Texas Medicaid - Welcome to TMHP

January/February 2003

No. 168

Texas Medicaid B i m o n t h l y u p d a t e t o t h e Te x a s M e d i c a i d P r o v i d e r P r o c e d u r e s M a n u a l

• • • BULLETIN • • •

Have you visited www.eds-nhic.com lately? You can find out when workshops will be held in your area, download forms and manuals, and learn about important updates of the Texas Medicaid Program.

New Acronym Guide Refer to page 34 for a listing of the acronyms and their definitions used in this issue of the Texas Medicaid Bulletin.

Bulletin Contents, No. 168 HIPAA Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 All Providers 2002 HCPCS Additional Procedure Codes ............................................................................. 4 2003 HCPCS Implementation ............................................................................................... 4 2003 Provider Manual Distribution ....................................................................................... 4 Annual Influenza Vaccination Reminder ................................................................................. 4 Apnea Monitor .................................................................................................................... 5 Breast and Cervical Cancer Control Program .......................................................................... 6 Breast Pumps ..................................................................................................................... 6 Clarification of ASC and HASC Services Policy ....................................................................... 7 Customer Service Escalation Process ................................................................................... 8 Doppler Examinations/Noninvasive Diagnostic Studies .......................................................... 9 Elective Abortion Modifiers ................................................................................................. 10 Electrocardiogram (EKG, ECG) ............................................................................................ 10 Epoetin Alpha ................................................................................................................... 10 Extracorporeal Membrane Oxygenation (ECMO) .................................................................... 11 Eye Surgery by Laser ......................................................................................................... 11 Gynecological and Reproductive Health Services .................................................................. 11 Hearing Testing ................................................................................................................. 12 Hepatitis A Expansion ........................................................................................................ 12 Hepatitis B Prophylaxis Policy Revision ............................................................................... 12 Hospital Outpatient Observation Room Services Clarification ................................................ 13 Influenza Vaccine .............................................................................................................. 14 Injections – Gamma Globulin .............................................................................................. 14 Intravenous Gamma Globulin (IVIG) ..................................................................................... 15 Magnetic Resonance Angiography (MRA) ............................................................................. 15 Nasal Sinus Endoscopy ..................................................................................................... 15 Nerve Conduction Studies .................................................................................................. 16 Outpatient Behavioral Health Services ................................................................................ 16 Pediatric Pneumogram ....................................................................................................... 16 Pneumococcal Conjugate Vaccine ....................................................................................... 17 Radiation Therapy ............................................................................................................. 17 Regional Anesthesia .......................................................................................................... 17

www.eds-nhic.com National Heritage Insurance Company (NHIC) is the insurer and contract administrator for the Texas Medicaid Program under contract with the Texas Health and Human Services Commission (HHSC) Indicates updated information

Bulletin Contents, No. 168, continued All Providers, continued Respiratory Care Equipment ................................................................................................19 Training Specialist Telephone Number Correction .................................................................19 Visits – Hospital Concurrent Care ........................................................................................19 Visits – Neonatal Intensive Care ..........................................................................................19 Visits – New Versus Established Patient ..............................................................................20

ASC/HASC Providers 2002 ASC/HASC Fee Schedule Correction ...........................................................................20

CCIP Providers Documentation Requirements .............................................................................................20

Laboratory Providers CLIA Waived Tests Update ..................................................................................................20

Managed Care Providers Managed Care Authorization Removal ..................................................................................21

THSteps–CCP Providers THSteps–CCP Rehabilitation Services (Policy Revision) .........................................................21

THSteps Medical Providers Helpful Information in this Bulletin for THSteps Medical Providers ..........................................22

Excluded Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 Forms/Guides Enrolling in the Electronic Funds Transfer Program ................................................................29 Extended Outpatient Psychotherapy/Counseling Request Form ..............................................30 NHIC Electronic Funds Transfer Authorization Agreement .......................................................31 Provider Information Change Form .......................................................................................32 Provider Information Change Form Completion Instructions ...................................................33 Acronym Guide ...................................................................................................................34

Texas Medicaid Bulletin, No. 168

2


HIPAA Awareness

Congress enacted the Health Insurance Portability and Accountability Act (HIPAA), to reform the health care insurance market and simplify the health care administrative processes. As a Medicaid provider, you will be required to comply with HIPAA Electronic Data Interchange (EDI) and Privacy Regulations. Entities covered by HIPAA (called “covered entities”) must comply with the HIPAA EDI and Privacy Regulations. Covered entities include the following: • • • • • • •

Health plans, which include health insurers and health maintenance organizations (HMOs) Blue Cross Blue Shield Medicare Medicaid Employee Retirement Income Security Act of 1974 (ERISA) Health care providers, which include hospitals, physicians, clinics, and contracted providers who do business electronically Health care clearinghouses

The Texas Medicaid Program filed an extension with the Centers for Medicare and Medicaid Services (CMS) and will implement HIPAA EDI requirements by October 16, 2003. HIPAA requires covered entities that exchange covered transactions to comply with national EDI standards. You can find extensive information about “covered entities” and “covered transactions” on the Centers for Medicare and Medicaid Services (CMS) Web site at www.cms.gov/hipaa. Providers who use vendor software or TDHconnect 2.0 will be impacted by this mandate. HIPAA also requires the use of national standard codes. Medicaid local procedure codes and modifiers currently in use also will be impacted. Look for more information in upcoming bulletins and workshops about Texas Medicaid’s implementation of these national standard codes. Privacy Implementation Date: April 14, 2003 EDI Implementation Date: October 16, 2003

Important dates to remember

Privacy provisions must be implemented by April 14, 2003. Enhancements will be made to TDHconnect 2.0 to ensure that providers submit HIPAA-compliant transactions after October 16, 2003. These enhancements will require changes to the information providers input. Watch for important information on HIPAA in future bulletins, banner messages, and provider workshops. Visit the following Web sites for information and other helpful links: Resource

Web Site Address

Centers for Medicare and Medicaid Services (CMS)

www.cms.gov/hipaa

Health and Human Services Commission

www.hhsc.state.tx.us/NDIS/NDISTaskForce.html

Provider workshops

www.eds-nhic.com/provenrl/mcwork.htm

Other helpful links

www.hipaaadvisory.com, www.hipaacomply.com

Send questions to [email protected]. ■ January/February 2003

3


All Providers

Annual Influenza Vaccination Reminder The Recommendations of the Advisory Committee on Immunization Practices (ACIP) on the Prevention and Control of Influenza are updated annually. The most recent update was on April 12, 2002, and included new or updated information about:

2002 HCPCS Additional Procedure Codes Effective for dates of service on or after December 1, 2002, the following procedure codes were not approved by the Texas Health and Human Services Commission (HHSC) as a payable benefit of the Medicaid program: Type of Service

• • •

G0245 through G0250, Q0144, Q3019, Q3020, Q3030

9

K0561 through K0580

4/I/T

G0252 through G0254 ■

2003 HCPCS Implementation

The 2002--2003 trivalent vaccine virus strains:

Because young, otherwise healthy children are at increased risk for influenza-related hospitalization, influenza vaccination of healthy children aged 6--23 months is encouraged when feasible.

Implementation of the annual 2003 Health Care Financing Administration Common Procedural Coding System (HCPCS) additions, changes, and deletions will not coincide with Medicare’s implementation on January 1, 2003. A special Medicaid bulletin with the actual effective date outlining affected procedures and policy will be sent to providers at a future date.

Vaccination of children aged older than 6 months who have certain medical conditions continues to be strongly recommended. On June 20, 2002, the ACIP adopted a Vaccines for Children (VFC) resolution that will go into effect on March 1, 2003. This resolution will approve the routine administration of influenza vaccine for VFC-eligible children age 6–23 months and children younger than age 19 who are household contacts of children younger than age 2. Effective for the 2003–2004 influenza season, influenza vaccine will be recommended and provided for all children age 6–23 months, including healthy children and their household contacts younger than age 19.

NHIC will not accept HCPCS 2003 procedure additions until the actual effective date is published. Retain electronic claims submission reject reports and/or Remittance and Status (R&S) reports to appeal denials received on the new procedure codes. ■

2003 Provider Manual Distribution The 2003 Texas Medicaid Provider Procedures Manual will be distributed during January 2003. One provider manual will be mailed to each Texas Provider Identifier (TPI) on file with the National Heritage Insurance Company (NHIC).

Current TVFC-Eligibility for Influenza Vaccine Currently, the Texas Vaccines for Children (TVFC) Program only provides influenza vaccine for children younger than age 19 at high-risk for complications of influenza disease who are:

The 2003 Texas Medicaid Provider Procedures Manual – Texas Health Steps (formerly known as the Texas Medicaid Service Delivery Guide) will be mailed to all Texas Health Steps (THSteps) medical, dental, and medical case management providers by March 15, 2003.

• • • • • •

On January 15, 2003, and on March 15, 2003, electronic versions of the 2003 Texas Medicaid Provider Procedures Manual and the 2003 Texas Medicaid Provider Procedures Manual – Texas Health Steps, respectively, will be available on www.eds-nhic.com, www.texmednet.com, www.hhsc.state.tx.us, and www.tdh.state.tx.us. ■


Influenza vaccine for children age 6–23 months

• A/Moscow/10/99 (H3N2)-like • A/New Caledonia/20/99 (H1N1)-like • B/Hong Kong/330/2001-like • The availability of certain influenza vaccine doses with reduced thimerosal content The ACIP statement specifically addresses the vaccination of infants by stating:

Procedure Codes

1

The timing of influenza vaccination by risk group

4

Medicaid-eligible Uninsured Underinsured American Indian Alaskan Native Enrolled in the Children’s Health Insurance Plan


Current Influenza Vaccine Recommendations

Apnea Monitor Procedure code L-E0608, Apnea monitor, is a benefit of the THSteps – Comprehensive Care Program (CCP) for infants. Effective for dates of service on or after December 1, 2002, Apnea monitors, used to measure chest movement and heart rate in the home, may be paid for two months without prior authorization for infants with one of the following diagnoses:

During the 2002–2003 flu season, groups recommended for vaccination against influenza include:

•

Children younger than age 19 who are receiving long-term aspirin therapy and may be at risk for developing Reye syndrome after influenza disease

• •

People age 50 and older

People of any age who: • Are residents of nursing and other chronic-care facilities that house people who have chronic medical conditions • Have chronic disorders of the pulmonary or cardiovascular systems including asthma • Have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic disease (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]) • Women who will be in the second or third trimester of pregnancy during the influenza season October and November are the optimal times to administer influenza vaccine. During October, particular emphasis should be placed on administering vaccine to patients at high-risk for influenza disease complications. Vaccination efforts should continue into December and longer as long as vaccine is available.

Dose

No. of Doses

6-35 months†

0.25 mL

1 or 2*

3-8 years

0.50 mL

1 or 2*

9 years or older

0.50 mL

1

•

Older children, adolescents, and adults: intramuscular in deltoid muscle

Reflux esophagitis

53012

Acute esophagitis

53019

Other esophagitis

53081

Esophageal reflux

7707

Bronchopulmonary dysplasia

78603

Apnea

V198

Family history of other conditions, (i.e., sudden infant death syndrome)

•

A completed CCP Prior Authorization Request Form, signed and dated by the physician

•

Documentation to support medical necessity and appropriateness of the apnea monitor

•

A physician interpretation, signed and dated by the physician, of the last two months of apnea monitor downloads Apnea monitors will only be authorized if the documentation supports medical necessity. Procedure code 5-93272, Patient demand single or multiple event recording with presumptive memory loop, per 30-day period of time: physician review and interpretation only, may be used by the physician to bill for the interpretation of the apnea monitor recordings.

