 RVUs)

I 95875 $41.46 (1.52 RVUs)

T 95875 $28.09 (1.03 RVUs)

Nerve Conduction (conversion factor = $27.276)

5 95900 $39.55 (1.45 RVUs)

I 95900 $16.09 (0.59 RVU)


5 95903 $46.37 (1.70 RVUs)

I 95903 $22.64 (0.83 RVU)

T 95903 $23.73 (0.87 RVU)

5 95904 $34.91 (1.28 RVUs)

I 95904 $13.09 (0.48 RVU)

T 95904 $21.82 (0.80 RVU)

Electrophysiology

5 95920 $113.47 (4.16 RVUs)

I 95920 $81.28 (2.98 RVUs)

T 95920 $32.19 (1.18 RVUs)

5 95921 $54.82 (2.01 RVUs)

I 95921 $33.55 (1.23 RVUs)

Reprocessing of Claims for Hydration Intravenous (IV) Infusion

TMHP has identified an issue that impacts claims submitted by acute care hospital providers with dates of service on or after January 1, 2006, and procedure code 90760 performed in the outpatient hospital setting. Claims might have been reimbursed incorrectly.

Affected claims will be reprocessed, and payments will be adjusted accordingly. No action by the provider is necessary.




Type of Service


T 95921 $21.28 (0.78 RVU)

5 95922 $65.74 (2.41 RVUs)

I 95922 $36.00 (1.32 RVUs)

T 95922 $29.73 (1.09 RVUs)

5 95923 $86.19 (3.16 RVUs)

I 95923 $34.10 (1.25 RVUs)

T 95923 $52.10 (1.91 RVUs)

Evoked Potential (conversion factor = $27.276)

5 95925 $87.83 (3.22 RVUs)

I 95925 $20.73 (076 RVU)

T 95925 $67.10 (2.46 RVUs)

5 95926 $86.19 (3.16 RVUs)

I 95926 $20.46 (0.75 RVU)

T 95926 $65.74 (2.41 RVUs)

5 95927 $88.37 (3.24 RVUs)

I 95927 $21.00 (0.77 RVU)

T 95927 $67.37 (2.47 RVUs)

5 95928 $139.93 (5.13 RVUs

I 95928 $55.92 (2.05 RVUs)

T 95928 $84.01 (3.08 RVUs)

5 95929 $147.56 (5.41 RVUs)

I 95929 $56.19 (2.06 RVUs)

T 95929 $91.37 (3.35 RVUs)

5 95930 $77.46 (2.84 RVUs)

I 95930 $13.37 (0.49 RVU)

T 95930 $64.10 (2.35 RVUs)

5 95933 $48.01 (1.76 RVUs)

I 95933 $22.64 (0.83 RVU)

T 95933 $25.37 (0.93 RVU)

5 95934 $35.73 (1.31 RVUs)

Type of Service


I 95934 $19.37 (0.71 RVU)

T 95934 $16.37 (0.60 RVU)

5 95936 $31.64 (1.16 RVUs)

I 95936 $21.00 (0.77 RVU)

T 95936 $10.64 (0.39 RVU)

5 95937 $42.82 (1.57 RVUs)

I 95937 $25.91 (0.95 RVU)

T 95937 $16.91 (0.62 RVU)

5 95970 $37.10 (1.36 RVUs)

5 95971 $42.82 (1.57 RVUs)

5 95972 $76.37 (2.80 RVUs)

5 95973 $41.73 (1.53 RVUs)

5 95974 $127.65 (4.68 RVUs)

5 95975 $70.92 (2.60 RVUs)

5 95978 $151.65 (5.56 RVUs)

5 95979 $67.92 (2.49 RVUs)

Other









5 96101 $115.00



Reinstated Components for Some Radiology and Laboratory Procedure CodesEffective July 1, 2009, some total, technical, and professional interpretation components were made non-payable for some CSHCN Services Program radiology and laboratory procedure codes. Effective October 1, 2009, for dates of service on or after July 1, 2009, the total, professional interpretation, or technical components of the following radiology procedure codes were reinstated as indicated and may be reimbursed:

Procedure Code(s) Changes

Radiology Procedures

74340 The total component was reinstated. Procedure code may be reimbursed as the total or professional interpretation component.

