November 2003 Long Term Care Bulletin, No. 16 › LTC_Provider_Bulletin › 2003 › 016_LTC.pdf · November 2003, No. 16 3 LTC Bulletin Contract Transition to TMHP The Texas Medicaid

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Visit the Long Term Care section on the NHIC Web site at www.eds-nhic.com.

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November 2003, No. 16

LTC Bulletin, No. 16, Contents

Contract Transition to TMHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Request for Electronic Transmission Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Implementation of Twelve-Month Claims Submittal Rule EffectiveNovember 1, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

TDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4TDMHMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Health Insurance Portability and Accountability Act Awareness . . . . . . . . . . . . . 4Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Enforcement of HIPAA Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Provider Education and Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Vendor and Provider Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

LTC HIPAA Electronic Data Interchange (EDI) Implementation . . . . . . . . . . . . . . . 6The Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Client Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6MESAV Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Diagnosis Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Updates to August 2003 LTC Bulletin Articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Claim Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Paper Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Claims for DOS Prior to October 16, 2003, Filed on or after October 16, 2003 . . . . . . . 8Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Service Code Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Place of Service Codes Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Place of Service Codes for the 837I – Institutional Claim Format . . . . . . . . . . . . . . . . 12Place of Service Codes for the 837P – Professional Claim Format . . . . . . . . . . . . . . . 12

Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14DHS/TDMHMR Modifier Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

LTC Bill Code Crosswalk Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16How to Use the LTC Bill Code Crosswalk Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

www.eds-nhic.comhe National Heritage Insurance Company (NHIC) is the insurer and contract administrator for the Texas Medicaid

Program under contract with the Texas Health and Human Services Commission (HHSC)

LTC Bulletin, No. 16, Contents (continued)

Long Term Care Bill Code Crosswalk Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Service Group 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Service Group 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Service Group 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Service Group 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Service Group 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Service Group 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Service Group 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Service Group 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Service Group 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Service Group 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Service Group 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Service Group 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Service Group 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Service Group 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Explanation of Benefits Code Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Helpful Hints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

LTC Web Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Reminders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Resources for Long Term Care Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85General Table – All Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85TDMHMR/ICF–MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85DHS – Provider Claims Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86DHS LTC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87NHIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Your NHIC Training Specialists by Territory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

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Contract Transition to TMHPThe Texas Medicaid & Healthcare Partnership (TMHP) will take over the Claims Management System (CMS) contract effective January 1, 2004. The current contract with NHIC for long-term care claims processing ends in 2003, although there is a transition period extending into the new year to ensure a smooth takeover by the new contractor. TMHP, the new contractor, is a partnership of contractors managed by ACS with technical services being provided by Accenture.

TMHP will assume responsibility and operations of all software computer systems that NHIC currently operates. This includes Compass21, the LTC Claims Management System (CMS), and the Nursing Facility CARE Form System.

Transition work is in progress with NHIC, TMHP, and the State agencies involved with this contract: the Health and Human Services Commission, the Department of Human Services (DHS), and the Texas Department of Mental Health and Mental Retardation (TDMHMR). In addition to planning for a smooth cutover to the new contractor, TMHP is testing software transferred from NHIC and documenting operational procedures. The operational procedures are being prepared to replicate the way LTC providers and State computer systems already work with NHIC in order to minimize change during the transition.

Although the new contract includes improvements and some new requirements, the focus was on no new development and no significant procedural changes for the first year of the contract in order to support an effective transition from NHIC operations.

It will be necessary to incur some scheduled processing downtime late this year and in early January to successfully transition to TMHP. Although cutoff schedules remain tentative, planners anticipate that the acute-care system (Compass21) will be unavailable for a longer time than the LTC systems.

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At time of publication, the following was the tentative plan for startup of TMHP operations:

Texas Medicaid Turnover Planning - LTC Claims Management System

Note: All dates and times in the following table are tentative and subject to change.

A copy of the DHS information letter informing LTC providers of this contract change may be found at the following DHS and NHIC Web sites:

• www.eds-nhic.com/LTC/default.htm

• www.dhs.state.tx.us/programs/communitycare/infoletters (For Community Care Provider Agencies)

• www.dhs.state.tx.us/providers/LTC-Policy/index.html (For Nursing Facilities and Therapy Providers)

A follow-up letter is planned for release in December. It is important for all providers to monitor their mail and the LTC Web site to ensure that no important information is overlooked. Providers will be receiving material from TMHP as well as from NHIC and the State agencies, DHS and TDMHMR, through the end of the year. ■

Transaction/Interface Files Last NHIC First TMHP

Paper claims 12/19/2003 12/27/2003

Electronic claims 12/26/2003

12 noon

01/05/2004

MESAV 12/31/2003

6 p.m.

01/02/2004 =>

01/05/2004

R&S 12/27/2003 01/06/2004

CSI transactions 12/31/2003

6 p.m.

01/02/2004 =>

01/05/2004

3618, 3652, 3619 Received from providers - paper

12/19/2003 01/05/2004

3618, 3652, 3619 Received from providers - electronic

12/23/2003 01/05/2004

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http://www.eds-nhic.com/LTC/default.htm

Request for Electronic Transmission ReportsElectronic providers are required to retain all claim and electronic file transmission records. Providers must verify that all claims submitted to HHSC or its agent are received and accepted, and claims transmissions are tracked against claims payments to detect and correct all claim errors. If you are missing an electronic file transmission record, you may request a copy of the transmission report(s) by contacting the NHIC EDI helpdesk at 888-863-3638. Requests for transmission reports produced in the previous 30 days will be provided at no cost to the providers. Requests for transmission reports produced more than 30 days prior to the request will result in a charge of $500 plus 8.25 percent sales tax of $41.25 for a total charge of $541.25. This cost is per transmission report. Providers that hold a tax exempt certificate will not be charged the 8.25 percent sales tax. Provider payment will be required with the submission of the completed transmission report order form to NHIC. ■

Implementation of Twelve-Month Claims Submittal Rule Effective November 1, 2003

TDHS

The Code of Federal Regulations (CFR), Title 42, 447.45(d)(1) states that the Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Effective November 1, 2002, the Texas Department of Human Services (DHS) requires provider agencies to submit claims for services to DHS within this timeframe. Although the rules were effective November 1, 2002, they were not to be applied to claims until November 1, 2003.

Electronic versions of the various information letters related to the 12-month claims filing deadline may be found at the following addresses:

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• For LTC Community Care Providers:www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html – under CMS.

• For Hospice and Nursing Facility Providers:www.dhs.state.tx.us/providers/LTC-Policy/index.html – in the Communications section, click Provider Letters. ■

TDMHMR

The Code of Federal Regulations, Title 42, 447.45(d)(1) states that the Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Effective January 6, 2003, the Texas Department of Mental Health and Mental Retardation (TDMHMR) will require provider agencies to submit claims for services to DHS within this time frame. Although the rules were effective January 5, 2003, they will not be applied to claims until on or after January 5, 2004. The information letter and the Code of Federal Regulations (CFR) were sent to TDMHMR providers. ■

Health Insurance Portability and Accountability Act Awareness

Overview

Congress enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to reform the health care insurance market and simplify health care administrative processes. Entities required to comply with HIPAA provisions (covered entities) include Medicaid providers. Covered entities include health plans (health insurers, HMOs, Blue Cross/Blue Shield, etc.), health care providers (physicians, hospitals, health care contractors, and others who do business electronically), and health care clearinghouses. Covered entities were required to implement HIPAA Privacy provisions by April 14, 2003, and must have complied with HIPAA Electronic Data Interchange (EDI) provisions by October 16, 2003. These entities must also comply with HIPAA Security provisions by April 21, 2005.

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http://www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html

http://www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html

http://www.dhs.state.tx.us/providers/LTC-Policy/index.html

http://www.dhs.state.tx.us/providers/LTC-Policy/index.html

Visit the following Web sites for HIPAA information and other helpful links:

Centers for Medicare and Medicaid Services (CMS):

• www.cms.gov/hipaa

Department of Health and Human Services (HHS) Office of Civil Rights (OCR):

• www.hhs.gov/ocr/hipaa

Frequently Asked Questions:

• www.eds-nhic.com/HIPAA.htm

EDS-NHIC LTC Home Page:

• www.eds-nhic.com/LTC/default.htm

Approved HIPAA implementation guides and current listing of national remark and reason codes:

• www.wpc-edi.com/hipaa/HIPAA_40.asp

Health and Human Services Commission (HHSC):

• www.hhsc.state.tx.us/NDIS/NDISTaskForce.html

Texas Department of Human Services (DHS):

• www.dhs.state.tx.us/providers/hipaa

Texas Department of Mental Health and Mental Retardation (TDMHMR):

• www.mhmr.state.tx.us/hipaa.html ■

Enforcement of HIPAA Regulations

The Department of Health and Human Services (HHS) has determined that the Office for Civil Rights (OCR) will enforce the HIPAA Privacy standards. The Centers for Medicare and Medicaid Services (CMS) is responsible for enforcing the standards for EDI transactions and code sets, security, and national identifiers. CMS will also continue to enforce the insurance portability requirements under Title I of HIPAA.

Note: HHSC, DHS, TDMHMR, and NHIC are not responsible for enforcing HIPAA provisions. ■


Provider Education and Outreach

Long Term Care (LTC) Provider Workshops and Videoconference

The DHS/TDMHMR HIPAA Project team conducted 29 HIPAA Electronic Data Interchange (EDI) Workshops for LTC providers throughout Texas in July and August in order to prepare providers for the billing and other changes due to HIPAA implementation. The workshops were a resounding success, with attendance exceeding 1,900 persons. The materials presented at the workshop are available on the DHS HIPAA team Web site at www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html.

The Project Team also presented a videoconference on October 6, 2003, in an effort to reach LTC providers who were not able to attend one of the live workshops in July or August. The videoconference was transmitted from the Texas Department of Health (TDH) Auditorium K-100 to nine remote sites in Abilene, Arlington, Brownsville, El Paso, Fort Worth, Houston, Tyler, Victoria, and Wichita Falls. Courtesy of the TDH video conference staff, LTC providers were able to register online for the videoconference. Over 500 attendees took advantage of the opportunity to learn how their billing procedures would change as a result of HIPAA implementation. The DHS/TDMHMR HIPAA Project Team plans to present additional EDI workshops for LTC providers in November 2003.

NHIC TDHconnect Workshops for LTC Providers

Area NHIC Training Specialists presented TDHconnect 3.0 HIPAA Workshops for LTC providers during September and October. These workshops were designed to address changes in the Medicaid claims processing software, TDHconnect, as a result of HIPAA EDI compliance requirements. The training specialists provided a live demonstration of the software.

Note: LTC providers who use TDHconnect 2.0 will be required to use the new version, TDHconnect 3.0, on and after October 16, 2003. ■

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http://www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html


http://www.cms.gov/hipaa

http://www.hhs.gov/ocr/hipaa

http://www.eds-nhic.com/HIPAA.htm


http://www.wpc-edi.com/hipaa/HIPAA_40.asp

http://www.hhsc.state.tx.us/NDIS/NDISTaskForce.html

http://www.dhs.state.tx.us/providers/hipaa

http://www.mhmr.state.tx.us/hipaa.html

Vendor and Provider TestingVendors and providers not using TDHconnect to submit claims, eligibility requests, or to receive an ER&S report were requested to test transactions with NHIC to assure they could send HIPAA-compliant transactions by October 16, 2003.

Organizations who wished to test with NHIC were requested to complete a vendor intake form (found in the NHIC Companion Guides for each transaction type) identify a contact and the transaction(s) used, and send it to [email protected]. A test facilitator contacted each organization to schedule a test time.

Phase One of the testing process was completed in July. During this phase, an organization’s ability to transmit HIPAA-compliant transactions was verified. Files were submitted through the EBX Model Office BBS.

Phase Two occured between August 2003 and October 2003 for Acute Care (Compass21). This phase involved sending files and receiving responses to and from NHIC. Files submitted during Phase One testing of the mapping process were also used in Phase Two.

Phase Three occured between September 2003 and October 2003 for validation of Long Term Care submitters sending files to CMS. During this phase, providers were able to send and receive HIPAA-compliant files to and from NHIC.

If you have any questions regarding the testing process at NHIC, send an electronic message to [email protected]. ■

LTC HIPAA Electronic Data Interchange (EDI) Implementation

The Solution

HIPAA EDI requires Texas Medicaid Long Term Care to accept, process, and return compliant electronic transactions for claims, eligibility inquiries, claim status inquiries, remittance and status, and prior authorization by October 16, 2003. As reported in the August 2003 LTC Bulletin, No. 15, HHSC, along with

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its claims administrator, NHIC, analyzed the Claims Management System (CMS) with respect to HIPAA EDI requirements, and determined the best solution was to retain the existing claims processing system for paying claims. Given this decision and the need to become HIPAA compliant, all transactions coming in would be HIPAA compliant, but would be translated back into the “old” billing format in order to process and pay claims. In other words, the claim coming into the CMS for payment would contain the national procedure code, place of service (POS) code, and other requisite information. Once the electronic claim is received by NHIC, it would be converted back to the “old” bill code to process as usual, using information contained on the claim plus that contained in various state systems. The derivation of the “old” bill code from the national code requires the provider to submit not only the national procedure code, but also additional information to help point to the correct bill code. This information must be submitted in HIPAA-compliant formats. ■

Client Address

Client address is a required field under the HIPAA EDI rules. The client address is available on the client’s Medicaid card. In the case of residential care facilities, such as nursing homes, ICF-MR, assisted living, and hospice, the client address may be the same as the facility address. ■

MESAV Templates

During the HIPAA LTC provider workshops, many providers indicated that they needed to rebuild their MESAV templates every time because their templates were scrambled upon receiving a response. One possible solution, or means to prevent duplicate entry responses in your template, is to save the template without request dates. It appears that if you enter and save an initial request date, then resubmit the template with new dates, TDHconnect interprets this as two requests. After entering the template information, without request dates, save the template. When submitting the request,


add the dates of interest; however, when you are asked if you want to modify the template, respond “No.” This should solve the problem of duplicate entries. ■

Diagnosis Code

Required or Situational

A diagnosis code is required on the Institutional claim format (837I) and is situational on the Professional claim format (837P).

The 837P Implementation Guide defines “Situational,” as it relates to diagnosis, as: “Required on all claims/encounters except claims for which there are no diagnoses (for example, taxi claims).”

In TDHconnect, the Diagnosis Code field is not bolded on the 837P, meaning that for TDHconnect users, the field is not “required.” This was done to allow situations where diagnosis code is not required (that is, PACE, requisition fees, meals, and ERS) to be able to pass the Electronic Business Exchange (EBX) edits.

Exceptions

A diagnosis code is required for all claims except the following:

• Claims submitted for services to CCAD-Service Group 7 clients

• Claims for meals, regardless of service group

• Claims for ERS, regardless of service group

• Claims for “atypical” services (for example, transportation, requisition fees, and PACE) ■

Updates to August 2003 LTC Bulletin ArticlesThe state and NHIC have continued to make significant progress since the August 2003 LTC Bulletin, No. 15, was published. This progress has resulted in the need to repeat and/or update a few articles from that bulletin.


Claim Formats

Removal of diagnosis code requirement for Community Care for the Aged and Disabled Program (CCAD - Service Group 7) resulted in changes to the LTC Bill Code Crosswalk table. It was necessary for the DHS HIPAA Project Team to cross reference all CCAD bill codes to national HCPCS or CPT codes, rather than use the revenue codes as originally done. This change may result in certain providers having to use a different claim format.

Remember to do the following to choose a claim format when billing electronically:

Go to the crosswalk table and find the line that defines the service you are billing.

• If the line shows a revenue code in the National Code fields, use the 837I - Institutional format, even if there is also a HCPCS or CPT code indicated.

• If there is no revenue code, look at the Procedure Code Qualifier field. If the procedure code qualifier is:

❑ AD, use the 837D - dental format.❑ HC, use the 837P - professional format.❑ ZZ, use the 837P - professional format.

Note: Paper submitters use the DHS form 1290 (Long Term Care Claim) regardless of the National Code. ■

Paper Claims

The Form 1290, Long Term Care Claim, and instructions were revised to include the changes described in this bulletin. While the Form 1290 and instructions were mailed to all providers (both electronic and paper submitters) in September 2003, the form was not effective until October 16, 2003. The form is also available via the DHS Web site at www.dhs.state.tx.us/handbooks/providers/index.htm. ■

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Claims for DOS Prior to October 16, 2003, Filed on or after October 16, 2003

Claims for dates of service (DOS) prior to HIPAA implementation (October 16, 2003), but filed on or after October 16, 2003, will need to adhere to the HIPAA regulations regarding format and fields. However, the code used in the procedure code field will be that which was effective on the DOS, except those noted below.

For example, if you provided LVN Nursing Services on September 1, 2003, for a service group 17 clients with a 13A service code – and billed on or after October 16, 2003 – you would use the local bill code in effect on the DOS, which was G0302. If you provided and billed the same service on October 18, 2003 – to the same client with the same authorizations – you would bill using HCPCS code S9124 or T1003.

Exceptions

Nursing Facility/Hospice/ICF-MR Daily Care: Services for daily care by nursing facility, hospice, and ICF-MR providers will be billed using the revenue code only (as listed in the Bill Code CrosswalkTable) for dates of service on or after October 16, 2003. For dates of service prior to October 16, 2003 – but billed after HIPAA implementation (October 16, 2003, or later) – both the revenue code listed in the Bill Code Crosswalk table and the local bill code used prior to HIPAA implementation must be used.

Hospice Physician Services: Hospice physician services will be billed using the national revenue code and the appropriate CPT-4 code regardless of the date of service if filed after October 16, 2003.

Adaptive Aids/DME: Services provided under the Adaptive Aids/DME local code (G0500) will be billed after HIPAA implementation (October 16, 2003) using the appropriate national code, regardless of the date of service. Consult the Bill Code Crosswalk table for the appropriate code(s) to use.

LTC Bul let in 8

Dental: Dental services claimed on or after October 16, 2003 will be billed using the national code for the dental service provided regardless of the date(s) of service using the dental claim form. Consult the Bill Code Crosswalk table for the appropriate code.

Other Exceptions: If the Bill Code Crosswalk table shows a revenue code for the service, the revenue code listed will be used regardless of the date of service. If the DOS is prior to October 16, 2003, the revenue code must be accompanied by the local bill code in the procedure code field. If the DOS is on or after October 16, 2003, if a HCPCS code or CPT-4 code is noted in the appropriate column of the Bill Code Crosswalk table, this code must be entered in the procedure code field. ■

Units

Every detail line requires the provider to enter the number of units being billed. The units entered are associated with the authorized service code/bill code. The authorized and used units, as well as the type of unit, can be found on the MESAV Service Authorization Detail tab.

If you bill one unit per month (that is, ERS), you can bill for October 2003 by:

1. Billing two detail lines. Using ERS as an example, the detail lines would be similar to the table below:

2. Billing one unit for October 1, 2003, to October 1, 2003. This would be applicable for the month of October 2003 only. Remember to submit this claim after the last date of service in October.

Begin Date

End Date

Procedure Code

QualifierProcedure

Code Units

10/01/03 10/15/03 ZZ G1000 0.5

10/16/03 10/31/03 HC S5161 0.5

Begin Date

End Date

Procedure Code

QualifierProcedure

Code Units

10/01/03 10/01/03 ZZ G1000 1 ■


Service Code Table

The following table lists the service codes and their definitions.

Service Codes Table

Service Code Definition of Service Code

1 Daily Care

1T Daily Care - Transitional Add-On

3 ECF

4 Ventilator(s)

5 Dental

5A Dental - Waiver Programs

6 Nurse Aid Training

7 Occupational Therapy/Assessment

7A Occupational Therapy - Nursing Facility Specialized Services

8 Physical Therapy/Assessment

8A Physical Therapy - Nursing Facility Specialized Services

9 Speech-Language Pathology/Assessment

9A Speech Therapy - Nursing Facility Specialized Services

10 Habilitation

10A Habilitation - Delegated Nursing

10B Habilitation - Supportive Employment/Prevocational

10C Habilitation - Day

11 Respite - In-Home

11A Respite - Out-of-Home

11B Respite - Foster Care

11C Respite - Assisted Living Apartment

11CV VFI Respite - Assisted Living Apartment

11D Respite - Assisted Living Apartment

11DV VFI Respite - Assisted Living RC Apartment

11E Respite - Assisted Living RC Nonapartment

11EV VFI Respite - Assisted Living RC Nonapartment

11F Respite - Nursing Facility

11FV VFI Respite - Nursing Facility

11G Respite - Camp

11H Respite - Day Care/Licensed Child Care Facility

11J Respite - Licenses Special Care Facility

11K Respite - ICF/MR

11L Respite - Hospital

11M Respite - HCSS (RN/LVN)

11N Respite - LVN

11P Respite - RN

11Q Respite - PAS Delegated

11R Adjunct - PAS HCSS

11S Adjunct - LVN

11T Adjunct - RN

9 LTC Bul le t inNovember 2003, No. 16

11U Adjunct - PAS HCSS

11V Adjunct - PAS Delegated

12 Case Management

12A Targeted Case Management

13 Nursing Services

13A Nursing Services - LVN

13B Nursing Services - RN

14 Psychological Services

15 Adaptive Aids/DME

16 Home Modifications

17 Personal Assistance Services (PAS)

17A PAS Delegated

17B PAS Protective Supervision

17V VFI - Personal Assistance Services (PAS)

17C PAS Family Care

17CV VFI - PAS Family Care

17D PAS Frail Elderly (1929b)

17DV VFI - PAS Frail Elderly (1929b)

17E PAS Chore

18 Adult Foster Care

19 Assisted Living Apartment

19A Assisted Living - Residential Care - Nonapartment

19B Assisted Living - Residential Care - Apartment

19C Assisted Living - Personal Care 3

19D Assisted Living - Emergency Care

19E Assisted Living - Habilitation Hours

19F Assisted Living - Habilitation Less than 24 Hours

19G Assisted Living - Family Surrogate Services

19H Assisted Living - Bed Hold

19I Residential Care Bed Hold - Nonapartment Title XX

19J Residential Care Bed Hold - Apartment Title XX

19K Residential Care Apartment Title XX

19L Residential Care Nonapartment Title XX

19M Residential Care Emergency Care Title XX

19N Residential Care - Room and Board - Nonapartment

19O Residential Care - Room and Board - Apartment

20 Emergency Response Services

21 Prescriptions

22 Medical Supplies

24 Tracheostomy Cleaning (NF Only)

25 Meals

26 In-Home Family Support Program

27 Consumer Managed Personal Attendant Services (CMPAS)

Service Codes Table



27A CMPAS - Voucher Fiscal Intermediary

28 Special Services to Persons with Disabilities (SSPD) - Case Management

28A Special Services to Persons with Disabilities (SSPD)

29 Day Activity/Health Services - Title XIX

29A Day Activity/Health Services - Title XX

30 Physician Directed Care

31 Nursing Facility Room and Board

32 Medicare Pharmacy Coinsurance

33 Medicare Respite Coinsurance

34 Dietary

35 Audiology

36 Social Work

37 Supported Employment

38 Residential Support

39 Monthly Premium

40 Assessment (Full/Partial/Annual)

40A Pre-Assessment

41 Requisition Fees - Adaptive Aids

41A Requisition Fees - Medical Supplies

41B Requisition Fees - Minor Home Modifications

41C Specifications - Adaptive Aids

41D Specifications - Home Modifications

41E Requisition Fees - Dental

42 Specialized Therapies

43 Behavior Communication Specialist

44 Orientation and Mobility

45 Intervenor

46 TDMHMR Night Residential Support Services

47 TDMHMR Supervised Living Services

48 Transportation

49 Child Support Services

50 Personal Needs Allowance

51 Independent Advocacy

52 Community Support Services

53 Transitional Services

53A Transitional Support Services

60 Unlimited Prescriptions

99 Expedited Services �

Service Codes Table



Place of Service Codes Table

HIPAA claim format requirements for the Institutional (837I) and the Professional (837P) claim formats have necessitated a change to the place of service (POS) table originally published in the August 2003 LTC Bulletin, No. 15, and in the 2003 LTC User Manual for Paper Submitters. The professional and institutional claim will require TDHconnect providers to use one of the following codes in the POS field:

Place of Service Codes for the 837I – Institutional Claim Format

Place of Service Codes for the 837P – Professional Claim Format

Place of Service (POS) Codes Table for the 837I

Place of Service Code Place of Service Name Place of Service Description

18 Swing Bed - Hospital

25 Skilled Nursing Level I For all Nursing Homes/Nursing Facilities except when billing for Medicare co-insurance (Note: These are UB-92 defined levels – not to be confused with Texas TILE.)

27 Skilled Nursing Level III To be used by Nursing Homes/Nursing Facilities when billing for Medicare co-insurance (Note: These are UB-92 defined levels – not to be confused with Texas TILE.)