•

Electrodes and lead wires for the apnea monitor are a benefit only if the client owns the apnea monitor. If the apnea monitor is rented, the electrodes and lead wires are considered part of the rental fee. The electrodes and lead wires may be considered for purchase with the

Two doses administered one month apart are recommended for children younger than age 9 who are receiving influenza vaccine for the first time For questions about TVFC influenza vaccine recommendations, contact the Texas Department of Health (TDH) Public Health Regional Immunization Program Manager or TVFC Consultant. For questions about influenza vaccine supply, contact John Haynes or Lisa Davis at 800-252-9152 (TDH Immunization Division). ■


Esophagitis, unspecified

53011

• The child is older than age 4 months • The initial two-month rental period has expired Prior authorization must be obtained in writing and must include all the following components:

Route: Infants and young children: intramuscular in anterolateral aspect of thigh

53010

Prior authorization is required for rental of an apnea monitor when one of the following conditions is met:

† Fluvirin™ (Evans Vaccines, Ltd.) is approved for use only among people age 4 and older.

•

Description

All apnea monitors provided to THSteps–CCP clients must be capable of recording apneic episodes.

Dosage information for influenza vaccine by age group include: Age

Diagnosis Code

5


Apnea Monitor/Pediatric Pneumogram

following procedure codes only with documentation of medical necessity and a statement from the physician that the client owns the monitor: Procedure Code

Description

9-A4556

Electrodes (e.g., apnea monitor), per pair

9-A4557

Lead wires (e.g., apnea monitor), per pair

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are payable for procedure codes L-E0608, Apnea monitor, and 5/I/T-94772, Circadian respiratory pattern recording (pediatric pneumogram) 12- to 24-hour continuous recording, infant:

Apnea Monitor/Pulse Oximeter Combination Procedure code 9-5474X, Combination apnea monitor/ pulse oximeter, single unit, rental, requires prior authorization. This combination unit is an evaluative tool to measure ongoing abnormally prolonged apnea with associated risk for hypoxemia. Prior authorization must be obtained in writing and must include all the following components:

•

A completed CCP Prior Authorization Request Form, signed and dated by the physician

Documentation to support medical necessity and appropriateness of the combination apnea monitor/ pulse oximeter to include evaluation of the risk of hypoxemia associated with apneic and/or bradycardia episodes Prior authorization of the combination apnea monitor/ pulse oximeter will be given for one month with the above documentation. A one-month extension may be considered with documentation to support the medical necessity of the extension.

77081

Primary apnea of newborn

77082

Other apnea of newborn

77083

Cyanotic attacks of newborn

77084

Respiratory failure of newborn

77089

Other respiratory problems after birth

Breast and Cervical Cancer Control Program The Breast and Cervical Cancer Prevention and Treatment Act of 2000 gives states the authority to provide Medicaid eligibility to low-income women who need treatment for breast or cervical cancer. The Centers for Medicare and Medicaid Services (CMS) recently approved a state plan amendment (SPA) to the Texas Medicaid Program to provide full Medicaid benefits to uninsured women younger than age 65 who are screened under the TDH Breast and Cervical Cancer Control Program (BCCCP) and found to need treatment.

Procedure code 5-93272, Patient demand single or multiple event recording with presumptive memory loop, per 30-day period of time: physician review and interpretation only, may be used by the physician to bill for the interpretation of the combination apnea monitor/pulse oximeter recordings.

Call the TDH BCCCP at 800-452-1955 or 512-458-7644 for additional information and/or to ask questions about the Breast and Cervical Cancer Control Program.

Effective for dates of service on or after December 1, 2002:

•

Description

Effective for dates of service on or after November 1, 2002, diagnosis code 7708, Other respiratory problems after birth, is no longer a benefit of the Texas Medicaid Program. ■

•

•

Diagnosis Code

For providers in your areas, visit the BCCCP Web site at: www.tdh.state.tx.us/bcccp. ■

Procedure codes L-E0608 and 9-5474X will no longer be a benefit of the Texas Medicaid Program in place of service (POS) 1 (office).

Breast Pumps

The apnea monitor and apnea monitor/pulse oximeter combination rental will no longer be a benefit of the Texas Medicaid Program for provider type 54 (medical supply company).

Effective for dates of service on or after February 1, 2003, breast pumps, procedure codes J-E0602, Manual, any type, and J-E0603, Electric, any type, are payable for mothers and their infants. Breast pumps must be:

• Prior authorized through Home Health Services • Purchased only • Limited to once every three years A manual breast pump may be considered for purchase only with the appropriate documentation supporting medical necessity.


6


An electric breast pump may be considered for purchase only with appropriate documentation supporting medical necessity and an explanation of why a manual breast pump was not effective. Supporting documentation may include an evaluation from a lactation consultant or registered nurse (RN), such as an experienced perinatal nurse.

X-ray services, provided with emergency conditions, may be billed separately with documentation that the complicating condition arose after the initiation of the surgery. No separate payment outside of the ASC/HASC reimbursement rate will be made for prosthetic devices. Medical and prosthetic devices such as implantable pumps and intraocular lenses, may be supplied by the ASC/HASC and implanted, inserted, or otherwise applied during a covered surgical procedure.

A Title XIX Durable Medicaid Equipment (DME)/Medical Supplies Physician Order Form (Title XIX Order Form) prescribing DME and/or medical supplies, completed and signed by the attending physician must be obtained before requesting prior authorization. The original Title XIX Order Form must be maintained by the provider and prescribing physician in the client’s medical record. The Title XIX Order Form must include the procedure code(s) for the items requested.

Refer to:

Section 8, Ambulatory Surgical Centers, and Section 24, Hospital, in the 2003 Texas Medicaid Provider Procedures Manual for ASC/HASC reimbursement methodology.

Multiple Surgeries

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

When multiple surgical procedures are performed on the same day, only the procedure with the highest surgical code grouping is reimbursed.

Procedure code J/L-E0604, Hospital grade breast pump, is not a benefit of Texas Medicaid Title XIX Home Health Services. ■

Incomplete Day Surgeries

Refer to:

When ASC/HASC providers bill the Texas Medicaid Program for an incomplete surgical procedure, reimbursement must be based on the following criteria.

Clarification of ASC and HASC Services Policy

Facilities are to use either diagnosis codes V641 through V643 or modifiers 73, Discontinued outpatient procedure prior to anesthesia administration, or 74, Discontinued outpatient procedure after anesthesia administration, to indicate that a surgical procedure, type of service (TOS) F, was not completed. Claims billed with V641 through V643 or modifiers 73 or 74 will suspend for review of the medical documentation submitted with the claim. Providers are to submit the operative report, anesthesia report, and reason the operation was not completed.

ASC/HASC Procedures Ambulatory surgical centers (ASCs), either freestanding or hospital-based (HASC), provide same-day elective surgery for clients who do not require a hospital admission and are not expected to require extensive postoperative care. The Texas Medicaid Fee Schedule, ASC/HASC Report, contains a list of procedures and corresponding reimbursement of the Texas Medicaid Program. A list of procedure codes and payment categories are sent to providers upon enrollment with the Texas Medicaid Program and when periodic updates occur. When billing for services, if no procedure code listed in the Texas Medicaid Fee Schedule covers the services provided, procedure code F-Y9999, Unlisted procedure; ASC, may be used with a description of the services.

Diagnosis Code

ASC/HASC Global Services

Description

V641

Surgical or other procedure not carried out because of contraindication

V642

Surgical or other procedure not carried out because of patient’s decision

V643

Procedure not carried out for other reasons

Reimbursement to ASC/HASC facilities for canceled or incomplete surgeries, due to patient complications, is to be made according to the following criteria, depending on the extent to which the anesthesia or surgery proceeded:

The ASC/HASC payment represents a global payment and includes room charges and supplies. Covered services provided are billed as one inclusive charge. All facility services provided in conjunction with the surgery (for example, laboratory, radiology, anesthesia supplies, medical supplies) are considered part of the global payment and cannot be itemized or billed separately. Routine X-ray and laboratory services, directly related to the surgical procedure being performed, are not reimbursed separately. All nonroutine laboratory and


The Texas Medicaid Fee Schedule.

7

•

Reimburse at 0 percent of ASC/HASC group payment schedule for a procedure that is terminated either for nonmedical or medical reasons before the ASC has expended substantial resources

•

Reimburse at 33 percent of ASC/HASC group payment schedule up to the administration of anesthesia


•

claim. The reason for the surgery (principal diagnosis), any additional substantiated conditions, and the procedure must be included on the inpatient claim.

Reimburse at 67 percent of ASC/HASC group payment schedule after the administration of anesthesia but before incision

•

Reimburse at 100 percent of ASC/HASC group payment schedule after incision Surgeries that were canceled due to incomplete preoperative procedures will not be reimbursed.

Inpatients may occasionally require a surgery that has been designated as an outpatient procedure. The physician must document the need for this surgery as an inpatient procedure before the procedure is performed. These claims are subject to retrospective review.

Complications Following Scheduled Day Surgery

Effective for dates of service on or after February 1, 2003:

If a condition of the scheduled day surgery requires additional care beyond the recovery period, the client may be placed in outpatient observation (stay less than 24 hours). The observation period should be billed as an outpatient claim.

•

Procedure code 9-Y0012 will no longer be a benefit of the Texas Medicaid Program.

•

The group rate for the following procedure codes is changing from group rate 10 to group rate 7:

If the client requires inpatient admission following the observation stay, the admission date for the inpatient claim is the date that the client was placed in observation. All charges for services provided from the time of observation placement (excluding the surgical procedure) should be included on the inpatient claim. The principal diagnosis to be used on the inpatient claim is the complication of the surgery that necessitated the extended stay. The day surgery procedure should be billed as an outpatient procedure. If a complication occurs for which the patient requires inpatient admission immediately following the day surgery (no observation period), the day surgery must be billed as an outpatient procedure. The inpatient admission is to be billed as an inpatient claim. The principal diagnosis to be used on the inpatient claim is the complication of the surgery that necessitated the extended stay. The day surgery procedure should not be included on the inpatient claim. The inpatient admission must be medically necessary and is subject to retrospective review.

Description

F-65710

Keratoplasty (corneal transplant); lamellar

F-65730

Keratoplasty (corneal transplant); penetrating (except in aphakia)

F-65750

Keratoplasty (corneal transplant); penetrating (in aphakia)

F-65755

Keratoplasty (corneal transplant); penetrating (in pseudophakia)

Refer to:

The Texas Medicaid Fee Schedule for specific information. ■

Customer Service Escalation Process NHIC Customer Service has recently restructured to better serve the Medicaid provider community. After listening to provider feedback, NHIC has expanded its call tracking system to improve its ability to assist the provider community with your Medicaid inquiries. When a provider calls NHIC Customer Service at 800-925-9126 initially, the following will occur:

Unscheduled Day Surgery If a client is first treated in the emergency room and then requires emergency surgery as an outpatient, claims for emergency, unscheduled outpatient surgical procedures should be filed itemizing each service (such as room charge, laboratory, radiology, anesthesia, and supplies). Providers must bill unscheduled day surgery procedures and emergency services as outpatient procedures. If a condition of the unscheduled day surgery requires additional care beyond the recovery period, the client may be placed on outpatient observation status. The observation period must be billed on the same outpatient claim.

•

A Customer Service Representative (CSR) will ask for a TPI number(s), as well as a brief description of the issue.

•

The CSR will record this information and assist with the inquiry.

•

If the CSR determines that the inquiry requires additional research, he or she will escalate the issue to a research analyst for completion.

•

The CSR will provide a ticket number specifically assigned to the issue.

