ICD-10 Bulletin

ome benefit information has changed since this bulletin was published on April 6, 2015. Items that have changed are designated by an asterisk (*) and by purple text in the title.

Please click on the purple title link to see the most recent changes posted on the TMHP website at www.tmhp.com and www.tmhp.com/Pages/CodeUpdates/ICD10_benefit updates.aspx.

MAY 2015 NO. 8

2015 International Classification of Diseases, Tenth Revision, Special Bulletin

ICD-10 SpeCIal BulletInICD-10 SpeCIal BulletIn

2015 ICD-10 ImplementationOn October 1, 2015, the Texas Medicaid & Healthcare Partnership (TMHP) will apply the 2015 annual Interna-tional Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) updates that are effective for dates of service on or after October 1, 2015, and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) updates that are effective for inpatient hospital dates of admission on or after October 1, 2015.

This special bulletin includes the ICD-10 updates for Texas Medicaid, the Children with Special Health Care Needs (CSHCN) Services Program, the Department of State Health Services (DSHS) Family Planning Program (DFPP), and the Texas Women’s Health Program (TWHP). This bulletin is intended to notify providers of program and coding changes related to the 2015 updates for ICD-10-CM and ICD-10-PCS.

All providers are encouraged to review the “General Information” section of this bulletin. Policy updates for a specific program or provider type are discussed in designated sections of the bulletin.

Important: At this time, the lists in this bulletin that identify the ICD-10-CM replacements for specific Interna-tional Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes may not be all-inclusive. As medical policies continue to be updated, the list or lists of ICD-10-CM diagnosis codes for specific benefits are subject to change. Providers will be notified if lists change.

Note: This bulletin does not contain a complete list of ICD-10-CM diagnosis codes or ICD-10-PCS surgical procedure codes. The complete list of 2015 ICD-10 codes can be found in the 2015 ICD-10 coding manual available through the Centers for Medicare & Medicaid Services (CMS).

Date of Admission Versus Date of DischargeInpatient hospital claims must be coded according to the date of discharge, instead of the date of admission, as is current practice:

• If the client is discharged on or before September 30, 2015, ICD-9-CM diagnosis and surgical procedure codes must be submitted on the claim.

• If the client is discharged on or after October 1, 2015, ICD-10-CM diagnosis codes and ICD-10-PCS surgical procedure codes must be submitted on the claim.

S

http://www.tmhp.com/Pages/CodeUpdates/ICD-10.aspx

http://www.tmhp.com/Pages/CodeUpdates/ICD10_benefit%20updates.aspx

INSIDE

General 1

2015 ICD-10 Implementation .......................................................................................................................................................................1

Date of Admission Versus Date of Discharge .........................................................................................................................................1

ICD-10 Organization and Coding Structure .......................................................................................................................................... 3

Claims Filing and Appeals ............................................................................................................................................................................ 5

Claim Forms: Paper and Electronic Submissions ................................................................................................................................. 6

Authorization and Prior Authorization Updates .................................................................................................................................. 6

Medicaid Fee-For-Service and Managed Care Providers 7

Texas Medicaid Benefit Changes ................................................................................................................................................................7

Code Updates Web Page...............................................................................................................................................................................7

* Diagnostic Doppler Sonography ...........................................................................................................................................................26

Behavioral Health Services 84

ICD-10 and DSM Diagnosis Codes for Behavioral Health Services ..............................................................................................84

Texas Health Steps (THSteps) Medical Providers 106

THSteps Medical Benefit Changes ........................................................................................................................................................106

Texas Health Steps (THSteps) Dental Providers 107

THSteps Dental Benefit Changes...........................................................................................................................................................107

Home Health Providers 108

Home Health Benefit Changes ............................................................................................................................................................. 108

Respiratory Equipment and Supplies–Home Health .....................................................................................................................110

Comprehensive Care Program (CCP) Providers 111

CCP Benefit Changes ..................................................................................................................................................................................111

Texas Medicaid Forms 115

Prior Authorization Forms ....................................................................................................................................................................... 115

DSHS Family Planning Program Providers 116

DSHS Family Planning Program Benefit Changes ........................................................................................................................... 116

Texas Women’s Health Program (WHP) Providers 116

TWHP Benefit Changes ............................................................................................................................................................................. 116

Medical Transportation Program (MTP) Providers 117

MTP Benefit Changes .................................................................................................................................................................................117

Inpatient Hospital ICD-10-PCS Surgical Procedure Code Updates 117

ICD-10 and DRG Code Changes for Inpatient Hospital Providers ..............................................................................................117

CSHCN Services Program Providers 118

CSHCN Services Program Benefit Changes .......................................................................................................................................118

CSHCN Services Program Forms 144

Changes to Forms ...................................................................................................................................................................................... 144

ICD-10 Organization and Coding StructureThe new ICD-10 classification system provides significant improvements by capturing greater detailed information as code descriptions are more specific and will have the ability to expand and capture additional advancements in clinical medicine in the future. ICD-10 consists of the following two coding sets:

• ICD-10-CM is the diagnosis classification system developed by the Centers for Disease Control and Prevention (CDC) for use in all United States health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM).

• ICD-10-PCS is the procedure classification system developed by CMS for use in the United States for surgical services rendered in the inpatient hospital settings only. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

The following table outlines the differences between the ICD-9-CM system and the ICD-10-CM/PCS system:Type of Code ICD-9-CM ICD-10

Diagnosis codes

• 3-5 digits• Approximately 13,000 codes• Digit 1 is either alpha (E or V) or

numeric• Digit 2-5 are numeric• The decimal is after the third digit

• 3-7 digits• Approximately 68,000 codes• Digit 1 is an alpha-character• Digit 2 is a numeric character• Digits 3-7 are either alpha or numeric (alpha

digits are not case sensitive)• The letter U is not used• The decimal is after the third digit

Surgical procedure codes

• 3-4 digits• Approximately 3,000 codes• Each digit is numeric• No decimals

• 7 digits• Approximately 87,000 available codes• Each digit is either alpha or numeric (alpha digits

are not case sensitive and letters O and I are not used to avoid confusion with numbers 0 and 1)

• No decimals

Providers may refer to the following resources for more information about ICD-10 organization and coding structure:

• The CMS ICD-10 web page at www.cms.gov/Medicare/Coding/ICD10/index.html.

• The TMHP Code Updates — ICD-10 Implementation web page at www.tmhp.com/Pages/CodeUpdates/ICD-10.aspx.

Combination Diagnosis CodesThere are two types of combination diagnosis codes in the ICD-10 coding system:

• A single diagnosis code that describes the condition and the cause and intent in one code descriptor including any associated secondary condition(s).

More than one diagnosis code is required to fully describe a diagnosis and an associated complication that is not included in the description of the single code. In the Texas Medicaid and CSHCN Services Program benefit sections within this bulletin, TMHP refers to these code pairs as “combinations” or “combination codes,” and requires that both diagnosis codes be present on the claim for consideration of reimbursement.

ICD-10 Special Bulletin, No. 8 3 2015 Texas Medicaid

General Information

CPT only copyright 2014 American Medical Association. All rights reserved.

http://www.cms.gov/Medicare/Coding/ICD10/index.html


Code pairs should not be used when the classification provides a single code that clearly identifies all the elements documented in the diagnosis. When a single code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.

Important: To avoid fraudulent billing, providers must submit the diagnosis code or codes that are most appropriate for the services provided. Claims are subject to retrospective review, and payments may be recouped (i.e., deducted from the provider’s weekly payment) if correct coding is not used, including, but not limited to, combination diagnosis codes.

EnhancementsICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification are updated to be consistent with current clinical practice. Non-specific codes are still available for use when medical record documentation does not support a more specific code.

The following new features can be found in ICD-10-CM:

• Laterality (Left, Right, Bilateral) Note: Providers must continue to submit the appropriate LT, RT, or 50 modifier with the procedure code as applicable. The laterality of the ICD-10 diagnosis codes does not replace the modifier coding requirement for specific procedure codes.

• Combination codes for certain conditions and common associated symptoms and manifestations as well as combination codes for poisonings and their associated external cause

• Obstetric codes identify trimester instead of episode of care

• Character “X” is used as a 5th character placeholder in certain 6-character codes to allow for future expansion and to fill in other empty characters when a code that is less than 6 characters in length requires a 7th character

• Two types of Excludes notes

• Inclusion of clinical concepts that do not exist in ICD-9-CM (e.g., under-dosing, blood type, blood alcohol level)

• A number of codes are significantly expanded (e.g., injuries, diabetes, substance abuse, postoperative complications)

• Codes for postoperative complications are expanded and a distinction is made between intraoperative complica-tions and post-procedural disorders

Additionally, the following changes can be found in ICD-10-CM:

• Injuries are grouped by anatomical site rather than by type of injury.

• Category restructuring and code reorganization occur in a number of ICD-10-CM chapters, resulting in the classification of certain diseases and disorders that are different from ICD-9-CM.

• Certain diseases are reclassified to different chapters or sections to reflect current medical knowledge.

• New code definitions (for example, definition of acute myocardial infarction is now 4 weeks rather than 8 weeks).

• The codes corresponding to ICD-9-CM “V” codes (Factors Influencing Health Status and Contact with Health Services) and “E” codes (External Causes of Injury and Poisoning) are incorporated into the main classification (in ICD-9-CM they were separated into supplementary classifications).

• Full descriptions are used.


General Information


• Extensions specify encounter – ICD-10-CM has added code alpha character extensions (seventh character) in appropriate sections to provide specific information about the characteristics of the encounter. Extensions have different meanings depending on the section.

• Standard definitions have been added to facilitate the coding process.

Notable Classifications

Behavioral Health Services ICD-10 diagnosis coding is more closely aligned with the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis coding. ICD-10 diagnosis codes must be used to submit claims for services rendered.

Providers are encouraged to be aware of the similarities and differences between ICD-10 and DSM diagnosis coding, but DSM diagnosis codes are not compliant with Health Insurance Portability and Accountability Act (HIPAA) claim coding regulations and must not be used to submit claims. Claims that are submitted with DSM diagnosis codes will not be reimbursed.

All medical record documentation requirements will continue to apply on or after October 1, 2015, including the requirement to document the appropriate DSM diagnosis codes in the client’s medical record.

Substance Abuse, Use, and DependencyICD-10-CM diagnosis codes for substance abuse, use, and dependence are more specific to the level of service.

Claims Filing and AppealsProfessional and outpatient services rendered on or before September 30, 2015, must be submitted separately from services rendered on or after October 1, 2015. The following applies:

• Dates of service on or before September 30, 2015, must be submitted on one claim.

• Dates of service on or after October 1, 2015, must be submitted on a separate claim.

Effective for dates of service on or after October 1, 2014, inpatient hospital claims must be coded according to the date of discharge. For the transition from ICD-9 to ICD-10 effective October 1, 2015, providers must code diagnoses as follows:

• If the client is discharged on or before September 30, 2015, ICD-9-CM diagnosis and surgical procedure codes must be submitted on the claim.

• If the client is discharged on or after October 1, 2015, ICD-10-CM diagnosis codes and ICD-10-PCS surgical procedure codes must be submitted on the claim.

Inpatient Hospital Surgical Procedure CodingThe ICD-10-PCS procedure codes are inpatient hospital surgical procedure codes and must be submitted, as appli-cable, only on inpatient hospital claims.

Note: For professional and outpatient procedures and services, providers must continue to use the American Medical Association (AMA) Current Procedural Terminology (CPT) manual and the CMS Health Care Common Procedure Coding System (HCPCS) manual.


General Information


Claim Forms: Paper and Electronic SubmissionsTexMedConnect and the TMHP Electronic Data Interchange (EDI) has been updated to accommodate 5010 transactions and ICD-10 coding structures and can now accept ICD-9-CM codes and ICD-10 codes as necessary.

The following paper claim forms have also been updated to accommodate the new ICD-10 coding structure. The new forms are effective as follows:

Form Effective Date2012 ADA Dental paper claim form

TMHP website article: Correction To “Changes to Dental Claim Form Submissions Effective January 1, 2014”

Information posted December 13, 2013

January 1, 2014

CMS-1500 paper claim form

TMHP website articles: Updated CMS-1500 Claim Form to be Accepted Beginning January 6, 2014, Information posted November 15, 2013

Correction to “Updated CMS-1500 Claim Form Will be Accepted Beginning January 6, 2014” Information posted December 13, 2013

January 6, 2014

Family Planning 2017 Claims Form

TMHP website article: TBD

April 1, 2014

Authorization and Prior Authorization UpdatesEffective October 1, 2015, for dates of service on or after October 1, 2015, the ICD-9-CM diagnosis and surgical procedure codes will no longer be accepted by Texas Medicaid or the CSHCN Services Program.

Effective October 1, 2015, regardless of the requested dates of service, providers must include ICD-10-CM diagnosis codes when submitting prior authorization requests to TMHP. Prior authorization requests must be submitted as follows:Diagnosis Coding Receipt DateICD-9-CM procedure codes Received by TMHP on or before September 30, 2015ICD-10-PCS procedure codes Received by TMHP on or after October 1, 2015

The prior authorization request forms have been updated for ICD-10 and posted to this website.

For Authorizations that are placed in pending status on or before September 30, 2015, information received on or after October 1, 2015, must adhere to the deadlines identified in the above table.

Reminder: Services that are submitted without the appropriate prior authorization will be denied. Providers are responsible for meeting all filing deadlines and for ensuring that the authorization or prior authorization number appears on the claim or that the appropriate documentation is submitted with the claim.

Important: Authorization or prior authorization is a condition for reimbursement; it is not a guarantee of payment.

For a list of Prior Authorization Department telephone numbers, providers may refer to the “TMHP Telephone and Address Guide” in the current Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, on page vii, and TMHP-CSHCN Services Program Contact Information” in the current CSHCN Services Program Provider Manual, Section 1.1, on page 1-2.


General Information


http://www.tmhp.com/News_Items/2013/12-Dec/12-13-13 Correction To Changes to Dental Claim Form Submissions Effective January 1.pdf

http://www.tmhp.com/News_Items/2013/12-Dec/12-13-13 Correction To Changes to Dental Claim Form Submissions Effective January 1.pdf

http://www.tmhp.com/News_Items/2013/11-Nov/11-15-13 Updated CMS1500 Claim Form to be Accepted Beginning January 6.pdf

http://www.tmhp.com/News_Items/2013/11-Nov/11-15-13 Updated CMS1500 Claim Form to be Accepted Beginning January 6.pdf

http://www.tmhp.com/News_Items/2013/12-Dec/12-13-13 Correction to Updated CMS-1500 Claim Form Will be Accepted Beginning January 6.pdf

http://www.tmhp.com/News_Items/2013/12-Dec/12-13-13 Correction to Updated CMS-1500 Claim Form Will be Accepted Beginning January 6.pdf

MEDICAID FEE-FOR-SERVICE AND MANAGED CARE PROVIDERS

Texas Medicaid Benefit ChangesThe following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.

For questions, call the TMHP Contact Center at 1-800-925-9126.

Note: This article applies to claims submitted to TMHP for processing. For claims processed by a Medicaid managed care organization (MCO), providers must refer to the MCO for information about benefits, limitations, prior authorizations, and reimbursement.

Aerosol Treatment Outpatient SettingProcedure codes 94640, 94644, and 94645 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B59 E840 E8411 E8419 E848 E849 J09X1 J09X2 J121 J15212J188 J189 J210 J211 J218 J219 J398 J410 J411 J418J42 J430 J431 J432 J438 J439 J440 J441 J449 J4520J4521 J4522 J4530 J4531 J4532 J4540 J4541 J4542 J4550 J4551J4552 J45901 J45902 J45909 J45990 J45991 J45998 J471 J479 J670J671 J672 J673 J674 J675 J676 J677 J678 J679 J690J691 J698 J705 J95851 J9801 J9809 K449 P270 P271 P278T50995A T50995D T50995S

Procedure codes J7605, J7608, J7622, J7626, J7631, J7633, J7639, J7644, and J7682 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)A150 E840 J09X1 J09X2 J121 J15212 J188 J189 J210 J211J218 J219 J410 J411 J418 J42 J430 J431 J432 J438J439 J440 J441 J449 J4520 J4521 J4522 J4530 J4531 J4532J4540 J4541 J4542 J4550 J4551 J4552 J45901 J45902 J45909 J45990J45991 J45998 J471 J479 J60 J61 J620 J628 J630 J631J632 J633 J634 J635 J64 J660 J661 J662 J668 J670J671 J672 J673 J674 J675 J676 J677 J678 J679 J680J681 J682 J683 J684 J689 J690 J691 J698 J700 J701J705 J708 J709 J9801 Q334

Code Updates Web PageProviders are encouraged to refer to the TMHP Code Updates – ICD-10 Implementation web page at www.tmhp.com/Pages/CodeUpdates/ICD-10.aspx for all notifications about the 2015 ICD-10 implementation.


Medicaid Fee-For-Service and Managed Care Providers



Reimbursement for aerosol pentamidine treatment is limited to the following diagnoses:Diagnosis Codes (Submitted as stand-alone diagnosis codes)A481 B20 B4481 B59 B9733 B9734 B9735

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.3, “Aerosol Treatment” for additional information.

Alglucosidase AlfaAlglucosidase alfa procedure codes J0220 and J0221 may be prior authorized for clients of any age with a diagnosis of glycogen storage disease Type II (GSD Type II) (Pompe disease). The most appropriate ICD-10 diagnosis code must be indicated on the prior authorization request and on the claim.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.41.3, “Alglucosidase Alfa (Myozyme),” for additional information.

Allergen ImmunotherapyProcedure codes 95115, 95117, 95145, 95146, 95147, 95148, 95149, 95165, and 95170 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H1045 H65191 H65192 H65193 H65194 H65195 H65196 H6501H6502 H6503 H6504 H6505 H6506 H65111 H65112 H65113H65114 H65115 H65116 H65491 H65492 H65493 J301 J305J3081 J309 J4520 J4530 J4540 J4550 J4552 J45902J45909 J45998 L500 T531X4D T532X4D T533X4D T534X4D T536X4DT59812D T63001A T63002A T63003A T63003D T63003S T63004A T63004DT63004S T63011A T63011D T63011S T63012A T63013A T63014A T63021AT63022A T63023A T63023D T63023S T63024A T63024D T63024S T63031AT63031D T63031S T63032A T63033A T63034A T63041A T63042A T63043AT63043D T63043S T63044A T63044D T63044S T63061A T63061D T63062AT63063A T63063D T63064A T63064D T63064S T63071A T63071D T63072AT63073A T63073D T63073S T63074A T63074D T63074S T63081A T63081DT63081S T63082A T63083A T63083D T63084A T63084D T63084S T63091AT63091D T63092A T63093A T63093D T63093S T63094A T63094D T63094ST63111A T63111D T63112A T63113A T63113S T63113D T63114A T63114DT63114S T63121A T63121D T63122A T63123A T63123D T63123S T63124AT63124D T63124S T63191A T63191D T63192A T63193A T63193D T63193ST63194A T63194D T63194S T632X1A T632X1D T632X2A T632X3A T632X3DT632X3S T632X4A T632X4D T632X4S T63301A T63301D T63302A T63303AT63303D T63304A T63304D T63304S T63311A T63311D T63312A T63313AT63314A T63314D T63314S T63321A T63321D T63322A T63323A T63323DT63323S T63324A T63324D T63324S T63331A T63331D T63332A T63333AT63333D T63333S T63334A T63334D T63334S T63391A T63391D T63392AT63393A T63393D T63393S T63394A T63394D T63394S T63411A T63411DT63412A T63413A T63413D T63414A T63414D T63414S T63421A T63421DT63422A T63423A T63423D T63424A T63424D T63424S T63431A T63431DT63432A T63433A T63433D T63434A T63434D T63434S T63441A T63441D




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T63442A T63443A T63443D T63444A T63444D T63444S T63451A T63451DT63452A T63453A T63453D T63453S T63454A T63454D T63454S T63461AT63461D T63462A T63463A T63463D T63463S T63464A T63464D T63464ST63481A T63481D T63482A T63483A T63483D T63483S T63484A T63484DT63484S T63511A T63511D T63512A T63513A T63514A T63591A T63591DT63592A T63593A T63594A T63611A T63611D T63612A T63613A T63614AT63621A T63621D T63622A T63623A T63624A T63631A T63631D T63632AT63633A T63634A T63691A T63691D T63692A T63693A T63694A T63711AT63711D T63712A T63713A T63714A T63791A T63791D T63792A T63793AT63794A T63811A T63811D T63812A T63813A T63814A T63821A T63821DT63822A T63823A T63824A T63831A T63831D T63832A T63833A T63834AT63891A T63891D T63892A T63893A T63894A T6391XA T6391XD T6392XAT6393XA T6394XA T65824D

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.4.1, “Allergy Immunotherapy,” for additional information.

Ambulance ServicesEffective for dates of service on or after October 1, 2015, the following condition codes must be used to identify emergency medical conditions for ambulance transports:

Ambulance Emergency Condition CodesB9689 B999 E869 F068 F10929 F19939 F29 G4489G8929 H579 I469 I499 J9600 J984 M549 O2690R002 R0602 R0689 R079 R092 R0989 R100 R109R238 R4182 R4189 R4589 R509 R52 R55 R569R58 R6889 R7309 S0590XA T07 T148 T17300A T300T50904A T59891A T5994XA T672XXA T675XXA T68XXXA T699XXA T7500XAT751XXA T754XXA T782XXA T7840XA T8189XA T82519A T887XXA Y710Y828 Z209 Z7401 Z779 Z9181 Z9981 Z9989

An emergency transport may be reimbursed by Texas Medicaid when it is submitted with modifier ET and one or more of the emergency medical condition codes in the above table.

The requesting facility or physician must include with the claim, documentation that describes the client’s condition which necessitated the ambulance transport. Medicaid recognizes limitations of usual ambulance personnel for establishing a diagnosis, and recognizes that diagnosis coding of a client’s condition using International Classifica-tion of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) when reporting ambulance transport services may be less specific than for services reported by other professional providers.

Providers who submit ICD-10-CM diagnosis codes should choose the code that best describes the client’s condition at the time of transport. Diagnoses that are “rule out” or “suspected” diagnoses should not be reported using specific ICD-10-CM diagnosis codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding, or injury diagnosis code.

Refer to: The Texas Medicaid Provider Procedures Manual, Ambulance Services Handbook, subsection 2.2.1 “Emergency Ambulance Transport Services,” for additional information.





* Ambulatory Blood Pressure MonitoringProcedure codes 93784, 93786, 93788, and 93790 may be reimbursed when they are submitted with ICD-10-CM diagnosis code R030, (submitted as a stand-alone diagnosis code).

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assis-tants Handbook, subsection 9.2.26.1, “Ambulatory Blood Pressure Monitoring,” for additional information.

Ambulatory ElectroencephalogramProcedure codes 95950, 95951, 95953, and 95956 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F05 F060 F068 G253 G3101 G3109 G3183 G40001G40009 G40011 G40019 G40101 G40109 G40111 G40119 G40201G40209 G40211 G40219 G40301 G40309 G40311 G40319 G40401G40409 G40411 G40419 G40501 G40509 G40801 G40802 G40803G40804 G40811 G40812 G40813 G40814 G4089 G40901 G40909G40911 G40919 G40A11 G40A19 G40B01 G40B09 G40B11 G40B19G912 O99351 O99352 O99353 O99354 O99355 P90 P912R410 R4182 R5601 R561 R569 S060X1A S060X1D S060X1SS060X2A S060X2D S060X2S

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.26.2, “Ambulatory Electroencephalogram (Ambulatory EEG),” for additional information.

Ambulatory Surgical Center (ASC) and Hospital Ambulatory Surgical Center (HASC) ServicesIncomplete surgical procedures may be reimbursed to ASC and HASC facilities when they are submitted with the most appropriate diagnosis code or modifier as follows:

ICD-10-CM Diagnosis CodesDiagnosis Codes (Submitted as stand-alone diagnosis codes)Z5309 Z5329 Z538

ModifiersModifier Description73 Discontinued outpatient procedure prior to anesthesia administration74 Discontinued outpatient procedure after anesthesia administration

ASC and HASC facilities must use the most appropriate diagnosis code or modifier as identified above to indicate that a surgical procedure was not completed. Claims billed with diagnosis codes Z5309, Z5329, Z538, or modifiers 73 or 74 will suspend for review of the medical documentation submitted with the claim. Providers are to submit the operative report, the anesthesia report, and the reason the operation was not completed.

Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Services Handbook, subsection 4.2.3.6, “Incomplete Day Surgeries;” and subsection 5.2.2, “Incomplete Surgical Procedures,” for additional information.




http://www.tmhp.com/ICD10_Updates_Med/07-15-15%20Update%20to%20Ambulatory%20Blood%20Pressure%20Monitoring%20for%20Texas%20Medicaid.pdf

Anesthesia ReimbursementProcedure code 99140 is not reimbursed for diagnosis codes O80 or O82 when one of these diagnoses is documented as the referenced diagnosis on the claim. The referenced diagnosis must indicate the complicating condition. Emergency is defined as existing when a delay in treatment of the client would lead to a significant increase in the threat to life or body part.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.6.5, “Complicated Anesthesia;” and subsection 9.2.46, “Obstetrics and Prenatal Care,” for additional information.

Bacillus Calmette-Guérin (BCG) VaccineProcedure code 90585 may be reimbursed when it is submitted with the ICD-10-CM diagnosis code Z23 (submitted as a stand-alone diagnosis code).

Procedure codes 90586 and J9031 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)C670 C671 C672 C673 C674 C675 C676 C677 C678 C679C7911 D090

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.9, “Bacillus Calmette-Guérin (BCG) Intravesical for Treatment of Bladder Cancer,” for additional information.

BlepharoplastyProcedure codes 67901, 67902, 67903, 67904, 67906, and 67908 may be reimbursed for services rendered to clients who are 21 years of age and older without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H0231 H0232 H0234 H0235 H02411 H02412 H02413 H02421 H02422 H02423

H02431 H02432 H02433

Procedure codes 67901, 67902, 67903, 67904, 67906, 67908, and 67909 may be reimbursed for services rendered to clients who are 20 years of age and younger without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Q100 Q101 Q102 Q103

Procedure codes 15820, 15821, 67911, 67961, 67966, 67971, 67973, 67974, and 67975 are not restricted to specific diagnosis codes. The most appropriate, valid ICD-10 diagnosis code or codes must be submitted on the claim.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.13, “Blepharoplasty Procedures,” for additional information.




* Botulinum Toxin Type A and Type BBotulinum toxin type A and type B procedure code J0585 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes for J0585 (Submitted as stand-alone diagnosis codes)G114 G2401 G241 G243 G244 G245 G248 G250 G251 G252G253 G35 G360 G370 G371 G372 G374 G375 G378 G379G43701 G43709 G43711 G43719 G800 G801 G802 G803 G804 G808G809 G8110 G8111 G8112 G8113 G8114 G8220 G8221 G8222 G8250G8251 G8252 G8253 G8254 G830 G8310 G8311 G8312 G8313 G8314G8320 G8321 G8322 G8323 G8324 G8330 G8331 G8332 G8333 G8334G834 H4901 H4902 H4903 H4911 H4912 H4913 H4921 H4922 H4923H4931 H4932 H4933 H4941 H4942 H4943 H499 H5000 H50011 H50012H50021 H50022 H50031 H50032 H50041 H50042 H5005 H5006 H5007 H5008H5010 H50111 H50112 H50121 H50122 H50131 H50132 H50141 H50142 H5015H5016 H5017 H5018 H5021 H5022 H5034 H5040 H5030 H50311 H50312H5032 H50331 H50332 H50411 H50412 H5042 H5043 H5050 H5051 H5052H5053 H5054 H5055 H5060 H50611 H50612 H5069 H50811 H50812 H5089H510 H5111 H5112 H5121 H5122 H5123 H518 H519 I69031 I69032I69033 I69034 I69041 I69042 I69043 I69044 I69051 I69052 I69053 I69054I69061 I69062 I69063 I69064 I69065 I69098 I69131 I69132 I69133 I69134I69141 I69142 I69143 I69144 I69151 I69152 I69153 I69154 I69161 I69162I69163 I69164 I69165 I69198 I69231 I69232 I69233 I69234 I69241 I69242I69243 I69244 I69251 I69252 I69253 I69254 I69261 I69262 I69263 I69264I69265 I69298 I69331 I69332 I69333 I69334 I69341 I69342 I69343 I69344I69351 I69352 I69353 I69354 I69361 I69362 I69363 I69364 I69365 I69398I69831 I69832 I69833 I69834 I69841 I69842 I69843 I69844 I69851 I69852I69853 I69854 I69861 I69862 I69863 I69864 I69865 I69898 J385 K117K220 K600 K601 K602 M436 M62838 N3281 M722 N318 R490R498

Procedure code J0586 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes for J0586 (Submitted as stand-alone diagnosis codes)G114 G241 G243 G244 G245 G248 G35 G360 G370 G371G372 G374 G375 G378 G379 G800 G801 G802 G804 G808G809 G8110 G8111 G8112 G8113 G8114 J385 M436 M62838 M722

Procedure code J0587 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes for J0587 (Submitted as stand-alone diagnosis codes)G243 K117




http://www.tmhp.com/ICD10_Updates_Med/06-02-15%20ICD10%20Update%20to%20Botulinum%20Toxin%20Type%20A%20and%20Type%20B%20for%20Texas%20Medicaid.pdf

Procedure code J0588 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes for J0588 (Submitted as stand-alone diagnosis codes)G243 G245 G8110 G8111 G8112 G8113 G8114

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.8, “Botulinum Toxin Type A and Type B,” for additional information.

Cardiac RehabilitationProcedure codes 93797, 93798, and S9472 and revenue code B943 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)I110 I201 I208 I209 I2101 I2102 I2109 I2111 I2119 I2121I2129 I213 I214 I220 I221 I222 I228 I229 I501 I5020I5021 I5022 I5023 I5030 I5031 I5032 I5033 I5040 I5041 I5042I5043 I509 Z941 Z943 Z951 Z952 Z953 Z954 Z955 Z9861

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.19, “Cardiac Rehabilitation;” and the Inpatient and Outpatient Hospital Services Handbook, subsection 4.2.6, “Cardiac Rehabilitation,” for additional information.

Chiropractic Manipulative Treatment (CMT)CMT procedure codes may be reimbursed when they are submitted with diagnosis of subluxation of the spine. The level of subluxation must be indicated by using one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)M9900 M9901 M9902 M9903 M9904 M9905 M9908

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, Section 2.2, “Services, Benefits, Limitations, and Prior Authorization,” for additional information.

Clubfoot CastingProcedure codes 29450 and 29750 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)M21541 M21542 M21549 Q660 Q661 Q662 Q663 Q664Q6651 Q6652 Q666 Q667 Q6681 Q6682 Q6689

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.63.1, “Clubfoot Casting,” for additional information.




* Colony Stimulating FactorsProcedure codes J1442, J2505 and J2820 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C000 C001 C002 C003 C004 C005 C006 C008 C01C020 C021 C022 C023 C024 C028 C029 C030 C031C039 C040 C041 C048 C049 C050 C051 C052 C059C060 C061 C062 C0689 C069 C07 C080 C081 C089C090 C091 C099 C100 C101 C102 C103 C104 C108C109 C110 C111 C112 C113 C118 C119 C12 C130C131 C132 C138 C139 C140 C142 C148 C153 C154C155 C158 C159 C160 C161 C162 C163 C164 C165C166 C168 C169 C170 C171 C172 C173 C178 C179C180 C181 C182 C183 C184 C185 C186 C187 C188C189 C19 C20 C210 C211 C218 C220 C221 C222C223 C227 C228 C229 C23 C240 C241 C248 C249C250 C251 C252 C253 C254 C257 C258 C259 C260C261 C269 C300 C301 C310 C311 C312 C313 C318C319 C320 C321 C322 C323 C328 C329 C33 C3401C3402 C3411 C3412 C342 C3431 C3432 C3481 C3482 C3491C3492 C37 C380 C381 C382 C383 C384 C388 C390C399 C4001 C4002 C4011 C4012 C4021 C4022 C4031 C4032C4081 C4082 C410 C411 C412 C413 C414 C430 C4311C4312 C4321 C4322 C4331 C4339 C434 C4351 C4352 C4359C4361 C4362 C4371 C4372 C438 C439 C460 C461 C463C464 C4651 C4652 C467 C469 C478 C480 C481 C482C488 C490 C4911 C4912 C4921 C4922 C493 C494 C495C496 C498 C499 C4A0 C4A11 C4A12 C4A21 C4A22 C4A31C4A39 C4A4 C4A51 C4A52 C4A59 C4A61 C4A62 C4A71 C4A72C4A8 C50011 C50012 C50021 C50022 C50111 C50112 C50121 C50122C50211 C50212 C50221 C50222 C50311 C50312 C50321 C50322 C50411C50412 C50421 C50422 C50511 C50512 C50521 C50522 C50611 C50612C50621 C50622 C50811 C50812 C50821 C50822 C50911 C50912 C50921C50922 C510 C511 C512 C519 C52 C530 C531 C538C539 C540 C541 C542 C543 C548 C55 C561 C562C5701 C5702 C5711 C5712 C5721 C5722 C573 C574 C577C578 C579 C58 C600 C601 C602 C608 C609 C61C6201 C6202 C6211 C6212 C6291 C6292 C6301 C6302 C6311C6312 C632 C637 C638 C639 C641 C642 C651 C652C661 C662 C670 C671 C672 C673 C674 C675 C676C677 C678 C679 C680 C681 C688 C689 C6901 C6902C6911 C6912 C6921 C6922 C6931 C6932 C6951 C6952 C6961C6962 C6981 C6982 C6991 C6992 C700 C701 C710 C711C712 C713 C714 C715 C716 C717 C718 C719 C720




http://www.tmhp.com/ICD10_Updates_Med/06-02-15%20ICD10%20Update%20to%20Colony%20Stimulating%20Factors%20for%20Texas%20Medicaid.pdf

Diagnosis Codes (Submitted as stand-alone diagnosis codes)C721 C7221 C7222 C7231 C7232 C7241 C7242 C7259 C729C73 C7401 C7402 C7411 C7412 C750 C751 C752 C753C754 C755 C758 C759 C760 C761 C762 C763 C7641C7642 C7651 C7652 C768 C770 C771 C772 C773 C774C775 C778 C779 C7801 C7802 C781 C782 C7839 C784C785 C786 C787 C7889 C7901 C7902 C7911 C7919 C792C7931 C7949 C7951 C7952 C7961 C7962 C7971 C7972 C7981C7982 C7989 C7A010 C7A011 C7A012 C7A020 C7A021 C7A022 C7A023C7A024 C7A025 C7A026 C7A090 C7A091 C7A092 C7A093 C7A094 C7A095C7A096 C7A098 C7A1 C7A8 C7B01 C7B02 C7B03 C7B04 C7B09C7B1 C7B8 C800 C801 C802 C8101 C8102 C8103 C8104C8105 C8106 C8107 C8108 C8109 C8111 C8112 C8113 C8114C8115 C8116 C8117 C8118 C8119 C8121 C8122 C8123 C8124C8125 C8126 C8127 C8128 C8129 C8131 C8132 C8133 C8134C8135 C8136 C8137 C8138 C8139 C8141 C8142 C8143 C8144C8145 C8146 C8147 C8148 C8149 C8171 C8172 C8173 C8174C8175 C8176 C8177 C8178 C8179 C8191 C8192 C8193 C8194C8195 C8196 C8197 C8198 C8199 C8201 C8202 C8203 C8204C8205 C8206 C8207 C8208 C8209 C8211 C8212 C8213 C8214C8215 C8216 C8217 C8218 C8219 C8221 C8222 C8223 C8224C8225 C8226 C8227 C8228 C8229 C8231 C8232 C8233 C8234C8235 C8236 C8237 C8238 C8239 C8241 C8242 C8243 C8244C8245 C8246 C8247 C8248 C8249 C8251 C8252 C8253 C8254C8255 C8256 C8257 C8258 C8259 C8261 C8262 C8263 C8264C8265 C8266 C8267 C8268 C8269 C8281 C8282 C8283 C8284C8285 C8286 C8287 C8288 C8289 C8291 C8292 C8293 C8294C8295 C8296 C8297 C8298 C8299 C8301 C8302 C8303 C8304C8305 C8306 C8307 C8308 C8309 C8311 C8312 C8313 C8314C8315 C8316 C8317 C8318 C8319 C8331 C8332 C8333 C8334C8335 C8336 C8337 C8338 C8339 C8351 C8352 C8353 C8354C8355 C8356 C8357 C8358 C8359 C8371 C8372 C8373 C8374C8375 C8376 C8377 C8378 C8379 C8381 C8382 C8383 C8384C8385 C8386 C8387 C8388 C8389 C8391 C8392 C8393 C8394C8395 C8396 C8397 C8398 C8399 C8401 C8402 C8403 C8404C8405 C8406 C8408 C8409 C8411 C8412 C8413 C8414 C8415C8416 C8417 C8418 C8419 C8441 C8442 C8443 C8444 C8445C8446 C8447 C8448 C8449 C8461 C8462 C8463 C8464 C8465C8466 C8467 C8468 C8469 C8471 C8472 C8473 C8474 C8475C8476 C8477 C8478 C8479 C8491 C8492 C8493 C8494 C8495C8496 C8497 C8498 C8499 C84A1 C84A2 C84A3 C84A4 C84A5C84A6 C84A7 C84A8 C84A9 C84Z1 C84Z2 C84Z3 C84Z4 C84Z5C84Z6 C84Z7 C84Z8 C84Z9 C8511 C8512 C8513 C8514 C8515C8516 C8517 C8518 C8519 C8521 C8522 C8523 C8524 C8525C8526 C8527 C8528 C8529 C8581 C8582 C8583 C8584 C8585




Diagnosis Codes (Submitted as stand-alone diagnosis codes)C8586 C8587 C8588 C8589 C8591 C8592 C8593 C8594 C8595C8596 C8597 C8598 C8599 C860 C861 C862 C863 C864C865 C866 C880 C882 C883 C884 C888 C9000 C9001C9002 C9010 C9011 C9012 C9020 C9021 C9022 C9030 C9031C9032 C9100 C9101 C9102 C9110 C9111 C9112 C9130 C9131C9132 C9140 C9141 C9142 C9150 C9151 C9152 C9160 C9161C9162 C91A0 C91A1 C91A2 C91Z0 C91Z1 C91Z2 C9200 C9201C9202 C9210 C9211 C9212 C9220 C9221 C9222 C9230 C9231C9232 C9240 C9241 C9242 C9250 C9251 C9252 C9260 C9261C9262 C9290 C9291 C92Z0 C92Z1 C92Z2 C9292 C92A0 C92A1C92A2 C9300 C9301 C9302 C9310 C9311 C9312 C9330 C9331C9332 C93Z0 C93Z1 C93Z2 C9400 C9401 C9402 C9420 C9421C9422 C9430 C9431 C9432 C9440 C9441 C9442 C946 C9480C9481 C9482 C9500 C9501 C9502 C9510 C9511 C9512 C9590C9591 C9592 C960 C962 C964 C965 C966 C96A C96ZD0001 D0002 D0003 D0004 D0005 D0006 D0007 D0008 D001D002 D010 D011 D012 D013 D0149 D015 D017 D020D021 D0221 D0222 D023 D030 D0311 D0312 D0321 D0322D0339 D034 D0361 D0362 D0371 D0372 D038 D039 D040D0411 D0412 D0421 D0422 D0439 D044 D045 D0461 D0462D0471 D0472 D048 D0501 D0502 D0511 D0512 D0581 D0582D060 D061 D067 D070 D071 D072 D0739 D074 D075D0761 D0769 D090 D0919 D0921 D0922 D093 D098 D45D4981 D4989 D600 D601 D608 D6109 D611 D612 D613D6189 D700 D701 D702 D703 D704 P615 T451X1A T451X1DT451X1S T451X2A T451X2D T451X2S T451X3A T451X3D T451X3S T451X4A T451X4DT451X4S T8601 T8602 T8603 T8609 Z5111 Z5112 Z5189 Z9481Z9484

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.12, “Colony Stimulating Factors (Filgrastim, Pegfilgrastim, and Sargramostim),” for additional information.

Colorectal Cancer ScreeningProcedure codes G0104 and G0106 may be reimbursed once every five years as recommended by the ACS and US Preventive Services Task Force (USPSTF) when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z0000* Z0001* Z1210 Z1211 Z1213 Z859 Z86010

*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more frequently than recommended by the USPSTF.

Procedure code G0121 may be reimbursed once every ten years for patients who do not meet the criteria for high-risk as recommended by the ACS and USPSTF. Procedure code G0121 must be submitted with one of the following average risk ICD-10-CM diagnosis codes:




Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z0000* Z0001* Z1210 Z1211 Z1213 Z86010

*Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but no more frequently than recommended by the USPSTF.

Procedure codes G0105 and G0120 may be reimbursed once every two years for clients who meet the definition of high-risk when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)K5000 K50011 K50012 K50013 K50014 K50018 K5010 K50111 K50112 K50113K50114 K50118 K5080 K50811 K50812 K50813 K50814 K50818 K5090 K50911K50912 K50913 K50914 K50918 K50919 K5120 K51211 K51212 K51213 K51214K51218 K5130 K51311 K51312 K51313 K51314 K51318 K5180 K51811 K51812K51813 K51814 K51818 K5190 K51911 K51912 K51913 K51914 K51918 K51919K5281 K5282 K5289 K529 Z800 Z8371 Z85038 Z85048 Z859 Z86010

Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Services Handbook, subsection 4.2.8, “Colorectal Cancer Screening;” subsection 5.2.6, “Colorectal Cancer Screening;” and the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.15.2,

“Colorectal Cancer Screening,” for additional information.

Cytogenetics TestingCytogenetics testing procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C8280 C8281 C8282 C8283 C8284 C8285 C8286 C8287 C8288C8289 C8291 C8292 C8293 C8294 C8295 C8296 C8297 C8298C8299 C8310 C8311 C8312 C8313 C8314 C8315 C8316 C8317C8318 C8319 C8380 C8381 C8382 C8383 C8384 C8385 C8386C8387 C8388 C8389 C8440 C8441 C8442 C8443 C8444 C8445C8446 C8447 C8448 C8449 C8461 C8462 C8463 C8464 C8465C8466 C8467 C8468 C8469 C8471 C8472 C8473 C8474 C8475C8476 C8477 C8478 C8479 C8581 C8582 C8584 C8585 C8586C8587 C8588 C8589 C884 C888 C9012 C9100 C9101 C9102C9110 C9111 C9112 C9190 C9191 C9192 C91Z0 C91Z1 C91Z2C9200 C9201 C9202 C9210 C9211 C9212 C9220 C9221 C9222C9230 C9231 C9232 C9240 C9241 C9242 C9250 C9251 C9252C9260 C9261 C9262 C9290 C9291 C9292 C92A0 C92A1 C92A2C92Z0 C92Z1 C92Z2 C9300 C9301 C9302 C9310 C9311 C9312C9330 C9331 C9390 C9391 C9392 C93Z0 C93Z1 C93Z2 C9400C9401 C9402 C9420 C9421 C9422 C9430 C9431 C9432 C9480C9481 C9482 C9500 C9501 C9502 C9510 C9511 C9512 C9590C9591 C9592 D45 D821 E230 E291 E300 E343 E83110E8359 F70 F71 F72 F73 F78 F800 F801 F802F804 F8089 F810 F812 F8181 F8189 F819 F82 F840F88 F900 F901 F902 F908 H0589 H9325 I77810 I77811




Diagnosis Codes (Submitted as stand-alone diagnosis codes)I77812 I77819 M2600 M2601 M2602 M2603 M2604 M2605 M2606M2607 M2609 N4601 N4611 N6482 N910 N911 N913 N914N949 N970 N978 O010 O011 O019 O021 O0289 O09511O09512 O09513 O09521 O09522 O09523 O350XX0 O350XX1 O350XX2 O350XX3O350XX4 O350XX5 O350XX9 O351XX0 O351XX1 O351XX2 O351XX3 O351XX4 O351XX5O351XX9 O352XX0 O352XX1 O352XX2 O352XX3 O352XX4 O352XX5 O352XX9 P293Q000 Q001 Q002 Q010 Q011 Q012 Q018 Q02 Q030Q031 Q038 Q040 Q041 Q042 Q045 Q046 Q048 Q050Q051 Q052 Q054 Q055 Q056 Q057 Q058 Q062 Q064Q068 Q0701 Q0702 Q0703 Q078 Q079 Q100 Q101 Q102Q103 Q104 Q106 Q107 Q110 Q111 Q112 Q113 Q120Q121 Q123 Q124 Q128 Q129 Q130 Q131 Q132 Q133Q134 Q135 Q1381 Q1389 Q140 Q141 Q142 Q143 Q148Q150 Q158 Q159 Q160 Q161 Q162 Q163 Q164 Q165Q169 Q170 Q171 Q172 Q173 Q174 Q175 Q178 Q179Q180 Q181 Q182 Q183 Q184 Q185 Q186 Q187 Q188Q189 Q200 Q201 Q202 Q203 Q204 Q205 Q206 Q208Q209 Q210 Q211 Q212 Q213 Q214 Q218 Q219 Q220Q221 Q222 Q223 Q224 Q225 Q228 Q230 Q231 Q232Q233 Q234 Q238 Q240 Q241 Q242 Q243 Q244 Q245Q246 Q248 Q249 Q250 Q251 Q252 Q253 Q254 Q2572Q259 Q260 Q261 Q262 Q263 Q265 Q266 Q268 Q269Q270 Q271 Q272 Q2730 Q2731 Q2732 Q2733 Q2734 Q274Q278 Q279 Q280 Q281 Q282 Q283 Q288 Q289 Q300Q301 Q302 Q303 Q308 Q309 Q310 Q311 Q312 Q313Q315 Q318 Q320 Q321 Q322 Q323 Q324 Q330 Q331Q332 Q333 Q334 Q335 Q336 Q338 Q339 Q348 Q349Q351 Q353 Q359 Q360 Q369 Q370 Q371 Q372 Q373Q374 Q375 Q380 Q381 Q382 Q383 Q384 Q385 Q386Q387 Q388 Q391 Q392 Q393 Q394 Q395 Q396 Q398Q400 Q401 Q402 Q408 Q409 Q410 Q411 Q412 Q419Q420 Q421 Q422 Q423 Q428 Q430 Q431 Q432 Q433Q434 Q435 Q437 Q438 Q440 Q441 Q442 Q443 Q444Q445 Q446 Q447 Q450 Q451 Q452 Q453 Q458 Q459Q5001 Q5002 Q501 Q502 Q5031 Q5032 Q5039 Q504 Q505Q506 Q510 Q5110 Q5111 Q512 Q515 Q516 Q517 Q51811Q51821 Q51828 Q520 Q5210 Q522 Q523 Q524 Q525 Q526Q5270 Q5271 Q5279 Q528 Q529 Q5300 Q5301 Q5302 Q5310Q5311 Q5312 Q5320 Q5321 Q5322 Q539 Q540 Q541 Q542Q543 Q544 Q548 Q550 Q551 Q5521 Q5522 Q5523 Q5529Q553 Q554 Q555 Q5561 Q5562 Q5563 Q5564 Q5569 Q558Q559 Q560 Q561 Q562 Q563 Q564 Q600 Q601 Q603Q604 Q606 Q6101 Q6119 Q612 Q613 Q614 Q615 Q618Q619 Q6211 Q6212 Q622 Q6231 Q6239 Q624 Q625 Q6261




Diagnosis Codes (Submitted as stand-alone diagnosis codes)Q6262 Q6263 Q628 Q630 Q631 Q632 Q633 Q638 Q640Q6410 Q6411 Q6412 Q6419 Q642 Q6431 Q6432 Q6433 Q6439Q644 Q645 Q646 Q6471 Q6472 Q6473 Q6474 Q6475 Q649Q6501 Q6502 Q651 Q6531 Q6532 Q654 Q6581 Q6582 Q6589Q660 Q662 Q663 Q664 Q6651 Q6652 Q666 Q667 Q6681Q6682 Q6689 Q670 Q671 Q672 Q673 Q674 Q675 Q676Q677 Q678 Q680 Q681 Q682 Q683 Q684 Q688 Q690Q691 Q692 Q699 Q7001 Q7002 Q7003 Q7011 Q7012 Q7013Q7021 Q7022 Q7023 Q7031 Q7032 Q7033 Q709 Q7101 Q7102Q7103 Q7111 Q7112 Q7113 Q7131 Q7132 Q7133 Q7141 Q7142Q7143 Q7151 Q7152 Q7153 Q7161 Q7162 Q7163 Q71811 Q71812Q71813 Q71891 Q71892 Q71893 Q7191 Q7192 Q7193 Q7201 Q7202Q7203 Q7211 Q7212 Q7213 Q7231 Q7232 Q7233 Q7241 Q7242Q7243 Q7251 Q7252 Q7253 Q7261 Q7262 Q7263 Q7271 Q7272Q7273 Q72811 Q72812 Q72813 Q72891 Q72892 Q72893 Q7291 Q7292Q7293 Q730 Q731 Q738 Q740 Q742 Q743 Q748 Q749Q750 Q751 Q752 Q753 Q754 Q755 Q758 Q759 Q760Q761 Q762 Q763 Q76411 Q76412 Q76413 Q76414 Q76415 Q76425Q76426 Q76427 Q76428 Q7649 Q765 Q766 Q767 Q768 Q770Q771 Q772 Q774 Q775 Q776 Q777 Q780 Q781 Q782Q783 Q784 Q788 Q789 Q790 Q791 Q792 Q793 Q794Q7959 Q796 Q798 Q799 Q800 Q801 Q802 Q803 Q804Q808 Q820 Q821 Q822 Q823 Q824 Q825 Q828 Q830Q831 Q832 Q833 Q838 Q840 Q841 Q842 Q843 Q844Q845 Q846 Q848 Q849 Q8503 Q851 Q858 Q859 Q870Q871 Q87410 Q87418 Q8742 Q8743 Q8901 Q8909 Q891 Q892Q893 Q894 Q897 Q898 Q899 Q900 Q901 Q902 Q909Q910 Q911 Q912 Q913 Q914 Q915 Q916 Q917 Q920Q921 Q922 Q925 Q9261 Q9262 Q927 Q928 Q930 Q931Q932 Q933 Q934 Q935 Q937 Q9381 Q9388 Q9389 Q950Q952 Q958 Q960 Q961 Q962 Q963 Q964 Q968 Q969Q970 Q971 Q972 Q973 Q978 Q980 Q981 Q984 Q985Q986 Q987 Q988 Q990 Q991 Q992 Q998 Q999 R480Z31430 Z31438 Z315 Z36 Z810 Z8279 Z8489

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)Q6501 Q6532

Q6502 Q6531

If the combination diagnosis codes are submitted, both diagnosis codes that are indicated in the combination must be submitted on the claim. Claims may be subject to retrospective review and recoupment if both of the diagnosis codes in the chosen combination are not submitted.

