november 2003 long term care bulletin, no. 16 › ltc_provider_bulletin › 2003 › 016_ltc.pdf ·...
TRANSCRIPT
Long Term CareB
UL
LE
TIN
Visit the Long Term Care section on the NHIC Web site at www.eds-nhic.com.
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November 2003, No. 16
LTC Bulletin, No. 16, Contents
Contract Transition to TMHP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Request for Electronic Transmission Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Implementation of Twelve-Month Claims Submittal Rule EffectiveNovember 1, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
TDHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4TDMHMR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Health Insurance Portability and Accountability Act Awareness . . . . . . . . . . . . . 4Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Enforcement of HIPAA Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Provider Education and Outreach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Vendor and Provider Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
LTC HIPAA Electronic Data Interchange (EDI) Implementation . . . . . . . . . . . . . . . 6The Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Client Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6MESAV Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Diagnosis Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Updates to August 2003 LTC Bulletin Articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Claim Formats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Paper Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Claims for DOS Prior to October 16, 2003, Filed on or after October 16, 2003 . . . . . . . 8Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Service Code Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Place of Service Codes Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Place of Service Codes for the 837I – Institutional Claim Format . . . . . . . . . . . . . . . . 12Place of Service Codes for the 837P – Professional Claim Format . . . . . . . . . . . . . . . 12
Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Modifier Field 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14DHS/TDMHMR Modifier Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
LTC Bill Code Crosswalk Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16How to Use the LTC Bill Code Crosswalk Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
www.eds-nhic.comhe National Heritage Insurance Company (NHIC) is the insurer and contract administrator for the Texas Medicaid
Program under contract with the Texas Health and Human Services Commission (HHSC)
LTC Bulletin, No. 16, Contents (continued)
Long Term Care Bill Code Crosswalk Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Service Group 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Service Group 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Service Group 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Service Group 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Service Group 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Service Group 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Service Group 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Service Group 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Service Group 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54Service Group 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Service Group 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Service Group 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Service Group 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Service Group 18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Explanation of Benefits Code Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Helpful Hints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
LTC Web Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Reminders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Resources for Long Term Care Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85General Table – All Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85TDMHMR/ICF–MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85DHS – Provider Claims Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86DHS LTC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87NHIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Your NHIC Training Specialists by Territory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
2 November 2003, No. 16LTC Bul let in 2
Contract Transition to TMHPThe Texas Medicaid & Healthcare Partnership (TMHP) will take over the Claims Management System (CMS) contract effective January 1, 2004. The current contract with NHIC for long-term care claims processing ends in 2003, although there is a transition period extending into the new year to ensure a smooth takeover by the new contractor. TMHP, the new contractor, is a partnership of contractors managed by ACS with technical services being provided by Accenture.
TMHP will assume responsibility and operations of all software computer systems that NHIC currently operates. This includes Compass21, the LTC Claims Management System (CMS), and the Nursing Facility CARE Form System.
Transition work is in progress with NHIC, TMHP, and the State agencies involved with this contract: the Health and Human Services Commission, the Department of Human Services (DHS), and the Texas Department of Mental Health and Mental Retardation (TDMHMR). In addition to planning for a smooth cutover to the new contractor, TMHP is testing software transferred from NHIC and documenting operational procedures. The operational procedures are being prepared to replicate the way LTC providers and State computer systems already work with NHIC in order to minimize change during the transition.
Although the new contract includes improvements and some new requirements, the focus was on no new development and no significant procedural changes for the first year of the contract in order to support an effective transition from NHIC operations.
It will be necessary to incur some scheduled processing downtime late this year and in early January to successfully transition to TMHP. Although cutoff schedules remain tentative, planners anticipate that the acute-care system (Compass21) will be unavailable for a longer time than the LTC systems.
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At time of publication, the following was the tentative plan for startup of TMHP operations:
Texas Medicaid Turnover Planning - LTC Claims Management System
Note: All dates and times in the following table are tentative and subject to change.
A copy of the DHS information letter informing LTC providers of this contract change may be found at the following DHS and NHIC Web sites:
• www.eds-nhic.com/LTC/default.htm
• www.dhs.state.tx.us/programs/communitycare/infoletters (For Community Care Provider Agencies)
• www.dhs.state.tx.us/providers/LTC-Policy/index.html (For Nursing Facilities and Therapy Providers)
A follow-up letter is planned for release in December. It is important for all providers to monitor their mail and the LTC Web site to ensure that no important information is overlooked. Providers will be receiving material from TMHP as well as from NHIC and the State agencies, DHS and TDMHMR, through the end of the year. ■
Transaction/Interface Files Last NHIC First TMHP
Paper claims 12/19/2003 12/27/2003
Electronic claims 12/26/2003
12 noon
01/05/2004
MESAV 12/31/2003
6 p.m.
01/02/2004 =>
01/05/2004
R&S 12/27/2003 01/06/2004
CSI transactions 12/31/2003
6 p.m.
01/02/2004 =>
01/05/2004
3618, 3652, 3619 Received from providers - paper
12/19/2003 01/05/2004
3618, 3652, 3619 Received from providers - electronic
12/23/2003 01/05/2004
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Request for Electronic Transmission ReportsElectronic providers are required to retain all claim and electronic file transmission records. Providers must verify that all claims submitted to HHSC or its agent are received and accepted, and claims transmissions are tracked against claims payments to detect and correct all claim errors. If you are missing an electronic file transmission record, you may request a copy of the transmission report(s) by contacting the NHIC EDI helpdesk at 888-863-3638. Requests for transmission reports produced in the previous 30 days will be provided at no cost to the providers. Requests for transmission reports produced more than 30 days prior to the request will result in a charge of $500 plus 8.25 percent sales tax of $41.25 for a total charge of $541.25. This cost is per transmission report. Providers that hold a tax exempt certificate will not be charged the 8.25 percent sales tax. Provider payment will be required with the submission of the completed transmission report order form to NHIC. ■
Implementation of Twelve-Month Claims Submittal Rule Effective November 1, 2003
TDHS
The Code of Federal Regulations (CFR), Title 42, 447.45(d)(1) states that the Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Effective November 1, 2002, the Texas Department of Human Services (DHS) requires provider agencies to submit claims for services to DHS within this timeframe. Although the rules were effective November 1, 2002, they were not to be applied to claims until November 1, 2003.
Electronic versions of the various information letters related to the 12-month claims filing deadline may be found at the following addresses:
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• For LTC Community Care Providers:www.dhs.state.tx.us/programs/communitycare/infoletters/cbaccadletters.html – under CMS.
• For Hospice and Nursing Facility Providers:www.dhs.state.tx.us/providers/LTC-Policy/index.html – in the Communications section, click Provider Letters. ■
TDMHMR
The Code of Federal Regulations, Title 42, 447.45(d)(1) states that the Medicaid agency must require providers to submit claims no later than 12 months from the date of service. Effective January 6, 2003, the Texas Department of Mental Health and Mental Retardation (TDMHMR) will require provider agencies to submit claims for services to DHS within this time frame. Although the rules were effective January 5, 2003, they will not be applied to claims until on or after January 5, 2004. The information letter and the Code of Federal Regulations (CFR) were sent to TDMHMR providers. ■
Health Insurance Portability and Accountability Act Awareness
Overview
Congress enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to reform the health care insurance market and simplify health care administrative processes. Entities required to comply with HIPAA provisions (covered entities) include Medicaid providers. Covered entities include health plans (health insurers, HMOs, Blue Cross/Blue Shield, etc.), health care providers (physicians, hospitals, health care contractors, and others who do business electronically), and health care clearinghouses. Covered entities were required to implement HIPAA Privacy provisions by April 14, 2003, and must have complied with HIPAA Electronic Data Interchange (EDI) provisions by October 16, 2003. These entities must also comply with HIPAA Security provisions by April 21, 2005.
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Visit the following Web sites for HIPAA information and other helpful links:
Centers for Medicare and Medicaid Services (CMS):
• www.cms.gov/hipaa
Department of Health and Human Services (HHS) Office of Civil Rights (OCR):
• www.hhs.gov/ocr/hipaa
Frequently Asked Questions:
• www.eds-nhic.com/HIPAA.htm
EDS-NHIC LTC Home Page:
• www.eds-nhic.com/LTC/default.htm
Approved HIPAA implementation guides and current listing of national remark and reason codes:
• www.wpc-edi.com/hipaa/HIPAA_40.asp
Health and Human Services Commission (HHSC):
• www.hhsc.state.tx.us/NDIS/NDISTaskForce.html
Texas Department of Human Services (DHS):
• www.dhs.state.tx.us/providers/hipaa
Texas Department of Mental Health and Mental Retardation (TDMHMR):
• www.mhmr.state.tx.us/hipaa.html ■
Enforcement of HIPAA Regulations
The Department of Health and Human Services (HHS) has determined that the Office for Civil Rights (OCR) will enforce the HIPAA Privacy standards. The Centers for Medicare and Medicaid Services (CMS) is responsible for enforcing the standards for EDI transactions and code sets, security, and national identifiers. CMS will also continue to enforce the insurance portability requirements under Title I of HIPAA.
Note: HHSC, DHS, TDMHMR, and NHIC are not responsible for enforcing HIPAA provisions. ■
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Provider Education and Outreach
Long Term Care (LTC) Provider Workshops and Videoconference
The DHS/TDMHMR HIPAA Project team conducted 29 HIPAA Electronic Data Interchange (EDI) Workshops for LTC providers throughout Texas in July and August in order to prepare providers for the billing and other changes due to HIPAA implementation. The workshops were a resounding success, with attendance exceeding 1,900 persons. The materials presented at the workshop are available on the DHS HIPAA team Web site at www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html.
