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All Providers 1ECMO Policy Update 1Benefit Changes for Cytogenetics Testing 2New Family Planning Services Can Be Provided by FQHCs 4ASC/HASC Texas Medicaid Fee Schedule Update 4Nursing Facility Care Restriction 4Infliximab Diagnosis Codes 4Procedure Code 93651 Update 4Medicaid Benefit Changes 5Payment Error Corrected for Procedure Code 1-J7320 5Latest Edition of Provider Manual Mailed to Providers 5Aerosol Treatment Benefit Changes 6Scheduled System Maintenance 6Benefit Changes for Complete Blood Counts 7Rate Change for Indian Health Services Facilities 7Skin Therapy Benefit Changes 8DSHS Laboratory Submission Deadline Changing 8Enrollment of Respiratory Therapists for CSHCN 8TMHP Provider Relations Representatives 9Changes to Benefit Criteria for Helicobacter Pylori Testing 10Revised CMS-1500 Claim Form Instructions 112007 HCPCS Implementation 12Electroencephalogram Changes 14Article Corrections 14

Home Health Providers 15Billing Visits with TDHconnect 15Physical and Occupational Therapy Benefit Change 15Home Health DME Procedure Code Update 15Phototherapy Benefit Update 16Elastomeric Devices and IV Supplies and Equipment 18

Primary Care Case Management Providers 21Authorization Removed For Some Gallbladder Surgeries 21OB/GYN Care for PCCM Clients 21Quick Tips for PCCM Provider Enrollment 21

School Health and Related Services Providers 22SHARS Billing Update 22

Texas Health Steps Dental Providers 22THSteps Diagnostic Dental Services 22

Texas Health Steps Medical Providers 23Correction to THSteps and FQHC Providers Administration Fees Article 23

Excluded Providers 24Excluded Providers 24

FormsDME Certification and Receipt Form 26Provider Information Change Form 27Electronic Funds Transfer Authorization Agreement 29CMS-1500 Claim Form 31Title XIX Home Health DME Medical Supplies Physician Order Form 33

Texas Medicaid Provider Procedures Manual Appendix N 35

MARCH/APRIL 2007 NO. 203

Bimonthly update to the Texas Medicaid Provider Procedures ManualT EXAS MEDICAID BULLETINBimonthly update to the Texas Medicaid Provider Procedures ManualT EXAS MEDICAID BULLETIN

Copyright AcknowledgmentsUse of the American Medical Association’s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: “Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.”The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: “CDT 2007/2008 [including procedure codes, definitions (descriptions), and other data] is copyrighted by the American Dental Association. (c) 2006 American Dental Association. All Rights Reserved. Applicable Federal Acquisition Regulation System/Department of Defense Acquisition Regulation System (FARS/DFARS) restrictions apply.”

ECMO Policy Update

Effective for dates of service on or after February 1, 2007, the age and diagnosis restrictions have been removed from extracorporeal membrane oxygenation (ECMO) procedure codes 2-33960, 2-33961, and 2-36822. Reimbursement is considered for, but not limited to, the following clinical indications:

Persistent pulmonary hypertensionMeconium aspiration syndromeRespiratory distress syndromeAdult respiratory distress syndromeCongenital diaphragmatic herniaSepsisPneumoniaPre- and post-operative congenital heart disease or heart transplantationReversible causes of cardiac failureCardiomyopathyMyocarditisAspiration pneumoniaPulmonary contusion Pulmonary embolism

Payment may be recouped if services were provided in the presence of certain contraindicated conditions.

Additionally, procedure codes 2-33960, 2-33961, and 2-36822 are no longer benefits of the Texas Medicaid Program for advanced practice nurses and registered nurse/nurse-midwives.

For more information, call the TMHP Contact Center at 1-800-925-9126.

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Diagnosis Codes

7402 74100 74101 74102 7410374190 74191 74192 74193 74207421 7422 7423 7424 7425174253 74259 7428 7429 7430074303 74306 74310 74311 7431274320 74321 74322 74330 7433174332 74333 74334 74335 7433674337 74339 74341 74342 7434374344 74345 74346 74347 7434874349 74351 74352 74353 7435474355 74356 74357 74358 7435974361 74362 74363 74364 7436574366 74369 7438 7439 7440074401 74402 74403 74404 7440574409 7441 74421 74422 7442374424 74429 7443 74441 7444274443 74446 74447 74449 744574481 74482 74483 74484 744897449 7450 74510 74511 7451274519 7452 7453 7454 745574560 74561 74569 7457 74587459 74600 74601 74602 746097461 7462 7463 7464 74657466 7467 74681 74682 7468374684 74685 74686 74687 746897469 7470 74710 74711 7472074721 74722 74729 7473 7474074741 74742 74749 7475 7476074761 74762 74763 74764 7476974781 74782 74783 74789 74797480 7481 7482 7483 74847485 74860 74861 74869 74887489 74900 74901 74902 7490374904 74910 74911 74912 7491374914 74920 74921 74922 7492374924 74925 7500 75010 7501175012 75013 75015 75016 7501975021 75022 75023 75024 7502575026 75027 75029 7503 75047505 7506 7507 7508 7509

Benefit Changes for Cytogenetics Testing

Cytogenetic testing is a benefit of the Texas Medicaid Program and may be a part of an evaluation for pregnancy problems, unusual physical features, or learning difficulties.

Clinical evidence supports the significance of cytogenetic evaluation in the diagnosis, prognosis, and treatment of acute leukemias and lymphomas, especially in children. The detection of the well-defined, recurring genetic abnormali-ties often enables a correct diagnosis along with important prognostic information affecting the treatment protocol.

Effective for dates of service on or after February 1, 2007, providers should use the following procedure codes to bill TMHP for cytogenetic tests:

Tissue Cultures Procedure Codes5-88230 5-88233 5-88235 5-88237 5-88239

Chromosome Analysis Procedure Codes5-88245 5-88248 5-88249 5-882615-88262 5-88263 5-88264 5-882805-88283 5-88285 5-88289

Molecular Cytogenetics Procedure Codes5-88271 5-88272 5-88273 5-882745-88275 5-88291

The cytogenetic testing procedure codes are limited to the following diagnosis codes in addition to the current diagnosis limitations found in the 2007 Texas Medicaid Provider Procedures Manual, Section 36.4.22.4, “Cytoge-netics Testing for Leukemia and Lymphoma,” located on pages 36-191 through 36-193:

Diagnosis Codes2533 2572 2590 2594 2754927911 29900 29901 31400 3140131500 31501 31502 31509 31513152 31531 31532 31539 31543155 3158 3159 317 31803181 3182 319 37641 5240052401 52402 52403 52404 5240552406 52407 52409 6060 60616260 6261 6280 6289 6299630 631 632 65500 6550165503 65510 65511 65513 6552065521 65523 65950 65951 6595365960 65961 65963 7400 7401

Texas Medicaid Bulletin, No. 203 2 March/April 2007

All Providers

CPT only copyright 2007 American Medical Association. All rights reserved.

Diagnosis Codes

7510 7511 7512 7513 75147515 75160 75161 75162 751697517 7518 7519 7520 7521075211 75219 7522 7523 7524075241 75242 75249 75251 7525275261 75262 75263 75264 7526575269 7527 75281 75289 75297530 75310 75311 75312 7531375314 75315 75316 75319 7532075321 75322 75323 75329 75337534 7535 7536 7537 75387539 7540 7541 7542 7543075431 75432 75433 75435 7544075441 75442 75443 75444 7545075451 75452 75453 75459 7546075461 75462 75469 75470 7547175479 75481 75482 75489 7550075501 75502 75510 75511 7551275513 75514 75520 75521 7552275523 75524 75525 75526 7552775528 75529 75530 75531 7553275533 75534 75535 75536 7553775538 75539 7554 75550 7555175552 75553 75554 75555 75556

75557 75558 75559 75560 7556175562 75563 75564 75565 7556675567 75569 7558 7559 756075610 75611 75612 75613 7561475615 75616 75617 75619 75627563 7564 75650 75651 7565275653 75654 75655 75656 756597566 75670 75671 75679 7568175682 75683 75689 7569 75707571 7572 75731 75732 7573375739 7574 7575 7576 75787579 7580 7581 7582 7583175832 75833 75839 7584 75857586 7587 75881 75889 75897590 7591 7592 7593 75947595 7596 7597 75981 7598275983 75989 7599 V184 V195V198 V2631 V2632 V2633 V280

Providers may be reimbursed for any combination of the following procedure codes when submitted for the same client on the same day:

One tissue culture procedure code: 5-88230, 5-88233, 5-88235, 5-88237, or 5-88239

One molecular cytogenetic study procedure code: 5-88272, 5-88273, 5-88274, or 5-88275

One chromosome analysis procedure code from each of the following subcategories:

Chromosome Analysis – Breakage Syndromes (subcategory): procedure code 5-88245, 5-88248, or 5-88249Chromosome Analysis – Cell Counts (subcategory): procedure code 5-88261, 5-88262, 5-88263, or 5-88264

More than one procedure code from any of the above individual categories/subcategories submitted for the same date of service will be denied as part of another service. Six procedures per category/subcategory are allowed within 365 days.

If an additional chromosome analysis procedure is required, providers must use one of the following procedure codes: 5-88280, 5-88283, 5-88285, 5-88289, or 5-88271. More than one additional analysis procedure code submitted for the same client for the same date of service will be denied as part of another service. Reimbursement for chromosome analysis procedure code 5-88283 has increased from $94.79 to $97.36.

Multiple deoxyribonucleic acid (DNA) probe studies (procedure code 5-88271) may be considered for reimburse-ment on the same day with a limitation of six days per year. Claims may be reviewed retrospectively to ensure that the DNA probe study is medically necessary and appropriate.

Other benefit changes include:

Procedure codes 5-88267 and 5-88235 are for female patients only.Procedure codes 5-88240 and 5-88241 are no longer a benefit.Type of service (TOS) G is no longer valid for cytogenetic testing procedure codes. Providers should use TOS 5.

Cytogenetic testing is no longer a benefit of the Texas Medicaid Program when provided in the inpatient hospital setting.


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Texas Medicaid Bulletin, No. 2033March/April 2007

All Providers


New Family Planning Services Can Be Provided by FQHCsEffective November 1, 2006, for dates of service on or after January 1, 2006, federally qualified health centers (FQHCs) that also contract with the Texas Department of State Health Services (DSHS) for Title V or Title XX family planning services may receive Title V and Title XX reimbursement for sterilization procedure codes 2-58600 and 2-55250.

All denied Title V and Title XX sterilization claims filed by FQHCs for dates of service on or after January 1, 2006, that include procedure codes 2-58600 and 2-55250 will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.


ASC/HASC Texas Medicaid Fee Schedule UpdateTMHP has identified an error in the current Ambulatory Surgery Center/Hospital Ambulatory Surgical Center (ASC/HASC) Texas Medicaid Fee Schedule located on the TMHP website at www.tmhp.com. Procedure code F-41899 with modifier EP was incorrectly listed with a group rate of 5. The correct group rate for this procedure code is group 4.

The fee schedule on the website has been corrected. Claims submitted for procedure code F-41899 with modifier EP were correctly processed with group 4 pricing. No action on the part of the provider is necessary.

For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Contact Center at 1-800-568-2413.

All Providers

Nursing Facility Care RestrictionEffective November 30, 2006, for dates of service on or after January 1, 2006, procedure codes 1-99305 and 1-99306 are limited to one service per client in a six month period. Claims submitted for dates of service on or after January 1, 2006, that include these procedure codes will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.


Infliximab Diagnosis CodesEffective for dates of service on or after March 1, 2007, the following diagnosis codes may be considered for reim-bursement when billed with procedure code 1-J1745:

Diagnosis Codes5550 5551 5552 5559 5560 55615562 5563 5565 5566 5568 55695651 56981 6960 6961 7140 71417142 71430 7200


Procedure Code 93651 UpdateEffective December 1, 2006, for dates of service on or after January 1, 2004, procedure code 2-93651 is a benefit of the Texas Medicaid Program when performed in an outpatient setting by the following provider types:

County Indigent Health Care Program (CIHCP)

Advanced practice nurse

Physician and physician group

Registered nurse/nurse midwife

Portable X-ray supplier

Radiological lab

Physiological lab

Claims submitted for dates of service on or after January 1, 2004, that include procedure code 2-93651 will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.


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Texas Medicaid Bulletin, No. 203 4 March/April 2007CPT only copyright 2007 American Medical Association. All rights reserved.

Latest Edition of Provider Manual Mailed to Providers

The 2007 Texas Medicaid Provider Procedures Manual was mailed on compact disc (CD) to all currently enrolled providers in January 2007. The CD contains an electronic version of the manual in Adobe® Portable Document Format (PDF). TMHP has identified an error in Appendix N,

“THSteps Dental Guidelines.” During the PDF conversion process a number of letters were not recognized and are missing in the text.

This issue only affects Appendix N in the file labeled TMPPM07.pdf on the CD, and does not affect Appendix N located in the Individual Chapters subfolder.

This version of the 2007 manual was also posted onto the TMHP website on January 1, 2007. A corrected PDF file has since been posted, and providers are encouraged to download the corrected file. In addition, a corrected Appendix N is available beginning on page 35 of this bulletin.

Medicaid Benefit Changes

Podiatry and Related ServicesEffective for dates of service on or after February 1, 2007, treatment for deformities of the foot and lower extremity that includes flat foot as a component of the deformity is a benefit of the Texas Medicaid

Program. The client must present significant pain in the foot, leg, or knee resulting in a decrease in or loss of function, along with a secondary condition such as valgus deformity or plantar fasciitis.

Treatment of flat foot (flexible pes planus) that is solely cosmetic in nature is not a benefit of the Texas Medicaid Program.

Sinus IrrigationEffective on or after February 1, 2007, procedure code 2-30210 may be considered for reimbursement when submitted for the same date of service as a tonsillec-tomy, adenoidectomy, or nasal surgery. If procedure code 2-30210 is submitted for the same date of service as a tonsillectomy, adenoidectomy, or nasal surgery, the reimbursement for procedure code 2-30210 is half of the Medicaid-allowable fee.

