TEXAS MEDICAID BULLETIN Bimonthly update to the Texas Medicaid Provider Procedures Manual

MAY/JUNE 2007

NO. 204

New Standardized MRAN Template Form The Texas Health and Human Services Commission (HHSC) has approved two standardized Medicare Remittance Advice Notice (MRAN) forms for claims submitted to TMHP for paper crossover claims. Effective May 21, 2007, all paper Medicare crossover claims must be filed to TMHP with the new standardized MRAN form and a completed claim form. In addition, all crossover claims, resubmissions, and appeals must be submitted with the standardized MRAN form regardless of the date of service or versions of MRANs used for prior submissions. The new mandatory standardized MRAN form includes a field for the National Provider Identifier (NPI) in addition to the fields required previously. These new forms will be required for claims submitted on the CMS-1500 claim form (physician Medicare crossovers claim type 30) and UB-04 CMS-1450 claim form (previously the UB-92 inpatient and outpatient Medicare crossovers claim types 31 and 50). Effective May 21, 2007, crossover claims not submitted on the new, standardized MRAN form will be returned to the provider at the address listed on the claim. The new standardized MRAN forms are located on page 50 of this bulletin, and are available on the TMHP website at www.tmhp.com, under the Provider Forms section of the home page. For more information, call the TMHP Contact Center at 1-800-925-9126. Copyright Acknowledgments Use 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 2007 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: “CDT 2007/2008 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. © 2006 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.”

INSIDE All Providers 1 New Standardized MRAN Template Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Physician Evaluation and Management Benefits Are Changing . . . . . . . . . .2 Prior Authorization Reminder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2007 HCPCS Updates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 CSHCN Renal Dialysis Services Transition to TMHP . . . . . . . . . . . . . . . . . . . . . . .6 Foster Care Managed Care Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Ambulance Fax Cover Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 New Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Scheduled System Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Medicaid Benefit Updates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Implementation of Integrated Care Management . . . . . . . . . . . . . . . . . . . . . .10 Substitute Physician Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Texas Medicaid Provider Procedures Manual Updates. . . . . . . . . . . . . . . . . . . 11 Newborn Services Benefit Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Payable Provider Types for Radiology Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Reinstatement of Excluded Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Correction to Published Rate for Procedure Code F-41899 . . . . . . . . . . . . . .13 Prognostic Breast and Gynecological Cancer Studies . . . . . . . . . . . . . . . . . . .14 Free Delivery of Medicaid Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Paper R&S Report Moving to Web . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Human Papillomavirus Vaccine Benefit Changes. . . . . . . . . . . . . . . . . . . . . . . .16 Benefit Changes for Cranial Molding Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Medicaid Identification Form Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Benefit Criteria Changes for Hospital Critical Care Visits . . . . . . . . . . . . . . . . .18 2007 Childhood and Adolescent Immunization Schedule Released. . . . .19 Uniform Billing Claim Form Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Family Planning Providers 26 Checking Women’s Health Program Client Eligibility . . . . . . . . . . . . . . . . . . . .26 Family Planning 2017 Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Primary Care Case Management Providers 28 Verification of PCCM Primary Care Provider on Medicaid ID Required . . 28 CHS Provides Service for Helping Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Primary Care Physician No Longer Autoassigned at Enrollment . . . . . . . . 29 Revised Cost Report Settlement Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 School Health and Related Services Providers 30 Corrections to SHARS Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Texas Health Steps Dental Providers 32 ADA Dental Claim Form Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Therapeutic Dental Procedures Changing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Excluded Providers

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Forms

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Physician Evaluation and Management Benefits Are Changing Evaluation and management services are a benefit of the Texas Medicaid Program. Evaluation and management services are divided into a broad set of categories and subcategories (e.g., outpatient services, inpatient services). Medical documentation for evaluation and management services must consist of the appropriate components (e.g., history, physical exam, medical decision making) as designated in the 1995 and 1997 Physician Evaluation and Management guidelines as published by the Center for Medicare & Medicaid Services and the Current Procedural Terminology (CPT) manual.

extensive) are included in the cost of the procedure and are not reimbursed separately. An office visit provided for a separately identifiable service on the same day as a planned procedure, is considered for reimbursement with medical documentation. The modifier 25 should be appended to the evaluation and management code to indicate that the evaluation was provided for a separately identifiable service. Office Visits Procedure Codes 1-99201 1-99202 1-99203 1-99211 1-99212 1-99213

Office or Other Outpatient Services

Outpatient services are defined as services rendered in an outpatient setting such as a physician’s office, ambulatory facility, and/or other outpatient settings.

1-99205 1-99215

Procedures inclusive to evaluation and management services will be denied as part of another procedure when billed on the same day, by the same provider, as an office visit or outpatient consultation visit. (Procedure codes 3-99241, 3-99242, 3-99243, 3-99244, and 3-99245.)

New and Established Client Services

Effective for dates of service on or after May 1, 2007, new client visits will be allowed every three years for physician evaluation and management services per client, per provider.

Charges for inconvenience or after hours services (procedure codes 1-99050, 1-99056, or 1-99060) by emergency department based physicians or emergency department-based groups are not allowed.

A new client is defined as one who has not received any professional services from a physician, or physician within the same group practice of the same specialty within the past three years. An established client is one who has received professional services from a physician, or physician within the same group practice of the same specialty within the last three years.

Preventive Care Visits

Preventive health visits are available under the Texas Medicaid Program as follows:

• Texas Health Steps (THSteps) preventive health visits (medical checkups) are available for clients birth to 21 years of age

Providers may use procedure codes 1-99201, 1-99202, 1-99203, 1-99204, and 1-99205 when billing for new client services provided in the office, in outpatient, or other ambulatory facility. Providers may use procedure codes 1-99211, 1-99212, 1-99213, 1-99214, and 1-99215 when billing for established client services provided in the office, or in an outpatient or other ambulatory facility.

• Women’s health (breast exams, Pap smears) When a client’s office visit is billed on the same day as a THSteps medical checkup or exception to periodicity visit, the office visit must be billed as an established client visit. If a new client visit is billed on the same day as a THSteps medical checkup or exception to periodicity visit, then the new client visit will be denied.

If an established client visit is billed on the same day as a new client visit in any setting by the same provider for any diagnosis, the established client visit will be denied as part of another procedure on the same day. New or established client care visits are limited to one per day for the same provider regardless of diagnosis.

Emergency Department Services

Emergency department procedure codes 1-99281, 1-99282, 1-99283, 1-99284, and 1-99285 are used to describe evaluation and management services provided in the emergency department to new or established clients.

Office visits provided on the same day as a planned procedure (minor or Texas Medicaid Bulletin, No. 204

1-99204 1-99214

If an emergency department visit is billed on the same day, by the same provider, as an office visit, outpatient 2

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consultation, or nursing facility service (procedure codes 1-99304, 1-99305, 1-99306, 1-99307, 1-99308, 1-99309, and 1-99310), the emergency department visit may be considered for reimbursement and the office, consultation, and/or nursing facility visit is denied.

services for a period of more than 6 hours, but fewer than 24 hours, regardless of the hour of the initial contact, whether or not the client remains under physician care beyond midnight. Observation may take place in any patient care area of the hospital or outpatient setting.

Emergency department visits will be denied when billed on the same day as an observation service (procedure codes 1-99217, 1-99218, 1-99219, and 1-99220) by the same provider.

Observation care discharge day management may be billed to report services provided to a client upon discharge from observation status if the discharge date is other than the initial date of admission. Procedure codes 1-99211, 1-99212, 1-99213, 1-99214, 1-99215, 1-99218, 1-99219, and 1-99220 will be denied if billed on the same day as procedure codes 1-99217, 1-99234, 1-99235, and 1-99236 by the same provider. Evaluation and management services provided in any place of service other than the inpatient hospital, billed on the same day as a physician observation visit, by the same provider, will be denied.

Multiple emergency department visits on the same day, billed by the same provider, must have the times for each visit documented on the claim form, or more than one visit on the same day can be indicated by adding the modifier 76 to the claim form. Medical documentation is required to support this charge. Critical care provided on the same day as an emergency room visit may be billed when the services are rendered during a separate encounter. Medical documentation is required to support this charge.

If a physician observation visit (procedure codes 1-99217, 1-99218, 1-99219, 1-99220, 1-99234, 1-99235, and 1-99236) is billed on the same day as prolonged services (procedure codes 1-99354 and 1-99355) by the same provider, the prolonged services will be denied as part of another procedure on the same day.

Services Outside of Business Hours

Texas Medicaid limits reimbursement for after-hours charges (procedure codes 1-99050, 1-99056, and 1-99060) to office-based providers rendering services after routine office hours and/or on an emergency basis.

If dialysis treatment and physician observation visits are billed the same day, by the same provider, same specialty, other than Nephrology and Internal Medicine specialists, the dialysis treatment will be paid and the physician observation visit will be denied.

An office-based provider may bill an after hours charge in addition to a visit for providing services after his/her routine office hours. This should be billed when a provider, in his/her clinical judgment, deems it medically necessary to interrupt his/her schedule to care for a client with an emergent condition. A provider’s routine office hours are those hours posted at the physician’s office as the usual office hours. Texas Medicaid reimburses office-based physicians an inconvenience charge when any of the following exists:

Prolonged Physician Services

Prolonged services may be provided in the office, outpatient, or inpatient setting and involve direct (face-toface) client contact that is beyond the usual service and exceeds the time threshold of the following evaluation and management codes being billed on that day:

• The physician leaves the office or home to see a client in the emergency room. • The physician leaves the home and returns to the office to see a client after the physician’s routine office hours. • The physician is interrupted from routine office hours to attend to another client’s emergency outside of the office. Charges for inconvenience or after hours services, by emergency department-based physicians or emergency department-based groups are not reimbursed separately. Hospital observation services (procedure codes 1-99217, 1-99218, 1-99219, and 1-99220) is for professional

CPT only copyright 2007 American Medical Association. All rights reserved.

1-99203 1-99213 1-99223 3-99242 3-99252 1-99342 1-99348

1-99204 1-99214 1-99231 3-99243 3-99253 1-99343 1-99349

1-99205 1-99215 1-99232 3-99244 3-99254 1-99344 1-99350

Procedure codes 1-99354 and 1-99356 should be used in conjunction with the evaluation and management code to report the first hour of prolonged service and

Observation Services

May/June 2007

Procedure Codes 1-99201 1-99202 1-99211 1-99212 1-99221 1-99222 1-99233 3-99241 3-99245 3-99251 3-99255 1-99341 1-99345 1-99347

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will be limited to one per day. Procedure codes 1-99355 and 1-99357 should be used to report each additional 30 minutes and will be limited to a quantity of three units or one and one-half hours per day. Prolonged services of fewer than 30 minutes duration should not be reported separately.

If treatment is initiated and the client returns for follow up care, an established client visit should be billed. If the purpose of the referral is to transfer care, a consultation may not be billed. The medical records, maintained by both the referring and consulting providers, must identify their counterpart and reason for consultation.

Prolonged services in the inpatient setting involving direct (face-to-face) client contact that is beyond the usual service are considered for reimbursement on the same day as an initial hospital visit or a subsequent hospital visit.

Inpatient Services

The following hospital visits, observation, and discharge codes are limited to one per day for the same provider:

Initial Hospital Visit Procedure Codes 1-99221 1-99222 1-99223 3-99251 3-99252 3-99253 3-99254 3-99255 Subsequent Hospital Visit Procedure Codes 1-99231 1-99232 1-99233 3-99251 3-99252 3-99253 3-99254 3-99255

Procedure Codes 1-99221 1-99222 1-99232 1-99233 1-99236 1-99238

Concurrent care will not be paid to providers of the same specialty for the same or related diagnoses. Diagnoses will be considered related when there is a three-digit match of the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code.

Prolonged physician services and physician standby services without face to face contact (procedure codes 1-99358, 1-99359, and 1-99360) are not a benefit of the Texas Medicaid Program.

Consultation Services

Denied concurrent care will be considered on an appeal basis when accompanied by documentation of medical necessity. Concurrent care will be considered for reimbursement to providers of different specialties when services are provided for unrelated diagnoses involving different organ systems.

A consultation is an evaluation and management service provided at the request of another provider for the evaluation of a specific condition or illness. 3-99244 3-99254

3-99245 3-99255

If a hospital admission (procedure codes 1-99221, 1-99222, and 1-99223) and physician observation visit are billed on the same day by the same provider, the hospital admission will be paid and the physician observation visit will be denied.

A consultation must consist of the following in order to be billed as such: • There must be a request from the referring provider for the evaluation of a particular condition or illness.

If an initial hospital visit (procedure codes 1-99221, 1-99222, and 1-99223) following admission is billed on the same day by the same provider as an emergency department visit, inpatient consultation (procedure codes 3-99251, 3-99252, 3-99253, 3-99254, and 3-99255), office visit, or outpatient consultation, the initial hospital visit will be paid and the other visits will be denied.

• There must be correspondence from the consulting provider back to the referring provider indicating his medical findings. During a consultation, the consulting provider may initiate diagnostic and therapeutic services if necessary. Texas Medicaid Bulletin, No. 204

1-99231 1-99235

Concurrent care exists when services are provided to a client by more than one physician on the same day during a period of hospitalization in the inpatient hospital setting. Concurrent care is appropriate when the level of care and the documented clinical circumstances require the skills of different specialties to successfully manage the client in accordance with accepted standards of good medical practice.

Procedure code 1-99356 should be used to report the first hour of prolonged service and will be limited to one per day. Procedure code 1-99357 should be used to report each additional 30 minutes and will be limited to a quantity of three units or one and one-half hours per day. Prolonged physician services will not be reimbursed in addition to critical care and/or emergency room visits billed on the same day.

Consultation Procedure Codes 3-99241 3-99242 3-99243 3-99251 3-99252 3-99253

1-99223 1-99234 1-99239

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Nursing Facility Services

If a subsequent hospital visit (procedure codes 1-99231, 1-99232, and 1-99233) following admission is billed on the same day by the same provider as an emergency department visit or an office visit/ outpatient consultation, the subsequent hospital visit will be paid and the other visits will be denied.

Initial nursing facility assessments (procedure codes 1-99304, 1-99305, and 1-99306), subsequent nursing facility care (procedure codes 1-99307, 1-99308, 1-99309, and 1-99310), and annual nursing facility assessments (procedure code 1-99318) are a benefit of the Texas Medicaid Program when billed for services rendered in a nursing facility. Initial nursing facility assessments, include all services related to an admission to the nursing facility.

Only one initial hospital care visit may be paid to the same provider within a 30-day period regardless of diagnosis. Subsequent care visits may be considered for reimbursement during this time period. A subsequent hospital visit may be reimbursed on the same day to the same provider when critical care services (procedure codes 1-99291 and 1-99292) are billed.

All evaluation and management services, irrespective of the place of service, provided in conjunction with the admission by the same provider, are considered part of the initial nursing facility care when performed on the same day as the admission.

Evaluation and management services provided in a hospital setting following a major procedure, provided by the same provider and/ or in direct follow-up for post-surgical care, are included in the surgeon’s global surgical fee and will be denied as included in another procedure.

Comprehensive initial nursing facility assessments (procedure codes 1-99304, 1-99305, and 1-99306) are limited to one every six months.

A physician who did not perform the surgery and provides postoperative surgical care in the time frame that is included in the global surgical fee must bill with modifier 55. This may only be done when the surgeon submits a charge for surgical care only and there was an agreement between the physicians to split the care of the client.