The Project Team also presented a videoconference on October 6, 2003, in an effort to reach LTC providers who were not able to attend one of the live workshops in July or August. The videoconference was transmitted from the Texas Department of Health (TDH) Auditorium K-100 to nine remote sites in Abilene, Arlington, Brownsville, El Paso, Fort Worth, Houston, Tyler, Victoria, and Wichita Falls. Courtesy of the TDH video conference staff, LTC providers were able to register online for the videoconference. Over 500 attendees took advantage of the opportunity to learn how their billing procedures would change as a result of HIPAA implementation. The DHS/TDMHMR HIPAA Project Team plans to present additional EDI workshops for LTC providers in November 2003.
NHIC TDHconnect Workshops for LTC Providers
Area NHIC Training Specialists presented TDHconnect 3.0 HIPAA Workshops for LTC providers during September and October. These workshops were designed to address changes in the Medicaid claims processing software, TDHconnect, as a result of HIPAA EDI compliance requirements. The training specialists provided a live demonstration of the software.
Note: LTC providers who use TDHconnect 2.0 will be required to use the new version, TDHconnect 3.0, on and after October 16, 2003. ■
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Vendor and Provider TestingVendors and providers not using TDHconnect to submit claims, eligibility requests, or to receive an ER&S report were requested to test transactions with NHIC to assure they could send HIPAA-compliant transactions by October 16, 2003.
Organizations who wished to test with NHIC were requested to complete a vendor intake form (found in the NHIC Companion Guides for each transaction type) identify a contact and the transaction(s) used, and send it to [email protected]. A test facilitator contacted each organization to schedule a test time.
Phase One of the testing process was completed in July. During this phase, an organization’s ability to transmit HIPAA-compliant transactions was verified. Files were submitted through the EBX Model Office BBS.
Phase Two occured between August 2003 and October 2003 for Acute Care (Compass21). This phase involved sending files and receiving responses to and from NHIC. Files submitted during Phase One testing of the mapping process were also used in Phase Two.
Phase Three occured between September 2003 and October 2003 for validation of Long Term Care submitters sending files to CMS. During this phase, providers were able to send and receive HIPAA-compliant files to and from NHIC.
If you have any questions regarding the testing process at NHIC, send an electronic message to [email protected]. ■
LTC HIPAA Electronic Data Interchange (EDI) Implementation
The Solution
HIPAA EDI requires Texas Medicaid Long Term Care to accept, process, and return compliant electronic transactions for claims, eligibility inquiries, claim status inquiries, remittance and status, and prior authorization by October 16, 2003. As reported in the August 2003 LTC Bulletin, No. 15, HHSC, along with
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its claims administrator, NHIC, analyzed the Claims Management System (CMS) with respect to HIPAA EDI requirements, and determined the best solution was to retain the existing claims processing system for paying claims. Given this decision and the need to become HIPAA compliant, all transactions coming in would be HIPAA compliant, but would be translated back into the “old” billing format in order to process and pay claims. In other words, the claim coming into the CMS for payment would contain the national procedure code, place of service (POS) code, and other requisite information. Once the electronic claim is received by NHIC, it would be converted back to the “old” bill code to process as usual, using information contained on the claim plus that contained in various state systems. The derivation of the “old” bill code from the national code requires the provider to submit not only the national procedure code, but also additional information to help point to the correct bill code. This information must be submitted in HIPAA-compliant formats. ■
Client Address
Client address is a required field under the HIPAA EDI rules. The client address is available on the client’s Medicaid card. In the case of residential care facilities, such as nursing homes, ICF-MR, assisted living, and hospice, the client address may be the same as the facility address. ■
MESAV Templates
During the HIPAA LTC provider workshops, many providers indicated that they needed to rebuild their MESAV templates every time because their templates were scrambled upon receiving a response. One possible solution, or means to prevent duplicate entry responses in your template, is to save the template without request dates. It appears that if you enter and save an initial request date, then resubmit the template with new dates, TDHconnect interprets this as two requests. After entering the template information, without request dates, save the template. When submitting the request,
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add the dates of interest; however, when you are asked if you want to modify the template, respond “No.” This should solve the problem of duplicate entries. ■
Diagnosis Code
Required or Situational
A diagnosis code is required on the Institutional claim format (837I) and is situational on the Professional claim format (837P).
The 837P Implementation Guide defines “Situational,” as it relates to diagnosis, as: “Required on all claims/encounters except claims for which there are no diagnoses (for example, taxi claims).”
In TDHconnect, the Diagnosis Code field is not bolded on the 837P, meaning that for TDHconnect users, the field is not “required.” This was done to allow situations where diagnosis code is not required (that is, PACE, requisition fees, meals, and ERS) to be able to pass the Electronic Business Exchange (EBX) edits.
Exceptions
A diagnosis code is required for all claims except the following:
• Claims submitted for services to CCAD-Service Group 7 clients
• Claims for meals, regardless of service group
• Claims for ERS, regardless of service group
• Claims for “atypical” services (for example, transportation, requisition fees, and PACE) ■
Updates to August 2003 LTC Bulletin ArticlesThe state and NHIC have continued to make significant progress since the August 2003 LTC Bulletin, No. 15, was published. This progress has resulted in the need to repeat and/or update a few articles from that bulletin.
7November 2003, No. 16
Claim Formats
Removal of diagnosis code requirement for Community Care for the Aged and Disabled Program (CCAD - Service Group 7) resulted in changes to the LTC Bill Code Crosswalk table. It was necessary for the DHS HIPAA Project Team to cross reference all CCAD bill codes to national HCPCS or CPT codes, rather than use the revenue codes as originally done. This change may result in certain providers having to use a different claim format.
Remember to do the following to choose a claim format when billing electronically:
Go to the crosswalk table and find the line that defines the service you are billing.
• If the line shows a revenue code in the National Code fields, use the 837I - Institutional format, even if there is also a HCPCS or CPT code indicated.
• If there is no revenue code, look at the Procedure Code Qualifier field. If the procedure code qualifier is:
❑ AD, use the 837D - dental format.❑ HC, use the 837P - professional format.❑ ZZ, use the 837P - professional format.
Note: Paper submitters use the DHS form 1290 (Long Term Care Claim) regardless of the National Code. ■
Paper Claims
The Form 1290, Long Term Care Claim, and instructions were revised to include the changes described in this bulletin. While the Form 1290 and instructions were mailed to all providers (both electronic and paper submitters) in September 2003, the form was not effective until October 16, 2003. The form is also available via the DHS Web site at www.dhs.state.tx.us/handbooks/providers/index.htm. ■
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Claims for DOS Prior to October 16, 2003, Filed on or after October 16, 2003
Claims for dates of service (DOS) prior to HIPAA implementation (October 16, 2003), but filed on or after October 16, 2003, will need to adhere to the HIPAA regulations regarding format and fields. However, the code used in the procedure code field will be that which was effective on the DOS, except those noted below.
For example, if you provided LVN Nursing Services on September 1, 2003, for a service group 17 clients with a 13A service code – and billed on or after October 16, 2003 – you would use the local bill code in effect on the DOS, which was G0302. If you provided and billed the same service on October 18, 2003 – to the same client with the same authorizations – you would bill using HCPCS code S9124 or T1003.
Exceptions
Nursing Facility/Hospice/ICF-MR Daily Care: Services for daily care by nursing facility, hospice, and ICF-MR providers will be billed using the revenue code only (as listed in the Bill Code CrosswalkTable) for dates of service on or after October 16, 2003. For dates of service prior to October 16, 2003 – but billed after HIPAA implementation (October 16, 2003, or later) – both the revenue code listed in the Bill Code Crosswalk table and the local bill code used prior to HIPAA implementation must be used.
Hospice Physician Services: Hospice physician services will be billed using the national revenue code and the appropriate CPT-4 code regardless of the date of service if filed after October 16, 2003.
Adaptive Aids/DME: Services provided under the Adaptive Aids/DME local code (G0500) will be billed after HIPAA implementation (October 16, 2003) using the appropriate national code, regardless of the date of service. Consult the Bill Code Crosswalk table for the appropriate code(s) to use.
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Dental: Dental services claimed on or after October 16, 2003 will be billed using the national code for the dental service provided regardless of the date(s) of service using the dental claim form. Consult the Bill Code Crosswalk table for the appropriate code.
Other Exceptions: If the Bill Code Crosswalk table shows a revenue code for the service, the revenue code listed will be used regardless of the date of service. If the DOS is prior to October 16, 2003, the revenue code must be accompanied by the local bill code in the procedure code field. If the DOS is on or after October 16, 2003, if a HCPCS code or CPT-4 code is noted in the appropriate column of the Bill Code Crosswalk table, this code must be entered in the procedure code field. ■
Units
Every detail line requires the provider to enter the number of units being billed. The units entered are associated with the authorized service code/bill code. The authorized and used units, as well as the type of unit, can be found on the MESAV Service Authorization Detail tab.
If you bill one unit per month (that is, ERS), you can bill for October 2003 by:
1. Billing two detail lines. Using ERS as an example, the detail lines would be similar to the table below:
2. Billing one unit for October 1, 2003, to October 1, 2003. This would be applicable for the month of October 2003 only. Remember to submit this claim after the last date of service in October.