Physician Inpatient Ventilator ManagementEffective on or after March 1, 2007, the benefit for inpatient ventilator management services provided by physicians has changed for the Texas Medicaid Program. Ventilation assist and management procedures 1-94002 and 1-94003 are not payable when billed by the same provider on the same date of service as the procedure codes listed below:

Procedure Codes1-99221 1-99222 1-99223 1-992311-99232 1-99234 1-99235 1-992361-99238 1-99239 1-99251 1-992521-99253 1-99254 1-99255 1-992911-99292 1-99293 1-99294 1-992951-99296 1-99298 1-99299 1-993001-99360


Payment Error Corrected for Procedure Code 1-J7320TMHP has identified an issue impacting claims that include procedure code 1-J7320 for the Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Programs. Although procedure code 1-J7320 was added as a benefit with the 2006 Healthcare Common Procedure Coding System (HCPCS) implementation effective for dates of service on and after January 1, 2006, the procedure code has been denied as a discontinued code.

Claims submitted for dates of service from January 1, 2006, through November 30, 2006, that include procedure code 1-J7320 will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.


Texas Medicaid Bulletin, No. 2035March/April 2007CPT only copyright 2007 American Medical Association. All rights reserved.

All Providers


All Providers

Aerosol Treatment Benefit Changes

Procedure code 1-94640 is no longer a benefit of the Texas Medicaid Program for the following diagnosis codes:

Diagnosis Codes042 0796 46401 46410 46411 4642046430 46431 4644 46450 46451 46604786 47875 4788 48031 48284 4905173 5184 5186

Procedure codes 1-94640 and B-412 are a benefit of the Texas Medicaid Program for the following diagnosis codes:

Diagnosis Codes1363 27700 27701 27702 27703 2770946611 46619 4801 486 4910 491149120 49121 49122 4918 4919 49204928 49300 49301 49302 49310 4931149312 49320 49321 49322 49381 4938249390 49391 49392 4940 4941 49504951 4952 4953 4954 4955 49564957 4958 4959 496 5070 50715078 5533 7707

Procedure code 1-94640 is no longer a benefit of the Texas Medicaid Program in the office setting for the following providers: nephrologist, renal dialysis facility, or radiological/physiological lab.

Procedure code B-412 is no longer a benefit of the Texas Medicaid Program in the outpatient hospital setting for psychiatric hospital providers.


Effective for dates of service on or after February 1, 2007, benefits for aerosol and pentamidine treatments have changed for the Texas Medicaid Program.

Procedure code 1-J2545 will be considered for reimburse-ment in an outpatient hospital setting when submitted by the following providers:

CIHCP


Physician


Radiological/physiological lab

Radiation treatment center

Nephrologist

Renal dialysis facility

Rural health clinic

Pentamidine medication treatments will be considered for reimbursement in a skilled nursing facility setting when submitted by the following providers: CIHCP, advanced practice nurse, physician, or a registered nurse/nurse midwife.

Pentamidine medication treatments are no longer a benefit of the Texas Medicaid Program in the office or home setting when submitted by the following providers: medical supplier (durable medical equipment [DME]), radiation treatment center, nephrologist, or renal dialysis facility provider.

Procedure code 1-94642 will be considered for reim-bursement in the inpatient hospital setting when submitted by the following providers:

CIHCP


Physician


Hospital

Radiological/physiological lab

Rural health clinic

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Scheduled System Maintenance

System maintenance for the TMHP claims processing system is scheduled as follows:

6:00 p.m. to 11:59 p.m., Sunday, March 11, 2007

6:00 p.m. to 11:59 p.m., Sunday, April 15, 2007

During system maintenance some applications related to the claims engine will be unavailable. Specific details regarding the affected applica-tions are posted on the TMHP website at www.tmhp.com.

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All Providers

Benefit Changes for Complete Blood Counts

Procedure codes 5-85041, 5-85048, and 5-85049 will be denied as part of another service when billed with procedure code 5-85025 or 5-85027.


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Effective for dates of service on or after March 1, 2007, the following benefit changes have been implemented for complete blood count procedure codes.

The following procedure codes are no longer reimbursed for outpatient hospital claim type 023:

Procedure Codes

I-85007 I-85008 I-85009 I-85013 I-85014I-85018 I-85041 I-85044 I-85048

The following procedure codes are no longer payable in the inpatient hospital setting when billed by independent lab, hospital, nephrologist, renal dialysis facility, or rural health clinic: 5-85004, 5-85032, and 5-85049.

The following procedure codes will be denied as part of another service when billed with procedure code 5-85025 for the same date of service by the same provider:

Procedure Codes5-85004 5-85007 5-85008 5-850095-85013 5-85014 5-85018 5-850275-85032 5-85041 5-85048 5-85049

Procedure code 5-85004 is denied as part of another service when billed with procedure code 5-85007, 5-85009, 5-85025, or 5-85027 for the same date of service by the same provider.

Procedure code 5-85008 is denied as part of another service when billed for the same date of service by the same provider with procedure codes 5-85004, 5-85025, 5-85027, 5-85032, 5-85048, or 5-85049.

Procedure codes 5-85013, 5-85014, or 5-85018 is denied as part of another service when billed with procedure code 5-85025 or 5-85027 for the same date of service by the same provider.

Procedure code 5-85032 is denied as part of another service when billed with procedure code: 5-85025, 5-85027, 5-85041, 5-85048, or 5-85049.

Procedure code 5-85044 is denied as part of another service when billed with procedure code 5-85045 or 5-85046.

Procedure code 5-85045 is denied as part of another service when billed with procedure code 5-85046.

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Rate Change for Indian Health Services Facilities

Effective for dates of service on or after January 1, 2006, the Medicaid encounter rate for outpatient services provided in Indian Health Services (IHS) facilities operating under the authority of Public Law 93-638 increased from $223 to $242. This rate increase applies only to IHS facilities operating under the authority of Public Law 93-638. The IHS facility must be a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act.

The reimbursement methodology for outpatient services provided in IHS facilities operating under the authority of Public Law 93-638 is located in Title 1 Texas Administrative Code (TAC) §355.8620.

Claims paid at the previous encounter rate for dates of service on or after January 1, 2006, will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Skin Therapy Benefit Changes Effective December 1, 2006 for dates of service on or after November 1, 1994, diagnosis code 70901 (Vitiligo) is payable for the following procedure codes:

Procedure Codes2-11900 2-11901 1-969001-96910 1-96912 1-96913

Effective December 1, 2006, for dates of service on or after December 1, 2003, diagnosis code 70901 (Vitiligo) is payable for procedure codes 2-96920, 2-96921, and 2-96922.

Claims submitted for dates of service on or after December 1, 2003, that include the following procedure codes with diagnosis 70901 will be reprocessed, and payments will be adjusted accordingly:

Procedure Codes2-11900 2-96922 2-119011-96900 1-96910 1-969121-96913 2-96920 2-96921

No action on the part of the provider is necessary.

Effective for dates of service on or after February 19, 2007, procedure codes 1-96900, 1-96910, 1-96912, 1-96913, 2-96920, 2-96921, and 2-96922 may be reimbursed when billed with the following diagnosis codes:

Diagnosis Codes20210 20211 2021220213 20214 2021520216 20217 20218


DSHS Laboratory Submission Deadline ChangingEffective Spring 2007, the Department of State Health Services (DSHS) laboratory submission deadline is changing. In order to meet test requirements, the DSHS laboratory must receive all specimens submitted for lead, total hemoglobin, and hemoglobin types testing within five days of collection. The DSHS laboratory will reject specimens that are not received by the fifth day after collection.

Only specimens collected on the same day should be “batched” for mailing. Specimens should not be held beyond the day of collection to batch for mailing.

Refer to the DSHS laboratory web site at www.dshs.state.tx.us/lab/cc_spec-col.shtm#General for information about:

Specimen collection, handling, and mailing

Supplies for collecting and shipping specimens to the DSHS laboratory, including postage-paid mailing labels

Requesting supplies that are free of charge when used for collection of specimens for routine Texas Health Steps (THSteps) checkups

Supplies can also be ordered from the DSHS laboratory with a valid THSteps Texas Provider Identifier (TPI) number by telephone at 1-888-963-7111, ext. 7661, or 1-512-458-7661.

For more information, call the DSHS Laboratory at 1-888-963-7111, ext. 6030, or 1-512-458-7111, ext. 6030.

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Enrollment of Respiratory Therapists for CSHCN

Effective for dates of service on or after March 2, 2007, TMHP is enrolling respiratory therapist providers, and processing claims for services covered by the CSHCN Services Program. Providers who are interested in enrolling in the CSHCN Services Program as a respiratory therapist can call the TMHP-CSHCN Contact Center at 1-800-568-2413.


All Providers

TMHP Provider Relations RepresentativesTMHP provider relations representatives offer a variety of services designed to inform and educate the provider community about policies and claims filing procedures for the Texas Medicaid Program. Provider relations representatives assist providers through telephone contact, onsite visits, and scheduled workshops. The map and table below indicate the TMHP provider relations representatives and the areas they serve. Additional information, including a regional listing by county and workshop information, is available on the TMHP website at www.tmhp.com/Providers. (Click on the Regional Support link, and then choose the region.)


All Providers


Territory Regional Area Representative Telephone Number1 Amarillo, Childress, and Lubbock Elizabeth Ramirez 1-512-506-62172 Midland, Odessa, and San Angelo Mindy Wiggins 1-512-506-34233 Alpine, El Paso, and Van Horn Isaac Romero 1-512-506-35304 Del Rio, Eagle Pass, and Laredo Candice Myers 1-512-506-72715 Brownsville, Harlingen, and McAllen Cynthia Gonzales 1-512-506-79916 Abilene, Brownwood, and Wichita Falls Matthew Cogburn 1-512-506-70957 Brady, Round Rock, and Waco Andrea Daniell 1-512-506-76008 Austin Will McGowan 1-512-506-35269 Kerrville and San Antonio * Mary Regalado-Poole 1-512-506-342210 Corpus Christi, San Antonio, and Victoria* Jill Ray 1-512-506-355411 Cleburne, Denton, and Fort Worth Rita Martinez 1-512-506-799012 Corsicana, Dallas, and Groesbeck* Sandra Peterson 1-512-506-355213 Dallas and Whitesboro* Olga Fletcher 1-512-506-357814 Paris, Texarkana, and Tyler Trilby Foster 1-512-506-705315 Beaumont and Lufkin Gene Allred 1-512-506-342516 Bryan/College Station, Conroe, and Houston* Linda Wood 1-512-506-768217 Katy, Houston, and Wharton* Rachelle Moore 1-512-506-344718 Galveston and Matagorda John Miller 1-512-506-358619 Austin, Houston, and Waller* Stephen Hirschfelder 1-512-506-3446*Dallas, Houston, and San Antonio territories are shared by two or more provider representatives. These territories are divided by ZIP codes. Refer to the TMHP website at www.tmhp.com for the assigned representative to contact in each ZIP code.



All Providers

Effective for dates of service on or after March 1, 2007, the benefit criteria, indications, and limitations for Helicobacter pylori (H. pylori) testing changed for the Texas Medicaid Program.

These services are no longer considered for reimbursement in the inpatient hospital setting. Providers should use the following procedure codes when submitting claims to TMHP for H. pylori testing:

Test Procedure CodesBreath Testing 5-83013 and 5-83014Serology Testing 5-83009 and 5-86677Stool Testing 5-87338

Procedure code 5-87339 is no longer a benefit of the Texas Medicaid Program.IndicationsH. pylori is accepted as an etiologic factor in duodenal ulcers, peptic ulcer disease, gastric carcinoma, and primary B cell gastric lymphoma. H. pylori testing can be indicated for symptomatic clients with a documented history of chronic/recurrent duodenal ulcer, gastric ulcer, or chronic gastritis. The history must delineate the failed conservative treatment for the condition.

H. pylori testing is not indicated or covered for any of the following:

New onset uncomplicated dyspepsia

Dyspepsia responsive to conservative treatment (e.g., withdrawal of non-steroidal anti-inflammatory drugs [NSAID] and/or use of antisecretory agents)

Screening for H. pylori in asymptomatic clients

Dyspeptic clients requiring endoscopy and biopsy

H. pylori testing is not indicated under the following circumstances:

There has been a negative endoscopy in the previous six weeks.

An endoscopy is planned.

H. pylori is of new onset and still being treated.

Benefits and LimitationsSerology testing is not indicated or covered for monitoring response to therapy.

If a follow-up breath or stool test is used to document eradication of H. pylori, medical record documenta-

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Changes to Benefit Criteria for Helicobacter Pylori Testing

tion must verify the history of the following previous complication(s):

The client remains symptomatic after a treatment regimen for H. pylori.

The client is asymptomatic after H. pylori eradication therapy but has a history of hemorrhage, perforation, or outlet obstruction from peptic ulcer disease.

The client has a history of ulcer on chronic NSAID or anti-coagulant therapy.

Serology testing is a benefit once per year when submitted for the same client by any provider with the appropriate diagnosis code. Serology, stool, and breath testing are limited to the following diagnosis codes:

Diagnosis Codes1510 1511 1512 1513 15141515 1516 1518 1519 5310053101 53110 53111 53120 5312153130 53131 53140 53141 5316053161 53171 53191 53200 5320153210 53211 53220 53221 5323053231 53240 53241 53250 5325153260 53261 53270 53271 5329053291 53300 53301 53310 5331153320 53321 53330 53331 5334053341 53350 53351 53361 5337053371 53390 53391 53400 5340153410 53411 53420 53430 5343153440 53441 53450 53451 5346053461 53471 53490 53491 5350053501 53510 53511 53520 5352153530 53531 53540 53541 5355053551 53560 53561 5368

Procedure codes 5-83013, 5-83014, and 5-87338 are eligible for reimbursement for diagnosis code 04186 in addition to the diagnosis codes listed above.

