T exas Medicaid Bulletin - TMHP · 2011-01-28 · MARCH/APRIL 2011 NO. 234 Bimonthly update to the Texas Medicaid Provider Procedures Manual T exas Medicaid Bulletin Enhancements

MARCH/APRIL 2011 NO. 234

Bimonthly update to the Texas Medicaid Provider Procedures ManualT exas Medicaid BulletinBimonthly update to the Texas Medicaid Provider Procedures ManualT exas Medicaid Bulletin

Enhancements to Online Fee Look-up (OFL) on the PortalEffective March 25, 2011, enhancements are being made to the OFL on the Texas Medicaid & Healthcare Partnership (TMHP) website at www.tmhp.com. The OFL may be used to interactively search for fee information on specific procedure codes and to retrieve fee information for the current date or for a specific date of service (DOS).

The OFL will be enhanced to allow users to retrieve up to 24 months of DOS-specific information, including any retroactive changes. Users will be able to retrieve 24 months of history only if the date of service searched displays the current date. Specific DOS searches will retrieve only pricing for that specific DOS. This new functionality applies to the OFL Fee and Batch Searches. Static Fee schedules will continue to be generated on a quarterly basis.

Note: Batch search results that exceed 65,000 rows will generate additional worksheets in the Excel workbook. A maximum of five worksheets can be generated per workbook.

Upon implementation, providers will be able to use these new OFL features by following these steps:

1) Navigate to the TMHP website at www.tmhp.com.

2) Click on Providers at the top of the page.

3) Select the Fee Schedules hyperlink on the left side of the page.

4) Select the Fee Search hyperlink.

5) Select from the following search type options:

— Single procedure code

— List of procedure codes (i.e. up to ten procedure codes)

— Range of procedure codes

— All applicable procedure codes

6) Enter search criteria with procedure codes, provider type, provider specialty, program, date of service (leave defaulted to today’s date), claim type, and then submit the request.

7) The search results data is displayed.

Above is an example of what the interactive search results will return

http://www.tmhp.com

http://www.tmhp.com

Contact InformationFor additional information about Texas Medicaid, call the TMHP Contact Center at 1-800-925-9126.

For additional information about Primary Care Case Management (PCCM) articles in this bulletin, call the PCCM Provider Helpline at 1-888-834-7226.

For additional information about articles pertaining to the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP-CSHCN Contact Center at 1-800-568-2413.

CONTENTS

All Providers 1Enhancements to Online Fee Look-up (OFL) on the Portal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Provider Feedback Sought on 2010 Texas Medicaid Provider Procedures Manual . . . . . . . . . . . . . . . . . . . . . . . . . 2

Additional Substance Use Disorder (SUD) Treatment Services to Be a Benefit of Texas Medicaid . . . . . . . . . . . . 4

New Substance Use Disorder Services Procedure Codes Become Benefits for Texas Medicaid . . . . . . . . . . . . . 14

Correction to “Substance Use Disorder Services to be a Benefit of Texas Medicaid” . . . . . . . . . . . . . . . . . . . . . . 15

Vendor Drug Program (VDP) Website Revised . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Reimbursement Rates Implemented for Procedure Codes That Are New Benefits of Texas Medicaid . . . . . . . . . 16

Texas Medicaid Benefit Criteria for Wound Care Supplies and Systems Has Changed . . . . . . . . . . . . . . . . . . . . . 23

Reimbursement Rates Implemented for Second Quarter 2010 HCPCS Procedure Codes . . . . . . . . . . . . . . . . . . 24

Initial List of Certified EHR Products is Available Online . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Reimbursement Rates for Some DME Services “E” Procedure Codes Have Changed for Texas Medicaid . . . . . 25

Change to the Personal Care Services Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Scheduled System Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Benefit Criteria for Cranial Molding Orthosis Will Change for CCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Clarification of Medicaid for Breast and Cervical Cancer Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Potentially Preventable Readmissions Information Available on the TMHP Website . . . . . . . . . . . . . . . . . . . . . . . 32

Acute Care Services Provided Off-Campus to Medicaid Eligible State Supported Living Center Residents (SSLC) Reimbursed by Texas Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

New Web Page Created for February 2011 NCCI Guideline Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

Medicaid Buy-In for Children (MBIC) Program Available to Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . 34

TMHP Contact Center Has Implemented an Enhanced Tracking System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Additional 1 Percent Reimbursement Reduction for February 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Texas Medicaid Claims Reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Claims Reprocessing for Procedure Code 84443 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Issue with Global Surgical Period Changes That Were Effective May 1, 2010 . . . . . . . . . . . . . . . . . . . . . . . .36

Invalid and Discontinued Procedure Codes 85028, 86335, and J6000 Claims Reprocessing . . . . . . . . . . . .36

Reimbursement Rate Changes That Became Effective April 1, 2010 Claims Reprocessing . . . . . . . . . . . . . . 37

TMHP to Reprocess NDC Claims for Depo-Medrol Procedure Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

TMHP Will Reprocess Some National Drug Code (NDC) Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Provider Feedback Sought on 2010 Texas Medicaid Provider Procedures ManualTMHP is soliciting provider feedback on the revised formatting and organization that was used for the 2010 Texas Medicaid Provider Procedures Manual. Providers can go to the following website address to take the survey: www.surveymonkey.com/s/95BZDG2.

The survey will be available for providers to take through February 16, 2011.

All Providers

Texas Medicaid Bulletin, No. 234 2 March/April 2011CPT only copyright 2010 American Medical Association. All rights reserved.

http://www.surveymonkey.com/s/95BZDG2

CONTENTSClaims Reprocessing for Some Procedure Codes that were Reimbursed Incorrectly . . . . . . . . . . . . . . . . . . .39

Claims Reprocessing for April 2011 Reimbursement Rate Changes for Procedure Codes 90806, 90847, and 90853 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Claims Reprocessing for Personal Care Services, Occupational Therapy, and Physical Therapy . . . . . . . . .39

Updates to Previously Published Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Correction to “Age and Gender Restrictions to Change for Some Medicaid Services” . . . . . . . . . . . . . . . . . .40

Update to “FMAP and EFMAP Rate Changes” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Update to “TMHP to Change Processing and Reporting of DRG Claim Reimbursements” . . . . . . . . . . . . . .40

Correction to “Texas Medicaid and PCCM Procedure Code Updates for May 8, 2010” . . . . . . . . . . . . . . . . . 41

Clarification and Correction of “Hearing Services Claims for Clients with Medicaid Managed Care Plans Must be Billed to TMHP” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

New Clarification to “Reimbursement Rates for Some Procedure Codes Will Change April 1, 2010” . . . . . . . 44

Correction to “Correction to Medicaid Benefits to Change for Nonsurgical Vision Services” . . . . . . . . . . . . . 44

Correction to the 2010 Texas Medicaid Provider Procedures Manual, Managed Care Handbook . . . . . . . . . . 44

Family Planning Providers 44Reimbursement Rate Change for Family Planning Procedure Code J1055 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Hospital Providers 45Correction to “Present on Admission Value is Required on Hospital Claims” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Managed Care Providers 45TMHP Routinely Audits PCCM Medical Records of THSteps Medical Checkups . . . . . . . . . . . . . . . . . . . . . . . . . 45

PCCM Service Area Changing in September 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Hearing Services Claims for Clients with Medicaid Managed Care Plans Must be Billed to TMHP . . . . . . . . . . . .50

THSteps Providers 53THSteps Medical and Dental Checkups for Migrant Farm Workers and Their Families . . . . . . . . . . . . . . . . . . . . .53

Vision Providers 54Additional Provider Type and Place of Service Restrictions Added for Some Vision Procedure Codes . . . . . . . . 54

Excluded Providers 55

Forms 59Electronic Funds Transfer (EFT) Authorization Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Provider Information Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Statement for Initial Wound Therapy System In-Home Use Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

Statement for Recertification of Wound Therapy System In-Home Use Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Residential Detoxification Authorization Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Residential Substance Abuse Treatment Authorization Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

Ambulatory (outpatient) Detoxification Authorization Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

Copyright AcknowledgmentsUse of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regula tion System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to gov ernment use.”

The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright © 2009 American Dental Association. All Rights Reserved. Applicable FARS/DFARS restrictions apply.”

Texas Medicaid Bulletin, No. 2343March/April 2011

All Providers

CPT only copyright 2010 American Medical Association. All rights reserved.

ALL PROVIDERS

Additional Substance Use Disorder (SUD) Treatment Services to Be a Benefit of Texas MedicaidEffective for dates of service on or after January 1, 2011, additional SUD treatment services are benefits of Texas Medicaid. The additional SUD treatment services include residential detoxification, ambulatory (outpatient) detoxification, and residential treatment. The residential detoxification and residential treatment benefits apply to clients in the following programs:

• Primary Care Case Management (PCCM)

• Fee-for-Service

• State of Texas Access Reform (STAR) Medicaid managed care

• STAR+PLUS Medicaid managed care

Ambulatory (outpatient) detoxification is available to PCCM and fee-for-service clients effective January 1, 2011.

These benefits are available to clients of all ages. Clients who are 20 years of age and younger already have access to these benefits through Texas Medicaid.

Reminder: Effective September 1, 2010, the following SUD treatment services were made benefits of Texas Medicaid: assessment, outpatient treatment, and medication assisted therapy. Also effective September 1, 2010, ambulatory detoxification was made a benefit only for clients enrolled in STAR and STAR+PLUS Medicaid managed care programs.

Note: STAR and STAR+PLUS Medicaid managed care health plans may or may not mirror the billing requirements presented in this article. This article applies to clients in PCCM and fee-for-service Medicaid. Contact the client’s STAR or STAR+PLUS health plan for more information on specific billing and prior authorization requirements.

Detoxification Services OverviewSUD detoxification services must be provided by a chemical dependency treatment facility (CDTF) that is licensed and regulated by the Department of State Health Services (DSHS) to provide SUD services within the scope of that facility’s DSHS license.

Detoxification services are a set of interventions that are aimed at managing acute physiological substance dependence. According to the Texas Administrative Code (TAC) §448.902 detoxification services include, but are not limited to, the following components:

• Evaluation

• Monitoring

• Medication

• Daily interactions

Clients who are admitted to a detoxification program must meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for physiological substance dependence and must meet the admission requirements based on a nationally recognized standard.

Texas Medicaid Bulletin, No. 234 4 March/April 2011

All Providers


Services and provider requirements that are associated with this benefit can be found in Texas Department of Insurance (TDI) regulations (28 TAC, part 1 chapter 3 subchapter HH and TAC §448.902). Medical necessity for substance use disorder services are determined based on the TDI regulations and nationally recognized standards, such as those from the American Society of Addiction Medicine (ASAM) or the Center for Substance Abuse Treatment (CSAT).

Crisis stabilization is not a component of detoxification; however, crisis stabilization for a mental health condition may be provided under a client’s mental health benefits as needed if the service is medically necessary and the clinical criteria for psychiatric care are met.

The following SUD services are not a benefit of Texas Medicaid:

• Detoxification services for hashish, cocaine, or marijuana addiction.

• Detoxification with an opioid when the client has had two or more unsuccessful opioid detoxification episodes (has left the program against medical advice) within a 12-month period (see 42 Code of Federal Regulations (CFR) §8).

• Detoxification or substance abuse counseling services that are provided by electronic means (e.g., telemedicine, e-mail, or telephone).

Effective January 1, 2011, the following SUD services procedure codes are a benefit of Texas Medicaid and may be reimbursed to a CDTF for services that are rendered in the outpatient setting:

Procedure CodesH0016 H0031 H0032 H0047 H0050 H2017 H2035 S9445

Ambulatory (Outpatient) DetoxificationAmbulatory (outpatient) detoxification (procedure code H0016) requires prior authorization and is appropriate when the client’s medical needs do not require close monitoring.

Procedure codes H0016, H0050, and S9445 must be used concurrently when billing for ambulatory (outpatient) detoxification along with modifier HF.

Ambulatory (outpatient) detoxification is limited to once per day. Ambulatory (outpatient) detoxification is not a stand-alone service and must be provided in conjunction with ambulatory substance use treatment services.

Procedure code H0050 is only reimbursed once a day, regardless of the time spent with the client.

Ambulatory (outpatient) detoxification (procedure codes H0050 and S9445) will be denied if billed without procedure code H0016.

Residential DetoxificationResidential detoxification (procedure code H2017) requires prior authorization. Residential detoxification is appropriate when a client’s medical needs do not warrant acute inpatient hospital admission, but the severity of the anticipated withdrawal requires close monitoring.

Medically supervised hospital inpatient detoxification is appropriate when one of the following criteria is met:

• The client has complex medical needs or complicated comorbid conditions that necessitate hospitalization for stabilization.

• The services that are provided to a client are incidental to other medical services that are provided as a part of an acute care hospital stay.


All Providers


Procedure code H0031, H0032, H0047, H2017, or S9445 must be used concurrently when billing for residential detoxification along with modifier HF and is limited to once per day.

Procedure code H2017 is only reimbursed a flat fee once a day, regardless of the time spent with the client.

Residential detoxification (procedure codes H0031, H0032, H0047, or S9445) will be denied if billed without procedure code H2017.

Room and board for residential detoxification (procedure code H0047) is limited to once per day. Procedure code H0047 may be reimbursed for clients who are 21 years of age and older as an access based fee. For clients who are 20 years of age and younger, procedure code H0047 should be billed as an informational detail.

Residential TreatmentResidential treatment (procedure code H2035) may be a benefit of Texas Medicaid when provided by a CDTF in a residential facility.

Residential treatment requires prior authorization and may be authorized for up to 35 days per episode of care, with a maximum of two episodes of care per rolling six-month period and four episodes of care per rolling year (12 months from the date of service).

Residential treatment services include counseling and psychoeducation and must be billed concurrently using procedure codes H0047 and H2035 along with modifier HF. (Procedure code H2035 is limited to once per day.) Residential treatment procedure code H0047 will be denied if billed without procedure code H2035.

Prior Authorization RequirementsPrior authorization is required for the following services:

• Ambulatory (outpatient) detoxification services

• Residential detoxification services

• Residential treatment services

Prior authorization for ambulatory or residential detoxification or treatment services will not be issued for clients who are 13 years of age and younger unless the request is accompanied by a waiver from the DSHS Regulatory and Licensing Division.

Authorization will be considered for the least restrictive environment appropriate to the client’s medical need as determined in the client’s plan of care and based on national standards.

Providers must submit the appropriate prior authorization request form for the initial or continuation of ambulatory (outpatient) or residential detoxification treatment and residential treatment services.

Providers must submit one of the following forms to obtain prior authorization:

• Ambulatory (outpatient) Detoxification Authorization Request Form

• Residential Substance Abuse Treatment Authorization Request Form

• Residential Detoxification Authorization Request Form

The authorization forms are available starting on page 63 of this bulletin and on the TMHP website at www.tmhp.com under Texas Medicaid/Forms.


All Providers


http://www.tmhp.com

The primary procedure code (H0016, H2017, or H2035) must be documented on the prior authorization request form.

The prior authorization procedure to follow depends on the program in which the client is enrolled, as shown in the following table:

Program Prior Authorization ProcessFee-for-Service Prior authorization requests for substance use disorder services may be submitted to

the TMHP Prior Authorization Unit on the TMHP website, by fax at 1-512-514-4211 or by mail to:

Texas Medicaid & Healthcare Partnership TMHP Prior Authorization Department 12357-B Riata Trace Parkway, Suite 150

Austin TX 78727

Providers may contact the TMHP Prior Authorization Unit by telephone at 1-800-213-8877, Option 2, to obtain information about substance use disorder benefits, the prior authorization process, or the status of a prior authorization request. Prior authorization for substance use disorder services cannot be obtained through this line.Requests for a continuation of services must be received on or before the last day that was authorized or denied. When the TMHP Prior Authorization Unit notifies the provider by fax and the date of the determination letter is on or after the last date authorized or denied, the request for continuation is due by 5:00 p.m., Central Time of the next business day.

Requests for a continuation of services will be denied if they are not received on or before the last day of the current authorization period.

Online prior authorization requests for substance use disorder services are not currently available. Providers will be notified in a future notification when prior authorization requests for substance use disorder services can be submitted online.

PCCM Authorization for PCCM urgent or emergent inpatient detoxification services must be obtained before submission of the claim. Scheduled PCCM inpatient admissions for detoxification require authorization before admission. Prior authorization requests for PCCM clients may be submitted to the PCCM Outpatient Prior Authorization Department on the TMHP website, by telephone at 1-888-302-6167, or by fax at 1-512-302-5039.

STAR and STAR+PLUS

Generally, prior authorization and extensions for Medicaid managed care clients in STAR or STAR+PLUS are handled by the client’s health plan. Contact the client’s health plan for more information. Prior authorization is not required for substance use disorder services for dual eligible clients enrolled as STAR PLUS Medicaid Qualified Medicare Beneficiaries (MQMBs).

The following sections define the admission and continued stay criteria for ambulatory (outpatient) detoxification, residential detoxification, and residential treatment.


All Providers


Admission Criteria for Ambulatory (Outpatient) DetoxificationTo be considered eligible for treatment in an ambulatory detoxification service, a client must meet the following conditions:

Chemical substance withdrawal• The client is expected to have a stable withdrawal from alcohol or drugs.

• The diagnosis must meet the criteria for the definition of substance (chemical) dependence, as detailed in the most current revision of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

Medical functioningThe client must meet all of the following criteria:

• No history of recent seizures or past history of seizures during withdrawal.

• No clinical evidence of altered mental state as manifested by disorientation to self, alcoholic hallucinations, toxic psychosis, or altered level of consciousness (clinically significant obtundation, stupor, or coma).

• The symptoms are due to withdrawal and not due to a general medical condition. Absence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb coordination).

• Stable vital signs as interpreted by a physician. The client must also be without a previous history of complications from acute chemical substance withdrawal and judged to be free of a health risk as determined by a physician.

• No evidence of a coexisting serious injury or systemic illness either newly discovered or progressive in nature.

• Absence of serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains, arrhythmia, or hypotension.

• Clinical condition that allows for a comprehensive and satisfactory assessment.

Family, social, academic dysfunctionThe client must meet at least one of the following criteria with regards to family, social, and academic dysfunction:

• The client’s social system and significant other(s) are supportive of recovery to the extent that the client can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the client’s addiction.

• The client’s family or significant other(s) are willing to participate in the ambulatory (outpatient) detoxification treatment program.

• The client may or may not have a primary or social support system to assist with immediate recovery, but the client has the social skills to obtain such a support system or to become involved in a self-help fellowship.

