T exas Medicaid Bulletin - tmhp.com · setting. These procedure codes are for female clients 10 years of age through 55 years of age. Procedure code 5-86336 is limited to one procedure

CONTENTS

All Providers 1Electronic Data Interface Batch Identification Numbers Changed . . 1

Notification of Prior Authorizations that Have Been Closed Early . . . . 1

Molecular Laboratory Services New Reimbursement Rates . . . . . . . . .2

TMHP Provider Relations Representatives . . . . . . . . . . . . . . . . . . . . . . . . . . .3

17-Alpha Hydroxyprogesterone Caproate is a Benefit . . . . . . . . . . . . . . .4

First Quarter HCPCS Changes for Texas Medicaid . . . . . . . . . . . . . . . . . . .4

Second Quarter 2009 HCPCS Updates Now Available . . . . . . . . . . . . . . .4

Second-Quarter Procedure Code Review Updates . . . . . . . . . . . . . . . . . .5

Scheduled System Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Update to Personal Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Update to Third-Party Resources Type of Coverage Codes . . . . . . . . 24

Original Signatures Required on All Prior Authorization Request Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Revised Texas Medicaid Fee Schedules Available . . . . . . . . . . . . . . . . . 24

Enhancements to TexMedConnect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Inmates of Public Correctional Institutions Ineligible for Coverage of Medicaid Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Changes to Reimbursement Rates for Clinical Laboratory . . . . . . . . . 26

New AIS Eligibility Inquiry Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Billing for Critical Care Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Texas Medicaid Claims Reprocessing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Changes to Reimbursement Rates for Medical Services and Blood Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

New DME Procedure Code Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Anesthesia and Kidney Transplant Benefit Changes . . . . . . . . . . . . . . . .42

Implant Services Reimbursement Rates Implemented . . . . . . . . . . . . 43

Medical Direction Criteria Changed for Anesthesia Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Evaluation and Management Procedure Code Limitation Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Revised Taxonomy Codes for Hearing Aid Providers . . . . . . . . . . . . . . .45

Diagnosis Codes Payable for Azacitidine (Vidaza) . . . . . . . . . . . . . . . . . .45

Enrollment for Providers of Hearing Services . . . . . . . . . . . . . . . . . . . . . . 46

How Texas Medicaid and the CSHCN Services Program are Different from PACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

WHP Providers and Performance of Elective Abortion . . . . . . . . . . . . 49

Updates to Previously Published Information . . . . . . . . . . . . . . . . . . . . . 49

SEpTEmbEr/OCTObEr 2009 NO. 225

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

Continued on page 2

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 2008 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government 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 © 2008 American Dental Association. All Rights Reserved. Applicable FARS/DFARS restrictions apply.”

Electronic Data Interchange Batch Identification Numbers ChangedEffective July 31, 2009, the format for the 8-character batch identification number assigned to claims received through the Texas Medicaid & Healthcare Partnership (TMHP) Electronic Data Interchange (EDI) Gateway is changing. The “H” character, currently indicating the hour of the day that the TMHP EDI gateway receives a file, will be replaced with an “S” character to create a unique 4-character sequence number. This new, unique sequence number will allow an increase in the number of claims processed through the TMHP EDI Gateway every day. The new format for the batch ID is JJJYSSSS:

JJJ = the Julian date the file is received by TMHP EDI.

Y = the last digit of the calendar year the file is received by TMHP EDI.

SSSS = the unique 4-character sequence number assigned by EDI to the claim filed.

Additional information is available on the TMHP website at www.tmhp.com and will be published in the 2009 November/December, Texas Medicaid Bulletin, No 226 and the November 2009 Children with Special Health Care Needs Bulletin, No. 72.

Notification of Prior Authorizations that Have Been Closed EarlyEffective August 28, 2009, TMHP sends providers a notification by mail when a prior authorization has been closed early. The letter will include the beginning date of service, the revised ending date of the authorization, and the reason for the early closure. When a client decides to change providers or elects to discontinue prior-authorized services before the authori-zation ends, that authorization will be updated to reflect the early closure date and the reason for closure.

•

•

•

Ambulance Providers 51Modifier Usage on Emergency Ambulance Claims . . . . . . . . . . . . . . . . .51

Family Planning Providers 51Family Planning Title XIX Retroactive Eligibility . . . . . . . . . . . . . . . . . . . . .51

Maternity Service Clinic Evaluation and Management . . . . . . . . . . . . . .51

FQHC Providers 52Mental Health Services for FQHC Providers . . . . . . . . . . . . . . . . . . . . . . . . 52

Additional Dental Code Payable to FQHC Providers . . . . . . . . . . . . . . . 52

Managed Care Providers 52Adding a PCCM Family Member to a Closed Provider Panel . . . . . . . 52

Evercare Integrated Care Prior Authorization Requirements . . . . . . . 52

Excluded Providers 53

Forms 53Provider Information Change Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

Electronic Funds Transfer (EFT) Authorization Agreement . . . . . . . . . 58

CONTENTSContinued from page 1

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.

Molecular Laboratory Services New Reimbursement RatesEffective for dates of services on or after July 1, 2009, Texas Medicaid has implemented initial molecular laboratory services procedure codes. Procedure codes 5-86336, 5-S3800, and 5-S3835 are new benefits and are payable to independent laboratories, privately-owned laboratories, hospitals in an outpatient setting, and physicians in an office setting. These procedure codes are for female clients 10 years of age through 55 years of age. Procedure code 5-86336 is limited to one procedure every 210 days and procedure codes 5-S3800 and 5-S3835 are limited to one procedure per lifetime. Authorization is required for procedure code 5-S3835.The initial reimbursement rates were adopted following a public rate hearing that was held on May 12, 2009. The following reimbursement rates are effective for dates of service on or after July 1, 2009, for molecular laboratory services for female clients 10 years of age through 55 years of age:

TOS procedure Code provider Types reimbursement rate

Laboratory Services (total component)5 S3800 Independent or privately-owned laboratories, hospitals (in an

outpatient setting), physicians (in an office setting)$160.30

5 S3835 Independent or privately-owned laboratories, hospitals (in an outpatient setting), physicians (in an office setting)

$1,036.10

5 86336 Sole Community Hospitals (SCHs) $22.575 86336 Laboratories other than the Department of State Health

Services (DSHS) Laboratory and SCHs$21.84

Laboratory Services (interpretation)I S3835 Will be paid as part of the total component TOS 5

Laboratory Services (technical)T S3835 Will be paid as part of the total component TOS 5TOS=Type of Service

Texas Medicaid Bulletin, No. 225 2 September/October 2009

All Providers

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

Territory regional Area representativeTelephone Number

1 Amarillo, Childress, and Lubbock Julie Winters 1-512-506-62172 Midland, Odessa, and San Angelo Mindy Wiggins 1-512-506-34233 Alpine, El Paso, and Van Horn Alma Gonzales 1-512-506-35304 Del Rio, Eagle Pass, and Laredo Christina Salinas 1-512-506-72715 Brownsville, Harlingen, and McAllen Cynthia Gonzales 1-512-506-79916 Abilene, Brownwood, and Wichita Falls Cynthia Rowlett 1-512-506-70957 Brady, North Austin,* Round Rock, and Waco Rhonda Williams 1-512-506-76008 South Austin,* Bastrop, Buda, Guadalupe, and San Marcos Yvonne Olivo 1-512-506-35269 Kerrville and San Antonio* Kathe Barrett 1-512-506-342210 Corpus Christi, San Antonio,* and Victoria Alan Brown 1-512-506-355411 Cleburne, Denton, and Fort Worth Tamara House 1-512-506-799012 Corsicana, Dallas,* and Groesbeck Sandra Peterson 1-512-506-355213 Dallas,* Paris, and Whitesboro Demekia Merritt 1-512-506-357814 Texarkana and Tyler Trilby Foster 1-512-506-705315 Beaumont and Lufkin Gene Allred 1-512-506-342516 Bryan/College Station, Conroe, and Houston* Linda Wood 1-512-506-768217 Houston,* Ft. Bend Stephen

Hirschfelder1-512-506-3447

18 Chambers, Galveston, Brazoria, Houston,* Wharton, and Matagorda

Michael Duffee 1-512-506-3586

Out-of-State Provider Representative Joann Kunde 1-512-506-7858*Austin, Dallas, Houston, and San Antonio territories are shared by two or more provider representatives. These territories are divided by ZIP Codes. Refer to the TMHP website at www.tmhp.com for the assigned representative to contact in each ZIP Code.

TMHP Provider Relations RepresentativesTMHP Provider Relations representatives offer a variety of services that inform and educate the provider community about Texas Medicaid policies and claims filing procedures. Technical support and training are also provided for TexMedConnect. Provider Relations representatives assist providers through telephone contact, onsite visits, and scheduled workshops. The map at right and the table below indicate the TMHP Provider Relations representatives and the areas they serve. Additional information, including a regional listing by county and workshop information, is available on the TMHP website at www.tmhp.com/Providers. (Click on the Regional Support link, and then choose the region.)

Texas Medicaid Bulletin, No. 2253September/October 2009

All Providers


Second Quarter 2009 HCPCS Updates Now AvailableThe second quarter 2009 Healthcare Common Procedure Coding System (HCPCS) additions, changes, and deletions that are effective for dates of service on or after July 1, 2009, are now available. Deleted procedure codes are no longer benefits of Texas Medicaid, Medicaid Managed Care, or the CSHCN Services Program. The following information is effective for dates of service on or after July 1, 2009.

2009 HCpCS AdditionsThe following is a list of new procedure codes that do not replace existing procedure codes:

procedure Code

medicaid Allowable

CSHCN Services program Allowable

1-Q4115 NC NC1-Q4116 NC NC1-Q2023* NC MR1-C9250 NC NC1-C9251 NC NC1-C9252 NC NC1-C9253 NC NC9-C9360 NC NC9-C9361 NC NC9-C9362 NC NC9-C9363 NC NC9-C9364 NC NCNC=Not covered, MR=Manually reviewed

CSHCN Services Program prior authorization is required for procedure code 1-Q2023. The product name and the manufacturer or the National Drug Code (NDC) must be used to identify the product. Procedure code 1-Q2023 is not reimbursed by Texas Medicaid.

modifiersThe following new modifiers are effective for dates of service on or after June 1, 2009: PA, PB, PC, PI, and PS. Providers may contact the appropriate copyright holder to obtain modifier descriptions.

procedure Code Description ChangesThe descriptions for procedure codes 9-C9358 and 1-C9359 have changed. Providers must contact the appropriate copyright holder to obtain procedure code descriptions.

17-Alpha Hydroxyprogesterone Caproate is a BenefitEffective June 1, 2009, for dates of service on or after June 1, 2009, providers may bill 17-alpha hydroxypro-gesterone caproate (17P) intramuscular injections for a pregnant client who has a history of preterm delivery before 37 weeks of gestation and who has not experienced preterm labor in the current pregnancy.

Providers should note that progesterone therapy as a technique to prevent preterm labor is considered investi-gational and not medically necessary for pregnant women who do not meet the above criteria or for those with other risk factors for preterm delivery, including, but not limited to, multiple gestations, short cervical length, or positive tests for cervicovaginal fetal fibronectin.17P for intramuscular injection is not commercially available, but it can be compounded by a pharmacy provider. Claims for 17P must be submitted using procedure code J3490 and diagnosis code V2341. A claim must include documentation that the patient was pregnant during weeks 16 through 36, has a history of preterm delivery before 37 weeks of gestation, and has not experienced preterm labor during the current pregnancy. A maximum of 250 mg of 17P will be reimbursed per week. This drug is manually priced.

Progesterone therapy as a

technique to prevent preterm labor

is considered investigational

First Quarter HCPCS Changes for Texas MedicaidNon-Warranty DmE repairsEffective for dates of service on or after July 1, 2009, procedure code 9-K0739 may be billed with prior authorization for non-warranty repairs of durable medical equipment (DME). Procedure code 9-K0739 may be reimbursed to home health DME suppliers and medical DME suppliers in the home setting. Procedure code 9-K0739 will be denied if it is billed with the same date of service as procedure code 9-E1340 by any provider.


All Providers


Second-Quarter Procedure Code Review UpdatesTo align with Centers for Medicare & Medicaid Services (CMS) requirements for easy access to all Texas Medicaid fees, TMHP has completed the second-quarter procedure code review. Effective for dates of service on or after July 1, 2009, provider type, place of service (POS), and type of service (TOS) changes were made to some procedure codes. Provider type changes are now available in the updated fee schedules, and providers are encouraged to confirm coverage by reviewing the fee schedules before submitting claims.

New Assistant Surgery benefitsThe following procedure codes may be reimbursed as assistant surgery with the rates indicated:

TOS procedure Code Age Access based Fee or Calculated Fee

8 20251 Birth through 20 years of age $54.82 (2.01 RVUs, $27.276 conversion factor)8 20251 21 years of age or older $57.568 20805 All Manually reviewed8 20816 All Manually reviewed8 20822 Birth through 20 years of age $142.108 20822 21 years of age or older $243.44 (8.50 RVUs, $28.640 conversion factor)8 20824 All Manually reviewed8 20827 All Manually reviewed8 20838 All Manually reviewed8 21502 All $52.37 (1.92 RVUs, $27.276 conversion factor)8 21557 All $89.178 21600 Birth through 20 years of age $53.46 (1.96 RVUs, $27.276 conversion factor)8 21600 21 years of age or older $63.87 (2.23 RVUs, $28.640 conversion factor)8 21627 Birth through 20 years of age $45.82 (1.68 RVUs, $27.276 conversion factor)8 21627 21 years of age or older $63.29 (2.21 RVUs, $28.640 conversion factor)8 21810 All $67.37 (2.47 RVUs, $27.276 conversion factor)8 22100 All $70.64 (2.59 RVUs, $27.276 conversion factor)8 22101 Birth through 20 years of age $73.37 (2.69 RVUs, $27.276 conversion factor)8 22101 21 years of age or older $95.37 (3.33 RVUs, $28.640 conversion factor)8 22110 Birth through 20 years of age $105.56 (3.87 RVUs, $27.276 conversion factor)8 22110 21 years of age or older $118.00 (4.12 RVUs, $28.640 conversion factor)8 22112 Birth through 20 years of age $106.38 (3.90 RVUs, $27.276 conversion factor)8 22112 21 years of age or older $116.56 (4.07 RVUs, $28.640 conversion factor)8 22114 Birth through 20 years of age $91.92 (3.37 RVUs, $27.276 conversion factor)8 22114 21 years of age or older $117.42 (4.10 RVUs, $28.640 conversion factor)8 22212 Birth through 20 years of age $175.93 (6.45 RVUs, $27.276 conversion factor)8 22212 21 years of age or older $184.728 22222 Birth through 20 years of age $162.56 (5.96 RVUs, $27.276 conversion factor)8 22222 21 years of age or older $179.86 (6.28 RVUs, $28.640 conversion factor)8 22520 Birth through 20 years of age $60.01 (2.20 RVUs, $27.276 conversion factor)8 22520 21 years of age or older $68.45 (2.39 RVUs, $28.640 conversion factor)8 22900 Birth through 20 years of age $46.91 (1.72 RVUs, $27.276 conversion factor)8 22900 21 years of age or older $49.21TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 23000 All $36.00 (1.32 RVUs, $27.276 conversion factor)8 23020 Birth through 20 years of age $76.37 (2.80 RVUs, $27.276 conversion factor)8 23020 21 years of age or older $80.158 23035 Birth through 20 years of age $69.28 (2.54 RVUs, $27.276 conversion factor)8 23035 21 years of age or older $80.48 (2.81 RVUs, $28.640 conversion factor)8 23077 Birth through 20 years of age $107.74 (3.95 RVUs, $27.276 conversion factor)8 23077 21 years of age or older $138.62 (4.84 RVUs, $28.640 conversion factor)8 23100 Birth through 20 years of age $67.37 (2.47 RVUs, $27.276 conversion factor)8 23100 21 years of age or older $70.718 23156 Birth through 20 years of age $77.74 (2.85 RVUs, $27.276 conversion factor)8 23156 21 years of age or older $81.528 23172 All $55.64 (2.04 RVUs, $27.276 conversion factor)8 23174 All $85.10 (3.12 RVUs, $27.276 conversion factor)8 23221 All $165.29 (6.06 RVUs, $27.276 conversion factor)8 23332 Birth through 20 years of age $100.65 (3.69 RVUs, $27.276 conversion factor)8 23332 21 years of age or older $105.728 23405 Birth through 20 years of age $75.55 (2.77 RVUs, $27.276 conversion factor)8 23405 21 years of age or older $79.418 23406 All $98.19 (3.60 RVUs, $27.276 conversion factor)8 23440 Birth through 20 years of age $84.83 (3.11 RVUs, $27.276 conversion factor)8 23440 21 years of age or older $88.948 23490 All $101.47 (3.72 RVUs, $27.276 conversion factor)8 23491 Birth through 20 years of age $130.65 (4.79 RVUs, $27.276 conversion factor)8 23491 21 years of age or older $137.298 23530 All $66.83 (2.45 RVUs, $27.276 conversion factor)8 23615 All $102.328 23630 Birth through 20 years of age $78.83 (2.89 RVUs, $27.276 conversion factor)8 23630 21 years of age or older $82.678 23670 Birth through 20 years of age $94.65 (3.47 RVUs, $27.276 conversion factor)8 23670 21 years of age or older $99.448 24100 All $44.19 (1.62 RVUs, $27.276 conversion factor)8 24126 All $75.28 (2.76 RVUs, $27.276 conversion factor)8 24134 Birth through 20 years of age $87.01 (3.19 RVUs, $27.276 conversion factor)8 24134 21 years of age or older $91.378 24138 All $68.19 (2.50 RVUs, $27.276 conversion factor)8 24155 Birth through 20 years of age $108.56 (3.98 RVUs, $27.276 conversion factor)8 24155 21 years of age or older $113.878 24301 Birth through 20 years of age $87.01 (3.19 RVUs, $27.276 conversion factor)8 24301 21 years of age or older $91.378 24320 All $94.10 (3.45 RVUs, $27.276 conversion factor)8 24330 All $88.92 (3.26 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 24340 All $72.28 (2.65 RVUs, $27.276 conversion factor)8 24342 Birth through 20 years of age $102.29 (3.75 RVUs, $27.276 conversion factor)8 24342 21 years of age or older $107.508 24470 All $80.74 (2.96 RVUs, $27.276 conversion factor)8 24498 Birth through 20 years of age $107.19 (3.93 RVUs, $27.276 conversion factor)8 24498 21 years of age or older $112.508 24802 All $124.11 (4.55 RVUs, $27.276 conversion factor)8 24925 Birth through 20 years of age $62.73 (2.30 RVUs, $27.276 conversion factor)8 24925 21 years of age or older $65.768 24930 Birth through 20 years of age $86.19 (3.16 RVUs, $27.276 conversion factor)8 24930 21 years of age or older $90.468 24940 All $146.148 25085 Birth through 20 years of age $54.42 (1.90 RVUs, $28.640 conversion factor)8 25085 21 years of age or older $48.01 (1.76 RVUs, $27.276 conversion factor)8 25107 All $55.37 (2.03 RVUs, $27.276 conversion factor)8 25119 All $68.74 (2.52 RVUs, $27.276 conversion factor)8 25126 Birth through 20 years of age $69.28 (2.54 RVUs, $27.276 conversion factor)8 25126 21 years of age or older $81.05 (2.83 RVUs, $28.640 conversion factor)8 25136 All $51.82 (1.90 RVUs, $27.276 conversion factor)8 25145 Birth through 20 years of age $58.37 (2.14 RVUs, $27.276 conversion factor)8 25145 21 years of age or older $71.31 (2.49 RVUs, $28.640 conversion factor)8 25215 Birth through 20 years of age $80.46 (2.95 RVUs, $27.276 conversion factor)8 25215 21 years of age or older $84.548 25250 Birth through 20 years of age $58.92 (2.16 RVUs, $27.276 conversion factor)8 25250 21 years of age or older $61.958 25251 All $86.19 (3.16 RVUs, $27.276 conversion factor)8 25263 Birth through 20 years of age $65.19 (2.39 RVUs, $27.276 conversion factor)8 25263 21 years of age or older $82.77 (2.89 RVUs, $28.640 conversion factor)8 25300 Birth through 20 years of age $78.28 (2.87 RVUs, $27.276 conversion factor)8 25300 21 years of age or older $82.168 25301 Birth through 20 years of age $73.92 (2.71 RVUs, $27.276 conversion factor)8 25301 21 years of age or older $77.498 25316 All $107.74 (3.95 RVUs, $27.276 conversion factor)8 25320 All $111.98 (3.91 RVUs, $28.640 conversion factor)8 25335 All $115.38 (4.23 RVUs, $27.276 conversion factor)8 25355 Birth through 20 years of age $92.74 (3.40 RVUs, $27.276 conversion factor)8 25355 21 years of age or older $101.96 (3.56 RVUs, $28.640 conversion factor)8 25370 Birth through 20 years of age $119.74 (4.39 RVUs, $27.276 conversion factor)8 25370 21 years of age or older $129.17 (4.51 RVUs, $28.640 conversion factor)8 25392 All $126.56 (4.64 RVUs, $27.276 conversion factor)8 25393 All l144.56 (5.30 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 25444 Birth through 20 years of age $103.10 (3.78 RVUs, $27.276 conversion factor)8 25444 21 years of age or older $108.378 25490 Birth through 20 years of age $88.37 (3.24 RVUs, $27.276 conversion factor)8 25490 21 years of age or older $94.23 (3.29 RVUs, $28.640 conversion factor)8 25491 All $92.74 (3.40 RVUs, $27.276 conversion factor)8 25492 All $114.01 (4.18 RVUs, $27.276 conversion factor)8 25628 Birth through 20 years of age $74.19 (2.72 RVUs, $27.276 conversion factor)8 25628 21 years of age or older $83.63 (2.92 RVUs, $28.640 conversion factor)8 25645 Birth through 20 years of age $66.55 (2.44 RVUs, $27.276 conversion factor)8 25645 21 years of age or older $69.938 25676 Birth through 20 years of age $73.37 (2.69 RVUs, $27.276 conversion factor)8 25676 21 years of age or older $77.088 25905 Birth through 20 years of age $76.65 (2.81 RVUs, $27.276 conversion factor)8 25905 21 years of age or older $88.78 (3.10 RVUs, $28.640 conversion factor)8 25907 Birth through 20 years of age $64.37 (2.36 RVUs, $27.276 conversion factor)8 25907 21 years of age or older $77.33 (2.70 RVUs, $28.640 conversion factor)8 25922 All $62.19 (2.28 RVUs, $27.276 conversion factor)8 25924 All $76.37 (2.80 RVUs, $27.276 conversion factor)8 25929 All $58.92 (2.16 RVUs, $27.276 conversion factor)8 26260 All $61.92 (2.27 RVUs, $27.276 conversion factor)8 26261 All $80.74 (2.96 RVUs, $27.276 conversion factor)8 26352 Birth through 20 years of age $68.74 (2.52 RVUs, $27.276 conversion factor)8 26352 21 years of age or older $86.78 (3.03 RVUs, $28.640 conversion factor)8 26357 Birth through 20 years of age $73.37 (2.69 RVUs, $27.276 conversion factor)8 26357 21 years of age or older $92.79 (3.24 RVUs, $28.640 conversion factor)8 26358 Birth through 20 years of age $79.92 (2.93 RVUs, $27.276 conversion factor)8 26358 21 years of age or older $98.24 (3.43 RVUs, $28.640 conversion factor)8 26372 All $72.83 (2.67 RVUs, $27.276 conversion factor)8 26373 Birth through 20 years of age $72.01 (2.64 RVUs, $27.276 conversion factor)8 26373 21 years of age or older $90.22 (3.15 RVUs, $28.640 conversion factor)8 26390 Birth through 20 years of age $82.37 (3.02 RVUs, $27.276 conversion factor)8 26390 21 years of age or older $90.79 (3.17 RVUs, $28.640 conversion factor)8 26392 Birth through 20 years of age $90.28 (3.31 RVUs, $27.276 conversion factor)8 26392 21 years of age or older $105.40 (3.68 RVUs, $28.640 conversion factor)8 26420 Birth through 20 years of age $59.73 (2.19 RVUs, $27.276 conversion factor)8 26420 21 years of age or older $76.18 (2.66 RVUs, $28.640 conversion factor)8 26434 All $53.46 (1.96 RVUs, $27.276 conversion factor)8 26474 All $48.28 (1.77 RVUs, $27.276 conversion factor)8 26479 Birth through 20 years of age $53.73 (1.97 RVUs, $27.276 conversion factor)8 26479 21 years of age or older $66.16 (2.31 RVUs, $28.640 conversion factor)8 26494 All $76.10 (2.79 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 26497 All $85.37 (3.13 RVUs, $27.276 conversion factor)8 26499 All $80.74 (2.96 RVUs, $27.276 conversion factor)8 26517 All $76.37 (2.80 RVUs, $27.276 conversion factor)8 26518 Birth through 20 years of age $74.74 (2.74 RVUs, $27.276 conversion factor)8 26518 21 years of age or older $90.50 (3.16 RVUs, $28.640 conversion factor)8 26530 Birth through 20 years of age $57.01 (2.09 RVUs, $27.276 conversion factor)8 26530 21 years of age or older $60.72 (2.12 RVUs, $28.640 conversion factor)8 26531 Birth through 20 years of age $70.37 (2.58 RVUs, $27.276 conversion factor)8 26531 21 years of age or older $73.968 26541 Birth through 20 years of age $85.65 (3.14 RVUs, $27.276 conversion factor)8 26541 21 years of age or older $89.868 26550 Birth through 20 years of age $40.608 26550 21 years of age or older $181.00 (6.32 RVUs, $28.640 conversion factor)8 26555 All $169.718 26560 Birth through 20 years of age $61.29 (2.14 RVUs, $28.640 conversion factor)8 26560 21 years of age or older $48.55 (1.78 RVUs, $27.276 conversion factor)8 26561 Birth through 20 years of age $96.28 (3.53 RVUs, $27.276 conversion factor)8 26561 21 years of age or older $101.238 26562 Birth through 20 years of age $96.56 (3.54 RVUs, $27.276 conversion factor)8 26562 21 years of age or older $150.07 (5.24 RVUs, $28.640 conversion factor)8 26565 All $71.89 (2.51 RVUs, $28.640 conversion factor)8 26568 Birth through 20 years of age $83.46 (3.06 RVUs, $27.276 conversion factor)8 26568 21 years of age or older $95.37 (3.33 RVUs, $28.640 conversion factor)8 26580 All Manually reviewed8 26587 All $111.70 (3.90 RVUs, $28.640 conversion factor)8 26590 Birth through 20 years of age $56.848 26590 21 years of age or older $145.78 (5.09 RVUs, $28.640 conversion factor)8 26686 Birth through 20 years of age $68.19 (2.50 RVUs, $27.276 conversion factor)8 26686 21 years of age or older $71.538 26820 All $71.46 (2.62 RVUs, $27.276 conversion factor)8 26842 All $81.56 (2.99 RVUs, $27.276 conversion factor)8 26843 Birth through 20 years of age $67.37 (2.47 RVUs, $27.276 conversion factor)8 26843 21 years of age or older $77.90 (2.72 RVUs, $28.640 conversion factor)8 26844 Birth through 20 years of age $77.19 (2.83 RVUs, $27.276 conversion factor)8 26844 21 years of age or older $88.78 (3.10 RVUs, $28.640 conversion factor)8 26852 All $67.64 (2.48 RVUs, $27.276 conversion factor)8 26862 Birth through 20 years of age $60.01 (2.20 RVUs, $27.276 conversion factor)8 26862 21 years of age or older $79.05 (2.76 RVUs, $28.640 conversion factor)8 26863 All $36.00 (1.32 RVUs, $27.276 conversion factor)8 27001 All $61.86 (2.16 RVUs, $28.640 conversion factor)8 27003 Birth through 20 years of age $66.01 (2.42 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 27003 21 years of age or older $69.428 27005 Birth through 20 years of age $59.46 (2.18 RVUs, $27.276 conversion factor)8 27005 21 years of age or older $84.77 (2.96 RVUs, $28.640 conversion factor)8 27006 Birth through 20 years of age $91.10 (3.34 RVUs, $27.276 conversion factor)8 27006 21 years of age or older $95.738 27048 All $54.99 (1.92 RVUs, $28.640 conversion factor)8 27049 Birth through 20 years of age $112.92 (4.14 RVUs, $27.276 conversion factor)8 27049 21 years of age or older $118.458 27097 Birth through 20 years of age $78.55 (2.88 RVUs, $27.276 conversion factor)8 27097 21 years of age or older $82.398 27098 Birth through 20 years of age $78.55 (2.88 RVUs, $27.276 conversion factor)8 27098 21 years of age or older $82.398 27100 All $90.56 (3.32 RVUs, $27.276 conversion factor)8 27105 All $85.10 (3.12 RVUs, $27.276 conversion factor)8 27158 All $161.75 (5.93 RVUs, $27.276 conversion factor)8 27187 Birth through 20 years of age $150.29 (5.51 RVUs, $27.276 conversion factor)8 27187 21 years of age or older $157.868 27202 All $62.46 (2.29 RVUs, $27.276 conversion factor)8 27259 Birth through 20 years of age $183.718 27259 21 years of age or older $174.84 (6.41 RVUs, $27.276 conversion factor)8 27267 All $65.028 27268 All $60.43 (2.11 RVUs, $28.640 conversion factor)8 27269 All $144.63 (5.05 RVUs, $28.640 conversion factor)8 27305 Birth through 20 years of age $45.55 (1.67 RVUs, $27.276 conversion factor)8 27305 21 years of age or older $53.84 (1.88 RVUs, $28.640 conversion factor)8 27306 Birth through 20 years of age $30.28 (1.11 RVUs, $27.276 conversion factor)8 27306 21 years of age or older $43.82 (1.53 RVUs, $28.640 conversion factor)8 27325 All $59.19 (2.17 RVUs, $27.276 conversion factor)8 27329 Birth through 20 years of age $117.56 (4.31 RVUs, $27.276 conversion factor)8 27329 21 years of age or older $123.458 27356 Birth through 20 years of age $83.46 (3.06 RVUs, $27.276 conversion factor)8 27356 21 years of age or older $87.578 27358 Birth through 20 years of age $46.10 (1.69 RVUs, $27.276 conversion factor)8 27358 21 years of age or older $48.308 27381 Birth through 20 years of age $104.74 (3.84 RVUs, $27.276 conversion factor)8 27381 21 years of age or older $109.848 27386 Birth through 20 years of age $112.10 (4.11 RVUs, $27.276 conversion factor)8 27386 21 years of age or older $117.688 27390 Birth through 20 years of age $45.82 (1.68 RVUs, $27.276 conversion factor)8 27390 21 years of age or older $50.12 (1.75 RVUs, $28.640 conversion factor)8 27392 Birth through 20 years of age $80.46 (2.95 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 27392 21 years of age or older $84.368 27393 Birth through 20 years of age $57.83 (2.12 RVUs, $27.276 conversion factor)8 27393 21 years of age or older $60.628 27397 All $90.28 (3.31 RVUs, $27.276 conversion factor)8 27403 Birth through 20 years of age $82.92 (3.04 RVUs, $27.276 conversion factor)8 27403 21 years of age or older $87.118 27412 All $75.28 (2.76 RVUs, $27.276 conversion factor)8 27418 Birth through 20 years of age $109.92 (4.03 RVUs, $27.276 conversion factor)8 27418 21 years of age or older $115.388 27435 Birth through 20 years of age $77.74 (2.85 RVUs, $27.276 conversion factor)8 27435 21 years of age or older $91.93 (3.21 RVUs, $28.640 conversion factor)8 27495 Birth through 20 years of age $159.56 (5.85 RVUs, $27.276 conversion factor)8 27495 21 years of age or older $167.628 27602 Birth through 20 years of age $52.64 (1.93 RVUs, $27.276 conversion factor)8 27602 21 years of age or older $60.43 (2.11 RVUs, $28.640 conversion factor)8 27612 Birth through 20 years of age $75.01 (2.75 RVUs, $27.276 conversion factor)8 27612 21 years of age or older $78.688 27626 All $97.38 (3.57 RVUs, $27.276 conversion factor)8 27650 Birth through 20 years of age $81.01 (2.97 RVUs, $27.276 conversion factor)8 27650 21 years of age or older $85.058 27654 Birth through 20 years of age $100.65 (3.69 RVUs, $27.276 conversion factor)8 27654 21 years of age or older $105.818 27656 Birth through 20 years of age $37.10 (1.36 RVUs, $27.276 conversion factor)8 27656 21 years of age or older $41.24 (1.44 RVUs, $28.640 conversion factor)8 27658 Birth through 20 years of age $43.91 (1.61 RVUs, $27.276 conversion factor)8 27658 21 years of age or older $46.108 27659 Birth through 20 years of age $59.73 (2.19 RVUs, $27.276 conversion factor)8 27659 21 years of age or older $62.828 27665 Birth through 20 years of age $49.64 (1.82 RVUs, $27.276 conversion factor)8 27665 21 years of age or older $52.248 27675 Birth through 20 years of age $64.92 (2.38 RVUs, $27.276 conversion factor)8 27675 21 years of age or older $68.238 27676 Birth through 20 years of age $76.10 (2.79 RVUs, $27.276 conversion factor)8 27676 21 years of age or older $79.968 27687 Birth through 20 years of age $55.37 (2.03 RVUs, $27.276 conversion factor)8 27687 21 years of age or older $58.158 27715 Birth through 20 years of age $126.29 (4.63 RVUs, $27.276 conversion factor)8 27715 21 years of age or older $132.528 27745 Birth through 20 years of age $90.83 (3.33 RVUs, $27.276 conversion factor)8 27745 21 years of age or older $95.368 27871 Birth through 20 