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November/December 2004

Texas Medicaid

Bimonthly update to the Texas Medicaid Provider Procedures Manual

No. 183

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Bulletin Contents, No. 183

All Providers Corrections to HCPCS Special Bulletin .................................................. 2 Early Childhood Intervention Referrals................................................... 2 Eligibility Requirements for Pregnant Women ........................................ 3 Epoetin Procedures ................................................................................ 3 Federal Financial Participation Rates..................................................... 3 Filing Deadline for New Providers .......................................................... 3 ICD-9 Implementation............................................................................. 4 ICD-9 Policy Update ............................................................................. 18 Injection Procedure............................................................................... 25 Letter from Medical Director ................................................................. 25 Risperidone LA ..................................................................................... 25 Scheduled System Maintenance .......................................................... 25 TMHP Provider Relations Representatives .......................................... 26 Vendor Drug Program Clinical Edits ..................................................... 27 Upcoming Workshops........................................................................... 27 Case Management for Children and Pregnant Women (CPW) Providers Performing Provider Numbers .............................................................. 28 Freestanding Renal Dialysis Facilities Renal Dialysis Billing ............................................................................ 28 Home Health/THSteps-CCP Providers Augmentative Communication Devices ................................................ 29 Enteral Nutritional Products.................................................................. 30 Hospital Providers Transplant Facilities .............................................................................. 31 RSV-IgIM (Palivisumab) Reimbursement ............................................. 31 School Health and Related Services (SHARS) Providers SHARS Billing ....................................................................................... 32 Texas Health Network Providers It Takes Two .......................................................................................... 36 Member ID Cards ................................................................................. 37 PCPs are Key Players........................................................................... 37 Texas Health Network Contact Numbers.............................................. 37 Excluded Providers Excluded Providers............................................................................... 38 Forms Provider Information Change Form ...................................................... 41 Electronic Funds Transfer Authorization............................................... 43 Workshop Schedules Ambulance Workshop........................................................................... 45 Acute Care TDHconnect ....................................................................... 46

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BULLETIN

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CPT codes, descriptions, and other data only are copyright 2004 American Medical Association (or such other date of publication of CPT). All Rights Reserved. CPT is a trademark of the AMA. Applicable Federal Acquisition Regulation System/ Department of Defense Regulation System (FARS/DFARS) Restrictions Apply to Government Use.

All Providers

Corrections to HCPCS Special Bulletin

e following are corrections to the HCPCS Special Bulletin, Number 180. Page 9 incorrectly listed procedure code L-E0470, Rad w/o backup non-inv intfc, as payable at $256.60 for Children with Special Health Care Needs (CSHCN) providers. Procedure code L-E0470 is payable for all Texas health and human services programs at $99.77. Claims submitted with procedure code L-E0470 from July 1, 2004, through July 30, 2004, are being reprocessed for the purpose of recovering overpayments. No action on the provider's part is required. Page 17 listed procedure code J-E0470, Rad w/o backup non-inv intfc, incorrectly as MR (manually reviewed to determine price). Procedure code J-E0470 is payable for all programs at $1296.95. Claims submitted with procedure code J-E0470 from July 1, 2004, through July 30, 2004, are being reprocessed. No action on the provider's part is required. Page 17 listed procedure code L-E0470, Rad w/o backup non-inv intfc incorrectly as noncovered. Procedure code L-E0470 is payable for all programs at $99.77. Claims submitted with procedure code L-E0470 from July 1, 2004, through July 30, 2004, are being reprocessed. No action on the provider's part is required. Page 17 listed procedure code L-E0472, Rad w backup invasive intrfc, as noncovered. Procedure code L-E0472 is payable for all programs at $395.22. Claims submitted with procedure code L-E0472 from July 1, 2004, through July 30, 2004, are being reprocessed. No action on the provider's part is required. Page 17 listed procedure code 9-A6450, Lt compres band >=5"/yd, as noncovered. Procedure code 9-A6450 is payable for all programs at $1.08. Claims submitted with procedure code 9-A6450 from July 1, 2004,

through August 7, 2004, are being reprocessed. No action on the provider's part is required. Page 17 listed procedure code 9-A6451, Mod compres band w>=3"<5"/yd, as noncovered. Procedure code 9-A6451 is payable for all programs at $0.99. Claims submitted with procedure code 9-A6451 from July 1, 2004, through August 7, 2004, are being reprocessed. No action on the provider's part is required. Page 18 listed procedure code J-E2361, 22nf sealed lead acid battery, as noncovered. Procedure code J-E2361 is payable for all programs at $139.47. Claims submitted with procedure code J-E2361 from July 1, 2004, through July 30, 2004, are being reprocessed. No action on the provider's part is required. Page 21 listed procedure codes V2762, V2782, V2783, and V2784 (polycarbonate lens) as benefits of the Medicaid program. ese procedure codes are only payable to CSHCN providers through the Department of State Health Services (DSHS). For claims with dates of service on or after July 1, 2004, these procedure codes are denied as not a benefit of the Texas Medicaid Program. For questions about any of the procedures listed above, call the TMHP Contact Center at 1-800-925-9126.

Early Childhood Intervention Referrals

e Texas Early Childhood Intervention (ECI) Program provides services to families of infants and toddlers with disabilities and developmental delays. Federal and state regulations require that physicians and healthcare providers refer children under

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the age of three who may be in need of comprehensive early intervention services to an ECI-contracted provider within two business days of identification. A medical diagnosis is not needed. If professionals or family members suspect developmental delays, the child should be referred. A referral is when the family has been informed about ECI and given enough information to contact/call an ECI program. For more information visit the ECI website at www.eci.state.tx.us or call the ECI Care Line at 1-800-250-2246 and request the ECI Referral Brochure and ECI Directory. ECI developmental brochures, containing information and checklists of developmental milestones, may also be ordered for providers to give to families.

Federal Financial Participation Rates

Effective October 1, 2004, the Federal Financial Participation (FFP) rate for regular Medicaid reimbursement increased from 60.22 percent to 60.87 percent. e FFP rate for the Breast and Cervical Cancer Program increased 72.15 percent to 72.61 percent.

Filing Deadline for New Providers

A system enhancement implemented on September 15, 2004, calculates the 95-day filing deadline based on newly enrolled providers' date of enrollment. As a result, providers should not submit claims for services provided to eligible Medicaid clients until enrollment with TMHP is complete and the provider is in receipt of a letter with their new Texas Provider Identifier (TPI). After receipt of their new TPI, providers should submit claims promptly to ensure they are within 95 days of their date of enrollment with the Texas Medicaid Program. is 95-day filing deadline only applies to newly enrolled acute-care providers' billing and performing provider TPIs. All other providers must adhere to the claims filing time limits described in the Texas Medicaid Provider Procedures Manual, Section 4, Claims Filing.

Eligibility Requirements for Pregnant Women

Effective September 1, 2004, Medicaid benefits were restored to pregnant women with incomes up to 185 percent of the Federal Poverty Level (FPL). Previously, only those pregnant women 19 years and older at 158 percent of the FPL were eligible for Medicaid enrollment.

Epoetin Procedures

HCFA Common Procedure Coding System (HCPCS) procedure codes Q4055 and Q4054 were implemented without the appropriate diagnosis codes. ese codes now have the appropriate diagnosis codes. Claims submitted from July 1, 2004, through August 7, 2004, with these procedure codes will be reprocessed. No action on the provider's part is required.

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ICD-9 Implementation

Each year the Centers for Medicare & Medicaid Services (CMS) issues its changes to the hospital inpatient prospective payment system and new fiscal year rates. ese changes result in new, revised, or invalid diagnosis codes, procedure codes, diagnosis related groups (DRGs), and major diagnostic categories (MDCs), published annually in the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). e new codes are valid for dates of service on or after November 1, 2004, with the exception of inpatient DRG hospital claims, which are valid for admission dates on or after November 1, 2004. e following is a complete list of new, revised, and invalid ICD-9-CM codes. For policy changes related to the ICD-9-CM implementation, please see page 18 of this bulletin.

New Diagnosis Codes

Diagnosis Code 06640 06641 06642 06649 07070 07071 25200 25201 25202 25208 2734 27785 27786 27787 34700 34701 34710 34711 38003 45340 45341 45342 4772 49122 52106 Description West Nile Fever, unspecified West Nile Fever with encephalitis West Nile Fever with other neurologic manifestation West Nile Fever with other complications Unspecified viral hepatitis C without hepatic coma Unspecified viral hepatitis C with hepatic coma Hyperparathyroidism, unspecified Primary hyperparathyroidism Secondary hyperparathyroidism, non-renal Other hyperparathyroidism Alpha-1-antitrypsin deficiency Disorders of fatty acid oxidation Peroxisomal disorders Disorders of mitochondrial metabolism Narcolepsy, without cataplexy Narcolepsy, with cataplexy Narcolepsy in conditions classified elsewhere, without cataplexy Narcolepsy in conditions classified elsewhere, with cataplexy Chondritis of pinna Venous embolism and thrombosis of unspecified deep vessels of lower extremity Venous embolism and thrombosis of deep vessels of proximal lower extremity Venous embolism and thrombosis of deep vessels of distal lower extremity Allergic rhinitis, due to animal (cat) (dog) hair and dander Obstructive chronic bronchitis with acute bronchitis Dental caries pit and fissure

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Diagnosis Code 52107 52108 52110 52111 52112 52113 52114 52115 52120 52121 52122 52123 52124 52125 52130 52131 52132 52133 52134 52135 52140 52141 52142 52149 52320 52321 52322 52323 52324 52325 52407 52420 52421 52422 52423 52424 52425

Description Dental caries of smooth surface Dental caries of root surface Excessive attrition, unspecified Excessive attrition, limited to enamel Excessive attrition, extending into dentine Excessive attrition, extending into pulp Excessive attrition, localized Excessive attrition, generalized Abrasion, unspecified Abrasion, limited to enamel Abrasion, extending into dentine Abrasion, extending into pulp Abrasion, localized Abrasion, generalized Erosion, unspecified Erosion, limited to enamel Erosion, extending into dentine Erosion, extending into pulp Erosion, localized Erosion, generalized Pathological resorption, unspecified Pathological resorption, internal Pathological resorption, external Other pathological resorption Gingival recession, unspecified Gingival recession, minimal Gingival recession, moderate Gingival recession, severe Gingival recession, localized Gingival recession, generalized Excessive tuberosity of jaw Unspecified anomaly of dental arch relationship Angle's class I Angle's class II Angle's class III Open anterior occlusal relationship Open posterior occlusal relationship