The following procedure codes will not be payable on the same date of service by the same provider: 5-86677, 5-83009, 5-87338, and either 5-83013 or 5-83014. Procedure codes 5-83013 and 5-83014 may be considered for reimburse-ment on the same day.

Effective for dates of service on or after March 1, 2007, procedure codes 5-83009, 5-83013, 5-83014, 5-86677, 5-87338, and 5-87339 will no longer be benefits for optom-etrists, podiatrists, optometric groups, or podiatric groups.

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All Providers

The National Uniform Claim Committee (NUCC) revised version of the CMS-1500 claim form (version 08/05) will be accepted at TMHP effective April 2, 2007. Beginning with this effective date, all participating Texas Medicaid providers are required to submit the new version of the form for all claim submissions and appeals, regardless of the version used for prior submissions. With the exception of paper Medicare crossover claims, any new version of the CMS-1500 claim form received before April 2, 2007, will be returned to the provider.

Note: Beginning May 21, 2007, all paper Medicare crossover claims must include an attached claim form.

CMS-1500 RevisionsThe following guidelines describe what information must be entered in the revised fields of the CMS-1500 claim form effective April 2, 2007. All other required fields on the CMS-1500 claim form, as outlined in the 2007 Texas Medicaid Provider Procedures Manual, remain in effect.

Revised CMS-1500 Claim Form Instructions

Field Description Guidelines

17a (shaded)

Other ID # The Other ID number, such as a nine-digit provider identifier or UPIN of the referring provider, ordering provider, or other source. For limited clients, use a nine-digit provider identifier.

24 Various 24A through 24J – General Notes:Each line contains two sections: a shaded and an unshaded portion. All required information in Fields 24A through 24J should be entered in the unshaded portion, unless otherwise specified.Please note that the CMS-1500 claim form is designed to list only six line items in Field 24. If more than six line items are billed for the entire claim, attach additional forms with no more than 27 line items for the entire claim.Type of service (TOS) codes are no longer required for claim submission.

24C – EMG (national description)/THSteps Medical Checkup Condition Indicator (state description):

Enter the appropriate condition indicator for THSteps medical checkups.24J – Rendering Provider ID #:

Members of a group practice must identify the rendering provider’s TPI in the shaded area of Field 24J.

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32 Facility Provider Information

32 – Service facility location information, if other than home or office:If services were provided in a place other than the patient’s home or the provider’s facility, enter the name, address, and ZIP code of the facility, such as hospital, birthing center, and nursing facility, where the service was provided. For ambulance transfers, if the destination is a hospital or nursing facility, enter the name and address of the facility. Independently practicing health care professionals must enter the name and number of the school district/cooperative where the child is enrolled. For laboratory specimens sent to an outside laboratory for additional testing, the complete name and address of the outside laboratory should be entered. The laboratory should bill the Texas Medicaid Program for the services performed.

32b – Other ID #:Enter the other ID number, such as a nine-digit provider identifier or UPIN, of the service facility location.

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33 Billing Provider Information

33 – Billing provider information and telephone number:Enter the billing provider’s name, street, city, state, ZIP +4 code, and telephone number.

33b – Other ID #:Enter the billing provider’s TPI number.

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•For changes relating to NPI implementation, refer to the NPI Special Bulletin, No. 202. For more information, call the TMHP Contact Center at 1-800-925-9126.


All Providers


2007 HCPCS Implementationprovided. If pricing is in place at the time the service is provided, providers must have obtained prior authoriza-tion through the established prior authorization process for the service to be considered for reimbursement; retroactive authorization will not be considered in that instance.

As a reminder, providers must submit the procedure codes that are most appropriate for the services provided even if the procedure codes are not a benefit of the Texas Medicaid Program at this time.

All HCPCS additions, changes, and deletions are effective for dates of service on or after January 1, 2007. The Texas Medicaid HCPCS Special Bulletin, No. 200 includes Texas Medicaid and CSHCN Services Programs’ HCPCS updates and is intended to notify providers of program and coding changes related to the 2007 HCPCS, Current Dental Terminology (CDT), and Current Procedural Terminology (CPT) updates.

The following procedure codes require prior authorization or precertification:

Procedure Code Prior Authorization Requirements2-15731 MCF-15731 CSHCN, MC2-22526 MCF-22526 CSHCN, MC2-22527 MC F-22527 CSHCN, MC 2-25109 MC F-25109 CSHCN, MC 2-33203 MC F-33203 CSHCN, MC 8-33203 MC 2-33675 MC 8-33675 MC 2-33676 MC 8-33676 MC 2-33677 MC 8-33677 MC 2-33724 MC 8-33724 MC 2-33726 MC 8-33726 MC 2-35883 MCF-35883 CSHCN, MC(CSHCN) Prior authorization required for the CSHCN Services Program. (M) Prior authorization required for Medicaid. (MC) Precertification required for Medicaid Managed Care.

The Texas Medicaid Program is adopting a number of procedure codes during the 2007 Health Care Common Procedure Coding System (HCPCS) implementation. The procedure codes must go through a rate hearing process, as required by Chapter 32 of the Human Resources Code, §32.0282, and Title 1 of the Texas Administrative Code, §355.201, which require public hearings to receive comments on Medicaid payment rates. A special 2007 HCPCS webpage has been created to provide updates as reimbursement rates are established. The webpage is located on the TMHP website at www.tmhp.com/C4/HCPCS/default.aspx. Providers are encouraged to monitor the 2007 HCPCS website regularly for these updates.

Services That Do Not Require Prior AuthorizationServices provided before the reimbursement rates are adopted through the rate hearing process will be denied as part of another service until the applicable reimbursement rate is adopted. The client cannot be billed for these services. Providers must submit the procedure codes as the services are performed to meet all filing deadlines. TMHP will reprocess claims as the appropriate reimbursement rates are established. No further action by providers is necessary.

Services That Require Prior AuthorizationFor procedure codes that require prior authorization but are awaiting the rate hearing, providers must submit the claims for reimbursement as the services are provided (without the prior authorization number) in order to meet the filing deadlines. However, the request for prior authorization cannot be submitted until the reimburse-ment rate for the service has been approved. Once the appropriate reimbursement rate has been approved, retroactive authorization may be granted.

Providers are encouraged to check the 2007 HCPCS website regularly for updates and submit the request for prior authorization with documentation of medical necessity as soon as a reimbursement rate has been approved. TMHP will automatically reprocess claims as reimbursement rates are approved. Claims that require prior authorization will be denied if no authorization number is found. Providers may also pursue an autho-rization at that time and appeal the claim with the approved authorization number.

Retroactive authorization is only granted for those procedure codes scheduled to go through the rate hearing process but do not have pricing at the time the service is


All Providers


Procedure Code Prior Authorization Requirements2-35884 MC F-35884 CSHCN, MC4-37210 MCI-37210 MCT-37210 MC2-49324 MC F-49324 CSHCN, MC 2-49325 MC F-49325 CSHCN, MC2-49326 MC F-49326 CSHCN, MC2-49435 MCF-49435 CSHCN, MCF-49436 CSHCN2-57296 MCF-57296 CSHCN8-57296 MC 2-58541 MC 8-58541 MC F-58541 CSHCN, MC 2-58542 MC F-58542 MC 8-58542 CSHCN, MC 2-58543 MC 8-58543 MCF-58543 CSHCN, MC 2-58544 MC8-58544 MC F-58544 CSHCN, MC 2-58548 MC 8-58548 MC F-58548 CSHCN, MC 2-58957 MC 8-58957 MC 2-58958 MC 8-58958 MC2-64910 MC F-64910 CSHCN, MC 2-64911 MC F-64911 CSHCN, MCT-70554 CSHCN, M, MC I-70555 CSHCN, M, MC4-77021 M, MCI-77021 M, MCT-77021 M, MCI-77022 M, MC(CSHCN) Prior authorization required for the CSHCN Services Program. (M) Prior authorization required for Medicaid. (MC) Precertification required for Medicaid Managed Care.

Procedure Code Prior Authorization Requirements4-91111 MC 9-A4600 M, MC9-A4461 M, MC9-A4601 M, MC9-A8000 M, MC9-A8001 M, MC9-A8002 M, MC9-A8003 M, MC9-A8004 M, MCW-D8693 M, MCW-D9120 CSHCN, M, MCJ-E0676 CSHCN, M, MCL-E0676 CSHCN, M, MCL-E0936 CSHCN, M, MCJ-E2373 CSHCN, M, MCJ-E2375 CSHCN, M, MCJ-E2376 CSHCN, M, MCL-E2377 CSHCN, M, MCJ-E2381 CSHCN, M, MCJ-E2382 CSHCN, M, MCJ-E2383 CSHCN, M, MCJ-E2384 CSHCN, M, MCJ-E2385 CSHCN, M, MCJ-E2386 CSHCN, M, MCJ-E2387 CSHCN, M, MCJ-E2388 CSHCN, M, MCJ-E2389 CSHCN, M, MCJ-E2390 CSHCN, M, MCJ-E2391 CSHCN, M, MCJ-E2392 CSHCN, M, MCJ-E2393 CSHCN, M, MC J-E2394 CSHCN, M, MCJ-E2395 CSHCN, M, MC9-L1001 CSHCN, M, MC9-L3806 CSHCN, M, MC9-L3808 CSHCN, M, MC9-L3915 CSHCN, M, MC9-L5993 CSHCN, M, MC9-L5994 CSHCN, M, MC9-L6611 CSHCN, M, MC9-L6624 CSHCN, M, MC9-L6639 CSHCN, M, MC(CSHCN) Prior authorization required for the CSHCN Services Program. (M) Prior authorization required for Medicaid. (MC) Precertification required for Medicaid Managed Care.


All Providers


Procedure Code Prior Authorization Requirements9-L6703 CSHCN, M, MC9-L6704 CSHCN, M, MC9-L6706 CSHCN, M, MC9-L6707 CSHCN, M, MC9-L6708 CSHCN, M, MC9-L6709 CSHCN, M, MC9-L7007 CSHCN, M, MC9-T4543 CSHCN, M, MC(CSHCN) Prior authorization required for the CSHCN Services Program. (M) Prior authorization required for Medicaid. (MC) Precertification required for Medicaid Managed Care.


Electroencephalogram ChangesEffective for dates of service on or after February 1, 2007, ambulatory electroencephalograms procedure code 5/I/T-95950, 5/I/T-95951, 5/I/T-95953, or 5/I/T-95956 may be eligible for reimbursement when billed with one of the following diagnosis codes:

Diagnosis Code Description33111 Pick’s disease33119 Other frontotemporal dementia33182 Dementia with Lewy bodies85011 Concussion; with brief loss of

consciousness of 30 minutes or less85012 Concussion; with brief loss of

consciousness of 31 to 59 minutes or less

Ambulatory electroencepholograms are no longer a benefit of the Texas Medicaid Program for diagnosis code 78031 (Febrile convulsions).

Additionally, the time unit for monitoring is 24 hours. Benefits are limited to three 24-hour units for each physician for the same patient in a 6-month period when medically necessary.


Article Corrections

Therapeutic PhlebotomyThis is a correction to the “Therapeutic Phlebotomy” article published in the November/December 2006 Texas Medicaid Bulletin, No. 199, located on page 20. Diagnosis code 2384 was inadvertently repeated with the incorrect description. Diagnosis code 2750 was omitted as a payable diagnosis for procedure code 99195. The complete article follows.

Effective for dates of service on or after November 1, 2006, procedure code 99195 is a benefit of the Texas Medicaid Program when billed with the following diagnosis codes:

Diagnosis Code Description2384 Polycythemia vera2750 Disorders of iron metabolism2771 Disorder of porphyrin metabolism2859 Anemia, unspecified2890 Polycythemia secondary2896 Familial polycythemia7764 Polycythemia of newborn

Additionally, procedure code 99195 will no longer be payable to the following provider types:

Inpatient hospital


Clinical nurse specialist

Physician assistant

Certified nurse midwife

RSV Prophylaxis Benefit The article entitled “RSV Prophylaxis Benefits Change,” posted on the TMHP website on September 1, 2006, and published in the November/December 2006 Texas Medicaid Bulletin, No. 199, page 3, contained an incorrect DSHS contact telephone number which appeared in the following sentence, “For more information, call DSHS at 1-800-252-9152.” The sentence should have read, “For more information, call the DSHS Infectious Disease Control Unit at 1-512-458-7455.”

For more information and the corrected article, visit the TMHP website at www.tmhp.com.

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Home Health Providers

HOME HEALTH PROVIDERS

Billing Visits with TDHconnectDue to a TDHconnect systems limitation, home health providers were previously instructed to enter a quantity of 1 when billing for visits, regardless of the actual number of units. TDHconnect has now been updated to allow providers to enter the correct number of units along with the correct maximum statewide visit rate.

Home health providers that submit claims using TDHconnect should input the quantity and billed amount as follows:

Enter the correct number of units in the quantity (Qty) columnLeave the Unit Price blankEnter the amount billed (subject to maximum statewide rate) under Total Charges

For example, if a home visit by a skilled nurse bills for one hour, the provider enters the information as follows:

Quantity: 4.0 (skilled nursing is per 15 minute increments)Unit Price: leave blankTotal Charges: usual and customary

Entering the correct number of units will allow statistics to be compiled for use in future rate setting.

The reimbursement schedule for statewide visit rates for home health agencies is as follows:

Visit Service Category Maximum Statewide Rate* per visit

Skilled Nurse (SN)1 $100.94Home Health Aide (AD)1 $47.03Physical Therapy (PT)2 $116.36Occupational Therapy (OT)2 $118.62Speech-language Therapy (ST)2

$119.61

* Any visit resulting in payment to the home health agency is subject to a 2.5 percent Medicaid payment reduction.

1. Skilled nurse and home health aide visits are limited to three visits per day, with any combination of the two visits.

2. Physical, occupational, and speech-language therapy visits are each limited to one visit per day. Therapy evaluations may also be considered for payment in addition to therapy treatments.

