1Index

AAbdominal flat plate (AFP) 16-7Abuse and neglect reporting requirements 2-14Accident resources and refunds 5-11Accident-related claims 5-11Accounts receivables 6-5ACD

see Augmentative communication devices (ACDs)Acquired immunodeficiency syndrome (AIDS) 3-3Acronyms and Initialisms Dictionary A-1Acute lymphoblastic leukemia (ALL) 30-128Acute medical episodes 23-8Acute nonlymphoblastic leukemia (ANLL) 30-128Adalimumab 30-83Adaptive feeder seats 17-4

commode chair 17-10Adaptive strollers 17-6

authorization requirements 17-6Add date 3-14Addresses

administrative review requests 4-10, 7-6CLIA applications 24-3CLIA number notification 24-3CSHCN Enrollment 2-8DSHS-CSHCN Provider Relations 1-5information change requests 2-10TMHP Provider Enrollment 2-2TMHP Publications i-iiTMHP-CSHCN Appeals and Adjustments 1-2TMHP-CSHCN Claims 1-2TMHP-CSHCN electronic claims and rejected reports 1-2TMHP-CSHCN Enrollment 1-2TMHP-CSHCN other correspondence 1-3TMHP-CSHCN Prior Authorization and Authorization 1-2TMHP-CSHCN TPR 1-2

Adjustment to claims 6-5Administrative review

authorizations 7-2prior authorizations 7-2

Advanced practice nurse (APN)authorization requirements 8-2benefits and limitations 8-2claims information 8-3electronic claims submission 5-21enrollment 8-2reimbursement 8-3

Advanced practice registered nurse (APRN) 8-1Aerosol treatments 30-6

pentamidine 30-6AFP

see Abdominal flat plate (AFP)

AIDSsee Acquired immunodeficiency syndrome (AIDS)

Air transportation (deceased clients) 35-2authorization requirements 35-2benefits and limitations 35-2

AISsee Automated inquiry system (AIS)

ALLsee Acute lymphoblastic leukemia (ALL)

Allergy servicesbenefits and limitations 30-9

Ambulancebilling for ambulance services 9-7claims information

emergency air ambulance 9-4emergency ground ambulance transportation 9-3nonemergency ground ambulance 9-6

electronic claims submission 5-21emergency air ambulance transportation 9-4

authorization requirements 9-4benefits and limitations 9-4

emergency ground transportation 9-2authorization requirements 9-2benefits and limitations 9-2

enrollment 9-2nonemergency ground transportation 9-5

authorization requirements 9-5benefits and limitations 9-5

origin and destination modifiers 9-7reimbursement 9-8

Ambulation aids 17-6ambulation belts 17-6canes 17-6crutches 17-6gait 17-6gait trainers 17-7prescription shoes 27-6prone/supine standers 17-15

authorization requirements 17-15benefits and limitations 17-15

walkers 17-6Ambulation belts 17-6Ambulatory electroencephalogram (EEG)

diagnosis codes 30-43Ambulatory surgery

authorization requirements 23-12Ambulatory surgical center (ASC)

authorization requirements 23-12benefits and limitations 23-12hospital-based 23-12

authorization requirements 23-12benefits and limitations 23-12electronic claims submission 5-27

CPT only copyright 2009 American Medical Association. All rights reserved. Index–1

Index–2

freestanding surgical centers 23-12reimbursement 23-13

Americans with Disabilities Act 17-19Anesthesia

administered by surgeon 30-106anesthesiology/anesthesiologists 30-9conversion factor 30-13dental 14-41

anesthesia provided in a ASC/HASC 14-33dental (general) 30-12modifiers 30-11monitored care 30-10regional 30-9reimbursement 30-13

time-based fees 30-14services incidental to anesthesia 30-12services incidental to surgery 30-12services not incidental to anesthesia 30-13services not incidental to surgery 30-13

Anesthesiologymedical direction 30-9see Anesthesia

ANLLsee Acute nonlymphoblastic leukemia (ANLL)

Anterior temporal lobectomies 16-6, 30-14authorization requirements 30-14

Antibiotic desensitization 30-9Apnea monitors 33-5Appeals 7-2

120-day 2-4administrative review 4-10, 7-5

address 4-10, 7-6requirements 7-6

AIS appeals 7-4allowed AIS appeals 7-4authorization or prior authorization 7-2claims filed prior to enrollment 2-4clients eligible for Medicaid 3-12disallowed AIS appeals 7-4electronic

advantages of electronic appeal submission 7-3disallowed electronic appeals 7-4electronic submission 7-3rejections 7-4

exceptions to claims filing deadlines 5-6address 5-6

fair hearing 4-10address 4-10

methods for appealing 7-3paper 7-5provider enrollment 7-7submitted incorrectly 7-5telephone appeals 7-4time limits 5-14

ASCsee Ambulatory surgical center (ASC)

Assistant surgeons 30-107Audiology evaluation 19-3Audiometry

procedure codes 19-3Audiometry evaluation 19-3

Audiometry/hearing services 30-14Augmentative communication devices (ACDs)

authorization requirements 10-2modifications 10-4repairs 10-5

benefits and limitations 10-2claims information 10-5electronic claims submission 5-21enrollment criteria 10-2excluded items 10-5modifications 10-4prior authorization requirements

Prior Authorization Request for Augmentative Communication Devices B-13purchases or rental 10-3replacement 10-5

purchases or rentals 10-3reimbursement 10-6repairs 10-4replacement 10-5

Authorization/prior authorization 28-2, 28-3additional medical nutritional services

nutritional assessment, counseling, and products services

Prior Authorization Request for Additional Nutri-tional Assessment, Counseling, and Products B-5

address 1-2advanced practice nurse (APN) 8-2ambulance

emergency air ambulance transportation 9-4emergency ground transportation 9-2nonemergency ground transportation 9-5

ambulatory surgical center (ASC) 23-12anterior temporal lobectomies 30-14appeals 7-2augmentative communication devices (ACDs) 10-2

modifications 10-4purchase and rental 10-3repairs 10-5replacement 10-5

authorization deadline calendar for 2009 7-9authorization deadline calendar for 2010 7-10authorization deadline calendar for 2011 7-11Authorization Request for Extension of Outpatient Therapy (TP2) B-93Authorization Request for Hemophilia Blood Factor Products B-84authorizations 4-3blood pressure devices and supplies 11-2bone growth stimulators 30-16bone-anchored hearing aid (BAHA) 19-10certified registered nurse anesthetist (CRNA) 12-2certified respiratory care practitioner 13-2certified respiratory care practitioner (CRCP) 13-2chemotherapy 30-18cleft/craniofacial surgeries 30-110clinician-directed care coordination services 30-23

Authorization Request for Non-Face-to-Face Clini-cian-Directed Care Coordination Services B-87,

CPT only copyright 2009 American Medical Association. All rights reserved.

B-89cochlear implants 19-13cranial molding orthoses 27-5denials 4-9dental 14-3

diagnostic procedures 14-4orthodontia 14-10preventive services 14-14Prior Authorization Request for Dental or Orth-odontia Services B-19therapeutic services 14-16treatment in ASC/HASC 14-33

diabetic equipment and supplies 15-2diagnostic radiology services 16-2diapers, pull-ups, briefs, or liners B-25diapers, pull-ups, underpads, briefs, or liners 18-5durable medical equipment (DME) 17-5, 17-21, B-30

adaptive strollers 17-6car seats 17-14continuous passive motion device 17-7custom commode chair 17-10enuresis alarms 17-7foot rest 17-11gait trainers 17-7gastrostomy devices 18-11heavy-duty commode chair 17-11hospital beds 17-8hospital cribs and enclosed beds 17-9hygiene equipment 17-10mobile commode chair 17-10Prior Authorization and Authorization Request for Durable Medical Equipment (DME) B-30replacement pail or pan 17-11standers, prone or supine 17-15stationary commode chair 17-10travel chairs 17-15wheelchairs 17-16

dynamic splints 27-4electrodiagnostic (EDX) testing 30-52expendable medical supplies 18-5fair hearing 4-10general information 4-2glucose monitors 15-5hearing services 19-3home health (skilled nursing) 21-2, 21-3home health aid (HHA) visits 20-4home health services 20-2hospice 22-3

Prior Authorization Request for Hospice Services B-39

hospitalinpatient behavioral health 23-7

hospital inpatient/outpatient 23-3hospital, inpatient 23-5

Prior Authorization Request for Inpatient Hospital Admission B-46rehabilitation 23-7

initial inpatient 23-6inpatient admission

after hours 4-8inpatient behavioral health

Prior Authorization Request for Inpatient Psychiat-ric Care B-42

inpatient rehabilitation servicesPrior Authorization Request for Inpatient Rehabili-tation Admission B-51

insulin pumps 15-6limitations 4-2magnetic resonance imaging (MRI) 16-5medical foods 25-3medical nutritional counseling services 20-7, 25-5medical nutritional products 25-6

formulary 25-6medical nutritional services

counseling 25-4medical foods

Prior Authorization Request for Medical Foods B-55

products 25-6neurostimulator devices and supplies 26-2occupational therapy (OT) 20-6Omalizumab 30-97

Authorization Request for Omalizumab B-58oral surgery procedures 30-110orthotic and prosthetic devices 27-2outpatient hospital 23-10outpatient physical therapy and occupational therapy 29-4physical therapy (PT) 20-6physician 30-5, 30-6podiatry 30-101prescription shoes 27-6Prior Authorization Request for Chest Physiotherapy Devices B-17Prior Authorization Request for Inpatient Surgery—For Surgeons Only B-77Prior Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons B-80prior authorizations 4-5radiation therapy services 31-2

stereotactic radiosurgery 31-9reciprocating gait orthoses 27-4reconstructive and cosmetic procedures 30-112reduction mammoplasty 30-113removable shoe insert 27-4renal (kidney) transplants 23-9renal dialysis 32-2, 32-7

Prior Authorization Request for Renal Dialysis Treatment B-68

request for codes pending rate hearing 4-2respiratory equipment 33-5

Prior Authorization Request for Apnea Monitor B-8Prior Authorization Request for Pulse Oximeter Devices B-65Prior Authorization Request for Respiratory Care—CRCP B-70

respiratory equipment and supplies 33-2respiratory syncytial virus

Prior Authorization Request for Palivizumab

CPT only copyright 2009 American Medical Association. All rights reserved. Index–3

Index–4

(Synagis) B-61rhizotomy 30-115services that require authorization 4-3services that require prior authorization 4-5signature requirements 4-2skilled nursing (SN) services 20-5social work services 20-7specialty team/center 30-109, 30-127speech-language pathology (SLP) 20-7speech-language pathology (SLP) services 34-2stem cell transplant 23-10stem cell transplants 30-127submitting a prior authorization request 4-8submitting a request 4-5surgery 30-106

