TMHP (Texas Medicaid ) billing updates




EFFECTIVE FEBRUARY 19, 2010, FOR DATES OF SERVICES ON OR AFTER JANUARY 1, 2010, REIMBURSEMENT RATES FOR THE FOLLOWING SERVICES WILL CHANGE FOR TEXAS MEDICAID: RESPIRATORY SYSTEM SURGERY, DIAGNOSTIC RADIOLOGY, NUCLEAR MEDICINE, MUSCULOSKELETAL SYSTEM SURGERY, RADIOPHARMACEUTICALS, AND RADIOLOGY (PORTABLE X-RAY) SERVICES. AFFECTED CLAIMS WITH DATES OF SERVICE FROM JANUARY 1, 2010, THROUGH FEBRUARY 18, 2010, WILL BE REPROCESSED,AND PAYMENTS WILL BE ADJUSTED ACCORDINGLY. NO ACTION ON THE PART OF PROVIDER IS REQUIRED.EFFECTIVE FEBRUARY 19, 2010, FOR DATES OF SERVICES ON OR AFTER JANUARY 1, 2010, REIMBURSEMENT RATES FOR SIGN LANGUAGE OR ORAL INTERPRETIVE SERVICES PROCEDURE CODE T1013 WITH MODIFIER U1 OR UA WILL CHANGE FOR TEXAS MEDICAID. THE REIMBURSEMENT RATE FOR PROCEDURE CODE T1013 WITH MODIFIER U1 WILL BE $73.60. THE REIMBURSEMENT RATE FOR PROCEDURE CODE T1013 WITH MODIFIER UA WILL BE $14.75. AFFECTED CLAIMS WITH DATES OF SERVICE FROM JANUARY 1, 2010, THROUGH FEBRUARY 18, 2010, WILL BE REPROCESSED, AND PAYMENTS WILL BE ADJUSTED ACCORDINGLY.

ALSO, EFFECTIVE JANUARY 15, 2010, THE U8 MODIFIER FOR PROCEDURE CODE T1019, WHICH IS USED BY A CDSA TO SUBMIT CLAIMS FOR THE MONTHLY ADMINISTRATIVE FEE, MUST BE PRIOR AUTHORIZED. THE U8 MODIFIER WILL BE PRIOR AUTHORIZED FOR THOSE TEXAS MEDICAID CLIENTS WHO ARE USING THE CDS OPTION FOR PCS ONLY. CLAIMS FOR THE MONTHLY ADMINISTRATIVE FEE MUST BE SUBMITTED TO THE PROGRAM WITH THE HIGHEST REIMBURSEMENT RATE.

EFFECTIVE FOR DATES OF SERVICE ON OR AFTER MARCH 1, 2010, BENEFIT CRITERIA FOR PEDIATRIC CRITICAL CARE WILL CHANGE FOR TEXAS MEDICAID. SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE (PROCEDURE CODES 99472 OR 99476) WILL BE DENIED AS PART OF THE INITIAL INPATIENT PEDIATRIC CRITICAL CARE (PROCEDURE CODES 99471 OR 99475) WHEN BILLED ON THE SAME DAY, BY THE SAME PROVIDER. SUBSEQUENT INTENSIVE CARE (PROCEDURE CODES 99478,99479, OR 99480) WILL NO LONGER BE DENIED WHEN BILLED ON THE SAME DATE OF SERVICE BY THE SAME PROVIDER AS PEDIATRIC CRITICAL CARE PROCEDURE CODE99475 OR 99476.

EFFECTIVE FEBRUARY 19, 2010, FOR DATES OF SERVICES ON OR AFTER JANUARY 1, 2010, REIMBURSEMENT RATES FOR FAMILY PLANNING SERVICES PROCEDURE CODE H1010 WILL CHANGE FOR TEXAS MEDICAID. FOR CLIENTS WHO ARE BIRTH THROUGH 20 YEARS OF AGE, THE REIMBURSEMENT RATE FOR PROCEDURE CODE H1010 WILL BE $11.46 (0.40 RELATIVE VALUE UNIT [RVU], $28.640 CONVERSION FACTOR). FOR CLIENTS WHO ARE 21 YEARS OF AGE OR OLDER, THE REIMBURSEMENT RATE WILL BE $10.91 (0.40 RELATIVE VALUE UNIT [RVU], $27.276 CONVERSION FACTOR). AFFECTED CLAIMS FOR DATES OF SERVICE FROM JANUARY 1, 2010, THROUGH FEBRUARY 18, 2010, WILL BE REPROCESSED, AND PAYMENTS WILL BE ADJUSTED ACCORDINGLY. NO ACTION ON THE PART OF THE PROVIDER IS REQUIRED.