28 Swing Bed - Nursing Facility

32 Home Health - Inpatient To be used when billing for hospice inpatient services

33 Home Health Outpatient

34 Home Health Outpatient - Other

66 Intermediate Care Facility ICF-MR

74 Outpatient Rehabilitation Facility

75 Comprehensive Outpatient Rehabilitation Facility

79 Clinic - Other

81 Hospice - Special Facility

89 Special Facility - Other

Place of Service (POS) Codes Table for the 837P

Code Name Description

03 School A facility whose primary purpose is education

04 Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to homeless individuals

11 Office A location (other than a hospital, skilled nursing facility, military treatment facility, community health center, State or local public health clinic, or intermediate care facility) where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis

12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence

13 Assisted Living Facility

Congregate residential facility with selfcontained living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services

14 Group Home Congregate residential foster care setting

22 Outpatient Hospital A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization

24 Ambulatory Surgical Center

A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis


33 Custodial Care Facility A facility that provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component

34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided

41 Ambulance-Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured

42 Ambulance-Air or Water

An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured

49 Independent Clinic A location, not part of a hospital and not described by any other place of service, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only

50 Federally Qualified Health Center

A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under general direction of a physician

53 Community Mental Health Center

A facility that provides one or more of the following mental health services:

• Outpatient • 24-hour emergency care• Day treatment• Partial hospitalization• Psychosocial rehabilitation • Screening for admission to State mental health facilities• Consultation• Education

62 Comprehensive Outpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services may include one or more of the following:

• Physical therapy• Occupational therapy• Speech pathology• Social services• Psychological services• Orthotics and prosthetic services

71 State or Local Public Health Clinic

A facility maintained by either a State or local health department that provides ambulatory primary medical care under the general supervision of a physician

72 Rural Health Clinic A certified facility, located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician

99 Other Place of Service Other place of service not identified

Place of Service (POS) Codes Table for the 837P

Code Name Description


ModifiersAs previously described in this bulletin, the HIPAA solution chosen for the DHS/TDMHMR Claims Management System (CMS) is to recreate the state-defined local code from the HIPAA-compliant information being sent by the provider and supplemental information found in our various subsystems (that is, provider or client). In certain instances, to accurately recreate the bill codes, the solution requires the use of modifiers to define or clarify service group, budget, service provider type, occupancy, dwelling type, and others. The table below depicts the modifiers to be used, the modifier description, and the modifier field placement. Since the circumstances requiring the use of a modifier vary, and the dependencies cannot always be accurately depicted in a chart, it is not possible to show definitively when a modifier will be used. Remember to use the modifiers as noted below.

Modifier Field 1

Use only if you have a single contract with multiple service groups. If your contract contains more than one service group, use Modifier Field 1 to depict the service group of the client for which you are billing services.

Modifier Field 2

Use if it is shown on the crosswalk, or your contract requires you to specify a budget when filing a claim.

Modifier Field 3

Use only if it is shown on the crosswalk.

Modifier Field 4

Use only if it is shown on the crosswalk.

The new version of the modifier table follows this article. Providers may also access the table on the DHS HIPAA Project Team Web site at www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html.

DHS/TDMHMR Modifier Table

Refer to the “Long Term Care Bill Code Crosswalk Table” on page 17 to determine if modifiers are necessary to bill for your particular service.

Modifier Field # Modifier Modifier Description

1 U1 Service Group 1









1 UA Service Group 11

1 UB Service Group 16

1 UC Service Group 17

1 UD Service Group 18



2 U1 Budget #1

2 U2 Budget #2

2 U3 Level/Priority 1

2 U4 Level 2

2 U5 Level 3

2 U6 Level 4

2 U7 Level 5

2 U8 Level 6

2 U9 Level 7

2 UA Level 8

2 TG Complex/High Tech Level of Care

3 U1 Assisted Living/Single Occupancy

3 U2 Residential Care/Double Occupancy

3 U3 Training

3 U4 Prevocational Services

3 U5 Activities of Daily Living

3 U7 Full

3 U8 Partial

3 GO Services Provided by an Occupational Therapist

3 GP Services Provided by a Physical Therapist

3 GN Services Provided by a Speech-Language Pathologist

3 AJ Clinical Social Worker

3 TD Registered Nurse (RN)

3 TE Licensed Practical/Vocational Nurse (LPN/LVN)

4 U1 Apartment

4 U2 Nonapartment

4 U4 Participating Provider

4 U5 Nonparticipating Provider

Modifier Field # Modifier Modifier Description


LTC Bill Code Crosswalk Table

The DHS/TDMHMR HIPAA Project Team has modified the LTC Bill Code Crosswalk Table since it was published in the August 2003 LTC Bulletin, No. 15, and the 2003 LTC User Manual for Paper Submitters. The project team intends to keep modifications/changes to a minimum; however, testing of the HIPAA software, legislative mandates, policy/program changes, and national code updates can result in changes to the crosswalk table. Due to publishing deadlines, the version that appears in this bulletin is the one posted to the DHS Web site on October 1, 2003. To access the most current version of the LTC Bill Code crosswalk, providers should refer to the DHS HIPAA Project Team Web site at www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html. The crosswalk table will be updated on a quarterly basis, with the next update due in early 2004.

How to Use the LTC Bill Code Crosswalk Table

The left side of the LTC Bill Code Crosswalk Table provides the Texas LTC Local Codes for the service group, bill code, service code, and bill code description used to bill for services before HIPAA. The right side of the table identifies the National Standard Codes you will use on your claims effective October 16, 2003. Your contract and MESAV information will tell you the service codes and service groups for which you have authorization to provide services.

To use the crosswalk table, follow the guidelines below:

1. Find your service group, service code, and, if possible, the bill code you have used in the past to bill for the service(s) and follow the row across to the National Codes section to find the new codes to use effective on and after October 16, 2003.

2. If the bill code has been mapped to a national HCPCS code, you will find an entry of “HC” or “AD” in the procedure code qualifier field and information in either the HCPCS or CPT code fields (or, in some cases, in the HCPCS or CPT and the revenue code fields). If the bill code only has a national revenue code shown, no entry will be found in the procedure code qualifier field.

3. If there are entries in the modifier fields, you will need to use those modifiers in the designated fields when completing the detail line for that service.

4. If there is a “ZZ” in the procedure code qualifier field, you will continue to use the existing bill code to claim reimbursement.

5. The table contains a field called “End Date.” If this field has an entry, it means that services provided after the stated end date will not be paid. �


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nsD

1N

0600

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erge

ncy

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tal

ADD

72

50

Sur

gica

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oval

of R

esid

ual T

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tsD

1N

0600

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ncy

Den

tal

ADD

75

10

Inci

sion

and

Dra

inag

e of

Abs

cess

- In

trao

ral S

oft

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1N

0600

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20

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and

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Abs

cess

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trao

ral S

oft

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1N

0600

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tal

ADD

92

15

Loca

l Ane

sthe

sia

D

1N

0600

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tal

ADD

92

20

Gen

eral

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sthe

sia

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t 30 M

inut

esD

1N

0600

5Em

erge

ncy

Den

tal

ADD

92

21

Gen

eral

Ane

sthe

sia

- Eac

h Ad

ditio

nal 1

5 M

inut

esD

1N

0700

6N

urse

’s A

id T

rain

ing

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inin

g C

ours

eZZ

Loca

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e to

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.P

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id T

rain

ing

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lls T

est

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ssed

ZZLo

cal c

ode

to b

e re

tain

ed.

P

1N

0702

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’s A

id T

rain

ing

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lls T

est

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iled

ZZLo

cal c

ode

to b

e re

tain

ed.

P

1N

0703

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id T

rain

ing

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ten

Test

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ssed

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tain

ed.

P

1N

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’s A

id T

rain

ing

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ten

Test

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iled

ZZLo

cal c

ode

to b

e re

tain

ed.

P

1N

0705

6N

urse

’s A

id T

rain

ing-

Ora

l Tes

t -

Pass

edZZ

Loca

l cod

e to

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ined

.P

Ser

vice

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up 1

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ode

Cro

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Tabl

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iona

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vice

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eR

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2M

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efin

itio

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omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

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ust

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sed

for

serv

ices

ren

dere

d fo

r 1

0/1

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Exce

pt for

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ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.

18 November 2003, No. 16LTC Bul let in

1N

0706

6N

urse

’s A

id T

rain

ing-

Ora

l Tes

t -

Faile

dZZ

Loca

l cod

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ined

.P

1N

0707

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urse

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id T

rain

ing

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inin

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ater

ials

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cal c

ode

to b

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tain

ed.

P

1N

0708

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urse

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id T

rain

ing

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ompl

ete

Trai

ning

Cou

rse

ZZLo

cal c

ode

to b

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tain

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P

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97

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ality

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837I;

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=837D

Not

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for

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Exce

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ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


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, vo

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mun

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au

dito

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End

Dat

eC

laim

Typ

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File

: I=

837I;

P=837P

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2G

0400

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ccup

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01

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Ser

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Ser

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ilita

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.P

2G

0100

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Res

pite

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tain

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P

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0101

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Res

pite

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DS

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tain

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P

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Res

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0171

11

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ome

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S -

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cyZZ

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l cod

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be

reta

ined

.P

2G

0200

12

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anag

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t08/3

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0201

12

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are

in t

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by

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P

Not

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Z qu

alifi

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be u

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for

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ices

ren

dere

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6/0

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Exce

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: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

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hysi

cian

Ser

vice

s.

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End

Dat

eC

laim

Typ

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File

: I=

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ust

be u

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for

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Exce

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: D

ME/

Adap

tive

Aids

, D

enta

l, an

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hysi

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Ser

vice

s.


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0301

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91

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08

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P

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Psyc

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Indi

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phy

sica

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, lan

guag

e in

terp

rete

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ther

m

echa

nism

s of

non

verb

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unic

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n, in

an

offic

e or

ou

tpat

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Psyc

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08

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pla

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m

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unic

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an

offic

e or

ou

tpat

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fac

ility

, ap

prox

imat

ely

45 -

50 m

inut

es fac

e-to

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ith t

he p

atie

nt

P

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14

Psyc

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Indi

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phy

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, lan

guag

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terp

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ther

m

echa

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s of

non

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unic

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an

offic

e or

ou

tpat

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fac

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, ap

prox

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75 -

80 m

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nt

P

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0403

14

Psyc

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vice

sH

C9

08

16

Indi

vidu

al p

sych

othe

rapy

, in

sigh

t or

ient

ed, be

havi

or

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d/or

sup

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in a

n in

patie

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part

ial h

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tal,

or r

esid

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l car

e se

ttin

g, a

ppro

xim

atel

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0 -

30

min

utes

fac

e-to

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with

pat

ient

P

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

18

Indi

vidu

al p

sych

othe

rapy

, in

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or

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n in

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ial h

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tal,

or r

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ttin

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ppro

xim

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5 -

50

min

utes

fac

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P

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0403

14

Psyc

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vice

sH

C9

08

21

Indi

vidu

al p

sych

othe

rapy

, in

sigh

t or

ient

ed, be

havi

or

mod

ifyin

g an

d/or

sup

port

ive,

in a

n in

patie

nt h

ospi

tal,

part

ial h

ospi

tal,

or r

esid

entia

l car

e se

ttin

g, a

ppro

xim

atel

y 7

5 -

80

min

utes

fac

e-to

-face

with

pat

ient

P

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

23

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r or o

ther

m

echa

nism

s of

non

verb

al c

omm

unic

atio

n, in

an

inpa

tient

ho

spita

l, pa

rtia

l hos

pita

l or

resi

dent

ial c

are

sett

ing,

ap

prox

imat

ely

20 -

30 m

inut

es fa

ce-to

-face

with

the

patie

nt

P

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

26

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r or o

ther

m

echa

nism

s of

non

verb

al c

omm

unic

atio

n, in

an

inpa

tient

ho

spita

l, pa

rtia

l hos

pita

l or

resi

dent

ial c

are

sett

ing,

ap

prox

imat

ely

45 -

50 m

inut

es fa

ce-to

-face

with

the

patie

nt

P

Ser

vice

Gro

up 2

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

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odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

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4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

28

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r or o

ther

m

echa

nism

s of

non

verb

al c

omm

unic

atio

n, in

an

inpa

tient

ho

spita

l, pa

rtia

l hos

pita

l or

resi

dent

ial c

are

sett

ing,

ap

prox

imat

ely

75 -

80 m

inut

es fa

ce-to

-face

with

the

patie

nt

P

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

45

Psyc

hoan

alys

isP

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

47

Fam

ily p

sych

othe

rapy

(co

njoi

nt c

ouns

elin

g) w

ith p

atie

nt

pres

ent

P

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

62

Phar

mac

olog

ical

man

agem

ent,

incl

udin

g pr

escr

iptio

n/us

e/re

view

of m

edic

atio

nP

2G

0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

61

00

Psyc

holo

gica

l tes

ting

P

2G

0500

15

Adap

tive

Aids

ADD

99

99

Uns

peci

fied

Adju

nctiv

e Pr

oced

ure,

by

Rep

ort

D

2G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

00

3N

on-e

mer

genc

y tr

ansp

orta

tion;

enc

ount

er/t

ripP

2G

0500

15

DM

E/Ad

aptiv

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CT2

03

9Ve

hicl

e M

odifi

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2G

0500

15

DM

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51

99

Pers

onal

Car

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m, N

OS

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chP

2G

0500

15

DM

E/Ad

aptiv

e Ai

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63

6M

ultip

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onal

pat

ient

sup

port

sys

tem

, with

inte

grat

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ft,

patie

ntP

2G

0500

15

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aptiv

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03

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Cha

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ny a

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pes

with

cas

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5 in

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or

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P

2G

0500

15

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CE1

13

0S

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CE1

39

9D

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edic

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quip

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isce

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P

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0500

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DM

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ds09/3

0/03

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0500

15

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CE1

90

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ynth

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unic

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15

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90

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on-e

lect

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nP

2G

0500

15

DM

E/Ad

aptiv

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dsH

CT2

02

9S

peci

aliz

ed m

edic

al e

quip

men

t, n

ot o

ther

wis

e sp

ecifi

ed,

wai

ver

P

2G

0608

16

Hom

e M

odifi

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CS

51

65

Hom

e M

odifi

catio

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r se

rvic

eP

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0701

17

Pers

onal

Ass

ista

nce

Ser

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s -

Leve

l 2 -

Prio

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08/3

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2G

1200

22

Med

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Sup

plie

s H

CT2

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8S

peci

aliz

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uppl

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ot o

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wis

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ecifi

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aive

rP

2G

0720

27

Con

sum

er M

anag

ed P

erso

nal

Atte

ndan

t S

ervi

ces

08/3

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2G

0721

27

Clie

nt M

anag

ed A

tten

dant

Ser

vice

s -

Vouc

her

08/3

1/03

2G

0202

40

Prea

sses

smen

t08/3

1/03

Ser

vice

Gro

up 2

- Lo

ng T

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ode

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Tabl

eTe

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Loc

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Ser

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Bill

C

ode

Ser

vice

C

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Bill

Cod

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escr

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roce

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C

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Qua

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HC

PC

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Cod

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even

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Cod

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2M

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3M

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4D

efin

itio

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omm

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End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

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3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


2G

0203

40

Cas

e M

anag

emen

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rtia

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CT1

00

1U

8N

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sses

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alua

tion

P

2G

0203

40

Cas

e M

anag

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rtia

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sess

men

tH

CT1

02

3U

8S

cree

ning

to

dete

rmin

e th

e ap

prop

riate

ness

of

cons

ider

atio

n of

an

indi

vidu

al for

par

ticip

atio

n in

a

spec

ified

pro

gram

, pr

ojec

t or

tre

atm

ent

prot

ocol

, pe

r en

coun

ter

P

2G

0204

40

Dire

ct P

rovi

der

Full

Asse

ssm

ent

HC

T10

23

U7

Scr

eeni

ng t

o de

term

ine

the

appr

opria

tene

ss o

f co

nsid

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of a

n in

divi

dual

for

par

ticip

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a

spec

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pro

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, pr

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coun

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P

2G

0205

40

Annu

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0605

40

Spe

cific

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M M

ods

08/3

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2G

0515

41

ADP

Aide

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equi

sitio

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es

0 -

49

9.9

9ZZ

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99

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cal c

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tain

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P

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0517

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equi

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es

1

00

0.0

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14

99

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P

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0518

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15

00

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9.9

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Loca

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0519

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equi

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2

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24

99

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P

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0520

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25

00

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99

9.9

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Loca

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e to

be

reta

ined

.P

2G

0521

41

ADP

Aide

s/R

equi

sitio

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es

30

00

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0522

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3

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39

99

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ed.

P

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0523

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ADP

Aide

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equi

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es

4

00

0.0

0 -

44

99

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ZZLo

cal c

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tain

ed.

P

2G

0524

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ADP

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45

00

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99

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.P

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0525

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P

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0 -

49

9.9

908/3

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0610

41

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Mod

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equi

sitio

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5

00

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99

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08/3

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escr

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efin

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End

Dat

eC

laim

Typ

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File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

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ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


2G

0612

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Mod

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equi

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2

00

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24

99

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08/3

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0613

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Mod

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equi

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25

00

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99

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908/3

1/03

2G

0614

41

MH

Mod

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equi

sitio

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es

2

50

0.0

0 -

29

99

.99

08/3

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2G

0615

41

MH

Mod

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equi

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30

00

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- 3

49

9.9

908/3

1/03

2G

0616

41

MH

Mod

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equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

08/3

1/03

2G

0617

41

MH

Mod

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equi

sitio

n Fe

es

4

00

0.0

0 -

44

99

.99

08/3

1/03

2G

0618

41

MH

Mod

s/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

908/3

1/03

2G

0619

41

MH

Mod

s/R

equi

sitio

n Fe

es

50

00

.00

- 5

49

9.9

908/3

1/03

2G

0620

41

MH

Mod

s/R

equi

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es

55

00

.00

- 5

99

9.9

908/3

1/03

2G

0621

41

MH

Mod

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equi

sitio

n Fe

es

60

00

.00

- 6

49

9.9

908/3

1/03

2G

0622

41

MH

Mod

s/R

equi

sitio

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es

65

00

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- O

VER

08/3

1/03

2G

0404

42

Spe

cial

ized

The

rapi

esH

CQ

00

82

Activ

ity t

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py fur

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con

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with

par

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hosp

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e. m

usic

, ar

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pla

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iona

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P

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42

Spe

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The

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35

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f ca

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ome

man

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f da

ily li

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and

com

pens

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prov

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min

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P

2G

0404

42

Spe

cial

ized

The

rapi

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C9

75

37

Com

mun

ity/w

ork

rein

tegr

atio

n tr

aini

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. sh

oppi

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tran

spor

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ork

task

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one

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min

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P

2S

0105

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ilita

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patie

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MR

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IMD

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t of

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indi

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lan

of tre

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o be

use

d fo

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es p

rovi

ded

by a

hom

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alth

aid

e or

ce

rtifi

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P

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port

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per

15 m

inut

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Ser

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Gro

up 2

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ode

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Tabl

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Loc

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Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


2S

0107

10B

Hab

ilita

tion

- Pre

voca

tiona

lH

CT2

01

5U

4H

abili

tatio

n pr

evoc

atio

nal,

wai

ver,

per

hou

rP

2G

0128

11A

Res

pite

- O

ut-o

f-Hom

eH

CS

51

51

Uns

kille

d R

espi

te C

are,

per

die

mP

2G

0170

11A

Out

-of-H

ome

Res

pite

CD

SZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0302

13A

Nur

sing

Ser

vice

s - L

VNH

CS

91

24

Nur

sing

Car

e in

the

Hom

e, b

y LV

NP

2G

0302

13A

Nur

sing

Ser

vice

s - L

VNH

CT1

00

3LP

N/L

VN s

ervi

ces

up t

o 15 m

inut

esP

2G

0303

13B

Nur

sing

Ser

vice

s - R

NH

CS

91

23

Nur

sing

Car

e in

the

Hom

e, b

y R

NP

2G

0303

13B

Nur

sing

Ser

vice

s - R

NH

CT1

00

1N

ursi

ng a

sses

smen

t/ev

alua

tion

P

2G

0303

13B

Nur

sing

Ser

vice

s - R

NH

CT1

00

2R

N s

ervi

ces

up t

o 15 m

inut

esP

2S

9800

13C

Nur

sing

Ser

vice

s by

Hig

hly

Tech

nica

l R

N,

per

hour

HC

S9

80

0TG

Hom

e Th

erap

y; p

rovi

sion

of in

fusi

on, sp

ecia

lty d

rug

adm

inis

trat

ion,

and

/or

asso

ciat

ed n

ursi

ng s

ervi

ces

and

proc

edur

es, by

hig

hly

tech

nica

l R.N

., p

er h

our

P

2T1

003

13D

Nur

sing

Ser

vice

s LV

NH

CT1

00

3TG

LPN

/LVN

ser

vice

s, u

p to

15 m

inut

esP

2G

0705

17A

PAS

Del

egat

ed (

For

Futu

re U

se)

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0706

17B

PAS

Pro

tect

ive

Sup

ervi

sion

(Fo

r Fu

ture

Use

)ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0937

19E

Assi

sted

Liv

ing

- Hab

ilita

tion

24

hou

r08/3

1/03

2G

0938

19F

Assi

sted

Liv

ing

- Hab

ilita

tion

Less

Th

an 2

4 h

our

08/3

1/03

2G

0722

27A

CM

PAS

- C

lient

Dire

cted

Ser

vice

sZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0723

27A

CM

PAS

- C

lient

Dire

cted

Ser

vice

sZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0207

40A

Prea

sses

smen

tH

CT2

02

4S

ervi

ce a

sses

smen

t/pl

an o

f ca

re d

evel

opm

ent,

wai

ver

P

2G

0623

41B

MH

Mod

s/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0624

41B

MH

Mod

s/R

equi

sitio

n Fe

es

5

00

.00

- 9

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0625

41B

MH

Mod

s/R

equi

sitio

n Fe

es

10

00

.00

- 1

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0626

41B

MH

Mod

s/R

equi

sitio

n Fe

es

1

50

0.0

0 -

19

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0627

41B

MH

Mod

s/R

equi

sitio

n Fe

es

20

00

.00

- 2

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0628

41B

MH

Mod

s/R

equi

sitio

n Fe

es

2

50

0.0

0 -

29

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0629

41B

MH

Mod

s/R

equi

sitio

n Fe

es

30

00

.00

- 3

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0630

41B

MH

Mod

s/R

equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

Ser

vice

Gro

up 2

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


2G

0631

41B

MH

Mod

s/R

equi

sitio

n Fe

es

4

00

0.0

0 -

44

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0632

41B

MH

Mod

s/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0633

41B

MH

Mod

s/R

equi

sitio

n Fe

es

50

00

.00

- 5

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0634

41B

MH

Mod

s/R

equi

sitio

n Fe

es

55

00

.00

- 5

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0635

41B

MH

Mod

s/R

equi

sitio

n Fe

es

6

00

0.0

0 -

64

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0636

41B

MH

Mod

s/R

equi

sitio

n Fe

es

6

50

0.0

0 -

Ove

rZZ

Loca

l cod

e to

be

reta

ined

.P

2G

0607

41C

Spe

cific

atio

ns A

dapt

ive

Aids

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0604

41D

Spe

cific

atio

ns H

M M

ods

ZZLo

cal c

ode

to b

e re

tain

ed.