years of age $80.74 (2.96 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 27871 21 years of age or older $84.778 28086 Birth through 20 years of age $42.82 (1.57 RVUs, $27.276 conversion factor)8 28086 21 years of age or older $45.098 28102 All $69.01 (2.53 RVUs, $27.276 conversion factor)8 28107 All $48.28 (1.77 RVUs, $27.276 conversion factor)8 28114 Birth through 20 years of age $86.46 (3.17 RVUs, $27.276 conversion factor)8 28114 21 years of age or older $97.95 (3.42 RVUs, $28.640 conversion factor)8 28122 Birth through 20 years of age $53.46 (1.96 RVUs, $27.276 conversion factor)8 28122 21 years of age or older $61.58 (2.15 RVUs, $28.640 conversion factor)8 28202 Birth through 20 years of age $59.73 (2.19 RVUs, $27.276 conversion factor)8 28202 21 years of age or older $62.608 28210 All $55.92 (2.05 RVUs, $27.276 conversion factor)8 28250 Birth through 20 years of age $48.82 (1.79 RVUs, $27.276 conversion factor)8 28250 21 years of age or older $51.328 28260 Birth through 20 years of age $57.01 (2.09 RVUs, $27.276 conversion factor)8 28260 21 years of age or older $64.15 (2.24 RVUs, $28.640 conversion factor)8 28264 Birth through 20 years of age $94.37 (3.46 RVUs, $27.276 conversion factor)8 28264 21 years of age or older $99.168 28360 Birth through 20 years of age $106.54 (3.72 RVUs, $28.640 conversion factor)8 28360 21 years of age or older $56.848 29820 Birth through 20 years of age $87.56 (3.21 RVUs, $27.276 conversion factor)8 29820 21 years of age or older $91.888 29821 Birth through 20 years of age $105.29 (3.86 RVUs, $27.276 conversion factor)8 29821 21 years of age or older $110.448 29822 Birth through 20 years of age $90.56 (3.32 RVUs, $27.276 conversion factor)8 29822 21 years of age or older $94.958 29823 Birth through 20 years of age $112.65 (4.13 RVUs, $27.276 conversion factor)8 29823 21 years of age or older $118.418 29824 Birth through 20 years of age $73.65 (2.70 RVUs, $27.276 conversion factor)8 29824 21 years of age or older $77.408 29825 Birth through 20 years of age $101.47 (3.72 RVUs, $27.276 conversion factor)8 29825 21 years of age or older $106.498 29826 Birth through 20 years of age $84.56 (3.10 RVUs, $27.276 conversion factor)8 29826 21 years of age or older $88.718 29827 Birth through 20 years of age $125.47 (4.60 RVUs, $27.276 conversion factor)8 29827 21 years of age or older $131.848 29834 Birth through 20 years of age $59.46 (2.18 RVUs, $27.276 conversion factor)8 29834 21 years of age or older $62.468 29835 Birth through 20 years of age $61.37 (2.25 RVUs, $27.276 conversion factor)8 29835 21 years of age or older $64.478 29836 Birth through 20 years of age $71.46 (2.62 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 29836 21 years of age or older $75.108 29837 All $65.19 (2.39 RVUs, $27.276 conversion factor)8 29843 All $56.73 (2.08 RVUs, $27.276 conversion factor)8 29844 Birth through 20 years of age $58.64 (2.15 RVUs, $27.276 conversion factor)8 29844 21 years of age or older $61.548 29845 Birth through 20 years of age $71.19 (2.61 RVUs, $27.276 conversion factor)8 29845 21 years of age or older $74.838 29847 All $67.64 (2.48 RVUs, $27.276 conversion factor)8 29851 Birth through 20 years of age $112.10 (4.11 RVUs, $27.276 conversion factor)8 29851 21 years of age or older $117.688 29855 Birth through 20 years of age $103.10 (3.78 RVUs, $27.276 conversion factor)8 29855 21 years of age or older $108.248 29856 All $120.01 (4.40 RVUs, $27.276 conversion factor)8 29860 Birth through 20 years of age $59.46 (2.18 RVUs, $27.276 conversion factor)8 29860 21 years of age or older $75.32 (2.63 RVUs, $28.640 conversion factor)8 29861 Birth through 20 years of age $88.37 (3.24 RVUs, $27.276 conversion factor)8 29861 21 years of age or older $92.848 29862 Birth through 20 years of age $97.38 (3.57 RVUs, $27.276 conversion factor)8 29862 21 years of age or older $102.148 29863 All $88.92 (3.26 RVUs, $27.276 conversion factor)8 29884 Birth through 20 years of age $83.46 (3.06 RVUs, $27.276 conversion factor)8 29884 21 years of age or older $87.528 29885 Birth through 20 years of age $83.74 (3.07 RVUs, $27.276 conversion factor)8 29885 21 years of age or older $87.948 29887 Birth through 20 years of age $95.74 (3.51 RVUs, $27.276 conversion factor)8 29887 21 years of age or older $100.498 29888 Birth through 20 years of age $101.47 (3.72 RVUs, $27.276 conversion factor)8 29888 21 years of age or older $114.27 (3.99 RVUs, $28.640 conversion factor)8 29889 All $140.91 (4.92 RVUs, $28.640 conversion factor)8 29891 Birth through 20 years of age $82.92 (3.04 RVUs, $27.276 conversion factor)8 29891 21 years of age or older $87.208 29892 All $85.65 (3.14 RVUs, $27.276 conversion factor)8 29894 Birth through 20 years of age $67.37 (2.47 RVUs, $27.276 conversion factor)8 29894 21 years of age or older $70.718 29895 Birth through 20 years of age $82.92 (3.04 RVUs, $27.276 conversion factor)8 29895 21 years of age or older $86.938 29897 Birth through 20 years of age $90.01 (3.30 RVUs, $27.276 conversion factor)8 29897 21 years of age or older $94.448 29898 Birth through 20 years of age $103.38 (3.79 RVUs, $27.276 conversion factor)8 29898 21 years of age or older $108.468 29899 Birth through 20 years of age $115.38 (4.23 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 29899 21 years of age or older $123.44 (4.31 RVUs, $28.640 conversion factor)8 29904 All $71.60 (2.50 RVUs, $28.640 conversion factor)8 29905 All $77.04 (2.69 RVUs, $28.640 conversion factor)8 29906 All $81.34 (2.84 RVUs, $28.640 conversion factor)8 30540 Birth through 20 years of age $67.92 (2.49 RVUs, $27.276 conversion factor)8 30540 21 years of age or older $71.398 30545 Birth through 20 years of age $104.19 (3.82 RVUs, $27.276 conversion factor)8 30545 21 years of age or older $109.388 31075 Birth through 20 years of age $92.74 (3.40 RVUs, $27.276 conversion factor)8 31075 21 years of age or older $97.428 31205 Birth through 20 years of age $85.10 (3.12 RVUs, $27.276 conversion factor)8 31205 21 years of age or older $95.08 (3.32 RVUs, $28.640 conversion factor)8 31420 Birth through 20 years of age $82.65 (3.03 RVUs, $27.276 conversion factor)8 31420 21 years of age or older $91.93 (3.21 RVUs, $28.640 conversion factor)8 31584 Birth through 20 years of age $128.47 (4.71 RVUs, $27.276 conversion factor)8 31584 21 years of age or older $166.68 (5.82 RVUs, $28.640 conversion factor)8 31588 Birth through 20 years of age $147.048 31588 21 years of age or older $154.398 31590 All $175.838 31595 All $69.83 (2.56 RVUs, $27.276 conversion factor)8 31601 Birth through 20 years of age $49.37 (1.81 RVUs, $27.276 conversion factor)8 31601 21 years of age or older $51.878 31611 Birth through 20 years of age $46.37 (1.70 RVUs, $27.276 conversion factor)8 31611 21 years of age or older $59.00 (2.06 RVUs, $28.640 conversion factor)8 32402 Birth through 20 years of age $71.19 (2.61 RVUs, $27.276 conversion factor)8 32402 21 years of age or older $74.658 32810 All $79.748 33508 Birth through 20 years of age $1.91 (0.07 RVU, $27.276 conversion factor)8 33508 21 years of age or older $2.00 (0.07 RVU, $28.640 conversion factor)8 33973 Birth through 20 years of age $80.74 (2.96 RVUs, $27.276 conversion factor)8 33973 21 years of age or older $84.778 33975 Birth through 20 years of age $160.93 (5.90 RVUs, $27.276 conversion factor)8 33975 21 years of age or older $169.048 33976 Birth through 20 years of age $219.30 (8.04 RVUs, $27.276 conversion factor)8 33976 21 years of age or older $230.368 33977 Birth through 20 years of age $140.74 (5.16 RVUs, $27.276 conversion factor)8 33977 21 years of age or older $147.928 33978 Birth through 20 years of age $160.93 (5.90 RVUs, $27.276 conversion factor)8 33978 21 years of age or older $169.048 33979 Birth through 20 years of age $129.83 (4.76 RVUs, $27.276 conversion factor)8 33979 21 years of age or older $308.45 (10.77 RVUs, $28.640 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 33980 Birth through 20 years of age $140.47 (5.15 RVUs, $27.276 conversion factor)8 33980 21 years of age or older $450.79 (15.74 RVUs, $28.640 conversion factor)8 34800 All $139.38 (5.11 RVUs, $27.276 conversion factor)8 34802 Birth through 20 years of age $153.84 (5.64 RVUs, $27.276 conversion factor)8 34802 21 years of age or older $161.628 34804 All $153.84 (5.64 RVUs, $27.276 conversion factor)8 34808 All $26.46 (0.97 RVU, $27.276 conversion factor)8 34812 Birth through 20 years of age $43.37 (1.59 RVUs, $27.276 conversion factor)8 34812 21 years of age or older $45.558 34813 All $30.82 (1.13 RVUs, $27.276 conversion factor)8 34825 Birth through 20 years of age $83.19 (3.05 RVUs, $27.276 conversion factor)8 34825 21 years of age or older $87.64 (3.06 RVUs, $28.640 conversion factor)8 34826 Birth through 20 years of age $26.46 (0.97 RVU, $27.276 conversion factor)8 34826 21 years of age or older $27.828 34833 All $77.19 (2.83 RVUs, $27.276 conversion factor)8 34834 All $40.64 (1.49 RVUs, $27.276 conversion factor)8 34900 Birth through 20 years of age $114.01 (4.18 RVUs, $27.276 conversion factor)8 34900 21 years of age or older $119.658 35302 All $135.56 (4.97 RVUs, $27.276 conversion factor)8 35303 All $135.56 (4.97 RVUs, $27.276 conversion factor)8 35304 All $135.56 (4.97 RVUs, $27.276 conversion factor)8 35305 All $135.56 (4.97 RVUs, $27.276 conversion factor)8 35306 All $135.56 (4.97 RVUs, $27.276 conversion factor)8 35450 All $114.56 (4.20 RVUs, $27.276 conversion factor)8 35452 All $54.55 (2.00 RVUs, $27.276 conversion factor)8 35454 Birth through 20 years of age $77.46 (2.84 RVUs, $27.276 conversion factor)8 35454 21 years of age or older $81.488 35456 Birth through 20 years of age $89.47 (3.28 RVUs, $27.276 conversion factor)8 35456 21 years of age or older $93.898 35458 Birth through 20 years of age $98.74 (3.62 RVUs, $27.276 conversion factor)8 35458 21 years of age or older $103.568 35459 Birth through 20 years of age $65.46 (2.40 RVUs, $27.276 conversion factor)8 35459 21 years of age or older $68.608 35480 All $115.65 (4.24 RVUs, $27.276 conversion factor)8 35481 All $56.19 (2.06 RVUs, $27.276 conversion factor)8 35482 All $78.01 (2.86 RVUs, $27.276 conversion factor)8 35483 Birth through 20 years of age $90.28 (3.31 RVUs, $27.276 conversion factor)8 35483 21 years of age or older $94.768 35484 Birth through 20 years of age $100.10 (3.67 RVUs, $27.276 conversion factor)8 35484 21 years of age or older $105.128 35485 Birth through 20 years of age $67.37 (2.47 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 35485 21 years of age or older $70.758 35490 Birth through 20 years of age $115.65 (4.24 RVUs, $27.276 conversion factor)8 35490 21 years of age or older $121.578 35491 All $56.19 (2.06 RVUs, $27.276 conversion factor)8 35492 Birth through 20 years of age $78.01 (2.86 RVUs, $27.276 conversion factor)8 35492 21 years of age or older $82.028 35572 Birth through 20 years of age $43.64 (1.60 RVUs, $27.276 conversion factor)8 35572 21 years of age or older $45.928 35875 Birth through 20 years of age $84.56 (3.10 RVUs, $27.276 conversion factor)8 35875 21 years of age or older $88.818 35883 All $153.84 (5.64 RVUs, $27.276 conversion factor)8 36261 All $35.46 (1.30 RVUs, $27.276 conversion factor)8 36838 Birth through 20 years of age $144.02 (5.28 RVUs, $27.276 conversion factor)8 36838 21 years of age or older $151.088 37207 Birth through 20 years of age $61.92 (2.27 RVUs, $27.276 conversion factor)8 37207 21 years of age or older $65.078 37208 Birth through 20 years of age $30.82 (1.13 RVUs, $27.276 conversion factor)8 37208 21 years of age or older $32.498 37606 All $55.37 (2.03 RVUs, $27.276 conversion factor)8 38120 All $120.00 (4.19 RVUs, $28.640 conversion factor)8 38308 Birth through 20 years of age $38.46 (1.41 RVUs, $27.276 conversion factor)8 38308 21 years of age or older $50.98 (1.78 RVUs, $28.640 conversion factor)8 38380 All $54.01 (1.98 RVUs, $27.276 conversion factor)8 38542 Birth through 20 years of age $47.19 (1.73 RVUs, $27.276 conversion factor)8 38542 21 years of age or older $49.638 38564 Birth through 20 years of age $87.01 (3.19 RVUs, $27.276 conversion factor)8 38564 21 years of age or older $91.248 38740 Birth through 20 years of age $55.10 (2.02 RVUs, $27.276 conversion factor)8 38740 21 years of age or older $77.61 (2.71 RVUs, $28.640 conversion factor)8 39503 All $259.848 44015 Birth through 20 years of age $28.91 (1.06 RVUs, $27.276 conversion factor)8 44015 21 years of age or older $30.348 44950 All $72.75 (2.54 RVUs, $28.640 conversion factor)8 44955 All Manually reviewed8 47010 Birth through 20 years of age $76.37 (2.80 RVUs, $27.276 conversion factor)8 47010 21 years of age or older $134.04 (4.68 RVUs, $28.640 conversion factor)8 47379 All Manually reviewed8 47550 All $23.788 47801 Birth through 20 years of age $80.74 (2.96 RVUs, $27.276 conversion factor)8 47801 21 years of age or older $120.29 (4.20 RVUs, $28.640 conversion factor)8 48001 All $112.65 (4.13 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 48510 Birth through 20 years of age $92.74 (3.40 RVUs, $27.276 conversion factor)8 48510 21 years of age or older $121.15 (4.23 RVUs, $28.640 conversion factor)8 49324 All $42.82 (1.57 RVUs, $27.276 conversion factor)8 49325 All $46.10 (1.69 RVUs, $27.276 conversion factor)8 49326 All $21.28 (0.78 RVU, $27.276 conversion factor)8 49425 Birth through 20 years of age $94.10 (3.45 RVUs, $27.276 conversion factor)8 49425 21 years of age or older $98.848 49435 All $13.64 (0.50 RVU, $27.276 conversion factor)8 49436 All $20.18 (0.74 RVU, $27.276 conversion factor)8 49491 All $77.46 (2.84 RVUs, $27.276 conversion factor)8 49495 Birth through 20 years of age $54.308 49495 21 years of age or older $51.82 (1.90 RVUs, $27.276 conversion factor)8 49568 Birth through 20 years of age $35.46 (1.30 RVUs, $27.276 conversion factor)8 49568 21 years of age or older $37.258 49585 All $49.83 (1.74 RVUs, $28.640 conversion factor)8 50290 All $109.10 (4.00 RVUs, $27.276 conversion factor)8 50562 Birth through 20 years of age $68.74 (2.52 RVUs, $27.276 conversion factor)8 50562 21 years of age or older $78.47 (2.74 RVUs, $28.640 conversion factor)8 50593 All $60.14 (2.10 RVUs, $28.640 conversion factor)8 50815 All $186.84 (6.85 RVUs, $27.276 conversion factor)8 50949 All Manually reviewed8 51045 Birth through 20 years of age $52.92 (1.94 RVUs, $27.276 conversion factor)8 51045 21 years of age or older $61.86 (2.16 RVUs, $28.640 conversion factor)8 51535 Birth through 20 years of age $93.56 (3.43 RVUs, $27.276 conversion factor)8 51535 21 years of age or older $98.208 51880 All $61.408 51980 All $94.80 (3.31 RVUs, $28.640 conversion factor)8 52647 Birth through 20 years of age $89.19 (3.27 RVUs, $27.276 conversion factor)8 52647 21 years of age or older $93.718 53085 All $78.83 (2.89 RVUs, $27.276 conversion factor)8 53230 Birth through 20 years of age $81.56 (2.99 RVUs, $27.276 conversion factor)8 53230 21 years of age or older $85.748 53235 Birth through 20 years of age $69.55 (2.55 RVUs, $27.276 conversion factor)8 53235 21 years of age or older $85.35 (2.98 RVUs, $28.640 conversion factor)8 53415 Birth through 20 years of age $130.92 (4.80 RVUs, $27.276 conversion factor)8 53415 21 years of age or older $151.51 (5.29 RVUs, $28.640 conversion factor)8 53442 All $65.19 (2.39 RVUs, $27.276 conversion factor)8 53447 All $103.10 (3.78 RVUs, $27.276 conversion factor)8 53449 Birth through 20 years of age $84.56 (3.10 RVUs, $27.276 conversion factor)8 53449 21 years of age or older $88.768 53500 Birth through 20 years of age $81.56 (2.99 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 53500 21 years of age or older $97.66 (3.41 RVUs, $28.640 conversion factor)8 59070 All $46.64 (1.71 RVUs, $27.276 conversion factor)8 59074 All $43.91 (1.61 RVUs, $27.276 conversion factor)8 59076 All $53.46 (1.96 RVUs, $27.276 conversion factor)8 59140 Birth through 20 years of age $46.10 (1.69 RVUs, $27.276 conversion factor)8 59140 21 years of age or older $48.488 59150 All $92.51 (3.23 RVUs, $28.640 conversion factor)8 59151 All $89.93 (3.14 RVUs, $28.640 conversion factor)8 59870 Birth through 20 years of age $35.19 (1.29 RVUs, $27.276 conversion factor)8 59870 21 years of age or older $55.56 (1.94 RVUs, $28.640 conversion factor)8 60650 Birth through 20 years of age $120.008 60650 21 years of age or older $142.63 (4.98 RVUs, $28.640 conversion factor)8 61140 Birth through 20 years of age $145.11 (5.32 RVUs, $27.276 conversion factor)8 61140 21 years of age or older $152.238 61156 All $158.47 (5.81 RVUs, $27.276 conversion factor)8 61250 All $94.37 (3.46 RVUs, $27.276 conversion factor)8 61253 Birth through 20 years of age $111.83 (4.10 RVUs, $27.276 conversion factor)8 61253 21 years of age or older $117.368 62142 Birth through 20 years of age $122.47 (4.49 RVUs, $27.276 conversion factor)8 62142 21 years of age or older $128.498 62143 Birth through 20 years of age $105.56 (3.87 RVUs, $27.276 conversion factor)8 62143 21 years of age or older $120.57 (4.21 RVUs, $28.640 conversion factor)8 62161 All $176.71 (6.17 RVUs, $28.640 conversion factor)8 62162 Birth through 20 years of age $187.39 (6.87 RVUs, $27.276 conversion factor)8 62162 21 years of age or older $213.65 (7.46 RVUs, $28.640 conversion factor)8 62163 Birth through 20 years of age $118.65 (4.35 RVUs, $27.276 conversion factor)8 62163 21 years of age or older $142.34 (4.97 RVUs, $28.640 conversion factor)8 64704 Birth through 20 years of age $48.55 (1.78 RVUs, $27.276 conversion factor)8 64704 21 years of age or older $51.008 64708 Birth through 20 years of age $66.28 (2.43 RVUs, $27.276 conversion factor)8 64708 21 years of age or older $69.568 64712 Birth through 20 years of age $83.74 (3.07 RVUs, $27.276 conversion factor)8 64712 21 years of age or older $87.948 64713 Birth through 20 years of age $98.74 (3.62 RVUs, $27.276 conversion factor)8 64713 21 years of age or older $103.618 64714 Birth through 20 years of age $80.19 (2.94 RVUs, $27.276 conversion factor)8 64714 21 years of age or older $84.098 64716 All $51.82 (1.90 RVUs, $27.276 conversion factor)8 64732 All $42.28 (1.55 RVUs, $27.276 conversion factor)8 64761 All $51.82 (1.90 RVUs, $27.276 conversion factor)8 64771 All $64.92 (2.38 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units