Begin Date
End Date
Procedure Code
QualifierProcedure
Code Units
10/01/03 10/15/03 ZZ G1000 0.5
10/16/03 10/31/03 HC S5161 0.5
Begin Date
End Date
Procedure Code
QualifierProcedure
Code Units
10/01/03 10/01/03 ZZ G1000 1 ■
8 November 2003, No. 16
Service Code Table
The following table lists the service codes and their definitions.
Service Codes Table
Service Code Definition of Service Code
1 Daily Care
1T Daily Care - Transitional Add-On
3 ECF
4 Ventilator(s)
5 Dental
5A Dental - Waiver Programs
6 Nurse Aid Training
7 Occupational Therapy/Assessment
7A Occupational Therapy - Nursing Facility Specialized Services
8 Physical Therapy/Assessment
8A Physical Therapy - Nursing Facility Specialized Services
9 Speech-Language Pathology/Assessment
9A Speech Therapy - Nursing Facility Specialized Services
10 Habilitation
10A Habilitation - Delegated Nursing
10B Habilitation - Supportive Employment/Prevocational
10C Habilitation - Day
11 Respite - In-Home
11A Respite - Out-of-Home
11B Respite - Foster Care
11C Respite - Assisted Living Apartment
11CV VFI Respite - Assisted Living Apartment
11D Respite - Assisted Living Apartment
11DV VFI Respite - Assisted Living RC Apartment
11E Respite - Assisted Living RC Nonapartment
11EV VFI Respite - Assisted Living RC Nonapartment
11F Respite - Nursing Facility
11FV VFI Respite - Nursing Facility
11G Respite - Camp
11H Respite - Day Care/Licensed Child Care Facility
11J Respite - Licenses Special Care Facility
11K Respite - ICF/MR
11L Respite - Hospital
11M Respite - HCSS (RN/LVN)
11N Respite - LVN
11P Respite - RN
11Q Respite - PAS Delegated
11R Adjunct - PAS HCSS
11S Adjunct - LVN
11T Adjunct - RN
9 LTC Bul le t inNovember 2003, No. 16
11U Adjunct - PAS HCSS
11V Adjunct - PAS Delegated
12 Case Management
12A Targeted Case Management
13 Nursing Services
13A Nursing Services - LVN
13B Nursing Services - RN
14 Psychological Services
15 Adaptive Aids/DME
16 Home Modifications
17 Personal Assistance Services (PAS)
17A PAS Delegated
17B PAS Protective Supervision
17V VFI - Personal Assistance Services (PAS)
17C PAS Family Care
17CV VFI - PAS Family Care
17D PAS Frail Elderly (1929b)
17DV VFI - PAS Frail Elderly (1929b)
17E PAS Chore
18 Adult Foster Care
19 Assisted Living Apartment
19A Assisted Living - Residential Care - Nonapartment
19B Assisted Living - Residential Care - Apartment
19C Assisted Living - Personal Care 3
19D Assisted Living - Emergency Care
19E Assisted Living - Habilitation Hours
19F Assisted Living - Habilitation Less than 24 Hours
19G Assisted Living - Family Surrogate Services
19H Assisted Living - Bed Hold
19I Residential Care Bed Hold - Nonapartment Title XX
19J Residential Care Bed Hold - Apartment Title XX
19K Residential Care Apartment Title XX
19L Residential Care Nonapartment Title XX
19M Residential Care Emergency Care Title XX
19N Residential Care - Room and Board - Nonapartment
19O Residential Care - Room and Board - Apartment
20 Emergency Response Services
21 Prescriptions
22 Medical Supplies
24 Tracheostomy Cleaning (NF Only)
25 Meals
26 In-Home Family Support Program
27 Consumer Managed Personal Attendant Services (CMPAS)
Service Codes Table
Service Code Definition of Service Code
10 November 2003, No. 16LTC Bul let in 10
27A CMPAS - Voucher Fiscal Intermediary
28 Special Services to Persons with Disabilities (SSPD) - Case Management
28A Special Services to Persons with Disabilities (SSPD)
29 Day Activity/Health Services - Title XIX
29A Day Activity/Health Services - Title XX
30 Physician Directed Care
31 Nursing Facility Room and Board
32 Medicare Pharmacy Coinsurance
33 Medicare Respite Coinsurance
34 Dietary
35 Audiology
36 Social Work
37 Supported Employment
38 Residential Support
39 Monthly Premium
40 Assessment (Full/Partial/Annual)
40A Pre-Assessment
41 Requisition Fees - Adaptive Aids
41A Requisition Fees - Medical Supplies
41B Requisition Fees - Minor Home Modifications
41C Specifications - Adaptive Aids
41D Specifications - Home Modifications
41E Requisition Fees - Dental
42 Specialized Therapies
43 Behavior Communication Specialist
44 Orientation and Mobility
45 Intervenor
46 TDMHMR Night Residential Support Services
47 TDMHMR Supervised Living Services
48 Transportation
49 Child Support Services
50 Personal Needs Allowance
51 Independent Advocacy
52 Community Support Services
53 Transitional Services
53A Transitional Support Services
60 Unlimited Prescriptions
99 Expedited Services �
Service Codes Table
Service Code Definition of Service Code
11 LTC Bul le t inNovember 2003, No. 16
Place of Service Codes Table
HIPAA claim format requirements for the Institutional (837I) and the Professional (837P) claim formats have necessitated a change to the place of service (POS) table originally published in the August 2003 LTC Bulletin, No. 15, and in the 2003 LTC User Manual for Paper Submitters. The professional and institutional claim will require TDHconnect providers to use one of the following codes in the POS field:
Place of Service Codes for the 837I – Institutional Claim Format
Place of Service Codes for the 837P – Professional Claim Format
Place of Service (POS) Codes Table for the 837I
Place of Service Code Place of Service Name Place of Service Description
18 Swing Bed - Hospital
25 Skilled Nursing Level I For all Nursing Homes/Nursing Facilities except when billing for Medicare co-insurance (Note: These are UB-92 defined levels – not to be confused with Texas TILE.)
27 Skilled Nursing Level III To be used by Nursing Homes/Nursing Facilities when billing for Medicare co-insurance (Note: These are UB-92 defined levels – not to be confused with Texas TILE.)
28 Swing Bed - Nursing Facility
32 Home Health - Inpatient To be used when billing for hospice inpatient services
33 Home Health Outpatient
34 Home Health Outpatient - Other
66 Intermediate Care Facility ICF-MR
74 Outpatient Rehabilitation Facility
75 Comprehensive Outpatient Rehabilitation Facility
79 Clinic - Other
81 Hospice - Special Facility
89 Special Facility - Other
Place of Service (POS) Codes Table for the 837P
Code Name Description
03 School A facility whose primary purpose is education
04 Homeless Shelter A facility or location whose primary purpose is to provide temporary housing to homeless individuals
11 Office A location (other than a hospital, skilled nursing facility, military treatment facility, community health center, State or local public health clinic, or intermediate care facility) where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis
12 Home Location, other than a hospital or other facility, where the patient receives care in a private residence
13 Assisted Living Facility
Congregate residential facility with selfcontained living units providing assessment of each resident's needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services
14 Group Home Congregate residential foster care setting
22 Outpatient Hospital A portion of a hospital that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization
24 Ambulatory Surgical Center
A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis
12 November 2003, No. 16LTC Bul let in 12
33 Custodial Care Facility A facility that provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component
34 Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided
41 Ambulance-Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured
42 Ambulance-Air or Water
An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured
49 Independent Clinic A location, not part of a hospital and not described by any other place of service, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only
50 Federally Qualified Health Center
A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under general direction of a physician
53 Community Mental Health Center
A facility that provides one or more of the following mental health services:
• Outpatient • 24-hour emergency care• Day treatment• Partial hospitalization• Psychosocial rehabilitation • Screening for admission to State mental health facilities• Consultation• Education
62 Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services may include one or more of the following:
• Physical therapy• Occupational therapy• Speech pathology• Social services• Psychological services• Orthotics and prosthetic services
71 State or Local Public Health Clinic
A facility maintained by either a State or local health department that provides ambulatory primary medical care under the general supervision of a physician
72 Rural Health Clinic A certified facility, located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician
99 Other Place of Service Other place of service not identified
Place of Service (POS) Codes Table for the 837P
Code Name Description
13 LTC Bul le t inNovember 2003, No. 16
ModifiersAs previously described in this bulletin, the HIPAA solution chosen for the DHS/TDMHMR Claims Management System (CMS) is to recreate the state-defined local code from the HIPAA-compliant information being sent by the provider and supplemental information found in our various subsystems (that is, provider or client). In certain instances, to accurately recreate the bill codes, the solution requires the use of modifiers to define or clarify service group, budget, service provider type, occupancy, dwelling type, and others. The table below depicts the modifiers to be used, the modifier description, and the modifier field placement. Since the circumstances requiring the use of a modifier vary, and the dependencies cannot always be accurately depicted in a chart, it is not possible to show definitively when a modifier will be used. Remember to use the modifiers as noted below.
Modifier Field 1
Use only if you have a single contract with multiple service groups. If your contract contains more than one service group, use Modifier Field 1 to depict the service group of the client for which you are billing services.
Modifier Field 2
Use if it is shown on the crosswalk, or your contract requires you to specify a budget when filing a claim.
Modifier Field 3
Use only if it is shown on the crosswalk.
Modifier Field 4
Use only if it is shown on the crosswalk.
The new version of the modifier table follows this article. Providers may also access the table on the DHS HIPAA Project Team Web site at www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html.