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Diagnosis Code 52426 52427 52428 52429 52430 52431 52432 52433 52434 52435 52436 52437 52439 52450 52451 52452 52453 52454 52455 52456 52457 52459 52464 52475 52476 52481 52482 52489 52520 52521 52522 52523 52524 52525 52526 52871 52872

Description Excessive horizontal overlap Reverse articulation Anomalies of interarch distance Other anomalies of dental arch relationship Unspecified anomaly of tooth position Crowding of teeth Excessive spacing of teeth Horizontal displacement of teeth Vertical displacement of teeth Rotation of teeth Insufficient interocclusal distance of teeth (ridge) Excessive interocclusal distance of teeth Other anomalies of tooth position Dentofacial functional abnormality, unspecified Abnormal jaw closure Limited mandibular range of motion Deviation in opening and closing of the mandible Insufficient anterior guidance Centric occlusion maximum intercuspation discrepancy Non-working side interference Lack of posterior occlusal support Other dentofacial functional abnormalities Temporomandibular joint sounds on opening and/or closing the jaw Vertical displacement of alveolus and teeth Occlusal plane deviation Anterior soft tissue impingement Posterior soft tissue impingement Other specified dentofacial anomalies Unspecified atrophy of edentulous alveolar ridge Minimal atrophy of the mandible Moderate atrophy of the mandible Severe atrophy of the mandible Minimal atrophy of the maxilla Moderate atrophy of the maxilla Severe atrophy of the maxilla Minimal keratinized residual ridge mucosa Excessive keratinized residual ridge mucosa

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Diagnosis Code 52879 53086 53087 58881 58889 61800 61801 61802 61803 61804 61805 61809 61881 61882 61883 61889 62130 62131 62132 62133 62210 62211 62212 62920 62921 62922 62923 69284 70521 70522 70700 70701 70702 70703 70704 70705

Description Other disturbances of oral epithelium, including tongue Infection of esophagostomy Mechanical complication of esophagostomy Secondary hyperparathyroidism (of renal origin) Other specified disorders resulting from impaired renal function Unspecified prolapse of vaginal walls Cystocele, midline Cystocele, lateral Urethrocele Rectocele Perineocele Other prolapse of vaginal walls without mention of uterine prolapse Incompetence or weakening of pubocervical tissue Incompetence or weakening of rectovaginal tissue Pelvic muscle wasting Other specified genital prolapse Endometrial hyperplasia, unspecified Simple endometrial hyperplasia without atypia Complex endometrial hyperplasia without atypia Endometrial hyperplasia with atypia Dysplasia of cervix, unspecified Mild dysplasia of cervix Moderate dysplasia of cervix Female genital mutilation status, unspecified Female genital mutilation Type I status Female genital mutilation Type II status Female genital mutilation Type III status Contact dermatitis and other eczema due to animal (cat) (dog) dander Primary focal hyperhidrosis Secondary focal hyperhidrosis Decubitus ulcer, unspecified site Decubitus ulcer, elbow Decubitus ulcer, upper back Decubitus ulcer, lower back Decubitus ulcer, hip Decubitus ulcer, buttock

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Diagnosis Code 70706 70707 70709 75831 75832 75833 75839 78058 78838 79095 79503 79504 79505 79508 7966 V0171 V0179 V0183 V0184 V4611 V4612 V4983 V5844 V5866 V5867 V694 V7231 V7232 V7240 V7241 V8401 V8402 V8403 V8404 V8409 V848

Description Decubitus ulcer, ankle Decubitus ulcer, heel Decubitus ulcer, other site Cri-du-chat syndrome Velo-cardio-facial syndrome Other microdeletions Other autosomal deletions Sleep related movement disorder Overflow incontinence Elevated C-reactive protein (CRP) Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL) Papanicolaou smear of cervix with high grade squamous intraepithelial lesion (HGSIL) Cervical high risk human papillomavirus (HPV) DNA test positive Nonspecific abnormal papanicolaou smear of cervix, unsatisfactory smear Nonspecific abnormal findings on neonatal screening Contact or exposure to varicella Contact or exposure to other viral diseases Contact or exposure to escherichia coli (E. coli) Contact or exposure to meningococcus Dependence on respirator, status Encounter for respirator dependence during power failure Awaiting organ transplant status Aftercare following organ transplant Long-term (current) use of aspirin Long-term (current) use of insulin Lack of adequate sleep Routine gynecological examination Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear Pregnancy examination or test, pregnancy unconfirmed Pregnancy examination or test, negative result Genetic susceptibility to malignant neoplasm of breast Genetic susceptibility to malignant neoplasm of ovary Genetic susceptibility to malignant neoplasm of prostate Genetic susceptibility to malignant neoplasm of endometrium Genetic susceptibility to other malignant neoplasm Genetic susceptibility to other disease

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New Procedure Codes (None require precertification from the Texas Health Network)

Procedure Code K-00016 K-00017 K-00021 K-00022 K-00023 K-00024 K-00025 K-00028 K-00029 K-00031 K-00032 K-00033 K-00034 K-00035 K-00039 K-00061 K-00062 K-00063 K-00064 K-00065 K-00091 K-00092 K-00093 K-02764 K-03768 K-03790 K-04438 K-04467 K-04468 K-04495 K-04496 K-04497 K-04498 K-08165 K-08166 Description Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Infusion of vasopressor agent Intravascular imaging of extracranial cerebral vessels Intravascular imaging of intrathoracic vessels Intravascular imaging of peripheral vessels Intravascular imaging of coronary vessels Intravascular imaging of renal vessels Intravascular imaging, other specified vessel(s) Intravascular imaging, unspecified vessel(s) Computer assisted surgery with CT/CTA Computer assisted surgery with MR/MRA Computer assisted surgery with fluoroscopy Imageless computer assisted surgery Computer assisted surgery with multiple datasets Other computer assisted surgery Percutaneous angioplasty or atherectomy of precerebral (extracranial) vessel(s) Percutaneous angioplasty or atherectomy of intracranial vessel(s) Percutaneous insertion of carotid artery stent(s) Percutaneous insertion of other precerebral (extracranial) artery stent(s) Percutaneous insertion of intracranial vascular stent(s) Transplant from live related donor Transplant from live non-related donor Transplant from cadaver Insertion of palatal implant Insertion of percutaneous external heart assist device Insertion of left atrial appendage device Laparoscopic gastroenterostomy Laparoscopic procedures for creation of esophagogastric sphincteric competence Laparoscopic gastroplasty Laparoscopic gastric restrictive procedure Laparoscopic revision of gastric restrictive procedure Laparoscopic removal of gastric restrictive device(s) (Laparoscopic) adjustment of size of adjustable gastric restrictive device Vertebroplasty Kyphoplasty

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Procedure Code K-08453 K-08454 K-08455 K-08459 K-08460 K-08461 K-08462 K-08463 K-08464 K-08465 K-08466 K-08467 K-08468 K-08469 K-08694 K-08695 K-08696 K-08949 K-09978

Description Implantation of internal limb lengthening device with kinetic distraction Implantation of other internal limb lengthening device Insertion of bone void filler Insertion of other spinal devices Insertion of spinal disc prosthesis, not otherwise specified Insertion of partial spinal disc prosthesis, cervical Insertion of total spinal disc prosthesis, cervical Insertion of spinal disc prosthesis, thoracic Insertion of partial spinal disc prosthesis, lumbosacral Insertion of total spinal disc prosthesis, lumbosacral Revision or replacement of artificial spinal disc prosthesis, cervical Revision or replacement of artificial spinal disc prosthesis, thoracic Revision or replacement of artificial spinal disc prosthesis, lumbosacral Revision or replacement of artificial spinal disc prosthesis, not otherwise specified Insertion or replacement of single array neurostimulator pulse generator Insertion or replacement of dual array neurostimulator pulse generator Insertion or replacement of other neurostimulator pulse generator Automatic implantable cardioverter/defibrillator (AICD) check Aquapheresis

Invalid Diagnosis Codes

Diagnosis Code 0664 2520 347 5211 5212 5213 5214 5232 5242 5243 5245 5248 5252 5287 Description West Nile Fever Hyperparathyroidism Cataplexy and narcolepsy Excessive attrition Abrasion Erosion Pathological resorption Gingival recession Anomalies of dental arch relationship Anomalies of tooth position Dentofacial functional abnormalities Other specified dentofacial anomalies Atrophy of edentulous alveolar ridge Other disturbances of oral epithelium, including tongue

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Diagnosis Code 5888 6180 6188 6213 6221 7070 7583 V017 V461 V723 V724

Description Other specified disorders resulting from impaired renal function Prolapse of vaginal walls without mention of uterine prolapse Other specified genital prolapse Endometrial cystic hyperplasia Dysplasia of cevix (uteri) Decubitus ulcer Autosomal deletion syndromes Other viral diseases Respirator Gynecological examination Pregnancy examination or test, pregnancy unconfirmed

Invalid Procedure Codes

ere are no invalid procedure codes for the 2005 ICD-9-CM implementation.