Prior Authorization Request for Inpatient Sur-gery—For Surgeons Only B-77Prior Authorization Request for Outpatient Sur-gery—For Outpatient Facilities and Surgeons B-80

therapeutic apheresis 30-120total parenteral nutrition (TPN) 25-33transportation

deceased client 35-2vision related services 36-2, 36-5, 36-10

Authorizations 4-3see Authorization/prior authorization

Automated inquiry system (AIS) 1-3claim corrections 7-4services provided 1-3User’s Guide 1-3verifying client eligibility 3-9

Azacitidine (Viadaza) 30-83

BBanner messages 37-3Banner pages 6-2Bilateral procedures 30-108Bi-level positive airway pressure (BiPAP) systems 33-2, 33-6Billing clients 2-13BiPAP

see Bi-level positive airway pressure (BiPAP) systemsBlood factor products 23-3, 30-14

inpatient/outpatientbenefits and limitations 23-3

procedure codes 30-15Blood pressure devices and supplies

authorization requirements 11-2benefits and limitations 11-2claims information 11-7diagnosis codes 11-2documentation of receipt 11-7enrollment 11-2reimbursement 11-7

Blue Cross Blue Shield 5-10nonparticipating physicians 5-10

Bone growth stimulators 30-15internal 30-16noninvasive 30-16

ultrasound 30-16prior authorization requirements 30-16

Bone-anchored hearing aid (BAHA) 19-9prior authorization requirements 19-10reimbursement 19-11

Botulinum toxin, types A and B 30-86type A diagnosis codes 30-86type B diagnosis code 30-89

Breast reconstruction 30-114Bus transportation (deceased clients)

authorization requirements 35-2benefits and limitations 35-2

CCalendars

authorization and filing deadline calendar for 2009 7-9authorization and filing deadline calendar for 2010 5-15, 7-10authorization and filing deadline calendar for 2011 5-16, 7-11fair hearing and administrative review 7-12, 7-13, 7-14

Cancer screeningbenefits and limitations 30-24colorectal diagnosis codes 30-24

Canes 17-6CAPD

see Continuous ambulatory peritoneal dialysis (CAPD)Car seats 17-13

prior authorization requirements 17-14Cardiac blood pool imaging 16-3Cardiorespiratory (apnea) monitors 33-5Casting 30-17CBC

see Complete blood count (CBC)CCPD

see Continuous cycling peritoneal dialysis (CCPD)Cerebrovascular accident (CVA) 30-129, 34-5Certificate

independent laboratory waiver 24-3physician-performed microscopy procedure 24-3

Certified registered nurse anesthetist (CRNA)authorization requirements 12-2benefits and limitations 12-2claims information 12-3electronic claims submission 5-21enrollment 12-2reimbursement 12-3

Certified respiratory care practitioner (CRCP)authorization requirements 13-2claims information 13-3electronic claims submission 5-21enrollment criteria 13-2reimbursement 13-3

Certolizumab pegol 30-83CHAMPUS/CHAMPVA 5-7Chemistry tests 24-27Chemotherapy

authorization requirements 30-18benefits and limitations 30-18inpatient/outpatient

benefits and limitations 23-4

CPT only copyright 2009 American Medical Association. All rights reserved.

procedure codes 30-18Child support 2-14Children’s Health Insurance Program of Texas (CHIP)

eligibility 3-11CHIP

see Children’s Health Insurance Program of Texas (CHIP)

Cidofovir 30-83Circumcision 30-109Claim number, explanation 6-3Claim refunds 6-7Claim reissues 6-7Claim status inquiry (CSI) 37-2Claim voids 6-7Claims

accidentsthird-party liability 5-12

processed by the Vendor Drug Program 3-3Claims filing

adjustments 6-5billing 5-41CMS-1450 5-27dates on claims 5-40deadlines 5-4

exceptions 5-5extensions 4-8fiscal agent payment 5-6

dental emergency claims 14-42dental paper billing 14-41electronic claims submission 1-2, 5-40exception requests 5-6exceptions, holiday or weekend 5-5hospital

inpatient claims 5-4interim claims 5-4outpatient claims 5-4

hospital-based ambulatory surgical center (HASC) claims 23-14incomplete information 5-14inpatient claims 23-13laboratory tests 30-99outpatient claims 23-13paper ADA Dental Claim Form 5-37processed by date of service 5-4refunds 5-10span dates 5-40TMHP processing procedures 5-4when a service is a benefit of Medicare 5-4

Claims filing formsInstitutional UB-04 CMS-1450 5-13Professional (CMA-1500) 5-13

Claims filing instructions 5-21CMS-1450 5-27CMS-1500 5-21deadlines 5-4dental 14-41DSHS 5-3modifier requirements 17-21multipage claim forms 5-13

Institutional UB-04 CMS-1450 5-13Professional (CMS-1500 5-13

paper ADA Dental Claim Form 5-37processed by date of service 5-4provider types and selection of claim forms 5-21TMHP 5-3TPR 5-8

Claims in process 6-8Claims information

advanced practice nurse (APN) 8-3ambulance emergency air transportation 9-4ambulance emergency ground transportation 9-3ambulance nonemergency ground transportation 9-6augmentative communication devices (ACDs) 10-5blood pressure devices and supplies 11-7certified registered nurse anesthetist (CRNA) 12-3certified respiratory care practitioner (CRCP) 13-3dental 5-37, 14-41diabetic equipment and supplies 15-7diagnostic radiology services 16-7durable medical equipment (DME) 17-21expendable medical supplies 18-11hearing services 19-13home health (skilled nursing) 21-3home health services 20-8hospice 22-3hospital 23-13laboratory services 24-32medical foods 25-3medical nutritional counseling services 25-5medical nutritional products 25-13neurostimulator devices and supplies 26-9occupational therapy 29-6orthodontics 14-11orthotic and prosthetic devices 27-8outpatient

behavioral health 28-9physical therapy 29-6

physician 30-145group billing procedure 30-145

radiation therapy services 31-10reimbursement

national drug codes (NDC) 5-19renal dialysis 32-8respiratory equipment 33-12speech-language pathology (SLP) services 34-6total parenteral nutrition (TPN) 25-33transportation of remains of deceased clients 35-2vision-related services 36-11

Claims payment summary 6-8claims - paid or denied 6-4claims in process 6-8EOB codes appendix 6-9

Cleft lip/palate 34-4Cleft/craniofacial center team approval requirements 2-7Cleft/craniofacial surgery 14-38

authorization requirements 30-110benefits and limitations 30-109physician 30-109surgical procedures 4-9

CLIAsee Clinical Laboratory Improvement Amendments

CPT only copyright 2009 American Medical Association. All rights reserved. Index–5

Index–6

(CLIA) of 1988Client benefits 3-2

claims processed by the Vendor Drug Program 3-3Medical Transportation Program 3-3program limitations and exclusions 3-4, 3-5services provided outside Texas 3-3

Client eligibility 3-1, 3-7CHIP/CSHCN benefits 3-11financial eligibility criteria 3-7Medicaid/CSHCN benefits 3-12Medically Needy Program (MNP)

claims filing 3-13provider assistance to clients 3-13spend down processing 3-13

renal dialysis 32-2telephone appeals 7-4verifying 3-9

Clients eligible for MedicaidMedically Needy Program (MNP) 3-12

Clinical brachytherapy (radiation therapy)procedure codes 31-3

Clinical brachytherapy (surgery)procedure codes 31-3

Clinical Laboratory Improvement Amendments (CLIA) of 1988 24-3

regulations 24-3requirements 2-6, 24-3

Clinical laboratory servicesoutpatient services 24-32

Clinical nurse specialist (CNS)enrollment 8-2

Clinical pathology services 24-6Clinical treatment

planning 31-4Clinician-directed care coordination services

authorization requirements 30-23benefits and limitations 30-19face-to-face 30-20non-face-to-face 30-20

Clofarabine (Clorar) 30-84CML

see Chronic myelogenous leukemia (CML)CMS-1500

paper claim form example 5-26paper claim form instructions 5-22

Cochlear implantpostsurgery rehabilitation

authorization requirements 34-5Cochlear implants 19-11, 23-4

authorization requirements 19-13benefits and limitations 30-24, 34-5sound processor replacement 19-13

Codescoding 5-17

diagnosis coding 5-17procedure coding 5-17

CPT 5-17HCPCS 5-18ICD-9-CM 5-17

Colorectal cancer screening 30-24Commode chair

heavy dutyauthorization requirements 17-11

level 1 stationaryprior authorization requirements 17-10

level 2 mobileprior authorization requirements 17-10

level 3 customprior authorization requirements 17-10

replacement pail or panauthorization requirements 17-11

seat lift mechanism 17-12with integrated seat lifts 17-11

Complaints 2-9Complete blood count (CBC) 24-28, 30-98Computed tomography (CT) scan 16-3Cone-beam imaging 14-6Confidential information

release of 2-11Consultations 30-56Contact information

CSHCN regional offices 1-5CSHCN telephone and fax communication 1-2TMHP Contact Center 1-3TMHP-CSHCN regional representatives 1-3TMHP-CSHCN Services Program Contact Center i-iii

Continuous ambulatory peritoneal dialysis (CAPD) 32-2, 32-4, 32-5, 32-6Continuous cycling peritoneal dialysis (CCPD) 32-2, 32-3, 32-5, 32-6Continuous positive airway pressure (CPAP) systems 33-2, 33-6Controlled dose inhalation drug delivery system 33-7Corrections and resubmissions (appeals)

time limits 5-14Cosurgery 30-107Cough stimulating devices 33-7Counseling 28-6CPAP

see Continuous positive airway pressure (CPAP) systems

CPT codessee Codes

Cranial molding orthoses 27-5Craniofacial anomaly 34-4CRCP

see Certified respiratory care practitioner (CRCP)Critical care 30-25, 30-28

intensive (noncritical) low birth weight services 30-29newborn resuscitation critical care services 30-30pediatric services 30-27

CRNAsee Certified registered nurse anesthetist (CRNA)

Crutches 17-6CSHCN

central and regional offices 1-5Eligibility Form 3-8program history i-iProvider Manual i-iregional offices

Region 1 1-6

CPT only copyright 2009 American Medical Association. All rights reserved.