EFFECTIVE MARCH 1, 2010, CLAIMS SUBMITTED BY FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH CLINIC (RHC) PROVIDERS FOR GYNECOLOGICAL SERVICES PROVIDED TO PRIMARY CARE CASE MANAGEMENT (PCCM) CLIENTS MUST BE BILLED WITH THE APPROPRIATE ENCOUNTER CODE AND A MODIFIER GY IN THE CLAIMS DETAILS. OBSTETRIC SERVICES PROVIDED TO PCCM CLIENTS BY FQHC AND RHC PROVIDERS MUST CONTINUE TO BE BILLED WITH THE APPROPRIATE ENCOUNTER CODE AND A MODIFIER TH.

FQHC AND RHC PROVIDERS MUST CONTINUE TO BILL WITH MODIFIER TU FOR AFTER-HOURS CARE PROVIDED TO PCCM CLIENTS. CLAIMS SUBMITTED BY RHC PROVIDERS FOR BEHAVIORAL HEALTH SERVICES PROVIDED TO PCCM CLIENTS MUST INCLUDE THE APPROPRIATE BEHAVIORAL HEALTH DIAGNOSIS CODE. REMINDER: CLAIMS SUBMITTED FOR SERVICES OTHER THAN FREEDOM OF CHOICE SERVICES PROVIDED TO PCCM CLIENTS WHO ARE NOT ASSIGNED ON A PANEL REPORT FOR AN FQHC OR RHC MUST INCLUDE THE CLIENT'S PRIMARY CARE PROVIDER INFORMATION IN THE REFERRING PROVIDER FIELD ON THE CLAIM FORM.

THIS IS A CLARIFICATION TO A BANNER MESSAGE THAT FIRST APPEARED ON THE NOVEMBER 13, 2009, REMITTANCE AND STATUS (R&S) REPORT, AND TO A WEB ARTICLE THAT WAS POSTED ON THE TMHP WEBSITE AT http://www.tmhp.com/ ON NOVEMBER 9, 2009, TITLED PHYSICAL, OCCUPATIONAL, AND SPEECH THERAPY FOR CCP UPDATE. THIS MESSAGE CLARIFIES THE AUTHORIZATION AND CLAIMS PROCESSES FOR PROCEDURE CODE 97535.PROCEDURE CODE 97535 IS USED FOR SPEECH THERAPY (ST) SERVICES FOR TRAINING FOR AUGMENTATIVE COMMUNICATION DEVICES (ACD). TO REQUEST PRIOR AUTHORIZATION FOR 97535 FOR ST SERVICES, PROVIDERS MUST SUBMIT THE PROCEDURE CODE WITH THE GN MODIFIER. ALL CLAIMS FOR PROCEDURE CODE 97535 FOR ST SERVICES MUST BE BILLED WITH THE GN MODIFIER.

EFFECTIVE JANUARY 1, 2010, PROVIDERS MUST SPECIFICALLY REQUEST PROCEDURE CODE 97535 SEPARATE FROM REQUESTS FOR OTHER THERAPY SERVICES (PHYSICAL [PT], OCCUPATIONAL [OT], AND ST). PROCEDURE CODE 97535 IS NOT INCLUDED IN PT AND OT AUTHORIZATIONS UNLESS SPECIFICALLY REQUESTED. PRIOR AUTHORIZATION REQUESTS FOR PROCEDURE CODE 97535 MUST INCLUDE THE APPROPRIATE MODIFIER FOR THE TYPE OF THERAPY BEING REQUESTED AND SPECIFY THE AMOUNT OF TIME REQUESTED FOR THIS PROCEDURE CODE.

EFFECTIVE FEBRUARY 25, 2010, FOR DATES OF SERVICE ON OR AFTER JANUARY 1, 2009, THE LIMITATIONS FOR SOME LABORATORY SERVICES PROCEDURE CODES CHANGED FOR TEXAS MEDICAID AND THE CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) SERVICES PROGRAM. AFFECTED CLAIMS WILL BE REPROCESSED, AND PAYMENTS WILL BE ADJUSTED ACCORDINGLY. NO ACTION ON THE PROVIDER IS REQUIRED.

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