Revised Diagnosis Descriptions

Diagnosis code 04182 07041 07051 25000 25001 25002 25003 25010 25011 25012 25013 25020 25021 25022 25023 25030 25031 25032 Description Bacteroides fragilis Acute hepatitis C with hepatic coma Acute hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled Diabetes with ketoacidosis, type II or unspecified type, uncontrolled Diabetes with ketoacidosis, type I [juvenile type], uncontrolled Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled Diabetes with hyperosmolarity, type I [juvenile type],uncontrolled Diabetes with other coma, type II or unspecified type, not stated as uncontrolled Diabetes with other coma, type I [juvenile type], not stated as uncontrolled Diabetes with other coma, type II or unspecified type, uncontrolled

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Diagnosis Code 25033 25040 25041 25042 25043 25050 25051 25052 25053 25060 25061 25062 25063 25070 25071 25072 25073 25080 25081 25082 25083 25090 25091 25092 25093 2865 29040 29041 29042 29043 2911

Description Diabetes with other coma, type I [juvenile type], uncontrolled Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with renal manifestations, type II or unspecified type, uncontrolled Diabetes with renal manifestations, type I [juvenile type],uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type],not stated as uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type],uncontrolled Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Diabetes with neurological manifestations, type I [juvenile type], uncontrolled Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled Diabetes with peripheral circulatory disorders, type II orunspecified type, uncontrolled Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with other specified manifestations, type II or unspecified type, uncontrolled Diabetes with other specified manifestations, type I [juvenile type], uncontrolled Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled Diabetes with unspecified complication, type II or unspecified type, uncontrolled Diabetes with unspecified complication, type I [juvenile type], uncontrolled Hemorrhagic disorder due to intrinsic circulating anticoagulants Vascular dementia, uncomplicated Vascular dementia, with delirium Vascular dementia, with delusions Vascular dementia, with depressed mood Alcohol-induced persisting amnestic disorder

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Diagnosis Code 2912 2913 2915 29189 2919 2920 29211 29212 29282 29283 29284 2930 29381 29382 29383 29384 29389 2939 2940 2948 2949 29540 29541 29542 29543 29544 29545 29560 29561 29562 29563 29564 29565 29570 29571 29572 29573

Description Alcohol-induced persisting dementia Alcohol-induced psychotic disorder with hallucinations Alcohol-induced psychotic disorder with delusions Other specified alcohol-induced mental disorders Unspecified alcohol-induced mental disorders Drug withdrawal Drug-induced psychotic disorder with delusions Drug-induced psychotic disorder with hallucinations Drug-induced persisting dementia Drug-induced persisting amnestic disorder Drug-induced mood disorder Delirium due to conditions classified elsewhere Psychotic disorder with delusions in conditions classified elsewhere Psychotic disorder with hallucinations in conditions classified elsewhere Mood disorder in conditions classified elsewhere Anxiety disorder in conditions classified elsewhere Other specified transient mental disorders due to conditions classified elsewhere, other Unspecified transient mental disorder in conditions classified elsewhere Amnestic disorder in conditions classified elsewhere Other persistent mental disorders due to conditions classified elsewhere Unspecified persistent mental disorders due to conditions classified elsewhere Schizophreniform disorder, unspecified Schizophreniform disorder, subchronic Schizophreniform disorder, chronic Schizophreniform disorder, subchronic with acute exacerbation Schizophreniform disorder, chronic with acute exacerbation Schizophreniform disorder, in remission Schizophrenic disorders, residual type, unspecified Schizophrenic disorders, residual type, subchronic Schizophrenic disorders, residual type, chronic Schizophrenic disorders, residual type, subchronic with acute exacerbation Schizophrenic disorders, residual type, chronic with acute exacerbation Schizophrenic disorders, residual type, in remission Schizoaffective disorder, unspecified Schizoaffective disorder, subchronic Schizoaffective disorder, chronic Schizoaffective disorder, subchronic with acute exacerbation

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Diagnosis Code 29574 29575 29600 29601 29602 29603 29604 29605 29606 29640 29641 29642 29643 29644 29645 29646 29650 29651 29652 29653 29654 29655 29656 29660 29661 29662 29663 29664 29665 29666

Description Schizoaffective disorder, chronic with acute exacerbation Schizoaffective disorder, in remission Bipolar I disorder, single manic episode, unspecified Bipolar I disorder, single manic episode, mild Bipolar I disorder, single manic episode, moderate Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior Bipolar I disorder, single manic episode, in partial or unspecified remission Bipolar I disorder, single manic episode, in full remission Bipolar I disorder, most recent episode (or current) manic, unspecified Bipolar I disorder, most recent episode (or current) manic, mild Bipolar I disorder, most recent episode (or current) manic, moderate Bipolar I disorder, most recent episode (or current) manic, severe, without mention of psychotic behavior Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior Bipolar I disorder, most recent episode (or current) manic, in partial or unspecified remission Bipolar I disorder, most recent episode (or current) manic, in full remission Bipolar I disorder, most recent episode (or current) depressed, unspecified Bipolar I disorder, most recent episode (or current) depressed, mild Bipolar I disorder, most recent episode (or current) depressed, moderate Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of psychotic behavior Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with psychotic behavior Bipolar I disorder, most recent episode (or current) depressed, in partial or unspecified remission Bipolar I disorder, most recent episode (or current) depressed, in full remission Bipolar I disorder, most recent episode (or current) mixed, unspecified Bipolar I disorder, most recent episode (or current) mixed, mild Bipolar I disorder, most recent episode (or current) mixed, moderate Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of psychotic behavior Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with psychotic behavior Bipolar I disorder, most recent episode (or current) mixed, in partial or unspecified remission Bipolar I disorder, most recent episode (or current) mixed, in full remission

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Diagnosis Code 2967 29680 29689 29690 29699 2971 2973 29900 29901 29910 29911 29980 29981 29990 29991 30001 30012 30013 30014 30016 30021 30029 3004 3006 30089 3009 30122 3014 30181 30182 30183 3020 3023 3026 30271 30273 30274

Description Bipolar I disorder, most recent episode (or current) unspecified Bipolar disorder, unspecified Other and unspecified bipolar disorders, other Unspecified episodic mood disorder Other specified episodic mood disorder Delusional disorder Shared psychotic disorder Autistic disorder, current or active state Autistic disorder, residual state Childhood disintegrative disorder, current or active state Childhood disintegrative disorder, residual state Other specified pervasive developmental disorders, current or active state Other specified pervasive developmental disorders, residual state Unspecified pervasive developmental disorder, current or active state Unspecified pervasive developmental disorder, residual state Panic disorder without agoraphobia Dissociative amnesia Dissociative fugue Dissociative identity disorder Factitious disorder with predominantly psychological signs and symptoms Agoraphobia with panic disorder Other isolated or specific phobias Dysthymic disorder Depersonalization disorder Other somatoform disorders Unspecified nonpsychotic mental disorder Schizotypal personality disorder Obsessive-compulsive personality disorder Narcissistic personality disorder Avoidant personality disorder Borderline personality disorder Ego-dystonic sexual orientation Transvestic fetishism Gender identity disorder in children Hypoactive sexual desire disorder Female orgasmic disorder Male orgasmic disorder

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Diagnosis Code 30275 30276 30285 30410 30411 30412 30413 30540 30541 30542 30543 3070 30721 30722 30723 3073 30745 30746 30751 30753 30789 3090 30924 30928 3093 3094 30981 3101 31323 31381 3139 3151 31531 31532 3154 5217

Description Premature ejaculation Dyspareunia, psychogenic Gender identity disorder in adolescents or adults Sedative, hypnotic or anxiolytic dependence, unspecified Sedative, hypnotic or anxiolytic dependence, continuous Sedative, hypnotic or anxiolytic dependence, episodic Sedative, hypnotic or anxiolytic dependence, in remission Sedative, hypnotic or anxiolytic abuse, unspecified Sedative, hypnotic or anxiolytic abuse, continuous Sedative, hypnotic or anxiolytic abuse, episodic Sedative, hypnotic or anxiolytic abuse, in remission Stuttering Transient tic disorder Chronic motor or vocal tic disorder Tourette's disorder Stereotypic movement disorder Circadian rhythm sleep disorder Sleep arousal disorder Bulimia nervosa Rumination disorder Other, pain disorder related to psychological factors Adjustment disorder with depressed mood Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with disturbance of conduct Adjustment disorder with mixed disturbance of emotions and conduct Posttraumatic stress disorder Personality change due to conditions classified elsewhere Selective mutism Oppositional defiant disorder Unspecified emotional disturbance of childhood or adolescence Mathematics disorder Expressive language disorder Mixed receptive-expressive language disorder Developmental coordination disorder Intrinsic posteruptive color changes

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Diagnosis Code 76070 76071 76072 76073 76074 76075 76076 76079 7808 79500 79501 79502 79509 V074

Description Noxious influences affecting fetus or newborn via placenta or breast milk, unspecified noxious substance Noxious influences affecting fetus or newborn via placenta or breast milk, alcohol Noxious influences affecting fetus or newborn via placenta or breast milk, narcotics Noxious influences affecting fetus or newborn via placenta or breast milk, hallucinogenic agents Noxious influences affecting fetus or newborn via placenta or breast milk, anti-infectives Noxious influences affecting fetus or newborn via placenta or breast milk, cocaine Noxious influences affecting fetus or newborn via placenta or breast milk, diethylstilbestrol [DES] Noxious influences affecting fetus or newborn via placenta or breast milk, other Generalized hyperhidrosis Abnormal glandular Papanicolaou smear of cervix Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US) Papanicolaou smear of cervix with atypical squamous cells cannot exclude high grade squamous intraepithelial lesion (ASC-H) Other abnormal Papanicolaou smear of cervix and cervical HPV Hormone replacement therapy (postmenopausal)

Revised Procedure Code Descriptions

Procedure code K-00055 K-00122 K-00293 K-00393 K-00394 K-00492 K-00493 K-03611 K-03612 K-03613 K-03614 K-03762 K-03763 K-03765 K-03766 Description Insertion of drug-eluting peripheral vessel stent(s) Removal of intracranial neurostimulator lead(s) Implantation or replacement of intracranial neurostimulator lead(s) Implantation or replacement of spinal neurostimulator lead(s) Removal of spinal neurostimulator lead(s) Implantation or replacement of peripheral neurostimulator lead(s) Removal of peripheral neurostimulator lead(s) (Aorto)coronary bypass of one coronary artery (Aorto)coronary bypass of two coronary arteries (Aorto)coronary bypass of three coronary arteries (Aorto)coronary bypass of four or more coronary arteries Insertion of non-implantable heart assist system Repair of heart assist system Implant of external heart assist system Insertion of implantable heart assist system

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Procedure code K-03950 K-03990 K-08605

Description Angioplasty or atherectomy of other non-coronary vessel(s) Insertion of non-drug-eluting peripheral vessel stents(s) Incision with removal of foreign body or device from skin and subcutaneous tissue

Invalid DRG Codes

DRG Code 483 DRG Title Trac w mech vent 96+hrs or pdx except face, mouth & neck dx

New DRG Codes

DRG Code 541 542 543 DRG Title Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses With Major O.R. Procedure Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses Without Major O.R. Procedure Craniotomy with Implantation of Chemotherapeutic Agent or Acute Complex Central Nervous System Principal Diagnosis

ICD-9 Policy Update

e following policy changes have been made to support the 2005 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) implementation.

Aerosol Treatments, Outpatient Setting

Effective for dates of service on and after November 1, 2004, the new diagnosis code 49122 (Obstructive chronic bronchitis with acute bronchitis) will be payable for outpatient aerosol treatments.

Ambulatory Electroencephalography (A/EEG)

Effective for dates of service on and after November 1, 2004, the following revised diagnosis codes will be payable for Ambulatory Electroencephalography: Diagnosis Code 2930 2948 Description Acute delirium, epileptic; confusional state Other specified organic brain syndromes (chronic), epileptic psychosis NOS

Antihemophilic Factor

Effective for dates of service on and after November 1, 2004, the revised diagnosis code 2865 (Hemorrhagic disorder due to intrinsic circulating anticoagulants) will be payable for Antihemophilic Factor.