All Providers


TOS procedure Code Age Access based Fee or Calculated Fee8 64786 All $137.47 (5.04 RVUs, $27.276 conversion factor)8 64835 All $95.08 (3.32 RVUs, $28.640 conversion factor)8 64836 All $93.65 (3.27 RVUs, $28.640 conversion factor)8 64837 All $53.19 (1.95 RVUs, $27.276 conversion factor)8 64840 All $107.19 (3.93 RVUs, $27.276 conversion factor)8 64857 Birth through 20 years of age $120.01 (4.40 RVUs, $27.276 conversion factor)8 64857 21 years of age or older $126.158 64859 Birth through 20 years of age $38.46 (1.41 RVUs, $27.276 conversion factor)8 64859 21 years of age or older $40.328 64872 All Manually reviewed8 64874 All Manually reviewed8 64876 All Manually reviewed8 64892 All $122.20 (4.48 RVUs, $27.276 conversion factor)8 64910 All $79.37 (2.91 RVUs, $27.276 conversion factor)8 64911 All $96.28 (3.53 RVUs, $27.276 conversion factor)8 65105 All $90.688 65260 All $89.47 (3.28 RVUs, $27.276 conversion factor)8 65900 Birth through 20 years of age $101.048 65900 21 years of age or older $101.048 66165 All $86.46 (3.17 RVUs, $27.276 conversion factor)8 66220 All $62.46 (2.29 RVUs, $27.276 conversion factor)8 67255 Birth through 20 years of age $125.978 67255 21 years of age or older $125.978 67430 All $110.20 (4.04 RVUs, $27.276 conversion factor)TOS= Type of service, RVU=Relative value units

Components No Longer a benefitThe procedure codes in the following tables are benefits of Texas Medicaid; however, various components (i.e., TOS) are not a benefit. Providers may refer to the Texas Medicaid fee schedules that are available on the TMHP website at www.tmhp.com for the components that continue to be reimbursed for each procedure code.Procedure code 22999 is no longer a benefit for assistant surgery (TOS 8), and procedure code 75809 is no longer a benefit for the technical component (TOS T).The following procedure codes are no longer benefits for the total component (TOS 4 or 5 as indicated) and the technical component (TOS T):

procedure Codes

4/T-70170 4/T-71090 4/T-73530 4/T-74190 4/T-74235 4/T-74300 4/T-743014/T-74305 4/T-74328 4/T-74329 4/T-74330 4/T-74355 4/T-74360 4/T-743634/T-74400 4/T-74410 4/T-74415 4/T-74420 4/T-74425 4/T-74445 4/T-744504/T-74470 4/T-75801 4/T-75803 4/T-75805 4/T-75807 4/T-75810 4/T-758944/T-75896 4/T-75898 4/T-75900 4/T-75940 4/T-75945 4/T-75946 4/T-759704/T-75980 4/T-75982 4/T-75992 4/T-75993 4/T-75994 4/T-75996 4/T-760014/T-76125 4/T-76930 4/T-76932 4/T-76940 4/T-76945 4/T-76975 5/T-95824


All Providers


The following procedure codes are no longer benefits for the professional component (TOS I) and the technical component (TOS T):

procedure Codes

I/T-76150 I/T-76350 I/T-76496I/T-76497 I/T-76498 I/T-76499I/T-92978 I/T-92979 I/T-93303I/T-93304 I/T-93307 I/T-93308I/T-93318 I/T-93320 I/T-93321I/T-93325 I/T-93350 I/T-93501I/T-93505 I/T-93508 I/T-93510I/T-93511 I/T-93514 I/T-93524I/T-93526 I/T-93527 I/T-93528I/T-93529 I/T-93530 I/T-93531I/T-93532 I/T-93533 I/T-93613I/T-94799 I/T-95829 I/T-95920I/T-95955 I/T-95999

The following procedure codes are no longer benefits for the total component (TOS 4, 5, or 6 as indicated):

procedure Codes

4-74340 4-75952 4-75953 6-78804*5-91030 5-91052 5-91065 5-932705-93271 4-93982

* Procedure code 78804 is reimbursed as a radiology service (TOS 4) instead of a radiation therapy service (TOS 6).

The following procedure codes are no longer benefits for the professional component (TOS I):

procedure Codes

I-78599 I-82045 I-82656 I-82977I-83036 I-83630 I-84066 I-84163I-84260 I-84445 I-84481 I-85097I-86077 I-86078 I-86079 I-86490I-86510 I-86850 I-86860 I-86870I-86901 I-86920 I-86921 I-86922I-86950 I-86999 I-87807 I-89100I-89105 I-89130 I-89132 I-89135I-89136 I-89140 I-89141 I-89240I-93280 I-93722 I-95857

place of Service Updates: AdditionsThe following procedure codes are reimbursed in the office setting:

procedure Codes

I-70557* I-70558* I-70559*I-76001 4-76937 T-784604/T-78461 4/T-78464 4/T-784654/T-78472 4/T-78473 4/T-784814/T-78483 4/T-78494 4/T-78496I-84166 I-91030 I-91052I-91065 I-92541 I-92542I-92543 I-92544 I-92545I-92546 5-92564 I-92587I-92588 2-92979 2-929802-92981 2-92982 2-929842-92986 2-92987 2-929902-92995 2-92996 2-929972-92998 2-93508 2-935302-93531 2-93532 2-935332-93539 2-93540 2-935412-93542 2-93543 2-935442-93545 2/I-93571 2/I-93572I-93600 I-93602 I-93603I-93609 I-93610 I-93612I-93615 I-93616 I-93623I-93660 I-93724 I-93740I-93770 I-93799 I-94720I-94725 I-94750 I-95075I-95812 I-95813 I-95816I-95819 I-95822 I-95827I-95921 I-95922 I-95923I-95950 I-95951 I-95953I-95954 I-95956 I-95958

* Procedure codes I-70557, I-70558, and I-70559 may also be reimbursed in the outpatient hospital setting.

The following procedure codes are reimbursed in the inpatient hospital setting:

procedure Codes

I-72291 1-92507 1-92531 1-925321-92533 1-92534 1-92541 1-925421-92543 1-92544 1-92545 1-925461-92630 1-92633 1-92640 1-95990


All Providers


The following procedure codes are reimbursed in the outpatient hospital setting:

procedure Codes

4-70554 I-70557* I-70558* I-70559*6-77499 1-95004 1-95010 1-950151-95024 1-95028 1-95044 1-950521-95056 1-95065 1-95070 1-95071* Procedure codes I-70557, I-70558, and I-70559 may also be reimbursed in the office setting.

The following procedure codes are reimbursed in the independent laboratory and birthing center settings:

procedure Codes

9-A0382 9-A0422 9-A0424 9-A04259-A0428 9-A0429 9-A0430 9-A04319-A0435 9-A0436

The following procedure codes are no longer reimbursed in the settings indicated:

procedure Codes Settings No Longer reimbursed 6-77432, W-D8999

Inpatient and outpatient hospital

1-90585 Other locations*1-92508 Home, outpatient hospital, other

locations*9-A0380, 9-A0384

Independent laboratory, birthing center, and other locations*

* Providers may refer to the 2009 Texas Medicaid Provider Proce-dures Manual section 5.3.1.1, “Place of Service (POS) Coding,” on page 5-18, for more information about coding POS for other locations.

Providers may refer to the Texas Medicaid fee schedules for the provider types that may be reimbursed for each procedure code and setting.

place of Service Updates: No Longer benefitsThe following procedure codes are no longer reimbursed in the home, skilled nursing facility (SNF) or interme-diary care facility (ICF), outpatient hospital, independent laboratory, or nursing home (extended care facility [ECF]) setting:

procedure Codes

T-77072 T-77077 T-77080 T-93225

The following procedure codes are no longer reimbursed in the inpatient hospital setting:

procedure Codes

4-75960 5-80048 5-80051 5-800535-80055 5-80074 5-80076 5-801005-80101 5-80150 5-80156 5-801625-80164 5-80170 5-80178 5-801845-80185 5-80188 5-80196 5-801975-80202 5-80299 5-81025 5-820035-82009 5-82043 5-82055 5-821085-82120 5-82140 5-82150 5-822325-82247 5-82248 5-82270 5-822715-82272 5-82274 5-82306 5-823305-82340 5-82355 5-82360 5-823655-82378 5-82436 5-82495 5-825075-82533 5-82550 5-82553 5-825705-82575 5-82607 5-82627 5-826705-82746 5-82785 5-82948 5-829505-82951 5-82977 5-83001 5-830025-83037 5-83090 5-83516 5-835205-83525 5-83605 5-83690 5-837215-83785 5-83874 5-83880 5-838915-83892 5-83893 5-83894 5-838965-83897 5-83898 5-83900 5-839015-83902 5-83903 5-83909 5-839125-83914 5-83925 5-83945 5-839705-83986 5-84030 5-84066 5-840755-84100 5-84105 5-84132 5-841335-84134 5-84144 5-84146 5-841535-84155 5-84156 5-84160 5-841635-84295 5-84300 5-84305 5-843115-84392 5-84403 5-84436 5-844395-84443 5-84450 5-84466 5-844785-84480 5-84484 5-84520 5-845605-84681 5-84703 5-85097 5-853785-85379 5-85651 5-85652 5-856605-85730 5-86000 5-86003 5-860055-86038 5-86039 5-86140 5-861415-86160 5-86225 5-86235 5-862555-86256 5-86300 5-86301 5-863045-86308 5-86318 5-86430 5-864315-86485 5-86593 5-86603 5-866315-86665 5-86695 5-86696 5-86702


All Providers


procedure Codes5-86703 5-86705 5-86706 5-867095-86710 5-86738 5-86756 5-867595-86762 5-86781 5-86787 5-868035-86805 5-86807 5-86813 5-868175-86850 5-86880 5-86885 5-869005-86901 5-86920 5-86921 5-869225-87015 5-87040 5-87045 5-870465-87070 5-87075 5-87077 5-870815-87086 5-87088 5-87116 5-871475-87177 5-87184 5-87186 5-872055-87206 5-87209 5-87210 5-872205-87230 5-87276 5-87324 5-873505-87390 5-87420 5-87425 5-874305-87449 5-87491 5-87496 5-875295-87536 5-87591 5-87621 5-876535-87798 5-87802 5-87804 5-878075-87810 5-87850 5-87880 5-878995-88104 5-88108 5-88112 5-881725-88173 5-88300 5-88302 5-883045-88307 5-88309 5-88311 5-883125-88313 5-88368 5-89050 5-890515-89055 5-89220 2-91010 2-910202-91038 2-91120 2-91122 I-930181-96570 9-A9502 5-G0103 0-P9059

The following procedure codes are no longer a benefit in the inpatient hospital or independent laboratory setting:

procedure Codes

4-78007 4-78700 5-92552 5-925675-92568 5-93025 5-93230 5-932685-93784 5-94720 5-94750 5-958125-95813 5-95816 5-95819 5-95822

The following procedure codes are no longer a benefit in the SNF, ICF, or ECF setting:

procedure Codes

4-70553 4-72156 4-72157 4-721584-93975 4-93976 4-93978 4-939794-93981 1-H2011 1-H2014 1-H2017

The following procedure codes are no longer a benefit in the independent laboratory setting:

procedure Codes

5-92551 5-93015 5-95923 5-959505-95956 5-95958 9-A9500 9-A9505

The following procedure codes are no longer reimbursed in the home, SNF, ICF, independent laboratory, or ECF setting:

procedure Codes

T-70210 T-70220 T-70360 T-70450T-70490 T-70546 T-70551 T-70553T-71100 T-71101 T-71110 T-71111T-71250 T-71555 T-72020 T-72040T-72050 T-72070 T-72072 T-72080T-72090 T-72100 T-72110 T-72114T-72170 T-72190 T-72192 T-73000T-73020 T-73030 T-73060 T-73070T-73080 T-73090 T-73110 T-73120T-73130 T-73140 T-73500 T-73510T-73520 T-73550 T-73560 T-73562T-73564 T-73590 T-74000 T-74010T-74020 T-74150 T-74183 T-76536T-76700 T-76705 T-76770 T-76830T-76856 T-76870 T-76880 T-78708T-93226 T-93975 T-93976 T-93978T-93979 T-94720 T-95812 T-95956

The following procedure codes are no longer reimbursed in the home, SNF, ICF, or ECF setting:

procedure Codes

T-70491 I-71100 I-71101 I-71110I-71120 T-71260 I-72020 I-72040I-72070 I-72072 I-72074 I-72080I-72110 I-72120 I-72170 I-72190T-72193 T-72194 T-72200 I-72220T-72220 I-73000 I-73010 I-73020I-73030 I-73060 I-73070 I-73080I-73110 I-73120 I-73130 I-73140I-73500 I-73510 I-73520 I-73550


All Providers


procedure Codes

I-73560 I-73562 I-73564 T-73565I-73590 T-73721 I-74000 I-74010I-74020 I-74022 T-74160 T-74170T-76942 T-78007 T-78478 T-78480T-78707 T-93231 T-93232 T-93555T-93556 I-93975 I-93976

The following procedure codes are no longer reimbursed in the settings indicated:

procedure Codes Settings No Longer reimbursed 1-90386, 1-S0023

Home and ECF

4-78414 Office, inpatient hospital, outpatient hospital, independent laboratory

5-95920, 5-95955

Office, independent laboratory

T-88112 Inpatient hospital, outpatient hospital5-94799 Inpatient hospital, outpatient hospital,

independent laboratory1-92520 ECF

procedures that require modifier QWThe following procedure codes must be submitted with modifier QW:

procedure Codes: modifier QW required

5-80178 5-82042 5-82150 5-822475-82270 5-82330 5-82570 5-829775-83002 5-83520 5-84075 5-841325-84157 5-84295 5-84443 5-84550

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

Sunday, September 13, 2009, 6:00 p.m. to 11:59 p.m.

Sunday, October 11, 6:00 p.m. to 11:59 p.m.

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

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Effective for dates of service on or after June 1, 2009, Texas Medicaid providers may be eligible to receive an enhanced rate when they provide prior authorized personal care services (PCS) to clients whose behavioral health condition affects the ability to perform activities of daily living (ADL) or instrumental activities of daily living (IADL).

A PCS provider must have a prior authorization indicating the availability of the enhanced rate for PCS provided to clients with a behavioral health condition. The DSHS case manager conducts the personal care assessment and authorizes the enhanced rate when supported by information gathered during the assessment. The provider’s authorization letter will indicate the PCS hours approved and the modifier for the enhanced rate.The PCS authorized by DSHS must be billed using procedure code 1-T1019 and the appropriate modifier. The following table includes the modifiers that are billed to receive the enhanced rate:

provider Type modifierEnhanced

rateAll PCS providers (except Con-sumer-Directed Service Agency [CDSA])

UA $3.26

CDSA under the Consumer-Directed Services (CDS) option

UB $3.06

The primary practitioner must maintain the Practitioner Statement of Need in the client’s medical record. In addition, DSHS must maintain the Practitioner Statement of Need with the client’s assessment and other forms related to the client’s case.If the primary practitioner does not have documenta-tion, including a Practitioner Statement of Need, that the client has a physical, cognitive, or behavioral health condition that impacts the client’s ability to perform an ADL or IADL, PCS payments may be recouped.

Providers may be eligible to receive

an enhanced rate when they

provide prior authorized PCS

Update to Personal Care Services


All Providers


Update to Third-Party Resources Type of Coverage CodesEffective August 29, 2009, TMHP has updated the TexMedConnect and Electronic Data Interchange (EDI) systems with a new type of coverage code for clients who have a Medicare Advantage Plan (MAP). The eligibility verification screen will display “M” on the Other Insurance Segments if the client is enrolled in a MAP in addition to Medicaid. For detailed information about claims for clients enrolled in a MAP, providers can refer to previous MAP articles in banner messages and on the TMHP website at www.tmhp.com. The following table defines the types-of-coverage codes for third-party resources (TPR):

Code Description

@ AG IV_D8 Vision policyC Inpatient/outpatientD Dental policyF Medicare supplement policyK Prescription drugM Medicare Advantage PlanN Inpatient N1 Long term care/nursing facility N2 Comprehensive + well checksR Maternity services not coveredS Accident only or invalid segmentT Cancer onlyV Non-assignable indemnity policy or cannot IDX HMO policyY Comprehensive policy

reminder: Prior authorization request forms with signature lines must be signed and dated by the medical or dental provider who is familiar with the client before the forms are submitted to TMHP. All signatures on these forms must be current, unaltered, and handwritten. Computerized or stamped signatures are not permitted. Forms that are submitted without a hand-written signature

will be rejected. The form that contains the original signature must be kept in the client’s medical record for future access.Submission of prior authorization requests via the secure pages of the TMHP website at www.tmhp.com does not replace adherence to docu-mentation requirements outlined in the 2009 Texas Medicaid Provider Procedures Manual.