Initial nursing facility assessments, subsequent nursing facility care, or nursing facility discharge day management (procedure codes 1-99315 and 1-99316) billed on the same day as initial hospital care (procedure codes 1-99221, 1-99222, and 1-99223) by the same provider will be denied as part of another procedure. Subsequent nursing facility care evaluation and management procedure codes (procedure codes 1-99307, 1-99308, 1-99309, and 1-99310) are limited to one per day regardless of diagnosis.

Discharge

Discharge day management (procedure codes 1-99238 and 1-99239) billed on the same date of service as the admission by the same provider will be denied. Discharge management billed on the same date of service as an emergency room visit by the same provider will be denied, but may be considered for reimbursement upon appeal, if the services were provided at a separate time.

Domiciliary, Rest Home, or Custodial Care

Domiciliary and rest home care procedure codes, used to report evaluation and management services in a facility which provides room, board, and other personal assistance services, may be considered for reimbursement when billed using the following procedure codes for new and established client visits:

Only one discharge management service will be considered for reimbursement per day. Subsequent hospital visits billed on the same day as discharge management, by the same provider, will be denied.

Procedure Codes 1-99324 1-99325 1-99334 1-99335

Initial and/or subsequent hospital visit codes (procedure codes 1-99221, 1-99222, 1-99223, 1-99231, 1-99232, and 1-99233) billed on the same day as hospital discharge day management is denied as part of another procedure billed on the same day.

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

1-99326 1-99336

1-99327 1-99337

1-99328

Established client visits billed on the same day as a new client visit by the same provider will be denied as part of another procedure. Established client visits are limited to one per day regardless of diagnosis.

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Home Services

2007 HCPCS Updates

New client visits will be limited to once every three years. A subsequent home visit (procedure codes 1-99347, 1-99348, 1-99349, and 1-99350) billed on the same day as a new client home visit (procedure codes 1-99344 and 1-99345) by the same provider will be denied as part of another procedure billed on the same day, regardless of the diagnosis.

The following is a list of new, noncovered, HCPCS procedure codes that do not replace existing codes: Procedure Allowable Procedure Allowable Code Code G0377 NC G8348 NC G8349 NC G8350 NC G8351 NC G8352 NC G8353 NC G8354 NC G8355 NC G8356 NC G8357 NC G8358 NC G8359 NC G8360 NC G8361 NC G8362 NC G8363 NC G8364 NC G8365 NC G8366 NC G8367 NC G8368 NC Q4083 NC Q4084 NC Q4085 NC Q4086 NC

Home services (services that are provided in a private residence) will be considered for reimbursement when billed Noncovered Procedure Codes with the following procedure codes: Effective for dates of service on or after January 1, 2007, Healthcare Common Procedure Coding System Procedure Codes (HCPCS) procedure codes were added as noncovered 1-99341 1-99342 1-99343 1-99344 1-99345 benefits of the Texas Medicaid and Children with 1-99347 1-99348 1-99349 1-99350 Special Health Care Needs (CSHCN) Services Programs.

Subsequent home evaluation and management codes are limited to one per day regardless of diagnosis. For more information, call the TMHP Contact Center at 1-800-925-9126.

Prior Authorization Reminder TMHP has identified an issue impacting claims for tracheostomy tubes procedure codes A7520, A7521, and A7522, with dates of service on or after July 1, 2004. Claims that were submitted for more than one tracheostomy tube per month may have been paid incorrectly. Tracheostomy tubes are limited to one per month.

NC = Not covered

First Quarter 2007 HCPCS Update

Claims submitted for dates of service on or after July 1, 2004, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

TMHP implemented first quarter 2007 HCPCS additions, changes, and deletions effective for dates of service on or after April 1, 2007. Deleted procedure codes are no longer a benefit of the Texas Medicaid, Medicaid Managed Care, and CSHCN Services Programs.

Billable procedure codes for tracheostomy tubes are procedure codes A7520, A7521, and A7522. However, A7520 was inadvertently omitted from the 2007 Texas Medicaid Provider Procedures Manual Section 25.5.23.18, “Tracheostomy Tubes” on page 24-55.

Details of these changes are available on the TMHP 2007 HCPCS webpage at www.tmhp.com/C4/HCPCS/default.aspx. For more information, call the TMHP Contact Center at 1-800-925-9126.

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

CSHCN Renal Dialysis Services Transition to TMHP Effective for dates of service on or after May 4, 2007, claims processing and authorizations for renal dialysis services covered by the CSHCN Services Program are transitioning from Department of State Health Services (DSHS)-CSHCN to TMHP-CSHCN. Providers who are interested in providing renal dialysis services for the CSHCN Services Program may call the TMHP-CSHCN Contact Center at 1-800-568-2413.

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Foster Care Managed Care Program Senate Bill 6, 79th Legislature, Regular Session, 2005, directed HHSC to develop a new health care delivery system for Texas children in foster care. The new model, which begins October 1, 2007, will include children in foster care, young adults voluntarily remaining in foster care, and young adults who were previously in foster care and are still receiving Medicaid services. HHSC has contracted with Superior Health Plan to provide and coordinate health care services statewide to this population. With one health plan managing the entire foster care population, HHSC can ensure accountability for outcomes and track children’s health care as they move from one placement to another. To continue providing Medicaid services to this population, providers must be contracted with Superior Health Plan. Providers should contact Superior Health Plan at 1-866-439-2042 for more information on becoming a network provider. The new health care delivery system is an enhanced managed care model with additional features tailored to address the needs of this unique population, its caregivers, and the Department of Family and Protective Services (DFPS).

• Improved access to health history and medical records via web-based health passport.

Features of the health care delivery system for foster children include:

• A 7-day, 24-hour nurse hotline for caregivers and caseworkers.

• An expedited enrollment process so that children can begin receiving services as soon as they are taken into state conservatorship.

• A medical advisory committee to monitor provider performance. HHSC will automatically enroll eligible individuals for the new health care delivery system beginning August 2007. Clients will receive a packet of information about the program, at which time they will have an opportunity to choose a primary care provider. Children will begin receiving services through the model on October 1, 2007.

• Improved access to services through a defined network of providers. • A medical home through a primary care provider to coordinate care and promote better preventive health. • Service coordination to assist children, caregivers, and caseworkers with accessing the services and information they need.

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

Ambulance Fax Cover Sheet The following is a correction to information published in the 2007 Texas Medicaid Provider Procedures Manual, Section B.3, “Ambulance Fax Cover Sheet,” on page B-6. The telephone number listed for the Ambulance Unit was incorrect. The correct telephone number is 1-800-540-0694. The revised Ambulance Fax Cover Sheet is available on the TMHP website at www.tmhp.com and on page 42 of this bulletin.

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New Benefits Injection-Galsulfase

Medicaid Program. Procedure code 1-J9027 will require prior authorization to be considered for payment. Submit prior authorization requests for clofarabine to the Special Medical Prior Authorization Department at fax number 1-512-514-4213.

Effective April 1, 2007, for dates of service on or after February 1, 2007, galsulfase injections is a benefit of the Texas Medicaid Program with an allowable fee of $1516.12. Procedure code 1-J1458 is limited to diagnosis code 2775. Procedure code 1-J1458 may be reimbursed to physicians, county indigent health care programs, advanced practice nurses when performed in an office setting, and hospitals when performed in the outpatient or inpatient setting.

Clofarabine may be prior authorized for the treatment of relapsed or refractory acute lymphoblastic leukemia (diagnosis code 20400). Prior authorization for treatment with clofarabine is limited to a maximum of six weeks. The number of anticipated injections and the dosage per injection must be provided in the prior authorization request.

Claims received before April 1, 2007, for dates of services on or after February 1, 2007, that include procedure code 1-J1458 will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

The prior authorization request must include documentation of a diagnosis of refractory or relapsed acute lymphoblastic leukemia (diagnosis code 20400) and documentation of at least two previously failed chemotherapy regimens. Prior authorization should be obtained before services are rendered whenever it is possible, but requests will not be accepted more than three business days before the date on which treatment is initiated.

Fluocinolone Acetonide (Retisert®) Intravitreal Implant

Effective April 1, 2007, procedure code 1-J7311 is a benefit of the Texas Medicaid Program for dates of service on or after February 1, 2007. Ambulatory surgical centers (both free-standing and hospital-based) and hospitals may submit procedure code 1-J7311 for the fluocinolone acetonide (Retisert®) intravitreal implant when services are rendered in the inpatient hospital and/or outpatient hospital settings for clients 12 years of age and older.

The prior authorization number and the number of units (based on the dosage given) must be submitted on the claim to be considered for payment. Failure to place the prior authorization number on the claim or to obtain prior authorization within the allotted time frame will result in denied claims.

Procedure code 1-J7311 is only considered for reimbursement with a posterior uveitis diagnosis (36320) of more than six months in duration and only when the condition has been unresponsive to oral or systemic medication treatment. Prior authorization is required.

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

Scheduled System Maintenance

Claims that have been denied for dates of service on or after February 1, 2007, through March 31, 2007, with procedure code 1-J7311 must be appealed with the appropriate authorization to be considered for reimbursement. Retroactive authorizations may be considered.

System maintenance for the TMHP claims processing system is scheduled as follows: • Sunday, May 27, 2007, 3:00 p.m. through Monday, May 28, 2007, 6:00 p.m.

To request retrospective and/or prior authorizations, providers must submit requests to the Special Medical Prior Authorization Department by fax at 1-512-514-4213.

• Sunday, June 10, 2007, 6:00 p.m. to 11:59 p.m. During system maintenance some 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.

Clofarabine Injection

Effective for dates of service on or after April 1, 2007, procedure code 1-J9027 is a benefit of the Texas Texas Medicaid Bulletin, No. 204

8

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Medicaid Benefit Updates Allergy Vials or Extracts

Procedure codes 2-36555, 2-36556, 2-36568, 2-36569, and 2-36625 may be reimbursed when billed by certified registered nurse anesthetists (CRNAs) and CRNA groups.

Effective for dates of service on or after April 1, 2007, benefit changes will be implemented for allergy vials or extracts. The Texas Medicaid Program reimbursement rate for allergy immunotherapy injections (procedure codes 1-95115 and 1-95117) will be increased. Procedure code 1-95115 will be increased from $6.09 to $11.18, and procedure code 1-95117 will be increased from $9.14 to $14.18.

Transesophageal echocardiography (procedure codes 4/I/T-93312, 4-93313, 4/I/T-93314, 4/I/T-93315, 4-93316, and 4/I/T-93317) when performed for diagnostic purposes with documentation of a formal report due to a separate incident not related to the original surgery after the post-operative recovery period may be considered on appeal with the appropriate documentation.

The following procedure codes will not be reimbursed separately when billed with procedure codes 1-95115 or 1-95117 unless there is a significant, separately identifiable service administered:

EOB Error Corrected for HPV Vaccines

TMHP has identified an issue impacting claims submitted for the human papillomavirus (HPV) vaccine (procedure code 1-90649) between February 1, 2007, and February 14, 2007, that were denied with explanation of benefit (EOB) 00207 (Not a benefit). Claims were denied correctly but received the incorrect EOB.

Procedure Codes 1-99201

1-99202

1-99203

1-99204

1-99205

1-99211

1-99212

1-99213

1-99214

1-99215

1-99217

1-99218

1-99219

1-99220

Procedure codes 1-95115, 1-95117, 1-95145, 1-95146, 1-95147, 1-95148, 1-95149, 1-95165, 1-95170, or 1-95180 may be reimbursed when billed with the following diagnosis codes: Diagnosis Codes 37214 38100 38105 38106 4779 49300 49312 49320 49392 7080

38101 38110 49301 49321 78607

38102 38119 49302 49322 7862

38103 4770 49310 49390 9895

38104 4778 49311 49391

Claims submitted for procedure code 1-90649 during this time period that were denied with EOB 00207 will be reprocessed and assigned the correct EOB. No action on the part of the provider is necessary.

Services Incidental to Surgery and Anesthesia

Incorrectly Denied Procedure Code E-V2200

Effective for dates of service on or after April 1, 2007, benefit changes were implemented for services incidental to surgery and/or anesthesia for the Texas Medicaid Program.

TMHP has identified an issue impacting claims submitted with procedure code E-V2200 for Medicaid fee-for-service clients who are 100 years of age or older. Claims submitted with this procedure code for dates of service October 16, 2003, through February 27, 2007, for clients 100 years of age or older were inappropriately denied as not a benefit.

The following procedure codes are no longer considered incidental to surgery or anesthesia, and may be reimbursed separately in the inpatient and outpatient setting: Procedure Codes 2-36555 2-36556 2-36561 2-36563 2-36569 2-36620

2-36557 2-36565 2-36625

2-36558 2-36566 2-93503

On February 28, 2007, claims submitted for dates of service October 16, 2003, through February 27, 2007, that include procedure code E-V2200 were reprocessed, and payments were adjusted accordingly. No action on the part of the provider is necessary.

2-36560 2-36568

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

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

9

Texas Medicaid Bulletin, No. 204

All Providers

Implementation of Integrated Care Management

Substitute Physician Billing TMHP routinely performs retrospective reviews of

Integrated Care Management (ICM), a new managed care program for certain Medicaid recipients who are aged (over 65 years of age) or who have disabilities, is set to begin operations in the Dallas and Tarrant Service Areas on July 1, 2007. Counties included in the ICM service areas are Collin, Dallas, Denton, Ellis, Hood, Hunt, Johnson, Kaufman, Navarro, Parker, Rockwall, Tarrant, and Wise. The goals of ICM include improving patient health and social outcomes, improving access to care, constraining costs, and integrating services. ICM will have several common managed care features, including client assignment to a medical home, utilization management, and care coordination. The ICM program integrates health care and long-term services and supports, such as helping with daily activities, home modifications, respite, and personal assistance. Eligible adult Medicaid recipients, including those who qualify for Medicaid based on supplemental security income (SSI) eligibility or who qualify for 1915(c) waiver (community-based alternative) waiver services, will automatically be enrolled in ICM. Children under 21 years of age who receive SSI can participate on a voluntary basis.

The 2007 Texas Medicaid Provider Procedures Manual, Section 36.3.2 “Substitute Physician,” specifies that physicians may bill for the service of a substitute physician who sees clients in the billing physician’s practice under either an informal arrangement of less than 14 days or a formal renewable arrangement of up to 90 days. The name, address, and NPI in Field 33 of the claim form must be the billing provider’s, not the substituting physician’s. The substitute physician is not required to enroll with Medicaid. The substitute physician’s name and address must be documented on the claim in Field 19. When a physician bills for a substitute physician, the modifier Q5 or Q6 must follow the procedure code in Field 24D for services provided by the substitute physician. The Q5 modifier is used to indicate an informal reciprocal arrangement (period not to exceed 14 continuous days) and the Q6 modifier is used to indicate a formal renewable locum tenens or temporary arrangement (up to 90 days).

Medicare enrollment does not affect eligibility for ICM. For ICM members who are dual-eligible (enrolled in both Medicaid and Medicare), the ICM is only responsible for long-term services and supports. Primary acute care and pharmacy services for this population are covered through Medicare. Enrollment in ICM will not change the way a client receives their Medicare services. HHSC has selected Evercare of Texas, LLC, to be the agency’s implementing partner for ICM. Evercare is affiliated with United Health Group. Medicaid providers in the Tarrant and Dallas service areas who are interested in participating in the ICM program must complete a separate contract and credentialing process through Evercare of Texas, LLC. For information and instructions on contracting with Evercare, providers can call the United Health Care Network Management department at 1-866-574-6088.

