radiology, laboratory, and physiological lab services - TMHP

TE X A S M E D I C A I D P R O V I D E R P R O C E D U R E S M A N U A L : V O L . 2

RADIOLOGY, LABORATORY, ANDPHYSIOLOGICAL LAB SERVICES HANDBOOK

RL-2CPT ONLY - COPYRIGHT 2009 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.

TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2


RADIOLOGY, LABORATORY, AND PHYSIOLOGICAL LAB SERVICES HANDBOOK

RADIOLOGY, LABORATORY, AND PHYSIOLOGICAL LAB SERVICES

HANDBOOK

Table of Contents

1. General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .RL-5

2. Independent Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .RL-5

2.1 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .RL-52.1.1 Clinical Laboratory Improvement Amendments (CLIA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-5

2.1.1.1 CLIA Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-52.1.1.2 CLIA Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-62.1.1.3 Waiver Certificates and Physician-Performed Microscopy Procedure

(PPMP) Certificates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-6

2.2 Services/Benefits, Limitations and Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . .RL-72.2.1 Reference Labs and Lab Handling Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-7

2.2.1.1 Family Planning Lab Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-72.2.2 Laboratory Paneling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-8

2.2.2.1 Complete Blood Count (CBC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-82.2.2.2 Chemistry Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-92.2.2.3 Urinalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-9

2.2.3 Ferritin and Iron Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-102.2.4 Laboratory Services for Clients on Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-112.2.5 Organ or Disease Panels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-112.2.6 Texas Health Steps (THSteps) Outpatient Laboratory Services . . . . . . . . . . . . . . . . . . . . . RL-122.2.7 Repeated Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-12

2.2.7.1 Modifier 91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-122.2.7.2 Modifier 76 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-13

2.2.8 Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-13

2.3 Documentation Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-13

2.4 Claims Filing and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-132.4.1 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-13

2.4.1.1 Electronic Filing for Laboratory Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-142.4.2 Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-14

3. Physician-performed Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-15

4. Radiology, Physiological Laboratory, and Portable X-Ray Supplier . . . . . . . . . . . . . . . . . . . . RL-15

4.1 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-15

4.2 Services/Benefits, Limitations and Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . RL-154.2.1 Ambulatory Electroencephalogram (A/EEG). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-154.2.2 Contrast Materials/Radiopharmaceuticals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-15

4.2.2.1 Procedure Codes and Diagnosis Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-164.2.2.2 Prior Authorization for Contrast Materials/Radiopharmaceuticals . . . . . . . . . . . RL-16

4.2.3 Radiology Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-164.2.3.1 Cardiac Blood Pool Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-174.2.3.2 CT, CTA, MRI, and MRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-17

4.2.3.2.1 CT and CTA Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-174.2.3.2.2 MRI and MRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-18



4.2.3.2.3 CT, CTA, MRI, and MRA Authorization Requirements. . . . . . . . . . . . . . . . . . . . . RL-194.2.3.2.4 Completing and Submitting the Authorization Request . . . . . . . . . . . . . . . . . RL-21

4.2.3.3 Myocardial Perfusion Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-224.2.3.4 Positron-Emission Tomography (PET) Scans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-22

4.2.3.4.1 Brain Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-224.2.3.4.2 Tumor Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-224.2.3.4.3 Prior Authorization for PET Scans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-22

4.2.4 Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-234.2.5 Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-23

4.3 Documentation Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-23

4.4 Claims Filing and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-234.4.1 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-23

4.4.1.1 Diagnosis Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-234.4.1.2 Modifier Requirements for Type of Service Assignment. . . . . . . . . . . . . . . . . . . . . RL-24

4.4.2 Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-24

5. Claims Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-25

6. Contact TMHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-25

7. Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-25RL.1 Radiology Prior Authorization Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-26

8. Claim Form Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-27RL.2 Independent Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-28RL.3 Office Visit with Lab and Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-29RL.4 Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RL-30RL.5 Radiological/Physiological Laboratory and Portable X-Ray Supplier . . . . . . . . . . . . . . . . . . . . . . RL-31

Note: A comprehensive Index, including Volume 1 and all handbooks from Volume 2, is included at the end of Volume 1 (General Information).



RADIOLOGY, LABORATORY, AND PHYSIOLOGICAL LAB SERVICES

HANDBOOK

1. GENERAL INFORMATION

This information is intended for Texas Medicaid independent (freestanding) laboratories, radiological laboratories, and physiological laboratories.The handbook provides information about Texas Medicaid's benefits, policies, and procedures applicable to these providers.

Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide healthcare services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Adminis-trative Code (TAC) §371.1617(a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver healthcare items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance.

Refer to: Section 1, Provider Enrollment and Responsibilities (Vol. 1, General Information)

Subsection 8.1, “Medicaid Managed Care” in Section 8, “Managed Care” (Vol. 1, General Information)

2. INDEPENDENT LABORATORY

2.1 EnrollmentTo enroll in Texas Medicaid, the independent (freestanding) laboratory must do the following:

• Be independent from a physician's office or hospital

• Meet staff, equipment, and testing capability standards for certification by HHSC

• Have Medicare certification

• Submit a current copy of the medical director's physician license, if the lab has physician involvement

2.1.1 Clinical Laboratory Improvement Amendments (CLIA)

2.1.1.1 CLIA RequirementsTo be eligible for reimbursement by Medicare and Medicaid, all providers performing laboratory tests must do the following:

• Pay a fee to the Centers for Medicare & Medicaid Services (CMS).



• Contact HHSC at 1-512-834-6650 to receive a CLIA registration and/or certification number. Submit CLIA applications to the following address:

Health Facility Licensing and Certification DivisionHHSC

1100 West 49th StreetAustin, TX 78756

• Notify TMHP of the assigned CLIA number at the following address:

Texas Medicaid & Healthcare PartnershipProvider Enrollment

PO Box 200795Austin, TX 78720-0795

TMHP monitors claims submitted by clinical laboratories for CLIA numbers. Without a CLIA number on file with TMHP, claims for laboratory services will be denied.

2.1.1.2 CLIA RegulationsCMS implemented CLIA rules and regulations. The CLIA regulations were published in the February 28, 1992, Federal Register and have been amended several times since. The regulations are found at Title 42 Code of Federal Regulations, Part 493. The CLIA rules and regulations are available on the CMS website at www.cms.gov.

CLIA regulations set standards designed to improve quality in all laboratory testing and include specifi-cations for quality control (QC), quality assurance (QA), patient test management, personnel, and proficiency testing. These regulations concern all laboratory testing used for the assessment of human health or the diagnosis, prevention, or treatment of disease. Under CLIA 88, all clinical laboratories (including those located in physicians' offices), regardless of location, size, or type of laboratory, must meet standards based on the complexity of the test(s) they perform.

2.1.1.3 Waiver Certificates and Physician-Performed Microscopy Procedure (PPMP) Certificates

CLIA certificates may limit the holder to performing only certain tests. Medicaid bills must accurately reflect those services authorized by the CLIA program and no other procedures. Two types of certificates limit holders to only certain test procedures: Waiver and PPMP certificates.