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Diabetic Supplies/Equipment

Effective for dates of service on and after November 1, 2004, the following revised diagnosis codes will be payable for diabetic supplies/equipment: Diagnosis Code 25000 25003 25010 25013 25020 25023 25030 25033 25040 25043 25050 25053 25060 25063 25070 25073 25080 25083 25090 25093 Description Diabetes mellitus without mention of complication Diabetes mellitus without mention of complication Diabetes with ketoacidosis Diabetes with ketoacidosis Diabetes with hyperosmolarity Diabetes with hyperosmolarity Diabetes with other coma Diabetes with other coma Diabetes with renal manifestations Diabetes with renal manifestations Diabetes with ophthalmic manifestations Diabetes with ophthalmic manifestations Diabetes with neurological manifestations Diabetes with neurological manifestations Diabetes with peripheral circulatory disorders Diabetes with peripheral circulatory disorders Diabetes with other specified manifestations Diabetes with other specified manifestations Diabetes with unspecified complications Diabetes with unspecified complications

Doctor of Dentistry Services as a Limited Physician

Effective for dates of service on and after November 1, 2004, the following diagnosis codes will no longer be payable for Doctor of Dentistry services: Diagnosis Code 5242 5245 5287 Description Dental Arch Anomaly ABN Dentofacial Function Oral Epithelium Dis Nec

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e following new diagnosis codes will be payable for Doctor of Dentistry services: Diagnosis Code 52420 52421 52422 52423 52424 52425 52426 52427 52428 52429 52450 52451 52452 52453 52454 52455 52456 52457 52459 52871 52872 52879 Description Unspecified anomaly of dental arch relationship Angle's class I Angle's class II Angle's class III Open anterior occlusal relationship Open posterior occlusal relationship Excessive horizontal overlap Reverse articulation Anomalies of interarch distance Other anomalies of dental arch relationship Dentofacial functional abnormality, unspecified Abnormal jaw closure Limited mandibular range of motion Deviation in opening and closing of the mandible Insufficient anterior guidance Centric occlusion maximum intercuspation discrepancy Non-working side interference Lack of posterior occlusal support Other dentofacial functional abnormalities Minimal keratinized residual ridge mucosa Excessive keratinized residual ridge mucosa Other disturbances of oral epithelium, including tongue

Doppler Examinations/Noninvasive Diagnostic Studies

Effective for dates of service on and after November 1, 2004, the following new diagnosis codes will be payable for Doppler examinations/noninvasive diagnostic studies: Diagnosis Code 45340 45341 45342 Description Venous embolism and thrombosis of unspecified deep vessels of lower extremity Venous embolism and thrombosis of deep vessels of proximal lower extremity Venous embolism and thrombosis of deep vessels of distal lower extremity

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Electrocardiogram (EKG, ECG)

Effective for dates of service on and after November 1, 2004, the following new diagnosis codes will be payable for electrocardiograms: Diagnosis Code V4983 V5844 Description Awaiting organ transplant status Aftercare following organ transplant

Electronic Blood Pressure Monitoring Device

Effective for dates of service on and after November 1, 2004, the new diagnosis code 58889 (Other specific disorders resulting from impaired renal function) will be payable for electronic blood pressure monitoring devices.

Esophageal pH Probe Monitoring

Effective for dates of service on and after November 1, 2004, the following new diagnosis codes will be payable for esophageal pH probe monitoring: Diagnosis Code 53086 53087 Description Infection of esophagostomy Mechanical complication of esophagostomy

Gynecological Reproductive Health Services

Effective for dates of service on and after November 1, 2004, the deleted diagnosis code 6213 (Endometrial cystic hyperplasia) will no longer be payable for gynecological reproductive health services. e following new diagnosis codes will be payable for gynecological reproductive health services: Diagnosis Code 62130 62131 62132 62133 Description Endometrial hyperplasia, unspecified Simple endometrial hyperplasia without atypia Complex endometrial hyperplasia without atypia Endometrial hyperplasia with atypia

Hepatitis B Prophylaxis

Effective for dates of service on and after November 1, 2004, the revised diagnosis code 2865 (Hemorrhagic disorder due to intrinsic circulating anticoagulants) will be payable for Hepatitis B Prohylaxis.

Immunosuppressive Drugs

Effective for dates of service on and after November 1, 2004, the new diagnosis code V5844 (Aftercare following organ transplant) will be payable for immunosuppressive drugs.

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Injections ­ Gamma Globulin

Effective for dates of service on and after November 1, 2004, the deleted diagnosis code V017 (Contact or exposure to other communicable disease; other viral diseases) will no longer be payable for Gamma Globulin injections. e new diagnosis code V0179 (Contact or exposure to other viral diseases) will be payable for Gamma Globulin injections.

Injections ­ Interferon

Effective for dates of service on and after November 1, 2004, the following new diagnosis codes will be payable for interferon injections: Diagnosis Code 07070 07071 Description Unspecified viral hepatitis C without hepatic coma Unspecified viral hepatitis C with hepatic coma

Injections ­ Iron

Effective for dates of service on and after November 1, 2004, the deleted diagnosis code 5888 (Other specified disorders resulting from impaired renal function) will no longer be payable for Iron injections. e following new diagnosis codes will be payable for Iron injections: Diagnosis Code 58881 58889 Description Secondary hyperparathyroidism (of renal origin) Other specified disorders resulting from impaired renal function

Injections ­ Vitamin B12

Effective for dates of service on and after November 1, 2004, the following revised diagnosis codes will be payable for Vitamin B12 injections: Diagnosis Code 25060 25061 25062 25063 Description Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Diabetes with neurological manifestations, type I [juvenile type], uncontrolled

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Nerve Conduction Studies

Effective for dates of service on and after November 1, 2004, the following revised diagnosis codes will be payable for nerve conduction studies: Diagnosis code 25060 25061 25062 25063 New Description Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled Diabetes with neurological manifestations, type II or unspecified type, uncontrolled Diabetes with neurological manifestations, type I [juvenile type], uncontrolled

Outpatient Behavioral Health Services

Effective for dates of service on and after November 1, 2004, the following revised diagnosis codes will be payable for outpatient behavioral health services: Diagnosis Code 29040 29043 2911 2912 2915 29189 2919 2920 2930 2939 2940 2949 29600 29606 29640 29646 29650 29656 29660 29666 2967 29680 Description Arteriosclerotic dementia Arteriosclerotic dementia Alcohol amnestic syndrome Other alcoholic dementia Alcoholic jealousy Other alcohol withdrawal Unspecified alcoholic psychosis Drug withdrawal syndrome Transient organic psychotic conditions Transient organic psychotic conditions Other organic psychotic conditions (chronic) Includes: Other organic psychotic conditions (chronic) Includes: Manic disorder, single episode Manic disorder, single episode Bipolar affective disorder, manic Bipolar affective disorder, manic Bipolar affective disorder, depressed Bipolar affective disorder, depressed Bipolar affective disorder, mixed Bipolar affective disorder, mixed Bipolar affective disorder, unspecified Manic-depressive psychosis, other and unspecified

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Diagnosis Code 29689 29690 29699 29900 29910 29980 29990 29991 30029 3004 3006 30089 3009 3014 3020 3070 3090 3101 3139 31532 3154

Description Manic-depressive psychosis, other and unspecified Other and unspecified affective psychoses Other and unspecified affective psychoses Infantile autism (current or residual) Disintegrative psychosis Other specified early childhood psychoses Unspecified childhood psychoses Psychoses with origin specific to childhood Phobic disorders Neurotic depression Depersonalization syndrome Other neurotic disorders Unspecified neurotic disorder Compulsive personality disorder Sexual deviations and disorders Special symptoms or syndromes, not elsewhere classified Adjustment reaction Organic personality syndrome Disturbance of emotions specific to childhood and adolescence Developmental speech or language disorder Coordination disorder

Polysomnography/Multiple Sleep Latency Test

Effective for dates of service on and after November 1, 2004, the following new diagnosis codes will be payable for polysomnography: Diagnosis Code 34700 34701 34710 34711 Description Narcolepsy, without cataplexy Narcolepsy, with cataplexy Narcolepsy in conditions classified elsewhere, without cataplexy Narcolepsy in conditions classified elsewhere, with cataplexy

Podiatry Services

Effective for dates of service on and after November 1, 2004, the revised diagnosis code 25060 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled) will be payable for podiatry services.

Respiratory Equipment and Supplies

Effective for dates of service on and after November 1, 2004, the new diagnosis code 49122 (Obstructive chronic bronchitis with acute bronchitis) will be payable for nebulizers and mucous clearance valves.

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Skin erapy

Effective for dates of service on and after November 1, 2004, the new diagnosis code 69284 (Contact dermatitis and other eczema due to animal (cat) (dog) dander) will be payable for skin therapy.

Ultrasound, Ophthalmic

Effective for dates of service on and after November 1, 2004, the following revised diagnosis codes will be payable for ophthalmic ultrasound: Diagnosis code 25050 25051 25052 25053 New Description Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type],not stated as uncontrolled Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled Diabetes with ophthalmic manifestations, type I [juvenile type],uncontrolled

For more information on the ICD-9-CM update, call the TMHP Contact Center at 1-800-925-9126.

Injection Procedure

Claims submitted with procedure code 2-38792, Identify sentinel node, have been incorrectly suspending for manual pricing. Claims submitted on or after August 26, 2004, with procedure code 2-38792 are being reimbursed with a maximum fee of $26.73. No action on the provider's part is required.

Scheduled System Maintenance

e next system maintenance to the TMHP claims process system is scheduled as follows: · Sunday, November 21, 2004, 6:00 p.m. to 11:50 p.m. · Sunday, December 19, 2004, 6:00 p.m. to 11:59 p.m. During system maintenance, some claims engine-related applications are unavailable. Specific details regarding the affected applications are posted on the TMHP website at www.tmhp.com. Providers requiring additional information concerning the scheduled maintenance may call the EDI Help Desk at 1-888-863-3638.

Letter from Medical Director

Texas Medicaid and CHIP Medical Director Dr. John Hellerstedt has issued a letter to all providers about the 2004-2005 Respiratory Syncytial Virus (RSV) season. e letter can be accessed via the TMHP website at www.tmhp.com.

Risperidone LA

Effective for dates of service on or after November 17, 2004, procedure code S0163, Injection, risperidone LA, has been added as a benefit of the Texas Medicaid Program with an allowable fee of $124.23 per 12.5 mgs.