• The client does not live in an environment where licit or illicit mood altering substances are being used.


All Providers


Emotional and behavioral statusThe client must meet all of the following criteria with regards to emotional and behavioral status:

• The client is coherent, rational, and oriented for treatment.

• The mental state of the client does not preclude the client’s ability to comprehend and understand the materials presented, and the client is able to participate in the ambulatory detoxification treatment process.

• Documentation exists in the medical record that the client expresses an interest to work toward ambulatory detoxification treatment goals.

• The client has no neuropsychiatric condition that places client at imminent risk of harming self or others (e.g. pathological intoxication or alcohol idiosyncratic intoxication).

• The client has no neurological, psychological, or uncontrolled behavior that places the client at imminent risk of harming self or others (depression, anguish, mood fluctuations, overreactions to stress, lower stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, negative emotions, or anxiety).

• The client has no documented DSM-IV axis I condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the client.

• The client has no mental confusion or fluctuating orientation.

Chemical substance useThe client must meet the criteria in at least one of the following conditions for recent chemical substance use:

• The client’s chemical substance use is excessive, and the client has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).

• The client is motivated to stop using alcohol or drugs and is in need of a supportive structured treatment program to facilitate withdrawal from chemical substances.

Continued Stay Criteria for Ambulatory (Outpatient) DetoxificationA client is considered eligible for continued stay in the ambulatory detoxification treatment service when the client meets at least one of the conditions for either chemical substance withdrawal or psychiatric or medical complications.

Prior authorization for ambulatory (outpatient) treatment services beyond the annual limitation of 135 hours of group services and 26 hours of individual services per calendar year, may be considered for clients who are 20 years of age and younger with documentation from a physician (who does not need to be affiliated with the CDTF) of the supporting medical necessity for continued treatment services. Requests must be submitted before providing the extended services.

The documentation must include the following information:

• The client is meeting treatment goals.

• The client demonstrates insight and understanding into relationship with mood altering chemicals, but continues to present with issues addressing the life functions of work, social, or primary relationships without the use of mood-altering chemicals.


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• One of the following:

— Although physically abstinent from chemical substance use, the client remains mentally preoccupied with such use to the extent that the client is unable adequately to address primary relationships or social or work tasks. Nevertheless, there are indications that, with continued treatment, the client will effectively address these issues.

— Although other psychiatric or medical complications exist that affect the client’s treatment, documentation exists that the client continues to show treatment progress and that there is evidence to support the benefits of continued treatment.

Chemical substance withdrawal• The client, while physically abstinent from chemical substance use, is exhibiting incomplete stable

withdrawal from alcohol or drugs, as evidenced by psychological and physical cravings.

• The client, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol or drugs, as evidenced by significant drug levels.

Psychiatric or medical complications• Documentation in the medical record indicates an intervening medical or psychiatric event that was

serious enough to interrupt ambulatory detoxification treatment, but also that the client is again progressing in treatment.

Admission Criteria for Residential Detoxification Detoxification services may be authorized for up to 21 days. The level of service and number of days authorized are based on the substance(s) of abuse, level of intoxication and withdrawal potential, and the client’s medical needs.

Requests for detoxification services for clients who are 20 years of age and younger and who need more than 21 days of residential detoxification require Medical Director review with documentation of medical necessity from a physician familiar with the client.

Clients are eligible for admission to a residential detoxification service when they have failed two previous individual treatment episodes of ambulatory (outpatient) detoxifications or when they have a diagnosis that meets the criteria for the definition of chemical dependence, as detailed in either the most current revision of the ICD-9-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners.

In addition, the client must meet at least one of the following criteria for chemical substance withdrawal, major medical complication, or major psychiatric illness for admission to residential treatment for detoxification:

Chemical substance withdrawal• Impaired neurological functions as evidenced by:

— Extreme depression (e.g., suicidal).

— Altered mental state with or without delirium as manifested by disorientation to self; alcoholic hallucinosis, toxic psychosis, altered level of consciousness, as manifested by clinically significant obtundation, stupor, or coma.

— History of recent seizures or past history of seizures on withdrawal.


All Providers


— The presence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb incoordination).

— Unstable vital signs combined with a history of past acute withdrawal syndromes that are interpreted by a physician to be indication of acute alcohol or drug withdrawal.

— Evidence of coexisting serious injury or systemic illness, newly discovered or progressive.

— Clinical condition (e.g., agitation, intoxication, or confusion) that prevents satisfactory assessment of the above conditions and indicates placement in residential detoxification service may be justified.

— Neuropsychiatric changes of such severity and nature that they put the client at imminent risk of harming self or others (e.g., pathological intoxication or alcohol idiosyncratic intoxication, etc.).

— Serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains arrhythmia, or hypotension.

Major Medical ComplicationsThe individual must present a documented condition or disorder that, in combination with alcohol or drug use, presents a determined health risk (e.g., gastrointestinal bleeding, gastritis, severe anemia, uncontrolled diabetes mellitus, hepatitis, malnutrition, cardiac disease, hypertension, etc.).

Major psychiatric illnessThe client must meet at least one of the following conditions with regards to major psychiatric illness:

• Documented DSM III-R AXIS I condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the individual.

• Severe neurological and psychological symptoms: (e.g., anguish, mood fluctuations, overreactions to stress, lowered stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, extreme negative emotions, or extreme anxiety).

• Danger to others or homicidal.

• Uncontrolled behavior that endangers self or others, or documented neuropsychiatric changes of a severity and nature that place the individual at imminent risk of harming self or others.

• Mental confusion or fluctuating orientation.

Continued Stay Criteria for Residential DetoxificationEligibility for continued stay for residential detoxification services is based on the client meeting at least one of the criteria for chemical substance withdrawal, major medical complications, or major psychiatric complications.

Chemical substance withdrawalIncomplete medically stable withdrawal from alcohol or drugs, as evidenced by documentation of at least one of the following conditions:

• Unstable vital signs.

• Continued disorientation.

• Abnormal laboratory findings related to chemical dependency.


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• Continued cognitive deficit related to withdrawal so that the client is unable to recognize alcohol or drug use as a problem.

• Laboratory finding that, in the judgment of a physician, indicates that a drug has not sufficiently cleared the client’s system.

Major medical complicationsDocumentation in the medical record must indicate that a medical condition or disorder (e.g., uncontrolled diabetes mellitus) continues to present a health risk and is actively being treated.

Major psychiatric complicationsThe client must meet at least one of the following:

• Documentation in the medical record that a DSM III-R AXIS I psychiatric condition or disorder that, in combination with alcohol or drug use, continues to present a major health risk, is actively being treated.

• Documentation in the medical record that severe neurological or psychological symptoms have not been satisfactorily reduced but are actively being treated.

Admission Criteria for Residential Treatment The diagnosis meets the criteria for the definition of chemical dependence, as detailed in the most current revision of the ICD-9-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

Clients must meet the following conditions in order to receive treatment in a residential treatment service program:

Medical functioningThe following must be present for medical functioning:

• Documented medical assessment following admission (except in instances where the client is being referred from an inpatient service) indicates that the client is medically stable and not in acute withdrawal.

• The client is not bed-confined and has no medical complications that would hamper participation in the residential service.

Family, social, or academic dysfunction and logistic impairmentsAt least one of the following must be present for family, social, or academic dysfunction and logistic impairment:

• The client manifests severe social isolation or withdrawal from social contacts.

• The client lives in an environment (social and interpersonal network) in which treatment is unlikely to succeed (e.g., a chaotic family dominated by interpersonal conflict, which undermines client’s efforts to change).

• The client’s family or significant other(s) are opposed to the client’s treatment efforts and are not willing to participate in the treatment process.

• Family members or significant other(s) living with the client manifest current chemical dependence disorders and are likely to undermine treatment.

• Logistic impairments (e.g., distance from treatment facility or mobility limitations) preclude participation in a partial hospitalization or ambulatory (outpatient) treatment service.


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Emotional and behavioral statusThe client must meet all three of the following criteria for emotional and behavioral status:

• The client is coherent, rational, and oriented for treatment.

• The mental state of the client does not preclude the client’s ability to comprehend and understand the materials presented and participate in rehabilitation or treatment process.

• The medical record contains documentation that with continued treatment the client will be able to improve or internalize the client’s motivation toward recovery within the recommended length of stay time frames (e.g., becoming less defensive, verbalizing, and working on alcohol or drug related issues). Interventions, treatment goals, or contracts are in place to help the client deal with or confront the blocks to treatment (e.g., family intervention or employee counseling confrontation).

Chemical substance useThe client must meet at least one of the following criteria for chemical substance use:

• The client’s chemical substance use is excessive, and the client has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).

• Virtually all of the client’s daily activities revolve around obtaining, using, or recuperating from the effects of chemical substances, and the client requires a secured environment to control the client’s access to chemical substances.

Clients who are 13 through 17 years of age must meet all above conditions and the following conditions in order to receive treatment in an adolescent residential treatment service program.

• At the maturation level, the adolescent client must meet both of the following criteria:

— The client is assessed as manifesting physical maturation at least in middle adolescent range (i.e., post-pubescent; not growth-retarded).

— The history of the adolescent reflects cognitive development of at least 11 years of age.

• The adolescent client must display at least one of the following with regards to developmental status:

— Documented history of inability to function within the expected age norms despite normal cognitive and physical maturation (e.g., refusal to interact with family members, overt prostitution, felony, or other criminal charges).

— A recent history of moderate to severe conduct disorder, as defined in the Diagnostic and Statistical Manual for Professional Practitioners, or impulsive disregard for social norms and rights of others.

— Documented difficulty in meeting developmental expectations in a major area of functioning (e.g., social, academic, or psychosexual) to an extent that interferes with the capacity to remain behaviorally stable.

Continued Stay Criteria for Residential TreatmentAt least one of the following conditions must be present for continued stay in a residential treatment program:

• Chemical dependency rehabilitation or treatment complications:

— The client recognizes or identifies with the severity of the alcohol or drug problem but demonstrates minimal insight into the client’s defeating the use of alcohol or drugs. However, documentation in the medical record indicates that the client is progressing in treatment.


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— The client identifies with the severity of the alcohol or drug problem and manifests insight into the client’s personal relationship with mood-altering chemicals, yet does not demonstrate behaviors that indicate the development of problem-solving skills that are necessary to cope with the problem.

— The client would predictably relapse if moved to a lesser level of care.

• Psychiatric or medical complications:

— Documentation in the medical record indicates an intervening medical or psychiatric event that was serious enough to interrupt rehabilitation or treatment, but the client is again progressing in treatment.

— Documentation in the medical record indicates that the client is being held pending an immediate transfer to a psychiatric, acute medical service, or inpatient detoxification alcohol or drug service.

Reimbursement LimitationsAmbulatory (outpatient) treatment (procedure codes H0004 and H0005) will be denied if billed on the same date of service as residential detoxification procedure codes H0031, H0032, H0047, H2017 or residential treatment procedure code H2035.

Medication assisted therapy (procedure codes H0020 and H2010) will be denied as part of another service when billed for the same date of service as any of the following procedure codes:

Procedure CodesH0016 H0031 H0032 H0047 H0050 H2017 H2035 S9445

New Substance Use Disorder Services Procedure Codes Become Benefits for Texas MedicaidEffective for dates of service on or after January 1, 2011, some substance use disorder services procedure codes are benefits of Texas Medicaid.

The following substance use disorder services procedure codes and reimbursement rates are effective January 1, 2011:

TOSProcedure

Code ModifierProvider

Type Age Range 1/1/11 Medicaid Fee1 H0016 HF 8 All ages $8.421 H0031 HF 8 All ages $16.851 H0032 HF 8 All ages $25.271 H0047 HF 8 All ages $25.001 H2035 HF 8 Birth through 20 years of age $125.001 H2035 HF 8 21 years of age and older $49.001 S9445 HF 8 All ages $50.549 H0050 HF 8 All ages $26.939 H2017 HF 8 All ages $31.20

TOS = Type of Service, 1 = Medical services, 9 = Other services (DME purchased), Modifier HF = Substance Abuse Program, Provider type 8 = Chemical dependency treatment facility


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Correction to “Substance Use Disorder Services to be a Benefit of Texas Medicaid”This is a correction to an article titled “Substance Use Disorder Services to be a Benefit of Texas Medicaid,” which was published in the November/December 2010 Texas Medicaid Bulletin, No. 232, and on the TMHP website on August 13, 2010.

Under the Authorization Requirements section of the article, the age range of “21 years of age or younger” was incorrectly stated in the following statements:

• Prior authorization is required for ambulatory (outpatient) treatment of clients who are 21 years of age and younger and who exceed the benefit limitation of 135 hours of group services and 26 hours of individual services per calendar year.

• Ambulatory (outpatient) treatment services for clients who are 21 years of age and younger unless calendar year hours are exceeded.

The correct age range is: 20 years of age and younger.

The department name and fax number for prior authorization requests for fee-for-service clients was also incorrect.

The correct information is: Prior authorization requests for fee-for-service clients may be submitted to the TMHP Prior Authorization Unit online at www.tmhp.com, by fax at 1-512-514-4211, or by mail to:

Texas Medicaid & Healthcare Partnership TMHP Prior Authorization Department 12357-B Riata Trace Parkway, Suite 150

Austin TX 78727

Vendor Drug Program (VDP) Website RevisedThe VDP website at www.txvendordrug.com has been revised so that it is easier to navigate.

Users who have previously bookmarked pages on the VDP website may need to update their Favorites or Bookmarks to point to the new pages.

Some of the new links include:

• Preferred Drug List

• Online Prior Authorization Status Search

• Prescription Drug Prior Authorization Call Center

• Online Pharmacy Search

For more information, providers can e-mail the Texas Health and Human Services Commission (HHSC) at [email protected].


All Providers


http://www.tmhp.com

http://www.txvendordrug.com/

http://www.txvendordrug.com/pdl

http://www.txvendordrug.com/formulary/formulary-search.shtml

http://www.txvendordrug.com/pdl/prior.shtml

http://www.txvendordrug.com/providers/medicaid-pharm-search.shtml

mailto:[email protected]

Reimbursement Rates Implemented for Procedure Codes That Are New Benefits of Texas MedicaidEffective for dates of service on or after January 1, 2011, new procedure codes for the following services are benefits of Texas Medicaid: medical procedures and devices, miscellaneous DME, neurostimulators, physician-administered drugs, radiology, diagnostic imaging, therapeutic radiopharmaceuticals, and obstetric services.

The reimbursement rates are for procedure codes that are new benefits of Texas Medicaid for clients who are 20 years of age and younger. Some of the procedure codes require prior authorization and some may be reimbursed without prior authorization.

Medical Procedures and DevicesThe following reimbursement rates are effective January 1, 2011, for Medical Procedures and Devices. These services are benefits for clients who are birth through 20 years of age:

TOSProcedure

Code

Previous Medicare

RVU

1-1-11 Medicaid

RVU CF1-1-11

Medicaid FeeRequires Prior Authorization

Prior Authorization

Department2 54231 3.71 3.71 $28.640 $106.25 Yes SMPA2 54235 2.37 2.37 $28.640 $67.88 Yes SMPA2 54250 3.35 3.35 $28.640 $95.94 Yes SMPA5 91022 4.31 4.31 $28.640 $123.44 No N/AI 91022 2.12 2.12 $28.640 $60.72 No N/AT 91022 2.19 2.19 $28.640 $62.72 No N/A5 91055 3.83 3.83 $28.640 $109.69 No N/AI 91055 1.42 1.42 $28.640 $40.67 No N/AT 91055 2.41 2.41 $28.640 $69.02 No N/A1 92547 0.13 0.13 $28.640 $3.72 No N/A5 93024 2.87 2.87 $28.640 $82.20 No N/AI 93024 1.60 1.60 $28.640 $45.82 No N/AT 93024 1.27 1.27 $28.640 $36.37 No N/A1 93229 0.00 $20.91 No N/A5 93290 0.86 0.86 $28.640 $24.63 No N/A1 93297 0.73 0.73 $28.640 $20.91 No N/A1 93352 0.81 0.81 $28.640 $23.20 No N/A1 94660 1.59 1.59 $28.640 $45.54 No N/A1 94662 1.01 1.01 $28.640 $28.93 No N/A1 94667 0.55 0.55 $28.640 $15.75 No N/A1 94668 0.54 0.54 $28.640 $15.47 No N/A5 94762 0.27 0.27 $28.640 $7.73 No N/A1 94777 0.00 $20.05 No N/A5 95957 10.13 10.13 $28.640 $290.12 No N/AI 95957 2.82 2.82 $28.640 $80.76 No N/AT 95957 7.31 7.31 $28.640 $209.36 No N/A


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TOSProcedure

Code

Previous Medicare

RVU

1-1-11 Medicaid

RVU CF1-1-11


Prior Authorization

Department9 A4648 Manually

pricedNo N/A

9 A7042 $182.16 No N/A9 E0616 $3,095.50 No N/AJ E0616 $3,095.50 No N/A4 Q0035 0.45 0.45 $28.640 $12.89 No N/AI Q0035 0.23 0.23 $28.640 $6.59 No N/AT Q0035 0.22 0.22 $28.640 $6.30 No N/AJ Q0480 $61,608.13 Yes CCPJ Q0481 $9,939.77 No N/AJ Q0482 $3,113.31 No N/AJ Q0483 $12,825.47 No N/AJ Q0484 $2,490.66 No N/AJ Q0485 $240.48 No N/AJ Q0486 $200.14 No N/AJ Q0487 $233.51 No N/AJ Q0488 $10,250.00 No N/AJ Q0489 $11,119.01 No N/AJ Q0490 $480.96 No N/AJ Q0491 $756.11 No N/AJ Q0492 $60.93 No N/AJ Q0493 $173.44 No N/AJ Q0494 $146.76 No N/AJ Q0495 $2,857.31 No N/AJ Q0496 $1,025.52 No N/AJ Q0497 $320.22 No N/AJ Q0498 $351.35 No N/AJ Q0499 $114.16 No N/AJ Q0500 $20.89 No N/AJ Q0501 $349.35 No N/AJ Q0502 $444.74 No N/AJ Q0503 $889.53 No N/AJ Q0504 $469.37 Yes CCP9 Q0505 Manually

pricedYes CCP

J Q0505 Manually priced

Yes CCP

1 Q9956 $42.03 No N/A1 Q9957 $63.04 No N/A

TOS = Type of Service, 1 = Medical services, 2 = Surgery, 4 = Radiology, 5 = Laboratory, 9 = Other (Supplies), I = Professional component, J = Durable Medical Equipment (DME) purchase, T = Technical component, RVU = Relative value unit, CF = Conversion factor, SMPA = Special Medical Prior Authorization Department, CCP = Comprehensive Care Program


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Prior Authorization• SMPA— The prior authorization request must be submitted to

the TMHP Special Medical Prior Authorization Department (SMPA) with documentation supporting medical necessity for the requested service.