70170, 71090, 73530, 74190, 74235, 74300, 74301, 74305, 74328, 74329, 74330, 74355, 74360, 74363, 74400, 74410, 74415, 74420, 74425, 74445, 74450, 74470, 75801, 75803, 75805, 75807, 75810, 75894, 75896, 75898, 75900, 75940, 75945, 75946, 75970, 75980, 75982, 75992, 76001, 76125, 76930, 76932, 76940, 76945, 76975

The total and technical components were reinstated.

Procedure codes may be reimbursed as the total, professional interpretation, or technical components.

75809 The technical component was reinstated.

Procedure code may be reimbursed as the total, professional interpretation, or technical component.

78282 The total and technical components were reinstated.


93318 The profession interpretation and technical components were reinstated.


Laboratory Procedures

91030, 91052, 91065 Effective October 1, 2009, for dates of service on or after July 1, 2009, the total component was reinstated as a labora-tory service instead of a radiology service for procedure codes 91030, 91052, and 91065. The total component and profes-sional interpretation component may be reimbursed as appro-priate.

93271 The total component was reinstated.

Procedure code may be reimbursed as the total component.

95829, 95955 The professional interpretation and technical components were reinstated.

Procedure codes may be reimbursed as the total, professional interpretation, or technical component.





Additionally, the total component for procedure code 78414 was reinstated and procedure code 78414 may be reimbursed as the total, professional interpretation and technical components as follows:

Component Reimbursement

Total May be reimbursed to APRNs, physician assistants (PAs), physicians, independent laboratories, CNMs, radiation treatment centers, hospitals, nephrology (hemodialysis, renal dialysis) providers, renal dialysis facilities, radiological and physiological labora-tories, and hospital-based Rural Health Clinics (RHCs) in the office or independent laboratory setting.

May be reimbursed to radiation treatment centers, hospitals, nephrology (hemodialysis, renal dialysis) providers, renal dialysis facilities, radiological and physiological laboratories, and hospital-based RHCs in the inpatient hospital or outpatient hospital setting.

Professional interpretation May be reimbursed to physicians in the office, inpatient hospital, or outpatient hospital setting.

Technical May be reimbursed to physicians and radiological and physiological laboratories in the office setting.

Claims submitted with dates of service from July 1, 2009, to September 30, 2009, and the procedure codes indicated in this article with the components being reinstated will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.Providers may refer to the TMHP OFL for components that may be reimbursed and for reimbursement rates.

Claims Reprocessing for End-Stage Renal Disease Dialysis Services

TMHP has identified an issue that affects claims submitted with dates of service from January 1, 2009, through October 8, 2009, and procedure codes 90967, 90968, 90969, or 90970. These claims may have been denied in error.

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

Reminder: When billing procedure codes 90967, 90968, 90969, or 90970, providers must itemize each date of service on the claim to be considered for payment.

Diagnosis Codes for Procedure Code J3488 (Reclast)

TMHP has identified an issue that affects claims submitted with dates of service from January 1, 2008, through September 8, 2009, and procedure code J3488 with diagnosis code 73300. These claims may have been denied in error. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Effective for claims with dates of service December 1, 2009, and after, procedure code J3488 is payable with diagnosis codes 73301, 73302, 73303, 73309, and 73390 in addition to diagnosis codes 73300 and 7310. Diagnosis codes 73300 and 7310 were effective January 1, 2008.

Reimbursement Rate Change for Cochlear ImplantsEffective for dates of service on or after November 1, 2009, the CSHCN Services Program reimbursement rate for cochlear implants changed. The reimbursement rate for procedure code L8614 changed from $15,522.20 to $23,380.00.



CSHCN Services Program Contact InformationCSHCN Services Program Telephone and Fax Communication

Contacts Telephone Number Fax NumberTMHP-CSHCN Services Program Contact Center 1-800-568-2413

Prior Authorization and Authorization 1-512-514-4222

Provider Enrollment 1-800-568-2413 1-512-514-4214

DSHS-CSHCN Services Program Customer Service 1-800-252-8023

TMHP Electronic Data Interchange (EDI) Help Desk 1-888-863-3638 1-512-514-4228

Third-Party Resource (TPR) 1-800-846-7307 1-512-514-4225

Appeal Submission through AIS Line 1-800-568-2413

Written Communication with CSHCN Services Program

Correspondence AddressFirst-Time Claims and resubmissions of all “zero allowed, zero paid” claims and claims originally denied as an “Incomplete Claim” on an R&S report