P

2G

0637

41E

Den

tal/

Req

uisi

tion

Fees

0 -

49

9.9

908/3

1/03

2G

0638

41E

Den

tal/

Req

uisi

tion

Fees

5

00

.00

- 9

99

.99

08/3

1/03

2G

0639

41E

Den

tal/

Req

uisi

tion

Fees

1

00

0.0

0 -

14

99

.99

08/3

1/03

2G

0640

41E

Den

tal/

Req

uisi

tion

Fees

1

50

0.0

0 -

19

99

.99

08/3

1/03

2G

0641

41E

Den

tal/

Req

uisi

tion

Fees

2

00

0.0

0 -

24

99

.99

08/3

1/03

2G

0642

41E

Den

tal/

Req

uisi

tion

Fees

2

50

0.0

0 -

29

99

.99

08/3

1/03

2G

0643

41E

Den

tal/

Req

uisi

tion

Fees

3

00

0.0

0 -

34

99

.99

08/3

1/03

2G

0644

41E

Den

tal/

Req

uisi

tion

Fees

3

50

0.0

0 -

39

99

.99

08/3

1/03

2G

0645

41E

Den

tal/

Req

uisi

tion

Fees

40

00

.00

- 4

49

9.9

908/3

1/03

2G

0646

41E

Den

tal/

Req

uisi

tion

Fees

4

50

0.0

0 -

49

99

.99

08/3

1/03

2G

0647

41E

Den

tal/

Req

uisi

tion

Fees

5

00

0.0

0 -

OVE

R08/3

1/03

2N

0600

5A

Den

tal S

ervi

ces

08/3

1/03

Ser

vice

Gro

up 2

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

3

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

3G

0400

7O

ccup

atio

nal T

hera

pyH

CG

01

52

GO

Ser

vice

s of

a o

ccup

atio

nal t

hera

pist

in a

hom

e he

alth

se

ttin

g; p

er 1

5 m

inut

esP

3G

0401

8Ph

ysic

al T

hera

pyH

CG

01

51

GP

Ser

vice

s of

a p

hysi

cal t

hera

pist

in a

hom

e he

alth

set

ting;

pe

r 1

5 m

inut

esP

3G

0402

9S

peec

h Th

erap

yH

CG

01

53

GN

Spe

ech

or la

ngua

ge p

atho

logi

st in

hom

e he

alth

set

ting;

per

1

5 m

inut

esP

3G

0101

11

Res

pite

- In

-Hom

e ZZ

Loca

l cod

e to

be

reta

ined

. (V

FI P

aym

ent)

P

3G

0103

11

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 1

08/3

1/03

3G

0104

11

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 3

08/3

1/03

3G

0105

11

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

6)

08/3

1/03

3G

0106

11

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

08/3

1/03

3G

0107

11

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

6)

08/3

1/03

3G

0109

11

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 2

08/3

1/03

3G

0171

11

In-H

ome

Res

pite

CD

S -

Agen

cyZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1105

11

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

5)

08/3

1/03

3G

1106

11

Res

pite

/Res

iden

tial C

are

- Ap

artm

ent

(Lev

el 5

)08/3

1/03

3G

1107

11

Res

pite

/Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 5

)08/3

1/03

3G

2105

11

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

4)

08/3

1/03

3G

2106

11

Res

pite

/Res

iden

tial C

are

- Ap

artm

ent

(Lev

el 4

)08/3

1/03

3G

2107

11

Res

pite

/Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 4

)08/3

1/03

3G

3105

11

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

3)

08/3

1/03

3G

3106

11

Res

pite

/Res

iden

tial C

are

- Ap

artm

ent

(Lev

el 3

)08/3

1/03

3G

3107

11

Res

pite

/Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 3

)08/3

1/03

3G

4105

11

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

2)

08/3

1/03

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

4106

11

Res

pite

/Res

iden

tial C

are

- Ap

artm

ent

(Lev

el 2

)08/3

1/03

3G

4107

11

Res

pite

/Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 2

)08/3

1/03

3G

5105

11

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

1)

08/3

1/03

3G

5106

11

Res

pite

/Res

iden

tial C

are

- Ap

artm

ent

(Lev

el 1

)08/3

1/03

3G

5107

11

Res

pite

/Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 1

)08/3

1/03

3N

0201

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0202

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0203

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0204

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0205

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0206

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0207

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0208

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0209

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0210

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0211

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0212

11

Res

pite

- In

-Hom

e08/3

1/03

3N

0500

11

Vent

ilato

r - F

ull

08/3

1/03

3N

0501

11

Vent

ilato

r - P

artia

l08/3

1/03

3G

0200

12

Cas

e M

anag

emen

t08/3

1/03

3G

0300

13

Nur

sing

- R

NH

CS

91

23

TDN

ursi

ng C

are

in t

he H

ome,

by

RN

P

3G

0300

13

Nur

sing

- R

NH

CT1

00

1TD

Nur

sing

ass

essm

ent/

eval

uatio

nP

3G

0300

13

Nur

sing

- R

NH

CT1

00

2TD

RN

ser

vice

s up

to

15 m

inut

esP

3G

0301

13

Nur

sing

- LV

NH

CS

91

24

TEN

ursi

ng C

are

in t

he H

ome,

by

LVN

P

3G

0301

13

Nur

sing

- LV

NH

CT1

00

3TE

LPN

/LVN

ser

vice

s up

to

15 m

inut

esP

3G

0500

15

Adap

tive

Aids

ADD

99

99

Uns

peci

fied

Adju

nctiv

e Pr

oced

ure,

by

Rep

ort

D

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

03

9Ve

hicl

e M

odifi

catio

ns, w

aive

r; p

er s

ervi

ceP

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE0

63

6M

ultip

ositi

onal

pat

ient

sup

port

sys

tem

, with

inte

grat

ed li

ft,

patie

ntP

Ser

vice

Gro

up 3

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ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

03

1R

olla

bout

Cha

ir, a

ny a

nd a

ll ty

pes

with

cas

tors

5 in

ches

or

grea

ter

P

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

13

0S

tand

ard

Whe

elch

air,

fixe

d fu

ll le

ngth

arm

s, fi

xed

or s

win

g aw

ay d

etac

habl

eP

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

39

9D

urab

le M

edic

al E

quip

men

t, M

isce

llane

ous

P

3G

0500

15

DM

E/Ad

aptiv

e Ai

ds09/2

8/03

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

90

0S

ynth

esiz

ed S

peec

h Au

gmen

tativ

e C

omm

unic

atio

n D

evic

e w

ith D

ynam

ic D

ispl

ayP

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

90

2C

omm

unic

atio

n B

oard

, N

on-e

lect

roni

c Au

gmen

tativ

e or

Al

tern

ativ

e C

omm

unic

atio

nP

3G

0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

02

9S

peci

aliz

ed m

edic

al e

quip

men

t, n

ot o

ther

wis

e sp

ecifi

ed,

wai

ver

P

3G

0608

16

Hom

e M

odifi

catio

nsH

CS

51

65

Hom

e M

odifi

catio

ns; pe

r se

rvic

eP

3+9

99

99

17

Expe

dite

d Pa

ymen

tZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0700

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Leve

l 308/3

1/03

3G

0701

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Leve

l 2 -

Prio

rity

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

3G

0800

18

Adul

t Fo

ster

Car

e - L

evel

1H

CS

51

40

31

05

A fla

t ra

te c

harg

e in

curr

ed o

n ei

ther

a d

aily

bas

is o

r to

tal

stay

bas

is for

anc

illar

y se

rvic

es o

nly.

I

3G

0801

18

Adul

t Fo

ster

Car

e - L

evel

2H

CS

51

40

31

05

A fla

t ra

te c

harg

e in

curr

ed o

n ei

ther

a d

aily

bas

is o

r to

tal

stay

bas

is for

anc

illar

y se

rvic

es o

nly.

I

3G

0802

18

Adul

t Fo

ster

Car

e - L

evel

3H

CS

51

40

31

05

A fla

t ra

te c

harg

e in

curr

ed o

n ei

ther

a d

aily

bas

is o

r to

tal

stay

bas

is for

anc

illar

y se

rvic

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nly.

I

3G

0900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 6

)H

CT2

03

1U

1U

1As

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ed li

ving

, w

aive

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er d

iem

P

3G

0900

19

Assi

sted

Liv

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rtm

ent

(Lev

el 6

)H

CT2

03

10

24

0U

1U

1Al

l Inc

lusi

ve A

ncill

ary

I

3G

0901

19

Res

iden

tial C

are

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artm

ent

(Lev

el 6

)08/3

1/03

3G

0902

19

Res

iden

tial C

are

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onap

artm

ent

(Lev

el 6

)08/3

1/03

3G

0905

19

Assi

sted

Liv

ing/

Res

iden

tial C

are

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rson

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are

08/3

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3G

1900

19

Assi

sted

Liv

ing

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rtm

ent

(Lev

el 5

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

r; p

er d

iem

P

3G

1900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 5

)H

CT2

03

10

24

0U

1U

1Al

l Inc

lusi

ve A

ncill

ary

I

3G

1901

19

Res

iden

tial C

are

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artm

ent

(Lev

el 5

)08/3

1/03

3G

1902

19

Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 5

)08/3

1/03

Ser

vice

Gro

up 3

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ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

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roce

dure

C

ode

Qua

lifie

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HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

2900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 4

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

r; p

er d

iem

P

3G

2900

19

Assi

sted

Liv

ing

- Apa

rtm

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(Lev

el 4

)H

CT2

03

10

24

0U

1U

1Al

l Inc

lusi

ve A

ncill

ary

I

3G

2901

19

Res

iden

tial C

are

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artm

ent

(Lev

el 4

)08/3

1/03

3G

2902

19

Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 4

)08/3

1/03

3G

3900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 3

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

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er d

iem

P

3G

3900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 3

)H

CT2

03

10

24

0U

1U

1Al

l Inc

lusi

ve A

ncill

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I

3G

3901

19

Res

iden

tial C

are

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artm

ent

(Lev

el 3

)08/3

1/03

3G

3902

19

Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 3

)08/3

1/03

3G

4900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 2

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

r; p

er d

iem

P

3G

4900

19

Assi

sted

Liv

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- Apa

rtm

ent

(Lev

el 2

)H

CT2

03

10

24

0U

1U

1Al

l Inc

lusi

ve A

ncill

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I

3G

4901

19

Res

iden

tial C

are

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artm

ent

(Lev

el 2

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1/03

3G

4902

19

Res

iden

tial C

are

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onap

artm

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(Lev

el 2

)08/3

1/03

3G

5900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 1

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

r; p

er d

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P

3G

5900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 1

)H

CT2

03

10

24

0U

1U

1Al

l Inc

lusi

ve A

ncill

ary

I

3G

5901

19

Res

iden

tial C

are

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artm

ent

(Lev

el 1

)08/3

1/03

3G

5902

19

Res

iden

tial C

are

- N

onap

artm

ent

(Lev

el 1

)08/3

1/03

3G

1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

60

In

stal

latio

n an

d Te

stin

gP

3G

1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

61

Mon

thly

Ser

vice

Fee

(ex

clud

es in

stal

latio

n an

d te

stin

g)P

3G

1000

20

Emer

genc

y R

espo

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Ser

vice

sH

CS

51

62

Purc

hase

Onl

yP

3G

1100

21

Pres

crip

tions

- di

scon

tinue

d08/3

1/03

3G

0500

22

DM

E/Ad

aptiv

e Ai

dsH

CT2

02

8S

peci

aliz

ed S

uppl

y, N

ot o

ther

wis

e sp

ecifi

ed, w

aive

rP

3G

1200

22

Med

ical

Sup

plie

s H

CS

51

99

Pers

onal

Car

e Ite

m, N

OS

, ea

chP

3C

0100

25

Hom

e D

eliv

ered

Mea

ls08/3

1/03

3C

0101

25

Wai

ver

Mea

lsH

CS

51

70

Per

mea

l, in

clud

es p

repa

ratio

n an

d de

liver

yP

3G

0202

40

Prea

sses

smen

t08/3

1/03

3G

0205

40

Annu

al A

sses

smen

t08/3

1/03

3G

0206

40

Asse

ssm

ent-M

DS

Hom

e N

ot u

sed

curr

ently

. Was

dev

elop

ed a

s a

plac

ehol

der i

n th

e ev

ent

the

MD

S r

epla

ces

the

3652.

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0605

40

Spe

cific

atio

ns H

M M

ods

08/3

1/03

3G

0515

41

ADP

Aide

s/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0516

41

ADP

Aide

s/R

equi

sitio

n Fe

es

5

00

.00

- 9

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0517

41

ADP

Aide

s/R

equi

sitio

n Fe

es

1

00

0.0

0 -

14

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0518

41

ADP

Aide

s/R

equi

sitio

n Fe

es

15

00

.00

- 1

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0519

41

ADP

Aide

s/R

equi

sitio

n Fe

es

2

00

0.0

0 -

24

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0520

41

ADP

Aide

s/R

equi

sitio

n Fe

es

25

00

.00

- 2

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0521

41

ADP

Aide

s/R

equi

sitio

n Fe

es

30

00

.00

- 3

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0522

41

ADP

Aide

s/R

equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0523

41

ADP

Aide

s/R

equi

sitio

n Fe

es

4

00

0.0

0 -

44

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0524

41

ADP

Aide

s/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0525

41

ADP

Aide

s/R

equi

sitio

n Fe

es

50

00

.00

- O

VER

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0609

41

MH

Mod

s/R

equi

sitio

n Fe

es

0 -

49

9.9

908/3

1/03

3G

0610

41

MH

Mod

s/R

equi

sitio

n Fe

es

5

00

.00

- 9

99

.99

08/3

1/03

3G

0611

41

MH

Mod

s/R

equi

sitio

n Fe

es

15

00

.00

- 1

99

9.9

908/3

1/03

3G

0612

41

MH

Mod

s/R

equi

sitio

n Fe

es

2

00

0.0

0 -

24

99

.99

08/3

1/03

3G

0613

41

MH

Mod

s/R

equi

sitio

n Fe

es

25

00

.00

- 2

99

9.9

908/3

1/03

3G

0614

41

MH

Mod

s/R

equi

sitio

n Fe

es

2

50

0.0

0 -

29

99

.99

08/3

1/03

3G

0615

41

MH

Mod

s/R

equi

sitio

n Fe

es

30

00

.00

- 3

49

9.9

908/3

1/03

3G

0616

41

MH

Mod

s/R

equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

08/3

1/03

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0617

41

MH

Mod

s/R

equi

sitio

n Fe

es

4

00

0.0

0 -

44

99

.99

08/3

1/03

3G

0618

41

MH

Mod

s/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

908/3

1/03

3G

0619

41

MH

Mod

s/R

equi

sitio

n Fe

es

50

00

.00

- 5

49

9.9

908/3

1/03

3G

0620

41

MH

Mod

s/R

equi

sitio

n Fe

es

55

00

.00

- 5

99

9.9

908/3

1/03

3G

0621

41

MH

Mod

s/R

equi

sitio

n Fe

es

60

00

.00

- 6

49

9.9

908/3

1/03

3G

0622

41

MH

Mod

s/R

equi

sitio

n Fe

es

65

00

.00

- O

VER

08/3

1/03

3G

1101

41

Pres

crip

tion/

Req

uisi

tion

Fees

08/3

1/03

3G

1201

41

Med

ical

S/R

equi

sitio

n Fe

es

0 -

49

9.9

908/3

1/03

3G

1202

41

Med

ical

S/R

equi

sitio

n Fe

es

50

0.0

0 -

99

9.9

908/3

1/03

3G

1203

41

Med

ical

S/R

equi

sitio

n Fe

es

10

00

.00

- 1

49

9.9

908/3

1/03

3G

1204

41

Med

ical

S/R

equi

sitio

n Fe

es

15

00

.00

- 1

99

9.9

908/3

1/03

3G

1205

41

Med

ical

S/R

equi

sitio

n Fe

es

20

00

.00

- 2

49

9.9

908/3

1/03

3G

1206

41

Med

ical

S/R

equi

sitio

n Fe

es

25

00

.00

- 2

99

9.9

908/3

1/03

3G

1207

41

Med

ical

S/R

equi

sitio

n Fe

es

3

00

0.0

0 -

34

99

.99

08/3

1/03

3G

1208

41

Med

ical

S/R

equi

sitio

n Fe

es

35

00

.00

- 3

99

9.9

908/3

1/03

3G

1209

41

Med

ical

S/R

equi

sitio

n Fe

es

40

00

.00

- 4

49

9.9

908/3

1/03

3G

1210

41

Med

ical

S/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

908/3

1/03

3G

1211

41

Med

ical

S/R

equi

sitio

n Fe

es

50

00

.00

- O

VER

08/3

1/03

3G

0237

52

Com

mun

ity S

uppo

rt S

ervi

ces

08/3

1/03

3G

0238

53

Tran

sitio

nal S

ervi

ces

08/3

1/03

3G

0128

11A

Res

pite

- O

ut-o

f-Hom

e08/3

1/03

3G

0132

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 1

HC

S5

15

1U

3U

nski

lled

Res

pite

Car

e, p

er d

iem

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0132

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 1

HC

S5

15

10

66

0U

3U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0133

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 2

HC

S5

15

1U

4U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0133

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 2

HC

S5

15

10

66

0U

4U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0134

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 3

HC

S5

15

1U

5U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0134

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 3

HC

S5

15

10

66

0U

5U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0172

11B

Adul

t Fo

ster

Car

e C

DS

- Ag

ency

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0135

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

6)

HC

S5

15

10

66

0U

8U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0135

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

6)

HC

S5

15

1U

8U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0136

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

5)

HC

S5

15

10

66

0U

7U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0136

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

5)

HC

S5

15

1U

7U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0137

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

4)

HC

S5

15

10

66

0U

6U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0137

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

4)

HC

S5

15

1U

6U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0138

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

3)

HC

S5

15

10

66

0U

5U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0138

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

3)

HC

S5

15

1U

5U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0139

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

2)

HC

S5

15

10

66

0U

4U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0139

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

2)

HC

S5

15

1U

4U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0140

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

1)

HC

S5

15

10

66

0U

3U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0140

11C

Res

pite

- As

sist

ed L

ivin

g -

Apar

tmen

t (L

evel

1)

HC

S5

15

1U

3U

1U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0173

11C

VR

espi

te A

ssis

ted

Livi

ng,

Apar

tmen

t C

DS

- Pa

rtic

ipan

tZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0174

11C

VR

espi

te A

ssis

ted

Livi

ng,

Apar

tmen

t C

DS

- Ag

ency

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0142

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

HC

S5

15

10

66

0U

8U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0142

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

HC

S5

15

1U

8U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0143

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

5)

HC

S5

15

10

66

0U

7U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0143

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

5)

HC

S5

15

1U

7U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0144

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

4)

HC

S5

15

10

66

0U

6U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0144

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

4)

HC

S5

15

1U

6U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0145

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

3)

HC

S5

15

10

66

0U

5U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0145

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

3)

HC

S5

15

1U

5U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0146

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

2)

HC

S5

15

10

66

0U

4U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0146

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

2)

HC

S5

15

1U

4U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0147

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

1)

HC

S5

15

10

66

0U

3U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0147

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

1)

HC

S5

15

1U

3U

2U

1U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0175

11D

VR

espi

te R

esid

entia

l Car

e Ap

artm

ent

CD

S -

Part

icip

ant

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0176

11D

VR

espi

te R

esid

entia

l Car

e Ap

artm

ent

CD

S -

Agen

cyZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0149

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

6)

HC

S5

15

10

66

0U

8U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0149

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

6)

HC

S5

15

1U

8U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0150

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

5)

HC

S5

15

10

66

0U

7U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0150

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

5)

HC

S5

15

1U

7U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0151

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

4)

HC

S5

15

10

66

0U

6U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0151

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

4)

HC

S5

15

1U

6U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0152

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

3)

HC

S5

15

10

66

0U

5U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0152

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

3)

HC

S5

15

1U

5U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0153

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

2)

HC

S5

15

10

66

0U

4U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0153

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

2)

HC

S5

15

1U

4U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0154

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

1)

HC

S5

15

10

66

0U

3U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

3G

0154

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

1)

HC

S5

15

1U

3U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

3G

0177

11EV

CD

S-R

espi

te R

esid

entia

l Car

e -

Non

apar

tmen

t, P

artic

ipan

tZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0178

11EV

CD

S-R

espi

te R

esid

entia

l Car

e -

Non

apar

tmen

t, A

genc

yZZ

Loca

l cod

e to

be

reta

ined

.P

3N

1201

11F

Res

pite

NF

- Tile

20

1H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1202

11F

Res

pite

NF

- Tile

20

2H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1203

11F

Res

pite

NF

- Tile

20

3H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1204

11F

Res

pite

NF

- Tile

20

4H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1205

11F

Res

pite

NF

- Tile

20

5H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1206

11F

Res

pite

NF

- Tile

20

6H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1207

11F

Res

pite

NF

- Tile

20

7H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1208

11F

Res

pite

NF

- Tile

20

8H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1209

11F

Res

pite

NF

- Tile

20

9H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1210

11F

Res

pite

NF

- Tile

21

0H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1211

11F

Res

pite

NF

- Tile

21

1H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3N

1212

11F

Res

pite

NF

- Tile

21

2H

CS

51

51

06

63

Dai

ly R

espi

te C

harg

eI

3G

0179

11FV

CD

S-R

espi

te N

ursi

ng F

acili

ty -

Part

icip

ant

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0180

11FV

CD

S-R

espi

te N

ursi

ng F

acili

ty -

Agen

cyZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0216

12A

Targ

eted

Cas

e M

anag

emen

t08/3

1/03

3G

0302

13A

Nur

sing

Ser

vice

s - L

VNH

CS

91

24

Nur

sing

Car

e in

the

Hom

e, b

y LV

NP

3G

0302

13A

Nur

sing

Ser

vice

s - L

VNH

CT1

00

3LP

N/L

VN s

ervi

ces

up t

o 15 m

inut

esP

3G

0303

13B

Nur

sing

Ser

vice

s - R

NH

CS

91

23

Nur

sing

Car

e in

the

Hom

e, b

y R

NP

3G

0303

13B

Nur

sing

Ser

vice

s - R

NH

CT1

00

1N

ursi

ng a

sses

smen

t/ev

alua

tion

P

3G

0303

13B

Nur

sing

Ser

vice

s - R

NH

CT1

00

2R

N s

ervi

ces

up t

o 15 m

inut

esP

3S

9800

13C

Nur

sing

Ser

vice

s by

Hig

hly

Tech

nica

l R

N,

per

hour

HC

S9

80

0TG

Hom

e Th

erap

y; p

rovi

sion

of in

fusi

on, sp

ecia

lty d

rug

adm

inis

trat

ion,

and

/or

asso

ciat

ed n

ursi

ng s

ervi

ces

and

proc

edur

es, by

hig

hly

tech

nica

l R.N

., p

er h

our

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3T1

003

13D

Nur

sing

Ser

vice

s LV

N (

Hig

hly

Tech

nica

l)H

CT1

00

3TG

LPN

/LVN

ser

vice

s, u

p to

15 m

inut

esP

3G

0717

17V

CD

S-P

AS-P

artic

ipan

tZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0719

17V

CD

S-P

AS-A

genc

yZZ

Loca

l cod

e w

ill r

emai

n fo

r bi

lling

of th

e ag

ency

fee

for

VFI

.P

3G

0921

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

HC

T20

31

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0921

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

3G

0922

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

5)

HC

T20

31

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0922

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

5)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

3G

0923

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

4)

HC

T20

31

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0923

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

4)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

3G

0924

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

3)

HC

T20

31

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0924

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

3)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

3G

0925

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

2)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

3G

0926

19A

AL R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

1)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

3G

0928

19B

AL R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

6)

HC

T20

31

U2

U2

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0929

19B

AL R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

5)

HC

T20

31

U2

U2

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0930

19B

AL R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

4)

HC

T20

31

U2

U2

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0931

19B

AL R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

3)

HC

T20

31

U2

U2

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0932

19B

AL R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

2)

HC

T20

31

U2

U2

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0933

19B

AL R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

1)

HC

T20

31

U2

U2

Assi

sted

livi

ng,

wai

ver;

per

die

mP

3G

0935

19C

Assi

sted

Liv

ing

- Per

sona

l Car

e 3

HC

T20

31

U1

Assi

sted

livi

ng, w

aive

r; p

er d

iem

P

3G

0722

27A

CM

PAS

- C

lient

Dire

cted

Ser

vice

s09/3

0/03

3G

0207

40A

Prea

sses

smen

tH

CT2

02

4S

ervi

ce a

sses

smen

t/pl

an o

f ca

re d

evel

opm

ent,

wai

ver

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

1212

41A

Med

ical

S/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1213

41A

Med

ical

S/R

equi

sitio

n Fe

es

50

0.0

0 -

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1214

41A

Med

ical

S/R

equi

sitio

n Fe

es

10

00

.00

- 1

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1215

41A

Med

ical

S/R

equi

sitio

n Fe

es

15

00

.00

- 1

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1216

41A

Med

ical

S/R

equi

sitio

n Fe

es

20

00

.00

- 2

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1217

41A

Med

ical

S/R

equi

sitio

n Fe

es

25

00

.00

- 2

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1218

41A

Med

ical

S/R

equi

sitio

n Fe

es

3

00

0.0

0 -

34

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

1219

41A

Med

ical

S/R

equi

sitio

n Fe

es

35

00

.00

- 3

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1220

41A

Med

ical

S/R

equi

sitio

n Fe

es

40

00

.00

- 4

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1221

41A

Med

ical

S/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

1222

41A

Med

ical

S/R

equi

sitio

n Fe

es

50

00

.00

- O

VER

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0623

41B

MH

Mod

s/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0624

41B

MH

Mod

s/R

equi

sitio

n Fe

es

5

00

.00

- 9

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0625

41B

MH

Mod

s/R

equi

sitio

n Fe

es

10

00

.00

- 1

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0626

41B

MH

Mod

s/R

equi

sitio

n Fe

es

1

50

0.0

0 -

19

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0627

41B

MH

Mod

s/R

equi

sitio

n Fe

es

20

00

.00

- 2

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0628

41B

MH

Mod

s/R

equi

sitio

n Fe

es

2

50

0.0

0 -

29

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0629

41B

MH

Mod

s/R

equi

sitio

n Fe

es

30

00

.00

- 3

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0630

41B

MH

Mod

s/R

equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0631

41B

MH

Mod

s/R

equi

sitio

n Fe

es

4

00

0.0

0 -

44

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


3G

0632

41B

MH

Mod

s/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0633

41B

MH

Mod

s/R

equi

sitio

n Fe

es

50

00

.00

- 5

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0634

41B

MH

Mod

s/R

equi

sitio

n Fe

es

55

00

.00

- 5

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0635

41B

MH

Mod

s/R

equi

sitio

n Fe

es

6

00

0.0

0 -

64

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0636

41B

MH

Mod

s/R

equi

sitio

n Fe

es

6

50

0.0

0 -

Ove

rZZ

Loca

l cod

e to

be

reta

ined

.P

3G

0607

41C

Spe

cific

atio

ns A

dapt

ive

Aids

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0604

41D

Spe

cific

atio

ns H

M M

ods

ZZLo

cal c

ode

to b

e re

tain

ed.

P

3G

0637

41E

Den

tal/

Req

uisi

tion

Fees

0 -

49

9.9

908/3

1/03

3G

0638

41E

Den

tal/

Req

uisi

tion

Fees

5

00

.00

- 9

99

.99

08/3

1/03

3G

0639

41E

Den

tal/

Req

uisi

tion

Fees

1

00

0.0

0 -

14

99

.99

08/3

1/03

3G

0640

41E

Den

tal/

Req

uisi

tion

Fees

15

00

.00

- 1

99

9.9

908/3

1/03

3G

0641

41E

Den

tal/

Req

uisi

tion

Fees

2

00

0.0

0 -

24

99

.99

08/3

1/03

3G

0642

41E

Den

tal/

Req

uisi

tion

Fees

2

50

0.0

0 -

29

99

.99

08/3

1/03

3G

0643

41E

Den

tal/

Req

uisi

tion

Fees

3

00

0.0

0 -

34

99

.99

08/3

1/03

3G

0644

41E

Den

tal/

Req

uisi

tion

Fees

3

50

0.0

0 -

39

99

.99

08/3

1/03

3G

0645

41E

Den

tal/

Req

uisi

tion

Fees

40

00

.00

- 4

49

9.9

908/3

1/03

3G

0646

41E

Den

tal/

Req

uisi

tion

Fees

45

00

.00

- 4

99

9.9

908/3

1/03

3G

0647

41E

Den

tal/

Req

uisi

tion

Fees

50

00

.00

- O

VER

08/3

1/03

3G

0239

53A

Tran

sitio

nal S

uppo

rt S

ervi

ces

08/3

1/03

3N

0600

5A

Den

tal S

ervi

ces

08/3

1/03

Ser

vice

Gro

up 3

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

4

Ser

vice

Gro

up

5

Ser

vice

Gro

up 4

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

4F0

100

1IC

F/M

R C

ampu

s/S

tate

- LO

C 1

C

ontr

act

Spe

cific

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

4F0

101

1IC

F/M

R C

ampu

s/S

tate

- LO

C 5

C

ontr

act

Spe

cific

10/3

1/02

4F0

102

1IC

F/M

R C

ampu

s/S

tate

- LO

C 6

C

ontr

act

Spe

cific

10/3

1/02

4F0

103

1IC

F/M

R C

ampu

s/S

tate

- LO

C 8

C

ontr

act

Spe

cific

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

4F0

104

1IC

F/M

R C

ampu

s/S

tate

-LO

C 1

4/3

0/9

6

4F0

105

1IC

F/M

R C

ampu

s/S

tate

-LO

C 5

4/3

0/9

6

4F0

106

1IC

F/M

R C

ampu

s/S

tate

-LO

C 6

4/3

0/9

6

4F0

210

1IC

F/M

R C

ampu

s/S

tate

-LO

N 1

08/3

1/03

4F0

211

1IC

F/M

R C

ampu

s/S

tate

-LO

N 5

08/3

1/03

4F0

212

1IC

F/M

R C

ampu

s/S

tate

-LO

N 6

08/3

1/03

4F0

213

1IC

F/M

R C

ampu

s/S

tate

-LO

N 8

08/3

1/03

4F0

214

1IC

F/M

R C

ampu

s/S

tate

-LO

N 9

08/3

1/03

4Z9

948

1N

onre

coup

able

Adm

inis

trat

ive

Cla

im

- Gro

up 4

ZZLo

cal c

ode

to b

e re

tain

ed.