• CCP— The prior authorization request must be submitted to the Comprehensive Care Program (CCP) with a completed CCP Request form and documentation supporting medical necessity for the device.

These requests can also be completed online through the TMHP website at www.tmhp.com.

Miscellaneous Durable Medical EquipmentThe following reimbursement rates are effective January 1, 2011, for miscellaneous durable medical equipment. These services are benefits for clients who are birth through 20 years of age, and were not a benefit prior to January 1, 2011:

TOSProcedure

Code Modifier1-1-11 Medicaid

FeeRequires Prior Authorization

Prior Authorization Department

J E0617 $2,394.40 Yes CCPL E0617 $239.44 Yes CCP9 K0607 U1 $152.96 Yes CCP9 K0609 U2 $704.78 Yes CCP9 S8420 $409.59 Yes CCP9 S8421 $80.00 Yes CCP9 S8422 $357.93 Yes CCP9 S8423 $257.07 Yes CCP9 S8424 $30.00 Yes CCP9 S8425 $168.51 Yes CCP9 S8426 $174.00 Yes CCP9 S8427 $57.20 Yes CCP9 S8428 $42.00 Yes CCP9 S8429 $20.00 Yes CCP9 S8450 $8.00 Yes CCP9 S8451 $20.00 Yes CCP9 S8452 $22.00 Yes CCP

TOS = Type of Service, 9 = Purchased used, J = Purchased new, L = Purchased rental, CCP = Comprehensive Care Program

Prior AuthorizationThe prior authorization request must be submitted to the CCP with a completed CCP Request form and documentation supporting medical necessity for the device.


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http://www.tmhp.com

NeurostimulatorsThe following reimbursement rates are effective January 1, 2011, for neurostimulators. These services are benefits for clients who are birth through 20 years of age:

TOSProcedure

CodeASC Fee

Group

Current Medicare

RVU

1-1-11 Medicaid

RVU CF

1-1-11 Medicaid


2 64565 4.81 4.81 $28.640 $137.76 Yes*F 64565 9 $1,162.72 Yes*2 64575 7.93 7.93 $28.640 Group 9 Yes*F 64575 9 Group 9 Yes*2 64577 11.00 11.00 $28.640 $315.04 Yes*F 64577 9 Group 9 Yes*5 95980 1.26 1.26 $28.640 $36.09 No5 95981 0.82 0.82 $28.640 $23.48 No5 95982 1.38 1.38 $28.640 $39.52 No9 L8695 $11.40 Yes*J L8695 $11.40 Yes*

TOS = Type of Service, 2 = Surgery, 8 = Assistant surgery, 9 = Other DME, F = Ambulatory surgical center (ASC)/Hospital based ambulatory surgical center (HASC), J = DME purchase, RVU = Relative value unit, CF = Conversion factor, *Prior Authorization Department = Special Medical Prior Authorization Department (SMPA)

Prior AuthorizationThe prior authorization request must be submitted to the TMHP Special Medical Prior Authorization Department with documentation supporting medical necessity for the requested service.

Obstetric ServicesThe following reimbursement rates are effective January 1, 2011, for obstetric services. These services are benefits for clients who are birth through 20 years of age:

TOSProcedure

Code

1-1-11 Medicaid

RVU1-1-11

Medicaid CF1-1-11


Prior Authorization

Department2 59030 2.81 $28.640 $80.48 No N/A2 59050 1.42 $28.640 $40.67 No N/A2 59051 1.19 $28.640 $34.08 No N/A2 59072 14.66 $28.640 $419.86 Yes SMPA*2 59612 24.09 $28.640 $689.94 No N/A2 59620 28.02 $28.640 $802.49 No N/A8 59620 4.48 $28.640 $128.31 No N/A2 S2401 $1,143.88 Yes SMPA*8 S2401 $183.02 Yes SMPA*2 S2402 $1,172.52 Yes SMPA*8 S2402 $187.60 Yes SMPA*2 S2403 $1,452.33 Yes SMPA*


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TOSProcedure

Code

1-1-11 Medicaid

RVU1-1-11

Medicaid CF1-1-11


Prior Authorization

Department8 S2403 $232.37 Yes SMPA*2 S2405 $1,985.32 Yes SMPA*8 S2405 $317.65 Yes SMPA*2 S2409 Manually

pricedYes SMPA*

8 S2409 Manually priced

Yes SMPA*

2 S2411 $543.59 No N/A8 S2411 $86.97 No N/A9 S8415 $75.00 No N/A

TOS = Type of Service, 2 = Surgery, 8 = Assistant surgery, 9 = Purchased Used durable medical equipment (DME), RVU = Relative value unit, CF = Conversion factor, SMPA = Special Medical Prior Authorization Department

Prior AuthorizationThe prior authorization request must be submitted to the TMHP SMPA with documentation supporting medical necessity for the requested service, and (*) indicates that documentation indicating that the facility is a member of the North American Fetal Therapy Network [NAFTNet] must be included with claim submission.

Note: The approved prior authorization for the surgery service will be applied to the assistant surgery services. No additional prior authorization is required for the assistant surgery service.

Physician-Administered Drugs and BiologicalsThe following reimbursement rates are effective January 1, 2011, for physician-administered drugs and biologicals. These services are benefits for clients who are birth through 20 years of age:

TOS Procedure Code 1-1-11 Medicaid FeeRequires Prior Authorization


1 J1640 $8.45 No N/A1 J1655 $2.80 No N/A1 J2250 $0.09 No N/A1 J2805 $72.75 No N/A1 J2850 $20.31 No N/A1 J3486 $6.42 No N/A1 J3590 Manually priced Yes SMPA1 J7030 $0.47 No N/A1 J7040 $0.56 No N/A1 J7042 $0.33 No N/A1 J7050 $0.28 No N/A1 J7060 $1.11 No N/A1 J7070 $2.22 No N/A1 J7120 $1.04 No N/A


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TOS Procedure Code 1-1-11 Medicaid FeeRequires Prior Authorization


1 J7308 $136.42 No N/A1 J8999 Manually priced Yes SMPA1 J9017 $37.37 No N/A1 J9098 $467.93 No N/A1 J9165 Manually priced No N/A1 J9175 $4.07 No N/A1 Q0163 $0.02 No N/A1 Q0164 $0.04 No N/A1 Q0165 $0.05 No N/A1 Q0166 $3.77 No N/A1 Q0167 $7.09 No N/A1 Q0168 $14.08 No N/A1 Q0169 $0.40 No N/A1 Q0170 $0.03 No N/A1 Q0171 $0.01 No N/A1 Q0172 $0.03 No N/A1 Q0173 $0.75 No N/A1 Q0175 $0.58 No N/A1 Q0176 $0.55 No N/A1 Q0177 $0.05 No N/A1 Q0178 $0.06 No N/A1 Q0179 $5.96 No N/A1 Q0180 $63.12 No N/A1 Q0181 Manually priced Yes SMPA1 S0017 $0.74 No N/A1 S0028 $0.77 No N/A1 S0166 $6.51 No N/A1 S0189 $63.75 No N/A1 S0196 $157.99 Yes SMPA1 S5010 $11.97 No N/A1 S5011 $14.83 No N/A1 S5550 $0.54 No N/A1 S5551 $0.59 No N/A1 S5552 $0.20 No N/A1 S5553 $0.56 No N/A

TOS = Type of Service, 1 = Medical services, SMPA = Special Medical Prior Authorization Department

Prior AuthorizationThe prior authorization request must be submitted to the TMHP SMPA with documentation supporting medical necessity for the requested service.


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Radiology and Diagnostic ImagingThe following reimbursement rates are effective January 1, 2011, for radiology and diagnostic imaging. These services are benefits for clients who are birth through 20 years of age:

TOSProcedure

Code Modifier RVU CF

1-1-11 Medicaid


Prior Authorization

Department4 74775 $67.10 No N/AI 74775 0.85 $28.640 $24.34 No N/AT 74775 $43.91 No N/AI 75956 10.11 $28.640 $289.55 No N/AI 75957 10.11 $28.640 $289.55 No N/AI 75958 5.76 $28.640 $164.97 No N/AI 75959 5.06 $28.640 $144.92 No N/A6 77321 2.47 $28.640 $70.74 No N/A6 77470 4.18 $28.640 $119.72 No N/A4 93990 5.40 $28.640 $154.66 No N/AI 93990 0.36 $28.640 $10.31 No N/AT 93990 5.04 $28.640 $144.35 No N/A4 G0365 5.39 $28.640 $154.37 No N/A4 G0365 52 $77.18 No N/AI G0365 0.35 $28.640 $10.02 No N/AI G0365 52 $5.01 No N/AT G0365 5.04 $28.640 $144.35 No N/AT G0365 52 $72.17 No N/A

TOS = Type of Service, 4 = Radiology, 6 = Radiation therapy, I = Professional component, T = Technical component, RVU = Relative value unit, CF = Conversion factor, Modifier 52 = Reduced services

Therapeutic RadiopharmaceuticalsThe following reimbursement rates are effective January 1, 2011, for therapeutic radiopharmaceuticals. These services are benefits for clients who are birth through 20 years of age:

TOSProcedure

Code 1-1-11 Medicaid FeeRequires Prior Authorization


1 G3001 $2,323.53 Yes SMPA9 A9544 $2,363.85 Yes SMPA

TOS = Type of Service, 1 = Medical services, 9 = Other (supplies), SMPA = Special Medical Prior Authorization Department

Prior AuthorizationThe prior authorization request must be submitted to the TMHP SMPA with documentation supporting medical necessity for the requested service. These requests can also be completed online through the TMHP website at www.tmhp.com.


All Providers


http://www.tmhp.com

Texas Medicaid Benefit Criteria for Wound Care Supplies and Systems Has ChangedEffective for dates of service on or after January 1, 2011, benefit criteria for wound care supplies and systems has changed for Texas Medicaid.

Modifier AW is required when billing for procedure code A6545.

The following procedure codes are benefits only when provided in the home setting by home health DME and medical supplier (DME) providers:

Procedure CodesA4216 A4217 A4450 A4465 A6407 A6441 A6442 A6443 A6444 A6445A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455A6456 A6550 E2402

A licensed health-care provider with appropriate training is required to perform a dressing change for a pulsatile jet irrigation wound care system or a negative pressure wound therapy (NPWT) system (formerly known as a sealed suction wound care system). These dressing changes are no longer limited to registered nurses.

Procedure codes A6000, E0231, and E0232 are no longer a benefit of Texas Medicaid.

The following services are not a benefit of Texas Medicaid:

• Wound care supplies for use in the office or outpatient setting.

• Equipment and supplies for stand-by use.

• Portable hyperbaric oxygen chambers that are placed directly over the wound and provide higher concentrations of oxygen to the damaged tissue.

• Non-sterile gloves, when the gloves are for use by a health-care provider, in the home setting.

• Metabolically active skin equivalents or skin equivalents used in wound care, in the home setting.

• Rental or purchase of an electrical stimulation or electromagnetic wound treatment device (E0769), for use by the client or caregiver in the home setting.

Prior Authorization ChangesProviders must list all previous wound care therapy regimens, if appropriate, when requesting prior authorization for wound care supplies. It is no longer considered a contraindication to wound therapy, such as NPWT, when a client has less than six months to live.

The Statement for Initial Wound Therapy System In-Home Use and Statement for Recertification of Wound Therapy System In-Home Use prior authorization forms have been revised to reflect the change in contraindications. For online prior authorization requests that are submitted through the TMHP website, the Statement for Wound Therapy System In-Home Use option of the Home Health Title XIX form has also been revised to reflect the change in contraindications.

The revised forms are available starting on page 63 of this bulletin and on the TMHP website.

When used for NPWT, procedure code A7000 is limited to 10 per month, unless submitted documentation supports medical necessity for additional canisters. Procedure codes A4244, A4246, and A4247 are considered for prior authorization on an as-needed basis and are no longer limited to one per month. Procedure code A4455 no longer requires prior authorization.


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Initial List of Certified EHR Products is Available Online

The Office of the National Coordinator (ONC) for Health Information Technology (HIT) has released the initial list of certified electronic health record (EHR) products that comply

with meaningful use eligibility requirements for the EHR Incentive Payment program. The Certified Health IT Product List at http://onc-chpl.force.com/ehrcert, includes products that have

been tested and certified to meet Centers for Medicare & Medicaid Services (CMS) meaningful use criteria.

The list will help providers explore their options for EHR software as they take the first steps in becoming compliant with meaningful use standards. The ONC will update the certified product list often. Providers should refer to the ONC webpage at http://healthit.hhs.gov/portal/server.pt /community/healthit_hhs_gov__home/1204 for the most up-to-date information.

For more information about HHSC’s Health IT Initiative, providers may refer to the following resources:

• To sign up for e-mail updates about HHSC’s Health IT initiative refer to the HHSC website at https://service.govdelivery.com/service/multi_subscribe.html?code=TXHHSC.

• For more information about upcoming webinars, events, and answers to questions, refer to the TMHP website at www.tmhp.com/Pages/HealthIT/HIT_Home.aspx.

• Questions may be e-mailed to [email protected].

HIT

Initiatives

Reimbursement Rates Implemented for Second Quarter 2010 HCPCS Procedure CodesEffective for dates of service on or after January 1, 2011, reimbursement rates were implemented for Healthcare Common Procedure Coding System (HCPCS) procedure codes that are new for the second quarter 2010.

The following table includes the new procedure codes, which are benefits of Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program effective for dates of service on or after January 1, 2011:

Type of Service Procedure Code Fee1 C9264 $3.521 C9265 $223.781 C9266 $382.781 C9268 Manually priced1 C9367 Manually priced


All Providers


http://onc-chpl.force.com/ehrcert

http://onc-chpl.force.com/ehrcert

http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__home/1204



https://service.govdelivery.com/service/multi_subscribe.html?code=TXHHSC

http://www.tmhp.com/Pages/HealthIT/HIT_Home.aspx


Reimbursement Rates for Some DME Services “E” Procedure Codes Have Changed for Texas MedicaidEffective for dates of service on or after February 1, 2011, reimbursement rates for some DME services “E” procedure codes have changed for Texas Medicaid.

The following reimbursement rates for DME “E” codes are effective for dates of services on or after February 1, 2011:

TOSProcedure

Code Modifier Age Range Previous Medicaid Fee 2/1/11 Medicaid FeeL E0144 All ages $18.16 $16.41 L E0147 All ages $36.98 $52.02 L E0167 All ages $1.08 $0.99 L E0175 All ages $6.22 $5.21 J E0190 All ages $34.44 $50.00 L E0196 All ages $30.99 $34.11 L E0197 All ages $18.00 $18.83 L E0217 All ages $52.73 $47.36 J E0218 All ages $257.51 $391.84 L E0218 All ages Manually reviewed $54.99 J E0236 All ages $443.70 $464.60 J E0247 All ages $64.72 $96.41 J E0248 All ages $109.68 $150.67 J E0280 All ages $38.20 $34.57 L E0280 All ages $4.11 $3.72 J E0305 All ages $159.67 $161.00 J E0305 All ages Manually reviewed $161.00 J E0315 All ages Manually reviewed $172.20 J E0328 All ages $4,510.00 $5,412.00 L E0328 All ages $451.00 $541.20 L E0424 All ages $175.79 $173.17 L E0431 All ages $31.79 $28.77 L E0434 All ages $31.79 $28.77 L E0439 All ages $175.79 $173.17 L E0441 All ages $33.43 $38.50 L E0443 All ages $18.31 $38.50 L E0444 All ages $18.31 $38.50 J E0445 All ages $583.00 $553.50 L E0445 All ages $58.30 $55.35 L E0445 TF All ages $158.66 $133.66 L E0459 All ages $30.23 $45.42 J E0470 All ages $1,296.95 $3,018.86

TOS = Type of service, J = DME purchase, L = DME Rental or lease


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TOSProcedure

Code Modifier Age Range Previous Medicaid Fee 2/1/11 Medicaid FeeL E0480 All ages $37.70 $39.03 L E0483 All ages $1,116.29 $1,005.81 L E0550 All ages $45.10 $46.46 J E0561 All ages $107.00 $96.84 L E0561 All ages $10.69 $9.67 J E0562 All ages $299.73 $272.60 L E0562 All ages $28.72 $27.25 J E0565 All ages $1,316.56 $640.60 L E0565 All ages $82.08 $64.06 J E0570 All ages $105.25 $139.39 J E0574 All ages $402.60 $422.70 J E0575 All ages $319.93 $1,079.20 J E0580 All ages $134.04 $121.31 L E0580 All ages $13.40 $12.13 J E0601 All ages $930.20 $1,209.26 J E0619 All ages $3,250.00 $2,276.20 L E0619 All ages $250.00 $227.62 J E0625 All ages $600.00 $409.18 L E0625 All ages $60.00 $40.92 L E0630 All ages $96.63 $106.98 J E0635 All ages $1,565.42 $2,177.65 J E0635 Birth through 20

years of age$1,565.42 $2,177.65

J E0635 All ages $1,565.42 $2,177.65 J E0635 TG All ages $1,565.42 Manually reviewed J E0637 All ages $3,062.70 $3,556.34 J E0638 UA All ages $1,742.50 $2,349.30 J E0638 UB All ages $2,637.12 $2,927.40 J E0641 All ages $2,979.88 $2,813.58 J E0642 All ages $2,196.78 $3,001.20 L E0650 All ages $67.94 $57.84 L E0652 All ages $430.57 $453.31 L E0655 All ages $11.31 $8.65 L E0660 All ages $17.07 $13.14 L E0665 All ages $14.49 $11.23 L E0666 All ages $14.59 $10.74 L E0668 All ages $39.58 $43.41 J E0676 All ages $384.20 Manually reviewed L E0676 All ages $38.42 Manually reviewed J E0779 All ages $167.30 $175.70