DHS/TDMHMR Modifier Table
Refer to the “Long Term Care Bill Code Crosswalk Table” on page 17 to determine if modifiers are necessary to bill for your particular service.
Modifier Field # Modifier Modifier Description
1 U1 Service Group 1
1 U2 Service Group 2
1 U3 Service Group 3
1 U4 Service Group 4
1 U5 Service Group 5
1 U6 Service Group 6
1 U7 Service Group 7
1 U8 Service Group 8
1 U9 Service Group 9
1 UA Service Group 11
1 UB Service Group 16
1 UC Service Group 17
1 UD Service Group 18
14 November 2003, No. 16LTC Bul let in 14
2 U1 Budget #1
2 U2 Budget #2
2 U3 Level/Priority 1
2 U4 Level 2
2 U5 Level 3
2 U6 Level 4
2 U7 Level 5
2 U8 Level 6
2 U9 Level 7
2 UA Level 8
2 TG Complex/High Tech Level of Care
3 U1 Assisted Living/Single Occupancy
3 U2 Residential Care/Double Occupancy
3 U3 Training
3 U4 Prevocational Services
3 U5 Activities of Daily Living
3 U7 Full
3 U8 Partial
3 GO Services Provided by an Occupational Therapist
3 GP Services Provided by a Physical Therapist
3 GN Services Provided by a Speech-Language Pathologist
3 AJ Clinical Social Worker
3 TD Registered Nurse (RN)
3 TE Licensed Practical/Vocational Nurse (LPN/LVN)
4 U1 Apartment
4 U2 Nonapartment
4 U4 Participating Provider
4 U5 Nonparticipating Provider
Modifier Field # Modifier Modifier Description
15 LTC Bul le t inNovember 2003, No. 16
LTC Bill Code Crosswalk Table
The DHS/TDMHMR HIPAA Project Team has modified the LTC Bill Code Crosswalk Table since it was published in the August 2003 LTC Bulletin, No. 15, and the 2003 LTC User Manual for Paper Submitters. The project team intends to keep modifications/changes to a minimum; however, testing of the HIPAA software, legislative mandates, policy/program changes, and national code updates can result in changes to the crosswalk table. Due to publishing deadlines, the version that appears in this bulletin is the one posted to the DHS Web site on October 1, 2003. To access the most current version of the LTC Bill Code crosswalk, providers should refer to the DHS HIPAA Project Team Web site at www.dhs.state.tx.us/providers/hipaa/ltc_conference/index.html. The crosswalk table will be updated on a quarterly basis, with the next update due in early 2004.
How to Use the LTC Bill Code Crosswalk Table
The left side of the LTC Bill Code Crosswalk Table provides the Texas LTC Local Codes for the service group, bill code, service code, and bill code description used to bill for services before HIPAA. The right side of the table identifies the National Standard Codes you will use on your claims effective October 16, 2003. Your contract and MESAV information will tell you the service codes and service groups for which you have authorization to provide services.
To use the crosswalk table, follow the guidelines below:
1. Find your service group, service code, and, if possible, the bill code you have used in the past to bill for the service(s) and follow the row across to the National Codes section to find the new codes to use effective on and after October 16, 2003.
2. If the bill code has been mapped to a national HCPCS code, you will find an entry of “HC” or “AD” in the procedure code qualifier field and information in either the HCPCS or CPT code fields (or, in some cases, in the HCPCS or CPT and the revenue code fields). If the bill code only has a national revenue code shown, no entry will be found in the procedure code qualifier field.
3. If there are entries in the modifier fields, you will need to use those modifiers in the designated fields when completing the detail line for that service.
4. If there is a “ZZ” in the procedure code qualifier field, you will continue to use the existing bill code to claim reimbursement.
5. The table contains a field called “End Date.” If this field has an entry, it means that services provided after the stated end date will not be paid. �
16 November 2003, No. 16LTC Bul let in 16
Lo
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sive
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llary
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17 LTC Bul le t inNovember 2003, No. 16
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sthe
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’s A
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1N
0705
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Loc
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vice
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eC
laim
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837I;
P=837P
;D
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Not
e: T
he Z
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Exce
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ME/
Adap
tive
Aids
, D
enta
l, an
d H
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hysi
cian
Ser
vice
s.
18 November 2003, No. 16LTC Bul let in
1N
0706
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Gro
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Tabl
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Ser
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G
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837I;
P=837P
;D
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Not
e: T
he Z
Z qu
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Exce
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ME/
Adap
tive
Aids
, D
enta
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hysi
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Ser
vice
s.
19 LTC Bul le t inNovember 2003, No. 16
Ser
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Gro
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2
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0465
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44
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0466
9A
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ssm
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aliz
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ceH
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25
06
04
44
Eval
uatio
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spe
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lang
uage
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com
mun
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au
dito
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Gro
up 2
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Tabl
eTe
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LTC
Loc
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Nat
iona
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Ser
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G
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Bill
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2G
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Hab
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08/3
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0124
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Hab
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CD
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Loca
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be
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.P
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0100
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Res
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to b
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P
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0101
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Res
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-Hom
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P
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0102
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Res
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CD
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e to
be
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.P
2G
0200
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e M
anag
emen
t08/3
1/03
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0201
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Cas
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CT2
02
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man
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per
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0300
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91
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3.
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: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
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ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 1
- Lo
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ill C
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Tabl
eTe
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LTC
Loc
al C
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Nat
iona
l Cod
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Ser
vice
G
roup
Bill
C
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Ser
vice
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eC
laim
Typ
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: I=
837I;
P=837P
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Not
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he Z
Z qu
alifi
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r 1
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3.
Exce
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: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
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ce P
hysi
cian
Ser
vice
s.
20 November 2003, No. 16LTC Bul let in
2G
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eval
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ser
vice
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to
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24
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P
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13
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sing
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00
3TE
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/LVN
ser
vice
s up
to
15 m
inut
esP
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
01
Psyc
hiat
ric d
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ostic
inte
rvie
w e
xam
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P
2G
0403
14
Psyc
holo
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vice
sH
C9
08
10
Indi
vidu
al p
sych
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, in
tera
ctiv
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sing
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y eq
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phy
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l dev
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, lan
guag
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an
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0403
14
Psyc
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sH
C9
08
12
Indi
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tera
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an
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, ap
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45 -
50 m
inut
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-fa
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P
2G
0403
14
Psyc
holo
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sH
C9
08
14
Indi
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an
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P
2G
0403
14
Psyc
holo
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vice
sH
C9
08
16
Indi
vidu
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ifyin
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utes
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P
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0403