To view the complete article regarding the implementa-tion of statewide visit rates for home health agencies, refer to page 16 of the September/October 2005 Texas Medic-aid Bulletin, No. 190, available on the TMHP website at www.tmhp.com.

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Physical and Occupational Therapy Benefit ChangeEffective November 16, 2006, for dates of service on or after March 1, 2006, procedure codes 1-97001 and 1-97003 are benefits of the Texas Medicaid Program for home health durable medical equipment (DME) providers when performed in the home (place of service [POS] 2).

Previously submitted claims for dates of service on or after March 1, 2006, for procedure codes 1-97001 and 1-97003 will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.


Home Health DME Procedure Code UpdateThe following is a correction to a banner message that appeared on the Remittance and Status report beginning December 12, 2006. The banner stated that procedure code 9-B4157 is a benefit for the Texas Medicaid Program. The banner should have indicated that this procedure code is also a benefit for the Children with Special Health Care Needs (CSHCN) Services Program. The following is the complete, corrected article.

Effective December 8, 2006, for dates of service on or after January 1, 2005, procedure code 9-B4157 is payable to home health DME providers. Claims submitted by home health DME providers for dates of service on or after January 1, 2005, that include procedure code 9-B4157 will be reprocessed and payments will be adjusted accordingly. No action on the part of the provider is necessary. Procedure code 9-B4157 is a benefit of the Texas Medicaid, Medicaid Managed Care, and CSHCN Services Programs.

For more information, call the TMHP Contact Center at 1-800-925-9126 or CSHCN Contact Center at 1-877-888-2350.


Phototherapy Benefit UpdateEffective for dates of service on or after February 1, 2007, the rental of a phototherapy device is a benefit of Texas Medicaid Title XIX Home Health Services for infants in the home setting when submitted with one of the following diagnosis codes:

Diagnosis Codes7740 7741 7742 7743077431 77439 7744 77457746

The guidelines and requirements for prior authorization have been defined below.

A home phototherapy device uses light exposure with white, blue, or green lights to increase bilirubin excretion in the infant with elevated bilirubin levels. Home photo-therapy services include parent/guardian education and obtaining laboratory specimens. Laboratories performing analysis of specimens can bill according to established procedures.

Clients younger than 21 years of age who do not qualify based on the Texas Medicaid Title XIX Home Health Services benefit criteria for home phototherapy devices can be considered through the Comprehensive Care Program (CCP).

Procedure code L-E0202 can be submitted for reimburse-ment consideration of a home phototherapy device.

Prior Authorization RequirementsHome phototherapy devices require prior authorization and are provided only for the days that are medically necessary.

A completed Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form prescribing DME and/or medical supplies must be signed and dated by the prescribing physician familiar with the client prior to requesting authorization. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed Title XIX Form must be maintained by the requesting provider and the prescribing physician. The original signature copy must be kept by the physician in the client’s medical record.

To avoid unnecessary denials, the physician must provide correct and complete information, including documen-tation for medical necessity of the equipment and/or

supplies requested. The physician must maintain docu-mentation of medical necessity in the client’s medical record. The requesting provider may be asked for additional information to clarify or complete a request for the home phototherapy device.

The DME Certification and Receipt Form is required and must be completed before reimbursement can be made for any DME that is delivered to a client. The certifica-tion form must include the name of the item, the date the client received the DME, and the signatures of the provider and the client or primary caregiver. This form must be maintained by the DME provider in the client’s medical record.

Consideration for the rental of a home phototherapy device includes, but is not limited to, the following primary diagnosis codes:

Diagnosis Code Description7740 Perinatal jaundice from hereditary

hemolytic anemias7741 Perinatal jaundice from other

excessive hemolysis7742 Neonatal jaundice associated with

preterm delivery77430 Neonatal jaundice due to delayed

conjugation, cause unspecified77431 Neonatal jaundice due to delayed

conjugation in diseases classified elsewhere

77439 Other neonatal jaundice due to delayed conjugation from other causes

7744 Perinatal jaundice due to hepatocel-lular damage

7745 Perinatal jaundice from other causes7746 Unspecified fetal and neonatal

jaundice7747 Kernicterus of fetus or newborn not

due to isoimmunization

Prior authorization requirements are based on the current American Academy of Pediatrics (AAP) standards and guidelines.

Lower risk infants are defined as greater than or equal to 38 weeks of gestation and well. Indications for photo-


The rental of phototherapy devices may be prior authorized for eligible infants.


therapy in the home setting for infants 35 weeks of gestation or greater at low risk are:

0 through 24 hours of age with a bilirubin level of 6–10 mg/dl



Greater than 72 hours of age with a bilirubin level of 16–21 mg/dl

Risk factors can include, but are not limited to, isoimmune hemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or a serum albumin level less than 3.0 g/dl (if measured).

Documentation of medical necessity is required if the infant does not meet the guidelines above. Prior autho-rization may be given for up to a maximum of seven days at a time, with documentation of the following medical necessity criteria:

Serum bilirubin level (in mg/dl)

Gestational age

Any known risk factors (for example, breastfeeding, jaundice within the first 24 hours, and blood group incompatibility)

Physician’s Plan of Care (POC) for intervention after seven days

Anticipated number of days the client will need the phototherapy light

Documentation of parental education regarding the importance of monitoring and follow-up

Note: Total serum bilirubin levels listed are guides for prior authorization only.

A new prior authorization is required for requests beyond seven days. Home phototherapy devices will not be considered for prior authorization if the client has an open authorization for skilled nursing visits (SNV) for hyperbilirubenemia.

As stated in the AAP standards and guidelines, the Texas Medicaid Program expects that there will be

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ongoing assessments for risk of severe hyperbiliruben-emia for all infants receiving home phototherapy.

Newborn babies may not have a Medicaid number at the time that services are ordered by the physician and provided by the supplier. In these cases, autho-rization may be given retroactively for those services rendered between the start date and the date the client’s Medicaid number becomes available.

The provider is responsible for verifying the effective dates of client eligibility. The provider has 95 days from the date the client’s Medicaid number is available (add date) to obtain authorization for services already rendered. Services provided after the client’s Medicaid number becomes available must be prior authorized within three business days.

Clients younger than 21 years of age who do not qualify based on the Title XIX Home Health Services benefit criteria for home phototherapy devices can be considered through the CCP.

ReimbursementItems and/or services addressed in this policy are either reimbursed at a maximum fee determined by HHSC or are manually priced. If an item is manually priced, manufacturer suggested retail pricing (MSRP) must be submitted for consideration of rental or purchase with the appropriate procedure codes. Manually priced items are reimbursed at the retail price minus a discount (18 percent) or as determined by HHSC.

Routine maintenance of rental equipment is the provider’s responsibility. Rental of a phototherapy device is reimbursed as a daily global fee. The global fee includes SNVs for client teaching, monitoring, and customary and routine laboratory work. SNVs are denied as part of the phototherapy device rental.

Providers may not bill for those days the phototherapy device is at the client’s home and is not in use.

For copies of the forms referenced in this article see the following pages in the forms section:

Home Health Title XIX DME/Medical Supplies Physician Order Form–Page 33

DME Certification and Receipt Form–Page 26


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Elastomeric Devices and IV Supplies and Equipment

Central IV lines, such as peripherally inserted central catheters, subclavian, and vena cava cathetersCentral venous lines, such as Broviac and Hickman catheterImplantable ports, such as Port-a-Cath

Stationary infusion pumps are electrical devices without a battery or with a battery that requires frequent recharging (more frequently than every four hours) and are used to deliver an intravenous solution or parenteral drugs at a steady flow rate. Stationary infusion pumps may be a benefit when the infusion rate must be more consistent than can be obtained with gravity drainage.

Ambulatory infusion pumps are electrical devices with an extended battery life (four hours or longer without recharging) and are used to deliver an intravenous solution or parenteral drugs at a steady flow rate. Ambulatory infusion pumps may be a benefit under the following conditions:

When the length of infusion is greater than two hoursWhen the client must be involved in activities away from homeWhen the infusion rate must be more consistent than can be obtained with gravity drainage

Elastomeric infusion pumps are non-electrical, single use, simplified devices that deliver parenteral drugs at a fixed volume and flow rate. Elastomeric infusion pumps may be a benefit for short-term use when the caregiver cannot administer the infusion using a pump.

Repair of purchased equipment is a benefit. All repairs within the first six months after delivery are considered part of the purchase price.

Needleless systems are not medically necessary, and therefore, not a benefit of Title XIX Home Health Services.

IV supplies and equipment that do not meet the criteria for coverage through Title XIX Home Health Services may be considered through Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for clients younger than 21 years of age.

Prior authorization of IV equipment and supplies may be considered when administration of the drug in the home is medically necessary and is appropriate in the home setting. Prior authorization is required for:

DME and related accessories

IV supplies

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Effective for dates of service on or after March 1, 2007, benefit limitations have been updated for elastomeric devices, and new documentation guidelines will be established for intravenous (IV) supplies and equipment for the Texas Medicaid Program.

Elastometric DevicesElastomeric devices for intermittent intravenous infusions require prior authorization. When prior authorized, procedure code 9-A4305 is considered for reimbursment with an allowable rate of $19.99 and procedure code 9-A4306 is considered for reimbursment with an allowable rate of $60.00. Elastomeric devices are no longer prior authorized using procedure code J/L-E1399.

Intravenous (IV) Supplies and EquipmentEffective for dates of service on or after March 1, 2007, new documentation guidelines have been established for supporting medical neccessity for intravenous (IV) supplies and equipment.

The following procedure codes for equipment and supplies utilized in the delivery of intravenous (IV) therapy are benefits of the Title XIX Home Health Services Program:

Procedure Codes9-A4206 9-A4207 9-A4208 9-A42099-A4212 9-A4216 9-A4222 9-A42459-A4247 9-A4300 9-A4305 9-A43069-A4450 9-A4452 9-A4930 9-A62069-A6207 9-A6257 9-A6258 9-A64029-A9900 9-S1015 J/L-E0776 J/L-E0779J/L-E0780 J/L-E0781 J/L-E0791

Additional supply procedure codes may be considered with documentation of medical necessity. To be considered for reimbursement of a home health benefit:

The client must be eligible for home health benefits.The criteria for the requested supplies/equipment must be met.The supplies/equipment requested must be medically necessary. Federal financial participation must be available.The requested supplies/equipment must be safe for use in the home.

Types of intravenous access devices include but are not limited to:

Peripheral IV lines

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The following documentation must be provided when requesting prior authorization for IV supplies and equipment:

Diagnostic information pertaining to the underlying diagnosis/conditionA physician’s order and documentation supporting medical necessityThe medication being administered, the duration of drug therapy, and the frequency of administration

The following standards are used when considering prior authorization of IV supplies:

Aseptic technique is acceptable for the IV catheter insertion and site care; the sterile technique is not required. Non-sterile gloves are acceptable for insertion of a peripheral IV catheter and for changing any IV site dressing. The sterile technique may be medically necessary under certain conditions (e.g. clients who are immunocompromised).

A peripheral IV site is rotated no more frequently than every 72 hours but at least once a week.

The IV administration set, extension set, and any add-on devices are changed every 72 hours.

One IV access catheter is used per insertion.

For locked catheters, use one syringe to flush the catheter before administration of an intermittent infusion to assess patency. Use two syringes to flush the catheter after the intermittent infusion—one to clear the medication and one to infuse the anticoagulant or other medication used to maintain IV patency between doses (e.g. heparin).

An injection port is cleaned prior to administering an intermittent infusion and capped after the infusion.

To care for the IV catheter site, disinfect the site with an appropriate antiseptic such as two percent chlorhexi-dine-based preparation, tincture of iodine, or 70 percent alcohol. Cover with sterile gauze, transparent dressing, or semi-permeable dressing. Replace the dressing if it becomes damp, loosened, or visibly soiled.

Stopcocks increase the risk for infection and should not be routinely used for infusion administration.

Routine use of in-line filters is not recommended for infection control.

Non-sterile/sterile gloves for use by a health care provider such as a registered nurse (RN), licensed vocational nurse (LVN), or attendant in the home setting, are not a benefit of Texas Medicaid Title XIX Home Health Services.

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If additional supplies are needed beyond these standards, prior authorization may be considered with documenta-tion supporting medical necessity. Supporting documenta-tion for additional IV access catheters includes but is not limited to dehydration, vein scarring, and fragile veins (including, but not limited to, infant and elderly clients).

Supporting documentation for more frequent IV site changes includes but is not limited to phlebitis, infiltration, and extravasation. Supporting documentation for more frequent IV tubing or add-on changes includes but is not limited to phlebitis, IV catheter-related infection, and cases where the administered infusion requires more frequent tubing changes.

Elastomeric devices are specialized infusion devices that may be considered for prior authorization under the following conditions:

When the device is used for short-term medication administration (less than two weeks duration)

When the device is expected to increase client compliance

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necessity. Technician fees are considered part of the cost of the repair. Providers are responsible for maintaining documentation in the client’s medical record specifying the repairs and supporting medical necessity. All repairs within the first six months after delivery are considered part of the purchase price. Additional documentation, such as the purchase date, serial number, and manufacturer’s information, may be required.

IV therapy supplies and equipment are not considered a benefit when the infusion/medication being adminis-tered meets one or more of the following conditions:

The infusion/medication is not considered medically necessary to the treatment of the client’s illness.

The administration exceeds the frequency and/or duration ordered by the physician.

The infusion/medication is a chemotherapeutic agent or blood product.

The infusion/medication is not approved by the Food and Drug Administration (FDA). Exception: For the service to be considered for reimbursement, the physician

must document why the off-label use is medically appropriate and not likely to result in an adverse reaction. In order to consider coverage of an off-label (non-FDA approved) use of a drug, documentation must include why a drug usually indicated for the specific diagnosis or condition has not been effective for the client.

Elastomeric devices may be considered for reimbursement using procedure codes 9-A4305 and 9-A4306. Infusion pump rental is limited to once per month for a maximum of four months per lifetime. Purchase of an infusion pump may be considered when the client has a chronic need for infusion therapy.