When physicians in a group practice bill substitute physician services, the performing provider identifier of the physician for whom the substitute provided services must be in Field 24K. Physicians must familiarize themselves with these requirements and document accordingly. Those services not supported by the required documentation as detailed above will be subject to recoupment.

For services provided to ICM members, TMHP will pay claims according to the Medicaid fee-for-service and Primary Care Case Management (PCCM) processes.

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

For more information call the TMHP Contact Center at 1-800-925-9126. Texas Medicaid Bulletin, No. 204

provider claims, including medical record reviews, to compare services billed to the associated client’s clinical record documentation. Medical record review findings indicate that physicians do not always follow Medicaid guidelines when submitting claims for services provided by a substitute physician.

10

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Texas Medicaid Provider Procedures Manual Updates The following are updates and corrections to the 2007 Texas Medicaid Provider Procedures Manual.

• Post-lingual deafness or pre-lingual deafness • Clients 12 months of age or older

®

Herceptin (Trastuzumab)

• Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system

On November 16, 2006, the Food and Drug Administration (FDA) approved a new indication for Herceptin® (Trastuzumab). Effective November 16, 2006, Herceptin® is payable as part of a treatment regimen containing doxorubicin, cyclophosphamide, and paclitaxel for the adjuvant treatment of patients with HER2-overexpressing node-positive breast cancer. This is an update to Section 36.4.21.54 “Trastuzumab.” Current diagnosis restrictions still apply.

• No contraindications to surgery The payment for cochlear implant is limited to the following diagnosis codes: Diagnosis Codes 38910 38911 38915 38916

Physician Nursing Facility Visits

Section 36.3.5.2 “Physician Nursing Facility Visits,” located on page 36-19, incorrectly indicates that procedure codes 1-99339 and 1-99340 are a benefit of the Texas Medicaid Program. Procedure codes 1-99339 and 1-99340 are not a benefit of the Texas Medicaid Program.

38912 38918

38914 3892

Prior authorization is not required for these diagnosis codes.

Telemedicine Services

The following is a correction to information provided in Section 36.4.8 “Cochlear Implants.” The clients age restriction should be 12 months of age and older. The corrected information follows:

Section 36.3.5.3, “Telemedicine Services” on page 36-19 was incorrectly included as part of Section 36.3.5 “Physician Services in a Long Term Care (LTC) Nursing Facility.” Telemedicine is a separate category of physician services and should have been identified as a separate benefit and limitation within the “Physician” section of the 2007 Texas Medicaid Provider Procedures Manual.

A cochlear implant, when medically indicated, is a payable benefit of the Texas Medicaid Program. Reimbursement is provided only for those clients who meet all of the following criteria:

Telemedicine services are not a covered physician service within an LTC nursing facility. Also, Sections 36.3.5.4, “Hub Site Provider,” and 36.3.5.5, “Remote Site Provider,” should have been subordinate to Telemedicine Services.

Cochlear Implants

• Diagnosis of total bilateral sensorineural deafness that cannot be mitigated by use of a hearing aid in clients whose auditory cranial nerve is able to be stimulated

Additional Corrections

The following are additional corrections to information provided in the 2007 Texas Medicaid Provider Procedures Manual:

• Cognitive ability to use auditory cues and a willingness to undergo an extended program of rehabilitation

• Section 8.3.2.4, “Prior Authorization Types, Definitions Short Term” incorrectly states that the Texas Medicaid Program no longer approves authorizations for a year. At this time, prior authorization will be considered for up to one year.

For information about THSteps Preventive Care Visits,

• Section 24.5.9.3, “Incontinence Procedure Codes with Limitations,” the limitation for procedure code A5120 should be 30 per month.

see “Physician Evaluation and Management Benefits

• Section 24.5.10.4, “Sealed Suction Wound Care System,” procedure code 9-A655 should be 9-A6550.

Are Changing” on page 2

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

of this bulletin. May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

11

Texas Medicaid Bulletin, No. 204

All Providers

Newborn Services Benefit Changes Effective for dates of service on or after April 1, 2007, newborn services have changed for the Texas Medicaid Program. The CPT 2007 manual defines a neonate as 0 through 28 days of age, and a pediatric client as 29 days through 24 months of age. Based on the new neonate definition, a provider may bill for no more than 28 days of neonatal intensive care visits. After the 28th day, providers must bill using the pediatric critical care procedure codes.

Procedure Codes 4/I/T-71015 4/I/T-71020 1-90765 1-90766 5/I/T-93561 5/I/T-93562 5/I/T-94375 1-94640 1-94645 1-94660 5-94761 5-94762

Procedure Codes 2-31720 2-31730 2-36450 2-36455 2-61000 2-61001

2-32020 2-49081

The following are reimbursement criteria for newborn care procedure codes 1-99431, 1-99432, 1-99433, and 1-99435:

Procedure code 1-99295 may be considered for reimbursement once per lifetime per critically ill neonate client. Procedure code 1-99296 will be denied when billed on the same day, by any provider as procedure code 1-99295.

• Procedure codes 1-99431, 1-99432, and 99435 may be reimbursed once per lifetime, any provider. • Procedure code 1-99433 is a per-diem code and may be reimbursed for normal newborn subsequent care. Procedure code 1-99433 is a benefit once per day in the hospital setting.

Subsequent hospital visits (procedure codes 1-99231, 1-99232, and 1-99233) and neonatal critical care codes (procedure codes 1-99296, 1-99298, 1-99299, and 1-99300) are limited to one per day, by any provider.

• Procedure code 1-99433 will be denied if billed on the same day as procedure code 1-99431.

The following procedures billed on the same day, by the same provider, as procedure codes 1-99295, 1-99296, 1-99298, 1-99299, and 1-99300 will be denied as part of another procedure:

Texas Medicaid Bulletin, No. 204

2-32000 2-49080 1-99440

Prolonged service procedure codes 1-99356 and 1-99357 will be denied when billed on the same day as neonatal critical care services (procedure codes 1-99295 and 1-99296) or low birth weight (LBW) or very low birth weight (VLBW) infants (1-99298, 1-99299, and 1-99300).

Procedure code 1-99295 should be billed for the initial day of neonatal critical care, and procedure code 1-99296 should be billed for subsequent neonatal critical care, regardless of the time that the physician spends with the critically ill neonate who is 28 days of age or younger.

2-36000 2-36410 2-36440 2-36600 2-36660 2-51010 2-62272

1-90761 1-92953 1-94003 1-94644 5-94760

The following procedure codes may be reimbursed separately on the same day, by the same provider as procedure codes 1-99295 and 1-99296:

Procedure codes 1-99295 and 1-99296 may be used only during the period of time the neonate client is considered to be critically ill. After the neonate client is no longer considered critically ill, the evaluation and management (E/M) codes for subsequent hospital care (procedure codes 1-99231, 1-99232, and 1-99233) may be used.

Procedure Codes 2-31500 2-31502 2-36405 2-36406 2-36420 2-36430 2-36540 2-36555 2-36625 2-36640 2-51000 2-51005 2-51702 2-62270

1-90760 1-91105 1-94002 1-94642 1-94662 1-99090

• Procedure code 1-99435 may be reimbursed when newborns are admitted and discharged on the same day from the hospital or birthing center. If a client is readmitted within the first 30 days of life, the provider should bill an initial admission code.

2-36400 2-36415 2-36510 2-36620 2-43752 2-51701 4/I/T-71010

Hospital discharge (procedure codes 1-99238 and 1-99239) will be denied when billed on the same day, by the same provider as the following procedure codes: Procedure Codes 1-99295 1-99296 1-99431 1-99432 12

1-99298 1-99433

1-99299 1-99435

1-99300

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

If procedure code 1-99436 is billed on the same day as any of the following outpatient evaluation and management codes, the outpatient evaluation and management code will be denied: Procedure Codes 1-99201 1-99202 1-99211 1-99212

1-99203 1-99213

1-99204 1-99214

1-99205 1-99215

Payment may be considered on appeal with supporting documentation.

Current Reimbursement $350.00 $225.00 $97.65

New Reimbursement $682.17 $296.22 $100.00

A list of recently excluded providers/individuals is available in each Texas Medicaid Bulletin. Refer to Excluded Providers on page 33 of this bulletin. For a complete list of excluded individuals and entities, visit the OIG website at www.hhsc.state.tx.us/OIE/ Exclusionlist/ado/exclusion.asp.

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

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

Payable Provider Types for Radiology Codes

Correction to Published Rate for Procedure Code F-41899

Effective February 5, 2007, for dates of service on or after January 1, 2007, physician assistants, advance practice nurses, and physicians are considered for payment of the professional component of the following procedure codes: Procedure Codes I-76776 I-77001 I-77011 I-77012 I-77031 I-77032 I-77053 I-77054 I-77057 I-77058 I-77073 I-77074 I-77077 I-77079 I-77082 I-77083

I-77002 I-77014 I-77051 I-77055 I-77059 I-77075 I-77080 I-77084

Providers and individuals who have been excluded from the Texas Medicaid Program may be reinstated only by the HHSC, Office of Inspector General (OIG). Appeal and reinstatement procedures are included in the written notification providers/individuals receive upon exclusion or suspension from the Texas Medicaid Program. If the OIG approves an individual’s request for reinstatement, a written notice will be sent to that individual. The written notification will specify the date on which participation in the Medicaid program will be effective.

The following table contains new reimbursement for procedure codes 1-99295, 1-99296, and 1-99299: Procedure Code 1-99295 1-99296 1-99299

Reinstatement of Excluded Providers

I-77003 I-77021 I-77052 I-77056 I-77072 I-77076 I-77081

Claims submitted for dates of service on or after January 1, 2007, will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Contact Center at 1-800-568-2413.

The following is a correction to a banner message that first appeared on the December 1, 2006, Remittance and Status (R&S) report, the 2007 February CSHCN Provider Bulletin, No. 62, and the March/April 2007 Texas Medicaid Bulletin, No. 203, regarding the published fee schedule for procedure code F-41899. The articles incorrectly state that the fee for procedure code F-41899 with EP modifier is a group 4 rate. The correct rate for procedure code F-41899 with modifier EP is a flat rate of $630, effective December 1, 2006. The fee schedule posted on the TMHP website has been corrected. Claims submitted for procedure code F-41899 with modifier EP were processed correctly. No action on the part of the provider is necessary. For more information, call the TMHP Contact Center at 1-800-925-9126.

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

13

Texas Medicaid Bulletin, No. 204

All Providers

Prognostic Breast and Gynecological Cancer Studies Effective for dates of service on or after April 1, 2007, benefits for breast cancer studies (BRCA) and for prognostic breast and gynecological cancer studies have changed for the Texas Medicaid Program.

5-83905, and 5-83906) are not a benefit for the following breast cancer diagnosis codes: Diagnosis Codes 1740 1741 1745 1746 1759 1982

BRCA1 and BRCA2 Testing

Effective for dates of service on or after April 1, 2007, benefits for BRCA studies have changed. Procedure codes G-S3820, G-S3822, and G-S3823, are no longer a benefit of the Texas Medicaid Program and will be replaced with procedure codes 5-S3820, 5-S3822, and 5-S3823. Procedure codes 5-S3820, 5-S3822, and 5-S3823 require prior authorization for the consideration of payment.

5-83891 5-83897 5-83903 5-83908

5-83892 5-83898 5-83904 5-83909

1743 1749 2330

1744 1750

Authorization Requirements

Prior authorization is required for gene mutation analysis (procedure codes 5-S3820, 5-S3822, and 5-S3823). There must be documentation of one or more of the following:

The following procedure codes, which describe the three basic steps of testing for a BRCA mutation, will not be reimbursed on the same date of service as gene mutation analyses (procedure codes 5-S3820, 5-S3822, and 5-S3823). Procedure Codes 5-83080 5-83890 5-83894 5-83896 5-83901 5-83902 5-83906 5-83907

1742 1748 19881

5-83893 5-83900 5-83905 5-83912

Procedure codes 5-S3820, 5-S3822, and 5-S3823 are limited to once per lifetime.

• For non-Ashkenazi Jewish women, these patterns include: º Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 or younger º A combination of three or more first- or seconddegree relatives with breast cancer, regardless of age of diagnosis º A combination of both breast and ovarian cancer among first- and second-degree relatives with ovarian cancer º A first-degree relative with bilateral breast cancer º A combination of two or more first- or seconddegree relatives with ovarian cancer, regardless of diagnosis º A first-or second-degree relative with both breast and ovarian cancer, at any age º A history of breast cancer in a male relative • For women of Ashkenazi Jewish heritage, an increasedrisk family history includes any first- or second-degree relative on the same side of the family with breast or ovarian cancer.

The procedure codes that describe the three basic steps for testing for a BRCA mutation, b-hexasominidase (5-83080), isolation and separation of DNA (5-83890, 5-83891, 5-83892, 5-83893, 5-83894, 5-83896, and 5-83897), molecular diagnostics (5-83898, 5-83900, 5-83901, 5-83902, 5-83907, 5-83908, 5-83909, and 5-83912), and mutation scanning or identification (5-83903, 5-83904, Texas Medicaid Bulletin, No. 204

14

A written prior authorization request, signed and dated by the referring provider, must be submitted. All signatures must be current, unaltered, original and handwritten. Computerized or stamped signatures will not be accepted. The original signature copy must be kept in the physician’s medical record for the client. To complete the prior authorization process, the provider must send the request to the TMHP Special Medical Prior Authorization Department and include documen-

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

tation of medical necessity. The request can be faxed to 1-512-514-4213 or mailed to the following address:

Gene mutation analyses (procedure codes 5-S3820, 5-S3822, and 5-S3823) will not be reimbursed on the same date of service as the following procedure codes:

Texas Medicaid & Healthcare Partnership Special Medical Prior Authorization Department 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727

Procedure Codes 5-83890 5-83891 5-83894 5-83896 5-83900 5-83901 5-83904 5-83905 5-83908 5-83909

To facilitate a determination of medical necessity and avoid unnecessary denials, the physician must provide correct and complete information, including accurate medical necessity of the services requested.

Procedure codes 5-84233, 5-84234, 5-88360, and 5-88361 are a benefit of the Texas Medicaid Program when ordered by a physician for the purpose of determining the best course of treatment for a client with breast and/or gynecological cancers. Estrogen and progesterone receptor assays may be provided for the following diagnosis codes:

Effective for dates of service on or after April 1, 2007, benefits for prognostic breast and gynecological cancer studies have changed. Procedure code I/T-88361 is no longer a benefit of the Texas Medicaid Program. The following procedure codes are limited to once per lifetime: 5-83891 5-83896 5-83901 5-83905 5-83909

5-83893 5-83898 5-83903 5-83907 5-83080

Claims filed using these procedure codes may be considered upon appeal.

Prognostic Breast and Gynecological Cancer Studies

Procedure Codes 5-83080 5-83890 5-83893 5-83894 5-83898 5-83900 5-83903 5-83904 5-83907 5-83908

5-83892 5-83897 5-83902 5-83906 5-83912

5-83892 5-83897 5-83902 5-83906 5-83912

Diagnosis Codes 1740 1741 1742 1746 1748 1749 1821 1828 1982

1743 1750 19881

1744 1759 2330

1745 1820

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

Authorization is not required for these services.