Region 11 1-16Region 2 1-6Region 3 1-7Region 4 1-8Region 5 North 1-9Region 5 South and 6 1-11Region 7 1-12Region 8 1-14Region 9 and 10 1-15

CSIsee Claim status inquiry (CSI)

CTsee Computed tomography (CT) scan

Custom DMEcar seats 17-13travel restraints 17-14

see Durable medical equipment (DME)CVA

see Cerebrovascular accident (CVA)Cytogenetics testing for leukemia and lymphoma 24-7Cytopathology

sites other than vaginal, cervical, and uterine 24-22studies 30-99vaginal, cervical, and uterine sites 24-22

DDalteparin sodium 30-84Darbepoietin 30-89

diagnosis codes 30-89, 30-92Dates on claims 5-40Day surgery

inpatient stays 23-14Denials

authorization/prior authorization 4-9verbal 5-8, 5-9

Denileukin diftitox 30-84Dental

adjunctive general servicesprocedure codes 14-29

anesthesia (general) 30-12anesthesia provided in an ASC/HASC 14-33

Criteria for Dental Therapy Under General Anesthesia B-101

anesthesia provided in an office settingprocedure codes 14-31

benefits and limitations 14-3claims filing information 5-37, 14-41

electronic billing 14-41emergency claims 14-42instructions 14-41paper billing 14-41

cone-beam imaging 14-6dental treatment in ASC/HASC

anesthesiadental rehabilitation or restoration services 14-33

diagnostic proceduresclinical oral evaluation 14-5first dental home 14-6prior authorization requirements 14-4

radiographs or diagnostic imaging 14-7tests and oral pathology procedures 14-8

diagnostic services 14-4doctor of dentistry services as a limited physician 14-34

anesthesia 14-41cleft/craniofacial surgery 14-38evaluation and management 14-40laboratory 14-40radiology 14-40surgery

surgical procedure codes 14-34enrollment 14-3implants

procedure codes 14-26maxillofacial prosthetics

procedure codes 14-25noncovered counseling services

dental nutrition counseling 14-15tobacco counseling 14-15

oral and maxillofacial surgeryprocedure codes 14-28

orthodontia services 14-9local codes 14-11prior authorization requirements 14-10

Prior Authorization Request for Dental or Orth-odontia Services B-22

required documentation 14-10periodontic services

procedure codes 14-22preventive services

authorization requirements 14-14benefits and limitations 14-14dental prophylaxis and topical fluoride treatment 14-15noncovered counseling services 14-15oral hygiene instruction 14-14sealants 14-15space maintainers 14-15

prior authorization requirements 14-3prophylaxis and topical fluoride treatment

procedure codes 14-15prosthetic services, fixed

procedure codes 14-27prosthodontic services, fixed

procedure codes 14-27prosthodontics (removable) and maxillofacial prosthetics

procedure codes 14-24reimbursement 14-43

tooth identification and surface identification systems 14-42

restorationsprocedure codes 14-17

root canalsprocedure codes 14-21

screening 30-60supernumerary tooth identification 14-43therapeutic services 14-16

adjunctive general services 14-29

CPT only copyright 2009 American Medical Association. All rights reserved. Index–7

Index–8

anesthesia 14-30authorization requirements

interrupted treatment plan 14-16dental behavior management 14-31endodontics 14-19

pulp caps 14-19root canals 14-20

implants 14-26internal bleaching of tooth 14-32maxillofacial prosthetics 14-25oral and maxillofacial surgery 14-28periodontics 14-22prior authorization requirements 14-16prosthodontics (removable) and maxillofacial prosthetics 14-23prosthodontics, fixed 14-26restorations 14-16

treatment in ASC/HASC 14-32authorization requirements 14-33

treatment in hospitals 14-32Diabetic equipment and supplies

authorization requirements 15-2benefits and limitations 15-2claims information 15-7enrollment 15-2glucose monitors 15-2insulin pumps 15-6reimbursement 15-7

Diabetic supplies and equipmentdocumentation of receipt 15-7

Diagnosis codesallogenic transplants 30-128ambulatory electroencephalogram (EEG) 30-43autologous transplants 30-128blood pressure devices and supplies 11-2botulinum toxin type A 30-86botulinum toxin type B 30-89cancer screening, colorectal 30-24clubfoot casting 30-17darbepoietin 30-89, 30-92dorsal column neurostimulation (DCN) 26-3electroencephalogram (EEG) (ambulatory) 30-43electromyography (EMG) 30-44erythropoietin alfa (EPO) 30-89, 30-92extracorporeal shock wave lithotripsy 30-61gamma globulin 30-94glucose monitors 15-2growth hormone 30-93high frequency chest wall compression system (HFCWCS) 33-8intracranial neurostimulation (ICN) 26-3intraoperative echography 30-31multiple latency test 30-105orthodontia 14-9pediatric pneumogram 30-105polysomnography 30-103positron emission tomography 16-6renal dialysis 32-3rhizotomy 30-115septoplasty 30-115

stem cell transplants 30-129Strontium 89 31-10therapeutic apheresis 30-120total parenteral nutrition (TPN) 25-14vision examinations 36-7, 36-8vision related services 36-4

Diagnosis coding 5-17Diagnostic dental procedures

clinical oral evaluation 14-5first dental home 14-6prior authorization requirements 14-4radiographs or diagnostic imaging 14-7tests and oral pathology procedures 14-8

Diagnostic dental services 14-4Diagnostic radiology services

authorization requirements 16-2benefits and limitations 16-2cardiac blood pool imaging 16-3claims filing 16-7computed tomography (CT) scan 16-3contrast material 16-3enrollment 16-2hospital 16-8magnetic resonance angiography (MRA) 16-4magnetic resonance imaging (MRI) 16-4mammography certification 16-6noncovered 16-7positron emission tomography (PET) 16-6provided by hospitals 16-2provided by physician or at physician offices or clinics

abdominal flat plates 16-7provided by physician, APRN, physician groups, and clinics 16-2reimbursement 16-8

radiologistprovided by or at an ASC/HSCS 16-8

X-rays and ultrasounds 16-7Diapers

Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners B-25

Diapers, briefs, pull-ups, or liners 18-5Direct supervision 30-5DME

see Durable medical equipment (DME)DO

see Doctor of osteopathyDoctor of dentistry services as a limited physician 14-34

anesthesia 14-41cleft/craniofacial surgery 14-38

procedure codes 14-38evaluation and management 14-40laboratory procedures 14-40radiology procedures 14-40

Doctor of osteopathy 8-2Documentation of receipt

blood pressure devices and supplies 11-7diabetic supplies and equipment 15-7orthotic and prosthetic devices 27-7

Documentation requirements 2-10

CPT only copyright 2009 American Medical Association. All rights reserved.

medical records 30-145Dorsal column neurostimulation (DCN) 26-2

diagnosis codes 26-3procedure codes 26-3

DSHS Health Region map 1-18Durable medical equipment (DME)

adaptive feeder seats 17-4commode chair 17-10

adaptive strollers 17-6authorization requirements 17-6

ambulation aids 17-6ambulation belts 17-6authorization 17-21

Prior Authorization and Authorization Request for Durable Medical Equipment (DME) B-30

authorization requirements 17-5benefits and limitations 17-5canes 17-6car seats

prior authorization requirements 17-14car seats and travel restraints 17-13claims filing 5-21claims information 17-21cochlear implant

authorization requirements 34-5cochlear implants 34-5commode chair

prior authorization requirements 17-10seat lift mechanism 17-12with integrated seat lifts 17-11

continuous passive motion deviceauthorization requirements 17-7

crutches 17-6custom commode chair

authorization requirements 17-10custom DME 17-4documentation of receipt 17-20Documentation of Receipt form B-104Documentation of Receipt form (Spanish) B-105enrollment 17-3

custom DME 17-3Enuresis alarms

prior authorization requirements 17-7foot rest

authorization requirements 17-11gait 17-6gait trainers 17-7

authorization requirements 17-7gastrostomy devices 18-11

authorization requirements 18-11nonobturated 18-11obturated 18-11

heavy-duty commode chairauthorization requirements 17-11

hospital bedsauthorization requirements 17-8

hospital beds (manual and electric) 17-8hospital cribs and enclosed beds 17-9

prior authorization requirements 17-9hygiene equipment 17-9

authorization requirements 17-10infusion pumps 17-12mobile commode chair

authorization requirements 17-10modifier requirements 17-21noncovered rehabilitative and therapeutic DME 17-19portable hydrocollator units 17-12portable paraffin units 17-12portable wheelchair ramps 17-19pressure reducing pads 17-8program overview and guidelines 17-4, 17-5prone/supine standers 17-15

authorization requirements 17-15reimbursement 17-21rental 17-20repairs and modifications 17-20replacement pail or pan

authorization requirements 17-11respiratory equipment

enrollment 33-2standard DME 17-4standard wheelchairs 17-4standers, prone and supine 17-15

authorization requirements 17-15TENS units 17-15transfer boards 17-15travel chairs 17-15

prior authorization requirements 17-15walkers 17-6wheelchair

battery 17-18power elevating leg lifts 17-18power seat elevation system 17-18

wheelchairs 17-16authorization requirements 17-16custom manual wheelchairs 17-17manual wheelchairs 17-16positioning equipment 17-18power wheelchairs 17-17

approval criteria 17-17ramps 17-19Wheelchair Seating Evaluation Form B-121

Dynamic splints 27-4Dysphagia (swallowing disorder) 34-4

EE/M

see Evaluation and management (E/M) servicesECG

see Electrocardiogram (ECG)Echoencephalography 30-31EDI

see Electronic Data Interchange (EDI)EEG

see Electoencephalogram (EEG)EFT

see Electronic funds transfer (EFT)Electrocardiogram (ECG) 3-6Electrodiagnostic (EDX) testing 30-44

CPT only copyright 2009 American Medical Association. All rights reserved. Index–9

Index–1

authorization requirements 30-52benefits and limitations 30-52inpatient/outpatient

benefits and limitations 23-4Electroencephalogram (EEG) (ambulatory) 30-43

benefits and limitations 30-43diagnosis codes 30-43procedure codes 30-44

Electromyography (EMG) 30-44diagnosis codes 30-44procedure codes 30-44, 30-52

Electronic analysis for implantable neurostimulatorsprocedure codes 26-7

Electronic claim submission 5-40Electronic Data Interchange (EDI)

electronic submittersautomated maintenance process 37-5

electronic transmission reports 37-5forms 37-7gaining access 37-5getting help 37-2overview 37-2services available 37-2submitting claims 37-4supported file types 37-6TexMedConnect 37-4third-party billing agents 37-5third-party vendor implementation 37-6TMHP website 37-3training 37-5vendor software 37-4

Electronic funds transfer (EFT) 5-41, 5-42, 6-7advantages 5-41enrollment procedures 5-42

Electronic Remittance and Status (ER&S) reportElectronic Remittance and Status (ER&S) Agreement B-130