•

The receiving research analyst will call by the close of the next business day to assist in resolving the issue. Important: Referencing the ticket number during any follow-up communications will facilitate easier access to the original inquiry. ■

Planned Admission for Day Surgery If a client is admitted for a day surgery, whether scheduled or emergency, and has either an American Society of Anesthesiologists (ASA) Classification of Physical Status of III, IV, or V or Classification of Heart Disease IV, the procedure may be considered an inpatient procedure and should be billed on an inpatient


Procedure Code

8


Doppler Examinations/Noninvasive Diagnostic Studies

Effective for dates of service on or after November 1, 2002, diagnosis code 44502, Atheroembolism, lower extremity, is added as payable for the procedure codes listed in the following table:

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for the procedure codes listed below: Diagnosis Code

Description

44321

Dissection of carotid artery

44329

Dissection of other artery

44589

Atheroembolism, other site

Procedure Code

Description

4/I/T-93875

Noninvasive physiologic studies of extracranial arteries, complete bilateral study (e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)

4/I/T-93880

Duplex scan of extracranial arteries; complete bilateral study

4/I/T-93882

Duplex scan of extracranial arteries; complete unilateral or limited study

Procedure Code

Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study

4/I/T-93925

Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study

4/I/T-93926

Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study

Effective for dates of service on or after November 1, 2002, diagnosis code 44501, Atheroembolism, upper extremity, is added as payable for the procedure codes listed in the following table: Procedure Code

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for the procedure codes listed below:

Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study

4/I/T-93931

Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for the procedure codes listed below:

Description

44501

Atheroembolism, upper extremity

Diagnosis Code

44502

Atheroembolism, lower extremity

4548

Procedure Code

Description

4/I/T-93923

Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood pressure measurements, segmental plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia)


Description

4/I/T-93930

Diagnosis Code

4/I/T-93922

Description

4/I/T-93924

9

Description Varicose veins of the lower extremities, with other complications

45910

Postphlebitic syndrome without complications

45911

Postphlebitic syndrome with ulcer

45912

Postphlebitic syndrome with inflammation

45913

Postphlebitic syndrome with ulcer and inflammation

45919

Postphlebitic syndrome with other complication

Procedure Code

Description

4/I/T-93965

Noninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography)

4/I/T-93970

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

4/I/T-93971

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study



Description

44323

Dissection of renal artery

44581

Atheroembolism, kidney

Procedure Code

Description

4/I/T-93975

Modifiers should not be used if an abortion is billed for other reasons, such as a spontaneous or missed abortion. ■

Electrocardiogram (EKG, ECG) Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for the procedure codes listed below: Diagnosis Code

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

Description

41406

Coronary atherosclerosis of coronary artery of transplanted heart

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study

41412

Dissection of coronary artery

42820

Systolic heart failure

42821

Acute systolic heart failure

Effective for dates of service on or after November 1, 2002, diagnosis code 44322, Dissection of iliac artery, is added as payable for the procedure codes listed in the following table:

42822

Chronic systolic heart failure

42823

Acute on chronic systolic heart failure

42830

Unspecified diastolic heart failure

42831

Acute diastolic heart failure

42832

Chronic diastolic heart failure

42833

Acute on chronic diastolic heart failure

4/I/T-93976

Procedure Code

Description

4/I/T-93978

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

4280

Unspecified combined systolic and diastolic heart failure

4/I/T-93979

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; limited study

42841

Acute combined systolic and diastolic heart failure

42842

Chronic combined systolic and diastolic heart failure

42843

Acute on chronic combined systolic and diastolic heart failure

Effective for dates of service on or after November 1, 2002, the following diagnosis codes have revised descriptions: Diagnosis Code

Description

Procedure Code

41410

Aneurysm of heart (wall)

5-93040

41411

Aneurysm of coronary vessels

Rhythm ECG, one to three leads: with interpretation and report

41419

Other aneurysm of heart, other

T-93005

Electrocardiogram, routine ECG with at least 12 leads: tracing only, without interpretation and report

T-93041

Rhythm ECG, one to three leads: tracing only without interpretation and report ■

Effective for dates of service on or after November 1, 2002, diagnosis code 4591, Postphlebitic syndrome, is no longer a benefit of the Texas Medicaid Program. ■

Epoetin Alpha

Elective Abortion Modifiers

Effective for dates of service on or after February 1, 2003, the following provider types will no longer be payable for procedure codes 1-Q0136 and 1-Q9920 through 1-Q9936 in POS 1 (office), 2 (home), and 8 (nursing facility–extended care facility):

The following article is a reminder to providers about elective abortion modifiers. Abortion modifiers should only be used when billing for elective abortions for one of the following reasons:

• Rape • Incest • Endangerment to the mother’s life This information, as well as the specific modifier codes to use, can be found in section 34.4.18.1 of the 2003 Texas Medicaid Provider Procedures Manual.


Description

Provider Type

10

Description

40

Medical supplier (DME); Licensed Master Social Worker – Advanced Clinical Practitioner (LMSW–ACP)

60

Hospital–Long term, limited, or specialized care


Eye Surgery by Laser

Provider Type

Description

61

Hospital–Private full care

62

Hospital-Private, outpatient service/emergency care only

79

Rural health clinic–hospital-based ■

Effective for dates of service on or after November 1, 2002, diagnosis code 36583, Aqueous misdirection, is added as payable for the procedure codes listed in the following table: Procedure Code

Extracorporeal Membrane Oxygenation (ECMO) Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for the procedure codes listed below: Diagnosis Code

Description

74783

Persistent fetal circulation

77181

Septicemia (sepsis) of newborn

77183

Bacteremia of newborn

77189

Other infections specific to the perinatal period

Procedure Code

Description

2-36822

Removal of cannula for prolonged extracorporeal circulation for cardiopulmonary insufficiency

2-33960

Prolonged extracorporeal circulation for cardiopulmonary insufficiency; initial 24 hours

2-33961

Prolonged extracorporeal circulation for cardiopulmonary insufficiency; each additional 24 hours (List separately in addition to code for primary procedure)

Iridectomy, with corneoscleral or corneal section; for removal of lesion

2-66605

Iridectomy, with corneoscleral or corneal section; with cyclectomy

2-66710

Ciliary body destruction; cyclophotocoagulation

2-66761

Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) (one or more sessions)

2-66762

Iridoplasty by photocoagulation (one or more sessions) e.g., for improvement of vision, for widening of anterior chamber angle

2-66770

Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) ■

Gynecological and Reproductive Health Services

Insertion of cannula(s) for prolong extracorporeal circulation for cardiopulmonary insufficiency (ECMO) (separate procedure)

2-3396X

Description

2-66600

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for procedure code 2-57520, Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair, cold knife or laser: Diagnosis Code

Effective for dates of service on or after November 1, 2002, diagnosis code 7718, Other infections specific to the perinatal period, is no longer a benefit of the Texas Medicaid Program. ■

Description

79500

Nonspecific abnormal Papanicolaou smear of cervix, unspecified

79501

Atypical squamous cell changes of undetermined significance favor benign (ASCUS favor benign)

79502

Atypical squamous cell changes of undetermined significance favor dysplasia (ASCUS favor dysplasia)

79509

Other nonspecific abnormal Papanicolaou smear of cervix

Effective for dates of service on or after November 1, 2002, diagnosis code 7950, Nonspecific abnormal Papanicolaou smear of cervix, is no longer a benefit of the Texas Medicaid Program. ■


11


Hearing Testing

conjunction with other childhood vaccines as children present for services. In all other Texas counties, hepatitis A vaccine can be provided through the TVFC only to American Indian and Alaskan Native children who are age 18 years and younger.

Effective for dates of service on or after December 1, 2002, procedure codes 5-92560, 9-92562, and 5-92564 are not a benefit of the Texas Medicaid Program: Procedure Code

Description

5-92560

Békésy audiometry; screening

5-92562

Loudness balance test; alternate binaural or monaural

5-92564

Short increment sensitivity index (SISI) ■

For questions about this expansion, contact Jack Sims or Robin Todd at 800-252-9152. ■

Hepatitis B Prophylaxis Policy Revision This policy applies to the reimbursement for the hepatitis B vaccine and the hepatitis B immune globulin for those clients who are not otherwise covered by the TVFC Program.

Hepatitis A Expansion

Administration of the hepatitis B vaccine is indicated for immunization against infection caused by all known subtypes of the hepatitis B virus. The hepatitis B vaccine is medically necessary for patients who have been exposed to the hepatitis B virus. This vaccine will not prevent hepatitis caused by other agents, such as hepatitis A, hepatitis C, or other viruses known to infect the liver.

Effective immediately, all American Indian and Alaskan Native children age 2 years through 18 residing or presenting for immunization services in Texas are eligible to be vaccinated against hepatitis A through the TVFC Program. The National Immunization Program has received a legal interpretation from the Centers for Disease Control and Preventions’ Office of General Counsel, regarding American Indian/Alaska Native children and Hepatitis A vaccine coverage through the VFC program.

The Texas Medicaid Program allows coverage of the hepatitis B vaccine for clients who are at high risk of contracting the disease. The following procedure codes are payable for clients age 19 years and older:

Documents considered include:

• • •

ACIP VFC Resolution No. 6/95-2 Procedure Code

ACIP VFC Resolution No. 2/99-4

ACIP Hepatitis A Recommendations, MMWR Vol. 48/No. RR-12 Oct. 1,1999 The interpretation follows: Since the purpose of the 1999 VFC resolution 2/99-4 was to consolidate previous VFC resolutions, the fact that it does not explicitly refer to American Indian and Alaska Native children does not change the fact that they were intended to be included within the groups of eligible recipients for Hepatitis A vaccine, as noted in Table 1 of VFC resolution 6/95-2. In addition, the interpretation of communities to mean more than simply geographic areas seems reasonable and should justify administration to all American Indian and Alaska Native children. Hepatitis A vaccine is not offered statewide through the TVFC to all children. The TVFC provides vaccine coverage for children age 18 years or younger who live in a county where the average annual hepatitis A disease rate was at least 10/100,000 population in the past 10 years. Each year, the county rates are analyzed and new counties are added if necessary. Currently, 56 Texas counties meet these criteria, with 32 requiring hepatitis A for school entry. For all 56 counties, hepatitis A vaccine is a routinely recommended childhood vaccine, and should be administered in


Description

1-90740

Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3-dose schedule), for intramuscular use

1-90746

Hepatitis B vaccine, adult dosage, for intramuscular use

1-90747

Hepatitis B vaccine; dialysis or immunosuppressed patient dosage (4-dose schedule), for intramuscular use

Procedure codes 1-90740, 1-90746, and 1-90747 are covered for the following diagnoses: Diagnosis Code

12

Description

V017

Contact with or exposure to communicable diseases; other viral diseases

V018

Contact with or exposed to communicable diseases; other communicable diseases

V053

Need for prophylactic vaccination and inoculation against single disease: Viral hepatitis

042

Human immunodeficiency virus (HIV) disease

0795– 07959

Viral and chlamydial infection in conditions classified elsewhere and of unspecified site; Retrovirus

2040– 20891

Leukemias


Diagnosis Code

The state-mandated administration of the hepatitis B vaccine to newborns before discharge from the hospital has been established as the accepted standard of care and will not be considered as a reason to upcode to a different diagnosis-related group (DRG).

Description

28260– 28269

Sickle cell anemia

2860–2869

Coagulation defects

2870–2879

Purpura and other hemorrhagic conditions

317

Mild mental retardation

3180–3182

Other specified mental retardation

319

Unspecified mental retardation

The administration of the hepatitis B vaccine to newborns is included in the DRG payment and will not be reimbursed separately. Refer to:

Procedure code 1-90782, Therapeutic, prophylactic or diagnostic injection (specify material injected): subcutaneous or intramuscular, is payable for the administration of the hepatitis B vaccines.

TDH provides hepatitis B vaccine free of charge to physicians, hospitals, birthing centers, and THSteps providers for administration to Medicaid-eligible clients age 19 to 21.

The immunization administration procedure codes 1-90471 and 1-90472 are not benefits of the Texas Medicaid Program for administration of the hepatitis B vaccine.

Refer to:

Mentally retarded Medicaid-eligible individuals residing in a private (nonstate) institution for the mentally retarded (ICF-MR), are classified as at a continuing high risk for hepatitis B with an ongoing exposure potential. When provided and billed by the attending physician, Medicaid will allow coverage of hepatitis B vaccine for all inpatients of an ICF-MR (private) facility.

Section 40, Texas Health Steps (THSteps), in the 2003 Texas Medicaid Provider Procedures Manual for more information. ■

Hospital Outpatient Observation Room Services Clarification Some Medicaid patients, while not requiring hospital admission, may require an extended period of observation (less than 24 hours) in the hospital environment as an outpatient, during which time appropriate observations and appropriate ancillary services may be obtained to determine the patient’s future medical management. Observation services may be provided in any part of the hospital where a patient can be assessed, examined, monitored, or treated.