P

4Z9

949

1R

ecou

pabl

e Ad

min

istr

ativ

e C

laim

- G

roup

4ZZ

Loca

l cod

e to

be

reta

ined

.P

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.

Ser

vice

Gro

up 5

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

5F0

108

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

8 C

ontr

act

Spe

cific

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

5F0

109

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

1 C

ontr

act

Spe

cific

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

6

5F0

110

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

5 C

ontr

act

Spe

cific

10/3

1/02

5F0

111

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

6 C

ontr

act

Spe

cific

10/3

1/02

5F0

112

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

14/3

0/9

6

5F0

113

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

54/3

0/9

6

5F0

114

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

64/3

0/9

6

5F0

115

1IC

F/M

R S

tate

/Com

mun

ity

Res

iden

tial L

OC

84/3

0/9

6

5F0

215

1IC

F/M

R S

tate

/Com

mun

ity -

LON

108/3

1/03

5F0

216

1IC

F/M

R S

tate

/Com

mun

ity -

LON

508/3

1/03

5F0

217

1IC

F/M

R S

tate

/Com

mun

ity -

LON

608/3

1/03

5F0

218

1IC

F/M

R S

tate

/Com

mun

ity -

LON

808/3

1/03

5F0

219

1IC

F/M

R S

tate

/Com

mun

ity -

LON

908/3

1/03

5Z9

958

1N

onre

coup

able

adm

inis

trat

ive

clai

m

- gro

up 5

ZZLo

cal c

ode

to b

e re

tain

ed.

P

5Z9

959

1R

ecou

pabl

e ad

min

istr

ativ

e cl

aim

- gr

oup

5ZZ

Loca

l cod

e to

be

reta

ined

.P

Ser

vice

Gro

up 6

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

C

ode

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

6F0

200

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

OC

112/3

1/96

6F0

201

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

OC

512/3

1/96

6F0

202

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

OC

612/3

1/96

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.

Ser

vice

Gro

up 5

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


6F0

203

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

OC

6A

12/3

1/96

6F0

204

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

OC

812/3

1/96

6F0

205

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

ON

10

10

0Al

l Inc

lusi

ve R

oom

& B

oard

Plu

s An

cilla

ryI

6F0

206

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

ON

50

10

0Al

l Inc

lusi

ve R

oom

& B

oard

Plu

s An

cilla

ryI

6F0

207

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

ON

60

10

0Al

l Inc

lusi

ve R

oom

& B

oard

Plu

s An

cilla

ryI

6F0

208

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

ON

80

10

0Al

l Inc

lusi

ve R

oom

& B

oard

Plu

s An

cilla

ryI

6F0

209

1IC

F/M

R N

onst

ate

Com

mun

ity

Res

iden

tial L

ON

90

10

0Al

l Inc

lusi

ve R

oom

& B

oard

Plu

s An

cilla

ryI

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E13

99

02

90

Sta

ndin

g B

oard

I

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

S8

47

00

29

0G

ait

Trai

ners

I

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E11

30

02

90

Whe

elch

air

I

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E19

00

02

90

Elec

tron

ic C

omm

unic

atio

n D

evic

eI

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E19

02

02

90

Com

mun

icat

ion

Dev

ice

I

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E10

35

02

90

Trav

el C

hair

I

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E01

86

02

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Air

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atio

n M

attr

ess

I

6G

0508

15

DM

E/Ad

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e Ai

ds -

LO

N 5

HC

E10

31

02

90

Adap

tive

Str

olle

rI

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E13

40

02

90

Ref

urbi

shed

/Mod

ified

Whe

elch

air

I

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

L39

52

02

90

Pros

thet

ic/O

rtho

ticI

6G

0508

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 5

HC

E02

50

02

90

Hos

pita

l Wat

erbe

dI

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E13

99

02

90

Sta

ndin

g B

oard

I

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

S8

47

00

29

0G

ait

Trai

ners

I

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E10

35

02

90

Trav

el C

hair

I

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E01

86

02

90

Air

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atio

n M

attr

ess

I

6G

0509

15

DM

E/Ad

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e Ai

ds -

LO

N 6

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E10

31

02

90

Adap

tive

Str

olle

rI

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E13

40

02

90

Ref

urbi

shed

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ified

Whe

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air

I

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

L39

52

02

90

Pros

thet

ic/O

rtho

ticI

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E11

30

02

90

Whe

elch

air

I

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E19

00

02

90

Elec

tron

ic C

omm

unic

atio

n D

evic

eI

6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E19

02

02

90

Com

mun

icat

ion

Dev

ice

I

Ser

vice

Gro

up 6

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

C

ode

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


6G

0509

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 6

HC

E02

50

02

90

Hos

pita

l Wat

erbe

dI

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

E11

30

02

90

Whe

elch

air

I

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

E19

00

02

90

Elec

tron

ic C

omm

unic

atio

n D

evic

eI

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

E19

02

02

90

Com

mun

icat

ion

Dev

ice

I

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

E13

99

02

90

Sta

ndin

g B

oard

I

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

S8

47

00

29

0G

ait

Trai

ners

I

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

E10

35

02

90

Trav

el C

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6G

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Air

Flot

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n M

attr

ess

I

6G

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15

DM

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aptiv

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LO

N 8

HC

E10

31

02

90

Adap

tive

Str

olle

rI

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

E13

40

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90

Ref

urbi

shed

/Mod

ified

Whe

elch

air

I

6G

0510

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 8

HC

L39

52

02

90

Pros

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ic/O

rtho

ticI

6G

0510

15

DM

E/Ad

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e Ai

ds -

LO

N 8

HC

E02

50

02

90

Hos

pita

l Wat

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dI

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E13

99

02

90

Sta

ndin

g B

oard

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

S8

47

00

29

0G

ait

Trai

ners

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E10

35

02

90

Trav

el C

hair

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E01

86

02

90

Air

Flot

atio

n M

attr

ess

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E10

31

02

90

Adap

tive

Str

olle

rI

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E13

40

02

90

Ref

urbi

shed

/Mod

ified

Whe

elch

air

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

L39

52

02

90

Pros

thet

ic/O

rtho

ticI

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E11

30

02

90

Whe

elch

air

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E19

00

02

90

Elec

tron

ic C

omm

unic

atio

n D

evic

eI

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E19

02

02

90

Com

mun

icat

ion

Dev

ice

I

6G

0511

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 9

HC

E02

50

02

90

Hos

pita

l Wat

erbe

dI

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E11

30

02

90

Whe

elch

air

I

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E19

00

02

90

Elec

tron

ic C

omm

unic

atio

n D

evic

eI

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E19

02

02

90

Com

mun

icat

ion

Dev

ice

I

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E13

99

02

90

Sta

ndin

g B

oard

I

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

S8

47

00

29

0G

ait

Trai

ners

I

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E10

35

02

90

Trav

el C

hair

I

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E01

86

02

90

Air

Flot

atio

n M

attr

ess

I

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E10

31

02

90

Adap

tive

Str

olle

rI

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E13

40

02

90

Ref

urbi

shed

/Mod

ified

Whe

elch

air

I

Ser

vice

Gro

up 6

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

C

ode

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

7

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

L39

52

02

90

Pros

thet

ic/O

rtho

ticI

6G

0512

15

DM

E/Ad

aptiv

e Ai

ds -

LO

N 1

HC

E02

50

02

90

Hos

pita

l Wat

erbe

dI

6F0

220

1T

Tran

sitio

nal A

ddon

/ N

onst

ate

Ope

rate

d LO

N 1

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

6F0

221

1T

Tran

sitio

nal A

ddon

/ N

onst

ate

Ope

rate

d LO

N 5

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

6F0

222

1T

Tran

sitio

nal A

ddon

/ N

onst

ate

Ope

rate

d LO

N 6

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

6F0

223

1T

Tran

sitio

nal A

ddon

/ N

onst

ate

Ope

rate

d LO

N 8

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

6F0

224

1T

Tran

sitio

nal A

ddon

/ N

onst

ate

Ope

rate

d LO

N 9

01

00

All I

nclu

sive

Roo

m &

Boa

rd P

lus

Anci

llary

I

Ser

vice

Gro

up 7

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

7G

0103

11

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 1

08/3

1/03

7G

0108

11

Res

pite

- Ad

ult

Fost

er C

are

- C

CAD

Lev

el08/3

1/03

7G

0120

11

Res

pite

- Pe

rson

al A

ssis

tanc

e S

ervi

ces

08/3

1/03

7G

0121

11

Res

pite

- Pe

rson

al A

ssis

tanc

e S

ervi

ces

HC

S5

15

0U

nski

lled

resp

ite c

are,

not

hos

pice

; pe

r 15 m

inut

esP

7G

0122

11

Res

pite

- S

itter

Ser

vice

sZZ

Ret

ain

loca

l cod

e un

til fur

ther

cla

rific

atio

n of

ser

vice

is

obta

ined

P

7G

0123

11

Res

pite

- Ad

ult

Day

Car

e08/3

1/03

7G

0124

11

Res

pite

- N

ursi

ng F

acili

ty

08/3

1/03

7G

0125

11

Res

pite

- H

ospi

tal

08/3

1/03

7G

0126

11

Assi

sted

Liv

ing

CC

AD R

C A

part

men

t08/3

1/03

7G

0127

11

Assi

sted

Liv

ing

CC

AD R

C

Non

apar

tmen

t08/3

1/03

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.

Ser

vice

Gro

up 6

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

C

ode

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


7+9

99

99

17

Expe

dite

d Pa

ymen

tZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0701

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Leve

l 2 -

Prio

rity

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

7G

0702

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Leve

l 1 -

Non

prio

rity

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

7G

0703

17

FC P

riorit

y Pr

ior

to 0

9/1

99

708/3

1/03

7G

0704

17

FC N

on P

riorit

y Pr

ior

to 0

9/1

99

808/3

1/03

7G

0800

18

Adul

t Fo

ster

Car

e - L

evel

108/3

1/03

7G

0803

18

Adul

t Fo

ster

Car

e - C

CAD

Lev

elH

CS

51

40

Adul

t fo

ster

car

e, p

er d

iem

P

7G

0903

19

Assi

sted

Liv

ing

- Bed

Hol

d08/3

1/03

7G

0904

19

Assi

sted

Liv

ing

- Em

erge

ncy

Car

e08/3

1/03

7G

0906

19

Assi

sted

Liv

ing

- Res

iden

tial C

are

Apar

tmen

t08/3

1/03

7G

0907

19

Assi

sted

Liv

ing

- Res

iden

tial C

are

Non

apar

tmen

t08/3

1/03

7G

1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

60

In

stal

latio

n an

d Te

stin

gP

7G

1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

61

Mon

thly

Ser

vice

Fee

(ex

clud

es in

stal

latio

n an

d te

stin

g)P

7G

1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

62

Purc

hase

Onl

yP

7C

0100

25

Hom

e D

eliv

ered

Mea

lsH

CS

51

70

Per

mea

l, in

clud

es p

repa

ratio

n an

d de

liver

yP

7C

0101

25

Hom

e D

eliv

ered

Mea

ls08/3

1/03

7C

0400

26

IHFS

Cap

ital E

xpen

ditu

res

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7C

0401

26

IHFS

Sub

sidy

Gra

nts

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7C

0402

26

SS

I Clie

nt P

aym

ent

08/3

1/03

7G

0710

27

Sup

port

ed H

ome

Livi

ng -

LON

108/3

1/03

7G

0720

27

Con

sum

er M

anag

ed P

erso

nal

Atte

ndan

t S

ervi

ces

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7G

0721

27

Clie

nt M

anag

ed A

tten

dant

Ser

vice

s -

Vouc

her

08/3

1/03

7C

0300

28

SS

PD -

Day

Car

eH

CS

51

01

Day

Car

e S

ervi

ces,

Adu

lt, p

er h

alf da

yP

7C

0301

28

SS

PD -

24

hou

r At

tend

ant

Car

e09/3

0/03

7C

0301

28

SS

PD -

24

hou

r At

tend

ant

Car

e09/3

0/03

7C

0302

28

SS

PD -

Oth

er09/3

0/03

7N

0201

28

SS

PD -

24

hou

r At

tend

ant

Car

e(T

ile 2

01

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

Ser

vice

Gro

up 7

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


7N

0202

28

SS

PD -

24

hou

r At

tend

ant

Car

e (T

ile 2

02

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0203

28

SS

PD -

24

hou

r At

tend

ant

Car

e (T

ile 2

03

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0204

28

SS

PD -

24

hou

r At

tend

ant

Car

e(T

ile 2

04

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0205

28

SS

PD -

24

hou

r At

tend

ant

Car

e (T

ile 2

05

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0206

28

SS

PD -

24

hou

r At

tend

ant

Car

e(T

ile 2

06

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0207

28

SS

PD -

24

hou

r At

tend

ant

Car

e(T

ile 2

07

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0208

28

SS

PD -

24

hou

r At

tend

ant

Car

e (T

ile 2

08

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0209

28

SS

PD -

24

hou

r At

tend

ant

Car

e(T

ile 2

09

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0210

28

SS

PD -

24

hou

r At

tend

ant

Car

e(T

ile 2

10

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0211

28

SS

PD -

24

hou

r At

tend

ant

Car

e (T

ile 2

11

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0212

28

SS

PD -

24

hou

r At

tend

ant

Car

e (T

ile 2

12

)H

CS

51

26

Atte

ndan

t C

are,

per

die

mP

7N

0500

28

Vent

ilato

r - F

ull

08/3

1/03

7N

0501

28

Vent

ilato

r - P

artia

l08/3

1/03

7N

1201

28

Res

pite

NF

- Tile

20

1H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1202

28

Res

pite

NF

- Tile

20

2H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1203

28

Res

pite

NF

- Tile

20

3H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1204

28

Res

pite

NF

- Tile

20

4H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1205

28

Res

pite

NF

- Tile

20

5H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1206

28

Res

pite

NF

- Tile

20

6H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1207

28

Res

pite

NF

- Tile

20

7H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1208

28

Res

pite

NF

- Tile

20

8H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1209

28

Res

pite

NF

- Tile

20

9H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1210

28

Res

pite

NF

- Tile

21

0H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1211

28

Res

pite

NF

- Tile

21

1H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7N

1212

28

Res

pite

NF

- Tile

21

2H

CS

51

51

Uns

kille

d R

espi

te C

are,

not

Hos

pice

, pe

r di

emP

7C

0200

29

Day

Act

ivity

/Hea

lth S

ervi

ces

(DAH

S)

HC

S5

10

1D

ay C

are

Ser

vice

s, A

dult,

per

hal

f da

yP

Ser

vice

Gro

up 7

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


7C

0201

29

Day

Act

ivity

/Hea

lth S

ervi

ces

- D

AHS

Titl

e XX

Neg

otia

ted

Rat

e08/3

1/03

7G

0129

11A

Res

pite

- Ad

ult

Day

Car

e ZZ

Ret

ain

loca

l cod

e un

til fur

ther

cla

rific

atio

n of

ser

vice

is

obta

ined

or

new

pla

ce o

f se

rvic

e fo

r ad

ult

day

care

is

appr

oved

by

CM

S.

P

7G

0130

11A

Res

pite

- H

ospi

tal

06

60

Res

pite

Car

e, g

ener

al (

Not

e: T

o cr

ossw

alk

back

to

the

loca

l cod

e, p

lace

of se

rvic

e m

ust

be a

ccur

ate.

)I

7G

0131

11B

Res

pite

- Ad

ult

Fost

er C

are

-C

CAD

Lev

el0

66

0I

7G

0141

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (C

CAD

)H

CS

51

51

U2

U1

Uns

kille

d R

espi

te C

are,

per

die

mP

7G

0148

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (C

CAD

)H

CS

51

51

U2

U2

Uns

kille

d R

espi

te C

are,

per

die

mP

7G

0155

11F

Res

pite

- N

ursi

ng F

acili

ty

06

60

Res

pite

Car

e, g

ener

al (

Not

e: T

o cr

ossw

alk

back

to

the

loca

l cod

e, p

lace

of se

rvic

e m

ust

be a

ccur

ate.

)I

7G

0740

17C

PAS

Fam

ily C

are

- Lev

el 2

(Prio

rity)

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

7G

0741

17C

PAS

Fam

ily C

are

- Lev

el 1

(N

onpr

iorit

y)H

CS

51

25

Atte

ndan

t C

are

Ser

vice

s, p

er 1

5 m

inut

esP

7G

0745

17C

VPA

S F

amily

Car

e - C

DS

-Par

ticip

ant

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7G

0746

17C

VPA

S F

amily

Car

e Le

vel 1

(Non

prio

rity)

C

DS

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7G

0747

17C

VPA

S F

amily

Car

e - C

DS

- Ag

ency

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7G

0742

17D

PAS

Com

mun

ity A

tten

dant

Ser

vice

s (1

92

9B

) - L

evel

2 (

Prio

rity)

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

7G

0743

17D

PAS

Com

mun

ity A

tten

dant

Ser

vice

s (1

92

9B

) - L

evel

1 (

Non

prio

rity)

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

7G

0748

17D

VPA

S C

omm

unity

Att

enda

nt S

ervi

ces

Leve

l 1 (

Non

prio

rity)

CD

SZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0749

17D

VPA

S C

omm

unity

Att

enda

nt S

ervi

ces

Leve

l 2 (

prio

rity)

CD

SZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0750

17D

VPA

S C

omm

unity

Att

enda

nt S

ervi

ces

- C

DS

- Ag

ency

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7G

0717

17V

CD

S-P

AS-P

artic

ipan

tZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0718

17V

PAS

Lev

el 1

(N

onpr

iorit

y) C

DS

ZZLo

cal c

ode

to b

e re

tain

ed.

P

7G

0719

17V

CD

S-P

AS-A

genc

yZZ

Loca

l cod

e w

ill r

emai

n fo

r bi

lling

of th

e ag

ency

fee

for

VFI

.P

7G

0920

19A

Assi

sted

Liv

ing

- Res

iden

tial C

are

Apar

tmen

t08/3

1/03

7G

0927

19B

Assi

sted

Liv

ing

- Res

iden

tial C

are

Non

apar

tmen

t08/3

1/03

Ser

vice

Gro

up 7

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


7G

0936

19D

Assi

sted

Liv

ing

- Em

erge

ncy

Car

e08/3

1/03

7G

0934

19H

Assi

sted

Liv

ing

- Bed

Hol

d -

Apar

tmen

t08/3

1/03

7G

0943

19I

Res

iden

tial C

are

Bed

Hol

d -

Non

apar

tmen

t - T

itle

XXZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0944

19J

Res

iden

tial C

are

- Bed

Hol

d -

Apar

tmen

t - T

itle

XXZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0944

19J

Res

iden

tial C

are

- Bed

Hol

d -

Apar

tmen

t - T

itle

XXZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0944

19J

Res

iden

tial C

are

- Bed

Hol

d -

Apar

tmen

t - T

itle

XXZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0944

19J

Res

iden

tial C

are

- Bed

Hol

d -

Apar

tmen

t - T

itle

XXZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0945

19K

Res

iden

tial C

are

- Apa

rtm

ent

- Ti

tle X

XH

CT1

02

0U

2U

1Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

7G

0946

19L

Res

iden

tial C

are

- Non

apar

tmen

t -

Title

XX

HC

T10

20

U2

U2

Pers

onal

car

e se

rvic

es, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

7G

0947

19M

Res

iden

tial E

mer

genc

y C

are

- Titl

e XX

- A

part

men

tH

CT1

02

0Pe

rson

al c

are

serv

ices

; pe

r di

emP

7G

0948

19N

Res

iden

tial C

are

- Roo

m &

Boa

rd -

Non

apar

tmen

tZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0949

19O

Res

iden

tial C

are

- Roo

m &

Boa

rd -

Apar

tmen

tZZ

Loca

l cod

e to

be

reta

ined

.P

7G

0722

27A

CM

PAS

- C

lient

Dire

cted

Ser

vice

sZZ

Loca

l cod

e to

be

reta

ined

.P

7C

0303

28A

SS

PD -

Cas

e M

anag

emen

tH

CT1

01

6C

ase

Man

agem

ent,

eac

h 15 m

inut

esP

7C

0202

29A

Day

Act

ivity

/Hea

lth S

ervi

ces

(DAH

S)

- Titl

e 2

0H

CS

51

01

Day

Car

e S

ervi

ces,

Adu

lt, p

er h

alf da

yP

Ser

vice

Gro

up 7

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

8

Ser

vice

Gro

up 8

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

8T0

100

1R

outin

e in

Hom

e C

are

HC

T20

42

06

51

Hos

pice

Rou

tine

Hom

e C

are;

per

die

mI

8T0

200

1C

ontin

uous

Hom

e C

are

HC

T20

43

06

52

Hos

pice

Con

tinuo

us H

ome

Car

e; p

er h

our

I

8T0

300

1In

patie

nt R

espi

te C

are

HC

T20

44

06

55

Hos

pice

Inpa

tient

Res

pite

Car

eI

8T0

301

1G

ener

al In

patie

nt C

are

HC

T20

45

06

56

Hos

pice

Gen

eral

Inpa

tient

Car

e (n

onre

spite

)I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C3

64

89

06

57

Plac

emen

t ce

ntra

l ven

ous

cath

eter

; pe

rcut

ansi

ous,

ove

r ag

e tw

oI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C3

65

33

06

57

inse

rtio

n of

impl

anta

ble

veno

us a

cces

s po

rt w

ith o

r with

out

subc

utan

eous

res

ervo

irI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C4

90

80

06

57

Perit

oneo

cent

esis

, ab

dom

inal

par

acen

tesi

s or

per

itone

al

lava

ge (di

agno

stic

or

ther

apeu

tic) in

itial

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C7

10

10

06

57

Rad

iolo

gic

exam

inat

ion;

che

st; si

ngle

vie

w fro

ntal

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C7

40

00

06

57

Rad

iolo

gic

exam

inat

ion;

abd

omen

; si

ngle

ant

erop

oste

rior

view

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C7

40

20

06

57

Rad

iolo

gic

exam

inat

ion;

abd

omen

; co

mpl

ete,

incl

udin

g de

cubi

tus

and/

or e

rect

vie

ws

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C8

50

23

06

57

Blo

od c

ount

; he

mog

ram

and

pla

tele

t co

unt,

aut

o, a

nd

man

ual d

iffer

entia

l WB

C c

ount

(C

BC

)I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

01

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

new

pat

ient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

02

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

new

pat

ient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

03

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

new

pat

ient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

04

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

new

pat

ient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

05

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

new

pat

ient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

11

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

n es

tabl

ishe

d pa

tient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

12

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

n es

tabl

ishe

d pa

tient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

13

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

n es

tabl

ishe

d pa

tient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

14

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

n es

tabl

ishe

d pa

tient

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

15

06

57

Offic

e or

oth

er o

utpa

tient

vis

it fo

r th

e ev

alua

tion

and

man

agem

ent

of a

n es

tabl

ishe

d pa

tient

I

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

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for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

21

06

57

Initi

al h

ospi

tal c

are,

per

day

for

the

eva

luat

ion

and

man

agem

ent

of p

atie

nt; lo

w c

ompl

exity

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

22

06

57

Initi

al h

ospi

tal c

are,

per

day

for

the

eva

luat

ion

and

man

agem

ent

of p

atie

nt; m

oder

ate

com

plex

ityI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

23

06

57

Initi

al h

ospi

tal c

are,

per

day

for

the

eva

luat

ion

and

man

agem

ent

of p

atie

nt; hi

gh c

ompl

exity

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

31

06

57

Sub

sequ

ent

hosp

ital c

are,

per

day

, for

the

eva

luat

ion

and

man

agem

ent

of a

pat

ient

with

tw

o of

thr

ee k

ey

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

32

06

57

Sub

sequ

ent

hosp

ital c

are,

per

day

, for

the

eva

luat

ion

and

man

agem

ent

of a

pat

ient

with

tw

o of

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ee k

ey

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

33

06

57

Sub

sequ

ent

hosp

ital c

are,

per

day

, for

the

eva

luat

ion

and

man

agem

ent

of a

pat

ient

with

tw

o of

thr

ee k

ey

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

38

06

57

Hos

pita

l dis

char

ge d

ay m

anag

emen

t; 3

0 m

inut

es o

r le

ssI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

39

06

57

Hos

pita

l dis

char

ge d

ay m

anag

emen

t; m

ore

than

30

min

utes

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

51

06

57

Initi

al in

patie

nt c

onsu

ltatio

n fo

r a n

ew/e

stab

lishe

d pa

tient

, w

hich

req

uire

s th

ree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

52

06

57

Initi

al in

patie

nt c

onsu

ltatio

n fo

r a n

ew/e

stab

lishe

d pa

tient

, w

hich

req

uire

s th

ree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

53

06

57

Initi

al in

patie

nt c

onsu

ltatio

n fo

r a n

ew/e

stab

lishe

d pa

tient

, w

hich

req

uire

s th

ree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

54

06

57

Initi

al in

patie

nt c

onsu

ltatio

n fo

r a n

ew/e

stab

lishe

d pa

tient

, w

hich

req

uire

s th

ree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

55

06

57

Initi

al in

patie

nt c

onsu

ltatio

n fo

r a n

ew/e

stab

lishe

d pa

tient

, w

hich

req

uire

s th

ree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

61

06

57

Follo

w-u

p in

patie

nt c

onsu

ltatio

n fo

r an

esta

blis

hed

patie

nt

requ

iring

tw

o of

thr

ee k

ey c

ompo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

62

06

57

Follo

w-u

p in

patie

nt c

onsu

ltatio

n fo

r an

esta

blis

hed

patie

nt

requ

iring

tw

o of

thr

ee k

ey c

ompo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

63

06

57

Follo

w-u

p in

patie

nt c

onsu

ltatio

n fo

r an

esta

blis

hed

patie

nt

requ

iring

tw

o of

thr

ee k

ey c

ompo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

01

06

57

Eval

uatio

n an

d m

anag

emen

t of n

ew o

r est

ablis

hed

patie

nt

invo

lvin

g an

nual

nur

sing

fac

ility

ass

essm

ent

with

thr

ee

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

02

06

57

Eval

uatio

n an

d m

anag

emen

t of n

ew o

r est

ablis

hed

patie

nt

invo

lvin

g nu

rsin

g fa

cilit

y as

sess

men

t w

ith t

hree

co

mpo

nent

s

I

Ser

vice

Gro

up 8

- Lo

ng T

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Car

e B

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Cro

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Tabl

eTe

xas

LTC

Loc

al C

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Nat

iona

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es

Ser

vice

G

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Bill

C

ode

Ser

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C

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Bill

Cod

e D

escr

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dure

C

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Qua

lifie

r

HC

PC

S

Cod

eC

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Cod

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2M

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3M

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4D

efin

itio

n/C

omm

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End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