Electronic Remittance and Status (ER&S) reportsgeneral information 6-2

Electronic transmission reports 37-5Eligibility Form sample 3-10Eligibility verification (EV)

client 3-7Medicaid 3-12

Embalmingauthorization requirements 35-2benefits and limitations 35-2

Emergency air ambulance transportation 9-4Emergency ground ambulance transportation 9-2Emergency Medical Transportation and Labor Act (EMTALA)Emergency services

benefits and limitations 30-55defined 9-2, 9-4emergency room 30-55hospital emergency room 30-146hospital-based emergency department 23-10observation room 30-57prolonged physician services 30-56

EMGsee Electromyography (EMG)

EMTALAsee Emergency Medical Transportation and Labor Act

Enoxaparin sodium 30-84Enrollment

advanced practice nurse (APN) 8-2ambulance 9-2augmentative communication devices (ACDs) 10-2blood pressure devices and supplies 11-2certified registered nurse anesthetist (CRNA) 12-2certified respiratory care practitioner (CRCP) 13-2dental/orthodontia 14-3diabetic equipment and supplies 15-2diagnostic radiology services 16-2durable medical equipment (DME) 17-3, 33-2

custom DME 17-3electronic funds transfer (EFT) 5-42expendable medical supplies 18-2family support services 2-8hearing services 19-2home health (skilled nursing) 21-2home health services 20-2hospice 22-2hospital 23-2laboratory services 24-2medical foods 25-2medical nutritional services 25-2

counseling 25-4neurostimulator devices and supplies 26-2occupational therapy 29-2orthotic and prosthetic devices 27-2outpatient behavioral health 28-2outpatient physical therapy 29-2physician 30-4

independent practices 30-4specialty team/center 30-109substitute 30-5

radiation therapy 31-2renal dialysis 32-2respiratory equipment 33-2specialty team/center 23-3speech-language pathology (SLP) services 34-2substitute physician 2-8TMHP-CSHCN address 1-2total parenteral nutrition (TPN) 25-13vision related services 36-2

Enuresis alarmsprior authorization requirements 17-7

EOB see Explanation of benefits see Explanation of benefits (EOB)

EOPSsee also Explanation of pending status (EOPS) 6-2, 6-4see Explanation of pending status (EOPS)

Epirubicin hydrochloride 30-84EPO

see Erthropoietin Alfa (EPO)Epoprostenol 30-84ER&S

see Electronic Remittance and Status (ER&S) ReportErythropoietin alfa (EPO) 30-89

0 CPT only copyright 2009 American Medical Association. All rights reserved.

diagnosis codes 30-89, 30-92ESWL

see Extracorporeal shock wave lithotripsy (ESWL)EV

see Eligibility verification (EV)Evaluation and management (E/M) services

benefits and limitations 30-53consultations 30-56emergency services 30-55initial and subsequent hospital care 30-54inpatient professional services 30-54new or established patient visits 30-53observation room services 30-57office and outpatient services 30-53prolonged physician services 30-56

Excluded orthoses 27-5Expendable medical supplies

authorization requirements 18-5benefits and limitations 18-2claims information 18-11diapers, pull-ups, and liners 18-5enrollment 18-2examples of covered supplies 18-4gastrostomy devices 18-11reimbursement 18-12

Explanation of benefits (EOB) 3-12, 5-7codes appendix 6-9

Explanation of pending status (EOPS) 6-9, 7-4Extracorporeal shock wave lithotripsy (ESWL) 30-61Eye prostheses 27-7

FFair hearing 4-10Fair hearing requests

authorizations 7-2prior authorizations 7-2

Family support services 2-8Fees

global 30-108lab handling 24-31

Ferritin and iron studies 24-29Filing deadlines 5-4

120-day 5-1490-day 3-1495-day 5-4calendars 5-15, 5-16, 7-9, 7-10, 7-11exceptions 5-6fair hearing and administrative review calendars 7-12, 7-13, 7-14third-party resources 5-9

Financial transactions 6-5void and stop 6-7

Fiscal agent payment deadline 5-6Fluocinolone acetonide intravitreal implant (Retisert)

inpatient/outpatientbenefits and limitations 23-4

Fondaparinux sodium 30-84Foot rest

authorization requirements 17-11Form instructions

Authorization and Prior Authorization Request B-98

Authorization Request for Extension of Outpatient Therapy (TP2) B-91Authorization Request for Hemophilia Blood Factor Products B-82Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services B-85Authorization Request for Outpatient Therapy (TP1), Initial B-95Home Health (Skilled Nursing) Referral and Treatment Plan B-106Instructions for Completing the Provider Information Change Form B-132Physician/Dentist Assessment Form (PAF) Instructions B-110Physician/Dentist Assessment Form (PAF) Instructions (Spanish) B-111Prior Authorization Request for Additional Nutritional Assessment, Counseling, and Products B-3Prior Authorization Request for Apnea Monitor Rental B-6Prior Authorization Request for Augmentative Communication Devices (ACDs) B-10Prior Authorization Request for Chest Physiotherapy Devices B-15Prior Authorization Request for Dental or Orthodontia Services B-19Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners B-23Prior Authorization Request for Durable Medical Equipment (DME) B-26Prior Authorization Request for External Insulin Pump B-35Prior Authorization Request for Hospice Services B-37Prior Authorization Request for Inpatient Hospital Admission B-43Prior Authorization Request for Inpatient Psychiatric Care B-40Prior Authorization Request for Inpatient Rehabilitation Admission B-48Prior Authorization Request for Inpatient Surgery—For Surgeons Only B-75, 1-1Prior Authorization Request for Medical Foods B-53Prior Authorization Request for Omalizumab B-56Prior Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons B-78Prior Authorization Request for Palivizumab (Synagis) B-58, B-59Prior Authorization Request for Pulse Oximeter Devices B-63Prior Authorization Request for Renal Dialysis Treatment B-66Prior Authorization Request for Respiratory Care—CRCP B-69Prior Authorization Request for Stem Cell or Renal Transplant B-71Wheelchair Seating Evaluation Form B-117

FormsAuthorization and Prior Authorization Request B-100Authorization Request for Apnea Monitor Rental B-8Authorization Request for Extension of Outpatient

CPT only copyright 2009 American Medical Association. All rights reserved. Index–11

Index–1

Therapy (TP2) B-93Authorization Request for Hemophilia Blood Factor Products B-84Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services B-87

Specialist or Subspecialist Telephone Consulta-tion Form B-89

Authorization Request for Omalizumab B-58Authorization Request for Outpatient Therapy (TP1), Initial B-97Claim Status Inquiry (CSI) Authorization B-127Criteria for Dental Therapy Under General Anesthesia B-101Criteria for Dental Therapy Under General Anesthesia, Attachment 1 B-103Department of State Health Services Form to Release CSHCN Services Program Claims History B-136Department of State Health Services Form to Release CSHCN Services Program Claims History (Spanish) B-137Documentation of Receipt B-104Documentation of Receipt (Spanish) B-105Electronic Funds Transfer (EFT) Notification B-128Electronic Remittance and Status (ER&S) Agreement B-130Home Health (Skilled Nursing) Referral and Treatment Plan B-108Physician/Dentist Assessment Form (PAF) B-112Prior Authorization and Authorization Request for Durable Medical Equipment (DME) B-30Prior Authorization Request for Additional Nutritional Assessment, Counseling, and Products B-5Prior Authorization Request for Augmentative Communication Devices B-10Prior Authorization Request for Augmentative Communication Devices (ACDs) B-13Prior Authorization Request for Chest Physiotherapy Devices B-17Prior Authorization Request for Dental or Orthodontia Services B-19Prior Authorization Request for Diapers, Pull-ups, Underpads, Briefs, or Liners B-25Prior Authorization Request for External Insulin Pump B-36Prior Authorization Request for Hospice Services B-39Prior Authorization Request for Inpatient Hospital Admission B-46Prior Authorization Request for Inpatient Psychiatric Care B-42Prior Authorization Request for Inpatient Rehabilitation Admission B-51Prior Authorization Request for Medical Foods B-55Prior Authorization Request for Outpatient Surgery—For Outpatient Facilities and Surgeons B-80Prior Authorization Request for Palivizumab (Synagis) B-61Prior Authorization Request for Pulse Oximeter Devices B-65Prior Authorization Request for Renal Dialysis

Treatment B-68Prior Authorization Request for Respiratory Care—CRCP B-70Prior Authorization Request for Stem Cell or Renal Transplant B-73Provider Information Change Form B-133Refund Information Form B-134Reimbursement Request for Transportation of the Remains of Deceased Clients B-114Tort Response Form B-135Vision Care Eyeglass Client Certification Form B-115Vision Care Eyeglass Client Certification Form (Spanish) B-116Wheelchair Seating Evaluation Form B-121

Formula 25-6Freestanding ambulatory surgical centers

electronic claims submission 5-21

GGait 17-6Gait trainers 17-7

authorization requirements 17-7Gamma globulin

diagnosis codes 30-94Gastrostomy devices 18-11

authorization requirements 18-11benefits and limitations 30-61electronic claims submission 5-21

Genetic services 30-61electronic claims submission 5-21

Global fees 30-108anesthesiologists 30-108surgeons 30-108

Glucose monitors 15-2diagnosis codes 15-2prior authorization requirements 15-5

Granisetron hydrochloride 30-84Group

billing procedure 30-145practices 30-4practices enrollment 30-4

Growth hormone 30-93Gynecological

cytopathology studies 30-99Pap smears 30-99

HHASC

see Hospital-based ambulatory surgical center (HASC)HBOT

see Hyperbaric oxygen therapy (HBOT)HCPCS

see Healthcare common procedure coding system (HCPCS)

Health Insurance Portability and Accountability Act (HIPAA) 2-11, 5-17, 7-3, 14-12, 37-2Health maintenance organization (HMO) 5-7Healthcare common procedure coding system (HCPCS)

Level I codes 5-17Level II codes 5-18modifiers 5-20

2 CPT only copyright 2009 American Medical Association. All rights reserved.

place of service coding 5-20Hearing aid

accessories 19-6binaural procedure codes 19-6devices 19-5devices and accessories 19-5modifications 19-7monaural procedure codes 19-6repairs 19-7supplies 19-6warranty 19-7

Hearing aidsprocessed by Program for Amplification for Children of Texas (PACT) 3-3

Hearing servicesaudiology evaluation 19-3audiometry evaluation 19-3authorization requirements 19-3benefits and limitations 19-3claims information 19-13enrollment 19-2fitting and dispensing 19-7

required documentation 19-8reimbursement 19-13see Audiometry

Helicobacter pylori (H. pylori) 24-23physician 30-100

HFCWCSsee High frequency chest wall compression systems (HFCWCS)

HHAsee Home health aid (HHA) visits

High frequency chest wall compression systems (HFCWCS) 33-2, 33-3, 33-8Hip orthoses (HO) 27-3HIPAA

see Health Insurance Portability and Accountability Act (HIPAA)

