T exas Medicaid Bulletin - TMHP

1 Texas Medicaid Bulletin Bimonthly update to the Texas Medicaid Provider Procedures Manual November/December 2008 No. 219. INSIDE. Medicare Paper Claims All Providers 1. Providers that receive paper Medicare Remittance Medicare Paper Claims .. 1. Advice Notices (MRANs) from Medicare or a Medicare Vaccine/Toxoid Reimbursement Changes .. 2. intermediary may submit these MRANs to the Texas New Vaccine/Toxoid Availability .. 5. Medicaid & Healthcare Partnership ( tmhp ). All Incontinence Procedure Limitations Clarification .. 5. Medicare crossover paper claims must include a Pulse Oximeter Probe Benefit Changes .. 5. HHSC Response to Recent Hurricanes .. 5. completed claim form. Payment Error Rate Measurement Frequently Paper Medicare crossover claims may also be submitted Asked Questions .. 6. to tmhp using the Centers for Medicare & Medicaid Prior Authorization Reminder .. 9. services (CMS) approved software Medicare Remit Automated Maintenance Process for Electronic Submitters.

2 9. Easy Print (MREP) for professional services or 2008 HCPCS Procedure Code Additions .. 9. PC Print for institutional services . Providers submitting Reimbursement Rates Adopted Following Public Hearings .. 10. paper MRANs from Medicare, MREP, or PC Print Benefit Criteria for Anesthesia services Have Changed .. 18. are not required to submit the tmhp Standardized Texas Medicaid Claims Reprocessing .. 22. MRAN form. services Provided by LCSWs, LMFTs, LPCs, and Psychologists .. 23. Scheduled System Maintenance .. 23. Providers that do not receive paper MRANs from Updates to Previously Published Information .. 23. Medicare or a Medicare intermediary or cannot retrieve Updated Tips for Expediting Paper Claims .. 30. MRANs from MREP or PC Print, must submit the Claims Submission for Inpatient Hospital Clients .. 31. tmhp Standardized MRAN form. The tmhp Partial SDA Rebase for DRG Inpatient Hospital Providers.

3 31. Standardized MRAN form is available in the 2008 Prior Authorization Request Changes for Breast and Texas Medicaid Provider Procedures Manual and on Colorectal Cancer Screening .. 31. the tmhp website at The tmhp False Claim Employee Education .. 31. Standardized MRAN form must be typed or comput Reminder for FQHC Providers .. 32. er generated. Handwritten forms are not accepted and Revised Texas Medicaid Fee Schedules .. 32. are returned to the provider. Reminder for Rural Health Clinic Providers .. 34. Family Planning Providers 34. Limitation for Family Planning Contraceptives .. 34. Use of the American Medical Association's (AMA) copyrighted Gynecological and Reproductive Health services Benefit .. 34. Current Procedural Terminology (CPT) is allowed in this publication Contraceptive Device Now Payable to FQHCs and RHCs .. 34. with the following disclosure: Current Procedural Terminology (CPT) is copyright 2007 American Medical Association.

4 All rights Managed Care Providers 35. reserved. No fee schedules, basic units, relative values, or related Help Available for PCCM Providers with Clients Who listings are included in CPT. The AMA assumes no liability for the Frequently Miss Appointments .. 35. data contained herein. Applicable Federal Acquisition Regula tion No Referral or Prior Authorization Needed for System/Department of Defense Regulation System (FARS/DFARS) PCCM Evacuees .. 35. restrictions apply to gov ernment use.. STAR Health Mental Health Rehabilitation Claims Must Be Submitted to Integrated Mental Health services .. 36. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology Primary Care Provider Flyers Available for PCCM Providers .. 37. (CDT) codes: CDT 2007/2008 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association.

5 2006 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.. Continued on page 2. All Providers Vaccine/Toxoid Reimbursement Changes Vaccines/toxoids that the Advisory Committee on an administration fee without a modifier when a vaccine/. Immunization Practices (ACIP) identifies as routine, toxoid with one state defined component is administered. or medically necessary, are benefits of Texas Medicaid . A vaccine/toxoid billed without a modifier has a reimburse . The administration of these vaccines/toxoids is also a ment rate of $ benefit of Texas Medicaid . The provider must bill an administration fee with state . The administration of vaccines/toxoids to clients who defined modifier U2 when a vaccine/toxoid with two state . are birth through 20 years of age is a benefit of Texas defined components is administered.