Refer to: The section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional informa-tion about submitting claims with combination diagnosis codes.




The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.41.6, “Cytogenetics Testing,” for additional information.

* Developmental and Neurological Assessment and TestingMedically necessary assessment of aphasia procedure code 96105 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)R4701 R471 R4702 R4781 R4789

Neurobehavioral examination procedure code 96116 may be reimbursed when one of the following ICD-10-CM medical or psychiatric diagnoses exists that establishes the need for a detailed evaluation of neurological impairment:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)A8100 A8101 A8109 A8181 A8183 A8189 A819 B1001 B1009B451 D8681 E7500 E7501 E7502 E7509 E7510 E7511 E7519E7523 E7525 E7529 E754 F0150 F0151 F0280 F0281 F0390F0391 F04 F05 F060 F061 F062 F0630 F0631 F0632F0633 F0634 F064 F068 F070 F0781 F0789 F09 F1010F10121 F1014 F10150 F10180 F10181 F10188 F1019 F1020 F10221F1024 F10250 F1026 F1027 F10280 F10281 F10288 F1029 F10921F1094 F10950 F1096 F1097 F10980 F10981 F10988 F1099 F1110F11121 F11150 F11151 F1120 F11220 F11221 F11229 F1123 F11250F11251 F11920 F11921 F11929 F1193 F11950 F11951 F1210 F12120F12121 F12129 F12150 F12151 F12220 F12221 F12229 F12250 F12251F1290 F12920 F12921 F12929 F12950 F12951 F1310 F13120 F13121F13129 F13150 F13151 F13220 F13221 F13229 F13230 F13231 F13232F13239 F13250 F13251 F13920 F13921 F13929 F13930 F13931 F13932F13939 F13950 F13951 F1410 F14120 F14121 F14129 F14150 F14151F14182 F14220 F14221 F14229 F1423 F14250 F14251 F14920 F14921F14929 F14950 F14951 F1510 F15120 F15121 F15129 F15150 F15151F15220 F15221 F15229 F1523 F15250 F15251 F15920 F15921 F15929F1593 F15950 F15951 F1610 F16121 F16129 F16150 F16151 F16220F16221 F16229 F16250 F16251 F16920 F16921 F16929 F16950 F16951F17203 F17213 F17223 F17293 F1810 F18120 F18121 F18129 F18150F18151 F18220 F18221 F18229 F18250 F18251 F18920 F18921 F18929F18950 F18951 F1910 F19120 F19121 F19129 F19150 F19151 F1919F19220 F19221 F19229 F19230 F19231 F19232 F19239 F19250 F19251F1929 F19920 F19921 F19929 F19930 F19931 F19932 F19939 F19950F19951 F1999 F200 F201 F202 F203 F205 F2081 F2089F209 F21 F22 F23 F24 F250 F251 F258 F259F28 F29 F3010 F3011 F3012 F3013 F302 F303 F304F308 F309 F3110 F3111 F3112 F3113 F312 F3130 F3131




http://www.tmhp.com/ICD10_Updates_Med/06-02-15%20ICD10%20Update%20to%20Developmental%20and%20Neurological%20Assessment%20Testing%20for%20Texas%20Medicaid.pdf

Diagnosis Codes (Submitted as stand-alone diagnosis codes)F3132 F314 F315 F3160 F3161 F3162 F3163 F3164 F3170F3173 F3174 F3175 F3176 F3177 F3178 F3181 F3189 F319F320 F321 F322 F323 F324 F325 F328 F329 F330F331 F332 F333 F3341 F3342 F338 F339 F340 F341F348 F349 F39 F4001 F4002 F4010 F4011 F40210 F40218F40220 F40228 F40230 F40231 F40232 F40233 F40240 F40241 F40242F40243 F40248 F40290 F40291 F40298 F408 F409 F410 F411F413 F418 F419 F42 F430 F4310 F4311 F4312 F4320F4321 F4322 F4323 F4324 F4325 F4329 F438 F439 F440F441 F442 F444 F445 F446 F447 F4481 F4489 F449F450 F451 F4520 F4521 F4522 F4529 F4541 F4542 F458F459 F481 F482 F488 F489 F5000 F5001 F5002 F502F508 F509 F5101 F5102 F5103 F5104 F5105 F5109 F5111F5112 F5113 F5119 F513 F514 F515 F518 F519 F520F521 F5221 F5222 F5231 F5232 F524 F525 F526 F528F529 F53 F600 F601 F602 F603 F604 F605 F606F607 F6081 F6089 F609 F630 F631 F632 F633 F6381F6389 F639 F641 F642 F648 F649 F650 F651 F652F653 F654 F6551 F6552 F6581 F6589 F659 F66 F6810F6811 F6812 F6812 F6813 F688 F70 F71 F72 F73F79 F801 F802 F804 F819 F82 F840 F842 F843F845 F848 F849 F88 F89 F900 F901 F902 F908F909 F910 F911 F912 F913 F918 F919 F930 F938F939 F940 F941 F942 F948 F950 F951 F952 F958F959 F980 F981 F9821 F9829 F983 F984 F985 F988F989 G000 G001 G002 G003 G008 G009 G01 G02G030 G031 G032 G038 G039 G0400 G0401 G0402 G042G0430 G0431 G0432 G0439 G0481 G0489 G0490 G0491 G053G054 G060 G061 G062 G07 G210 G300 G301 G308G309 G3101 G3109 G311 G3181 G3182 G3183 G3185 G319G3289 G35 G40001 G40009 G40011 G40019 G40101 G40109 G40111G40119 G40201 G40209 G40211 G40219 G40301 G40309 G40311 G40319G40501 G40509 G40801 G40802 G40803 G40804 G40811 G40812 G40813G40814 G40821 G40822 G40823 G40824 G4089 G40901 G40909 G40911G40919 G40A01 G40A09 G40A11 G40A19 G40B01 G40B09 G40B11 G40B19G450 G451 G452 G454 G458 G459 G468 G910 G911G912 G92 G930 G931 G9340 G9341 G9349 G937 G9381G9389 G939 G94 H93291 H93292 H93293 I6000 I6001 I6002I6010 I6011 I6012 I6020 I6021 I6022 I6030 I6031 I6032




Diagnosis Codes (Submitted as stand-alone diagnosis codes)I604 I6050 I6051 I6052 I606 I607 I608 I609 I610I611 I612 I613 I614 I615 I616 I618 I619 I6200I6201 I6202 I6203 I621 I629 I6300 I63011 I63012 I63019I6302 I63031 I63032 I63039 I6309 I6310 I63111 I63112 I63119I6312 I63131 I63132 I63139 I6319 I6320 I63211 I63212 I63219I6322 I63231 I63232 I63239 I6329 I6330 I63311 I63312 I63319I63321 I63322 I63329 I63331 I63332 I63339 I63341 I63342 I63349I6339 I6340 I63411 I63412 I63419 I63421 I63422 I63429 I63431I63432 I63439 I63441 I63442 I63449 I6349 I6350 I63511 I63512I63519 I63521 I63522 I63529 I63531 I63532 I63539 I63541 I63542I63549 I6359 I6501 I6502 I6503 I6509 I651 I6521 I6522I6523 I6529 I658 I659 I6601 I6602 I6603 I6609 I6611I6612 I6613 I6619 I6621 I6622 I6623 I6629 I663 I668I669 I671 I672 I674 I675 I676 I677 I6781 I6782I6789 I679 I680 I682 I688 I6900 I6901 I69020 I69021I69022 I69023 I69028 I69031 I69032 I69033 I69034 I69039 I69041I69042 I69043 I69044 I69049 I69051 I69052 I69053 I69054 I69059I69061 I69062 I69063 I69064 I69065 I69069 I69090 I69091 I69092I69093 I69098 I6910 I6911 I69120 I69121 I69122 I69123 I69128I69131 I69132 I69133 I69134 I69139 I69141 I69142 I69143 I69144I69149 I69151 I69152 I69153 I69154 I69159 I69161 I69162 I69163I69164 I69165 I69169 I69190 I69191 I69192 I69193 I69198 I6920I6921 I69220 I69221 I69222 I69223 I69228 I69231 I69232 I69233I69234 I69239 I69241 I69242 I69243 I69244 I69249 I69251 I69252I69253 I69254 I69259 I69261 I69262 I69263 I69264 I69265 I69269I69290 I69291 I69292 I69293 I69298 I6930 I6931 I69320 I69321I69322 I69323 I69328 I69331 I69332 I69333 I69334 I69339 I69341I69342 I69343 I69344 I69349 I69351 I69352 I69353 I69354 I69359I69361 I69362 I69363 I69364 I69365 I69369 I69390 I69391 I69392I69393 I69398 I6980 I6981 I69820 I69821 I69822 I69823 I69828I69831 I69832 I69833 I69834 I69839 I69841 I69842 I69843 I69844I69849 I69851 I69852 I69853 I69854 I69859 I69861 I69862 I69863I69864 I69865 I69869 I69890 I69891 I69892 I69893 I69898 I6990I6991 I69920 I69921 I69922 I69923 I69928 I69931 I69932 I69933I69934 I69939 I69941 I69942 I69943 I69944 I69949 I69951 I69952I69953 I69954 I69959 I69961 I69962 I69963 I69964 I69965 I69969I69990 I69991 I69992 I69993 I69998 P102 P103 P520 P521P5221 P5222 P523 P525 P84 P90 P9160 P9161 P9162P9163 R0901 R0902 R37 R41840 R41841 R41842 R41843 R41844




Diagnosis Codes (Submitted as stand-alone diagnosis codes)R4189 R450 R453 R454 R45850 R45851 R4586 R4587 R4589R5600 R569 S060X0A S060X0D S060X0S S060X1A S060X1D S060X1S S060X2AS060X2D S060X2S S060X3A S060X4A S060X5A S060X5D S060X5S S060X6A S060X6DS060X6S S060X9A S060X9D S060X9S S06306D S06306S S06310A S06310D S06310SS06311A S06311D S06311S S06312A S06312D S06312S S06313A S06313D S06313SS06314A S06314D S06314S S06315A S06315D S06315S S06316A S06316D S06316SS06319A S06319D S06319S S06320A S06320D S06320S S06321A S06321D S06321SS06322A S06322D S06322S S06323A S06323D S06323S S06324A S06324D S06324SS06325A S06325D S06325S S06326A S06326D S06326S S06329A S06329D S06329SS06330A S06330D S06330S S06331A S06331D S06331S S06332A S06332D S06332SS06333A S06333D S06333S S06334A S06334D S06334S S06335A S06335D S06335SS06336A S06336D S06336S S06339A S06339D S06339S S06340A S06340D S06340SS06341A S06341D S06341S S06342A S06342D S06342S S06343A S06343D S06343SS06344A S06344D S06344S S06345A S06345D S06345S S06346A S06346D S06346SS06349A S06349D S06349S S06350A S06350S S06351A S06351D S06351S S06352AS06352D S06352S S06353A S06353D S06353S S06354A S06354D S06354S S06355AS06355D S06355S S06356A S06356D S06356S S06359A S06360A S06360D S06360SS06361A S06361D S06361S S06362A S06362D S06362S S06363A S06363D S06363SS06364A S06364D S06364S S06365A S06365D S06365S S06366A S06366D S06366SS06369A S06369D S06369S S06370A S06370D S06370S S06371A S06371D S06371SS06372A S06372D S06372S S06373A S06373D S06373S S06374A S06374D S06374SS06375A S06375D S06375S S06376A S06376D S06376S S06379A S06379D S06379SS06380A S06380D S06380S S06381A S06381D S06381S S06382A S06382D S06382SS06383A S06383D S06383S S06384A S06384D S06384S S06385A S06385D S06385SS06386A S06386D S06386S S06389A S06389D S06389S S064X0A S064X0D S064X0SS064X1A S064X1D S064X1S S064X2A S064X2D S064X2S S064X3A S064X3D S064X3SS064X4A S064X4D S064X4S S064X5A S064X5D S064X5S S064X6A S064X6D S064X6SS064X9A S064X9D S064X9S S065X0A S065X0D S065X0S S065X1A S065X1D S065X1SS065X2A S065X2D S065X2S S065X3A S065X3D S065X3S S065X4A S065X4D S065X4SS065X5A S065X5D S065X5S S065X6A S065X6D S065X6S S065X7A S065X8A S065X9AS065X9D S065X9S S066X0A S066X0D S066X0S S066X1A S066X1D S066X1S S066X2AS066X2D S066X2S S066X3A S066X3D S066X3S S066X4A S066X4D S066X4S S066X5AS066X5D S066X5S S066X6A S066X6D S066X6S S066X9A S066X9D S066X9S S06890AS06890D S06890S S06891A S06891D S06891S S06892A S06892D S06892S S06893AS06893D S06893S S06894A S06894D S06894S S06895A S06895D S06895S S06896AS06896D S06896S S06897S S06899A S06899D S06899S S069X0A S069X0D S069X0SS069X1A S069X1D S069X1S S069X2A S069X2D S069X2S S069X3A S069X3D S069X3SS069X4A S069X4D S069X4S S069X5A S069X5D S069X5S S069X6A S069X6D S069X6SS069X9A S069X9D S069X9S T5801XA T5801XD T5801XS T5802XA T5802XD T5803XA




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T5803XD T5804XA T5804XD T5804XS T5811XA T5811XD T5811XS T5812XA T5812XDT5813XA T5813XD T5814XA T5814XD T5814XS T582X1A T582X1D T582X1S T582X2AT582X2D T582X3A T582X3D T582X4A T582X4D T588X1A T588X1D T588X1S T588X2AT588X2D T588X3A T588X3D T588X3S T588X4A T588X4D T588X4S T5891XA T5891XDT5891XS T5892XA T5892XD T5893XA T5893XD T5894XA T5894XD T71111A T71111DT71111S T71112A T71112S T71113A T71113D T71113S T71114A T71114D T71114ST71121A T71121D T71121S T71122A T71122S T71123A T71123D T71123S T71124AT71124S T71131A T71131D T71131S T71132A T71133A T71133D T71133S T71134AT71134D T71134S T71141A T71141D T71141S T71143A T71143D T71143S T71144AT71144D T71144S T71151A T71151D T71151S T71152A T71152D T71152S T71153AT71153D T71153S T71154A T71154D T71154S T71161A T71162A T71163A T71164AT71191A T71192A T71193A T71194A T71194D T71194S T7120XA T7121XA T71221AT71222A T71223A T71224A T71231A T71232A T71233A T71233D T71234A T7129XAT719XXA T751XXA T751XXD T751XXS Z134 Z13850 Z13858 Z1389 Z634Z658 Z69021 Z6982 Z72810 Z72811 Z73810 Z73811 Z73812 Z73819Z818 Z8651 Z8659 Z87820 Z87890

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)F0390, F05

S0190XA, S06330A

S0190XA, S06331A

S0190XA, S06332A

S0190XA, S06334A

S0190XA, S06333A

S0190XA, S06335A

S0190XA, S06336A

S0190XA, S06339A

S0190XA, S06330A

S0190XA, S06332A

S0190XA, S06331A

S0190XA, S06334A

S0190XA, S06333A

S0190XA, S06335A

S0190XA, S06336A

S0190XA, S06339A

S0190XA, S06370A

S0190XA, S06380A

S0190XA, S06372A

S0190XA, S06382A

S0190XA, S06381A

S0190XA, S06371A

S0190XA, S06383A

S0190XA, S06384A

S0190XA, S06373A

S0190XA, S06374A

S0190XA, S06375A

S0190XA, S06385A

S0190XA, S06386A

S0190XA, S06376A

S0190XA, S06386A

S0190XA, S06376A

S0190XA, S06389A

S0190XA, S06379A

S0190XA, S06370A

S0190XA, S06380A

S0190XA, S06382A

S0190XA, S06371A

S0190XA, S06372A

S0190XA, S06381A

S0190XA, S06383A

S0190XA, S06374A

S0190XA, S06373A

S0190XA, S06384A

S0190XA, S06383A

S0190XA, S06373A

S0190XA, S06376A

S0190XA, S06386A

S0190XA, S06379A

S0190XA, S06389A

S0190XA, S06330A

S0190XA, S06331A

S0190XA, S06332A

S0190XA, S06334A

S0190XA, S06333A

S0190XA, S06335A

S0190XA, S06336A

S0190XA, S06339A

S0190XA, S066X0A

S0190XA, S066X1A

S0190XA, S066X2A

S0190XA, S066X3A

S0190XA, S066X5A

S0190XA, S066X6A

S0190XA, S066X9A

S0190XA, S065X0A

S0190XA, S065X1A

S0190XA, S065X2A

S0190XA, S065X4A

S0190XA, S065X3A

S0190XA, S065X4A

S0190XA, S065X3A

S0190XA, S065X5A

S0190XA, S065X6A

S0190XA, S065X9A

S0190XA, S064X0A

S0190XA, S064X1A

S0190XA, S064X2A

S0190XA, S064X4A

S0190XA, S064X3A

S0190XA, S064X5A

S0190XA, S064X6A

S0190XA, S064X9A




Combination Diagnosis Codes (Must be submitted in pairs)S0190XA, S06360A

S0190XA, S06361A

S0190XA, S06362A

S0190XA, S06364A

S0190XA, S06363A

S0190XA, S06365A

S0190XA, S06366A

S0190XA, S06369A

S060X0A, S06890A

S0190XD, S06330D

S0190XD, S06331D

S0190XD, S06332D

S0190XD, S06334D

S0190XD, S06333D

S0190XD, S06335D

S0190XD, S06336D

S0190XD, S06339D

S0190XD, S06330D

S0190XD, S06332D

S0190XD, S06331D

S0190XD, S06334D

S0190XD, S06333D

S0190XD, S06335D

S0190XD, S06336D

S0190XD, S06339D

S0190XD, S06370D

S0190XD, S06380D

S0190XD, S06372D

S0190XD, S06382D

S0190XD, S06381D

S0190XD, S06371D

S0190XD, S06383D

S0190XD, S06384D

S0190XD, S06373D

S0190XD, S06374D

S0190XD, S06375D

S0190XD, S06385D

S0190XD, S06386D

S0190XD, S06376D

S0190XD, S06386D

S0190XD, S06376D

S0190XD, S06389D

S0190XD, S06379D

S0190XD, S06370D

S0190XD, S06380D

S0190XD, S06382D

S0190XD, S06371D

S0190XD, S06372D

S0190XD, S06381D

S0190XD, S06383D

S0190XD, S06374D

S0190XD, S06373D

S0190XD, S06384D

S0190XD, S06383D

S0190XD, S06373D

S0190XD, S06376D

S0190XD, S06386D

S0190XD, S06379D

S0190XD, S06389D

S0190XD, S06330D

S0190XD, S06331D

S0190XD, S06332D

S0190XD, S06334D

S0190XD, S06333D

S0190XD, S06335D

S0190XD, S06336D

S0190XD, S06339D

S0190XD, S066X0D

S0190XD, S066X1D

S0190XD, S066X2D

S0190XD, S066X3D

S0190XD, S066X5D

S0190XD, S066X6D

S0190XD, S066X9D

S0190XD, S065X0D

S0190XD, S065X1D

S0190XD, S065X2D

S0190XD, S065X4D

S0190XD, S065X3D

S0190XD, S065X4D

S0190XD, S065X3D

S0190XD, S065X5D

S0190XD, S065X6D

S0190XD, S065X9D

S0190XD, S064X0D

S0190XD, S064X1D

S0190XD, S064X2D

S0190XD, S064X4D

S0190XD, S064X3D

S0190XD, S064X5D

S0190XD, S064X6D

S0190XD, S064X9D

S0190XD, S06360D

S0190XD, S06361D

S0190XD, S06362D

S0190XD, S06364D

S0190XD, S06363D

S0190XD, S06365D

S0190XD, S06366D

S0190XD, S06369D

S060X0D, S06890D

S0190XS, S06330S

S0190XS, S06331S

S0190XS, S06332S

S0190XS, S06334S

S0190XS, S06333S

S0190XS, S06335S

S0190XS, S06336S

S0190XS, S06339S

S0190XS, S06330S

S0190XS, S06332S

S0190XS, S06331S

S0190XS, S06334S

S0190XS, S06333S

S0190XS, S06335S

S0190XS, S06336S

S0190XS, S06339S

S0190XS, S06370S

S0190XS, S06380S

S0190XS, S06372S

S0190XS, S06382S

S0190XS, S06381S

S0190XS, S06371S

S0190XS, S06383S

S0190XS, S06384S

S0190XS, S06373S

S0190XS, S06374S

S0190XS, S06375S

S0190XS, S06385S

S0190XS, S06386S

S0190XS, S06376S

S0190XS, S06386S

S0190XS, S06376S

S0190XS, S06389S

S0190XS, S06379S

S0190XS, S06370S

S0190XS, S06380S

S0190XS, S06382S

S0190XS, S06371S

S0190XS, S06372S

S0190XS, S06381S

S0190XS, S06383S

S0190XS, S06374S

S0190XS, S06373S

S0190XS, S06384S

S0190XS, S06383S

S0190XS, S06373S

S0190XS, S06376S

S0190XS, S06386S

S0190XS, S06379S

S0190XS, S06389S

S0190XS, S06330S

S0190XS, S06331S

S0190XS, S06332S

S0190XS, S06334S

S0190XS, S06333S

S0190XS, S06335S

S0190XS, S06336S

S0190XS, S06339S

S0190XS, S066X0S

S0190XS, S066X1S

S0190XS, S066X2S

S0190XS, S066X3S

S0190XS, S066X5S

S0190XS, S066X6S

S0190XS, S066X9S

S0190XS, S065X0S

S0190XS, S065X1S




Combination Diagnosis Codes (Must be submitted in pairs)S0190XS, S065X2S

S0190XS, S065X4S

S0190XS, S065X3S

S0190XS, S065X4S

S0190XS, S065X3S

S0190XS, S065X5S

S0190XS, S065X6S

S0190XS, S065X9S

S0190XS, S064X0S

S0190XS, S064X1S

S0190XS, S064X2S

S0190XS, S064X4S

S0190XS, S064X3S

S0190XS, S064X5S

S0190XS, S064X6S

S0190XS, S064X9S

S0190XS, S06360S

S0190XS, S06361S

S0190XS, S06362S

S0190XS, S06364S

S0190XS, S06363S

S0190XS, S06365S

S0190XS, S06366S

S0190XS, S06369S

S060X0S, S06890S


Retrospective review may be performed for all evaluation and management (E/M) procedure codes, including those listed in the Evaluation and Management Section of the Current Procedural Terminology (CPT) Manual, when they are billed with one of the diagnosis codes listed in the above tables for procedure code 96116.


The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.25, “Developmental and Neurological Assessment and Testing;” subsection 9.2.25.1, “Assessment of Aphasia;” and subsection 9.2.25.4, “Neurobehavioral Testing” for additional information.

* Diagnostic Doppler SonographyDiagnostic Doppler sonography procedure codes must be submitted with the most appropriate ICD-10-CM diagnosis codes as indicated in this article. Extracranial arterial Doppler procedure codes 93880 and 93882 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D446 D447 D7801 D7802 D7811 D7812 D7821 D7822E3601 E3602 E3611 E3612 G450 G453 G454 G458G459 G8100 G8101 G8102 G8103 G8104 G8110 G8111G8112 G8113 G8114 G8190 G8191 G8192 G8193 G8194G9731 G9732 G9748 G9749 G9751 G9752 H3401 H3402H3403 H3411 H3412 H3413 H34211 H34212 H34213 H34231H34232 H34233 H34811 H34812 H34813 H34821 H34822 H34823H34831 H34832 H34833 H349 H3582 H5310 H53121 H53122H53123 H53131 H53132 H53133 H532 H5340 H53411 H53412H53413 H53421 H53422 H53423 H53431 H53432 H53433 H53451H53452 H53453 H53461 H53462 H5347 H53481 H53482 H53483H59111 H59112 H59113 H59119 H59121 H59122 H59123 H59129

* Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, ** Use R220 or R221 to report pulsatile neck mass, *** Use R0989 to report carotid bruit




http://www.tmhp.com/ICD10_Updates_Med/10-31-14%20ICD-10%20Medicaid%20Diagnostic%20Doppler%20Sonography.pdf

Diagnosis Codes (Submitted as stand-alone diagnosis codes)H59211 H59212 H59213 H59219 H59221 H59222 H59223 H59229H59311 H59312 H59313 H59319 H59321 H59322 H59323 H59329H9521 H9522 H9531 H9532 H9541 H9542 I610 I611I612 I613 I614 I615 I616 I618 I619 I6300I63011 I63012 I6302 I63031 I63032 I6309 I6310 I63111I63112 I6312 I63131 I63132 I6319 I6320 I6329 I63311I63312 I63321 I63322 I63331 I63332 I63411 I63412 I63421I63422 I63431 I63432 I63511 I63512 I63521 I63522 I63531I63532 I6359 I638 I6501 I6502 I6503 I651 I6521I6522 I6523 I658 I659 I6601 I6602 I6603 I6609I6611 I6612 I6613 I6619 I6621 I6622 I6623 I663I669 I671 I672 I677 I6781 I6782 I67848 I6789I679 I680 I682 I6990 I69920 I69921 I69922 I69923I69961 I69962 I69963 I69964 I69965 I69969 I69990 I69991I69992 I69993 I7100 I720 I728 I770 I771 I772I773 I776 I7789 I779 I97410 I97411 I97418 I9742I9751 I9752 I97610 I97611 I97618 I9762 J9561 J9562J9571 J9572 J95830 J95831 K9161 K9162 K9171 K9172K91840 K91841 L7601 L7602 L7611 L7612 L7621 L7622M300 M303 M310 M311 M312 M3130 M3131 M314M315 M316 M96810 M96811 M96820 M96821 M96830 M96831N9961 N9962 N9971 N9972 N99820 N99821 R0989*** R200R201 R202 R203 R208 R209 R220** R221** R260R261 R2681 R2689 R269 R270 R278 R279 R295R4701 R4702 R471 R4781 R4789 R5084 R55* R561S090XXA S090XXD S090XXS S15001A S15001D S15002A S15002D S15009AS15009D S15011A S15011D S15012A S15012D S15021A S15021D S15022AS15022D S15091A S15091D S15092A S15092D S15211A S15211D S15212AS15212D S15221A S15221D S15222A S15222D S15291A S15291D S15292AS15292D S15311A S15311D S15312A S15312D S15321A S15321D S15322AS15322D S15391A S15391D S15392A S15392D S158XXA S158XXD S159XXAS159XXD S159XXS S178XXA S178XXD S25111A S25111D S25112A S25112DS25121A S25121D S25122A S25122D S25191A S25191D S25192A S25192DT794XXA T794XXD T8030XA T8030XD T8030XS T80310A T80310D T80310ST80311A T80311D T80311S T80319A T80319D T80319S T8039XA T8039XDT8039XS T8040XA T8040XD T8040XS T80410A T80410D T80410S T80411AT80411D T80411S T80419A T80419D T80419S T8049XA T80910A T80910D





Diagnosis Codes (Submitted as stand-alone diagnosis codes)T80910S T80911A T80911D T80911S T80919A T80A0XA T80A0XD T80A0XST80A10A T80A10D T80A10S T80A11A T80A11D T80A11S T80A19A T80A19DT80A19S T80A9XA T80A9XD T80A9XS T8130XA T8130XD T8131XA T8131XDT8131XS T8132XA T8132XD T8132XS T8133XA T8133XD T8133XS T81500AT81500D T81500S T81501A T81501D T81501S T81502A T81502D T81502ST81503A T81503D T81503S T81504A T81505A T81505D T81505S T81506AT81506D T81506S T81507A T81507D T81507S T81508A T81508D T81508ST81509A T81510A T81510D T81510S T81511A T81511D T81511S T81512AT81512D T81512S T81513A T81513D T81513S T81514A T81515A T81515DT81515S T81516A T81516D T81516S T81517A T81517D T81517S T81518AT81518D T81518S T81519A T81520A T81520D T81520S T81521A T81521DT81521S T81522A T81522D T81522S T81523A T81523D T81523S T81524AT81525A T81525D T81525S T81526A T81526D T81526S T81527A T81527DT81527S T81528A T81528D T81528S T81529A T81530A T81530D T81530ST81531A T81532A T81533A T81534A T81535A T81536A T81537A T81538AT81539A T81590A T81591A T81592A T81593A T81594A T81595A T81596AT81597A T81598A T81599A T8160XA T8160XD T8160XS T8161XA T8169XAT8169XD T8169XS T8183XA T8183XD T8183XS T82390A T82390D T82390ST82391A T82391D T82391S T82392A T82392D T82392S T8249XA T8249XDT8249XS T82590A T82590D T82590S T82591A T82591D T82591S T82593AT82593D T82593S T82595A T82595D T82595S T82598A T82598D T82598ST888XXA T888XXD T888XXS Z09 Z95820 Z95828 Z978 Z983Z9862 Z9889


Transcranial Doppler procedure codes 93886, 93888, 93890, 93892, and 93893 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D7801 D7802 D7811 D7812 D7821 D7822 E3601 E3602E3611 E3612 G450 G453 G454 G458 G459 G8100G8101 G8102 G8103 G8104 G8110 G8111 G8112 G8113G8114 G8190 G8191 G8192 G8193 G8194 G8220 G8221G8222 G8250 G8251 G8252 G8253 G8254 G830 G8310G8311 G8312 G8313 G8314 G8320 G8321 G8322 G8323G8324 G8330 G8331 G8332 G8333 G8334 G839 G9381G9382 G9389* G9731 G9732 G9748 G9749 G9751 G9752H3401 H3402 H3403 H3411 H3412 H3413 H34211 H34212

* Use G9389 to identify assessment of suspected brain death, ** Use I749 to report paradoXical cerebral embolism, *** Use R55 when symptomatology indicates a strong clinical suspicion of vertebrobasilar insufficiency, **** Use R0989 to report carotid bruit




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H34213 H34231 H34232 H34233 H34811 H34812 H34813 H34821H34822 H34823 H34831 H34832 H34833 H349 H3582 H4901H4902 H4903 H4911 H4912 H4913 H4921 H4922 H4923H4931 H4932 H4933 H4941 H4942 H4943 H499 H52511H52512 H52513 H5310 H53121 H53122 H53123 H53131 H53132H53133 H532 H5340 H53411 H53412 H53413 H53421 H53422H53423 H53431 H53432 H53433 H53451 H53452 H53453 H53461H53462 H5347 H53481 H53482 H53483 H59111 H59112 H59113H59119 H59121 H59122 H59123 H59129 H59211 H59212 H59213H59219 H59221 H59222 H59223 H59229 H59311 H59312 H59313H59319 H59321 H59322 H59323 H59329 H9521 H9522 H9531H9532 H9541 H9542 I6000 I6001 I6002 I6010 I6011I6012 I6020 I6021 I6022 I6030 I6031 I6032 I604I6050 I6051 I6052 I606 I607 I608 I609 I610I611 I612 I613 I614 I615 I616 I618 I619I6300 I63011 I63012 I6302 I63031 I63032 I6309 I6310I63111 I63112 I6312 I63131 I63132 I6319 I6320 I6329I63311 I63312 I63321 I63322 I63331 I63332 I63411 I63412I63421 I63422 I63431 I63432 I63511 I63512 I63521 I63522I63531 I63532 I638 I6501 I6502 I6503 I651 I6521I6522 I6523 I658 I659 I6601 I6602 I6603 I6609I6611 I6612 I6613 I6619 I6621 I6622 I6623 I663I669 I671 I672 I675 I677 I6781 I6782 I67848I6789 I679 I680 I682 I69098 I6990 I69920 I69921I69922 I69923 I69961 I69962 I69963 I69964 I69965 I69969I69990 I69991 I69992 I69993 I7090 I7091 I720 I728I749** I770 I771 I772 I773 I776 I7789 I779I97410 I97411 I97418 I9742 I9751 I9752 I97610 I97611I97618 I9762 J9561 J9562 J9571 J9572 J95830 J95831K9161 K9162 K9171 K9172 K91840 K91841 L7601 L7602L7611 L7612 L7621 L7622 M300 M303 M310 M311M312 M3130 M3131 M314 M315 M316 M96810 M96811M96820 M96821 M96830 M96831 N9961 N9962 N9971 N9972N99820 N99821 Q282 Q283 R0989**** R200 R201 R202R203 R208 R209 R260 R261 R2681 R2689 R269R270 R278 R279 R295 R42 R4701 R471 R5084R55*** R561 R683 S090XXA S090XXD S090XXS S15001A S15001D





Diagnosis Codes (Submitted as stand-alone diagnosis codes)S15002A S15002D S15009A S15009D S15011A S15011D S15012A S15012DS15021A S15021D S15022A S15022D S15091A S15091D S15092A S15092DS15211A S15211D S15212A S15212D S15221A S15221D S15222A S15222DS15291A S15291D S15292A S15292D S15311A S15311D S15312A S15312DS15321A S15321D S15322A S15322D S15391A S15391D S15392A S15392DS158XXA S158XXD S159XXA S159XXD S159XXS S178XXA S178XXD S25111AS25111D S25112A S25112D S25121A S25121D S25122A S25122D S25191AS25191D S25192A S25192D T794XXA T794XXD T8030XA T8030XD T8030XST80310A T80310D T80310S T80311A T80311D T80311S T80319A T80319DT80319S T8039XA T8039XD T8039XS T8040XA T8040XD T8040XS T80410AT80410D T80410S T80411A T80411D T80411S T80419A T80419D T80419ST8049XA T80910A T80910D T80910S T80911A T80911D T80911S T80919AT80A0XA T80A0XD T80A0XS T80A10A T80A10D T80A10S T80A11A T80A11DT80A11S T80A19A T80A19D T80A19S T80A9XA T80A9XD T80A9XS T8130XAT8130XD T8131XA T8131XD T8131XS T8132XA T8132XD T8132XS T8133XAT8133XD T8133XS T81500A T81500D T81500S T81501A T81501D T81501ST81502A T81502D T81502S T81503A T81503D T81503S T81504A T81505AT81505D T81505S T81506A T81506D T81506S T81507A T81507D T81507ST81508A T81508D T81508S T81509A T81510A T81510D T81510S T81511AT81511D T81511S T81512A T81512D T81512S T81513A T81513D T81513ST81514A T81515A T81515D T81515S T81516A T81516D T81516S T81517AT81517D T81517S T81518A T81518D T81518S T81519A T81520A T81520DT81520S T81521A T81521D T81521S T81522A T81522D T81522S T81523AT81523D T81523S T81524A T81525A T81525D T81525S T81526A T81526DT81526S T81527A T81527D T81527S T81528A T81528D T81528S T81529AT81530A T81530D T81530S T81531A T81532A T81533A T81534A T81535AT81536A T81537A T81538A T81539A T81590A T81591A T81592A T81593AT81594A T81595A T81596A T81597A T81598A T81599A T8160XA T8160XDT8160XS T8161XA T8169XA T8169XD T8169XS T8183XA T8183XD T8183XST82390A T82390D T82390S T82391A T82391D T82391S T82392A T82392DT82392S T8249XA T8249XD T8249XS T82590A T82590D T82590S T82591AT82591D T82591S T82593A T82593D T82593S T82595A T82595D T82595ST82598A T82598D T82598S T888XXA T888XXD T888XXS Z09 Z95820Z95828 Z9862





In addition to the diagnosis codes in the above table, procedure codes 93886 and 93888 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D5700 D5702 D571 D5720 D57212 D57219 D5780 D57812 D57819

Peripheral arterial Doppler procedure codes 93922, 93923, 93924, 93925, 93926, 93930, and 93931 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Peripheral Arterial Doppler Section 1: Eligible Diagnosis Codes for All Peripheral Arterial Doppler Study Procedure Codes

Procedure CodesD7801 D7802 D7811 D7812 D7821 D7822 E1051 E1052E1059 E1151 E1159 E1351 E1359 E3601 E3602 E3611E3612 G540 G9731 G9732 G9748 G9749 G9751 G9752H59111 H59112 H59113 H59119 H59121 H59122 H59123 H59129H59211 H59212 H59213 H59219 H59221 H59222 H59223 H59229H59311 H59312 H59313 H59319 H59321 H59322 H59323 H59329H9521 H9522 H9531 H9532 H9541 H9542 I200 I201I208 I209 I2101 I2102 I2109 I2111 I2119 I2129I214 I240 I241 I248 I249 I2510 I25110 I25111I25118 I25119 I252 I253 I2541 I2542 I25700 I25701I25708 I25709 I25710 I25711 I25718 I25719 I25730 I25731I25738 I25739 I25750 I25751 I25758 I25759 I25760 I25761I25768 I25769 I25790 I25791 I25798 I25799 I25810 I25811I25812 I2589 I2602 I2692 I700 I70201 I70202 I70203I70211 I70212 I70213 I70221 I70222 I70223 I70231 I70232I70233 I70234 I70238 I70241 I70242 I70243 I70244 I70248I70261 I70262 I70263 I70301 I70302 I70303 I70308 I70309I70311 I70312 I70313 I70318 I70319 I70321 I70322 I70323I70328 I70329 I7035 I70368 I70369 I70391 I70392 I70393I70411 I70412 I70413 I70421 I70422 I70423 I70501 I70502I70503 I70508 I70509 I70511 I70512 I70513 I70518 I70519I70521 I70522 I70523 I70528 I70529 I70538 I70539 I70548I70549 I70561 I70562 I70563 I70568 I70569 I70591 I70592I70593 I70598 I70599 I70601 I70602 I70603 I70608 I70609I70611 I70612 I70613 I70618 I70619 I70621 I70622 I70623I70628 I70629 I70639 I70649 I7065 I70668 I70669 I70691I70692 I70693 I70698 I70699 I70701 I70702 I70703 I70708I70709 I70711 I70712 I70713 I70718 I70719 I70721 I70722I70723 I70728 I70729 I70738 I70739 I70748 I70749 I7075




Procedure CodesI70761 I70762 I70763 I70768 I70769 I70791 I70792 I70793I70798 I70799 I7092 I7100 I7101 I7102 I7103 I711I712 I713 I714 I715 I716 I718 I723 I728I7300 I731 I7381 I7389 I739 I7401 I7409 I7411I745 I748 I749 I7581 I7589 I76 I770 I771I772 I773 I775 I776 I7771 I7772 I7773 I7774I7779 I7789 I779 I798 I96 I97410 I97411 I97418I9742 I9751 I9752 I97610 I97611 I97618 I9762 J9561J9562 J9571 J9572 J95830 J95831 K9161 K9162 K9171K9172 K91840 K91841 L7601 L7602 L7611 L7612 L7621L7622 L98411 L98412 L98413 L98414 L98419 L98421 L98422L98423 L98424 L98429 L98491 L98492 L98493 L98494 L98499M25551 M25552 M314 M315 M316 M340 M341 M342M3489 M349 M79601 M79602 M79604 M79605 M79621 M79622M79631 M79632 M79641 M79642 M79651 M79652 M79661 M79662M79671 M79672 M96810 M96811 M96820 M96821 M96830 M96831N183 N184 N185 N186 N9961 N9962 N9971 N9972N99820 N99821 Q279 R1900 R1901 R1902 R1903 R1904R1905 R1906 R1907 R5084 R561 S2590XA S2590XD S358X9AS358X9D S45091A S45091D S45092A S45092D S45111A S45111D S45112AS45112D S45191A S45191D S45192A S45192D S45211A S45211D S45212AS45212D S45291A S45291D S45292A S45292D S45811A S45811D S45812AS45812D S45891A S45891D S45891S S45892A S45892D S45892S S55011AS55011D S55012A S55012D S55091A S55092A S55111A S55111D S55112AS55112D S55191A S55192A S65011A S65011D S65012A S65012D S65091AS65092A S65111A S65112A S65191A S65192A S65211D S65212D S65291AS65292A S65311A S65311D S65312A S65312D S65391A S65392A S65411AS65412A S65419A S65491A S65491D S65492A S65492D S65499D S65499SS65510A S65511A S65512A S65513A S65514A S65515A S65516A S65517AS65518A S65590A S65591A S65592A S65593A S65594A S65595A S65596AS65597A S65598A S65598D S65599D S75011A S75011D S75012A S75012DS75021A S75021D S75022A S75022D S75091A S75091D S75092A S75092DS75111A S75111D S75112A S75112D S75121A S75121D S75122A S75122DS75191A S75191D S75192A S75192D S75211A S75211D S75212A S75212DS75221A S75221D S75222A S75222D S75291A S75291D S75292A S75292DS85001A S85001D S85002A S85002D S85011A S85011D S85012A S85012DS85091A S85091D S85092A S85092D S85101A S85101D S85102A S85102DS85109A S85131A S85131D S85132A S85132D S85141A S85141D S85142A




Procedure CodesS85142D S85151A S85151D S85152A S85152D S85171A S85171D S85172AS85172D S85181A S85181D S85182A S85182D S85311A S85311D S85312AS85391A S85392A S85411A S85412A S85491A S85492A S85501A S85501DS85502A S85502D S85511A S85511D S85512A S85512D S85591A S85591DS85592A S85592D S85811A S85811D S85812A S85812D S85891A S85891DS85892A S85892D S95111A S95111D S95112A S95112D S95191A S95191DS95192A S95192D T8030XA T8030XD T8030XS T80310A T80310D T80310ST80311A T80311D T80311S T80319A T80319D T80319S T8039XA T8039XDT8039XS T8040XA T8040XD T8040XS T80410A T80410D T80410S T80411AT80411D T80411S T80419A T80419D T80419S T8049XA T80910A T80910DT80910S T80911A T80911D T80911S T80919A T80A0XA T80A0XD T80A0XST80A10A T80A10D T80A10S T80A11A T80A11D T80A11S T80A19A T80A19DT80A19S T80A9XA T80A9XD T80A9XS T8131XA T8131XD T8131XS T8132XAT8132XD T8132XS T81718A T81718D T81718S T81719A T81719D T81719ST8172XA T8172XD T8172XS T82390A T82390D T82390S T82391A T82391DT82391S T82392D T82392S T8249XA T8249XD T8249XS T82590A T82590DT82590S T82591A T82591D T82591S T82593A T82593D T82593S T82595AT82595D T82595S T82598A T82598D T82598S T827XXA T827XXD T827XXST82817A T82817D T82817S T82818A T82818D T82818S T82827A T82827DT82827S T82828A T82828D T82828S T82837A T82837D T82837S T82838AT82838D T82838S T82847A T82847D T82847S T82848A T82848D T82848ST82857A T82857D T82857S T82858A T82858D T82858S T82867A T82867DT82867S T82868A T82868D T82868S T82897A T82897D T82897S T82898AT82898D T82898S T829XXA T829XXD T829XXS T8381XA T8381XD T8381XST8382XA T8382XD T8382XS T8383XA T8383XD T8383XS T8384XA T8384XDT8384XS T8385XA T8385XD T8385XS T8386XA T8386XD T8386XS T8389XAT8389XD T8389XS T839XXA T839XXD T839XXS T8481XA T8481XD T8481XST8482XA T8482XD T8482XS T8483XA T8483XD T8483XS T8484XA T8484XDT8484XS T8485XA T8485XD T8485XS T8486XA T8486XD T8486XS T8489XAT8489XD T8489XS T849XXA T849XXD T849XXS T8581XA T8581XD T8581XST8582XA T8582XD T8582XS T8583XA T8583XD T8583XS T8584XA T8584XDT8584XS T8585XA T8585XD T8585XS T8586XA T8586XD T8586XS T8589XAT8589XD T8589XS T859XXA T859XXD T859XXS T8600 T8601 T8602T8603 T8609 T8610 T8611 T8612 T8613 T8619 T8620T8621 T8622 T8623 T86290 T86298 T8640 T8641 T8642T8643 T8649 T86810 T86811 T86812 T86818 T86819 T86850T86851 T86852 T86858 T86859 T86890 T86891 T86892 T86898T86899 T8690 T8691 T8692 T8693 T8699 T871X1 T871X2




Procedure CodesT888XXA Z01810 Z01818 Z09 Z4803 Z48812 Z86711 Z951Z955 Z95820 Z95828 Z9861 Z9862Combination Diagnosis Codes (Must be submitted together)E1151, E1165

Procedure codes 93886 and 93888 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Section 2 includes additional diagnosis codes for upper extremity conditions.Diagnosis Codes (Submitted as stand-alone diagnosis codes)

I742 I75011 I75012 I75013 M79A11 M79A12 Q2731 S45311AS45311D S45311S S45312A S45312D S45312S S45391A S45391D S45391SS45392A S45392D S45392S S45811A S45811D S45811S S45812A S45812DS45812S S45891A S45891D S45891S S45892A S45892D S45892S S45899AS45899D S45899S S45911A S45911D S45911S S45912A S45912D S45912SS45991A S45991D S45991S S45992A S45992D S45992S S55211A S55211DS55211S S55212A S55212D S55212S S55291A S55291D S55291S S55292AS55292D S55292S S55811A S55811D S55811S S55812A S55812D S55812SS55891A S55891D S55891S S55892A S55892D S55892S S55911A S55911DS55911S S55912A S55912D S55912S S55991A S55991D S55991S S55992AS55992D S55992S S65811A S65811D S65811S S65812A S65812D S65812SS65891A S65891D S65891S S65892A S65892D S65892S S65911A S65911DS65911S S65912A S65912D S65912S S65991A S65991D S65991S S65992AS65992D S65992S T870X1 T870X2 T870X9

Procedure codes 93886 and 93888 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Section 3 includes additional diagnosis codes for lower extremity conditions.Diagnosis Codes (Submitted as stand-alone diagnosis codes)L89500 L89501 L89502 L89503 L89504 L89509 L89510 L89511L89512 L89513 L89514 L89519 L89520 L89521 L89522 L89523L89524 L89529 L97111 L97112 L97113 L97114 L97119 L97121L97122 L97123 L97124 L97129 L97211 L97212 L97213 L97214L97219 L97221 L97222 L97223 L97224 L97229 L97311 L97312L97313 L97314 L97319 L97321 L97322 L97323 L97324 L97329L97401 L97411 L97412 L97413 L97414 L97419 L97421 L97422L97423 L97424 L97429 L97511 L97512 L97513 L97514 L97519L97521 L97522 L97523 L97524 L97529 L97911 L97912 L97913L97914 L97919 L97921 L97922 L97923 L97924 L97929 M79A21M79A22 Q2732 S75811A S75811D S75811S S75812A S75812D S75812SS75819A S75819D S75819S S75891A S75891D S75891S S75892A S75892D