When the hepatitis B vaccine is provided to clients with end-stage renal disease who are directly exposed, separate payment may be made as the vaccine and its administration are not included in dialysis services. Hepatitis B immune globulin is effective for dates of service on or after November 1, 2002.

The Texas Medicaid Program will reimburse at reasonable cost as determined by the state or its designee for medically necessary hospital outpatient observation services. The hospital outpatient observation period is less than 24 hours when medically necessary, thus avoiding an inpatient admission that is not medically necessary. Outpatient means a patient is in an organized medical facility, and receives professional services for less than a 24-hour period regardless of the following:

Hepatitis B immune globulin, I.M. (HBIG), provides coverage for acute exposure to the hepatitis B virus. Procedure code 1-90371, Hepatitis B immune globulin (HBIG), human, for intramuscular use, is payable for clients age 19 years and older. Procedure code 1-90371 is covered for diagnosis code V017, Contact with or exposure to communicable diseases: other viral diseases.

Vaccine Coverage under the TVFC Program

• The hour of admission • If a bed is used • If the patient remains in the facility past midnight When a patient is admitted to the hospital as an inpatient and discharged in less than 24 hours, the hospital may request that the physician change the admission order status from inpatient to outpatient observation. This billing practice is acceptable under the Texas Medicaid Program when the physician makes the changes to the admitting order from inpatient status to outpatient observation status before the hospital submits the claim for reimbursement. The hospital

All children from birth through age 18 are approved to be vaccinated against hepatitis B with vaccine supplied by the TDH TVFC Program. It is not necessary for a client, age 0-18, to be included in a hepatitis B high-risk group to be eligible for the state-supplied vaccine. The TDH immunization schedule begins immunizing for hepatitis B at birth. TDH will replace the hepatitis B vaccine that hospitals administer to newborns free of charge.


Appendix K, Immunizations, in the 2003 Texas Medicaid Provider Procedures Manual for more information.

13


outpatient observation room service commences with the first clinical contact of a patient by the hospital’s professional/licensed staff.

Diagnosis Code

Description

42820

Unspecified systolic heart failure

Procedure code 9-Y0013, Observation room, is used when billing for observation room services.

42821

Acute systolic heart failure

42822

Chronic systolic heart failure

When a patient’s status changes from observation to inpatient admission, the date of the inpatient admission is the date the client was placed on observation status. This rule applies regardless of the length of time the patient was in observation or whether the date of inpatient admission is the following day. All charges, including the observation room, are billed on the inpatient claim.

42823

Acute on chronic systolic heart failure

42830

Unspecified diastolic heart failure

42831

Acute diastolic heart failure

42832

Chronic diastolic heart failure

42833

Acute on chronic diastolic heart failure

42840

Unspecified combined systolic and diastolic heart failure

If a condition of the scheduled day surgery requires additional care beyond the recovery period, the client may be placed in outpatient observation (stay less than 24 hours). The observation period should be billed as an outpatient claim with supporting documentation.

42841

Acute combined systolic and diastolic heart failure

42842

Chronic combined systolic and diastolic heart failure

42843

Acute on chronic combined systolic and diastolic heart failure

4386

Alterations of sensations

4387

Disturbances of vision

43883

Facial weakness

43884

Ataxia

43885

Vertigo

Procedure Code

Description

The facility may elect to bill the services as an admission but is subject to retrospective review and possible denial if the admission was not medically necessary with subsequent recoupment of the DRG payment. If the admission is denied as not medically necessary by the HHSC’s UR Department, the hospital may appeal the denial to the state. The hospital may not rebill for the outpatient observation services to NHIC on a claim type 23 after receiving an admission denial from the HHSC’s UR Department. Exception: The hospital may submit a revised outpatient

claim (claim type 23) for the medically necessary outpatient services to NHIC when authorized by the state. In these cases, the state has determined the records document that the hospital originally placed the patient in an outpatient observation status on an outpatient basis. The hospital outpatient observation room benefit is subject to retrospective hospital surveillance and utilization review, as well as quality review. ■

27702

Cystic fibrosis with pulmonary manifestation

27703

Cystic fibrosis with gastrointestinal manifestation

27709

Cystic fibrosis with other manifestations

41406

Coronary atherosclerosis of coronary artery of transplanted heart

41412

Dissection of coronary artery


1-90658

Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use

1-90659

Influenza virus vaccine, whole virus, for intramuscular or jet injection

1-90660

Influenza virus vaccine, live, for intranasal use ■

Effective for dates of service on or after November 1, 2002, diagnosis code V0189, Contact with or exposure to communicable diseases, other communicable diseases, is a payable diagnosis for the following procedure codes:

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable for the procedure codes listed below: Description

Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use

Injections – Gamma Globulin

Influenza Vaccine

Diagnosis Code

1-90657

14

Procedure Code

Description

1-J1561

Injection, immune globulin; intravenous, 500 mg

1-J1563

Injection, immune globulin; intravenous, 1 GM

1-1046X

Injection, immune globulin (human); intravenous, 2.5 GM

1-1048X

Injection, immune globulin (human); intravenous, 3 GM


Magnetic Resonance Angiography (MRA)

Effective for dates of service on or after November 1, 2002, the preceding procedure codes are no longer payable when billed with diagnosis code V018, Contact with or exposure to communicable diseases, other communicable diseases. ■


Intravenous Gamma Globulin (IVIG)

Description

4386

Late effects of cerebrovascular disease, alterations of sensations

4387

Late effects of cerebrovascular disease, disturbances of vision

43883

Late effects of cerebrovascular disease, facial weakness

Description

43884

Late effects of cerebrovascular disease, ataxia

1-1046X

Gamimune, 5%, 2.5 GM

43885

Late effects of cerebrovascular disease, vertigo

1-1048X

Sandoglobin, 3 GM

Procedure Code

Description

Effective for dates of service on or after December 1, 2002, the descriptions of the following procedure codes have changed:

End-Dated Descriptions Procedure Code

Revised Descriptions Procedure Code

4/I/T-70544

Magnetic resonance angiography, head; without contrast material(s)

Description

4/I/T-70545

1-1046X

Injection, immune globulin (human); intravenous, 2.5 GM

Magnetic resonance angiography, head; with contrast material(s)

4/I/T-70546

1-1048X

Injection, immune globulin (human); intravenous, 3 GM

Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

4/I/T-70547

Magnetic resonance angiography, neck; without contrast material(s)

4/I/T-70548

Magnetic resonance angiography, neck; with contrast material(s)

4/I/T-70549

Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences ■

Effective for dates of service on or after December 1, 2002, procedure code 1-Z1048, Injection, Gamimune 50 cc, is no longer a payable procedure code for intravenous gamma globulin (IVIG) injections. Effective for dates of service on or after December 1, 2002, the following provider types will no longer be payable for IVIG injections in POS 1 (office), 2 (home), and 8 (extended care facility): Provider Type

Description

32

Podiatrist

60

Hospital–Long term, limited, or specialized care

61

Hospital–Private full care

62

Hospital–Private, outpatient service/emergency care only

95

Podiatry group ■


Nasal Sinus Endoscopy Effective for dates of service on or after December 1, 2002:

15

•

Procedure code 2-31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure), will be payable in POS 1 (office).

•

Provider types 10 (advanced practice nurse) and 33 (registered nurse/nurse-midwife) will no longer be payable for procedure code 2-31237. ■


Nerve Conduction Studies

ordered admissions. A copy of the court document should accompany prior authorization requests. The following services are independent of, the exception to, and do not count toward the 30-visits/encounter limit:


Description

35781

Chronic inflammatory demyelinating polyneuritis

35782

Critical illness polyneuropathy

35789

Other inflammatory and toxic neuropathy

Procedure Code 5/I/T-95900

Description

Nerve conduction, amplitude and latency/ velocity study, each nerve; motor, with F wave study

5/I/T-95904

Nerve conduction, amplitude and latency/ velocity study, each nerve; sensory or mixed

5/I/T-95934

H-Reflex, amplitude and latency study; record gastrocnemius/soleus muscle

5/I/T-95936

H-Reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle ■

Mental health mental retardation (MHMR) services Laboratory and radiology services

Each hour of the following will count as one visit/ encounter towards the 30-visit/encounter limit:

• • •

Effective for dates of service on or after February 1, 2003, all authorization requests for extension of outpatient psychotherapy sessions beyond the annual limit will be limited to 10 visits/encounters per request.

Therapy Psychological testing Neuropsychological testing ■

Pediatric Pneumogram A pneumogram is a 12- to 24-hour recording of breathing effort, heart rate, oxygen level, and airflow to the lungs during sleep. The study is useful in identifying abnormal breathing patterns, with or without bradycardia, especially in premature infants.

All requests for prior authorization of extensions beyond the initial annual 30-visit limit must include the following: Client name and Medicaid number

The following procedure code is used when billing for the pediatric pneumogram: 5/I/T-94772, Circadian respiratory pattern recording (pediatric pneumogram), 12- to 24-hour continuous recording, infant.

Provider name and TPI

Clinical update, including current symptoms and response to past treatment and treatment plan (length of treatment, type of therapy, and frequency of visits) Refer to: Page 30 for a copy of the Extended Outpatient Psychotherapy/Counseling Request Form.

The following diagnoses are payable for a pediatric pneumogram in infants up through age 11 months:

The number of visits authorized will be dependent on the client’s symptoms and response to past treatment. If the client requires additional extensions, the provider must submit a new request for prior authorization at the end of each extension period. The additional request(s) must include new documentation about the client’s current condition. Prior authorization for an extension of outpatient behavioral health services will be granted when the treatment is mandated by the courts for court-


• • •

Procedure code 5-96100, Psychological testing, will be limited to eight hours of testing per calendar year, any provider and if performed on the same date of service. Additionally, procedure code 5-96117, Neuropsychological testing, will be denied as part of another service and limited to eight hours per calendar year, any provider. This testing is payable on the same date of service as procedure codes 1-90801, Initial psychiatric exam, or 1-90802, Interactive psychiatric diagnostic interview examination.

Outpatient Behavioral Health Services

• • •

School Health and Related Services (SHARS) behavioral rehabilitative services

Procedure code 1-90862, Pharmacological management Psychological or neuropsychological testing will be limited to a total of four hours per day per client, any provider. Documentation of medical necessity must be maintained in the client’s chart.

Nerve conduction, amplitude and latency/ velocity study, each nerve; motor, without F wave study

5/I/T-95903

•

16

Diagnosis Code

Description

5300

Achalasia and cardiospasm

53010

Esophagitis, unspecified

53011

Reflux esophagitis

53012

Acute esophagitis

53019

Other esophagitis

53081

Esophageal reflux


Radiation Therapy

Diagnosis Code

Description

7685

Severe birth asphyxia

7686

Mild to moderate birth asphyxia

7689

Unspecified birth asphyxia in liveborn infant

769

Respiratory distress syndrome

7707

Chronic respiratory disease arising in the perinatal period

78603

Apnea

78606

Tachypnea

78607

Wheezing

78609

Other dyspnea and respiratory abnormalities

Effective for dates of service on or after December 1, 2002, procedure code T-77418, Intensity modulated treatment delivery, single or multiple fields/ arcs, via narrow spatially and temporally modulated beams (e.g., binary, dynamic multileaf collimator [MLC]), per treatment session, will no longer be a benefit of the Texas Medicaid Program. ■

Regional Anesthesia The following article is a clarification to the regional anesthesia policy.

All Procedures

Electromyograms, polysomnography, EEGs, and EKGs will be denied when billed on the same day as a pediatric pneumogram.

Regional anesthesia, or nerve block, involves the blocking of nerve impulses with a local anesthetic. It is administered by a physician and requires special techniques and attention, especially during the initial phase of instituting the block. Nerve blocks used for the treatment of a medical condition should be billed with the appropriate procedure code with a quantity of one.

Pediatric pneumograms may be reimbursed on the same date of service as the apnea monitor (rented monthly) if documentation supports the medical necessity. Pneumogram supplies are considered part of the technical component of the reimbursement and will be denied if billed separately.