All Providers


TOSProcedure

Code Modifier Age Range Previous Medicaid Fee 2/1/11 Medicaid FeeL E0781 All ages $252.64 $243.57 J E0784 All ages $4,387.82 $4,383.60 L E0784 All ages $415.43 $438.36 L E0920 All ages $39.23 $48.45 L E0930 All ages $37.82 $47.97 L E0936 All ages $76.80 $50.00 L E0940 All ages $28.40 $31.17 L E0946 All ages $37.91 $38.04 J E0992 All ages $97.50 $84.92 J E1029 All ages $369.54 $334.43 L E1050 All ages $82.78 $72.61 J E1060 All ages Manually reviewed $1,162.94 L E1060 All ages $104.01 $116.29 L E1070 All ages $88.70 $91.53 L E1083 All ages $51.71 $49.27 L E1084 All ages $81.18 $83.77 L E1085 All ages $58.67 $65.38 L E1086 All ages $70.85 $78.67 L E1087 All ages $108.13 $119.04 L E1088 All ages $132.60 $147.06 L E1089 All ages $104.18 $118.71 L E1090 All ages $116.94 $126.90 L E1092 All ages $121.13 $134.94 L E1093 All ages $106.01 $116.05 L E1100 All ages $96.00 $109.00 L E1130 All ages $41.47 $45.61 L E1140 All ages $60.29 $63.61 L E1150 All ages $71.61 $75.37 L E1160 All ages $53.37 $55.36 J E1161 All ages $2,906.00 $2,484.39 L E1161 All ages $223.53 $248.44 L E1170 All ages $84.09 $93.78 L E1171 All ages $79.76 $84.16 L E1172 All ages $81.06 $84.73 L E1180 All ages $85.33 $100.28 L E1190 All ages $100.59 $121.55 L E1195 All ages $99.21 $115.77 L E1200 All ages $72.29 $70.70 L E1230 All ages $187.49 $207.77 J E1231 All ages $4,681.35 $3,043.84



All Providers


TOSProcedure

Code Modifier Age Range Previous Medicaid Fee 2/1/11 Medicaid FeeL E1231 All ages $360.10 $304.38 J E1232 All ages $4,845.38 $2,245.33 L E1232 All ages $224.54 $224.53 J E1233 All ages $2,625.60 $2,326.52 L E1233 All ages $201.97 $232.65 J E1234 All ages $2,689.60 $2,025.40 L E1234 All ages $206.89 $202.55 L E1237 All ages $113.54 $147.60 L E1238 All ages $126.15 $164.00 L E1240 All ages $87.48 $97.98 L E1250 All ages $61.31 $72.93 L E1260 All ages $80.57 $90.09 J E1270 All ages $701.12 $828.90 L E1270 All ages $66.35 $82.89 J E1280 All ages $1,124.17 $1,378.20 L E1280 All ages $108.94 $137.82 L E1285 All ages $91.09 $118.36 L E1290 All ages $97.39 $103.45 L E1295 All ages $98.85 $111.36 J E1300 All ages $1,409.87 $170.00 L E1300 All ages $140.99 $17.00 J E1310 All ages $3,083.22 $2,254.77 J E1353 All ages $43.59 $29.75 L E1355 All ages $3.36 $2.24 L E1390 All ages $175.79 $173.17 L E1510 All ages $831.00 $1,013.13 J E1520 All ages $393.09 $380.31 L E1520 All ages $39.31 $38.03 J E1530 All ages $565.60 $547.22 L E1530 All ages $56.56 $54.72 J E1540 All ages $10.39 $22.96 J E1570 All ages $347.70 $200.23 L E1570 All ages $34.72 $20.02 J E1575 All ages $1.27 $1.63 J E1594 All ages $5,200.00 $6,544.00 L E1594 All ages $520.00 $654.40 L E1600 All ages $377.00 $364.75 J E1620 All ages $1,174.36 $1,754.74 L E1620 All ages $123.05 $175.47 L E1635 All ages $71.47 $628.88



All Providers


TOSProcedure

Code Modifier Age Range Previous Medicaid Fee 2/1/11 Medicaid FeeJ E1637 All ages $2.50 $5.33 L E1701 All ages Manually reviewed $9.47 L E1702 All ages Manually reviewed $23.70 L E1800 All ages $91.92 $111.56 L E1802 All ages $326.80 $343.14 L E1805 All ages $94.33 $112.76 L E1810 All ages $92.05 $113.09 L E1812 All ages $90.29 $85.99 L E1815 All ages $94.33 $113.09 L E1825 All ages $94.33 $112.76 L E1830 All ages $94.33 $112.76 J E1840 All ages $3,827.10 $4,018.50 J E2205 All ages Manually reviewed $34.30 J E2206 All ages Manually reviewed $42.71 L E2402 All ages $1,716.46 $1,553.40 J E2511 All ages $892.16 $361.60


Change to the Personal Care Services BenefitPersonal Care Services (PCS) are a benefit of Texas Medicaid for clients who are 20 years of age and younger and who require assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), and health-related functions because of a physical, cognitive, or behavioral limitation related to the client’s disability or chronic health condition.

Effective for dates of service on or after December 31, 2010, “exercise” and “range of motion” are no longer PCS benefits; however, these services may be benefits through physical therapy, private duty nursing, or home health skilled nursing.

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

• Sunday, March 13, 2011, 4:00 p.m. until 11:59 a.m.

• Sunday, April 10, 2011, 4:00 p.m. until 11:59 a.m.

During scheduled system maintenance, some applications related to the claims engine will be unavailable. Details about the affected applications are available on the TMHP website at www.tmhp.com.


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http://www.tmhp.com

Benefit Criteria for Cranial Molding Orthosis Will Change for CCPA cranial molding orthosis (procedure code S1040) is a benefit of the Comprehensive Care Program (CCP) for clients who are 3 through 12 months of age if the orthosis is prior authorized and any of the following applies:

• The client presents with nonsynostotic (positional) plagiocephaly with an associated functional impairment, including orofacial musculoskeletal or neurocognitive disorders, or if the client has not yet developed an impairment, there must be documented evidence that the use of the cranial molding orthosis will modify or prevent the development of such impairments.

• The client requires a cranial molding orthosis as part of the treatment plan for shaping the skull in cases of post operative synostotic plagiocephaly.

The cranial molding orthosis for positional plagiocephaly may be considered for prior authorization with documentation of all of the following:

• The plan of treatment or follow-up schedule.

• The assessment and recommendations of the appropriate primary care physician, pediatric subspecialist, craniofacial team, or pediatric neurosurgeon.

• A full description of the physical findings, precise diagnosis, age of onset, and the etiology of the deformity.

• Reports of any radiological procedures that were used to make the diagnosis.

• The client is at least 3 months of age but not more than 12 months of age.

• Anthropometric measurements that document a cranial asymmetry that is greater than 10-mm.

• Documentation of any repositioning interventions that were attempted, which may include:

— Documentation of aggressive repositioning, with or without physical therapy, of at least three months duration without improvement in cranial asymmetry.

— Repositioning the client’s head to the opposite side of the preferred position when the client is either lying down, reclined, or sitting.

— Gently turning and stretching the client’s neck at each diaper change.

— Repositioning the client’s bed to encourage the client to look away from the flattened side to view other objects of interest.

— The trial of repositioning intervention has failed to improve the deformity and is judged to be unlikely to do so.

Note: Due to the mobility of children over six months of age and the limited timeframe during which the orthosis may be effective, repositioning is not indicated for this age group, with the exception of clients who have a diagnosis of muscular torticollis.

Muscular torticollis (wry neck), which is characterized by tight or shortened neck muscles that result in a head tilt or turn, is often associated with the secondary development of positional plagiocephaly; therefore, all clients with muscular torticollis and positional plagiocephaly must undergo early, aggressive treatment (stretching, positioning and physiotherapy) before they will be considered for prior authorization for cranial orthosis.

For clients who have a cranial molding orthosis and are requesting a new one, providers must submit documentation of medical necessity that includes new anthropometric measurements.


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A completed CCP Prior Authorization Request Form that includes the durable medical equipment (DME) must be signed and dated by the prescribing physician who is familiar with the client’s condition. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed CCP Prior Authorization Request Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept by the physician in the client’s medical record.

To complete the prior authorization request on paper, the provider must fax or mail the completed CCP Prior Authorization Request Form to the CCP Prior Authorization Unit at the following address and retain a copy of the signed and dated form in the client’s medical record at the provider’s place of business:

Texas Medicaid & Healthcare Partnership Comprehensive Care Program (CCP)

PO Box 200735 Austin, TX 78720-0735

Fax: 1-512-514-4212

To complete the prior authorization request electronically, the provider must complete the prior authorization requirements through any approved electronic method and retain a copy of the signed and dated CCP Prior Authorization Request Form in the client’s medical record at the provider’s place of business.

Clarification of Medicaid for Breast and Cervical Cancer EligibilityA woman may be eligible for initial enrollment in the Medicaid for Breast and Cervical Cancer (MBCC) Program if she has an active disease as indicated by a biopsy that confirmed a precancerous or cancerous breast or cervical diagnosis that meets the specifications in the Medicaid for Breast and Cervical Cancer Guidelines for Determination of Qualifying Diagnosis. The guidelines are available on the DSHS website at www.dshs.state.tx.us/chscontracts/pdf/MBCCQualifyingDx072009.pdf.

Women who only require monitoring for hormonal treatment or triple negative receptor breast cancer (TNRBC) do not qualify for initial MBCC enrollment.

Once a woman is enrolled in the MBCC program, eligibility may continue if she meets at least one of the following criteria:

• She is being treated for an active disease as defined above.

• She has completed active treatment while in MBCC and now is receiving hormonal treatment.

• She has completed active treatment while in MBCC and now is receiving active disease surveillance for TNRBC.

A woman no longer in MBCC may reapply if diagnosed with a new breast or cervical cancer or a metastatic or recurrent breast or cervical cancer.


All Providers


www.dshs.state.tx.us/chscontracts/pdf/MBCCQualifyingDx072009.pdf

Potentially Preventable Readmissions Information Available on the TMHP WebsiteEffective January 14, 2011, information related to potentially preventable readmissions (PPR) is available on the TMHP website at www.tmhp.com when providers log into their account. PPR is defined as a return hospitalization of a client within 15 days of the initial discharge date when the return hospitalization could have been the result of deficiencies in care or treatment provided to the client during a previous hospital stay or in follow-up after hospital discharge.

H.B. 1218, 81st Legislature, Regular Session, 2009, establishes Texas Government Code, Section 531.913, which requires confidential information be provided to each hospital in the state regarding the hospital’s performance with respect to PPR. This information will be updated annually.

PPR rates will be calculated for services rendered to Texas Medicaid clients in acute care facilities. A statewide average rate will be calculated for all hospitals within Texas as well as a rate for each individual hospital, which will allow hospitals to compare their rate of PPR to the statewide average. Hospitals will only have access to the statewide average and their specific PPR rate. Rates of each individual hospital will not be shared with other hospitals or with the general public at this time.

Claim data for hospital stays that occurred between September 2008 and August 2009, will be used for the reports that were issued January 3, 2011. The claim data includes fee-for-service, PCCM, and Medicaid managed care programs.

In addition to the individual hospital’s PPR rate and the statewide average hospital PPR rate, the following information is available through the provider’s TMHP website account:

• General information explaining how PPR is one method used to measure health-care quality

• A description of how PPR is calculated

• A data breakdown of PPR rates by types of admissions and types of readmissions

• Detailed claims data used to calculate the provider’s specific PPR rate and to contribute to the statewide hospital average

The PPR rates look at combined performance over many acute inpatient stays. The PPR methodology classifies individual hospital admissions as unique and unrelated or as potentially preventable. The methodology does not attempt to classify any stay as specifically or clearly preventable.

PPR rates do not include hospital readmissions caused by unrelated events after discharge. PPR does include readmissions of clients to a hospital for any of the following:

• The same condition or procedure for which the client was previously admitted.

• An infection or other complication resulting from care previously provided.

• A condition or procedure that indicates that a surgical intervention performed during a previous admission did not achieve the anticipated outcome.

• Another condition or procedure of a similar nature to the original admission, as determined by the executive commissioner.

PPR rates will be calculated for

services rendered to Texas Medicaid

clients in acute care facilities.


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http://www.tmhp.com

Acute Care Services Provided Off-Campus to Medicaid Eligible State Supported Living Center Residents (SSLC) Reimbursed by Texas MedicaidEffective March 1, 2011, Medicaid providers who render off-campus acute care services to Medicaid-eligible State Supported Living Center (SSLC) residents will be required to submit claims directly to Medicaid. This change is applicable only to residents of the SSLCs operated by the Department of Aging and Disability Services (DADS). There are 13 SSLCs in Texas that provide campus-based direct services and support to people who have intellectual and developmental disabilities.

Currently, SSLCs must contract with and reimburse Medicaid and non-Medicaid providers of all disciplines to provide off-campus acute care services to Medicaid-eligible residents. Claims for acute care services that are provided after March 1, 2011, must be submitted directly to Medicaid. SSLC claims that are submitted to an SSLC for Medicaid-eligible residents for services provided after the March 1, 2011 date will not be reimbursed by SSLCs.

Claims and prior authorization requests for these individuals must be submitted to Medicaid after March 1, 2011. These requests must be submitted according to guidelines for acute care services as indicated in the 2010 Texas Medicaid Provider Procedures Manual and Texas Medicaid Bulletin articles.

HHSC provides this information to help hospitals measure their quality of care and to make decisions about how it can be improved. PPR information should help providers to focus their attention on the critical time of transition between inpatient and outpatient phases of treatment for an acute illness. PPR information can highlight complications from treatment that become evident only after discharge.

HHSC and TMHP have scheduled informational workshops for providers. Additional information, including dates and locations of the workshops, is available on the TMHP website.

New Web Page Created for February 2011 NCCI Guideline ImplementationEffective February 25, 2010, for dates of service on or after October 1, 2010, providers must comply with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines. TMHP has created the NCCI Compliance web page at www.tmhp.com to provide updates as TMHP systematically implements the new guidelines. A link to the CMS website is also available on the new web page. Providers are encouraged to refer to this website regularly for the most up-to-date information.

Providers can refer to the article titled Mandatory State Use of NCCI and Compliance with NCCI Guidelines, which was published on the TMHP website on August 13, 2010, for more information about the CMS NCCI mandate.


All Providers


http://www.tmhp.com/Pages/CodeUpdates/NCCI.aspx

Medicaid Buy-In for Children (MBIC) Program Available to Children with DisabilitiesEffective January 1, 2011, TMHP has implemented the MBIC program. The MBIC program is mandated by S.B. 187, 81st Legislature, Regular Session, 2009, to provide acute care Medicaid coverage for children who are 18 years of age and younger and have disabilities. This new Medicaid program created a state option for children who are ineligible for Supplemental Security Income (SSI) for reasons other than disability.

Applications for the program will be accepted on or after January 1, 2011. Children with disabilities must meet the following requirements to be eligible for MBIC:

• Be 18 years of age or younger.

• Have a family income that is no more than 300 percent of the Federal Poverty Level (FPL) before allowable deductions.

• Meet citizenship, immigration, and residency requirements.

• Be unmarried.

• Not reside in a public institution.

Exception: Clients who are enrolled in the MBIC program before they enter a nursing facility or intermediate care facility for persons with intellectual disabilities (ICF-MR) will continue to receive MBIC benefits until eligibility for the appropriate institutional Medicaid program is determined.

On or after January 1, 2011, MBIC clients will be enrolled as Medicaid fee-for-service or Medicaid managed care clients, as applicable. MBIC clients are identified by Type Program (TP) 88 on the Medicaid Identification (Form H3087). MBIC clients have access to the same benefits as Medicaid clients who have disabilities. Claims and prior authorization requests for MBIC clients may be submitted according to current guidelines for Medicaid fee-for-service and Medicaid managed care services as indicated in the Texas Medicaid Provider Procedures Manual and subsequent Texas Medicaid Bulletin articles.

MBIC benefits are available to enrolled clients through the end of the month that contains their 19th birthday. Clients whose birthday falls on the last day of February of a leap year (i.e., February 29, 2004) will be eligible for benefits through the end of March following their 19th year.

TMHP Contact Center Has Implemented an Enhanced Tracking SystemEffective February 1, 2011, the TMHP Contact Center began using an enhanced tracking system for all provider inquiries. As a result of the new system, the tracking number assigned to a provider inquiry will begin with a low numbering sequence.

Providers could encounter longer than average hold times during implementation of the new tracking system.

For faster service during this implementation, providers should use the TMHP website for eligibility verifications, claim status inquiries, and claim payment inquiries.

TMHP appreciates provider participation and understanding as this enhanced tracking system is implemented.


All Providers


Additional 1 Percent Reimbursement Reduction for February 2011Effective for dates of service on or after February 1, 2011, Medicaid fee-for-service (FFS), Medicaid managed care, family planning (Titles V, X, and XX services), and the Children with Special Health Care Needs (CSHCN) Services Program will institute an additional 1 percent reduction in the final payment amounts for professional and outpatient facility services. The additional 1 percent reduction will be added to the 1 percent reduction that was effective for dates of service on or after September 1, 2010, resulting in a 2 percent total reduction that will be applied to the current Medicaid rate for affected services with dates of service on or after February 1, 2011.

The 2 percent total reduction (including the 1 percent from September 1, 2010 and the 1 percent for February 1, 2011) will be applied to the following services:

• Services rendered to Medicaid Title XIX FFS clients

• Services rendered to Medicaid managed care Primary Care Case Management (PCCM) clients

• The Medicaid managed care case management fee that is remitted to Primary Care Case Management (PCCM) primary care providers for each PCCM client in the provider’s panel

• Family planning Titles V, X, and XX services

• Services rendered to CSHCN Services Program clients

Note: Medicaid Title XIX personal care services (PCS) were included in the 1 percent reduction from September 1, 2010, but will not be included in the additional 1 percent reduction for February 1, 2011. Only 1 percent total reduction will be applied to PCS.

The following will not be affected by the 2 percent total reduction:

• School Health and Related Services (SHARS)

• Tax Equity and Fiscal Responsibility Act (TEFRA)-reimbursed inpatient hospitals (children’s and state teaching hospitals)

• State hospital freestanding psychiatric facilities

• DARS-ECI Case Management and Developmental Rehabilitation Program

• Rural health clinics (RHCs)

• Department of State Health Services (DSHS) clinical labs

• Birthing centers

• Indian Health Services

• Medicare crossover claims

• Case Management and Rehabilitative Services—Blind Children’s Vocational Discovery and Development Program

• Case Management and Rehabilitative Services—Early Child Intervention

• Case Management and Rehabilitative Services—Mental Retardation

• Outpatient Behavioral Health—Chemical Dependency Treatment Facility

Note: FQHC reimbursement for Titles V, X, and XX family planning services will be reduced by an additional 1 percent effective for dates of service on or after February 1, 2011. All other FQHC services will not be reduced by an additional 1 percent. However, the 1 percent reimbursement reduction to be applied to alternative prospective payment system (APPS) annual adjustment effective on or after January 1, 2011, will remain in effect.