Revised Texas Medicaid Fee Schedules Available

Effective July 5, 2009, the revised Texas Medicaid Fee Schedules are available on the TMHP website at www.tmhp.com. Providers can request a free paper copy of a fee schedule by calling the TMHP Contact Center at 1-800-925-9126.


All Providers


Original Signatures Required on All Prior Authorization Request Forms

Enhancements to TexMedConnect

Inmates of Public Correctional Institutions Ineligible for Coverage of Medicaid Services

Federal financial participation (FFP) is not available to reimburse providers for services provided to Texas Medicaid clients who are inmates of public correc-tional institutions or holding facilities (Code of Federal Regulations, Title 42, 435.1009). Services rendered to the following Texas Medicaid clients during their incarceration or detention are the responsi-bility of the correctional institution or holding facility:

Prisoners

Those who have been arrested or detained pending disposition of charges

Those held under court order as material witnesses

Juveniles

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•

As outlined in the 2009 Texas Medicaid Provider Procedures Manual, section 1.6, “Texas Medicaid Limitations and Exclusions” on page 1-25, Texas Medicaid does not reimburse providers for services or supplies provided to any resident or inmate during their incarceration. The correc-tional or holding facilities are responsible for any services received during the incarceration period. Claims identified during retrospective review as having been paid while the Texas Medicaid client was an inmate of a public institution are adjusted and the payment recouped from the provider who rendered services.

On August 29, 2009, TMHP implemented new features to make it easier to navigate and enter data on TexMedConnect. Acute care providers are also able to get more client eligibility information through the online system.The new TexMedConnect features include the following:

Eligibility Verification requestsA short description of a client’s base plan, which identifies the client’s Medicaid coverage, such as the Supplemental Security Income (SSI) program, to be included with all other current acute care eligibility verification information.

A display of a client’s acute care eligibility from the requested date through the end of the current month for Medicaid, Medicaid Managed Care, Medicare, Lock-in, TPR, and third-party liability (TPL) inquiries.

Ability to request, view, and print eligibility information for one or more clients in a Client Group List at one time. (Results will be available for 60 days on the new Eligibility Batch History screen.)

GeneralPre-populated values for dental claims of “AD-American Dental Association” in the Procedure ID field, “11-Office” in the Place of Service field, and the number “1” in the Quantity field.

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A drop-down list of options for the Frequency Code field under the Patient tab in the Appeal Information section.

Display of the provider name along with the NPI, taxonomy, address, and benefit codes:

On the Remittance and Status Report (R&S) web page.

In the list of available providers to select from when using the look-up on the Provider tab of the Claim Submission screen.

Automatic display of other insurance information based on client data entered on the Other Insurance/Submit Claim tab.

Alphabetized template listings on the Claims Individual Template List page.

Option to return directly to the Batch History–List of Claims screen after resubmitting an interactive claim that was rejected or received an error in a previously submitted batch.

Option to return directly to the Claims Individual Template List page for the same provider after submitting an interactive claim using an individual template.

For screenshots relating to this article, refer to the TMHP website at www.tmhp.com.

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All Providers


Changes to Reimbursement Rates for Clinical LaboratoryEffective for dates of services on or after April 1, 2009, Texas Medicaid reimbursement rates for clinical laboratory procedure codes have changed. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. The following reimbursement rates are effective for clinical laboratory services:

TOSprocedure Code reimbursement rate

5 78267 $11.025 78268 $94.425 80047 $11.875 80048 $11.875 80051 $9.835 80053 $14.825 80061 $18.795 80069 $12.175 80074 $66.765 80076 $11.455 80100 $15.585 80101 $19.315 80102 $18.575 80150 $21.135 80152 $25.095 80154 $25.925 80156 $20.415 80157 $18.595 80158 $25.315 80160 $24.125 80162 $18.615 80164 $18.995 80166 $21.735 80168 $19.055 80170 $22.975 80172 $22.835 80173 $20.415 80174 $24.125 80176 $20.595 80178 $9.265 80182 $18.995 80184 $16.05


5 80185 $18.595 80186 $19.305 80188 $23.265 80190 $23.485 80192 $23.485 80194 $20.465 80195 $19.245 80196 $9.955 80197 $19.245 80198 $19.835 80200 $22.595 80201 $16.705 80202 $18.995 80299 $19.195 80400 $45.725 80402 $121.865 80406 $108.845 80408 $175.915 80410 $112.615 80412 $462.015 80414 $72.385 80415 $78.345 80416 $185.015 80417 $61.675 80418 $812.395 80420 $100.975 80422 $64.575 80424 $70.795 80426 $208.055 80428 $93.475 80430 $109.975 80432 $189.355 80434 $141.795 80435 $144.345 80436 $103.855 80438 $70.655 80439 $94.205 80440 $81.505 81000 $4.44


All Providers



5 81001 $4.445 81002 $3.595 81003 $3.155 81005 $3.035 81015 $4.255 81020 $5.165 81025 $8.875 81050 $4.205 82000 $17.375 82003 $28.375 82009 $6.115 82010 $10.265 82013 $9.915 82016 $18.645 82017 $13.985 82024 $54.145 82030 $28.445 82040 $6.945 82042 $7.265 82043 $7.805 82044 $6.415/I 82045 $47.585 82055 $15.155 82075 $16.905 82085 $13.605 82088 $57.125 82101 $42.085 82103 $18.835 82104 $20.275 82105 $23.515 82106 $23.515 82107 $90.285 82108 $35.715 82120 $5.275 82127 $18.645 82128 $18.645 82131 $23.645 82135 $23.085 82136 $13.985 82139 $13.985 82140 $20.43


5 82143 $9.635 82145 $21.795 82150 $9.085 82154 $40.425 82157 $41.035 82160 $35.055 82163 $12.265 82164 $20.465 82172 $21.725 82175 $26.595 82180 $13.855 82190 $20.905 82205 $16.055 82232 $22.685 82239 $24.015 82240 $37.265 82247 $7.045 82248 $7.045 82252 $6.375 82261 $13.985 82270 $4.565 82271 $4.565 82272 $4.565 82274 $22.295 82286 $9.665 82300 $32.445 82306 $38.085 82307 $45.175 82308 $37.545 82310 $7.235 82330 $19.155 82331 $7.265 82340 $8.465 82355 $16.215 82360 $18.055 82365 $18.085 82370 $17.565 82373 $25.325 82374 $6.855 82375 $17.285 82376 $8.40


All Providers



5 82378 $26.595 82379 $13.985 82380 $12.935 82382 $24.105 82383 $35.135 82384 $35.405 82387 $18.645 82390 $15.055 82397 $19.805 82415 $17.765 82435 $6.435 82436 $7.055 82438 $6.855 82441 $8.415 82465 $6.115 82480 $11.055 82482 $10.775 82485 $28.945 82486 $25.325 82487 $22.385 82488 $29.955 82489 $25.925 82491 $25.325 82492 $25.325 82495 $28.435 82507 $38.985 82520 $21.245 82523 $26.205 82525 $17.405 82528 $31.555 82530 $23.435 82533 $22.865 82540 $6.495 82541 $25.325 82542 $25.325 82543 $25.325 82544 $25.325 82550 $9.135 82552 $18.785 82553 $8.625 82554 $8.62


5 82565 $7.185 82570 $7.265 82575 $13.245 82585 $12.025 82595 $9.075 82600 $27.205 82607 $21.135 82608 $20.075 82610 $19.065 82615 $11.445 82626 $35.425 82627 $31.165 82633 $29.075 82634 $29.075 82638 $17.165 82646 $28.945 82649 $36.035 82651 $36.185 82652 $53.955 82654 $19.415/I 82656 $16.185 82657 $25.325 82658 $25.325 82664 $36.655 82666 $27.655 82668 $26.355 82670 $39.175 82671 $45.265 82672 $12.265 82677 $33.905 82679 $34.995 82690 $24.235 82693 $20.885 82696 $33.055 82705 $7.135 82710 $23.555 82715 $23.875 82725 $18.665 82726 $25.325 82728 $19.095 82731 $90.28


All Providers



5 82735 $26.005 82742 $27.745 82746 $20.615 82747 $24.235 82757 $24.315 82759 $12.655 82760 $15.705 82775 $29.525 82776 $11.475 82784 $13.045 82785 $23.095 82787 $5.875 82800 $11.885 82803 $27.125 82805 $39.775 82810 $12.235 82820 $14.015 82926 $7.645 82928 $9.185 82938 $24.805 82941 $24.725 82943 $12.265 82945 $5.505 82946 $19.055 82947 $5.505 82948 $4.445 82950 $6.655 82951 $18.055 82952 $5.495 82953 $21.245 82955 $12.265 82960 $8.495 82963 $30.125 82965 $10.845 82975 $22.205 82977 $10.095 82978 $19.985 82979 $9.525 82980 $25.685 82985 $21.135 83001 $26.05


5 83002 $25.965 83003 $23.375 83008 $23.535 83009 $94.425 83010 $17.645 83012 $24.105 83013 $94.425 83014 $11.025 83015 $26.405 83018 $30.785 83020 $18.055 83021 $25.325 83026 $3.315 83030 $11.605 83033 $8.355 83036 $13.605 83037 $13.605 83045 $4.035 83050 $4.125 83051 $10.245 83055 $6.905 83060 $8.085 83065 $9.665 83068 $9.525 83069 $5.535 83070 $6.655 83071 $9.635 83080 $13.985 83088 $41.405 83090 $23.645 83150 $14.615 83491 $24.555 83497 $6.525 83498 $38.075 83499 $35.335 83500 $31.755 83505 $34.075 83516 $16.185 83518 $11.885 83519 $18.945 83520 $18.15


All Providers



5 83525 $16.025 83527 $18.155 83528 $22.295 83540 $9.085 83550 $12.265 83570 $12.395 83582 $19.865 83586 $17.945 83593 $30.745 83605 $14.975 83615 $8.465 83625 $17.945/I 83630 $27.515 83631 $27.515 83632 $28.335 83633 $6.525 83634 $4.035 83655 $16.965 83661 $30.815 83662 $26.525 83663 $26.525 83664 $26.525 83670 $12.845 83690 $9.665 83695 $18.155 83700 $15.785 83701 $34.795 83704 $44.235 83718 $11.485 83719 $16.315 83721 $13.375 83727 $24.105 83735 $9.395 83775 $10.345 83785 $34.465 83788 $25.325 83789 $25.325 83805 $24.715 83825 $18.185 83835 $23.755 83840 $22.895 83857 $15.05


5 83858 $9.525 83864 $27.915 83866 $13.445 83872 $8.225 83873 $24.125 83874 $18.115 83880 $47.585 83883 $19.065 83885 $34.345 83887 $33.205 83890 $5.625 83891 $5.625 83892 $5.625 83893 $5.625 83894 $5.625 83896 $5.625 83897 $5.625 83898 $14.275 83900 $28.535 83901 $14.275 83902 $14.275 83903 $14.275 83904 $14.275 83905 $14.275 83906 $14.275 83907 $18.725 83908 $14.275 83909 $14.275 83912 $5.625 83913 $18.725 83914 $14.275 83915 $15.645 83916 $28.195 83918 $23.085 83919 $23.085 83921 $23.085 83925 $27.275 83930 $6.905 83935 $6.905 83937 $39.915 83945 $18.055 83950 $90.28


All Providers



5 83951 $90.285 83970 $57.865 83986 $5.015 83992 $20.605 83993 $27.515 84022 $15.925 84030 $7.725 84035 $2.855 84060 $10.355 84066 $13.545 84075 $7.265 84078 $10.235 84080 $12.265 84081 $23.165 84085 $9.455 84087 $14.475 84100 $6.655 84105 $7.265 84106 $6.005 84110 $11.855 84119 $12.075 84120 $20.615 84126 $35.705 84127 $16.335 84132 $6.435 84133 $6.035 84134 $11.835 84135 $26.825 84138 $24.465 84140 $28.985 84143 $31.565 84144 $29.245 84146 $27.175 84150 $34.995 84152 $25.785 84153 $25.785 84154 $25.785 84155 $5.145 84156 $5.145 84157 $5.145 84160 $7.265/I 84163 $12.24


5 84165 $15.055/I 84166 $25.005 84181 $23.885 84182 $25.235 84202 $12.385 84203 $12.075 84206 $24.975 84207 $39.385 84210 $15.225 84220 $13.225 84228 $16.315 84233 $90.285 84234 $90.935 84235 $73.355 84238 $51.255 84244 $30.845 84252 $28.375 84255 $35.785 84260 $24.385 84270 $30.465 84275 $13.825 84285 $33.005 84295 $6.745 84300 $6.825 84302 $6.825 84305 $29.805 84307 $25.635 84311 $9.795 84315 $3.515 84375 $27.485 84376 $6.525 84377 $6.525 84378 $4.035 84379 $4.035 84392 $6.655 84402 $35.695 84403 $36.195 84425 $9.525 84430 $12.265 84432 $22.515 84436 $9.635 84437 $9.07


All Providers



5 84439 $12.645 84442 $20.735 84443 $23.555 84445 $71.275 84446 $19.875 84449 $25.235 84450 $7.255 84460 $7.425 84466 $12.905 84478 $8.065 84479 $9.075 84480 $19.875 84481 $23.755 84482 $10.785 84484 $13.805 84485 $10.525 84488 $10.235 84490 $10.675 84510 $14.575 84512 $10.345 84520 $5.535 84525 $5.275 84540 $6.655 84545 $9.255 84550 $6.335 84560 $6.655 84577 $8.085 84578 $4.555 84580 $8.085 84583 $7.055 84585 $21.735 84586 $19.565 84588 $47.585 84590 $16.255 84591 $16.255 84597 $9.525 84600 $22.535 84620 $16.605 84630 $15.965 84681 $29.165 84702 $12.245 84703 $10.53


5 84704 $12.245 85002 $6.315 85004 $9.075 85007 $4.825 85008 $4.825 85009 $5.215 85013 $3.325 85014 $3.325 85018 $3.325 85025 $10.905 85027 $9.075 85032 $6.035 85041 $4.225 85044 $6.035 85045 $5.625 85046 $7.825 85048 $3.565 85049 $6.275 85055 $37.535 85130 $16.685 85170 $5.075 85175 $6.375 85210 $18.205 85220 $24.745 85230 $25.095 85240 $9.005 85244 $28.625 85245 $11.475 85246 $11.475 85247 $11.475 85250 $26.685 85260 $25.095 85270 $25.095 85280 $27.125 85290 $22.915 85291 $12.465 85292 $26.545 85293 $26.545 85300 $16.615 85301 $15.165 85302 $16.855 85303 $19.38


All Providers



5 85305 $16.255 85306 $19.345 85307 $19.345 85335 $18.055 85337 $14.615 85345 $6.035 85347 $5.975 85348 $5.225 85360 $11.775 85362 $9.665 85366 $11.475 85370 $13.055 85378 $9.995 85379 $13.055 85380 $13.055 85384 $11.905 85385 $11.905 85390 $7.245 85397 $11.475 85400 $12.395 85410 $10.815 85415 $24.105 85420 $9.175 85421 $11.475 85441 $5.895 85445 $9.555 85460 $10.855 85461 $9.305 85475 $12.435 85520 $18.355 85525 $16.615 85530 $19.055 85536 $9.075 85540 $12.065 85547 $12.065 85549 $26.295 85555 $9.375 85557 $12.265 85576 $30.125 85597 $20.345 85610 $5.515 85611 $5.52


5 85612 $9.805 85613 $9.805 85635 $13.805 85651 $4.975 85652 $3.785 85660 $7.745 85670 $8.105 85675 $9.005 85705 $11.915 85730 $8.415 85732 $9.075 85810 $16.375 86000 $9.785 86001 $6.705 86003 $6.705 86005 $11.175 86021 $21.105 86022 $13.725 86023 $8.085 86038 $16.945 86039 $15.655 86060 $10.235 86063 $8.105 86140 $7.265 86141 $18.155 86146 $11.015 86147 $11.015 86148 $11.015 86155 $22.405 86156 $9.395 86157 $11.305 86160 $16.835 86161 $16.835 86162 $26.335 86171 $9.005 86185 $12.545 86200 $18.155 86215 $18.585 86225 $19.265 86226 $16.975 86235 $25.135 86243 $28.76


All Providers



5 86255 $16.905 86256 $16.905 86277 $22.065 86280 $11.485 86294 $27.495 86300 $29.165 86301 $29.165 86304 $29.165 86308 $7.265 86309 $9.075 86310 $10.345 86316 $29.165 86317 $21.015 86318 $18.155 86320 $31.415 86325 $31.345 86327 $31.805 86329 $12.915 86331 $16.805 86332 $34.175 86334 $31.325 86335 $41.145 86337 $24.255 86340 $21.135 86341 $24.255 86343 $17.475 86344 $11.195 86353 $68.725 86355 $52.885 86356 $37.535 86357 $52.885 86359 $52.885 86360 $65.865 86361 $37.535 86367 $52.885 86376 $20.405 86378 $27.605 86382 $23.705 86384 $15.965 86403 $14.285 86406 $12.595 86430 $7.96