Providers holding waiver CLIA certificates are authorized to perform only the following tests:

The QW modifier is a CLIA requirement for specific codes based on their complexity and must be included or claims will be denied.

Procedure Codes80047-QW 80048-QW 80051-QW 80053-QW 80061-QW 80101-QW 80178-QW 8100281003-QW 81025 82010-QW 82042-QW 82044-QW 82055-QW 82120-QW 82150-QW82247-QW 82270-QW 82271-QW 82272-QW 82274-QW 82330-QW 82465-QW 82523-QW82570-QW 82679-QW 82947-QW 82950-QW 82951-QW 82952-QW 82977-QW 82985-QW83001-QW 83002-QW 83026 83036-QW 83037-QW 83518-QW 83520-QW 83605-QW83718-QW 83721-QW 83880-QW 83986-QW 84075-QW 84132-QW 84157-QW 84295-QW84443 84450-QW 84460-QW 84478-QW 84520-QW 84703-QW 85013 85014-QW85018-QW 85576-QW 85610-QW 85651 86294-QW 86308-QW 86318-QW 86618-QW86701-QW 86703-QW 87077-QW 87210-QW 87449-QW 87804-QW 87880-QW

http://www.cms.gov

http://www.cms.gov



Holders of PPMP certificates are authorized to perform all the procedures listed for waiver certificate in addition to the following tests:

2.2 Services/Benefits, Limitations and Prior Authorization Texas Medicaid only covers professional and technical services that an independent laboratory is certified by Medicare to perform.

2.2.1 Reference Labs and Lab Handling Fees Independent laboratories may be reimbursed for tests that they perform and for lab handling fees for tests that they forward to another laboratory (reference laboratory).

An independent laboratory that forwards a specimen to another laboratory without performing any tests on that specimen may not bill for any laboratory tests. An independent laboratory may only bill Texas Medicaid for tests referred to another laboratory (independent or hospital) if it performs at least one test that it is Medicare-certified to perform and forwards a portion of the same specimen to another laboratory (reference laboratory) to have one or more tests performed.

In this instance, the referring laboratory may bill for tests it has performed and all tests it is to perform on the specimen. When billing, the following information must be on the claim:

An independent laboratory that forwards a specimen to another laboratory (independent or hospital) may bill a handling fee (procedure code 99001) for collecting and forwarding the specimen to the other laboratory if the specimen is collected by routine venipuncture or catheterization.

Routine venipunctures or finger, heel, and ear sticks for collection of specimen(s) (procedure code 36415) are not a benefit of Texas Medicaid.

Only one handling fee may be charged per day, per client, unless specimens are sent to two or more different laboratories; this must be documented on the claim.

2.2.1.1 Family Planning Lab Tests

Family planning agencies must use procedure code 99000 with a family planning diagnosis code to bill their laboratory handling charges for laboratory specimens sent out; modifier FP must be omitted. Providers may refer to the appropriate section in the provider manual for instructions for billing family planning services. As with procedure code 99000, only one handling fee may be charged for each laboratory to the agency that sends specimens, regardless of the number of specimens taken.

When family planning test specimens such as Pap smears are collected, providers must direct the laboratory to indicate the claim for the test is to be billed as a family planning service.

Procedure Codes81000 81001 81015 81020 89190 Q0111 Q0112 Q0113 Q0115

Information CMS-1500“Yes” box must be checked Block 20The name, address, and ZIP code of the reference lab to where the specimens have been forwarded.

Block 32

Texas Provider Identifier (TPI) and National Provider Identifier (NPI) of the reference lab must be indicated next to each procedure to be performed by the reference lab.

Block 24-J Note: The TPI goes in the shaded area of the

block. The NPI goes in the unshaded area of the block.



Refer to: Subsection 3.3, “Services/Benefits, Limitations, and Prior Authorization” in the Gyneco-logical and Reproductive Health, Obstetrics, and Family Planning Services Handbook, for the complete list of family planning diagnosis codes.

2.2.2 Laboratory PanelingThe reimbursement for the complete panel procedure code represents the total payment for all laboratory services covered under that panel. The Texas Medicaid allowable fee for the individual components of the complete lab panel does not exceed the fee for the complete lab panel. The provider is reimbursed the lesser of the combined fees for the two or more laboratory services delivered or the single panel fee.

When all of the components of the panel are performed, the complete panel procedure code must be billed. When only two or more components of the panel are performed, the individual procedure codes for each laboratory test performed may be billed.

Medicare policy pertaining to laboratory paneling procedures was implemented by Texas Medicaid.

Refer to: Subsection 6.3.34, “Laboratory Services” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

2.2.2.1 Complete Blood Count (CBC)

A complete blood count (CBC) is a comprehensive service that includes components. Either a CBC procedure code or the components may be reimbursed. All laboratory services must be documented in the patient’s medical record as medically necessary and referenced to an appropriate diagnosis code when billed.

Texas Medicaid considers a baseline CBC appropriate for the evaluation and management of existing and suspected disease processes. CBCs should be individualized and based on client history, clinical indications or proposed therapy and will not be reimbursed for screening purposes.

Blood counts may be reimbursed using the following procedure codes:

When related CBC procedure codes are billed with the same date of service by the same provider, the first procedure code may be reimbursed and the other procedure codes will be denied.

Procedure CodesComplete Blood Count Procedure Codes85025 85027 85032Hemogram or CBC with platelet panel codes 85025 to 85027 may be reimbursed when two or more components of a CBC and a platelet count are performed. The individual tests will be denied if billed with the same date of service.Hemogram Component Procedure Codes85013 85014 85018 85041 85048Differential Analysis Procedure Codes85004 85007 85008 85009Platelet Procedure Codes85049Reticulocyte Procedure Codes85044 85045 85046Reticulocyte procedure codes 85044, 85045, and 85046 may be reimbursed in addition to a CBC.



The following procedure codes will be denied as part of another service when billed with procedure code 85025 for the same date of service by the same provider:

The procedure codes in Column A of the following table will be denied when billed by the same provider with the same date of service as the procedure codes in Column B:

2.2.2.2 Chemistry Tests

The following chemistry tests may be reimbursed individually unless a complete panel is performed:

2.2.2.3 Urinalysis

The total component for the following procedure codes may be reimbursed for urinalysis laboratory services:

Procedure Codes85004 85007 85008 85009 85013 85014 85018 85027 8503285041 85048 85049

Column A (Denied) Column B85004 85007, 85009, 85025, 8502785007 8502585008 85004, 85025, 85027, 85032, 852048, 8504985009 8502585013, 85014, 85018 85025, 8502785027 8502585032 85025, 85027, 85041, 85047, 8504985041 85025, 8502785044 85045, 8504685045 8504685048 85025, 8502785049 85025, 85027

Procedure Codes82040 82150 82247 82248 82310 82373 82374 82435 8246582550 82565 82945 82947 82948 82977 83090 83615 8366383664 83690 83735 83921 84075 84078* 84100 84132 8415284155 84160 84295 84450 84460 84478 84520 84550 84591* Procedure code 84078 is considered a component of the multiple chemistry panels.