14
Psyc
holo
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vice
sH
C9
08
18
Indi
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utes
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P
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0403
14
Psyc
holo
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l Ser
vice
sH
C9
08
21
Indi
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, in
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5 -
80
min
utes
fac
e-to
-face
with
pat
ient
P
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
23
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r or o
ther
m
echa
nism
s of
non
verb
al c
omm
unic
atio
n, in
an
inpa
tient
ho
spita
l, pa
rtia
l hos
pita
l or
resi
dent
ial c
are
sett
ing,
ap
prox
imat
ely
20 -
30 m
inut
es fa
ce-to
-face
with
the
patie
nt
P
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
26
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r or o
ther
m
echa
nism
s of
non
verb
al c
omm
unic
atio
n, in
an
inpa
tient
ho
spita
l, pa
rtia
l hos
pita
l or
resi
dent
ial c
are
sett
ing,
ap
prox
imat
ely
45 -
50 m
inut
es fa
ce-to
-face
with
the
patie
nt
P
Ser
vice
Gro
up 2
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
21 LTC Bul le t inNovember 2003, No. 16
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
28
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r or o
ther
m
echa
nism
s of
non
verb
al c
omm
unic
atio
n, in
an
inpa
tient
ho
spita
l, pa
rtia
l hos
pita
l or
resi
dent
ial c
are
sett
ing,
ap
prox
imat
ely
75 -
80 m
inut
es fa
ce-to
-face
with
the
patie
nt
P
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
45
Psyc
hoan
alys
isP
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
47
Fam
ily p
sych
othe
rapy
(co
njoi
nt c
ouns
elin
g) w
ith p
atie
nt
pres
ent
P
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
62
Phar
mac
olog
ical
man
agem
ent,
incl
udin
g pr
escr
iptio
n/us
e/re
view
of m
edic
atio
nP
2G
0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
61
00
Psyc
holo
gica
l tes
ting
P
2G
0500
15
Adap
tive
Aids
ADD
99
99
Uns
peci
fied
Adju
nctiv
e Pr
oced
ure,
by
Rep
ort
D
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
00
3N
on-e
mer
genc
y tr
ansp
orta
tion;
enc
ount
er/t
ripP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
03
9Ve
hicl
e M
odifi
catio
ns, w
aive
r; p
er s
ervi
ceP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CS
51
99
Pers
onal
Car
e Ite
m, N
OS
, ea
chP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE0
63
6M
ultip
ositi
onal
pat
ient
sup
port
sys
tem
, with
inte
grat
ed li
ft,
patie
ntP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
03
1R
olla
bout
Cha
ir, a
ny a
nd a
ll ty
pes
with
cas
tors
5 in
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or
grea
ter
P
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
13
0S
tand
ard
Whe
elch
air,
fixe
d fu
ll le
ngth
arm
s, fi
xed
or s
win
g aw
ay d
etac
habl
eP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
39
9D
urab
le M
edic
al E
quip
men
t, M
isce
llane
ous
P
2G
0500
15
DM
E/Ad
aptiv
e Ai
ds09/3
0/03
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
0S
ynth
esiz
ed S
peec
h Au
gmen
tativ
e C
omm
unic
atio
n D
evic
e w
ith D
ynam
ic D
ispl
ayP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
2C
omm
unic
atio
n B
oard
, N
on-e
lect
roni
c Au
gmen
tativ
e or
Al
tern
ativ
e C
omm
unic
atio
nP
2G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
9S
peci
aliz
ed m
edic
al e
quip
men
t, n
ot o
ther
wis
e sp
ecifi
ed,
wai
ver
P
2G
0608
16
Hom
e M
odifi
catio
nsH
CS
51
65
Hom
e M
odifi
catio
ns; pe
r se
rvic
eP
2G
0701
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 2 -
Prio
rity
08/3
1/03
2G
1200
22
Med
ical
Sup
plie
s H
CT2
02
8S
peci
aliz
ed S
uppl
y, N
ot o
ther
wis
e sp
ecifi
ed, w
aive
rP
2G
0720
27
Con
sum
er M
anag
ed P
erso
nal
Atte
ndan
t S
ervi
ces
08/3
1/03
2G
0721
27
Clie
nt M
anag
ed A
tten
dant
Ser
vice
s -
Vouc
her
08/3
1/03
2G
0202
40
Prea
sses
smen
t08/3
1/03
Ser
vice
Gro
up 2
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
22 November 2003, No. 16LTC Bul let in
2G
0203
40
Cas
e M
anag
emen
t Pa
rtia
l As
sess
men
tH
CT1
00
1U
8N
ursi
ng A
sses
smen
t/Ev
alua
tion
P
2G
0203
40
Cas
e M
anag
emen
t Pa
rtia
l As
sess
men
tH
CT1
02
3U
8S
cree
ning
to
dete
rmin
e th
e ap
prop
riate
ness
of
cons
ider
atio
n of
an
indi
vidu
al for
par
ticip
atio
n in
a
spec
ified
pro
gram
, pr
ojec
t or
tre
atm
ent
prot
ocol
, pe
r en
coun
ter
P
2G
0204
40
Dire
ct P
rovi
der
Full
Asse
ssm
ent
HC
T10
23
U7
Scr
eeni
ng t
o de
term
ine
the
appr
opria
tene
ss o
f co
nsid
erat
ion
of a
n in
divi
dual
for
par
ticip
atio
n in
a
spec
ified
pro
gram
, pr
ojec
t or
tre
atm
ent
prot
ocol
, pe
r en
coun
ter
P
2G
0205
40
Annu
al A
sses
smen
t08/3
1/03
2G
0605
40
Spe
cific
atio
ns H
M M
ods
08/3
1/03
2G
0515
41
ADP
Aide
s/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0516
41
ADP
Aide
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0517
41
ADP
Aide
s/R
equi
sitio
n Fe
es
1
00
0.0
0 -
14
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0518
41
ADP
Aide
s/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0519
41
ADP
Aide
s/R
equi
sitio
n Fe
es
2
00
0.0
0 -
24
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0520
41
ADP
Aide
s/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0521
41
ADP
Aide
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0522
41
ADP
Aide
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0523
41
ADP
Aide
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0524
41
ADP
Aide
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0525
41
ADP
Aide
s/R
equi
sitio
n Fe
es
50
00
.00
- O
VER
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0609
41
MH
Mod
s/R
equi
sitio
n Fe
es
0 -
49
9.9
908/3
1/03
2G
0610
41
MH
Mod
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
08/3
1/03
2G
0611
41
MH
Mod
s/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
908/3
1/03
Ser
vice
Gro
up 2
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
23 LTC Bul le t inNovember 2003, No. 16
2G
0612
41
MH
Mod
s/R
equi
sitio
n Fe
es
2
00
0.0
0 -
24
99
.99
08/3
1/03
2G
0613
41
MH
Mod
s/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
908/3
1/03
2G
0614
41
MH
Mod
s/R
equi
sitio
n Fe
es
2
50
0.0
0 -
29
99
.99
08/3
1/03
2G
0615
41
MH
Mod
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
908/3
1/03
2G
0616
41
MH
Mod
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
08/3
1/03
2G
0617
41
MH
Mod
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
08/3
1/03
2G
0618
41
MH
Mod
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
908/3
1/03
2G
0619
41
MH
Mod
s/R
equi
sitio
n Fe
es
50
00
.00
- 5
49
9.9
908/3
1/03
2G
0620
41
MH
Mod
s/R
equi
sitio
n Fe
es
55
00
.00
- 5
99
9.9
908/3
1/03
2G
0621
41
MH
Mod
s/R
equi
sitio
n Fe
es
60
00
.00
- 6
49
9.9
908/3
1/03
2G
0622
41
MH
Mod
s/R
equi
sitio
n Fe
es
65
00
.00
- O
VER
08/3
1/03
2G
0404
42
Spe
cial
ized
The
rapi
esH
CQ
00
82
Activ
ity t
hera
py fur
nish
ed in
con
nect
ion
with
par
tial
hosp
italiz
atio
n, I.
e. m
usic
, ar
t, d
ance
, or
pla
y th
erap
ies
that
are
not
prim
arily
rec
reat
iona
l, pe
r vi
sit
P
2G
0404
42
Spe
cial
ized
The
rapi
esH
C9
75
35
Sel
f ca
re/h
ome
man
agem
ent
trai
ning
(I.e
. ac
tiviti
es o
f da
ily li
ving
and
com
pens
ator
y tr
aini
ng, m
eal p
repa
ratio
n,
safe
ty p
roce
dure
s, a
nd in
stru
ctio
n in
use
of ad
aptiv
e eq
uipm
ent)
dire
ct o
ne o
n on
e co
ntac
t by
prov
ider
, eac
h 15
min
utes
P
2G
0404
42
Spe
cial
ized
The
rapi
esH
C9
75
37
Com
mun
ity/w
ork
rein
tegr
atio
n tr
aini
ng (I.e
. sh
oppi
ng,
tran
spor
tatio
n, m
oney
man
agem
ent,
avo
catio
nal a
ctiv
ities
an
d/or
wor
k en
viro
nmen
t/m
odifi
catio
n an
alys
is, w
ork
task
an
alys
is), d
irect
one
on
one
cont
act
by p
rovi
der,
eac
h 15
min
utes
P
2S
0105
10A
Hab
ilita
tion
- Del
egat
ed N
ursi
ngH
CS
51
25
Atte
ndan
t C
are
Ser
vice
s, p
er 1
5 m
inut
esP
2S
0105
10A
Hab
ilita
tion
- Del
egat
ed N
ursi
ngH
CT1
01
9Pe
rson
al C
are
Ser
vice
s, p
er 1
5 m
inut
es, no
t fo
r an
in
patie
nt o
r re
side
nt o
f a h
ospi
tal,
nurs
ing
faci
lity,
ICF-
MR
or
IMD
, par
t of
the
indi
vidu
aliz
ed p
lan
of tre
atm
ent (n
ot t
o be
use
d fo
r se
rvic
es p
rovi
ded
by a
hom
e he
alth
aid
e or
ce
rtifi
ed n
urse
ass
ista
nt)
P
2S
0106
10B
Hab
ilita
tion
- Sup
port
ive
Empl
oy
Empl
oym
ent
HC
T20
19
Hab
ilita
tion,
Sup
port
ive
Empl
oym
ent,
per
15 m
inut
esP
Ser
vice
Gro
up 2
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
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HC
PC
S
Cod
eC
PT
Cod
eR
even
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Cod
eM
odifi
er
1M
odifi
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2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
24 November 2003, No. 16LTC Bul let in
2S
0107
10B
Hab
ilita
tion
- Pre
voca
tiona
lH
CT2
01
5U
4H
abili
tatio
n pr
evoc
atio
nal,
wai
ver,
per
hou
rP
2G
0128
11A
Res
pite
- O
ut-o
f-Hom
eH
CS
51
51
Uns
kille
d R
espi
te C
are,
per
die
mP
2G
0170
11A
Out
-of-H
ome
Res
pite
CD
SZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0302
13A
Nur
sing
Ser
vice
s - L
VNH
CS
91
24
Nur
sing
Car
e in
the
Hom
e, b
y LV
NP
2G
0302
13A
Nur
sing
Ser
vice
s - L
VNH
CT1
00
3LP
N/L
VN s
ervi
ces
up t
o 15 m
inut
esP
2G
0303
13B
Nur
sing
Ser
vice
s - R
NH
CS
91
23
Nur
sing
Car
e in
the
Hom
e, b
y R
NP
2G
0303
13B
Nur
sing
Ser
vice
s - R
NH
CT1
00
1N
ursi
ng a
sses
smen
t/ev
alua
tion
P
2G
0303
13B
Nur
sing
Ser
vice
s - R
NH
CT1
00
2R
N s
ervi
ces
up t
o 15 m
inut
esP
2S
9800
13C
Nur
sing
Ser
vice
s by
Hig
hly
Tech
nica
l R
N,
per
hour
HC
S9
80
0TG
Hom
e Th
erap
y; p
rovi
sion
of in
fusi
on, sp
ecia
lty d
rug
adm
inis
trat
ion,
and
/or
asso
ciat
ed n
ursi
ng s
ervi
ces
and
proc
edur
es, by
hig
hly
tech
nica
l R.N
., p
er h
our
P
2T1
003
13D
Nur
sing
Ser
vice
s LV
NH
CT1
00
3TG
LPN
/LVN
ser
vice
s, u
p to
15 m
inut
esP
2G
0705
17A
PAS
Del
egat
ed (
For
Futu
re U
se)
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0706
17B
PAS
Pro
tect
ive
Sup
ervi
sion
(Fo
r Fu
ture
Use
)ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0937
19E
Assi
sted
Liv
ing
- Hab
ilita
tion
24
hou
r08/3
1/03
2G
0938
19F
Assi
sted
Liv
ing
- Hab
ilita
tion
Less
Th
an 2
4 h
our
08/3
1/03
2G
0722
27A
CM
PAS
- C
lient
Dire
cted
Ser
vice
sZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0723
27A
CM
PAS
- C
lient
Dire
cted
Ser
vice
sZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0207
40A
Prea
sses
smen
tH
CT2
02
4S
ervi
ce a
sses
smen
t/pl
an o
f ca
re d
evel
opm
ent,
wai
ver
P
2G
0623
41B
MH
Mod
s/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0624
41B
MH
Mod
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0625
41B
MH
Mod
s/R
equi
sitio
n Fe
es
10
00
.00
- 1
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0626
41B
MH
Mod
s/R
equi
sitio
n Fe
es
1
50
0.0
0 -
19
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0627
41B
MH
Mod
s/R
equi
sitio
n Fe
es
20
00
.00
- 2
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0628
41B
MH
Mod
s/R
equi
sitio
n Fe
es
2
50
0.0
0 -
29
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0629
41B
MH
Mod
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0630
41B
MH
Mod
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
Ser
vice
Gro
up 2
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
25 LTC Bul le t inNovember 2003, No. 16
2G
0631
41B
MH
Mod
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0632
41B
MH
Mod
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0633
41B
MH
Mod
s/R
equi
sitio
n Fe
es
50
00
.00
- 5
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0634
41B
MH
Mod
s/R
equi
sitio
n Fe
es
55
00
.00
- 5
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0635
41B
MH
Mod
s/R
equi
sitio
n Fe
es
6
00
0.0
0 -
64
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0636
41B
MH
Mod
s/R
equi
sitio
n Fe
es
6
50
0.0
0 -
Ove
rZZ
Loca
l cod
e to
be
reta
ined
.P
2G
0607
41C
Spe
cific
atio
ns A
dapt
ive
Aids
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0604
41D
Spe
cific
atio
ns H
M M
ods
ZZLo
cal c
ode
to b
e re
tain
ed.