Hip-knee-ankle-foot orthoses (HKAFO) 27-3HIV

see Human immunodeficiency virus (HIV)HKAFO

see Hip-knee-ankle-foot orthoses (HKAFO)HLA

see Human leukocyte antigen (HLA)HO

see Hip orthoses (HO)Home health (skilled nursing)

authorization requirements 21-2, 21-3Home Health (Skilled Nursing) Referral and Treat-ment Plan B-108

benefits and limitations 21-2claims filing 5-27claims information 21-3enrollment 21-2reimbursement 21-3

Home health aid (HHA)supervision 20-3

Home health aid (HHA) visits 20-3medical nutritional counseling 20-7occupational therapy (OT) 20-5

limitations 20-5physical therapy (PT) 20-5

limitations 20-5prior authorization requirements 20-4skilled nursing (SN) services 20-4

limitations 20-4social work services 20-7speech-language pathology (SLP) 20-6

Home health services 20-1authorization requirements 20-2benefits and limitations 20-2claims information 20-8enrollment 20-2prior authorization requirements 20-2reimbursement 20-8

Hospiceauthorization requirements 22-2benefits and limitations 22-2claims filing 5-27enrollment 22-2prior authorization requirements 22-3

Prior Authorization Request for Hospice Services B-39

reimbursement 22-4Hospital

ambulatory surgical center (ASC) 23-12authorization requirements 23-12benefits and limitations 23-12freestanding surgical center 23-12

authorization requirementsinpatient 23-5outpatient 23-10

beds (manual and electric) 17-8billing 5-41blood factor products 23-3change of ownership 23-2chemotherapy 23-4claims information 23-13cribs and enclosed beds 17-9

prior authorization requirements 17-9dental treatment in hospital/ambulatory surgical centers

authorization requirements 14-33dental treatment in hospital/ambulatory surgical centers (HASCs) 14-32diagnostic radiology services 16-8eligibility 23-2emergency inpatient hospital admissions 23-6enrollment 23-2initial inpatient prior authorization requests 23-6inpatient

claims filing 5-27hospital extensions 23-6rehabilitation services 23-7renal (kidney) transplants 23-8stem cell transplants 23-9

inpatient behavioral health 23-6authorization requirements 23-7

Prior Authorization Request for Inpatient Psychi-atric Care B-42

CPT only copyright 2009 American Medical Association. All rights reserved. Index–13

Index–1

benefits and limitations 23-6inpatient rehabilitation

authorization requirements 23-7benefits and limitations 23-7

inpatient services 23-5authorization requirements 23-5benefits and limitations 23-5

inpatient/outpatientauthorization requirements 23-3benefits and limitaitons 23-3

laboratory services 23-5, 24-5magnetic resonance angiography (MRA) 16-4magnetic resonance imaging (MRI) 16-4outpatient behavioral health services 23-10outpatient services 23-10

authorization requirements 23-10benefits and limitations 23-10claims filing 5-27hospital-based emergency services 23-10observation 23-11

positron emission tomography (PET) 16-6radiation treatment delivery/port films 31-8rehabilitation services

Prior Authorization Request for Inpatient Rehabili-tation Admission B-51

reimbursementhospital-based emergency services 23-12inpatient services 23-10outpatient services 23-12

renal (kidney) transplants 23-8specialty team/center 23-3stem cell transplants 23-9, B-71Strontium-89 31-10Technetium TC 99M 31-10

Hospital bedsauthorization requirements 17-8

Hospital-based ambulatory surgical center (HASC)claims filing 23-14

Hospital-based emergency department professional services 30-55Human immunodeficiency virus (HIV) 3-3, 30-6, 30-94Human leukocyte antigen (HLA) 23-9, 30-128, 30-129Hygiene equipment 17-9

authorization requirements 17-10Hyperbaric oxygen therapy (HBOT)

benefits and limitations 30-62

IIbutilide fumarate 30-84ICN

see Internal control number (ICN)Immune globulin 30-93Immunizations

assessment 30-76benefits and limitations 30-76reporting 30-76Texas Vaccines for Children (TVFC) Program 30-76vaccine information statement (VIS) 30-76

Incomplete claims 6-4appeal deadlines 5-14

Independent laboratory 24-1electronic claims submission 5-21physician-performed microscopy procedure certificates 24-4reimbursement 24-32services 24-1waiver certificate 24-3

Independent practices 30-4Infliximab 30-84Information change requests 2-10Infusion pumps 17-12Inhalation therapy

see Aerosol treatmentsInitial and subsequent hospital care

benefits and limitations 30-54Initial inpatient prior authorization requests 23-6Injectable medications

adalimumab 30-83azacitidine (Viadaza) 30-83benefits and limitations 30-82botulinum toxin 30-86certolizumab pegol 30-83cidofovir 30-83clofarabine (Clorar) 30-84dalteparin sodium 30-84darbepoietin 30-89denileukin diftitox 30-84enoxaparin sodium 30-84epirubicin hydrochloride 30-84epoprostenol 30-84erythropoietin alfa (EPO) 30-89fondaparinux sodium 30-84granisetron hydrochloride 30-84growth hormone 30-93ibutilide fumarate 30-84immune globulin 30-93immunizations 30-76infliximab 30-84leuprolide acetate 30-97lioresal 30-84natalizumab 30-84porfimer sodium 30-84reclast 30-84rituximab 30-84sumatriptan succinate 30-84topotecan HCL 30-85trastuzumab 30-85valrubicin 30-85

Injection administrationbenefits and limitations 30-82

Injections 30-82billed by physician 30-82modifiers 30-82procedure codes 30-83

Inpatientclaims filing 23-13hospital extensions 23-6professional services 30-54

benefits and limitations 30-54critical care 30-25emergency services 30-55

4 CPT only copyright 2009 American Medical Association. All rights reserved.

hospital-based emergency department 30-55initial and subsequent hospital care (nonintensive) 30-54observation room services 30-57

rehabilitation services 23-7Inpatient behavioral health 23-6

authorization requirements 23-7benefits and limitations 23-6

Inpatient hospital services 23-5Inpatient rehabilitation

authorization requirements 23-7benefits and limitations 23-7

Inpatient staysscheduled day surgery 23-14

Inpatient/outpatientbenefits and limitations

blood factor products 23-3chemotherapy 23-4electrodiagnostic (EDX) testing 23-4fluocinolone acetonide intravitreal implant (Retisert) 23-4

Inpatient/outpatient benefits and limitationslaboratory services 23-5

Insulin Pumpsprior authorization requirements 15-6

Insulin pumps 15-6Insurance Premium Payment Assistance Program (IPPA) 3-2Intensity modulated radiation therapy (IMRT) 31-4Intermittent peritoneal dialysis (IPD) 32-2Intermittent positive pressure breathing (IPPB) 3-6Internal control number (ICN) 6-2Intracranial neurostimulation (ICN) 26-3

diagnosis codes 26-3procedure codes 26-4

Intracranial pressure monitoring 30-98Intraocular lenses (IOL) 30-100Intraoperative echography 30-31

diagnosis codes 30-31IOL

see Intraocular lenses (IOL)IPD

see Intermittent peritoneal dialysis (IPD)IPPA

see Insurance Premium Payment Assistance Program (IPPA)

IPPBsee Intermittent positive pressure breathing (IPPB)

IRS levies 6-6

JJuvenile rheumatoid arthritis (JRA) 29-3, 29-4, 29-5

KKidneys, ureters, and bladder (KUB) 16-7Knee orthoses (KO) 27-3Knee-ankle-foot orthoses (KAFO) 27-3

LLaboratory panel tests

complete blood count (CBC) 24-28

organ or disease 24-27panel tests 24-27

Laboratory servicesauthorization requirements 24-4benefits and limitations 24-4, 30-98chemistry tests 24-27claims filing for lab tests 30-99claims information 24-32CLIA 24-3clinical pathology 30-99cytogenetics testing for leukemia and lymphoma 24-7cytopathology of sites other than vaginal, cervical, and uterine 24-22cytopathology of vaginal, cervical, and uterine sites 24-22cytopathology studies 30-99enrollment 24-2ferritin and iron studies 24-29handling fee 30-98handling fees 24-31Helicobacter pylori (H. pylori) 24-23hospital

reimbursement 23-5hospital laboratory services 24-5independent laboratory 24-5inpatient/outpatient benefits and limitations 23-5organ or disease panels 24-27other procedures 24-6panel tests 24-27pathology consultation 30-99physician 30-98physician-owned laboratory services 24-5, 24-6receiving labs 24-31reimbursement 24-32, 30-99urinalysis 24-30

Laboratory testsclaims filing 30-99

Land transportation (deceased clients)authorization requirements 35-2benefits and limitations 35-2

LBWsee Low birth weight (LBW)

LDLsee Low density lipoprotein (LDL)

Leuprolide acetate 30-97Limitations 20-4, 20-5Limitations and exclusions 3-4, 3-5Lioresal 30-84Low birth weight (LBW) 30-25Low density lipoprotein (LDL) 30-125

MMagnetic resonance angiography (MRA) 16-4

abdomen 16-4chest 16-4head and/or neck 16-4lower extremities 16-4pelvis 16-4

Magnetic resonance imaging (MRI) 16-4authorization requirements 16-5

CPT only copyright 2009 American Medical Association. All rights reserved. Index–15

Index–1

benefits and limitaitons 16-5Mammography certification 16-6Manual pricing

reimbursement 5-42Manufacturer’s suggested retail price (MSRP) 25-4, 33-12Maximum allowable fee schedule

reimbursement 5-42Medicaid

eligibility 3-12spend down claims filing 3-14

Medical foods 25-2authorization requirements 25-3

Prior Authorization Request for Medical Foods B-55

benefits and limitations 25-3electronic claims submission 5-21enrollment 25-2

Medical nutritional counseling services 20-7Prior Authorization Request for Additional Nutritional Assessment, Counseling, and Products B-3Prior Authorization Request for Nutritional Assessment, Counseling, and Products (Additional) B-5prior authorization requirements 20-7

Medical nutritional productsauthorization requirements 25-6benefits and limitations 25-6claims information 25-13enrollment 25-6

Medical nutritional products and services 25-6electronic claims submission 5-21

Medical nutritional servicesauthorization requirements

medical nutritional products formulary 25-6enrollment 25-2

medical foods 25-2medical foods 25-2

authorization requirements 25-3benefits and limitations 25-3claims information 25-3enrollment 25-2reimbursement 25-4

medical nutritional counseling services 25-4authorization requirements 25-4, 25-5benefits and limitations 25-4claims information 25-5enrollment 25-4reimbursement 25-5

medical nutritional productsauthorization requirements 25-6benefits and limitations 25-6enrollment 25-6reimbursement 25-13

medical nutritional products and services 25-6Medical radiation physics, dosimetry, treatment devices, and special services 31-4Medical record documentation requirements 2-10Medical Transportation Program (MTP) 3-3Medically Needy Program (MNP) 3-7, 3-12