Diagnosis Codes (Submitted as stand-alone diagnosis codes)S75892S S75911A S75911D S75911S S75912A S75912D S75912S S75991AS75991D S75991S S75992A S75992D S75992S S85811A S85811D S85811SS85812A S85812D S85812S S85891A S85891D S85891S S85892A S85892DS85892S S85911A S85911D S85911S S85912A S85912D S85912S S85991AS85991D S85991S S85992A S85992D S85992S S95811A S95811D S95811SS95812A S95812D S95812S S95891A S95891D S95891S S95892A S95892DS95892S S95911A S95911D S95911S S95912A S95912D S95912S S95991AS95991D S95991S S95992A S95992D S95992S

Peripheral venous Doppler procedure codes 93965, 93970, and 93971 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D7811 D7812 E3611 E3612 G9748 G9749 H59211 H59212H59213 H59219 H59221 H59222 H59223 H59229 H9531 H9532I2602 I2690 I2692 I2699 I2782 I7401 I7409 I749I8001 I8002 I8003 I8011 I8012 I8013 I80211 I80212I80213 I80221 I80222 I80223 I80231 I80232 I80233 I80291I80292 I80293 I803 I808 I809 I82220 I82221 I82290I82291 I82401 I82402 I82403 I82411 I82412 I82413 I82421I82422 I82423 I82431 I82432 I82433 I824Y1 I824Y2 I824Y3I824Z1 I824Z2 I824Z3 I82501 I82502 I82503 I82511 I82512I82513 I82521 I82522 I82523 I82531 I82532 I82533 I82541I82542 I82543 I825Y1 I825Y2 I825Y3 I825Z1 I825Z2 I825Z3I82601 I82602 I82603 I82611 I82612 I82613 I82621 I82622I82623 I82701 I82702 I82703 I82711 I82712 I82713 I82721I82722 I82723 I82811 I82812 I82813 I82890 I82891 I82A11I82A12 I82A13 I82A21 I82A22 I82A23 I82B11 I82B12 I82B13I82B21 I82B22 I82B23 I82C11 I82C12 I82C13 I82C21 I82C22I82C23 I83011 I83012 I83013 I83014 I83015 I83018 I83019I83021 I83022 I83023 I83024 I83025 I83028 I83029 I8311I8312 I83204 I83211 I83212 I83213 I83214 I83215 I83218I83219 I83221 I83222 I83223 I83224 I83225 I83228 I83229I83811 I83812 I83813 I83891 I83892 I83893 I8390 I87001I87002 I87003 I87011 I87012 I87013 I87021 I87022 I87023I87031 I87032 I87033 I87091 I87092 I87093 I871 I87301I87302 I87303 I87311 I87312 I87313 I87321 I87322 I87323I87331 I87332 I87333 I87391 I87392 I87393 I9751 I9752J9571 J9572 K9171 K9172 L7611 L7612 L89500 L89501L89502 L89503 L89504 L89509 L89510 L89511 L89512 L89513L89514 L89519 L89520 L89521 L89522 L89523 L89524 L89529




Diagnosis Codes (Submitted as stand-alone diagnosis codes)L97111 L97112 L97113 L97114 L97119 L97121 L97122 L97123L97124 L97129 L97211 L97212 L97213 L97214 L97219 L97221L97222 L97223 L97224 L97229 L97311 L97312 L97313 L97314L97319 L97321 L97322 L97323 L97324 L97329 L97401 L97411L97412 L97413 L97414 L97419 L97421 L97422 L97423 L97424L97429 L97511 L97512 L97513 L97514 L97519 L97521 L97522L97523 L97524 L97529 L97911 L97912 L97913 L97914 L97919L97921 L97922 L97923 L97924 L97929 M7121 M7122 M79601M79602 M79604 M79605 M79621 M79622 M79631 M79632 M79641M79642 M79651 M79652 M79661 M79662 M79671 M79672 M79A11M79A12 M79A21 M79A22 M96820 M96821 N9971 N9972 O2220O2221 O2222 O2223 O2230 O2231 O2232 O2233 O2290O2291 O2292 O2293 O870 O871 O879 O88211 O88212O88213 O88219 O8822 O8823 Q2731 Q2732 Q278 Q279R220 R221 R222 R2231 R2232 R2233 R2241 R2242R2243 R5084 R561 R600 R601 R609 S2590XA S2590XDS358X9A S358X9D S45091A S45091D S45092A S45092D S45111A S45111DS45112A S45112D S45191A S45191D S45192A S45192D S45211A S45211DS45212A S45212D S45291A S45291D S45292A S45292D S45311A S45312AS45391A S45392A S45811A S45811D S45812A S45812D S45891A S45891DS45891S S45892A S45892D S45892S S45899A S45911A S45912A S45991AS45992A S55011A S55011D S55012A S55012D S55091A S55092A S55111AS55111D S55112A S55112D S55191A S55192A S55211A S55212A S55291AS55292A S55811A S55812A S55891A S55892A S55911A S55912A S55991AS55992A S65011A S65011D S65012A S65012D S65091A S65092A S65111AS65112A S65191A S65192A S65211D S65212D S65291A S65292A S65311AS65311D S65312A S65312D S65391A S65392A S65411A S65412A S65419AS65491A S65491D S65492A S65492D S65499D S65499S S65510A S65511AS65512A S65513A S65514A S65515A S65516A S65517A S65518A S65590AS65591A S65592A S65593A S65594A S65595A S65596A S65597A S65598AS65598D S65599D S65811A S65811D S65812A S65812D S65891A S65892AS65911A S65911D S65912A S65991A S65992A S75011A S75011D S75012AS75012D S75021A S75021D S75022A S75022D S75091A S75091D S75092AS75092D S75111A S75111D S75112A S75112D S75121A S75121D S75122AS75122D S75191A S75191D S75192A S75192D S75211A S75211D S75212AS75212D S75221A S75221D S75222A S75222D S75291A S75291D S75292AS75292D S75811A S75812A S75819A S75891A S75892A S75911A S75912AS75991A S75992A S85001A S85001D S85002A S85002D S85011A S85011DS85012A S85012D S85091A S85091D S85092A S85092D S85101A S85101D




Diagnosis Codes (Submitted as stand-alone diagnosis codes)S85102A S85102D S85109A S85131A S85131D S85132A S85132D S85141AS85141D S85142A S85142D S85151A S85151D S85152A S85152D S85171AS85171D S85172A S85172D S85181A S85181D S85182A S85182D S85311AS85311D S85312A S85391A S85392A S85411A S85412A S85491A S85492AS85501A S85501D S85502A S85502D S85511A S85511D S85512A S85512DS85591A S85591D S85592A S85592D S85811A S85811D S85812A S85812DS85891A S85891D S85892A S85892D S85911A S85912A S85991A S85992AS95111A S95111D S95112A S95112D S95191A S95191D S95192A S95192DS95811A S95811D S95812A S95812D S95891A S95891D S95892A S95892DS95911A S95912A S95991A S95992A T801XXA T801XXD T801XXS T8030XAT8030XD T8030XS T80310A T80310D T80310S T80311A T80311D T80311ST80319A T80319D T80319S T8039XA T8039XD T8039XS T8040XA T8040XDT8040XS T80410A T80410D T80410S T80411A T80411D T80411S T80419AT80419D T80419S T8049XA T80910A T80910D T80910S T80911A T80911DT80911S T80919A T80A0XA T80A0XD T80A0XS T80A10A T80A10D T80A10ST80A11A T80A11D T80A11S T80A19A T80A19D T80A19S T80A9XA T80A9XDT80A9XS T81718A T81718D T81718S T81719A T81719D T81719S T8172XAT8172XD T8172XS T82390A T82391A T82392A T8249XA T82590A T82591AT82593A T82595A T82598A T82818A T82818D T82828A T82828D T82838AT82838D T82848A T82848D T82858A T82858D T82868A T82868D T82898AT888XXA Z01818 Z86711 Z940 Z951Combination Diagnosis Codes (Must be submitted in pairs)T8172XA I2690

T800XXA I2690

T81718A I2690

T82817A I2690

T82818A I2690


Refer to: The section titled Combination Diagnosis Codes on page 3 of this bulletin for additional informa-tion about submitting claims with combination diagnosis codes.

The Texas Medicaid Provider Procedures Manual, Radiology and Laboratory Services Handbook, subsection 3.2.7.3 “Diagnostic Doppler Sonography” for additional information.

Dimethyl Sulfoxide (DMSO)Procedure code J1212 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)N3010 N3011

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39, “Medications - Injectable,” for additional information.




Doctor of Dentistry Services as a Limited PhysicianImmune globulin injection procedure code J1571 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D611 D612 D613 D619 D804 D805 D838 D8982 D8989 G7000N19 Z205 Z206 Z20828

Patient evaluation and management services and consultation procedure codes may be reimbursed when they are submitted with the most appropriate ICD-10-CM diagnosis codes.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.3.2.2, “Evaluation and Management Procedure Codes;” and subsection 9.3.2.4, “Immune Globulin by a Doctor of Dentistry as a Limited Physician,” for additional information.

Evoked Response TestsElectromyography (EMG) and nerve conduction studies (NCS) procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C701 C720 C721 E0842 E0942 E1041 E1042 E10610E1141 E1142 E1144 E11610 E1342 E5111 E5112 E512E518 E519 E560 E568 E786 E851 E852 E853E858 E859 G120 G121 G1221 G1222 G1229 G128G129 G130 G243 G2589 G26 G320 G360 G370G375 G501 G510 G511 G512 G513 G514 G518G519 G522 G523 G527 G528 G540 G541 G542G543 G544 G545 G548 G549 G5601 G5602 G5611G5612 G5621 G5622 G5631 G5632 G5641 G5642 G5681G5682 G5691 G5692 G5701 G5702 G5711 G5712 G5721G5722 G5731 G5732 G5741 G5742 G5751 G5752 G5761G5762 G5771 G5772 G5781 G5782 G5791 G5792 G587G588 G589 G59 G600 G601 G602 G603 G608G609 G610 G6181 G6189 G619 G620 G621 G622G6281 G6282 G629 G63 G650 G651 G652 G7000G7001 G701 G702 G7081 G7089 G709 G710 G7111G7112 G7113 G7114 G7119 G712 G713 G718 G719G721 G722 G723 G7241 G7249 G7281 G7289 G729G731 G733 G737 G800 G801 G802 G803 G804G808 G809 G8311 G8312 G8313 G8314 G8321 G8322G8323 G8324 G834 G8381 G8382 G8383 G8384 G8389G839 G9009 G902 G904 G9050 G90511 G90512 G90513G90519 G90521 G90522 G90523 G90529 G9059 G909 G950G9511 G9519 G9520 G9529 G9581 G9589 G959 G990G992 I776 I951 J3800 J3801 J3802 K5902 K5909K592 K594 K624 K6289 M05411 M05412 M05421 M05422M05431 M05432 M05441 M05442 M05451 M05452 M05461 M05462




Diagnosis Codes (Submitted as stand-alone diagnosis codes)M05471 M05472 M0549 M05511 M05512 M05521 M05522 M05531M05532 M05541 M05542 M05551 M05552 M05561 M05562 M05571M05572 M0559 M05711 M05712 M05721 M05722 M05731 M05732M05741 M05742 M05751 M05752 M05761 M05762 M05769 M05771M05772 M05779 M0579 M05811 M05812 M05821 M05822 M05831M05832 M05841 M05842 M05851 M05852 M05861 M05862 M05871M05872 M0589 M06011 M06012 M06021 M06022 M06031 M06032M06041 M06042 M06051 M06052 M06061 M06062 M06071 M06072M0608 M0609 M06811 M06812 M06821 M06822 M06831 M06832M06841 M06842 M06852 M06861 M06862 M06871 M06872 M0688M0689 M069 M21271 M21272 M21331 M21332 M21511 M21512M216X1 M216X2 M21831 M21832 M21931 M21932 M320 M3210M3211 M3212 M3213 M3214 M3215 M3219 M328 M329M3300 M3301 M3302 M3309 M3310 M3311 M3312 M3319M3320 M3321 M3322 M3329 M3390 M3391 M3392 M3399M340 M341 M342 M3481 M3482 M3483 M3489 M358M360 M4321 M4322 M4323 M4324 M4325 M4326 M4327M4328 M436 M438X9 M4644 M4645 M4646 M4647 M4711M4712 M4713 M4714 M4715 M4716 M4717 M4718 M4721M4722 M4723 M4724 M4725 M4726 M4727 M4728 M47811M47812 M47813 M47814 M47815 M47816 M47817 M47818 M47891M47892 M47893 M47894 M47895 M47896 M47897 M47898 M4801M4802 M4803 M4804 M4805 M4806 M4807 M4808 M5000M5001 M5002 M5003 M5011 M5012 M5013 M5020 M5021M5022 M5023 M5030 M5031 M5032 M5033 M5080 M5081M5082 M5083 M5091 M5092 M5093 M5104 M5105 M5106M5107 M5124 M5125 M5126 M5127 M5134 M5135 M5136M5137 M5184 M5185 M5186 M5187 M5410 M5411 M5412M5413 M5414 M5415 M5416 M5417 M5431 M5432 M545M546 M5489 M60011 M60012 M60021 M60022 M60031 M60032M60041 M60042 M60044 M60045 M60046 M60051 M60052 M60061M60062 M60070 M60071 M60073 M60074 M60076 M60077 M6008M6009 M60111 M60112 M60121 M60122 M60131 M60132 M60141M60142 M60151 M60152 M60161 M60162 M60171 M60172 M6018M6019 M609 M6250 M62511 M62512 M62519 M62521 M62522M62529 M62531 M62532 M62539 M62541 M62542 M62549 M62551M62552 M62559 M62561 M62562 M62569 M62571 M62572 M62579M6258 M6259 M6281 M629 M791 M792 M79601 M79602M79604 M79605 M79621 M79622 M79631 M79632 M79641 M79642M79651 M79652 M79661 M79662 M79671 M79672 M797 M961N393 N3941 N3942 N3943 N3944 N3945 N3946 N39490N39498 N94819 R150 R151 R152 R159 R200 R201R202 R203 R208 R209 R260 R261 R2681 R2689R269 R290 R295 R32 R3914 R4702 R471 R4781




Diagnosis Codes (Submitted as stand-alone diagnosis codes)R4789 R498 R6884 S14101A S14101D S14101S S14102A S14102DS14102S S14103A S14103D S14103S S14104A S14104D S14104S S14105AS14105D S14105S S14106A S14106D S14106S S14107A S14107D S14107SS14108A S14108D S14108S S14109A S14109D S14109S S14111A S14111DS14111S S14112A S14112D S14112S S14113A S14113D S14113S S14114AS14114D S14114S S14115A S14115D S14115S S14116A S14116D S14116SS14117A S14117D S14117S S14118A S14118D S14118S S14121A S14121DS14121S S14122A S14122D S14122S S14123A S14123D S14123S S14124AS14124D S14124S S14125A S14125D S14125S S14126A S14126D S14126SS14127A S14127D S14127S S14128A S14128D S14128S S14131A S14131DS14131S S14132A S14132D S14132S S14133A S14133D S14133S S14134AS14134D S14134S S14135A S14135D S14135S S14136A S14136D S14136SS14137A S14137D S14137S S14138A S14138D S14138S S14141A S14141DS14141S S14142A S14142D S14142S S14143A S14143D S14143S S14144AS14144D S14144S S14145A S14145D S14145S S14146A S14146D S14146SS14147A S14147D S14147S S14148A S14148D S14148S S14151A S14151DS14151S S14152A S14152D S14152S S14153A S14153D S14153S S14154AS14154D S14154S S14155A S14155D S14155S S14156A S14156D S14156SS14157A S14157D S14157S S14158A S14158D S14158S S142XXA S142XXDS142XXS S143XXA S143XXD S143XXS S144XXA S144XXD S144XXS S145XXAS145XXD S145XXS S148XXA S148XXD S148XXS S149XXA S149XXD S149XXSS24101A S24101D S24101S S24102A S24102D S24102S S24103A S24103DS24103S S24104A S24104D S24104S S24109A S24109D S24109S S24111AS24111D S24111S S24112A S24112D S24112S S24113A S24113D S24113SS24114A S24114D S24114S S24131A S24131D S24131S S24132A S24132DS24132S S24133A S24133D S24133S S24134A S24134D S24134S S24141AS24141D S24141S S24142A S24142D S24142S S24143A S24143D S24143SS24144A S24144D S24144S S24151A S24151D S24151S S24152A S24152DS24152S S24153A S24153D S24153S S24154A S24154D S24154S S242XXAS242XXD S242XXS S243XXA S243XXD S243XXS S244XXA S244XXD S244XXSS248XXA S248XXD S248XXS S249XXA S34109A S34109D S34111A S34111DS34111S S34112A S34112D S34112S S34113A S34113D S34113S S34114AS34114D S34114S S34115A S34115D S34115S S34121A S34121D S34121SS34122A S34122D S34122S S34123A S34123D S34123S S34124A S34124DS34124S S34125A S34125D S34125S S34131A S34131D S34131S S34132AS34132D S34132S S34139A S34139D S34139S S3421XA S3421XD S3421XSS3422XA S3422XD S3422XS S343XXA S343XXD S343XXS S344XXA S344XXDS344XXS S345XXA S345XXD S345XXS S4400XA S4400XD S4400XS S4401XAS4401XD S4401XS S4402XA S4402XD S4402XS S4410XA S4410XD S4410XSS4411XA S4411XD S4411XS S4412XA S4412XD S4412XS S4420XA S4420XDS4420XS S4421XA S4421XD S4421XS S4422XA S4422XD S4422XS S4430XAS4430XD S4430XS S4431XA S4431XD S4431XS S4432XA S4432XD S4432XSS4440XA S4440XD S4440XS S4441XA S4441XD S4441XS S4442XA S4442XDS4442XS S4450XA S4450XD S4450XS S4451XA S4451XD S4451XS S4452XA




Diagnosis Codes (Submitted as stand-alone diagnosis codes)S4452XD S4452XS S448X1A S448X1D S448X1S S448X2A S448X2D S448X2SS448X9A S448X9D S448X9S S4491XA S4491XD S4491XS S4492XA S4492XDS4492XS S5400XA S5400XD S5400XS S5401XA S5401XD S5401XS S5402XAS5402XD S5402XS S5410XA S5410XD S5410XS S5411XA S5411XD S5411XSS5412XA S5412XD S5412XS S5420XA S5420XD S5420XS S5421XA S5421XDS5421XS S5422XA S5422XD S5422XS S5430XA S5430XD S5430XS S5431XAS5431XD S5431XS S5432XA S5432XD S5432XS S5490XA S5490XD S5490XSS5491XA S5491XD S5491XS S5492XA S5492XD S5492XS S6400XA S6400XDS6400XS S6401XA S6401XD S6401XS S6402XA S6402XD S6402XS S6410XAS6410XD S6410XS S6411XA S6411XD S6411XS S6412XA S6412XD S6412XSS6420XA S6420XD S6420XS S6421XA S6421XD S6421XS S6422XA S6422XDS6422XS S6430XA S6430XD S6430XS S6431XA S6431XD S6431XS S6432XAS6432XD S6432XS S64490A S64490D S64490S S64491A S64491D S64491SS64492A S64492D S64492S S64493A S64493D S64493S S64494A S64494DS64494S S64495A S64495D S64495S S64496A S64496D S64496S S64497AS64497D S64497S S64498A S64498D S64498S S648X1A S648X1D S648X1SS648X2A S648X2D S648X2S S648X9A S648X9D S648X9S S6490XA S6490XDS6490XS S6491XA S6491XD S6491XS S6492XA S7401XA S7401XD S7401XSS7402XA S7402XD S7402XS S7411XA S7411XD S7411XS S7412XA S7412XDS7412XS S7421XA S7421XD S7421XS S7422XA S7422XD S7422XS S748X1AS748X1D S748X1S S748X2A S748X2D S748X2S S7491XA S7491XD S7491XSS7492XA S7492XD S7492XS S8401XA S8401XD S8401XS S8402XA S8402XDS8402XS S8411XA S8411XD S8411XS S8412XA S8412XD S8412XS S8421XAS8421XD S8421XS S8422XA S8422XD S8422XS S84801A S84801D S84801SS84802A S84802D S84802S S8491XA S8491XD S8491XS S8492XA S8492XDS8492XS S9421XA S9421XD S9421XS S9422XA S9422XD S9422XS S9431XAS9431XD S9431XS S9432XA S9432XD S9432XS S948X1A S948X1D S948X1SS948X2A S948X2D S948X2S S948X9D S948X9S S9490XD S9491XA S9491XSS9492XA S9492XD S9492XS

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.28.2, “Electromyography and Nerve Conduction Studies,” for additional information.

Genetic Testing for Colorectal CancerICD-10-CM diagnosis code Z800 will only be allowed on the claim when it is submitted with the following procedure codes:

Procedure Codes81201 81202 81203 81210 81275 81292 81293 81294 81295 8129681297 81298 81299 81300 81301 81317 81318 81319

Refer to: The Texas Medicaid Provider Procedures Manual, Medical and Nursing Specialists, Physicians, and Physicians Assistants Handbook, subsection 9.2.15.3, “Genetic Testing for Colorectal Cancer,” for more information.




Family Planning Diagnosis Codes Family planning annual examinations may be reimbursed when the applicable evaluation and management (E/M) procedure code is submitted with one of the following family planning ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z30011 Z30013 Z30014 Z30018 Z3002 Z3009 Z302 Z3040 Z3041 Z3042Z30430 Z30431 Z30432 Z30433 Z3049 Z308 Z309 Z9851 Z9852

Refer to: The Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health and Family Planning Services Handbook, subsection 5.6, “Diagnostic Hysteroscopy;” subsection 3.3.8.6, “TWHP Services After Sterilization;” subsection 5.12, “Surgery for Masculinized Females;” and subsection 2.2,

“Services, Benefits, Limitations, and Prior Authorization,” for additional information.

Gynecological and Reproductive Health ServicesEffective for dates of service on or after October 1, 2015, diagnostic hysteroscopy procedure code 58555 is restricted to the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D250 N840 N8500 N856 N897 N920 N921 N923 N924 N925N930 N938 N950 Q5110 Q5111 Q512 Q51818

Hysterosalpingography procedure code 74740 may be reimbursed when billed with diagnosis code Z302.

Surgical correction of abnormalities of the external genitalia for masculinized females (procedure codes 56805 and 57335) may be reimbursed for clients who are 20 years of age and younger when one of the following ICD-10-CM diagnosis codes is submitted on the claim:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)E250 E258 E259 E271 E272 E2740 E2749 E3450 E3451 E3452 Q560Q561 Q562 Q563 Q564

Refer to: The Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health Services Handbook, subsection 3.3, “Services, Benefits, Limitations, and Prior Authorization,” for additional information.

Hearing DevicesPrior authorization for a unilateral or bilateral cochlear implant may be granted for clients who are 12 months of age and older with appropriate documentation of the required criteria and the most appropriate ICD-10-CM diagnosis code.

Prior authorization for the auditory brainstem implant (ABI) may be granted for clients who are 12 years of age or older and is limited to a condition of neurofibromatosis, type II or schwannomatosis.

Prior authorization for the bone anchored hearing aid (BAHA) device may be granted for clients who are five years of age or older with documentation of an appropriate ICD-10-CM diagnosis code that indicates a condition including, but not limited to, one of the following:

• Conductive hearing loss

• Sensorineural hearing loss

• Other anomalies of external ear with impairment of hearing

• Anomalies of skull and face bones





Refer to: The Texas Medicaid Provider Procedures Manual Vision and Hearing Services Handbook, subsection 3.2.1.1, “Prior Authorization;” subsection 3.2.2.1, “Prior Authorization;” and subsection 3.2.3.1, “Prior Autho-rization,” for information about the required criteria documentation that must be submitted with prior authorization requests.

* Helicobactor PyloriSerology testing (procedure codes 83009 and 86677), breath testing (procedure codes 78267, 78268, 83013 and 83014), and stool testing (procedure code 87338) may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C160 C161 C162 C163 C164 C165 C166 C168 K250 K251K252 K253 K254 K255 K256 K257 K260 K261 K262 K263K264 K265 K266 K267 K270 K271 K272 K273 K274 K275K276 K277 K280 K281 K282 K283 K284 K285 K286 K287K2900 K2901 K2920 K2921 K2931 K2940 K2941 K2960 K2961 K2980K2981 K2990 K2991

Additionally, H. Pylori breath and stool testing procedure codes 78267, 78268, 83013, and 83014 may be reimbursed when submitted with ICD-10-CM diagnosis code B9681.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.26.8, “Helicobacter Pylori (H. pylori),” for additional information.

Hematopoietic InjectionsProcedure code J0881 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C9000 C9001 C9002 D460 D461 D4621 D46A D46B D611 D612D613 D6189 D619 D630 D631 D644 D6481 D6489 D649 N181N182 N183 N184 N185 N186 N189 N19 Z5111 Z5112

Procedure code J0882 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D631 N181 N182 N183 N184 N185 N186 N189 N19

Procedure code J0885 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B20 C9000 C9001 C9002 D460 D461 D4621 D4622 D464 D469D46A D46B D46C D46Z D471 D479 D47Z9 D611 D612 D613D6189 D619 D630 D631 D644 D6481 D6489 D649 N181 N182N183 N184 N185 N186 N189 N19 P612




http://www.tmhp.com/ICD10_Updates_Med/05-18-15%20Helicobacter%20Pylori%20for%20Texas%20Medicaid.pdf

http://eopm/eopm/Provider_manuals/TMPPM/Output/Vol2_Medical_Specialists_and_Physicians_Services_Handbook.30.001.shtml#1820346


Procedure code J0886 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D631 N181 N182 N183 N184 N185 N186 N189 N19

Refer to: The Texas Medicaid Provider Procedures Manual Clinics and Other Outpatient Facility Services Handbook, subsection 6.2.9.4, “Hematopoietic Injections;” and the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.13, “Hematopoietic Injections,” for additional information.

Hepatitis Prophylaxis (Hepatitis B Immune Globulin and Hepatitis B Vaccine, Dialysis)Hepatitis immune globulin (HBIg) procedure codes 90371, J1571, and J1573 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z205 Z206 Z20828

HBIg procedure codes 90740 and 90747 for dialysis use are not restricted to specific diagnosis codes. The most appropriate ICD-10-CM diagnosis code or code combination must be submitted with the claim.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.37, “Immunizations for Clients Who Are 21 Years of Age or Older,” for additional information.

Injections – Chelating AgentsProcedure code J3520 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E8352 T460X1A T460X1D T460X1S T460X2A T460X2D T460X2S T460X3AT460X3D T460X3S T460X4A T460X4D T460X4S

Procedure code J0470 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)T560X1A T560X1D T560X1S T560X2A T560X2D T560X2S T560X3A T560X3DT560X3S T560X4A T560X4D T560X4S T561X1A T561X1D T561X1S T561X2AT561X2D T561X2S T561X3A T561X3D T561X3S T561X4A T561X4D T561X4ST564X1A T564X1D T564X1S T564X2A T564X2D T564X2S T564X3A T564X3DT564X3S T564X4A T564X4D T564X4S T565X1A T565X1D T565X1S T565X2AT565X2D T565X2S T565X3A T565X3D T565X3S T565X4A T565X4D T565X4ST566X1A T566X1D T566X1S T566X2A T566X2D T566X2S T566X3A T566X3DT566X3S T566X4A T566X4D T566X4S T56811A T56811D T56811S T56812AT56812D T56812S T56813A T56813D T56813S T56814A T56814D T56814ST56891A T56891D T56891S T56892A T56892D T56892S T56893A T56893DT56893S T56894A T56894D T56894S T5691XA T5691XD T5691XS T5692XAT5692XD T5692XS T5693XA T5693XD T5693XS T5694XA T5694XD T5694XST570X1A T570X1D T570X1S T570X2A T570X2D T570X2S T570X3A T570X3DT570X3S T570X4A T570X4D T570X4S




http://eopm/eopm/Provider_manuals/TMPPM/Output/Vol2_Clinics_and_Other_Outpatient_Facility_Services_Handbook.25.001.shtml#2000695



Procedure code J0600 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)T560X1A T560X1D T560X1S T560X2A T560X2D T560X2S T560X3A T560X3DT560X3S T560X4A T560X4D T560X4S T564X1A T564X1D T564X1S T564X2AT564X2D T564X2S T564X3A T564X3D T564X3S T564X4A T564X4D T564X4ST565X1A T565X1D T565X1S T565X2A T565X2D T565X2S T565X3A T565X3DT565X3S T565X4A T565X4D T565X4S T566X1A T566X1D T566X1S T566X2AT566X2D T566X2S T566X3A T566X3D T566X3S T566X4A T566X4D T566X4ST56811A T56811D T56811S T56812A T56812D T56812S T56813A T56813DT56813S T56814A T56814D T56814S T56891A T56891D T56891S T56892AT56892D T56892S T56893A T56893D T56893S T56894A T56894D T56894ST5691XA T5691XD T5691XS T5692XA T5692XD T5692XS T5693XA T5693XDT5693XS T5694XA T5694XD T5694XS

Procedure code J0895 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D560 D561 D562 D563 D568 D569 D5700 D5701D5702 D571 D5720 D57211 D57212 D57219 D5740 D57411D57412 D57419 D5780 D57811 D57812 D57819 E83111 E83118N181 N182 N183 N184 N185 N186 N189 N19T454X1A T454X1D T454X1S T454X2A T454X2D T454X2S T454X3A T454X3DT454X3S T454X4A T454X4D T454X4S T470X1A T470X1D T470X1S T470X2AT470X2D T470X2S T470X3A T470X3D T470X3S T470X4A T470X4D T470X4ST471X1A T471X1D T471X1S T471X2A T471X2D T471X2S T471X3A T471X3DT471X3S T471X4A T471X4D T471X4S T564X1A T564X1D T564X1S T564X2AT564X2D T564X2S T564X3A T564X3D T564X3S T564X4A T564X4D T564X4ST565X1A T565X1D T565X1S T565X2A T565X2D T565X2S T565X3A T565X3DT565X3S T565X4A T565X4D T565X4S T566X1A T566X1D T566X1S T566X2AT566X2D T566X2S T566X3A T566X3D T566X3S T566X4A T566X4D T566X4ST56811A T56811D T56811S T56812A T56812D T56812S T56813A T56813DT56813S T56814A T56814D T56814S T56891A T56891D T56891S T56892AT56892D T56892S T56893A T56893D T56893S T56894A T56894D T56894ST5691XA T5691XD T5691XS T5692XA T5692XD T5692XS T5693XA T5693XDT5693XS T5694XA T5694XD T5694XS

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.10, “Chelating Agents,” for additional information.

* Injection-Clofarabine (Clorar®)This policy was not included in the original bulletin.






http://www.tmhp.com/ICD10_Updates_Med/07-29-15%20Injection-Clofarabine%20Clorar%20for%20Texas%20Medicaid.pdf

Injections – Immune GlobulinsProcedure codes 90291 and J0850 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z940 Z941 Z942 Z943 Z944 Z9483

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.15, “Immune Globulin,” for additional information.

* Iron StudiesFerritin, iron, iron binding capacity, transferrin, iron stain, and peripheral blood lab tests (procedure codes 82728, 83540, 83550, 84466, and 85536) may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D460 D461 D4620 D4621 D4622 D464 D469 D46A D46B D46CD46Z D471 D473 D479 D47Z1 D47Z9 D500 D501 D508 D509D510 D511 D512 D513 D518 D519 D520 D521 D528 D529D530 D531 D532 D538 D539 D560 D561 D562 D563 D564D568 D569 D5700 D5701 D5702 D571 D5720 D57211 D57212 D57219D5740 D57411 D57412 D57419 D5780 D57811 D57812 D57819 D582 D588D589 D598 D599 D630 D631 D638 D640 D641 D642 D643D649 D732 D7381 E0801 E0810 E0811 E0821 E0822 E0829 E08311E08319 E08321 E08329 E08331 E08339 E08341 E08349 E08351 E08359 E0836E0839 E0840 E0841 E0842 E0843 E0844 E0849 E0851 E0859 E08610E08618 E08620 E08621 E08622 E08628 E08630 E08638 E08641 E08649 E0865E0869 E088 E089 E0901 E0910 E0911 E0940 E0941 E0942 E0943E0944 E0949 E0951 E0959 E09610 E09618 E09620 E09621 E09622 E09628E09630 E09638 E09641 E09649 E0965 E0969 E098 E099 E1010 E1011E1021 E1022 E1029 E10311 E10319 E10321 E10329 E10331 E10339 E10341E10349 E10351 E10359 E1036 E1039 E1040 E1041 E1042 E1043 E1044E1049 E1051 E1052 E1059 E10610 E10618 E10620 E10621 E10622 E10628E10630 E10638 E10641 E10649 E1065 E1069 E108 E109 E1101 E1121E1122 E1129 E11311 E11319 E11321 E11329 E11331 E11339 E11341 E11349E11351 E11359 E1136 E1139 E1140 E1141 E1142 E1143 E1144 E1149E1151 E1152 E1159 E11610 E11618 E11620 E11621 E11622 E11628 E11630E11638 E11641 E11649 E1165 E1169 E118 E119 E1301 E1310 E1311E1321 E1322 E1329 E13311 E13319 E13321 E13329 E13331 E13339 E13341E13349 E13351 E13359 E1336 E1339 E1340 E1341 E1342 E1343 E1344E1349 E1351 E1352 E1359 E13610 E13620 E13621 E13622 E13628 E13630E13638 E13641 E13649 E1365 E1369 E138 E139 E8310 E83110 E83111E83118 E8319 G2589 G259 G26 I420 I425 I428 I43 I440I441 I442 I4430 I4439 I444 I445 I4460 I4469 I447 I450I4510 I4519 I452 I453 I454 I455 I456 I4581 I4589 I459I470 I471 I472 I479 I480 I481 I482 I483 I484 I4891I4892 I4901 I4902 I491 I493 I4940 I4949 I495 I498 I499I501 I5020 I5021 I5022 I5023 I5030 I5031 I5032 I5033 I5040




http://www.tmhp.com/ICD10_Updates_Med/06-02-15%20ICD10%20Update%20to%20Iron%20Studies%20for%20Texas%20Medicaid.pdf

Diagnosis Codes (Submitted as stand-alone diagnosis codes)I5041 I5042 I5043 I509 I781 K7011 K7031 K7151 K730 K738K739 K740 K741 K7460 K7469 K754 K7581 K760 K7689 K769L649 L659 L818 L819 L989 M1310 M13111 M13112 M13121 M13122M13131 M13132 M13141 M13142 M13151 M13152 M13161 M13162 M13171 M13172M13811 M13812 M13821 M13822 M13831 M13832 M13841 M13842 M13851 M13852M13861 M13862 M13871 M13872 M1388 M1389 M150 M151 M152 M153M154 M158 M160 M1611 M1612 M162 M1631 M1632 M164 M1651M1652 M166 M167 M170 M1711 M1712 M172 M1731 M1732 M174M175 M1811 M1812 M182 M19011 M19012 M19021 M19022 M19031 M19032M19041 M19042 M19071 M19072 M19111 M19112 M19121 M19122 M19131 M19132M19141 M19142 M19171 M19172 M19211 M19212 M19221 M19222 M19231 M19232M19241 M19242 M19271 M19272 M1990 M1991 M1992 M1993 N500 N5201N5202 N5203 N521 N5231 N5232 N5233 N5234 N5239 N529 N910N911 N912 N913 N914 N915 R001 R160 R161 R162 R180R188 R740 R7871 R7879 R7889 R790 R7989 R799

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)E0801, E0865

E0810, E0865

E0821, E0865

E08311, E0865

E08319, E0865

E0836, E0865

E0840, E0865

E0851, E0865

E0865, E08311

E0865, E08319

E0865, E08321

E0865, E08329

E0865, E08331

E0865, E08339

E0865, E08341

E0865, E08349

E0865, E08351

E0865, E08359

E0865, E0836

E0865, E0839

E0865, E0840

E0865, E0841

E0865, E0842

E0865, E0843

E0865, E0844

E0865, E0849

E0865, E0851

E0865, E0852

E0865, E0859

E0865, E0869

E0865, E088

E0865, E0901

E0865, E0910

E0865, E0921

E0865, E09311

E0865, E09319

E0865, E0936

E0865, E0940

E0865, E0951

E0865, E0969

E0865, E098

E0865, E1310

E0865, E1365

E0865, E138

E1010, E1065

E1011, E1065

E1011, E10641

E1021, E1065

E10311, E1065

E10319, E1065

E1036, E1065

E1039, E1065

E1040, E1065

E1051, E1065

E1065, E1069

E1065, E108

E1065, E1022

E1065, E1029

E1065, E10321

E1065, E10329

E1065, E10331

E1065, E10339

E1065, E10341

E1065, E10349

E1065, E10351

E1065, E10359

E1065, E1041

E1065, E1042

E1065, E1043

E1065, E1044

E1065, E1049

E1065, E10610

E1065, E1052

E1065, E1059

E1100, E1165

E1101, E1165

E1121, E1165

E11311, E1165

E11319, E1165

E1136, E1165

E1139, E1165

E1140, E1165

E1151, E1165

E1165, E1169

E1165, E118

E1165, E11321

E1165, E11329

E1165, E11331

E1165, E11339

E1165, E11341

E1165, E11349

E1165, E11351

E1165, E11359

E1321, E0865



The Texas Medicaid Provider Procedures Manual Radiology and Laboratory Services Handbook, subsection 2.2.9, “Iron Studies,” for additional information.




Lung Volume Reduction SurgeryPreoperative pulmonary rehabilitation services procedure codes G0302, G0303, G0304 and postdischarge pulmonary surgery services procedure code G0305 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)J430 J431 J432 J438 J983

Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Services Handbook, subsection 4.2.15, “Lung Volume Reduction Surgery (LVRS);” and the Medical and Nursing Special-ists, Physicians, and Physician Assistants Handbook, subsection 9.2.42, “Lung Volume Reduction Surgery (LVRS),” for additional information.

Mastectomy and Breast ReconstructionMastectomy and breast reconstruction procedures are limited to the following diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C50011 C50012 C50021 C50022 C50111 C50112 C50121 C50122C50211 C50212 C50221 C50222 C50311 C50312 C50321 C50322C50411 C50412 C50421 C50422 C50511 C50512 C50521 C50522C50611 C50612 C50621 C50622 C50811 C50812 C50821 C50822C50921 C50922 C7981 D0501 D0502 D0511 D0512 D0581D0582

The following ICD-10-CM diagnosis codes are a benefit of Texas Medicaid for simple, subcutaneous, radical, and modified radical mastectomies and for all breast reconstruction procedures: Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z1501 Z803 Z853 Z9011 Z9012 Z9013

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.43, “Mastectomy and Breast Reconstruction,” for additional information.

NeurostimulatorsSome benefit criteria for neurostimulators will change. Neurostimulators are a benefit of Texas Medicaid when medically necessary. Neurostimulators procedures and the rental of devices and associated supplies, such as leads and form fitting conductive garments are a benefit of Texas Medicaid.

Sacral Nerve Stimulators (SNS)The surgical implantation of an SNS and purchase of a device may be considered for prior authorization for clients with:

• Urinary incontinence secondary to urethral instability and/or detrusor muscle instability.

• Chronic voiding dysfunction.

• Non-obstructive urinary retention.

• Fecal incontinence.

Vagal Nerve Stimulators (VNS)The surgical implantation of a VNS and purchase of a device (procedure code L8686 TG when submitted for durable medical equipment [other or purchased new] services) may be considered for prior authorization for clients




with partial onset intractable seizures when there is failure, contraindication, or intolerance to all suitable medical and pharmacological management.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.44.12, “Sacral Nerve Stimulators (SNS);” subsection 9.2.44 “Neuro-stimulators;” and subsection 9.2.44.13, “Vagal Nerve Stimulators (VNS),” for additional information.

Obstetric ServicesProviders must submit claims for obstetric services procedure codes with the most appropriate ICD-10-CM diagnosis codes as indicated below. Procedure code J1725 may be reimbursed when submitted with the following ICD-10-CM diagnosis code:Diagnosis Code (Submitted as stand-alone diagnosis code)O09211

Procedure codes 99460 or 99463 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)P002 P003 P0089 P009 Z372 Z373 Z374 Z3751 Z3752 Z3753Z3754 Z3759 Z3761 Z3762 Z3763 Z3764 Z3769 Z377 Z3800 Z381Z3830 Z384 Z3861 Z3862 Z3863 Z3864 Z3865 Z3866 Z3868 Z3869Z387

Procedure codes 99406 or 99407 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)O99330 O99331 O99332 O99333 O99334 O99335

Procedure code 82731 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)O4700 O4702 O4703 O479

Procedure codes 36460, 59012, or 76941 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)O353XX0 O353XX1 O353XX2 O353XX3 O353XX4 O353XX5 O353XX9 O358XX0O360110 O360111 O360112 O360113 O360114 O360115 O360119 O360120O360121 O360122 O360123 O360124 O360125 O360129 O360130 O360131O360132 O360133 O360134 O360135 O360139 O360190 O360191 O360192O360193 O360194 O360195 O360199 O360910 O360911 O360912 O360913O360914 O360915 O360919 O360920 O360921 O360922 O360923 O360924O360925 O360929 O360930 O360931 O360932 O360933 O360934 O360935O360939 O360990 O360991 O360992 O360993 O360994 O360995 O360999O361110 O361111 O361112 O361113 O361114 O361115 O361119 O361120O361121 O361122 O361123 O361124 O361125 O361129 O361130 O361131O361132 O361133 O361134 O361135 O361139 O361190 O361191 O361192






Diagnosis Codes (Submitted as stand-alone diagnosis codes)O361193 O361194 O361195 O361199 O361910 O361911 O361912 O361913O361914 O361915 O361919 O361920 O361921 O361922 O361923 O361924O361925 O361929 O361930 O361931 O361932 O361933 O361934 O361935O361939 O361990 O361991 O361992 O361993 O361994 O361995 O361999O368210 O368211 O368212 O368213 O368214 O368215 O368219 O368220O368221 O368222 O368223 O368224 O368225 O368229 O368230 O368231O368232 O368233 O368234 O368235 O368239 O368290 O368291 O368292O368293 O368294 O368295 O368299 O4690 O4691 O4692 O4693

Procedure code 59001 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)O401XX0 O401XX1 O401XX2 O401XX3 O401XX4 O401XX5 O401XX9 O402XX0O402XX1 O402XX2 O402XX3 O402XX4 O402XX5 O402XX9 O403XX0 O403XX1O403XX2 O403XX3 O403XX4 O403XX5 O403XX9 O409XX0 O409XX1 O409XX2O409XX3 O409XX4 O409XX5 O409XX9

Procedure codes 59070, 59074, or 59076 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)O360110 O360111 O360112 O360113 O360114 O360115 O360119 O360120O360121 O360122 O360123 O360124 O360125 O360129 O360130 O360131O360132 O360133 O360134 O360135 O360139 O360190 O360191 O360192O360193 O360194 O360195 O360199 O360910 O360911 O360912 O360913O360914 O360915 O360919 O360920 O360921 O360922 O360923 O360924O360925 O360929 O360930 O360931 O360932 O360933 O360934 O360935O360939 O360990 O360991 O360992 O360993 O360994 O360995 O360999O361110 O361111 O361112 O361113 O361114 O361115 O361119 O361120O361121 O361122 O361123 O361124 O361125 O361129 O361130 O361131O361132 O361133 O361134 O361135 O361139 O361190 O361191 O361192O361193 O361194 O361195 O361199 O361910 O361911 O361912 O361913O361914 O361915 O361919 O361920 O361921 O361922 O361923 O361924O361925 O361929 O361930 O361931 O361932 O361933 O361934 O361935O361939 O361990 O361991 O361992 O361993 O361994 O361995 O361999

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 9.2.47.2, “Hospital Visits and Routine Care;” subsection 9.2.48.10, “Tobacco Use Cessation Counseling;” subsec-tion 9.2.48.4, “Fetal Fibronectin;” subsection 9.2.48.5, “Fetal Intrauterine Transfusion (FIUT);” subsec-tion 9.2.48.1, “Amniocentesis, Cordocentesis, and Ultrasonic Guidance;” and subsection 9.2.48.11,

“Transabdominal Amnioinfusion,” for additional information.




Otology and Audiometry ServicesAcoustic reflex testing procedure code 92568 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D333 G510 G511 G518 G519 H8001 H8002 H8003H8011 H8012 H8013 H8021 H8022 H8023 H8081 H8082H8083 H8091 H8092 H8093 H8101 H8102 H8103 H8111H8112 H8113 H8121 H8122 H8123 H81311 H81312 H81313H81319 H81391 H81392 H81393 H8141 H8142 H8143 H818X1H818X2 H818X3 H8191 H8192 H8193 H8301 H8302 H8303H8311 H8312 H8313 H832X1 H832X2 H832X3 H838X1 H838X2H838X3 H838X9 H8391 H8392 H8393 H900 H9011 H9012H902 H903 H9041 H9042 H905 H906 H9071 H9072H908 H9101 H9102 H9103 H9121 H9122 H9123 H918X1H918X2 H918X3 H9191 H9192 H9193 H9311 H9312 H9313H93211 H93212 H93213 H93221 H93222 H93223 H93231 H93232H93233 H93241 H93242 H93243 H93291 H93292 H93293 H933X1H933X2 H933X3 H933X9 Q179 R42

Refer to: The Texas Medicaid Provider Procedures Manual Vision and Hearing Services Handbook, subsection 2.2.3.5, “Limitations,” for additional information.

Pediatric PneumogramPediatric pneumogram procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes for clients who are birth through 11 months of age: Diagnosis Codes (Submitted as stand-alone diagnosis codes)K200 K208 K209 K210 K219 K220 P220 P228 P270 P271P278 P282 P283 P284 P285 P2881 P2889 P84 R0600 R0609R062 R063 R0681 R0682 R0683 R0689 R6813

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physician, and Physician Assistants Handbook, subsection 9.2.26.10, “Pediatric Pneumogram,” for additional information.

Physician Evaluation and Management Services

Preventive Care VisitsOnly one preventive care visit (procedure code 99385, 99386, 99387, 99395, 99396, or 99397) may be considered for reimbursement each rolling year, any provider. Providers must bill the preventive services with ICD-10-CM diagnosis code Z0000, Z0001, Z01411, or Z01419.

Laboratory Services, Immunizations and Diagnostic ScreeningsLaboratory services, immunizations, and diagnostic screenings recommended by the U.S. Preventive Services Task Force (USPSTF) may be reimbursed using the most accurate ICD-10-CM diagnosis code that represents the client’s condition. Diagnosis code Z0000 or Z0001 may each be used once per rolling year for each screen if no other diagnosis is appropriate for the service rendered, but no more frequently than recommended by the USPSTF.




Concurrent CareConcurrent care will not be paid to providers of the same specialty for the same or related diagnoses. A diagnosis will be considered related when up to six digits match the primary ICD-10-CM diagnosis code. Denied concurrent care will be considered on appeal when accompanied by documentation of medical necessity.