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Texas Medicaid Claims ReprocessingThe following claims issues have been identified. All affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Claims Reprocessing for Procedure Code 84443TMHP has identified an issue that affects claims submitted by laboratory providers with dates of service on or after April 2, 2007, and procedure code 84443. Claims with dates of service on or after April 2, 2007, may have been denied in error. According to Centers for Medicaid & Medicare Services (CMS) Clinical Laboratory Improvement Amendments (CLIA) guidelines, procedure code 84443 must be billed with the QW modifier to be considered a waived CLIA test for providers with laboratory certificate types 2 and 4.

Issue with Global Surgical Period Changes That Were Effective May 1, 2010TMHP has identified an issue with the global surgical period changes that were implemented for dates of service on or after May 1, 2010.

Hospital visits by the surgeon during the same hospitalization as the surgery are usually considered to be related to the surgery and, as a result, not separately billable; however, separate payment for such visits can be allowed if any of the following conditions apply:

• Immunotherapy management is provided by the transplant surgeon. Immunosuppressant therapy following transplant surgery is covered separately from other postoperative services, so postoperative immunosuppressant therapy is not part of the global fee allowance for the transplant surgery. This coverage applies regardless of the setting.

• Critical care is provided by the surgeon for a burn or trauma patient.

• The hospital visit is for a diagnosis that is unrelated to the original surgery.

If any of these circumstances occur, the surgeon may bill modifier 24 to indicate an unrelated evaluation and management service was performed by the same physician during a postoperative period.

Providers who submitted claims that qualify for these exceptions may have had their claims denied in error. Affected claims for dates of service on or after May 1, 2010, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is required.

Invalid and Discontinued Procedure Codes 85028, 86335, and J6000 Claims ReprocessingAfter a review of invalid and discontinued procedure codes, TMHP identified an issue that impacts claims with procedure code 85028, 86335, or J6000. These claims may have been processed incorrectly. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action by the provider is required.


All Providers


Reimbursement Rate Changes That Became Effective April 1, 2010 Claims ReprocessingOn February 19, 2010, TMHP announced reimbursement rate changes for several services effective for dates of service on or after April 1, 2010. Although the rates were effective April 1, 2010, claims were reimbursed at the old rates until the new rates could be implemented in the claims processing system. Providers who submitted claims for certain services provided from April 1, 2010, until the revised rates were implemented may have funds recouped. The claims processing system is now updated with the new reimbursement rates. Reprocessing of affected claims has begun, and payments are being adjusted to reflect the differences between the new rates and the previous rates.

Details are available on the TMHP website at www.tmhp.com.

TMHP to Reprocess NDC Claims for Depo-Medrol Procedure CodeTMHP has identified an issue that affects claims submitted with dates of service on or after February 1, 2010, and procedure code J1040 (depo-medrol) by Medicaid fee-for-service, Primary Care Case Management (PCCM), Family Planning, and the Children with Special Health Care Needs (CSHCN) Services Program providers. These claims may have been denied in error because some National Drug Code (NDC) numbers (values) were not included in the NDC-to-Healthcare Common Procedure Coding System (HCPCS) crosswalk.

Claims that were submitted with dates of service on or after February 1, 2010, with medical procedure code J1040 and at least one of the following NDC numbers will be reprocessed:

Procedure Code J104000009347501 00009030602 00009030612

TMHP Will Reprocess Some National Drug Code (NDC) ClaimsTMHP has identified an issue that affects claims submitted by Medicaid and Primary Care Case Management (PCCM) providers with various dates of service between November 2008 and February of 2010 and any of the following procedure codes in combination with specific National Drug Code (NDC) numbers (values):

Procedure CodesJ0696 J1170 J1566 J1626 J1885 J2405 J2430 J2550 J3010 J3370 J7190J7192 J9000 J9040 J9045 J9060 J9178 J9190 J9206 J9217 J9265 J9390

These claims may have been reimbursed incorrectly or denied in error.

Claims submitted with the following procedure codes and National Drug Code (NDC) combination will be reprocessed:

Procedure Code J0696 NDC values00004196501 00004196505 00004200278 00004200378Procedure Code J1170 NDC values00074233211 00074233311 00074233326 00074233411 00074241421 00074245311Procedure Code J1566 NDC values00944047172 00944047180


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http://www.tmhp.com

Procedure Code J1626 NDC values00703787103 66758003501 66758003601 64679066102 66758003702 00703797301Procedure Code J1885 NDC value00074379601Procedure Code J2405 NDC values00143977106 00173046100Procedure Code J2430 NDC value00703408511Procedure Code J2550 NDC values00591315754 00591315854 66758060119 67457015210 00143986822 0014398692200409231202 66860009803 66860009903Procedure Code J3010 NDC value58298052502Procedure Code J3370 NDC value00074433201Procedure Code J7190 NDC value00944293503Procedure Code J7192 NDC values00026037220 00026037230Procedure Code J9000 NDC value10019092001Procedure Code J9040 NDC value00703315491Procedure Code J9045 NDC values00015321430 00015323011 00703327601 00703327801 50111096576 50111096676Procedure Code J9060 NDC values00015322022 00015322122 10019091002Procedure Code J9178 NDC value00591346983Procedure Code J9190 NDC value00187395364Procedure Code J9206 NDC values00591318902 10518010310 10518010311Procedure Code J9217 NDC values00300210801 00300244001 00300334601 00300364201 00300366301 00300368301Procedure Code J9265 NDC values00015347530 00015347630 00015347911 00172375377 00172375473 1051801020710518010209 55390051420 55390051450Procedure Code J9390 NDC values00173065601 00173065644


All Providers


Claims Reprocessing for Some Procedure Codes that were Reimbursed IncorrectlyTMHP has identified an issue that impacts claims submitted with dates of service from April 1, 2010, through November 16, 2010, and some procedure codes that were updated effective for dates of service on or after April 1, 2010. The affected procedure codes were not reimbursed according to the updated reimbursement rate.

Claims submitted with the following procedure codes and dates of service from April 1, 2010, through November 16, 2010, will be reprocessed:

Procedure CodesSurgical Component33470 33508 33510 34834 35236 36406 45123 45340 45381 4538646320 54001 54670 55860 92511 92987 93651 93652 93662 96920Assistant Surgery Component33470 33508 34834 46705 56631Professional Interpretation Component77079 93321 93555 93975Technical Component77079Medical Services Component92597

For the published rates, providers may refer to the articles titled “Claims Reprocessing for Reimbursement Rate Changes That Became Effective April 1, 2010 (1 of 2),” and “Claims Reprocessing for Reimbursement Rate Changes That Became Effective April 1, 2010 (2 of 2),” which were published on the TMHP website on November 16, 2010.

Claims Reprocessing for April 2011 Reimbursement Rate Changes for Procedure Codes 90806, 90847, and 90853TMHP has identified an issue that impacts claims that were submitted with procedure code 90806, 90847, or 90853 and dates of service on or after April 1, 2010. The reprocessing of affected claims to apply the April 2010 reimbursement rate updates did not occur. Affected claims will now be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Providers can refer to the article titled “TMHP Updating Reimbursement Rates That Are Effective for April 1, 2010,” which was published on the TMHP website on July 22, 2010, for the rate information for these procedure codes.

Claims Reprocessing for Personal Care Services, Occupational Therapy, and Physical TherapyTMHP has identified an issue that impacts claims that were submitted by consumer directed services agencies (CDSAs) for personal care services (PCS) and by home health agencies for occupational therapy (OT) and physical therapy (PT). PCS claims that were submitted with dates of service from January 1, 2010, through December 17, 2010, and OT and PT claims that were submitted with dates of service from August 1, 2009, through December 17, 2010, may not have been processed according to the prior authorizations for these services.


All Providers


http://www.tmhp.com/News_Items/2010/11-12-10 Claims Reprocessing Reimb rate change_PT 1.pdf

http://www.tmhp.com/News_Items/2010/11-12-10 Claims Reprocessing Reimb rate change_PT 1.pdf

http://www.tmhp.com/News_Items/2010/11-16-10 Claims Reprocessing Begins on Reimbursement Rate Changes Eff April 1 PT 2.pdf

http://www.tmhp.com/News_Items/2010/11-16-10 Claims Reprocessing Begins on Reimbursement Rate Changes Eff April 1 PT 2.pdf

http://www.tmhp.com/News_Items/2010/07-22-10 TMHP Updating Reimbursement Rates That Are Effective for April 1, 2010.pdf

http://www.tmhp.com/News_Items/2010/07-22-10 TMHP Updating Reimbursement Rates That Are Effective for April 1, 2010.pdf

Updates to Previously Published InformationThe following are updates and corrections to articles that were published in previous bulletins or on the TMHP website at www.tmhp.com as either banner messages or web articles.

Correction to “Age and Gender Restrictions to Change for Some Medicaid Services”This is a correction to an article titled “Age and Gender Restrictions to Change for Some Medicaid Services,” which was published in the September/October 2010 Texas Medicaid Bulletin, No. 231, and on May 7, 2010, on the TMHP website.

The article incorrectly indicated that effective for dates of service on or after July 1, 2010, the age restriction for procedure codes 31520, 36510, 36660, 54000, and 54160 would be 29 days of age and younger.

The correct information is: Effective for dates of service on or after July 1, the age restriction for procedure codes 2010, 31520, 36510, 36660, 54000, and 54160 is 28 days of age and younger.

Update to “FMAP and EFMAP Rate Changes”This is an update to an article titled “FMAP and EFMAP Rate Changes,” which was published in the January/February, 2011, Texas Medicaid Bulletin, No 233. The rates have changed for second and third quarters.

The Education, Jobs, and Medicaid Assistance Act will extend the temporary increase in the Federal Medical Assistance Percentage (FMAP) that was part of the federal stimulus package. The FMAP increase will be at a lower rate and will cover the second and third quarters of the 2011 federal fiscal year. The FMAP will return to the original, pre-stimulus package rate in the fourth quarter of the 2011 federal fiscal year.

• Effective for dates of service between October 1, 2010, and December 31, 2010, the FMAP will remain at 70.94 percent.

• Effective for dates of service between January 1, 2011, and March 31, 2011, the FMAP will decrease to 68.11 percent.

• Effective for dates of service between April 1, 2011, and June 30, 2011, the FMAP will decrease to 66.23 percent.

• Effective for dates of service between July 1, 2011, and September 30, 2011, the FMAP will decrease to 60.56 percent.

FMAP is the federal government’s contribution to states for Medicaid expenditures and is used for Medicaid fee-for-service and managed care. The FMAP changes affect only providers who certify expenses and are paid only the federal share of their claims.

Effective for dates of service on or after October 1, 2010, the Enhanced Federal Medical Assistance Percentage (EFMAP) rate will increase from 71.11 percent to 72.39 percent.

Update to “TMHP to Change Processing and Reporting of DRG Claim Reimbursements”This is an update to an article titled “TMHP to Change Processing and Reporting of DRG Claims Reimbursements,” which was published on the TMHP website on October 29, 2010.


All Providers


http://www.tmhp.com

http://www.tmhp.com/News_Items/2010/05-07-10 Age and Gender Restrictions to Change for Some Medicaid Services.pdf

The original article stated that effective December 17, 2010, TMHP will make changes to the way it reimburses and reports diagnosis-related group (DRG) claims. While changes to claims reporting will be effective December 17, 2010, the effective date of claims reimbursement changes were postponed to February 25, 2011.

Inpatient claims with admission dates on or after September 1, 2010, will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Correction to “Texas Medicaid and PCCM Procedure Code Updates for May 8, 2010”This is a correction to an article titled “Texas Medicaid and PCCM Procedure Code Updates for May 8, 2010” that was published on the TMHP website at www.tmhp.com on May 14, 2010. The article indicated incorrect procedure codes and an incorrect effective date of service for changes applied to the surgical component of procedure code 93226. The following is the correct information:

Effective May 8, 2010, for dates of service on or after February 1, 2010, procedure code 93226 may be reimbursed to hospital providers for services rendered in the outpatient hospital setting. Affected claims that were submitted between February 1, 2010, and May 7, 2010, will be reprocessed, and payments will be adjusted accordingly. No further action on the part of the provider is necessary.

Note: Claims that were submitted between July 1, 2009, and January 31, 2010, will not be reprocessed as indicated in the original article.

Effective May 8, 2010, for dates of service on or after July 1, 2009, procedure code 93225 may be reimbursed to hospital providers for services rendered in the outpatient hospital setting. Affected claims have been reprocessed, and payments have been adjusted accordingly. No further action on the part of the provider is necessary.

No changes were applied to procedure code 93325 or 93326 as indicated in the original article.

Clarification and Correction of “Hearing Services Claims for Clients with Medicaid Managed Care Plans Must be Billed to TMHP”This is a clarification and correction of an article titled “Hearing Services Claims for Clients with Medicaid Managed Care Plans Must Be Billed to TMHP,” which was published on November 12, 2010, on the TMHP website.

The article applies only to non-implantable hearing devices and related services that are rendered by audiologist or hearing aid fitter and dispenser providers (as applicable) to clients of a Medicaid managed care plan.

The article also included incorrect information about how to submit authorization requests for procedure codes that are on the carve-out list for Supplemental Security Income (SSI) clients who are 20 years of age and younger. The correct information is as follows: For all clients who are 20 years of age and younger, including SSI clients, prior authorization requests and claims for procedure codes that are in the carve-out list must be submitted to TMHP regardless of the health plan.

The following is the complete, corrected, and revised article:

The Texas Medicaid hearing services benefit includes non-implantable hearing devices and services and covers those hearing services that are rendered to clients with suspected or confirmed hearing loss.

The Texas Medicaid hearing services benefit is considered a carve-out service for Medicaid managed care clients who are 20 years of age and younger if the services are rendered by an audiologist or hearing aid fitter


All Providers


http://www.tmhp.com

and dispenser provider. Prior authorization requests and claims for carved-out services must be submitted to TMHP instead of the managed care organization (MCO) that administers the client’s Medicaid managed care plan.

Important: Non-implantable hearing devices and services are carved out only for clients who are 20 years of age or younger when the services are rendered by an audiologist or hearing aid fitter and dispenser provider.

For services rendered by all other provider types, including physician and hospital providers, and for clients who are 21 years of age and older, any necessary prior authorization requests and all claims must be submitted to the MCO that administers the client’s Medicaid managed care plan unless otherwise indicated in the tables below.

Refer to: The 2010 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, section 8.5.5, “STAR Health Claims Filing” for more information about services that are carved out for clients who are 20 years of age and younger and enrolled in a Texas Medicaid managed care plan (other than Primary Care Case Management [PCCM]) that is administered by an MCO.

The 2010 Texas Medicaid Provider Procedures Manual, Vol. 1, General Information, section 8.1.13, “TMHP Claims Filing Information,” and section 8.1.3, “Authorizations and Claim Processing Exceptions by Program,” for more information about claims filing and authorizations.

Carved-Out Services for Clients Who Are 20 Years of Age and YoungerThe following procedure codes for non-implantable hearing devices and related services are carved-out for managed care clients who are 20 years of age and younger when the services are rendered by audiologist or hearing aid fitter and dispenser providers as appropriate:

Table A: Carved-Out Services92550 92551 92552 92553 92555 92556 92557 92562 92563 92564 9256792568 92570 92579 92582 92585 92586 92587 92588 92591 92592 92593V5010 V5011 V5014 V5030 V5040 V5090 V5100 V5110 V5160 V5170 V5180V5200 V5210 V5220 V5240 V5241 V5244 V5245 V5246 V5247 V5249 V5250V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261V5264 V5265 V5266 V5267 V5275 V5298

For the services that meet the criteria for being carved out, any necessary authorization requests and claims are submitted to TMHP.

Services That Are Not Carved Out for Medicaid Managed Care ClientsThe following services are not carved out for Medicaid managed care clients regardless of client age or provider type:

• All implantable hearing devices and related services are not carved out for managed care clients of any age.

• The procedure codes in the following table are not carved out for managed care clients of any age:

Table B: Non-Carved-Out Services92502 92504 92571 92572 92575 92576 92577 92584 92620 92621 92625


All Providers


Any necessary authorization requests and claims for services that are not carved out should be submitted to the MCO that administers the client’s Medicaid managed care plan unless otherwise indicated in the tables below.

Prior Authorization Submissions and Claims FilingProviders can refer to the following table to determine where to submit any necessary prior authorization requests and claims for Texas Medicaid clients:

Service Client AgeSubmitted By Provider Type:

Submit Prior Authorization Requests To:

Submit Claims To:

SSI Clients Enrolled in the STAR ProgramCarved-out services (Table A)

20 years of age or younger

Audiologist or Hearing Aid Fitter/Dispenser (HAFD)

TMHP TMHP

Non-carved-out services (Table B)

20 years of age or younger

Audiologist or HAFD The MCO that administers the client’s Medicaid managed care plan (MCO)

TMHP

Tables A and B 21 years of age or older

Audiologist or HAFD MCO TMHP

Tables A and B Any age A provider type other than an audiologist or HAFD (Other)

MCO TMHP

Implantable devices and services

Any age Any provider type MCO TMHP

All Other Managed Care Clients Regardless of Managed Care PlanTable A 20 years of age or

youngerAudiologist or HAFD TMHP TMHP

Table B 20 years of age or younger

Audiologist or HAFD MCO MCO


Audiologist or HAFD MCO MCO

Tables A and B Any age Other MCO MCOImplantable devices and services

Any age Any provider type MCO MCO

Texas Medicaid Fee-For-Service and PCCM ClientsTable A 20 years of age or

youngerAny provider type TMHP TMHP

Table B 20 years of age or younger

Any provider type TMHP TMHP


Any provider type TMHP TMHP

Implantable devices and services

Any age Any provider type TMHP TMHP

Standard third party resource (TPR) rules apply to all hearing services claims regardless of the client’s age.