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TMHP Provider Relations Representatives

TMHP provider relations representatives provide services to inform and educate providers about Texas Medicaid Program policies and claims filing procedures. Provider relations representatives assist providers through telephone contact, onsite visits, and scheduled workshops. See the map at right and the table below for the contact information in each region.

Territory 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Regional Area Amarillo and Lubbock Abilene, Midland, Odessa, and San Angelo El Paso Del Rio, Kerrville, and N. San Antonio Brownsville, Falfurrias, and Laredo Corpus Christi and S. San Antonio

Provider Representative Elizabeth Ramirez Diane Molina Isaac Romero Ralph Cervantes Cynthia Gonzales Will McGowan

Telephone Number 1-512-506-6217 1-512-506-3423 1-512-506-3530 1-512-506-3422 1-512-506-7991 1-512-506-3554 1-512-506-3447 1-512-506-3446 1-512-506-7682 1-512-506-3425 1-512-506-3552 1-512-506-3578 1-512-506-7990 1-512-506-7600

Galveston, Harris County, and Beverly Standley Wharton Harris County Conroe and Harris County Beaumont and Lufkin Dallas, Tyler, and Waxahachie Dallas and Texarkana Eastland, Fort Worth, and Wichita Falls Linda Dickson Linda Wood Gene Allred Sandra Peterson Olga Fletcher Rita Martinez

Austin, Bryan, College Station, Andrea Daniell Marble Falls, and Waco

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Vendor Drug Program Clinical Edits

HHSC is implementing clinical edits in the Medicaid Vendor Drug Program. Clinical edits check patients' Medicaid medical and drug claims histories to help determine whether the information on file indicates that the patient's medical condition matches the edit criteria for dispensing the requested drug without need of additional prior authorization. e edits are based on evidence-based clinical criteria and nationally recognized peer-reviewed information. Clinical edits, along with the Preferred Drug List (PDL), help optimize the use of program funds while ensuring access to care through the therapeutically prudent use of pharmaceuticals. HHSC implemented new edits for Proton Pump Inhibitors and Cox-2 medications for Medicaid nursing home recipients in August 2004, and for the general Medicaid population in September 2004. Also, in September, HHSC implemented an additional edit for Erectile Dysfunction drugs. Additional edits will be phased in over time after HHSC receives feedback on proposed edits from the Texas Drug Utilization Review (DUR) Board, the Texas Medical Association, and other stakeholders.

will be able to receive certain products. e criteria may include age, diagnosis from medical history, or inferred diagnosis from prescription claims history. ese criteria will be posted on the Vendor Drug Program website. · When a pharmacy submits a Medicaid claim for a product subject to a clinical edit, the SmartPA system will check the patient's available medical and prescription drug claims histories to determine whether the information in the system shows that the patient's condition meets the established criteria. · If the patient's medical and claims histories demonstrate the criteria are met, the claim will be approved. · If the patient's medical and claims histories do not meet the criteria, the pharmacy will receive a message indicating that the prescriber needs to call the Texas Prior Authorization Call Center at 1-877-PA-TEXAS. For more information on the clinical edits, visit the HHSC Vendor Drug Program website at www.hhsc.state.tx.us/HCF/vdp/vdpstart.html.

How the Clinical Edits Work

With the clinical edits, prior authorization calls may be required for both preferred and non-preferred drugs. e prior authorization process will be similar to the process already used for the PDL. Prior authorizations will be handled both through SmartPA (an automated, pointof-sale system) and the Texas Prior Authorization Call Center. SmartPA helps minimize the need for prior authorization phone calls. · HHSC will establish clinical criteria by which recipients

Upcoming Workshops

TMHP is conducting Ambulance and TDHconnect workshops in your area during the month of November. A schedule of the workshop dates, times, and locations is included on pages 45 and 46 of this bulletin. Additional information and online registration for these workshops is available at www.tmhp.com. Providers can register online for the workshop of their choice by selecting Register for a Workshop from the I would like to... links on the right hand side of the page.

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Case Management for Children and Pregnant Women (CPW) Providers / Freestanding Renal Dialysis Facilities

Performing Provider Numbers

Effective for dates of services on or after January 1, 2005, Case Management for Children and Pregnant Women (CPW) agencies will be required to include a prior authorization number, billing provider number, and case manager performing provider number on all claims. is process will require all case managers working for a CPW agency to enroll with the Texas Medicaid Program and receive a performing provider number. CPW agency providers that are currently enrolled with Medicaid as facilities will be transitioned to provider groups. is transition does not require any action by the agency. TMHP will assign a group TPI number for each facility Each agency case manager working for a CPW agency must apply for a performing provider number (the agency TPI base with a different suffix). Each case manager must complete the Provider Information Form and Provider Assurances sections of the Medicaid Enrollment Packet. All requests for prior authorization received by the Department of State Health Services (DSHS) on or after December 15, 2004, must include both the agency's group TPI and the case manager's individual performing provider number. Without both numbers, CPW services for dates of service on or after January 1, 2005, will not be authorized. Watch the CPW website (www.tdh.state.tx.us/ caseman/caseman.htm) and mail for correspondence from DSHS with policy changes. For more information, contact the CPW program at 1-512-458-7111, ext. 2168.

Renal Dialysis Billing

Effective September 3, 2004, all claims for services submitted by freestanding renal dialysis facilities on a UB-92 (HCFA-1450) form based on procedure codes rather than revenue codes are being denied. Claims for services based on procedure codes, including drugs and other injections, must be billed using an HCFA-1500 claim form. Beginning October 16, 2003, freestanding renal dialysis facilities were required to submit all claims using a UB-92 (HCFA-1450) form or another form meeting the criteria defined in Section 37 of the 2004 Texas Medicaid Provider Procedures Manual. However, use of the UB-92 for billing services other than dialysis treatments (such as injectables and laboratory services) by freestanding facilities resulted in inaccurate payments. In November 2003, providers were contacted and instructed to submit claims for dialysis treatments, based on revenue codes, using a UB-92 form or another appropriate form. Renal dialysis providers also were instructed to begin submitting claims for all other services, not based on revenue codes, using a HCFA-1500 form or another appropriate form. ese claim submission instructions are still in effect. Effective for claims received on or after September 3, 2004, all claims submitted for services other than dialysis treatments (such as injectables and laboratory services) billed by a freestanding renal dialysis facility on a UB-92 are denied. Providers can request an adjustment by sending a copy of the page of the Remittance and Status report showing the denied claim and a corrected HCFA-1500 claim form. If the claim is within the original 95-day filing deadline, providers may resubmit the claim on the HCFA-1500 claim form. For more information, call the TMHP Contact Center at 1-800-925-9126.

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Home Health / THStesps-CCP Providers

Augmentative Communication Devices

An Augmentative Communication Device (ACD) system is a benefit of Texas Medicaid and may be considered for prior authorization as a Home Health benefit when the eligibility criteria for Home Health Services are met. · e documentation submitted with the request supports the determination of medical necessity based on the criteria listed in the policy. · Federal financial participation must be available. · e requested equipment or supplies must be safe for use in the home. Prior authorization is required for rental or purchase of an ACD system provided through Texas Medicaid Title XIX Home Health Services. To obtain prior authorization, the following documentation must be submitted: · Before requesting prior authorization, a completed Home Health (Title XIX) DME/ Medical Supplies Physician Order Form (Title XIX Form), prescribing the DME and/or accessories must be signed and dated by a physician familiar with the client. All signatures must be original, unaltered, and handwritten. Computerized or stamped signatures will not be accepted. e date of the Title XIX Form can be no more than three months prior to the service start date. e completed Title XIX Form must include the procedure codes and quantities for services requested and must be maintained by the DME provider and the prescribing physician in the client's medical record. · To facilitate a determination of medical necessity and avoid unnecessary denials when requesting prior authorization for an ACD system, the physician must provide correct and complete information supporting the medical necessity of the equipment and/or supplies requested, including: -- Diagnosis/condition causing impairment of communication -- Accurate diagnostic information pertaining to any other medical diagnoses/conditions, to include the client's overall health status -- e formal written ACD system evaluation performed by a speech-language pathologist (SLP) and submitted on an Augmentative Communication Device (ACD) System Form, completed by the SLP, which contains all of the following information: · Medical status/condition and medical diagnoses underlying the client's expressive speech-language disorder that gives rise to the need for an ACD system Current expressive speech-language disorder, including the type, severity, anticipated course of the disorder, and present language skills A description of the practical limitations of the client's current aided and unaided modes of communication Other forms of therapy/intervention that have been considered and ruled out e rationale for the recommended ACD system and each accessory, including a statement as to why the recommended device is the most appropriate, least costly alternative for the client and how the recommended system will benefit the client Documentation that the client possesses the cognitive and physical abilities to use the recommended system A comprehensive description of how the ACD system will be integrated into the client's everyday life, including home, school, or work

·

·

· ·

·

·

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Home Health / THStesps-CCP Providers

·

A treatment plan that includes training in the basic operation of the recommended ACD system necessary to ensure optimal use by the client and, if appropriate, the client's caregiver, and a therapy schedule for the client to gain proficiency in using the ACD system A description of the client's speechlanguage goals and how the recommended ACD system will assist the client in achieving these goals A description of the anticipated changes, modifications or upgrades of the ACD system necessary to meet the client's short and long term speech-language needs Identification of the assistance/support needed by, and available to, the client to use and maintain the ACD system A statement that the SLP is financially independent of the ACD system manufacturer/vendor Texas Medicaid may request additional information to clarify or complete a request for an ACD system and accessories e SLP evaluation must be dated prior to the date on the physician's prescription (Title XIX Form)

Enteral Nutritional Products

All enteral nutritional products paid under the Texas Medicaid Program are paid based on units of 100 calories (as documented by the manufacturer) with the appropriate "B" code (as documented by the Statistical Analysis Durable Medical Equipment Regional Carrier [SADMERC] Product Classification List for Enteral Nutrition in effect at the time) and with the appropriate modifier based on the product's average wholesale price (AWP) less 10.5 percent (as documented by the Red Book). It is the provider's responsibility to know the correct "B" code, the correct units of 100 calories, and the modifier for requesting prior authorization and for payment. Supporting documentation for these components must be maintained in the provider's records and be made available upon request by HHSC or TMHP. Payment is based on the lower of billed charges or the Medicaid allowed fee, with the Medicaid allowed fee based on the appropriate "B" code, modifier, and units of 100 calories. It is the provider's responsibility to know when products are discontinued by the manufacturer, when container sizes change and when names change. Please submit requests for prior authorization and payment accordingly. e Palmetto GBA SADMERC Product Classification List is located on its website (www.palmettogba.com).