Group Clinical VisitsGroup clinical visits may be reimbursed for the management of the conditions of diabetes, asthma, or pregnancy. Group clinical visit procedure codes may be reimbursed when they are submitted with one of the following ICD-10 diagnosis codes:

Diabetes Diagnosis Codes

Diagnosis Codes (Submitted as stand-alone diagnosis codes)E1010 E1011 E1021 E1022 E1029 E10311 E10319 E10321E10329 E10331 E10339 E10341 E10349 E10351 E10359 E1036E1039 E1040 E1041 E1042 E1043 E1044 E1049 E1051E1052 E1059 E10610 E10618 E10620 E10621 E10622 E10628E10630 E10638 E10641 E10649 E1065 E1069 E108 E109E1101 E1121 E1122 E1129 E11311 E11319 E11321 E11329E11331 E11339 E11341 E11349 E11351 E11359 E1136 E1139E1140 E1141 E1142 E1143 E1144 E1149 E1151 E1152E1159 E11610 E11641 E1169 E118 E119 E1301 E1310E1311 E1321 E1322 E1329 E13311 E13319 E13321 E13329E13331 E13339 E13341 E13349 E13351 E13359 E1336 E1339E1340 E1341 E1342 E1343 E1344 E1349 E1351 E1352E1359 E13610 E13641 E138 E139

Combination Diagnosis Codes

Combination Diagnosis Codes (Must be submitted in pairs)E1010, E1065

E1011, E10641

E1011, E1065

E1021, E1065

E1022, E1065

E1029, E1065

E10311, E1065

E10319, E1065

E10321, E1065

E10329, E1065

E10331, E1065

E1036, E1065

E1039, E1065

E10339, E1065

E10341, E1065

E10349, E1065

E10351, E1065

E10359, E1065

E1051, E1065

E1052, E1065

E1059, E1065

E10610, E1065

E1140, E1165

E1040, E1065

E1041, E1065

E1042, E1065

E1043, E1065

E1044, E1065

E1049, E1065

E1065, E1069

E1065, E108

E1100, E1165

E1101, E1165

E1121, E1165

E11311, E1165

E11319, E1165

E1136, E1165

E1139, E1165

E1151, E1165

E1165, E1169

E1165, E118

E13319, E1165

E13321, E1165

E13329, E1165

E13331, E1165

E1336, E1165

E1339, E1165

E13339, E1165

E13341, E1165

E13349, E1165

E13351, E1165

E13359, E1165






Asthma Diagnosis CodesDiagnosis Codes (Submitted as stand-alone diagnosis codes)J440 J441 J449 J4520 J4521 J4522 J4530 J4531 J4532 J4540J4541 J4542 J4550 J4551 J4552 J45901 J45902 J45909 J45990 J45991J45998

Pregnancy-related Diagnosis CodesDiagnosis Codes (Submitted as stand-alone diagnosis codes)O0901 O0902 O0903 O0911 O0912 O0913 O09211 O09212O09213 O09291 O09292 O09293 O0931 O0932 O0933 O0941O0942 O0943 O09511 O09512 O09513 O09521 O09522 O09523O09611 O09612 O09613 O09621 O09622 O09623 O0971 O0972O0973 O09811 O09812 O09813 O09821 O09822 O09823 O09891O09892 O09893 O0991 O0992 O0993 Z331 Z3401 Z3402Z3403 Z3481 Z3482 Z3483

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.61.4, “Group Clinical Visits;” subsection 9.2.61.1, “Office or Other Outpatient Hospital Services;” and subsection 9.2.61.6, “Inpatient Hospital Services,” for additional information.

Prognostic Breast and Gynecological Cancer StudiesProcedure codes 84233, 84234, 88360, and 88361 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes for breast or uterine cancer as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C50011 C50012 C50021 C50022 C50111 C50112 C50121 C50122C50211 C50212 C50221 C50222 C50311 C50312 C50321 C50322C50411 C50412 C50421 C50422 C50511 C50512 C50521 C50522C50611 C50612 C50621 C50622 C50811 C50812 C50821 C50822C50921 C50922 C540 C541 C542 C543 C548 C792C7981 D0501 D0502 D0511 D0512 D0581 D0582

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.17, “Prognostic Breast and Gynecological Cancer Studies,” for additional information.

Pulmonary Function StudiesHigh Altitude Simulation Test (HAST) procedure codes 94452 and 94453 must be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E840 E8411 E8419 E848 E849 I270 I271 I272 I2781 I2789I279 J410 J411 J418 J42 J430 J431 J432 J438 J439J440 J441 J449 J471 J479 J60 J700 J701 J708 J709J82 J8401 J8402 J8403 J8409 J8410 J849 J9610 J9611 J9612




http://eopm/eopm/Provider_manuals/TMPPM/output/Vol2_Medical_Specialists_and_Physicians_Services_Handbook.30.001.shtml#1816506


Diagnosis Codes (Submitted as stand-alone diagnosis codes)J982 P270 P271 P278 Q332 Q334 Q336

When Billing HAST procedure codes 94452 and 94453 with one of the following ICD-10-CM diagnosis codes listed below, evidence of hypoxemia must be documented in the client’s medical record:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E840 E8419 E848 E849 I270 I271 I272 I2781 I2789 I279J410 J411 J418 J42 J430 J431 J432 J438 J439 J440J441 J449 J471 J479 J60 J700 J708 J709 J82 P270P271 P278

Refer to: The Texas Medicaid Provider Procedures Manual Inpatient and Outpatient Hospital Handbook, subsection 4.2.19.4, “Pulmonary Function Studies,” for additional information.

Rabies Post Exposure TreatmentPostexposure rabies vaccine procedure codes 90375, 90376, and 90675 may be reimbursed when they are submitted with the following ICD-10-CM diagnosis code:Diagnosis Code (Submitted as stand-alone diagnosis code)Z203

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.38, “Postexposure Prophylaxis for Rabies,” for additional information.

Renal Dialysis ServicesRenal dialysis services for acute renal failure and end-stage renal disease (ESRD) may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)N170 N171 N172 N178 N179 N181 N182 N183 N184 N185N186 N189

Procedure code G0257 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)N185 N186

Refer to: The Texas Medicaid Provider Procedures Manual Clinics and Other Outpatient Facility Services Handbook, subsection 6.2.4, “Facility Revenue Codes;” and subsection 6.2.1.1, “Unscheduled or Emergency Dialysis in a Non-Certified ESRD Facility,” for additional information.

Skin TherapyProcedure codes 11900 and 11901 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)B070 B081 B550 B551 B552 B559 D863 L400L401 L402 L403 L404 L4050 L4051 L4052 L4053




Diagnosis Codes (Submitted as stand-alone diagnosis codes)L4054 L4059 L408 L410 L411 L412 L413 L414L415 L418 L42 L440 L700 L701 L702 L703L704 L705 L708 L710 L711 L718 L730 L732L910 L928 T2000XA T2000XD T2000XS T20011A T20011D T20011ST20012A T20012D T20012S T2002XA T2002XD T2002XS T2003XA T2003XDT2003XS T2004XA T2004XD T2004XS T2005XA T2005XD T2005XS T2006XAT2006XD T2006XS T2007XA T2007XD T2007XS T2009XA T2009XD T2009XST2010XA T2010XD T2010XS T20111A T20111D T20111S T20112A T20112DT20112S T2012XA T2012XD T2012XS T2013XA T2013XD T2013XS T2014XAT2014XD T2014XS T2015XA T2015XD T2015XS T2016XA T2016XD T2016XST2017XA T2017XD T2017XS T2019XA T2019XD T2019XS T2020XA T2020XDT2020XS T20211A T20211D T20211S T20212A T20212D T20212S T2022XAT2022XD T2022XS T2023XA T2023XD T2023XS T2024XA T2024XD T2024XST2025XA T2025XD T2025XS T2026XA T2026XD T2026XS T2027XA T2027XDT2027XS T2029XA T2029XD T2029XS T2030XA T2030XD T2030XS T20311AT20311D T20311S T20312A T20312D T20312S T2032XA T2032XD T2032XST2033XA T2033XD T2033XS T2034XA T2034XD T2034XS T2035XA T2035XDT2035XS T2036XA T2036XD T2036XS T2037XA T2037XD T2037XS T2039XAT2039XD T2039XS T2040XA T2040XD T2040XS T20411A T20411D T20411ST20412A T20412D T20412S T2042XA T2042XD T2042XS T2043XA T2043XDT2043XS T2044XA T2044XD T2044XS T2045XA T2045XD T2045XS T2046XAT2046XD T2046XS T2047XA T2047XD T2047XS T2049XA T2049XD T2049XST2050XA T2050XD T2050XS T20511A T20511D T20511S T20512A T20512DT20512S T2052XA T2052XD T2052XS T2053XA T2053XD T2053XS T2054XAT2054XD T2054XS T2055XA T2055XD T2055XS T2056XA T2056XD T2056XST2057XA T2057XD T2057XS T2059XA T2059XD T2059XS T2060XA T2060XDT2060XS T20611A T20611D T20611S T20612A T20612D T20612S T2062XAT2062XD T2062XS T2063XA T2063XD T2063XS T2064XA T2064XD T2064XST2065XA T2065XD T2065XS T2066XA T2066XD T2066XS T2067XA T2067XDT2067XS T2069XA T2069XD T2069XS T2070XA T2070XD T2070XS T20711AT20711D T20711S T20712A T20712D T20712S T2072XA T2072XD T2072XST2073XA T2073XD T2073XS T2074XA T2074XD T2074XS T2075XA T2075XDT2075XS T2076XA T2076XD T2076XS T2077XA T2077XD T2077XS T2079XAT2079XD T2079XS T2100XA T2100XD T2100XS T2101XA T2101XD T2101XST2102XA T2102XD T2102XS T2103XA T2103XD T2103XS T2104XA T2104XDT2104XS T2106XA T2106XD T2106XS T2107XA T2107XD T2107XS T2110XAT2110XD T2110XS T2111XA T2111XD T2111XS T2112XA T2112XD T2112XST2113XA T2113XD T2113XS T2114XA T2114XD T2114XS T2116XA T2116XDT2116XS T2117XA T2117XD T2117XS T2119XA T2119XD T2119XS T2120XA




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T2120XD T2120XS T2121XA T2121XD T2121XS T2122XA T2122XD T2122XST2123XA T2123XD T2123XS T2124XA T2124XD T2124XS T2126XA T2126XDT2126XS T2127XA T2127XD T2127XS T2130XA T2130XD T2130XS T2131XAT2131XD T2131XS T2132XA T2132XD T2132XS T2133XA T2133XD T2133XST2134XA T2134XD T2134XS T2136XA T2136XD T2136XS T2137XA T2137XDT2137XS T2140XA T2140XD T2140XS T2141XA T2141XD T2141XS T2142XAT2142XD T2142XS T2143XA T2143XD T2143XS T2144XA T2144XD T2144XST2146XA T2146XD T2146XS T2147XA T2147XD T2147XS T2150XA T2150XDT2150XS T2151XA T2151XD T2151XS T2152XA T2152XD T2152XS T2153XAT2153XD T2153XS T2154XA T2154XD T2154XS T2156XA T2156XD T2156XST2157XA T2157XD T2157XS T2159XA T2159XD T2159XS T2160XA T2160XDT2160XS T2161XA T2161XD T2161XS T2162XA T2162XD T2162XS T2163XAT2163XD T2163XS T2164XA T2164XD T2164XS T2166XA T2166XD T2166XST2167XA T2167XD T2167XS T2170XA T2170XD T2170XS T2171XA T2171XDT2171XS T2172XA T2172XD T2172XS T2173XA T2173XD T2173XS T2174XAT2174XD T2174XS T2176XA T2176XD T2176XS T2177XA T2177XD T2177XST2200XA T2200XD T2200XS T22011A T22011D T22011S T22012A T22012DT22012S T22021A T22021D T22021S T22022A T22022D T22022S T22031AT22031D T22031S T22032A T22032D T22032S T22041A T22041D T22041ST22042A T22042D T22042S T22049D T22051A T22051D T22051S T22052AT22052D T22052S T22061A T22061D T22061S T22062A T22062D T22062ST22091A T22091D T22091S T22092A T22092D T22092S T2210XA T2210XDT2210XS T22111A T22111D T22111S T22112A T22112D T22112S T22121AT22121D T22121S T22122A T22122D T22122S T22131A T22131D T22131ST22132A T22132D T22132S T22141A T22141D T22141S T22142A T22142DT22142S T22151A T22151D T22151S T22152A T22152D T22152S T22161AT22161D T22161S T22162A T22162D T22162S T22191A T22191D T22191ST22192A T22192D T22192S T2220XA T2220XD T2220XS T22211A T22211DT22211S T22212A T22212D T22212S T22221A T22221D T22221S T22222AT22222D T22222S T22231A T22231D T22231S T22232A T22232D T22232ST22239D T22241A T22241D T22241S T22242A T22242D T22242S T22249DT22251A T22251D T22251S T22252A T22252D T22252S T22261A T22261DT22261S T22262A T22262D T22262S T22291A T22291D T22291S T22292AT22292D T22292S T2230XA T2230XD T2230XS T22311A T22311D T22311ST22312A T22312D T22312S T22321A T22321D T22321S T22322A T22322DT22322S T22331A T22331D T22331S T22332A T22332D T22332S T22341AT22341D T22341S T22342A T22342D T22342S T22351A T22351D T22351ST22352A T22352D T22352S T22361A T22361D T22361S T22362A T22362DT22362S T22369D T22391A T22391D T22391S T22392A T22392D T22392S




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T2240XA T2240XD T2240XS T22411A T22411D T22411S T22412A T22412DT22412S T22421A T22421D T22421S T22422A T22422D T22422S T22431AT22431D T22431S T22432A T22432D T22432S T22441A T22441D T22441ST22442A T22442D T22442S T22451A T22451D T22451S T22452A T22452DT22452S T22461A T22461D T22461S T22462A T22462D T22462S T22491AT22491D T22491S T22492A T22492D T22492S T2250XA T2250XD T2250XST22511A T22511D T22511S T22512A T22512D T22512S T22521A T22521DT22521S T22522A T22522D T22522S T22531A T22531D T22531S T22532AT22532D T22532S T22541A T22541D T22541S T22542A T22542D T22542ST22551A T22551D T22551S T22552A T22552D T22552S T22561A T22561DT22561S T22562A T22562D T22562S T22591A T22591D T22591S T22592AT22592D T22592S T2260XA T2260XD T2260XS T22611A T22611D T22611ST22612A T22612D T22612S T22621A T22621D T22621S T22622A T22622DT22622S T22631A T22631D T22631S T22632A T22632D T22632S T22641AT22641D T22641S T22642A T22642D T22642S T22649D T22651A T22651DT22651S T22652A T22652D T22652S T22661A T22661D T22661S T22662AT22662D T22662S T22691A T22691D T22691S T22692A T22692D T22692ST2270XA T2270XD T2270XS T22711A T22711D T22711S T22712A T22712DT22712S T22721A T22721D T22721S T22722A T22722D T22722S T22731AT22731D T22731S T22732A T22732D T22732S T22741A T22741D T22741ST22742A T22742D T22742S T22751A T22751D T22751S T22752A T22752DT22752S T22761A T22761D T22761S T22762A T22762D T22762S T22791AT22791D T22791S T22792A T22792D T22792S T23001A T23001D T23001ST23002A T23002D T23002S T23011A T23011D T23011S T23012A T23012DT23012S T23021A T23021D T23021S T23022A T23022D T23022S T23031AT23031D T23031S T23032A T23032D T23032S T23041A T23041D T23041ST23042A T23042D T23042S T23051A T23051D T23051S T23052A T23052DT23052S T23061A T23061D T23061S T23062A T23062D T23062S T23071AT23071D T23071S T23072A T23072D T23072S T23091A T23091D T23091ST23092A T23092D T23092S T23101A T23101D T23101S T23102A T23102DT23102S T23111A T23111D T23111S T23112A T23112D T23112S T23121AT23121D T23121S T23122A T23122D T23122S T23131A T23131D T23131ST23132A T23132D T23132S T23141A T23141D T23141S T23142A T23142DT23142S T23151A T23151D T23151S T23152A T23152D T23152S T23161AT23161D T23161S T23162A T23162D T23162S T23171A T23171D T23171ST23172A T23172D T23172S T23191A T23191D T23191S T23192A T23192DT23192S T23201A T23201D T23201S T23202A T23202D T23202S T23211AT23211D T23211S T23212A T23212D T23212S T23221A T23221D T23221ST23222A T23222D T23222S T23231A T23231D T23231S T23232A T23232D




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T23232S T23241A T23241D T23241S T23242A T23242D T23242S T23251AT23251D T23251S T23252A T23252D T23252S T23261A T23261D T23261ST23262A T23262D T23262S T23271A T23271D T23271S T23272A T23272DT23272S T23291A T23291D T23291S T23292A T23292D T23292S T23301AT23301D T23301S T23302A T23302D T23302S T23311A T23311D T23311ST23312A T23312D T23312S T23321A T23321D T23321S T23322A T23322DT23322S T23331A T23331D T23331S T23332A T23332D T23332S T23341AT23341D T23341S T23342A T23342D T23342S T23351A T23351D T23351ST23352A T23352D T23352S T23361A T23361D T23361S T23362A T23362DT23362S T23371A T23371D T23371S T23372A T23372D T23372S T23391AT23391D T23391S T23392A T23392D T23392S T23401A T23401D T23401ST23402A T23402D T23402S T23411A T23411D T23411S T23412A T23412DT23412S T23421A T23421D T23421S T23422A T23422D T23422S T23431AT23431D T23431S T23432A T23432D T23432S T23441A T23441D T23441ST23442A T23442D T23442S T23451A T23451D T23451S T23452A T23452DT23452S T23461A T23461D T23461S T23462A T23462D T23462S T23471AT23471D T23471S T23472A T23472D T23472S T23491A T23491D T23491ST23492A T23492D T23492S T23501A T23501D T23501S T23502A T23502DT23502S T23511A T23511D T23511S T23512A T23512D T23512S T23521AT23521D T23521S T23522A T23522D T23522S T23531A T23531D T23531ST23532A T23532D T23532S T23541A T23541D T23541S T23542A T23542DT23542S T23551A T23551D T23551S T23552A T23552D T23552S T23561AT23561D T23561S T23562A T23562D T23562S T23571A T23571D T23571ST23572A T23572D T23572S T23591A T23591D T23591S T23592A T23592DT23592S T23601A T23601D T23601S T23602A T23602D T23602S T23611AT23611D T23611S T23612A T23612D T23612S T23621A T23621D T23621ST23622A T23622D T23622S T23631A T23631D T23631S T23632A T23632DT23632S T23641A T23641D T23641S T23642A T23642D T23642S T23651AT23651D T23651S T23652A T23652D T23652S T23661A T23661D T23661ST23662A T23662D T23662S T23671A T23671D T23671S T23672A T23672DT23672S T23691A T23691D T23691S T23692A T23692D T23692S T23701AT23701D T23701S T23702A T23702D T23702S T23711A T23711D T23711ST23712A T23712D T23712S T23721A T23721D T23721S 0T23722A T23722DT23722S T23731A T23731D T23731S T23732A T23732D T23732S T23741AT23741D T23741S T23742A T23742D T23742S T23751A T23751D T23751ST23752A T23752D T23752S T23761A T23761D T23761S T23762A T23762DT23762S T23771A T23771D T23771S T23772A T23772D T23772S T23791AT23791D T23791S T23792A T23792D T23792S T24001A T24001D T24001ST24002A T24002D T24002S T24011A T24011D T24011S T24012A T24012D




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T24012S T24021A T24021D T24021S T24022A T24022D T24022S T24031AT24031D T24031S T24032A T24032D T24032S T24091A T24091D T24091ST24092A T24092D T24092S T24101A T24101D T24101S T24102A T24102DT24102S T24111A T24111D T24111S T24112A T24112D T24112S T24121AT24121D T24121S T24122A T24122D T24122S T24131A T24131D T24131ST24132A T24132D T24132S T24191A T24191D T24191S T24192A T24192DT24192S T24201A T24201D T24201S T24202A T24202D T24202S T24211AT24211D T24211S T24212A T24212D T24212S T24221A T24221D T24221ST24222A T24222D T24222S T24229D T24231A T24231D T24231S T24232AT24232D T24232S T24291A T24291D T24291S T24292A T24292D T24292ST24301A T24301D T24301S T24302A T24302D T24302S T24311A T24311DT24311S T24312A T24312D T24312S T24321A T24321D T24321S T24322AT24322D T24322S T24331A T24331D T24331S T24332A T24332D T24332ST24391A T24391D T24391S T24392A T24392D T24392S T24401A T24401DT24401S T24402A T24402D T24402S T24411A T24411D T24411S T24412AT24412D T24412S T24421A T24421D T24421S T24422A T24422D T24422ST24431A T24431D T24431S T24432A T24432D T24432S T24491A T24491DT24491S T24492A T24492D T24492S T24501A T24501D T24501S T24502AT24502D T24502S T24511A T24511D T24511S T24512A T24512D T24512ST24521A T24521D T24521S T24522A T24522D T24522S T24531A T24531DT24531S T24532A T24532D T24532S T24591A T24591D T24591S T24592AT24592D T24592S T24601A T24601D T24601S T24602A T24602D T24602ST24611A T24611D T24611S T24612A T24612D T24612S T24621A T24621DT24621S T24622A T24622D T24622S T24631A T24631D T24631S T24632AT24632D T24632S T24691A T24691D T24691S T24692A T24692D T24692ST24701A T24701D T24701S T24702A T24702D T24702S T24711A T24711DT24711S T24712A T24712D T24712S T24721A T24721D T24721S T24722AT24722D T24722S T24731A T24731D T24731S T24732A T24732D T24732ST24791A T24791D T24791S T24792A T24792D T24792S T25011A T25011DT25011S T25012A T25012D T25012S T25021A T25021D T25021S T25022AT25022D T25022S T25031A T25031D T25031S T25032A T25032D T25032ST25091A T25091D T25091S T25092A T25092D T25092S T25111A T25111DT25111S T25112A T25112D T25112S T25121A T25121D T25121S T25122AT25122D T25122S T25131A T25131D T25131S T25132A T25132D T25132ST25191A T25191D T25191S T25192A T25192D T25192S T25211A T25211DT25211S T25212A T25212D T25212S T25221A T25221D T25221S T25222AT25222D T25222S T25231A T25231D T25231S T25232A T25232D T25232ST25291A T25291D T25291S T25292A T25292D T25292S T25311A T25311DT25311S T25312A T25312D T25312S T25321A T25321D T25321S T25322A




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T25322D T25322S T25331A T25331D T25331S T25332A T25332D T25332ST25391A T25391D T25391S T25392A T25392D T25392S T25411A T25411DT25411S T25412A T25412D T25412S T25421A T25421D T25421S T25422AT25422D T25422S T25431A T25431D T25431S T25432A T25432D T25432ST25491A T25491D T25491S T25492A T25492D T25492S T25511A T25511DT25511S T25512A T25512D T25512S T25521A T25521D T25521S T25522AT25522D T25522S T25531A T25531D T25531S T25532A T25532D T25532ST25591A T25591D T25591S T25592A T25592D T25592S T25611A T25611DT25611S T25612A T25612D T25612S T25621A T25621D T25621S T25622AT25622D T25622S T25631A T25631D T25631S T25632A T25632D T25632ST25711A T25711D T25711S T25712A T25712D T25712S T25721A T25721DT25721S T25722A T25722D T25722S T25731A T25731D T25731S T25732AT25732D T25732S T25791A T25791D T25791S T25792A T25792D T25792ST2601XA T2601XD T2601XS T2602XA T2602XD T2602XS T2611XA T2611XDT2611XS T2612XA T2612XD T2612XS T2621XA T2621XD T2621XS T2622XAT2622XD T2622XS T2631XA T2631XD T2631XS T2632XA T2632XD T2632XST2641XA T2641XD T2641XS T2642XA T2642XD T2642XS T2651XA T2651XDT2651XS T2652XA T2652XD T2652XS T2661XA T2661XD T2661XS T2662XAT2662XD T2662XS T2671XA T2671XD T2671XS T2672XA T2672XD T2672XST2681XA T2681XD T2681XS T2682XA T2682XD T2682XS T2691XA T2691XDT2691XS T2692XA T2692XD T2692XS T271XXA T271XXD T271XXS T275XXAT275XXD T275XXS T280XXA T280XXD T280XXS T281XXA T281XXD T281XXST282XXA T282XXD T282XXS T283XXA T283XXD T283XXS T2840XA T2840XDT2840XS T28411A T28411D T28411S T28412A T28412D T28412S T2849XAT2849XD T2849XS T285XXA T285XXD T285XXS T286XXA T286XXD T286XXST287XXA T287XXD T287XXS T288XXA T288XXD T288XXS T2890XA T2890XDT2890XS T28911A T28911D T28911S T28912A T28912D T28912S T2899XAT2899XD T2899XS T300 T304 T310 T3110 T3111 T3120T3121 T3122 T3130 T3131 T3132 T3133 T3140 T3141T3142 T3143 T3144 T3150 T3151 T3152 T3153 T3154T3155 T3160 T3161 T3162 T3163 T3164 T3165 T3166T3170 T3171 T3172 T3173 T3174 T3175 T3176 T3177T3180 T3181 T3182 T3183 T3184 T3185 T3186 T3187T3188 T3190 T3191 T3192 T3193 T3194 T3195 T3196T3197 T3198 T3199 T320 T3210 T3211 T3220 T3221T3222 T3230 T3231 T3232 T3233 T3240 T3241 T3242T3243 T3244 T3250 T3251 T3252 T3253 T3254 T3255T3260 T3261 T3262 T3263 T3264 T3265 T3266 T3270T3271 T3272 T3273 T3274 T3275 T3276 T3277 T3280




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T3281 T3282 T3283 T3284 T3285 T3286 T3287 T3288T3290 T3291 T3292 T3293 T3294 T3295 T3296 T3297T3298 T3299

Procedure codes 96900, 96910, 96912, 96913, 96920, 96921, and 96922 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)A672 B070 B081 B550 B551 B552 B559 C8401 C8402 C8403C8404 C8405 C8406 C8407 C8408 C8409 H02731 H02732 H02734 H02735L100 L101 L102 L103 L104 L105 L1081 L1089 L120 L121L122 L128 L130 L131 L138 L139 L200 L2081 L2082 L2083L2084 L2089 L210 L211 L218 L219 L22 L230 L231 L232L233 L235 L236 L237 L2381 L240 L241 L242 L243 L244L245 L246 L247 L2481 L270 L271 L272 L278 L279 L300L301 L302 L303 L304 L305 L400 L401 L402 L403 L404L4050 L4051 L4052 L4053 L4054 L4059 L408 L410 L411 L412L413 L414 L415 L418 L42 L440 L560 L561 L562 L563L564 L565 L570 L571 L572 L573 L574 L575 L580 L581L700 L701 L702 L703 L704 L705 L708 L710 L711 L718L730 L80

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.68, “Skin Therapy,” for additional information.

* Sleep StudiesActigraphy procedure code 95803 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F5104 F5105 F5113 G2581 G4700 G4701 G4709 G4710 G4711 G4712G4713 G4714 G4719 G4720 G4721 G4722 G4723 G4724 G4725 G4726G4727 G4729 G4761

Multiple sleep latency test (MSLT) procedure code 95805 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E662 F5104 F5105 G2581 G4700 G4701 G4709 G4730 G47411 G47419G47421 G47429 G4753 G4761

Pneumocardiogram procedure code 95807 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)G4731 G4733 G4734 G4735 G4736 G4737 P282 P283 P284 P285P2911 P2912 R063 R0681 R0902 R230 R6813




http://www.tmhp.com/ICD10_Updates_Med/07-15-15%20Updated%20Sleep%20Studies%20for%20Texas%20Medicaid.pdf

Polysomnography procedure codes 95782, 95783, 95808, 95810, and 95811 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)E6601 E662 F10182 F10282 F10982 F11182 F11282 F11982 F13182 F13282F13982 F14182 F14282 F14982 F15182 F15282 F15982 F19182 F19282 F19982F5101 F5102 F5103 F5104 F5105 F5109 F5111 F5112 F5113 F5119F513 F514 F515 F518 F519 G120 G121 G1221 G128 G2581G373 G4700 G4701 G4710 G4711 G4712 G4713 G4719 G4720 G4721G4722 G4723 G4724 G4725 G4726 G4727 G4729 G4730 G4731 G4732G4733 G4734 G4735 G4736 G4737 G4739 G47411 G47419 G47421 G47429G4750 G4751 G4752 G4753 G4754 G4759 G4761 G4762 G4763 G4769G478 G479 G710 G712 G809 G8250 G901 G931 J353 J9610J9611 J9612 N5201 N5202 N5203 Q040 Q041 Q042 Q078 Q308Q311 Q312 Q313 Q315 Q318 Q320 Q321 Q322 Q323 Q324Q672 Q673 Q674 Q750 Q751 Q752 Q753 Q754 Q755 Q758Q759 Q770 Q771 Q773 Q774 Q775 Q777 Q778 Q779 Q781Q789 Q870 R0681 R0902

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.69, “Sleep Studies,” for additional information.

Therapeutic ApheresisTherapeutic apheresis with extracorporeal affinity column adsorption and plasma reinfusion may be considered for reimbursement when billed for the low density lipoprotein (LDL) apheresis (such as Liposorber LA 15) or the protein A immunoadsorption columns (such as Prosorba).

Therapeutic apheresis using the LDL apheresis column may be reimbursed for familial hypercholesterolemia diagnosis code E780.

Procedure codes 36511, 36512, 36513, 36514, 36515, and 36516 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)C880 C882 C883 C888 C9000 C9002 C9010 C9011C9012 C9020 C9021 C9022 C9030 C9031 C9032 C9100C9101 C9102 C9110 C9111 C9112 C9130 C9131 C9132C9140 C9141 C9142 C9150 C9151 C9152 C9160 C9161C9162 C9190 C9191 C9192 C91A0 C91A1 C91A2 C91Z0C91Z1 C91Z2 C9200 C9201 C9202 C9210 C9211 C9212C9220 C9221 C9222 C9230 C9231 C9232 C9240 C9241C9242 C9250 C9251 C9252 C9260 C9261 C9262 C9290C9291 C9292 C92A0 C92A1 C92A2 C92Z0 C92Z1 C92Z2C9300 C9301 C9302 C9310 C9311 C9312 C9330 C9331C9332 C9391 C9392 C93Z0 C93Z1 C93Z2 C9400 C9401





Diagnosis Codes (Submitted as stand-alone diagnosis codes)C9402 C9420 C9421 C9422 C9430 C9431 C9432 C9440C9441 C9442 C9480 C9481 C9482 C9500 C9501 C9502C9510 C9511 C9512 C9590 C9591 C9592 D45 D472D473 D474 D5700 D5701 D5702 D571 D5720 D57211D57212 D57219 D57412 D5780 D57811 D57812 D57819 D588D589 D590 D591 D592 D593 D594 D599 D6182D65 D682 D68311 D6851 D6852 D6859 D6861 D6862D6869 D688 D690 D691 D692 D693 D6941 D6942D6949 D696 D698 D699 D72828 D732 D740 D748D749 D750 D751 D7589 D759 D761 D762 D763D77 D890 D892 E0842 E0942 E1042 E1142 E780G603 G610 G6181 G6189 G620 G621 G622 G6281G6282 G63 G64 G650 G7000 G7001 G731 I00I010 I012 I018 I019 I773 I776 I7789 K716K7200 K7201 K7581 K759 K760 K762 K767 K7689K77 K8041 K8043 K8045 K8047 K8061 K8063 K8065K8081 L100 L101 L102 L103 L104 L105 L1081L1089 L109 L900 L940 L941 L943 M05011 M05012M05021 M05022 M05031 M05032 M05041 M05042 M05051 M05052M05061 M05062 M05071 M05072 M0509 M05411 M05412 M05421M05422 M05431 M05432 M05441 M05442 M05451 M05452 M05461M05462 M05471 M05472 M0549 M05611 M05612 M05621 M05622M05631 M05632 M05641 M05642 M05651 M05652 M05661 M05662M05671 M05672 M0569 M069 M08011 M08012 M08021 M08022M08031 M08032 M08041 M08042 M08051 M08052 M08061 M08062M08071 M08072 M0809 M083 M08411 M08412 M08421 M08422M08431 M08432 M08441 M08442 M08451 M08452 M08461 M08462M08471 M08472 M0848 M08832 M08841 M08842 M08851 M08852M08861 M08931 M08932 M08941 M08942 M08951 M08952 M08961M08962 M310 M311 M320 M3210 M3219 M328 M3300M3301 M3302 M3309 M3310 M3311 M3312 M3319 M3320M3321 M3322 M3329 M3390 M3391 M3392 M3399 M340M341 M342 M3481 M3482 M3483 M3489 N000 N001N002 N003 N004 N005 N006 N007 N008 N010N011 N012 N013 N014 N015 N016 N017 N018N032 N034 N035 N037 N040 N042 N044 N045N047 N048 N049 N052 N054 N055 N058 N059N08 N171 N172 T8690 T8691 T8692 T8693 T8699




Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, Section 9, “Physician;” subsection 9.2 “Services, Benefits, Limitations, and Prior Authorization;” and subsection 9.2.73, “Therapeutic Apheresis,” for additional information.

Therapeutic PhlebotomyTherapeutic phlebotomy procedure code 99195 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D45 D649 D750 D751 E800 E801 E8020 E8021 E8029 E8310E83110 E83118 E8319 P611

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.74, “Therapeutic Phlebotomy” for additional information.

Therapeutic RadiopharmaceuticalsSodioum phosphate p-32 may be considered for prior authorization when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C7951 C7952 C9110 C9112 C9192 C91Z2 C9292 C92Z2 C9512 C9592 D45

Tositumomab or Ibritumomab Tiuxetan may be considered for prior authorization when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C8259 C8399 C8499 C84A9 C84Z9 C8519 C8529 C8589 C8599

Chromic phosphate p-32 suspension may be considered for prior authorization when the most appropriate procedure code is submitted with one of the following ICD-10 diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C782 C786

Strontium-89 chloride may be considered for prior authorization when the most appropriate procedure code is submitted with one of the following ICD-10 diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C7951 C7952

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.75, “Therapeutic Radiopharmaceuticals,” for additional information.

Transplants – Nonsolid OrganPrior authorization requests for stem cell transplants must be submitted with the most appropriate diagnosis codes or combination diagnosis codes as indicated. Texas Medicaid recognizes the following covered indications for stem cell transplants:

Allogeneic• Hematological malignancy






• Lymphatic malignancy

• Bone marrow disorders

• Hemoglobinopathies

• Platelet function disorders

• Immunodeficiency disorders

• Inherited metabolic disorders

• Multiple myeloma/plasma cell disorders

Autologous• Hematological malignancy

• Lymphatic malignancy

• Germ cell tumors

• Brain tumors

• Small round blue cell tumors of childhood

• Multiple myeloma/plasma cell disorders

Indications for additional infusions• Infusion of stem cells for failure to graft (autologous)

• Donor leukocyte infusion for persistent or relapsed malignant disease (allogeneic)

Indications for re-transplantation• Relapse of disease

• Failure to engraft or poor graft function

Reimbursement for autologous islet cell transplantation is limited to procedure code 48160. Stem cell transplants for conditions other than those listed will be considered on a case-by-case basis. Documentation for prior authoriza-tion must be submitted to determine whether the transplant is medically necessary and appropriate.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.51.7.1, “Allogeneic and Autologous Bone Marrow and Stem Cell Transplantation;” subsection 9.2.51.7.2, “Autologous Islet Cell Transplantation;” and subsection 9.2.51.7.3, “Prior Authorization for Nonsolid Organ Transplants,” for additional information.

Vaccines and ToxoidsAll immunizations must be reported with ICD-10-CM diagnosis code Z23. The type of immunization given will be identified by the procedure code.

Vaccines and toxoids may be reimbursed for clients who are birth through 20 years of age when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z00121 Z00129




Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 5.3.6, “THSteps Medical Checkups;” subsection 5.3.11.3, “Immunizations;” subsection 5.4.1, “Separate Identifiable Acute Care Evaluation and Management Visit;” Appendix B.3.2.2, “Immunizations (Vaccine/Toxoids);” subsec-tion 5.5.1, “Claims Information;” Claims Filing Handbook, subsection 6.3.1, “Diagnosis Coding;” and the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.36, “Immuni-zations for Clients Birth through 20 Years of Age,” for additional information.

Vision Services NonsurgicalProcedure codes S0620 and S0621 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z0100 Z0101

Prosthetic eyeglasses or contact lenses may be reimbursed when the appropriate procedure code is submitted with one of the following diagnosis codes: Diagnosis Codes (Submitted as stand-alone diagnosis codes)H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131H27132 H27133 Q123 Z961

Temporary prosthetic eyeglasses or contact lenses after cataract surgery may be reimbursed when the appropriate procedure code is submitted with the following diagnosis code: Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z961

Ultraviolet protection procedure code V2755 may be reimbursed when it is submitted with one of the following diagnosis codes: Diagnosis Codes (Submitted as stand-alone diagnosis codes)H2701 H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131H27132 H27133 Q123 Z961

An eye examination with or without refraction (procedure code 92002, 92004, 92012, 92014, or 92015) may be reimbursed when it is billed with one of the following diagnoses codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)A179 A182 A184 A1850 A1851 A1852 A1853 A1854A1859 A186 A187 A1881 A1884 A1885 A1889 A211A238 A239 A281 A300 A301 A303 A305 A308A309 A35 A3982 A400 A401 A403 A409 A4101A411 A412 A413 A414 A4150 A4151 A4152 A4153A4159 A4189 A419 A422 A4289 A429 A438 A439A480 A483 A488 A4901 A492 A493 A498 A5143A5430 A5431 A5432 A5433 A5439 A711 A719 A740A800 A801 A802 A8030 A8039 A804 A809 A8100A8109 A811 A812 A8181 A8189 A819 B0050 B0053B0059 B0581 B081 B20 B250 B251 B252 B258B259 B300 B301 B302 B303 B308 B333 B338




Diagnosis Codes (Submitted as stand-alone diagnosis codes)B471 B5801 B5809 B950 B951 B952 B953 B954B955 B9561 B957 B958 B960 B961 B963 B964B965 B966 B967 B9681 B9682 B9689 B970 B9711B9712 B9730 B9733 B9734 B9735 B9739 B977 C6901C6902 C6911 C6912 C6921 C6922 C6931 C6932 C6941C6942 C6951 C6952 C6961 C6962 C6981 C6982 C6991C6992 C7940 C7949 D0921 D0922 D3101 D3102 D3111D3112 D3121 D3122 D3131 D3132 D3141 D3142 D3151D3152 D3161 D3162 D3191 D3192 E08311 E08319 E08321E08329 E08331 E08339 E08341 E08349 E08351 E08359 E0836E0842 E09311 E09319 E09321 E09329 E09331 E09339 E09341E09349 E09351 E09359 E0936 E0942 E1010 E1011 E1021E1022 E1029 E10311 E10319 E10321 E10329 E10331 E10339E10341 E10349 E10351 E10359 E1036 E1039 E1040 E1041E1042 E1043 E1044 E1049 E1051 E1052 E1059 E10610E10618 E10620 E10621 E10622 E10628 E10630 E10638 E10641E10649 E1065 E1069 E108 E109 E1101 E1121 E1122E1129 E11311 E11319 E11321 E11329 E11331 E11339 E11341E11349 E11351 E11359 E1136 E1139 E1140 E1141 E1142E1143 E1144 E1149 E1151 E1152 E1159 E11610 E11620E11621 E11622 E11628 E11630 E11638 E11641 E11649 E1165E1169 E118 E119 E1301 E1310 E1311 E1321 E1322E1329 E13311 E13319 E13321 E13329 E13331 E13339 E13341E13349 E13351 E13359 E1336 E1339 E1340 E1341 E1342E1343 E1344 E1349 E1351 E1352 E1359 E13610 E13641E138 E139 F6089 G35 G360 G43001 G43009 G43011G43019 G43101 G43109 G43111 G43119 G43401 G43409 G43411G43419 G43501 G43509 G43511 G43519 G43601 G43609 G43611G43619 G43701 G43709 G43711 G43719 G43801 G43809 G43811G43819 G43821 G43829 G43831 G43839 G43901 G43909 G43919G43A0 G43A1 G43B0 G43B1 G43C0 G43C1 G43D0 G43D1G500 G510 G511 G512 G514 G518 G519 G527G932 H00011 H00012 H00014 H00015 H00021 H00022 H00024H00025 H00031 H00032 H00034 H00035 H0011 H0012 H0014H0015 H01001 H01002 H01004 H01005 H01011 H01012 H01014H01015 H01021 H01022 H01024 H01025 H01111 H01112 H01113H01114 H01115 H01116 H01119 H01121 H01122 H01124 H01125H01131 H01132 H01134 H01141 H01142 H01144 H01145 H018H019 H02001 H02002 H02004 H02005 H02011 H02012 H02014H02015 H02021 H02022 H02024 H02025 H02031 H02032 H02034H02035 H02036 H02041 H02042 H02044 H02045 H02051 H02052H02054 H02055 H02101 H02102 H02104 H02105 H02111 H02112H02114 H02115 H02121 H02122 H02124 H02125 H02131 H02132H02134 H02135 H02141 H02142 H02144 H02145 H02201 H02202




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H02204 H02205 H02211 H02212 H02214 H02215 H02221 H02222H02224 H02225 H02231 H02232 H02234 H02235 H0231 H0232H0234 H0235 H02401 H02402 H02403 H02421 H02422 H02423H02431 H02432 H02433 H02511 H02512 H02514 H02515 H02521H02522 H02524 H02525 H02526 H02531 H02532 H02534 H02535H0259 H0261 H0262 H0264 H0265 H0270 H02711 H02712H02714 H02715 H02721 H02722 H02724 H02725 H02731 H02732H02734 H02735 H0279 H02811 H02812 H02813 H02814 H02815H02816 H02821 H02822 H02824 H02825 H02831 H02832 H02834H02835 H02841 H02842 H02844 H02845 H02851 H02852 H02854H02855 H02861 H02862 H02864 H02865 H02871 H02872 H02874H02875 H0289 H029 H04001 H04002 H04003 H04011 H04012H04013 H04021 H04022 H04023 H04031 H04032 H04033 H04111H04112 H04113 H04121 H04122 H04123 H04131 H04132 H04133H04141 H04142 H04143 H04151 H04152 H04153 H04159 H04161H04162 H04163 H0419 H04201 H04202 H04203 H04211 H04212H04213 H04301 H04302 H04303 H04311 H04312 H04313 H04331H04332 H04333 H04411 H04412 H04413 H04421 H04422 H04423H04431 H04432 H04433 H04511 H04512 H04513 H04521 H04522H04523 H04541 H04542 H04543 H04551 H04552 H04553 H04559H04561 H04562 H04563 H04571 H04572 H04573 H04611 H04612H04613 H0469 H04811 H04812 H04813 H0489 H0500 H05011H05012 H05013 H05021 H05022 H05023 H05031 H05032 H05033H05041 H05042 H05043 H0510 H05111 H05112 H05113 H05121H05122 H05123 H0520 H05211 H05212 H05213 H05221 H05222H05223 H05231 H05232 H05233 H05241 H05242 H05243 H05251H05252 H05253 H05261 H05262 H05263 H0530 H05311 H05312H05313 H05321 H05322 H05323 H05331 H05332 H05333 H05341H05342 H05343 H05351 H05352 H05353 H05401 H05402 H05403H05411 H05412 H05413 H05421 H05422 H05423 H0551 H0552H0553 H05811 H05812 H05813 H05821 H05822 H05823 H0589H059 H10011 H10012 H10013 H10021 H10022 H10023 H1011H1012 H1013 H10211 H10212 H10213 H10221 H10222 H10223H10231 H10232 H10233 H1031 H1032 H1033 H10401 H10402H10403 H10411 H10412 H10413 H10421 H10422 H10423 H10431H10432 H10433 H1044 H1045 H10501 H10502 H10503 H10511H10512 H10513 H10521 H10522 H10523 H10531 H10532 H10533H10811 H10812 H10813 H1089 H109 H11001 H11002 H11003H11011 H11012 H11013 H11021 H11022 H11023 H11031 H11032H11033 H11041 H11042 H11043 H11051 H11052 H11053 H11061H11062 H11063 H1110 H11111 H11112 H11113 H11121 H11122H11123 H11131 H11132 H11133 H11141 H11142 H11143 H11151H11152 H11153 H11211 H11212 H11213 H11221 H11222 H11223H11231 H11232 H11233 H11241 H11242 H11243 H1131 H1132




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H1133 H11411 H11412 H11413 H11421 H11422 H11423 H11431H11432 H11433 H11441 H11442 H11443 H11811 H11812 H11813H11821 H11822 H11823 H1189 H119 H15001 H15002 H15003H15011 H15012 H15013 H15021 H15022 H15023 H15031 H15032H15033 H15041 H15042 H15043 H15051 H15052 H15053 H15091H15092 H15093 H15101 H15102 H15103 H15111 H15112 H15113H15121 H15122 H15123 H15811 H15812 H15813 H15821 H15822H15823 H15831 H15832 H15833 H15841 H15842 H15843 H15851H15852 H15853 H1589 H159 H16001 H16002 H16003 H16011H16012 H16013 H16021 H16022 H16023 H16031 H16032 H16033H16041 H16042 H16043 H16051 H16052 H16053 H16061 H16062H16063 H16071 H16072 H16073 H16101 H16102 H16103 H16111H16112 H16113 H16121 H16122 H16123 H16131 H16132 H16133H16141 H16142 H16143 H16201 H16202 H16203 H16211 H16212H16213 H16221 H16222 H16223 H16231 H16232 H16233 H16241H16242 H16243 H16251 H16252 H16253 H16261 H16262 H16263H16291 H16292 H16293 H16301 H16302 H16303 H16311 H16312H16313 H16321 H16322 H16323 H16331 H16332 H16333 H16391H16392 H16393 H16401 H16402 H16403 H16411 H16412 H16413H16421 H16422 H16423 H16431 H16432 H16433 H16441 H16442H16443 H168 H169 H1701 H1702 H1703 H1711 H1712H1713 H17811 H17812 H17813 H17821 H17822 H17823 H1789H179 H18001 H18002 H18003 H18011 H18012 H18013 H18021H18022 H18023 H18031 H18032 H18033 H18041 H18042 H18043H18051 H18052 H18053 H18061 H18062 H18063 H1811 H1812H1813 H1820 H18211 H18212 H18213 H18221 H18222 H18223H18231 H18232 H18233 H1830 H18311 H18312 H18313 H18321H18322 H18323 H18331 H18332 H18333 H1840 H18411 H18412H18413 H18421 H18422 H18423 H1843 H18441 H18442 H18443H18451 H18452 H18453 H18461 H18462 H18463 H1849 H1850H1851 H1852 H1853 H1854 H1855 H1859 H18601 H18602H18603 H18611 H18612 H18613 H18621 H18622 H18623 H18711H18712 H18713 H18721 H18722 H18723 H18731 H18732 H18733H18739 H18811 H18812 H18813 H18821 H18822 H18823 H18831H18832 H18833 H18891 H18892 H18893 H189 H2000 H20011H20012 H20013 H20021 H20022 H20023 H20031 H20032 H20033H20041 H20042 H20043 H20051 H20052 H20053 H2011 H2012H2013 H2021 H2022 H2023 H20811 H20812 H20813 H20821H20822 H20823 H209 H2101 H2102 H2103 H211X1 H211X2H211X3 H21211 H21212 H21213 H21221 H21222 H21223 H21231H21232 H21233 H21241 H21242 H21243 H21251 H21252 H21253H21261 H21262 H21263 H21271 H21272 H21273 H2129 H21301H21302 H21303 H21311 H21312 H21313 H21321 H21322 H21323H21341 H21342 H21343 H21351 H21352 H21353 H2141 H2142




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H2143 H21501 H21502 H21503 H21511 H21512 H21513 H21521H21522 H21523 H21531 H21532 H21533 H21541 H21542 H21543H21551 H21552 H21553 H21561 H21562 H21563 H2181 H2182H2189 H219 H22 H25011 H25012 H25013 H25031 H25032H25033 H25041 H25042 H25043 H25091 H25092 H25093 H2511H2512 H2513 H2521 H2522 H2523 H25811 H25812 H25813H2589 H259 H26001 H26002 H26003 H26011 H26012 H26013H26031 H26032 H26033 H26041 H26042 H26043 H26051 H26052H26053 H26061 H26062 H26063 H2609 H26101 H26102 H26103H26111 H26112 H26113 H26121 H26122 H26123 H26131 H26132H26133 H2620 H26211 H26212 H26213 H26221 H26222 H26223H26231 H26232 H26233 H2631 H2632 H2633 H2640 H26411H26412 H26413 H26491 H26492 H26493 H268 H269 H2701H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123H27131 H27132 H27133 H278 H279 H28 H30001 H30002H30003 H30011 H30012 H30013 H30021 H30022 H30023 H30031H30032 H30033 H30041 H30042 H30043 H30101 H30102 H30103H30111 H30112 H30113 H30121 H30122 H30123 H30131 H30132H30133 H30141 H30142 H30143 H3021 H3022 H3023 H30811H30812 H30813 H30891 H30892 H30893 H3091 H3092 H3093H31001 H31002 H31003 H31011 H31012 H31013 H31021 H31022H31023 H31091 H31092 H31093 H31101 H31102 H31103 H31111H31112 H31113 H31121 H31122 H31123 H31129 H3120 H3121H3122 H3123 H3129 H31301 H31302 H31303 H31311 H31312H31313 H31321 H31322 H31323 H31401 H31402 H31403 H31411H31412 H31413 H31419 H31421 H31422 H31423 H318 H319H33001 H33002 H33003 H33011 H33012 H33013 H33021 H33022H33023 H33031 H33032 H33033 H33041 H33042 H33043 H33051H33052 H33053 H33101 H33102 H33103 H33111 H33112 H33113H33119 H33191 H33192 H33193 H3321 H3322 H3323 H33301H33302 H33303 H33311 H33312 H33313 H33321 H33322 H33323H33331 H33332 H33333 H3341 H3342 H3343 H338 H3401H3402 H3403 H3411 H3412 H3413 H34211 H34212 H34213H34231 H34232 H34233 H34811 H34812 H34813 H34821 H34822H34823 H34831 H34832 H34833 H349 H3500 H35011 H35012H35013 H35021 H35022 H35023 H35031 H35032 H35033 H35041H35042 H35043 H35051 H35052 H35053 H35061 H35062 H35063H35071 H35072 H35073 H3509 H35101 H35102 H35103 H35111H35112 H35113 H35121 H35122 H35123 H35131 H35132 H35133H35141 H35142 H35143 H35151 H35152 H35153 H35161 H35162H35163 H35171 H35172 H35173 H3521 H3522 H3523 H3530H3531 H3532 H3533 H35341 H35342 H35343 H35351 H35352H35353 H35361 H35362 H35363 H35371 H35372 H35373 H35381H35382 H35383 H3540 H35411 H35412 H35413 H35421 H35422