Local, regional, or general anesthesia provided by the surgeon is not a separately payable benefit of the Texas Medicaid Program when performed by the operating surgeon. If such services were billed, even if the Current Procedural Terminology (CPT) modifier 47 (Anesthesia by Surgeon) is used, the services will be included in the global fee for the surgical procedure(s). However, the delivering physician may be reimbursed for both services, as indicated in the Delivering Physician Providing Anesthesia section on page 18.

Effective for dates of service on or after December 1, 2002:

•

A pediatric pneumogram will be limited to two services without prior authorization based on the diagnoses listed in the table above. Additional studies may be considered under the THSteps–CCP with documentation of medical necessity and will require prior authorization.

•

Diagnosis codes 78604, Cheyne-Stokes respirations, and 78605, Shortness of breath, will no longer be payable for the pediatric pneumogram.

•

The pediatric pneumogram will no longer be payable in POS 2 (home), 3 (inpatient hospital), 4 (skilled nursing facility), and 8 (extended care facility).

•

The pediatric pneumogram will no longer be a benefit for provider types 43 (radiation treatment center), 72 (nephrology) and 73 (renal dialysis facility).

•

The rental of the pneumogram will be limited to infants from birth through 11 months. ■

Obstetrical Procedures Epidural anesthesia is a form of regional anesthesia frequently used for labor and/or delivery. A small catheter is placed in the epidural space of the spinal canal. Multiple injections are made through the catheter during the course of labor and delivery. Providers should bill services using the appropriate CPT code. The following are clarifying examples.

Pneumococcal Conjugate Vaccine Effective for dates of service October 1, 2000, through April 25, 2002, NHIC will reprocess claims that denied incorrectly for procedure code 9-5498X, Administration of the pneumococcal conjugate vaccine, outside of a THSteps medical checkup. This procedure code remains a valid, billable code. ■


17


amount is then multiplied by the appropriate conversion factor. The anesthesia procedure codes listed in the following table are used for labor and delivery:

Regional Anesthesia for Labor Only When a separate provider other than the surgeon or obstetrician is billing for epidural anesthesia for labor only, the set-fee, nontime-based reimbursement is made based on the allowed payable amount for the surgical codes listed in the following table: Procedure Code 2-62311

2-62319

Procedure Code

Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)

7-01968

Cesarean delivery following neuraxial labor analgesia/anesthesia

7-01969

Cesarean hysterectomy following neuraxial labor analgesia/anesthesia

Description Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)

Delivering Physician Providing Anesthesia

Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal)

The procedure codes for vaginal and Cesarean delivery are listed in the following table: Procedure Code

Procedure codes 2-62311 and 2-62319 also may be reimbursed to an ASC/HASC facility (TOS F), subject to multiple ambulatory surgical guidelines.

When a separate provider other than the surgeon or obstetrician is billing for general anesthesia for delivery only, reimbursement is derived by adding the relative value unit (RVU) to the time spent with the client. Time spent with the client means the anesthesia provider must be physically in the room with the client. The time, in minutes, is divided by either 15 or 30 minutes, depending on the modifier billed. This amount is then multiplied by the appropriate conversion factor. The anesthesia procedure codes listed in the following table are used for delivery only. Description

7-01960

Anesthesia for; vaginal delivery only

7-01961

Anesthesia for; Cesarean delivery only

7-01963

Anesthesia for; Cesarean hysterectomy without any labor/anesthesia care

Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

2/8-59515

Cesarean delivery only; including postpartum care

2-59614

Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

2/8-59622

Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery; including postpartum care

The delivering physician may bill and be reimbursed separately at full allowance for both the obstetrical anesthesia and the vaginal or Cesarean delivery. The time element representing when the physician is physically present and monitoring the continuous epidural is calculated from the time of insertion of the epidural catheter until the vaginal or Cesarean delivery commences.

Clarification of Reimbursement for Anesthesia Complicated by Emergency Conditions (1-99140) Procedure code 1-99140, Anesthesia complicated by emergency conditions, is not reimbursed for diagnosis codes 650, Normal delivery, or 66970, Cesarean delivery, without mention of indication, unspecified as to episode of care or not applicable, when one of these diagnoses is documented as the referenced diagnosis on the claim. Reimbursement may be considered when the referenced diagnosis indicates the complicating emergency condition, such as eclampsia. ■

Anesthesia for Labor and Delivery When a separate provider other than the surgeon or obstetrician is billing for epidural anesthesia for labor and delivery, reimbursement is made in the same manner as reimbursement for general anesthesia. Reimbursement is derived by adding the RVU to the time spent with the client. Time spent with the client means the anesthesia provider must be physically in the room with the client. The time, in minutes, is divided by either 15 or 30 minutes, depending on the modifier billed. This


Description

2-59410

Anesthesia for Delivery Only

Procedure Code

Description

7-01967

18


Respiratory Care Equipment

Visits – Hospital Concurrent Care

Effective for dates of service on or after November 1, 2002, the following diagnosis codes are added as payable diagnoses for the procedure codes listed below:

The following article is a clarification of the hospital concurrent care visits policy. Concurrent care exists when services are provided to a client by more than one physician on the same day during a period of hospitalization in the inpatient hospital setting. Generally, current care is appropriate when major multiple organ failure requires the skills of different specialties concurrently on a daily basis to successfully manage the client. Concurrent care will not be paid to providers of the same specialty for the same or related diagnoses. Diagnosis will be considered related when there is a three-digit match of the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code. Denied concurrent care will be considered on an appeal basis when accompanied by documentation of medical necessity.

Diagnosis Code

Description

27702

Cystic fibrosis with pulmonary manifestations

27703

Cystic fibrosis with gastrointestinal manifestations

27709

Cystic fibrosis with other manifestations

Procedure Code

Description

J-E0570

Nebulizer; with compressor

9-A7003

Administration set, with small volume nonfiltered pneumatic nebulizer, disposable

9-A7004

Small volume nonfiltered pneumatic nebulizer, disposable

9-A7005

Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable

9-A7006

Administration set, with small volume filtered pneumatic nebulizer

9-A7007

Large volume nebulizer, disposable, unfilled, used with aerosol compressor

9-A7013

Filter, disposable, used with aerosol compressor

J-E0575

Nebulizer; ultrasonic

L-E0500

IPPB machine, all types, with built in nebulization; manual or automatic valves; internal or external power source

9-5388X

Mucous clearance valve (e.g., Flutter®)

9-5800X

High frequency chest wall compression system vest (e.g., ThAIRapy®), purchase

9-5801X

High frequency chest wall compression system generator (e.g., ThAIRapy®), rental/month

9-5480X

High frequency chest wall compression system generator (e.g., ThAIRapy®), purchase

L-E0481

Intrapulmonary Percussive Ventilation System and Related Accessories ■

Concurrent care will be paid to providers of different specialties when providing services for unrelated diagnoses involving different organ systems. All concurrent care will be subject to retrospective review. Documentation of medical necessity for concurrent care must be maintained by the physician as required by federal law and should include, but is not limited to, the following: Orders by the attending physician that concurrent care was requested from a specific specialty with valid reasons stated for the request.

•

The physician rendering concurrent care must have the name of the requesting physician documented.

•

If the attending physician is requesting a consultation only, the request must be clearly stated in his or her orders. ■

Visits – Neonatal Intensive Care Effective for dates of service on or after February 1, 2003, the following procedure codes will no longer be paid separately in addition to the neonatal intensive care codes: Procedure Code

Training Specialist Telephone Number Correction This article corrects the “Your NHIC Training Specialists by Territory” article, which appeared on page 15 in the November/December 2002 Texas Medicaid Bulletin, No. 166. The telephone number for Toni Emmons, training specialist for territory 1, Amarillo/Lubbock, should read 512-514-3267, not 512-514-3627. ■


•

Description

1-99440

Newborn resuscitation; provision of positive pressure ventilation and/or chest compressions, in the presence of acute inadequate ventilation and/or cardiac output

2-62272

Spinal puncture, therapeutic for drainage of cerebrospinal fluid; by needle or catheter

Neonatal intensive care codes are comprehensive per diem (daily) care codes for physicians personally delivering and personally supervising the delivery of health care by the neonatal intensive care team to the neonate or infant and may be billed only once per day per neonate or infant. ■

19


Inpatient Stay

Visits – New Versus Established Patient

Providers must request authorization of an inpatient stay by completing the Psychiatric Hospital Inpatient Admission Form in its entirety and faxing it to NHIC before or on the day of the client’s admission.

The following article is a clarification of the new versus established patient visits policy. A new patient is defined as one who is new to the physician and whose medical and administrative records need to be established. An established patient is defined as one whose medical and administrative records are available to the physician.

Exception: If the admission is after 5 p.m., on a holiday,

or a weekend, NHIC must receive it by 5 p.m. on the next business day following admission.

A new patient visit is limited to one every two year, per patient, per provider. Established patient visits billed on the same day as a new patient visit by the same provider for any diagnosis will be denied as part of another procedure on the same day. Established patient care visits are also limited to one per day for the same provider regardless of diagnosis. ■

If the admission occurs after 2 p.m. on a business day and the provider is unable to submit the Psychiatric Hospital Inpatient Admission Form by 5 p.m., the provider should do the following:

• Call the CCIP Unit of the admission that day • Fax the admission form the following business day The Psychiatric Hospital Inpatient Admission Form must provide documentation supporting hospitalization and current diagnosis. Additional supporting documentation may be attached to the form.

ASC/HASC Providers

Extended Stay

2002 ASC/HASC Fee Schedule Correction

If a client requires continuation of care in an inpatient setting, complete a Psychiatric Inpatient (Extended) Request Form in its entirety and fax it to NHIC. All requests for continuation of stay must have prior authorization, and requests for continuation of stay must be received on or before the last day authorized or denied. If the date of the NHIC determination letter is on or after the last day authorized or denied, the request for continuation of stay is due by 5 p.m. of the next business day.

The maximum fee amounts are missing for procedure codes F-69930, F-9000X, and F-9008X on page 90 of the 2002 Ambulatory Surgical Center/Hospital-based Ambulatory Surgical Center Fee Schedule report. The applicable fees are as follows: Procedure Code

Maximum Fee

F-66930

$11,840.96

F-9000X

$515.00

F-9008X

$4,931.93

The Psychiatric Inpatient (Extended) Request Form must reflect the need for continued stay in relation to the original need for admission with a description of the current symptoms and observed behavior. Additional documentation or information supporting the need for continued stay may be attached to the form.

Only the printed version of the fee schedule was affected. ■

All prior authorization requests not submitted to or received by NHIC within these parameters are denied through the date the request for service is received. A toll-free telephone and fax line are available to complete the authorization process. Contact the NHIC CCIP Unit at 800-213-8877, fax 512-514-4211. ■

CCIP Providers Documentation Requirements The following article is a reminder to Comprehensive Care Inpatient Psychiatric Program (CCIP) providers about documentation requirements. To expedite requests for authorization to freestanding and state psychiatric facilities, you must follow the documentation requirements for inpatient and extended stays as stated in the 2003 Texas Medicaid Provider Procedures Manual.


Laboratory Providers CLIA Waived Tests Update Effective on October 2, 2002, CPT code 82274QW was granted waived status under the Clinical Laboratory Improvement Amendments (CLIA). The QW modifier is a CLIA requirement for this code and must be submitted or claims will be denied. ■

20


Managed Care Providers

Prior authorization for inpatient rehabilitation will be considered for clients who meet all the following criteria:

•

The client has an acute problem and/or an acute exacerbation of a chronic problem resulting in a significant decrease in functional ability and will benefit from inpatient rehabilitation care

•

The client is expected to improve within a 60-day period and be restored to one of the following: • A more functional lifestyle for an acute condition • The previous level of function for an exacerbation of a chronic condition The intensity of necessary rehabilitative service cannot be provided in the outpatient setting

Managed Care Authorization Removal Effective for dates of service on and after January 1, 2003, managed care authorization (precertification) will no longer be required for the following CPT codes for claims processed by NHIC: CPT Code

Description

2/F-69436

Tympanostomy

2/F-42820

Tonsillectomy and adenoidectomy; under age 12

2/F-42830

Adenoidectomy; under age 12

2/F-43239

Diagnostic endoscopic procedure ■

• •

•

This therapy will be provided for a minimum of three hours per day for five days per week Inpatient rehabilitation may be prior authorized for up to two months when the attending physician submits documentation of medical necessity.