Free Delivery of Medicaid Prescriptions Many Medicaid pharmacies across the state offer free delivery of prescriptions to Medicaid clients. To find out which pharmacies offer home delivery, refer clients to the HHSC website at www.hhsc.state.tx.us/HCF/vdp/vdpstart.html or the TMHP client helpline at 1-888-302-6688.

• Offering no-charge prescription delivery to all Medicaid recipients requesting delivery in the same manner as to the general public

Contracted Medicaid pharmacy providers are reimbursed a delivery fee that is included in the medication dispensing fee formula. The delivery fee is paid to HHSC-approved pharmacy providers, who have certified that delivery services meet minimum conditions for payment of the delivery fee.

• Providing the delivery service without requiring retention of the Medicaid client’s form (H3087/3087)

• Displaying publicly the availability of prescription delivery services at no charge in a prominent place in the pharmacy store (window/door)

This delivery fee is not applicable for mail order prescriptions. For more information, call the Vendor Drug Help Desk at 1-800-435-4165 and ask for Pharmacy Contracts.

The conditions include: • Deliveries are made to individuals rather than to institutions, such as nursing homes

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

15

Texas Medicaid Bulletin, No. 204

All Providers

Paper R&S Report Moving to Web TMHP is phasing out paper Remittance and Status (R&S) reports. Providers who currently receive paper R&S reports by mail will access their R&S reports only through the TMHP website at www.tmhp.com. The transition from paper R&S reports began April 15, 2007, and will continue through June 15, 2007. The date for the transition from paper R&S reports depends on the Texas Provider Identifier (TPI) of the provider. After the transition, providers will be able to access an exact replica of the paper R&S report online without having to wait to receive it through the mail. Providers will be transitioned to the online R&S over an eight-week period. The first week that a provider will receive only the online R&S report depends on the first four digits of the provider’s TPI. For example, a provider with TPI 123456789 would use “1234,” which falls in the “0985 through 1309” range. The schedule for transition is as follows: Date April 16, 2007 April 23, 2007 April 30, 2007 May 7, 2007 May 14, 2007 May 21, 2007 May 29, 2007 June 04, 2007

First 4 digits of TPI 0000 through 0798 0799 through 0984 0985 through 1309 1310 through 1376 1377 through 1493 1494 through 1621 1622 through 1800 1801 through 1825

Effective for dates of service on or after February 1, 2007, the HPV vaccine procedure code 1/S-90649 is a benefit of the Texas Medicaid Program, including THSteps, for clients 19 through 20 years of age. Claims for the HPV vaccine will be considered for reimbursement to providers who administer the HPV vaccine to clients 19 through 20 years of age. The reimbursement fee for procedure code 1/S-90649 is $128.88. The appropriate administration CPT code will also be considered for reimbursement. The HPV vaccine procedure code 1/S-90649 is informational for clients 9 through 18 years of age and is only considered for reimbursement to providers who administer the HPV vaccine to clients 9 through 18 years of age when the vaccine is not available through the Texas Vaccine for Children (TVFC) Program and billed with modifier U1. The appropriate administration CPT code will be considered for reimbursement. The vaccine CPT code must be included on the claim to receive reimbursement for the administration CPT code. Providers must use the TVFC Program as the source for the HPV vaccine for TVFC-eligible clients when TVFC has HPV available for shipment. Providers must be enrolled in the TVFC Program to obtain HPV vaccines. “Not available” is defined by the TVFC Program as: • A new vaccine approved by the Advisory Committee on Immunization Practices (ACIP) that has not been negotiated or added to a Vaccine for Children (VFC) contract

To access their R&S reports online, providers must first create a provider administrator account on the TMHP website. To create an account, providers should go to the home page and click Activate my Account under the “I Would Like to…” link on the right-hand side of the page. Online R&S reports are posted on Mondays and are available for a period of 90 days.

• Funding for a new vaccine that has not been established by the TVFC Program • A vaccine that has national supply and/or distribution issues Providers should submit claims with modifier U1 only if using privately purchased vaccine when the vaccine is not available through the TVFC Program.

For more information, call the TMHP Contact Center at 1-800-925-9126. For assistance with passwords and technical issues, call the EDI Help Desk at 1-888-863-3638.

Texas Medicaid Bulletin, No. 204

Human Papillomavirus Vaccine Benefit Changes

16

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers

Benefit Changes for Cranial Molding Devices Effective for dates of service on or after May 1, 2007, prior authorization for cranial molding device (9-S1040) has changed for the Texas Medicaid Program. Procedure code 9-S1040 will only be reimbursed to medical suppliers of durable medical equipment (DME) in the home setting.

• Alternative treatment course of two months that has been tried with documented evidence of supervised “tummy time” during periods of wakefulness and repositioning the infant’s head such that the child lies opposite to the preferred position with stretching exercises

Cranial molding devices may be prior authorized for reimbursement through the THSteps/ Comprehensive Care Program (CCP) with written documentation that supports the medical necessity and includes all of the following:

• Plan of treatment and/or follow up schedule Only Medicaid-enrolled providers may be authorized for reimbursement. Positional plagiocephaly is a benign, typically self-limited physical finding, and is not a pathological condition. The use of cranial molding devices as a treatment of positional plagiocephaly is cosmetic in nature; and therefore, is not medically necessary. The definition for cosmetic includes surgery or other services used primarily to improve appearance and not to restore or correct significant deformity resulting from disease, trauma, congenital or developmental anomalies, or previous therapeutic process.

• The assessment and recommendations of the appropriate primary care physician, pediatric subspecialist, or craniofacial team • A full description of the physical findings, precise diagnosis, age of onset, and the etiology of the deformity including an X-ray or computerized tomography (CT) report • The age of the client (3 to 18 months of age) • Anthropometric measurements: º For children less than 6 months of age: documentation of aggressive repositioning and/or physical therapy of at least 3 months duration without improvement, and data documenting greater than 12mm of asymmetry in one or more of the anthropometric measurements: cranial vault, skull base, and orbitotragial cranial depths º For children over 6 months of age, but less than 18 months of age, data documenting greater than 12mm of asymmetry in one or more of the anthropometric measurements: cranial vault, skull base, and orbitotragial cranial depths

Requests for cranial molding devices will be considered for prior authorization for use after surgery for cranial deformities, including craniosynostosis. Cranial molding devices may be considered as a benefit of the Medicaid Program when included as part of a treatment plan to reshape a skull deformity due to pathologic processes. For more information, call the TMHP Contact Center at 1-800-925-9126.

Medicaid Identification Form Changes Effective May 2007, the Medicaid Identification Form (H3087/H3087-G1) has changed. The Intermediate Care Facility for the Mentally Retarded (ICF-MR) Dental Services check box has been renamed Dental Services. A check mark under this heading shows eligibility for dental therapeutic and/or emergency services for THSteps/ICF-MR clients during the specified month. To verify a client’s eligibility for Medicaid dental checkup services, providers may call the TMHP Contact Center or access the TMHP website at www.tmhp.com. The revised version of the Medicaid Identification Form (H3087) is available on page 49 of this bulletin. May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

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Texas Medicaid Bulletin, No. 204

All Providers

Benefit Criteria Changes for Hospital Critical Care Visits Effective for dates of service on or after April 1, 2007, hospital critical care visits benefit criteria have changed for the Texas Medicaid Program. The following procedure codes will not be reimbursed separately when submitted for reimbursement with procedure codes 1-99291 and 1-99292: Procedure Codes 2-36000 2-36410 2-36600 2-43752 4/I/T-71020 1-90940 1-92004 1-92012 5-93040 T-93041 5/I/T-93562 1-94002 1-94662 5-94760 5/I-95833 1-99090 1-99203 1-99204 1-99212 1-99213 1-99238 1-99239

2-36415 4/I/T-71010 1-91105 1-92014 I-93042 1-94003 5-94761 1-99201 1-99205 1-99214

the physician is not at bedside, he must be immediately available to the patient. The physician must devote his full attention to the patient and therefore, cannot render evaluation and management services to any other patient during the same period of time. Critical care is usually given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, neonatal intensive care unit, or the emergency department care facility.

2-36540 4/I/T-71015 1-92002 2-92953 5/I/T-93561 1-94660 5-94762 1-99202 1-99211 1-99215

Procedure codes 1-99291, 1-99292, 1-99293, and 1-99294 are per-day charges and should be submitted for reimbursement for hospital critical care visits. The following limitations apply to procedure codes 1-99291 and 1-99292: • Procedure code 1-99291 should be used for the first 30 to 74 minutes of critical care, even if the time spent by the physician is not continuous on that day. • Procedure code 1-99292 should be used for each additional 30 minutes beyond the first 74 minutes of critical care for up to 6 units, or 3 hours per day. If the number of units is not stated on the claim, only a quantity of one will be allowed.

Effective for dates of service on or after April 1, 2007, the following procedure codes will not be reimbursed separately when billed with procedure codes 1-99293 and 1-99294: Procedure Codes 2-31500 2-31502 2-36405 2-36406 2-36420 2-36430 2-36540 2-36555 2-36625 2-36640 2-51000 2-51005 2-51702 2-62270 4/I/T-71015 4/I/T-71020 1-90765 1-90766 5/I/T-93561 5/I/T-93562 5/I/T-94375 1-94640 1-94662 1-94664 5-94762 1-99090 1-99223 1-99231 1-99234 1-99235 1-99239

2-36000 2-36410 2-36440 2-36600 2-36660 2-51010 2-62272 1-90760 1-91105 1-94002 1-94642 5-94760 1-99221 1-99232 1-99236

Services for a patient who is not critically ill and unstable, but who happens to be in a critical care unit, must be reported using subsequent hospital visit codes or hospital consultation codes.

2-36400 2-36415 2-36510 2-36620 2-43752 2-51701 4/I/T-71010 1-90761 1-92953 1-94003 1-94660 5-94761 1-99222 1-99233 1-99238

Critical care procedure codes 1-99291, 1-99292, 1-99293, or 1-99294 provided on the same day as a major surgery must be submitted with documentation indicating the critical care was unrelated to the specific anatomic injury or general surgical procedure. Procedure codes 1-99291, 1-99292, 1-99293, or 1-99294 must be submitted by the provider rendering the critical care service at the time of crisis. Critical care involves high complexity decision-making to access, manipulate, and support vital system functions. While providers from various specialties (e.g., cardiology or neurology) may be consulted to render an opinion and/or assist in the management of a particular portion of the care, only the provider managing the care of the critically ill patient during a life-threatening crisis may submit the critical care procedure codes for reimbursement. If procedure code 1-99291 is provided by different physicians, meets the initial 30-minute time requirement for each physician, and is provided at separate distinct times, the initial provider’s claim will be considered

Critical care is a benefit of the Texas Medicaid Program. Critical care includes the care of critically ill patients that require the constant attention of the physician. If

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All Providers

Inpatient pediatric critical care (procedure codes 1-99293 and 1-99294) is a per-day charge. Only one physician can submit pediatric critical care procedure codes for reimbursement per client per day. If an inpatient evaluation and management service is submitted by the same provider with the same date of service as pediatric critical care, the inpatient evaluation and management will be denied. Critical care provided to an adult or child in an outpatient setting (e.g., emergency room) which does not result in admission, should be submitted using procedure codes 1-99291 and 1-99292. If a hospital discharge (procedure code 1-99238 or 1-99239) is billed on the same day as pediatric critical care (procedure code 1-99293 or 1-99294) the hospital discharge will be denied and the critical care procedure code(s) will be considered for reimbursement.

for reimbursement. The second provider’s claim will be denied but may be considered on appeal. The time spent by each physician cannot overlap—two physicians cannot submit the critical care procedure codes for care delivered at the same time.

If outpatient critical care (procedure code 1-99291 or 1-99292) is provided by the same provider to a patient at a distinctly different time from another outpatient evaluation and management service, both services may be considered for reimbursement with supporting medical record documentation.

Supporting medical record documentation must be provided by the second physician that includes the time in which the critical care was rendered. In addition, a statement must be submitted indicating the physician was the only provider managing the care of the critically ill patient during the life-threatening crisis. If the provider’s time exceeds the 74-minute time threshold for procedure code 1-99291, procedure code 1-99292 may be submitted in addition to procedure code 1-99291 for each additional 30 minutes. Procedure code 1-99292 may not be submitted as a stand-alone code.

Prolonged physician services (procedure code 1-99354, 1-99355, 1-99356, or 1-99357) will be denied when submitted for reimbursement by the same provider with the same date of service as critical care procedure codes 1-99291 and 1-99292. Claims may be subject to retrospective review. For more information, call the TMHP Contact Center at 1-800-925-9126.

2007 Childhood and Adolescent Immunization Schedule Released The Centers for Disease Control and Prevention (CDC) has released the 2007 Recommended Childhood and Adolescent Immunization Schedule that indicates the recommended age for routine administration of currently licensed childhood vaccines.

and the American Academy of Family Physicians (AAFP). Providers who offer immunization services should obtain and refer to the schedule or schedules that affect their client population(s). The 2007 schedule can be viewed on page 47 of this bulletin or downloaded from the CDC website at: www.cdc.gov/nip/recs/child-schedule.pdf.

The 2007 schedule has been separated into two age groups: 0 through 6 years of age (childhood schedule) and 7 through 18 years of age (adolescent schedule). The 2007 Recommended Childhood and Adolescent Immunization Schedule is approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP),

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

For information about the 2007 Recommended Childhood and Adolescent Schedules, call the Department of State Health Services (DSHS) Immunization Branch at 1-800-252-9152.

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Texas Medicaid Bulletin, No. 204

All Providers

Uniform Billing Claim Form Change The National Uniform Billing Committee (NUBC) has approved the replacement of the current uniform UB-92 CMS-1450 claim form with the new UB-04 CMS-1450 claim form. TMHP will begin accepting the new UB-04 claim form on May 21, 2007. All providers of the Texas Medicaid Program who currently submit claims on the UB-92 CMS-1450 are required to use the new UB-04 CMS-1450 claim form for all claim submissions and appeals, regardless of the version used for prior submissions. All claims submitted on the new UB-04 CMS-1450 claim form that are received by TMHP before May 21, 2007, will be returned to providers. For descriptions and guidelines describing the information that must be entered in the revised fields of the paper UB-04 CMS-1450 claim form, refer to the following table.

UB-04 CMS-1450 Paper Claim Form Revisions

The following table includes the required and optional fields that were revised for the new paper UB-04 CMS-1450 claim form. All other required fields on the UB-04 CMS-1450 claim form remain in effect, as outlined in the 2007 Texas Medicaid Provider Procedures Manual, Section 5.6.4, “HCFA-1450 (UB-92) Instruction Table,” on page 5-34. Field 2

Description Unlabeled

Guidelines Optional—No guidelines for this field.

3a

Patient control number

Optional—Any alphanumeric character (limit 16) entered in this field will be referenced on the R&S report.

3b

Medical record number

Enter the client’s medical record number (limited to ten digits) assigned by the hospital.