Procedure Codes81000 81001 81002 81003 81005 81015 81020 84578 8458084583



Procedure code 84578 may be reimbursed when billed with the same date of service as the following urinalysis procedure codes:

The procedure codes in Column A of the following table will be denied when billed by the same provider with the same date of service as the procedure codes in Column B:

When related urinalysis procedure codes are billed with the same date of service by the same provider, the first procedure code may be reimbursed and all other procedure codes will be denied. Providers may appeal with an appropriate urinalysis procedure code that combines the related components.

2.2.3 Ferritin and Iron StudiesProcedure codes 82728, 83540, 83550, 84466, and 85536, may be reimbursed when medically necessary and when submitted with one of the following diagnosis codes:

Procedure Codes81000 81001 81002 81003 81005 81020

Column A (Denied) Column B84578 84580, 8458381002, 81015 8100081002, 81003, 81007, 81015 8100181000 81003, 81005, 8102082044 81015

Procedure Codes23871 23872 23873 23874 23875 23876 23877 23879 24900 2490124910 24911 24920 24921 24930 24931 24940 24941 24950 2495124960 24961 24970 24971 24980 24981 24990 24991 25000 2500125002 25003 25010 25011 25012 25013 25020 25021 25022 2502325030 25031 25032 25033 25040 25041 25042 25043 25050 2505125052 25053 25060 25061 25062 25063 25070 25071 25072 2507325080 25081 25082 25083 25090 25091 25092 25093 2570 25722578 2579 2750 2800 2801 2808 2809 2810 2811 28122813 2814 2818 2819 28241 28242 28249 28260 28261 2826228263 28264 28268 28269 2827 2828 2829 2839 2850 2852128522 28529 2859 33399 4254 4260 42610 42611 42612 426134262 4263 4264 42650 42651 42652 42653 42654 4266 426742681 42682 42689 4269 4270 4271 4272 42731 42732 4274142742 42760 42761 42769 42781 42789 4279 4280 4281 4282042821 42822 42823 42831 42832 42833 42840 42841 42842 428434289 4481 57140 57141 57142 57149 5715 5718 5719 57385739 60784 6083 6260 6261 70400 70900 70909 7099 713071500 71504 71509 71510 71511 71512 71513 71514 71515 7151671517 71518 71520 71521 71522 71523 71524 71525 71526 7152771528 71530 71531 71532 71533 71534 71535 71536 71537 71538



Procedure codes 82728, 83540, 83550, 84466, and 85536 may be reimbursed when submitted by the same provider with the same date of service with the following exception: procedure code 83550 will be denied if billed with the same date of service by the same provider as procedure code 84466. Modifier 91 may be used to submit more than one of the same procedure code with the same date of service when medically necessary.

2.2.4 Laboratory Services for Clients on DialysisLaboratory services may be reimbursed when performed for clients on dialysis. Charges for routine laboratory tests performed according to the established frequencies are included in the facility's dialysis charge billed to Texas Medicaid regardless of where the tests were performed. Routine laboratory services performed by an outside laboratory are billed to the facility.

Nonroutine laboratory services for clients dialyzing in a facility and all lab work for clients on continuous ambulatory peritoneal dialysis (CAPD) may be billed separately from the dialysis charge.

Refer to: Subsection 4.2.8, “Laboratory and Radiology Services ” in Outpatient Services Handbook (Vol. 2, Provider Handbooks) for more information.

2.2.5 Organ or Disease PanelsOrgan panels are specific laboratory studies that have been combined under a problem-oriented classi-fication as an approach to diagnosis.

The following list of panels includes all components that must be included to report the panel code. Individual laboratory studies considered part of a specific panel will be denied when they are billed by the same provider with the same date of service as the panel procedure code.

71580 71589 71590 71591 71592 71593 71594 71595 71596 7159771598 71640 71641 71642 71643 71644 71645 71646 71647 7164871649 71650 71651 71652 71653 71654 71655 71656 71657 7165871659 71660 71661 71662 71663 71664 71665 71666 71667 7168071681 71682 71683 71684 71685 71686 71687 71688 71689 7169071691 71692 71693 71694 71695 71696 71697 71698 71699 78917892 78951 78959 7904 7906

80047 - Panel must include:82330 82374 82435 82565 82947 84132 84295 8452080048 - Panel must include:82310 82374 82435 82565 82947 84132 84295 8452080050 - Panel must include:80053 85025 or 85027 and 85004

OR85027 and 85007 or 85009 8444380051 - Panel must include:82374 82435 84132 8429580053 - Panel must include:82040 82247 82310 82374 82435 82565 82947 84075 84132 8415584295 84450 84460 8452080055 - Panel must include:

Procedure Codes



Organ and disease panel codes 80048, 80051, and 80053 must be used instead of the general multi-channel automated panel codes.

2.2.6 Texas Health Steps (THSteps) Outpatient Laboratory ServicesThe following procedure codes will be denied if submitted by a THSteps medical provider or an outside laboratory with the same date of service as a THSteps medical check up:

The following procedure codes may be reimbursed separately to an outside laboratory but will be denied if submitted by a THSteps medical provider with the same date of service as a THSteps medical check up:

The procedure codes in the above table are subject to retrospective review and recoupment of inappro-priate payments.

Refer to: Subsection 6.3.2.6, “Laboratory Procedures” in Children's Services Handbook (Vol.2, Provider Handbooks).

2.2.7 Repeated Procedures

2.2.7.1 Modifier 91 Modifier 91 should be used for repeat clinical diagnostic tests as follows:

• Modifier 91 must not be used when billing the initial procedure. It must be used to indicate the repeated procedure.

• If more than two services are billed on the same day by the same provider, regardless of the use of modifier 91, the claim or detail is denied.

• If a repeated procedure performed by the same provider on the same day is billed without modifier 91, it is denied as a duplicate procedure.

85025 or 85027 and 85004OR

85027 and 85007 or 85009 87340 86762 86592 86850 86900AND

8690180061 - Panel must include:82465 83718 8447880069 - Panel must include:82040 82310 82374 82435 82565 82947 84100 84132 84295 8452080074 - Panel must include:86705 86709 86803 8734080076 - Panel must include:82040 82247 82248 84075 84155 84450 84460

Laboratory Test Procedure Codes83020 83021 83655 85013 85014 85018 86403 87490 8759088141 88142 88143 88147 88148 88150 88152 88153 8815488164 88165 88166 88167 88174 88175 84203

Laboratory Test Procedure Codes80061 82465 82947 82952 83718 84478 86592 86689 86701



• If a claim is denied for a quantity more than two or as a duplicate procedure, the times of these procedures and services must be documented on appeal.

• Modifier 91 is not required and must not be used when billing multiple quantities of a supply.

Providers may appeal claims that have been denied for documentation of time. Most procedure codes initially requiring modifier 91 will continue to be audited for modifier 91.