03

06

57

Eval

uatio

n an

d m

anag

emen

t of n

ew o

r est

ablis

hed

patie

nt

invo

lvin

g an

nual

nur

sing

fac

ility

at

initi

al a

dmit/

read

mit

with

thr

ee c

ompo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

11

06

57

Sub

sequ

ent n

ursi

ng fa

cilit

y, p

er d

ay, f

or th

e ev

alua

tion

and

man

agem

ent o

f new

or e

stab

lishe

d pa

tient

requ

iring

two

of

thre

e co

mpo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

12

06

57

Sub

sequ

ent n

ursi

ng fa

cilit

y, p

er d

ay, f

or th

e ev

alua

tion

and

man

agem

ent o

f new

or e

stab

lishe

d pa

tient

requ

iring

two

of

thre

e co

mpo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

13

06

57

Sub

sequ

ent n

ursi

ng fa

cilit

y, p

er d

ay, f

or th

e ev

alua

tion

and

man

agem

ent o

f new

or e

stab

lishe

d pa

tient

requ

iring

two

of

thre

e co

mpo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

21

06

57

Dom

icili

ary

or r

est

hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

a n

ew p

atie

nt r

equi

ring

thre

e co

mpo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

22

06

57

Dom

icili

ary

or r

est

hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

a n

ew p

atie

nt r

equi

ring

thre

e co

mpo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

23

06

57

Dom

icili

ary

or r

est

hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

a n

ew p

atie

nt r

equi

ring

thre

e co

mpo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

31

06

57

Dom

icili

ary

or r

est

hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

an

esta

blis

hed

patie

nt r

equi

ring

two

of

thre

e co

mpo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

32

06

57

Dom

icili

ary

or r

est

hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

an

esta

blis

hed

patie

nt r

equi

ring

two

of

thre

e co

mpo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

33

06

57

Dom

icili

ary

or r

est

hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

an

esta

blis

hed

patie

nt r

equi

ring

two

of

thre

e co

mpo

nent

s

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

41

06

57

Hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

a n

ew

patie

nt, re

quiri

ng t

hree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

42

06

57

Hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

a n

ew

patie

nt, re

quiri

ng t

hree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

43

06

57

Hom

e vi

sit

for

the

eval

uatio

n an

d m

anag

emen

t of

a n

ew

patie

nt, re

quiri

ng t

hree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

45

06

57

Hom

e vi

sit

esta

blis

hed

patie

nt, th

ree

key

com

pone

nt; 75

min

utes

with

pat

ient

and

/or

fam

ilyI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

47

06

57

Hom

e vi

sit

esta

blis

hed

patie

nt, th

ree

key

com

pone

nt; 15

min

utes

with

pat

ient

and

/or

fam

ilyI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

48

06

57

Hom

e vi

sit

esta

blis

hed

patie

nt, th

ree

key

com

pone

nt; 25

min

utes

with

pat

ient

and

/or

fam

ilyI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

49

06

57

Hom

e vi

sit

esta

blis

hed

patie

nt, th

ree

key

com

pone

nt; 40

min

utes

with

pat

ient

and

/or

fam

ilyI

Ser

vice

Gro

up 8

- Lo

ng T

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Car

e B

ill C

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Cro

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Tabl

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Loc

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Nat

iona

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es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

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Bill

Cod

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escr

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onP

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C

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Qua

lifie

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HC

PC

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Cod

eC

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Cod

eR

even

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1M

odifi

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2M

odifi

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3M

odifi

er

4D

efin

itio

n/C

omm

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End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

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: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

50

06

57

Hom

e vi

sit

esta

blis

hed

patie

nt, th

ree

key

com

pone

nt; 60

min

utes

with

pat

ient

and

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fam

ilyI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

52

06

57

Hom

e vi

sit

for

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eval

uatio

n an

d m

anag

emen

t of

an

esta

blis

hed

patie

nt, r

equi

ring

two

of th

ree

key

com

pone

nts

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

54

06

57

Prol

onge

d ph

ysic

ian

in t

he o

ffic

e or

oth

er o

utpa

tient

se

ttin

g, firs

t ho

urI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

55

06

57

Prol

onge

d ph

ysic

ian

in t

he o

ffic

e or

oth

er o

utpa

tient

se

ttin

g, r

equi

ring

cont

act

beyo

nd, ea

ch a

dditi

onal

30

min

utes

I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

56

06

57

Prol

onge

d ph

ysic

ian

visi

t, in

patie

nt s

ettin

g, firs

t ho

urI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

57

06

57

Prol

onge

d ph

ysic

ian

visi

t, in

patie

nt s

ettin

g, e

ach

addi

tiona

l 3

0 m

inut

esI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

41

06

57

Offic

e C

onsu

lt N

ew/E

stab

lishe

d Pa

tient

, R

equi

res

Thre

e K

ey C

ompo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

42

06

57

Offic

e C

onsu

lt N

ew/E

stab

lishe

d Pa

tient

, R

equi

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Thre

e K

ey C

ompo

nent

sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

43

06

57

Offic

e C

onsu

lt N

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stab

lishe

d Pa

tient

, R

equi

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Thre

e K

ey C

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sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

44

06

57

Offic

e C

onsu

lt N

ew/E

stab

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, R

equi

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Thre

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ey C

ompo

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sI

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

93

44

06

57

Hom

e Vi

sit

New

Pat

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I

8T0

302

30

Phys

icia

n D

irect

Car

eH

C9

92

45

06

57

Offic

e C

onsu

lt N

ew/E

stab

lishe

d Pa

tient

, R

equi

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Thre

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ey C

ompo

nent

sI

8T0

303

30

Phys

icia

n D

irect

Car

e-S

peci

al08/3

1/0

3

8F0

100

31

ICF/

MR

Cam

pus/

Sta

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Con

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8H

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8F0

100

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8F0

101

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Con

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2

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Sta

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Con

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2

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8H

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I

8F0

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ICF/

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LOC

8

Con

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8F0

108

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8F0

108

31

ICF/

MR

Sta

te/C

omm

unity

R

esid

entia

l LO

C 8

Con

trac

t S

peci

ficH

CT2

04

60

65

9H

ospi

ce L

TC R

oom

& B

oard

I

Ser

vice

Gro

up 8

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


8F0

109

31

ICF/

MR

Sta

te/C

omm

unity

R

esid

entia

l LO

C 1

Con

trac

t S

peci

ficH

CT2

04

60

65

8H

ospi

ce L

TC R

oom

& B

oard

I

8F0

109

31

ICF/

MR

Sta

te/C

omm

unity

R

esid

entia

l LO

C 1

Con

trac

t S

peci

ficH

CT2

04

60

65

9H

ospi

ce L

TC R

oom

& B

oard

I

8F0

110

31

ICF-

MR

Sta

te C

omm

unity

Res

iden

tial

LOC

5 C

ontr

act

Spe

cific

10/3

1/0

2

8F0

111

31

ICF-

MR

Sta

te C

omm

unity

Res

iden

tial

LOC

6 C

ontr

act

Spe

cific

10/3

1/0

2

8F0

113

31

ICF-

MR

Sta

te C

omm

unity

R

esid

entia

l (LO

C 5

)04/3

0/9

6

8F0

114

31

ICF-

MR

Sta

te C

omm

unity

Res

iden

tial

(LO

C 6

)04/3

0/96

8F0

205

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 1

)H

CT2

04

60

65

8H

ospi

ce L

TC R

oom

& B

oard

I

8F0

205

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 1

)H

CT2

04

60

65

9O

ther

(H

ospi

ce L

TC R

oom

& B

oard

)I

8F0

206

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 5

)H

CT2

04

60

65

8H

ospi

ce L

TC R

oom

& B

oard

I

8F0

206

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 5

)H

CT2

04

60

65

9O

ther

(H

ospi

ce L

TC R

oom

& B

oard

)I

8F0

207

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 6

)H

CT2

04

60

65

8H

ospi

ce L

TC R

oom

& B

oard

I

8F0

207

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 6

)H

CT2

04

60

65

9O

ther

(H

ospi

ce L

TC R

oom

& B

oard

)I

8F0

208

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 8

)H

CT2

04

60

65

8H

ospi

ce L

TC R

oom

& B

oard

I

8F0

208

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 8

)H

CT2

04

60

65

9O

ther

(H

ospi

ce L

TC R

oom

& B

oard

)I

8F0

209

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 9

)H

CT2

04

60

65

8H

ospi

ce L

TC R

oom

& B

oard

I

8F0

209

31

ICF-

MR

Non

-Sta

te C

omm

unity

R

esid

entia

l (LO

N 9

)H

CT2

04

60

65

9O

ther

(H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0201

31

Nur

sing

Fac

ility

, Ti

le 2

01

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0201

31

Nur

sing

Fac

ility

, Ti

le 2

01

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0202

31

Nur

sing

Fac

ility

, Ti

le 2

02

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0202

31

Nur

sing

Fac

ility

, Ti

le 2

02

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0203

31

Nur

sing

Fac

ility

, Ti

le 2

03

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0203

31

Nur

sing

Fac

ility

, Ti

le 2

03

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0204

31

Nur

sing

Fac

ility

, Ti

le 2

04

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

Ser

vice

Gro

up 8

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


8N

0204

31

Nur

sing

Fac

ility

, Ti

le 2

04

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0205

31

Nur

sing

Fac

ility

, Ti

le 2

05

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0205

31

Nur

sing

Fac

ility

, Ti

le 2

05

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0206

31

Nur

sing

Fac

ility

, Ti

le 2

06

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0206

31

Nur

sing

Fac

ility

, Ti

le 2

06

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0207

31

Nur

sing

Fac

ility

, Ti

le 2

07

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0207

31

Nur

sing

Fac

ility

, Ti

le 2

07

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0208

31

Nur

sing

Fac

ility

, Ti

le 2

08

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0208

31

Nur

sing

Fac

ility

, Ti

le 2

08

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0209

31

Nur

sing

Fac

ility

, Ti

le 2

09

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0209

31

Nur

sing

Fac

ility

, Ti

le 2

09

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0210

31

Nur

sing

Fac

ility

, Ti

le 2

10

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0210

31

Nur

sing

Fac

ility

, Ti

le 2

10

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0211

31

Nur

sing

Fac

ility

, Ti

le 2

11

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0211

31

Nur

sing

Fac

ility

, Ti

le 2

11

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8N

0212

31

Nur

sing

Fac

ility

, Ti

le 2

12

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8N

0212

31

Nur

sing

Fac

ility

, Ti

le 2

12

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

201

31

VA D

aily

Car

e - T

ile 2

01

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

201

31

VA D

aily

Car

e - T

ile 2

01

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

202

31

VA D

aily

Car

e - T

ile 2

02

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

202

31

VA D

aily

Car

e - T

ile 2

02

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

203

31

VA D

aily

Car

e - T

ile 2

03

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

203

31

VA D

aily

Car

e - T

ile 2

03

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

204

31

VA D

aily

Car

e - T

ile 2

04

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

204

31

VA D

aily

Car

e - T

ile 2

04

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

205

31

VA D

aily

Car

e - T

ile 2

05

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

205

31

VA D

aily

Car

e - T

ile 2

05

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

206

31

VA D

aily

Car

e - T

ile 2

06

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

206

31

VA D

aily

Car

e - T

ile 2

06

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

207

31

VA D

aily

Car

e - T

ile 2

07

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

207

31

VA D

aily

Car

e - T

ile 2

07

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

208

31

VA D

aily

Car

e - T

ile 2

08

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

Ser

vice

Gro

up 8

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

9

8V0

208

31

VA D

aily

Car

e - T

ile 2

08

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

209

31

VA D

aily

Car

e - T

ile 2

09

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

209

31

VA D

aily

Car

e - T

ile 2

09

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

210

31

VA D

aily

Car

e - T

ile 2

10

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

210

31

VA D

aily

Car

e - T

ile 2

10

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

211

31

VA D

aily

Car

e - T

ile 2

11

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

211

31

VA D

aily

Car

e - T

ile 2

11

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8V0

212

31

VA D

aily

Car

e - T

ile 2

12

HC

T20

46

06

58

Hos

pice

LTC

Roo

m &

Boa

rdI

8V0

212

31

VA D

aily

Car

e - T

ile 2

12

HC

T20

46

06

59

Oth

er (H

ospi

ce L

TC R

oom

& B

oard

)I

8T0

400

32

Med

icar

e Ph

arm

acy

Coi

nsur

ance

ZZLo

cal c

ode

to b

e re

tain

ed.

P

8T0

401

33

Med

icar

e R

espi

te C

oins

uran

ceZZ

Loca

l cod

e to

be

reta

ined

.P

Ser

vice

Gro

up 9

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

9N

0500

4Ve

ntila

tor

- Ful

l08/3

1/03

9N

0501

4Ve

ntila

tor

- Par

tial

08/3

1/03

9N

0700

6N

urse

’s A

id T

rain

ing

- Tra

inin

g C

ours

e08/3

1/03

9N

0701

6N

urse

’s A

id T

rain

ing

- Ski

lls T

est

- Pa

ssed

08/3

1/03

9N

0702

6N

urse

’s A

id T

rain

ing

- Ski

lls T

est

- Fa

iled

08/3

1/03

9N

0703

6N

urse

’s A

id T

rain

ing

- Writ

ten

Test

- Pa

ssed

08/3

1/03

9N

0704

6N

urse

’s A

id T

rain

ing

- Writ

ten

Test

- Fa

iled

08/3

1/03

9N

0705

6N

urse

’s A

id T

rain

ing-

Ora

l Tes

t -

Pass

ed08/3

1/03

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.

Ser

vice

Gro

up 8

- Lo

ng T

erm

Car

e B

ill C

ode

Cro

ssw

alk

Tabl

eTe

xas

LTC

Loc

al C

odes

Nat

iona

l Cod

es

Ser

vice

G

roup

Bill

C

ode

Ser

vice

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Typ

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End

Dat

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Typ

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File

: I=

837I;

P=837P

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11

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End

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Typ

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File

: I=

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16

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Typ

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: I=

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16

G0300

13

Nur

sing

- R

NH

CT1

00

2TD

RN

ser

vice

s up

to

15 m

inut

esP

16

G0301

13

Nur

sing

- LV

NH

CS

91

24

TEN

ursi

ng C

are

in t

he H

ome,

by

LVN

P

16

G0301

13

Nur

sing

- LV

NH

CT1

00

3TE

LPN

/LVN

ser

vice

s up

to

15 m

inut

esP

16

G0500

15

Adap

tive

Aids

ADD

99

99

Uns

peci

fied

Adju

nctiv

e Pr

oced

ure,

by

Rep

ort

D

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

03

9Ve

hicl

e M

odifi

catio

ns, w

aive

r; p

er s

ervi

ceP

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE0

63

6M

ultip

ositi

onal

pat

ient

sup

port

sys

tem

, with

inte

grat

ed li

ft,

patie

ntP

16

G0500

15

DM

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aptiv

e Ai

dsH

CE1

03

1R

olla

bout

Cha

ir, a

ny a

nd a

ll ty

pes

with

cas

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5 in

ches

or

grea

ter

P

16

G0500

15

DM

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aptiv

e Ai

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CE1

13

0S

tand

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Whe

elch

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fixe

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ay d

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16

G0500

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39

9D

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edic

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quip

men

t, M

isce

llane

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P

16

G0500

15

DM

E/Ad

aptiv

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ds09/2

8/03

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

90

0S

ynth

esiz

ed S

peec

h Au

gmen

tativ

e C

omm

unic

atio

n D

evic

e w

ith D

ynam

ic D

ispl

ayP

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

90

2C

omm

unic

atio

n B

oard

, N

on-e

lect

roni

c Au

gmen

tativ

e or

Al

tern

ativ

e C

omm

unic

atio

nP

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CS

51

99

Pers

onal

Car

e Ite

m, N

OS

, ea

chP

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

02

9S

peci

aliz

ed m

edic

al e

quip

men

t, n

ot o

ther

wis

e sp

ecifi

ed,

wai

ver

P

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

02

8S

peci

aliz

ed S

uppl

y, N

ot o

ther

wis

e sp

ecifi

ed, w

aive

rP

16

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

00

3N

onem

erge

ncy

tran

spor

tatio

n; e

ncou

nter

/trip

P

16

G0608

16

Hom

e M

odifi

catio

nsH

CS

51

65

Hom

e M

odifi

catio

ns; pe

r se

rvic

eP

16

G0730

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Res

iden

tial

HC

T20

16

Hab

ilita

tion,

res

iden

tial,

wai

ver;

per

15 m

inut

es.

P

16

G0731

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Cho

re08/3

1/03

16

G0900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 6

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

r; p

er d

iem

P

16

G0908

19

Assi

sted

Liv

ing

(Les

s th

an 2

4 h

ours

)08/3

1/03

16

G0909

19

AL R

esid

entia

l Car

e - H

abili

tatio

n (2

4

hour

s)08/3

1/03

16

G1100

21

Pres

crip

tions

- di

scon

tinue

d08/3

1/03

Ser

vice

Gro

up 1

6 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


16

G0720

27

Con

sum

er M

anag

ed P

erso

nal

Atte

ndan

t S

ervi

ces

ZZLo

cal c

ode

to b

e re

tain

ed.

P

16

G0721

27

Clie

nt M

anag

ed A

tten

dant

Ser

vice

s -

Vouc

her

08/3

1/03

16

U0210

34

DIE

TAR

Y S

ERVI

CES

HC

S9

46

5D

iabe

tic m

anag

emen

t, d

ietic

ian

visi

tP

16

U0210

34

DIE

TAR

Y S

ERVI

CES

HC

S9

47

0N

utrit

iona

l cou

nsel

ing,

die

ticia

n vi

sit

P

16

U0210

34

DIE

TAR

Y S

ERVI

CES

HC

97

80

2M

edic

al n

utrit

ion

ther

apy,

initi

al a

sses

smen

t an

d in

terv

entio

n, e

ach

15 m

inut

esP

16

G0202

40

Prea

sses

smen

t08/3

1/03

16

G0230

43

Beh

avio

r C

omm

unic

atio

n S

peci

alis

tZZ

Loca

l cod

e to

be

reta

ined

.P

16

G0231

44

Orie

ntat

ion

and

mob

ility

HC

97

53

7C

omm

unity

/wor

k re

inte

grat

ion

trai

ning

(th

at is

, sh

oppi

ng,

tran

spor

tatio

n, m

oney

man

agem

ent,

avo

catio

nal a

ctiv

ities

an

d/or

wor

k en

viro

nmen

t/m

odifi

catio

n an

alys

is, w

ork

task

an

alys

is), d

irect

one

on

one

cont

act

by p

rovi

der,

eac

h 15

min

utes

P

16

G0231

44

Orie

ntat

ion

and

mob

ility

HC

97

53

5S

elf c

are/

hom

e m

anag

emen

t tra

inin

g (t

hat i

s, a

ctiv

ities

of

daily

livi

ng a

nd c

ompe

nsat

ory

trai

ning

, m

eal p

repa

ratio

n,

safe

ty p

roce

dure

s, a

nd in

stru

ctio

n in

use

of ad

aptiv

e eq

uipm

ent)

dire

ct o

ne o

n on

e co

ntac

t by

prov

ider

, eac

h 15

min

utes

P

16

G0232

45

Inte

rven

orH

C9

75

35

Sel

f car

e/ho

me

man

agem

ent t

rain

ing

(tha

t is,

act

iviti

es o

f da

ily li

ving

and

com

pens

ator

y tr

aini

ng, m

eal p

repa

ratio

n,

safe

ty p

roce

dure

s, a

nd in

stru

ctio

n in

use

of ad

aptiv

e eq

uipm

ent)

dire

ct o

ne o

n on

e co

ntac

t by

prov

ider

, eac

h 15

min

utes

P

16

G0236

45

Inte

rven

or C

DS

- Ag

ency

ZZLo

cal c

ode

to b

e re

tain

ed.

P

16

G0238

53

Tran

sitio

nal S

ervi

ces

08/3

1/03

16

G0119

11A

Res

pite

- O

ut-o

f-Hom

e - C

DS

08/3

1/03

16

G0128

11A

Res

pite

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ut-o

f-Hom

eH

CS

51

51

Uns

kille

d R

espi

te C

are,

per

die

mP

16

G0170

11A

Out

-of-H

ome

Res

pite

CD

SZZ

Loca

l cod

e to

be

reta

ined

.P

16

G0216

12A

Targ

eted

Cas

e M

anag

emen

t08/3

1/03

16

S9800

13C

Nur

sing

Ser

vice

s by

Hig

hly

Tech

nica

l R

N,

per

hour

HC

S9

80

0TG

Hom

e Th

erap

y; p

rovi

sion

of in

fusi

on, sp

ecia

lty d

rug

adm

inis

trat

ion,

and

/or

asso

ciat

ed n

ursi

ng s

ervi

ces

and

proc

edur

es, by

hig

hly

tech

nica

l R.N

., p

er h

our

P

16

T1003

13D

Nur

sing

Ser

vice

s LV

NH

CT1

00

3TG

LPN

/LVN

ser

vice

s, u

p to

15 m

inut

esP

16

G0744

17E

PAS

Cho

reH

CS

51

20

Cho

re S

ervi

ces,

per

15 m

inut

esP

16

G0717

17V

CD

S-P

AS-P

artic

ipan

tZZ

Loca

l cod

e to

be

reta

ined

.P

16

G0718

17V

PAS

Lev

el 1

(N

onpr

iorit

y) C

DS

ZZLo

cal c

ode

to b

e re

tain

ed.

P

16

G0719

17V

CD

S-P

AS-A

genc

yZZ

Loca

l cod

e w

ill r

emai

n fo

r bi

lling

of th

e ag

ency

fee

for

VFI

.P

Ser

vice

Gro

up 1

6 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

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atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

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C

ode

Qua

lifie

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HC

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S

Cod

eC

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Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


16

G0937

19E

Assi

sted

Liv

ing

- Hab

ilita

tion

24

hou

rH

CT2

03

3U

1R

esid

entia

l car

e, n

ot o

ther

wis

e sp

ecifi

ed (N

OS

), w

aive

r;

per

diem

P

16

G0938

19F

Assi

sted

Liv

ing

- Hab

ilita

tion

Less

Th

an 2

4 h

our

HC

T10

20

Pers

onal

car

e se

rvic

es, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

16

G0938

19F

Assi

sted

Liv

ing

- Hab

ilita

tion

Less

Th

an 2

4 h

our

02

40

A fla

t ra

te c

harg

e in

curr

ed o

n ei

ther

a d

aily

bas

is o

r to

tal

stay

bas

is for

anc

illar

y se

rvic

es o

nly

I

16

G0722

27A

CM

PAS

- C

lient

Dire

cted

Ser

vice

sZZ

Loca

l cod

e to

be

reta

ined

.P

16

G0207

40A

Prea

sses

smen

tH

CT2

02

4S

ervi

ce a

sses

smen

t/pl

an o

f ca

re d

evel

opm

ent,

wai

ver

P

16

G0637

41E

Den

tal/

Req

uisi

tion

Fees

0 -

49

9.9

908/3

1/03

16

G0638

41E

Den

tal/

Req

uisi

tion

Fees

5

00

.00

- 9

99

.99

08/3

1/03

16

G0639

41E

Den

tal/

Req

uisi

tion

Fees

1

00

0.0

0 -

14

99

.99

08/3

1/03

16

G0640

41E

Den

tal/

Req

uisi

tion

Fees

1

50

0.0

0 -

19

99

.99

08/3

1/03

16

G0641

41E

Den

tal/

Req

uisi

tion

Fees

2

00

0.0

0 -

24

99

.99

08/3

1/03

16

G0642

41E

Den

tal/

Req

uisi

tion

Fees

2

50

0.0

0 -

29

99

.99

08/3

1/03

16

G0643

41E

Den

tal/

Req

uisi

tion

Fees

30

00

.00

- 3

49

9.9

908/3

1/03

16

G0644

41E

Den

tal/

Req

uisi

tion

Fees

3

50

0.0

0 -

39

99

.99

08/3

1/03

16

G0645

41E

Den

tal/

Req

uisi

tion

Fees

40

00

.00

- 4

49

9.9

908/3

1/03

16

G0646

41E

Den

tal/

Req

uisi

tion

Fees

4

50

0.0

0 -

49

99

.99

08/3

1/03

16

G0647

41E

Den

tal/

Req

uisi

tion

Fees

5

00

0.0

0 -

OVE

R08/3

1/03

16

G0239

53A

Tran

sitio

nal S

uppo

rt S

ervi

ces

08/3

1/03

16

N0600

5A

Den

tal S

ervi

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08/3

1/03

Ser

vice

Gro

up 1

6 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

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atio

nal C

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Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

up

17

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

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roce

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C

ode

Qua

lifie

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HC

PC

S

Cod

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PT

Cod

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even

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Cod

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odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

17

G0400

7O

ccup

atio

nal T

hera

pyH

CG

01

52

GO

Ser

vice

s of

an

occu

patio

nal t

hera

pist

in a

hom

e he

alth

se

ttin

g; p

er 1

5 m

inut

esP

17

G0401

8Ph

ysic

al T

hera

pyH

CG

01

51

GP

Ser

vice

s of

a p

hysi

cal t

hera

pist

in a

hom

e he

alth

set

ting;

pe

r 1

5 m

inut

esP

17

G0402

9S

peec

h Th

erap

yH

CG

01

53

GN

Spe

ech

or la

ngua

ge p

atho

logi

st in

hom

e he

alth

set

ting;

per

1

5 m

inut

esP

17

S0101

10

Hab

ilita

tion

- AD

LsH

CT2

02

1U

5D

ay h

abili

tatio

n, w

aive

r; p

er 1

5 m

inut

es.