5 86431 $7.965 86480 $86.875 86590 $15.475 86592 $5.985 86593 $6.175 86602 $11.465 86603 $11.465 86606 $11.465 86609 $11.465 86611 $11.465 86612 $11.465 86615 $18.485 86617 $21.715 86618 $23.885 86619 $18.765 86622 $11.465 86625 $11.465 86628 $11.465 86631 $11.465 86632 $11.465 86635 $11.465 86638 $11.465 86641 $11.465 86644 $20.185 86645 $11.465 86648 $11.465 86651 $11.465 86652 $11.465 86653 $11.465 86654 $11.465 86658 $11.465 86663 $18.395 86664 $21.455 86665 $25.425 86666 $11.465 86668 $14.575 86671 $11.465 86674 $20.645 86677 $11.465 86682 $11.465 86684 $22.205 86687 $11.76


All Providers



5 86688 $13.995 86689 $27.135 86692 $24.065 86694 $20.185 86695 $18.485 86696 $27.135 86698 $11.465 86701 $12.445 86702 $14.795 86703 $19.225 86704 $16.905 86705 $16.495 86706 $15.055 86707 $16.215 86708 $17.375 86709 $15.785 86710 $19.015 86713 $21.465 86717 $11.465 86720 $11.465 86723 $11.465 86727 $11.465 86729 $11.465 86732 $18.485 86735 $18.305 86738 $18.575 86741 $11.465 86744 $11.465 86747 $21.075 86750 $18.485 86753 $11.465 86756 $11.465 86757 $27.135 86759 $18.485 86762 $20.185 86765 $18.065 86768 $11.465 86771 $18.485 86774 $20.755 86777 $20.185 86778 $17.895 86781 $12.26


5 86784 $11.465 86787 $11.465 86788 $11.465 86789 $20.185 86790 $11.465 86793 $11.465 86800 $22.295 86803 $20.015 86804 $21.715 86805 $73.295 86806 $66.705 86807 $55.465 86808 $41.605 86812 $36.175 86813 $72.765 86816 $39.045 86817 $72.765 86821 $72.765 86822 $51.245 86880 $7.535 86885 $8.025 86886 $7.265 86900 $4.185/I 86901 $4.185 86903 $13.235 86904 $13.325 86905 $5.365 86906 $10.865 86940 $11.495 86941 $16.975 87001 $18.535 87003 $20.345 87015 $9.365 87040 $14.475 87045 $13.225 87046 $13.225 87070 $12.075 87071 $13.225 87073 $13.225 87075 $13.265 87076 $11.335 87077 $11.33


All Providers



5 87081 $9.305 87084 $12.075 87086 $11.325 87088 $11.355 87101 $10.815 87102 $11.775 87103 $12.645 87106 $14.475 87107 $14.475 87109 $14.615 87110 $27.465 87116 $15.155 87118 $15.345 87140 $7.815 87143 $17.565 87147 $7.265 87149 $28.105 87152 $7.335 87158 $7.335 87164 $15.055 87166 $15.835 87168 $5.985 87169 $5.985 87172 $5.985 87176 $8.255 87177 $12.265 87181 $6.655 87184 $9.675 87185 $6.655 87186 $12.125 87187 $14.525 87188 $9.305 87190 $7.925 87197 $21.055 87205 $5.985 87206 $7.535 87207 $8.405 87209 $25.195 87210 $5.985 87220 $5.985 87230 $27.68


5 87250 $27.415 87252 $36.545 87253 $23.815 87254 $27.415 87255 $47.465 87260 $16.825 87265 $16.825 87267 $16.825 87269 $16.825 87270 $16.825 87271 $16.825 87272 $16.825 87273 $16.825 87274 $16.825 87275 $16.825 87276 $16.825 87277 $16.825 87278 $16.825 87279 $16.825 87280 $16.825 87281 $16.825 87283 $16.825 87285 $16.825 87290 $16.825 87299 $16.825 87300 $16.825 87301 $16.825 87305 $16.825 87320 $16.825 87324 $16.825 87327 $16.825 87328 $16.825 87329 $16.825 87332 $16.825 87335 $16.825 87336 $16.825 87337 $16.825 87338 $20.165 87340 $14.485 87341 $14.485 87350 $16.16


All Providers



5 87380 $23.025 87385 $16.825 87390 $24.735 87391 $24.735 87400 $16.825 87420 $16.825 87425 $16.825 87427 $16.825 87430 $16.825 87449 $16.825 87450 $13.435 87451 $13.435 87470 $28.105 87471 $49.205 87472 $39.775 87475 $28.105 87476 $49.205 87477 $39.775 87480 $28.105 87481 $49.205 87482 $39.775 87485 $28.105 87486 $49.205 87487 $39.775 87490 $28.105 87491 $49.205 87492 $39.775 87495 $28.105 87496 $49.205 87497 $39.775 87498 $49.205 87500 $49.205 87510 $28.105 87511 $49.205 87512 $39.775 87515 $28.105 87516 $49.205 87517 $39.775 87520 $28.105 87521 $49.205 87522 $39.77


5 87525 $28.105 87526 $49.205 87527 $39.775 87528 $28.105 87529 $49.205 87530 $39.775 87531 $28.105 87532 $49.205 87533 $39.775 87534 $28.105 87535 $49.205 87536 $119.275 87537 $28.105 87538 $49.205 87539 $39.775 87540 $28.105 87541 $49.205 87542 $39.775 87550 $28.105 87551 $49.205 87552 $39.775 87555 $28.105 87556 $49.205 87557 $39.775 87560 $28.105 87561 $49.205 87562 $39.775 87580 $28.105 87581 $49.205 87582 $39.775 87590 $28.105 87591 $49.205 87592 $39.775 87620 $28.105 87621 $49.205 87622 $39.775 87640 $49.205 87641 $49.205 87650 $28.105 87651 $49.205 87652 $39.77


All Providers



5 87653 $49.205 87660 $28.105 87797 $28.105 87798 $49.205 87799 $60.045 87800 $56.225 87801 $98.395 87802 $16.825 87803 $16.825 87804 $16.825/I 87807 $16.825 87808 $16.825 87809 $16.825 87810 $16.825 87850 $16.825 87880 $16.825 87899 $16.825 87900 $182.705 87901 $256.875 87902 $256.875 87903 $684.895 87904 $36.545 88142 $28.405 88143 $28.405 88147 $15.965 88148 $21.305 88150 $14.805 88152 $14.805 88153 $14.805 88154 $14.805 88155 $8.405 88164 $14.805 88165 $14.805 88166 $14.805 88167 $14.805 88174 $29.945 88175 $37.135 88230 $163.305 88233 $197.265 88235 $206.405 88237 $177.03


5 88239 $206.775 88240 $11.905 88241 $11.905 88245 $208.665 88248 $242.735 88249 $242.735 88261 $247.735 88262 $174.705 88263 $210.645 88264 $174.705 88267 $215.185 88269 $233.135 88271 $30.025 88272 $37.535 88273 $45.035 88274 $48.795 88275 $56.295 88280 $35.175 88283 $96.145 88285 $26.635 88289 $48.275 88371 $31.145 88372 $31.895 88720 $7.045 89050 $6.625 89051 $7.725 89055 $5.985 89060 $10.025 89125 $6.055 89160 $5.165 89190 $6.655 89225 $4.685 89235 $7.725 G0103 $25.785 G0306 $10.905 G0307 $9.075 P2038 $7.055 Q0111 $5.985 Q0112 $5.985 Q0113 $7.585 Q0115 $13.87


All Providers


New AIS Eligibility Inquiry ResponsesEffective August 31, 2009, the Automated Inquiry System (AIS) eligibility inquiry responses provide more detail about a client’s type of Medicaid coverage.AIS responses indicate whether the client has Regular Medicaid, Emergency Only, or No Medicaid coverage. The AIS responses also indicate whether the client has primary Medicare coverage with secondary Medicaid coverage or has limited Medicaid coverage, such as Medically Needy, pregnancy-related, Breast and Cervical Cancer Program (BCCP), or CHIP Perinatal.The following table lists detailed AIS responses:

Type of Coverage AIS response

Temporary Assistance for Needy Families (TANF)Medical Assistance Only (MAO)Supplemental Security Income (SSI)Other types of regular Medicaid coverage

“Regular Medicaid coverage”

Medically Needy, spend downPregnancy relatedPregnancy related, spend down

“Limited Medicaid coverage”

Breast and Cervical Cancer Program (BCCP) “Limited Medicaid coverage: breast and cervical cancer presumptively eligible”

Presumptive eligibility “Limited Medicaid coverage: Presumptive eligibility”Women’s Health Program (WHP) “Limited Medicaid coverage – Women’s Health Program

family planning services only”CHIP Perinatal “Limited Medicaid coverage - CHIP Perinatal”Home Health Aid Project “Limited Medicaid coverage – Home Health Aid project”Emergency Coverage “Emergency Only”Medicaid Qualified Medicare Beneficiary (MQMB) “Medicare coverage primary with Medicaid coverage

secondary”Qualified Medicare Beneficiary (QMB) “Qualified Medicare Beneficiary – coinsurance and/or

deductible only through Medicaid”

Effective for dates of services on or after June 1, 2009, procedure code 1-99292 may be reimbursed in addition to procedure code 1-99291 when billed by the provider who performed procedure code 1-99291 or by a member of the same group as that provider. Reminder: If the provider’s time exceeds the 74-minute time threshold for procedure code 1-99291, procedure code 1-99292 may be billed in addition to procedure code 1-99291 for each additional 30 minutes. Procedure code 1-99292 will be denied if billed without procedure code 1-99291.

Billing for Critical Care Update


All Providers


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.

Allergy Testing Claims reprocessingTMHP identified an issue that affects claims submitted with dates of service from January 1, 2004, through July 31, 2009, and allergy testing procedure code 95075. Procedure code 95705 is reimbursed as a medical service (TOS 1) and not as a laboratory service (TOS 5). Claims may have been denied incorrectly.

Emergency medical Condition Code for Ambulance Claims reprocessingTMHP has identified an issue that affects claims with dates of service on or after July 1, 2008, and emergency medical condition code 30500. These claims may have been denied in error.Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

bottle Feeder for Infant with Cleft palateOn June 26, 2009, the Texas Medicaid reimbursement rate for procedure code 9-S8265 changed. The new reim-bursement rate of $28.54 was adopted following a public rate hearing that was held on May 12, 2009, and is effective for dates of services on or after January 1, 2009.

Contraceptives Claims reprocessingTMHP has identified an issue that impacts claims submitted with procedure codes 1-J7303, J7304, or 1-S4993 and dates of service on or after October 1, 2008. Claims with these procedure codes and dates of service may have been denied in error with an explanation of benefits (EOB) message indicating that services exceeded allowed benefit limitations.

Immune Globulins Claims reprocessingTMHP has identified an issue that impacts claims submitted with procedure code 1-J1568, 1-J1572, or 1-90284, and dates of service on or after January 1, 2008. These claims may have had payments reduced in error or been denied in error with an EOB message that indicated the allowed benefit limitations had been exceeded.

Flu Vaccine reimbursement ratesTMHP has identified an issue that affects claims with dates of service on or after August 1, 2008, and procedure code 1-90656. Claims for clients 21 years of age or older may have been paid incorrectly. The correct reimbursement rates for procedure code 1-90656 for clients 21 years of age or older are:

$14.83 for dates of service from August 1, 2008, through September 30, 2008.

$17.37 for dates of service from October 1, 2008, through March 31, 2009.

$17.15 for dates of service on or after April 1, 2009.

pelvic pneumography Claims reprocessingTMHP has identified an issue that impacts claims submitted with dates of service on or after January 1, 2008, and procedure code 2-49440 for male clients. Claims may have been denied incorrectly. Procedure code 2-49440 applies to male and female clients.

Technical Component procedure CodesThis is a clarification to an article that was posted on the TMHP website at www.tmhp.com on May 15, 2009, titled: “Update to Rate Changes for Some Medical Services, Surgical, Interpretation, and Technical Component.” The article included updated reimbursement rates for procedure codes T-93532 and T-93641. Claims submitted with dates of services on or after April 1, 2009, and procedure codes T-93532 and T-93641 for the technical components may have been reimbursed at an incorrect rate.

Ultraviolet Lenses Diagnosis restrictionsTMHP has identified an issue that impacts claims submitted with dates of service from October 16, 2003, through June 30, 2009, and procedure code E-V2755.Effective for dates of service on or after October 16, 2003, procedure code E-V2755 is restricted to diagnosis codes 37931 and 74335. Some claims may have been reimbursed incorrectly.

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Family Planning Providers

see also:

“Family Planning Title XIX Retroactive

Eligibility Claims Reprocessing” and

“Maternity Service Clinic Evaluation and

Management Claims Reprocessing” in

the Family Planning Section on page 51.


All Providers


New DME Procedure Code Benefit

Effective for dates of service on or after July 1, 2009, procedure code 9-K0739 is a new benefit of both Medicaid and the CSHCN Services Program. The reimbursement rate for procedure code 9-K0739 is $13.21 and is payable for clients of all ages.

Procedure code 9-K0739 may be billed with prior autho-rization for non-warranty repairs of DME and may be reimbursed to home health DME suppliers and medical DME suppliers in the home setting. Procedure code 9-K0739 will be denied if it is billed with the same date of service as procedure code 9-E1340 by any provider.

Changes to Reimbursement Rates for Medical Services and Blood ProductsEffective for dates of services on or after July 1, 2009, Texas Medicaid reimbursement rates changed for medical services and blood products procedure codes. The reimbursement rates were adopted following a public rate hearing that was held on May 12, 2009. The following reimbursement rates are effective July 1, 2009, for medical services and blood products:

TOS procedure Code reimbursement rate

medical Services1 M0064 $32.08

($1.12 RVUs $28.640 conversion factor)

blood products0 P9010 $230.400 P9011 $31.129 P9016 $188.929 P9017 $76.739 P9019 $73.259 P9020 $394.959 P9021 $136.829 P9022 $261.649 P9023 $58.830 P9031 $111.670 P9032 $164.420 P9033 $128.190 P9034 $468.660 P9035 $514.820 P9036 $469.53TOS=Type of Service, RVUs=Relative Value Units

TOS procedure Code reimbursement rate

0 P9037 $653.500 P9038 $250.690 P9039 $341.430 P9040 $251.330 P9040 $251.330 P9041 $19.120 P9041 $19.120 P9043 $15.620 P9043 $15.620 P9044 $85.160 P9045 $70.020 P9046 $24.670 P9047 $69.220 P9048 $196.270 P9050 $1,669.990 P9051 $144.130 P9052 $711.890 P9053 $649.240 P9054 $101.680 P9055 $480.410 P9056 $226.310 P9057 $424.670 P9058 $301.430 P9059 $75.620 P9060 $64.25TOS=Type of Service, RVUs=Relative Value Units


All Providers


Anesthesia and Kidney Transplant Benefit ChangesEffective for dates of service on or after August 1, 2009, some provider type and POS limitations changed for the following Texas Medicaid services: kidney transplants and anesthesia services. Additionally, provider type, POS, and TOS changes will be applied to some other procedure codes. Reminder: Provider type changes will be available in the updated fee schedules, and providers are encouraged to confirm coverage by reviewing the fee schedules before submitting claims.

Anesthesia ServicesThe following procedure codes are no longer reimbursed in the office setting:

procedure Codes

7-00103 7-00104 7-00120 7-001247-00144 7-00147 7-00148 7-001727-00174 7-00176 7-00210 7-002127-00214 7-00215 7-00216 7-002187-00220 7-00222 7-00320 7-003227-00350 7-00352 7-00402 7-004047-00406 7-00452 7-00470 7-004727-00474 7-00500 7-00529 7-005307-00534 7-00540 7-00542 7-005607-00562 7-00604 7-00620 7-006227-00632 7-00670 7-00700 7-007507-00752 7-00754 7-00756 7-007707-00790 7-00792 7-00800 7-008027-00820 7-00830 7-00832 7-008407-00844 7-00860 7-00862 7-008647-00866 7-00870 7-00872 7-008737-00880 7-00904 7-00906 7-009087-00912 7-00914 7-00916 7-009227-00924 7-00926 7-00928 7-009307-00944 7-01120 7-01140 7-011507-01160 7-01170 7-01180 7-011907-01202 7-01210 7-01212 7-012147-01230 7-01232 7-01234 7-012507-01260 7-01270 7-01272 7-012747-01360 7-01392 7-01400 7-014027-01404 7-01430 7-01432 7-014407-01442 7-01444 7-01464 7-014707-01472 7-01474 7-01480 7-014827-01484 7-01486 7-01490 7-01500

procedure Codes

7-01502 7-01520 7-01522 7-016307-01632 7-01634 7-01636 7-016387-01650 7-01652 7-01654 7-016567-01670 7-01710 7-01712 7-017147-01716 7-01732 7-01740 7-017427-01744 7-01756 7-01758 7-017607-01770 7-01772 7-01780 7-017827-01830 7-01832 7-01840 7-018427-01844 7-01850 7-01852 7-019657-01966 7-01999 2-59160

The following procedure codes are no longer reimbursed in the office or outpatient hospital setting:

procedure Code

7-00546 7-00548 7-00580 7-007947-00796 7-00846 7-00848 7-008687-00882 7-00932 7-00934 7-009362-59851

The following benefit changes apply to the procedure codes as indicated:

procedure Codes

Settings No Longer reimbursed

Settings To be reimbursed

7-00561, 7-00625, 7-00626

Outpatient hospital No changes

7-01960 Office, birthing center No changes7-01961, 7-01967, 7-01968

Birthing center No changes

Procedure codes 8-57267 and 8-57291 are also reimbursed as assistant surgery in the inpatient and outpatient hospital settings.

Kidney TransplantsProcedure code 7-00868 is no longer reimbursed in the office or outpatient hospital setting. The following procedure codes are no longer reimbursed in the outpatient hospital setting:

procedure Codes

2/8-50220 2/8-50225 2/8-50230 2/8-502342/8-50236 2/8-50240 2/8-50400


All Providers


Procedure code 2/8-50543 will be reimbursed in the outpatient hospital setting. Providers may refer to the Texas Medicaid fee schedules for the provider types that may be reimbursed.