All Providers


New Clarification to “Reimbursement Rates for Some Procedure Codes Will Change April 1, 2010”This is a clarification to an article titled “Reimbursement Rates for Some Procedure Codes Will Change April 1, 2010,” which was posted on the TMHP website at www.tmhp.com on February 19, 2010. The following facility and non-facility reimbursement rate changes for cardiovascular services, digestive system services, and urinary system services are available on the TMHP website.

Rate increases, are presented in green and rate decreases, are presented in red:

• Cardiovascular Services

• Digestive System Services

• Urinary System Services

Correction to “Correction to Medicaid Benefits to Change for Nonsurgical Vision Services”This is a correction to an article titled “Correction to “Medicaid Benefits to Change for Nonsurgical Vision Services,” which was posted on the TMHP website on August 31, 2010.

The article included incomplete payable settings for procedure codes 92012, 92014, S0620, and S0621.

The correct information is:

Procedure codes 92012, 92014, S0620, and S0621 are payable in the office, inpatient hospital, nursing home (skilled nursing facility or intermediate care facility) and outpatient hospital setting.

Correction to the 2010 Texas Medicaid Provider Procedures Manual, Managed Care HandbookThis is a correction to the 2010 Texas Medicaid Provider Procedures Manual, Vol. 1 Managed Care Handbook, section 8.1.10, “Primary Care Provider Requirements and Information.” This section incorrectly included

“Early Childhood Intervention (ECI) targeted case management” as a self-referred service for federally qualified health centers (FQHCs). FQHCs are not ECI providers.

FAMILY PLANNING PROVIDERS

Reimbursement Rate Change for Family Planning Procedure Code J1055Effective for dates of service on or after January 1, 2011, the reimbursement rate for family planning procedure code J1055 has changed. The new reimbursement rate for procedure code J1055 and type of service (TOS) 1 is $69.87.

The previous reimbursement rate for procedure code J1055 and TOS 1 was $61.91.


All Providers/Family Planning Providers


http://www.tmhp.com

http://www.tmhp.com/News_Items/2010/12-13-10%20New%20Clarification%20to%20Reimbursement%20Rates%20for%20Some%20Procedure%20Codes%20Will%20Change%20April%201%202010.pdf



HOSPITAL PROVIDERS

Correction to “Present on Admission Value is Required on Hospital Claims”This is a correction to an article titled “Present on Admission Value is Required on Hospital Claims,” which was published in the September/October 2010 Texas Medicaid Bulletin, No. 231, and on the TMHP website. The article incorrectly included “E” series diagnosis codes in the list of diagnosis codes that are exempt from present on admission (POA) reporting.

Providers should refer to the article titled “Additional Diagnosis Codes Exempt from Present-on-Admission Reporting” that was posted on October 29, 2010, for a complete, corrected list of all diagnosis codes that are exempt from the POA reporting requirement.

MANAGED CARE PROVIDERS

TMHP Routinely Audits PCCM Medical Records of THSteps Medical CheckupsMedical records are subject to routine audits by Primary Care Case Management (PCCM) staff to ensure quality and continuity of care. Primary care providers who perform Texas Health Steps (THSteps) medical checkups must document all of the components of the checkup.

Primary care providers who perform THSteps comprehensive medical checkups must document all of the components of the checkup. All of the components of the age-appropriate checkup must be completed or documentation must be included in the medical record why a component was not completed with a follow-up appointment scheduled to complete the component before a provider submits a claim for a comprehensive checkup.

If the component cannot be completed due to extenuating circumstances, such as the client’s illness or lack of cooperation or a parent’s refusal to give consent for a specific component, the provider must document in the client’s medical record why the component was not completed and must schedule a follow-up visit as appropriate.

A checkup is considered complete if the provider has attempted to complete all of the required components and documentation supports the reason why the required component could not be completed.

Providers can refer to the 2010 Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 6.3.1.9,”THSteps Medical Checkups Periodicity Schedule,” on page CH-197, for a list of criteria that are included in an age-appropriate examination.

As the medical home, primary care providers should monitor when their clients are due for checkups and provide that checkup at the appropriate time. If the provider is not enrolled in THSteps, they should work with any THSteps provider to get the medical records for their clients (e.g., establish a referral relationship).

Clinical charts are subject to quality reviews, including random chart reviews. An audit is routinely performed by PCCM staff to confirm that all of the required components of the THSteps medical checkup


Hospital Providers/Managed Care Providers


http://www.tmhp.com/News_Items/2010/10-29-10 Additional Diagnosis Codes Exempt From POA Report.pdf

http://www.tmhp.com/News_Items/2010/10-29-10 Additional Diagnosis Codes Exempt From POA Report.pdf

are documented in the client’s medical records and are appropriate to the client’s age. PCCM providers can refer to the 2010 Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 6.4.1,

“THSteps Medical Checkups—Documentation of Completed Checkups,” on page CH 213 for the details of the documentation requirements.

TMHP will contact PCCM primary care providers and schedule a date for the audit appointment. The provider’s office can prepare for the audit by having the charts ready for the coordinators to review.

If the office has electronic medical records, the provider’s office can designate an area to view the records on a computer. The provider can expedite this process by assigning someone to help the reviewer look at the charts or an office employee can print out the dates of service, screenings, laboratory results, and immunization records.

If the office does not have electronic medical records, the paper charts should be pulled and ready for the reviewer at the time of the appointment.

PCCM primary care providers may be audited if there are any clients who are 20 years of age and younger on the provider’s panel even if the provider does not render THSteps services.

The provider’s office is always welcome to call the reviewer with any questions. The reviewer’s direct line is located on the bottom of the letter that is mailed to the provider’s office.

The following information is included in the audit:

• The dates of service.

• Clear reference to the previous visit by the same provider or results obtained from another provider.

• Documentation that all components of checkups were completed.

In acknowledgement of the practical situations that occur in the office or clinical settings, the American Academy of Pediatrics (AAP) has stressed the philosophy that the components of all medical checkups should be performed when appropriate to the needs of the individual client. Consequently, completion of all recommended components of a THSteps medical checkup may require follow-up visits. The Centers for Medicare & Medicaid Services (CMS) has clarified, in its Medicaid Guide to State Entities, the following expectations for the content of comprehensive health visits.

The required checkup components, as indicated in the periodicity schedule, include:

• Comprehensive health history, including developmental and nutritional assessment, mental health and tuberculosis screening.

• Comprehensive unclothed physical examination, (head circumference is only until the age of 2 years).

• Appropriate immunizations as indicated in the Recommended Childhood and Adolescent Immunization Schedule.

• Age-appropriate laboratory tests for anemia, lead poisoning, newborn screening,

• Health education, including anticipatory guidance.

Additionally, the provider should document the following:

• Age-appropriate vision and hearing screening.

• Referral to a THSteps dental provider to establish a dental home beginning at 6 months of age if performed.

• Oral evaluation and fluoride varnish application if appropriate from 6 through 35 months of age if the provider is certified by the Texas Department of State Health Services (DSHS).


Managed Care Providers


PCCM Service Area Changing in September 2011STAR Expanding to 28 Counties; STAR+PLUS Expanding to 21 PCCM CountiesPrimary Care Case Management (PCCM) Medicaid clients in 28 of the counties contiguous to existing State of Texas Access Reform (STAR) and STAR+PLUS service areas will no longer receive Medicaid-covered health care services from PCCM. Based on the type of Medicaid they receive, PCCM clients in these counties will move to either STAR or STAR+PLUS managed care. However, SSI children remain voluntary enrollees in managed care, and SSI adults are voluntary STAR enrollees if STAR+PLUS is not available in their county. These changes to PCCM, STAR, and STAR+PLUS Medicaid Managed Care Program service areas become effective September 1, 2011.

The Harris Service Area, which consists of Harris County, and the Harris Expansion Service Area, which consists of Brazoria, Fort Bend, Galveston, Montgomery, and Waller counties will be combined into a single service area. A new service area called “Jefferson” will also be created. The Jefferson Service Area is part of the expansion into the Harris contiguous counties. It has been separated from the Harris Service Area for administrative reasons and renamed Jefferson to avoid confusion with the current Harris Expansion Service Area. The Jefferson Service Area will consist of Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, and Walker counties.

PCCM Medicaid Clients (non- SSI or SSI-related)Non-Supplemental Security Income (SSI) or SSI-related PCCM Medicaid clients living in the Bexar, El Paso, Harris, Jefferson, Lubbock, Nueces, and Travis service areas will be transitioned into the STAR program (Medicaid Managed Care).

SSI-Related PCCM Medicaid ClientsSSI and SSI-related PCCM Medicaid clients who live in the Bexar, Harris, Jefferson, Nueces, and Travis service areas will be transitioned into the STAR+PLUS program.

SSI and SSI-related PCCM Medicaid clients who live in the El Paso and Lubbock service areas are voluntary enrollees into the STAR program.

STAR ProgramThe principal objectives of the STAR Program are to emphasize early intervention and to promote improved access to quality care, thereby significantly improving health outcomes for the target populations, with a special focus on prenatal and well-child care.

Medicaid providers who are in the STAR service areas and who would like to participate in the STAR Program must complete a separate contract and credentialing process with the health maintenance organizations (HMOs) of their choice. Providers and hospital representatives who are interested in contracting with a STAR HMO should contact the HMO. HMO contact information is included in the table on page 48.

STAR+PLUSThe STAR+PLUS program integrates acute care and long term services and supports into a Medicaid managed care delivery system for the aged, blind, and disabled (ABD). Enrollment in STAR+PLUS is mandatory for SSI or SSI-related clients who are 21 years of age and older, but it is voluntary for SSI and SSI-related clients who are 20 years of age and younger.




Medicaid providers who are in STAR+PLUS service areas and who would like to participate in the STAR+PLUS Program must complete a separate contract and credentialing process with the HMOs of their choice. Providers or hospital representatives who are interested in contracting with a STAR+PLUS HMO should contact the HMO.

STAR and STAR+PLUS Expansion ChartThe following table lists the counties that will be affected by the 2011 STAR and STAR+PLUS expansion and that will be transitioned from PCCM to STAR or STAR+PLUS:

STAR and STAR+PLUS Expansion 2011

Service Area Current CountiesSTAR Expansion Counties

STAR+PLUS Expansion Counties

Bexar Atascosa, Bexar, Comal, Guadalupe, Kendall, Medina, Wilson

Bandera Bandera

Dallas Collin, Dallas, Ellis, Hunt, Kaufman, Navarro, Rockwall

No Change No Change

El Paso El Paso Hudspeth No ChangeHarris (includes Harris & Harris Expansion Counties)

Brazoria, Fort Bend, Galveston, Harris, Montgomery, Waller

Austin, Matagorda, Wharton

Austin, Matagorda, Wharton

Jefferson (New Service Area – Harris Contiguous Counties)

New Service Area Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker

Chambers, Hardin, Jasper, Jefferson, Liberty, Newton, Orange, Polk, San Jacinto, Tyler, Walker

Lubbock Bailey, Crosby, Floyd, Garza, Hale, Hockley, Lamb, Lubbock, Lynn, Terry

Carson, Deaf Smith, Hutchinson, Potter, Randall, Swisher

No Change

Nueces Aransas, Bee, Calhoun, Jim Wells, Kleberg, Nueces, Refugio, San Patricio, Victoria

Brooks, Goliad, Karnes, Kenedy, Live Oak

Brooks, Goliad, Karnes, Kenedy, Live Oak

Tarrant Denton, Hood, Johnson, Parker, Tarrant, Wise

No Change No Change

Travis Bastrop, Burnet, Caldwell, Lee, Hays, Travis, Williamson

Fayette Fayette

STAR and STAR+PLUS HMO representative contact information is as follows:

Representative Telephone number E-mail addressAetna Better HealthBrooke Burnside 214-200-8120 [email protected] Head (DFW) 817-861-7747 [email protected] Valle (Travis/Bexar) 512-382-4980 [email protected] Gonzalez (Nueces) 361-994-5513 [email protected] Lynn Turner (Harris/Jefferson)

713-218-5179 [email protected]








Representative Telephone number E-mail addressCommunity First Health PlansMartin Jimenez 210-358-6180

[email protected]

Community Health ChoiceMark Kline 713-295-2394 [email protected] Rossi 713-314-5627 [email protected] Children’s Health PlanMelinda Lopez 361-694-6551 or 877-324-3627 [email protected] Paso FirstFrank Dominguez 915-298-7198 Ext. 1085 [email protected] Swoveland 888-303-6163 [email protected] Webb 806-356-5273 [email protected] McGrath 888-562-5442 Ext. 206511 [email protected] Varner 888-562-5442 Ext. 204059 [email protected] Eubank 817-602-0832 [email protected] Health PlanKristy Salinas 866-615-9399 Ext. 42716 [email protected]

[email protected] Children’s Health PlanDebra Sparks 832-828-1045 [email protected] Health PlansLucie Lara 713-296-4951 [email protected]

For additional information, refer to the TMHP website at www.tmhp.com. Click on Providers at the top of the page, then click on PCCM at the top of the next page.

kidsVulnerable

you!need

Our State’s most

Help the children in your community who need it most. Enroll in the Children with Special Health Care Needs (CSHCN) Services Program today. Go to www.dshs.state.tx.us/cshcn to learn more about the program, then visit the TMHP website at www.tmhp.com to enroll.
















www.dshs.state.tx.us/cshcn

http://www.tmhp.com

Hearing Services Claims for Clients with Medicaid Managed Care Plans Must be Billed to TMHPClaims ReprocessingTMHP has identified an issue that impacts Texas Medicaid claims that were submitted by audiologist providers with procedure code 92562, 92564, 92592, or 92593 (hearing aid devices and services) for clients who are 20 years of age and younger and enrolled in a Medicaid managed care plan other than Primary Care Case Management (PCCM). These claims may have been denied or electronically rejected incorrectly with an explanation of benefits (EOB) that directed providers to bill the client’s Medicaid managed care plan.

Affected claims that were submitted electronically with dates of service between September 1, 2009, and October 29, 2010, and then rejected must be resubmitted before January 1, 2011.

Affected claims that were submitted with dates of service between September 1, 2009, and October 29, 2010, and then denied will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Claims Filing ClarificationThe Texas Medicaid hearing services benefit covers hearing services that are rendered to clients who have suspected or confirmed hearing loss.

TMHP processes hearing services authorization requests (if necessary) and claims for the following Texas Medicaid clients:

• Texas Medicaid fee-for-service clients of any age

• PCCM clients of any age

• Medicaid managed care clients who are 20 years of age and younger regardless of the client’s Medicaid managed care plan

For clients who are 20 years of age and younger and enrolled in a Medicaid managed care plan (other than PCCM) through a managed care organization (MCO), TMHP processes authorization requests (if necessary) and claims for the following hearing services rendered by audiologist or hearing aid fitter and dispenser providers (as applicable) to clients with suspected or confirmed hearing loss regardless of the client’s Texas Medicaid managed care plan:

• Hearing aid devices

• Hearing aid fitting and dispensing visits

• The following diagnostic hearing services:

Procedure Codes92550 92551 92552 92553 92555 92556 92557 92562 92563 92564 9256792568 92570 92579 92582 92585 92586 92587 92588 92591 92592 92593

Note: The procedure codes listed in the above table must be submitted to the client’s MCO (if applicable) if the services are rendered by a provider other than an audiologist or a fitter and dispenser provider.

All other hearing services not listed in the above table that are rendered to clients who are 20 years of age and younger must be submitted to the client’s Texas Medicaid managed care plan.




Prior authorization requests (as necessary) and claims for the Texas Medicaid hearing services procedure codes in the following table must be submitted to TMHP for clients who are 20 years of age and younger regardless of the client’s Medicaid managed care plan:

Procedure Code General Description Submit to:Diagnostic Hearing Services92550 Tympanometry TMHP92551 Pure tone hearing test TMHP92552 Pure tone hearing test TMHP92553 Air and bone audiometry TMHP92555 Speech audiometry threshold TMHP92556 Speech audiometry with speech recognition TMHP92557 Comprehensive audiometry testing TMHP92562 Loudness balance test TMHP92563 Tone decay hearing test TMHP92564 SISI hearing test TMHP92567 Tympanometry TMHP92568 Acoustic reflex testing TMHP92570 Acoustic immittance testing TMHP92579 Visual reinforcement audiometry TMHP92582 Conditioning play TMHP92585 Auditory evoked potentials, comprehensive (auditory brainstem

response)TMHP

92586 Auditory evoked potentials, limited TMHP92587 Evoked otoacoustic emissions, limited TMHP92588 Evoked otoacoustic emissions, comprehensive TMHPHearing Aid Exams and Visits92591 Hearing aid examination for both ears TMHP92592 Hearing aid revisit (monaural) TMHP92593 Hearing aid revisit (binaural) TMHPHearing Aid AssessmentV5010 Assessment for hearing aid TMHPFitting and Dispensing VisitsV5011 Fitting/orientation/checking of hearing aid TMHPV5030 Hearing aid dispensing fee TMHPV5040 Binaural dispensing fee TMHPV5090 Hearing aid dispensing fee TMHPV5100 Dispensing fee TMHPV5110 Monaural dispensing fee TMHPV5160 Fitting/orientation/checking of hearing aid TMHPV5170 Hearing aid dispensing fee TMHPV5180 Hearing aid dispensing fee TMHPV5200 Binaural dispensing fee TMHPV5210 Hearing aid dispensing fee TMHPV5220 Dispensing fee TMHP




Procedure Code General Description Submit to:Fitting and Dispensing Visits (continued)V5240 Monaural dispensing fee TMHPV5241 Fitting/orientation/checking of hearing aid TMHPMonaural and Binaural Hearing AidsV5244 Monaural hearing aid TMHPV5245 Monaural hearing aid TMHPV5246 Monaural hearing aid TMHPV5247 Monaural hearing aid TMHPV5249 Binaural hearing aid TMHPV5250 Binaural hearing aid TMHPV5251 Binaural hearing aid TMHPV5252 Binaural hearing aid TMHPV5253 Binaural hearing aid TMHPV5254 Monaural hearing aid TMHPV5255 Monaural hearing aid TMHPV5256 Monaural hearing aid TMHPV5257 Monaural hearing aid TMHPV5258 Binaural hearing aid TMHPV5259 Binaural hearing aid TMHPV5260 Binaural hearing aid TMHPV5261 Binaural hearing aid TMHPV5298 Unlisted hearing aid TMHPMolds, Impressions, and AccessoriesV5264 Ear mold TMHPV5265 Ear mold TMHPV5266 Replacement battery TMHPV5267 Hearing aid accessories (ear clips, boots, etc.) TMHPV5275 Ear impression TMHPRepairs and ModificationsV5014 Hearing aid dispensing fee TMHPFor SSI clients who are enrolled in the STAR program, prior authorization requests (if necessary) must be submitted to the client’s STAR plan, and the claims must be submitted to TMHP.