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H35423 H35431 H35432 H35433 H35441 H35442 H35443 H35451H35452 H35453 H35461 H35462 H35463 H3550 H3551 H3552H3553 H3554 H3561 H3562 H3563 H3570 H35711 H35712H35713 H35721 H35722 H35723 H35731 H35732 H35733 H3581H3582 H3589 H359 H36 H40001 H40002 H40003 H40011H40012 H40013 H40021 H40022 H40023 H40031 H40032 H40033H40041 H40042 H40043 H40051 H40052 H40053 H40061 H40062H40063 H4010X0 H4010X1 H4010X2 H4010X3 H4010X4 H4011X0 H4011X1H4011X2 H4011X3 H4011X4 H401210 H401211 H401212 H401213 H401214H401220 H401221 H401222 H401223 H401224 H401230 H401231 H401232H401233 H401234 H401310 H401311 H401312 H401313 H401314 H401320H401321 H401322 H401323 H401324 H401330 H401331 H401332 H401333H401334 H40141 H40142 H40143 H401510 H401511 H401512 H401513H401514 H401520 H401521 H401522 H401523 H401524 H401530 H401531H401532 H401533 H401534 H4020X0 H4020X1 H4020X2 H4020X3 H4020X4H40211 H40212 H40213 H402210 H402211 H402212 H402213 H402214H402220 H402221 H402222 H402223 H402224 H402230 H402231 H402232H402233 H402234 H402290 H40231 H40232 H40233 H40241 H40242H40243 H4031X0 H4031X1 H4031X2 H4031X3 H4031X4 H4032X0 H4032X1H4032X2 H4032X3 H4032X4 H4033X0 H4033X1 H4033X2 H4033X3 H4033X4H4040X4 H4041X0 H4041X1 H4041X2 H4041X3 H4041X4 H4042X0 H4042X1H4042X2 H4042X3 H4042X4 H4043X0 H4043X1 H4043X2 H4043X3 H4043X4H4051X0 H4051X1 H4051X2 H4051X3 H4051X4 H4052X0 H4052X1 H4052X2H4052X3 H4052X4 H4053X0 H4053X1 H4053X2 H4053X3 H4053X4 H4061X0H4061X1 H4061X2 H4061X3 H4061X4 H4062X0 H4062X1 H4062X2 H4062X3H4062X4 H4063X0 H4063X1 H4063X2 H4063X3 H4063X4 H40811 H40812H40813 H40821 H40822 H40823 H40831 H40832 H40833 H4089H409 H42 H4301 H4302 H4303 H4311 H4312 H4313H4321 H4322 H4323 H43311 H43312 H43313 H43391 H43392H43393 H43811 H43812 H43813 H43821 H43822 H43823 H4389H439 H44001 H44002 H44003 H44011 H44012 H44013 H44021H44022 H44023 H44111 H44112 H44113 H44121 H44122 H44123H44131 H44132 H44133 H4419 H4421 H4422 H4423 H4430H44311 H44312 H44313 H44319 H44321 H44322 H44323 H44391H44392 H44393 H4440 H44411 H44412 H44413 H44421 H44422H44423 H44431 H44432 H44433 H44441 H44442 H44443 H44449H4450 H44511 H44512 H44513 H44521 H44522 H44523 H44531H44532 H44533 H44601 H44602 H44603 H44611 H44612 H44613H44621 H44622 H44623 H44631 H44632 H44633 H44641 H44642H44643 H44651 H44652 H44653 H44691 H44692 H44693 H44701H44702 H44703 H44711 H44712 H44713 H44721 H44722 H44723H44731 H44732 H44733 H44741 H44742 H44743 H44751 H44752H44753 H44791 H44792 H44793 H44811 H44812 H44813 H44821H44822 H44823 H4489 H449 H4601 H4602 H4603 H4611




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H4612 H4613 H462 H463 H468 H469 H47011 H47012H47013 H47021 H47022 H47023 H47031 H47032 H47033 H47091H47092 H47093 H4710 H4711 H4712 H4713 H47141 H47142H47143 H4720 H47211 H47212 H47213 H4722 H47231 H47232H47233 H47291 H47292 H47293 H47311 H47312 H47313 H47321H47322 H47323 H47331 H47332 H47333 H47391 H47392 H47393H4741 H4742 H4743 H4749 H47511 H47512 H47521 H47522H47531 H47532 H47611 H47612 H47621 H47622 H47631 H47632H47641 H47642 H479 H4901 H4902 H4903 H4911 H4912H4913 H4921 H4922 H4923 H4931 H4932 H4933 H4941H4942 H4943 H49889 H499 H5000 H50011 H50012 H50021H50022 H50031 H50032 H50041 H50042 H5005 H5006 H5007H5008 H5010 H50111 H50112 H50121 H50122 H50131 H50132H50141 H50142 H5015 H5016 H5017 H5018 H5021 H5022H5030 H50311 H50312 H5032 H50331 H50332 H5034 H5040H50411 H50412 H5042 H5043 H5050 H5051 H5052 H5053H5054 H5055 H5060 H50611 H50612 H5069 H50811 H50812H5089 H510 H5111 H5112 H5121 H5122 H5123 H518H519 H5201 H5202 H5203 H5211 H5212 H5213 H52201H52202 H52203 H52211 H52212 H52213 H52221 H52222 H52223H5231 H5232 H524 H52511 H52512 H52513 H52519 H52521H52522 H52523 H52531 H52532 H52533 H526 H527 H53001H53002 H53003 H53011 H53012 H53013 H53021 H53022 H53023H53031 H53032 H53033 H5310 H5311 H53121 H53122 H53123H53131 H53132 H53133 H53141 H53142 H53143 H53149 H5315H5316 H5319 H532 H5330 H5331 H5332 H5333 H5334H5340 H53411 H53412 H53413 H53421 H53422 H53423 H53431H53432 H53433 H53451 H53452 H53453 H53461 H53462 H5347H53481 H53482 H53483 H5350 H5351 H5352 H5353 H5354H5355 H5359 H5360 H5361 H5362 H5363 H5369 H5371H5372 H538 H539 H543 H5441 H5442 H5461 H5462H547 H548 H5500 H5501 H5502 H5503 H5504 H5509H5581 H5589 H5700 H5701 H5702 H5703 H5704 H57051H57052 H57053 H5711 H5712 H5713 H578 H579 H59021H59022 H59023 H59091 H59092 H59093 H5988 H5989 I10K9081 L121 L510 L511 L512 L513 L518 L519L631 L632 L638 L639 L648 L651 L652 L658L660 L662 L668 L669 L718 L719 M320 M3210M3219 M328 M329 M3500 M3501 M3509 M60009 P113P158 Q100 Q101 Q102 Q103 Q104 Q105 Q106Q107 Q110 Q111 Q112 Q120 Q121 Q122 Q123Q124 Q128 Q130 Q131 Q132 Q133 Q134 Q135Q1381 Q1389 Q140 Q141 Q142 Q143 Q148 Q150Q158 Q159 Q752 Q840 Q841 Q842 R29891 R42




Diagnosis Codes (Submitted as stand-alone diagnosis codes)R483 R51 S0011XA S0011XD S0011XS S0012XA S0012XD S0012XSS00211A S00211D S00211S S00212A S00212D S00212S S00221A S00221DS00221S S00222A S00222D S00222S S00241A S00241D S00241S S00242AS00242D S00242S S00251A S00251D S00251S S00252A S00252D S00252SS00261A S00261D S00261S S00262A S00262D S00262S S00271A S00271DS00271S S00272A S00272D S00272S S01101A S01101D S01101S S01102AS01102D S01102S S01111A S01111D S01111S S01112A S01112D S01112SS01121A S01121D S01121S S01122A S01122D S01122S S01129A S01131AS01131D S01131S S01132A S01132D S01132S S01141A S01141D S01141SS01142A S01142D S01142S S01151A S01151D S01151S S01152A S01152DS01152S S01159A S04011A S04011D S04011S S04012A S04012D S04012SS0402XA S0402XD S0402XS S04031A S04031D S04031S S04032A S04032DS04032S S04041A S04041D S04041S S04042A S04042D S04042S S0411XAS0411XD S0411XS S0412XA S0412XD S0412XS S0421XA S0421XD S0421XSS0422XA S0422XD S0422XS S0431XA S0431XD S0431XS S0432XA S0432XDS0432XS S0441XA S0441XD S0441XS S0442XA S0442XD S0442XS S0451XAS0451XD S0451XS S0452XA S0452XD S0452XS S0461XS S0462XS S0471XSS0472XS S04811S S04812S S04891S S04892S S0501XA S0501XD S0501XSS0502XA S0502XD S0502XS S0511XA S0511XD S0511XS S0512XA S0512XDS0512XS S0521XA S0521XD S0521XS S0522XA S0522XD S0522XS S0531XAS0531XD S0531XS S0532XA S0532XD S0532XS S0540XA S0540XD S0540XSS0541XA S0541XD S0541XS S0542XA S0542XD S0542XS S0551XA S0551XDS0551XS S0552XA S0552XD S0552XS S0561XA S0561XD S0561XS S0562XAS0562XD S0562XS S0571XA S0571XD S0571XS S0572XA S0572XD S0572XSS058X1A S058X1D S058X1S S058X2A S058X2D S058X2S S0591XA S0591XDS0591XS S0592XA S0592XD S0592XS T1501XA T1501XD T1501XS T1502XAT1502XD T1502XS T1511XA T1511XD T1511XS T1512XA T1512XD T1512XST1581XA T1581XD T1581XS T1582XA T1582XD T1582XS T1591XA T1591XDT1591XS T1592XA T1592XD T1592XS T2000XA T2000XD T2000XS T2009XAT2009XD T2009XS T2010XA T2010XD T2010XS T2019XA T2019XD T2019XST2020XA T2020XD T2020XS T2029XA T2029XD T2029XS T2030XA T2030XDT2030XS T2039XA T2039XD T2039XS T2059XA T2059XD T2059XS T2601XAT2601XD T2601XS T2602XA T2602XD T2602XS T2611XA T2611XD T2611XST2612XA T2612XD T2612XS T2621XA T2621XD T2621XS T2622XA T2622XDT2622XS T2631XA T2631XD T2631XS T2632XA T2632XD T2632XS T2641XAT2641XD T2641XS T2642XA T2642XD T2642XS T2651XA T2651XD T2651XST2652XA T2652XD T2652XS T2661XA T2661XD T2661XS T2662XA T2662XDT2662XS T2671XA T2671XD T2671XS T2672XA T2672XD T2672XS T2691XAT2691XD T2691XS T2692XA T2692XD T2692XS T360X5S T361X5S T362X5ST363X5S T364X5S T365X5S T366X5S T367X5S T368X5S T3695XS T370X5ST371X5S T372X5S T373X5S T374X5S T375X5S T378X5S T3795XS T380X5ST381X5S T382X5S T383X5S T384X5S T385X5S T386X5S T387X5S T38805ST38815S T38895S T38905S T38995S T39015S T39095S T391X5S T392X5ST39315S T39395S T394X5S T398X5S T3995XS T400X5S T401X5S T402X5S




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T403X5S T404X5S T405X5S T40605S T40695S T407X5S T408X5S T40905ST40995S T410X5S T411X5S T41205S T41295S T413X5S T4145XS T415X5ST420X5S T421X5S T422X5S T423X5S T424X5S T425X5S T426X5S T4275XST428X5S T43015S T43025S T431X5S T43205S T43215S T43225S T43295ST433X5S T434X5S T43505S T43595S T43605S T43615S T43625S T43635ST43695S T438X5S T4395XS T440X5S T441X5S T442X5S T443X5S T444X5ST445X5S T446X5S T447X5S T448X5S T44905S T44995S T450X5S T451X5ST452X5S T453X5S T454X5S T45515S T45525S T45605S T45615S T45625ST45695S T457X5S T458X5S T4595XS T460X5S T461X5S T462X5S T463X5ST464X5S T465X5S T466X5S T467X5S T468X5S T46905S T46995S T470X5ST471X5S T472X5S T473X5S T474X5S T475X5S T476X5S T477X5S T478X5ST4795XS T480X5S T481X5S T48205S T48295S T483X5S T484X5S T485X5ST486X5S T48905S T48995S T490X5S T491X5S T492X5S T493X5S T494X5ST495X1A T495X1D T495X1S T495X2A T495X2D T495X2S T495X3A T495X3DT495X3S T495X4A T495X4D T495X4S T495X5S T496X5S T497X5S T498X5ST4995XS T500X5S T501X5S T502X5S T503X5S T504X5S T505X5S T506X5ST507X5S T508X5S T50905S T50995S T50A15S T50A25S T50A95S T50B15ST50B95S T50Z15S T50Z95S T8131XA T8131XD T8131XS T8132XA T8132XDT8132XS T814XXA T814XXD T814XXS T8183XA T8183XD T8183XS T8189XAT8189XD T8189XS T819XXA T819XXD T819XXS T8521XA T8521XD T8521XST8522XA T8522XD T8522XS T8529XA T8529XD T8529XS T85310A T85310DT85310S T85311A T85311D T85311S T85318A T85318D T85318S T85320AT85320D T85320S T85321A T85321D T85321S T85328A T85328D T85328ST85390A T85390D T85390S T85391A T85391D T85391S T85398A T85398DT85398S T8579XA T8579XD T8579XS T8581XA T8581XD T8581XS T8582XAT8582XD T8582XS T8583XA T8583XD T8583XS T8584XA T8584XD T8584XST8585XA T8585XD T8585XS T8586XA T8586XD T8586XS T8589XA T8589XDT8589XS T886XXS T887XXS Z0389 Z09 Z1289 Z4421 Z4422Z48810 Z5189 Z525 Z7901 Z7902 Z791 Z792 Z793Z794 Z7951 Z7952 Z79810 Z79811 Z79818 Z7982 Z7983Z79891 Z79899 Z9001 Z947 Z961 Z970 Z9841 Z9842Z9849 Z9883

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)B394, H32

B395, H32

B399, H32

E1010, E1065

E1036, E1065

E1039, E1065

E1040, E1065

E1021, E1065

E10311, E1065

E10319, E1065

E1051, E1065

E1069, E1065

E108, E1065

E118, E1165

E1100, E1165

E1101, E1165

E1121, E1165

E11311, E1165

E11319, E1165

E1136, E1165

E1139, E1165

E1140, E1165

E1151, E1165

E1169, E1165






Ophthalmological Ultrasound procedure codes 76510, 76511, 76512, 76513, 76516, and 76519 may be reimbursed when they are billed with one of the following diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)A1859 C6941 C6942 C6961 C6962 C7940 C7949 D0921D0922 D3141 D3142 D3161 D3162 D487 D4981 E08311E08319 E08321 E08329 E08331 E08339 E08341 E08349 E08351E08359 E0836 E0839 E0840 E0841 E0842 E0843 E0844E0849 E0851 E0859 E08610 E08618 E08620 E08621 E08622E08628 E08630 E08638 E08649 E0865 E0869 E088 E09311E09319 E09321 E09329 E09331 E09339 E09341 E09349 E09351E09359 E0936 E0939 E0940 E0941 E0942 E0943 E0944E0949 E0951 E0959 E09610 E09618 E09620 E09621 E09622E09628 E09630 E09638 E09649 E0965 E0969 E098 E10311E10319 E10321 E10329 E10331 E10339 E10341 E10349 E10351E10359 E1036 E1039 E11311 E11319 E11321 E11329 E11331E11339 E11341 E11349 E11351 E11359 E1136 E1139 E13311E13319 E13321 E13329 E13331 E13339 E13341 E13349 E13351E13359 E1336 E1339 E1340 E1341 E1342 E1343 E1344E1349 E1359 E13610 E13620 E13621 E13622 E13628 E13638E13649 E1365 E1369 E138 H02813 H02816 H04151 H04152H04153 H04159 H0551 H0552 H0553 H1701 H1702 H1703H1711 H1712 H1713 H17811 H17812 H17813 H17821 H17822H17823 H1789 H179 H18001 H18002 H18003 H18011 H18012H18013 H18021 H18022 H18023 H18031 H18032 H18033 H18041H18042 H18043 H18051 H18052 H18053 H18061 H18062 H18063H1811 H1812 H1813 H1820 H18211 H18212 H18213 H18221H18222 H18223 H18231 H18232 H18233 H1830 H18311 H18312H18313 H18321 H18322 H18323 H18331 H18332 H18333 H1840H18411 H18412 H18413 H18421 H18422 H18423 H1843 H18441H18442 H18443 H18451 H18452 H18453 H18461 H18462 H18463H1849 H1850 H1851 H1852 H1853 H1854 H1855 H1859H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622H18623 H1870 H18711 H18712 H18713 H18721 H18722 H18723H18731 H18732 H18733 H18739 H18791 H18792 H18793 H18811H18812 H18813 H18821 H18822 H18823 H18831 H18832 H18833H18891 H18892 H18893 H189 H2101 H2102 H2103 H2181H2182 H2189 H22 H25011 H25012 H25013 H25031 H25032H25033 H25041 H25042 H25043 H25091 H25092 H25093 H2511H2512 H2513 H2521 H2522 H2523 H25811 H25812 H25813




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H2589 H259 H26001 H26002 H26003 H26011 H26012 H26013H26031 H26032 H26033 H26041 H26042 H26043 H26051 H26052H26053 H26061 H26062 H26063 H2609 H26101 H26102 H26103H26111 H26112 H26113 H26121 H26122 H26123 H26131 H26132H26133 H2620 H26211 H26212 H26213 H26221 H26222 H26223H26231 H26232 H26233 H2631 H2632 H2633 H2640 H26411H26412 H26413 H26491 H26492 H26493 H268 H269 H2701H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123H27131 H27132 H27133 H278 H279 H28 H31101 H31102H31103 H31111 H31112 H31113 H31121 H31122 H31123 H31129H3123 H31301 H31302 H31303 H31311 H31312 H31313 H31321H31322 H31323 H31401 H31402 H31403 H31411 H31412 H31413H31419 H31421 H31422 H31423 H33001 H33002 H33003 H33011H33012 H33013 H33021 H33022 H33023 H33031 H33032 H33033H33041 H33042 H33043 H33051 H33052 H33053 H33101 H33102H33103 H33111 H33112 H33113 H33119 H33191 H33192 H33193H3321 H3322 H3323 H33301 H33302 H33303 H33311 H33312H33313 H33321 H33322 H33323 H33331 H33332 H33333 H3341H3342 H3343 H338 H3401 H3402 H3403 H3411 H3412H3413 H34211 H34212 H34213 H34231 H34232 H34233 H34811H34812 H34813 H34821 H34822 H34823 H34831 H34832 H34833H349 H3500 H35011 H35012 H35013 H35021 H35022 H35023H35031 H35032 H35033 H35041 H35042 H35043 H35051 H35052H35053 H35061 H35062 H35063 H35071 H35072 H35073 H3509H35101 H35102 H35103 H35111 H35112 H35113 H35121 H35122H35123 H35131 H35132 H35133 H35141 H35142 H35143 H35151H35152 H35153 H35161 H35162 H35163 H35171 H35172 H35173H3521 H3522 H3523 H3530 H3531 H3532 H3533 H35341H35342 H35343 H35351 H35352 H35353 H35361 H35362 H35363H35371 H35372 H35373 H35381 H35382 H35383 H3540 H35411H35412 H35413 H35421 H35422 H35423 H35431 H35432 H35433H35441 H35442 H35443 H35451 H35452 H35453 H35461 H35462H35463 H3550 H3551 H3552 H3553 H3554 H3561 H3562H3563 H3570 H35711 H35712 H35713 H35721 H35722 H35723H35731 H35732 H35733 H3581 H3582 H3589 H36 H4301H4302 H4303 H43811 H43812 H43813 H44601 H44602 H44603H44611 H44612 H44613 H44621 H44622 H44623 H44631 H44632H44633 H44641 H44642 H44643 H44651 H44652 H44653 H44691H44692 H44693 H44701 H44702 H44703 H44711 H44712 H44713H44721 H44722 H44723 H44731 H44732 H44733 H44741 H44742H44743 H44751 H44752 H44753 H44791 H44792 H44793 H578Q120 Q121 Q122 Q123 Q124 Q128 S0551XA S0551XDS0551XS S0552XA S0552XD S0552XS T1501XA T1501XD T1501XS T1502XAT1502XD T1502XS T1511XA T1511XD T1511XS T1512XA T1512XD T1512XS




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T1581XA T1581XD T1581XS T1582XA T1582XD T1582XS T1591XA T1591XDT1591XS T1592XA T1592XD T1592XS

Combination diagnosis codesCombination Diagnosis Codes (Must be submitted in pairs)

E0821, E0865

E08311, E0865

E08319, E0865

E0836, E0865

E0840, E0865

E0851, E0865

E0869, E0865

E088, E0865

E0921, E0865

E09311, E0865

E09319, E0865

E0936, E0865

E0940, E0865

E0951, E0865

E0969, E0865

E098, E0865

E10311, E1065

E10319, E1065

E1036, E1065

E1039, E1065

E11311, E1165

E11319, E1165

E1136, E1165

E1139, E1165



Ophthalmological ultrasound procedure code 76514 may be reimbursed once per lifetime or as medically necessary dependent on the diagnosis code that is submitted. Procedure code 76514 may be reimbursed once per lifetime when it is submitted with one of the following diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes): Once per lifetime limitationH40001 H40002 H40003 H40011 H40012 H40013 H40021 H40022H40023 H40031 H40032 H40033 H40041 H40042 H40043 H40051H40052 H40053 H40061 H40062 H40063 H4010X0 H4010X1 H4010X2H4010X3 H4010X4 H4011X0 H4011X1 H4011X2 H4011X3 H4011X4 H401210H401211 H401212 H401213 H401214 H401220 H401221 H401222 H401223H401224 H401230 H401231 H401232 H401233 H401234 H401310 H401311H401312 H401313 H401314 H401320 H401321 H401322 H401323 H401324H401330 H401331 H401332 H401333 H401334 H40141 H40142 H40143H401510 H401511 H401512 H401513 H401514 H401520 H401521 H401522H401523 H401524 H401530 H401531 H401532 H401533 H401534 H4020X0H4020X1 H4020X2 H4020X3 H4020X4 H40211 H40212 H40213 H402210H402211 H402212 H402213 H402214 H402220 H402221 H402222 H402223H402224 H402230 H402231 H402232 H402233 H402234 H402290 H40231H40232 H40233 H40241 H40242 H40243 H4031X0 H4031X1 H4031X2H4031X3 H4031X4 H4032X0 H4032X1 H4032X2 H4032X3 H4032X4 H4033X0H4033X1 H4033X2 H4033X3 H4033X4 H4041X0 H4041X1 H4041X2 H4041X3H4041X4 H4042X0 H4042X1 H4042X2 H4042X3 H4042X4 H4043X0 H4043X1H4043X2 H4043X3 H4043X4 H4051X0 H4051X1 H4051X2 H4051X3 H4051X4H4052X0 H4052X1 H4052X2 H4052X3 H4052X4 H4053X0 H4053X1 H4053X2H4053X3 H4053X4 H4061X0 H4061X1 H4061X2 H4061X3 H4061X4 H4062X0H4062X1 H4062X2 H4062X3 H4062X4 H4063X0 H4063X1 H4063X2 H4063X3




Diagnosis Codes (Submitted as stand-alone diagnosis codes): Once per lifetime limitationH4063X4 H40811 H40812 H40813 H40821 H40822 H40823 H40831H40832 H40833 H4089 H409 H42 H44511 H44512 H44513Q150

Ophthalmological ultrasound procedure code 76514 may be reimbursed as medically necessary when it is submitted with one of the following diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes) One Per LifetimeH40001 H40002 H40003 H40011 H40012 H40013 H40021 H40022 H40023 H40031 H40032 H40033 H40041 H40042 H40043 H40051 H40052 H40053 H40061 H40062 H40063 H4010X0 H4010X1 H4010X2 H4010X3 H4010X4 H4011X0 H4011X1 H4011X2 H4011X3 H4011X4 H401210 H401211 H401212 H401213 H401214 H401220 H401221 H401222 H401223 H401224 H401230 H401231 H401232 H401233 H401234 H401310 H401311 H401312 H401313 H401314 H401320 H401321 H401322 H401323 H401324 H401330 H401331 H401332 H401333 H401334 H40141 H40142 H40143 H401510 H401511 H401512 H401513 H401514 H401520 H401521 H401522 H401523 H401524 H401530 H401531 H401532 H401533 H401534 H4020X0 H4020X1 H4020X2 H4020X3 H4020X4 H40211 H40212 H40213 H402210 H402211 H402212 H402213 H402214 H402220 H402221 H402222 H402223 H402224 H402230 H402231 H402232 H402233 H402234 H402290 H40231 H40232 H40233 H40241 H40242 H40243 H4031X0 H4031X1 H4031X2 H4031X3 H4031X4 H4032X0 H4032X1 H4032X2 H4032X3 H4032X4 H4033X0 H4033X1 H4033X2 H4033X3 H4033X4 H4041X0 H4041X1 H4041X2 H4041X3 H4041X4 H4042X0 H4042X1 H4042X2 H4042X3 H4042X4 H4043X0 H4043X1 H4043X2 H4043X3 H4043X4 H4051X0 H4051X1 H4051X2 H4051X3 H4051X4 H4052X0 H4052X1 H4052X2 H4052X3 H4052X4 H4053X0 H4053X1 H4053X2 H4053X3 H4053X4 H4061X0 H4061X1 H4061X2 H4061X3 H4061X4 H4062X0 H4062X1 H4062X2 H4062X3 H4062X4 H4063X0 H4063X1 H4063X2 H4063X3 H4063X4 H40811 H40812 H40813 H40821 H40822 H40823 H40831 H40832 H40833 H4089 H409 H42 H44511 H44512 H44513Q150 Diagnosis Codes (Submitted as stand-alone diagnosis codes): As medically necessaryA1859 H1701 H1702 H1703 H1711 H1712 H1713 H17811H17812 H17813 H17821 H17822 H17823 H1789 H179 H18001H18002 H18003 H18011 H18012 H18013 H18021 H18022 H18023H18031 H18032 H18033 H18041 H18042 H18043 H18051 H18052H18053 H18061 H18062 H18063 H1811 H1812 H1813 H1820H18211 H18212 H18213 H18221 H18222 H18223 H18231 H18232H18233 H1830 H18311 H18312 H18313 H18321 H18322 H18323H18331 H18332 H18333 H1840 H18411 H18412 H18413 H18421




Diagnosis Codes (Submitted as stand-alone diagnosis codes): As medically necessaryH18422 H18423 H1843 H18441 H18442 H18443 H18451 H18452H18453 H18461 H18462 H18463 H1849 H1850 H1851 H1852H1853 H1854 H1855 H1859 H18601 H18602 H18603 H18611H18612 H18613 H18621 H18622 H18623 H1870 H18711 H18712H18713 H18791 H18792 H18793 H18831 H18832 H18833 H21551H21552 H21553 H4040X4 H4041X0 H4041X1 H4041X2 H4041X3 H4041X4H4042X0 H4042X1 H4042X2 H4042X3 H4042X4 H4043X0 H4043X1 H4043X2H4043X3 H4043X4 H4720 H47211 H47212 H47213 H4722 H47231H47232 H47233 H47291 H47292 H47293 H5201 H5202 H5203Q133 Q134 Q150 T85310A T85310D T85310S T85311A T85311DT85311S T85318A T85318D T85318S T85320A T85320D T85320S T85321AT85321D T85321S T85328A T85328D T85328S T85390A T85390D T85390ST85391A T85391D T85391S T85398A T85398D T85398S Z48810 Z947

Corneal topography procedure code 92025 may be reimbursed when it is submitted with one of the following diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H10811 H10812 H10813 H11001 H11002 H11003 H11011 H11012H11013 H11021 H11022 H11023 H11031 H11032 H11033 H11041H11042 H11043 H11051 H11052 H11053 H11061 H11062 H11063H11821 H11822 H11823 H1189 H16001 H16002 H16003 H16011H16012 H16013 H16021 H16022 H16023 H16031 H16032 H16033H16041 H16042 H16043 H16051 H16052 H16053 H16061 H16062H16063 H16071 H16072 H16073 H1701 H1702 H1703 H1711H1712 H1713 H17811 H17812 H17813 H17821 H17822 H17823H1789 H179 H1811 H1812 H1813 H1820 H18221 H18222H18223 H18231 H18232 H18233 H1840 H18411 H18412 H18413H18451 H18452 H18453 H18461 H18462 H18463 H1849 H18601H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623H1870 H18711 H18712 H18713 H18721 H18722 H18723 H18731H18732 H18733 H18739 H18791 H18792 H18793 H18831 H18832H18833 S0521XA S0521XD S0521XS S0522XA S0522XD S0522XS S0531XAS0531XD S0531XS S0532XA S0532XD S0532XS T2611XA T2611XD T2611XST2612XA T2612XD T2612XS T2661XA T2661XD T2661XS T2662XA T2662XDT2662XS T85310A T85310D T85310S T85311A T85311D T85311S T85318AT85318D T85318S T85320A T85320D T85320S T85321A T85321D T85321ST85328A T85328D T85328S T85390A T85390D T85390S T85391A T85391DT85391S T85398A T85398D T85398S Z48810 Z947 Z9841 Z9842Z9849 Z9883

Polcycarbonate lens procedure code V2784 may be reimbursed when it is submitted with one of the following diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F840 F843 F845 F848 F849 F951 G20 G2111




Diagnosis Codes (Submitted as stand-alone diagnosis codes)G2119 G213 G214 G218 G3183 G3184 G35 G40001G40009 G40019 G40101 G40109 G40111 G40119 G40201 G40209G40211 G40219 G40301 G40309 G40311 G40401 G40409 G40411G40419 G40501 G40509 G40801 G40802 G40803 G40804 G40813G4089 G40901 G40909 G40911 G40919 G40A01 G40A09 G40A11G40A19 G40B01 G40B09 G40B11 G40B19 G710 G7111 G7112G7113 G7114 G7119 G712 G713 G718 G720 G722G723 G7241 G7249 G7281 G7289 G729 G737 G800G801 G802 G804 G808 G809 H33001 H33002 H33003H33011 H33012 H33013 H33021 H33022 H33023 H33031 H33032H33033 H33041 H33042 H33043 H33051 H33052 H33053 H33191H33192 H33193 H3321 H3322 H3323 H33301 H33302 H33303H33311 H33312 H33313 H33321 H33322 H33323 H33331 H33332H33333 H3341 H3342 H3343 H338 H53001 H53002 H53003H53011 H53012 H53013 H53021 H53022 H53023 H53031 H53032H53033 H5441 H5442 H5451 H5452 H8101 H8102 H8103H8109 H8110 H8111 H8112 H8113 H8120 H8121 H8122H8123 H81311 H81312 H81313 H81319 H81391 H81392 H81393H81399 H8301 H8302 H8303 H8309 H8311 H8312 H8313H8319 H832X1 H832X2 H832X3 H832X9 P100 P101 P104P108 P524 P526 P528 Q8740 Q87410 Q87418 Q8742Q8743 Q900 Q901 Q902 Q909 S06890A S06890D S06890SS06891A S06891D S06891S S06892A S06892D S06892S S06893A S06893DS06893S S06894A S06894D S06894S S06895A S06895D S06895S S06896AS06896D S06896S S06899A S06899D S06899S S069X0A S069X0D S069X0SS069X1A S069X1D S069X1S S069X2A S069X2D S069X2S S069X3A S069X3DS069X3S S069X4A S069X4D S069X4S S069X5A S069X5D S069X5S S069X6AS069X6D S069X6S S069X9A S069X9D S069X9S T8521XA T8521XD T8521XST8522XA T8522XD T8522XS T8529XA T8529XD T8529XS T85310A T85310DT85310S T85311A T85311D T85311S T85318A T85318D T85318S T85320AT85320D T85320S T85321A T85321D T85321S T85328A T85328D T85328ST85390A T85390D T85390S T85391A T85391D T85391S T85398A T85398DT85398S T8579XA T8579XD T8579XS

Combination diagnosis codesCombination Diagnosis Codes (Must be submitted in pairs)S06890A, S0190XA

S06891A, S0190XA

S06892A, S0190XA

S06893A, S0190XA

S06894A, S0190XA

S06895A, S0190XA

S06896A, S0190XA

S06899A, S0190XA






Sensorimotor examination procedure code 92060 and orthoptic and pleoptic training procedure code 92065 may be reimbursed when they are submitted with one of the following diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H50011 H50012 H50021 H50022 H50031 H50032 H50041 H50042H5005 H5006 H5007 H5008 H50111 H50112 H50121 H50122H50131 H50132 H50141 H50142 H5015 H5016 H5017 H5018H5021 H5022 H50311 H50312 H5032 H50331 H50332 H5034H50411 H50412 H5042 H5043 H5051 H5052 H5053 H5054H5055 H50611 H50612 H5069 H50811 H50812 H5089 H5111H5112 H518 H53011 H53012 H53013 H53021 H53022 H53023H53031 H53032 H53033 H5501 H5502 H5503 H5504 H5509H5581 H5589

Eye photography procedure codes 92285, 92286, and 92287 may be reimbursed when they are submitted with one of the following diagnosis codes or combination diagnosis codes as indicated:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)A000 A001 A009 A179 A1803 A182 A184 A1850 A1851 A1852A1853 A1854 A1859 A186 A187 A1881 A1884 A1885 A1889 A211A230 A231 A232 A233 A238 A239 A240 A281 A300 A301A303 A305 A308 A309 A35 A3686 A3982 A400 A401 A403A409 A4101 A411 A412 A413 A414 A4150 A4151 A4152 A4153A4159 A4189 A419 A420 A421 A422 A4289 A429 A430 A431A438 A439 A480 A483 A488 A4901 A492 A493 A498 A711A719 A740 A800 A801 A802 A8030 A8039 A804 A809 A811A812 A8181 A8189 A819 B0050 B0053 B0059 B0581 B081 B0820B0821 B0822 B083 B09 B1001 B1009 B1081 B1082 B20 B250B251 B252 B258 B259 B300 B301 B302 B303 B308 B309B333 B334 B338 B471 B479 B950 B951 B952 B953 B954B955 B9561 B957 B958 B960 B961 B963 B964 B965 B966B967 B9681 B9682 B9689 B970 B9711 B9712 B9730 B9733 B9734B9735 B9739 B977 E1010 E1011 E1021 E1022 E1029 E10311 E10319E10321 E10329 E10331 E10339 E10341 E10349 E10351 E10359 E1036 E1039E1040 E1041 E1042 E1043 E1044 E1049 E1051 E1052 E1059 E10610E10618 E10620 E10621 E10622 E10628 E10630 E10638 E10641 E10649 E1065E1069 E108 E109 E1101 E1121 E1122 E1129 E11311 E11319 E11321E11329 E11331 E11339 E11341 E11349 E11351 E11359 E1136 E1139 E1140E1141 E1142 E1143 E1144 E1149 E1151 E1152 E1159 E11610 E11620E11621 E11622 E11628 E11630 E11638 E11641 E11649 E1165 E1169 E118E119 E1301 E1310 E1311 E1321 E1322 E1329 E13311 E13319 E13321E13329 E13331 E13339 E13341 E13349 E13351 E13359 E1336 E1339 E1340E1341 E1342 E1343 E1344 E1349 E1351 E1352 E1359 E13610 E13641E138 E139 F0150 F0151 F0280 F0281 F0390 F04 F05 F060F061 F062 F0630 F0631 F0632 F0633 F0634 F064 F068 F070F0781 F09 F1010 F10120 F10121 F10129 F1014 F10150 F10151 F10159




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F10180 F10181 F10182 F10188 F1019 F1020 F1021 F10220 F10221 F10229F10230 F10231 F10239 F1024 F10250 F10251 F10259 F1026 F1027 F10280F10281 F10282 F10288 F1029 F10921 F10929 F10950 F10951 F10959 F1096F1097 F10980 F10982 F1099 F1110 F11121 F1114 F11150 F11151 F11159F11181 F11182 F11188 F1119 F1120 F1121 F11221 F11222 F1123 F1124F11250 F11251 F11259 F11281 F11282 F11288 F1129 F11921 F11922 F1193F1194 F11950 F11951 F11959 F11981 F11982 F11988 F1199 F1210 F12121F12122 F12150 F12151 F12159 F12180 F12188 F1219 F1220 F1221 F12221F12222 F12250 F12251 F12259 F12280 F12288 F1229 F1290 F12921 F12922F12950 F12951 F12959 F12980 F12988 F1299 F1310 F13120 F13150 F13151F13159 F13180 F13181 F13182 F13188 F1320 F1321 F13230 F13232 F13239F13250 F13251 F13259 F1326 F1327 F13280 F13281 F13282 F13288 F13950F13951 F13959 F1396 F1397 F13980 F13981 F13982 F13988 F1410 F14121F14122 F1414 F14150 F14151 F14159 F14180 F14181 F14182 F14188 F1419F1420 F1421 F14221 F14222 F1423 F1424 F14250 F14251 F14259 F14280F14281 F14282 F14288 F1429 F14921 F14922 F1494 F14950 F14951 F14959F14980 F14981 F14982 F14988 F1499 F1510 F15121 F15122 F1514 F15150F15151 F15159 F15180 F15181 F15182 F15188 F1519 F1520 F1521 F15221F15222 F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282 F15288F1529 F15920 F15921 F15922 F1593 F1594 F15950 F15951 F15959 F15980F15981 F15982 F15988 F1599 F1610 F16121 F16122 F1614 F16150 F16151F16159 F16180 F16183 F16188 F1619 F1620 F1621 F16221 F1624 F16250F16251 F16259 F16280 F16283 F16288 F1629 F16921 F1694 F16950 F16951F16959 F16980 F16983 F16988 F1699 F17200 F17201 F17203 F17208 F17209F17210 F17218 F17220 F17228 F17290 F17298 F1810 F18121 F1814 F18150F18151 F18159 F1817 F18180 F18188 F1819 F1820 F1821 F18221 F1824F18250 F18251 F18259 F1827 F18280 F18288 F1829 F18921 F1894 F18950F18951 F18959 F1897 F18980 F18988 F1899 F1910 F19121 F19122 F1914F19150 F19151 F19159 F1916 F1917 F19180 F19181 F19182 F19188 F1919F1920 F1921 F19221 F19222 F19230 F19232 F19239 F1924 F19250 F19251F19259 F1926 F1927 F19280 F19281 F19282 F19288 F1929 F19921 F19922F19930 F19932 F19939 F1994 F19950 F19951 F19959 F1996 F1997 F19980F19981 F19982 F19988 F1999 F200 F201 F202 F205 F2081 F2089F209 F21 F22 F23 F24 F250 F251 F258 F259 F28F29 F3010 F3011 F3012 F3013 F302 F303 F304 F308 F310F3110 F3111 F3112 F3113 F312 F3130 F3131 F3132 F314 F315F3160 F3161 F3162 F3163 F3164 F3170 F3171 F3172 F3173 F3174F3175 F3176 F3177 F3178 F3181 F3189 F319 F320 F321 F322F323 F324 F325 F328 F329 F330 F331 F332 F333 F3340F3341 F3342 F338 F339 F340 F341 F348 F349 F39 F4000F4001 F4002 F4010 F4011 F40210 F40218 F40220 F40228 F40230 F40231F40232 F40233 F40240 F40241 F40242 F40243 F40248 F40290 F40291 F40298F408 F409 F410 F411 F413 F418 F419 F42 F430 F4310F4311 F4312 F4320 F4321 F4322 F4323 F4324 F4325 F4329 F438




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F440 F441 F444 F446 F447 F4481 F4489 F449 F450 F451F4520 F4521 F4522 F4529 F4541 F4542 F458 F459 F481 F488F489 F5000 F5001 F5002 F502 F508 F509 F5101 F5102 F5103F5104 F5109 F5111 F5112 F5119 F513 F514 F515 F518 F519F520 F521 F5221 F5222 F5231 F5232 F524 F525 F526 F528F529 F53 F551 F553 F59 F600 F601 F602 F603 F604F605 F606 F607 F6081 F6089 F609 F630 F631 F632 F633F6381 F6389 F639 F641 F642 F648 F650 F651 F652 F653F654 F6551 F6552 F6581 F6589 F659 F66 F6810 F6811 F6812F6813 F688 F800 F801 F802 F804 F8089 F809 F810 F812F8181 F8189 F819 F82 F840 F843 F845 F848 F849 F88F89 F900 F901 F902 F908 F909 F911 F912 F913 F918F919 F930 F938 F939 F940 F941 F942 F948 F950 F951F952 F958 F959 F980 F981 F9821 F9829 F983 F984 F985F988 F989 F99 G44209 H9325 K9081 L081 L444 M60009 R37R451 R457 R480 Z87890

Combination diagnosis codesCombination Diagnosis Codes (Must be submitted in pairs)E1010, E1065

E1011, E1065

E1021, E1065

E10311, E1065

E10319, E1065

E1036, E1065

E1039, E1065

E1040, E1065

E1051, E1065

E1069, E1065

E108, E1065

E1100, E1165

E1101, E1165

E1121, E1165

E11311, E1165

E11319, E1165

E1136, E1165

E1139, E1165

E1140, E1165

E1151, E1165

E1169, E1165

E118, E1165

F0390, F05



The Texas Medicaid Provider Procedures Manual Radiology and Laboratory Services Handbook, subsection 3.2.7.8, “Nonsurgical Vision Services,” for additional information.

Vitamin B12 (Cyanocobalamin) InjectionsVitamin B12 procedure code J3420 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B700 D510 D511 D512 D513 D518 D520 D521 D528 D529D531 D649 E538 E710 E71110 E71111 E71118 E71120 E71121 E71128E7119 E712 E7210 E7211 E7212 E7219 E723 E7251 E7259 E728G621 G63 H4611 H4612 H4613 H463 K5660 K900 K901 K902K903 K9089 K909 K911 K912 Z903 Z9221 Z980




http://eopm/eopm/Provider_manuals/TMPPM/Output/Vol2_Radiology_and_Laboratory_Services_Handbook.33.01.shtml#1831927

For the list of diagnoses in the table above, documentation in the medical records must include rationale as to why the client was unable to be treated with oral therapy.

Refer to: The Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, subsection 9.2.39.25, “Vitamin B12 (Cyanocobalamin) Injections,” for additional information.