4

Type of bill (TOB) This field has been expanded from 3 to 4 characters with a 0 always as the Most commonly used: first digit. Claims will be processed based on the last three digits. 111 Inpatient hospital Enter the three-digit TOB code. 131 Outpatient hospital First digit—type of facility: 141 Nonpatient (labora1 Hospital tory or radiology charges) 2 Skilled nursing 331 Home health 3 Home health agency agency* 7 Clinic (rural health clinic (RHC), federally qualified health center 711 RHCs (FQHC), renal dialysis center (RDC) 721 RDCs 8 Special facility 731 FQHCs * Use TOB 331 only. All Second digit—bill classification (except clinics and special facilities): other TOBs are invalid 1 Inpatient (including Medicare Part A) and will deny. 2 Inpatient (Medicare Part B only) 3 Outpatient 4 Other (for hospital-referenced diagnostic services, for example, laboratories and X-rays) 7 Intermediate care Second digit—bill classification (clinics only): 1 Rural health 2 Hospital-based or independent RDC 3 Free standing 5 Comprehensive Outpatient Rehabilitation Facility (CORF) Third digit—frequency: 0 Nonpayment/zero claim 1 Admit through discharge 2 Interim—first claim 3 Interim—continuing claim 4 Interim—last claim 5 Late charges—only claim 6 Adjustment of prior claim 7 Replacement of prior claim

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All Providers

Field 7

Description Unlabeled

Guidelines Optional—No guidelines for this field.

8a

Patient identifier

Optional—Enter the patient identification number if different than the subscriber/insured’s identification number.

8b

Patient name

Enter the client’s last name, first name, and middle initial as printed on the Medicaid Identification Form.

9a–9b

Patient address

Starting in 9a, enter the client’s complete address as described (street, city, state, and ZIP code).

10

Birth date

Enter the month, day, and year (MM/DD/YYYY) the client was born.

11

Sex

Indicate the client’s sex by entering an “M” or “F.”

12

Admission date

Enter the date (MM/DD/YYYY) of admission for inpatient claims; date of service (DOS) for outpatient claims; start of care (SOC) for home health claims. Note: Providers that receive a transfer patient from another hospital must enter the original admission date to identify the payor.

13

Admission hour

Use military time (00 to 23) for the time of admission for inpatient claims or time of treatment for outpatient claims. Code 99 is not acceptable. This field is not required for nonpatients (TOB 141), home health claims (TOB 331), RHCs (TOB 711), RDCs (TOB 721), or FQHCs (TOB 731).

14

Type of admission

Enter the appropriate type of admission code for inpatient claims: 1 Emergency 2 Urgent 3 Elective 4 Newborn (This code requires the use of special source of admission code in Field 15.) 5 Trauma center

15

Source of admission

Enter the appropriate source of admission code for inpatient claims. For type of admission 1, 2, or 3: 1 Physician referral 2 Clinic referral 3 Health maintenance organization (HMO) referral 4 Transfer from a hospital 5 Transfer from a skilled nursing facility 6 Transfer from another health care facility 7 Emergency room 8 Court/Law enforcement 9 Information not available For type of admission 4 (newborn): 1 Normal delivery 2 Premature delivery 3 Sick baby 4 Extramural birth 5 Information not available

16

Discharge hour

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

For inpatient claims, enter the hour of discharge or death. Use military time (00 to 23) to express the hour of discharge. If this is an interim bill (patient status of “30”), leave the field blank. Code 99 is not acceptable.

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Texas Medicaid Bulletin, No. 204

All Providers

Field 17

Description Patient status

Guidelines For inpatient claims, enter the appropriate two-digit code to indicate the client’s status as of the statement “through” date: 01 Routine discharge 02 Discharged to another short-term general hospital 03 Discharged to a skilled nursing facility (SNF) 04 Discharged to intermediate care facility (ICF) 05 Discharged to another type of institution 06 Discharged to care of home health service organization 07 Left against medical advice 08 Discharged/transferred to home under care of a Home IV provide 09 Admitted as an inpatient to this hospital (only for use on Medicare outpatient hospital claims) 20 Expired or did not recover 30 Still patient (To be used only when the client has been in the facility for 30-consecutive days if payment is based on diagnosis-related group [DRG]) 40 Expired at home (hospice use only) 41 Expired in a medical facility (hospice use only) 42 Expired—place unknown (hospice use only) 43 Federal Hospital (such as a Veteran’s Administration [VA] hospital) 50 Hospice—Home 51 Hospice—Medical Facility 61 Medicare-approved swing bed 62 Inpatient rehabilitation facility (IRF), including rehabilitation distinct part of a hospital 63 Long term care hospital (LTCH) 64 Medicaid-only nursing facility 65 Psychiatric hospital or psychiatric distinct part unit of a hospital 66 Discharged/transferred to a critical access hospital (CAH) Enter the two-digit condition code “05” and date (MM/DD/YYYY) the legal claim was filed for recovery of funds potentially due a client as a result of legal action initiated by or on behalf of the client if this condition is applicable to the claim.

18–28

Condition codes

29

Accident state

Optional—Accident (ACDT) state.

30

Unlabeled

Optional—No guidelines for this field.

31–34

Occurrence codes and dates

Enter the appropriate code(s) and date(s). Medicaid-required codes are found in the 2007 Texas Medicaid Provider Procedure Manual, Section 5.6.5 “Occurrence Codes” page 5-41. Fields 54, 61, 62, and 80 must also be completed as required.

35–36

Occurrence span codes and dates

For inpatient claims, enter code “71” if this hospital admission is a readmission within seven days of a previous stay. Enter the dates of the previous stay.

39–41

Value codes

Accident hour—For inpatient claims, if the client was admitted as the result of an accident, enter value code 45 with the time of the accident using military time (00 to 23). Use code 99 if the time is unknown. For inpatient claims, enter value code 80 with the total days represented on this claim that are to be covered. Usually this is the difference between the admission and discharge dates. In all circumstances the number in this field will be equal to the number of covered accommodation days listed in Field 46. For inpatient claims, enter value code 81 with the total days represented on this claim that are not covered. The sum of Fields 39–41 must equal the total days billed as reflected in Field 6.

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All Providers

Field 45 (line 23) 57 67

67A–67Q

Description Creation date

Guidelines Enter the date the bill was submitted.

Other ID#

Enter the TPI number (non-NPI ID number) of the billing provider.

Principal DX code and Present on admission (POA) indicator

Enter the ICD-9-CM diagnosis code in the unshaded area for the principal diagnosis to the highest level of specificity available. Optional—POA indicator. Enter the applicable POA indicator in the shaded area for inpatient claims.

Other DX codes and POA Enter the ICD-9-CM diagnosis code in the unshaded area to the highest indicator level of specificity available for each additional diagnosis. Enter one diagnosis per field. A diagnosis is not required for clinical laboratory services provided to nonpatients (TOB 141). Exception: A diagnosis is required when billing for estrogen receptor assays, plasmapheresis, and cancer antigen CA 125, immunofluorescent studies, surgical pathology, and alpha-fetoprotein. Note: ICD-9-CM diagnosis codes entered in 67I–67Q are not required for systematic claims processing. Optional—POA indicator. Enter the applicable POA indicator in the shaded area for inpatient claims.

68

Unlabeled

Optional—No guidelines for this field.

69

Admit DX code

Enter the ICD-9-CM diagnosis code indicating the cause of admission or include narrative. Note: The admitting diagnosis is only for inpatient claims.

70a–70c

Patient’s reason DX

Optional—New field indicating the client’s reason for visit on unscheduled outpatient claims.

71

Prospective payment system (PPS) code

Optional—The PPS code is assigned to the claim to identify the DRG based on the grouper software called for under contract with the primary payer.

72a–72c

External cause of injury (ECI) and POA indicator

Optional—Enter the ICD-9-CM diagnosis code in the unshaded area to the highest level of specificity available for each additional diagnosis. POA Indicator—Enter the applicable POA indicator in the shaded area for inpatient claims.

73

Unlabeled

Optional—No guidelines for this field.

74

Principal procedure code and date

Enter the ICD-9-CM procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.

74a– 74e

Other procedure codes and dates

Enter the ICD-9-CM procedure code for each surgical procedure and the date (MM/DD/YYYY) each was performed.

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

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Texas Medicaid Bulletin, No. 204

All Providers

Field 76

Description Attending provider

Guidelines Attending provider name and identifiers: For inpatient claims, enter the physician’s license number or Universal Provider Identification Number (UPIN) of the provider who performed the service/procedure and/or is responsible for the treatment and plan of care in the following format: 11233333 1 Two-digit state indicator (for example, TX for Texas) 2 Licensing board indicator examples B = Doctor of Medicine (MD) or Doctor of Osteopathy (DO) D = Dentist P = Podiatrist C = Chiropractor 3 License number. Example: TXBL1234 If the provider has a temporary license number, enter “TEMPO.” Example: TXBTEMPO. Procedures are defined as those listed in the ICD-9-CM coding manual volume 3, which includes surgical, diagnostic, or medical procedures. For outpatient claims, enter the license number of the physician referring the client to the hospital. TPI must be entered in field to the right of qualifier box, if applicable.

77

Operating provider

Enter operating provider name and identifiers. This is required when a surgical procedure code is listed on the claim. Include the name and ID number of the individual with the primary responsibility for performing the surgical procedure(s). TPI must be entered in field to the right of qualifier box, if applicable.

78–79

Other (a or b) provider

Other provider name and identifiers: For outpatient claims, enter the license number for the following: • The ordering physician for all laboratory and radiology services. (If a different physician ordered laboratory or radiology services enter his/her license number in Field 76 and enter the referring/attending physician’s license number or UPIN in this field.) • The designated physician for a limited client when the physician performed or authorized nonemergency care. • Referring provider—The provider who sends the client to another provider for services. Required on an outpatient claim when the referring provider is different than the attending physician. Note: If the referring physician is a resident, Fields 76 and 78 must identify the physician who is supervising the resident. Other operating physician—An individual performing a secondary surgical procedure or assisting the operating physician. Required when another operating physician is involved. Rendering provider—The health care professional who performs, delivers, or completes a particular medical service or non-surgical procedure. TPI must be entered in field to the right of qualifier box, if applicable.

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All Providers

Field FL80

Description Remarks

Guidelines This field is used to explain special situations such as the following: • The home health agency must document in writing the number of Medicare visits used in the nursing plan of care and also in this field. • If a client stays beyond dismissal time, indicate the medical reason if additional charge is made. • If billing for a private room, the medical necessity must be indicated and signed by the physician. • If services are the result of an accident, the cause and location of the accident must be entered in this field. The time must be entered in Field 39. • If laboratory work is sent out, the name and address or the Medicaid provider identifier of the facility where the work was forwarded must be entered in this field. • If the client is deceased, enter the date of death. • If services were rendered on the date of death, enter the time of death. • If the services resulted from a family planning provider’s referral, write “family planning referral.” • If services were provided at another facility, indicate the name and address of the facility where the services were rendered. • Enter the date of onset for clients receiving dialysis services. • Request for 110-day rule for a third party insurance.

81a – 81d

Code code (CC)

Optional—Area to capture additional information necessary to adjudicate the claim. Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere on the claim data set.

The following table describes fields that have been deleted from the new UB-04 CMS-1450 claim form and are no longer required for claims processing. Field numbers listed on the following table correspond to the fields in the original UB-92 HCFA 1450 claim form: Field Description 66 Employer location 79 Procedure coding method 85 Provider signature 86 Date bill submitted Details about the UB-04 CMS-1450 claim form and instructions for paper billers are available on the TMHP website at www.tmhp.com. Information about electronic billing changes are available in the revised EDI Companion Guide located on the TMHP website. Refer to the National Provider Identifier (NPI) Special Bulletin, No. 205, for additional information about electronic billing and TDHconnect. For changes relating to NPI implementation, refer to the National Provider Identifier (NPI) Special Bulletin, No. 202 and the upcoming National Provider Identifier (NPI) Special Bulletin, No. 205. For more information, call the TMHP Contact Center at 1-800-925-9126.

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

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Texas Medicaid Bulletin, No. 204

Family Planning Providers

FAMILY PLANNING PROVIDERS

Checking Women’s Health Program Client Eligibility or Social Security number, the TMHP website and TDHconnect cannot respond with the client’s most current Medicaid number because there is more than one number in the system. A “Duplicate Patient ID Found” error message will appear at the top of the screen.

“Duplicate Patient ID Found” Error Message

Providers can verify whether Women’s Health Program applicants have been certified in the program and retrieve certified clients’ Medicaid identification numbers by searching the TMHP database at www.tmhp.com or through TDHconnect. Some providers have reported getting a “Duplicate Patient ID Found” error message when searching for certain clients using combinations of the applicant’s last name, date of birth, and Social Security number.

When searching for a Women’s Health Program applicant and the “Duplicate Patient ID Found” error message is received, the client’s Medicaid number will not be accessible online. Providers must call the TMHP Contact Center and speak to a representative to verify if the client is certified in the Women’s Health Program and if so, request the client’s current Women’s Health Program Medicaid number.

The “Duplicate Patient ID Found” error message happens when a client has had a previous period of Medicaid eligibility and the TMHP system may have more than one identification number for the client. When providers search for a client who was previously on Medicaid using their last name, date of birth, and/

Texas Medicaid Bulletin, No. 204

For more information, call the TMHP Contact Center at 1-800-925-9126 from 7 a.m. to 7 p.m., Central Time, Monday through Friday.

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May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Family Planning Providers

Family Planning 2017 Claim Form The Family Planning 2017 Claim Form for paper billers has been revised for the implementation of the NPI.

revised version of the Family Planning 2017 Claim Form before May 21, 2007, will be returned to the provider.

Effective May 21, 2007, all Title V, Title X, and Title XX family planning providers and any participating Texas Medicaid Program providers who currently use the Family Planning 2017 claim form must use the revised version of the Family Planning 2017 Claim Form for claim submissions and appeals, regardless of the version used for prior submissions. Claims submitted on the

The following table describes the information that must be entered in the revised fields of the Family Planning 2017 Claim Form for paper billers. All other required fields are unchanged, as outlined in the 2007 Texas Medicaid Provider Procedures Manual, Section 5.8.1, “Family Planning 2017 Claim Form Instruction,” on page 5-49.

Field 2a 24a 27a 32C 32h (a)

38b**

Description Billing provider TPI Insured’s Policy/ Group No. Referring Other ID

Family Planning 2017 Revisions

Guidelines Enter the provider’s nine-digit TPI. Enter the insurance policy number or group number.

If a service that is not a family planning service is being billed and the service requires a referring provider identifier, enter the referring provider identifier. TPI number is required for the referring provider. Reserved for Local Leave this field blank. Use Note: Type of service (TOS) codes are no longer required for claims submission. Performing provider Members of a group practice (with the exception of pathology and renal dialysis # (Other ID) groups) must identify the nine-digit TPI of the doctor/clinic within the group who performed the service. Note: TMHP recommends that providers complete this field for Titles V, X, and XX if the procedure code that is entered would normally require a performing provider identifier, for Title XIX claims. If a claim or encounter that was submitted for V, X, or XX is later determined to be eligible for payment by Title XIX and the performing provider identifier is missing, the claim will be denied with a request for this information. To avoid unnecessary claim or encounter denial, complete this information for all claims and encounters. Service Facility TPI is required in the following circumstances: (Other ID) • If the services were provided in a place other than the client’s home or the provider’s facility, enter the nine-digit TPI of the facility (i.e. hospital or birthing center) where the service was provided. • If an independently practicing health care professional provided the service, the TPI number of the school district or cooperative where the child is enrolled (School Health and Related Services [SHARS]/ early childhood intervention [ECI]) must be entered in this field. • If laboratory specimens were sent to an outside laboratory for additional testing, the nine-digit TPI of the outside laboratory must be entered in this field or the complete name and address should be entered in field 38. The laboratory should bill the Texas Medicaid Program for the services performed.