TMHP-CSHCN Services Program PO Box 200855 Austin, Texas 78720-0855

Appeals and Adjustments TMHP Attn: CSHCN Services Program Appeals, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, Texas 78727

Prior Authorization and Authorization TMHP Attn: CSHCN Services Program Authorizations, MC-A11 12357-B Riata Trace Parkway, Suite 150 Austin, Texas 78727

Provider Enrollment TMHP-CSHCN Services Program Provider Enrollment PO Box 200795 Austin, Texas 78720-0795

Third-Party Resource (TPR) TMHP-TPR PO Box 202948 Austin, Texas 78720-2948

Electronic Claims and Rejected Reports (Past the 95-day filing deadline)

TMHP PO Box 200645 Austin, Texas 78720-0645

Authorizations for Family Support Services Only CSHCN Services Program Purchased Health Services Unit, MC1938 Texas Department of State Health Services PO Box 149347 Austin, Texas 78714-9347

Other Correspondence (Must be addressed and sent to a specific individual or department)

TMHP-CSHCN Services Program Attn: (Individual or Department) 12357-B Riata Trace Parkway, Suite 150 Austin, Texas 78727




Effective Date_09012009/Revised Date_08212009

Instructions for Completing the Provider Information Change Form

Signatures• The provider’s signature is required on the Provider Information Change Form for any and all changes requested

for individual provider numbers.

• A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers.

Address• Performing providers (physicians performing services within a group) may not change accounting information.

• For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form.

• For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers.

Tax Identification Number (TIN) • TIN changes for individual practitioner provider numbers can only be made by the individual to whom the

number is assigned.

• Performing providers cannot change the TIN.

Provider Demographic Information

An online provider lookup (OPL) is available, which allows users such as Medicaid clients and providers to view information about Medicaid-enrolled providers. To maintain the accuracy of your demographic information, please visit the OPL at www.tmhp.com. Please review the existing information and add or modify any specific practice limitations accordingly. This will allow clients more detailed information about your practice.

General• TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier

(NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form.

• The W-9 form is required for all name and TIN changes.

• Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Fax: 512-514-4214

Forms



Provider Information Change Form Texas Medicaid fee-for-service, Children with Special Health Care Needs (CSHCN) Services Program, and Primary Care Case Management(PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.

Check the box to indicate a PCCM Provider Date : / /

Nine-Digit Texas Provider Identifier (TPI): Provider Name:

National Provider Identifier (NPI): Primary Taxonomy Code:

Atypical Provider Identifier (API): Benefit Code:

List any additional TPIs that use the same provider information:

TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI: TPI:

Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form.

Street address City County State Zip Code Telephone: ( ) Fax Number: ( ) Email:

Accounting/Mailing Address—All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email:

Secondary Address

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email:

Type of Change (check the appropriate box)

Change of physical address, telephone, and/or fax number

Change of billing/mailing address, telephone, and/or fax number

Change/add secondary address, telephone, and/or fax number

Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field

Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID number: Effective Date:

Exact name reported to the IRS for this Tax ID:

Provider Demographic Information—Note: This information can be updated on www.tmhp.com.

Languages spoken other than English:

Provider office hours by location:

Accepting new clients by program (check one): Accepting new clients Current clients only No

Patient age range accepted by provider:

Additional services offered (check one): HIV High Risk OB Hearing Services for Children

Participation in the Woman’s Health Program? Yes No Patient gender limitations: Female Male Both

Signature and date are required or the form will not be processed.

Provider signature: Date: / /

Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Fax: 512-514-4214


Forms


Electronic Funds Transfer (EFT) Information

— A STATE MEDICAID CONTRACTOR23


Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider’s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.

The following items are specific to EFT:

• Pre–notification to your bank takes place on the cycle following the application processing.

• Future deposits are received electronically after pre–notification. • The Remittance and Status (R&S) report furnishes the details of individual credits

made to the provider’s account during the weekly cycle. • Specific deposits and associated R&S reports are cross–referenced by both the

provider identifiers (i.e., NPI, TPI, and API) and R&S number. • EFT funds are released by TMHP to depository financial institutions each Friday. • The availability of R&S reports is unaffected by EFT and they continue to arrive in

the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date.