P

17

G0101

11

Res

pite

- In

-Hom

e ZZ

Loca

l cod

e to

be

reta

ined

. (V

FI P

aym

ent)

P

17

G0301

13

Nur

sing

- LV

NH

CS

91

24

TEN

ursi

ng C

are

in t

he H

ome,

by

LVN

P

17

G0301

13

Nur

sing

- LV

NH

CT1

00

3TE

LPN

/LVN

ser

vice

s up

to

15 m

inut

esP

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

01

Psyc

hiat

ric d

iagn

ostic

inte

rvie

w e

xam

inat

ion

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

10

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r, o

r oth

er

mec

hani

sms

of n

onve

rbal

com

mun

icat

ion,

in a

n of

fice

or

outp

atie

nt fac

ility

, ap

prox

imat

ely

20 -

30 m

inut

es fac

e-to

-fa

ce w

ith t

he p

atie

nt

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

12

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r, o

r oth

er

mec

hani

sms

of n

onve

rbal

com

mun

icat

ion,

in a

n of

fice

or

outp

atie

nt fac

ility

, ap

prox

imat

ely

45 -

50 m

inut

es fac

e-to

-fa

ce w

ith t

he p

atie

nt

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

14

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r, o

r oth

er

mec

hani

sms

of n

onve

rbal

com

mun

icat

ion,

in a

n of

fice

or

outp

atie

nt fac

ility

, ap

prox

imat

ely

75 -

80 m

inut

es fac

e-to

-fa

ce w

ith t

he p

atie

nt

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

16

Indi

vidu

al p

sych

othe

rapy

, in

sigh

t or

ient

ed, be

havi

or

mod

ifyin

g an

d/or

sup

port

ive,

in a

n in

patie

nt h

ospi

tal,

part

ial h

ospi

tal,

or r

esid

entia

l car

e se

ttin

g, a

ppro

xim

atel

y 2

0 -

30

min

utes

fac

e-to

-face

with

pat

ient

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

18

Indi

vidu

al p

sych

othe

rapy

, in

sigh

t or

ient

ed, be

havi

or

mod

ifyin

g an

d/or

sup

port

ive,

in a

n in

patie

nt h

ospi

tal,

part

ial h

ospi

tal,

or r

esid

entia

l car

e se

ttin

g, a

ppro

xim

atel

y 4

5 -

50

min

utes

fac

e-to

-face

with

pat

ient

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

21

Indi

vidu

al p

sych

othe

rapy

, in

sigh

t or

ient

ed, be

havi

or

mod

ifyin

g an

d/or

sup

port

ive,

in a

n in

patie

nt h

ospi

tal,

part

ial h

ospi

tal,

or r

esid

entia

l car

e se

ttin

g, a

ppro

xim

atel

y 7

5 -

80

min

utes

fac

e-to

-face

with

pat

ient

P

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

23

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r, o

r oth

er

mec

hani

sms

of n

onve

rbal

com

mun

icat

ion,

in a

n in

patie

nt

hosp

ital,

part

ial h

ospi

tal o

r re

side

ntia

l car

e se

ttin

g,

appr

oxim

atel

y 2

0 -

30 m

inut

es fa

ce-to

-face

with

the

patie

nt

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

26

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r, o

r oth

er

mec

hani

sms

of n

onve

rbal

com

mun

icat

ion,

in a

n in

patie

nt

hosp

ital,

part

ial h

ospi

tal o

r re

side

ntia

l car

e se

ttin

g,

appr

oxim

atel

y 45 -

50 m

inut

es fa

ce-to

-face

with

the

patie

nt

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

28

Indi

vidu

al p

sych

othe

rapy

, in

tera

ctiv

e, u

sing

pla

y eq

uipm

ent,

phy

sica

l dev

ices

, lan

guag

e in

terp

rete

r, o

r oth

er

mec

hani

sms

of n

onve

rbal

com

mun

icat

ion,

in a

n in

patie

nt

hosp

ital,

part

ial h

ospi

tal o

r re

side

ntia

l car

e se

ttin

g,

appr

oxim

atel

y 75 -

80 m

inut

es fa

ce-to

-face

with

the

patie

nt

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

45

Psyc

hoan

alys

isP

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

47

Fam

ily p

sych

othe

rapy

(co

njoi

nt c

ouns

elin

g) w

ith p

atie

nt

pres

ent

P

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

08

62

Phar

mac

olog

ical

man

agem

ent,

incl

udin

g pr

escr

iptio

n/us

e/re

view

of m

edic

atio

nP

17

G0403

14

Psyc

holo

gica

l Ser

vice

sH

C9

61

00

Psyc

holo

gica

l tes

ting

P

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

03

9Ve

hicl

e M

odifi

catio

ns, w

aive

r; p

er s

ervi

ceP

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE0

63

6M

ultip

ositi

onal

pat

ient

sup

port

sys

tem

, with

inte

grat

ed li

ft,

patie

ntP

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

03

1R

olla

bout

Cha

ir, a

ny a

nd a

ll ty

pes

with

cas

tors

5 in

ches

or

grea

ter

P

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

13

0S

tand

ard

Whe

elch

air,

fixe

d fu

ll le

ngth

arm

s, fi

xed

or s

win

g aw

ay d

etac

habl

eP

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

39

9D

urab

le M

edic

al E

quip

men

t, M

isce

llane

ous

P

17

G0500

15

DM

E/Ad

aptiv

e Ai

ds09/2

8/03

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

90

0S

ynth

esiz

ed S

peec

h Au

gmen

tativ

e C

omm

unic

atio

n D

evic

e w

ith D

ynam

ic D

ispl

ayP

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

90

2C

omm

unic

atio

n B

oard

, N

on-e

lect

roni

c Au

gmen

tativ

e or

Al

tern

ativ

e C

omm

unic

atio

nP

17

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

02

9S

peci

aliz

ed m

edic

al e

quip

men

t, n

ot o

ther

wis

e sp

ecifi

ed,

wai

ver

P

17

G0608

16

Hom

e M

odifi

catio

nsH

CS

51

65

Hom

e M

odifi

catio

ns; pe

r se

rvic

eP

17

G0701

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Leve

l 2 -

Prio

rity

HC

S5

12

5At

tend

ant

Car

e S

ervi

ces,

per

15 m

inut

esP

17

G0800

18

Adul

t Fo

ster

Car

e - L

evel

1H

CS

51

40

31

05

U3

Adul

t fo

ster

car

e, p

er d

iem

I

17

G0801

18

Adul

t Fo

ster

Car

e - L

evel

2H

CS

51

40

31

05

U4

Adul

t fo

ster

car

e, p

er d

iem

I

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0802

18

Adul

t Fo

ster

Car

e - L

evel

3H

CS

51

40

31

05

U5

Adul

t fo

ster

car

e, p

er d

iem

I

17

G0900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 6

)H

CT2

03

1U

1U

1As

sist

ed li

ving

, w

aive

r; p

er d

iem

P

17

G1900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 5

)08/3

1/03

17

G2900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 4

)08/3

1/03

17

G3900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 3

)08/3

1/03

17

G4900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 2

)08/3

1/03

17

G5900

19

Assi

sted

Liv

ing

- Apa

rtm

ent

(Lev

el 1

)08/3

1/03

17

G1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

60

In

stal

latio

n an

d Te

stin

gP

17

G1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

61

Mon

thly

Ser

vice

Fee

(ex

clud

es in

stal

latio

n an

d te

stin

g)P

17

G1000

20

Emer

genc

y R

espo

nse

Ser

vice

sH

CS

51

62

Purc

hase

Onl

yP

17

G1200

22

Med

ical

Sup

plie

s H

CS

51

99

Pers

onal

Car

e Ite

m, N

OS

, ea

chP

17

G1200

22

Med

ical

Sup

plie

s H

CT2

02

8S

peci

aliz

ed S

uppl

y, N

ot o

ther

wis

e sp

ecifi

ed, w

aive

rP

17

C0100

25

Hom

e D

eliv

ered

Mea

ls08/3

1/03

17

C0101

25

Wai

ver

Mea

lsH

CS

51

70

Per

mea

l, in

clud

es p

repa

ratio

n an

d de

liver

yP

17

U0210

34

Die

tary

Ser

vice

sH

CS

94

65

Dia

betic

man

agem

ent,

die

ticia

n vi

sit

P

17

U0210

34

Die

tary

Ser

vice

sH

CS

94

70

Nut

ritio

nal c

ouns

elin

g, d

ietic

ian

visi

tP

17

U0210

34

Die

tary

Ser

vice

sH

C9

78

02

Med

ical

nut

ritio

n th

erap

y, in

itial

ass

essm

ent

and

inte

rven

tion,

eac

h 15 m

inut

esP

17

U0300

35

Audi

olog

y/AU

H

CV5

00

8H

earin

g S

cree

ning

P

17

U0300

35

Audi

olog

y/AU

H

CV5

01

0H

earin

g Ai

d As

sess

men

tP

17

U0300

35

Audi

olog

y/AU

H

CV5

01

1Fi

ttin

g/O

rient

atio

n of

Hea

ring

Aid

P

17

U0300

35

Audi

olog

y/AU

H

CV5

02

0C

onfo

rmity

Eva

luat

ion

P

17

U0400

36

Soc

ial W

ork/

SW

HC

G0

15

5S

ervi

ces

of a

clin

ical

soc

ial w

orke

r in

the

hom

e he

alth

se

ttin

g, e

ach

15

min

utes

P

17

U0505

37

Sup

port

ed E

mpl

oym

ent/

SE

HC

T20

19

Hab

ilita

tion,

sup

port

ed e

mpl

oym

ent,

wai

ver;

per

15

min

utes

P

17

G0205

40

Annu

al A

sses

smen

t08/3

1/03

17

G0515

41

ADP

Aide

s/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0516

41

ADP

Aide

s/R

equi

sitio

n Fe

es

5

00

.00

- 9

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0517

41

ADP

Aide

s/R

equi

sitio

n Fe

es

1

00

0.0

0 -

14

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0518

41

ADP

Aide

s/R

equi

sitio

n Fe

es

15

00

.00

- 1

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0519

41

ADP

Aide

s/R

equi

sitio

n Fe

es

2

00

0.0

0 -

24

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0520

41

ADP

Aide

s/R

equi

sitio

n Fe

es

25

00

.00

- 2

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0521

41

ADP

Aide

s/R

equi

sitio

n Fe

es

30

00

.00

- 3

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0522

41

ADP

Aide

s/R

equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0523

41

ADP

Aide

s/R

equi

sitio

n Fe

es

4

00

0.0

0 -

44

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0524

41

ADP

Aide

s/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0525

41

ADP

Aide

s/R

equi

sitio

n Fe

es

50

00

.00

- O

VER

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0230

43

Beh

avio

r C

omm

unic

atio

n S

peci

alis

tZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0231

44

Orie

ntat

ion

and

Mob

ility

HC

97

53

7C

omm

unity

/wor

k re

inte

grat

ion

trai

ning

(th

at is

, sh

oppi

ng,

tran

spor

tatio

n, m

oney

man

agem

ent,

avo

catio

nal

activ

ities

, and

/or w

ork

envi

ronm

ent/

mod

ifica

tion

anal

ysis

, w

ork

task

ana

lysi

s), d

irect

one

on

one

cont

act b

y pr

ovid

er,

each

15

min

utes

P

17

G0231

44

Orie

ntat

ion

and

Mob

ility

HC

97

53

5S

elf c

are/

hom

e m

anag

emen

t tra

inin

g (t

hat i

s, a

ctiv

ities

of

daily

livi

ng a

nd c

ompe

nsat

ory

trai

ning

, m

eal p

repa

ratio

n,

safe

ty p

roce

dure

s, a

nd in

stru

ctio

n in

use

of ad

aptiv

e eq

uipm

ent)

dire

ct o

ne o

n on

e co

ntac

t by

prov

ider

, eac

h 15

min

utes

P

17

G0232

45

Inte

rven

orH

C9

75

35

Sel

f car

e/ho

me

man

agem

ent t

rain

ing

(tha

t is,

act

iviti

es o

f da

ily li

ving

and

com

pens

ator

y tr

aini

ng, m

eal p

repa

ratio

n,

safe

ty p

roce

dure

s, a

nd in

stru

ctio

n in

use

of ad

aptiv

e eq

uipm

ent)

dire

ct o

ne o

n on

e co

ntac

t by

prov

ider

, eac

h 15

min

utes

P

17

G0233

48

Tran

spor

tatio

nH

CA0

10

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Tax

iP

17

G0233

48

Tran

spor

tatio

nH

CA0

11

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Bus

P

17

G0233

48

Tran

spor

tatio

nH

CA0

12

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Min

i-Bus

, ot

her

nonp

rofit

tr

ansp

ort

syst

ems

P

17

G0233

48

Tran

spor

tatio

nH

CA0

13

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Whe

elch

air

Van

P

17

G0233

48

Tran

spor

tatio

nH

CA0

16

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Cas

ewor

ker

or S

ocia

l W

orke

rP

17

G0233

48

Tran

spor

tatio

nH

CA0

17

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Anc

illar

y; P

arki

ng F

ees,

To

lls, O

ther

P

17

G0233

48

Tran

spor

tatio

nH

CA0

21

0N

on-e

mer

genc

y Tr

ansp

orta

tion;

Anc

illar

y; M

eals

- Es

cort

P

17

G0233

48

Tran

spor

tatio

nH

CT2

00

1N

on-e

mer

genc

y tr

ansp

orta

tion;

pat

ient

att

enda

nt/e

scor

tP

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0233

48

Tran

spor

tatio

nH

CT2

00

3N

on-e

mer

genc

y tr

ansp

orta

tion;

enc

ount

er/t

ripP

17

G0233

48

Tran

spor

tatio

nH

CT2

00

4N

on-e

mer

genc

y tr

ansp

ort;

com

mer

cial

car

rier,

mul

ti-pa

ssP

17

G0233

48

Tran

spor

tatio

nH

CT2

00

5

Non

-em

erge

ncy

tran

spor

tatio

n; N

on-a

mbu

lato

ry s

tret

cher

va

nP

17

G0234

49

Chi

ld S

uppo

rt S

ervi

ces

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0235

51

Inde

pend

ent

Advo

cacy

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0238

53

Tran

sitio

nal S

ervi

ces

08/3

1/03

17

S0106

10B

Hab

ilita

tion

- Sup

port

ive

Empl

oy

Empl

oym

ent

08/3

1/03

17

S0107

10B

Hab

ilita

tion

- Pre

voca

tiona

lH

CT2

01

5U

4H

abili

tatio

n pr

evoc

atio

nal,

wai

ver,

per

hou

rP

17

S0125

10B

Hab

ilita

tion

- Pre

voca

tiona

l LO

N 1

In

term

itten

t08/3

1/03

17

S0126

10B

Hab

ilita

tion

- Pre

voca

tiona

l LO

N 5

Li

mite

d08/3

1/03

17

S0127

10B

Hab

ilita

tion

- Pre

voca

tiona

l LO

N 6

Pe

rvas

ive

08/3

1/03

17

S0128

10B

Hab

ilita

tion

- Pre

voca

tiona

l LO

N 8

Ex

tens

ive

08/3

1/03

17

S0108

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

HC

97

53

5S

elf c

are/

hom

e m

anag

emen

t tra

inin

g (t

hat i

s, a

ctiv

ities

of

daily

livi

ng a

nd c

ompe

nsat

ory

trai

ning

, m

eal p

repa

ratio

n,

safe

ty p

roce

dure

s, a

nd in

stru

ctio

n in

use

of ad

aptiv

e eq

uipm

ent)

dire

ct o

ne o

n on

e co

ntac

t by

prov

ider

, eac

h 15

min

utes

P

17

S0108

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

09

42

Educ

atio

n/Tr

aini

ngI

17

S0108

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

HC

97

53

7C

omm

unity

/wor

k re

inte

grat

ion

trai

ning

(th

at is

, sh

oppi

ng,

tran

spor

tatio

n, m

oney

man

agem

ent,

avo

catio

nal a

ctiv

ities

an

d/or

wor

k en

viro

nmen

t/m

odifi

catio

n an

alys

is, w

ork

task

an

alys

is), d

irect

one

on

one

cont

act

by p

rovi

der,

eac

h 15

min

utes

P

17

S0129

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

LON

1

Inte

rmitt

ent

08/3

1/03

17

S0130

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

LON

5

Lim

ited

08/3

1/03

17

S0131

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

LON

6

Perv

asiv

e08/3

1/03

17

S0132

10C

Hab

ilita

tion

- Day

Hab

ilita

tion

LON

8

Exte

nsiv

e08/3

1/03

17

G0119

11A

Res

pite

-RE-

LON

808/3

1/03

17

G0128

11A

Res

pite

- O

ut-o

f-Hom

eH

CS

51

51

Uns

kille

d R

espi

te C

are,

per

die

mP

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0132

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 1

HC

S5

15

10

66

0U

3U

nski

lled

Res

pite

Car

e, p

er d

iem

I

17

G0132

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 1

HC

S5

15

1U

3U

nski

lled

Res

pite

Car

e, p

er d

iem

P

17

G0133

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 2

HC

S5

15

10

66

0U

4U

nski

lled

Res

pite

Car

e, p

er d

iem

I

17

G0133

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 2

HC

S5

15

1U

4U

nski

lled

Res

pite

Car

e, p

er d

iem

P

17

G0134

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 3

HC

S5

15

10

66

0U

5U

nski

lled

Res

pite

Car

e, p

er d

iem

I

17

G0134

11B

Res

pite

- Ad

ult

Fost

er C

are

- Lev

el 3

HC

S5

15

1U

5U

nski

lled

Res

pite

Car

e, p

er d

iem

P

17

G0135

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

6)

HC

S5

15

10

66

0U

1U

1I

17

G0135

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

6)

HC

S5

15

1U

1U

1P

17

G0136

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

5)

08/3

1/03

17

G0137

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

4)

08/3

1/03

17

G0138

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

3)

08/3

1/03

17

G0139

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

2)

08/3

1/03

17

G0140

11C

Res

pite

- As

sist

ed L

ivin

g - A

part

men

t (L

evel

1)

08/3

1/03

17

G0142

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

HC

S5

15

10

66

0U

2U

1I

17

G0142

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

6)

HC

S5

15

1U

2U

1P

17

G0143

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

5)

08/3

1/03

17

G0144

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

4)

08/3

1/03

17

G0145

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

3)

08/3

1/03

17

G0146

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

2)

08/3

1/03

17

G0147

11D

Res

pite

- R

esid

entia

l Car

e -

Apar

tmen

t (L

evel

1)

08/3

1/03

17

G0149

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

6)

HC

S5

15

10

66

0U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

I

17

G0149

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

6)

HC

S5

15

1U

2U

2U

nski

lled

Res

pite

Car

e, p

er d

iem

P

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0150

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

5)

08/3

1/03

17

G0151

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

4)

08/3

1/03

17

G0152

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

3)

08/3

1/03

17

G0153

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

2)

08/3

1/03

17

G0154

11E

Res

pite

- R

esid

entia

l Car

e -

Non

apar

tmen

t (L

evel

1)

08/3

1/03

17

N1201

11F

Res

pite

NF

- Tile

20

10

66

3D

aily

Res

pite

Cha

rge

I

17

N1202

11F

Res

pite

NF

- Tile

20

20

66

3D

aily

Res

pite

Cha

rge

I

17

N1203

11F

Res

pite

NF

- Tile

20

30

66

3D

aily

Res

pite

Cha

rge

I

17

N1204

11F

Res

pite

NF

- Tile

20

40

66

3D

aily

Res

pite

Cha

rge

I

17

N1205

11F

Res

pite

NF

- Tile

20

50

66

3D

aily

Res

pite

Cha

rge

I

17

N1206

11F

Res

pite

NF

- Tile

20

60

66

3D

aily

Res

pite

Cha

rge

I

17

N1207

11F

Res

pite

NF

- Tile

20

70

66

3D

aily

Res

pite

Cha

rge

I

17

N1208

11F

Res

pite

NF

- Tile

20

80

66

3D

aily

Res

pite

Cha

rge

I

17

N1209

11F

Res

pite

NF

- Tile

20

90

66

3D

aily

Res

pite

Cha

rge

I

17

N1210

11F

Res

pite

NF

- Tile

21

00

66

3D

aily

Res

pite

Cha

rge

I

17

N1211

11F

Res

pite

NF

- Tile

21

10

66

3D

aily

Res

pite

Cha

rge

I

17

N1212

11F

Res

pite

NF

- Tile

21

20

66

3D

aily

Res

pite

Cha

rge

I

17

G0156

11G

Res

pite

- C

amp

HC

T20

37

06

63

Res

pite

Car

e, T

hera

peut

ic C

ampi

ng, D

ay, ea

ch s

essi

onI

17

G0157

11H

Res

pite

- D

ay C

are/

Lice

nsed

Chi

ld

Car

e Fa

cilit

yH

CT2

02

60

66

3R

espi

te C

are,

Spe

cial

ized

Chi

ldca

re, pe

r da

yI

17

G0159

11K

Res

pite

- IC

F/M

R0

66

0R

espi

te C

are,

gen

eral

(N

ote:

To

cros

swal

k ba

ck t

o th

e lo

cal c

ode,

pla

ce o

f se

rvic

e m

ust

be a

ccur

ate.

)I

17

G0160

11L

Res

pite

- H

ospi

tal

06

60

Res

pite

Car

e, g

ener

al (

Not

e: T

o cr

ossw

alk

back

to

the

loca

l cod

e, p

lace

of se

rvic

e m

ust

be a

ccur

ate.

)I

17

G0162

11N

Res

pite

- LV

N08/3

1/03

17

G0216

12A

Targ

eted

Cas

e M

anag

emen

t08/3

1/03

17

G0302

13A

Nur

sing

Ser

vice

s - L

VNH

CS

91

24

Nur

sing

Car

e in

the

Hom

e, b

y LV

NP

17

G0302

13A

Nur

sing

Ser

vice

s - L

VNH

CT1

00

3LP

N/L

VN s

ervi

ces

up t

o 15 m

inut

esP

17

G0303

13B

Nur

sing

Ser

vice

s - R

NH

CS

91

23

Nur

sing

Car

e in

the

Hom

e, b

y R

NP

17

G0303

13B

Nur

sing

Ser

vice

s - R

NH

CT1

00

1N

ursi

ng a

sses

smen

t/ev

alua

tion

P

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0303

13B

Nur

sing

Ser

vice

s - R

NH

CT1

00

2R

N s

ervi

ces

up t

o 15 m

inut

esP

17

G0705

17A

PAS

Del

egat

ed (

For

Futu

re U

se)

08/3

1/03

17

G0706

17B

PAS

Pro

tect

ive

Sup

ervi

sion

(Fo

r Fu

ture

Use

)08/3

1/03

17

G0744

17E

PAS

Cho

re08/3

1/03

17

G0921

19A

AL R

esid

entia

l Car

e - A

part

men

t

(L

evel

6)

HC

T20

31

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mP

17

G0921

19A

AL R

esid

entia

l Car

e - A

part

men

t

(L

evel

6)

HC

T20

31

02

40

U2

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mI

17

G0922

19A

Assi

sted

Liv

ing

Res

iden

tial C

are

Apar

tmen

t (L

evel

5)

08/3

1/03

17

G0923

19A

Assi

sted

Liv

ing

Res

iden

tial C

are

Apar

tmen

t (L

evel

4)

08/3

1/03

17

G0924

19A

Assi

sted

Liv

ing

Res

iden

tial C

are

Apar

tmen

t (L

evel

3)

08/3

1/03

17

G0925

19A

Assi

sted

Liv

ing

Res

iden

tial C

are

Apar

tmen

t (L

evel

2)

08/3

1/03

17

G0926

19A

Assi

sted

Liv

ing

Res

iden

tial C

are

Apar

tmen

t (L

evel

1)

08/3

1/03

17

G0928

19B

AL R

esid

entia

l Car

e - N

onap

artm

ent

(Lev

el 6

)H

CT2

03

1U

2U

2As

sist

ed li

ving

, w

aive

r; p

er d

iem

P

17

G0929

19B

Assi

sted

Liv

ing

Res

iden

tial C

are

Non

apar

tmen

t (L

evel

5)

08/3

1/03

17

G0930

19B

Assi

sted

Liv

ing

Res

iden

tial C

are

Non

apar

tmen

t (L

evel

4)

08/3

1/03

17

G0931

19B

Assi

sted

Liv

ing

Res

iden

tial C

are

Non

apar

tmen

t (L

evel

3)

08/3

1/03

17

G0932

19B

Assi

sted

Liv

ing

Res

iden

tial C

are

Non

apar

tmen

t (L

evel

2)

08/3

1/03

17

G0933

19B

Assi

sted

Liv

ing

Res

iden

tial C

are

Non

apar

tmen

t (L

evel

1)

08/3

1/03

17

G0935

19C

Assi

sted

Liv

ing

- Per

sona

l Car

e 3

HC

T20

31

U1

Assi

sted

livi

ng,

wai

ver;

per

die

mP

17

G0910

19E

Res

iden

tial S

uppo

rt L

OC

1H

CT1

02

00

24

0U

3U

2U

2A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0910

19E

Res

iden

tial S

uppo

rt L

OC

1H

CT1

02

0U

3Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0911

19E

Res

iden

tial S

uppo

rt L

ON

5H

CT1

02

00

24

0U

7U

2U

2A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0911

19E

Res

iden

tial S

uppo

rt L

ON

5H

CT1

02

0U

7Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

17

G0912

19E

Res

iden

tial S

uppo

rt L

ON

6H

CT1

02

00

24

0U

8U

2U

2A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0912

19E

Res

iden

tial S

uppo

rt L

ON

6H

CT1

02

0U

8Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

17

G0913

19E

Res

iden

tial S

uppo

rt L

ON

8H

CT1

02

00

24

0U

AU

2U

2A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly.