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When the device will better facilitate drug administration

When the device costs less than the cost pump rental/tubing

When the caregiver can not administer infusion via pump

The following criteria must be met for prior authorization of a stationary infusion pump:

An infusion pump is required to safely administer the drug.

Standard method of administra-tion of the drug is by prolonged infusion or intermittent infusion, and the infusion rate must be more consistent than can be obtained with gravity drainage.

The drug being administered requires IV infusion (i.e., the drug cannot be administered orally, intramuscularly, or by push technique).

The following criteria must be met for prior authorization of an ambulatory infusion pump:

An infusion pump is required to safely administer the drug.

Standard method of administra-tion of the drug is by prolonged infusion or intermittent infusion and the infusion rate must be more consistent than can be obtained with gravity drainage.

The drug being administered requires IV infusion (i.e., the drug cannot be administered orally, intramuscularly, or by push technique).

The infusion administration is more than two hours and the client is involved in activities away from home (such as physician visits).

Prior authorization may be considered for purchase of a pump (ambulatory or stationary) with documentation of medical necessity supporting chronic use. For clients who require cardiovascular medications, infusion pumps will not be purchased, but will be rented.

Repairs to client-owned equipment may be prior authorized as needed with documentation of medical

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PRIMARY CARE CASE MANAGEMENT PROVIDERS

Authorization Removed For Some Gallbladder SurgeriesEffective February 1, 2007, prior authorization is no longer required for Primary Care Case Management (PCCM) providers for the following procedure codes:

Procedure Code

2/8/F-47562 2/8/F-47563 2/8/F-475642/8-47600 2/8-47605 2/8-476102/8-47612 2/8-47620

For more information, contact the TMHP Contact Center at 1-800-925-9126.

OB/GYN Care for PCCM ClientsClients in the PCCM expansion area may select any Medicaid enrolled obstetrical and gynecological (OB/GYN) provider, family practitioner, or internal medicine provider for the following services:

One well-woman examination per year

Care related to pregnancy

Care for all active gyneco-logical conditions

Diagnosis, treatment, and referral to a Medicaid enrolled specialist for any disease or condition within the scope of the designated professional practice of a licensed obstetrician or gynecologist, including treatment of medical conditions concerning the breasts

A referral from the PCCM client’s primary care provider is not required as long as the provider rendering services is a Medicaid enrolled OB/GYN, family practitioner, or internal medicine provider.

This is an update to the information found in the 2007 Texas Medicaid Provider Procedures Manual, page 7-28, Section 7.5.9.1.

For more information, call the PCCM Provider Helpline at 1-888-834-7226 or the TMHP Contact Center at 1-800-925-9126.

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Quick Tips for PCCM Provider EnrollmentPCCM is a network of Medicaid primary care providers, clinics, and hospitals providing a medical home to Medicaid clients. Medicaid providers are not auto-matically enrolled in PCCM as a primary care provider. Medicaid enrollment and PCCM enrollment are two separate processes.

To enroll as a PCCM provider, Medicaid providers must submit the following documents and/or information to the TMHP Credentialing department for enrollment:

A completed Texas Department of Insurance Texas Standardized Credentialing application

A completed application addendum

A signed PCCM contract

A copy of the provider’s current medical license

A copy of the provider’s current malpractice insurance A Drug Enforcement Agency (DEA) registration certifica-tion (if applicable)

A Texas Department of Public Safety (DPS) certification

To avoid delays in the enrollment process, providers must complete the following commonly missed sections of the Texas Standardized Credentialing Application:

Degree and education information

Five year work history

Continuous access information

Signature and date for the attestation and release (pages 11 and 12)

The required enrollment documents are available on the TMHP website at www.tmhp.com for all applicable provider types including primary care providers, groups, rural health clinics, and federally qualified health clinics. Applications should be mailed to:

TMHP Attn: Provider Enrollment

PO Box 200795 Austin, TX 78720-0795

Providers can obtain a PCCM application via email or fax by calling the Provider Helpline at 1-888-834-7226 between 7 a.m. and 7 p.m., Monday through Friday.

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Primary Care Case Management Providers


SCHOOL HEALTH AND RELATED SERVICES PROVIDERS

SHARS Billing Update

Special Transportation ServicesSpecial transportation services require that vehicles be specially adapted in order to be reimbursable as a Medicaid service. Allowable special adaptive enhance-ments include such physical item enhancements as lifts, air conditioning, seat belts, etc. Effective for dates of service on or after September 1, 2006, addition of bus monitors or other personnel accompanying children is no longer considered an allowable special adaptive enhancement for Medicaid reimbursement under School Health and Related Services (SHARS) special transportation services.

Interim rates have not yet been determined for special transportation services and for individual and group personal care services on the school bus. Until interim rates are determined, any claims submitted for these three services will be processed without reimbursement and will be reprocessed for payment when the interim rates become available.

Educational Diagnosticians and Certified CounselorsEffective for dates of service on or after September 1, 2006, assessment services provided by state-certified educational diagnosticians and counseling services provided by state-certified school counselors are no longer covered or reim-bursable under SHARS. Claims should not be submitted for these providers for these services provided on or after September 1, 2006.

For more information, contact the TMHP Contact Center at 1-800-925-9126.

TEXAS HEALTH STEPS DENTAL PROVIDERS

THSteps Diagnostic Dental ServicesEffective for dates of service on or after March 1, 2007, diagnostic dental services benefits changed for

the Texas Health Steps (THSteps) Dental Program.

Age restrictions changed for the following procedure codes:

Procedure codes W-D0270 and W-D0272 changed from 2 through 20 years of age to 1 through 20 years of age.

Procedure code W-D0140 changed from 1 through 20 years of age to birth through 20 years of age.

Procedure code W-D0277 changed from 1 through 20 years of age to 2 through 20 years of age.

When filing paper claims for emergency or trauma-related services, student status for full-time students (FTS) will not be required in Block 19 of the American Dental Association (ADA) Dental Claim Form.

The following procedure codes are denied as part of another procedure:

Procedure code W-D0140 is denied when billed on the same date of service for the same provider as procedure code W-D0160.



For more information call the TMHP Contact Center at 1-800-925-9126.

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School Health and Related Services Providers/Texas Health Steps Dental Providers


TEXAS HEALTH STEPS MEDICAL PROVIDERS

Correction to THSteps and FQHC Providers Administration Fees ArticleThe following is a correction to the article published in the November/December 2006 Texas Medicaid Bulletin, No.199, entitled “THSteps and FQHC Providers Administration Fee” located on page 24. The article incorrectly stated Federally Qualified Health Center (FQHC) providers were eligible for administration fees in the office, home, and outpatient hospital places of service for procedure codes S-90714 and S-90715. The correct article follows.

Effective November 8, 2006, for dates of service on or after July 1, 2004, procedure code S-90715 will process as informational only for FQHC and Texas Health Steps (THSteps) providers. THSteps providers are eligible for an administration fee for clients 7 through 20 years of age in the office, home, and outpatient hospital places of service. Claims submitted for dates of service on or after July 1, 2004, that include this procedure code will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.

Effective November 8, 2006, for dates of service on or after January 1, 2006, procedure code S-90714 will process as informational only for FQHCs and THSteps providers. THSteps providers are eligible for an administration fee for clients 7 through 20 years of age in the office, home, and outpatient hospital places of service.

Claims submitted for dates of service on or after January 1, 2006, that include this procedure code will be reprocessed, and payments will be adjusted accordingly. No action on the part of the provider is necessary.


Texas Health Steps Medical Providers

Excluded ProvidersAs required by the Medicare and Medicaid Patient Protection Act of 1987, HHSC identifies providers or employees of providers who have been excluded from state and federal health care programs. Providers excluded from the Texas Medicaid Program and Title XX Programs must not order or prescribe services to clients after the exclusion date. Services rendered under the medical direction or under the prescribing orders of an excluded provider also will be denied. Providers who submit cost reports cannot include the salaries/wages/benefits of employees who have been excluded from Medicaid. Also, excluded employees are not permitted to provide Medicaid services to any patient/client.

Medicaid providers are responsible for checking the exclusion list on all employees upon hiring and periodically thereafter. Providers are liable for all fees paid to them by the Texas Medicaid Program for services rendered by excluded individuals. Providers are subject to a retrospective audit and recoupment of any Medicaid funds paid for services. It is strongly recommended that providers conduct frequent periodic checks of HHSC’s exclusion list. The HHSC-Sanctions Department submits updates to the exclusion list semi-monthly. Updates appear on the website after the 1st and 15th of each month.

Review the entire Texas Medicaid Program exclusion list at www.hhsc.state.tx.us/OIE/Exclusionlist/ado/exclusion.asp.

To report Medicaid providers who engage in fraud/abuse, call 1-512-424-6519 or 1-888-752-4888, or write to the following address:

Vicki Fischer, Director HHSC Office of Inspector General, Medicaid Provider Integrity

MC-1361 PO Box 85200

Austin, TX 78708-5200

Provider License Number

Start Date Type Provider

City State Add Date

Ballesteros, Oscar 188856 17-May-06 LVN San Antonio TX 19-Dec-06Bonilla, Iris 20-Jan-06 Houston TX 27-Nov-06Brooks, Randolph 10-Apr-06 Beaumont TX 20-Nov-06Campbell, Pamela C 92436 15-May-06 LVN Iowa Park TX 28-Dec-06Carmichael, Sharel Lynn 20-Sep-06 Other Waco TX 08-Jan-07Davis, Mary C 249123 8-Apr-05 RN Waiuku South

Aucklan 18-Dec-06

Dunn, Theresa L 164493 20-Apr-06 LVN Kirbyville TX 27-Dec-06Fenley, Tanya L 03-Jan-07 Bryan TX 08-Jan-07Fields, Bryan L 600890 18-Apr-06 RN Missouri City TX 18-Dec-06Gilliam, Robin R 655197 14-Feb-06 RN Texas City TX 18-Dec-06Gonzales, David L 0017279 29-Nov-06 DDS Pasadena TX 11-Dec-06Goodwin Jr., Garvis L 571987 4-May-06 RN Huntington TX 27-Dec-06Hale, Mandy 185177 09-May-06 LVN Powderly TX 03-Jan-07Hall, Cheryl L 153994 17-Aug-06 LVN Lubbock TX 04-Jan-07Hansen, Tammy F 695790 20-Apr-06 RN Ossining NY 03-Jan-07Harris, Susan Lynn 55747 20-Jun-06 RN Fort Worth TX 08-Jan-07Hernandez, Jennifer P 180827 18-May-06 LVN Temple TX 27-Dec-06Jennings, Pamela D 433481 26-Apr-06 RN West Monroe LA 19-Dec-06Jett, Kaylette M 172428 09-May-06 LVN Dayton TX 08-Jan-07Kesseler, Randall G G8212 7-Apr-06 DO Sanger TX 18-Dec-06


Excluded Providers

Provider License Number

Start Date Type Provider

City State Add Date

King, John Q E2656 5-Oct-06 MD Katy TX 28-Dec-06King, Patricia A 158459 25-Apr-06 LVN Houston TX 18-Dec-06Kulhanek, Anjanette T 192601 20-Apr-07 LVN Wichita Falls TX 11-Jan-07Laiho, Esa A 2-May-06 Houston TX 5-Dec-06LeBlanc, April 688043 10-Feb-06 RN Round Rock TX 03-Jan-07Loper, Tessa D 166657 02-May-06 LVN Sunray TX 05-Jan-07Martinez, Lupe 103928 09-May-06 LVN Odessa TX 08-Jan-07Mauskar, Anant M E9300 6-Dec-06 MD Houston TX 21-Dec-06McLemore, Aundrea L 188385 6-Apr-06 LVN Beckville TX 19-Dec-06Medellin, Martha S 55047 09-May-06 LVN San Antonio TX 08-Jan-07Mills, Billy G D0716 08-Apr-05 DO Cleburne TX 11-Jan-07Nathan, Michael M 661232 9-May-06 RN Hugo TX 28-Dec-06Ortho Clinic, The 30-Jul-00 Brownsville TX 28-Nov-06Park Plaza Physical Medicine, Inc.

20-Jan-06 Houston TX 27-Nov-06

Patt, Richard B J5440 6-Apr-06 MD Houston TX 18-Dec-06Payne, Pamela 552428 8-May-06 RN El Paso TX 19-Dec-06Perez, Alfred C 667399 11-May-06 RN San Antonio TX 19-Dec-06Perlas, Mario P 452859 20-Apr-06 RN Andrews TX 18-Dec-06Presley, Lydia 608307 09-May-06 RN Corinth TX 11-Jan-07Ramirez, Jennifer L 193548 12-May-06 LVN San Antonio TX 28-Dec-06Reed, Amy M 20-Mar-06 Collinsville TX 28-Nov-06Reyes-Vazquez, Jaime G 19976 28-Apr-06 DDS McAllen TX 18-Dec-06Rich, Steve D 154087 15-May-06 LVN Lucas TX 22-Dec-06Rivas, Juan Manuel 30-Jul-00 Brownsville TX 28-Nov-06Smith, Rhonda Janyell 20-Aug-06 Other Fort Worth TX 08-Jan-07Staggs, Stacy A 152087 15-Dec-05 LVN Dallas TX 03-Jan-07Stanley, Cisely M 703595 3-Apr-06 RN Abbeville LA 18-Dec-06Waldrop, Cynthia K 555978 21-Mar-06 RN Addison TX 03-Jan-07Walker, Beverly J 70777 12-Apr-06 LVN Dallas TX 28-Dec-06Walker, Pamela K 180082 9-May-06 LVN Austin TX 27-Dec-06Wenzel, Stephen M 689837 20-Apr-06 RN Fort Worth TX 08-Jan-07Wilson, Lynch D6290 25-Apr-06 MD Charleston SC 18-Dec-06


Excluded Providers


DME Certification and Receipt Form

This certification is required by section 32.024 of the Human Resources Code and must be completed before the

DME provider can be paid for durable medical equipment provided to a Medicaid client. This is to certify that on

(month, day, year)............................................:

• The client received the ..........................................(name of item/equipment) as prescribed by the physician.