However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer’s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer’s needs.

In all cases, credits received should be posted to the customer’s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date.

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return the agreement and either a voided check or a statement from your bank written on the bank’s letterhead to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1–800–925–9126 for assistance.

Forms


Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form

— A STATE MEDICAID CONTRACTOR23


NOTE: Complete all sections below and attach a voided check or a statement from your bank writtenon the bank’s letterhead.

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

National Provider Identifier (NPI)/Atypical Provider Identifier (API): Primary Taxonomy Code: Benefit Code:

Provider Accounting Address Provider Phone Number ( ) Ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one) Checking Savings

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period.

I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:


Forms


Page 1 of 2 Effective Date_06012009/Revised Date_08132009

CSHCN Services Program Prior Authorization Request forExternal Insulin Pump Form and Instructions

General Information • Ensure the most recent version of the Prior Authorization Request for External Insulin Pump form is

submitted. The form is available on the TMHP website at www.tmhp.com. • Complete all sections of this form. • Incomplete prior authorization requests are denied. Requests are considered only when completed and

received before the service is provided. • Print or type all information.• Contact the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000, option

2, Monday through Friday, from 7 a.m. to 7 p.m., Central Time, for assistance with this form.• This form may be submitted by mail to the following address:

TMHP-CSHCN Services Program Authorization Department 12357-B Riata Trace Parkway Ste #150 MC-A11

Austin, TX 78727 • This form may be submitted by fax to 1-512-514-4222. • Submit only the prior authorization form. Do not submit instruction pages. • Refer to: Chapter 14, “Diabetic Equipment and Supplies.”

Client Information Field Description GuidelinesFirst name Enter the client’s first name as indicated on the CSHCN Services Program

eligibility form Last name Enter the client’s last name as indicated on the CSHCN Services Program

eligibility formCSHCN Services Program number Enter the client’s ID number as indicated on the CSHCN Services Program

eligibility formDate of birth Enter the client’s date of birth as indicated on the CSHCN Services Program

eligibility formAddress/City/ZIP Enter the client’s address, city, and ZIPDiagnosis (ICD-9-CM) Enter the diagnosis code relevant to the client’s condition

Statement of Medical Necessity Field Description GuidelinesHCPCS Code / Service Description

Check the appropriate procedure code being requested

Most recent Hb/A1C results? Indicate the most recent Hb/A1C results Date Indicate the date of the most recent Hb/A1C results Check applicable boxes Check the applicable box

Provider Information and Required Signature Field Description GuidelinesProvider name Enter the provider’s name Contact person Enter the contact person Is the physician an endocrinologist?

Indicate “yes” or “no”

CSHCN TPI Enter the provider’s Texas provider identifier (TPI) NPI Enter the provider’s national provider identifier (NPI) Taxonomy code Enter the provider’s taxonomy code Benefit code Enter CSN Telephone number Enter the provider’s telephone number Fax number Enter the provider’s fax number Address/City/ZIP Enter the provider’s address, city, and ZIP Provider signature Provider must sign in this field Date Enter the date the form is signed

Forms



CSHCN Services Program Prior Authorization Request for External Insulin PumpClient Information

First name: Last name:

CSHCN Services Program number: 9- -00 Date of birth:

Address/City/ZIP:

Diagnosis (ICD-9-CM):

Statement of Medical Necessity

HCPCS Code Service Description

L-E0784 Initial rental for three months

J-E0784 Three-month trial successfully completed

Most recent Hb/A1C results? (please attach recent history of glucose levels)

Date:

Please check all applicable boxes

History of severe glycemic reactions or brittle diabetes?

Frequent hypo/hyperglycemic reactions?

History of nocturnal hypoglycemia?

History of extreme insulin sensitivity with very low insulin requirements?

History of wide fluctuations in blood glucose levels before meals?

History of Dawn phenomenon with fasting blood glucose levels > 200mg/dL?

History of day-to-day variations in work or meal schedules or activity requiring multiple injections?

The client possesses the cognitive and physical abilities to use the recommended insulin pump and a family or caregiver(s) willing to support the client in the use of the external insulin pump.