BEHAVIORAL HEALTH SERVICES

ICD-10 and DSM Diagnosis Codes for Behavioral Health Services

Inpatient Behavioral HealthPsychotherapy procedure code 90832, 90833, 90834, 90836, 90837, 90838, 90847, 90853, or 90899 for Alzheim-er’s disease or dementia may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 F0391 G3184 R41841

Psychological Testing and Neuropsychological TestingPsychological testing (procedure code 96101) and neuropsychological testing (procedure code 96118) may be reimbursed when they are submitted by a psychiatrist, psychologist, licensed psychological associate (LPA), or a provisionally licensed psychologist (PLP) with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)A8100 A8101 A8109 A8181 A8183 B1001 B1009 B451D8681 E7500 E7501 E7502 E7509 E7510 E7511 E7519E7523 E7525 E7529 E754 F0390 F0391 F04 F05F060 F061 F062 F0630 F0631 F0632 F0633 F0634F064 F068 F070 F0781 F09 F1010 F10120 F10121F10129 F1014 F10150 F10151 F10159 F10180 F10181 F10182F10188 F1019 F1020 F1021 F10220 F10221 F10229 F10230F10231 F10232 F10239 F1024 F10250 F10251 F10259 F1026F10280 F10281 F10282 F10288 F1029 F10920 F10921 F10929F1094 F10950 F10951 F10959 F1096 F10980 F10981 F10982F10988 F1099 F1110 F11120 F11121 F1114 F11150 F11151F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11220F11221 F11222 F11229 F1123 F1124 F11250 F11251 F11259F11281 F11282 F11288 F1129 F11920 F11921 F11922 F11929F1193 F1194 F11950 F11951 F11959 F11981 F11982 F11988F1199 F1210 F12120 F12121 F12122 F12129 F12150 F12151F12159 F12180 F12188 F1219 F1220 F1221 F12220 F12221

* These diagnosis codes are only payable to procedure code 96118


Behavioral Health Services


Diagnosis Codes (Submitted as stand-alone diagnosis codes)F12222 F12229 F12250 F12251 F12259 F12280 F12288 F1229F12920 F12921 F12922 F12929 F12950 F12951 F12959 F12980F12988 F1299 F1310 F13120 F13121 F13129 F1314 F13150F13151 F13159 F13180 F13181 F13182 F13188 F1320 F1321F13220 F13221 F13229 F13230 F13231 F13232 F13239 F1324F13250 F13251 F13259 F1326 F13280 F13281 F13282 F13288F13920 F13921 F13929 F13930 F13931 F13932 F13939 F1394F13950 F13951 F13959 F1396 F13980 F13981 F13982 F13988F1399 F1410 F14120 F14121 F14122 F14129 F1414 F14150F14151 F14159 F14180 F14181 F14182 F14188 F1419 F1420F1421 F14220 F14221 F14222 F14229 F1423 F1424 F14250F14251 F14259 F14280 F14281 F14282 F14288 F1429 F14920F14921 F14922 F14929 F1494 F14950 F14951 F14959 F14980F14981 F14982 F14988 F1499 F1510 F15120 F15121 F15122F15129 F1514 F15150 F15151 F15159 F15180 F15181 F15182F15188 F1519 F1520 F1521 F15220 F15221 F15222 F15229F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282F15288 F1529 F15920 F15921 F15922 F15929 F1593 F1594F15950 F15951 F15959 F15980 F15981 F15982 F15988 F1599F1610 F16120 F16121 F16122 F16129 F1614 F16150 F16151F16159 F16180 F16183 F16188 F1619 F1620 F16220 F16221F16229 F1624 F16250 F16251 F16259 F16280 F16283 F16288F1629 F16920 F16921 F16929 F1694 F16950 F16951 F16959F16980 F16983 F16988 F1699 F17208 F17209 F17218 F17219F17228 F17229 F17298 F17299 F1810 F18120 F18121 F18129F1814 F18150 F18151 F18159 F18180 F18188 F1819 F1820F1821 F18220 F18221 F18229 F1824 F18250 F18251 F18259F18280 F18288 F1829 F1890 F18920 F18921 F18929 F1894F18950 F18951 F18959 F18980 F18988 F1899 F1910 F19120F19121 F19122 F19129 F1914 F19150 F19151 F19159 F1916F19180 F19181 F19182 F19188 F1919 F1920 F1921 F19220F19221 F19222 F19229 F19230 F19231 F19232 F19239 F1924F19250 F19251 F19259 F1926 F19280 F19281 F19282 F19288F1929 F19920 F19921 F19922 F19929 F19930 F19931 F19932F19939 F1994 F19950 F19951 F19959 F1996 F19980 F19981F19982 F19988 F1999 F200 F201 F202 F203 F205F2081 F2089 F209 F21 F22 F23 F24 F250F251 F258 F259 F28 F29 F3010 F3011 F3012





Diagnosis Codes (Submitted as stand-alone diagnosis codes)F3013 F302 F303 F304 F308 F309 F310 F3110F3111 F3112 F3113 F312 F3130 F3131 F3132 F314F315 F3160 F3161 F3162 F3163 F3164 F3173 F3174F3175 F3176 F3177 F3178 F3181 F319 F320 F321F322 F323 F324 F325 F328 F329 F330 F331F332 F333 F3341 F3342 F339 F340 F341 F348F39 F4001 F4002 F4010 F4011 F40210 F40218 F40220F40228 F40230 F40231 F40232 F40233 F40240 F40241 F40242F40243 F40248 F40290 F40291 F40298 F408 F409 F410F411 F413 F418 F419 F42 F430 F4310 F4311F4312 F4320 F4321 F4322 F4323 F4324 F4325 F4329F438 F439 F440 F441 F444 F445 F446 F447F4481 F4489 F449 F450 F451 F4520 F4521 F4522F4529 F4541 F4542 F458 F459 F481 F482 F488F489 F5000 F5001 F5002 F502 F508 F509 F5101F5102 F5103 F5104 F5105 F5109 F5111 F5112 F5113F5119 F513 F514 F515 F518 F519 F520 F521F5221 F5222 F5231 F5232 F524 F525 F526 F529F54 F551 F553 F600 F601 F602 F603 F604F605 F606 F607 F6081 F6089 F609 F630 F631F632 F633 F6381 F6389 F639 F641 F642 F648F649 F650 F651 F652 F653 F654 F6551 F6552F6581 F6589 F659 F66 F6810 F6811 F6812 F6813F69 F70 F71 F72 F73 F79 F800 F801F802 F804 F8089 F809 F8181 F819 F82 F840F842 F843 F845 F849 F88 F900 F901 F902F908 F909 F911 F912 F913 F918 F919 F930F938 F939 F940 F941 F948 F950 F951 F952F959 F980 F981 F9821 F9829 F983 F984 F989G000 G001 G002 G003 G008 G009 G01 G02G030 G031 G038 G039 G0400 G0401 G0402 G042G0430 G0431 G0439 G0481 G0489 G0490 G0491 G053G054 G060 G061 G062 G07 G210 G3101 G3181G3182 G3184 G319 G3289 G35 G40001 G40009 G40011G40019 G40101 G40109 G40111 G40119 G40201 G40209 G40211G40219 G40301 G40309 G40311 G40319 G40801 G40802 G40803G40804 G40811 G40813 G40821 G40822 G40823 G40824 G4089G40901 G40909 G40911 G40919 G40A01 G40A09 G40A11 G40A19





Diagnosis Codes (Submitted as stand-alone diagnosis codes)G44209 G450 G451 G454 G458 G459 G468 G4720G4721 G4722 G4723 G4724 G4725 G4726 G4727 G4729G910 G911 G912 G92 G930 G931 G9340 G9341G9349 G937 G9381 G9389 G939 G94 H93291 H93292H93293 I6001 I6002 I6011 I6012 I6021 I6022 I6031I6032 I604 I6051 I6052 I606 I608 I610 I611I613 I614 I615 I616 I618 I6200 I6201 I6202I6203 I621 I6300 I63011 I63012 I6302 I63031 I63032I6309 I6310 I63111 I63112 I6312 I63131 I63132 I6319I6320 I63211 I63212 I63231 I63232 I6329 I63311 I63312I63321 I63322 I63331 I63332 I63341 I63342 I6339 I63411I63412 I63421 I63422 I63431 I63432 I63441 I63442 I6349I6350 I63511 I63512 I63519 I63521 I63522 I63529 I63531I63532 I63539 I63541 I63542 I63549 I6359 I6501 I6502I6503 I651 I6521 I6522 I6523 I658 I659 I6601I6602 I6603 I6611 I6612 I6613 I6621 I6622 I6623I663 I668 I669 I671 I672 I674 I675 I676I677 I6781 I6782 I6789 I679 I680 I682 I688I6901 I69020 I69021 I69022 I69023 I69028 I69031 I69032I69033 I69034 I69041 I69042 I69043 I69044 I69051 I69052I69053 I69054 I69061 I69062 I69063 I69064 I69065 I69090I69091 I69092 I69093 I69098 I6911 I69120 I69121 I69122I69123 I69128 I69131 I69132 I69133 I69134 I69141 I69142I69143 I69144 I69151 I69152 I69153 I69154 I69161 I69162I69163 I69164 I69165 I69190 I69191 I69192 I69193 I69198I6921 I69220 I69221 I69222 I69223 I69228 I69231 I69232I69233 I69234 I69241 I69242 I69243 I69244 I69251 I69252I69253 I69254 I69261 I69262 I69263 I69264 I69265 I69290I69291 I69292 I69293 I69298 I6931 I69320 I69321 I69322I69323 I69328 I69331 I69332 I69333 I69334 I69341 I69342I69343 I69344 I69351 I69352 I69353 I69354 I69361 I69362I69363 I69364 I69365 I69390 I69391 I69392 I69393 I69398I6981 I69820 I69821 I69822 I69823 I69828 I69831 I69832I69833 I69834 I69841 I69842 I69843 I69844 I69851 I69852I69853 I69854 I69861 I69862 I69863 I69864 I69865 I69890I69891 I69892 I69893 I69898 I69951 I69952 I69953 I69954I69961 I69962 I69963 I69964 I69965 P102 P103 P520P521 P5221 P5222 P523 P525 P84 P90 R0901





Diagnosis Codes (Submitted as stand-alone diagnosis codes)R0902 R413 R41840 R41841 R41842 R41843 R41844 R4189R450 R453 R454 R457 R45850 R45851 R4586 R4587R4589 R5600 R5601 R569 S060X0A S060X0D S060X0S S060X1AS060X1D S060X1S S060X2A S060X2D S060X2S S060X3A S060X3D S060X3SS060X4A S060X4D S060X4S S060X5A S060X5D S060X5S S060X6A S060X6DS060X6S S060X9A S060X9D S060X9S S06306D S06306S S06310A S06310DS06310S S06311A S06311D S06311S S06312A S06312D S06312S S06313AS06313D S06313S S06314A S06314D S06314S S06315A S06315D S06315SS06316A S06316D S06316S S06319A S06319D S06319S S06320A S06320DS06320S S06321A S06321D S06321S S06322A S06322D S06322S S06323AS06323D S06323S S06324A S06324D S06324S S06325A S06325D S06325SS06326A S06326D S06326S S06329A S06329D S06329S S06330A S06330DS06330S S06331A S06331D S06331S S06332A S06332D S06332S S06333AS06333D S06333S S06334A S06334D S06334S S06335A S06335D S06335SS06336A S06336D S06336S S06339A S06339D S06339S S06340A S06340DS06340S S06341A S06341D S06341S S06342A S06342D S06342S S06343AS06343D S06343S S06344A S06344D S06344S S06345A S06345D S06345SS06346A S06346D S06346S S06349A S06349D S06349S S06350A S06350SS06351A S06351D S06351S S06352A S06352D S06352S S06353A S06353DS06353S S06354A S06354D S06354S S06355A S06355D S06355S S06356AS06356D S06356S S06359A S06359D S06359S S06360A S06360D S06360SS06361A S06361D S06361S S06362A S06362D S06362S S06363A S06363DS06363S S06364A S06364D S06364S S06365A S06365D S06365S S06366AS06366D S06366S S06369A S06369D S06369S S06370A S06370D S06370SS06371A S06371D S06371S S06372A S06372D S06372S S06373A S06373DS06373S S06374A S06374D S06374S S06375A S06375D S06375S S06376AS06376D S06376S S06379A S06379D S06379S S06380A S06380D S06380SS06381A S06381D S06381S S06382A S06382D S06382S S06383A S06383DS06383S S06384A S06384D S06384S S06385A S06385D S06385S S06386AS06386S S06389A S06389D S06389S S064X0A S064X0D S064X0S S064X1AS064X1D S064X1S S064X2A S064X2D S064X2S S064X3A S064X3D S064X3SS064X4A S064X4D S064X4S S064X5A S064X5D S064X5S S064X6A S064X6DS064X6S S064X9A S064X9D S064X9S S065X0A S065X0D S065X0S S065X1AS065X1D S065X1S S065X2A S065X2D S065X2S S065X3A S065X3D S065X3SS065X4A S065X4D S065X4S S065X5A S065X5D S065X5S S065X6A S065X6DS065X6S S065X9A S065X9D S065X9S S066X0A S066X0D S066X0S S066X1AS066X1D S066X1S S066X2A S066X2D S066X2S S066X3A S066X3D S066X3SS066X4A S066X4D S066X4S S066X5A S066X5D S066X5S S066X6A S066X6D





Diagnosis Codes (Submitted as stand-alone diagnosis codes)S066X6S S066X9A S066X9D S066X9S S06890A S06890D S06890S S06891AS06891D S06891S S06892A S06892D S06892S S06893A S06893D S06893SS06894A S06894D S06894S S06895A S06895D S06895S S06896A S06896DS06896S S06897S S06899A S06899D S06899S S069X0A S069X0D S069X0SS069X1A S069X1D S069X1S S069X2A S069X2D S069X2S S069X3A S069X3DS069X3S S069X4A S069X4D S069X4S S069X5A S069X5D S069X5S S069X6AS069X6D S069X6S S069X9A S069X9D S069X9S T5801XA T5801XD T5801XST5802XA T5802XD T5803XA T5803XD T5804XA T5804XD T5804XS T5811XAT5811XD T5811XS T5812XA T5812XD T5813XA T5813XD T5814XA T5814XDT5814XS T582X1A T582X1D T582X1S T582X2A T582X2D T582X3A T582X3DT582X4A T582X4D T588X1A T588X1D T588X1S T588X2A T588X2D T588X3AT588X3D T588X3S T588X4A T588X4D T588X4S T5891XA T5891XD T5891XST5892XA T5892XD T5893XA T5893XD T5894XA T5894XD T71111A T71111DT71111S T71112A T71112S T71113A T71113D T71113S T71114A T71114DT71114S T71121A T71121D T71121S T71122A T71122S T71123A T71123DT71123S T71124A T71124S T71131A T71131D T71131S T71132A T71133AT71133D T71133S T71134A T71134D T71134S T71141A T71141D T71141ST71143A T71143D T71143S T71144A T71144D T71144S T71151A T71151DT71151S T71152A T71152D T71152S T71153A T71153D T71153S T71154AT71154D T71154S T71161A T71162A T71163A T71164A T71191A T71192AT71193A T71194A T71194D T71194S T7120XA T7121XA T71221A T71222AT71223A T71224A T71231A T71232A T71233A T71233D T71234A T7129XAT7402XA T7402XD T7402XS T7411XA T7411XD T7411XS T7412XA T7412XDT7412XS T7421XA T7421XD T7421XS T7422XA T7422XD T7422XS T751XXAT751XXD T751XXS T7602XA T7602XD T7602XS T7611XA T7611XD T7611XST7612XA T7612XD T7612XS T7621XA T7621XD T7621XS T7622XA T7622XDT7622XS Z134 Z1389 Z561 Z600 Z608 Z609 Z634Z644 Z658 Z69010 Z69020 Z69021 Z6982 Z72810 Z72811Z736 Z73810 Z73811 Z73812 Z73819 Z781 Z818 Z8651Z8659 Z87820 Z87890 Z9183


Combination Diagnosis Codes (Must be submitted in pairs)S06330A, S0190XA

S06331A, S0190XA

S06332A, S0190XA

S06333A, S0190XA

S06334A, S0190XA

S06335A, S0190XA

S06336A, S0190XA

S06339A, S0190XA

S06360A, S0190XA

S06361A, S0190XA

S06362A, S0190XA

S06363A, S0190XA

S06364A, S0190XA

S06365A, S0190XA

S06366A, S0190XA

S06369A, S0190XA

S06370A, S0190XA

S06371A, S0190XA

S06372A, S0190XA

S06373A, S0190XA

S06374A, S0190XA

S06375A, S0190XA

S06376A, S0190XA

S06379A, S0190XA

S06380A, S0190XA

S06381A, S0190XA

S06382A, S0190XA

S06383A, S0190XA

S06384A, S0190XA

S06385A, S0190XA

S06386A, S0190XA

S06389A, S0190XA




Combination Diagnosis Codes (Must be submitted in pairs)S064X0A, S0190XA

S064X1A, S0190XA

S064X2A, S0190XA

S064X3A, S0190XA

S064X4A, S0190XA

S064X5A, S0190XA

S064X6A, S0190XA

S064X9A, S0190XA

S065X0A, S0190XA

S065X1A, S0190XA

S065X2A, S0190XA

S065X3A, S0190XA

S065X4A, S0190XA

S065X5A, S0190XA

S065X6A, S0190XA

S065X9A, S0190XA

S066X0A, S0190XA

S066X1A, S0190XA

S066X2A, S0190XA

S066X3A, S0190XA

S066X4A, S0190XA

S066X5A, S0190XA

S066X6A, S0190XA

S066X9A, S0190XA

S06890A, S060X0A



Inpatient Behavioral Health Counseling/Psychotherapy and Psychiatric Diagnostic Interview Diagnosis CodesInpatient psychotherapy and counseling procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes: Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 * F0391 * F04 F05 F060 F061 F062 F0630F0631 F0632 F0633 F0634 F064 F068 F070 F09F1010 F10121 F1014 F10150 F10151 F10159 F10180 F10181F10182 F10188 F1019 F1020 F1021 F10221 F10230 F10231F10232 F10239 F1024 F10250 F10251 F10259 F1026 F10280F10281 F10282 F10288 F1029 F10921 F1094 F10950 F10951F10959 F1096 F10980 F10981 F10982 F10988 F1099 F1110F11120 F11121 F1114 F11150 F11151 F11159 F11181 F11182F11188 F1119 F1120 F1121 F11220 F11221 F11222 F11229F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288F1129 F11920 F11921 F11922 F11929 F1193 F1194 F11950F11951 F11959 F11981 F11982 F11988 F1199 F1210 F12120F12121 F12122 F12129 F12150 F12151 F12159 F12180 F12188F1219 F1220 F1221 F12220 F12221 F12222 F12229 F12250F12251 F12259 F12280 F12288 F1229 F12920 F12921 F12922F12929 F12950 F12951 F12959 F12980 F12988 F1299 F13120F13121 F13129 F1314 F13150 F13151 F13159 F13180 F13181F13182 F13188 F1320 F1321 F13220 F13221 F13229 F13230F13231 F13232 F13239 F1324 F13250 F13251 F13259 F1326F13280 F13281 F13282 F13288 F13920 F13921 F13929 F13930F13931 F13932 F13939 F1394 F13950 F13951 F13959 F1396F13980 F13981 F13982 F13988 F1399 F1410 F14120 F14121F14122 F14129 F1414 F14150 F14151 F14159 F14180 F14181F14182 F14188 F1419 F1420 F1421 F14220 F14221 F14222

* These diagnosis codes are not payable to procedure codes 90791 and 90792.




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F14229 F1423 F1424 F14250 F14251 F14259 F14280 F14281F14282 F14288 F1429 F14920 F14921 F14922 F14929 F1494F14950 F14951 F14959 F14980 F14981 F14982 F14988 F1499F1510 F15120 F15121 F15122 F15129 F1514 F15150 F15151F15159 F15180 F15181 F15182 F15188 F1519 F1520 F1521F15220 F15221 F15222 F15229 F1523 F1524 F15250 F15251F15259 F15280 F15281 F15282 F15288 F1529 F15920 F15921F15922 F15929 F1593 F1594 F15950 F15951 F15959 F15980F15981 F15982 F15988 F1599 F1610 F16120 F16121 F16122F16129 F1614 F16150 F16151 F16159 F16180 F16183 F16188F1619 F1620 F16220 F16221 F16229 F1624 F16250 F16251F16259 F16280 F16283 F16288 F1629 F16920 F16921 F16929F1694 F16950 F16951 F16959 F16980 F16983 F16988 F1699F17208 F17209 F17218 F17219 F17228 F17229 F17298 F17299F1810 F18120 F18121 F18129 F1814 F18150 F18151 F18159F18180 F18188 F1819 F1820 F1821 F18220 F18221 F18229F1824 F18250 F18251 F18259 F18280 F18288 F1829 F18920F18921 F18929 F1894 F18950 F18951 F18959 F18980 F18988F1899 F1910 F19120 F19121 F19122 F19129 F1914 F19150F19151 F19159 F1916 F19180 F19181 F19182 F19188 F1919F1920 F1921 F19220 F19221 F19222 F19229 F19230 F19231F19232 F19239 F1924 F19250 F19251 F19259 F1926 F19280F19281 F19282 F19288 F1929 F19920 F19921 F19922 F19930F19931 F19932 F19939 F1994 F19950 F19951 F19959 F1996F19980 F19981 F19982 F19988 F1999 F200 F201 F202F205 F2081 F209 F21 F22 F23 F24 F250F251 F258 F259 F29 F3010 F3011 F3012 F3013F302 F303 F304 F309 F310 F3110 F3111 F3112F3113 F312 F3130 F3131 F3132 F314 F315 F3160F3161 F3162 F3163 F3164 F3173 F3174 F3175 F3176F3177 F3178 F3181 F319 F320 F321 F322 F323F324 F325 F329 F330 F331 F332 F333 F3341F3342 F339 F340 F341 F39 F4001 F4002 F4010F4011 F40210 F40218 F40220 F40228 F40230 F40231 F40232F40233 F40240 F40241 F40242 F40243 F40248 F40290 F40291F40298 F408 F410 F411 F419 F42 F430 F4310F4311 F4312 F4320 F4321 F4322 F4323 F4324 F4325F438 F439 F440 F441 F444 F445 F446 F447F4481 F449 F450 F451 F4520 F4521 F4522 F4529F4541 F4542 F458 F459 F481 F482 F488 F489F5000 F5001 F5002 F502 F508 F509 F5101 F5102F5103 F5104 F5105 F5109 F5111 F5112 F5113 F5119F513 F514 F515 F518 F519 F520 F521 F5221





Diagnosis Codes (Submitted as stand-alone diagnosis codes)F5222 F5231 F5232 F524 F525 F526 F529 F54F551 F553 F600 F602 F603 F604 F605 F606F607 F6081 F609 F630 F631 F632 F633 F6381F6389 F639 F641 F642 F648 F649 F650 F651F652 F653 F654 F6551 F6552 F6581 F6589 F659F66 F6810 F6811 F6812 F6813 F69 F70 F72F73 F79 F800 F801 F802 F809 F8181 F819F82 F840 F842 F845 F849 F900 F901 F902F908 F909 F911 F912 F913 F918 F919 F930F938 F939 F940 F941 F948 F950 F951 F952F959 F980 F981 F9821 F9829 F983 F984 F989G3184 * G44209 G4720 G4721 G4722 G4723 G4724 G4725G4726 G4727 G4729 R413 R41840 R41841 R41842 R41843R41844 R4189 R45850 T7402XA T7402XD T7402XS T7411XA T7411XDT7411XS T7412XA T7412XD T7412XS T7421XA T7421XD T7421XS T7422XAT7422XD T7422XS T7602XA T7602XD T7602XS T7611XA T7611XD T7611XST7612XA T7612XD T7612XS T7621XA T7621XD T7621XS T7622XA T7622XDT7622XS Z0389 Z561 Z600 Z608 Z609 Z6331 Z6332Z634 Z635 Z638 Z644 Z655 Z658 Z69010 Z69020Z69021 Z6982 Z72810 Z72811 Z736 Z781 Z8651 Z9183


Pharmacological Management Pharmacological management services procedure codes M0064 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 F0391 F04 F05 F060 F061 F062 F0630 F0631 F0632F0633 F0634 F064 F068 F070 F09 F1010 F10120 F10121 F10129F1014 F10150 F10159 F10180 F10181 F10182 F10188 F1019 F1020 F1021F10220 F10221 F10229 F10230 F10232 F10239 F1024 F10250 F10259 F10280F10281 F10282 F10288 F1029 F10920 F10921 F10929 F1094 F10950 F10959F10980 F10981 F10982 F10988 F1099 F1110 F11120 F11121 F1114 F11150F11151 F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11220 F11221F11222 F11229 F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288F1129 F11920 F11921 F11922 F11929 F1193 F1194 F11950 F11951 F11959F11981 F11982 F11988 F1199 F1210 F12120 F12121 F12122 F12129 F12150F12151 F12159 F12180 F12188 F1219 F1220 F1221 F12220 F12221 F12222F12229 F12250 F12251 F12259 F12280 F12288 F1229 F12920 F12921 F12922F12929 F12950 F12951 F12959 F12980 F12988 F1299 F1310 F13120 F13121F13129 F1314 F13150 F13151 F13159 F13180 F13181 F13182 F13188 F1320F1321 F13220 F13221 F13229 F13230 F13231 F13232 F13239 F1324 F13250F13251 F13259 F1326 F13280 F13281 F13282 F13288 F13920 F13921 F13929F13930 F13931 F13932 F13939 F1394 F13950 F13951 F13959 F1396 F13980








Diagnosis Codes (Submitted as stand-alone diagnosis codes)F940 F941 F948 F950 F951 F952 F959 F980 F981 F9821F9829 F983 F984 F989 G44209 G4720 G4721 G4722 G4723 G4724G4725 G4726 G4727 G4729 R413 R41840 R41841 R41842 R41843 R41844R4189 R45850 Z561 Z6331 Z6332 Z635 Z638 Z655 Z658 Z781Z8651 Z9183

Refer to: The Texas Medicaid Provider Procedures Manual Behavioral Health, Rehabilitation, and Case Management Services Handbook, subsection 6.15, “Psychiatric Services for Hospitals,” for additional information.

Outpatient Behavioral HealthOutpatient behavioral health services may be reimbursed when services are performed in the office, home, skilled nursing or intermediate care facility (SNF/ICF), outpatient hospital, extended care facility (ECF), or other location when provided by one of the following provider types:

• Physician/psychiatrist (M.D. or D.O.)

• Advanced Practice Registered Nurse (APRN)

• Licensed Clinical Social Worker (LCSW)

• Physician Assistant (PA)

• Licensed Professional Counselor (LPC)

• Licensed Marriage and Family Therapist (LMFT)

• Licensed psychologist

• Licensed Psychological Associate (LPA) under the direct supervision of a psychologist in accordance with the Texas State Board of Examiners of Psychologists (TSBEP)

• Provisionally Licensed Psychologist (PLP) under the direct supervision of a psychologist in accordance with the TSBEP

Psychotherapy procedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90847, 90853, and 90899 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 F0391 G3184 R41841

Outpatient Behavioral Health Counseling/Psychotherapy and Psychiatric Diagnostic Interview Diagnosis CodesPsychiatric diagnostic evaluation procedure codes 90791 and 90792 and outpatient psychotherapy and counseling procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 F0391 F04 F05 F060 F061 F062 F0630F0631 F0632 F0633 F0634 F064 F068 F070 F09




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F1010 F10121 F1014 F10150 F10151 F10159 F10180 F10181F10182 F10188 F1019 F1020 F1021 F10221 F10230 F10231F10232 F10239 F1024 F10250 F10251 F10259 F1026 F10280F10281 F10282 F10288 F1029 F10921 F1094 F10950 F10951F10959 F1096 F10980 F10981 F10982 F10988 F1099 F1110F11120 F11121 F1114 F11150 F11151 F11159 F11181 F11182F11188 F1119 F1120 F1121 F11220 F11221 F11222 F11229F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288F1129 F11920 F11921 F11922 F11929 F1193 F1194 F11950F11951 F11959 F11981 F11982 F11988 F1199 F1210 F12120F12121 F12122 F12129 F12150 F12151 F12159 F12180 F12188F1219 F1220 F1221 F12220 F12221 F12222 F12229 F12250F12251 F12259 F12280 F12288 F1229 F12920 F12921 F12922F12929 F12950 F12951 F12959 F12980 F12988 F1299 F13120F13121 F13129 F1314 F13150 F13151 F13159 F13180 F13181F13182 F13188 F1320 F1321 F13220 F13221 F13229 F13230F13231 F13232 F13239 F1324 F13250 F13251 F13259 F1326F13280 F13281 F13282 F13288 F13920 F13921 F13929 F13930F13931 F13932 F13939 F1394 F13950 F13951 F13959 F1396F13980 F13981 F13982 F13988 F1399 F1410 F14120 F14121F14122 F14129 F1414 F14150 F14151 F14159 F14180 F14181F14182 F14188 F1419 F1420 F1421 F14220 F14221 F14222F14229 F1423 F1424 F14250 F14251 F14259 F14280 F14281F14282 F14288 F1429 F14920 F14921 F14922 F14929 F1494F14950 F14951 F14959 F14980 F14981 F14982 F14988 F1499F1510 F15120 F15121 F15122 F15129 F1514 F15150 F15151F15159 F15180 F15181 F15182 F15188 F1519 F1520 F1521F15220 F15221 F15222 F15229 F1523 F1524 F15250 F15251F15259 F15280 F15281 F15282 F15288 F1529 F15920 F15921F15922 F15929 F1593 F1594 F15950 F15951 F15959 F15980F15981 F15982 F15988 F1599 F1610 F16120 F16121 F16122F16129 F1614 F16150 F16151 F16159 F16180 F16183 F16188F1619 F1620 F16220 F16221 F16229 F1624 F16250 F16251F16259 F16280 F16283 F16288 F1629 F16920 F16921 F16929F1694 F16950 F16951 F16959 F16980 F16983 F16988 F1699F17208 F17209 F17218 F17219 F17228 F17229 F17298 F17299F1810 F18120 F18121 F18129 F1814 F18150 F18151 F18159F18180 F18188 F1819 F1820 F1821 F18220 F18221 F18229F1824 F18250 F18251 F18259 F18280 F18288 F1829 F18920F18921 F18929 F1894 F18950 F18951 F18959 F18980 F18988F1899 F1910 F19120 F19121 F19122 F19129 F1914 F19150F19151 F19159 F1916 F19180 F19181 F19182 F19188 F1919F1920 F1921 F19220 F19221 F19222 F19229 F19230 F19231F19232 F19239 F1924 F19250 F19251 F19259 F1926 F19280




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F19281 F19282 F19288 F1929 F19920 F19921 F19922 F19930F19931 F19932 F19939 F1994 F19950 F19951 F19959 F1996F19980 F19981 F19982 F19988 F1999 F200 F201 F202F205 F2081 F209 F21 F22 F23 F24 F250F251 F258 F259 F29 F3010 F3011 F3012 F3013F302 F303 F304 F309 F310 F3110 F3111 F3112F3113 F312 F3130 F3131 F3132 F314 F315 F3160F3161 F3162 F3163 F3164 F3173 F3174 F3175 F3176F3177 F3178 F3181 F319 F320 F321 F322 F323F324 F325 F329 F330 F331 F332 F333 F3341F3342 F339 F340 F341 F39 F4001 F4002 F4010F4011 F40210 F40218 F40220 F40228 F40230 F40231 F40232F40233 F40240 F40241 F40242 F40243 F40248 F40290 F40291F40298 F408 F410 F411 F419 F42 F430 F4310F4311 F4312 F4320 F4321 F4322 F4323 F4324 F4325F438 F439 F440 F441 F444 F445 F446 F447F4481 F449 F450 F451 F4520 F4521 F4522 F4529F4541 F4542 F458 F459 F481 F482 F488 F489F5000 F5001 F5002 F502 F508 F509 F5101 F5102F5103 F5104 F5105 F5109 F5111 F5112 F5113 F5119F513 F514 F515 F518 F519 F520 F521 F5221F5222 F5231 F5232 F524 F525 F526 F529 F54F551 F553 F600 F602 F603 F604 F605 F606F607 F6081 F609 F630 F631 F632 F633 F6381F6389 F639 F641 F642 F648 F649 F650 F651F652 F653 F654 F6551 F6552 F6581 F6589 F659F66 F6810 F6811 F6812 F6813 F69 F70 F72F73 F79 F800 F801 F802 F809 F8181 F819F82 F840 F842 F845 F849 F900 F901 F902F908 F909 F911 F912 F913 F918 F919 F930F938 F939 F940 F941 F948 F950 F951 F952F959 F980 F981 F9821 F9829 F983 F984 F989G3184 G44209 G4720 G4721 G4722 G4723 G4724 G4725G4726 G4727 G4729 R413 R41840 R41841 R41842 R41843R41844 R4189 R45850 T7402XA T7402XD T7402XS T7411XA T7411XDT7411XS T7412XA T7412XD T7412XS T7421XA T7421XD T7421XS T7422XAT7422XD T7422XS T7602XA T7602XD T7602XS T7611XA T7611XD T7611XST7612XA T7612XD T7612XS T7621XA T7621XD T7621XS T7622XA T7622XDT7622XS Z0389 Z561 Z600 Z608 Z609 Z6331 Z6332Z634 Z635 Z638 Z644 Z655 Z658 Z69010 Z69020Z69021 Z6982 Z72810 Z72811 Z736 Z781 Z8651 Z9183




Psychological and Neuropsychological TestingPsychological testing procedure code 96101 and neuropsychological testing procedure code 96118 may be reimbursed when they are submitted by a psychiatrist, psychologist, PLP, or LPA with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)A8100 A8101 A8109 A8181 A8183 B1001 B1009 B451D8681 E7500 E7501 E7502 E7509 E7510 E7511 E7519E7523 E7525 E7529 E754 F0390 F0391 F04 F05F060 F061 F062 F0630 F0631 F0632 F0633 F0634F064 F068 F070 F0781 F09 F1010 F10120 F10121F10129 F1014 F10150 F10151 F10159 F10180 F10181 F10182F10188 F1019 F1020 F1021 F10220 F10221 F10229 F10230F10231 F10232 F10239 * F1024 F10250 F10251 F10259 F1026F10280 F10281 F10282 F10288 F1029 F10920 F10921 F10929F1094 F10950 F10951 F10959 F1096 F10980 F10981 F10982F10988 F1099 F1110 F11120 F11121 F1114 * F11150 F11151F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11220F11221 F11222 F11229 F1123 F1124 F11250 F11251 F11259F11281 F11282 F11288 F1129 F11920 F11921 F11922 F11929F1193 F1194 F11950 F11951 F11959 F11981 F11982 F11988F1199 F1210 F12120 F12121 F12122 F12129 F12150 F12151F12159 F12180 F12188 F1219 F1220 F1221 F12220 F12221F12222 F12229 F12250 F12251 F12259 F12280 F12288 F1229F12920 F12921 F12922 F12929 F12950 F12951 F12959 F12980F12988 F1299 F1310 F13120 F13121 F13129 F1314 F13150F13151 F13159 F13180 F13181 F13182 F13188 F1320 F1321F13220 F13221 F13229 F13230 F13231 F13232 F13239 F1324F13250 F13251 F13259 F1326 F13280 F13281 F13282 F13288F13920 F13921 F13929 F13930 F13931 F13932 F13939 F1394F13950 F13951 F13959 F1396 F13980 F13981 F13982 F13988F1399 F1410 F14120 F14121 F14122 F14129 F1414 F14150F14151 F14159 F14180 F14181 F14182 F14188 F1419 F1420F1421 F14220 F14221 F14222 F14229 F1423 F1424 F14250F14251 F14259 F14280 F14281 F14282 F14288 F1429 F14920F14921 F14922 F14929 F1494 F14950 F14951 F14959 F14980F14981 F14982 F14988 F1499 F1510 F15120 F15121 F15122F15129 F1514 F15150 F15151 F15159 F15180 F15181 F15182F15188 F1519 F1520 F1521 F15220 F15221 F15222 F15229F1523 F1524 F15250 F15251 F15259 F15280 F15281 F15282F15288 F1529 F15920 F15921 F15922 F15929 F1593 F1594




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F15950 F15951 F15959 F15980 F15981 F15982 F15988 F1599F1610 F16120 F16121 F16122 F16129 F1614 F16150 F16151F16159 F16180 F16183 F16188 F1619 F1620 F16220 F16221F16229 F1624 F16250 F16251 F16259 F16280 F16283 F16288F1629 F16920 F16921 F16929 F1694 F16950 F16951 F16959F16980 F16983 F16988 F1699 F17208 F17209 F17218 F17219F17228 F17229 F17298 F17299 F1810 F18120 F18121 F18129F1814 F18150 F18151 F18159 F18180 F18188 F1819 F1820F1821 F18220 F18221 F18229 F1824 F18250 F18251 F18259F18280 F18288 F1829 F1890 F18920 F18921 F18929 F1894F18950 F18951 F18959 F18980 F18988 F1899 F1910 F19120F19121 F19122 F19129 F1914 F19150 F19151 F19159 F1916F19180 F19181 F19182 F19188 F1919 F1920 F1921 F19220F19221 F19222 F19229 F19230 F19231 F19232 F19239 F1924F19250 F19251 F19259 F1926 F19280 F19281 F19282 F19288F1929 F19920 F19921 F19922 F19929 F19930 F19931 F19932F19939 F1994 F19950 F19951 F19959 F1996 F19980 F19981F19982 F19988 F1999 F200 F201 F202 F203 F205F2081 F2089 F209 F21 F22 F23 F24 F250F251 F258 F259 F28 F29 F3010 F3011 F3012F3013 F302 F303 F304 F308 F309 F310 F3110F3111 F3112 F3113 F312 F3130 F3131 F3132 F314F315 F3160 F3161 F3162 F3163 F3164 F3173 F3174F3175 F3176 F3177 F3178 F3181 F319 F320 F321F322 F323 F324 F325 F328 F329 F330 F331F332 F333 F3341 F3342 F339 F340 F341 F348F39 F4001 F4002 F4010 F4011 F40210 F40218 F40220F40228 F40230 F40231 F40232 F40233 F40240 F40241 F40242F40243 F40248 F40290 F40291 F40298 F408 F409 F410F411 F413 F418 F419 F42 F430 F4310 F4311F4312 F4320 F4321 F4322 F4323 F4324 F4325 F4329F438 F439 F440 F441 F444 F445 F446 F447F4481 F4489 F449 F450 F451 F4520 F4521 F4522F4529 F4541 F4542 F458 F459 F481 F482 F488F489 F5000 F5001 F5002 F502 F508 F509 F5101F5102 F5103 F5104 F5105 F5109 F5111 F5112 F5113F5119 F513 F514 F515 F518 F519 F520 F521F5221 F5222 F5231 F5232 F524 F525 F526 F529F54 F551 F553 F600 F601 F602 F603 F604




Diagnosis Codes (Submitted as stand-alone diagnosis codes)F605 F606 F607 F6081 F6089 F609 F630 F631F632 F633 F6381 F6389 F639 F641 F642 F648F649 F650 F651 F652 F653 F654 F6551 F6552F6581 F6589 F659 F66 F6810 F6811 F6812 F6813F69 F70 F71 F72 F73 F79 F800 F801F802 F804 F8089 F809 F8181 F819 F82 F840F842 F843 F845 F849 F88 F900 F901 F902F908 F909 F911 F912 F913 F918 F919 F930F938 F939 F940 F941 F948 F950 F951 F952F959 F980 F981 F9821 F9829 F983 F984 F989G000 G001 G002 G003 G008 G009 G01 G02G030 G031 G038 G039 G0400 G0401 G0402 G042G0430 G0431 G0439 G0481 G0489 G0490 G0491 G053G054 G060 G061 G062 G07 G210 G3101 G3181G3182 G3184 G319 G3289 G35 G40001 G40009 G40011G40019 G40101 G40109 G40111 G40119 G40201 G40209 G40211G40219 G40301 G40309 G40311 G40319 G40801 G40802 G40803G40804 G40811 G40813 G40821 G40822 G40823 G40824 G4089G40901 G40909 G40911 G40919 G40A01 G40A09 G40A11 G40A19G44209 G450 G451 G454 G458 G459 G468 G4720G4721 G4722 G4723 G4724 G4725 G4726 G4727 G4729G910 G911 G912 G92 G930 G931 G9340 G9341G9349 G937 G9381 G9389 G939 G94 H93291 H93292H93293 I6001 I6002 I6011 I6012 I6021 I6022 I6031I6032 I604 I6051 I6052 I606 I608 I610 I611I613 I614 I615 I616 I618 I6200 I6201 I6202I6203 I621 I6300 I63011 I63012 I6302 I63031 I63032I6309 I6310 I63111 I63112 I6312 I63131 I63132 I6319I6320 I63211 I63212 I63231 I63232 I6329 I63311 I63312I63321 I63322 I63331 I63332 I63341 I63342 I6339 I63411I63412 I63421 I63422 I63431 I63432 I63441 I63442 I6349I6350 I63511 I63512 I63519 I63521 I63522 I63529 I63531I63532 I63539 I63541 I63542 I63549 I6359 I6501 I6502I6503 I651 I6521 I6522 I6523 I658 I659 I6601I6602 I6603 I6611 I6612 I6613 I6621 I6622 I6623I663 I668 I669 I671 I672 I674 I675 I676I677 I6781 I6782 I6789 I679 I680 I682 I688I6901 I69020 I69021 I69022 I69023 I69028 I69031 I69032I69033 I69034 I69041 I69042 I69043 I69044 I69051 I69052




Diagnosis Codes (Submitted as stand-alone diagnosis codes)I69053 I69054 I69061 I69062 I69063 I69064 I69065 I69090I69091 I69092 I69093 I69098 I6911 I69120 I69121 I69122I69123 I69128 I69131 I69132 I69133 I69134 I69141 I69142I69143 I69144 I69151 I69152 I69153 I69154 I69161 I69162I69163 I69164 I69165 I69190 I69191 I69192 I69193 I69198I6921 I69220 I69221 I69222 I69223 I69228 I69231 I69232I69233 I69234 I69241 I69242 I69243 I69244 I69251 I69252I69253 I69254 I69261 I69262 I69263 I69264 I69265 I69290I69291 I69292 I69293 I69298 I6931 I69320 I69321 I69322I69323 I69328 I69331 I69332 I69333 I69334 I69341 I69342I69343 I69344 I69351 I69352 I69353 I69354 I69361 I69362I69363 I69364 I69365 I69390 I69391 I69392 I69393 I69398I6981 I69820 I69821 I69822 I69823 I69828 I69831 I69832I69833 I69834 I69841 I69842 I69843 I69844 I69851 I69852I69853 I69854 I69861 I69862 I69863 I69864 I69865 I69890I69891 I69892 I69893 I69898 I69951 I69952 I69953 I69954I69961 I69962 I69963 I69964 I69965 P102 P103 P520P521 P5221 P5222 P523 P525 P84 P90 R0901R0902 R413 R41840 R41841 R41842 R41843 R41844 R4189R450 R453 R454 R457 R45850 R45851 R4586 R4587R4589 R5600 R5601 R569 S060X0A S060X0D S060X0S S060X1AS060X1D S060X1S S060X2A S060X2D S060X2S S060X3A S060X3D S060X3SS060X4A S060X4D S060X4S S060X5A S060X5D S060X5S S060X6A S060X6DS060X6S S060X9A S060X9D S060X9S S06306D S06306S S06310A S06310DS06310S S06311A S06311D S06311S S06312A S06312D S06312S S06313AS06313D S06313S S06314A S06314D S06314S S06315A S06315D S06315SS06316A S06316D S06316S S06319A S06319D S06319S S06320A S06320DS06320S S06321A S06321D S06321S S06322A S06322D S06322S S06323AS06323D S06323S S06324A S06324D S06324S S06325A S06325D S06325SS06326A S06326D S06326S S06329A S06329D S06329S S06330A S06330DS06330S S06331A S06331D S06331S S06332A S06332D S06332S S06333AS06333D S06333S S06334A S06334D S06334S S06335A S06335D S06335SS06336A S06336D S06339A S06339D S06339S S06340A S06340D S06340SS06341A S06341D S06341S S06342A S06342D S06342S S06343A S06343DS06343S S06344A S06344D S06344S S06345A S06345D S06345S S06346AS06346D S06346S S06349A S06349D S06349S S06350A S06350S S06351AS06351D S06351S S06352A S06352D S06352S S06353A S06353D S06353SS06354A S06354D S06354S S06355A S06355D S06355S S06356A S06356DS06356S S06359A S06359D S06359S S06360A S06360D S06360S S06361A




Diagnosis Codes (Submitted as stand-alone diagnosis codes)S06361D S06361S S06362A S06362D S06362S S06363A S06363D S06363SS06364A S06364D S06364S S06365A S06365D S06365S S06366A S06366DS06366S S06369A S06369D S06369S S06370A S06370D S06370S S06371AS06371D S06371S S06372A S06372D S06372S S06373A S06373D S06373SS06374A S06374D S06374S S06375A S06375D S06375S S06376A S06376DS06376S S06379A S06379D S06379S S06380A S06380D S06380S S06381AS06381D S06381S S06382A S06382D S06382S S06383A S06383D S06383SS06384A S06384D S06384S S06385A S06385D S06385S S06386A S06386DS06386S S06389A S06389D S06389S S064X0A S064X0D S064X0S S064X1AS064X1D S064X1S S064X2A S064X2D S064X2S S064X3A S064X3D S064X3SS064X4A S064X4D S064X4S S064X5A S064X5D S064X5S S064X6A S064X6DS064X6S S064X9A S064X9D S064X9S S065X0A S065X0D S065X0S S065X1AS065X1D S065X1S S065X2A S065X2D S065X2S S065X3A S065X3D S065X3SS065X4A S065X4D S065X4S S065X5A S065X5D S065X5S S065X6A S065X6DS065X6S S065X9A S065X9D S065X9S S066X0A S066X0D S066X0S S066X1AS066X1D S066X1S S066X2A S066X2D S066X2S S066X3A S066X3D S066X3SS066X4A S066X4D S066X4S S066X5A S066X5D S066X5S S066X6A S066X6DS066X6S S066X9A S066X9D S066X9S S06890A S06890D S06890S S06891AS06891D S06891S S06892A S06892D S06892S S06893A S06893D S06893SS06894A S06894D S06894S S06895A S06895D S06895S S06896A S06896DS06896S S06897S S06899A S06899D S06899S S069X0A S069X0D S069X0SS069X1A S069X1D S069X1S S069X2A S069X2D S069X2S S069X3A S069X3DS069X3S S069X4A S069X4D S069X4S S069X5A S069X5D S069X5S S069X6AS069X6D S069X6S S069X9A S069X9D S069X9S T5801XA T5801XD T5801XST5802XA T5802XD T5803XA T5803XD T5804XA T5804XD T5804XS T5811XAT5811XD T5811XS T5812XA T5812XD T5813XA T5813XD T5814XA T5814XDT5814XS T582X1A T582X1D T582X1S T582X2A T582X2D T582X3A T582X3DT582X4A T582X4D T588X1A T588X1D T588X1S T588X2A T588X2D T588X3AT588X3D T588X3S T588X4A T588X4D T588X4S T5891XA T5891XD T5891XST5892XA T5892XD T5893XA T5893XD T5894XA T5894XD T71111A T71111DT71111S T71112A T71112S T71113A T71113D T71113S T71114A T71114DT71114S T71121A T71121D T71121S T71122A T71122S T71123A T71123DT71123S T71124A T71124S T71131A T71131D T71131S T71132A T71133DT71133S T71134A T71134D T71134S T71141A T71141D T71141S T71143AT71143D T71143S T71144A T71144D T71144S T71151A T71151D T71151ST71152A T71152D T71152S T71153A T71153D T71153S T71154A T71154DT71154S T71161A T71162A T71163A T71164A T71191A T71192A T71193AT71194A T71194D T71194S T7120XA T7121XA T71221A T71222A T71223AT71224A T71231A T71232A T71233A T71233D T71234A T7129XA T7402XA




Diagnosis Codes (Submitted as stand-alone diagnosis codes)T7402XD T7402XS T7411XA T7411XD T7411XS T7412XA T7412XD T7412XST7421XA T7421XD T7421XS T7422XA T7422XD T7422XS T751XXA T751XXDT751XXS T7602XA T7602XD T7602XS T7611XA T7611XD T7611XS T7612XAT7612XD T7612XS T7621XA T7621XD T7621XS T7622XA T7622XD T7622XSZ134 Z1389 Z561 Z600 Z608 Z609 Z634 Z644Z658 Z69010 Z69020 Z69021 Z6982 Z72810 Z72811 Z736Z73810 Z73811 Z73812 Z73819 Z781 Z818 Z8651 Z8659Z87820 Z87890 Z9183Combination Diagnosis Codes (Must be submitted in pairs)S06330A, S0190XA

S06331A, S0190XA

S06332A, S0190XA

S06333A, S0190XA

S06334A, S0190XA

S06335A, S0190XA

S06336A, S0190XA

S06339A, S0190XA

S06360A, S0190XA

S06361A, S0190XA

S06362A, S0190XA

S06363A, S0190XA

S06364A, S0190XA

S06365A, S0190XA

S06366A, S0190XA

S06369A, S0190XA

S06370A, S0190XA

S06371A, S0190XA

S06372A, S0190XA

S06373A, S0190XA

S06374A, S0190XA

S06375A, S0190XA

S06376A, S0190XA

S06379A, S0190XA

S06380A, S0190XA

S06381A, S0190XA

S06382A, S0190XA

S06383A, S0190XA

S06384A, S0190XA

S06385A, S0190XA

S06386A, S0190XA

S06389A, S0190XA

S06890A, S060X0A

S064X0A, S0190XA

S064X1A, S0190XA

S064X2A, S0190XA

S065X2A, S0190XA

S065X3A, S0190XA

S065X4A, S0190XA

S065X5A, S0190XA

S065X6A, S0190XA

S065X9A, S0190XA

S066X0A, S0190XA

S066X1A, S090XA

S066X2A, S0190XA

S066X3A, S0190XA

S066X4A, S0190XA

S066X5A, S0190XA

S066X6A, S0190XA

S066X9A, S0190XA



Pharmacological Regimen Oversight and Pharmacological ManagementPharmacological regimen oversight services may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 F0391 F04 F05 F060 F061 F062 F0630 F0631 F0632F0633 F0634 F064 F068 F070 F09 F1010 F10120 F10121 F10129F1014 F10150 F10159 F10180 F10181 F10182 F10188 F1019 F1020 F1021F10220 F10221 F10229 F10230 F10232 F10239 F1024 F10250 F10259 F10280F10281 F10282 F10288 F1029 F10920 F10921 F10929 F1094 F10950 F10959F10980 F10981 F10982 F10988 F1099 F1110 F11120 F11121 F1114 F11150F11151 F11159 F11181 F11182 F11188 F1119 F1120 F1121 F11220 F11221F11222 F11229 F1123 F1124 F11250 F11251 F11259 F11281 F11282 F11288F1129 F11920 F11921 F11922 F11929 F1193 F1194 F11950 F11951 F11959F11981 F11982 F11988 F1199 F1210 F12120 F12121 F12122 F12129 F12150








Diagnosis Codes (Submitted as stand-alone diagnosis codes)F526 F529 F54 F551 F553 F600 F601 F602 F603 F604F605 F606 F607 F6081 F609 F630 F631 F632 F633 F6381F6389 F639 F641 F642 F648 F649 F650 F651 F652 F653F654 F6551 F6552 F6581 F6589 F659 F66 F6810 F6811 F6812F6813 F69 F70 F72 F73 F79 F800 F801 F802 F804F810 F812 F8181 F819 F82 F840 F843 F900 F901 F902F908 F909 F911 F912 F913 F918 F919 F930 F938 F939F940 F941 F948 F950 F951 F952 F959 F980 F981 F9821F9829 F983 F984 F989 G44209 G4720 G4721 G4722 G4723 G4724G4725 G4726 G4727 G4729 R413 R41840 R41841 R41842 R41843 R41844R4189 R45850 Z561 Z6331 Z6332 Z635 Z638 Z655 Z658 Z781Z8651 Z9183

Refer to: The Texas Medicaid Provider Procedures Manual Behavioral Health, Rehabilitation, and Case Management Services Handbook, subsection 6.4, “Outpatient Behavioral Health Services,” for more information.

* Substance Use Disorder Services (Abuse and Dependence)Procedure codes H0004 and H0005 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F1010 F10120 F10129 F10159 F10188 F1019 F1020 F1021 F10220 F10229F10230 F10232 F10239 F10259 F10281 F10288 F1029 F10920 F10929 F10959F10988 F1099 F1110 F11120 F11159 F11181 F11182 F11188 F1119 F1120F1121 F11220 F11222 F11229 F11259 F11281 F11282 F11288 F1129 F11920F11922 F11929 F11959 F11981 F11982 F11988 F1199 F1210 F12120 F12122F12129 F12159 F12180 F12188 F1219 F1220 F1221 F12220 F12222 F12229F12259 F12280 F12288 F1229 F12920 F12922 F12929 F12959 F12980 F12988F1299 F13120 F13129 F13159 F13180 F13181 F13182 F13188 F1320 F1321F13220 F13229 F13259 F13280 F13281 F13282 F13288 F13920 F13929 F13959F13980 F13981 F13982 F13988 F1399 F1410 F14120 F14122 F14129 F14159F14180 F14181 F14182 F14188 F1419 F1420 F1421 F14220 F14222 F14229F14259 F14280 F14281 F14282 F14288 F1429 F14920 F14922 F14929 F14959F14980 F14981 F14982 F14988 F1499 F1510 F15120 F15122 F15129 F15159F15180 F15181 F15182 F15188 F1519 F1520 F1521 F15220 F15222 F15229F15259 F15280 F15281 F15282 F15288 F1529 F15920 F15922 F15929 F15959F15980 F15981 F15982 F15988 F1599 F1610 F16120 F16122 F16129 F16159F16180 F16183 F16188 F1619 F1620 F16220 F16229 F16259 F16280 F16283F16288 F1629 F16920 F16929 F16959 F16980 F16983 F16988 F1699 F17208F17209 F17218 F17219 F17228 F17229 F17298 F17299 F1810 F18120 F18129F18159 F18180 F18188 F1819 F1820 F1821 F18220 F18229 F18259 F18280F18288 F1829 F18920 F18929 F18959 F18980 F18988 F1899 F1910 F19120F19122 F19129 F19159 F19180 F19181 F19182 F19188 F1919 F1920 F1921F19220 F19222 F19229 F19259 F19280 F19281 F19282 F19288 F1929 F19920F19922 F19929 F19959 F19980 F19981 F19982 F19988 F1999 F551 F553




http://www.tmhp.com/ICD10_Updates_Med/06-02-15%20ICD%2010%20Update%20to%20Substance%20Use%20Disorder%20for%20Texas%20Medicaid.pdf

Medication Assisted Therapy (MAT)Medication-assisted therapy (MAT) services may be considered on appeal for reimbursement on the same date of service as residential detoxification and residential treatment services for pregnant women with an opioid addiction, or for clients in current MAT treatment for an opioid addiction who are also receiving residential services for a substance other than opioids.