Prior authorization requests (as necessary) and claims for otology and audiology services rendered to clients who are enrolled with a Medicaid managed care plan (other than PCCM) must be submitted to the client’s Medicaid managed care organization (i.e., MCO).

The following procedure codes are for otology and audiology services benefits:

Procedure Code General Description Submit to:Ear and Throat Examinations92502 Ear and throat examination MCO92504 Ear microscopy examination MCODiagnostic Services92571 Filtered speech hearing test MCO92572 Staggered Spondaic word test MCO




Procedure Code General Description Submit to:Diagnostic Services (continued)92575 Sensorineural acuity test MCO92576 Synthetic sentence test MCO92577 Stenger speech test MCO92584 Electrocochleography MCO92620 Auditory function (60 minutes) MCO92621 Auditory function (each additional 15 minutes) MCO92625 Tinnitus assessment MCOFor SSI clients who are enrolled in the STAR program, prior authorization requests (if necessary) must be submitted to the client’s STAR plan, and the claims must be submitted to TMHP.

For clients who are 21 years of age and older and enrolled with a Medicaid managed care plan other than PCCM, authorization requests (if necessary) and claims for hearing services must be submitted to the appropriate Medicaid managed care plan.

Exception: For SSI clients who are 21 years of age and older and enrolled in the STAR program, authorization requests (if necessary) must be submitted to the client’s STAR plan, and the claims must be submitted to TMHP.

Standard third party resource (TPR) rules apply to all hearing services claims regardless of the client’s age.

For more information about claims filing and authorizations, providers may refer to the 2010 Texas Medicaid Provider Procedures Manual, Volume 1, General Information, section 8.1.13, “TMHP Claims Filing Information” and section 8.1.3, “Authorizations and Claim Processing Exceptions by Program.”

THSTEPS PROVIDERS

THSteps Medical and Dental Checkups for Migrant Farm Workers and Their FamiliesTexas Medicaid & Healthcare Partnership (TMHP) is working closely with the Texas Health and Human Services Commission (HHSC) to educate migrant farm workers and their children about services covered by Medicaid and the importance of receiving timely Texas Health Steps (THSteps) medical and dental checkups. The children of migrant farm workers are identified as needing additional assistance because of unconventional living conditions, migratory work patterns, unhealthy working conditions, poverty, poor nutrition, lack of education, and illiteracy—all factors that contribute to poor health. TMHP is continuing its efforts to increase the number of children who receive their THSteps medical and dental checkups on time.

Exceptions to the periodicity schedule are offered to allow children to receive their THSteps medical and dental checkups before their families migrate to another area for work. THSteps providers are required to bill claims as an exception to periodicity when the visit is outside of the periodicity schedule because of extenuating circumstances.

Children who are three years of age or older will still be considered “due” for a THSteps medical checkup on their birthday and will still be encouraged to have a yearly checkup as soon as they become due. A THSteps checkup should occur on or as soon after a child’s birthday as practical but will not be considered late unless the child does not have the checkup prior to their next birthday. Providers can perform one THSteps checkup per year for a child three years of age or older and submit a claim and still receive reimbursement, even for a checkup performed prior to the birth date or due date.


Managed Care Providers/THSteps Providers


For more information on billing an exception-to-periodicity checkup, providers can refer to section 6, “THSteps Medical”, subsection 6.3.1.6, “Exception-to-Periodicity Checkups” in the Children’s Services Handbook (Vol. 2, Provider Handbooks) on page CH-193 and section 5 , “Texas Health Steps (THSteps) Dental, subsection 5.3.8, “Periodicity for THSteps Dental Services”, on page CH-129.

Providers can refer their Primary Care Case Management (PCCM) clients and migrant families to PCCM Community Health Services coordinators for assistance by faxing the PCCM Community Health Services Referral Request Form, to 1-512-302-0318. The form is available on the TMHP website at www.tmhp.com and in the 2011 Texas Medicaid Provider Procedures Manual, (Vol. 1, General Information), Section 8, “Managed Care”, subsection 8.7, “Forms,” on page 8-89, or by calling 1-888-276-0702.

For more information on community health services, providers can refer to Section 8, “Managed Care”, subsection 8.6.11.2, “Client Support and Education,” on page 8-55.

PCCM Community Health Services coordinators identify and provide outreach to the children of the migrant farm worker population in Texas. Migrant families are educated on the availability of accelerated services for their children’s THSteps medical and dental checkups. Coordinators also educate migrant families on all available PCCM benefits and services as well as confirming that families have an established primary care provider.

In addition, TMHP is continuing to partner and build relationships with state and community agencies, independent school districts, migrant licensed-housing facilities, regional education service centers, and local business to identify and reach out to PCCM clients who are birth through 20 years of age in migrant farm families.

Note: All references to THSteps Medical, THSteps Dental and the PCCM Community Health Services Referral Request Form in this article, are available in the 2010 Texas Medicaid Provider Procedure Manual,

“Managed Care “(Vol. 1, General information) or the Children’s Services Handbook (Vol. 2, Provider Handbooks).

VISION PROVIDERS

Additional Provider Type and Place of Service Restrictions Added for Some Vision Procedure CodesEffective November 17, 2010, for dates of service on or after April 1, 2010, the following procedure codes may be reimbursed to optician or dispensing optical company providers for services that are rendered in the skilled nursing facility (SNF), intermediary care facility (ICF), or extended care facility (ECF) setting:

Procedure CodesV2020 V2025 V2100 V2101 V2102 V2103 V2104 V2105 V2106 V2107V2108 V2109 V2110 V2111 V2112 V2113 V2114 V2200 V2201 V2202V2203 V2204 V2205 V2206 V2207 V2208 V2209 V2210 V2211 V2212V2213 V2214 V2300 V2301 V2302 V2303 V2304 V2305 V2306 V2307V2308 V2309 V2310 V2311 V2312 V2313 V2314 V2410

Affected claims that were submitted with dates of service from April 1, 2010, and November 16, 2010, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

These changes are in addition to other current restrictions. Previously announced payable provider types and places of services may continue to be reimbursed.


THSteps Providers/Vision Providers


http://www.tmhp.com/Provider_Forms/Medicaid/PCCM_Community%20Health%20Services_Referral_Request%20_Form.pdf

http://www.tmhp.com/Provider_Forms/Medicaid/PCCM_Community%20Health%20Services_Referral_Request%20_Form.pdf

EXCLUDED PROVIDERS

Excluded ProvidersAs required by the Medicare and Medicaid Patient Protection Act of 1987, the Health and Human Services Commission (HHSC) identifies providers or employees of providers who have been excluded from state and federal health-care programs. Providers excluded from Texas Medicaid and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries, wages, or benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any client.

Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by Texas Medicaid for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of the HHSC exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list periodically and the updates appear on the website weekly.

Review the entire Texas Medicaid exclusion list at https://oig.hhsc.state.tx.us/Exclusions/Search.aspx.

To report Medicaid providers who engage in fraud/abuse, call 1-512-424-6519 or 1-800-436-6184, or write to the following address:

Brian Klozik, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361

PO Box 85200 Austin TX 78708-5200

ProviderLicense Number Add Date Type Provider City State

Effective Date

Akins, Jennifer 156425 16-Nov-10 LVN Corpus Christi TX 23-Mar-10Abdul-Hakeem, Rasheeda 203730 16-Dec-10 LVN Texas City TX 5-Aug-10Alaniz, Martha 8-Nov-10 Office worker Santa Rosa TX 26-Oct-10Albrecht, Michelle 657534 1-Nov-10 RN Austin TX 10-May-10Arnold, Mary 137221 16-Nov-10 LVN Snyder TX 23-Mar-10Atkinson, Jill 41039 16-Nov-10 LVN Alvin TX 14-Jun-10Barrios, Teresa 537050 1-Nov-10 RN San Antonio TX 9-Jun-10Bartee, Jack 7911 16-Nov-10 DDS Lubbock TX 16-Apr-10Behrmann, Layne 571045 1-Nov-10 RN Edgewood WA 14-Jun-10Boatright, Dayna 229722 3-Nov-10 RN Pasadena TX 18-Nov-09Bond, Frances 185605 8-Dec-10 LVN Fairfield TX 23-Jul-10Boyd, Rachel 197213 8-Nov-10 LVN Rockport TX 8-Sep-10Brigham, Byron 24719 17-Nov-10 R. Ph. Spring TX 5-Jun-10Brinkman, Mary 439901 8-Nov-10 RN Austin TX 8-Jun-10Brown, Holly 662275 12-Nov-10 RN Kimberling City MO 8-Jun-10Browning, Teresa 154832 16-Dec-10 LVN Brady TX 17-Aug-10Burns, Mary 87584 19-Nov-10 LVN Austin TX 23-Mar-10


Excluded Providers


https://oig.hhsc.state.tx.us/Exclusions/Search.aspx


Effective Date

Carpenter, Alisa 206649 8-Nov-10 LVN Opelika AL 11-May-10Cervantes, Diana 686957 14-Dec-10 RN Tyler TX 17-Aug-10Chanel, Chari 207640 19-Nov-10 LVN Pontiac MI 26-Mar-10Childs, Tammi 101889 19-Nov-10 LVN Corpus Christi TX 26-Mar-10Clark, Derrick 665159 9-Nov-10 RN Los Angeles CA 11-May-10Coburn, Terri 108726 19-Nov-10 LVN Weatherford TX 23-Mar-10Cokins, Leigh 518166 19-Nov-10 RN Galveston TX 8-Jun-10Cole, Sylvia 100320 2-Dec-10 Sp. Lang. Path. Houston TX 20-Jul-10Cox, Barbara 526992 1-Nov-10 RN Waco TX 8-Jun-10Cunningham, Linda 551183 19-Nov-10 RN Bedford TX 16-Jun-10Dawdy, Torii 562294 9-Nov-10 RN Naval Air Station/

JRBTX 11-May-10

De Casembroot, Carol 17471 12-Nov-10 RN Dickinson TX 8-Jun-10De, Carol 17471 12-Nov-10 RN Dickinson TX 8-Jun-10Deichler, Suzanne 698035 19-Nov-10 RN Soper OK 9-Jun-10D’Olivera, Therese 774271 23-Nov-10 RN College Station TX 17-Aug-10Draffen, Sandra 677768 7-Dec-10 RN Tyler TX 19-Jul-10Driscoll, John 562390 23-Nov-10 RN Wharton TX 23-Aug-10Ferguson, Georgia 78194 19-Nov-10 LVN Aubrey TX 25-Jun-10Forsvall, Laura 14396 9-Nov-10 DDS Baytown TX 16-Apr-10Garcia, Maravilla 186639 9-Nov-10 LVN Victoria TX 11-May-10Garf, Alan 148749 1-Nov-10 LVN Clifton TX 11-May-10Garland, Jerrica 189794 12-Nov-10 LVN Sherman TX 8-Jun-10Gary, Michelle 192179 9-Nov-10 LVN San Augustine TX 29-Apr-10Gilchrist, Rodereick 432751 19-Nov-10 RN Austin TX 7-Jun-10Godwin, Roger 5202 9-Nov-10 DDS Dallas TX 16-Apr-10Gooden, Constance 224110 14-Dec-10 RN Houston TX 4-May-09Green, Cleo 20206 14-Dec-10 LVN Dallas TX 24-Aug-10Griswold, Sharon 144488 19-Nov-10 LVN Bay City MI 23-Mar-10Hardin, Elizabeth 194336 9-Nov-10 LVN Tyler TX 11-May-10Harlan, Sherry 649238 3-Nov-10 RN Scottsdale AZ 18-Aug-09Hayes, Patsy 103026 9-Nov-10 LVN Houston TX 11-May-10Heart to Heart Medical Supply

23-Nov-10 DME Houston TX 20-Dec-09

Henry, Dawn 197137 1-Nov-10 LVN Friona TX 6-May-10Henry, Ronald 32362 23-Nov-10 R.Ph. Pittsburgh PA 2-Apr-10Hill, Sam 24923 6-Dec-10 Psychologist Corpus Christi TX 15-Nov-10Holcomb, Katharina 588391 7-Dec-10 RN Houston TX 8-Jun-10Holmes, Connie 648874 23-Nov-10 RN Temple TX 17-Aug-10Holmes, Donald 6-Dec-10 Owner Livingston TX 23-Nov-10Holmes, Mary 222717 7-Dec-10 RN Plano TX 13-Jul-10

Excluded Providers



Effective Date

Hoover, Charles 622089 1-Nov-10 RN Dayton TX 30-Apr-10Hudgins, Shelley 175888 9-Nov-10 LVN Montgomery TX 11-May-10Hudspeth, Carl 8434138 8-Nov-10 CNA Lorrain OH 26-Oct-10Isiwele, Enitan 8-Nov-10 Houston TX 9-Apr-10Jackson, Ola 10018057 6-Dec-10 CNA Houston TX 5-Aug-10James, Boni 680812 3-Nov-10 RN Denison TX 9-Jun-09Jeanniton, Helen 92942 19-Nov-10 LVN Keizer OR 25-Jun-10Johnstone-Slavin, Pamela 608831 10-Nov-10 RN McKinney TX 19-May-10Jorden, Murphy 170217 10-Nov-10 LVN Katy TX 11-May-10Kelly, Julie 536126 23-Nov-10 RN Arvada CO 16-Aug-10Kenemore, Terri 148846 19-Nov-10 LVN Early TX 8-Jun-10Konicki, Catherine 601367 19-Nov-10 RN Oakland CA 23-Mar-10Lackey, Ronnie 173202 16-Dec-10 LVN Cleburne TX 15-Aug-10Lapole, Carolyn 670725 23-Nov-10 RN Magnolia TX 25-Jun-10Lebeouf, Cindy 207279 4-Nov-10 LVN Houma LA 25-Jun-10Lester, Debra 171938 10-Nov-10 LVN Abernathy TX 11-May-10Lind, Gayla 95281 1-Nov-10 LVN Waco TX 10-May-10Lyons, William 8-Nov-10 Abilene TX 26-Oct-10Mallory, Martha 158185 17-Nov-10 LVN Austin TX 23-Jul-10Martin, Andrea 6-Dec-10 Bus. Manager Atlanta TX 23-Nov-10May, Jana 630815 8-Dec-10 RN Cuero TX 8-Jun-10McBee, Terri 129474 10-Nov-10 LVN Boerne TX 11-May-10McConchie-Lopez, Kelly 183204 23-Nov-10 LVN Santa Fe NM 23-Mar-10Meily, Don 722748 8-Dec-10 RN Frisco TX 23-Jul-10Melton, John 614408 23-Nov-10 RN Lubbock TX 17-Jun-10Moller, Theresa 628195 8-Dec-10 RN Giddings TX 8-Jun-10Morales, Jennifer 194761 23-Nov-10 LVN Fort Worth TX 8-Jun-10Moran, Jorge 2-Dec-10 DME Owner Post TX 20-Jul-10Moreno, Alfredo 508425 3-Nov-10 RN Mission TX 23-Jul-10Motley, Ryan 207329 12-Nov-10 LVN Nacogdoches TX 22-Jul-10Nickle, Callie 81094 10-Nov-10 LVN Big Spring TX 11-May-10O’Conner, Shirley 214002 4-Nov-10 LVN Fairfield CT 11-May-10Ohendalski, Susan 453834 23-Nov-10 RN Houston TX 25-Jun-10Okon, Eno 23-Nov-10 Owner Lawrenceville GA 18-Oct-10Orfi, Melodie 121103 23-Nov-10 LVN San Antonio TX 28-Jun-10Osondu, Chimezie 2-Dec-10 Owner El Reno OK 20-Jul-10Palmer, Shannon 177298 3-Nov-10 LVN Odessa TX 12-May-09Parker, Charmayne 696918 17-Nov-10 RN Hutto TX 8-Jun-10Patel, Rakesh 39163 14-Dec-10 Pharmacist Houston TX 28-May-10Patterson-Barrett, Brittanie 8-Nov-10 Garland TX 26-Oct-10Pedraza, Bernardino 155171 17-Nov-10 LVN Weslaco TX 23-Jul-10


Excluded Providers



Effective Date

Peregrino, Merrye 539647 23-Nov-10 RN Houston TX 22-Jun-10Perez, Erika 195785 23-Nov-10 LVN Plano TX 23-Mar-10Pinto, Cynthia 3198 10-Nov-10 Dental

hygienistAustin TX 16-Apr-10

Pletz, Amy 734528 1-Nov-10 RN Austin TX 11-May-10Poole, Mamie 507022 23-Nov-10 RN Dallas TX 17-Aug-10Register, Thomas 32771 3-Nov-10 Pharmacist Leander TX 5-Jun-09Riggle, Karen 626680 8-Dec-10 RN Massillon OH 8-Jun-10Roth, Richard 695348 1-Nov-10 RN New Lenox IL 12-May-10Sawyers, Edith 148600 23-Nov-10 LVN Wichita Falls TX 6-Apr-10Shelton, Misty 151996 4-Nov-10 LVN Atlanta TX 11-May-10Simmons, Heather 734002 7-Dec-10 RN Corpus Christi TX 9-Jul-10Sinnemabeech, Roberta 10-Nov-10 Book keeper Reno TX 22-Oct-10Sirtout, Melissa 188098 23-Nov-10 LVN Round Rock TX 23-Mar-10Soliz, Flor 176307 12-Nov-10 LVN Pascagoula MS 8-Jun-10Spraberry, Debra 622589 14-Dec-10 RN Abilene TX 19-Aug-10Tanner, Michael 753677 23-Nov-10 RN Phoenix AZ 17-Aug-10Torres, Raul 2-Dec-10 Mkting Dir. Big Spring TX 19-Aug-10Twice As Nice Medical Supply

23-Nov-10 Houston TX 20-Dec-09

White, Gwen 698592 8-Dec-10 RN San Antonio TX 8-Jun-10Woodworth, Donna 113274 7-Dec-10 LVN Bonham TX 29-Jun-10Young, Abilgail 677580 14-Dec-10 RN Brenham TX 16-Aug-10

Excluded Providers


Page � EFT Authorization

Rev. �0/22/09

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

The following items are specific to EFT:

Pre-notification to your bank occurs on the weekly cycle following the completion of enrollment in EFT.

Future deposits are received electronically after pre-notification.