THSteps–CCP Providers THSteps–CCP Rehabilitation Services (Policy Revision)

Requests for prior authorization of subsequent services may be considered based on medical necessity and are not to exceed 60 days. Requests for prior authorization of subsequent services must be received before the end-date of the preceding prior authorization.

The CCP is an expansion of the THSteps Program, as mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA ‘89), for Medicaid-eligible clients younger than age 21 years. CCP benefits are those procedures that exceed the current traditional Medicaid limitations, or those procedures that are currently not a benefit. CCP benefits may be considered for prior authorization with documentation of medical necessity.

Documentation Physician Signature The physician must sign and date the request for inpatient rehabilitation and treatment plan. All signatures must be original and handwritten. Computerized or stamped signatures will not be accepted.

Conditions requiring rehabilitation may be acute, an exacerbation of a chronic condition, or chronic. A condition is considered to be acute or an exacerbation only during the six months from the onset date of the acute condition or the exacerbation of the chronic condition. Acute rehabilitation is covered through traditional Medicaid. Requests for services beyond this time period may be considered case by case.

Prior Authorization – Initial Supporting documentation must include all the following components:

•

Prior Authorization Inpatient rehabilitation services provided to clients younger than age 21 in a freestanding rehabilitation facility require mandatory prior authorization, both for the initial admission and an extension of service.

• •


The client requires, and will receive, multidisciplinary team care, defined as at least two therapies (occupational, physical and/or speech therapy)

21

A comprehensive treatment plan to be followed during the inpatient rehabilitation admission that meets all the following criteria: • Is under the leadership of a physician • Incorporates an active interdisciplinary team • Consists of at least two appropriate physical modalities (physical, occupational and speech language therapy [PT/OT/ST]) designed to resolve or improve the client’s condition • Includes a minimum client/team interaction of three hours per day for five days per week The date of onset of the illness or injury requiring the rehabilitation admission A brief synopsis of previous medical treatment, including outcomes of the treatment relative to the debilitating condition


•

The expected outcome to be achieved by the active treatment plan, and the time interval at which this outcome should be achieved

Termination of Treatment

•

Discussion why outpatient PT, OT, and/or ST does not or has not met the client’s needs

•

•

Discussion that alternative treatment sites have been evaluated, and why they are inappropriate for the client’s needs

An active progressive treatment plan under the direction of a physician is not being aggressively pursued

•

Progress cannot be documented in 60 days by the interdisciplinary team

•

Authorization for inpatient rehabilitation can be terminated if:

Whether the client has a reasonable expectation for meaningful improvement from the treatment plan that will restore the client to his or her maximum expected function and/or achieve independent living capabilities in 60 days

•

Plateauing has occurred, indicating that reasonable additional progress cannot be anticipated or documented Reminder: Plateauing is defined as the point at which maximal improvement has been documented and continued improvement ceases. ■

Prior Authorization – Subsequent Services Supporting documentation must include all the following components:

•

• • •

THSteps Medical Providers

An updated comprehensive treatment plan to be followed during the inpatient rehabilitation admission that meets all the following criteria: • Is under the leadership of a physician • Incorporates an active interdisciplinary team • Consists of at least two appropriate physical modalities (PT/OT/ST) designed to resolve or improved the client’s condition Includes a minimum client/team interaction of three hours per day for five days per week

Helpful Information in this Bulletin for THSteps Medical Providers Refer to the following articles in this bulletin for helpful information:

• • • •

A brief synopsis of the outcomes of the previous treatment relative to the debilitating condition The expected outcome to be achieved by an extension of the active treatment plan, and the time interval at which this extension outcome should be achieved

•

Discussion why the initial two months of inpatient rehabilitation has not met the client’s needs and why the client cannot be treated in an outpatient setting

•

Whether the client has a reasonable expectation for meaningful improvement from the extension of the treatment plan that will restore the client to his or her maximum expected function and/or achieve independent living capabilities in 60 days


22

“Pneumococcal Conjugate Vaccine” on page 17 “Hearing Testing” on page 12 “Hepatitis A Expansion” on page 12 “Hepatitis B Prophylaxis Policy Revision” on page 12 ■


Excluded Providers In compliance with 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. 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 512-424-6519 or 888-752-4888, or writing to this address: Sharon E. Thompson, Director HHSC Office of Program Integrity PO Box 13247 Austin TX 78711-3247 Provider

License No#

Alviano Philip James

620750

Anderson Karen Joyce Andrews Krista Marie

City

State

Provider Type

Add Date

20-Apr-01

River Ridge

LA

RN

06-Aug-02

557301

12-Mar-01

Longview

TX

RN

29-Aug-02

153657

20-Jun-02

Winnsboro

TX

LVN

02-Aug-02

20-Mar-02

Houston

TX

24-Jan-02

Pineville

NC

20-Mar-02

Bryan

TX

Astrodome Chiropractic Clinic Bakeman Penny Elizabeth

654107

Barlow Jacqueline Armstrong

Exclusion Date

06-Aug-02 RN

24-Sep-02 06-Aug-02

Barron Joann Therese

608603

22-Mar-02

San Antonio

TX

RN

26-Aug-02

Bell Jimmie Mack

666356

24-Jan-02

Belton

TX

RN

11-Aug-02

Bieganowski Arthur C.

F2171

20-Mar-02

Fort Worth

TX

MD

30-Aug-02

20-Jun-02

El Paso

TX

Bieganowski Victor J.

02-Aug-02

Blackwood Opal Lynnzada

130613

20-Mar-02

Anna

TX

LVN

01-Aug-02

Blume Horst Gunther

D1551

17-May-02

Sioux City

IA

MD

26-Aug-02

Boldt-Ruiz Lisa Ann

158824

20-Mar-02

Cuero

TX

LVN

01-Aug-02

Boling Victor

4959

22-Jun-01

San Antonio

TX

LCD

13-Aug-02

Borg Elizabeth Ann

148459

10-Jun-02

McKinney

TX

LVN

29-Aug-02

Bradford Ginger Crooks

579664

23-Jan-26

Luling

LA

RN

11-Aug-02

Brashear Tammy Leigh

145773

20-Mar-02

Springtown

TX

LVN

06-Aug-02

Brooks Jess M.

B5748

09-Jun-98

Atlanta

TX

MD

06-Aug-02

Brown Clarence

118877

12-Jun-01

Van Vleck

TX

LVN

07-Aug-02

Brown Tanya Gaynell

159177

10-Jun-02

Lubbock

TX

LVN

13-Aug-02

Brown Willa

565206

19-Jul-01

Charlotte

NC

RN

17-Jun-02

Buchanan Darren Patrick

578907

08-Mar-02

Moncton NB Canada

RN

10-Aug-02

16-Nov-00

San Antonio

TX

Bulgeron Richard

16-Aug-02

Bull Larry George

618822

18-Apr-02

Fort Smith

AR

RN

02-Aug-02

Burgess Kimberly A.

105472

20-Jun-02

Arlington

TX

LVN

02-Aug-02

Burrow Sherry Lavon

167458

10-Jun-02

Tomball

TX

LVN

26-Aug-02

Burton Cori A.

610477

20-Mar-01

Fort Worth

TX

RN

10-Jun-02

20-Jun-02

Three Rivers

TX

Butler Jr. Paul G.


23

05-Aug-02


Provider

License No#

Calhoon Dawn Marie

454225

Callahan Jackie Lynn

085688

Exclusion Date

City

State

Provider Type

Add Date

20-May-02

Austin

TX

RN

16-Aug-02

11-Mar-02

Houston

TX

LVN

26-Aug-02

Campos Lucy B.

20-May-02

Pleasanton

CA

Carter Jason Michael

20-Sep-01

Arlington

TN

CFO

06-Aug-02

01-Aug-02

Cazalas Michael Anthony

607423

05-Jun-01

Corpus Christi

TX

RN

30-Aug-02

Chafin Ann T.

R-766614

20-Aug-01

Ocean Springs

MS

RN

01-Aug-02

20-Aug-01

Humble

TX

Charnetski Jr. Stanley

17-Jun-02

Cheshier Beverly

229371

20-Feb-01

Buchanan Dam

TX

RN

07-Aug-02

Clifton Jeanne K.

526355

15-Feb-02

Dallas

TX

RN

26-Aug-02

Clyton Mary Diane

571401

20-Jan-02

Santa Fe

TX

RN

11-Aug-02

19-Apr-01

Stafford

TX

DDS

06-Aug-02

20-Jun-02

Saint Amant

LA

LVN

29-Aug-02

Nashville

TN

Cobbs Charisse M. Collins Anthony Wayne

159626

Columbia Management Companies Inc.

01-Jul-01

28-Aug-02

Comeaux Gary Wayne

562166

08-Mar-02

League City

TX

RN

16-Aug-02

Connell Christopher

513235

20-Mar-01

Oklahoma City

OK

RN

06-Aug-02

Contreras Cheryl N.

17992

23-May-02

Rockwall

TX

DDS

06-Jun-02

Cooper Terri

137631

11-Jun-01

Idabel

OK

LVN

16-Aug-02

Cotton Beverly

112148

11-May-02

Missouri City

TX

LVN

04-Jun-02

Cox Tammy

651532

20-Mar-02

Lubbock

TX

RN

06-Aug-02

Cross Robin Marie

157475

11-Jun-01

Brownsville

TX

LVN

31-Jul-02

18-Apr-02

Metairie

LA

Cuccia Richard A.

10-Aug-02

Daigle Frances A.F.

213936

14-Aug-01

Denison

TX

RN

17-Jun-02

Delong Edith Greenhill

038538

20-May-02

Jefferson

TX

LVN

01-Aug-02

Dow John III

13075

15-Aug-02

Elkhart

TX

DDS

29-Aug-02

20-Oct-01

Missouri City

TX

Ekpo Asuquo Eyo

16-Aug-02

Ellig Michael Howard

151532

10-Jun-02

Odessa

TX

LVN

14-Aug-02

Elton Lisa Ann (Allred)

547643

16-Aug-02

Port Neches

TX

RN

10-Aug-02

Flint Mary A.

504878

20-Jan-02

Houston

TX

RN

30-Aug-02

Flowers Melva Dean

054706

11-Jun-02

Wake Village

TX

LVN

31-Jul-02

Fontenot Michelle

137904

10-Jun-02

Lake Jackson

TX

LVN

14-Aug-02

20-Mar-02

Fort Worth

TX

Fort Worth Injury and Rehabilitation Clinic, P.C.

11-Aug-02

Frederick Edmond Guinn

151061

10-Jun-02

Mauriceville

TX

LVN

14-Aug-02

Freeman April C. Hopkins

517080

20-May-02

Lubbock

TX

TN

30-Aug-02

Frnka (Casseday) Janis Joy

15968

20-Mar-02

Houston

TX

DDS

21-Jun-02

Fuller Cathy Michelle

130839

10-Jun-02

Hendrix

OK

LVN

28-Aug-02

Furrey Daniel Marlow

170465

11-Mar-02

St. Albans

NY

LVN

30-Aug-02

Garcia Omar Rene

582460

15-Mar-02

Woodway

TX

RN

16-Aug-02

Garcia Patricia Ann

121542

11-Mar-02

San Antonio

TX

LVN

29-Aug-02


24


Provider

License No#

Garrett Melissa Lou

Exclusion Date 21-May-02

City

State

Bridge City

TX

Provider Type

Add Date 30-Aug-02

Gaskins Shawna Gail

126553

12-Jun-01

Marlin

TX

LVN

26-Aug-02

Gilliam Melisa Sue

161529

11-Mar-02

Porter

TX

LVN

26-Aug-02

Gleason Kathryn

117372

11-Jun-02

San Antonio

TX

LVN

06-Aug-02

Gomez Gina Marie

129482

20-Mar-02

San Antonio

TX

LVN

01-Aug-02

Greene Debra Jo

102925

12-Jun-01

Hemphill

TX

LVN

28-Aug-02

Greenway Randall Todd

663022

18-Apr-02

Rogers

AR

RN

02-Aug-02

Hall Lisa Michelle

674671

20-May-02

Mesquite

TX

RN

01-Aug-02

Harris Janice F.