·

·

·

·

·

·

ACD systems for clients under 21 years of age who do not meet the criteria for Home Health Services may be considered under the Texas Health Steps Comprehensive Care Program (THSteps-CCP). e above conditions and requirements apply for THStepsCCP requests. For more information, call the TMHP Contact Center at 1-800-925-9126.

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Hospital Providers

Transplant Facilities

e Texas Health and Human Services Commission (HHSC) has responsibility for all Texas Medicaid hospital transplant center approvals. HHSC is extending certification approval until further notice for all approved existing transplant facilities. is applies to all current certifications, which were scheduled to expire on October 31, 2004. HHSC is developing a new approval process for initial facility certifications and recertifications with the Texas Medicaid Program. All facilities will be notified of the new process and timelines when completed by HHSC. No action on the part of currently approved Texas Medicaid facilities is necessary at this time. All facilities who wish to perform organ transplants for Texas Medicaid clients must have current certification and be in continuous compliance with the criteria set forth by the Organ Procurement and Transportation Network (OPTN) and receive certification from the United Network for Organ Sharing (UNOS) or the National Marrow Donor Program (NMDP). e Texas Medicaid Program does not approve or reimburse transplants in facilities that are not certified and in good standing with these credentialing organizations. ose facilities whose status of good standing has been suspended for any reason by the credentialing bodies will not be approved by the Texas Medicaid Program to provide transplant services until this status has been restored. HHSC will maintain the list of certified and approved Texas transplant facilities. e facility must also provide proof of continuous certification upon each review and recertification by

that credentialing body. e facility must notify HHSC within three business days of any change in compliance or certification status from UNOS or NMDP. Failure to notify HHSC within three business days of any changes in compliance or certification status may result in disapproval of current and pending transplant requests or recoupment of reimbursement. e Texas Medicaid Program requires that all transplant facilities requesting approval to perform transplants for Texas Medicaid clients provide proof of transplant facility certification. HHSC approval is dependent upon compliance with the transplant facility criteria of the OPTN and certification from UNOS or NMDP. ese private organizations conduct certification and review activities under federal contract to implement under the National Organ Transplant Act (NOTA) of 1984.

RSV-IgIM (Palivisumab) Reimbursement

Hospitals are reimbursed for RSV-IgIM (Palivisumab) at the hospital's interim rate, which is based on a percentage of the hospital's most recent Medicaid cost report settlement. In the spring of 2003, congenital heart disease was added as a covered diagnosis (refer to the May/June 2003 Texas Medicaid Bulletin, No. 172 for diagnosis codes). e client's medical record must contain adequate documentation showing the client's congenital heart disease to be hemodynamically significant. For more information, call the TMHP Contact Center at 1-800-925-9126.

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School Health and Related Services (SHARS) Providers

SHARS Billing

New guidelines have been implemented which may impact your Medicaid billing procedures. e following billing guidelines are effective for SHARS services delivered on or after September 1, 2004. When billing more than the recommended maximum billable time, providers must maintain documentation to support the reasonableness and necessity of the extra time. Review the guidelines associated with the procedures outlined below. Assessment Services (procedure code 96100) Assessment services under procedure code 96100 include activities related to the assessment of the functioning of a student for the purpose of determining the student's need for specific SHARS services and the development or revision of the student's Individualized Education Program (IEP) objectives. Assessment services are billable if they lead to the creation of an IEP for a student with disabilities who is Medicaid eligible and under 21 years of age, whether or not the IEP includes SHARS services. Billable time for assessment services includes direct psychological, educational, and intellectual testing time with the student present, indirect time for interpretation of testing results, and indirect time for report writing. Necessary observation of the student associated with testing is billable as direct testing time. Parent consultation (student present) that is required during the assessment due to a student's inability to communicate or perform certain required testing activities is billable as direct testing time. Indirect time spent in consultation (student not present) with parents, teachers, and other collaterals is not billable time. Indirect time spent gathering information and observing a student is not billable time. Assessment services performed outside the routine school day (e.g., after school or on weekends) are not reimbursable under the SHARS program, unless the service provider receives specific payment for this time outside the routine school day. is is due to the fact that SHARS rates are based on average hourly salaries of the applicable service providers and salaries

for school employees only cover the routine school day. Session notes are not required. However, the following documentation is required: start time, stop time, total minutes, and a notation as to the assessment activity performed (i.e., direct testing, interpretation, or report writing). To be reimbursable under the SHARS program, assessment services must be provided by a professional who either holds a valid TEA or State Board for Educator Certification (SBEC) Educational Diagnostician Certificate or is a licensed psychiatrist, licensed psychologist, or a licensed specialist in school psychology (LSSP). e recommended maximum billable time is eight hours over multiple days for one assessment. Audiology Evaluation (procedure code 92506) Billable audiology evaluation time under procedure code 92506 includes direct evaluation, testing, and observation time with the student present. Indirect time for interpretation and report writing is not billable time. To be reimbursable under the SHARS program, a licensed audiologist, an ASHA-certified, or an ASHA-equivalent audiologist must provide audiology evaluation services. No session notes are required. However, the following documentation is required: start time, stop time, total minutes, and a notation as to the audiology evaluation activity performed (i.e., direct evaluation; direct testing; or direct observation). e recommended maximum billable time is 12 units (three hours) over multiple days for one audiology evaluation. Audiology erapy (procedure code 92507) Billable audiology therapy time under procedure code 92507 includes direct therapy time with the student present and in an individual, one-on-one setting. Group therapy time is not billable under procedure code 92507. To be reimbursable under the SHARS program, a licensed audiologist, an ASHA-certified, or an ASHAequivalent audiologist must deliver audiology therapy services. Services provided by a licensed audiologist assistant, even under the supervision of a licensed audiologist, are not reimbursable under the SHARS program. Session notes are required to document

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School Health and Related Services (SHARS) Providers

audiology therapy services, including at a minimum: start time, stop time, total minutes, a description of the primary activity performed during the session, an observation of the student's behavior/performance during the session, and the IEP objectives to which the session related. e recommended maximum billable time is four units (one hour) per day for audiology therapy services. Counseling Services (procedure code H0004) Billable counseling services under procedure code H0004 include direct counseling services or counseling evaluation time with the student present and in an individual, one-on-one setting. Group counseling services are not billable under H0004. To be reimbursable under the SHARS program, counseling services must be provided by a professional holding a TEA or SBEC counseling certification, licensed professional counselor (LPC), licensed clinical social worker (LCSW, formerly LMSW-ACP), or licensed marriage and family therapist (LMFT). Counseling services provided by a licensed psychiatrist, licensed psychologist or LSSP should be billed under procedure code H0004 with modifier AH as psychological services. Session notes are required to document counseling services, including at a minimum: start time, stop time, total minutes, a description of the primary activity/issue performed/ discussed during the session, an observation of the student's behavior/performance during the session, and the IEP objectives to which the session related. e recommended maximum billable time is four units (one hour) for non-emergency situations. Emergency counseling requires a Behavior Improvement Plan (BIP). Psychological/Counseling Services (procedure code H0004 with modifier AH) Billing psychological (counseling) services under procedure code H0004 with modifier AH include direct psychological services (counseling) or counseling

evaluation time with the student present and in an individual, one-on-one setting. Group services are not billable under procedure code H0004 with modifier AH. To be reimbursable under the SHARS program, a licensed psychiatrist, licensed psychologist, or LSSP must provide psychological (counseling) services under this code and modifier. Counseling services provided by a LPC, LCSW, LMFT, TEA-certified school counselor or SBEC-certified school counselor should be billed under H0004 without any modifier. Session notes are required to document psychological (counseling) services, including at a minimum: start time, stop time, total minutes, a description of the primary activity/issue performed/discussed during the session, an observation of the student's behavior/performance during the session, and the IEP objectives to which the session related. e recommended maximum billable time is four units (one hour) for non-emergency situations. Emergency psychological (counseling) services require a Behavior Improvement Plan (BIP). School Health Services (procedure code T1002) Billable school health services under procedure code T1002 include skilled nursing tasks as defined by the Board of Nurse Examiners (BNE) and performed by a registered nurse (RN) or an advanced practice nurse (APN). Services provided by a licensed vocational nurse (LVN) / licensed practical nurse (LPN) or provided through RN delegation by a trained, unlicensed assistive person (e.g., school health aide, teacher, or teacher's aide) are not billable under the SHARS program. Billable services under procedure code T1002 include direct time with the student present and in an individual, one-on-one setting. Group school health services are not billable under procedure code T1002. Session notes are not required. However, the following documentation is required at a minimum: start time, stop time, total minutes, and a notation as to the type of school health services performed (e.g., catheterization; inhalation therapy; etc.). Total minutes of school health services must be accumulated for a

November/December 2004

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Texas Medicaid Bulletin, No. 183

School Health and Related Services (SHARS) Providers

client for the entire calendar day and then converted into 15-minute units of services and not converted to units of service for each school health services task throughout the day. Minutes of school health services cannot be accumulated over multiple days until a unit of service can be billed. If the total minutes of school health services for a student is less than eight minutes during one calendar day, those minutes are not billable that day or any other day. Occupational erapy Evaluation (procedure code 97003) Billable occupational therapy evaluation time under procedure code 97003 includes direct evaluation, testing, and observation time with the student present, including evaluation and fitting of a wheelchair or other adaptive assistive equipment. Indirect time for interpretation and report writing is not billable time. To be reimbursable under the SHARS program, occupational therapy evaluation services must be provided by a licensed occupational therapist. No session notes are required. However, the following documentation is required: start time, stop time, total minutes, and a notation as to the occupational therapy evaluation activity performed (i.e., direct evaluation, direct testing, or direct observation). e recommended maximum billable time is 12 units (three hours) over multiple days for one occupational therapy evaluation. Occupational erapy (procedure code 97530) Billable occupational therapy time under procedure code 97530 includes direct therapy time with the student present and in an individual, one-on-one setting. Group therapy time is not billable under procedure code 97530. To be reimbursable under the SHARS program, occupational therapy services must be delivered by a licensed occupational therapist. Services provided by a certified occupational therapist assistant (COTA), even under the supervision of a licensed occupational therapist, are not reimbursable under the SHARS program. erapists with

experience billing for Medicaid services outside the school environment are aware of numerous individual procedure codes applicable to specific therapeutic services and modalities. All of these various procedure codes are billable under the SHARS program under this single code. Session notes are required to document occupational therapy services including at a minimum: start time, stop time, total minutes, a description of the primary activity performed during the session, an observation of the student's behavior/performance during the session, and the IEP objectives to which the session related. e recommended maximum billable time is four units (one hour) per day for occupational therapy services. A physician prescription/referral is required before occupational therapy services can be billed under the SHARS program. Physical erapy Evaluation (procedure code 97001) Billable physical therapy evaluation time under procedure code 97001 includes direct evaluation, testing, and observation time with the student present, including evaluation and fitting of a wheelchair or other adaptive assistive equipment. Indirect time for interpretation and report writing is not billable time. To be reimbursable under the SHARS program, physical therapy evaluation services must be provided by a licensed physical therapist. No session notes are required. However, the following documentation is required: start time, stop time, total minutes, and a notation as to the physical therapy evaluation activity performed (i.e., direct evaluation, direct testing, or direct observation). e recommended maximum billable time is 12 units (three hours) over multiple days for one physical therapy evaluation. Physical erapy (procedure code 97110) Billable physical therapy time under procedure code 97110 includes direct therapy time with the student present and in an individual, one-on-one setting. Group therapy time is not billable under procedure code 97110. To be reimbursable under the SHARS program, physical therapy services must be delivered