The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider’s account during the weekly cycle.

Specific deposits and associated R&S reports are cross-referenced by both the provider identifiers (i.e., NPI, TPI, API) and R&S number.

EFT funds are released by TMHP to depository financial institutions each Thursday.

The availability of R&S reports is unaffected by EFT and they continue to arrive in the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

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

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

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

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or signed letter from your bank on bank letterhead with the agreement to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1-800-925-9126 if you need assistance.

•

•

•

•

•

•


Forms


Page 2 EFT Authorization

Rev. �0/22/09

Electronic Funds Transfer (EFT) NotificationNOTE: Complete all sections below and attach a voided check or a signed letter from your bank on bank letterhead.

Type of authorization: New Change

Provider name: Billing TPI: (9-digit)

National Provider Identifier (NPI)/Atypical Provider Identifier (API): Primary taxonomy code:

List any additional TPIs that use the same provider information:

TPI: TPI: TPI: TPI:

TPI: TPI: TPI: TPI:

Provider accounting address: Number Street Suite City State ZIP

Provider phone number:

Bank name: Bank phone number:

ABA/Transit number: Account number:

Bank address: Account type: (check one)

Checking Savings

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

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

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

Authorized signature: Date:

Title: E-mail address: (if applicable)

Contact name: Contact phone number:

Return this form to:Texas Medicaid & Healthcare Partnership

ATTN: Provider EnrollmentPO Box 200795

Austin, TX 78720-0795

Forms


Effective Date_09012009/Revised Date_08212009

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

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

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

National Provider Identifier (NPI): Primary Taxonomy Code:

Atypical Provider Identifier (API): Benefit Code:

List any additional TPIs that use the same provider information:

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

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

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

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

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email:

Secondary Address

Street Address City State Zip Code

Telephone: ( ) Fax Number: ( ) Email:

Type of Change (check the appropriate box)

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

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

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

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

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

Comments:

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

Tax ID number: Effective Date:

Exact name reported to the IRS for this Tax ID:

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

Languages spoken other than English:

Provider office hours by location:

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

Patient age range accepted by provider:

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

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

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

Provider signature: Date: / /

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

Fax: 512-514-4214


Forms


Effective Date_09012009/Revised Date_08212009

Instructions for Completing the Provider Information Change Form

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

for individual provider numbers.

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

Address

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

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

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

Tax Identification Number (TIN)

• TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned.

• Performing providers cannot change the TIN.

Provider Demographic Information

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

General

• TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form.

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

• Mail or fax the completed form to:

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

Forms


Statement for Initial Wound Therapy System In-Home Use

Effective Date_01012011/Revised Date _11162010

Patient Name: Patient Medicaid Number:

Patient Diagnosis: Patient Date of Birth: / /

Licensed Healthcare Professional Completing the Form(if not completed by physician) Name: Type of Licensure: Telephone (with area code):

Physician Reviewing or Completing the Form Name: License No: TPI: NPI:

Telephone (with area code):

Initial Wound Profile Must be reviewed and signed by the physician familiar with the client who is prescribing the wound care system. Answer “Yes” or “No” for each question and check any answers that apply. Type of Wound Therapy Requested: ( ) Negative Pressure ( )Other: Date:

1. Initial Wound Status and Measurements: Date of Measurement: Wound Wound

Type* Location L(cm) W

(cm) D (cm)

Description of Wound Bed** and Drainage

I

Tunneling (depth and position): Undermining (depth and position):

II


III


*Wound Type: A=Stage III or Stage IV pressure ulcer B=Preoperative myocutaneous flap/graft C=Recent (within 14 days) myocutaneous flap/graft D=DM ulcer E=Chronic open wound (30 days or longer) F=Venous stasis ulcer G=Other: please document wound type _________________________________ **Wound Bed Description: A= Beefy B= Dull pink/red C= White/grey/yellow/brown slough D=Black eschar Give the percentage of wound bed for each type identified (e.g., A: 100%)

NOTE: Include above information for each wound if more than one.

Indicators for Wound Therapy Must be reviewed and signed by the physician familiar with the client and who is prescribing the wound care system. Answer “Yes” or “No” for each question and check any answers that apply.

2. The patient’s history reflects one or more of the following: Yes □ No □ □ Previous failed wound care interventions. How long ago? _____________ How was this resolved? ____________________ □ Coexisting chronic illness □ Frequent reoccurrence of advanced pressure ulcers relating to severely limited mobility □ Wound care therapy was initiated in the hospital or skilled nursing facility (SNF). If “yes,” provide the following: Admission date: ______________ Admitting diagnosis: __________________________ Discharge date: ______________


Forms


Statement for Initial Wound Therapy System In-Home Use

Effective Date_01012011/Revised Date _11162010

3. The patient uses a pressure-reducing surface: Yes □ No □

□ Non-powered mattress overlay □ Powered mattress replacements

□ Non-powered mattress replacement □ Powered bed system

□ Powered mattress overlay □ Air fluidized bed NOTE: If “No,” why not? 4. The patient has an albumin greater than 3 mg/dl. Yes □ No □ Date of last albumin (within the past 30 days)______________ Results_______________ NOTE: If the patient has an albumin level of less than 3 mg/dl, please list the albumin level and describe the type of nutritional treatment the patient is receiving:_______________________________________________________________ 5. The patient has diabetes mellitus. Yes □ No □ Hemoglobin A1c level: ______________ Date Hemoglobin A1c drawn ___________________ (within the past 30 days)

6. The patient’s wound is free of necrotic tissue. Yes □ No □ NOTE: If the wound has recently been debrided, identify the type and date of debridement: □ Surgical Date________________ □ Physical Date_________________ □ Chemical Date________________ □ Autolytic Date_________________ 7. The patient’s wound is free of infection Yes □ No □ NOTE: If the wound is infected, identify the wound treatment, including the name, dosage, frequency, route, and duration of any medications: ______________________________ ________________________________________________________________________________ 8. The patient’s overall health status will allow wound healing. Yes □ No □ Describe all medical conditions which might affect wound healing. Address incontinence, if applicable, and what is being done to decrease contamination of the wound: ____________________________________________________________ ____________________________________________________________________________________________________

Contraindicators to Initial Wound Therapy (Check any that apply) 9. Does the patient have any of the following conditions? Yes □ No □ □ Fistulas to the body □ Skin cancer in the margins □ Wound is ischemic □ No demonstrable improvement □ Gangrene in wound over past 30 days □ Osteomylelitis (unless being treated-describe below) □ Presence of necrotic tissue, including bone ___________________________________________ 10. Name of family member/friend/caregiver who agrees to be available to assist patient:

________________________________________________________________________________

Physician Review and Certification

I have reviewed the information provided on this form, and certify that the wound care system ordered for the client is medically necessary. Physician Signature: Date:

Forms


Statement for Recertification of Wound Therapy System

In-Home Use

Effective Date 01012011/Revised Date 12312010

Patient Name: Patient Medicaid Number:

Patient Diagnosis: Patient Date of Birth: / /

Licensed Healthcare Professional Completing the Form(if not completed by Physician) Name: Type of Licensure: Telephone (with area code):

Physician Reviewing or Completing the Form

Name: License No. TPI:

NPI: Telephone (with area code):

Indicators for Continuation of Treatment Must be reviewed and signed by the physician familiar with the client who is prescribing the wound care system. Answer “Yes” or “No” for each question and check any answers that apply. Type of Wound Therapy Initiated: ( ) Negative Pressure ( )Other: Date:

1. Initial Wound Status and Measurements: Date of Measurement: Wound Wound

Type * Location L (cm) W

(cm) D (cm)

Description of Wound Bed ** and Drainage

I

Tunneling (depth and position):

Undermining (depth and position):

II



III



*Wound Type: A=Stage III or Stage IV pressure ulcer B=Preoperative myocutaneous flap/graft C=Recent (within 14 days) myocutaneous flap/graft D=DM ulcer E=Chronic open wound (30 days or longer) F=Venous stasis ulcer G=Other: please document wound type _____________________________________________ **. Wound Bed Description: A= Beefy B= Dull pink/red C= White/grey/yellow/brown slough D=Black eschar Give the percentage of wound bed for each type identified (e.g., A: 100%) NOTE: Include above information for each wound if more than one.

2. Has the wound status improved over the last 30 days? Yes □ No □ In addition to the recertification request form, please submit documentation describing treatment measures taken, and the medical necessity for continued wound therapy.

3. Current Wound Status and Measurements: Date of Measurement:


Forms


Statement for Recertification of Wound Therapy System

In-Home Use

Effective Date 01012011/Revised Date 12312010

Wound Wound Type*

Location L (cm)

W (cm)

D (cm)

Description of Wound Bed** and Drainage

I


II


III


4. The patient continues to use a pressure-reducing surface. Yes □ No □

NOTE: If “no,” why not? ____________________________________________________________________

5. Name of family member/friend/caregiver who continues to agree to assist patient:______________________________

Contraindicators to Continuation of Treatment (Check any that apply)

Does the patient have any of the following conditions? Yes □ No □

□ Fistulas to the body □ Skin cancer in the margins □ Wound is ischemic □ No demonstrable improvement in

wound over past 30 days □ Gangrene □ Presence of necrotic tissue,

including bone □ Osteomylelitis (unless being treated – describe below)

________________________________________________

Physician Review and Certification

I have reviewed the information provided on this form regarding the client’s wound progress, and certify that the client continues to meet medical necessity criteria for the wound care system.

Physician Signature: Date:

Forms


Residential Detoxification Authorization Request Form 12357-B Riata Trace Parkway, Suite 150

Austin, Texas 78727-6422 TMHP

Fax: 1-512-514-4211

I. Identifying Information Medicaid Number: Date submitted: / / Time: Client Name Last: First: Middle Initial: Date of birth: / / Age: Sex: Date of admission: / /

CDTF Information Facility Name: Contact Person: Address: Phone:

TPI: NPI: Fax:

II. Factors for Admission (for admission complete all sections except section V) Impaired neurological functions / altered mental state as evidenced by:

Failure of two previous treatment episodes of outpatient detoxification: Yes No

Extreme depression: Yes No History of recent seizures or past history of seizures on withdrawal: Yes No

Disorientation to self: Yes No Presence of any presumed new asymmetric and/or focal findings: Yes No

Alcoholic hallucinosis: Yes No Unstable vital signs combined with a history of past acute withdrawal syndromes: Yes No

Toxic psychosis: Yes No Clinical condition (e.g., agitation, intoxication, or confusion) which prevents satisfactory assessment: Yes No

Altered level of consciousness: Yes No

Serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains arrhythmia, or hypotension: Yes No

III. Medical Complications (e.g., GI bleeding; gastritis; anemia, severe; diabetes mellitus, uncontrolled; hepatitis; malnutrition; cardiac disease, hypertension, etc.)

IV. Psychiatric Symptoms Severe neurological and/or psychological symptoms: Yes No

Danger to self or others: Yes No

Mental confusion and/or fluctuating orientation: Yes No

V. Continued Stay (complete only sections I, V, VI and VII if additional detoxification days are required) Unstable vital signs: Yes No Continued disorientation: Yes No Abnormal laboratory findings related to chemical dependency: Yes No Cognitive deficit related to withdrawal affecting the client's ability to recognize alcohol/drug use as a problem: Yes No Laboratory finding that a drug has not sufficiently cleared the client's system: Yes No Major medical complications continuing to present a health risk: Major psychiatric complication continuing to present a health risk or severe neurological and/or psychological symptoms have not been satisfactorily reduced:

VI. Diagnosis (DSM): Axis I: Axis II: Axis III: Axis IV: Axis V: (GAF)

VII. Number of detoxification days requested: Signature: Date: / / Print name: Provider license number Effective Date_01012011/Revised Date_11012010


Forms


Residential Substance Abuse Treatment Authorization Request Form 12357-B Riata Trace Parkway, Suite 150


Fax: 1-512-514-4211

I. Identifying Information Medicaid Number: Date submitted: / / Time: Client Name Last: First: Middle Initial: Date of birth: / / Age: Sex: Date of admission: / /

CDTF InformationFacility Name: Contact Person: Address: Phone: TPI: NPI: Fax:

II. Factors for Admission (For admission complete all sections except section IV) Client is medically stable and not in acute withdrawal: Yes No

Client is coherent, rational, and oriented for treatment: Yes No

Client is not bed-confined or has no medical complications that would hamper participation in the residential service: Yes No

Client can comprehend and understand the materials presented: Yes No

Client manifests severe social isolation or withdrawal from social contacts: Yes No

Client can participate in rehabilitation/treatment process: Yes No

Client lives in an environment (social and interpersonal network) in which treatment is unlikely to succeed: Yes No

Client will be able to improve and/or internalize his/her motivation toward recovery: Yes No

Client's family/significant others are opposed to the client's treatment efforts and are not willing to participate in the treatment process: Yes No

Interventions, treatment goals, and/or contracts are in place to help the client deal with or confront the blocks to treatment: Yes No

Family members/significant other(s) living with the client manifest current chemical dependence disorders, and are likely to undermine treatment: Yes No

Client's chemical substance use is excessive, and the client has attempted to reduce or control it, but has been unable to do so: Yes No

Logistic impairments preclude participation in an outpatient treatment service: Yes No

Client's daily activities revolve around obtaining, using, and/or recuperating from the effects of chemical substances and the client requires a secured environment to control the client's access to chemical substances: Yes No

III. Adolescent Clients Only Adolescent is assessed as manifesting physical maturation at least in middle adolescent range: Yes No History of the adolescent reflects cognitive development of at least 11 years of age: Yes No History of inability to function within the expected age norms despite normal cognitive and physical maturation: Yes No Recent history of moderate/severe conduct disorder/impulsive disregard for social norms and rights of others: Yes No Difficulty in meeting developmental expectations in a major area of functioning to an extent which interferes with the capacity to remain behaviorally stable: Yes No

IV. Continued Stay (complete only sections I, IV, V and VI if additional residential days are required) Client recognizes/identifies with the severity of the alcohol/drug problem, but demonstrates minimal insight into defeating use of alcohol/drugs and the client is progressing in treatment: Yes No Client identifies severity of alcohol/drug problem and manifests insight into relationship with mood-altering chemicals, yet does not demonstrate behaviors indicating problem solving skills necessary to cope with the problem: Yes No Client would predictably relapse if moved to a lesser level of care: Yes No Documentation in the medical record indicates an intervening medical or psychiatric event which was serious enough to interrupt rehabilitation/treatment, but the client is again progressing in treatment: Yes No Documentation in the medical record indicates that the client is being held pending an immediate transfer to a psychiatric, acute medical service, or inpatient detoxification alcohol/drug service: Yes No

V. Diagnosis (DSM): Axis I: Axis II: Axis III: Axis IV: Axis V: (GAF)

VI. Number of residential days requested:

Signature: Date: / / Print name: Provider license number Effective Date_01012011/Revised Date_11012010

Forms


Ambulatory (Outpatient) Detoxification Authorization Request Form 12357-B Riata Trace Parkway,Suite 150


Fax: 1-512-514-4211

I. Identifying Information Medicaid Number: Date submitted: / / Time:

Name Last: First: Middle Initial:

Date of birth: / / Age: Sex: Date of admission: / /

CDTF Information Facility Name: Contact Person: Address: Phone: TPI: NPI: Fax:

For admission complete all sections except section VI

II. Criteria for Admission The individual is expected to have a stable withdrawal from alcohol/drugs: Yes No

Stable vital signs without a history of past acute withdrawal syndromes: Yes No

No history of recent seizures or past history of seizures on withdrawal: Yes No

Absence of any presumed new asymmetric and/or focal findings: Yes No

Disorientation to self: Yes No Altered level of consciousness: Yes No Alcoholic hallucinosis: Yes No Clinical condition allows for a comprehensive assessment: Yes No Toxic psychosis: Yes No Absence of serious disulfiram-alcohol (Antabuse) reaction: Yes No

III. Family, social, academic dysfunction Client’s social system/significant others are supportive of recovery to the extent that the client can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the client’s addiction: Yes No Client's family/significant others are willing to participate in the ambulatory detoxification treatment program: Yes No Client has the social skills to obtain such a support system and/or to become involved in a self-help fellowship: Yes No Client lives in environment where licit/illicit mood altering substances are used: Yes No

IV. Emotional/behavioral status Client is coherent, rational and oriented for treatment: Yes No

Client can comprehend and understand the materials presented: Yes No

Client can participate in ambulatory detoxification treatment process: Yes No

Client expresses an interest to work toward detoxification treatment goals: Yes No

Client has no neurological, psychological, or uncontrolled behavior that places the individual at imminent risk of harming self or others: Yes No Client has no mental confusion and/or fluctuating orientation: Yes No

V. Recent chemical substance use Client's chemical substance use is excessive, and the client has attempted to reduce or control it, but has been unable to do so: Yes No Client is motivated to stop using alcohol/drugs, and is in need of a supportive structured treatment program to facilitate withdrawal from chemical substances: Yes No

VI. Continued Stay Criteria for Ambulatory Detoxification (Complete only sections I, VI, VII and VIII if additional detoxification days are needed) Client, while physically abstinent from chemical substance use, exhibits incomplete stable withdrawal from alcohol/drugs, evidenced by psychological and physical cravings: Yes No Client, while physically abstinent from chemical substance use, is exhibiting incomplete stable withdrawal from alcohol/drugs, as evidenced by significant drug levels: Yes No Documentation in the medical record indicates an intervening medical or psychiatric event which was serious enough to interrupt ambulatory detoxification treatment, but the client is again progressing in treatment: Yes No

VII. Diagnosis (DSM): Axis I: Axis II: Axis III: Axis IV: Axis V: (GAF)

VIII. Number of detoxification days requested: Signature: Date: / / Print name: Provider license number Effective Date_01012011/Revised Date_11012010


Forms


March/april 2011 No. 234

Texas MedicaidBimonthly update to the Texas Medicaid Provider Procedures Manual

Contact Information

For information about Texas Medicaid, call the TMHP Contact Center at 1-800-925-9126.

For information about Primary Care Case Management (PCCM) call the PCCM Provider Helpline at 1-888-834-7226.

For information about the Children with Special Health Care Needs (CSHCN) Services Program, call the TMHP-CSHCN Contact Center at 1-800-568-2413.

Documents

T exas Medicaid Bulletin - TMHP · 2011-01-28 · MARCH/APRIL 2011 NO. 234 Bimonthly update to the Texas Medicaid Provider Procedures Manual T exas Medicaid Bulletin Enhancements