When appealing claims with modifier 91 for repeat procedures, providers must separate the details. One detail should be appealed without the modifier and one detail with the modifier, including documen-tation of times for each repeated procedure.

2.2.7.2 Modifier 76 Modifier 76 is limited as follows:

• Modifier 76 must not be used when billing the initial procedure. It must be used to indicate the repeated procedure.

• If more than two services are billed on the same day by the same provider, regardless of the use of modifier 76, the claim or detail is denied.

• If a repeated procedure performed by the same provider on the same day is billed without modifier 76, it is denied as a duplicate procedure.

• If a claim is denied for a quantity more than two or as a duplicate procedure, the times of these procedures/services must be documented on appeal.

• Modifier 76 is not required and must not be used when billing multiple quantities of a supply.

When appealing claims with modifier 76 for repeat procedures, providers must separate the details. One detail should be appealed without the modifier and one detail with the modifier, including documen-tation of times for each repeated procedure.

2.2.8 Prior AuthorizationPrior authorization is not required for laboratory services.

2.3 Documentation RequirementsAll services require documentation to support the medical necessity of the service rendered, including independent laboratory services. Independent laboratory services are subject to retrospective review and recoupment if documentation does not support the service billed.

Independent laboratory documentation must include the physician’s signed and dated order for the laboratory test(s). The specific tests ordered by the physician must be listed on the order. The test results must also be included in the documentation.

2.4 Claims Filing and Reimbursement2.4.1 Claims Information When family planning test specimens such as Pap smears are collected, providers must direct the laboratory to indicate the claim for the test is to be billed as a family planning service using diagnosis code V2509.

A National Provider Identifier (NPI) is required for all claims. In addition, for paper claims the Texas Provider Identifier (TPI) is required for the billing and performing provider only. NPI-only is required for all other fields.

Providers must submit independent laboratory services to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers must purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms.



When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to: Section 3, TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.

Section 6, Claims Filing (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

2.4.1.1 Electronic Filing for Laboratory Providers

Referring provider information is always required on laboratory claims. Failure to submit this data will result in a claim rejection on the TMHP Electronic Data Interchange (EDI).

When the place of service is 6 and the billing provider identifier belongs to a laboratory, there is no need to submit the same provider identifier in the facility ID field. This notation causes the claim to suspend processing unnecessarily, and may cause a delay in the disposition of the claim. For questions about the electronic fields, contact the commercial software vendor or the TMHP EDI Help Desk at 1-888-863-3638.

2.4.2 Reimbursement The Medicaid rates for independent laboratories are calculated in accordance with 1 TAC §355.8081 and §355.8610, and the Deficit Reduction Act (DEFRA) of 1984. By federal law, Medicaid payments for clinical laboratory services cannot exceed the Medicare payment for that service.

As the result of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982, independent laboratories are not directly reimbursed by Texas Medicaid when providing tests to clients registered as hospital inpatients. Hospital reimbursements (i.e., inpatient DRG reimbursement) include payment for all pathology and laboratory services, including those sent to referral laboratories. Hospital-based and referral laboratory providers must obtain reimbursement for the technical portion from the hospital. The technical portion includes the handling of specimens and the automated or technician-generated reading and reporting of results. These services are not billable to Medicaid-covered clients.

Refer to: Subsection 2.2, “Reimbursement Methodology” in Section 2, Texas Medicaid Reimbursement (Vol. 1, General Information).

Texas Medicaid pays up to the amount allowed for the total component for the same procedure, same client, same date of service, any provider.

• Providers who perform the technical service and interpretation must bill for the total component.

• Providers who perform only the technical service must bill for the technical component.

• Providers who perform only the interpretation must bill for the interpretation component.

Claims filed in excess of the amount allowed for the total component for the same procedure, same dates of service, same client, any provider, are denied. Claims are paid based on the order in which they are received.

For example, if a claim is received for the total component and TMHP has already made payment for the technical or interpretation component for the same procedure, same dates of service, same client, any provider, the claim for the total component will be denied as previously paid to another provider. The same is true if a total component has already been paid and claims are received for the individual components.



3. PHYSICIAN-PERFORMED RADIOLOGY SERVICES

Refer to: Section 6.3.54, “Radiation Therapy” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4. RADIOLOGY, PHYSIOLOGICAL LABORATORY, AND PORTABLE X-RAY SUPPLIER

4.1 Enrollment To enroll in Texas Medicaid, radiological and physiological laboratories and portable X-ray suppliers must be enrolled in Medicare. Both radiological and physiological laboratories must be directed by a physician.

All mammography providers, including those providing stereotactic biopsies, must be certified by the Bureau of Radiation Control (BRC). The Department of State Health Services (DSHS) issues mammog-raphy certification to providers who render mammography services. Providers can submit this certification to the TMHP Provider Enrollment Department in lieu of certification issued by the Food and Drug Administration (FDA) because mammography certification issued by DSHS is recognized by the FDA. TMHP will also accept mammography certification issued by the FDA. The certificate will contain the BRC certification number, dates of issue and expiration, type of service, and Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program provider identifiers.

Providers must check the expiration date of their mammography certification and submit an updated mammography certification prior to the expiration date. The certifications may be mailed or faxed to:

Texas Medicaid & Healthcare PartnershipProvider Enrollment

PO Box 200795Austin, TX 78720-0795

Fax: 1-512-514-4214

4.2 Services/Benefits, Limitations and Prior Authorization4.2.1 Ambulatory Electroencephalogram (A/EEG)

Refer to: Subsection 6.3.20.2, “Ambulatory Electroencephalogram (Ambulatory EEG)” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

4.2.2 Contrast Materials/Radiopharmaceuticals Radiopharmaceuticals, when used for therapeutic treatment, are benefits of Texas Medicaid.

Strontium-89 chloride (Metastron), Yttrium y-90, Iodine i-131, Sodium phosphate P-32, Chromic phosphate P-32, and Samarium Sm-152 are radionuclides, have been found to be effective for the long-term relief of pain due to bone metastases.

Tositumomab and Ibritumomab tiuxetan are benefits of Texas Medicaid and are indicated for the treatment of patients that have failed Rituximab and have CD20 antigen-expressing relapsed or refractory, low grade, follicular, or transformed non-Hodgkin's lymphoma or refractory non-Hodgkin's lymphoma.

Some diagnostic radiopharmaceuticals are benefits of Texas Medicaid. Providers can refer to the online fee lookup (OFL) or the applicable fee schedules on the TMHP web site at www.tmhp.com to review the diagnostic radiopharmaceuticals that are reimbursed by Texas Medicaid.

http://www.tmhp.com



4.2.2.1 Procedure Codes and Diagnosis RequirementsThe following diagnosis codes must be billed with the procedure codes indicated:

Strontium-89 chloride may be billed using procedure code A9600 and will be limited to a total of 10 mci intravenously injected every 90 days, any provider. Strontium-89 chloride is reimbursed as one service per day for the same provider on the same claim. Strontium-89 chloride and Samarium will be considered when billed with diagnosis 1985 (secondary malignant neoplasm of bone and bone marrow).