Medicationsinjectable 30-82oral 30-82

Methylmalonic acidemia and maple syrup urine disease (MSUD) 25-10, 25-11MNP

see Medically Needy Program (MNP)Modifier requirements for DME 17-21Modifiers 5-20

ambulance 9-7assistant surgeons 30-107injections and oral medications 30-82

MRAsee Magnetic resonance angiography (MRA)

MRIsee Magnetic resonance imaging (MRI)

MSRPsee Manufacturer’s suggested retail price (MSRP)

Mucus clearance valve 33-9Multiple sleep latency test 30-105Multiple surgeries 30-108

NNatalizumab 30-84National correct coding initiative (NCCI) 28-7National drug codes (NDC)

claims informationreimbursement 5-19

National provider identifier (NPI) 5-39NCS

see Nerve conduction studies (NCS)NDC

see National drug codes (NDC)Nebulizers 33-9Neonatal critical care services 30-28Nerve conduction studies (NCS) 30-44

procedure codes 30-44, 30-52Neuromuscular electrical stimulation (NMES) 26-4

clients with spinal cord injuries (SCI) 26-5muscle atrophy 26-4procedure codes 26-4

Neuropsychological testing 28-5Neurostimulator devices and supplies

authorization requirements 26-2benefits and limitations 26-2claims information 26-9dorsal column neurostimulation (DCN) 26-2enrollment 26-2intracranial neurostimulation (ICN) 26-3noncovered services 26-9percutaneous electrical nerve stimulation (PENS) 26-5reimbursement 26-9sacral nerve stimulation (SNS) 26-6supplies 26-8transcutaneous electrical nerve stimulation (TENS 26-6vagal nerve stimulation (VNS) 26-7

Neurostimulatorsdevices and supplies 30-100neuromuscular electrical stimulation (NMES) 26-4

6 CPT only copyright 2009 American Medical Association. All rights reserved.

Neutron-beam delivery 31-8New or established patient visits 30-53Noncovered

benefits and limitations 3-4, 3-5rehabilitative and therapeutic DME 17-19

Noncovered devicesshoes or shoe inserts 27-6

Noncovered servicesoutpatient behavioral health 28-6reconstructive and cosmetic procedures 30-112

Nonemergency ground transportation 9-5Nonobturated gastrostomy devices 18-11Nurse practitioner (NP)

enrollment 8-2

OObservation room services

benefits and limitations 30-57Obturated gastrostomy devices 18-11Occupational therapy (OT) 3-2, 5-21, 20-5, 22-2, 23-7, 29-3

authorization requirements 29-2benefits and limitations 29-2limitations 20-5prior authorization requirements 20-6

occupational therapy (OT) 20-5Omalizumab 30-97

Authorization Request for Omalizumab B-58OMT

see Osteopathic manipulative treatment (OMT)Online provider check amounts 37-6Ophthalmology

benefits and limitations 30-100intraocular lenses (IOL) 30-100Vitrasert ganciclovir implant 30-100

Oral medicationsbenefits and limitations 30-82modifiers 30-82

Oral surgery proceduresauthorization requirements 30-110

Orthodontia 14-9claims filing 5-37diagnosis codes 14-9local codes 14-11prior authorization requirements 14-10required documentation 14-10

Orthoses 27-3Orthotic and prosthetic devices

authorization requirements 27-2benefits and limitations 27-2claims information 5-21, 27-8cranial molding orthoses 27-5documentation of receipt 27-7dynamic splints 27-4enrollment 27-2excluded orthoses 27-5eye prostheses 27-7noncovered shoes or shoe inserts 27-6orthoses 27-3prescription shoes and lifts 27-6prostheses 27-6

reimbursement 27-8Osteopathic manipulative treatment (OMT) 29-2

benefits and limitations 30-100OT

see Occupational therapy (OT)Out-of-office services

benefits and limitations 30-56physician 30-56

Out-of-state providers 2-8, 3-3Outpatient

claims filing 23-13Outpatient (hospital) 30-146

authorization requirements 23-10benefits and limitations 23-10

Outpatient behavioral health servicesauthorization requirements 28-2, 28-3benefits and limitations 28-2claims information 28-9documentation requirements 28-3electronic claims submission 5-21enrollment 28-2noncovered services 28-6pharmacological management documentation 28-4, 28-6pharmacological regimen oversight documentation 28-4, 28-6reimbursement 28-4, 28-9

Outpatient hospital services 23-10Outpatient observation 23-11Outpatient physical therapy and occupational therapy

authorization requirements 29-4Authorization Request for Outpatient Therapy (TP2), Extension B-93

benefits and limitations 29-2claims information 29-6coordination with the public school system 29-6enrollment 29-2reimbursement 29-7

Outpatient services 30-53Outpatient speech-language pathology (SLP) services

authorization requirements 34-2benefits and limitations 34-2claims information 34-6coordination with the public school system 34-5enrollment 34-2reimbursement 34-6

Outpatient therapyelectronic claims submission 5-21

Oxygen concentrators 33-3

PPACT

see Program for Amplification for Children of Texas (PACT)

PAFsee Physician/Dentist Assessment Form

Paid or denied claims 6-4Pap smears 30-99Pathology services 30-99Payouts 6-6Pediatric pneumogram 30-105

CPT only copyright 2009 American Medical Association. All rights reserved. Index–17

Index–1

Pentamidine aerosol 30-6Percutaneous electrical nerve stimulation (PENS) 26-5Personal supervision 30-5PET

see Positron emission tomographyPharmacological management documentation requirements 28-4, 28-6Pharmacological regimen oversight documentation requirements 28-4, 28-6Phenylketonura (PKU) 25-3, 25-11Physical medicine 29-3, 30-101Physical therapy (PT) 20-5

benefits and limitations 29-3, 30-101limitations 20-5prior authorization requirements 20-6

physical therapy (PT) 20-5Physician

after-hours services 30-56allergy services 30-9anesthesia 30-9

administered by surgeon 30-106anterior temporal lobectomy 30-14assistant surgeons 30-107audiometry/hearing services 30-14augmentative communication devices (ACDs) 30-14authorization requirements 30-5benefits and limitations 30-5bilateral procedures 30-108bone growth stimulators 30-15casting 30-17chemotherapy 30-18

authorization requirements 30-18circumcision 30-109claims information 30-145

group billing procedure 30-145cleft/craniofacial procedures 30-109CLIA requirements 30-100clinician-directed care coordination services

benefits and limitations 30-19face-to-face 30-20non-face-to-face 30-20

clinician-directed care coordinaton servicesauthorization for nonface-to-face 30-23

cochlear implantsbenefits and limitations 30-24

colorectal cancer screening 30-24consultations 30-56cosurgery 30-107critical care services 30-25

intensive (noncritical) low birth weight 30-29neonatal 30-28newborn resuscitation 30-30pediatric 30-27

cytogentics testing 30-99documentation requirements 30-145echoencephalography 30-31electroencephalogram (EEG) (ambulatory) 30-43electronic claims submission 5-21emergency services 30-146enrollment 30-4

independent practices 30-4specialty team/center 30-109substitute 30-5

evaluation and management (E/M) services 30-53emergency 30-55emergency room 30-55initial and subsequent hosptial care (nonintensive) 30-54inpatient 30-54new or established patients 30-53observation room services 30-57office and outpatient services 30-53preventive care services 30-58teaching physicians 30-60

extracorporeal shock wave lithotripsygenetics 30-61global fees 30-108group practices 30-4helicobacter pylori (H. pylori) 30-100hyperbaric oxygen therapy (HBOT)immunizations 30-76injections and oral medications 30-82

30-84adalimumab 30-83administration billed by a physician 30-82azacitidine (Viadaza) 30-83botulinum toxin (type A and B) 30-86certolizumab pegol 30-83cidofovir 30-83clofarabine 30-84dalteparin sodium 30-84denileukin diftitox 30-84enoxaparin sodium 30-84epirubicin hydrochloride 30-84epoprostenol 30-84erythropoietin alfa (EPO) and darbepoietinfondaparinux sodium 30-84granisetron hydrochloride 30-84growth hormone 30-93ibutilide fumarate 30-84immune globulins 30-93infliximab 30-84leuprolide acetate 30-97lioresal 30-84natalizumab 30-84omalizumab 30-97procedure codes 30-83rituximab 30-84sumatriptan succinate 30-84topotecan HCL 30-85trastuzumab 30-85valrubicin 30-85

internal bone growth stimulators 30-16intracranial pressure monitoring 30-98intraoperative echography 30-31laboratory services 24-5, 24-6, 30-98

cytopathology studies (gynecological, Pap smears) 30-99handling fee 30-98

8 CPT only copyright 2009 American Medical Association. All rights reserved.

multiple surgeries 30-108noncovered reconstructive and cosmetic procedures 30-112noninvasive bone growth stimulators 30-16ophthalmological services 30-100

intraocular lenses (IOL)vitrasert ganciclovir implant 30-100

ostepathic manipulative treatment (OMT) 30-100outpatient hospital setting 30-146physical medicine 30-101physical therapy 30-101podiatry 30-101primary surgeons 30-106prolonged services 30-56psychological testing 30-101reconstructive and cosmetic procedures 30-112

medical review requirements 30-113reduction mammoplasty 30-113referrals to other providers 30-5reimbursement 30-146renal (kidney) transplants 30-126rhizotomy 30-115second opinions 30-108septoplasty 30-115services incidental to surgery or anesthesia 30-12sign language interpreting services 30-102stem cell transplant 30-127, 30-129

allogenic 30-128autologous 30-128

stem cell transplants 30-127substitute 30-5supervision 30-5surgery 30-106telemedicine 30-119telemedicine services

distant site 30-119patient site 30-120

therapeutic apheresis 30-120transplants 30-126unlisted surgical procedures 30-109

physician services 30-146Physician/Dentist Assessment Form 3-8PKU

see PhenylketonuraPlace of service (POS) 5-20

see Place of service A-4Podiatry

authorization requirements 30-101benefits and limitations 30-101electronic claims submission 5-21reimbursement 30-101

Polysomnography 30-103Porfimer sodium 30-84Portable hydrocollator units 17-12Portable paraffin units 17-12Positron emission tomography (PET) 16-6Prescription shoes and lifts 27-6Preventive care checkups 30-58

preventive health/medicine services 30-58Preventive services

authorization requirements 14-14

benefits and limitations 14-14dental prophylaxis and topical fluoride treatment 14-15noncovered counseling services

dental nutrition counseling 14-15tobacco counseling 14-15

noncovered dental counseling services 14-15oral hygiene instruction 14-14sealants 14-15space maintainers 14-15