**Field 38b Service Facility (Other ID) was previously published in the National Provider Identifier (NPI) Special Bulletin, No. 202 as field number 38a. Fields 38a and 38b have been updated.

For changes relating to NPI implementation, refer to the National Provider Identifier (NPI) Special Bulletin, No. 202, and the upcoming National Provider Identifier (NPI) Special Bulletin, No. 205. For information about electronic billing changes refer to the revised EDI Companion Guide located on the TMHP website and the National Provider Identifier (NPI) Special Bulletin, No. 205. Refer to page 45 of this bulletin to see the revised Family Planning 2017 Claim Form. For more information, call the TMHP Contact Center at 1-800-925-9126.

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

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Texas Medicaid Bulletin, No. 204

Primary Care Case Management Providers

CHS Provides Service for Helping Clients

PRIMARY CARE CASE MANAGEMENT PROVIDERS

Verification of PCCM Primary Care Provider on Medicaid ID Required

PCCM providers can request assistance from Community Health Services (CHS) for individual client counseling and education. The following are some of the services CHS provides:

Primary Care Case Management (PCCM) clients are required to obtain care from the primary care provider listed on their Medicaid Identification Form (H3087/3087). The transition period that previously allowed clients to receive health care from any provider while changing their primary care provider ended on April 13, 2007.

• Counseling for clients who do not keep appointments, or who inappropriately use the emergency room • Informing clients about the role of a primary care provider • Educating clients about the referral process for specialty services

Clients can continue to call 1-888-302-6688 to request a primary care provider change. It may take up to 45 days for the change to be listed on the client’s Medicaid ID. The daily primary care provider change list is no longer available. Any PCCM primary care provider can provide services to a PCCM client who has not yet selected or been assigned to a primary care provider. Medicaid ID cards for clients who do not yet have a primary care provider will read either “PCCNEWB01” for newborns, or “PCCPCCM01” for all clients except newborns, in place of the primary care provider’s name.

• Providing information about disease prevention, care coordination, and resource location CHS staff is available to meet with clients in a provider’s office. Providers can request a visit or refer PCCM clients for CHS services by calling 1-888-276-0702, Monday through Friday, 8 a.m. to 5 p.m., Central Time, or by faxing a PCCM Community Health Services Referral Request Form to 1-512-302-0318. This form is located on page 46 of this bulletin. Providers can refer up to four clients on a request form.

Providers can verify client eligibility in four ways:

For more information, call the PCCM Provider Helpline at 1-888-834-7226, or visit the TMHP website at www.tmhp.com.

• Medicaid ID • Electronically via TMHP EDI • Automated Inquiry System (AIS) at 1-800-925-9126 • The current month’s panel report Primary care providers must continue to provide their Texas Provider Identifier (TPI) number to specialists to ensure appropriate claims processing. Claims with invalid or missing provider numbers will be denied. Primary care providers are required to make arrangements for after-hours care. Referrals are allowed to clinics that offer after-hours care; however, the after-hours provider must include the primary care provider’s TPI number on the claim to receive payment. Administrative referrals will be issued only for urgent situations. For more information, call the PCCM Provider Helpline at 1-888-834-7226, or visit the TMHP website at www.tmhp.com/c18/pccm.

Texas Medicaid Bulletin, No. 204

28

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Primary Care Case Management Providers

Primary Care Physician No Longer Autoassigned at Enrollment (all clients except newborns) as the primary care provider, any PCCM enrolled primary care provider can render health care services to the client. The Medicaid Identification Form (H3087/3087) can be viewed on page 49 of this bulletin. See related article on page 17 of this bulletin.

Effective February 1, 2007, the primary care provider selection process allows new PCCM clients to choose their primary care provider before one is assigned. Previously, PCCM clients were assigned a primary care provider at the time of enrollment. In the new process, clients have 105 days to select a primary care provider for their newborn. All other PCCM clients have up to 75 days to select a primary care provider. If clients do not make a selection within the specified time period, a primary care provider will be assigned.

To select a primary care provider, PCCM clients can call the PCCM Client Helpline at 1-888-302-6688 or mail the Primary Care Provider Selection Form to the TMHP address on the form. For more information, visit the TMHP website at www.tmhp.com or call the PCCM Provider Helpline at 1-888-834-7226.

If the Medicaid Identification Form (H3087/3087) lists either PCCNEWB01 (newborns) or PCCPCCM01

Revised Cost Report Settlement Procedures HHSC has directed TMHP to revise the cost report settlement procedures for the Medicaid fee-forservice and PCCM Programs. The Texas Medicaid Program will pay the greater of the following options:

located in a metropolitan statistical area (MSA), and have been designated by Medicare as a sole community hospital or a rural referral center. The new cost report settlement procedures will be effective for dates of admission on or after September 1, 2003, for Medicaid fee-for-service providers, and for dates of admission on or after September 1, 2005, for PCCM providers.

• The Tax Equity Fiscal Responsibility Act of 1982 (TEFRA) costs (without the imposition of the TEFRA ceiling). • The diagnosis-related group (DRG) payments for hospitals that have fewer than 101 beds or for hospitals that have more than 100 beds, are not

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

For more information, call Richard Bledsoe (TMHP) at 1-512-506-7695.

29

Texas Medicaid Bulletin, No. 204

School Health and Related Services Providers

SCHOOL HEALTH AND RELATED SERVICES PROVIDERS

Corrections to SHARS Information TMHP has identified corrections in the SHARS information published in the following sections of the 2007 Texas Medicaid Provider Procedures Manual: • 42.6.1.1 Audiology Billing Table • 42.6.2.1 Counseling Services Billing Table • 42.6.4 Nursing Services • 42.6.7.4 Speech Therapy Billing Table • 42.6.10.1 Transportation Services in a School Setting Billing Table

Corrections to Section 42.6.1.1, “Audiology Billing Table”

The audiology billing table in Section 42.6.1.1, “Audiology Billing Table” did not state that modifier U9 must be used with procedure code 1-92506, and incorrectly states that modifier GN-U8 and GN-U1 must be used with procedure codes 1-92507 and 1-92508 when submitting counseling services for reimbursement. The correct modifier to use is modifier U9 with procedure code 1-92506 and modifier U9 or U1 with procedure codes 1-92507 and 1-92508. The correct audiology billing table follows: POS* Procedure Code Individual or Group 1, 2, or 9 1, 2, or 9 1, 2, or 9

1-92506 with modifier U9 1-92507 with modifier U9 1-92507 with modifier U1

Individual Individual Individual

1, 2, or 9 1, 2, or 9

1-92508 with modifier U9 1-92508 with modifier U1

Group Group

Unit of Service Licensed therapist Licensed therapist Licensed/certified assistant acting under the supervision or direction of a licensed audiologist Licensed therapist Licensed/certified assistant acting under the supervision or direction of a licensed audiologist

*Place of service: 1=Office/school; 2=Home; 9=Other locations

Providers must use a 15-minute unit of service for billing each procedure code. Important: The recommended maximum billable time for evaluation is three hours, which may be billed over several days. The recommended maximum billable time for direct therapy (group and/or individual) is a cumulative two hours per day. Providers must maintain documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Corrections to Section 42.6.2.1, “Counseling Services Billing Table”

The Counseling Services Billing Table on page 42-6 incorrectly states that modifier GN must be used with procedure codes 1-96152 and 1-96153 when submitting counseling services for reimbursement consideration. The correct modifier to use is modifier UB. The corrected table follows: POS* Procedure Code Individual or Group 1, 2, or 9 1, 2, or 9

1-96152 with modifier UB 1-96153 with modifier UB

Individual Group

*Place of service: 1 = Office/school; 2 = Home; 9 = Other locations

Providers must use a 15-minute unit of service for billing each procedure code. Important: The recommended maximum billable time is two hours per day. Providers must maintain documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Texas Medicaid Bulletin, No. 204

30

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

School Health and Related Services Providers

Corrections to Section 42.6.4, “Nursing Services”

In the 2007 TMPPM, Section 42.6.4, “Nursing Services,” the Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN) procedure codes were incorrectly left out of the procedure code table on page 42-7. The TD modifier is applicable to nursing services delivered by a registered nurse (RN) or advanced practice nurse (APN) and the U7 modifier is applicable to nursing services delivered through delegation. The TE modifier is applicable to nursing services delivered by an LVN/LPN. The corrected table follows: POS* Procedure Code Individual or Group Unit of Service 1, 2, or 9 1, 2, or 9 1, 2, or 9 1, 2, or 9 1, 2, or 9 1, 2, or 9 1, 2, or 9 1, 2, or 9 1, 2, or 9

1-T1002 with modifier TD 1-T1002 with modifier TD-UD 1-T1502 with modifier TD 1-T1002 with modifier U7 1-T1002 with modifier U7-UD 1-T1502 with modifier U7 1-T1003 with modifier TE 1-T1003 with modifier TE-UD 1-T1502 with modifier TE

Individual Group Delegation, individual Delegation, group Individual Group

15 minutes 15 minutes Medication administration, per visit 15 minutes 15 minutes Delegation, medication, administration, per visit 15 minutes 15 minutes Medication, Administration, per visit

* Place of service: 1=Office/school; 2=Home; 9=Other locations

Important: The recommended maximum billable time for direct nursing services is four hours per day. The recommended maximum billable units for procedure codes 1-T1502 with modifier TD, 1-T1502 with modifier U7, or 1-T1502 with modifier TE is a cumulative four medication administration visits per day. Providers must maintain documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Corrections to Section 42.6.7.4, “Speech Therapy Billing Table”

The Speech Therapy Billing Table on page 42-9 incorrectly states that modifier GP must be used with procedure code 1-92508 when submitting group speech therapy services for reimbursement. The correct modifier to use to be considered for reimbursement is modifier GN. The corrected table follows: POS* Procedure Code Individual or Unit of Service Group 1, 2, or 9 1, 2, or 9 1, 2, or 9

1-92506 with modifier GN 1-92507 with modifier GN-U8 1-92507 with modifier GN-U1

Individual Individual Individual

1, 2, or 9 1, 2, or 9

1-92508 with modifier GN-U8 1-92508 with modifier GN-U1

Group Group

Licensed therapist Licensed therapist Licensed/certified assistant acting under the supervision or direction of a speech-language pathologist (SLP) Licensed therapist Licensed/certified assistant acting under the supervision or direction of an SLP

*Place of service: 1=Office/school; 2=Home; 9=Other locations

Providers must use a 15-minute unit of service for billing each procedure code. Important: The recommended maximum billable time for evaluation is three hours, which may be billed over several days. The recommended maximum billable time for direct therapy (group and/or individual) is a cumulative of two hours per day. Providers must maintain documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Corrections to Section 42.6.10.1, “Transportation Services in a School Setting Billing Table”

The procedure code 1-T1003 is incorrect for transportation services. The correct transportation services procedure code to use is 1-T2003. The corrected table follows: POS* Procedure Code Unit of Service 1, 2, or 9

1-T2003

Per one-way trip

*Place of service: 1=Office/school; 2=Home; 9=Other locations

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

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

31

Texas Medicaid Bulletin, No. 204

Texas Health Steps Dental Providers

TEXAS HEALTH STEPS DENTAL PROVIDERS

ADA Dental Claim Form Changes Effective May 21, 2007, the 2002 American Dental Association (ADA) Dental Claim Form has been replaced with the new 2006 ADA Dental Claim Form. The 2006 ADA Dental Claim Form can be viewed on page 41 of this bulletin. All participating Texas Medicaid and Children with Special Health Care Needs (CSHCN) providers are required to submit the new version of the form for all claim submissions and appeals. All claims submitted on the new 2006 ADA Dental Claim Form received before May 21, 2007, will be returned to providers. Details about the ADA Dental Claim Form and instructions for paper billers are available on the TMHP website at www.tmhp.com. Information about electronic billing changes are also available on the TMHP website as well as in the revised EDI Companion Guide. Refer to the upcoming National Provider Identifier (NPI) Special Bulletin, No. 205, for additional information about electronic billing and TDHconnect.

ADA Dental Paper Claim Form Revisions

The descriptions and guidelines in the following table include required and optional fields which have been revised in the new ADA Dental Claim Form. All other required fields on the ADA Dental Claim Form remain in effect, as outlined in the 2007 Texas Medicaid Provider Procedures Manual, Section 5.7.1, “2002 ADA Dental Claim Form Instruction,” on page 5-45. Field Description 16 Plan/group 48 Billing dentist or dental entity 52A

Additional provider ID

58

Additional provider ID

Guidelines Enter the benefit code, if applicable, for the billing or performing provider. Name and address of billing group or individual provider (not the name and address of a provider employed within a group). Enter the Texas Provider Identifier (TPI) assigned to the billing dentist or dental entity. Enter the performing dentist’s TPI.

For changes relating to National Provider Identifier (NPI) implementation, refer to the National Provider Identifier (NPI) Special Bulletin, No. 202, and the upcoming National Provider Identifier (NPI) Special Bulletin, No. 205. For more information, call the TMHP Contact Center at 1-800-925-9126 or CSHCN Provider Contact Center at 1-800-568-2413.