I

17

G0913

19E

Res

iden

tial S

uppo

rt L

ON

8H

CT1

02

0U

APe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

17

G0937

19E

Assi

sted

Liv

ing

- Hab

ilita

tion

24

hou

rH

CT2

03

3U

1R

esid

entia

l car

e, n

ot o

ther

wis

e sp

ecifi

ed (N

OS

), w

aive

r;

per

diem

P

17

G0939

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

1H

CT1

02

00

24

0U

3A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0939

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

1H

CT1

02

0U

3Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

17

G0940

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

5H

CT1

02

00

24

0U

7A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0940

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

5H

CT1

02

0U

7Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

17

G0941

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

8H

CT1

02

00

24

0U

AA

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0941

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

8H

CT1

02

0U

APe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

wal

k Ta

ble

Texa

s LT

C L

ocal

Cod

esN

atio

nal C

odes

Ser

vice

G

roup

Bill

C

ode

Ser

vice

C

ode

Bill

Cod

e D

escr

ipti

onP

roce

dure

C

ode

Qua

lifie

r

HC

PC

S

Cod

eC

PT

Cod

eR

even

ue

Cod

eM

odifi

er

1M

odifi

er

2M

odifi

er

3M

odifi

er

4D

efin

itio

n/C

omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0942

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

6H

CT1

02

00

24

0U

8A

flat

rate

cha

rge

incu

rred

on

eith

er a

dai

ly b

asis

or

tota

l st

ay b

asis

for

anc

illar

y se

rvic

es o

nly

I

17

G0942

19G

Assi

sted

Liv

ing

- Fam

ily S

urro

gate

S

ervi

ces

LON

6H

CT1

02

0U

8Pe

rson

al c

are

serv

ices

, pe

r di

em, no

t fo

r an

inpa

tient

or

resi

dent

of a

hos

pita

l, nu

rsin

g fa

cilit

y, IC

F/M

R o

r IM

D, p

art

of t

he in

divi

dual

ized

pla

n of

tre

atm

ent

(Cod

e m

ay n

ot b

e us

ed to

iden

tify

serv

ices

pro

vide

d by

a h

ome

heal

th a

ide

or

cert

ified

nur

se a

ssis

tant

.)

P

17

G0207

40A

Prea

sses

smen

tH

CT2

02

4S

ervi

ce a

sses

smen

t/pl

an o

f ca

re d

evel

opm

ent,

wai

ver

P

17

G1212

41A

Med

ical

S/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1213

41A

Med

ical

S/R

equi

sitio

n Fe

es

50

0.0

0 -

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1214

41A

Med

ical

S/R

equi

sitio

n Fe

es

10

00

.00

- 1

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1215

41A

Med

ical

S/R

equi

sitio

n Fe

es

15

00

.00

- 1

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1216

41A

Med

ical

S/R

equi

sitio

n Fe

es

20

00

.00

- 2

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1217

41A

Med

ical

S/R

equi

sitio

n Fe

es

25

00

.00

- 2

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1218

41A

Med

ical

S/R

equi

sitio

n Fe

es

3

00

0.0

0 -

34

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G1219

41A

Med

ical

S/R

equi

sitio

n Fe

es

35

00

.00

- 3

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1220

41A

Med

ical

S/R

equi

sitio

n Fe

es

40

00

.00

- 4

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1221

41A

Med

ical

S/R

equi

sitio

n Fe

es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G1222

41A

Med

ical

S/R

equi

sitio

n Fe

es

50

00

.00

- O

VER

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0623

41B

MH

Mod

s/R

equi

sitio

n Fe

es

0 -

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0624

41B

MH

Mod

s/R

equi

sitio

n Fe

es

5

00

.00

- 9

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0625

41B

MH

Mod

s/R

equi

sitio

n Fe

es

10

00

.00

- 1

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0626

41B

MH

Mod

s/R

equi

sitio

n Fe

es

1

50

0.0

0 -

19

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0627

41B

MH

Mod

s/R

equi

sitio

n Fe

es

20

00

.00

- 2

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

Ser

vice

Gro

up 1

7 -

Long

Ter

m C

are

Bill

Cod

e C

ross

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C

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Ser

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Bill

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escr

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Qua

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End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

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ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


17

G0628

41B

MH

Mod

s/R

equi

sitio

n Fe

es

2

50

0.0

0 -

29

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0629

41B

MH

Mod

s/R

equi

sitio

n Fe

es

30

00

.00

- 3

49

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0630

41B

MH

Mod

s/R

equi

sitio

n Fe

es

3

50

0.0

0 -

39

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0631

41B

MH

Mod

s/R

equi

sitio

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es

4

00

0.0

0 -

44

99

.99

ZZLo

cal c

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to b

e re

tain

ed.

P

17

G0632

41B

MH

Mod

s/R

equi

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es

45

00

.00

- 4

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0633

41B

MH

Mod

s/R

equi

sitio

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es

50

00

.00

- 5

49

9.9

9ZZ

Loca

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e to

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.P

17

G0634

41B

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Mod

s/R

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sitio

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es

55

00

.00

- 5

99

9.9

9ZZ

Loca

l cod

e to

be

reta

ined

.P

17

G0635

41B

MH

Mod

s/R

equi

sitio

n Fe

es

6

00

0.0

0 -

64

99

.99

ZZLo

cal c

ode

to b

e re

tain

ed.

P

17

G0636

41B

MH

Mod

s/R

equi

sitio

n Fe

es

6

50

0.0

0 -

Ove

rZZ

Loca

l cod

e to

be

reta

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.P

17

G0607

41C

Spe

cific

atio

ns A

dapt

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ZZLo

cal c

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P

17

G0604

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Spe

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M M

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P

17

G0637

41E

Den

tal/

Req

uisi

tion

Fees

0 -

49

9.9

908/3

1/03

17

G0638

41E

Den

tal/

Req

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tion

Fees

5

00

.00

- 9

99

.99

08/3

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17

G0639

41E

Den

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Req

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tion

Fees

1

00

0.0

0 -

14

99

.99

08/3

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17

G0640

41E

Den

tal/

Req

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Fees

1

50

0.0

0 -

19

99

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08/3

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17

G0641

41E

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tal/

Req

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tion

Fees

2

00

0.0

0 -

24

99

.99

08/3

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17

G0642

41E

Den

tal/

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tion

Fees

2

50

0.0

0 -

29

99

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08/3

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17

G0643

41E

Den

tal/

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tion

Fees

3

00

0.0

0 -

34

99

.99

08/3

1/03

17

G0644

41E

Den

tal/

Req

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tion

Fees

3

50

0.0

0 -

39

99

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08/3

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17

G0645

41E

Den

tal/

Req

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tion

Fees

4

00

0.0

0 -

44

99

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08/3

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17

G0646

41E

Den

tal/

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tion

Fees

4

50

0.0

0 -

49

99

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08/3

1/03

Ser

vice

Gro

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End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


Ser

vice

Gro

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18

17

G0647

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Den

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Req

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Fees

5

00

0.0

0 -

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R08/3

1/03

17

G0239

53A

Tran

sitio

nal S

uppo

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17

N0600

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Emer

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2M

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3M

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4D

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itio

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omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

18

N0500

4Ve

ntila

tor

- Ful

l08/3

1/03

18

G0121

11

Res

pite

- Pe

rson

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ervi

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HC

S5

15

0U

nski

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; pe

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18

G0121

11

Res

pite

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HC

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00

66

2U

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; pe

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18

G0122

11

Res

pite

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itter

Ser

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s08/3

1/03

18

G0171

11

In-H

ome

Res

pite

CD

S -

Agen

cyZZ

Loca

l cod

e to

be

reta

ined

.P

18

G0500

15

DM

E/Ad

aptiv

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dsH

CT2

03

9Ve

hicl

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odifi

catio

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aive

r; p

er s

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ceP

18

G0500

15

DM

E/Ad

aptiv

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dsH

CE0

63

6M

ultip

ositi

onal

pat

ient

sup

port

sys

tem

, with

inte

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ed li

ft,

patie

ntP

18

G0500

15

DM

E/Ad

aptiv

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dsH

CE1

03

1R

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bout

Cha

ir, a

ny a

nd a

ll ty

pes

with

cas

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5 in

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grea

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P

18

G0500

15

DM

E/Ad

aptiv

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dsH

CE1

13

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Whe

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18

G0500

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39

9D

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P

18

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18

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18

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P

Not

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Z qu

alifi

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be u

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for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.

Ser

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Gro

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Long

Ter

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Texa

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C L

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Bill

C

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Ser

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Bill

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Qua

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2M

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3M

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4D

efin

itio

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omm

ents

End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


18

G0500

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DM

E/Ad

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02

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peci

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uppl

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ot o

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wis

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18

G0500

15

DM

E/Ad

aptiv

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dsH

CE1

90

00

29

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ynth

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peec

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gmen

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omm

unic

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evic

e w

ith D

ynam

ic D

ispl

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18

G0500

15

DM

E/Ad

aptiv

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90

20

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atio

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, N

on-e

lect

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gmen

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e or

Al

tern

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e C

omm

unic

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nI

18

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CT2

03

90

29

0Ve

hicl

e M

odifi

catio

ns, w

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18

G0500

15

DM

E/Ad

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02

90

29

0S

peci

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I

18

G0500

15

DM

E/Ad

aptiv

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dsH

CT2

02

80

29

0S

peci

aliz

ed S

uppl

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ot o

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wis

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aive

rI

18

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE0

63

60

29

0M

ultip

ositi

onal

pat

ient

sup

port

sys

tem

, with

inte

grat

ed li

ft,

patie

ntI

18

G0500

15

DM

E/Ad

aptiv

e Ai

dsH

CE1

03

10

29

0R

olla

bout

Cha

ir, a

ny a

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pes

with

cas

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5 in

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or

grea

ter

I

18

G0500

15

DM

E/Ad

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CE1

13

00

29

0S

tand

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Whe

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win

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18

G0500

15

DM

E/Ad

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90

29

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quip

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I

18

G0608

16

Hom

e M

odifi

catio

nsH

CS

51

65

Hom

e M

odifi

catio

ns; pe

r se

rvic

eP

18

G0608

16

Hom

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odifi

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CS

51

65

31

06

Hom

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eI

18

G0702

17

Pers

onal

Ass

ista

nce

Ser

vice

s -

Leve

l 1 -

Non

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08/3

1/03

18

G0238

53

Tran

sitio

nal S

ervi

ces

08/3

1/03

18

N1201

11F

Res

pite

NF

- Tile

20

10

66

3D

aily

Res

pite

Cha

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I

18

N1202

11F

Res

pite

NF

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20

20

66

3D

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Res

pite

Cha

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I

18

N1203

11F

Res

pite

NF

- Tile

20

30

66

3D

aily

Res

pite

Cha

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I

18

N1204

11F

Res

pite

NF

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Res

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I

18

N1205

11F

Res

pite

NF

- Tile

20

50

66

3D

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Res

pite

Cha

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I

18

N1206

11F

Res

pite

NF

- Tile

20

60

66

3D

aily

Res

pite

Cha

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I

18

N1207

11F

Res

pite

NF

- Tile

20

70

66

3D

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Res

pite

Cha

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I

18

N1208

11F

Res

pite

NF

- Tile

20

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66

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Res

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Cha

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I

18

N1209

11F

Res

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NF

- Tile

20

90

66

3D

aily

Res

pite

Cha

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I

18

N1210

11F

Res

pite

NF

- Tile

21

00

66

3D

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Res

pite

Cha

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I

18

N1211

11F

Res

pite

NF

- Tile

21

10

66

3D

aily

Res

pite

Cha

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I

18

N1212

11F

Res

pite

NF

- Tile

21

20

66

3D

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Res

pite

Cha

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I

18

G0156

11G

Res

pite

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T20

37

06

63

Res

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Car

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Ser

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Gro

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Bill

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Texa

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Bill

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Ser

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Bill

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Qua

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1M

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2M

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3M

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4D

efin

itio

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omm

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End

Dat

eC

laim

Typ

e to

File

: I=

837I;

P=837P

;D

=837D

Not

e: T

he Z

Z qu

alifi

er m

ust

be u

sed

for

serv

ices

ren

dere

d fo

r 1

0/1

6/0

3.

Exce

pt for

: D

ME/

Adap

tive

Aids

, D

enta

l, an

d H

ospi

ce P

hysi

cian

Ser

vice

s.


18

G0157

11H

Res

pite

- D

ay C

are/

Lice

nsed

Chi

ld

Car

e Fa

cilit

yH

CT2

02

60

66

3R

espi

te C

are,

Spe

cial

ized

Chi

ldca

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yI

18

G0158

11J

Res

pite

- Li

cens

ed S

peci

al C

are

Faci

lity

HC

S5

15

00

66

3R

espi

te C

are,

uns

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d, p

er 1

5 m

inut

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18

G0160

11L

Res

pite

- H

ospi

tal

06

60

Res

pite

Car

e, g

ener

al (

Not

e: T

o cr

ossw

alk

back

to

the

loca

l cod

e, p

lace

of se

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ust

be a

ccur

ate.

)I

18

G0161

11M

Res

pite

- H

CS

S (

RN

/LVN

)H

CS

91

24

06

61

TER

espi

te C

are

by a

n LV

N, pe

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urI

18

G0161

11M

Res

pite

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CS

S (

RN

/LVN

)H

CS

91

23

06

61

TDR

espi

te C

are

by a

n R

N, pe

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urI

18

G0162

11N

Res

pite

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NH

CT1

00

30

66

1TE

Res

pite

Car

e by

an

LVN

, pe

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urI

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Explanation of Benefits Code Table

Note: This is a correction to the Explanation of Benefits (EOB) Code Table that was published in the August 2003 Long Term Care Bulletin, No.15. EOB Code F0060 was listed in the table twice in error with RARC MA58 and MA06. The correct RARC that goes with F0060 is MA58.

HIPAA requires the use of new standard EOB codes, which will appear on the provider’s Claim Status Inquiry (CSI) and Remittance and Status report (R&S). EOB codes are used to report on claim payment/advice transactions. Because the new standard codes – referred to as Remittance Advice Remark Codes (RARC) – do not sufficiently explain the reason for the claim payment/advice, the state elected to provide the old codes in addition to the new codes to assist LTC providers in reviewing the R&S report:

Explanation of Benefits (EOB) Code Table

EOB Description RARC Description

F0001 Claim Header Record ID is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0002 Test/Production Flag is missing or invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0003 Program Type is a required field. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0004 Claim Type Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0005 Claim Header Source Identifier must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0006 Claim Header Source Identifier is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0007 Claim header signature indicator is missing or invalid.

M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0008 Claim Header Endorsement Number is an invalid value.


F0009 Detail Count must be present. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0010 Detail Count is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0011 Total Claim Positive Indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0012 Previous claims indicate more than five consecutive days billed.

MA32 Missing/incomplete/invalid number of covered days during the billing period.

F0013 The claim total amount billed is not in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0014 The Provider Number submitted is not in a valid format.

M57 Missing/incomplete/invalid provider identifier.

F0016 Last Name must be present in order to process a claim.

MA36 Missing/incomplete/invalid patient name.

F0018 The Client/Medicaid Number is missing or invalid. MA61 Missing/incomplete/invalid social security number or health insurance claim number.

F0021 Medicaid Patient Days % Positive/Negative Indicator must be present.

M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0022 Medicaid Patient Days % Positive/Negative Indicator is not a valid entry.


F0025 Medicaid Patient Days Percent is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0026 Medicare Patient Days % Positive/Negative Indicator must be present.


F0028 Medicare Patient Days % Positive/Negative Indicator is not a valid entry.



F0031 The Private Patient Days % entry is invalid. MA33 Missing/incomplete/invalid number of noncovered days during the billing period.

F0032 Medicare Patient Days percent is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0033 Private Patient Days % Positive/Negative Indicator must be present.


F0035 Private Patient Days % Positive/Negative Indicator is not a valid entry.


F0037 Private Patient Days % is missing. MA33 Missing/incomplete/invalid noncovered days during the billing period.

F0040 Trainee Social Security Number is missing or invalid. MA61 Did not complete or enter correctly the patient's social security number or health

F0041 Service group is missing, invalid, or not currently active.


F0042 The payee identification number submitted is invalid.

MA61 Missing/incomplete/invalid social security number or health insurance claim number.

F0044 Payee Identification Number must be submitted on claim.


F0045 Claim Header Adjustment Segment Indicator is an invalid value.


F0046 Claim Header Special Pay Segment Indicator is an invalid value.


F0048 Adjustment claims require an original ICN. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0050 Special Pay segment ID is invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0051 Fund Code is a required field. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0052 PAC Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0053 Special Pay Object Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0054 Special Pay Reason Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0055 Special Pay Type Indicator is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0056 Special Pay Service Code is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0057 Special Pay Agency must be present in order to process a claim.


F0058 Special Pay Region/Division Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0059 Special Pay Appropriation Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0060 Special Pay Begin Service Date is missing or invalid. MA58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0061 Special Pay End Service Date is missing or invalid. MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0062 Special Pay Expedited Payment Billing Month/Year is missing.

MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0063 Claim Detail Segment ID is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0064 Detail Number must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0065 Claim Detail Adjustment Line Reference Number is an invalid value.





F0067 Detail Number is greater than Detail Count in Header.


F0068 Detail Number is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0069 Detail Numbers are not consecutive. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0070 Line item is missing a Service Begin Date. MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0071 Services cannot be before January 1, 1971. MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0072 The Service End Date is missing. MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0073 The Service Begin Date must be on or before the Service End Date.


F0075 The Service Begin Date is not for the same month and year as the Service End Date.


F0077 Billing Code not present on claim line item. MA66 Missing/incomplete/invalid principal procedure code or date.

F0078 Claim Detail Training Hours Positive/Negative Indicator must be present.


F0080 Training Hours must be in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0081 Applied Income Positive/Negative Indicator must be present

MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.

F0083 Applied Income is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.

F0087 Copayment Amount is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.

F0089 Copayment Percent Positive/Negative Indicator must be present.


F0091 Copayment Percentage is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.

F0092 Units Billed Pos/Neg indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0094 Number of Units Billed is missing. M53 Did not complete or enter the appropriate number (one or more) of days or unit(s) of service.

F0095 Units Rate Pos/Neg indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0097 Unit Rate must is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0098 Claim Detail Line Item Total Positive/Negative Indicator must be present.


F0100 Line Item Total Billed must be in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0101 Claim Header Adjustment Segment is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0102 A Claim Header Adjustment Segment exists, claim header adjustment indicator is ‘N.’


F0106 Claim Leave Days must be in a valid format. MA33 Missing/incomplete/invalid noncovered days during the billing period.

F0107 The original line item in history is not in an adjustable status.

N36 Claim must meet primary payer's processing requirements before we can consider payment.

F0108 The original line item in history is not in an adjustable status.


F0110 Matching history detail not found or not in adjustable status.





F0111 Positive Line Item contains a negative Units Billed. M53 Missing/incomplete/invalid days or units of service.

F0112 Claim Header contains no details. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0113 Number of Details in Claim does not match header count.


F0114 Unable to determine Service Code from supplied information, verify Billing Code.

M67 Missing/incomplete/invalid other procedure code(s) and/or date(s).

F0115 Unable to determine Budget Key from supplied information.


F0116 The Units Billed must be greater than zero. M53 Missing/incomplete/invalid days or units of service.

F0117 Unit Rate must be greater than zero. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0118 Incorrect number of billed units for this service. M53 Missing/incomplete/invalid days or units of service.

F0119 Claims for month following submission must be submitted within last week of month before service.


F0121 Late billing - Claim must be filed 95 days from the end of the month of service.

MA119 Provider level adjustment for late claim filing applies to this claim.

F0123 Original ICN is not on file. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0125 Units billed exceed possible number of Units for Dates of Service.

M53 Missing/incomplete/invalid days or units of service.

F0126 Claim line items cannot span current Fiscal Years. N61 Rebill services on separate claims.

F0128 Provider is not enrolled to provide CMS services, or invalid provider number entered.

M57 Missing/incomplete/invalid provider identifier.

F0131 Provider has been placed on hold. N36 Claim must meet primary payer’s processing requirements before we can consider payment.

F0132 Provider is not authorized to perform this service for these Service Dates, verify Billing Code.

N54 Claim information is inconsistent with precertified/authorized services.

F0134 Provider authorized to provide services only to clients residing within Provider Region.


F0136 Provider is not authorized for Expedited Payment. N54 Claim information is inconsistent with precertified/authorized services.

F0138 A valid Service Authorization for this client for this Service on these dates is not available.


F0139 Client/Medicaid Number does not match information on file.


F0141 Client ID is a previous reference which is not valid for the service dates.

N30 Client ineligible for this service.

F0142 Client Medicaid Eligibility is not currently active or is on hold for dates of service.


F0143 Client last name not on file. MA36 Missing/incomplete/invalid patient name.

F0145 Client last name matched with former name on file. MA36 Missing/incomplete/invalid patient name.

F0147 Client’s LOS Type and Level do not match Service Group and Billing Code Requirements.


F0148 Provider not authorized to provide services billed for client.


F0150 Client not living in approved Nursing Facility on Service Dates.

MA134 Missing/Missing/incomplete/invalid provider number of the facility where the patient resides.

F0151 Cannot bill for more than five consecutive days for this service.


F0152 Records show that client has received this service for more than five consecutive days.





F0153 Client is eligible for Medicare enrollment. Bill Medicare first.

N104 This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at www.cms.hhs.gov.

F0155 Unable to determine appropriate Fund Code for Service billed, verify Medicaid Eligibility.


F0163 Item Code billed is not authorized for the Service provided.


F0165 This service has already been paid. Do not file for duplicate services.

M86 Service denied because payment already made for similar procedure within set time frame.

F0167 A claim for this procedure for this tooth has already been paid.


F0168 Claim denied because Trainee has already completed the full training course.


F0169 Claim denied because Trainee has not completed the full training course.

N36 Claim must meet primary payer’s processing requirements before we can consider payment.

F0170 Trainee has already passed a Skills Test. M86 Service denied because payment already made for similar procedure within set time frame.

F0171 Trainee has not previously passed a Skills Test. N36 Claim must meet primary payer’s processing requirements before we can consider payment.

F0172 Trainee has previously passed a written or oral examination.


F0173 Trainee has previously passed a written or oral examination.


F0174 Claim is for a service group that is mutually exclusive with service group for previous claim.


F0175 Claim is for a service that is mutually exclusive with a service for previous claim with the same Service Dates.


F0177 The Budget number is not valid for provider. M58 Resubmit the claim with the missing /correct information so that it may be processed.

F0179 Claim can not be paid because client is a Managed Care client.


F0181 Provider has already submitted an expedited payment for the current month.


F0182 Expedited payment must be for the current month. MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0184 Provider has submitted a claim for the current month of service, for the service code submitted on the claim.


F0185 Claim cannot process due to balance owed by provider to the State.


F0187 No units available from client Service Authorization. N54 Claim information is inconsistent with precertified/authorized services.

F0189 Amount of claim exceeds available budget. N131 Total payments under multiple contracts cannot exceed the allowance for this service.

F0191 Units billed exceeds allowable units for this client. N54 Claim information is inconsistent with precertified/authorized services.

F0193 All positive line items must be referenced to a negative line item.


F0194 Adjustment request received past the filing deadline.


F0195 Header Adjustment: total paid amount submitted does not match paid amount on history.

M54 Missing/incomplete/invalid total charges.

F0196 The sum of the Medicaid Patient Days % and/or Medicare Patient Days % and/or Private Patient Days % does not equal 100.





F0198 Cannot bill for future Service Dates or current date. MA06 Missing/incomplete/invalid beginning and/or ending date(s).

F0200 Procedure code is missing. MA66 Missing/incomplete/invalid principal procedure code or date.

F0201 An Item Code is required for this service. M58 Resubmit the claim with the missing /correct information so that it may be processed.

F0202 This Service requires a Tooth ID. N37 Missing/incomplete/invalid tooth number/letter.

F0203 The client's eligibility requires a Budget Number to be submitted.


F0204 The Budget Number is invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0205 Medicaid Patient Days % is greater than 100.0. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0206 Medicare Patient Days % is greater than 100.0. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0207 Private Patient Days % is greater than 100.0. M49 Missing/incomplete/invalid value code(s) and/or amount(s).

F0208 Leave Days may not exceed the Units Billed. MA32 Missing/incomplete/invalid number of covered days during the billing period.

F0209 Expedited claim has suspended, and will be processed beginning on the State-authorized submission date for this month.


F0211 Expedited claim submitted after the State-authorized submission date for this month.