P
2G
0637
41E
Den
tal/
Req
uisi
tion
Fees
0 -
49
9.9
908/3
1/03
2G
0638
41E
Den
tal/
Req
uisi
tion
Fees
5
00
.00
- 9
99
.99
08/3
1/03
2G
0639
41E
Den
tal/
Req
uisi
tion
Fees
1
00
0.0
0 -
14
99
.99
08/3
1/03
2G
0640
41E
Den
tal/
Req
uisi
tion
Fees
1
50
0.0
0 -
19
99
.99
08/3
1/03
2G
0641
41E
Den
tal/
Req
uisi
tion
Fees
2
00
0.0
0 -
24
99
.99
08/3
1/03
2G
0642
41E
Den
tal/
Req
uisi
tion
Fees
2
50
0.0
0 -
29
99
.99
08/3
1/03
2G
0643
41E
Den
tal/
Req
uisi
tion
Fees
3
00
0.0
0 -
34
99
.99
08/3
1/03
2G
0644
41E
Den
tal/
Req
uisi
tion
Fees
3
50
0.0
0 -
39
99
.99
08/3
1/03
2G
0645
41E
Den
tal/
Req
uisi
tion
Fees
40
00
.00
- 4
49
9.9
908/3
1/03
2G
0646
41E
Den
tal/
Req
uisi
tion
Fees
4
50
0.0
0 -
49
99
.99
08/3
1/03
2G
0647
41E
Den
tal/
Req
uisi
tion
Fees
5
00
0.0
0 -
OVE
R08/3
1/03
2N
0600
5A
Den
tal S
ervi
ces
08/3
1/03
Ser
vice
Gro
up 2
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
26 November 2003, No. 16LTC Bul let in
Ser
vice
Gro
up
3
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
3G
0400
7O
ccup
atio
nal T
hera
pyH
CG
01
52
GO
Ser
vice
s of
a o
ccup
atio
nal t
hera
pist
in a
hom
e he
alth
se
ttin
g; p
er 1
5 m
inut
esP
3G
0401
8Ph
ysic
al T
hera
pyH
CG
01
51
GP
Ser
vice
s of
a p
hysi
cal t
hera
pist
in a
hom
e he
alth
set
ting;
pe
r 1
5 m
inut
esP
3G
0402
9S
peec
h Th
erap
yH
CG
01
53
GN
Spe
ech
or la
ngua
ge p
atho
logi
st in
hom
e he
alth
set
ting;
per
1
5 m
inut
esP
3G
0101
11
Res
pite
- In
-Hom
e ZZ
Loca
l cod
e to
be
reta
ined
. (V
FI P
aym
ent)
P
3G
0103
11
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 1
08/3
1/03
3G
0104
11
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 3
08/3
1/03
3G
0105
11
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
6)
08/3
1/03
3G
0106
11
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
08/3
1/03
3G
0107
11
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
6)
08/3
1/03
3G
0109
11
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 2
08/3
1/03
3G
0171
11
In-H
ome
Res
pite
CD
S -
Agen
cyZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1105
11
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
5)
08/3
1/03
3G
1106
11
Res
pite
/Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 5
)08/3
1/03
3G
1107
11
Res
pite
/Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 5
)08/3
1/03
3G
2105
11
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
4)
08/3
1/03
3G
2106
11
Res
pite
/Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 4
)08/3
1/03
3G
2107
11
Res
pite
/Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 4
)08/3
1/03
3G
3105
11
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
3)
08/3
1/03
3G
3106
11
Res
pite
/Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 3
)08/3
1/03
3G
3107
11
Res
pite
/Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 3
)08/3
1/03
3G
4105
11
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
2)
08/3
1/03
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
27 LTC Bul le t inNovember 2003, No. 16
3G
4106
11
Res
pite
/Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 2
)08/3
1/03
3G
4107
11
Res
pite
/Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 2
)08/3
1/03
3G
5105
11
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
1)
08/3
1/03
3G
5106
11
Res
pite
/Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 1
)08/3
1/03
3G
5107
11
Res
pite
/Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 1
)08/3
1/03
3N
0201
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0202
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0203
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0204
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0205
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0206
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0207
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0208
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0209
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0210
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0211
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0212
11
Res
pite
- In
-Hom
e08/3
1/03
3N
0500
11
Vent
ilato
r - F
ull
08/3
1/03
3N
0501
11
Vent
ilato
r - P
artia
l08/3
1/03
3G
0200
12
Cas
e M
anag
emen
t08/3
1/03
3G
0300
13
Nur
sing
- R
NH
CS
91
23
TDN
ursi
ng C
are
in t
he H
ome,
by
RN
P
3G
0300
13
Nur
sing
- R
NH
CT1
00
1TD
Nur
sing
ass
essm
ent/
eval
uatio
nP
3G
0300
13
Nur
sing
- R
NH
CT1
00
2TD
RN
ser
vice
s up
to
15 m
inut
esP
3G
0301
13
Nur
sing
- LV
NH
CS
91
24
TEN
ursi
ng C
are
in t
he H
ome,
by
LVN
P
3G
0301
13
Nur
sing
- LV
NH
CT1
00
3TE
LPN
/LVN
ser
vice
s up
to
15 m
inut
esP
3G
0500
15
Adap
tive
Aids
ADD
99
99
Uns
peci
fied
Adju
nctiv
e Pr
oced
ure,
by
Rep
ort
D
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
03
9Ve
hicl
e M
odifi
catio
ns, w
aive
r; p
er s
ervi
ceP
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE0
63
6M
ultip
ositi
onal
pat
ient
sup
port
sys
tem
, with
inte
grat
ed li
ft,
patie
ntP
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
28 November 2003, No. 16LTC Bul let in
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
03
1R
olla
bout
Cha
ir, a
ny a
nd a
ll ty
pes
with
cas
tors
5 in
ches
or
grea
ter
P
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
13
0S
tand
ard
Whe
elch
air,
fixe
d fu
ll le
ngth
arm
s, fi
xed
or s
win
g aw
ay d
etac
habl
eP
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
39
9D
urab
le M
edic
al E
quip
men
t, M
isce
llane
ous
P
3G
0500
15
DM
E/Ad
aptiv
e Ai
ds09/2
8/03
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
0S
ynth
esiz
ed S
peec
h Au
gmen
tativ
e C
omm
unic
atio
n D
evic
e w
ith D
ynam
ic D
ispl
ayP
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
2C
omm
unic
atio
n B
oard
, N
on-e
lect
roni
c Au
gmen
tativ
e or
Al
tern
ativ
e C
omm
unic
atio
nP
3G
0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
9S
peci
aliz
ed m
edic
al e
quip
men
t, n
ot o
ther
wis
e sp
ecifi
ed,
wai
ver
P
3G
0608
16
Hom
e M
odifi
catio
nsH
CS
51
65
Hom
e M
odifi
catio
ns; pe
r se
rvic
eP
3+9
99
99
17
Expe
dite
d Pa
ymen
tZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0700
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 308/3
1/03
3G
0701
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 2 -
Prio
rity
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
3G
0800
18
Adul
t Fo
ster
Car
e - L
evel
1H
CS
51
40
31
05
A fla
t ra
te c
harg
e in
curr
ed o
n ei
ther
a d
aily
bas
is o
r to
tal
stay
bas
is for
anc
illar
y se
rvic
es o
nly.