• The equipment has been properly fitted to the client and/or meets the client’s needs.

• The client, the parent or guardian of the client, and/or the primary caregiver of the client, has received training and instruction regarding the equipment’s proper use and maintenance.

..................................................................................................................................................................

Signature of DME Supplier Signature of Client/Parent/Guardian/Primary Caregiver

Certificación y recibo de equipo médico duradero (DME)

Esta certificación es necesaria bajo la Sección 32.024 del Código de Recursos Humanos y se debe Ilenar antes

de poder reembolsar al proveedor del equipo médico duradero por cualquier equipo médico proporcionado al

cliente de Medicaid. Esto certifica que el: (mes, día, año)..........................................................................

• El cliente recibió [el] [la] [los] [las] ..................................(nombre del artículo o equipo) que el doctor recetó.

• El equipo ha sido adaptado correctamente para el cliente o satisface las necesidades del cliente.

• El cliente, su padre o tutor, o el cuidador principal del cliente, ha recibido entrenamiento e instrucción con respecto al uso y mantenimiento apropiado del equipo.

.................................................................................................................................................................Firma del Proveedor del Equipo Médico Duradero Firma del Cliente, Padre, Tutor o Cuidador principal

Forms

Provider Information Change Form Traditional Medicaid, Children with Special Health Care Needs (CSHCN), and Primary Care Case Management (PCCM) providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.

Check the box to indicate a PCCM Provider � Date:

9-digit Texas Provider Identifier (TPI): Provider Name:

List any additional TPIs that use the same provider information:

TPI:______________________ TPI:______________________ TPI:______________________

TPI:______________________ TPI:______________________ TPI:______________________

Physical Address* Accounting/Mailing Address** Secondary Address

City: City: City:

State: ZIP: State: ZIP: State: ZIP:

Phone: ( ) Phone: ( ) Phone: ( ) Fax: Fax: Fax:

Email: Email: Email:

Type of Change: (Check the appropriate box below.)

� Change of physical address, telephone, and/or fax number � Change of billing/mailing address, telephone, and/or fax number � Change/Add secondary address, telephone, and/or fax number � Change of provider status (e.g., termination from plan, moved out of area, specialist)

Explain in the Comments field � Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information—Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Tax ID Number: Effective Date:

Exact name reported to the IRS for this Tax ID:

The signature and date are required or the form will not be processed.

Provider Signature: Date:

Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795

Fax: 1-512-514-4214

* The physical address cannot be a PO Box. Traditional Medicaid providers who change their ZIP code must submit a copy of the Medicare letter along with this form.

** All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.


Forms

Instructions for Completing the Provider Information Change Form

Signatures:• The provider’s signature is required on the Provider Information Change Form for any and all

changes requested for individual provider numbers. • A signature by the authorized representative of a group or facility is acceptable for requested

changes to group or facility provider numbers.

Address:• Performing providers (physicians performing services within a group) may not change

accounting information. • For Traditional Medicaid, changes to the accounting or mailing address require a copy of the

W9 form. • For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter.

Tax Identification Number (TIN): • TIN changes for individual practitioner provider numbers can only be made by the individual to

whom the number is assigned. • Performing providers cannot change the TIN.

General:• Forms will be returned unprocessed if the nine-digit provider number is not indicated on the

Provider Information Change Form. • The W-9 form is required for all name and TIN changes. • Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Fax: 1-512-514-4214


Forms

Electronic Funds Transfer (EFT) Authorization Agreement Enter ONE Texas Provider Identifier (TPI) per Form

— A STATE MEDICAID CONTRACTOR 23

NOTE: Complete all sections below and attach a voided check or a photocopy of your deposit slip.

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

Provider Accounting Address Provider Phone Number ( ) ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one) Checking Savings

I (we) hereby authorize Texas Medicaid & Healthcare Partnership (TMHP) to present credit entries into the bank account referenced above and the depository named above to credit the same to such account. I (we) understand that I (we) am responsible for the validity of the information on this form. If the company erroneously deposits funds into my (our) account, I (we) authorize the company to initiate the necessary debit entries, not to exceed the total of the original amount credited for the current pay period.

I (we) agree to comply with all certification requirements of the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by the Texas Health and Human Services Commission (HHSC) or its health insuring contractor. I (we) understand that payment of claims will be from federal and state funds, and that any falsification or concealment of a material fact may be prosecuted under federal and state laws.

I (we) will continue to maintain the confidentiality of records and other information relating to clients in accordance with applicable state and federal laws, rules, and regulations.

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:


Forms

Electronic Funds Transfer (EFT) Information

— A STATE MEDICAID CONTRACTOR 23

Electronic Funds Transfer (EFT) is a payment method to deposit 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:

• Pre–notification to your bank takes place on the cycle following the application processing.

• Future deposits are received electronically after pre–notification. • 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 Texas

Provider Identifier (TPI) and R&S number. • EFT funds are released by TMHP to depository financial institutions each Friday. • The availability of R&S reports is unaffected by EFT and they continue to arrive in

the same manner and time frame as currently received.

TMHP must provide 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. Please contact your financial institution regarding posting time if funds are not available on the release date.

However, due to geographic factors, some receiving depository financial institutions do not receive their credit entries until the morning of the effective day and the internal records of these financial institutions will not be updated. As a result, tellers, bookkeepers, or automated teller machines (ATMs) may not be aware of the deposit and the customer’s withdrawal request may be refused. When this occurs, the customer or company should discuss the situation with the ACH coordinator of their institution who, in turn should work out the best way to serve their customer’s needs.

In all cases, credits received should be posted to the customer’s 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, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or deposit slip with the agreement to the TMHP address indicated on the form.

Call the TMHP Contact Center at 1–800–925–9126 for assistance.


Forms


1a. INSURED’S I.D. NUMBER (For Program in Item 1)

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

7. INSURED’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

11. INSURED’S POLICY GROUP OR FECA NUMBER

a. INSURED’S DATE OF BIRTH

b. EMPLOYER’S NAME OR SCHOOL NAME

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorizepayment of medical benefits to the undersigned physician or supplier forservices described below.

SEX

F

HEALTH INSURANCE CLAIM FORM

OTHER1. MEDICARE MEDICAID TRICARE CHAMPVA

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary

to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignmentbelow.

SIGNED DATE

ILLNESS (First symptom) ORINJURY (Accident) ORPREGNANCY(LMP)

MM DD YY15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

GIVE FIRST DATE MM DD YY14. DATE OF CURRENT:

19. RESERVED FOR LOCAL USE

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

FromMM DD YY

ToMM DD YY

1

2

3

4

5

625. FEDERAL TAX I.D. NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT?

(For govt. claims, see back)

31. SIGNATURE OF PHYSICIAN OR SUPPLIERINCLUDING DEGREES OR CREDENTIALS(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

SIGNED

MM DD YY

FROM TO

FROM TO

MM DD YY MM DD YY

MM DD YY MM DD YY

CODE ORIGINAL REF. NO.

$ CHARGES

28. TOTAL CHARGE 29. AMOUNT PAID 30. BALANCE DUE

$ $ $

PICA PICA

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

5. PATIENT’S ADDRESS (No., Street)

CITY STATE

ZIP CODE TELEPHONE (Include Area Code)

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

a. OTHER INSURED’S POLICY OR GROUP NUMBER

b. OTHER INSURED’S DATE OF BIRTH

c. EMPLOYER’S NAME OR SCHOOL NAME

d. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

( )

If yes, return to and complete item 9 a-d.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

20. OUTSIDE LAB? $ CHARGES

22. MEDICAID RESUBMISSION

23. PRIOR AUTHORIZATION NUMBER

MM DD YY

CA

RR

IER

PA

TIE

NT

AN

D IN

SU

RE

D IN

FO

RM

AT

ION

PH

YS

ICIA

N O

R S

UP

PL

IER

INF

OR

MA

TIO

N

M F

YES NO

YES NO

1. 3.

2. 4.

DATE(S) OF SERVICEPLACE OFSERVICE

PROCEDURES, SERVICES, OR SUPPLIES(Explain Unusual Circumstances)

CPT/HCPCS MODIFIERDIAGNOSISPOINTER

FM

SEXMM DD YY

YES NO

YES NO

YES NO

PLACE (State)

GROUPHEALTH PLAN

FECABLK LUNG

Single Married Other

3. PATIENT’S BIRTH DATE

6. PATIENT RELATIONSHIP TO INSURED

8. PATIENT STATUS

10. IS PATIENT’S CONDITION RELATED TO:

a. EMPLOYMENT? (Current or Previous)

b. AUTO ACCIDENT?

c. OTHER ACCIDENT?

10d. RESERVED FOR LOCAL USE

Employed Student Student

Self Spouse Child Other

(Medicare #) (Medicaid #) (Sponsor’s SSN) (Member ID#) (SSN or ID) (SSN) (ID)

( )

M

SEX

DAYSOR

UNITS

F. H. I. J.24. A. B. C. D. E.

PROVIDER ID. #

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

EMGRENDERING

32. SERVICE FACILITY LOCATION INFORMATION 33. BILLING PROVIDER INFO & PH #

NUCC Instruction Manual available at: www.nucc.org

c. INSURANCE PLAN NAME OR PROGRAM NAME

Full-Time Part-Time

17b. NPI

a. b. a. b.

NPI

NPI

NPI

NPI

NPI

NPI

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05

G.EPSDTFamilyPlan

ID.QUAL.

NPI NPI

CHAMPUS

( )

1500

APPROVED OMB-0938-0999 FORM CMS-1500 (08/05)

Forms


BECAUSE THIS FORM IS USED BY VARIOUS GOVERNMENT AND PRIVATE HEALTH PROGRAMS, SEE SEPARATE INSTRUCTIONS ISSUED BYAPPLICABLE PROGRAMS.

NOTICE: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information maybe guilty of a criminal act punishable under law and may be subject to civil penalties.

REFERS TO GOVERNMENT PROGRAMS ONLYMEDICARE AND CHAMPUS PAYMENTS: A patient’s signature requests that payment be made and authorizes release of any information necessary to processthe claim and certifies that the information provided in Blocks 1 through 12 is true, accurate and complete. In the case of a Medicare claim, the patient’s signatureauthorizes any entity to release to Medicare medical and nonmedical information, including employment status, and whether the person has employer group healthinsurance, liability, no-fault, worker’s compensation or other insurance which is responsible to pay for the services for which the Medicare claim is made. See 42CFR 411.24(a). If item 9 is completed, the patient’s signature authorizes release of the information to the health plan or agency shown. In Medicare assigned orCHAMPUS participation cases, the physician agrees to accept the charge determination of the Medicare carrier or CHAMPUS fiscal intermediary as the full charge,and the patient is responsible only for the deductible, coinsurance and noncovered services. Coinsurance and the deductible are based upon the chargedetermination of the Medicare carrier or CHAMPUS fiscal intermediary if this is less than the charge submitted. CHAMPUS is not a health insurance program butmakes payment for health benefits provided through certain affiliations with the Uniformed Services. Information on the patient’s sponsor should be provided in thoseitems captioned in “Insured”; i.e., items 1a, 4, 6, 7, 9, and 11.

BLACK LUNG AND FECA CLAIMSThe provider agrees to accept the amount paid by the Government as payment in full. See Black Lung and FECA instructions regarding required procedure anddiagnosis coding systems.

SIGNATURE OF PHYSICIAN OR SUPPLIER (MEDICARE, CHAMPUS, FECA AND BLACK LUNG)I certify that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by me or were furnishedincident to my professional service by my employee under my immediate personal supervision, except as otherwise expressly permitted by Medicare or CHAMPUSregulations.

For services to be considered as “incident” to a physician’s professional service, 1) they must be rendered under the physician’s immediate personal supervisionby his/her employee, 2) they must be an integral, although incidental part of a covered physician’s service, 3) they must be of kinds commonly furnished in physician’soffices, and 4) the services of nonphysicians must be included on the physician’s bills.

For CHAMPUS claims, I further certify that I (or any employee) who rendered services am not an active duty member of the Uniformed Services or a civilian employeeof the United States Government or a contract employee of the United States Government, either civilian or military (refer to 5 USC 5536). For Black-Lung claims,I further certify that the services performed were for a Black Lung-related disorder.

No Part B Medicare benefits may be paid unless this form is received as required by existing law and regulations (42 CFR 424.32).

NOTICE: Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subjectto fine and imprisonment under applicable Federal laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF MEDICARE, CHAMPUS, FECA, AND BLACK LUNG INFORMATION(PRIVACY ACT STATEMENT)

We are authorized by CMS, CHAMPUS and OWCP to ask you for information needed in the administration of the Medicare, CHAMPUS, FECA, and Black Lungprograms. Authority to collect information is in section 205(a), 1862, 1872 and 1874 of the Social Security Act as amended, 42 CFR 411.24(a) and 424.5(a) (6), and44 USC 3101;41 CFR 101 et seq and 10 USC 1079 and 1086; 5 USC 8101 et seq; and 30 USC 901 et seq; 38 USC 613; E.O. 9397.

The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the servicesand supplies you received are covered by these programs and to insure that proper payment is made.

The information may also be given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federalagencies, for the effective administration of Federal provisions that require other third parties payers to pay primary to Federal program, and as otherwise necessaryto administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosuresare made through routine uses for information contained in systems of records.

FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished.

FOR OWCP CLAIMS: Department of Labor, Privacy Act of 1974, “Republication of Notice of Systems of Records,” Federal Register Vol. 55 No. 40, Wed Feb. 28,1990, See ESA-5, ESA-6, ESA-12, ESA-13, ESA-30, or as updated and republished.

FOR CHAMPUS CLAIMS: PRINCIPLE PURPOSE(S): To evaluate eligibility for medical care provided by civilian sources and to issue payment upon establishmentof eligibility and determination that the services/supplies received are authorized by law.