Sodium phosphate P-32, therapeutic, will be considered when billed with diagnosis 20410 (lymphoid leukemia, chronic, without mention of remission), 20510 (myeloid leukemia, chronic, without mention of remission) and 2384 (polycythemia vera).

Chromic phosphate P-32 suspension will be considered when billed with diagnosis 1972 (secondary malignant neoplasm of the pleura) and 1976 (secondary malignant neoplasm of the retroperitoneum and peritoneum).

Modifier 76 must be used when billing a procedure code more than once per day, same provider.

4.2.2.2 Prior Authorization for Contrast Materials/Radiopharmaceuticals

Prior authorization is required for Tositumomab and Ibritumomab tiuxetan radiopharmaceuticals. Prior authorization must be requested through the Special Medical Prior Authorization (SMPA) department with appropriate documentation. Authorization for Tositumomab or Ibritumomab Tiuxetan may only be considered once per lifetime, any provider, and only one of the agents.

The following documentation is required when requesting prior authorization:

• A diagnosis of either a low-grade follicular or transformed B-cell non-Hodgkin's lymphoma (diagnosis code 20280 [other malignant lymphomas, unspecified site] must be documented)

• Has failed, relapsed, or become refractory to conventional chemotherapy; marrow involvement is less than 26 percent; platelet count is 100,000 cell/mm3 or greater; neutrophil count is 1,500 cells/mm3 or greater

• Has failed a trial of Rituximab

4.2.3 Radiology Procedures Providers may bill separately for the interpretation component for radiology procedures performed in the office setting. Technical component codes are denied when billed by a physician in the inpatient or outpatient hospital setting. Total component codes are denied when billed by a physician in any place of service other than the office.

Separate interpretation and technical components are monitored when billed with total components and reimbursement of the interpretation component and the technical component combined will not exceed the TOS 4 reimbursement for the total component.

Radiology interpretations in any place of service and ultrasound interpretations in the inpatient hospital setting billed by the attending physician are denied if the attending physician’s specialty is any of the following:

• ENT

Procedure Code Diagnosis CodesA9563 20410, 20412, 20422, 20492, 20510, 20512, 20522, 20582, 20592, 20812, 20822,

20882, 20892, 2384A9564 1972, 1976A9600 1985A9605 1985



• Family Practice

• Gynecology

• OB/GYN

• ENT

• Dentists (D.M.D, D.D.S.)

• Orthopedic Surgery

• Psychiatry

• Psychiatry

• Podiatry

Note: The 3-D obstetric ultrasound is not a benefit of Texas Medicaid.

Refer to: Subsection 4.2.5, “Prior Authorization” in this handbook.

4.2.3.1 Cardiac Blood Pool Imaging

Cardiac blood pool imaging is a benefit of Texas Medicaid. Cardiac blood pool imaging is a form of radionuclide angiocardiography in which images are taken at specific phases of the cardiac cycle over a series of several hundred cycles. The timing of the image recording is set, or gated, by the occurrence of specific electrocardiographic waveforms and the data can be used to determine average activity during specific cardiac cycle phases or can be accumulated and displayed in rapid sequence.

First pass technique refers to a form of radionuclide angiocardiography in which a rapid sequence of images is taken immediately after administration of a bolus of radionuclide, recording only the initial transit of the isotope through the central circulation.

Refer to: Subsection 2.3.3.16.1, “Cardiac Blood Pool Imaging ” in Hospital Services Handbook (Vol. 2, Provider Handbooks) and subsection 6.3.55.1, “Cardiac Blood Pool Imaging” in Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks) for the complete list of diagnosis restrictions for cardiac blood pool imaging procedure codes.

4.2.3.2 CT, CTA, MRI, and MRA Computed tomography (CT), computed tomography angiography (CTA), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA) services are benefits of Texas Medicaid.

4.2.3.2.1 CT and CTA Imaging

CT combines the use of a digital computer and a rotating X-ray device to create detailed cross-sectional images or “slices” of organs and body parts, such as the lungs, liver, kidneys, pancreas, pelvis, extrem-ities, brain, spine, and blood vessels. CT provides a detailed image of bony structures. CTA is used to visualize blood flow in arterial and venous vessels.

Refer to: Subsection 4.2.5, “Prior Authorization” in this handbook.

Note: Providers and facilities are required to use the lowest possible radiation dose consistent with acceptable image quality for CT examinations of children. It is recommended that providers and facilities utilize national standards for CT imaging, such as the American College of Radiology’s, “Practice Guidelines for Performing and Interpreting Diagnostic CT Examinations.”



4.2.3.2.2 MRI and MRA

MRI uses magnetic energy and radio waves to create cross-sectional images or “slices” of the human body. MRI is an effective diagnostic tool for detecting defects, diseases, and trauma. It is used to image many types of soft-tissue, including, but not limited to, the central nervous system, internal organs, and the musculoskeletal system. MRA is an MRI study of the arterial and venous blood vessels. MRA utilizes MRI technology and is used as an effective diagnostic tool to detect, diagnose, and aid the treatment of heart disorders, stroke, and blood vessel diseases.

Functional MRI (fMRI)Functional MRI (fMRI), similar to other brain mapping tests, is performed to map motor, sensory, language, and memory areas in neurosurgical patients. Because it is noninvasive, it does not carry the same level of risk as invasive mapping procedures (e.g., Wada test, ECS).

Texas Medicaid considers fMRI medically necessary when it is being used as part of a preoperative evalu-ation for a planned craniotomy and is required for localization of eloquent areas of the brain such as those responsible for speech, language, motor function, and senses, which might potentially be put at risk during the proposed surgery.

Intraoperative MRI (iMRI)Intraoperative MRI (iMRI) allows surgeons to pinpoint tumors before incision and to navigate to the tumor or lesion after the incision is made. Surgeons also use it during surgical resection to verify completeness of the resection (clear margins). Intraoperative MRI allows for imaging during the surgical procedure versus relying solely on scans taken before the surgical intervention.

Indications for intracranial neurosurgical procedures using iMRI include, but are not limited to, the following:

• Oncologic neurosurgical procedures

• Epilepsy

• Chiari surgery

• Deep brain stimulators

Intraoperative MRI does not require prior authorization.

The following cardiac MRI procedure codes in Column A must be billed in conjunction with the stress testing procedure codes in Column B:

The following procedure codes in Column A will be denied when billed with the procedure codes in Column B:

Column A:Cardiac MRI Procedure Codes

Column B:Stress Testing Procedure Codes

75559, 75563 93015, 93016, 93017, 93018

Column A: Denied when billed with Column B:Functional MRI (fMRI)01922, 70555 7055401922 70555Intraoperative MRI (iMRI)01922, 76350, 77021 7055701922, 36000, 36005, 36406, 36410, 70557, 76000, 76350, 76942, 77002, 77021, 96360, 96365, 96372, 96374, 96375

70558



Nonpayable neurofunctional testing procedure code 96020 must be reported in conjunction with the interpretation component for magnetic resonance imaging, brain, functional MRI procedure code 70555.