For Medication Assisted Therapy (MAT) in the scenarios below, one of each of the following opioid, non-opioid, and pregnancy diagnoses must be submitted on the claim.

Opioid MAT Diagnosis CodesDiagnosis Codes DescriptionF1120, F1121, F11220, F11221, F11222, F11229, F1123, F1124, F11259, F11281, F11282, F11288, F1129

Opioid type dependence

F1821, F1920, F1921 Combination of opioid type drugF1110 Opioid abuse

Non-Opioid MAT/Pregnancy Diagnosis CodesDiagnosis Codes DescriptionF1020, F1021 Other and unspecified alcohol dependenceF1320, F1321 Sedative, hypnotic or anxiolytic dependenceF1420, F1421 Cocaine dependenceF1520, F1521 Amphetamine and other psychostimulant dependenceF1620, F1621 Hallucinogen dependenceF1620, F1820, F1821, F1920, F1921 Other or unspecified drug dependenceF15120, F15129, F15220, F15229, F15920, F15929, F1610, F1810, F1890, F1910, F551, F553

Other, mixed, or unspecified drug abuse

O99320, O99321, O99322, O99323, O99325 Pregnancy

The diagnosis for admission criteria for residential treatment services must meet the definition of chemical depen-dence, as detailed in the most current revision of the ICD-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

Refer to: The Texas Medicaid Provider Procedures Manual Behavioral Health, Rehabilitation, and Case Management Services Handbook, Section 8, “Substance Use Disorder (SUD) Services (Abuse and Dependence),” for additional information.




TEXAS HEALTH STEPS (THSTEPS) MEDICAL PROVIDERS

THSteps Medical Benefit ChangesThe following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.


Texas Health Steps (THSteps) Environmental Lead InvestigationsProcedure code T1029 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)T560X1A T560X1D T560X1S T560X2A T560X2D T560X2S T560X3A T560X3DT560X3S T560X4A T560X4D T560X4S Z77011

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, Appendix C.4 “Environ-mental Lead Investigation Services,” for additional information.

Texas Health Steps (THSteps) Preventive Care Medical CheckupsICD-10-CM diagnosis codes Z00121 and Z00129 replace ICD-9-CM diagnosis code V202 for medical checkups, exception to periodicity checkups, and follow-up visits.

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, Subsection 5.5.1, “Claims Information,” for additional information.

If an acute or chronic condition requiring evaluation and management (E/M) beyond the required components for a medical checkup is discovered, a separate E/M procedure code may be considered for the same date of service as a checkup or the client can be referred for further diagnosis and treatment. The client’s medical record must contain documentation that the separate identifiable service(s) were medically necessary and include a diagnosis other than Z00121 or Z00129. Documentation must be made available to Texas Medicaid upon request.

The administration of an immunization at the time of a checkup is billed with diagnosis code Z00121 or Z00129 unless a more appropriate diagnosis code is available.

For oral evaluation and fluoride varnish in the medical home (OEFV), procedure code 99429 may be reimbursed when it is billed with diagnosis code Z00121 or Z00129.

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 5.3.4, “THSteps Medical Checkups,” for additional information.


Texas Health Steps (THSteps) Medical Providers


http://eopm/eopm/Provider_manuals/TMPPM/output/Vol2_Children's_Services_Handbook.17.001.shtml#2221629

TEXAS HEALTH STEPS (THSTEPS) DENTAL PROVIDERS

THSteps Dental Benefit ChangesThe following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.


Texas Health Steps (THSteps) Therapeutic Dental ServicesDental behavior management procedure code D9920 may be reimbursed when the client has a diagnosis of an intellectual disability described as mild, moderate, severe, profound, or unspecified. The most appropriate ICD-10 diagnosis code for mild, moderate, severe, profound, or unspecified intellectual disability must be included on the claim.

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 4.2.23, “Adjunc-tive General Services,” for additional information.


Texas Health Steps (THSteps) Dental Providers


HOME HEALTH PROVIDERS

Home Health Benefit ChangesThe following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.

Diabetic Equipment and Supplies – Home HealthDiabetic equipment and supplies may be reimbursed without prior authorization when the most appropriate procedure code is submitted with one of the following ICD-10-CM diabetic and non-diabetic diagnosis codes:Diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)E0800 E0801 E0810 E0811 E0821 E0822 E0829 E08311 E08319 E08321E08329 E08331 E08339 E08341 E08349 E08351 E08359 E0836 E0839 E0840E0841 E0842 E0843 E0844 E0849 E0851 E0859 E08610 E08618 E08620E08621 E08622 E08628 E08630 E08638 E08641 E08649 E0865 E0869 E088E089 E0900 E0901 E0910 E0911 E0921 E0922 E0929 E09311 E09319E09321 E09329 E09331 E09339 E09341 E09349 E09351 E09359 E0936 E0939E0940 E0941 E0942 E0943 E0944 E0949 E0951 E0959 E09610 E09618E09620 E09621 E09622 E09628 E09630 E09638 E09641 E09649 E0965 E0969E098 E099 E1010 E1011 E1021 E1022 E1029 E10311 E10319 E10321E10329 E10331 E10339 E10341 E10349 E10351 E10359 E1036 E1039 E1040E1041 E1042 E1043 E1044 E1049 E1051 E1052 E1059 E10610 E10618E10620 E10621 E10622 E10628 E10630 E10638 E10641 E10649 E1065 E1069E108 E109 E1100 E1101 E1121 E1122 E1129 E11311 E11319 E11321E11329 E11331 E11339 E11341 E11349 E11351 E11359 E1136 E1139 E1140E1141 E1142 E1143 E1144 E1149 E1151 E1152 E1159 E11610 E11618E11620 E11621 E11622 E11628 E11630 E11638 E11641 E11649 E1165 E1169E118 E119 E1300 E1301 E1310 E1311 E1321 E1322 E1329 E13311E13319 E13321 E13329 E13331 E13339 E13341 E13349 E13351 E13359 E1336E1339 E1340 E1341 E1342 E1343 E1344 E1349 E1351 E1352 E1359E13610 E13620 E13621 E13622 E13628 E13638 E13641 E13649 E1365 E1369E138 E139 O24011 O24012 O24013 O2402 O2403 O24414 O24424 O24434O99810 O99814 O99815 P702

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)E0800, E0865

E0801, E0865

E0821, E0865

E08311, E0865

E08319, E0865

E08321, E0865

E08329, E0865

E08331, E0865

E08339, E0865

E08341, E0865

E08349, E0865

E08351, E0865

E08359, E0865

E0836, E0865

E0839, E0865

E0840, E0865

E0865, E0841

E0865, E0842

E0865, E0843

E0865, E0844

E0865, E0849

E0865, E0851

E0865, E0852

E0865, E0859

E0865, E0869

E0865, E088

E0865, E0921

E0865, E09311

E0865, E09319

E0865, E0936

E0865, E0940

E0865, E0951


Home Health Providers



E0865, E098

E0865, E1365

E0865, E138

E0900, E0865

E0901, E0865

E1010, E1065

E1011, E10641

E1011, E1065

E1011, E1311

E1011, E13641

E10319, E1065

E1036, E1065

E1039, E1065

E1040, E1065

E1051, E1065

E1065, E1021

E1065, E1022

E1065, E1029

E1065, E10311

E1065, E10321

E1065, E10329

E1065, E10331

E1065, E10339

E1065, E10341

E1065, E10349

E1065, E10351

E1065, E10359

E1065, E1041

E1065, E1042

E1065, E1043

E1065, E1044

E1065, E1049

E1065, E1052

E1065, E1059

E1065, E10610

E1065, E1069

E1065, E108

E1065, E1141

E1065, E1142

E1065, E1143

E1065, E1144

E1065, E1149

E1065, E11610

E1065, E1340

E1065, E1341

E1065, E1342

E1065, E1343

E1065, E1344

E1065, E1349

E1065, E13610

E1100, E1165

E1101, E1165

E1121, E1122

E1121, E1129

E1121, E1165

E1121, E1321

E1121, E1322

E1121, E1329

E11311, E1165

E11319, E1165

E1136, E1165

E1139, E1165

E1140, E1165

E1151, E1165

E1165, E1169

E1165, E118

E1321, E0865


Non-diabetic Diagnosis CodesNon-diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)E161 E162 E71111 E71310 E71311 E71312 E71313 E71314 E71318E7132 E7420 E7421 E7429 E8881 K911 R7309 R81


The Texas Medicaid Provider Procedures Manual Durable Medical Equipment, Medical Supplies, and Nutri-tional Products Handbook, subsection 2.2.11,” Diabetic Equipment and Supplies;” and subsection 2.2.11.3,

“Glucose Testing Equipment and Other Supplies,” for additional information.

Incontinence Supplies – Home HealthA completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form for intermittent catheters and related insertion supplies may be granted for up to 12 months for quantities within the stated benefit limits for clients with certain chronic conditions.

The prior authorization request must include one of the following ICD-10-CM diagnosis codes to describe the client’s chronic condition:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G35 G8221 G8222 G8250 G8253 G8254 G834 N310 N311 N312N319 Q054 Q057 Q058 Q0701 Q0702 Q0703 Q6410 Q6412 Q6419Q760 Q794




Diagnosis codes R32 and R339 are not specific enough to allow for the extension of the prior authorization to 12 months.

Refer to: The Texas Medicaid Provider Procedures Manual Durable Medical Equipment, Medical Supplies, and Nutri-tional Products Handbook, subsection 2.2.13, “Incontinence Supplies,” for additional information.

Respiratory Equipment and Supplies–Home Health

NebulizersNebulizer and nebulizer supplies may be reimbursed without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B59 E840 E8411 E8419 E848 E849 J09X1 J09X2 J121 J1281J15212 J188 J189 J210 J211 J218 J219 J410 J411 J418J42 J430 J431 J432 J438 J439 J440 J441 J449 J4520J4530 J4540 J4550 J45901 J45902 J45909 J45990 J45991 J45998 J471J479 J670 J671 J672 J673 J674 J675 J676 J677 J678J679 J690 J691 J698 K449 P270 P271 P278

Purchase of nebulizers for diagnoses other than those listed in the above table may be considered for prior authori-zation when the request is submitted with documentation of medical necessity.

Ultrsonic nebulizers may be considered for prior authorization when the request is submitted with one of the following ICD-10-CM diagnosis codes and documentation of failure of standard therapy:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B59 E840 E8411 E8419 E848 E849 J09X1

The rental of an intermittent positive-pressure breathing (IPPB) device may be prior authorized when the request is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)

449 E840 E8411 E8419 E848 E849 G121 G128 G129 G710G7111 G7112 G7113 G7114 G7119 J09X1 J182 J811 J8402 J8410J84111 J84112 J84113 J84114 J84115 J84116 J84117 J842 J84842 J84843J84848 J951 J952 J953 J95821 J95822

The mucous clearance valve may be prior authorized when the request is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E840 E8411 E8419 E848 E849 J09X1 J40 J410 J411 J418J42 J430 J431 J432 J438 J439 J441 J449 J4520 J4521J4522 J4530 J4531 J4532 J4540 J4541 J4542 J4550 J4551 J4552J45901 J45902 J45909 J45990 J45991 J45998 J471 J479 J670 J671J672 J673 J674 J675 J676 J677 J678 J679




Prior authorization of the high-frequency chest wall compression system (HFCWCS) may be considered when the request is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)

E840 E8411 E8419 E848 E849 G121 G128 G129 G710 G800G801 G802 G804 G808 G809 G8381 G8382 G8383 G8384 G8389J09X1 J8410

Refer to: The Texas Medicaid Provider Procedures Manual Durable Medical Equipment, Medical Supplies, and Nutri-tional Products Handbook, Section 2, “Texas Medicaid (Title XIX) Home Health Services;” subsection 2.2,

“Services, Benefits, Limitations and Prior Authorization;” subsection 2.2.13.6.2, “Intermittent Catheters and Related Insertion Supplies;” and subsection 2.2.19, “Respiratory Equipment and Supplies,” for additional information.

COMPREHENSIVE CARE PROGRAM (CCP) PROVIDERS

CCP Benefit ChangesThe following Texas Medicaid benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.

Blood Pressure Devices - CCPManual and automated blood pressure devices may be reimbursed without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)I10 I110 I119 I120 I129 I130 I1310 I1311 I132 I150I151 I152 I158 I159 I2601 I2602 I2609 I2690 I2692 I2699I270 I271 I2781 I2782 I2789 I279 I340 I341 I342 I348I349 I350 I351 I352 I358 I359 I360 I361 I362 I368I369 I370 I371 I372 I378 I379 I421 I422 I424 I425I428 I429 I43 I440 I441 I442 I4430 I4439 I444 I445I4460 I4469 I447 I450 I4510 I4519 I452 I453 I454 I455I456 I4581 I4589 I459 I471 I472 I479 I480 I481 I482I483 I484 I4891 I4892 I495 I501 I5020 I5021 I5022 I5023I5030 I5031 I5032 I5033 I5040 I5041 I5042 I5043 I509 I950I951 I952 I953 I9581 I9589 I959 N010 N011 N012 N013N014 N015 N016 N017 N018 N050 N051 N052 N053 N054N055 N056 N057 N058 N059 N08 N1330 N1339 N13721 N13722N13729 N13731 N13732 N13739 N170 N171 N172 N178 N179 N181N182 N183 N184 N185 N186 N189 N250 N2589 Q200 Q201Q202 Q203 Q204 Q205 Q208 Q210 Q211 Q212 Q213 R001

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)T800XXA, 12690

T800XXA, I2699

T81718A, 12690

T81718A, 12699

T8172XA, 12690

T8172XA, 12699

T82817A, 12690

T82817A, 12699


Comprehensive Care Program (CCP) Providers


Combination Diagnosis Codes (Must be submitted in pairs)T82818A, 12690

T82818A, 12699


Prior authorization for manual and automated blood pressure devices is required for all diagnoses not listed in the above tables.


The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.5.4.1.1, “Manual and Automated Blood Pressure Devices,” and the Durable medical Equipment, Medical Supplies, and Nutritional Products Handbook, subsection 2.2.6.1, “Prior Authorization,” for additional information.

Cranial Molding Orthosis – CCPThe most appropriate ICD-10-CM diagnosis code that indicates synostotic plagiocephaly must be submitted with the cranial molding orthosis procedure code S1040.

Procedure code S1040 may be reimbursed for clients who are 3 through 18 months of age with synostotic plagiocephaly.

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.10.3, “Cranial Molding Orthosis,” for additional information.

Nutritional Products - CCPNutritional products may be reimbursed without prior authorization when they are submitted with the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C880 C965 C966 D472 D800 D801 D802 D803D804 D805 D806 D807 D808 D809 D810 D811D812 D814 D816 D817 D8189 D819 D820 D821D822 D823 D824 D828 D829 D830 D831 D832D838 D839 D840 D841 D848 D849 D890 D891D893 D8982 D8989 D899 E201 E670 E671 E672E673 E678 E68 E700 E701 E7020 E7021 E7029E7030 E70310 E70311 E70318 E70319 E70320 E70321 E70328E70329 E70330 E70331 E70338 E70339 E7039 E7040 E7041E7049 E705 E708 E709 E710 E71110 E71111 E71118E71120 E71121 E71128 E7119 E712 E7130 E71310 E71311E71312 E71313 E71314 E71318 E7132 E7139 E7140 E7141E7142 E7143 E71440 E71448 E7150 E71510 E71511 E71518E71520 E71521 E71522 E71528 E71529 E7153 E71540 E71541E71542 E71548 E7200 E7201 E7202 E7203 E7204 E7209E7210 E7211 E7212 E7219 E7220 E7221 E7222 E7223E7229 E723 E724 E7250 E7251 E7252 E7253 E7259





Diagnosis Codes (Submitted as stand-alone diagnosis codes)E728 E729 E730 E738 E739 E7400 E7401 E7402E7403 E7404 E7409 E7410 E7411 E7412 E7419 E7420E7421 E7429 E7431 E7439 E744 E748 E749 E7500E7509 E7510 E7511 E7519 E7521 E7522 E7523 E75240E75241 E75242 E75243 E75248 E75249 E7529 E753 E754E755 E756 E7601 E7602 E7603 E761 E76210 E76211E76219 E7622 E7629 E763 E768 E769 E770 E771E778 E779 E780 E781 E782 E783 E784 E785E786 E7870 E7879 E7881 E7889 E789 E791 E792E798 E799 E800 E801 E8020 E8021 E8029 E803E804 E805 E806 E807 E8300 E8301 E8309 E8310E8319 E8330 E8331 E8332 E8339 E8340 E8341 E8342E8349 E8350 E8351 E8352 E8359 E8381 E8389 E839E840 E8411 E8419 E848 E849 E850 E851 E852E853 E854 E858 E859 E860 E861 E869 E870E871 E872 E873 E874 E875 E876 E8770 E8779E878 E8801 E8809 E881 E882 E8840 E8841 E8842E8849 E8881 E8889 E889 H49811 H49812 H49813 M1000M10011 M10012 M10019 M10021 M10022 M10029 M10031 M10032M10039 M10041 M10042 M10049 M10051 M10052 M10059 M10061M10062 M10069 M10071 M10072 M10079 M1008 M1009 M10111M10112 M10121 M10122 M10131 M10132 M10141 M10142 M10151M10152 M10161 M10162 M10171 M10172 M10211 M10212 M10221M10222 M10231 M10232 M10241 M10242 M10251 M10252 M10261M10262 M10271 M10272 M1030 M10311 M10312 M10319 M10321M10322 M10329 M10331 M10332 M10339 M10341 M10342 M10349M10351 M10352 M10359 M10361 M10362 M10369 M10371 M10372M10379 M1038 M1039 M1040 M10411 M10412 M10419 M10421M10422 M10429 M10431 M10432 M10439 M10441 M10442 M10449M10451 M10452 M10459 M10461 M10462 M10469 M10471 M10472M10479 M1048 M1049 M109 M1A00X0 M1A00X1 M1A0110 M1A0111M1A0120 M1A0121 M1A0190 M1A0191 M1A0210 M1A0211 M1A0220 M1A0221M1A0290 M1A0291 M1A0310 M1A0311 M1A0320 M1A0321 M1A0390 M1A0391M1A0410 M1A0411 M1A0420 M1A0421 M1A0490 M1A0491 M1A0510 M1A0511M1A0520 M1A0521 M1A0590 M1A0591 M1A0610 M1A0611 M1A0620 M1A0621M1A0690 M1A0691 M1A0710 M1A0711 M1A0720 M1A0721 M1A0790 M1A0791M1A08X0 M1A08X1 M1A09X0 M1A09X1 M1A20X0 M1A20X1 M1A2110 M1A2111M1A2120 M1A2121 M1A2190 M1A2191 M1A2210 M1A2211 M1A2220 M1A2221M1A2290 M1A2291 M1A2310 M1A2311 M1A2320 M1A2321 M1A2390 M1A2391M1A2410 M1A2411 M1A2420 M1A2421 M1A2490 M1A2491 M1A2510 M1A2511M1A2520 M1A2521 M1A2590 M1A2591 M1A2610 M1A2620 M1A2621 M1A2690M1A2691 M1A2710 M1A2711 M1A2720 M1A2721 M1A2790 M1A2791 M1A28X0M1A28X1 M1A29X0 M1A29X1 M1A30X0 M1A30X1 M1A3110 M1A3111 M1A3120M1A3121 M1A3190 M1A3191 M1A3210 M1A3211 M1A3220 M1A3221 M1A3290




Diagnosis Codes (Submitted as stand-alone diagnosis codes)M1A3291 M1A3310 M1A3311 M1A3320 M1A3321 M1A3390 M1A3391 M1A3410M1A3411 M1A3420 M1A3421 M1A3490 M1A3491 M1A3510 M1A3511 M1A3520M1A3521 M1A3590 M1A3591 M1A3610 M1A3611 M1A3620 M1A3621 M1A3690M1A3691 M1A3710 M1A3711 M1A3720 M1A3721 M1A3790 M1A3791 M1A38X0M1A38X1 M1A39X0 M1A39X1 M1A40X0 M1A40X1 M1A4110 M1A4111 M1A4120M1A4121 M1A4190 M1A4191 M1A4210 M1A4211 M1A4220 M1A4221 M1A4290M1A4291 M1A4310 M1A4311 M1A4320 M1A4321 M1A4390 M1A4391 M1A4410M1A4411 M1A4420 M1A4421 M1A4490 M1A4491 M1A4510 M1A4511 M1A4520M1A4521 M1A4590 M1A4591 M1A4610 M1A4611 M1A4620 M1A4621 M1A4690M1A4691 M1A4710 M1A4711 M1A4720 M1A4721 M1A4790 M1A4791 M1A48X0M1A48X1 M1A49X0 M1A49X1 M1A9XX0 M1A9XX1 M359 N200 Z431Z87738 Z931 Z934

Prior authorization is required through CCP for nutritional products that are provided for clients who do not meet the requirements as outlined in the Texas Medicaid Provider Procedures Manual. A request for prior authorization must include the client’s diagnosis or condition identified by the most appropriate ICD-10-CM diagnosis code.

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.5.11, “Nutri-tional Products,” for additional information.

Respiratory Care Equipment–CCPRental of a cardiorespiratory (apnea) monitor with recording feature (procedure code E0619) may be considered for use in the home for two months without prior authorization for infants birth through four months of age if one of the following ICD-10-CM diagnosis codes is indicated on the claim:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G9009 I440 I441 I442 I4430 I4439 I471 I479 I498 K219P228 P270 P271 P278 P282 P283 P284 P285 P2889 P2911P2912 Q246 R000 R0681 Z8489

Diagnosis code 1498 includes atrial tachycardia (supraventricular tachycardia [SVT], atrioventricular nodal reentrant tachycardia [AV nodal re-entry], nodal, and sinoauricular) and bradycardia (nodal, sinoatrial).

For diagnosis code Z8489, providers must submit additional documentation to support medical necessity.

Refer to: The Texas Medicaid Provider Procedures Manual Children’s Services Handbook, subsection 2.6, “Durable Medical Equipment (DME) Supplier (CCP),” for additional information.





TEXAS MEDICAID FORMS

Prior Authorization FormsThe following Texas Medicaid prior authorization forms have been revised to accommodate the changes associ-ated with ICD-10. These forms must be used to request prior authorizations for services to be rendered on or after October 1, 2015.

PA FormsCCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services

CCP Prior Authorization Request Form

CCP Prior Authorization Request Form Instructions

Home Health Plan of Care (POC)

Home Health Plan of Care (POC) Instructions

Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form

Intrathecal Baclofen or Morphine Pump

Obstetric Ultrasound Prior Authorization Request Instructions

Private Duty Nursing Prior Authorization Forms

Request for CCP Outpatient Therapy

Request for Outpatient Physical, Occupational, or Speech Therapy (PT, OT, ST) Special Medical Prior Authorization Form Instructions

Special Medical Prior Authorization (SMPA) Request Form

The following are examples of claim forms submitted with ICD-10-CM diagnosis codes and dates of service on or after October 1, 2015:

• CMS-1500 claim form example and ICD-10 relevant instructions

• UB-04 claim form example and ICD-10 relevant instructions

• Family Planning 2017 claim form example and ICD-10 relevant instructions


Texas Medicaid Forms


http://www.tmhp.com/Provider_Forms/Medicaid/F00011_CCP_Prior_Auth_Req_for_Non-Face-to-Face_CDCC.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00012_CCP_Prior_Authorization_Request_Form.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00012_CCP_Prior-Authorization_Request_Form_Instructions.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00028_Home_Health_Plan_of_Care_(POC).pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00028_Home_Health_Plan_of_Care_(POC)_Instructions.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00030_Home_Health_Title_XIX_DME_Medical_Supplies_Order_Form.pdf

http://www.tmhp.com:8080/Provider_Forms/Medicaid/Intrathecal%20Baclofen%20or%20Morphine%20Pump.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00046_Obstetric_Ultrasound_Prior_Authorization_Request_Instructions.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/PDN/PDN%20Prior%20Authorization%20Form%20Packet.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00082_Request_for_CCP_Outpatient_Therapy.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00083_Request_for_Outpatient_PT_OT_ST_SMPA_Instructions.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00083_Request_for_Outpatient_PT_OT_ST_SMPA_Instructions.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/F00087_SMPA_Request_Form.pdf

DSHS FAMILY PLANNING PROGRAM PROVIDERS

DSHS Family Planning Program Benefit ChangesThe following DSHS Family Planning Program (formerly family planning Titles V, X, and XX) benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.


Diagnosis Codes for Family PlanningThe family planning annual examination may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z30011 Z30013 Z30014 Z30018 Z3002 Z3009 Z302 Z3040 Z3041 Z3042Z30430 Z30431 Z30432 Z30433 Z3049 Z308 Z309 Z9851 Z9852

Refer to: The Texas Medicaid Provider Procedures Manual Gynecological and Reproductive Health Services Handbook, subsection 4.2, “Services, Benefits, Limitations, and Prior Authorization,” for additional information.

TEXAS WOMEN’S HEALTH PROGRAM (WHP) PROVIDERS

TWHP Benefit ChangesThe following TWHP benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.


Diagnosis Codes for Family PlanningFor TWHP family planning claims to process correctly, providers must use one of the following diagnosis codes in conjunction with all TWHP family planning procedures and services:Diagnosis Codes (Submitted as stand-alone diagnosis codes)A5400 A5402 A5409 A541 Z30011 Z30018 Z3002 Z3009 Z302 Z3040Z3041 Z3042 Z30430 Z30431 Z30432 Z30433 Z3049 Z308 Z309 Z9851


DSHS Family Planning Program Providers/Texas Women’s Health Program (WHP) Providers


MEDICAL TRANSPORTATION PROGRAM (MTP) PROVIDERS

MTP Benefit ChangesThe following MTP benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.

MTP providers must use the following diagnosis code when submitting claims:Diagnosis Codes (Submitted as stand-alone diagnosis codes)R69 R99R69 Illness, unspecified; R99 Ill-defined and unknown cause of mortality

Refer to: The Texas Medicaid Provider Procedures Manual, Medical Transportation Program Handbook, subsection 6.3, “Important Codes for All MTP Providers.”


INPATIENT HOSPITAL ICD-10-PCS SURGICAL PROCEDURE CODE UPDATES

ICD-10 and DRG Code Changes for Inpatient Hospital ProvidersThis section includes information about the surgical procedure and DRG code changes related to ICD-10-PCS for inpatient hospital providers. These changes are effective for dates of discharge on or after October 1, 2015.

These changes apply to Texas Medicaid fee-for-service and Medicaid managed care claims and authorization requests that are submitted to TMHP for processing. If the client’s claims are submitted to and processed by a managed care organization (MCO), the provider must contact the client’s MCO for benefit, limitation, and processing information.

Note: This section does not contain a complete list of ICD-10-PCS surgical procedure codes. The complete list of 2015 ICD-10 codes including descriptions can be found in the 2015 ICD-10 coding manual available through CMS.

Providers may refer to the TMHP website for the complete list of DRG relative weights, mean lengths of stay, and day thresholds for effective for dates of admission of or after October 1, 2015. The information is available in the

“Software, Fee Schedules, Reference Codes: section under “Acute Care Reference Codes.”


Medical Transportation Program (MTP) Providers/Inpatient Hospital ICD-10-PCS Surgical Procedure Code


CSHCN SERVICES PROGRAM PROVIDERS

CSHCN Services Program Benefit ChangesThe following CSHCN Services Program benefit changes have been made to support the 2015 ICD-10 updates and are effective for dates of service on or after October 1, 2015.

For questions, call the TMHP-CSHCN Contact Center at 1-800-568-2413.

Ambulance ServicesEffective for dates of service on or after October 1, 2015, the following condition codes must be used to identify emergency medical conditions for ambulance transports:Ambulance Emergency Condition CodesB9689 B999 E869 F068 F10929 F19939 F29 G4489G8929 H579 I469 I499 J9600 J984 M549 O2690R002 R0602 R0689 R079 R092 R0989 R100 R109R238 R4182 R4189 R4589 R509 R52 R55 R569R58 R6889 R7309 S0590XA T07 T148 T17300A T300T50904A T59891A T5994XA T672XXA T675XXA T68XXXA T699XXA T7500XAT751XXA T754XXA T782XXA T7840XA T8189XA T82519A T887XXA Y710Y828 Z209 Z7401 Z779 Z9181 Z9981 Z9989

An emergency transport may be reimbursed by the CSHCN Services Program when it is submitted with modifier ET and one or more of the emergency medical condition codes in the above table.

The requesting facility or physician must include with the claim, documentation that describes the client’s condition which necessitated the ambulance transport. Medicaid recognizes limitations of usual ambulance personnel for establishing a diagnosis, and recognizes that diagnosis coding of a client’s condition using International Classifica-tion of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) when reporting ambulance transport services may be less specific than for services reported by other professional providers.

Providers who submit ICD-10-CM diagnosis codes should choose the code that best describes the client’s condition at the time of transport. Diagnoses that are “rule out” or “suspected” diagnoses should not be reported using specific ICD-10-CM diagnosis codes. In such instances where a diagnosis is not confirmed, it is more correct to use a symptom, finding, or injury diagnosis code.

Refer to: The CSHCN Services Program Provider Manual, Section 9.3 “Emergency Ambulance Transports,” for additional information.

Behavioral HealthProcedure codes 90832, 90833, 90834, 90836, 90837, 90838, 90847, and 90853 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F0390 F0391 G3184 R41841

Refer to: The CSHCN Services Program Provider Manual, section 29.2.8.1 “Treatment for Alzheimer’s and Dementia,” for additional information.


CSHCN Services Program Providers



* Blood Pressure DevicesBlood pressure devices, manual (procedure code A4660) and automated (procedure code A4670) may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)I10 I110 I119 I120 I129 I130 I1310 I1311 I132 I150I151 I152 I158 I159 I2541 I2582 I2601 I2602 I2609 I2690I2692 I2699 I270 I271 I2781 I2782 I2789 I279 I340 I341I342 I348 I349 I350 I351 I352 I358 I359 I360 I361I362 I368 I369 I370 I371 I372 I378 I379 I38 I39I421 I422 I423 I424 I425 I428 I440 I441 I442 I4430I4439 I444 I445 I4460 I4469 I447 I450 I4510 I4519 I452I454 I455 I456 I4589 I459 I471 I472 I479 I480 I481I482 I483 I484 I4891 I4892 I495 I501 I5020 I5021 I5022I5023 I5030 I5031 I5032 I5033 I5040 I5041 I5042 I5043 I509I950 I951 I952 I953 I9581 I9589 I959 N000 N001 N002N003 N004 N005 N006 N007 N008 N009 N010 N011 N012N013 N014 N015 N016 N017 N018 N019 N030 N031 N032N033 N034 N035 N036 N037 N038 N039 N040 N041 N042N043 N044 N045 N046 N047 N048 N049 N050 N051 N052N053 N054 N055 N056 N057 N058 N059 N08 N170 N171N172 N178 N179 N181 N182 N183 N184 N185 N186 N189N19 N250 N251 N2581 N2589 N259 N269 N270 N271 R001

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)T800XXA, I2690

T800XXA, I2699

T81718A, I2690

T81718A, I2699

T8172XA, I2690

T8172XA, I2699

T82817A, I2690

T82817A, I2699

T82818A, I2690

T82818A, I2699


Prior authorization is required for all diagnosis codes not listed in the above tables. Providers must maintain documentation to support medical necessity in the medical record.


The CSHCN Services Program Provider Manual, subsection 11.2.1.1, “Manual and Automated Blood Pressure Devices,” for additional information.




http://www.tmhp.com/ICD10_Benefits_CSHCN/Blood%20Pressure%20Devices.pdf

Bone Anchored Hearing DevicesPrior authorization for the bone-anchored hearing aid (BAHA) device may be granted for services rendered to clients who are five years of age and older with documentation of an appropriate indication that may be causing hearing impairment. Indications may include, but are not limited to, one of the following:

• Acquired deformities of auricle or pinna

• Congenital anomalies of the external ear canal, middle ear or skull and face bones

• Malignant neoplasm, benign neoplasm or carcinoma of the external ear canal and/or tympanic cavity

• Otosclerosis in clients who cannot undergo stapedectomy

• Severe chronic conductive or sensorineural hearing loss (i.e., otitis media, malformations of the inner ear)

Note: The most appropriate ICD-10 diagnosis code must be included on the claim.

Refer to: The CSHCN Services Program Provider Manual, subsection 20.3.1.1, “Prior Authorization Requirements,” for additional information.

* Botulinum Toxin, Type A and Type BProcedure codes J0585 (per unit) and J0586 (per 5 units) may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G114 G2401 G2402 G241 G243 G244 G245 G248 G249 G35G360 G370 G371 G372 G373 G374 G375 G378 G379 G512G513 G514 G518 G800 G801 G802 G803 G804 G808 G809G8111 G8112 G8113 G8114 G8191 G8192 G8193 G8194 G8220 G8221G8222 G8250 G8251 G8252 G8253 G8254 G830 G8310 G8311 G8312G8313 G8314 G8320 G8321 G8322 G8323 G8324 G8330 G8331 G8332G8333 G8334 G834 G8921 H4901 H4902 H4903 H4911 H4912 H4913H4921 H4922 H4923 H4931 H4932 H4933 H4941 H4942 H4943 H499H5000 H50011 H50012 H50021 H50022 H50031 H50032 H50041 H50042 H5005H5006 H5007 H5008 H5010 H50111 H50112 H50121 H50122 H50131 H50132H50141 H50142 H5015 H5016 H5017 H5018 H5021 H5022 H5030 H50311H50312 H5032 H50331 H50332 H5034 H5040 H50411 H50412 H5042 H5043H5050 H5051 H5052 H5053 H5054 H5055 H5060 H50611 H50612 H5069H50811 H50812 H5089 H510 H5111 H5112 H5121 H5122 H5123 H518H519 J385 J387 K117 K220 K594 K600 K601 K602 M436M62838 R252 R532

In addition to the diagnosis codes listed in the above table, procedure code J0585, may be indicated for, but is not limited to, treatment of the following diagnoses:Diagnosis Codes (Submitted as stand-alone diagnosis codes)N310 N311 N312 N318 N319 N3281 N3644

Note: The CSHCN Services Program requires a trial of botulinum toxin type A prior to the use of botulinum toxin type B.




http://www.tmhp.com/ICD10_Benefits_CSHCN/6-02-15%20Update%20to%20Botulinum%20Toxin%20Type%20A%20and%20Type%20B%20for%20the%20CSHCN%20Services%20Program.pdf

Procedure code J0587 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G243 G8921

Procedure code J0588 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G243 G245 G8111 G8112 G8113 G8114

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.24.5, “Botulinum Toxin (Type A and Type B),” for additional information.

Cochlear ImplantsAuditory brain implant (ABI) procedure code S2235 may be reimbursed when submitted with the following ICD-10-CM diagnosis code:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Q8502

Refer to: The CSHCN Services Program Provider Manual, subsection 20.3.2.5, “Limitations,” for additional information.

Cytogenetics TestingCytogenetics testing procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C8280 C8281 C8282 C8283 C8284 C8285 C8286 C8287 C8288 C8289C8291 C8292 C8293 C8294 C8295 C8296 C8297 C8298 C8299 C8310C8311 C8312 C8313 C8314 C8315 C8316 C8317 C8318 C8319 C8380C8381 C8382 C8383 C8384 C8385 C8386 C8387 C8388 C8389 C8440C8441 C8442 C8443 C8444 C8445 C8446 C8447 C8448 C8449 C8461C8462 C8463 C8464 C8465 C8466 C8467 C8468 C8469 C8471 C8472C8473 C8474 C8475 C8476 C8477 C8478 C8479 C8581 C8582 C8584C8585 C8586 C8587 C8588 C8589 C884 C888 C9012 C9100 C9101C9102 C9110 C9111 C9112 C9190 C9191 C9192 C91Z0 C91Z1 C91Z2C9200 C9201 C9202 C9210 C9211 C9212 C9220 C9221 C9222 C9230C9231 C9232 C9240 C9241 C9242 C9250 C9251 C9252 C9260 C9261C9262 C9290 C9291 C9292 C92A0 C92A1 C92A2 C92Z0 C92Z1 C92Z2C9300 C9301 C9302 C9310 C9311 C9312 C9330 C9331 C9390 C9391C9392 C93Z0 C93Z1 C93Z2 C9400 C9401 C9402 C9420 C9421 C9422C9430 C9431 C9432 C9480 C9481 C9482 C9500 C9501 C9502 C9510C9511 C9512 C9590 C9591 C9592 D45 D821 E230 E291 E300E343 E83110 E8359 F70 F71 F72 F73 F78 F800 F801F802 F804 F8089 F810 F812 F8181 F8189 F819 F82 F840F88 F900 F901 F902 F908 H0589 H9325 I77810 I77811 I77812I77819 M2600 M2601 M2602 M2603 M2604 M2605 M2606 M2607 M2609N6482 P293 Q000 Q001 Q002 Q010 Q011 Q012 Q018 Q02




Diagnosis Codes (Submitted as stand-alone diagnosis codes)Q030 Q031 Q038 Q040 Q041 Q042 Q045 Q046 Q048 Q050Q051 Q052 Q054 Q055 Q056 Q057 Q058 Q062 Q064 Q068Q0701 Q0702 Q0703 Q078 Q079 Q100 Q101 Q102 Q103 Q104Q106 Q107 Q110 Q111 Q112 Q113 Q120 Q121 Q123 Q124Q128 Q129 Q130 Q131 Q132 Q133 Q134 Q135 Q1381 Q1389Q140 Q141 Q142 Q143 Q148 Q150 Q158 Q159 Q160 Q161Q162 Q163 Q164 Q165 Q169 Q170 Q171 Q172 Q173 Q174Q175 Q178 Q179 Q180 Q181 Q182 Q183 Q184 Q185 Q186Q187 Q188 Q189 Q200 Q201 Q202 Q203 Q204 Q205 Q206Q208 Q209 Q210 Q211 Q212 Q213 Q214 Q218 Q219 Q220Q221 Q222 Q223 Q224 Q225 Q228 Q230 Q231 Q232 Q233Q234 Q238 Q240 Q241 Q242 Q243 Q244 Q245 Q246 Q248Q249 Q250 Q251 Q252 Q253 Q254 Q2572 Q259 Q260 Q261Q262 Q263 Q265 Q266 Q268 Q269 Q270 Q271 Q272 Q2730Q2731 Q2732 Q2733 Q2734 Q274 Q278 Q279 Q280 Q281 Q282Q283 Q288 Q289 Q300 Q301 Q302 Q303 Q308 Q309 Q310Q311 Q312 Q313 Q315 Q318 Q320 Q321 Q322 Q323 Q324Q330 Q331 Q332 Q333 Q334 Q335 Q336 Q338 Q339 Q348Q349 Q351 Q353 Q359 Q360 Q369 Q370 Q371 Q372 Q373Q374 Q375 Q380 Q381 Q382 Q383 Q384 Q385 Q386 Q387Q388 Q391 Q392 Q393 Q394 Q395 Q396 Q398 Q400 Q401Q402 Q408 Q409 Q410 Q411 Q412 Q419 Q420 Q421 Q422Q423 Q428 Q430 Q431 Q432 Q433 Q434 Q435 Q437 Q438Q440 Q441 Q442 Q443 Q444 Q445 Q446 Q447 Q450 Q451Q452 Q453 Q458 Q459 Q5001 Q5002 Q501 Q502 Q5031 Q5032Q5039 Q504 Q505 Q506 Q510 Q5110 Q5111 Q512 Q515 Q516Q517 Q51811 Q51821 Q51828 Q520 Q5210 Q522 Q523 Q524 Q525Q526 Q5270 Q5271 Q5279 Q528 Q529 Q5300 Q5301 Q5302 Q5310Q5311 Q5312 Q5320 Q5321 Q5322 Q539 Q540 Q541 Q542 Q543Q544 Q548 Q550 Q551 Q5521 Q5522 Q5523 Q5529 Q553 Q554Q555 Q5561 Q5562 Q5563 Q5564 Q5569 Q558 Q559 Q560 Q561Q562 Q563 Q564 Q600 Q601 Q603 Q604 Q606 Q6101 Q6119Q612 Q613 Q614 Q615 Q618 Q619 Q6211 Q6212 Q622 Q6231Q6239 Q624 Q625 Q6261 Q6262 Q6263 Q628 Q630 Q631 Q632Q633 Q638 Q640 Q6410 Q6411 Q6412 Q6419 Q642 Q6431 Q6432Q6433 Q6439 Q644 Q645 Q646 Q6471 Q6472 Q6473 Q6474 Q6475Q649 Q6501 Q6502 Q651 Q6531 Q6532 Q654 Q6581 Q6582 Q6589Q660 Q662 Q663 Q664 Q6651 Q6652 Q666 Q667 Q6681 Q6682Q6689 Q670 Q671 Q672 Q673 Q674 Q675 Q676 Q677 Q678Q680 Q681 Q682 Q683 Q684 Q688 Q690 Q691 Q692 Q699Q7001 Q7002 Q7003 Q7011 Q7012 Q7013 Q7021 Q7022 Q7023 Q7031Q7032 Q7033 Q709 Q7101 Q7102 Q7103 Q7111 Q7112 Q7113 Q7131Q7132 Q7133 Q7141 Q7142 Q7143 Q7151 Q7152 Q7153 Q7161 Q7162Q7163 Q71811 Q71812 Q71813 Q71891 Q71892 Q71893 Q7191 Q7192 Q7193




Diagnosis Codes (Submitted as stand-alone diagnosis codes)Q7201 Q7202 Q7203 Q7211 Q7212 Q7213 Q7231 Q7232 Q7233 Q7241Q7242 Q7243 Q7251 Q7252 Q7253 Q7261 Q7262 Q7263 Q7271 Q7272Q7273 Q72811 Q72812 Q72813 Q72891 Q72892 Q72893 Q7291 Q7292 Q7293Q730 Q731 Q738 Q740 Q742 Q743 Q748 Q749 Q750 Q751Q752 Q753 Q754 Q755 Q758 Q759 Q760 Q761 Q762 Q763Q76411 Q76412 Q76413 Q76414 Q76415 Q76425 Q76426 Q76427 Q76428 Q7649Q765 Q766 Q767 Q768 Q770 Q771 Q772 Q774 Q775 Q776Q777 Q780 Q781 Q782 Q783 Q784 Q788 Q789 Q790 Q791Q792 Q793 Q794 Q7959 Q796 Q798 Q799 Q800 Q801 Q802Q803 Q804 Q808 Q820 Q821 Q822 Q823 Q824 Q828 Q830Q831 Q832 Q833 Q838 Q840 Q841 Q842 Q843 Q844 Q845Q846 Q848 Q849 Q8503 Q851 Q858 Q859 Q870 Q871 Q87410Q87418 Q8742 Q8743 Q8901 Q8909 Q891 Q892 Q893 Q894 Q897Q898 Q899 Q900 Q901 Q902 Q909 Q910 Q911 Q912 Q913Q914 Q915 Q916 Q917 Q920 Q921 Q922 Q925 Q9261 Q9262Q927 Q928 Q930 Q931 Q932 Q933 Q934 Q935 Q937 Q9381Q9388 Q9389 Q950 Q952 Q958 Q960 Q961 Q962 Q963 Q964Q968 Q969 Q970 Q971 Q972 Q973 Q978 Q980 Q981 Q984Q985 Q986 Q987 Q988 Q990 Q991 Q992 Q998 Q999 R480Z31430 Z31438 Z315 Z810 Z8279 Z8489

Combination Diagnosis CodesCombination Diagnosis Codes (Must be submitted in pairs)Q6501, Q6532

Q6502, Q6531

Refer to: The CSHCN Services Program Provider Manual, Section 25 “Laboratory Services,” subsection 25.2.5.1 Cytogenetics Testing for additional information.

Dental Services – OrthodontiaThe most appropriate ICD-10-CM diagnosis code that supports medical necessity of the orthodontia service must be included in the documentation for prior authorization. Indications may include, but are not limited to, one of the following indications:

• Cleft lip

• Cleft palate

• Congenital anomalies of skull and face bones

• Dentofacial functional abnormalities

• Major anomalies of jaw size

Prior authorization is required for all orthodontic services except for the initial orthodontic visit. Providers must include in the prior authorization request all the required documentation.

Refer to: The CSHCN Services Program Provider Manual, subsection 14.2.3.2, “Required Documentation,” for the necessary documentation requirements.




Dental – Therapeutic ServicesDental behavior management procedure code D9920 may be considered for prior authorization in addition to therapeutic procedures when the prior authorization request includes the most appropriate ICD-10-CM diagnosis code that indicates an intellectual disability described as mild, moderate, severe, profound or unspecified.

Refer to: The CSHCN Services Program Provider Manual, subsection 14.2.5.10, “Dental Behavior Management” for all supporting documentation requirements.

Diabetic Equipment and SuppliesDiabetic supplies and related testing equipment supplies do not require prior authorization unless otherwise specified. Prior authorization is required when documentation of medical necessity supports additional quantities greater than the limitations defined for a client with exceptional needs.

Blood testing and supplies may be reimbursed without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes or combination diagnosis codes:

Diabetic Diagnosis CodesDiabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)E0800 E0801 E0810 E0811 E0821 E0822 E0829 E08311E08319 E08321 E08329 E08331 E08339 E08341 E08349 E08351E08359 E0836 E0839 E0840 E0841 E0842 E0843 E0844E0849 E0851 E0859 E08610 E08618 E08620 E08621 E08622E08628 E08630 E08638 E08641 E08649 E0865 E0869 E088E089 E0900 E0901 E0910 E0911 E0921 E0922 E0929E09311 E09319 E09321 E09329 E09331 E09339 E09341 E09349E09351 E09359 E0936 E0939 E0940 E0941 E0942 E0943E0944 E0949 E0951 E0959 E09610 E09618 E09620 E09621E09622 E09628 E09630 E09638 E09641 E09649 E0965 E0969E098 E099 E1010 E1011 E1021 E1022 E1029 E10311E10319 E10321 E10329 E10331 E10339 E10341 E10349 E10351E10359 E1036 E1039 E1040 E1041 E1042 E1043 E1044E1049 E1051 E1052 E1059 E10610 E10618 E10620 E10621E10622 E10628 E10630 E10638 E10641 E10649 E1065 E1069E108 E109 E1100 E1101 E1121 E1122 E1129 E11311E11319 E11321 E11329 E11331 E11339 E11341 E11349 E11351E11359 E1136 E1139 E1140 E1141 E1142 E1143 E1144E1149 E1151 E1152 E1159 E11610 E11618 E11620 E11621E11622 E11628 E11630 E11638 E11641 E11649 E1165 E1169E118 E119 E1300 E1301 E1310 E1311 E1321 E1322E1329 E13311 E13319 E13321 E13329 E13331 E13339 E13341E13349 E13351 E13359 E1336 E1339 E1340 E1341 E1342E1343 E1344 E1349 E1351 E1352 E1359 E13610 E13620E13621 E13622 E13628 E13638 E13641 E13649 E1365 E1369E138 E139 P702





E0801, E0865

E0810, E0865

E0821, E0865

E08311, E0865

E08319, E0865

E08321, E0865

E08329, E0865

E08331, E0865

E08339, E0865

E08341, E0865

E08349, E0865

E08351, E0865

E08359, E0865

E0836, E0865

E0839, E0865

E0840, E0865

E0851, E0865

E0865, E0841

E0865, E0842

E0865, E0843

E0865, E0844

E0865, E0849

E0865, E0851

E0865, E0852

E0865, E0859

E0865, E0869

E0865, E088

E0865, E0921

E0865, E09311

E0865, E09319

E0865, E0936

E0865, E0940

E0865, E0951

E0865, E0969

E0865, E098

E0865, E1365

E0865, E138

E0900, E0865

E0901, E0865

E0910, E0865

E1010, E1065

E1011, E10641

E1011, E1065

E1011, E1311

E1011, E13641

E10319, E1065

E1036, E1065

E1039, E1065

E1040, E1065

E1051, E1065

E1065, E1021

E1065, E1022

E1065, E1029

E1065, E10311

E1065, E10321

E1065, E10329

E1065, E10331

E1065, E10339

E1065, E10341

E1065, E10359

E1065, E1041

E1065, E1042

E1065, E1043

E1065, E1044

E1065, E1049

E1065, E10351

E1065, E1052

E1065, E1059

E1065, E10610

E1065, E1069

E1065, E108

E1065, E1141

E1065, E1142

E1065, E1143

E1065, E1144

E1065, E1149

E1065, E11610

E1065, E1340

E1065, E1341

E1065, E1342

E1065, E1343

E1065, E1344

E1065, E1349

E1065, E13610

E1100, E1165

E1101, E1165

E1121, E1122

E1121, E1129

E1121, E1321

E1121, E1322

E1121, E1329

E11311, E1165

E11319, E1169

E1136, E1165

E1139, E1165

E1140, E1165

E1151, E1165

E1165, E1169

E1165, E118

E1321, E0865


Non-diabetic Diagnosis Codes

Non-Diabetic Diagnosis Codes (Submitted as stand-alone diagnosis codes)E161 E162 E71111 E71310 E71311 E71312 E71313 E71314 E71318 E7132E7420 E7421 E7429 E8881 K911 R7309 R81

Blood testing supplies for diagnoses other than those listed in the above diagnosis tables may be considered for prior authorization with documentation of medical necessity.