I
3G
0801
18
Adul
t Fo
ster
Car
e - L
evel
2H
CS
51
40
31
05
A fla
t ra
te c
harg
e in
curr
ed o
n ei
ther
a d
aily
bas
is o
r to
tal
stay
bas
is for
anc
illar
y se
rvic
es o
nly.
I
3G
0802
18
Adul
t Fo
ster
Car
e - L
evel
3H
CS
51
40
31
05
A fla
t ra
te c
harg
e in
curr
ed o
n ei
ther
a d
aily
bas
is o
r to
tal
stay
bas
is for
anc
illar
y se
rvic
es o
nly.
I
3G
0900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 6
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
3G
0900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 6
)H
CT2
03
10
24
0U
1U
1Al
l Inc
lusi
ve A
ncill
ary
I
3G
0901
19
Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 6
)08/3
1/03
3G
0902
19
Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 6
)08/3
1/03
3G
0905
19
Assi
sted
Liv
ing/
Res
iden
tial C
are
- Pe
rson
al C
are
08/3
1/03
3G
1900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 5
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
3G
1900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 5
)H
CT2
03
10
24
0U
1U
1Al
l Inc
lusi
ve A
ncill
ary
I
3G
1901
19
Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 5
)08/3
1/03
3G
1902
19
Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 5
)08/3
1/03
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
29 LTC Bul le t inNovember 2003, No. 16
3G
2900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 4
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
3G
2900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 4
)H
CT2
03
10
24
0U
1U
1Al
l Inc
lusi
ve A
ncill
ary
I
3G
2901
19
Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 4
)08/3
1/03
3G
2902
19
Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 4
)08/3
1/03
3G
3900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 3
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
3G
3900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 3
)H
CT2
03
10
24
0U
1U
1Al
l Inc
lusi
ve A
ncill
ary
I
3G
3901
19
Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 3
)08/3
1/03
3G
3902
19
Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 3
)08/3
1/03
3G
4900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 2
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
3G
4900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 2
)H
CT2
03
10
24
0U
1U
1Al
l Inc
lusi
ve A
ncill
ary
I
3G
4901
19
Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 2
)08/3
1/03
3G
4902
19
Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 2
)08/3
1/03
3G
5900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 1
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
3G
5900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 1
)H
CT2
03
10
24
0U
1U
1Al
l Inc
lusi
ve A
ncill
ary
I
3G
5901
19
Res
iden
tial C
are
- Ap
artm
ent
(Lev
el 1
)08/3
1/03
3G
5902
19
Res
iden
tial C
are
- N
onap
artm
ent
(Lev
el 1
)08/3
1/03
3G
1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
60
In
stal
latio
n an
d Te
stin
gP
3G
1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
61
Mon
thly
Ser
vice
Fee
(ex
clud
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stal
latio
n an
d te
stin
g)P
3G
1000
20
Emer
genc
y R
espo
nse
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vice
sH
CS
51
62
Purc
hase
Onl
yP
3G
1100
21
Pres
crip
tions
- di
scon
tinue
d08/3
1/03
3G
0500
22
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
8S
peci
aliz
ed S
uppl
y, N
ot o
ther
wis
e sp
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ed, w
aive
rP
3G
1200
22
Med
ical
Sup
plie
s H
CS
51
99
Pers
onal
Car
e Ite
m, N
OS
, ea
chP
3C
0100
25
Hom
e D
eliv
ered
Mea
ls08/3
1/03
3C
0101
25
Wai
ver
Mea
lsH
CS
51
70
Per
mea
l, in
clud
es p
repa
ratio
n an
d de
liver
yP
3G
0202
40
Prea
sses
smen
t08/3
1/03
3G
0205
40
Annu
al A
sses
smen
t08/3
1/03
3G
0206
40
Asse
ssm
ent-M
DS
Hom
e N
ot u
sed
curr
ently
. Was
dev
elop
ed a
s a
plac
ehol
der i
n th
e ev
ent
the
MD
S r
epla
ces
the
3652.
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
30 November 2003, No. 16LTC Bul let in
3G
0605
40
Spe
cific
atio
ns H
M M
ods
08/3
1/03
3G
0515
41
ADP
Aide
s/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0516
41
ADP
Aide
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0517
41
ADP
Aide
s/R
equi
sitio
n Fe
es
1
00
0.0
0 -
14
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0518
41
ADP
Aide
s/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0519
41
ADP
Aide
s/R
equi
sitio
n Fe
es
2
00
0.0
0 -
24
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0520
41
ADP
Aide
s/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0521
41
ADP
Aide
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0522
41
ADP
Aide
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0523
41
ADP
Aide
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0524
41
ADP
Aide
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0525
41
ADP
Aide
s/R
equi
sitio
n Fe
es
50
00
.00
- O
VER
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0609
41
MH
Mod
s/R
equi
sitio
n Fe
es
0 -
49
9.9
908/3
1/03
3G
0610
41
MH
Mod
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
08/3
1/03
3G
0611
41
MH
Mod
s/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
908/3
1/03
3G
0612
41
MH
Mod
s/R
equi
sitio
n Fe
es
2
00
0.0
0 -
24
99
.99
08/3
1/03
3G
0613
41
MH
Mod
s/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
908/3
1/03
3G
0614
41
MH
Mod
s/R
equi
sitio
n Fe
es
2
50
0.0
0 -
29
99
.99
08/3
1/03
3G
0615
41
MH
Mod
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
908/3
1/03
3G
0616
41
MH
Mod
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
08/3
1/03
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
31 LTC Bul le t inNovember 2003, No. 16
3G
0617
41
MH
Mod
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
08/3
1/03
3G
0618
41
MH
Mod
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
908/3
1/03
3G
0619
41
MH
Mod
s/R
equi
sitio
n Fe
es
50
00
.00
- 5
49
9.9
908/3
1/03
3G
0620
41
MH
Mod
s/R
equi
sitio
n Fe
es
55
00
.00
- 5
99
9.9
908/3
1/03
3G
0621
41
MH
Mod
s/R
equi
sitio
n Fe
es
60
00
.00
- 6
49
9.9
908/3
1/03
3G
0622
41
MH
Mod
s/R
equi
sitio
n Fe
es
65
00
.00
- O
VER
08/3
1/03
3G
1101
41
Pres
crip
tion/
Req
uisi
tion
Fees
08/3
1/03
3G
1201
41
Med
ical
S/R
equi
sitio
n Fe
es
0 -
49
9.9
908/3
1/03
3G
1202
41
Med
ical
S/R
equi
sitio
n Fe
es
50
0.0
0 -
99
9.9
908/3
1/03
3G
1203
41
Med
ical
S/R
equi
sitio
n Fe
es
10
00
.00
- 1
49
9.9
908/3
1/03
3G
1204
41
Med
ical
S/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
908/3
1/03
3G
1205
41
Med
ical
S/R
equi
sitio
n Fe
es
20
00
.00
- 2
49
9.9
908/3
1/03
3G
1206
41
Med
ical
S/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
908/3
1/03
3G
1207
41
Med
ical
S/R
equi
sitio
n Fe
es
3
00
0.0
0 -
34
99
.99
08/3
1/03
3G
1208
41
Med
ical
S/R
equi
sitio
n Fe
es
35
00
.00
- 3
99
9.9
908/3
1/03
3G
1209
41
Med
ical
S/R
equi
sitio
n Fe
es
40
00
.00
- 4
49
9.9
908/3
1/03
3G
1210
41
Med
ical
S/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
908/3
1/03
3G
1211
41
Med
ical
S/R
equi
sitio
n Fe
es
50
00
.00
- O
VER
08/3
1/03
3G
0237
52
Com
mun
ity S
uppo
rt S
ervi
ces
08/3
1/03
3G
0238
53
Tran
sitio
nal S
ervi
ces
08/3
1/03
3G
0128
11A
Res
pite
- O
ut-o
f-Hom
e08/3
1/03
3G
0132
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 1
HC
S5
15
1U
3U
nski
lled
Res
pite
Car
e, p
er d
iem
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
32 November 2003, No. 16LTC Bul let in
3G
0132
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 1
HC
S5
15
10
66
0U
3U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0133
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 2
HC
S5
15
1U
4U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0133
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 2
HC
S5
15
10
66
0U
4U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0134
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 3
HC
S5
15
1U
5U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0134
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 3
HC
S5
15
10
66
0U
5U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0172
11B
Adul
t Fo
ster
Car
e C
DS
- Ag
ency
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0135
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
6)
HC
S5
15
10
66
0U
8U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0135
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
6)
HC
S5
15
1U
8U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0136
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
5)
HC
S5
15
10
66
0U
7U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0136
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
5)
HC
S5
15
1U
7U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0137
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
4)
HC
S5
15
10
66
0U
6U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0137
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
4)
HC
S5
15
1U
6U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0138
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
3)
HC
S5
15
10
66
0U
5U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0138
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
3)
HC
S5
15
1U
5U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0139
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
2)
HC
S5
15
10
66
0U
4U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0139
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
2)
HC
S5
15
1U
4U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0140
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
1)
HC
S5
15
10
66
0U
3U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0140
11C
Res
pite
- As
sist
ed L
ivin
g -
Apar
tmen
t (L
evel
1)
HC
S5
15
1U
3U
1U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0173
11C
VR
espi
te A
ssis
ted
Livi
ng,
Apar
tmen
t C
DS
- Pa
rtic
ipan
tZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0174
11C
VR
espi
te A
ssis
ted
Livi
ng,
Apar
tmen
t C
DS
- Ag
ency
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0142
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
HC
S5
15
10
66
0U
8U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0142
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
HC
S5
15
1U
8U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
33 LTC Bul le t inNovember 2003, No. 16
3G
0143
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
5)
HC
S5
15
10
66
0U
7U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0143
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
5)
HC
S5
15
1U
7U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0144
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