Only one iMRI procedure code may be billed per operative session. The interpretation component for procedure codes 70557, 70558, and 70559 must not be billed in conjunction with procedure code 61751, 77021, or 77022.

4.2.3.2.3 CT, CTA, MRI, and MRA Authorization Requirements

The following revenue codes require authorization:

The following procedure codes require authorization:

Prior authorization is required for outpatient nonemergent CT, CTA, MRI, fMRI, and MRA studies (i.e., those studies that are planned or scheduled). Retrospective authorization is required for outpatient urgent and emergent radiology procedures.

Prior authorization of nonemergent and retrospective authorization of urgent or emergent CT, CTA, MRI, and MRA studies will be considered on an individual basis adhering to standard clinical evidence-based guidelines. Documentation must support medical necessity for the study and must be maintained by the ordering physician and the radiologist in the client's medical record.

01922, 36000, 36005, 36406, 36410, 76000, 76350, 76942, 77002, 77021, 96360, 96365, 96372, 96374, 96375

70559

Revenue Codes350 351 352 359 610 611 612 619

Procedure Codes70336 70450 70460 70470 70480 70481 70482 70486 70487 7048870490 70491 70492 70496 70498 70540 70542 70543 70544 7054570546 70547 70548 70549 70551 70552 70553 70554 70555 7125071260 71270 71275 71550 71551 71552 71555 72125 72126 7212772128 72129 72130 72131 72132 72133 72141 72142 72146 7214772148 72149 72156 72157 72158 72159 72191 72192 72193 7219472195 72196 72197 72198 73200 73201 73202 73206 73218 7321973220 73221 73222 73223 73225 73700 73701 73702 73706 7371873719 73720 73721 73722 73723 73725 74150 74160 74170 7417574181 74182 74183 74185 75557 75559 75561 75563 75565 7557175572 75573 75574 75635 76376 76377 76380 76390 77011 7705877059

Column A: Denied when billed with Column B:



Nationally-accepted guidelines and radiology protocols based on medical literature are used in the authorization processes for both emergent and nonemergent studies. Medical literature used includes: American College of Radiology (specifically, their Appropriateness Criteria), American Academy of Neurology, American Academy of Orthopedic Surgeons, American College of Cardiology, the American Heart Association, and the National Comprehensive Cancer Care Network.

The following table summarizes the authorization requirements for emergency department visits, planned or scheduled visits for nonemergent conditions, outpatient visits for urgent conditions, outpa-tient visits for emergent conditions, and inpatient visits:

Condition Authorization RequirementsEmergency Department Visit

Authorization is not required for emergency department radiology services provided during an emergency department visit. The appropriate emergency radiology procedure code must be billed with the U6 modifier.

Nonemergent Condition: Planned or Scheduled

Prior authorization is required for outpatient nonemergent CT, CTA, MRI, fMRI, and MRA studies (i.e., those studies that are planned or scheduled).Note: Intraoperative MRI (iMRI) does not require prior authorization.

If the ordering physician or radiologist determines that a radiology procedure different from the authorized procedure is required or that additional radiology procedures are required, the following will apply:• The procedure performed is less complex than the procedure authorized but of the

same modality (e.g., an MRI with contrast is prior authorized and the actual procedure performed is an MRI without contrast). Full reimbursement is allowed for the billed procedure.

• The authorized procedure is performed and an additional higher-level procedure of the same modality is deemed necessary within the same authorization period. A separate authorization is required. The additional procedure must be prior autho-rized separately and submitted on a separate claim.

• The procedure billed is more complex than the procedure authorized but of the same modality. No authorization update will result in reimbursement according to the rate of the lesser authorized code. For full reimbursement, the authorization requires an update.

Important: The authorization number must be on the claim when it is submitted to TMHP for reimbursement. Only one authorization is allowed per claim. For the most accurate and efficient claims processing, TMHP recommends that the procedure code submitted on the claim match the procedure code that was authorized. Providers are encouraged to contact TMHP and update the prior authorization if the ordering physician or radiologist changes the actual procedure performed. Providers have 14 calendar days after the procedure is performed to update the prior authorization.The addition of post-three dimensional (3-D) reconstruction (procedure codes 76376 and 76377) CT, CTA, MRI, and MRA studies must be prior authorized. No additional payment will be made in absence of prior authorization. The 3-D obstetric ultrasound is not a benefit of Texas Medicaid.

Outpatient Urgent Condition

Retrospective authorization is required for unplanned radiology procedures performed during other planned or scheduled outpatient visits or procedures. The radiologist must determine, during the provision of prior authorized services, that additional or alternate procedures are medically indicated and that the urgent condition requires additional or alternate advanced diagnostic imaging (CT, CTA, MRI, and MRA).Retrospective authorization must be submitted no later than seven calendar days beginning the day after the study is completed.



Note: Prior authorization of non-emergent and retrospective authorization of urgent or emergent CT, CTA, MRI, and MRA studies will be considered on an individual basis adhering to standard clinical evidence-based guidelines. Documentation must support medical necessity for the study and must be maintained by the ordering physician and the radiologist in the client's medical record. Nationally-accepted guidelines and radiology protocols based on medical literature are used in the authorization processes for both emergent and non-emergent studies. Medical literature used includes: American College of Radiology (specifi-cally, their Appropriateness Criteria), American Academy of Neurology, American Academy of Orthopedic Surgeons, American College of Cardiology, the American Heart Association, and the National Comprehensive Cancer Care Network.

If there is no authorization, both the technical and professional interpretation components are denied.

4.2.3.2.4 Completing and Submitting the Authorization Request

Providers may request a prior authorization online through the TMHP website at www.tmhp.com. Providers may also request prior or retrospective authorization by calling the TMHP Radiology Services Prior Authorization Line at 1-800-572-2116, by fax to 1-800-572-2119, or by mail to:

Texas Medicaid & Healthcare Partnership730 Cool Springs Blvd, Suite 800

Franklin, TN 37067

Providers that make requests for authorization by telephone must provide all of the following information:

• Diagnosis

• Treatment history

• Treatment plan

• Medications

• Previous imaging results (Providers may be requested to provide additional documentation. The Radiology Prior Authorization Request form must be completed and maintained in the client's records.)

• Additional requested documentation

Refer to: Section 2, “Hospital (Medical/Surgical Acute Care Facility)” in Hospital Services Handbook (Vol. 2, Provider Handbooks).

Section 6, “Physician” in Medical and Nursing Specialists, Physicians, and Physician Assis-tants Handbook (Vol. 2, Provider Handbooks) for more information on MRI and contrast material.

The TMHP website at www.tmhp.com in the Provider Manual and Guides section of the homepage for the “Clinical Guidelines for Advanced Diagnostic Imaging,” the evidence-based guidelines used in authorizing advanced imaging services for TMHP. These guide-lines help providers determine the most appropriate treatment option for the client related to advanced imaging services.