Primary surgeons 30-106Prior authorization number (PAN) 7-4Prior authorizations 4-5Procedure codes

adjunctive general services 14-29anesthesia

incidental services 30-12nonincidental services 30-13

audiometric testing 19-4augmentative communication devices (ACDs) 10-2behavioral health services

12-hour system limitation 28-4blood factor products 30-15body and upper extremity

casts 30-17splints 30-18strapping 30-18

botulinum toxin type A 30-89breast reconstruction 30-114cardiac blood pool imaging 16-3cast removal or repair 30-18chemotherapy 30-18cleft and craniofacial procedures 30-110clinical brachytherapy (radiation therapy) 31-3clinical brachytherapy (surgery) 31-3clinical treatment planning 31-4critical care services 30-27cytopathology, vaginal, cervical, and uterine sites 24-22dental

anesthesia provided in an office setting 14-31dental implants 14-26dental restorations 14-17dental surgery 14-34dentist-physician

anesthesia 14-41cleft/craniofacial surgery 14-38evaluation and management 14-40laboratory 14-40radiology 14-40

dorsal column neurostimulation (DCN) 26-3dosimetry 31-4electroencephalogram (EEG) (ambulatory) 30-44electromyography (EMG) 30-44, 30-52electronic analysis for implantable neurostimulators 26-7end stage renal disease (ESRD) 32-7eye examinations and ophthalmoscopy or ophthalmological services 36-10eye prostheses 27-7

CPT only copyright 2009 American Medical Association. All rights reserved. Index–19

Index–2

gastrostomy devices 18-11genetics 30-61helicobacter pylori (H. pylori) 30-100hospital beds (manual and electric) 17-8immune globulins 30-93, 30-96injectable medications 30-83injections 30-83injections and oral medications 30-83intracranial neurostimulation (ICN) 26-4lenses

bifocal 36-3contact 36-4high-power 36-4single vision 36-3trifocal 36-4

lower extremitycasts 30-18splints 30-18strapping 30-18

magnetic resonance angiography (MRA)abdomen 16-4chest 16-4lower extremities 16-4pelvis 16-4

maxillofacial prosthetics 14-25medical radiation physics 31-4neonatal critical care 30-29nerve conduction studies (NCS) 30-44, 30-52neuromuscular electrical stimulation (NMES) 26-4noncovered reconstructive and cosmetic services 30-112oral and maxillofacial surgery 14-28oral surgery procedures 30-110other vision services 36-10outpatient physical therapy 29-3periodontic services 14-22physical medicine 30-101positron emission tomography (PET) 16-6pressure reducing pads 17-9preventive care 30-58prolonged physician services 30-56prophylaxis and topical fluoride treatment 14-15prosthetic services, fixed 14-27prosthodontic services, fixed 14-27prosthodontics (removable) and maxillofacial prosthetics 14-24proton-beam delivery 31-8radiation treatment delivery/port films 31-8radiation treatment devices 31-4radiation treatment management 31-8reconstructive and cosmetic services requiring medical review 30-113renal dialysis 32-4

supplies 32-6renal transplant 30-126rhizotomy 30-115root canals 14-21sacral nerve stimulation (SNS) 26-6special lenses 36-4special radiation services 31-4

special vision services 36-7stem cell transplants 30-127stereotactic radiosurgery 31-9surgery

incidental services 30-12nonincidental services 30-13

telemedicine services 30-120total parenteral nutrition (TPN) 25-14transcutaneous electrical nerve stimulation (TENS) 26-6vagal nerve stimulation (VNS) 26-7vision examination 36-6, 36-7waiver certificate 24-3

Procedure codingCPT 5-17modifiers 5-20place of service (POS) 5-20type of service (TOS) 5-20

Program for Amplification for Children of Texas (PACT)hearing aids 3-3

Program limitations and exclusions 3-4, 3-5Prolonged services

benefits and limitations 30-56physician 30-56

Prone/supine standers 17-15authorization requirements 17-15benefits and limitations 17-15

Protective helmets 27-7Proton- and neutron-beam delivery 31-8Provider Agreement 2-5Provider and principal information forms 2-5Provider certification/assignment 2-12Provider check amounts

online 37-6Provider complaints process 2-9Provider enrollment

appeals 7-7changes in enrollment 2-3cleft/craniofacial specialty teams 2-7determinations 2-4FQHCs and RHCs 2-6general information 2-2information change requests 2-10out-of-state providers 2-8Provider Agreement 2-5provider and principal information forms 2-5Provider Enrollment Application 2-4provider’s license 2-6providers paid by DSHS 2-8request for taxpayer identification number 2-6requirements for cleft/craniofacial center team approval 2-7transplant specialty centers 2-7types of providers 2-5

Provider responsibilitiesbilling clients 2-13general requirements 2-10provider certification/assignment 2-12release of confidential information 2-11retention of records 2-11utilization review 2-11

0 CPT only copyright 2009 American Medical Association. All rights reserved.

waste, abuse, and fraud 2-12Provider types and selection of claim forms 5-21Provider’s license 2-6Psychological testing 28-5, 30-101Psychotherapy 28-6PT

see Physical therapy (PT)Public school system

coordination with outpatient physical and occupational therapy 29-6coordination with speech-language pathology (SLP) services 34-5

Pulse oximeters 33-11

RR&S

see Remittance and Status (R&S) ReportsRadiation therapy services

authorization requirements 31-2benefits and limitations 31-2claims filing 5-21, 31-10clinical treatment management

proton- and neutron-beam delivery 31-8clinical treatment planning 31-4enrollment 31-2intensity modulated radiation therapy (IMRT) 31-4medical radiation physics, dosimetry, treatment devices, and special services 31-4noncovered services 31-5procedure code limitations 31-5radiation treatment management and delivery 31-8radioisotope therapy 31-9reimbursement 31-11stereotactic radiosurgery 31-9

authorization requirements 31-9Strontium-89 31-10Technetium TC 99M 31-10

Radiation treatment delivery/port films 31-8Radioallergosorbent (RAST) 30-9, 30-97Radioisotope therapy 31-9Radiologist

reimbursement 16-8Radiology services

claims filing 5-21see Diagnostic radiology services

Rail transportation (deceased clients)benefits and limitations 35-2

RASTsee Radioallergosorbent (RAST)

Receiving labs and handling fees 24-31Reciprocating gait orthoses (RGOs) 27-4, 29-5Reclast 30-84Reconstructive and cosmetic procedures 30-112

authorization requirements 30-112benefits and limitations 30-112medical review requirements 30-113noncovered 30-112

Record retention 2-11Reduction mammoplasty

authorization requirements 30-113benefits and limitations 30-113

Referrals to other providers 30-5Refunds 5-10

accident resources 5-11other insurance 5-11Refund Information Form B-134

Regional anesthesia 30-9Regional offices

DSHS 1-5TMHP 1-3

Rehabilitationinpatient claims filing 5-27

Reimbursementadvanced practice nurse (APN) 8-3ambulance 9-8anesthesia

time-based fees 30-14anesthesiology 30-13augmentative communication devices (ACDs) 10-6blood pressure devices and supplies 11-7bone-anchored hearing aid (BAHA) 19-11certified registered nurse anesthetist (CRNA) 12-3certified respiratory care practitioner (CRCP) 13-3claims information 19-13

national drug codes (NDC) 5-19clinical laboratory services 30-99

outpatient services 24-32dental/orthodontia 14-43diabetic equipment and supplies 15-7diagnostic radiology services 16-8durable medical equipment (DME) 17-21expendable medical supplies 18-12home health (skilled nursing) 21-3home health services 20-8hospice 22-4hospital

hospital-based emergency services 23-12inpatient services 23-10laboratory 23-5outpatient services 23-12

laboratory services 24-32manual pricing 5-42maximum allowable fee schedule 5-42medical nutritional services

medical foods 25-4medical nutritional counseling services 25-5medical nutritional products 25-13

medical services provided outside of Texas 2-8, 10-2neurostimulator devices and supplies 26-9orthotic and prosthetic devices 27-8out-of-state providers 3-3outpatient behavioral health 28-9outpatient physical therapy and occupational therapy 29-7physician 30-146podiatrists 30-101radiation therapy services 31-11renal dialysis 32-8respiratory equipment 33-13speech-language pathology (SLP) services 34-6stem cell transplants 30-127, 30-144

CPT only copyright 2009 American Medical Association. All rights reserved. Index–21

Index–2

Texas Medicaid Reimbursement Methodology (TMRM) 5-42total parenteral nutrition (TPN) 25-33transportation of remains of deceased clients 35-2vision related services 36-11

Release of confidential information 2-11Remittance and Status (R&S) Reports

accounts receivables 6-5adjustments to claims 6-5banner pages 6-2claim refunds 6-7claim reissues 6-7claim voids 6-7claims - paid or denied, incomplete claims 6-4claims in process 6-8claims payment summary 6-8electronic

see Electronic Remittance and Status (ER&S) Re-port

Remittance and Status (R&S) reportsexamples 6-9

accounts receivable 6-13adjustments 6-12backup withholding penalty information 6-14banner page 6-10claims - paid or denied 6-11explanation of EOB messages 6-21explanation of EOPS messages 6-22IRS levy information 6-15manual payouts 6-17refunds 6-18summary 6-20system payouts 6-16

explanation of benefits (EOB) codes 6-9explanation of row headings 6-3explanation of section headings 6-4financial transactions 6-5

void and stop 6-7general formatting guidelines 6-2general information 6-2incomplete claims 6-4IRS levies 6-6payouts 6-6stale-dated checks 6-7voids and stops 6-19

Removable shoe insert 27-4Renal (kidney) transplants

authorization requirements 23-9benefits and limitations 30-126hospital 23-8

Renal dialysisauthorization requirements 32-2benefits and limitations 32-2claims filing 5-27claims information 32-8client eligibility 32-2dialysis services 32-3dialysis training 32-6enrollment 32-2evaluation and management 32-7

maintenance hemodialysis 32-6method II (dealing direct) 32-5prior authorization requirements 32-7

Prior Authorization Request for Renal Dialysis Treatment B-68

reimbursement 32-8ultrafiltration 32-7

Rentalstranscutaneous electrical nerve stimulation (TENS) device 26-7

Requirements 9-5, 25-3Respiratory equipment

apnea monitors 33-5Prior Authorization Request for Apnea Monitor B-8

benefits and limitations 33-2rental or purchase 33-2

cardio respiratory (apnea) monitors 33-5claims information 33-12enrollment 33-2high frequency chest wall compression systems (HFCWCS) 33-8nebulizers 33-9other unspecified equipment 33-12oxygen concentrators 33-3prior authorization requirements 33-5