Texas Medicaid Bulletin, No. 183

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November/December 2004

School Health and Related Services (SHARS) Providers

by a licensed physical therapist. Services provided by a licensed physical therapist assistant (LPTA), even under the supervision of a licensed physical therapist, are not reimbursable under the SHARS program. erapists with experience billing for Medicaid services outside the school environment are aware of numerous individual procedure codes applicable to specific therapeutic services and modalities. All of these various procedure codes are billable under the SHARS program under this single code. Session notes are required to document physical therapy services, including at a minimum: start time, stop time, total minutes, a description of the primary activity performed during the session, an observation of the student's behavior/ performance during the session, and the IEP objectives to which the session related. e recommended maximum billable time is four units (one hour) per day for physical therapy services. A physician prescription/ referral is required before physical therapy services can be billed under the SHARS program. Speech-Language Pathology Evaluation (procedure code 92506 with modifier GN) Billable speech-language pathology (SLP) evaluation time under procedure code 92506 with modifier GN includes direct evaluation, testing, and observation time with the student present. Indirect time for interpretation and report writing is not billable time. To be reimbursable under the SHARS program, SLP therapy evaluation services must be provided by a TEA certified or SBEC certified speech therapist, American SpeechLanguage-Hearing Association (ASHA) speechlanguage pathologist (SLP) with Texas License; ASHAequivalent (i.e., SLP with master's degree and Texas license); or grandfathered Texas licensed SLP. No session notes are required. However, the following documentation is required: start time, stop time, total minutes, and a notation as to the SLP evaluation activity performed (i.e., direct evaluation, direct testing, or direct observation). e recommended maximum billable time is 12 units (three hours) over multiple days for one SLP evaluation.

Speech erapy (procedure code 92507 with modifier GN) Billable speech therapy time under procedure code 92507 with modifier GN includes direct therapy time with the student present and in an individual, oneon-one setting. Group therapy time is not billable under procedure code 92507 with modifier GN. To be reimbursable under the SHARS program, speech therapy services must be delivered by a TEA-certified or SBEC-certified speech therapist, ASHA SLP, ASHA equivalent, grandfathered Texas licensed SLP, or SLP licensed intern. Services provided by a licensed SLP assistant, even under the supervision of a licensed SLP, are not reimbursable under the SHARS program. Session notes are required to document speech therapy services, including at a minimum: start time, stop time, total minutes, a description of the primary activity performed during the session, an observation of the student's behavior/ performance during the session, and the IEP objectives to which the session related. e recommended maximum billable time is four units (one hour) per day for speech therapy services. A prescription/ referral from a physician or licensed SLP is required before speech therapy services can be billed under the SHARS program. Medical Services (procedure code 99499) Billable medical services under procedure code 99499 include direct diagnosis time with the student present or indirect time reviewing the student's records for the purpose of writing a prescription/referral for a specific SHARS service, or for the evaluation of the sufficiency of an ongoing SHARS service to see if any changes are needed in the prescription/referral. To be reimbursable under the SHARS program, medical services must be provided by a physician (MD/DO), physician's assistant (PA), or an APN. Session notes are not required to document medical services. However, the following documentation is required at a minimum: start time, stop time, total minutes, and a notation as to the type of medical services activity performed (i.e., direct

November/December 2004

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Texas Medicaid Bulletin, No. 183

School Health and Related Services (SHARS) Providers / Texas Health Network Providers

diagnosis time or indirect time reviewing student records). e recommended maximum billable time is four units (one hour) per day for medical services. Special Transportation Services (procedure code T2003) Special Transportation Services billable under procedure code T2003 cover a student one-way trip, effective on or after September 1, 2004. is change is being implemented because providers cannot accumulate one-way trips across days in order to bill a student round-trip and because not all students receive a round-trip during a day. e following one-way trips may be billed if the student receives a billable SHARS service and is transported from: · e student's residence to school; · School to the student's residence; · e student's residence to a provider's office that is contracted with the district; · A provider's office that is contracted with the district to the student's residence; · School to a provider's office that is contracted with the district; · A provider's office that is contracted with the district to the student's school; · School to another campus to receive a billable SHARS service; or · e campus where the student received a billable SHARS service back to the student's school. e one-way trips listed above are billable if the medical need for specialized transportation is identified in the student's IEP. Please call the TMHP Contact Center at 1-800-925-9126 if you have questions.

A Partner Approach to Member Education

e Texas Health Network understands educating its member population is important. e Texas Health Network recognizes a shared responsibility with its provider community and offers a number of educational services to its members. Texas Health Network case managers and health educators are available in each service area to educate Texas Health Network members on a variety of topics including: · Texas Health Steps (THSteps) · Emergency room protocol · Family planning · Behavioral health · Case management · Preventive health · Asthma · Prenatal care · Diabetes · Early childhood intervention To contact a representative in your area, please call the Texas Health Network Case Management Intake at 1-888-276-0702. e Texas Health Network provides a clinical nurse line for its members 24 hours a day, 7 days a week. e nurseline (1-800-304-5468) is staffed by registered nurses, and members may call with any clinical questions they have regarding symptoms or self-care. e helpline provides information and clinical assessment services and educates members on appropriate utilization of services.

It Takes Two

Texas Medicaid Bulletin, No. 183

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November/December 2004

Texas Health Network Providers

e Texas Health Network Member Helpline (1-888-302-6688) responds to members' non-clinical questions and concerns. e helpline shares information on how to access health care services appropriately, takes requests for PCP changes, and takes complaints. By offering the services listed above, the Texas Health Network can assist providers in educating the member population.

Member ID Cards

Effective August 1, 2004, Texas Health Network Member ID Cards are no longer distributed to Texas Health Network members. Providers can verify member eligibility by requesting the member's Medicaid Identification Form 3087, or by calling the TMHP Contact Center at 1-800-925-9126. Eligibility can also be verified through the TMHP website (www.tmhp.com). If calling the TMHP Contact Center, use the Automated Inquiry System (AIS), Option 1, for eligibility verification.

PCPs are Key Players

One important function of the Texas Health Network is to ensure that eligible members access the THSteps exams and immunizations they need to stay healthy. Primary care providers (PCPs) are instrumental in promoting preventive healthcare and are encouraged to continue to remind parents to make appointments for THSteps screenings according to the periodicity schedule. PCPs who are not THSteps providers are encouraged to direct members to a THSteps provider of their choice. e reminder and the results of the visit must be documented in the member's medical record. PCPs with an OB/GYN specialty are in an excellent position to remind adolescents of the importance of preventive health services available through THSteps. e PCP is also able to advise new mothers on the importance of keeping their infants up-to-date on THSteps checkups. A THSteps checkup is reimbursable only when all ageappropriate elements and immunizations listed on the periodicity schedule are completed and documented. Be sure to document vision and hearing screens, blood pressure (above age three), growth charts, and anticipatory guidance. THSteps providers are encouraged to forward a copy of the exam results to the member's PCP. PCPs interested in becoming a THSteps provider may contact TMHP at 1-800-925-9126 or visit the TMHP website at www.tmhp.com to download an enrollment application. Your local TMHP provider relations representative can also assist you in the enrollment process.

Texas Health Network Contact Numbers

Provider Helpline

Monday through Friday 7:00 a.m. ­ 7:00 p.m. 1-888-834-7226 Fax: 1-512-302-5068

Member Helpline

Monday through Friday 7:00 a.m. ­ 7:00 p.m. 1-888-302-6688

Utilization Management Helpline

Monday through Friday 7:00 a.m. ­ 7:00 p.m. 1-888-302-6167 Fax: 1-512-302-5039

Case Management Helpline

Monday through Friday 8:00 a.m. - 5:00 p.m. 1-888-276-0702

Prenatal Care Line

Monday through Friday 7:00 a.m. - 7:00 p.m. 1-877-518-0899

e Nurse Line: Clinical Helpline

24 hours a day, 7 days a week 1-800-304-5468

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Texas Medicaid Bulletin, No. 183

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 Medicaid and Title XX programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries/wages/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 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 frequent periodic checks of HHSC's exclusion list be conducted. HHSC-Sanctions department submits updates to the exclusion list semimonthly. Updates appear on the website by the 1st and 15th working day of each month. Review the entire Exclusion List for Texas Medicaid at www.hhsc.state.tx.us/OIE/exclusionlist/exclusion.asp. Report Medicaid providers who engage in fraud/abuse by calling 1-512-424-6519 or 1-888-752-4888, or by writing to the following address: Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity PO Box 13247 Austin TX 78711-3247 Provider Abney, Lucille Aboloye, Pius A Barklis, Sam S Beck, Dennis A Berry, Christy S Bigby, Peggy J Bonner, Jerry L Burnett, Karen H Bynum, Frances L Carcamo, Benjamin Clifton, Rhea S Coats, Kathy A Cole, Debbie R Coody, Elizabeth L. 138009 086175 554094 554664 214141 J0881 License No. K1307 28921 D6702 503017 158617 621566 Exclusion Date 05-Aug-04 20-Mar-04 31-Mar-04 11-Mar-04 11-May-04 16-Mar-04 18-Jun-04 26-Feb-04 22-Apr-04 04-Jun-04 20-Jul-04 22-Apr-04 08-Jun-04 11-Mar-04 City Houston Ft Worth Ft Worth Houston Houston Norman Irving Victoria Houston El Paso Dallas Iowa Park San Antonio Denham Springs

38

State TX TX TX TX TX OK TX TX TX TX TX TX TX LA

Provider Type PSY MD RN LVN RN DC RN RN MD DC LVN LVN RN

Add Date 01-Sep-04 10-Aug-04 10-Aug-04 26-Aug-04 07-Sep-04 10-Aug-04 26-Aug-04 05-Aug-04 23-Aug-04 02-Aug-04 30-Aug-04 05-Aug-04 01-Sep-04 03-Aug-04

Texas Medicaid Bulletin, No. 183

November/December 2004

Excluded Providers

Provider Cooper, Frank C Cox, Barbara S Davidson, Blake L Davis, Johnny M Ellis, Joe N Flores, Serafin C Fowler, ana Hairston, Roger K Hamilton, David M Haskins, Tammy D Hatten, Candace J Hendry, John J Hodge, Odessa A Hudson, Donna L Jarem, Bohdan J Johnson, Nathan J Jones, Walter C Jusko, Lynn Kimble, Rafaila King, Julia A Lambino, Gemma G. Liebel-Cook, Donna I Lorenz, Charles B Mayorga, Gilbert McMinn, Monty C McPeak, Catherine J Middleton, Helen K. Miller, Pattie A. Mills, Lindy L Miro, Aurelio Moreland, Joann Patel, Piyush Patsch, Michael W.