Provider Information and Required Signature

Provider name: (Type or print) Contact person:

Is the physician an endocrinologist? Yes No

CSHCN TPI: NPI:

Taxonomy code: Benefit code: CSN

Telephone number: Fax number:

Address/City/ZIP:

Provider signature: Date:


Forms



CSHCN Services Program Authorization Request forInitial Outpatient Therapy (TP1) Form and Instructions

General Information • Ensure the most recent version of the Authorization Request for Initial Outpatient Therapy (TP1) form

is submitted. The form is available on the TMHP website at www.tmhp.com. • Complete all sections of this form. • Incomplete authorization requests will cause the claim to be denied.• Print or type all information.• Contact the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000,

option 2, Monday through Friday, from 7 a.m. to 7 p.m., Central Time, for assistance with this form.• This form may be submitted by mail to the following address:


Austin, TX 78727 • This form may be submitted by fax to 1-512-514-4222. • Submit only the authorization form. Do not submit instruction pages. • Refer to: Chapter 28, “Physical Medicine and Rehabilitation” and Chapter 33, “Speech-Language

Pathology (SLP) Services.”

Client Information Field Description GuidelinesFirst name Enter the client’s first name as indicated on the CSHCN Services

Program eligibility form Last name Enter the client’s last name as indicated on the CSHCN Services

Program eligibility formCSHCN Services Program number

Enter the client’s ID number as indicated on the CSHCN Services Program eligibility form

Date of birth Enter the client’s date of birth as indicated on the CSHCN Services Program eligibility form

Address/City/ZIP Enter the client’s address, city, and ZIPDiagnosis (ICD-9-CM) Enter the diagnosis code relevant to the client’s condition

Evaluation Summary Field Description GuidelinesDate of evaluation Enter the date of evaluation.

Note: A copy of the initial evaluation must be attached.Type of evaluation Check the appropriate type of evaluation Comments

Service Request Field Description GuidelinesService request Indicate procedure code(s), modifier, the dates of service, and the

frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.

Physician name, signature, and date

Indicate the prescribing physician’s name, signature, and date of signature

PT name, signature, and date Indicate the physical therapist’s name, signature, and date of signature OT name, signature, and date Indicate the occupational therapist’s name, signature, and date of

signatureSLP name, signature, and date Indicate the speech language pathologist’s name, signature, and date

of signature


Forms


Provider Information and Required SignatureField Description GuidelinesProvider name Enter the provider’s name CSHCN TPI Enter the provider’s Texas provider identifier (TPI) NPI Enter the provider’s national provider identifier (NPI) Taxonomy code Enter the provider’s taxonomy code Benefit code Enter CSN Provider contact name Enter the provider’s contact name Telephone number Enter the provider’s telephone number Fax number Enter the provider’s fax number Address/City/ZIP Enter the provider’s address, city, and ZIP Provider signature Provider must sign in this field Date Enter the date the form is signed

Additional Requirements

• The GP or the GO modifier is required when requesting authorization for PT and OT services. PT should be requested using the GP modifier and OT should be requested using the GO modifier

• The GN modifier is required when requesting authorization for SLP services.


Forms


CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1) Please print or type requested information below.

Client Information



Address/City/ZIP:


Evaluation Summary: Date of evaluation: (A copy of the initial evaluation must be attached.)

Type of evaluation: Physical Therapy (PT) Occupational Therapy (OT) Speech Language Pathology (SLP)

Comments:

Service Request: Indicate procedure code(s), modifier, the dates of service, and the frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.

Procedure Code Modifier From Date To Date Frequency/Week Frequency/Month

Physician name: Physician signature: Date:

PT name: PT signature: Date:

OT name: OT signature: Date:

SLP name: SLP signature: Date:

Provider Information and Required Signature:Provider name:

CSHCN TPI: NPI:


Provider contact name:


Address/City/ZIP:

Signature of provider: Date:


Forms


CSHCN Services Program Authorization Request forExtension of Outpatient Therapy (TP2) Form and Instructions

General Information • Ensure the most recent version of the Authorization Request for Extension of Outpatient Therapy (TP2)

form is submitted. The form is available on the TMHP website at www.tmhp.com. • Complete all sections of this form. • Incomplete authorization requests will cause the claim to be denied.• Print or type all information.• Contact the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 or 1-512-514-3000,

option 2, Monday through Friday, from 7 a.m. to 7 p.m., Central Time, for assistance with this form.• This form may be submitted by mail to the following address:


Austin, TX 78727 • This form may be submitted by fax to 1-512-514-4222. • Submit only the authorization form. Do not submit instruction pages. • Refer to: Chapter 28, “Physical Medicine and Rehabilitation” and Chapter 33, “Speech-Language

Pathology (SLP) Services.”