Therapeutic Dental Procedures Changing The following is a correction to an article published in the January/February 2007 Texas Medicaid Bulletin, No. 201, entitled “Therapeutic Dental Procedures Changing” located on page 22. The article contained a list of therapeutic dental procedure codes and limitations, but did not specify the age restrictions for the first table. The corrected table follows. The following procedure codes are restricted to clients 6 through 20 years of age: Procedure Codes D3310 D3320 D3410 D3421

D3330 D3425

D3346 D3426

D3347 D3430

D3348 D3450

D3351 D3470

D3352 D3920

D3353 D3950

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

Texas Medicaid Bulletin, No. 204

32

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Excluded Providers

Excluded Providers As 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 the Texas Medicaid Program 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/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/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 the Texas Medicaid Program 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 semi-monthly. Updates appear on the website after the 1st and 15th of each month. Review the entire Texas Medicaid Program exclusion list at www.hhsc.state.tx.us/OIE/Exclusionlist/ado/exclusion.asp. To report Medicaid providers who engage in fraud/abuse, call 1-512-424-6519 or 1-888-752-4888, or write to the following address: Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity, MC-1361 PO Box 85200 Austin TX 78708-5200 Provider Airington, Tobie L Armstrong, Davill Barrett, Glenda C Best Medical Supplies Blake, Doris J Bledsoe, Derrick Blevins, Charles A Bourbeau, Thomas J Bradley, Regina Briggs, Gloria Burkholder, Jack C Calderon, Carolyn I Conway, Sandra K Curtis, Marla R Davis, Dorina D Draper, Spencer W Duke, Noble S Edem, Ededem E Edison Medical Supply Corporation Elston, Stephen F

License Number 163806 F3025 91059

203908 464652 170426 564167 605029 684795 446955 673838 562401

G9344

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Start Date 09-May-06 02-Jun-06 09-May-06 11-Aug-06 22-Feb-07 20-Jun-06 19-Oct-06 07-Jul-06 20-Sep-06 14-Feb-06 02-Sep-02 16-May-06 02-Nov-04 20-Jun-06 20-Jul-06 06-Apr-06 16-Feb-05 20-Feb-07 20-Feb-07 08-Dec-06

Type Provider LVN MD LVN DME

City

State

Add Date

Durant Houston Coolidge

OK TX TX

DME

Marlin Irving Montgomery Longview Richmond Harlingen Harlingen Sherman Texarkana Temple Las Vegas Canyon Lake Houston Houston Houston

TX TX AL TX TX TX TX TX AR TX TX TX TX TX TX

05-Feb-07 14-Feb-07 05-Feb-07 05-Mar-07 26-Feb-07 23-Jan-07 23-Feb-07 15-Mar-07 30-Jan-07 24-Jan-07 13-Feb-07 26-Feb-07 29-Jan-07 09-Feb-07 13-Mar-07 24-Jan-07 24-Jan-07 20-Feb-07 20-Feb-07

MD

Borger

TX

08-Mar-07

Owner OT RN Dir LVN RN RN RN RN RN RN

33

Texas Medicaid Bulletin, No. 204

Excluded Providers

Provider Fleming, Linda L Flores, Vergil M Garner, Neal E Gilmer, Marian A Gravell, Matthew Guest Care Management of Texas, LLC Guillen, Jason A Guillen, Roxanne C Hall-Herpin, Callie Hamed, Jill M Harris, Sheri L Hawthorne, Lorine Hayes, Arthur D Helm, Debra K HELP-Helping Each Other Live Positive Hobbs, Belinda J Hunt, Tami L Imeh, Sunny A Johnson, Chanika L Johnson, Donald R King, Robert B Maciel, Jose F Maewal, Hrishi K Maldonado, Felix G Marek, Cassandra L McCoy, Connie D McCray, Darrell D Mirzadeh, Lisa L Monroe, Sandra K Moulden, Mickeal L Newman, Jose Nunez, Margaret G Oetting, David G Olson, Doris E Overson, Tina L Perry, Priscilla L Pevsner, Paul H Ramirez Jr., Luis Ramirez, Roberto J Sertich, Pamela G

License Number 525320 135297 189435 638326

K5306 105884 317760 257765

504967 136095 183330 610429 132723 E7175 12035 172516 167220 153239 249361 649987 D5803 537323 677048 412555 508468 174813 H5655 151114 17659 532342

Texas Medicaid Bulletin, No. 204

Start Date 06-Jun-06 19-Oct-06 20-Apr-06 09-May-06 09-May-06 20-Jun-06

Type Provider RN LVN LVN RN

20-Nov-06 20-Nov-06 15-Oct-04 19-Oct-06 23-May-06 20-Nov-06 11-Jan-07 09-May-06 22-Feb-07

Owner Owner MD CAN LVN

09-May-06 09-May-06 22-Oct-06 19-Jun-06 09-May-06 12-Jun-06 02-Feb-07 08-Dec-06 05-Sep-06 20-Jul-06 09-May-06 09-May-06 09-May-06 09-May-06 19-Jul-06 08-Dec-06 27-Jun-06 03-Jul-06 22-Jun-06 17-Jul-06 09-May-06 25-Aug-06 09-May-06 21-Dec-06 09-May-06

RN LVN

owner RN LPC

LVN RN LVN MD Pharm RN LVN LVN LVN RN RN MD RN RN RN RN LVN MD LVN DDS RN

34

City

State

Add Date

Midland

TX

26-Feb-07

Mesquite Greensboro Waco Boerne Shreveport

TX NC TX TX LA

22-Feb-07 18-Jan-07 22-Feb-07 26-Feb-07 26-Feb-07

San Antonio San Antonio Richmond Copperas Cove Fort Worth Bryan Harlingen Ashdown Marlin

TX TX TX TX TX TX TX AR TX

21-Feb-07 21-Feb-07 09-Feb-07 20-Feb-07 22-Feb-07 23-Feb-07 12-Jan-07 09-Feb-07 26-Feb-07

Katy Atkins Beaumont Longview Shreveport Denison Laredo Fort Worth Brownsville Houston Abilene San Antonio Magnolia Malakoff Mansfield Dallas Keene Bradenton Pearland Lubbock Mena New York San Benito McAllen Helotes

TX AR TX TX LA TX TX TX TX TX TX TX TX TX TX TX TX FL TX TX AR NY TX TX TX

22-Feb-07 05-Feb-07 22-Jan-07 15-Mar-07 08-Mar-07 26-Feb-07 07-Feb-07 12-Mar-07 05-Feb-07 14-Feb-07 22-Feb-07 08-Mar-07 24-Jan-07 24-Jan-07 22-Feb-07 12-Mar-07 15-Mar-07 26-Feb-07 15-Mar-07 12-Mar-07 08-Mar-07 24-Jan-07 09-Feb-07 24-Jan-07 08-Mar-07

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Excluded Providers

Provider Silva, Sergio Sion, Julie B Staggs, Edward N Talmage, Edward A Tavares, Katherine R Tice, Frederick JR Vana, Sandy S Walters, Brenda J Weinberg, Max R Wolf, Dawn M

License Number J8773 683963 154125 D2722 640099 627191 43984 859

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Start Date 08-Sep-06 10-Jul-06 05-Jun-06 02-Jun-06 18-Aug-05 09-May-06 09-May-06 31-May-06 20-Sep-06 05-Mar-07

Type Provider MD RN LVN MD RN RN LVN Podia LPC

35

City

State

Add Date

Denver Victoria Harper Sugarland Galveston San Antonio Rancho Viejo Abilene Grand Junction Austin

CO TX TX TX TX TX TX TX CO TX

26-Feb-07 22-Feb-07 26-Feb-07 12-Mar-07 12-Feb-07 08-Mar-07 24-Jan-07 22-Feb-07 23-Jan-07 09-Mar-07

Texas Medicaid Bulletin, No. 204

Forms

Provider Information Change Form Traditional Medicaid, Children with Special Health Care Needs (CSHCN), 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:

9-digit Texas Provider Identifier (TPI):

Provider Name:

List any additional TPIs that use the same provider information: TPI:______________________

TPI:______________________

TPI:______________________

TPI:______________________

TPI:______________________

TPI:______________________

Physical Address*

Accounting/Mailing Address**

Secondary Address

City:

City:

City:

State: Phone:

ZIP:

(

)

State: Phone:

ZIP:

(

State:

ZIP:

Phone:

)

Fax:

Fax:

Fax:

Email:

Email:

Email:

(

)

Type of Change: (Check the appropriate box below.) 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:

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

Provider Signature:

Mail or fax the completed form to:

Date:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Fax: 1-512-514-4214

* The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare letter along with this form. ** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

37

Texas Medicaid Bulletin, No. 204

Forms

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 Traditional Medicaid, changes to the accounting or mailing address require a copy of the W9 form. For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter.

Tax Identification Number (TIN): • •

TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. Performing providers cannot change the TIN.

General: •

• •

Forms will be returned unprocessed if the nine-digit provider number is not indicated on the Provider Information Change Form. The W-9 form is required for all name and TIN changes. Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Fax: 1-512-514-4214

Texas Medicaid Bulletin, No. 204

38

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

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

NOTE:

Complete all sections below and attach a voided check or a photocopy of your deposit slip.

Type of Authorization:

NEW

CHANGE

Provider Name

Nine–Character Billing TPI

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:

May/June 2007

Input Date:

39

Texas Medicaid Bulletin, No. 204

CPT only copyright 2007 American Medical Association. All rights reserved.

— A STATE MEDICAID CONTRACTOR

23

Forms

Electronic Funds Transfer (EFT) Information 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 Texas Provider Identifier (TPI) 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 a voided check or deposit slip with the agreement to the TMHP address indicated on the form.

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

— A STATE MEDICAID CONTRACTOR

Texas Medicaid Bulletin, No. 204

23

40

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Dental Claim Form HEADER INFORMATION 1. Type of Transaction (Check all applicable boxes) Statement of Actual Services

Request for Predetermination / Preauthorization

EPSDT/ Title XIX 2. Predetermination / Preauthorization Number

PRIMARY INSURED INFORMATION 12. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

PRIMARY PAYER INFORMATION 3. Name, Address, City, State, Zip Code

15. Subscriber Identifier (SSN or ID#)

14. Gender

13. Date of Birth (MM/DD/CCYY)

M

OTHER COVERAGE

16. Plan/Group Number

4. Other Dental or Medical Coverage?

F

17. Employer Name

Yes (Complete 5-11)

No (Skip 5-11)

PATIENT INFORMATION

5. Other Insured’s Name (Last, First, Middle Initial, Suffix)

6. Date of Birth (MM/DD/CCYY)

Self

8. Subscriber Identifier (SSN or ID#)

7. Gender M

F

Spouse

Dependent Child

19. Student Status

FTS

Other

PTS

fold

fold

18. Relationship to Primary Insured (Check applicable box)

20. Name (Last, First, Middle Initial, Suffix), Address, City, State, Zip Code

10. Patient’ s Relationship to Other Insured (Check applicable box)

9. Plan/Group Number

Self

Spouse

Dependent

Other

11. Other Carrier Name, Address, City, State, Zip Code

22. Gender

21. Date of Birth (MM/DD/CCYY)

23. Patient ID/Account # (Assigned by Dentist)

M

F

RECORD OF SERVICES PROVIDED 25. Area 26. of Oral Tooth Cavity System

24. Procedure Date (MM/DD/CCYY)

28. Tooth Surface

27. Tooth Number(s) or Letter(s)

29. Procedure Code

30. Description

31. Fee

1 2 3 4 5 6 7 8 9 10

MISSING TEETH INFORMATION

Permanent

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

A

B

C

D

E

F

G

H

I

J

32. Other Fee(s)

32

31

30

29

28

27

26

25

24

23

22

21

20

19

18

17

T

S

R

Q

P

O

N

M

L

K

33.Total Fee fold

fold

34. (Place an 'X' on each missing tooth)

Primary

1

35. Remarks

AUTHORIZATIONS

ANCILLARY CLAIM/TREATMENT INFORMATION

36. I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.

38. Place of Treatment (Check applicable box)

Provider’s Office

Hospital

Patient /Guardian signature

42. Months of Treatment Remaining

Date

37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.

Subscriber signature

Model(s)

41. Date Appliance Placed (MM/DD/CCYY)

43. Replacement of Prosthesis? No

44. Date Prior Placement (MM/DD/CCYY)

Yes (Complete 44)

45. Treatment Resulting from (Check applicable box)

Auto accident

Other accident 47. Auto Accident State

46. Date of Accident (MM/DD/CCYY)

Date

Oral Image(s)

Yes (Complete 41-42)

Occupational illness / injury

X

Radiograph(s)

Other

40. Is Treatment for Orthodontics? No (Skip 41-42)

X

39. Number of Enclosures (00 to 99)

ECF

BILLING DENTIST OR DENTAL ENTITY (Leave blank if dentist or dental entity is not submitting

TREATING DENTIST AND TREATMENT LOCATION INFORMATION

48. Name, Address, City, State, Zip Code

53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.

claim on behalf of the patient or insured/subscriber)

X

Date

Signed (Treating Dentist)

54. Provider ID

55. License Number

56. Address, City, State, Zip Code 49. Provider ID

52. Phone Number (

50. License Number

)

51. SSN or TIN

–

57. Phone Number (

)

–

58. Treating Provider Specialty

© 2002, 2004 American Dental Association

J515 (Same as ADA Dental Claim Form – J516, J517, J518, J519)

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

41

Texas Medicaid Bulletin, No. 204

Forms

Texas Medicaid & Healthcare Partnership 12357-B RIATA TRACE PKWY, STE 150 Austin, TX 78727 DATE: _____________________________

TIME: ____________(AM) (PM)

FROM: ______________________________

TO:

AMBULANCE UNIT

PHONE: _____________________________

PHONE:

1-800-540-0694

FAX: ________________________________

FAX:

1-512-514-4205

*For clients who meet the definition of severely disabled: The client’s physical condition limits his/her mobility, which requires the client to be bed-confined at all times or life support systems to be monitored. If Hospital to Hospital or Hospital Discharge, supply: ORIGIN: _____________________________________

DESTINATION: ____________________________

All providers supply the following information: *The requestor’s name and title _______________________________________________________________ *The client’s full name _______________________________________________________________________ *The client’s Medicaid number ________________________________________________________________ *The initial transport date ____________________________________________________________________ *Full name of the transporting Ambulance Company _____________________________________________ *The Medicaid Provider Number of the transporting Ambulance Company ___________________________ *The type of Prior Authorization being requested: _____Annual (12 months) _____Short Term (1–60 days) Please supply one or more of the following documentation: *Admit and discharge records for dates of service *A history and physical that has been done within 6 months *The Care Plan with Daily Activity Sheet from the Nursing Home within 6 months *Home Health Care Plan within 6 months NUMBER OF PAGES INCLUDING COVER SHEET:____________________

Texas Medicaid Bulletin, No. 204

42

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

__

Forms

__

1

__

4

3a PAT. CNTL # b. MED. REC. #

2

6

5 FED. TAX NO.

8 PATIENT NAME

9 PATIENT ADDRESS

a

10 BIRTHDATE

11 SEX

31 OCCURRENCE CODE DATE

12

DATE

a c

ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT

32 OCCURRENCE DATE CODE

33 OCCURRENCE DATE CODE

18

7

STATEMENT COVERS PERIOD FROM THROUGH

b

b

TYPE OF BILL

19

20

34 OCCURRENCE CODE DATE

CONDITION CODES 24 22 23

21

35 CODE

25

26

27

36 CODE

OCCURRENCE SPAN FROM THROUGH

d

28

e

29 ACDT 30 STATE

37

OCCURRENCE SPAN FROM THROUGH

a

a

b

b

38

39 CODE

40 CODE

VALUE CODES AMOUNT

41 CODE

VALUE CODES AMOUNT

VALUE CODES AMOUNT

a b c d 42 REV. CD.

44 HCPCS / RATE / HIPPS CODE

43 DESCRIPTION

45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES

49

1

1

2

2

3

3

4

4

5

5

6

6

7

7

8

8

9

9

10

10

11

11

12

12

13

13

14

14

15

15

16

16

17

17

18

18

19

19

20

20

21

21 22

22

PAGE

23

OF

TOTALS

CREATION DATE

50 PAYER NAME

52 REL. INFO

51 HEALTH PLAN ID

53 ASG. BEN.

23

55 EST. AMOUNT DUE

54 PRIOR PAYMENTS

56 NPI

A

57

A

B

OTHER

B

PRV ID

C

C

58 INSURED’S NAME

59 P. REL 60 INSURED’S UNIQUE ID

62 INSURANCE GROUP NO.

61 GROUP NAME

A

A

B

B

C

C

63 TREATMENT AUTHORIZATION CODES

65 EMPLOYER NAME

64 DOCUMENT CONTROL NUMBER

A

A

B

B

C

C

66 DX

67 I

A J

69 ADMIT 70 PATIENT DX REASON DX PRINCIPAL PROCEDURE a. 74 DATE CODE

B K a

b

C L

OTHER PROCEDURE CODE DATE

b.

OTHER PROCEDURE CODE DATE

e.

c

D M

71 PPS CODE OTHER PROCEDURE CODE DATE

E N 75

72 ECI

F O a 76 ATTENDING

G P b NPI

LAST c.

OTHER PROCEDURE CODE DATE

d.