Additional provider Type/pOS Updates to procedure CodesRespiratory procedure code 31717 is no longer a benefit as a surgery. Providers may refer to the Texas Medicaid fee schedules for the component that may continue to be reimbursed for procedure code 31717.Urinary procedure code 2-50593 and cardiovascular procedure codes 2-35458 and 2-35452 are reimbursed in the outpatient hospital setting. Providers may refer to the Texas Medicaid fee schedules for the provider types that may be reimbursed.Cardiovascular procedure codes 2-34833, 2-34834, and 2-35883 and respiratory procedure code 2-32402 are no longer reimbursed in the outpatient hospital setting.

Medical Direction Criteria Changed for Anesthesia Reimbursement

Effective for dates of service on or after August 1, 2009, the medical direction criteria for anesthesia reimbursement changed for Texas Medicaid. Effective for dates of service on or after August 1, 2009, medical direction will be a covered service only if all of the following criteria are met:

The anesthesiologist performs a pre-anesthetic examination and evaluation.

The anesthesiologist prescribes the anesthesia plan.

The anesthesiologist personally participates in the critical and key portions of the anesthesia plan including, if applicable, induction and emergence.

The anesthesiologist ensures that a qualified professional can perform any procedures in the anesthesia plan that the anesthesiologist does not perform personally.

The anesthesiologist monitors the course of anesthesia administration at frequent intervals.

The anesthesiologist provides direct supervision when medically directing an anesthesia procedure. Direct supervision means the anesthesiologist must be immediately available to furnish assistance and direction.

The anesthesiologist provides indicated post-anesthesia care.

To be eligible for reimbursement for medical direction, the anesthesiologist must document in the client’s medical record that the anesthesiologist:

Performed the pre-anesthetic exam and evaluation.

Provided the indicated post-anesthesia care.

Was present during the critical and key portions of the anesthesia procedure including, if applicable, induction and emergence.

Was present during the anesthesia procedure to monitor the client’s status.

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Implant Services Reimbursement Rates ImplementedEffective for dates of services on or after July 1, 2009, Texas Medicaid implemented initial reimbursement rates for implant services procedure codes. These procedure codes are a new benefit of Texas Medicaid. The initial reimbursement rates were adopted following a public rate hearing that was held on May 12, 2009. Procedure codes 2-11981, 2-11982, and 2-11983 are benefits of Texas Medicaid when services are rendered in an office or outpatient hospital setting.The following reimbursement rates are effective for dates of service on or after July 1, 2009, for implant services:


Surgical Services2 11981 $98.81 ($3.45 RVUs,

$28.640 conversion factor )2 11982 $113.99 ($3.98 RVUs,

$28.640 conversion factor )2 11983 $175.85 ($6.14 RVUs,

$28.640 conversion factor )Ambulatory Surgical Center (ASC) Facility

F 11981 Group 1F 11982 Group 1F 11983 Group 1RVU= Relative Value Units


All Providers


Evaluation and Management Procedure Code Limitation ChangesEffective for dates of service on or after May 1, 2007, the limitation for new patient evaluation and management procedure codes changed from allowing one new patient visit every two years to allowing one new patient visit every three years following the last new or established patient visit reimbursed to the same provider or a provider in the same group. Some claims may have

been reimbursed incorrectly. Affected claims will be reprocessed, and payments will be adjusted accordingly. No further action on the part of the provider is necessary. The claims will be reprocessed as follows: Procedure codes in Column A of the following table will be denied if billed within three years of the procedure codes in Column B:

Column A (Denied) Column bTraditional medicaid

1/2-99201 1/2-99202 1-99201 2-99201* 1-99202 2-99202* 1-99203 2-99203* 1-992041/2-99203 1/2-99204 2-99204* 1-99205 2-99205* 1-99211 2-99211* 1-99212 2-99212*1/2-99205 1-99324 1-99213 2-99213* 1-99214 2-99214* 1-99215 2-99215* 1-992181-99325 1-99326 1-99219 1-99220 1-99221 1-99222 1-99223 1-99231 1-992321-99327 1-99328 1-99233 1-99234 1-99235 1-99236 3-99241 3-99242 3-992431/2-99341 1/2-99342 3-99244 3-99245 1-99304 1-99305 1-99306 1-99307 1-993081/2-99343 1/2-99344 1-99309 1-99310 1-99324 1-99325 1-99326 1-99327 1-993281/2-99345 1-99381 1-99334 1-99335 1-99336 1-99337 1-99341 2-99341* 1-99342

2-99342* 1-99343 2-99343* 1-99344 2-99344* 1-99345 2-99345*1-99347 2-99347* 1-99348 2-99348* 1-99349 2-99349* 1-993502-99350* 1-99381

medicaid managed Care1/2-99201 1/2-99202 1-99201 2-99201* 1-99202 2-99202* 1-99203 2-99203* 1-992041/2-99203 1/2-99204 2-99204* 1-99205 2-99205* 1-99211 2-99211* 1-99212 2-99212*1/2-99205 1-99324 1-99213 2-99213* 1-99214 2-99214* 1-99215 2-99215* 1-992181-99325 1-99326 1-99219 1-99220 1-99221 1-99222 1-99223 1-99231 1-992321-99327 1-99328 1-99233 1-99234 1-99235 1-99236 3-99241 3-99242 3-992431/2-99341 1/2-99342 3-99244 3-99245 1-99304 1-99305 1-99306 1-99307 1-993081/2-99343 1/2-99344 1-99309 1-99310 1-99324 1-99325 1-99326 1-99327 1-993281/2-99345 1-99381 1-99334 1-99335 1-99336 1-99337 1-99341 2-99341* 1-993421-99385 1-99386 2-99342* 1-99343 2-99343* 1-99344 2-99344* 1-99345 2-99345*

1-99347 2-99347* 1-99348 2-99348* 1-99349 2-99349* 1-993502-99350* 1-99381 1-99385 1-99386 1-99395 1-99396

CSHCN Services program1-99201 1-99202 1-99201 1-99202 1-99203 1-99204 1-99205 1-99211 1-992121-99203 1-99204 1-99213 1-99214 1-99215 1-99218 1-99219 1-99220 1-992211-99205 1-99382 1-99222 1-99223 1-99231 1-99232 1-99233 1-99234 1-992351-99383 1-99384 1-99236 3-99241 3-99242 3-99243 3-99244 3-99245 1-993041-99385 1-99386 1-99382 1-99383 1-99384 1-99385 1-99386 1-99387 1-993911-99387 1-99392 1-99393 1-99394 1-99395 1-99396 1-99397

* Billed with modifier TH

Important: This claims reprocessing effort does not effect Texas Health Steps (THSteps) procedures (TOS S).


All Providers


Revised Taxonomy Codes for Hearing Aid ProvidersEffective immediately, otologists and otorhinolaryngolo-gists (ENTs), hearing aid fitters and dispensers, and audiologists who are enrolled with Texas Medicaid or the CSHCN Services Program as hearing aid providers (i.e., the provider’s enrollment letter indicates “Hearing Aid”) must begin using the following taxonomy codes to submit electronic transactions for hearing aid services:

Specialty Taxonomy Code(s)

Hearing Aid: audiologist

237600000X, 237700000X

Hearing Aid: hearing aid fitter and dispenser

237600000X

Hearing Aid: otologist and ENT

237600000X, 237700000X

Note: Providers must continue to use National Provider Identifiers (NPIs) and NPI-related data (i.e., taxonomy code, benefit code if applicable, ZIP Code + 4, and physical address) on their claims and authorization trans-actions where applicable.To prevent inaccurate processing of claims and other transactions with TMHP, Hearing aid providers whose NPIs are only attested with taxonomy code 231H00000X, must re-attest their NPIs with the appropriate taxonomy code(s) as listed above The hearing aid taxonomy code(s) can be primary or secondary. Note: Providers whose enrollment letters indicate provider types other than “Hearing Aid” do not need to re-attest their NPIs.

Effective September 1, 2009, taxonomy code 231H00000X is no longer valid for audiologists enrolled as hearing aid fitters and dispensers (i.e., the provider’s enrollment letter indicates “Hearing Aid”).Claims for hearing services must be filed using the NPI and the appropriate attested taxonomy code as attested. Providers are encouraged to verify that they have attested all appropriate taxonomy codes.Providers may attest taxonomy codes on the TMHP website at www.tmhp.com by choosing Attest an NPI. Claims may be rejected or denied if an invalid or an unattested taxonomy code is used.Additional information about claims filing requirements may be found in the 2009 Texas Medicaid Provider Procedures Manual, Section 5, “Claims Filing,” on page 5-1.

Diagnosis Codes Payable for Azacitidine (Vidaza)Effective for dates of service on or after June 1, 2009, procedure code J9025 is restricted to clients who are 13 years of age or older and may be considered for reim-bursement when it is billed with any of the following diagnosis codes.

Diagnosis Code

20502 20510 20512 2052220532 20582 20592 2387223873 23874 23875 2850


All Providers


Enrollment for Providers of Hearing ServicesAs part of the Program for Amplification of the Children of Texas (PACT) hearing services transition effective for dates of service on or after September 1, 2009, TMHP is encouraging providers to ensure that they are enrolled appropriately. Audiologists must be enrolled with Texas Medicaid and the CSHCN Services Program as audiologists; hearing aid providers must be enrolled as hearing aid providers; and ENTs must be enrolled as physicians. Providers may use the following information as a guide to determine the correct way to enroll.

Enrollment OptionsOption 1: To enroll with Texas medicaid and the CSHCN Services program as a new provider typeTo be reimbursed for audiology services provided to Texas Medicaid or CSHCN Services Program clients on or after September 1, 2009, audiologists who are currently enrolled as hearing aid fitters and dispensers must complete the online Texas Medicaid provider enrollment application. Audiologists who enroll with Texas Medicaid are encouraged to enroll with the CSHCN Services Program as well. To apply for enrollment in Texas Medicaid and the CSHCN Service Program, follow these steps:

Access through the TMHP website at www.tmhp.com. Note: Providers who have already activated their account online may skip down to step 7. Providers who have not activated their account online may continue with Step 2.

Providers who have not activated their account online may establish an account by choosing Activate my Account, which is located on the right side of the page. Click on New Texas Medicaid Provider.

In the Provider Type field, choose Provider Enrollment from the drop-down menu.

Enter your provider account information.

Read the General Terms and Conditions and click in the I agree to these terms box if you agree to the terms. Click on the Create Provider Administrator button. The User Name and Password will be sent to the email address that was specified in the request.

Return to the home page.

1)

2)

3)

4)

5)

6)

Choose Access Provider Enrollment from the list on the right side of the page.

Enter the User Name and Password that you established for your account.

Choose Enrollment and follow the prompts to complete the enrollment application. You will be prompted to print, sign, and mail some pages to TMHP.

To simultaneously enroll as an audiologist in the CSHCN Services Program:

Upon completion of the online Texas Medicaid application, complete the Provider Agreement located on pages 7 through 11 of the paper CSHCN Provider Enrollment Application available for downloading and printing on the TMHP website. Mail the completed pages to TMHP at the following address:

Texas Medicaid & Healthcare Partnership Provider Enrollment

PO Box 200795 Austin, TX 78720-0795

Note: Providers who wish to provide hearing services to CSHCN Services Program clients must first enroll with Texas Medicaid before enrolling with the CSHCN Services Program.

Option 2: CSHCN Services program enrollment for audiologists who have been enrolled in Texas medicaid for less than 12 monthsProviders may refer to their enrollment letter for the effective date of their Texas Medicaid enrollment. If the effective date is within the last 12 months, providers must complete the following pages of the CSHCN Services Program Provider Enrollment Application available for downloading and printing on the TMHP website:

CSHCN Services Program Enrollment Information form. This form is an addendum to page 3 of the application. Use this form to designate the appropriate provider type.

Pages 3 through 6 of the application. Do not designate a provider type by checking any of the boxes on this page. Use the CSHCN Services Program Enrollment Information form to designate the appropriate provider type.

Page 7 through 11 of the application.

7)

8)

9)

10)

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All Providers


The completed information must be mailed to TMHP at the following address:

Texas Medicaid & Healthcare Partnership Attn: Provider Enrollment

PO Box 200795 Austin, TX 78720-0795

Important: To enroll as both an audiologist and as a hearing aid provider, providers must make a copy of the information listed above and complete a copy for each provider type.

Option 3: CSHCN Services program enrollment for audiologists who have been enrolled in Texas medicaid for more than 12 monthsProviders may refer to their enrollment letter for the effective date of their Texas Medicaid enrollment. If the effective date of enrollment is more than 12 months ago:

Complete the CSHCN Services Program Provider Enrollment Application along with the following forms (as applicable) available for downloading and printing on this website:

A copy of the CSHCN Services Program Enrollment Information form. This form is an addendum to page 3 of the application. Use this form to designate the appropriate provider type. Note: Do not designate a provider type by checking any of the boxes on this page. Use the CSHCN Services Program Enrollment Information form to designate the appropriate provider type.

A copy of the Provider Information Form (PIF-1) for each provider being enrolled into the CSHCN Services Program. If you are a newly enrolling group adding a performing provider, two copies of this form (one for the group, one for the provider) should be submitted.

A copy of the Principal Information Form (PIF-2) for each principal of all providers, including any individuals with an ownership interest in the entity.

A copy of the Disclosure of Ownership and Control Interest Statement.

A copy of the W-9 request for Taxpayer Identification Number and Certification listing the tax information for the entity.

A copy of the forms applicable for providers who are incorporated. Note: The CSHCN Services Program enrollment application and additional forms may be downloaded and printed from this website.

1)

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2) Mail the completed application to:

Texas Medicaid & Healthcare Partnership Attn: Provider Enrollment

PO Box 200795 Austin, TX 78720-0795

Important: To enroll as both an audiologist and as a hearing aid provider, providers must make a copy of the CSHCN Services Program Provider Enrollment Application and complete an application and all applicable forms for each provider type.

Finalizing EnrollmentWhen the application for enrollment is approved, TMHP sends newly enrolled providers a letter by mail welcoming them to Texas Medicaid or the CSHCN Services Program. Each provider also receives an approval letter by mail for each program that includes the Texas Medicaid or CSHCN Services Program provider identifier and provider type. After receiving the approval letter, a provider will be able to file claims to TMHP for children’s hearing services that are rendered on or after September 1, 2009. As a reminder, PACT services with dates of service before September 1, 2009, must be sent to DSHS for processing.

provider Communications and UpdatesThe TMHP website has a web page to hold all commu-nications about the PACT transition to the Texas Health and Human Services Commission (HHSC) for Texas Medicaid benefits and the DSHS-CSHCN Services Program for CSHCN Services Program benefits. The link to the Hearing Services for Children (PACT Transition) web page can be found by clicking the Providers tab at the top of the home page. TMHP is working with HHSC and the DSHS-CSHCN Services Program to update the hearing services benefits.


All Providers


How Texas Medicaid and the CSHCN Services Program are Different from PACTInformation about the Program for Amplification for Children of Texas (PACT) transition is available on the TMHP website at www.tmhp.com. The following frequently asked questions (FAQs) are available on the website and will be updated periodically. Providers are encouraged to refer to the website regularly for the latest information. Important: All services that are available through PACT may be reimbursed through Texas Medicaid and the CSHCN Services Program to appropriately-enrolled providers. The administration process may differ between programs. Providers are encouraged to review the FAQs frequently for updates and instructions.

DSHS-pACT Texas medicaid CSHCN Services programprovider Enrollment and Client Eligibility

Enrolls audiologists and otologists as PACT providers

Enrolls audiologists, hearing aid fitters and dispensers, and otologists and otorhinolaryn-gologists (ENTs) as separate provider typesNote: Otologists and ENTs are enrolled as physicians

Enrolls audiologists, hearing aid fitters and dispensers, and otologists and ENTs as separate provider typesNote: Otologists and ENTs are enrolled as physicians

Clients birth through 20 years of age with potential or con-firmed permanent hearing loss

Texas Medicaid clients of any age with dem-onstrated medical necessity according to Texas Medicaid policy

CSHCN Services Program clients of any age with demonstrated medical necessity according to CSHCN Services Program policy

ServicesHearing aid devices and accessoriesTesting, fitting, and dispensing services

Audiologists: Audiology and audiometry evaluation and diagnostic servicesHearing aid providers: Hearing aid devices and accessories, fitting and dispensing visits, and revisitsOtologists/ENTs: Physician otology and otorhinolaryngology services

FormsApplication (M-70)Risk Factor Checklist

Physician’s Examination Report (completed by the physician before referring the client to the audiologist for further testing and maintained in the client’s medical record)

Medical necessity documentation included by the physician in the client’s medical record before referring the client to the audiologist for further testing

Request for Hearing Aids (M-77)Otologic Examination (M-76) Request for Repair (M-80)

Submit the appropriate claim form to TMHP for reimbursement after the services are rendered. Prior authorization is required only for those services provided outside of benefit limitations. Pro-viders will be informed of specific benefit limitations and prior authorization procedures in future notifications.Important: TMHP does not provide the hearing aids and accessories. Providers must purchase hearing aids and accessories directly from the manufacturers and submit claims to TMHP for reimbursement.

Receipt for Hearing Aid (M-79)

Hearing Evaluation, Fitting, and Dispensing Report (Form 3503)A client-signed statement acknowledging receipt and a 30-day trial period certification statement (both created by the provider)Note: These forms are maintained in the client’s medical record and not submitted to TMHP.

Medical necessity documentation included by the audiologist and the fitter/dispenser in the client’s medical record A client-signed statement acknowledging receipt and a 30-day trial period certification statement (both created by the provider)Note: These forms are maintained in the client’s medical record and not submitted to TMHP.

State of Texas Pur-chase Voucher (M-72)

Submit the appropriate claim form to TMHP using the most applicable procedure code(s) for services rendered.