6 A vaccine/toxoid Health Steps (THSteps) when provided as part of billed with modifier U2 has a reimbursement rate of $ a THSteps periodic visit. A THSteps provider that The provider must bill an administration fee with bills for vaccines/toxoids with diagnosis or age restric . state defined modifier U3 when a vaccine/toxoid with tions will continue to be subject to those restrictions. three state defined components is administered. The Providers must include on the claim the diagnosis code legislation that created the federal Vaccines for Children of the condition necessitating the vaccine/toxoid. (VFC) program requires that the Department of Health The administration of vaccines/toxoids to clients and Human services establish a maximum reimbursement who are birth through 20 years of age is a benefit limit for the amount a provider can be reimbursed for of the THSteps Comprehensive Care Program administrations of vaccines to Texas Vaccines for Children (THSteps CCP) when provided as part of an acute (TVFC) eligible children.

7 The provider may not charge medical visit outside of a THSteps periodic visit. more than $ for administration of a TVFC vaccine if the child is eligible for TVFC. A vaccine/toxoid billed All providers must assess the immunization status of clients who are birth through 18 years of age at every encounter, or birth through 20 years of age when part of a THSteps medical checkup. Providers must MORE CONTENTS. administer any medically indicated vaccines/toxoids Continued from page 1. unless medically contraindicated or because of the parent's reason of conscience, including a religious THSteps CCP Providers 37. belief. The reason the indicated vaccine/toxoid was New Medicaid Rates for Personal Care services Adopted .. 37. not administered must be documented in the client's medical record. THSteps Dental Providers 37. THSteps Therapeutic Dental services Benefits to Change .. 37. The following procedure codes may be used when THSteps Therapeutic Dental services Reimbursement billing for vaccine/toxoid administration for clients Rate Change.

8 38. who are birth through 20 years of age: Provider Enrollment and Claims Filing for Dental Providers .. 38. Oral/Facial Photographic Images Claims Reprocessing .. 39. Procedure Codes THSteps Medical Providers 39. 1/S 90465 1/S 90466 1/S 90467 1/S 90468. Group Provider Claims for THSteps .. 39. 1/S 90471 1/S 90472 1/S 90473 1/S 90474 THSteps Checkup Benefit Changes .. 39. Only one vaccine administration fee may be Women's Health Program Providers 40. reimbursed to any provider for each vaccine/toxoid Claims Submitted by Women's Health Program Providers .. 40. administered per client, per day. Reimbursement for Excluded Providers 41. administration fees requires that the procedure codes Excluded Providers .. 41. for the administered vaccines/toxoids be submitted in addition to the administration fee. Forms 42. Primary Care Case Management (PCCM) Office Flyer .. 42. Vaccine/toxoid administration fees will be reimbursed Primary Care Case Management (PCCM) Referral Form.

9 43. based on the number of state defined components Provider Information Change Form .. 44. administered per injection. The provider must bill Electronic Funds Transfer (EFT) Authorization Agreement .. 47. Texas Medicaid Bulletin , No. 219 November/December 2008. CPT only copyright 2007 American Medical Association. All rights reserved. All Providers with modifier U3 for a client not eligible for VFC has a Number of State . reimbursement rate of $ Procedure Code Defined Components Descriptions for the U2 and U3 modifiers are as follows: 1/S 90718 1. 1/S 90721 2. Modifier Description 1/S 90723* 3. U2 State defined modifier: Administration 1/S 90732* 1. of vaccine/toxoid with two state defined 1/S 90733 1. components 1/S 90734* 1. U3 State defined modifier: Administration of vaccine/toxoid with three state defined 1/S 90740* 1. components 1/S 90743 1. 1/S 90744* 1. The following vaccine/toxoid procedure codes are a benefit for clients who are birth through 20 years of age: 1/S 90746* 1.

10 1/S 90747 1. Number of State 1/S 90748* 2. Procedure Code Defined Components 1/S 90749 1. 1/S 90632* 1 * Indicates a vaccine/toxoid distributed through TVFC. 1/S 90633* 1. 1/S 90636 2 Vaccines/toxoids may be reimbursed with modifier U1. 1/S 90645 1 when the vaccine/toxoid is not available for distribution through TVFC. Providers will be notified by TVFC. 1/S 90646 1 when vaccine/toxoids are not available. Vaccines/toxoids 1/S 90647 1 may be reimbursed as part of a THSteps periodic visit or 1/S 90648* 1 as part of an acute medical visit (through THSteps CCP). 1/S 90649* 1. Not available is defined as: a new vaccine approved by 1/S 90655* 1 the ACIP that has not been negotiated or added to a 1/S 90656* 1 TVFC contract; TVFC has not established funding for 1/S 90657* 1 a new vaccine; or national supply or distribution issues 1/S 90658* 1 limit availability. 1/S 90660* 1 Modifier U1 may not be used for failure to enroll 1/S 90669* 1 in TVFC or to maintain sufficient TVFC vaccine/.