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October 2010 Procedure Code Review Updates

Information posted August 6, 2010

Effective for dates of service on or after October 1, 2010, provider type and place of service changes will be applied to some Children with Special Health Care Needs (CSHCN) Services Program radiology, laboratory, surgical, and other/durable medical equipment (DME) procedure codes.

Radiology Services

The following radiology procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed as indicated: Procedure Code 91111 Reimbursement Information Total radiology component: · Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. · Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: · Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: · Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. Total radiology component: · Services rendered in the office setting may be reimbursed to physician providers. · Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: · Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to advanced practice registered nurse (APRN) and physician providers. Technical component: · Services rendered in the office setting may be reimbursed to APRN, physician, radiation treatment center, radiological laboratory, and physiological laboratory providers. · Services rendered in the outpatient hospital setting may be reimbursed to radiation treatment center providers. Total radiology component: · Services rendered in the office setting may be reimbursed to APRN, physician, radiological laboratory, and physiological laboratory

93318

G0202, G0204, G0206

providers. · Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: · Services rendered in the office setting may be reimbursed to APRN and physician providers. · Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to physician providers. Technical component: · Services rendered in the office setting may be reimbursed to APRN, physician, radiological laboratory, and physiological laboratory providers. The following reimbursement rates will be applied to the new radiology benefits: TOS Procedure Code 4 I T 4 I T 4 I T 4 I T 4 I T 91111 91111 91111 93318 93318 93318 G0202 G0202 G0202 G0204 G0204 G0204 G0206 G0206 G0206 Age Range 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 Rate $537.34 $46.32 $491.54 $169.66 $56.73 $112.92 $98.47 $26.46 $72.01 $119.47 $33.00 $86.46 $94.37 $26.46 $67.92

Laboratory Services

The following laboratory procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed as indicated for services rendered to clients who are one year of age or older: Procedure Code 94452, 94453 Reimbursement Information Total laboratory component: · Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers.

·

Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Professional interpretation component: · Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. Technical component: · Services rendered in the office setting may be reimbursed to physician, radiological laboratory, and physiological laboratory providers. · Services rendered in the independent laboratory setting may be reimbursed to independent laboratory providers. Procedure codes 94452 and 94453 may be reimbursed when they are billed with one of the following diagnosis codes: Diagnosis Codes 27700 4911 500 5168 27701 49120 5080 5169 27702 49121 5081 5181 27703 49122 5088 5183 27709 4918 5089 51883 4160 4919 515 7485 4161 4920 5160 74861 4168 4928 5161 7707 4169 4940 5162 4910 4941 5163

The following reimbursement rates will be applied to the new laboratory benefits: TOS Procedure Code 5 5 I I T T 5 5 I I T T 94452 94452 94452 94452 94452 94452 94453 94453 94453 94453 94453 94453 Age Range 21-999 0-20 0-20 21-999 0-20 21-999 21-999 0-20 0-20 21-999 0-20 21-999 Rate $40.91 $42.96 $11.46 $10.91 $117.42 $111.83 $55.10 $57.85 $14.89 $14.18 $42.96 $40.91

Surgical Services

The following surgical procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed as indicated: Procedure Code 30300, Reimbursement Information Surgical component:

30310

· ·

Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician and dentist providers. Services rendered in the outpatient hospital setting must be prior authorized.

32820

Surgical component: · Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to physician providers. · Services rendered in the outpatient hospital setting must be prior authorized. Surgical component: · Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician providers. · Services rendered in the outpatient hospital setting must be prior authorized.

45379

The following reimbursement rates will be applied to the new surgical benefits: TOS Procedure Code 2 2 2 2 2 2 2 30300 30300 30310 30310 32820 45379 45379 Age Range 0 - 20 21 - 999 0 - 20 21 - 999 0 - 20 0 - 999 21 - 999 Rate $156.66 $149.20 $145.78 $138.83 $1,027.32 $296.76 $311.60

Other/DME Services

The following other/DME procedure codes will be made benefits of the CSHCN Services Program and may be reimbursed to home health DME, DME medical supplier, and custom DME providers for services rendered in the home setting: Procedure Codes L8300 S8424 L8310 S8427 L8320 S8428 L8330 S8429 L8500 S8450 L8603 S8451 L8606 S8452 S8421

Prior authorization is required for these services. The following reimbursement rates will be applied to the new other/DME benefits: TOS Procedure Code 9 9 9 9 L8300 L8310 L8320 L8330 Age Range 0-999 0-999 0-999 0-999 Rate $54.64 $87.22 $39.08 $44.51

9 9 9 9 9 9 9 9 9 9 9

L8500 L8603 L8606 S8421 S8424 S8427 S8428 S8429 S8450 S8451 S8452

0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999 0-999

$523.50 $394.97 $198.49 $80.00 $30.00 $57.20 $42.00 $20.00 $8.00 $20.00 $22.00

For more information, call the TMHP-CSHCN Contact Center at 1-800-568-2413.

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