Prior Authorization Request for Respiratory Care—CRCP B-70

pulse oximeters 33-11Prior Authorization Request for Pulse Oximeter Devices B-65

reimbursement 33-13suction equipment 33-2tracheostomy tubes 33-12

Respiratory equipment and suppliesauthorization requirements 33-2benefits and limitations 33-2bi-level positive airway pressure (BiPAP) systems 33-6continuous positive airway pressure (CPAP) systems 33-6controlled dose inhalation drug delivery system 33-7mucus clearance valve 33-9

Respiratory syncytial virus (RSV)prior authorization requirements

Prior Authorization Request for Palivizumab (Synagis) B-61

RGOsee Reciprocating gait orthoses (RGOs)

Rhizotomyauthorization requirements 30-115

Rituximab 30-84

SSacral nerve stimulation (SNS) 26-6

procedure codes 26-6Seat lift mechanism

Durable medical equipment (DME)seat lift mechanism 17-12

Second opinions 30-108see Acquired immunodeficiency syndrome (AIDS)Septoplasty 30-115

2 CPT only copyright 2009 American Medical Association. All rights reserved.

Services incidental to surgery or anesthesiabenefits and limitations 30-12

Services not incidental to surgery or anesthesiabenefits and limitations 30-13

Services outside of business hoursbenefits and limitations 30-56physician 30-56

Services provided outside of Texas50 or fewer miles from Texas border 3-350 or more miles from Texas border 3-4benefits and limitations 2-8

Sign language interpreting services 30-102Skilled nursing

see Home health (skilled nursing)Skilled Nursing (SN) services

limitations 20-4Skilled nursing (SN) services 20-4

prior authorization requirements 20-5skilled nursing (SN) services 20-4Sleep studies 30-103

multiple sleep latency test 30-105pediatric pneumogram 30-105polysomnography 30-103

SLPsee Speech-language pathology (SLP)see Speech-language pathology (SLP) services

SNsee Skilled nursing (SN) services

SOsee Spinal orthoses (SO)

Social work services 20-7prior authorization requirements 20-7

Span dates 5-40Specialty team/center 30-127

authorization requirements 30-109enrollment 30-109procedures 23-3services 4-9

Speech-language pathology (SLP) 20-6prior authorization requirements 20-7

Speech-language pathology (SLP) services 5-21, 34-1authorization requirements 34-2benefits and limitations 34-2claims information 34-6cochlear implants surgery 34-5coordination with the public school system 34-5dysphagia (swallowing disorder) 34-4enrollment 34-2reimbursement 34-6

Spend down processingMedically Needy Program (MNP) 3-13

Spinal orthoses (SO) 27-3Stale-dated checks 6-7Standard DME 17-4Standers, prone or supine 17-15

authorization requirements 17-15Stem cell transplant

authorization requirements 23-10Stem cell transplants 4-9, 23-3

authorization requirements 30-127physician reimbursement 30-144

Stereotactic radiosurgery 31-9authorization requirements 31-9

Strontium-89 31-10Substitute physician 2-8Suction equipment 33-2Sumatriptan succinate 30-84Supernumerary tooth identification 14-43Surgery

anesthesia administered by surgeon 30-106assistant surgeons 30-107authorization requirements 30-106

Prior Authorization Request for Inpatient Sur-gery—For Surgeons Only B-77Prior Authorization Request for Outpatient Sur-gery—For Outpatient Facilities and Surgeons B-80

benefits and limitations 30-106bilateral procedures 30-108bone growth stimulators 30-15casting 30-17circumcision 30-109cleft/craniofacial by dentist physician 14-38cochlear implants 34-5cosurgery 30-107extracorporeal shock wave lithotripsy 30-61global fees 30-108incidental services 30-12internal bone growth stimulators 30-16multiple surgeries 30-108noninvasive bone growth stimulators 30-16primary surgeons 30-106second opinions 30-108septoplasty 30-115services not incidental to surgery 30-13unlisted surgical codes 30-109Vitrasert ganciclovir implant 30-100

TTeam/center requirements 30-109Technetium TC 99M tetrofosmin 31-10Telemedicine services 30-119

distant site 30-119patient site 30-120procedure codes 30-120

Telephone numbersCSHCN regional offices 1-5TMHP-CSHCN regional representatives 1-3TMHP-CSHCN Services Program Contact Center i-iii, 1-3

TENSsee Transcutaneous electric nerve stimulator (TENS)

Texas Family Code compliance 2-14abuse and neglect reporting requirements 2-14child support 2-14

Texas Health Steps (THSteps)client eligibility 3-12Comprehensive Care Program (THSteps-CCP)

Texas Medicaid & Healthcare Partnership (TMHP)Contact Center i-iii, 1-3, 2-14, 4-11Electronic Data Interchange (EDI) 37-1

appeal submission 7-3provider enrollment 2-2

CPT only copyright 2009 American Medical Association. All rights reserved. Index–23

Index–2

regional representatives 1-3website 37-3

banner messages 37-3file libraries 37-3publications 37-3

online searches 37-3Texas Medicaid Reimbursement Methodology (TMRM) 5-42Texas State Board of Dental Examiners (TSBDE) 14-30Texas Vaccines for Children (TVFC) Program 30-76TexMedConnect

orthodontia claims 14-11overview 37-4

Therapeutic apheresisauthorization requirements 30-120

Therapeutic servicesadjunctive general services 14-29

procedure codes 14-29anesthesia provided in an office setting

procedure codes 14-31dental 14-16

anesthesia 14-30behavior management 14-31restorations 14-16

dental restorationsprocedure codes 14-17

endodontics 14-19procedure codes 14-21pulp caps 14-19root canals 14-20

implants 14-26procedure codes 14-26

internal bleaching of tooth 14-32interrupted treatment plan 14-16maxillofacial prosthetics 14-25

procedure codes 14-25oral and maxillofacial surgery 14-28

procedure codes 14-28periodontics 14-22

procedure codes 14-22prior authorization requirements 14-16prosthetics, fixed

procedure codes 14-27prosthodontics (removable) and maxillofacial prosthetics 14-23

procedure codes 14-24prosthodontics, fixed 14-26

procedure codes 14-27Therapy

hyperbaric oxygen (HBOT) 30-62occupational 29-7physical 30-101speech-language pathology (SLP) services 34-1

Third-party liabilityclaims involving accidents 5-12

Third-party resources (TPR) 5-7accident resources 5-11accident-related claims 5-11address 1-2, 5-9Blue Cross Blue Shield nonparticipating

providers 5-10claims filing 5-8filing deadlines 5-9health maintenance organization (HMO) 5-7payment sources 5-7refunds involving claims for accidents 5-11refunds to TMHP resulting from other insurance 5-11verbal denials 5-8

Third-party vendor implementation for TMHP EDI services 37-6THKAO

see Thoracic hip-knee-ankle orthoses (THKAO)Thoracic hip, knee, and ankle orthoses (THKAO) 27-3THSteps

see Texas Health Steps (THSteps)THSteps-CCP

see THSteps-Comprehensive Care Program (THSteps-CCP)

TIDsee Tooth identification (TID)

TMHPsee Texas Medicaid & Healthcare Partnership (TMHP)

TMRMsee Texas Medicaid Reimbursement Methodology (TMRM)

Tooth identification (TID) 6-4, 14-26surface identification 14-42

Topotecan HCL 30-85Total parenteral nutrition (TPN) 3-2, 5-21, 25-13

authorization requirements 25-33benefits and limitations 25-13claims information 25-33electronic claims submission 5-21enrollment 25-13reimbursement 22-2, 25-33

TPNsee Total parenteral nutrition (TPN)

Tracheostomy tubes 33-12Transcutaneous electric nerve stimulator (TENS) 17-15Transcutaneous electrical nerve stimulation (TENS) 26-6

procedure codes 26-6purchase 26-7rental 26-7

Transfer boards 17-15Transplant specialty centers 2-7Transplants 30-126

allogenic transplants 30-128autologous 30-128renal (kidney) 23-8, 30-126

authorization requirements 23-9stem cell 23-9, 30-127, 30-129

authorization requirements 23-10Transportation

ambulance 9-1deceased client 35-1

air transportation 35-2authorization requirements 35-2benefits and limitations 35-2bus transportation 35-2claims information 35-2

4 CPT only copyright 2009 American Medical Association. All rights reserved.

embalming 35-2land transportation 35-2rail transportation 35-2reimbursement 35-2

emergency air ambulance 9-4authorization requirements 9-4benefits and limitations 9-4

emergency ground ambulance 9-2authorization requirements 9-2benefits and limitations 9-2

nonemergency ground ambulance 9-5authorization requirements 9-5benefits and limitations 9-5

Trastuzumab 30-85Travel chairs 17-15

prior authorization requirements 17-15Travel restraints 17-14TriCare (formerly CHAMPUS/CHAMPVA) 5-7TSBDE

see Texas State Board of Dental Examiners (TSBDE)TVFC

see Texas Vaccines for Children (TVFC) Program

UUB04 (CMS 1450)

paper claim form example 5-36paper claim form instructions 5-27

UB04 (CMS-1450) 5-27Unlisted surgical procedures 30-109Urinalysis 24-30Utilization review 2-11

VVaccine information statement (VIS) 30-76Vagal nerve stimulation (VNS) 26-7

procedure codes 26-7Valrubicin 30-85Vendor Drug Program (VDP) 3-3Verifying client eligibility 3-8Very low birth weight (VLBW) 30-25Vision related services

authorization requirements 36-2, 36-5, 36-10benefits and limitations 36-2bifocal lenses 36-3contact lenses 36-4electronic claims submission 5-21enrollment 36-2examinations 36-6frames, lenses, and contact lenses 36-2high-power lenses 36-4ophthalmology 30-100other services 36-10reimbursement 36-11single vision lenses 36-3specialized lenses 36-4trifocal lenses 36-4Vision Care Eyeglass Client Certification Form B-115Vision Care Eyeglass Client Certification Form (Spanish) B-116Vitrasert ganciclovir implant 30-100

Vision-related services

claims information 36-11Vitrasert ganciclovir implant 30-100VLBW

see Very low birth weight (VLBW)

WWaiting list information 3-11Walkers 17-6Waste, Abuse, and Fraud 2-12Wheelchair

battery 17-18power elevating leg lifts 17-18power seat elevation system 17-18

Wheelchairs 17-16authorization requirements 17-16custom manual wheelchairs 17-17manual wheelchairs 17-16portable ramps 17-19positioning equipment 17-18power wheelchairs 17-17

approval criteria 17-17ramps 17-19standard 17-4

CPT only copyright 2009 American Medical Association. All rights reserved. Index–25