F0214 Provider number is missing or invalid. M57 Missing/incomplete/invalid provider identifier.

F0215 Unable to determine Rate Key for detail or contract, verify Billing Code, if correct contact NHIC Helpdesk.


F0216 The payee identification number on the claim is not associated with the Client/Medicaid Number.


F0218 Expedited ceiling has not been calculated for contract for month of claim - unable to process expedited claims.


F0220 Client/Medicaid Number is missing. MA61 Missing/incomplete/invalid social security number or health insurance claim number.

F0222 Copayment amount exceeds claim line item amount.


F0223 Amount reduced, billed amount is greater than maximum allowed.


F0224 Applied Income amount exceeds claim line item amount.


F0225 Units billed exceeds allowable units for this client. N54 Claim information is inconsistent with precertified/authorized services.

F0226 Payable amount is the expedited payment ceiling amount.

N45 Payment based on authorized amount.

F0228 Units on claim exceeds available budget. M53 Missing/incomplete/invalid days or units of service.

F0229 Rate not found. N54 Claim information is inconsistent with precertified/authorized services.

F0230 County rate not found. N54 Claim information is inconsistent with precertified/authorized services.

F0231 Procedure rate not found. N54 Claim information is inconsistent with precertified/authorized services.

F0232 Amount changed due to difference in copayment. N45 Payment based on authorized amount.

F0233 Claim has more than 28 details. N36 Claim must meet primary payer’s processing requirements before we can consider payment.

F0234 Service is duplicate of another line item on same claim for same or overlapping service dates.





F0235 Positive Line Item contains a negative units billed. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0236 Unable to determine appropriate state accounting codes for this claim. NHIC is researching this problem.


F0237 Authorizing agency has changed or is not consistent for dates of service.


F0238 This line item is approved to pay. N14 Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.

F0239 Claim line item paid amount differs from claim line item billed amount.


F0240 Provider has an outstanding Sanction. N36 Claim must meet primary payer’s processing requirements before we can consider payment.

F0241 Applied Income or Copay must exist for the dates of service.


F0242 A change to the client’s service authorization has generated a recoupment for services, dates, or units no longer allowed.

MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).

F0243 A change in the rate for this service has generated repayment for this line item.


F0244 A change to the providers contract has generated a recoupment for services, or dates no longer allowed.


F0245 A change to the clients applied income or copayment has generated a recoupment for services previously billed.


F0246 A change to the units authorized for this client has been submitted by a state auditor.


F0247 The billed tooth ID has been previously billed. M86 Service denied because payment already made for similar procedure within set time frame.

F0248 A repayment for this line item was created to adjust a previous payment due to new updates to claim reference data.


F0249 Unable to determine region/division code for client. N36 Claim must meet primary payer’s processing requirements before we can consider payment.

F0250 Late billing - Claim must be filed 180 days from the end of the month of service or 180 days from the end of the eligibility add date.


F0251 NAT claims may only contain one detail line item. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.

F0252 Incorrect number of training hours for this training course billing code.


F0253 A completed NAT training course has been billed for earlier dates.


F0254 Only one incomplete training course per trainee is allowed for NAT.


F0255 Failed skills test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame.

F0256 This NAT service has been paid the maximum number of times.


F0257 An incomplete NAT training course has been billed for later dates.


F0258 Amount of claim exceeds available budget. N131 Total payments under multiple contracts cannot exceed the allowance for this service.

F0259 Failed oral test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame.

F0260 Failed written test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame.




F0261 Incorrect number of training hours for this training course billing code.


F0263 Records show that client has received this service for more than 14 consecutive days.


F0264 Claim is for a Billing Code that is mutually exclusive with Billing Code for previous Claim.


F0265 This claim is approved to pay. N14 Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.

F0266 Unable to determine appropriate state accounting codes for this claim. NHIC is researching this problem.


F0267 Unable to determine Budget Number from supplied information.


F0268 A valid service authorization for client for these service dates not available or claim dates cannot overlap more than one service authorization.


F0269 Claim Detail is an Exact Duplicate of History Claim Detail.


F0270 Cannot bill a positive line item for a separated alias client ID.


F0271 Client has received this service for more than 5 units per billing code per month.


F0272 The Billed Unit Rate exceeds the current maximum. M49 Missing/incomplete/invalid value code(s) and / or amount(s).

F0273 The Billed Units Count exceeds the current maximum.

M49 Missing/incomplete/invalid value code(s) and / or amount(s).

F0274 The Billed Applied Income/ Billed Copay Amount value has more than two decimal places.

M49 Missing/incomplete/invalid value code(s) and / or amount(s).

F0275 Claim must be filed via a HIPAA-compliant transaction set.


F0276 Procedure Qualifier is missing, invalid or not payable under the CMS LTC Program.


F0277 National Code is missing, invalid, not billable with Procedure Code Qualifier submitted or not payable under the CMS LTC program.


F0278 Claim must be filed with the appropriate HCPCS/CPT or Revenue Code.


F0999 Corresponding Negative Line Item or Header Denied.

N142 The original claim was denied. Resubmit a new claim, not a replacement claim. �




Helpful HintsKeep in mind the following helpful hints:

• The NHIC LTC Helpdesk operates Monday through Friday, 8 a.m. to 5 p.m. CST (excluding holidays). Call 800-626-4117 or 512-335-4729. Select from the following menu options:

• When contacting the LTC Helpdesk, have your nine-digit provider number ready.

• Claim form 1290 paper submitters: When submitting claims, be sure to correctly enter your nine-digit provider number in box 1 of claim form 1290.

• Send paper claims to the following address:National Heritage Insurance CompanyAttention: Long Term CarePO Box 200105Austin TX 78720-0105

Note: Delivery to NHIC could take three to five business days. Allow seven business days for the claim to appear in the system. Always have your provider number ready when calling the Helpdesk.

• Send overnight mail to:National Heritage Insurance CompanyAttention: Long Term Care12545 Riata Vista CircleAustin TX 78727-6524

Note: To avoid processing delays when sending overnight mail, make sure to include “Attention: Long Term Care.” Delivery to NHIC could take an additional day, depending on the time of day mailed. Allow three to five days for the claim to appear in the system. When calling to check the status, have your tracking number ready for the Helpdesk. ■

Option Description

1 Information about LTC claims

2Information about technical issues regarding TDHconnect

3Hear LTC banner messages if you are a paper submitter

LTC Bul let in 84

LTC Web SiteLTC has a page on the NHIC Web site at www.eds-nhic.com/LTC/default.htm. Refer to this site for helpful information on the LTC Program. ■

RemindersDo not forget to:

• Download your electronic R&S report weekly. R&S reports are available for 30 days only. Use dates from Friday to the following Monday.

• Make sure you create a financial summary when you create an R&S report.

• Download banner pages weekly from the LTCBNPG library on the TexMedNet File Libraries page at www.texmednet.com/library. The banners contain important, helpful information. Telephone the NHIC Helpdesk at 800-626-4117 if you have questions.

• Pull a MESAV request before contacting the NHIC LTC Helpdesk and requesting client information if your claim rejects. ■



http://www.texmednet.com/library/

http://www.texmednet.com/library/

Resources for Long Term Care QuestionsGeneral Table – All Providers

TDMHMR/ICF–MR

For questions about TDMHMR/ICF-MR, refer to the resources in the following table:

If you have questions about... Then contact...

HIPAA [email protected]

Cost Reports information (days paid, services paid) Information can be obtained by doing a Claim Status Inquiry (CSI) using TDHconnect.

How to prepare a Cost Report (forms, instructions) www.hhsc.state.tx.us/medicaid/programs/rad/index.html or call 512-338-6468 ■

If you have questions about… Then contact…

CARE Helpdesk 512-438-4720

Provider Warrants 512-206-5377

Applied Income Medicaid Eligibility (ME) worker for client

TPR Issues 512-490-4635

Health and Human Services Commission Network (HHSCN) 512-438-4720

ICF/MR Helpdesk Issues

Medicaid Administration Enrollment/Deductions• Provider vendor holds• Provider eligibility• Provider systems access forms

Medicaid Administration Billing

• Claims Management System billing claim form request• Service authorization• Client movement 3618• Durable medical equipment (DME)

Medicaid Administration UR/UC

• MR/RC assessment 3650• LOC claim form• Level of Service, LON, LOC• User documentation

512-206-5577 ■


mailto:[email protected]

http://www.hhsc.state.tx.us/medicaid/programs/rad/index.html

DHS – Provider Claims Services

For questions about Nursing Facilities, Hospice, Swing Beds, and Rehabilitation Specialized Services, refer to the resources in the following table:


Client Service Authorization• Service dates• Units of service approved• Service group service code

DHS512-490-4666 telephone512-490-4668 fax

ausmis31.dhs.state.tx.us/cmsmail

Level of Service

• TILE changes• Medical necessity



Provider Authorization System (PAS)• Provider enrollment• Deductions• Monetary penalties• Program enrollment staff issues• Provider on hold questions



Policy Questions/SAVERR/Client Eligibility• Applied income changes• Client financial eligibility issues• Client name changes



Regional Staff Issues• Contract manager issues• ME, CCAD, or CBA worker issues not resolved at

local/regional level• Administrative, clerical, technical staff issues• Caseworker/regional nurse issues



Hospice Issues DHS512-490-4666 telephone512-490-4668 fax


TPR Issues and/or Audits 512-490-4635 telephone �


http://ausmis31.dhs.state.tx.us/cmsmail






DHS LTC

For questions about Community Care - CBA - CLASS - Deaf and Blind - Consolidated Waiver - MDCP, refer to the resources in the following table:


Client Service Authorization• Client not registered• Missing/wrong service dates• 2060 scores, priority levels• Service group/code• Wrong copayment amount• Missing/wrong client information

Caseworker/Case Manager

Claim Form 3652• Medical necessity• TILE• Diagnoses


PAS and DAHS (SG7-SC 17 and SC29)

• Prior approval questions• Physician orders

Regional Prior Approval Nurse (PAN)

Policy Questions/SAVERR/Client Eligibility

• Applied income changes• Client financial eligibility issues• Client name changes

DHS512-490-4666 telephone512-490-4668 faxausmis31.dhs.state.tx.us/cmsmail

Client-Specific Policies/Procedures

• Financial/functional eligibility criteria• How to read/understand form 2101 or form 3671


Provider Policies/Procedures• Program rules• Rates• Enrollment procedures

Contract Manager

Provider Agencies’ Contract• Contract not registered• Clients not registered to contract• Missing/wrong budget/rates• Contract numbers• Missing/wrong service contract information• Provider on hold questions

Contract Managerausmis31.dhs.state.tx.us/cmsmail

Regional Staff Issues• Contract manager issues• ME, CCAD, or CBA worker issues not resolved at

local/regional level• Administrative, clerical, technical staff issues• Caseworker/regional nurse issues

DHS512-490-4666 telephone512-490-4668 faxausmis31.dhs.state.tx.us/cmsmail

Obtaining a copy of LTC claim form 1290 Contract Manager

The CLASS Program 877-438-5658

The Consolidated Waiver Program 512-438-3443 or 512-438-3444

The Deaf and Blind Program 512-438-2622

The Medically Dependent Children’s Program (MDCP) 877-438-5658

Status of claim after it has been transmitted to Fiscal by NHIC (When calling Fiscal, provide the DLN number assigned by NHIC.)

The Comptroller’s Web site: www.window.state.tx.us or TDHS Fiscal Office 512-438-3996 telephone or Contract Manager �





http://www.window.state.tx.us

NHIC

For questions about NHIC, refer to the resources in the following table:


Using TDHconnect or claim form 1290• Claim form 1290 completion• Claim form 1290 required fields• Claim adjustment questions• Claim status inquiries• Claim history questions• Claim rejection and denials• Understanding R&S• Research batch tracking

Long Term Care Helpdesk800-626-4117 (outside Austin)512-335-4729 (Austin)Option 1

TDHconnect Technical Issues• Obtain TDHconnect access• Modem and telecommunication issues• ANSI ASC X12 specification issues• ANSI ASC X12 testing and transmission• Obtain User ID and passwords• Process provider agreements• Verify system screens are functioning• Assist software developers with Electronic Data Interchange

(EDI) and connectivity

EDI Technical Helpdesk800-626-4117 (outside Austin)512-335-4729 (Austin)Option 2

Banner Messages in Audio

• Updated monthly• Paper submitters

800-626-4117 (outside Austin)512-335-4729 (Austin)Option 3

Medical Necessity/Client Appeal

• Additional information for claim form 3652• Client appeal request• Appeal/denial process and guidelines

Nursing Facility Division800-727-5436 Option 1 (Nurses)

General Inquiry • General policy about claim forms 3652, 3618, 3619• Denied Purpose Code E• Status of claim form 3652• TILE level• Effective dates of forms

Nursing Facility Division800-727-5436Option 2 (Customer Service)

Electronic transmission of claim forms 3652, 3618, and 3619• Weekly status reports• CARE Claim Form Software (CFS) installation• Problems with transmitting forms

Nursing Facility Division800-727-5436 (electronic claims submission)Option 3

MDS submission or reports

• General MDS guidelines• Interpreting Quality Indicator (QI) reports

Nursing Facility Division800-727-5436 (electronic claims submission)Option 3 �


Your NHIC Training Specialists by TerritoryThe NHIC has a team of training specialists to serve the Texas Medicaid Program provider community. These training specialists conduct educational workshops such as Success with Medicaid and TDHconnect. Feel free to contact the training specialist assigned to your territory to schedule a visit. You can find more information at www.eds-nhic.com/provenrl/imagemap.html.

Territory Regional Area Training SpecialistTelephone Number E-mail Address

1 Amarillo, Lubbock Toni Emmons 512-514-3267 [email protected]

2 Abilene, Odessa Christy Mangum 512-514-3215 [email protected]

3 El Paso TBD 512-514-3253 TBD

4 San Angelo Bob Perez 512-514-3605 [email protected]

5 San Marcos, Victoria JoAnn Kunde 512-514-3238 [email protected]

6 Austin, Georgetown Ginny Mahoney 512-514-3275 [email protected]

7 San Antonio, Eagle Pass Jill Ray 512-514-3606 [email protected]

8 Laredo, Harlingen Cynthia Gonzales 512-514-3221 [email protected]

9 San Antonio, Corpus Christi Jill Ray 512-514-3606 [email protected]

10 Bastrop, Bryan/College Station TBD 512-514-3608 TBD

11 Fort Worth, Wichita Falls Rita Martinez 512-514-3231 [email protected]

12 Dallas TBD 512-514-3270 TBD

13 Dallas, Arlington Elaine Watson 512-514-3216 [email protected]

14 Dallas, Tyler Dawn Pearce 512-514-3203 [email protected]

15 Beaumont, Nacogdoches John Miller 512-514-3249 [email protected]

16 Houston Jennifer Vandiver 512-514-3285 [email protected]

17 Houston, Galveston TBD 512-514-3241 TBD

18 Houston Linda Wood 512-514-3278 [email protected]

19 Waco Paul Spock 512-514-3254 [email protected]

20 Austin TBD 512-514-3607 TBD �




http://www.eds-nhic.com/provenrl/imagemap.html














Glossary of TermsThe table below is a collection of the terms and definitions used in this bulletin:

Term Definition

270 Health Care Eligibility Benefit Inquiry

271 Health Care Eligibility Benefit Response

276 Health Care Claims Status Request

277 Health Care Claims Status Response

278 Health Care Services Request for Review and Response (Prior Authorization)

835 Health Care Claims Payment/Advice

837 Health Care Claim

837D Dental Health Care Claim

837I Institutional Health Care Claim

837P Professional Health Care Claim

Accepted Terminology referring to paper-, electronic-, and system-generated claims that are accepted into the EDS-CMS system for processing

ADA American Dental Association (develops codes for dental procedures)

Adjustment Request Provider generated request to make a change on a previously submitted claim

AFC Adult Foster Care

ANSI American National Standards Institute, an organization that accredits various standards setting committees and monitors their compliance

Applied Income The portion of a client’s income to be applied towards the cost of his/her long term care services per Medicaid rules

Atypical Services that are deemed nonmedical in nature or those services determined by DHS/TDMHMR to not have an appropriate National Procedure/Revenue Code

Batch Scheduled processing of one or more logical documents grouped together as a file; a group of transactions for one provider within a transmission

Batch Number The number assigned to an individual batch within a transmission to ECMS

BBS Bulletin Board System

Bill Code Code depicting a service performed by the provider

Bill Code Crosswalk Table A reference table that translates or maps the information used in filing a claim now to information necessary to complete the claim after HIPAA implementation; see “Long Term Care Bill Code Crosswalk Table” on page 17.

Billing Cycle The period of time from the point of submitting a request for payment to the point of receipt of payment

Budget Number The budget a claim will bill against; the second modifier field will be used to denote which budget is being used.

CBA Community-based Alternatives Waiver Program

CCAD Community Care for the Aged and Disabled Program

Claim An original/initial request for payment of services for a single client that consists of one or more line item; a claim can be submitted on paper or electronically.

Claim Filing Indicator Code Code identifying the type of claim or expected adjudication process; found on the 835 and 837 transactions

Claim Frequency Code Code specifying the frequency of the claim; found on the 835 and 837 transactions

Claim History A record of all accepted claims submitted to CMS

Claim Status Codes A national administrative code set that identifies the status of health care claims; this code set is used in the X12 277 Claim Status Notification transaction.

Claim Status Inquiry (CSI) A transaction (276) requesting information on the status of a claim previously submitted to CMS for processing

Claim Type A code that identifies the category a claim falls within


Claims Management System Integrated, generic term for the computer platforms and applications that work together to support long term care programs for Texas

CLASS Community Living Assistance and Support Services Program

Client CMS term for the health care consumer eligible for long term care services through DHS or TDMHMR

Client Control Number (Patient Account Number)

User-defined number submitted on a claim to identify the health care consumer

Client Number The number assigned to an individual by DHS; the client becomes Medicaid eligible, the client number becomes their Medicaid number.

CMS Acronym for the DHS/TDMHMR claims management system

Code Set Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.

Compliance Date Under HIPAA, this is the date which a covered entity must comply with a standard, an implementation specification, or a modification. For EDI, it is October 16, 2003.

Covered Entity Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Consumer Managed Personal Attendant Services (CMPAS)

Financial intermediary services provided to eligible clients who supervise or have some who can supervise their attendant or have clients who are responsible for interviewing, selecting, training, supervising, and releasing their attendants

Copayment The assessed amount or percentage of the cost of services that the client or coinsurance is responsible for paying

CPT-4 Physician Current Procedural Terminology (for most acute care medical services)

CWP Consolidated Waiver Program

DAHS Day Activity and Health Services

Data Content Under HIPAA, this is all of the data elements and code sets inherent to a transaction.

DBMD Deaf-Blind with Multiple Disabilities Program

Deny Terminology referring to paper-, electronic-, and system-generated claims that are accepted into the EDS-CMS system for processing but are subsequently denied for claims payment

DHS Texas Department of Human Services

Diagnosis Code An ICD-9-CM diagnosis code identifying a diagnosed medical condition

DLN Document Locator Number

DME Durable Medical Equipment

Document Locator Number (DLN) Number assigned to identify each warrant request

EBX EDS Clearinghouse for Electronic Transmissions

EDI Acronym for Electronic Data Interchange

Edits Checkpoints for claim validity and long term care business rules in claims processing; four types of edits are acceptance, local, LTC policy, and validity.

EDS Electronic Data Systems

Electronic Data Interchange Electronic exchange of formatted data

Emergency Dental Services Program that provides dental care to residents in nursing facilities

Emergency Response Systems Services provided through electronic monitoring systems used to convey signals for assistance

EOB Explanation of Benefits

ERS Emergency Response Systems

ESI Eligibility Services Incorporated

Expedited Claims Claims submitted for rapid payment for services.

Explanation of Benefits Explanation of the disposition of a provider claim

Term Definition


Explanation of Benefits An explanation of the payment or denial of a provider claim

Finalized Claim A claim that has completed processing through CMS resulting in payment or denial of payment

Fund Code Code that identifies the source of funds to be paid to a provider for a particular service

Graphical User Interface (GUI) A graphical vs purely textual user interface of a computer; it provides a “picture-oriented” way to interact with technology.

HCPCS Health Care Common Procedural Coding System is a medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes.

Health Care Claim (837) Claim submitted by a provider requesting payment for services provided to the health care consumer

Health Care Clearinghouse Under HIPAA, an entity that processes or translates claims received from another entity in nonstandard format into HIPAA-compliant format

HIPAA Health Insurance Portability and Accountability Act of 1996

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HIPAA is a federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers, and employers; and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. (Public Law 104-191)

ICN Internal Control Number

Interactive Real time processing of a transaction taking place while the submitter remains directly or indirectly connected to the processing computer

Interactive Submission Submission of a single transaction to the Tandem MMIS

Interface The point at which two systems connect to pass data

Internal Control Number A number assigned by EDS-CMS to uniquely identify a claim

Item Code Defines the item authorized for purchase or the service authorized for payment; the item code will not be used for services or purchases made on or after October 16, 2003.

Line Item A claim line item consists of services performed for a client within a specified period of time.

Line Item Control Number Identifier assigned by the submitter to the respective line item

Local Code A generic term for code values that are defined for a state or other political subdivision, or for a specific payer; this term is most commonly used to describe HCPCS Level III Codes but also applies to other code sets as well.

LTC Long Term Care

MDCP Medically Dependent Children’s Program

Medicaid Federally funded program, administered by the states, to pay for health care for eligible individuals

Medical Record Number (Trace Sequence Number)

A unique number assigned to the client by the provider to assist in the retrieval of medical records

MESAV Medicaid Eligibility and Service Authorization Verification application

MHMR (TDMHMR) Texas Department of Mental Health and Mental Retardation

Modifier A two-digit code with a specific meaning used to further define the procedure code to assist in claims adjudication

NAT Nurse Aide Training

National Procedure Codes HCPCS, CPT, and dental codes representing services provided to the health care consumer

National Provider ID A system for uniquely identifying all providers of health care services, supplies, and equipment

NHIC National Heritage Insurance Company

Nonatypical Nonatypical services are those services that are considered medical/health related.

Term Definition


PACE Program of All Inclusive Care for the Elderly

PAS Personal Assistance Services

Patient Account Number (Client Control Number)

This is a unique identification number assigned by the provider to the claim patient to facilitate posting of payment information and identification of the billed claim; it is found on the 837 transactions.

Pended Claim Suspended claim

Per Authorized Unit Type Units approved to equal the cost of the authorized service

POS Place of Service is the location where services were obtained.

Principal Procedure Code Code identifying the principal procedure, product, or service; it is found on the 837I.

Procedure Code A standard national code used to uniquely identify a procedure, product, or service delivered to the client

Procedure Code Qualifier Code identifying the source of the procedure code

Provider Person, group, or agency who is contracted to perform a service for health care consumers

Provider Number (Provider ID) This is the contract number assigned to the Long Term Care provider/provider agency by the state of Texas; it was formerly known as Vendor Number. On ANSI provider systems, this will be the “Secondary Provider ID.”

Provider Taxonomy Code An administrative code set for identifying the provider type and area of specialization for all health care providers

R&S Remittance and Status Report

RC Respite Care

Reject Terminology referring to electronic- or system-generated claims that are not accepted into the EDS-CMS system for processing

Release of Information Code Code indicating whether the provider has on file, a signed statement permitting the release of medical data to other organizations

Remittance and Status Report An electronic or paper report that informs a provider on pending, paid, denied, or adjusted claims

Rendering Provider The name of the provider who performed the service

Response An electronic message returned to the submitter of an electronic transmission that contains information about a claim or query

Retroactive Adjustments Adjustments initiated by the state to a claim after it has been finalized

Revenue Code A three-(four) digit standard national code depicting the “revenue” center for the specific services being billed; revenue codes are used to classify types of services (that is, accommodations, ancillary services) and in some cases, must be used in tandem with HCPCS codes. (UB-92)

Service Authorization Approval by DHS/TDMHMR for a client to receive a service in a specified period of time from a contract provider

Service Code A code used to denote a specific service or category of service

Service From Date The date the service referenced in the claim or service line was initiated

Service Group The long term care program for which the client is eligible

SSPD Special Services to Persons with Disabilities

Standard Transaction Under HIPAA, this is a transaction that complies with the applicable HIPAA standard.

Suspended Claim A claim that has failed a program edit and is pending edit resolution before continued processing

TDHconnect A Windows-based application for personal computers to support provider electronic claims submissions, Medicaid eligibility/service verification authorization inquiries, claim status inquiries, electronic remittance and status, and adjustment request submissions for Long Term Care services

Template A TDHconnect window that shows all of the data fields needed to submit a claim or MESAV request; templates allow information to be saved for future use.

Term Definition


Texas Index of Level of Effort (TILE) The level of effort required by providers to provide the appropriate service(s) to a client based on an assessment of the client's medical need; a TILE is used in the calculation of the payment rate for certain services to a client. There are 11 different TILEs (values 201 through 211).

TILE Acronym for Texas index for level of effort

Trace Sequence Number (Medical Record Number)

Provider submitted number allowing the provider to associate a particular response to a claim that is sent as feedback by CMS to the original claim input

Transaction Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care.

Unit The authorized amount of service

Unit Rate The dollar amount applied to each unit being billed

VA Veteran’s Affairs

Warrants Checks or direct deposits from the Comptroller for payment to providers and vendors for services rendered to LTC clients �

Term Definition


Notes:


National Heritage Insurance Co.12545 Riata Vista CircleAustin TX 78727-6524

PRESORTED STANDARDUS POSTAGE PAID

AUSTIN TXPERMIT NO 2545

ATTENTION: BUSINESS OFFICE

LTC Bulletin

NHICan EDS company

Documents

November 2003 Long Term Care Bulletin, No. 16 › LTC_Provider_Bulletin › 2003 › 016_LTC.pdf · November 2003, No. 16 3 LTC Bulletin Contract Transition to TMHP The Texas Medicaid