OTHER PROCEDURE CODE DATE

77 OPERATING

81CC a

UB-04 CMS-1450

78 OTHER

b

LAST

c

79 OTHER

d

LAST

APPROVED OMB NO. 0938-0997

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

NUBC

™

National Uniform Billing Committee

43

68

73

QUAL FIRST

NPI

LAST 80 REMARKS

H Q c QUAL FIRST

NPI

QUAL FIRST

NPI

QUAL FIRST

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

Texas Medicaid Bulletin, No. 204

Forms

UB-04 NOTICE:

THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).

(b) The patient has represented that by a reported residential address outside a military medical treatment facility catchment area he or she does not live within the catchment area of a U.S. military medical treatment facility, or if the patient resides within a catchment area of such a facility, a copy of Non-Availability Statement (DD Form 1251) is on file, or the physician has certified to a medical emergency in any instance where a copy of a NonAvailability Statement is not on file;

Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill: 1. If third party benefits are indicated, the appropriate assignments by the insured /beneficiary and signature of the patient or parent or a legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the patient or the patient’s legal representative.

(c) The patient or the patient’s parent or guardian has responded directly to the provider’s request to identify all health insurance coverage, and that all such coverage is identified on the face of the claim except that coverage which is exclusively supplemental payments to TRICARE-determined benefits;

2. If patient occupied a private room or required private nursing for medical necessity, any required certifications are on file. 3. Physician’s certifications and re-certifications, if required by contract or Federal regulations, are on file.

(d) The amount billed to TRICARE has been billed after all such coverage have been billed and paid excluding Medicaid, and the amount billed to TRICARE is that remaining claimed against TRICARE benefits;

4. For Religious Non-Medical facilities, verifications and if necessary recertifications of the patient’s need for services are on file.

(e) The beneficiary’s cost share has not been waived by consent or failure to exercise generally accepted billing and collection efforts; and,

5. Signature of patient or his representative on certifications, authorization to release information, and payment request, as required by Federal Law and Regulations (42 USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other applicable contract regulations, is on file.

(f) Any hospital-based physician under contract, the cost of whose services are allocated in the charges included in this bill, is not an employee or member of the Uniformed Services. For purposes of this certification, an employee of the Uniformed Services is an employee, appointed in civil service (refer to 5 USC 2105), including part-time or intermittent employees, but excluding contract surgeons or other personal service contracts. Similarly, member of the Uniformed Services does not apply to reserve members of the Uniformed Services not on active duty.

6. The provider of care submitter acknowledges that the bill is in conformance with the Civil Rights Act of 1964 as amended. Records adequately describing services will be maintained and necessary information will be furnished to such governmental agencies as required by applicable law. 7. For Medicare Purposes: If the patient has indicated that other health insurance or a state medical assistance agency will pay part of his/her medical expenses and he/she wants information about his/her claim released to them upon request, necessary authorization is on file. The patient’s signature on the provider’s request to bill Medicare medical and non-medical information, including employment status, and whether the person has employer group health insurance which is responsible to pay for the services for which this Medicare claim is made.

(g) Based on 42 United States Code 1395cc(a)(1)(j) all providers participating in Medicare must also participate in TRICARE for inpatient hospital services provided pursuant to admissions to hospitals occurring on or after January 1, 1987; and (h) If TRICARE benefits are to be paid in a participating status, the submitter of this claim agrees to submit this claim to the appropriate TRICARE claims processor. The provider of care submitter also agrees to accept the TRICARE determined reasonable charge as the total charge for the medical services or supplies listed on the claim form. The provider of care will accept the TRICARE-determined reasonable charge even if it is less than the billed amount, and also agrees to accept the amount paid by TRICARE combined with the cost-share amount and deductible amount, if any, paid by or on behalf of the patient as full payment for the listed medical services or supplies. The provider of care submitter will not attempt to collect from the patient (or his or her parent or guardian) amounts over the TRICARE determined reasonable charge. TRICARE will make any benefits payable directly to the provider of care, if the provider of care is a participating provider.

8. For Medicaid purposes: The submitter understands that because payment and satisfaction of this claim will be from Federal and State funds, any false statements, documents, or concealment of a material fact are subject to prosecution under applicable Federal or State Laws. 9. For TRICARE Purposes: (a) The information on the face of this claim is true, accurate and complete to the best of the submitter’s knowledge and belief, and services were medically necessary and appropriate for the health of the patient;

SEE htt p : / / w w w .nubc.org/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING SPECIFICATIONS

Texas Medicaid Bulletin, No. 204

44

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Forms

Family Planning 2017 Claim Form

V 1. Family Planning Program: XIX XX

1a. Title X Only

3. Provider Name

Full Pay Partial Pay No Pay

4. Eligibility Date (V or XX ) (MM/DD/CCYY)

6. Patient’s Name (Last Name, First Name, Middle Initial)

8. County of Residence

9.

Date of Birth

14. Marital Status

Hispanic (5)

Non-Hispanic (0)

17. Number Live Births a=Oral Contraceptive b=1-Month hormonal injection c=3-Month hormonal injection d=Cervical cap/diaphragm e=Abstinence

20. Primary Birth Control Method at End of This Visit

21. If No Method Used at End of This Visit, Give Reason (Required only if #20 = r)

(1) Married (2) Never Married (3) Formerly Married

24a. Insured’s Policy/Group No.

18. Number Living Children

f= Hormonal Implant g=Male condom h=Female condom i=Hormonal/Contraceptive patch j=Spermicide (used alone)

a=Refused b=Pregnant

22. Is There Other Insurance Available? If Y, Complete Items Y N 23 – 25a

p=Other method k=Intrauterine device (IUD) l=Vaginal ring q=Method unknown m=Fertility awareness method (FAM) r=No method (if used n=Sterilization for #20, must o=Contraceptive sponge complete #21)

c=Inconclusive Preg Test d=Seeking Preg

24b. Benefit Code

28. Level of Practitioner Physician Nurse Mid Level

27a. Referring Other ID

29. Diagnosis Code (Relate Items 1,2,3,or 4 to Item 32D by Line # in 32E) 1. ______________._________

3. ______________._________

2. ______________._________

4. ______________._________

From DD

CCYY

MM

DD

B

CCYY

Place of Service

g=Medical

25. Other Insurance Pd. Amt. 25a. Date of Notification $

27b. Referring NPI

A

e=Infertile f=Rely on Partner

23. Other Insurance Name and Address

26. Name of Referring Provider

MM

(Medicaid PCN if XIX)

15a. Family Size

19. Primary Birth Control Method Before Initial Visit

Dates of Service To

Family Planning No.

12. Patient's Social Security Number -

Established Patient

13a. Ethnicity

White (1) Black (2) AmIndian/AlaskaNat (4) Asian (5) Unk/NotRep (6) NatHawaii/PacIsland (7) More than one race (8)

32.

5.

7a. ZIP code

11. Patient Status

New Patient

13. Race (Code #)

15. Family Income (All) $ 16. Number Times Pregnant

2b. Billing Provider NPI

7. Address (Street, City, State)

10. Sex F M

(MM/DD/CCYY)

2a. Billing Provider TPI

C

Reserved for Local Use

D

Procedures, Services, or Supplies CPT/HCPCS Modifier

30. Authorization Number

Other

31. Date of Occurrence (MM / DD / CCYY)

E

Dx. Ref. (29)

F

Units or Days (Quantity) No. of Participants (Teen Counseling)

G

$ Charges

H

Performing Provider #

32H(a) TPI

32H(b) NPI

32H(a) TPI

32H(b) NPI

32H(a) TPI

32H(b) NPI

32H(a) TPI

32H(b) NPI

32H(a) TPI

32H(b) NPI

33. Federal Tax ID Number/EIN 34. Patient’s Account No. (optional)

37. Signature of Physician or Supplier Date: Signed:

35. Patient Co-Pay Assessed (V, X or XX) $

38. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office)

38a. NPI

36. Total Charges

39. Physician’s, Supplier’s Billing Name, Address, Zip Code & Phone No.

38b. Other ID

Form Revised: January 2007

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

45

Texas Medicaid Bulletin, No. 204

Forms

PCP INFORMATION Provider Name:

Contact Name:

TPI Number:

Phone Number: CLIENT INFORMATION

CLIENT INFORMATION Client Name:

Client Name:

Medicaid ID#:

Medicaid ID#:

Phone Number: Reason for Referral:

Phone Number: Reason for Referral:

Case Management/Health Education Needs:

Case Management/Health Education Needs:

[ ] Appointment No Show [ ] Abuse of Emergency Room [ ] Abuse of Doctor/Staff [ ] Other: [ ] Treatment Plan Adherence

[ [ [ [ [ [

] Asthma [ ] Childhood Illness [ ] Community Resources ] Cardiac [ ] Nutrition [ ] Transportation ] Dental [ ] Parenting [ ] Behavioral Psych ] Diabetes [ ] Prenatal Disorder ] Exercise [ ] Tobacco Use ] Child/Adult with Special Health Care Needs

[ ] Appointment No Show [ ] Abuse of Emergency Room [ ] Abuse of Doctor/Staff [ ] Other: [ ] Treatment Plan Adherence

[ [ [ [ [ [

] Asthma [ ] Childhood Illness [ ] Community Resources ] Cardiac [ ] Nutrition [ ] Transportation ] Dental [ ] Parenting [ ] Behavioral Psych ] Diabetes [ ] Prenatal Disorder ] Exercise [ ] Tobacco Use ] Child/Adult with Special Health Care Needs

[ ] Other:

[ ] Other:

Comments:

Comments:

CLIENT INFORMATION

CLIENT INFORMATION Client Name:

Client Name:

Medicaid ID#:

Medicaid ID#:

Phone Number: Reason for Referral:

Phone Number: Reason for Referral:

Case Management/Health Education Needs:

Case Management/Health Education Needs:

[ ] Other:

[ ] Other:

Comments:

Comments:

[ ] Appointment No Show [ ] Abuse of Emergency Room [ ] Abuse of Doctor/Staff [ ] Other: [ ] Treatment Plan Adherence

[ [ [ [ [ [

] Asthma [ ] Childhood Illness [ ] Community Resources ] Cardiac [ ] Nutrition [ ] Transportation ] Dental [ ] Parenting [ ] Behavioral Psych ] Diabetes [ ] Prenatal Disorder ] Exercise [ ] Tobacco Use ] Child/Adult with Special Health Care Needs

[ ] Appointment No Show [ ] Abuse of Emergency Room [ ] Abuse of Doctor/Staff [ ] Other: [ ] Treatment Plan Adherence

[ [ [ [ [ [

] Asthma [ ] Childhood Illness [ ] Community Resources ] Cardiac [ ] Nutrition [ ] Transportation ] Dental [ ] Parenting [ ] Behavioral Psych ] Diabetes [ ] Prenatal Disorder ] Exercise [ ] Tobacco Use ] Child/Adult with Special Health Care Needs

For Primary Care Case Management Clients Only Fax to Community Health Services at (512) 302-0318 Referrals are also received by telephone at 1-888-276-0702 (M-F, 8 a.m. to 5 p.m., CST)

Texas Medicaid Bulletin, No. 204

46

May/June 2007 CPT only copyright 2007 American Medical Association. All rights reserved.

Forms Department of Health and Human Services • Centers for Disease Control and Prevention

Recommended Immunization Schedule for Persons Aged 0–6 Years—UNITED STATES • 2007 Vaccine

Birth

Age

Hepatitis B1

1 2 4 6 12 15 18 19–23 2–3 month months months months months months months months years

HepB

2

HepB

see footnote 1

HepB

Rota

Rota

Rota

DTaP

DTaP

DTaP

Haemophilus influenzae type b

Hib

Hib

Hib

Hib

Pneumococcal5

PCV

PCV

PCV

PCV

Inactivated Poliovirus

IPV

IPV

Rotavirus

Diphtheria,Tetanus,Pertussis3 4

Varicella8 Hepatitis A9

At birth:

• Administer monovalent HepB to all newborns before hospital discharge. • If mother is hepatitis surface antigen (HBsAg)-positive, administer HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. • If mother’s HBsAg status is unknown, administer HepB within 12 hours of birth. Determine the HBsAg status as soon as possible and if HBsAg-positive, administer HBIG (no later than age 1 week). • If mother is HBsAg-negative, the birth dose can only be delayed with physician’s order and mother’s negative HBsAg laboratory report documented in the infant’s medical record. After the birth dose: • The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The second dose should be administered at age 1–2 months. The final dose should be administered at age ≥24 weeks. Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody to HBsAg after completion of ≥3 doses of a licensed HepB series, at age 9–18 months (generally at the next well-child visit). 4-month dose: • It is permissible to administer 4 doses of HepB when combination vaccines are administered after the birth dose. If monovalent HepB is used for doses after the birth dose, a dose at age 4 months is not needed.

2. Rotavirus vaccine (Rota). (Minimum age: 6 weeks) • Administer the first dose at age 6–12 weeks. Do not start the series later than age 12 weeks. • Administer the final dose in the series by age 32 weeks. Do not administer a dose later than age 32 weeks. • Data on safety and efficacy outside of these age ranges are insufficient. 3. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). (Minimum age: 6 weeks) • The fourth dose of DTaP may be administered as early as age 12 months, provided 6 months have elapsed since the third dose. • Administer the final dose in the series at age 4–6 years. 4. Haemophilus influenzae type b conjugate vaccine (Hib). (Minimum age: 6 weeks) • If PRP-OMP (PedvaxHIB® or ComVax® [Merck]) is administered at ages 2 and 4 months, a dose at age 6 months is not required. • TriHiBit® (DTaP/Hib) combination products should not be used for primary immunization but can be used as boosters following any Hib vaccine in children aged ≥12 months.

PCV PPV

Catch-up immunization IPV

MMR

MMR

Varicella

Varicella

HepA (2 doses)

Meningococcal10

Range of recommended ages

Hib

Influenza (Yearly)

Measles, Mumps, Rubella7

1. Hepatitis B vaccine (HepB). (Minimum age: birth)

DTaP

IPV

Influenza6

This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of December 1, 2006, for children aged 0–6 years. Additional information is available at http://www.cdc.gov/nip/recs/child-schedule.htm. Any dose not administered at the recommended age should be administered at any subsequent visit, when indicated and feasible. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and

HepB Series

DTaP

4

4–6 years

Certain high-risk groups

HepA Series MPSV4

other components of the vaccine are not contraindicated and if approved by the Food and Drug Administration for that dose of the series. Providers should consult the respective Advisory Committee on Immunization Practices statement for detailed recommendations. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS). Guidance about how to obtain and complete a VAERS form is available at http://www.vaers, hhs.gov or by telephone, 800-822-7967.

5. Pneumococcal vaccine. (Minimum age: 6 weeks for pneumococcal conjugate vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPV]) • Administer PCV at ages 24–59 months in certain high-risk groups. Administer PPV to children aged ≥2 years in certain high-risk groups. See MMWR 2000;49(No. RR-9):1–35. 6. Influenza vaccine. (Minimum age: 6 months for trivalent inactivated influenza vaccine [TIV]; 5 years for live, attenuated influenza vaccine [LAIV]) • All children aged 6–59 months and close contacts of all children aged 0–59 months are recommended to receive influenza vaccine. • Influenza vaccine is recommended annually for children aged ≥59 months with certain risk factors, health-care workers, and other persons (including household members) in close contact with persons in groups at high risk. See MMWR 2006;55(No. RR-10):1–41. • For healthy persons aged 5–49 years, LAIV may be used as an alternative to TIV. • Children receiving TIV should receive 0.25 mL if aged 6–35 months or 0.5 mL if aged ≥3 years. • Children aged