Submit the appropriate claim form to TMHP using the most applicable procedure code(s) for services rendered.


All Providers


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

Correction and Clarification to CDTF ServicesThis is a correction and clarification to information that was published in the January 2009 Inpatient and Outpatient Behavioral Health Services Special Bulletin, No. 1, about chemical dependency treatment facility (CDTF) services. The list of diagnosis codes on page 14 of the special bulletin did not include all of the payable diagnosis codes for CDTF services.Effective for dates of service on or after January 1, 2009, CDTF services are limited to the following diagnosis codes:

Diagnosis Codes

29181 2919 2920 29289 292930300 30390 30400 30410 3042030430 30440 30450 30460 3048030500 30520 30530 30550 3056030570 30590

WHP Providers and Performance of Elective AbortionSection 32.0248(h), Human Resources Code, prohibits HHSC from paying WHP funds to a provider that performs elective abortions. To enable HHSC to comply with this requirement, a WHP Provider Certification form will be mailed on June 22, 2009, to all billing providers who have delivered WHP services during calendar years 2008 and 2009. The certification form asks billing providers to disclose whether they have performed elective abortions during calendar years 2008 and 2009.Billing providers must return this form to the TMHP Provider Enrollment department by July 22, 2009.TMHP will place a payment hold on all Medicaid fee-for-service claims filed by or on behalf of any billing provider who fails to respond by this date.

Claims that were submitted with the diagnosis codes listed in the diagnosis code table may have been denied incorrectly. Affected claims will be reprocessed, and payments will be adjusted accordingly. No further action on the part of the provider is necessary.CDTF services must be determined by a qualified credentialed counselor (QCC) (as defined by DSHS licensure standards) to be reasonable and necessary for a person who has a diagnosis of substance abuse or dependence. Substance abuse or dependence is based on the diagnostic criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). CDTF services must be billed with the appropriate International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code. Providers must consider the appropriate DSM diagnosis for the client’s condition and determine the comparable covered ICD-9-CM diagnosis code.CDTF services for caffeine or nicotine withdrawal are not a benefit of Texas Medicaid.

TMHP will remove the payment hold when it receives from the billing provider a WHP Provider Certification form stating the billing provider has not performed elective abortions.If a billing provider within a group discloses he or she has performed an elective abortion for any patient, the billing provider is ineligible to receive funds under the Medicaid WHP, and TMHP will place a payment hold on any Medicaid claims filed by or on behalf of that provider. In addition, HHSC may recoup WHP funds it determines were paid to a provider that has performed elective abortions during calendar years 2008 or 2009. A billing provider who is placed on a payment hold should continue to file Medicaid claims to ensure all claim-filing deadlines are met.HHSC appreciates billing providers’ cooperation with this certification requirement.


All Providers


Online Fee Lookup Functionality UpdateThis is an update to an article that was published on the TMHP website on May 8, 2009, titled “Online Fee Lookup Will Be Available to Texas Medicaid and CSHCN Services Program Providers”.

Fee Schedule EnhancementsTMHP implemented the online fee lookup (OFL) func-tionality on the TMHP website at www.tmhp.com for Texas Medicaid and the CSHCN Services Program on the weekend of June 26, 2009. Providers can access the OFL function to do the following:

Retrieve real-time fee information.

Search for procedure code reimbursement rates indi-vidually, in a list, or in a range.

Search and review contracted rates.

Retrieve up to 24-months of history for a procedure code by searching for specific dates of service within that 2-year period.

Search for benefits and limitations for dental and DME procedure codes.

The OFL web page includes a link for frequently asked questions (FAQs) about OFL functionality. Also, beginning in July 2009, computer-based training for using the online fee lookup functionality will be available to providers.

First Quarter procedure Code review CorrectionThis is a correction to an article that was posted on the TMHP website at www.tmhp.com on March 20, 2009, titled “Correction to First Quarter Procedure Code Review.” The article incorrectly indicates that effective for dates of service on or after April 1, 2009, procedure code 10022 is no longer reimbursed for the technical or professional components. The correct information is that effective for dates of service on or after April 1, 2009, procedure code I/T-10022 is a benefit and is reimbursed as follows: I-10022 is reimbursed at $75.65, and T-10022 is reimbursed at $27.74.

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Corrections to the 2009 Texas Medicaid Provider Procedures ManualLicensing InformationThis is a correction to the 2009 Texas Medicaid Provider Procedures Manual, section 1.1.4.11, “Copy of License/Temporary License/Certification,” on page 1-7. This section lists licensing boards from which TMHP directly receives information. The Texas State Board of Examiners of Psychologists, the Texas Board of Chiropractic Examiners, and the Texas State Board of Podiatric Medical Examiners should not have been included.The complete, corrected information follows.

1.1.4.11 Copy of License/Temporary License/CertificationProviders who must be licensed or certified in Texas must submit a copy of their current license or certifica-tion, except in the case of doctors, nurses, and dentists. TMHP directly obtains licensure information from the following licensing boards:

Texas Medical Board

Texas State Board of Dental Examiners

Texas Board of Nursing

Once enrolled in Texas Medicaid, a reminder letter will be automatically generated and sent to providers 60 days before the provider’s license expires. When the license is renewed, providers licensed by the boards listed above will not need to contact TMHP with renewal information. Licensed providers (other than doctors, nurses, and dentists) will be sent a reminder letter to submit a copy of their license renewal 60 days before their current license expires. Providers are also required to submit to TMHP, within 10 days of occurrence, notice that the provider’s license or certification has been partially or completely suspended, revoked, or retired. Not abiding by this license and certi-fication update requirement may impact a provider’s qualification to continued participation in Texas Medicaid.

Texas medicaid (Title XIX) Home Health Services Section 24This is a correction to the 2009 Texas Medicaid Provider Procedures Manual, section 24.4.29.21, “Procedure Codes and Limitations for Respiratory Equipment and Supplies” on page 24-64. The limitation that is shown for procedure code A7015 is incorrect. The correct limitation for procedure code A7015 is 1 per month.

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All Providers


AmbulAnce Providers

Modifier Usage on Emergency Ambulance ClaimsProviders must submit ambulance claims for emergency services using modifier ET with each procedure code. For facility-to-facility emergency transports, providers must use modifier ET and one of the facility-to-facility transfer modifiers HI, IH, or HH with each procedure code listed on the claim.Procedure codes without the appropriate modifiers will be denied.To assist the Health and Human Services Commission (HHSC) rate-setting staff determine the cost and fiscal

impact of assigning advanced life support services as a benefit, ambulance providers were instructed to use modifier TG when submitting a claim for emergency ambulance services that included advance life support services. HHSC has completed the review, so providers no longer need to include modifier TG when advance life support services have been provided.

Family Planning Providers

see also:

“Contraceptive Claims Reprocessing”

in the Texas Medicaid Claims

Reprocessing article on page 40.

Maternity Service Clinic Evaluation and ManagementTMHP has identified an issue that affects claims submitted by maternity service clinics (MSCs) with dates of service from January 1, 2009, through April 20, 2009, and the following procedure codes:

procedure Codes

1-99201 1-99202 1-99203 1-992041-99205 1-99211 1-99212 1-992131-99214 1-99215Reminder: MSCs must use the TH modifier when submit-ting claims for these procedure codes.

These claims may have been paid at an incorrect rate. Affected claims will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.For additional information providers can refer to the Texas Medicaid Provider Procedures Manual, section 31.3, “Benefits and Limitations,” on page 31-2.

FAmily PlAnning Providers

Family Planning Title XIX Retroactive EligibilityTMHP has identified an issue that impacts claims for providers who were reimbursed under the Family Planning Titles V or XX program with dates of service from May 11, 2007, through August 28, 2008. Title V and XX claim payments for clients who received retroactive Title XIX eligibility for that period will be recouped, and the claims will be reimbursed under the Title XIX program. When the claims are reprocessed, the Titles V, X, and XX Remittance and Status (R&S) Report will show that Title V or XX claims were adjusted, a Title V or Title XX accounts receivable was set up in the amount of the original claim, and the adjusted claims were added to the Title XIX R&S Report. This is the same retroactive claims repro-cessing procedure that currently occurs during each weekly claims cycle; however, this reprocessing effort, which covers almost 16 months, may result in significant claims activity on affected R&S Reports.If the total accounts receivable resulting from this repro-cessing effort for either state fiscal year 2007 or 2008 exceeds the provider’s “Funds Gone” balance for that state fiscal year, the provider will be responsible for repaying the difference to the Texas Department of State Health Services (DSHS) Family Planning Program. When the reprocessing effort is completed, providers that owe funds to DSHS will receive a letter from TMHP that includes the amount owed to DSHS and the process for repayment.

Ambulance Providers see also:

“Emergency Medical Condition Code for

Ambulance Claims Reprocessing” in the

Texas Medicaid Claims Reprocessing

article on page 40.


Ambulance Providers/Family Planning Providers


FQHc Providers

Mental Health Services for FQHC ProvidersFederally Qualified Health Centers (FQHCs) must bill using an appropriate modifier when billing for mental health services.FQHCs must bill using one of the following modifiers for mental health services:

Modifier AH - (Clinical Psychologist)

Modifier AM - ( Clinical Psychiatrist)

Modifier AJ - (Licensed Clinical Social Worker [LCSW])

Modifier U1 - (Licensed Professional Counselor [LPC])

Modifier U2 - (Licensed Marriage and Family Therapist [LMFT])

The following table shows the procedure codes for mental health services that require one of the listed modifiers:

mental Health procedure Codes

1-90801 1-90802 1-90804** 1-90805*1-90806** 1-90807* 1-90808** 1-90809*1-90810 1-90811* 1-90812 1-90813*1-90814 1-90815* 1-90816 1-90817*1-90818 1-90819* 1-90821 1-90822*1-90823 1-90824* 1-90826 1-90827*1-90828 1-90829* 1-90845 1-90847**1-90853** 1-90857 1-90865 5-961011-96118* Procedures cannot be performed by a psychologist.** Procedures may be performed by LCSWs, LMFTs, and LPCs.

LCSWs, LMFTs, and LPCs are expected to abide by their scopes and standards of practice.

Additional Dental Code Payable to FQHC ProvidersThis is an update to the 2009 Texas Medicaid Provider Procedures Manual, section 21.3, “Federally Qualified Health Center (FQHC) Benefits and Limitations” on page 21-3. Procedure code D2971 should be included in the list of Texas Health Steps (THSteps) dental services that may be reimbursed to FQHC providers.

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mAnAged cAre Providers

Adding a PCCM Family Member to a Closed Provider PanelA Primary Care Case Management (PCCM) client who selects the same primary care provider as another family member may be denied because of a closed panel. When this happens, clients are instructed to notify the primary care provider because TMHP can open a panel only at the request of a primary care provider. Providers can open or close their panel in two ways:

By changing the “Accepting New Clients” field in the online provider lookup function on the TMHP website at www.tmhp.com.

By submitting a completed Provider Information Change (PIC) form that indicates they want to open their panels. PIC forms must be mailed to the following address:

PCCM Credentialing MC-B05 PO Box 204270

Austin, TX 78720-0420

TMHP opens the primary care provider’s panel within 24 hours of receipt of the request. While the panel is open, any client may request to be added. The panel remains open until the provider asks for the panel to be closed by using the online provider lookup function or submitting another PIC form. For questions about this process, contact TMHP Provider Enrollment at 1-800-925-9126 option 2.

Evercare Integrated Care Prior Authorization RequirementsBeginning June 1, 2009, TMHP processes prior autho-rization requests for clients who have been reassigned to Medicaid fee-for-service. For clients who have been reassigned to State of Texas Access Reform (STAR) health maintenance organizations (HMOs), prior authorizations are processed by the STAR HMOs and then submitted to TMHP. Before June 1, 2009, providers requested prior authori-zations from Evercare for Integrated Care Management (ICM) clients. Prior authorizations obtained from Evercare that contain dates of service on or after June 1, 2009, remain valid. Providers are not required to obtain new authorizations until existing authorizations expire.

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FQHC Providers/Managed Care Providers


Excluded ProvidersAs required by the Medicare and Medicaid Patient Protection Act of 1987, 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 HHSC’s 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 Start Date

Type provider City State Add Date

Akpaffiong, Nene U. 30310 20-Jan-09 RPH Richmond TX 18-Jun-09Balderas, Amber Marie 203566 09-Jan-09 LVN San Antonio TX 19-May-09Berry, Jennifer Y. L3920 19-Mar-09 MD Houston TX 03-Jun-09Binder, Aaron R. 19-Feb-09 Owner Houston TX 19-May-09Brannon, Vergie M. 622930 19-Mar-09 RN Forney TX 23-Jun-09Campbell, Shelley D. 562026 09-Dec-08 RN Austin TX 19-May-09Castro, Belyn 8210651 20-May-09 CAN Abilene TX 26-May-09Coleman, Brent J. G3241 21-Jan-09 DO S Padre Island TX 03-Jun-09Crandall, Dora B. G5884 06-Feb-09 MD San Antonio TX 03-Jun-09Dubois, Shawn K. 15542 19-Mar-09 LPC Wimberley TX 23-Jun-09Eaves, Donald G. 4659 19-Mar-09 Chiro San Antonio TX 23-Jun-09Essang, Godspower J. 05-Jun-08 owner Stafford TX 22-May-09Etukudo, Akpan S. 20-Aug-07 Richmond TX 18-Jun-09Ewing, Stephen M. 19-Feb-09 Owner Big Spring TX 19-May-09Gower, Saul 19-Feb-09 Houston TX 18-Jun-09Interstate Medical Supply 20-Jan-08 DME Houston TX 18-Jun-09McClure, Clarence H. D9561 27-Jun-08 MD Galveston TX 17-Jun-09Med Tech Medical Supply 18-Oct-07 DME Georgetown TX 22-May-09Okwunwanne, Gloria O. 24-May-09 DME Bryan TX 29-May-09Olorondu, Collins C. 15-Jun-09 Richmond TX 17-Jun-09Pierce, Linda W. 127102 20-Mar-08 LVN Tyler TX 18-Jun-09Puryear, Billy H. D6314 27-Jun-08 DO Fort Worth TX 26-May-09


Excluded Providers


providerLicense Number Start Date

Type provider City State Add Date

Ranelle, John B. E9349 19-May-08 DO Harlingen TX 03-Jun-09Rapor, Arthur A. 24-May-09 DME Houston TX 29-May-09Rehoboth Equipment, Inc. 05-Jun-08 DME Bossier City LA 22-May-09Sanchez, Angela E. 134696 19-Feb-09 Tech Navasota TX 01-May-09Sandoval Jr, Eliseo NA 19-Mar-09 Owner Beaumont TX 24-Jun-09Shepherd, Mary K. 16204 08-May-09 LPC Quitman TX 08-May-09Smith, Suzanna K. 197979 30-Mar-08 LVN Kyle TX 18-Jun-09Sweatt, Karen E. 587650 23-Jul-07 RN Arlington TX 18-Jun-09Thomas, Sharon J. NA 19-Mar-09 Mrktr Bryan TX 23-Jun-09Thurman, Carmelita L. NA 19-Mar-09 DME Bryan TX 23-Jun-09Trebert, Gary R. 19-Feb-09 Owner Frisco TX 19-May-09Uresti, Melissa L. 128411 29-Apr-09 Tech Galveston TX 19-May-09Washington, Paula R. NA 19-Mar-09 PCA Ft Worth TX 23-Jun-09West Universal Healthcare & Rehab Servic

20-Nov-08 DME Houston TX 18-Jun-09

Wheeler, Wesley D. 5335 30-Jan-09 Chiro Houston TX 23-Jun-09Akpaffiong, Nene U. 30310 20-Jan-09 RPH Richmond TX 18-Jun-09


Excluded Providers


Effective Date_01012009/Revised Date_12172008

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

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



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

• ual practitioner provider numbers can only be made by the individual to whom the

• Performing providers cannot change the TIN.

Provider Demographic Information

e specific practice

limitations accordingly. This will allow clients more detailed information about your practice.

Gen r•

cable)nge. Forms will be returned if this information is not indicated on the Provider

e and TIN changes.

•ealthcare Partnership (TMHP)

Fax: 512-514-4214

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

Tax Identification Number (TIN) TIN changes for individnumber is assigned.

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, pleasvisit the OPL at www.tmhp.com. Please review the existing information and add or modify any

e al 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 appliin order to process the chaInformation Change Form.

• The W-9 form is required for all nam

Mail or fax the completed form to:

Texas Medicaid & HProvider Enrollment PO Box 200795 Austin, TX 78720-0795


Forms


Electronic Funds Transfer (EFT) Information

— A STATE MEDICAID CONTRACTOR23


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

The following items are specific to EFT:

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

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

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

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

the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

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

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

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

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

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


Forms


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

— A STATE MEDICAID CONTRACTOR23


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

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

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

Provider Accounting Address Provider Phone Number ( ) Ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one) Checking Savings

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

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

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

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:


Forms


Notes

12357 ‑ B Riata tRace PaRkway, Ste 150auStin, tX 78727

teXaS Medicaid & HealtHcaRe PaRtneRSHiP

a State Medicaid cOntRactOR

ATTENTION: BUSINESS OFFICE

September/OctOber 2009 NO. 225

Texas MedicaidBimonthly update to the Texas Medicaid Provider Procedures Manual

Look inside for these and other important updates:

Page 25 Enhancements to TexMedConnect

Page 25 Inmates of Public Correctional Institutions Ineligible for Coverage of Medicaid Services

Page 39 New AIS Eligibility Inquiry Responses

Page 45 Revised Taxonomy Codes for Hearing Aid Providers

PRSRT STDU.S. POSTAGE

PAIDTMHP

Documents

T exas Medicaid Bulletin - tmhp.com · setting. These procedure codes are for female clients 10 years of age through 55 years of age. Procedure code 5-86336 is limited to one procedure