Outpatient Emergent Condition

Retrospective authorization is required for unplanned radiology procedures performed during other planned or scheduled outpatient visits or procedures. The physician must determine that a medical emergency which imminently threatens life or limb exists and that the medical emergency requires advanced diagnostic imaging (CT, CTA, MRI, and MRA).

Inpatient Hospital

Authorization is not required for inpatient hospital radiology services.

Condition Authorization Requirements

http://www.tmhp.com

http://www.tmhp.com



Providers that make requests by fax or mail must complete and maintain the Radiology Authorization Form. The form must document the medical necessity of the test, including diagnosis, treatment history, treatment plan, medications, and previous imaging results. Providers may be asked to provide additional documentation.

Section 1 of the Radiology Authorization Form must be completed, signed, and dated by the ordering clinician or provider before requesting prior authorization for a CT, CTA, MRI or MRA. Section 2 of the Radiology Authorization Form must be completed, signed, and dated by the radiologist before requesting retrospective authorization for urgent or emergent studies.

Residents, physician assistants, and nurse practitioners may order radiological procedures; however, the ordering/referring clinician must sign the authorization form and use the group or supervising provider's provider identifier. The completed form with original signature must be maintained in the client's medical record by the clinician or provider who ordered the tests.

Note: The physician's signature must be current, unaltered, original, and handwritten. A comput-erized or stamped signature will not be accepted.

4.2.3.3 Myocardial Perfusion Imaging

Myocardial perfusion imaging, which uses radionuclides, is a noninvasive stress test that measures coronary blood flow (perfusion), especially to the left ventricle. Myocardial perfusion imaging is a benefit of Texas Medicaid when it is medically indicated. Myocardial perfusion imaging may be performed at rest and/or during stress using physical exercise or pharmacologicals.

Myocardial perfusion imaging studies will be limited to one study per day, including, but not limited to, the following procedure codes: 778451, 78452, 78453, and 78454. When multiple procedure codes are billed, the most inclusive code is reimbursed and all other codes are denied.

The interpretation component for procedure code 93017 and the interpretation component for procedure code 93018 will be denied if submitted for reimbursement on the same day as procedure code 93015.

When multiple procedure codes are billed, the most inclusive code is reimbursed and all other codes are denied.

4.2.3.4 Positron-Emission Tomography (PET) Scans

A PET scan is a noninvasive nuclear medicine procedure that images the chemical activity of body organs and tissues. The PET scan uses electronic detection of short-lived positron-emitting radiophar-maceuticals to measure metabolic, biochemical, and functional activity in tissue. A scanner then measures radioactivity as it is dispersed throughout the body, creating three-dimensional pictures of tissue function.

4.2.3.4.1 Brain Imaging

Brain imaging PET scans are benefits when either of the following is true:

• When used as part of a presurgical evaluation to localize a focus of refractory seizure activity with documentation of a history of seizures that are not controlled through medications.

• When differentiating recurrent brain tumors from scar tissue with documentation of a history of a primary brain tumor and a plan of treatment.

4.2.3.4.2 Tumor Imaging

Tumor-imaging PET scans are benefits and are limited to staging and restaging of recurrent tumors in which the PET scan may assist in determining the optimal clinical management of the client.

4.2.3.4.3 Prior Authorization for PET Scans

Prior authorization is required with documentation of medical necessity.



When requesting prior authorization for tumor-imaging PET scans, the provider must submit supporting documentation which indicates that standard imaging was not conclusive and that the provider’s rationale for this procedure supports medical necessity.

4.2.4 Radiation Therapy Refer to: Subsection 6.3.54, “Radiation Therapy” in Medical and Nursing Specialists, Physicians, and

Physician Assistants Handbook (Vol. 2, Provider Handbooks) for information about radiation therapy, including brachytherapy and stereotactic radiosurgery.

4.2.5 Prior AuthorizationPrior authorization is required for the following services:

• Tositumomab and Ibritumomab tiuxetan radiopharmaceuticals

• Outpatient nonemergent CT, CTA, MRI, fMRI, and MRA studies (i.e., those studies that are planned or scheduled). Retrospective authorization is required for outpatient urgent and emergent radiology procedures

• PET Scans

4.3 Documentation RequirementsAll services require documentation to support the medical necessity of the service rendered, including radiological and physiological laboratory services. Radiological and physiological laboratory services are subject to retrospective review and recoupment if documentation does not support the service billed.

4.4 Claims Filing and Reimbursement4.4.1 Claims Information Claims for radiological and physiological laboratory services and portable X-ray supplier services must include the referring/ordering provider. Radiological and physiological laboratory services and portable X-ray supplier services must be submitted to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Refer to: Section 3, TMHP Electronic Data Interchange (EDI) (Vol. 1, General Information) for information on electronic claims submissions.

Section 6, Claims Filing (Vol. 1, General Information) for general information about claims filing.

Subsection 6.5, “CMS-1500 Claim Filing Instructions” in Section 6, “Claims Filing” (Vol. 1, General Information). Blocks that are not referenced are not required for processing by TMHP and may be left blank.

4.4.1.1 Diagnosis Requirements A diagnosis is not required with a provider's request for payment except when providing the following services: Ambulatory Electroencephalogram (A/EEG), arteriogram, cardiac blood pool imaging, chest X-ray, computed tomography imaging (CT), echography, electrocardiogram (ECG), magnetic resonance angiography (MRA), magnetic resonance imaging (MRI), mammographies, noninvasive diagnostic studies, polysomnographies, and venographies. Claims for all services provided to clients eligible for “Emergency Care Only” must have a diagnosis to be considered for reimbursement. As with all procedures billed to Texas Medicaid, most baseline screening or comparison studies are not a benefit.



Refer to: Section 6, “Physician” in Medical and Nursing Specialists, Physicians, and Physician Assis-tants Handbook (Vol. 2, Provider Handbooks) for more information on these services.

4.4.1.2 Modifier Requirements for Type of Service Assignment For the radiology, physiological lab, and X-ray procedures in this chapter, providers must bill modifier 26 for the interpretation component or modifier TC for the technical component. No modifier is necessary for the total component.

Refer to: Subsection 6.2.7, “Modifier Requirements for TOS Assignment” in Section 6, “Claims Filing” (Vol. 1, General Information).

Subsection 6.3.2, “Type of Service (TOS)” in Section 6, “Claims Filing” (Vol. 1, General Information).

4.4.2 Reimbursement Radiological and physiological laboratory and portable X-ray supplier providers are reimbursed in accordance with 1 TAC §355.8081 and §355.8085. Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com.

Refer to: Subsection 2.2, “Reimbursement Methodology” in Section 2, Texas Medicaid Reimbursement (Vol. 1, General Information) for more information about reimbursement.