242650

20-Mar-02

Pearland

TX

RN

13-Jun-02

Haught Mary Nye

158916

10-Jun-02

McGregor

TX

LVN

27-Aug-02

Hayden Matthew Lemee

129100

10-Jun-02

Benbrook

TX

LVN

11-Aug-02

Hayes Michael B.

4669

20-Mar-02

Irving

TX

DC

18-Jun-02

Hempling William Hernick

633323

18-Apr-02

Metairie

LA

RN

14-Jun-02

20-Mar-02

San Antonio

TX

DDS

10-Jun-02

Hernandez Joe Bill Hewett Beverly F.

232724

02-Oct-01

North Richland Hills

TX

RN

13-Jun-02

Hines Glenola Joseph

055440

20-Mar-02

Houston

TX

LVN

06-Aug-02

14-Nov-01

Dallas

TX

MD

13-Aug-02

Hinkley Bruce S. Holder Rea Ann

159987

11-Mar-02

Azle

TX

LVN

31-Jul-02

Hordge Daniel Eugene

20771

14-Dec-02

Houston

TX

RX

30-Aug-02

Huckaby Jr. Winston

637367

24-Jan-02

Pasadena

TX

RN

08-Aug-02

Huebel Stacie Lynn

577673

15-Oct-01

Houston

TX

RN

27-Aug-02

Hughes Gail Marie

160149

11-Mar-02

Willis

TX

LVN

05-Aug-02

Hughes Janet Lynn

235256

01-Mar-02

Stephenville

TX

RN

08-Aug-02

Hunkin Jennifer

462203

12-Mar-02

McAllen

TX

RN

06-Aug-02

Hunt Samuel I.

8831

19-Oct-01

Waterflow

NM

DC

01-Aug-02

18-Oct-01

Irving

TX

DDS

06-Aug-02

Ip Stephen Climent Isaac Richard John

636375

12-Dec-01

Yellville

AR

RN

13-Aug-02

Jensen Inge Laura

179886

10-Jun-02

Sherman

TX

LVN

16-Aug-02

Jensen Lisa Gayle

102839

10-Jun-02

Huffman

TX

LVN

14-Aug-02

Johnson III Charles F.

D-3284

07-Dec-01

Temple

TX

MD

13-Jun-02

Johnson Diana Lee

112255

11-Mar-02

Trinity

TX

LVN

07-Aug-02

Johnson Mary Darlene

135461

10-Jun-02

Lufkin

TX

LVN

28-Aug-02

Jones Donald Earl

135472

18-Oct-01

Dallas

TX

LVN

06-Aug-02

18-Apr-02

Wichita Falls

TX

LVN

21-Jun-02

Jones Rhonda Renee Jordan Terry Lee

563121

20-Mar-01

Sherman

TX

RN

28-Aug-02

Kemp Anita Kay

601326

20-May-02

Roanoke

TX

RN

06-Aug-02

Kowalik Vance

640083

20-Jan-02

San Antonio

TX

RN

08-Aug-02

Krueger David W.

E-5556

17-May-02

Houston

TX

MD

16-Aug-02

Kula Gary Paul

F-4183

17-May-02

Norman

OK

MD

28-Aug-02


25


Provider

License No#

Landefeld Ronald A.

E-3988

Latham Kathy Russell Lee Laura D.

City

State

Provider Type

Add Date

07-Dec-01

Marion

OH

MD

13-Jun-02

540468

18-Jul-02

Ivanhoe

TX

RN

16-Aug-02

111755

11-Jun-01

New Caney

TX

LVN

29-Aug-02

18-Apr-02

Crane

TX

Lemon Rocky R.

Exclusion Date

21-Jun-02

Leonard Rhonda Lynn

583302

14-Aug-01

Frankston

TX

RN

17-Jun-02

LeSage Sahara

18087

20-Feb-02

League City

TX

DDS

30-Aug-02

Lewis Steven R.

5515

20-Feb-02

Flower Mound

TX

DC

01-Aug-02

20-Feb-02

Denison

TX

DC

21-Jun-02

Linsteadt, Elizabeth Lloyd (Sanders) Ginger Louise

165493

12-Jun-01

Iowa Park

TX

LVN

03-Sep-02

Lowe Theresa Yvonne

150510

11-Mar-02

Arlington

TX

LVN

30-Aug-02

Mabry Donnie Alene

520763

18-Apr-02

Meridian

MS

RN

27-Aug-02

Marquez Victoria Lynn

170222

20-Mar-02

El Paso

TX

LVN

16-Aug-02

Marr Jacqueline

587071

18-Apr-02

Clatskanie

OR

RN

26-Aug-02

Martin-Cadore Judith E.

F77338

20-Mar-02

League City

TX

MD

28-Aug-02

Martinez, Sylvia Ann

125587

10-Jun-02

Kingsville

TX

LVN

27-Aug-02

Mathews Weldon Wayne

244328

20-Mar-02

El Paso

TX

RN

06-Aug-02

Mathis Patricia

108216

20-Feb-02

Brenham

TX

NAC

13-Aug-02

30-May-02

Lewisburg

PA

Odessa

TX

LVN

05-Aug-02

Crane

TX

MD

16-Aug-02

Matthews Carl Gustavus

18-Jun-02

Mauck Sharon

056433

18-Apr-02

Maynard Billy Joe

C-0751

17-May-02

McCarver Warren Kirk

156583

12-Jun-01

Houston

TX

LVN

29-Aug-02

McCarty Teresia Dawnette

169870

18-Oct-01

San Marcos

TX

LVN

17-Jun-02

McClinton Mary Colleen

629152

20-Nov-01

McAllen

TX

RN

30-Aug-02

McDonald Anita Fletcher

122893

20-Dec-01

Palestine

TX

LVN

08-Aug-02

McGhee Stephanie

U47505

20-Feb-02

Houston

TX

DC

08-Aug-02

24-Oct-02

Lytle

TX

Mejia Manuel

05-Aug-02

Miles Lucy Marie

124893

20-Mar-02

Dallas

TX

LVN

01-Aug-02

Miller Trease Ann

140967

18-Oct-01

Bloomington

TX

LVN

30-Aug-02

Mojica Jo Ann

093250

10-Jun-02

Midland

TX

LVN

27-Aug-02

Moore Melissa Carole

145397

20-Mar-02

Midland

TX

LVN

06-Aug-02

Morrow III Hubert Wesley

546610

14-Aug-01

Sherman

TX

RN

17-Jun-02

Mumphrey Lydia Nicole

17412

10-Jun-02

Tatum

TX

LVN

11-Aug-02

20-Jun-02

Vidor

TX

LVN

26-Aug-02

Myers Debra Lee Myers Mary Richards

034992

11-Mar-02

Lufkin

TX

LVN

27-Aug-02

Noble Michael Brent

157996

10-Jun-02

Midlothian

TX

LVN

27-Aug-02

Noll Cindy

651271

20-Jan-02

Houston

TX

RN

13-Jun-02

Ogle Philip Barton

Unknown

20-Mar-02

Oklahoma City

OK

DC

01-Aug-02

Oliveira Elizabeth

C833

18-Apr-02

Slidell

LA

MD

14-Jun-02

O’Neal Robin Nannette

140790

10-Jun-02

Daingerfield

TX

LVN

11-Aug-02


26


Provider

License No#

O’Neil Jerri Lynn

555301

Paredez Jude

City

State

Provider Type

12-Feb-02

Houston

TX

RN

17-Sep-02

618478

31-Dec-01

Beaumont

TX

RN

14-Jun-02

Parsons Donna Jane

074730

20-Mar-02

Corsicana

TX

LVN

01-Aug-02

Parton Vicki Lynn

242632

13-Jun-01

Waco

TX

RN

26-Aug-02

Peralta Roniece Jean

461959

18-Apr-02

Klamath Falls

OR

RN

13-Aug-02

Peters Barbara Jo

453790

01-Oct-01

Clinton

IA

RN

29-Aug-02

Petrosino Linda M.

115729

10-Jun-02

Bumpus Mills

TN

LVN

11-Aug-02

Pitts Vesta Lee

601828

15-Feb-02

Plainview

TX

RN

10-Aug-02

Posey Richard M.

144664

10-Jun-02

Murphy

TX

LVN

30-Aug-02

Pruett Judy Kathleen

122463

11-Mar-02

Slidell

TX

LVN

17-Sep-02

Pyles Jocelyn N

096086

18-Apr-02

The Woodlands

TX

LVN

14-Jun-02

Quarles Kristi G.

174866

20-Jun-02

Cimarron

NM

LVN

01-Aug-02

Raymond Dana Allen

051948

11-Mar-02

San Antonio

TX

LVN

06-Aug-02

Reber Mary Ann S.

235115

20-May-02

Lytle

TX

RN

01-Aug-02

Reed Dandridge Julius

11680

02-Nov-01

Angleton

TX

DDS

27-Aug-02

Reed-Narried Joan D.

100937

20-Mar-02

Grand Prairie

TX

LVN

13-Jun-02

Richard Cindi Lynn

127763

11-Mar-02

Pollok

TX

LVN

01-Aug-02

Richardson Jo Carol

079935

10-Jun-02

Amarillo

TX

LVN

11-Aug-02

Ricci Cynthia L.

156069

20-Mar-02

Wichita Falls

TX

LVN

13-Jun-02

Riggins, Gloria L.J.

430169

18-Apr-02

Laurinsburg

NC

RN

18-Sep-02

Rikard Candace Noel

164315

18-Oct-01

Wichita Falls

TX

LVN

17-Jun-02

Robinson Kalvin M.

7048

18-Oct-01

Houston

TX

DC

17-Jun-02

20-Jun-02

Huntsville

TX

Rodriguez Charles

Exclusion Date

Add Date

13-Aug-02

Rodriguez Mary Christine

151787

10-Jun-02

Kerrville

TX

LVN

27-Aug-02

Rodriguez Ricardo

083738

20-Mar-02

Cotulla

TX

LVN

06-Aug-02

Rodriguez Rolando X.

J1772

16-Aug-00

San Antonio

TX

MD

21-Jun-02

Roper Stephen M.

174234

10-Jun-02

Brenham

TX

LVN

11-Aug-02

02-Apr-02

San Antonio

TX

MD

05-Aug-02

Rosales Anna Marie Lozana Rose James Timothy

560821

08-Mar-02

Houston

TX

RN

26-Aug-02

Rosemond Hellen Doris

095791

10-Jun-02

Houston

TX

LVN

13-Aug-02

Rucker Manuel W.

157841

10-Jun-02

Ft. Bragg

NC

LVN

14-Aug-02

Saenz Roger Louis

155865

10-Jun-02

San Antonio

TX

LVN

26-Aug-02

20-Sep-01

Miami

FL

Denton

TX

LVN

26-Aug-02

Salazar Hernan Efrain

07-Aug-02

Sallee Bonnie Jean

146497

10-Jun-02

Serrano Regina Landreth

067733

20-May-02

Arlington

TX

LVN

27-Aug-02

Shelton Annette Marie

G5606

20-Mar-01

Arlington

TX

MD

17-Jun-02

20-May-02

Houston

TX

Singletary Brittany

18-Jun-02

Smith Sharon Lynn

129520

20-Jun-02

Mexia

TX

LVN

03-Sep-02

Smutz Hally Rochelle

165781

20-Jun-02

Fort Worth

TX

LVN

06-Aug-02


27


Provider

License No#

Soh Judy Rami

610108

Sommer Deborah Jane

City

State

Provider Type

Add Date

12-Feb-02

Riverside

CA

RN

29-Aug-02

554274

20-Dec-01

Dickinson

TX

RN

05-Aug-02

Stedman Helen J.

213677

24-Jan-02

Coulce Dam

WA

RN

28-Aug-02

Stevens James B.