ROUTINE USE(S): Information from claims and related documents may be given to the Dept. of Veterans Affairs, the Dept. of Health and Human Services and/orthe Dept. of Transportation consistent with their statutory administrative responsibilities under CHAMPUS/CHAMPVA; to the Dept. of Justice for representation ofthe Secretary of Defense in civil actions; to the Internal Revenue Service, private collection agencies, and consumer reporting agencies in connection with recoupmentclaims; and to Congressional Offices in response to inquiries made at the request of the person to whom a record pertains. Appropriate disclosures may be madeto other federal, state, local, foreign government agencies, private business entities, and individual providers of care, on matters relating to entitlement, claimsadjudication, fraud, program abuse, utilization review, quality assurance, peer review, program integrity, third-party liability, coordination of benefits, and civil andcriminal litigation related to the operation of CHAMPUS.

DISCLOSURES: Voluntary; however, failure to provide information will result in delay in payment or may result in denial of claim. With the one exception discussedbelow, there are no penalties under these programs for refusing to supply information. However, failure to furnish information regarding the medical services renderedor the amount charged would prevent payment of claims under these programs. Failure to furnish any other information, such as name or claim number, would delaypayment of the claim. Failure to provide medical information under FECA could be deemed an obstruction.

It is mandatory that you tell us if you know that another party is responsible for paying for your treatment. Section 1128B of the Social Security Act and 31 USC 3801-3812 provide penalties for withholding this information.

You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988”, permits the government to verify information by way of computer matches.

MEDICAID PAYMENTS (PROVIDER CERTIFICATION)I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the State’s Title XIX plan and to furnishinformation regarding any payments claimed for providing such services as the State Agency or Dept. of Health and Human Services may request.

I further agree to accept, as payment in full, the amount paid by the Medicaid program for those claims submitted for payment under that program, with the exceptionof authorized deductible, coinsurance, co-payment or similar cost-sharing charge.

SIGNATURE OF PHYSICIAN (OR SUPPLIER): I certify that the services listed above were medically indicated and necessary to the health of this patient and werepersonally furnished by me or my employee under my personal direction.

NOTICE: This is to certify that the foregoing information is true, accurate and complete. I understand that payment and satisfaction of this claim will be from Federal and Statefunds, and that any false claims, statements, or documents, or concealment of a material fact, may be prosecuted under applicable Federal or State laws.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMBcontrol number for this information collection is 0938-0999. The time required to complete this information collection is estimated to average 10 minutes per response, including thetime to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning theaccuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland21244-1850. This address is for comments and/or suggestions only. DO NOT MAIL COMPLETED CLAIM FORMS TO THIS ADDRESS.

Forms


Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form

See instructions for completing Title XIX Home Health Durable Medical Equipment (DME)/Medical Supplies Physician Order Form. This order form cannot be accepted beyond 90 days from the date of the physician's signature. Fax completed form to 1-512-514-4209.

Section A: Requested Durable Medical Equipment and Supplies

This section was completed by (check one): � Requesting Physician � Supplier

Client name: _________________________________________________ Client Medicaid number: _________________________________________

Client date of birth: ______________/______________/_______________ Is client under 21 years of age? YES � NO �

Supplier name: _______________________________________________ Supplier Medicaid TPI number: ____________________________________

Supplier Address: _____________________________________________ City ______________________ State _____________ Zip ___________

Supplier telephone number: _____________________________________ Supplier Fax number: ___________________________________________

Prescribing physician name: _____________________________________ Physician telephone number: ______________________________________

Physician Fax number: ___________________________________________

I certify that the services being supplied under this order are consistent with the physician's determination of medical necessity and prescription. The prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

DME/medical supplies provider representative signature: ________________________________________ Date: _____/_____/______

DME/medical supplies provider representative name (Typed or Printed): ___________________________________________________

Itemnumber

HCPCScode

Description of DME/medical

supplies

Quantity Price Priorauthorization

required?

Beyond quantity

limit?1 Custom Item?1

1 � Y � N � Y � N � Y � N

2 � Y � N � Y � N � Y � N

3 � Y � N � Y � N � Y � N

4 � Y � N � Y � N � Y � N

5 � Y � N � Y � N � Y � N

1. If “Yes,” additional documentation must be provided to support determination of medical necessity.

� Check if additional documentation is attached as outlined in the TMPPM.

Is the DME Provider Medicare certified? YES � NO � If yes, indicate Medicare number: _______________________________________

Section B: Diagnosis and Medical Need InformationThis is a prescription for DME/supplies and must be filled out by the prescribing physician.

ICD-9 Brief Diagnosis Descriptor Requested Item Number

from Section A2Complete justification for determination of

medical necessity for requested item(s)2

(Refer to Section A, footnote 1)

__ __ __ . __ __

__ __ __ . __ __

__ __ __ . __ __

__ __ __ . __ __

2. Each item requested in Section A must have a correlating diagnosis and medical necessity justification. Enter all Item numbers from the table in Section A that pertain to each diagnosis.

If applicable, include height/weight, wound stage/dimensions and functional/mobility status in table below.

Height Weight Wound stage/dimensions Functionality/mobility status

Note: The "Date last seen" and "Duration of need" items below must be filled in!

Date last seen by physician: ____/____/____

Duration of need for DME: ____________ month (s) Duration of need for supplies: ____________ month (s)

By signing this form, I hereby attest that the information completed in Section “A” is consistent with the determination of the client's current medical necessity and prescription. By prescribing the identified DME and/or medical supplies, I certify the prescribed items are appropriate and can safely be used in the client’s home when used as prescribed.

Signature and attestation of prescribing physician: ______________________________________ Date: _____/_____/________Signature stamps and date stamps are not acceptable

Prescribing Physician’s TPI number: _________________________ Prescribing physician’s license number: ________________________

� Check if all of the information in Section A was complete at the time of the prescribing provider signature.

Forms


Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form Instructions

The applicable sections of this form must be completed and signed by the representative of the DME/medical supplies provider and the prescribing physician before DME/medical supplies providers contact TMHP Home Health Services for prior authorization. Either the supplies provider or the physician may initiate the form. This completed form must be retained in the records of both the DME/medical supplies provider and the physician, and is subject to retrospective review. This form becomes a prescription when the physician has signed section B.

In Section A, suppliers indicate HCFA Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code description, appropriate quantities, and retail price if item requires manual pricing. A price is not required for those items with a max fee listed in the Texas Medicaid Fee Schedule.

Example of DME:

Example of supplies:

In Section B physicians will indicate description, quantity or frequency of prescribed supplies, and if equipment should be customized.

Example of DME:

Example of supplies:

Physicians must include the diagnoses and pertinent justification of medical necessity for the supplies/DME. The estimated duration of need should specify the amount of time the supplies/DME will be needed, such as six weeks, three months, lifetime, etc. All appropriate boxes should be checked certifying safety, appropriateness, age, and homebound status of the client.

Exception: Clients age 21 or older needing diabetic supplies and related testing equipment are not required to be homebound.

Physicians must indicate their Texas professional license number. If the prescribing physician is out of state, he or she must provide the license number and state of professional licensure. Texas Medicaid P0 TPIs, ZO group TPIs, and UPIN numbers are not acceptable.

Reminder: Home health services are not a benefit for clients residing in a nursing facility, hospital, or intermediate care facility.

Note for DME: The DME company must also complete the DME Certification & Receipt form. All equipment is to be assembled, installed, and used pursuant to the manufacturer’s instructions and warning.

Code Description Quantity Price

J-E1399 Bathchair 1 $50.00

J-E1220 Customized wheelchair/manual 1 $2500.00

Code Description Quantity Price

9-A4253 Blood glucose test strips, per 50 strips 2 boxes NA

9-A4259 Lancets, per box of 100 1 box NA

9-A4245 Alcohol wipes, per box 1 box NA

Description Quantity Customized

Bathchair 1 no

Manual wheelchair 1 yes

Description Quantity Customized

Diabetic testing tid NA

Forms

A p p e n d i x

N


NTHSteps Dental Guidelines

N.1 American Academy of Pediatric Dentistry Periodicity Guidelines . . . . . . . . . . . . . . . . . . N-2N.2 American Dental Association Guidelines for Prescribing Dental Radiographs. . . . . . . . . N-5

N–2 CPT only copyright 2005 American Medical Association. All rights reserved.

Appendix N

N.1 American Academy of Pediatric Dentistry Periodicity Guidelines

Copyright © American Association of Pediatric Dentistry. Reprinted by permission.

84 American Academy of Pediatric DentistryClinical Guidelines

Guideline on Periodicity of Examination,Preventive Dental Services, Anticipatory Guidance,

and Oral Treatment for ChildrenOriginating Committee

Clinical Affairs Committee

Review CouncilCouncil on Clinical Affairs

Adopted1991

Revised1992, 1996, 2000, 2003

PurposeThe American Academy of Pediatric Dentistry (AAPD) in-tends this guideline to help practitioners make clinicaldecisions concerning preventive oral health care for infants,children, and adolescents. Because each child is unique,these recommendations are designed for the care of childrenwho have no contributory medical conditions and are de-veloping normally. These recommendations will need to bemodified for children with special health care needs or ifdisease or trauma manifests variations from the normal.

MethodsThis guideline is a compilation of pediatric oral health lit-erature and national reports and recommendations, inaddition to related policies and guidelines published in theAAPD Reference Manual.1-24 The related policies and guide-lines provide references for individual recommendations.Some recommendations are evidence-based, while othersrepresent best clinical practice and expert opinion.

BackgroundThe AAPD emphasizes the importance of professional oralhealth intervention very early in childhood. Caries-risk as-sessment11 is an essential element of contemporary clinicalcare for infants, children, and adolescents.Continuity of careis based on the assessed needs of the individual patient. Al-though evidenced-based research supporting the benefits ofan infant dental intervention is limited, there is sufficientevidence that certain groups of children are at greater riskfor development of early childhood caries (ECC) and wouldbenefit from infant oral health care. ECC can be a costly,devastating disease with a lasting detrimental impact on thedentition and systemic health issues.7 The characteristics ofECC and the availability of preventive methods support an-ticipatory guidance as an important strategy in addressingthis significant pediatric health problem. Major benefits ofearly intervention, in addition to assessment of risk status,include analysis of fluoride exposure and feeding practices,as well as oral hygiene counseling. The early dental visitshould be seen as the foundation upon which a lifetime of

preventive education and oral health care can be built. Cli-nicians must consider each infant’s, child’s, and adolescent’sindividual needs and risk indicators to determine the ap-propriate interval and frequency of dental visits.

Recommendations

Birth to 12 months1. Complete the clinical oral examination with appropri-

ate diagnostic tests to assess oral growth anddevelopment, pathology, and/or injuries; provide diag-nosis.

2. Provide oral hygiene counseling for parents, guardians,and caregivers, including the implications of the oralhealth of the caregiver.

3. Remove supragingival and subgingival stains or depos-its as indicated.

4. Assess the child’s systemic and topical fluoride status (in-cluding type of infant formula used, if any, and exposureto fluoridated toothpaste) and provide counseling re-garding fluoride. Prescribe systemic fluoridesupplements, if indicated, following assessment of totalfluoride intake from drinking water, diet, and oral hy-giene products.

5. Assess appropriateness of feeding practices, includingbottle and breast-feeding, and provide counseling as in-dicated.

6. Provide dietary counseling related to oral health.7. Provide age-appropriate injury prevention counseling for

orofacial trauma.8. Provide counseling for nonnutritive oral habits (eg, digit,

pacifiers).9. Provide required treatment and/or appropriate referral

for any oral diseases or injuries.10. Provide anticipatory guidance for parent/guardian/

caregiver.11. Consult with the child’s physician as needed.12. Based on evaluation and history, assess the patient’s risk

for oral disease.13. Determine the interval for periodic re-evaluation.

CPT only copyright 2005 American Medical Association. All rights reserved. N–3

THSteps Dental Guidelines

N

85Reference Manual 2005-2006 Clinical Guidelines

12 to 24 months1. Repeat birth to 12-month procedures every 6 months or

as indicated by individual patient’s risk status/susceptibil-ity to disease.

2. Assess appropriateness of feeding practices, including bottle,breast-feeding, and no-spill training cups, and providecounseling as indicated.

3. Review patient’s fluoride status–including any childcarearrangements, which may impact systemic fluoride intake–and provide parental counseling.

4. Provide topical fluoride treatments every 6 months or asindicated by the individual patient’s needs.

2 to 6 years1. Repeat 12- to 24-month procedures every 6 months or as

indicated by individual patient’s risk status/susceptibility todisease. Provide age-appropriate oral hygiene instructions.

2. Complete a radiographic assessment of pathology and/orabnormal growth and development, as indicated by indi-vidual patient’s needs.

3. Scale and clean the teeth every 6 months or as indicated byindividual patient’s needs.

4. Provide pit and fissure sealants for primary and permanentteeth as indicated by individual patient’s needs.

5. Provide counseling and services (athletic mouthguards) asneeded for orofacial trauma prevention.

6. Provide assessment/treatment or referral of developingmalocclusion as indicated by individual patient’s needs.

7. Provide required treatment and/or appropriate referral forany oral diseases, habits, or injuries as indicated.

8. Assess speech and language development and provide ap-propriate referral as indicated.

6 to 12 years1. Repeat 2- to 6-year procedures every 6 months or as indi-

cated by individual patient’s risk status /susceptibility todisease.

2. Provide substance abuse counseling (eg, smoking, smoke-less tobacco).

3. Provide counseling on intraoral and perioral piercing.

12 years and older1. Repeat 6- to 12-year procedures every 6 months or as in-

dicated by individual patient’s risk status/susceptibility todisease.

2. At an age determined by patient, parent/guardian, andpediatric dentist, refer the patient to a general dentist forcontinuing oral care.

References1. US Preventive Services Task Force. Guide to Clinical

Preventive Services. 2nd ed. Baltimore, Md: Williamsand Wilkins; 1996.

2. Lewis DW, Ismail AI. Periodic health examination,1995 Update: 2. Prevention of dental caries. CanadianTask Force on the Periodic Health Examination. CanMed Assoc J 1995;152:836-846.