Client Information Field Description GuidelinesFirst name Enter the client’s first name as indicated on the CSHCN Services

Program eligibility form Last name Enter the client’s last name as indicated on the CSHCN Services

Program eligibility formCSHCN Services Program number

Enter the client’s ID number as indicated on the CSHCN Services Program eligibility form

Date of birth Enter the client’s date of birth as indicated on the CSHCN Services Program eligibility form

Address/City/ZIP Enter the client’s address, city, and ZIPDiagnosis (ICD-9-CM) Enter the diagnosis code relevant to the client’s condition

Evaluation Summary Field Description GuidelinesDate of evaluation Enter the date of evaluation.

Note: A copy of the initial evaluation must be attached. Type of evaluation Check the appropriate type of evaluation Comments

Service Request Field Description GuidelinesService request Indicate procedure code(s), modifier, the dates of service, and the

frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.

Physician name, signature, and date

Indicate the prescribing physician’s name, signature, and date of signature

PT name, signature, and date Indicate the physical therapist’s name, signature, and date of signature OT name, signature, and date Indicate the occupational therapist’s name, signature, and date of

signatureSLP name, signature, and date Indicate the speech language pathologist’s name, signature, and date

of signature



Forms



Provider Information and Required SignatureField Description GuidelinesProvider name Enter the provider’s name CSHCN TPI Enter the provider’s Texas provider identifier (TPI) NPI Enter the provider’s national provider identifier (NPI) Taxonomy code Enter the provider’s taxonomy code Benefit code Enter CSN Provider contact name Enter the provider’s contact name Telephone number Enter the provider’s telephone number Fax number Enter the provider’s fax number Address/City/ZIP Enter the provider’s address, city, and ZIP Provider signature Provider must sign in this field Date Enter the date the form is signed

Functional Status, Goals, and Treatment Summary Field Description GuidelinesCurrent functional status Enter the current functional status New treatment goals Enter the new treatment goals Prior dates of service Enter the to and from prior dates of service Prior functional status Enter the prior functional status Prior treatment goals Enter the prior treatment goals Prior treatment provided Enter the prior treatment provided Additional comments Indicate additional comments

Additional Requirements

• Authorization requests for an extension require documentation of medical necessity.

• Request PT using the GP modifier and OT using the GO modifier.

• Request SLP using the GN modifier.

Forms


CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2) (page 1 of 2) This is a two-page form. Complete both pages and print or type requested information below.

Client Information



Address/City/ZIP:


Evaluation Summary:

Date of evaluation: (A copy of the initial evaluation must be attached.)

Type of evaluation: Physical Therapy (PT) Occupational Therapy (OT) Speech-Language Pathology (SLP)

Comments:

Service Request: Indicate procedure code(s), modifier, the dates of service, and the frequency per week or month. Dates of service cannot exceed six months. If possible, end requested date(s) of service on the last day of a month.

Procedure Code Modifier From Date To Date Frequency/Week Frequency/Month

Physician name: Physician signature: Date:

PT name: PT signature: Date:

OT name: OT signature: Date:

SLP name: SLP signature: Date:

Provider Information and Required Signature:Provider name:

CSHCN TPI: NPI:


Provider contact name:


Address/City/ZIP:

Signature of provider: Date:



Forms


CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2) (page 2 of 2)

Client Information:


CSHCN Services Program number: 9- -00

Functional Status, Goals, and Treatment Summary:

Current functional status:

New treatment goals:

Prior dates of service: From date: To date:

Prior functional status:

Prior treatment goals:

Prior treatment provided:

Additional comments:


Forms


ATTENTION: BUSINESS OFFICE

Pub. No. 07-12276

PRSRT STDU.S. POSTAGE

PAIDTMHP

February 2010PrOvIDEr BullETINChildren with Special Health Care Needs Services Program

CSHCN Services Program No. 73

Documents

CSHCN Services Program PrOvIDEr BullETIN - TMHP.com