J3910

07-Dec-01

Dallas

TX

MD

14-Jun-02

Stinson Reva Sue

119739

20-Mar-02

Odessa

TX

LVN

18-Jun-02

Storey George

132870

18-Apr-02

Wichita Falls

TX

LVN

13-Jun-02

18-Apr-02

Houston

TX

Synchronized Montrose Chiropractic, P.C.

Exclusion Date

21-Jun-02

Thompson Joy Renee

105392

20-Mar-02

Gatesville

TX

LVN

29-Jul-02

Thompson Paula Marie

597204

12-Dec-01

Victoria

TX

RN

21-Jun-02

Tomlinson Patricia Marie

168863

20-Jun-02

Junction

TX

LVN

02-Aug-02

Townsend Shirley Elaine

142422

20-Mar-02

Midland

TX

LVN

06-Aug-02

Turner Steven Leon

158358

10-Jun-02

Spring

TX

LVN

28-Aug-02

Valdivia Rodolfo Carlos

C-3885

20-Sep-01

El Paso

TX

DO

17-Jun-02

Vander-Heyden Jill Marie

175512

10-Jun-02

Killeen

TX

LVN

26-Aug-02

Walker Robin Elaine

671082

22-Oct-01

Austin

TX

RN

07-Aug-02

Walton Della Marie

065096

10-Jun-02

Houston

TX

LVN

16-Aug-02

Wancur Choox

32891

06-Sep-01

Houston

TX

Phr

07-Aug-02

Ward Helen Louise

246511

18-Oct-01

Arlington

TX

RN

30-Aug-02

Waters Carol D.

518522

15-Feb-02

Rowlett

TX

RN

16-Aug-02

Weatherholt Maria Elena

019365

10-Jun-02

Laredo

TX

LVN

14-Aug-02

Webb Kenneth Randle

123129

20-Jun-02

Fort Worth

TX

LVN

28-Aug-02

Weitzel Robert Allan

H2895

19-Oct-00

Salt Lake City

UT

MD

26-Nov-02

Westmoreland Vickie

145696

11-Mar-02

Wellington

TX

LVN

31-Jul-02

Westrum Cynthia Ann

097210

10-Jun-02

Hunt

TX

LVN

24-Aug-02

Wilson Karen Jann

135063

20-Mar-02

Lockney

TX

LVN

06-Aug-02

Wilson Ruthel W.

054583

20-Jun-02

Kerrville

TX

LVN

02-Aug-02

Wynn Judy Diane

252957

24-Jan-02

Cleburne

TX

RN

07-Aug-02

Yaworsky Patricia

568815

02-Oct-01

Kempner

TX

RN

21-Jun-02

Yen Albert A.

J-8847

05-Apr-02

Pearland

TX

MD

26-Aug-02


28


Forms/Guides Enrolling in the Electronic Funds Transfer Program NHIC ATTN: Provider Enrollment PO Box 200795 Austin TX 78720-0795 FAX: 512-514-4214

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

•

EFT funds are available to providers when banks open on Wednesday mornings and Thursday (if a bank holiday occurs).

•

Applications will be processed within five working days of receipt.

•

Prenotification to the bank takes place on the cycle following the application processing.

•

Ten days after prenotification, future deposits are received electronically.

•

The Remittance and Status (R&S) report furnishes the details of individual credits made to the provider’s account during the weekly cycle.

•

Specific deposits and associated R&S reports are cross-referenced by both provider number and R&S number.

•

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.

NHIC provides the following notification according to ACH guidelines: Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. The effective date for EFT under the Texas Medicaid Program is Wednesday (or Thursday) of each week. 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 customers or companies 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. To enroll in the EFT program, the provider should complete the Electronic Funds Transfer Authorization Agreement. A voided check or deposit slip must be submitted with the agreement to the NHIC address indicated on the form.


29


Extended Outpatient Psychotherapy/Counseling Request Form 1. Identifying information:

Medicaid #:

Last name: Date of birth:

Date:

/

/

First name: /

/ Age:

Provider:

Sex:

Middle initial:

Began current treatment:

/

/

Provider number:

Current living arrangements: ( ) with family ( ) group/foster home ( ) other: 2. Current DSM IV diagnosis (list all appropriate codes): Axis I diagnosis: Axis II diagnosis:

GAF:

Current substance abuse? ( ) none ( ) alcohol ( ) drugs ( ) alcohol and drugs 3. Primary symptoms that require additional therapy/counseling: Include date of most recent occurrence, frequency, duration, and severity:

4. History Psychiatric inpatient treatment ( ) yes ( ) no

Age at first admission:

Prior substance abuse? ( ) none ( ) alcohol ( ) drugs ( ) alcohol and drugs Significant medical disorders:

5. Current psychiatric medications (include dose and frequency):

6. Treatment plan with short term goal, interventions and expected outcome:

7. Number of additional sessions requested: List specific procedure codes requested: Dates from: / / How many of each type? IND

To: Group

/

Provider signature:

/ Family Date:

Print name:


30


NHIC Electronic Funds Transfer Authorization Agreement NOTE: Complete all sections below. ATTACH A VOIDED CHECK OR A PHOTOCOPY OF YOUR DEPOSIT SLIP. Enter one Provider Number per form. Type of Authorization_______NEW

_______CHANGE

Provider Name

Medicaid Nine-Character Texas Provider Identifier (TPI)

Provider Accounting Address

Provider Phone No.

Bank Name

ABA/Transit No.

Bank Phone No.

Account No.

Bank Address

Type Account (check one) Checking ______ Savings ______

I (we) hereby authorize National Heritage Insurance Company (NHIC) 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 (are) 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. Provider Signature ________________________________

Date ___________________________________________

Title ____________________________________________

Internet ID (if applicable) __________________________

________________________________________________

________________________________________________

Contact Name ___________________________________

Contact Phone No. _______________________________

Print Provider Name_______________________________

Return this form to: NHIC ATTN: Provider Enrollment PO Box 200795 Austin TX 78720-0795 FAX: 512-514-4214

Input By ______________________________________________


31

Date_________________________________


Provider Information Change Form To update your provider files, complete this form and mail or fax it 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:______________________________ __________________________________________________________________________________________________________

Physical Address (Cannot be a PO Box)

Accounting/Mailing Address (W-9 Form Required)

Secondary Address (Plan Use Only)

______________________________

______________________________

_________________________

______________________________

______________________________

_________________________

______________________________

______________________________

_________________________

______________________________ Telephone

______________________________ Telephone

_________________________ Telephone

______________________________ Fax

______________________________ Fax

_________________________ Fax

______________________________

______________________________

_________________________

Type of Change: (please check the appropriate box below)

r

Change of Physical Address, telephone and/or fax number

r

Change of Billing/Mailing Address, telephone and/or fax number

r

Change/Add Secondary Address, telephone and/or fax number

r

Change of Provider Status (i.e., termination from plan, moved out of area, specialist, etc.), Please Explain Below:

r

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: ________________________________________

Date: ___________________________

E-mail Address: _________________________________________

Send your completed change form to: NHIC ATTN: Provider Enrollment PO Box 200795 Austin TX 78720-0795 FAX: 512-514-4214

If Managed Care, please send this form via mail or fax to NHIC c/o your respective plan.

Name_________________________________________


TPI___________________

32


Provider Information Change Form Completion Instructions

Signatures

•

The provider’s signature is required on the following document for any and all changes requested for individual practitioner Texas Provider Identifiers (TPIs).

•

Signature by the authorized representative of a group or facility is acceptable for changes requested for group/facility TPIs.

Address

•

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

Tax Identification Number

•

Tax identification number changes for individual practitioner TPIs can only be made by the individual to which the number is assigned.

•

Performing providers cannot change tax identification numbers.

General

•

Forms will be returned unprocessed if the nine-character TPI is not indicated on the attached form.

•

W-9 form is required for all name and tax identification number changes.


33


Acronym Guide The following table lists the acronyms and their definitions used in the January/February 2003 Texas Medicaid Bulletin: Acronym

Definition

ABA

American Bankers Association

ABR

Auditory brainstem response

ACH

Automated Clearinghouse

ACIP

Advisory Committee on Immunization Practices

AIS

Automated Inquiry System

ASA

American Society of Anesthesiologists

ASC

Ambulatory surgical center

ASCUS

Atypical Squamous Cells of Uncertain Significance

ATM

Automated Teller Machine

BCCCP

Breast and Cervical Cancer Control Program

BSER

Brainstem evoked potential response

CCIP

Comprehensive Care Inpatient Psychiatric Program

CCP

Comprehensive Care Program

CFR

Code of Federal Regulations

CLIA

Clinical Laboratory Improvement Amendments

CMS

Centers for Medicare and Medicaid Services

CPT

Current Procedural Terminology

CSR

Customer service representative

CST

Central Standard Time

dB

Decibel

DC

Doctor of Chiropractic Medicine

DDS

Doctor of Dental Surgery

DME

Durable medical equipment

DRG

Diagnosis-related group

DSM

Diagnostic and Statistical Manual of Mental Disorders

ECMO

Extracorporeal Membrane Oxygenation

EDI

Electronic data interchange

EEG

Electroencephalogram

EFT

Electronic funds transfer

EKG

Electrocardiogram

ER

Emergency room

ERISA

Employee Retirement Income Security Act of 1974

FAQ

Frequently asked questions

GAF

Global Assessment of Functioning

GM

Gram

HASC

Hospital ambulatory surgical center

HBIG

Hepatitis B immune globulin

HCPCS

Health Care Financing Administration (HCFA) Common Procedure Coding System

HHSC

Health and Human Services Commission

HIPAA

Health Insurance Portability and Accountability Act

HIV

Human immunodeficiency virus

HMO

Health maintenance organization

ICD-9-CM

International Classification of Diseases, Ninth Revision, Clinical Modification

ICF-MR

Intermediate care facilities for the mentally retarded

IPPB

Intermittent Positive Pressure Breathing


34


Acronym

Definition

IRS

Internal Revenue Service

IVIG

Intravenous gamma globulin

LTC

Long Term Care

LMSW–ACP

Licensed Master Social Worker – Advanced Clinical Practitioner

LVN

Licensed Vocational Nurse

MD

Doctor of Medicine

mg

Milligram

MHMR

Mental Health Mental Retardation

MLC

Multileaf Collimator

MRA

Magnetic resonance angiography

NHIC

National Heritage Insurance Company

OAE

Otoacoustic emissions

OBRA ‘89

Omnibus Budget Reconciliation Act of 1989

OT

Occupational therapy

PACT

Program for Amplification of Children of Texas

PO

Post Office

POS

Place of service

PT

Physical therapy

R&S

Remittance and Status (report)

RN

Registered nurse

RVU

Relative value unit

SHARS

School Health and Related Services

SISI

Short increment sensitivity index

SPA

State plan amendment

SRT

Speech reception threshold

SSI

Supplemental Security Income

ST

Speech language therapy

STAR

State of Texas Access Reform

TANF

Temporary Assistance to Needy Families

TDH

Texas Department of Health

THSteps

Texas Health Steps

THSteps–CCP

Texas Health Steps – Comprehensive Care Program

TOS

Type of service

TPI

Texas Provider Identifier

TVFC

Texas Vaccines for Children

VFC

Vaccines for Children


35


Notes:


36


Notes:


37


Notes:


38


Notes:


39


Click the following links at www.eds-nhic.com for important information: •

Compass21 Frequently Asked Questions (FAQ)

•

Medicaid Workshop Schedules and FAQs

•

TDH-NHIC 2003 Publications—includes the 2003 Texas Medicaid Provider Procedures Manual, 2003 Texas Medicaid Service Delivery Guide, and Texas Medicaid Bulletins

•

Regional Support—lists NHIC Training Specialists

NHIC

an EDS company National Heritage Insurance Co. 12545 Riata Vista Circle Austin TX 78727-6524

ATTENTION: BUSINESS OFFICE

PRESORTED STANDARD US POSTAGE PAID AUSTIN TX PERMIT NO 156

Texas Medicaid - Welcome to TMHP

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