License No. 36431 526992 6979 682817 C3647 138449 K1458 25471 149611 100813 184291 128667 568925 D9829

Exclusion Date 20-Aug-04 08-Jun-04 20-Jul-04 16-Mar-04 06-Jun-03 18-Jun-04 12-Jun-01 04-Jun-04 26-Jan-01 08-Jun-04 11-May-04 22-Apr-04 22-Apr-04 16-Mar-04 04-Jun-04 20-Aug-04 20-Sep-01

City Houston Waco Richardson Alvin Houston Big Spring San Angelo Texarkana Austin Midland Lone Star Jacksonville Fresno Flowery Branch Houston Texarkana Ft Worth San Marcos Denton Creedmoor Katy Fort Worth Galveston Houston San Antonio Wichita Falls Texarkana Cleveland Lubbock Lubbock Frost Midland Houston

State TX TX TX TX TX TX TX AR TX TX NC CA GA TX TX TX TX TX TX TX TX TX TX TX TX

Provider Type Pharm RN DC RN MD Oth LVN MD PhD LVN LVN LVN LVN RN MD Owner RN LVN RN RN DC RN MD MD LVN RN LVN

Add Date 10-Sep-04 03-Sep-04 31-Aug-04 10-Aug-04 18-Aug-04 19-Aug-04 02-Aug-04 03-Sep-04 08-Sep-04 30-Jul-04 20-Aug-04 19-Aug-04 03-Sep-04 10-Aug-04 19-Aug-04 08-Sep-04 02-Aug-04 08-Sep-04 02-Sep-04 26-Aug-04 02-Aug-04 26-Aug-04 16-Aug-04 10-Aug-04 10-Aug-04 07-Sep-04 02-Aug-04 02-Aug-04 19-Aug-04 26-Aug-04 19-Aug-04 11-Aug-04 02-Aug-04

664169 745133 255075 696050 6308 577880 H3117 E2422 166450 583623 146108 664543 J5230 530511 G2452 650541

24-May-04 08-Jun-04 10-Feb-04 23-Apr-04 20-Jul-04 11-May-04 20-Jul-04 04-Jun-04 08-Jun-04 10-Feb-04 22-Apr-04 04-Mar-04 04-Jun-04 28-May-04 15-Jan-03 08-Jun-04

TX TX TX TX TX

RN MD RN MD RN

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Texas Medicaid Bulletin, No. 183

Excluded Providers

Provider Richards, Melinda J. Ridgeley, Deborah Ridgeley, Richard L Roath, James L Robbins, Donald W Robinson, Luke E Ross, Willie L Rutledge, David E Sparks, Karen H Spencer, Keivon J Stephenson (LaFleur), Rhonda Stuntz, Homer C Suits, Charles W Taylor, Robert L. Troublefield, Earl A Tucker, Deborah D Vaughan, Marybeth A. Watson, David G Wells, William E West, Cherry A Wilson, Gerald L. Young, Cynthia H

License No. 44332

Exclusion Date 22-Apr-04 20-Aug-04 20-Aug-04

City

State

Provider Type LVN Owner Owner LVN LVN MD LVN MD LVN

Add Date 02-Aug-04 09-Sep-04 09-Sep-04 04-Aug-04 30-Jul-04 19-Aug-04 10-Aug-04 10-Aug-04 02-Aug-04 02-Aug-04 19-Aug-04 10-Aug-04 20-Aug-04 19-Aug-04 26-Aug-04 03-Aug-04 02-Aug-04 09-Sep-04 10-Aug-04 10-Aug-04 10-Aug-04 30-Aug-04

Phoenix Taft Amarillo Kerrville Victoria Ladonia Harlingen Henderson Cedar Hill Sulphur Orange Wichita Falls Deer Park Amarillo Ft Davis Tyler Tyler Covington Franklin Lubbock Stanton

AZ CA TX TX TX TX TX

113093 144124 E4642 158413 E1730 66319 651826 C3887 G6765 597162

08-Jun-04 22-Apr-04 04-Jun-04 08-Jun-04 04-Jun-04 22-Apr-04 03-Jul-04 26-May-04 01-Aug-04 04-Jun-04 16-Mar-04 30-Jul-04 02-Aug-04

TX TX TX TX TX TX TX TX KY TX TX TX

RN MD DO RN DC LVN RN MD RN RN MD

691258 K4605 616260 650271 E7321

05-Feb-04 11-Aug-04 20-Mar-04 20-Jul-04 04-Jun-04 29-Aug-04

Texas Medicaid Bulletin, No. 183

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November/December 2004

Forms

Provider Information Change Form

Complete this form and submit to update your provider files. Mail or fax the completed form to the appropriate entity.

PLEASE PRINT OR TYPE THE INFORMATION SUBMITTED ON THIS FORM. Date: __________________

Nine-Character Texas Provider Identifier TPI):__________________

If you have more than one TPI that will also use this same information, list the other TPIs: _____________________________________________________________________________________

(Cannot be a P.O. Box)

Physical Address

(W-9 Form Required)

Accounting/Mailing Address

(Plan Use Only)

Secondary Address

____________________ ____________________ ____________________

______________________ Telephone ____________________ Fax

______________________ Telephone ___________________ Fax

____________________ ____________________ ____________________

___________________ Telephone ___________________ Fax

__________________ __________________ __________________

Type of Change: (please check the appropriate box below) 1 Change of Physical Address, telephone and/or fax number 1 Change of Billing/Mailing Address, telephone and/or fax number 1 Change/Add Secondary Address, telephone and/or fax number 1 Change of Provider Status (i.e., termination from plan, moved out of area, specialist, etc.), Please Explain: 1 Other (i.e., panel closing, capacity changes, age acceptance, etc.)

Explanation Required: _________________________________________________________________________________ _________________________________________________________________________________ Tax Information: IRS ID Number (attach W-9) _____________________________________ Effective Date: _________________ List the exact name reported to the IRS for the above Tax ID number: _____________________________________________ Must be signed and dated or changes cannot be completed:

Provider Signature: ______________________________ E-mail Address: _____________________________

TMHP-Texas Health Network Attn: THN, MC-A13 Credentialing/Contracting Department P.O. Box 204270 Austin, TX 78720-4270 Fax: 1-888-235-8399 Date

Date: ______________________

Send your completed change forms to:

TMHP-Traditional Medicaid Provider Enrollment Department PO Box 200795 Austin TX 78720-0795 Fax: 512-514-4214

______________

THN Representative

Office use

_______

__________________

TMHP Representative

Office use

______

Date

TO THE INDIVIDUAL FILLING THIS OUT: You have the right to ask us about this form. You also have the right to review the information you give us on the form. (There are a few exceptions). If the information is wrong, you can ask us to correct it. The Health and Human Services Commission has a method for asking for corrections. You can find it in Title 1 of the Texas Administrative Code, section §351.17 through §351.23. To talk to someone about this form or ask for corrections, please contact the Texas Health Network Provider Helpline. You can write to the Texas Health Network Provider Helpline at P.O. Box 14685, Austin, TX. 78761. You can also call the Texas Health Network Provider Helpline at 1-888-834-7226.

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Texas Medicaid Bulletin, No. 183

Forms

INSTRUCTIONS FOR COMPLETING PROVIDER INFORMATION CHANGE FORM

SIGNATURES: The provider's signature is required on the attached document for any/all changes requested for individual practitioner provider numbers. Signature by the authorized representative of a group or facility is acceptable for changes requested for group/facility provider numbers.

ADDRESS: Performing providers* may NOT change accounting information. (* a physician performing services within a group)

T.I.N. changes for individual practitioner provider numbers can only

TAX IDENTIFICATION NUMBER:

be made by the individual to which the number is assigned. Performing providers CANNOT change T.I.N. GENERAL: Forms will be returned unprocessed if the nine-digit provider number is not indicated on the attached form. W-9 form is required for all name and T.I.N. changes.

Texas Medicaid Bulletin, No. 183

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November/December 2004

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 providers 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:

Applications are processed within five workdays of receipt. Prenotification to your bank takes place on the cycle following the application processing. Future deposits are received electronically after prenotification. The Remittance and Status (R&S) report furnishes the details of individual credits made to the providers account during the weekly cycle. Specific deposits and associated R&S reports are crossreferenced 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.

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

TMHP must provide the following notification according to ACH guidelines:

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.

Contact TMHP Customer Service at 18009259126 if you need assistance.

Page 1 of 2 EFTAG11.17.2003_v1.0

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Texas Medicaid Bulletin, No. 183

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:

Provider Name

NEW

CHANGE

NineCharacter Billing TPI

Provider Accounting Address Street Address or PO Box

City

State

Zip

Provider Phone Number

ext.

Bank Name

ABA/Transit Number

Bank Phone Number

Account Number

Bank Address Street Address or PO Box

City

State

Zip

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 787200795

DO NOT WRITE IN THIS AREA For Office Use

Input By: Input Date:

Page 2 of 2

EFTAG11.17.2003_v1.0

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November/December 2004

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Workshop Schedules

Texas Medicaid Bulletin, No. 183

Workshop Schedules

Texas Medicaid Bulletin, No. 183

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November/December 2004

Notes

November/December 2004

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Texas Medicaid Bulletin, No. 183

November/December 2004

Texas Medicaid

No. 183

Bimonthly update to the Texas Medicaid Provider Procedures Manual

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