Texas Medicaid pays only up to the amount allowed for the total component for the same procedure submitted for reimbursement by the same provider for the same client with the same date of service. Providers who perform the technical service and the interpretation must bill the total component. Providers who perform only the technical service must bill the technical component, and those who perform only the interpretation must bill the interpretation component. The total component and the technical or interpretation component for the same procedure are not reimbursed separately when billed by any provider with the same date of service; the first claim in may be reimbursed and the additional claim(s) will be denied. Claims are considered for reimbursement based on the order in which they are received.

For example, if a claim is received for the total component, and TMHP has already made payment for the technical and/or interpretation component for the same procedure with the same date of service for the same client regardless of provider, the claim for the total component is denied. The same is true if a total component has already been paid and claims are received for the individual components.

Radiology and physiological laboratory and portable X-ray services are not payable when the client is in an inpatient setting. The reimbursement for these services are included in the diagnosis-related group (DRG) payment.

http://www.tmhp.com



5. CLAIMS RESOURCES

6. CONTACT TMHP

The TMHP Contact Center at 1-800-925-9126 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time.

7. FORMS

Resource LocationAcronym Dictionary Appendix F (Vol. 1, General Information)Automated Inquiry System (AIS) TMHP Telephone and Address Guide (Vol. 1,

General Information)CMS-1500 Claim Filing Instructions Subsection 6.5 (Vol. 1, General Information)Independent Laboratory Claim Form Example Form RL.2, Section 8 of this handbookRadiological/Physiological Laboratory and Portable X-Ray Supplier Claim Form Example

Form RL.5, Section 8 of this handbook

State and Federal Offices Communication Guide Appendix A (Vol. 1, General Information)TMHP Electronic Claims Submission Subsection 6.2 (Vol. 1, General Information)TMHP Electronic Data Interchange (EDI) Section 3 (Vol. 1, General Information)



RL.1 Radiology Prior Authorization Request FormRadiology Prior Authorization Request Form This form is used to obtain prior authorization (PA) for elective outpatient services or update an existing outpatient authorization.

Telephone number: 1-800-572-2116 Fax number: 1-800-572-2119 Date of Request: / /

Please check the appropriate action requested:

CT Scan CTA Scan MRI Scan MRA Scan Update/change codes from original PA request

Client Information

Name: Medicaid number: Date of Birth: / /

Facility Information

Name: Reference number:

Address:

TPI: NPI:

Taxonomy: Benefit Code:

Requesting/Referring Physician Information

Name: License number:

Address:

Telephone: Fax number:

TPI: NPI:

Taxonomy: Benefit Code:

Section 1

Service Types Outpatient Service(s) Emergent/Urgent Procedure

Date of Service: / / Procedures Requested:

Diagnosis Codes Primary: Secondary:

Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications,and previous imaging results:

Requesting/Referring Physician (Signature Required):

Print Name: Date: / /

Section 2— Updated Information (when necessary)

Date of Service: / / Procedures Requested:

Diagnosis Codes Primary: Secondary:

Clinical documentation supporting medical necessity for a procedure code change includes treatment history, treatment plan, medications, and previous imaging results:

Requesting/Referring Physician (signature required):

Print Name: Date: / /

Physician must complete and sign this form prior to requesting authorization. Requesting/Referring Physician License No.:

Requesting/Referring Physician NPI: Requesting/Referring Physician TPI:

Effective Date_07302007/Revised Date_08062007



8. CLAIM FORM EXAMPLES



RL.2 Independent Laboratory

1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE


9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIERDIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

x 123456789

Doe, Jane J. 08 03 1953 x

Comfort TX

78013

x

x

x

6 80053 1 18.17

12345 x

01 09 2009

ABC Laboratory Services1242 Medical PlaceComfort, TX 78013

9876543021

942 Hartford Drive

81.86

V72 6

01 01 2009 01 01 2009

512 555-1234

1234567089

01 01 2009 01 01 2009

01 01 2009 01 01 2009

6 88305 2 45.42

6 88346 2 18.27

x

x

Signature on File

Stan Levelson, M.D.

x

583 89

Signature on File1234567-01



RL.3 Office Visit with Lab and Radiology




CITY STATE







SEX

F





SIGNED DATE






FromMM DD YY

ToMM DD YY

1

2

3

4

5




SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY


$ CHARGES


$ $ $

PICA PICA



CITY STATE







YES NO

( )







MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.




FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG




8. PATIENT STATUS



b. AUTO ACCIDENT?

c. OTHER ACCIDENT?





( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #


EMGRENDERING




Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI


G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500


x 123456789

Doe, Jane 11 20 1963 x

Houston TX

77093

x

x

x

1 99212 1 25.00

x

01 09 2009

Duane P. Olseen, D.O.1111 Pax Dr.Houston, TX 77029713-555-1234

9876543021

6702 Field St. #129

425.00

785 1

01 05 2009 01 05 2009

713 555-1234

01 05 2009 01 05 2009

01 05 2009 01 05 2009

1 93005 TC 3 50.00

1 93224 2 350.00

Signature on File

427 9

Filed with Merchants on

09/01/95 have not heard

Back from OI.

Merchants Inc. Co.

1313 Main St. Card, TX 75633

Policy #73721, Subscriber #3198

786 50

Duane P. Olseen, DO

1234567-01

715 555-1234



RL.4 Radiation Therapy




CITY STATE







SEX

F





SIGNED DATE






FromMM DD YY

ToMM DD YY

1

2

3

4

5




SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY


$ CHARGES


$ $ $

PICA PICA



CITY STATE







YES NO

( )







MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.




FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG




8. PATIENT STATUS



b. AUTO ACCIDENT?

c. OTHER ACCIDENT?





( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #


EMGRENDERING




Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI


G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500


x 123456789

Doe, John 08 08 1957 x

San Antonio TX

78218

x

x

x

1 77427 105.00 1

12345 x

01 13 2010

Jared Blanco, MD1242 Garrick WayBryan, TX 77802

9876543021

901 West Street

105 .00

V10 72

01 01 2010 01 01 2010

Signature on File

Jared Blanco, MD

x

x

210 555-1234

01 13 2009

1234567-01



RL.5 Radiological/Physiological Laboratory and Portable X-Ray Supplier




CITY STATE







SEX

F





SIGNED DATE






FromMM DD YY

ToMM DD YY

1

2

3

4

5




SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY


$ CHARGES


$ $ $

PICA PICA



CITY STATE







YES NO

( )







MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.




FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG




8. PATIENT STATUS



b. AUTO ACCIDENT?

c. OTHER ACCIDENT?





( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #


EMGRENDERING




Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI


G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500


x 123456789

Doe, John 01 04 1961 x

Del Rio TX

78841

x

x

x

1 70030 1 19.35 1

12345 x

01 10 2009

Portable X-Ray Services1242 South MainDel Rio, TX 78840210-555-1234

9876543021

8001 Apt., Way #2

19.35

01 01 2009 01 01 2009

Signature on File

Blake Jones, M.D. 1234567089

V72 5

Signature on File

Signature on File1234567-01

210 555-1234

Documents

radiology, laboratory, and physiological lab services - TMHP