Refer to: The Section titled “Combination Diagnosis Codes” on page 3 of this bulletin for additional informa-tion about submitting claims with combination diagnosis codes.

The CSHCN Services Program Provider Manual, subsection 15.2.1 “Glucose Monitor and Supplies” for additional information.




Electroencephalogram (Ambulatory)Ambulatory electroencephalogram (A/EEG) procedure codes 95950, 95951, 95953, 95956, and 95957 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)F05 F060 F068 G253 G40001 G40009 G40011 G40019G40101 G40109 G40111 G40119 G40201 G40209 G40211 G40219G40301 G40309 G40311 G40319 G40401 G40409 G40411 G40419G40501 G40509 G40801 G40802 G40803 G40804 G40811 G40812G40813 G40814 G4089 G40901 G40909 G40911 G40919 G40A11G40A19 G40B01 G40B09 G40B11 G40B19 G912 G9381 G9389P912 R561 R569 Z85020 Z85030 Z85040 Z85060 Z85110Z85230 Z85520 Z85821 Z85841 Z85848 Z86011 Z8669 Z87728Z87798

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.16.2, “Ambulatory Electroencephalo-gram,” for additional information.

Evoked Response TestsElectromyography (EMG) and nerve conduction study (NCS) procedures may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C701 C720 C721 E0842 E0942 E1041 E1042 E10610E1141 E1142 E1144 E11610 E1342 E5111 E5112 E512E518 E519 E560 E568 E786 E851 E852 E853E858 E859 G120 G121 G1221 G1222 G1229 G128G129 G130 G243 G2589 G26 G320 G360 G370G375 G501 G510 G511 G512 G513 G514 G518G519 G522 G523 G527 G528 G540 G541 G542G543 G544 G545 G548 G549 G5601 G5602 G5611G5612 G5621 G5622 G5631 G5632 G5641 G5642 G5681G5682 G5691 G5692 G5701 G5702 G5711 G5712 G5721G5722 G5731 G5732 G5741 G5742 G5751 G5752 G5761G5762 G5771 G5772 G5781 G5782 G5791 G5792 G587G588 G589 G59 G600 G601 G602 G603 G608G609 G610 G6181 G6189 G619 G620 G621 G622G6281 G6282 G629 G63 G650 G651 G652 G7000G7001 G701 G702 G7081 G7089 G709 G710 G7111G7112 G7113 G7114 G7119 G712 G713 G718 G719G721 G722 G723 G7241 G7249 G7281 G7289 G729G731 G733 G737 G834 G8381 G8382 G8383 G8384G8389 G839 G9009 G902 G904 G9050 G90511 G90512G90513 G90519 G90521 G90522 G90523 G90529 G9059 G909G950 G9511 G9519 G9520 G9529 G9581 G9589 G959G990 G992 I776 I951 J3800 J3801 J3802 K5902K5909 K592 K594 K624 K6289 M05411 M05412 M05421




Diagnosis Codes (Submitted as stand-alone diagnosis codes)M05422 M05431 M05432 M05441 M05442 M05451 M05452 M05461M05462 M05471 M05472 M0549 M05511 M05512 M05521 M05522M05531 M05532 M05541 M05542 M05551 M05552 M05561 M05562M05571 M05572 M0559 M05711 M05712 M05721 M05722 M05731M05732 M05741 M05742 M05751 M05752 M05761 M05762 M05769M05771 M05772 M05779 M0579 M05811 M05812 M05821 M05822M05831 M05832 M05841 M05842 M05851 M05852 M05861 M05862M05871 M05872 M0589 M06011 M06012 M06021 M06022 M06031M06032 M06041 M06042 M06051 M06052 M06061 M06062 M06071M06072 M0608 M0609 M06811 M06812 M06821 M06822 M06831M06832 M06841 M06842 M06852 M06861 M06862 M06871 M06872M0688 M0689 M069 M21271 M21272 M21331 M21332 M21511M21512 M216X1 M216X2 M21831 M21832 M21931 M21932 M320M3210 M3211 M3212 M3213 M3214 M3215 M3219 M328M329 M3300 M3301 M3302 M3309 M3310 M3311 M3312M3319 M3320 M3321 M3322 M3329 M3390 M3391 M3392M3399 M340 M341 M342 M3481 M3482 M3483 M3489M358 M360 M4321 M4322 M4323 M4324 M4325 M4326M4327 M4328 M436 M438X9 M4644 M4645 M4646 M4647M4711 M4712 M4713 M4714 M4715 M4716 M4717 M4718M4721 M4722 M4723 M4724 M4725 M4726 M4727 M4728M47811 M47812 M47813 M47814 M47815 M47816 M47817 M47818M47891 M47892 M47893 M47894 M47895 M47896 M47897 M47898M4801 M4802 M4803 M4804 M4805 M4806 M4807 M4808M5000 M5001 M5002 M5003 M5011 M5012 M5013 M5020M5021 M5022 M5023 M5030 M5031 M5032 M5033 M5080M5081 M5082 M5083 M5091 M5092 M5093 M5104 M5105M5106 M5107 M5124 M5125 M5126 M5127 M5134 M5135M5136 M5137 M5184 M5185 M5186 M5187 M5410 M5411M5412 M5413 M5414 M5415 M5416 M5417 M5431 M5432M545 M546 M5489 M60011 M60012 M60021 M60022 M60031M60032 M60041 M60042 M60044 M60045 M60046 M60051 M60052M60061 M60062 M60070 M60071 M60073 M60074 M60076 M60077M6008 M6009 M60111 M60112 M60121 M60122 M60131 M60132M60141 M60142 M60151 M60152 M60161 M60162 M60171 M60172M6018 M6019 M609 M6250 M62511 M62512 M62519 M62521M62522 M62529 M62531 M62532 M62539 M62541 M62542 M62549M62551 M62552 M62559 M62561 M62562 M62569 M62571 M62572M62579 M6258 M6259 M6281 M629 M791 M792 M79601M79602 M79604 M79605 M79621 M79622 M79631 M79632 M79641M79642 M79651 M79652 M79661 M79662 M79671 M79672 M797M961 N393 N3941 N3942 N3943 N3944 N3945 N3946N39490 N39498 N94819 R150 R151 R152 R159 R200R201 R202 R203 R208 R209 R260 R261 R2681




Diagnosis Codes (Submitted as stand-alone diagnosis codes)R2689 R269 R290 R295 R32 R3914 R4702 R471R4781 R4789 R498 R6884 S14101A S14101D S14101S S14102AS14102D S14102S S14103A S14103D S14103S S14104A S14104D S14104SS14105A S14105D S14105S S14106A S14106D S14106S S14107A S14107DS14107S S14108A S14108D S14108S S14109A S14109D S14109S S14111AS14111D S14111S S14112A S14112D S14112S S14113A S14113D S14113SS14114A S14114D S14114S S14115A S14115D S14115S S14116A S14116DS14116S S14117A S14117D S14117S S14118A S14118D S14118S S14121AS14121D S14121S S14122A S14122D S14122S S14123A S14123D S14123SS14124A S14124D S14124S S14125A S14125D S14125S S14126A S14126DS14126S S14127A S14127D S14127S S14128A S14128D S14128S S14131AS14131D S14131S S14132A S14132D S14132S S14133A S14133D S14133SS14134A S14134D S14134S S14135A S14135D S14135S S14136A S14136DS14136S S14137A S14137D S14137S S14138A S14138D S14138S S14141AS14141D S14141S S14142A S14142D S14142S S14143A S14143D S14143SS14144A S14144D S14144S S14145A S14145D S14145S S14146A S14146DS14146S S14147A S14147D S14147S S14148A S14148D S14148S S14151AS14151D S14151S S14152A S14152D S14152S S14153A S14153D S14153SS14154A S14154D S14154S S14155A S14155D S14155S S14156A S14156DS14156S S14157A S14157D S14157S S14158A S14158D S14158S S142XXAS142XXD S142XXS S143XXA S143XXD S143XXS S144XXA S144XXD S144XXSS145XXA S145XXD S145XXS S148XXA S148XXD S148XXS S149XXA S149XXDS149XXS S24101A S24101D S24101S S24102A S24102D S24102S S24103AS24103D S24103S S24104A S24104D S24104S S24109A S24109D S24109SS24111A S24111D S24111S S24112A S24112D S24112S S24113A S24113DS24113S S24114A S24114D S24114S S24131A S24131D S24131S S24132AS24132D S24132S S24133A S24133D S24133S S24134A S24134D S24134SS24141A S24141D S24141S S24142A S24142D S24142S S24143A S24143DS24143S S24144A S24144D S24144S S24151A S24151D S24151S S24152AS24152D S24152S S24153A S24153D S24153S S24154A S24154D S24154SS242XXA S242XXD S242XXS S243XXA S243XXD S243XXS S244XXA S244XXDS244XXS S248XXA S248XXD S248XXS S249XXA S34109A S34109D S34111AS34111D S34111S S34112A S34112D S34112S S34113A S34113D S34113SS34114A S34114D S34114S S34115A S34115D S34115S S34121A S34121DS34121S S34122A S34122D S34122S S34123A S34123D S34123S S34124AS34124D S34124S S34125A S34125D S34125S S34131A S34131D S34131SS34132A S34132D S34132S S34139A S34139D S34139S S3421XA S3421XDS3421XS S3422XA S3422XD S3422XS S343XXA S343XXD S343XXS S344XXAS344XXD S344XXS S345XXA S345XXD S345XXS S4400XA S4400XD S4400XSS4401XA S4401XD S4401XS S4402XA S4402XD S4402XS S4410XA S4410XDS4410XS S4411XA S4411XD S4411XS S4412XA S4412XD S4412XS S4420XAS4420XD S4420XS S4421XA S4421XD S4421XS S4422XA S4422XD S4422XSS4430XA S4430XD S4430XS S4431XA S4431XD S4431XS S4432XA S4432XDS4432XS S4440XA S4440XD S4440XS S4441XA S4441XD S4441XS S4442XA




Diagnosis Codes (Submitted as stand-alone diagnosis codes)S4442XD S4442XS S4450XA S4450XD S4450XS S4451XA S4451XD S4451XSS4452XA S4452XD S4452XS S448X1A S448X1D S448X1S S448X2A S448X2DS448X2S S448X9A S448X9D S448X9S S4491XA S4491XD S4491XS S4492XAS4492XD S4492XS S5400XA S5400XD S5400XS S5401XA S5401XD S5401XSS5402XA S5402XD S5402XS S5410XA S5410XD S5410XS S5411XA S5411XDS5411XS S5412XA S5412XD S5412XS S5420XA S5420XD S5420XS S5421XAS5421XD S5421XS S5422XA S5422XD S5422XS S5430XA S5430XD S5430XSS5431XA S5431XD S5431XS S5432XA S5432XD S5432XS S5490XA S5490XDS5490XS S5491XA S5491XD S5491XS S5492XA S5492XD S5492XS S6400XAS6400XD S6400XS S6401XA S6401XD S6401XS S6402XA S6402XD S6402XSS6410XA S6410XD S6410XS S6411XA S6411XD S6411XS S6412XA S6412XDS6412XS S6420XA S6420XD S6420XS S6421XA S6421XD S6421XS S6422XAS6422XD S6422XS S6430XA S6430XD S6430XS S6431XA S6431XD S6431XSS6432XA S6432XD S6432XS S64490A S64490D S64490S S64491A S64491DS64491S S64492A S64492D S64492S S64493A S64493D S64493S S64494AS64494D S64494S S64495A S64495D S64495S S64496A S64496D S64496SS64497A S64497D S64497S S64498A S64498D S64498S S648X1A S648X1DS648X1S S648X2A S648X2D S648X2S S648X9A S648X9D S648X9S S6490XAS6490XD S6490XS S6491XA S6491XD S6491XS S6492XA S7401XA S7401XDS7401XS S7402XA S7402XD S7402XS S7411XA S7411XD S7411XS S7412XAS7412XD S7412XS S7421XA S7421XD S7421XS S7422XA S7422XD S7422XSS748X1A S748X1D S748X1S S748X2A S748X2D S748X2S S7491XA S7491XDS7491XS S7492XA S7492XD S7492XS S8401XA S8401XD S8401XS S8402XAS8402XD S8402XS S8411XA S8411XD S8411XS S8412XA S8412XD S8412XSS8421XA S8421XD S8421XS S8422XA S8422XD S8422XS S84801A S84801DS84801S S84802A S84802D S84802S S8491XA S8491XD S8491XS S8492XAS8492XD S8492XS S9421XA S9421XD S9421XS S9422XA S9422XD S9422XSS9431XA S9431XD S9431XS S9432XA S9432XD S9432XS S948X1A S948X1DS948X1S S948X2A S948X2D S948X2S S948X9D S948X9S S9490XD S9491XAS9491XS S9492XA S9492XD S9492XS

Prior authorization is required for any diagnosis other than those listed in the above table or when the number of NCS procedures performed during an evaluation exceeds the allowed maximum number of studies.

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.18.2, “Electromyography and Nerve Conduction Studies,” for additional information.

Expendable Medical SuppliesDiapers, briefs, pull-ups, or liners in any combination may be covered for clients who are 4 years of age and older who are incontinent as a direct result of a medical condition.

Diapers, briefs, pull-ups, or liners do not require prior authorization up to a combined total of 240 items per month when the most appropriate procedure code is submitted with an applicable diagnosis code. Click here to view the list of applicable diagnosis codes.




http://www.tmhp.com

http://www.tmhp.com/News_Items/2015/03-Mar/03-31-15%20Expendable%20Medical%20Supplies%20for%20the%20CSHCN%20Services%20Program.pdf

Hearing ServicesProcedure code 92568 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)D333 G510 G511 G518 G519 H8001 H8002 H8003H8011 H8012 H8013 H8021 H8022 H8023 H8081 H8082H8083 H8091 H8092 H8093 H8101 H8102 H8103 H8111H8112 H8113 H8121 H8122 H8123 H81311 H81312 H81313H81319 H81391 H81392 H81393 H8141 H8142 H8143 H818X1H818X2 H818X3 H8191 H8192 H8193 H8301 H8302 H8303H8311 H8312 H8313 H832X1 H832X2 H832X3 H838X1 H838X2H838X3 H838X9 H8391 H8392 H8393 H900 H9011 H9012H902 H903 H9041 H9042 H905 H906 H9071 H9072H908 H9101 H9102 H9103 H9109 H9121 H9122 H9123H918X1 H918X2 H918X3 H9191 H9192 H9193 H9311 H9312H9313 H93211 H93212 H93213 H93221 H93222 H93223 H93231H93232 H93233 H93241 H93242 H93243 H93291 H93292 H93293H933X1 H933X2 H933X3 H933X9 Q179 R42

Refer to: The CSHCN Services Program Provider Manual, subsection 20.2.3.5, “Limitations,” for additional information.

* Helicobacter pylori TestingSerology testing (procedure codes 83009, 86677, and 87339), breath testing (procedure codes 78267, 78268, 83013, and 83014), and stool testing (procedure code 87338) may be reimbursed when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C160 C161 C162 C163 C164 C165 C166 C168 K250 K251K252 K253 K254 K255 K256 K257 K260 K261 K262 K263K264 K265 K266 K267 K270 K271 K272 K273 K274 K275K276 K277 K280 K281 K282 K283 K284 K285 K286 K287K2900 K2901 K2931 K2940 K2941 K2960 K2961 K2980 K2981 K2990

Additionally, H. pylori breath and stool testing procedure codes 78267, 78268, 83013, 83014, and 87338 may be reimbursed when they are submitted with the following ICD-10-CM diagnosis code:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B9681

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.26.8, “Helicobacter pylori (H. pylori),” and subsection 25.2.8, “Helicobacter pylori (H.pylori),” for additional information.

Injection-ClofarabinePrior authorization of clofarabine (Clorar) injection is required. Documentation of the following must be submitted with the prior authorization request:

• Refractory or relapsed acute lymphoblastic leukemia (C9100 or C9102)

• At least two prior failed regimens




http://www.tmhp.com/ICD10_Benefits_CSHCN/05-18-15%20Helicobacter%20Pylori%20for%20CSHCN%20Services%20Program.pdf


Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.24.3, “Injection Procedure Codes,” for additional information.

Mastectomy and Reconstructive/Cosmetic ProceduresMastectomy and breast reconstruction procedure codes may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes: Diagnosis Codes (Submitted as stand-alone diagnosis codes)C50011 C50012 C50021 C50022 C50111 C50112 C50121 C50122C50211 C50212 C50221 C50222 C50311 C50312 C50321 C50322C50411 C50412 C50421 C50422 C50511 C50512 C50521 C50522C50611 C50612 C50621 C50622 C50811 C50812 C50821 C50822C50921 C50922 C7981 D0501 D0502 D0511 D0512 D0581D0582

The following additional diagnosis codes are benefits for simple, subcutaneous, radical, and modified radical mastectomies and for all breast reconstruction procedures:Diagnosis Codes (Submitted as stand-alone diagnosis codes)Z1501 Z803 Z853 Z9011 Z9012 Z9013

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.36.12, “Mastectomy and Related Services,” for additional information.

Medical FoodsThe Children with Special Health Care Needs (CSHCN) Services Program may cover medical foods for clients who have inborn errors of metabolism that prohibit them from eating a regular diet.

The following ICD10-CM diagnosis codes may be used for inborn metabolic disorders:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E700 E701 E7020 E7021 E7029 E7030 E70329 E70330 E70331 E70338E70339 E7039 E705 E708 E709 E710 E7119 E7201 E7202 E7203E7204 E7211 E7212 E7219 E7221 E7222 E7223 E7229 E723 E724H3120


Medical Nutritional ProductsProviders must include the most appropriate ICD-10-CM diagnosis code on claims for medical nutritional products. Prior authorization is required every six months for medical nutritional products if the client has one of the following conditions that is expected to be permanent or of indefinite duration:

• Anatomical, physiological, or motility disorder of the gastrointestinal tract

• Anatomical abnormality or disease of digestive system

• Malignancy

• Infantile cerebral palsy




• Cystic fibrosis

• Dysphagia

• Major trauma and burns

• Nutritional deficiencies (e.g., severe malnutrition, significant weight loss, low birth weight status)

• Inborn errors of amino acid metabolism

• Gastrostomy status or artificial opening of GI tract

• Metabolic disorder

• Immunity disorder

Note: Permanent impairment does not require a determination that there is no possibility that the client’s condition may improve in the future. If medical documentation substantiates that the impairment can reasonably be expected to exceed 3 months (90 days), the test of permanence is considered met. This is consistent with Center for Medicare and Medicaid Services (CMS) guidelines.

Prior authorization for other conditions must be reviewed by the CSHCN Services Program Medical Director or designee.


Medications-Blood Factor ProductsProviders may be reimbursed for blood factor products when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D66 D67 D680 D681 D682 D68311 D684 D688 D689 Z1402

Procedure codes J7180, J7181and J7200 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D682 D688 D689

Procedure codes C9136 and J7201 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D66 D682 D688 D689

Procedure code J7183 may be reimbursed when submitted with the following ICD-10-CM diagnosis code:

Diagnosis Code (Submitted as stand-alone diagnosis code)D680

Procedure codes J7193, J7194, and J7195 may be reimbursed when submitted with diagnosis code D67.




Procedure code J7189 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D66 D67 D682 D68311 D684 D688 D689 Z1402

Procedure codes J7186 and J7187 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D66 D680

Procedure codes J7185, J7190, J7192 and J7198 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)D66 D67 D681 D682 D68311 D688 D689

Providers can refer to the CSHCN Services Program Provider Manual, subsection 31.2.8, “Blood Factor Products,” and subsection 24.4.1.1, “Blood Factor Products,” for additional information.

Medications – Growth HormoneA valid ICD-10-CM diagnosis code must be submitted on claims for growth hormone (hGH) injections, and must indicate one of the following conditions:

• Chronic kidney disease

• Pituitary gland insufficiency

• Prader-Willi syndrome

• Turner syndrome

• Other specified disorders resulting from impaired renal function

Refer to: The CSHCN Services Program Provider Manual, Section 31 “Physician,” subsection 31.2.24.7 “Growth Hormone” for additional information.

NebulizersEffective for dates of service on or after October 1, 2015, a nebulizer with compressor or an ultrasonic nebulizer may be purchased for clients when the equipment is prescribed by a physician and submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)E840 E8411 E8419 E848 E849 J200 J201 J202 J203 J204J205 J206 J207 J208 J209 J210 J211 J218 J219 J440J441 J449 J4520 J4521 J4522 J4530 J4531 J4532 J4540 J4541J4542 J4550 J4551 J4552 J45901 J45902 J45909 J45998 J471 J479J690 J691




Ultrasonic Nebulizer Related Diagnosis CodesDiagnosis Codes (Submitted as stand-alone diagnosis codes)B20 B59 E840 E8411 E8419 E848 E849

Refer to: The CSHCN Services Program Provider Manual, 35.2.8 “Nebulizers” for additional information.

* Neurostimulators and Neuromuscular StimulatorsPrior authorization is not required for the purchase and implantation of a dorsal column neurostimulation (DCN), Intracranial neurostimulation (ICN), or percutaneous electrical nerve stimulation (PENS) device if the client has been diagnosed with one of the following:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G129 G20 G250 G251 G252 G500 G501 G5771G5772 G8921 G8928 G8929 G893 M4321 M4322 M4323M4324 M4325 M4326 M4327 M4328 M438X9 M4800 M4801M4802 M4803 M4804 M4805 M4806 M4807 M4808 M5021M5022 M5023 M5410 M792 S48011S S48012S S48021S S48022SS48111S S48112S S48121S S48122S S48911S S48912S S48921S S48922SS58011S S58012S S58021S S58022S S58111S S58112S S58121S S58122SS58911S S58912S S58921S S58922S S68011S S68012S S68021S S68022SS68110S S68111S S68112S S68113S S68114S S68115S S68116S S68117SS68120S S68121S S68122S S68123S S68124S S68125S S68126S S68127SS68128S S68411S S68412S S68421S S68511S S68512S S68521S S68522SS68610S S68611S S68612S S68613S S68614S S68615S S68616S S68617SS68621S S68622S S68623S S68624S S68625S S68626S S68627S S68712SS68721S S68722S S78011S S78012S S78021S S78022S S78111S S78112SS78121S S78122S S78911S S78912S S78921S S78922S S78929S S88011SS88012S S88021S S88022S S88111S S88112S S88121S S88122S S88911SS88912S S88921S S88922S S98011S S98012S S98021S S98022S S98111SS98112S S98121S S98122S S98131S S98132S S98141S S98211S S98221SS98222S S98311S S98312S S98321S S98322S S98911S S98912S S98921S

Prior Authorization

PENSPrior authorization for PENS is not required for clients who meet the following criteria:

• The client has a diagnosis indicating chronic pain that is refractory to conventional therapy.

• Treatment with transcutaneous electrical nerve stimulation (TENS) has failed or is contraindicated for the client.

Prior authorization for the implantation and purchase of DCN or ICN devices may be considered with a condition indication chronic pain that is refractory to conventional therapy.

Vagal Nerve Stimulation (VNS)Prior authorization for the implantation and purchase of VNS devices may be considered for clients with partial onset intractable seizures when there is a failure, contraindication or intolerance to all suitable medical and pharmacological management.




http://www.tmhp.com/ICD10_Benefits_CSHCN/06-16-15%20Neurostimulators%20and%20Neuromuscular%20Stimulators%20CSHCN%20.pdf

Sacral Nerve Stimulation (SNS)Prior authorization for the implantation and purchase of SNS devices may be considered with one of the following medical conditions:

• Urinary incontinence secondary to urethral instability

• Chronic voiding dysfunction

• Non-obstructive urinary retention

• Fecal incontinence

Refer to: The CSHCN Services Program Provider Manual, Section 27, “Neurostimulator Devices and Supplies,” for additional information.

Physician Evaluation and Management Services: Concurrent Inpatient CareConcurrent care will not be paid to providers of the same specialty for the same or related diagnoses. Concurrent care that is denied will be considered on appeal when the appeal is accompanied by documentation of medical necessity.

Diagnosis codes are considered related when up to six digits of the primary ICD-10-CM diagnosis codes match.

Refer to: The CSHCN Services Program Provider Manual, 31.2.17.2 “Inpatient Professional Services”for additional information.

Positron Emission Tomography (PET)PET procedure code 78608 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G40201 G40209 G40211 G40219 R569

PET procedure codes 78811, 78812, and 78813 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)C000 C001 C003 C004 C005 C006 C008 C430C4311 C4312 C4321 C4322 C4330 C4331 C4339 C434C4351 C4352 C4359 C4361 C4362 C4371 C4372 C438C439 C4400 C4409 C44102 C44109 C44112 C44119 C44122C44129 C44192 C44199 C44202 C44209 C44292 C44299 C44301C44309 C44390 C44391 C44399 C4440 C4449 C44500 C44501C44509 C44590 C44591 C44599 C44602 C44609 C44692 C44699C44702 C44709 C44792 C44799 C4480 C4489 C4490 C4499C518 C6201 C6202 C6210 C6291 C6292 C710 C711C712 C713 C714 C715 C716 C717 C718 C719C7641 C7642 C792 C7931 D030 D0311 D0312 D0321D0322 D0330 D0339 D034 D0351 D0352 D0359 D0361D0362 D0371 D0372 D038 D039 D4011 D4012 D430D431 D432




Refer to: The CSHCN Services Program Provider Manual, subsection 16.2.9 “Positron Emission Tomography (PET)” for additional information.

Preventive Care Medical Checkups and Developmental TestingThe generally accepted schedule for preventive care medical checkups is seven to eight visits the first year, four visits for 13 months through 30 months of age, and then annually thereafter.

Providers should submit claims with the most appropriate evaluation and management procedure code and include the most appropriate ICD-10-CM diagnosis code as follows: Client Diagnosis CodesChildren visits Z00121 or Z00129Adult visits Z0000 or Z0001

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.17.9, “Preventive Care Medical Checkups and Developmental Testing,” for additional information.

Rabies Postexposure TreatmentProcedure codes 90375, 90376, and 90675 may be reimbursed when they are submitted with the following ICD-10-CM diagnosis code:Diagnosis Code (Submitted as stand-alone diagnosis code)Z203

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.23.14 “Rabies Postexposure Prophylaxis,” for additional information.

Renal Dialysis ServicesRenal dialysis services must be submitted with the most appropriate ICD-10-CM diagnosis code that indicates one of the following acute or chronic clinical indications:

Acute indications for dialysis are as follows:

• Metabolic acidosis

• Electrolyte imbalance

• Drug overdose with dialysable toxin

• Fluid overload

• Complications of uremia

Chronic indications for dialysis are as follows:

• Symptomatic renal failure

• Low glomerular filtration rate (GFR)

• Difficulty in controlling fluid overload or electrolyte imbalance




Procedure code G0257 may be reimbursed for services rendered to clients with stage V chronic kidney disease and end-stage renal disease (ESRD).

Refer to: The CSHCN Services Program Provider Manual, Section 34.3, “Benefits, Limitations, and Authorization Requirements, for additional information.

Respiratory Equipment and SuppliesProviders must submit claims for respiratory equipment and supplies procedure codes with the most appropriate ICD-10-CM diagnosis codes as indicated below.

Cardiorespiratory (Apnea) MonitorsCardiorespiratory (apnea) monitors for infants who are birth through three months of age may be reimbursed without prior authorization when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G9009 I440 I441 I442 I4430 I4439 I471 I479 I498 K210K219 P228 P270 P271 P278 P282 P283 P284 P285 P2889P2911 P2912 Q246 R000 R0681 Z8489

Prior authorization for the purchase of a high frequency chest wall compression system (HFCWCS) may be consid-ered when the request is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E840 E8411 E8419 E848 E849 G121 G128 G129 G710 G800G801 G802 G804 G808 G809

Other diagnoses will be considered with documentation of medical necessity.

Prior authorization is not required for a large volume nebulizer with compressor when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)E840 E8411 E8419 E848 E849 J398 J471 J479 J9809 Z430 Z930

Prior authorization is not required for a filtered nebulizer or related compressor when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)B20 T8690 T8691 T8692 T8693 T8699

Prior authorization is not required for a controlled dose inhalation drug delivery system when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)I272 I2789

Prior authorization is not required for a small volume nebulizer with related compressor when the most appropriate procedure code is submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)A3701 A3711 A3781 A3791 A481 B20 B250 B440 B59 E840E8411 E8419 E848 E849 J09X1 J09X2 J120 J121 J122 J123




Diagnosis Codes (Submitted as stand-alone diagnosis codes)J1281 J1289 J129 J13 J14 J150 J151 J1520 J15211 J15212J1529 J153 J154 J155 J156 J157 J158 J159 J160 J168J17 J180 J181 J188 J189 J210 J211 J218 J219 J440J441 J449 J4520 J4521 J4522 J4530 J4531 J4532 J4540 J4541J4542 J4550 J4551 J4552 J45901 J45902 J45909 J45990 J45991 J45998J690 J691 Q334 T8601 T8602 T8603 T8609 T8611 T8612 T8613T8619 T8621 T8622 T8623 T86290 T86298 T8641 T8642 T8643 T8649T86810 T86811 T86812 T86818 T86830 T86831 T86832 T86838 T86850 T86851T86852 T86858 T86890 T86891 T86892 T86898 T8690 T8691 T8692 T8693T8699

Refer to: The CSHCN Services Program Provider Manual, Section 35 “Respiratory Equipment and Supplies” for additional information.

RhizotomyProcedure code 63185 or 63190 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)G800 G801 G802 G808 G809 G835 G8389

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.36.14, “Rhizotomy,” for additional information.

* Sleep StudiesProcedure code 94772 (Pediatric Pneumogram) may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)K208 K209 K210 K219 K220 P220 P228 P229 P270 P271P278 P279 P282 P283 P284 P285 P2881 P2889 P84 R0600R0609 R062 R063 R0681 R0682 R0683 R0689 R069 R6813

Procedure code 95805 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E662 G4700 G4710 G4711 G4712 G4720 G4733 G47411G47419 G47421 G47429 G478 G479

Procedure codes 95782, 95783, 95808, 95810, and 95811 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)E662 F5101 F5102 F5103 F5104 F5109 F5111 F5112 F5113 F5119F513 F514 F515 F518 F519 F984 G253 G2589 G259 G26G4700 G4701 G4710 G4711 G4712 G4713 G4714 G4719 G4720 G4721




http://www.tmhp.com/ICD10_Benefits_CSHCN/Sleep%20Studies.pdf

Diagnosis Codes (Submitted as stand-alone diagnosis codes)G4722 G4723 G4724 G4725 G4726 G4727 G4729 G4730 G4731 G4733G4734 G4735 G4736 G4737 G4739 G47411 G47419 G47421 G47429 G4750G4751 G4752 G4753 G4754 G4759 G4761 G4769 G478 G479 J9610J9611 J9612 R0600 R0609 R063 R0683 R0689 R069 R0901

Refer to: The CSHCN Services Program Provider Manual, subsection 24.4.1.4, “Sleep Studies,” for additional information.

Therapeutic ApheresisTherapeutic apheresis procedure codes 36511, 36512, 36513, and 36514, and apheresis with extracorporeal affinity adsorption and plasma reinfusion procedure codes 36515 and 36516 may be reimbursed when they are submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)C880 C882 C883 C888 C9000 C9002 C9010 C9012C9020 C9022 C9030 C9032 C9100 C9102 C9110 C9112C9130 C9132 C9140 C9142 C9150 C9152 C9160 C9162C9190 C9192 C91A0 C91A2 C91Z0 C91Z2 C9200 C9202C9210 C9220 C9230 C9232 C9240 C9242 C9250 C9252C9260 C9262 C9290 C9292 C92A0 C92A2 C92Z0 C92Z2C9300 C9302 C9310 C9312 C9330 C9332 C9390 C9392C93Z0 C93Z2 C9400 C9402 C9420 C9422 C9430 C9432C9440 C9442 C9480 C9482 C9500 C9502 C9510 C9512C9590 C9592 D45 D472 D473 D474 D5700 D5701D5702 D571 D5720 D57211 D57212 D57219 D5780 D57811D57812 D57819 D588 D589 D590 D591 D592 D593D594 D599 D6182 D65 D682 D68311 D688 D690D691 D692 D693 D6941 D6942 D6949 D696 D698D699 D72828 D740 D748 D749 D750 D751 D7589D759 D761 D762 D763 D77 D890 D892 E0842E0942 E1042 E1142 E780 G603 G610 G6181 G6189G620 G621 G622 G6281 G6282 G63 G64 G650G7000 G7001 G731 I00 I010 I012 I018 I019I773 I776 I7789 K716 K7200 K7201 K7581 K759K760 K762 K7689 K77 L100 L101 L102 L103L104 L105 L1081 L1089 L109 L900 L940 L941L943 M05011 M05012 M05021 M05022 M05031 M05032 M05041M05042 M05051 M05052 M05061 M05062 M05071 M05072 M0509M05411 M05412 M05421 M05422 M05431 M05432 M05441 M05442M05451 M05452 M05461 M05462 M05471 M05472 M0549 M05611M05612 M05621 M05622 M05631 M05632 M05641 M05642 M05651





Diagnosis Codes (Submitted as stand-alone diagnosis codes)M05652 M05661 M05662 M05671 M05672 M0569 M069 M08011M08012 M08021 M08022 M08031 M08032 M08041 M08042 M08051M08052 M08061 M08062 M08071 M08072 M0809 M083 M08411M08412 M08421 M08422 M08431 M08432 M08441 M08442 M08451M08452 M08461 M08462 M08471 M08472 M0848 M08832 M08841M08842 M08851 M08852 M08861 M08931 M08932 M08941 M08942M08951 M08952 M08961 M08962 M310 M311 M320 M3210M3219 M328 M3300 M3301 M3302 M3309 M3310 M3311M3312 M3319 M3320 M3321 M3322 M3329 M3390 M3391M3392 M3399 M340 M341 M342 M3481 M3482 M3483M3489 N000 N001 N002 N003 N004 N005 N006N007 N008 N010 N011 N012 N013 N014 N015N016 N017 N018 N032 N034 N035 N037 N040N042 N044 N045 N046 N047 N048 N049 N052N053 N054 N055 N056 N058 N059 N08 N171N172 T8690 T8691 T8692 T8699

Refer to: The CSHCN Services Program Provider Manual, subsection 31.2.37, “Therapeutic Apheresis,” for additional information.

Total Parenteral Nutrition (TPN)Prior authorization for TPN must be submitted with the most appropriate ICD-10-CM diagnosis code or combi-nation diagnosis codes as indicated. Prior authorization for TPN may be considered for clients with one of the following conditions:

• Anatomical, physiological, or motility disorder of the gastrointestinal tract

• Prolonged bowel rest

• Gastrointestinal fistula

• Malignancies

• Inborn errors of amino acid metabolism

• Cystic Fibrosis

• Major trauma and burns

• Severe malnutrition, significant weight loss and/or hypoproteinaemia when enteral therapy is not possible

• Other disease states or conditions in which oral or enteral feeding are not an option

Prior authorization requests for clients with conditions other than those listed above will be forwarded to the CSHCN Services Program Medical Director or designee for consideration.

Refer to: The CSHCN Services Program Provider Manual, subsection 26.6.2.1 “Prior Authorization Requirements”for additional information.




Vaccines and ToxoidsFor immunizations during an initial or follow-up office visit for a medical condition, the following may be reimbursed when an appropriate medical ICD-10-CM diagnosis is submitted with the claim:

• The office visit

• The vaccines and toxoids that are not obtained through TVFC

• The administration fee

When the client visit is only for immunization, the office visit will not be reimbursed. The administration fee and any vaccine/toxoid not obtained through TVFC may be reimbursed when ICD-10-CM diagnosis code Z23 refer-encing an immunization is submitted with the claim.

All immunizations must be reported with diagnosis code Z23. The type of immunization given will be identified by the procedure code.

BCG vaccine (procedure code 90585) may be reimbursed when submitted with diagnosis code Z23.

Botulinum antitoxin procedure code 90287 may be reimbursed when submitted with one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)A051 A4851 A4852 T50901A T50901D T50901S T50902A T50902DT50902S T50903A T50903D T50903S T50904A T50904D T50904S T50991AT50991D T50991S T50992A T50992D T50992S T50993A T50993D T50993ST50994A T50994D T50994S T50Z91A T50Z91D T50Z91S T50Z92A T50Z92DT50Z92S T50Z93A T50Z93D T50Z93S T50Z94A T50Z94D T50Z94S

Refer to: The CSHCN Services Program Provider Manual, Children’s Services Handbook, Section 31 “Immuniza-tions (Vaccines and Toxoids),” for additional information.

Vision Services NonsurgicalPrior authorization is not required for the prescription, eyewear, and fitting of one medically necessary pair of prescription eyeglasses (including frames and lenses) or one pair of contact lenses per calendar year if they are prescribed for one of the following ICD-10-CM diagnosis codes:

Diagnosis Codes (Submitted as stand-alone diagnosis codes)H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623 H2701H2702 H2703 H27111 H27112 H27113 H27121 H27122 H27123 H27131 H27132H27133 H35101 H35102 H35103 H35141 H35142 H35143 H35151 H35152 H35153H35161 H35162 H35163 H35171 H35172 H35173 H4421 H4422 H4423 H5201H5202 H5203 H5211 H5212 H5213 H52201 H52202 H52203 H52211 H52212H52213 H52221 H52222 H52223 H5231 H5232 H524 H53001 H53002 H53003H53011 H53012 H53013 H53021 H53022 H53023 H53031 H53032 H53033 Q123Q134 Z961

Authorization is required for medically necessary eyeglasses or contact lenses and their prescriptions and fittings within the same calendar year for diagnoses not listed in the above table. Requests for authorization must be




submitted using a CSHCN Services Program Authorization and Prior Authorization Request with the required documentation that includes proof of medical necessity.

Vision examinations with refraction (for the purpose of obtaining a prescription for eyewear) may be reimbursed once per calendar year and may be performed by ophthalmologists or optometrists. Vision examinations with refraction should be billed using procedure code S0620 or S0621, and is limited to the following diagnoses:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H18821 H18822 H18823 H269 H4421 H4422 H4423 H5201H5202 H5203 H5211 H5212 H5213 H52201 H52202 H52203H52211 H52212 H52213 H52221 H52222 H52223 H5231 H5232H524 H52511 H52512 H52513 H52521 H52522 H52523 H52531H52532 H52533 H526 H527 Z0100 Z0101

Polarization of lenses procedure code V2762 may be reimbursed when it is billed with one of the following diagnosis codes:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H2701 H2702 H2703 H27121 H27122 H27123 H27131 H27132H27133 H5089 Q123 Z961

Computerized corneal topography procedure code 92025 may be reimbursed when it is submitted with one of the following ICD-10-CM diagnosis codes as indicated:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H10211 H10212 H10213 H10811 H10812 H10813 H11001 H11002H11003 H11011 H11012 H11013 H11021 H11022 H11023 H11031H11032 H11033 H11041 H11042 H11043 H11051 H11052 H11053H11061 H11062 H11063 H1189 H16001 H16002 H16003 H16011H16012 H16013 H16021 H16022 H16023 H16031 H16032 H16033H16041 H16042 H16043 H16051 H16052 H16053 H16061 H16062H16063 H16071 H16072 H16073 H16101 H16102 H16103 H16111H16112 H16113 H16121 H16122 H16123 H16131 H16132 H16133H16141 H16142 H16143 H16201 H16202 H16203 H16211 H16212H16213 H16221 H16222 H16223 H16231 H16232 H16233 H16251H16252 H16253 H16261 H16262 H16263 H16291 H16292 H16293H16301 H16302 H16303 H16311 H16312 H16313 H16321 H16322H16323 H16331 H16332 H16333 H16391 H16392 H16393 H16401H16402 H16403 H16411 H16412 H16413 H16421 H16422 H16423H16431 H16432 H16433 H16441 H16442 H16443 H168 H169H1701 H1702 H1703 H1711 H1712 H1713 H17811 H17812H17813 H17821 H17822 H17823 H1789 H179 H1811 H1812H1813 H1820 H18221 H18222 H18223 H18231 H18232 H18233H1840 H18451 H18452 H18453 H18461 H18462 H18463 H1849H1850 H1851 H1852 H1853 H1854 H1855 H1859 H18601H18602 H18603 H18611 H18612 H18613 H18621 H18622 H18623H1870 H18711 H18712 H18713 H18721 H18722 H18723 H18731H18732 H18733 H18791 H18792 H18793 H18831 H18832 H18833




Diagnosis Codes (Submitted as stand-alone diagnosis codes)H52201 H52202 H52203 H52211 H52212 H52213 L511 L512L513 Q134 S0521XA S0521XD S0521XS S0522XA S0522XD S0522XSS0531XA S0531XD S0531XS S0532XA S0532XD S0532XS T2611XA T2611XDT2611XS T2612XA T2612XD T2612XS T2661XA T2661XD T2661XS T2662XAT2662XD T2662XS T85310A T85310D T85310S T85311A T85311D T85311ST85318A T85318D T85318S T85320A T85320D T85320S T85321A T85321DT85321S T85328A T85328D T85328S T85390A T85390D T85390S T85391AT85391D T85391S T85398A T85398D T85398S Z48810 Z947 Z9841Z9842 Z9849 Z9883

Contact lenses and their prescription and fitting are limited to the following diagnoses:Diagnosis Codes (Submitted as stand-alone diagnosis codes)H18601 H18602 H18603 H18611 H18612 H18613 H18621 H18622H18623 H2701 H2702 H2703 H27111 H27112 H27113 H27121H27122 H27123 H27131 H27132 H27133 H35101 H35102 H35103H35141 H35142 H35143 H35151 H35152 H35153 H35161 H35162H35163 H35171 H35172 H35173 H4421 H4422 H4423 H5201H5202 H5203 H5211 H5212 H5213 H52201 H52202 H52203H52211 H52212 H52213 H52221 H52222 H52223 H5231 H5232H524 H53001 H53002 H53003 H53011 H53012 H53013 H53021H53022 H53023 H53031 H53032 H53033 Q123 Q134 Z961

Refer to: The CSHCN Services Program Provider Manual, Section 39 “Vision Services,” for additional information.




CSHCN SERVICES PROGRAM FORMS

Changes to FormsEffective for dates of service on or after October 1, 2015, the following CSHCN Services Program forms have been revised to accommodate the changes associated with ICD-10. These forms must be used to request prior authori-zations/authorization for services to be rendered on or after October 1, 2015. Previous versions of the forms can be submitted for dates of service on or before September 30, 2015. Effective October 1, 2015, TMHP will no longer accept the previous versions of the forms.

Claim FormsThe following claim forms and instructions have been revised:

• CMS-1500 claim form example and ICD-10 relevant instructions

• UB-04 claim form example and ICD-10 relevant instructions

Prior Authorization FormsThe following prior authorization forms have been revised:• CSHCN Apnea Monitor Request Form and Instructions

• CSHCN Request for Augmentative Communication Devices (ACDs) Form and Instructions

• CSHCN Request for Chest Physiotherapy Devices Form and Instructions

• CSHCN Request for Dental or Orthodontia Services Form and Instructions

• CSHCN Request for Diapers, Pull-ups, Briefs, or Liners Form and Instructions

• CSHCN Durable Medical Equipment (DME) Form and Instructions

• CSHCN Request for External Insulin Pump Form and Instructions

• CSHCN Instructions for Prior Authorization Request for Hospice Services

• CSHCN Inpatient Pyschiatric Care Form and Instructions

• CSHCN Request for Inpatient Admission

• CSHCN Request for Inpatient Rehabilitation Admission Form and Instructions

• CSHCN Request for Medical Foods Form and Instructions

• CSHCN Medical Nutritional Services Form and Instructions

• CSHCN Request for Omalizumab Form and Instructions

• Texas Medicaid/CHIP Vendor Drug Program CSHCN Synagis® Request Form 2014-15 Season

• CSHCN Request for Pulse Oximeter Devices Form and Instructions

• CSHCN Renal Dialysis Treatment Form and Instructions

• CSHCN Respiratory Care Request Form

• CSHCN Stem Cell or Renal Transplant Request Form


CSHCN Services Program Forms


http://www.tmhp.com/Provider_Forms/CSHCN/Authorization/Apnea_Monitor_Rental_Auth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/ACD_Prior_Authorization_Form.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Chest_Physio_Authorization.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Dental_Orthodontia_Authorization.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Diapers_Pull-ups_Underads_Briefs_Liners.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Durable_Medical_Equipment_(DME).pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/External_Insulin_Pump_Prior_Auth_Form.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Hospice_Prior_Auth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Prior%20Auth%20Request%20for%20Inpatient_Psychiatric_Care%20(CSHCN).pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Inpatient_Hospital_PriorAuth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Inpatient_Rehab_PriorAuth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Medical_Foods.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Additional_Medical_Nutritional_Services.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Omalizumab_Auth.pdf

http://www.txvendordrug.com/downloads/cshcn_synagis_form.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Pulse_Oximeter_Auth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Renal_Dialysis_Prior_Authorization_Form.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Respiratory_Care_Prior_Authorization_Form.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Stem_Cell_%20or_Renal_Transplant.pdf

• CSHCN Inpatient Surgery Request Form

• CSHCN Outpatient Surgery Request Form

• CSHCN Blood Factor Products

• CSHCN Non-Face-to-Face Clinician Directed Care Request Form

• CSHCN Request for Extension of Outpatient Therapy (TP2)

• CSHCN Request for Initial Outpatient Therapy (TP1)

• CSHCN Request for Authorization and Prior Authorization Form and Instructions

• CSHCN Documentation of Receipt

• CSHCN Documentation of Receipt (Spanish)

• CSHCN Home Health (Skilled Nursing) Referral and Treatment Plan

• CSHCN Wheelchair Seating Evaluation Form and Instructions


CSHCN Services Program Forms


http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Surgery_Auth_Surgeons_Only.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Surgery_Auth_Outpatient_Facility_Surgeon.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Hemo_Blood_Factor_Auth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Authorization/Specialist%20or%20Subspecialist%20Telephone%20Consultation.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Authorization/TP2_Extension_Outpatient_Therapy_Auth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Authorization/TP1_Initial_Outpatient_Therapy_Auth.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Prior%20Auth/Generic%20Auth%20and%20Prior%20Auth%20Form.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Certification%20Documentation/Documentation_of_Receipt.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Certification%20Documentation/Documentation%20of%20Receipt_Spanish.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Certification%20Documentation/HH_Referral%20Treatment%20Plan.pdf

http://www.tmhp.com/Provider_Forms/CSHCN/Certification%20Documentation/Wheelchair_Seating_Eval.pdf

Documents

ICD-10 Bulletin