3. CDC. Recommendations for using fluoride to preventand control dental caries in the Unites States. MMWR2001;50(RR14):1-42.

4. US Dept of Health and Human Services. Oral Healthin American: A Report of the Surgeon General. Rockville,Md: US Dept of Health and Human Services, NationalInstitute of Dental and Craniofacial Research, NationalInstitutes of Health; 2000.

5. American Academy of Pediatric Dentistry. Policy onthe dental home. Pediatr Dent 2003;25(suppl):12.

6. American Academy of Pediatric Dentistry. Clinical guidelineon infant oral health care. Pediatr Dent 2003; 25(suppl):54.

7. American Academy of Pediatric Dentistry. Policy on earlychildhood caries: Classifications, consequences, and pre-ventive strategies. Pediatr Dent 2003;25(suppl):24-26.

8. American Academy of Pediatric Dentistry. Policy onearly childhood caries: Unique challenges and treat-ment options. Pediatr Dent 2003; 25(suppl):27-28.

9. American Academy of Pediatric Dentistry. Policy ondietary recommendations for infants, children, andadolescents. Pediatr Dent 2003;25(suppl):29.

10. American Academy of Pediatric Dentistry. Clinicalguideline on the role of prophylaxis in pediatric den-tistry. Pediatr Dent 2003;25(suppl):64-66.

11. American Academy of Pediatric Dentistry. Policy on theuse of a caries-risk assessment tool (CAT) for infants, chil-dren, and adolescents. Pediatr Dent 2003;25(suppl):18-20.

12. American Academy of Pediatric Dentistry. Clinical guide-line on fluoride therapy. Pediatr Dent 2003;25(suppl):67-68.

13. American Academy of Pediatric Dentistry. Policy onbreast-feeding. Pediatr Dent 2003;25(suppl):111.

14. American Academy of Pediatric Dentistry. Policy onoral habits. Pediatr Dent 2003; 25(suppl):31.

15. American Academy of Pediatric Dentistry. Clinicalguideline on pediatric restorative dentistry. PediatrDent 2003;25(suppl):84-86.

16. American Academy of Pediatric Dentistry. Clinicalguideline on prescribing dental radiographs. PediatrDent. 2003;25(suppl):112-113.

17. American Academy of Pediatric Dentistry. Policy onprevention of sports-related orofacial injuries. PediatrDent 2003;25(suppl):37.

18. American Academy of Pediatric Dentistry. Clinicalguideline on management of acute dental trauma.Pediatr Dent 2003;25(suppl):92-97.

19. American Academy of Pediatric Dentistry. Clinical guide-line on management of the developing dentition inpediatric dentistry. Pediatr Dent 2003;25(suppl):98-101.

20. American Academy of Pediatric Dentistry. Clinicalguideline on acquired temporomandibular disorders ininfants, children, and adolescents. Pediatr Dent 2003;25(suppl):102-103.

21. American Academy of Pediatric Dentistry. Policy ontobacco use. Pediatr Dent 2003;25(suppl):33-34.

22. American Academy of Pediatric Dentistry. Clinicalguideline on adolescent oral health care. Pediatr Dent2003;25(suppl):55-60.

23. American Academy of Pediatric Dentistry. Policy onintraoral and perioral piercing. Pediatr Dent 2003;25(suppl):35.

24. American Academy of Pediatric Dentistry. Policy onoral and maxillofacial surgery for infants, children, andadolescents. Pediatr Dent 2003;25(suppl):116.


Appendix N

86 American Academy of Pediatric DentistryClinical Guidelines

1. First examination at the eruption of the first tooth and no later than 12months.

2. By clinical examination.3. As per AAPD “Policy on the use of a caries-risk assessment tool (CAT)

for infants, children, and adolescents.”4. Especially for children at high risk for caries and periodontal disease.5. As per American Academy of Pediatrics/American Dental Association

guidelines and the water source.6. Up to at least 16 years.7. Appropriate discussion and counseling should be an integral part of each

visit for care.8. Initially, responsibility of parent; as child develops, jointly with parents;

then, when indicated, only child.

Since each child is unique, these recommendations are designedfor the care of children who have no contributing medical con-ditions and are developing normally. These recommendationswill need to be modified for children with special health careneeds or if disease or trauma manifests variations from normal.

The American Academy of Pediatric Dentistry (AAPD)emphasizes the importance of very early professional interven-tion and the continuity of care based on the individualizedneeds of the child.

9. At every appointment discuss the role of refined carbohydrates, frequencyof snacking.

10. Initially play objects, pacifiers, car seats; then when learning to walk,sports and routine playing.

11. At first discuss the need for additional sucking: digits vs pacifiers; then theneed to wean from the habit before malocclusion or skeletal dysplasia occurs.For school-aged children and adolescent patients, counsel regarding anyexisting habits such as fingernail biting, clenching, or bruxism.

12. As per AAPD “Clinical guideline on prescribing dental radiographs.”13. For caries-susceptible primary molars, permanent molars, premolars, and

anterior teeth with deep pits and/or fissures; placed as soon as possibleafter eruption.

Recommendations for Pediatric Oral Health Care

Age 6–12 months 12–24 months 2–6 years 6–12 years 12 years and older

Clinical oral examination1 • • • • •

Assess oral growth • • • • •and development2

Caries-risk assessment3 • • • • •

Prophylaxis and topical • • • •fluoride treatment4

Fluoride supplementation5,6 • • • • •

Anticipatory guidance7 • • • • •

Oral hygiene Parents/guardians/ Parents/guardians/ Patient/parents/ Patient/parents/ Patientcounseling8 caregivers caregivers guardians/caregivers guardians/caregivers

Dietary counseling9 • • • • •

Injury prevention counseling10 • • • • •

Counseling for • • • • •nonnutritive habits11

Substance abuse counseling • •

Counseling for intraoral/ • •perioral piercing

Radiographic assessment12 • • •

Treatment of dental • • • • •disease/injury

Assessment and treatment • • •of developing malocclusion

Pit and fissure sealants13 • • •

Assessment and/or •removal of third molars

Referral for regular •and periodic dental care



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s

Pos

teri

or b

itew

ing

exam

at 2

4-36

mon

th

inte

rval

s

Not

app

lica

ble

Cop

yrig

ht ©

Am

eric

an D

enta

l Ass

ocia

tion.

Rep

rinte

d by

per

mis

sion


Appendix N

Doc

umen

t cre

ated

: Nov

embe

r 20

04

GU

IDE

LIN

ES

FO

R P

RE

SCR

IBIN

GD

EN

TA

LR

AD

IOG

RA

PH

S,c

ont’

d.P

AT

IEN

TA

GE

AN

D D

EN

TA

LD

EV

EL

OP

ME

NT

AL

ST

AG

E

TY

PE

OF

EN

CO

UN

TE

RC

hild

wit

h P

rim

ary

Den

titi

on(p

rior

to

erup

tion

of

firs

t pe

rman

ent t

ooth

)

Chi

ld w

ith

Tra

nsit

iona

l Den

titi

on(a

fter

eru

ptio

n of

fir

stpe

rman

ent t

ooth

)

Ado

lesc

ent

wit

h P

erm

anen

t D

enti

tion

(pri

or to

eru

ptio

n of

th

ird

mol

ars)

Adu

lt D

enta

te a

nd

Par

tial

ly E

dent

ulou

sA

dult

Ede

ntul

ous

Rec

all

pati

ent*

with

pe

riod

onta

l dis

ease

Cli

nica

l jud

gmen

t as

to th

e ne

ed f

or a

nd ty

pe o

f ra

diog

raph

ic im

ages

for

the

eval

uati

on o

f pe

riod

onta

l di

seas

e. I

mag

ing

may

con

sist

of,

but

is n

ot li

mit

ed to

, sel

ecte

d bi

tew

ing

and/

or p

eria

pica

l im

ages

of

area

s w

here

per

iodo

ntal

dis

ease

(ot

her

than

non

spec

ific

gin

givi

tis)

can

be

iden

tifi

ed c

lini

call

y.

Not

app

licab

le

Pat

ien

t for

mon

itor

ing

of

grow

th a

nd d

evel

opm

ent

Cli

nica

l jud

gmen

t as

to n

eed

for

and

type

of

radi

ogra

phic

imag

es f

or e

valu

atio

n an

d/or

m

onit

orin

g of

den

tofa

cial

gro

wth

and

dev

elop

men

t

Cli

nica

l jud

gmen

t as

to

need

for

and

type

of

radi

ogra

phic

imag

es f

or

eval

uati

on a

nd/o

r m

onit

orin

g of

de

ntof

acia

l gro

wth

and

de

velo

pmen

t.P

anor

amic

or

peri

apic

al

exam

to a

sses

s de

velo

ping

thir

d m

olar

s

Usu

ally

not

indi

cate

d

Pat

ien

t wit

h ot

her

circ

umst

ance

s in

clud

ing,

bu

t not

lim

ited

to,

prop

osed

or

exis

ting

im

plan

ts, p

atho

logy

,re

stor

ativ

e/en

dodo

ntic

need

s, tr

eate

d pe

riod

onta

l di

seas

e an

d ca

ries

re

min

eral

izat

ion

Cli

nica

l jud

gmen

t as

to n

eed

for

and

type

of

radi

ogra

phic

imag

es f

or e

valu

atio

n an

d/or

mon

itor

ing

in th

ese

circ

umst

ance

s.

*Cli

nica

l sit

uati

ons

for

whi

ch r

adio

grap

hs m

ay b

e in

dica

ted

incl

ude

but

are

not

limit

ed t

o:

A.

Pos

itiv

e H

isto

rica

l F

indi

ngs

1.P

revi

ous

peri

odon

tal o

r en

dodo

ntic

trea

tmen

t2.

His

tory

of

pain

or

trau

ma

3.F

amil

ial h

isto

ry o

f de

ntal

ano

mal

ies

4.P

osto

pera

tive

eva

luat

ion

of h

eali

ng



N

Doc

umen

t cre

ated

: Nov

embe

r 20

04

5.R

emin

eral

izat

ion

mon

itor

ing

6.P

rese

nce

of im

plan

ts o

r ev

alua

tion

for

impl

ant p

lace

men

t

B.

Pos

itiv

e C

lini

cal S

igns

/Sym

ptom

s1.

Cli

nica

l evi

denc

e of

per

iodo

ntal

dis

ease

2.L

arge

or

deep

res

tora

tion

s3.

Dee

p ca

riou

s le

sion

s4.

Mal

pose

d or

cli

nica

lly

impa

cted

teet

h5.

Swel

ling

6.E

vide

nce

of d

enta

l/fa

cial

trau

ma

7.M

obil

ity

of te

eth

8.S

inus

trac

t (“f

istu

la”)

9.C

lini

call

y su

spec

ted

sinu

s pa

thol

ogy

10.

Gro

wth

abn

orm

alit

ies

11.

Ora

l inv

olve

men

t in

know

n or

sus

pect

ed s

yste

mic

dis

ease

12.

Pos

itiv

e ne

urol

ogic

fin

ding

s in

the

head

and

nec

k13

.E

vide

nce

of f

orei

gn o

bjec

ts14

.P

ain

and/

or d

ysfu

ncti

on o

f th

e te

mpo

rom

andi

bula

r jo

int

15.

Faci

al a

sym

met

ry16

.A

butm

ent t

eeth

for

fix

ed o

r re

mov

able

par

tial

pro

sthe

sis

17.

Une

xpla

ined

ble

edin

g18

.U

nexp

lain

ed s

ensi

tivi

ty o

f te

eth

19.

Unu

sual

eru

ptio

n, s

paci

ng o

r m

igra

tion

of

teet

h20

.U

nusu

al to

oth

mor

phol

ogy,

cal

cifi

cati

on o

r co

lor

21.

Une

xpla

ined

abs

ence

of

teet

h22

.C

lini

cal e

rosi

on∗∗

Fac

tors

incr

easi

ng r

isk

for

cari

es m

ay in

clud

e bu

t ar

e no

t li

mit

ed t

o:1.

Hig

h le

vel o

f ca

ries

exp

erie

nce

or d

emin

eral

izat

ion

2.H

isto

ry o

f re

curr

ent c

arie

s3.

Hig

h ti

ters

of

cari

ogen

ic b

acte

ria

4.E

xist

ing

rest

orat

ion(

s) o

f po

or q

uali

ty5.

Poo

r or

al h

ygie

ne6.

Inad

equa

te f

luor

ide

expo

sure

7.P

rolo

nged

nur

sing

(bo

ttle

or

brea

st)

8.F

requ

ent h

igh

sucr

ose

cont

ent i

n di

et9.

Poo

r fa

mil

y de

ntal

hea

lth

10.

Dev

elop

men

tal o

r ac

quir

ed e

nam

el d

efec

ts


Appendix N

Doc

umen

t cre

ated

: Nov

embe

r 20

04

11.

Dev

elop

men

tal o

r ac

quir

ed d

isab

ility

12.

Xer

osto

mia

13.

Gen

etic

abn

orm

alit

y of

teet

h14

.M

any

mul

tisu

rfac

e re

stor

atio

ns15

.C

hem

o/ra

diat

ion

ther

apy

16.

Eat

ing

diso

rder

s17

.D

rug/

alco

hol a

buse

18.

Irre

gula

r de

ntal

car

e

12357 - B RIATA TRACE PARKWAY, STE 150AUSTIN, TX 78727

TEXAS MEDICAID & HEALTHCARE PARTNERSHIP

A STATE MEDICAID CONTRACTOR

PLACE POSTAGE HERE

ATTENTION: BUSINESS OFFICE

MARCH/APRIL 2007 NO. 203

Texas MedicaidBimonthly update to the Texas Medicaid Provider Procedures Manual

Look inside for these and other important updates:

Page 4 New Family Planning Services Provided by FQHCs

Page 11 Revised CMS-1500 Claim Form Instructions

Page 12 2007 HCPCS Implementation

Page 21 Quick Tips for PCCM Provider Enrollment

Page 22 SHARS Billing Update

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