4)
HC
S5
15
10
66
0U
6U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0144
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
4)
HC
S5
15
1U
6U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0145
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
3)
HC
S5
15
10
66
0U
5U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0145
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
3)
HC
S5
15
1U
5U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0146
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
2)
HC
S5
15
10
66
0U
4U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0146
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
2)
HC
S5
15
1U
4U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0147
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
1)
HC
S5
15
10
66
0U
3U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0147
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
1)
HC
S5
15
1U
3U
2U
1U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0175
11D
VR
espi
te R
esid
entia
l Car
e Ap
artm
ent
CD
S -
Part
icip
ant
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0176
11D
VR
espi
te R
esid
entia
l Car
e Ap
artm
ent
CD
S -
Agen
cyZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0149
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
6)
HC
S5
15
10
66
0U
8U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0149
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
6)
HC
S5
15
1U
8U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0150
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
5)
HC
S5
15
10
66
0U
7U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0150
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
5)
HC
S5
15
1U
7U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0151
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
4)
HC
S5
15
10
66
0U
6U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0151
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
4)
HC
S5
15
1U
6U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0152
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
3)
HC
S5
15
10
66
0U
5U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0152
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
3)
HC
S5
15
1U
5U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
34 November 2003, No. 16LTC Bul let in
3G
0153
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
2)
HC
S5
15
10
66
0U
4U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0153
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
2)
HC
S5
15
1U
4U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0154
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
1)
HC
S5
15
10
66
0U
3U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
3G
0154
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
1)
HC
S5
15
1U
3U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
3G
0177
11EV
CD
S-R
espi
te R
esid
entia
l Car
e -
Non
apar
tmen
t, P
artic
ipan
tZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0178
11EV
CD
S-R
espi
te R
esid
entia
l Car
e -
Non
apar
tmen
t, A
genc
yZZ
Loca
l cod
e to
be
reta
ined
.P
3N
1201
11F
Res
pite
NF
- Tile
20
1H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1202
11F
Res
pite
NF
- Tile
20
2H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1203
11F
Res
pite
NF
- Tile
20
3H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1204
11F
Res
pite
NF
- Tile
20
4H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1205
11F
Res
pite
NF
- Tile
20
5H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1206
11F
Res
pite
NF
- Tile
20
6H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1207
11F
Res
pite
NF
- Tile
20
7H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1208
11F
Res
pite
NF
- Tile
20
8H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1209
11F
Res
pite
NF
- Tile
20
9H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1210
11F
Res
pite
NF
- Tile
21
0H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1211
11F
Res
pite
NF
- Tile
21
1H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3N
1212
11F
Res
pite
NF
- Tile
21
2H
CS
51
51
06
63
Dai
ly R
espi
te C
harg
eI
3G
0179
11FV
CD
S-R
espi
te N
ursi
ng F
acili
ty -
Part
icip
ant
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0180
11FV
CD
S-R
espi
te N
ursi
ng F
acili
ty -
Agen
cyZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0216
12A
Targ
eted
Cas
e M
anag
emen
t08/3
1/03
3G
0302
13A
Nur
sing
Ser
vice
s - L
VNH
CS
91
24
Nur
sing
Car
e in
the
Hom
e, b
y LV
NP
3G
0302
13A
Nur
sing
Ser
vice
s - L
VNH
CT1
00
3LP
N/L
VN s
ervi
ces
up t
o 15 m
inut
esP
3G
0303
13B
Nur
sing
Ser
vice
s - R
NH
CS
91
23
Nur
sing
Car
e in
the
Hom
e, b
y R
NP
3G
0303
13B
Nur
sing
Ser
vice
s - R
NH
CT1
00
1N
ursi
ng a
sses
smen
t/ev
alua
tion
P
3G
0303
13B
Nur
sing
Ser
vice
s - R
NH
CT1
00
2R
N s
ervi
ces
up t
o 15 m
inut
esP
3S
9800
13C
Nur
sing
Ser
vice
s by
Hig
hly
Tech
nica
l R
N,
per
hour
HC
S9
80
0TG
Hom
e Th
erap
y; p
rovi
sion
of in
fusi
on, sp
ecia
lty d
rug
adm
inis
trat
ion,
and
/or
asso
ciat
ed n
ursi
ng s
ervi
ces
and
proc
edur
es, by
hig
hly
tech
nica
l R.N
., p
er h
our
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
35 LTC Bul le t inNovember 2003, No. 16
3T1
003
13D
Nur
sing
Ser
vice
s LV
N (
Hig
hly
Tech
nica
l)H
CT1
00
3TG
LPN
/LVN
ser
vice
s, u
p to
15 m
inut
esP
3G
0717
17V
CD
S-P
AS-P
artic
ipan
tZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0719
17V
CD
S-P
AS-A
genc
yZZ
Loca
l cod
e w
ill r
emai
n fo
r bi
lling
of th
e ag
ency
fee
for
VFI
.P
3G
0921
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
HC
T20
31
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0921
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
3G
0922
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
5)
HC
T20
31
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0922
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
5)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
3G
0923
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
4)
HC
T20
31
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0923
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
4)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
3G
0924
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
3)
HC
T20
31
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0924
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
3)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
3G
0925
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
2)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
3G
0926
19A
AL R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
1)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
3G
0928
19B
AL R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
6)
HC
T20
31
U2
U2
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0929
19B
AL R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
5)
HC
T20
31
U2
U2
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0930
19B
AL R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
4)
HC
T20
31
U2
U2
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0931
19B
AL R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
3)
HC
T20
31
U2
U2
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0932
19B
AL R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
2)
HC
T20
31
U2
U2
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0933
19B
AL R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
1)
HC
T20
31
U2
U2
Assi
sted
livi
ng,
wai
ver;
per
die
mP
3G
0935
19C
Assi
sted
Liv
ing
- Per
sona
l Car
e 3
HC
T20
31
U1
Assi
sted
livi
ng, w
aive
r; p
er d
iem
P
3G
0722
27A
CM
PAS
- C
lient
Dire
cted
Ser
vice
s09/3
0/03
3G
0207
40A
Prea
sses
smen
tH
CT2
02
4S
ervi
ce a
sses
smen
t/pl
an o
f ca
re d
evel
opm
ent,
wai
ver
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
36 November 2003, No. 16LTC Bul let in
3G
1212
41A
Med
ical
S/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1213
41A
Med
ical
S/R
equi
sitio
n Fe
es
50
0.0
0 -
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1214
41A
Med
ical
S/R
equi
sitio
n Fe
es
10
00
.00
- 1
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1215
41A
Med
ical
S/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1216
41A
Med
ical
S/R
equi
sitio
n Fe
es
20
00
.00
- 2
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1217
41A
Med
ical
S/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1218
41A
Med
ical
S/R
equi
sitio
n Fe
es
3
00
0.0
0 -
34
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
1219
41A
Med
ical
S/R
equi
sitio
n Fe
es
35
00
.00
- 3
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1220
41A
Med
ical
S/R
equi
sitio
n Fe
es
40
00
.00
- 4
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1221
41A
Med
ical
S/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
1222
41A
Med
ical
S/R
equi
sitio
n Fe
es
50
00
.00
- O
VER
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0623
41B
MH
Mod
s/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0624
41B
MH
Mod
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0625
41B
MH
Mod
s/R
equi
sitio
n Fe
es
10
00
.00
- 1
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0626
41B
MH
Mod
s/R
equi
sitio
n Fe
es
1
50
0.0
0 -
19
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0627
41B
MH
Mod
s/R
equi
sitio
n Fe
es
20
00
.00
- 2
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0628
41B
MH
Mod
s/R
equi
sitio
n Fe
es
2
50
0.0
0 -
29
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0629
41B
MH
Mod
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0630
41B
MH
Mod
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0631
41B
MH
Mod
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
37 LTC Bul le t inNovember 2003, No. 16
3G
0632
41B
MH
Mod
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0633
41B
MH
Mod
s/R
equi
sitio
n Fe
es
50
00
.00
- 5
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0634
41B
MH
Mod
s/R
equi
sitio
n Fe
es
55
00
.00
- 5
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0635
41B
MH
Mod
s/R
equi
sitio
n Fe
es
6
00
0.0
0 -
64
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0636
41B
MH
Mod
s/R
equi
sitio
n Fe
es
6
50
0.0
0 -
Ove
rZZ
Loca
l cod
e to
be
reta
ined
.P
3G
0607
41C
Spe
cific
atio
ns A
dapt
ive
Aids
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0604
41D
Spe
cific
atio
ns H
M M
ods
ZZLo
cal c
ode
to b
e re
tain
ed.
P
3G
0637
41E
Den
tal/
Req
uisi
tion
Fees
0 -
49
9.9
908/3
1/03
3G
0638
41E
Den
tal/
Req
uisi
tion
Fees
5
00
.00
- 9
99
.99
08/3
1/03
3G
0639
41E
Den
tal/
Req
uisi
tion
Fees
1
00
0.0
0 -
14
99
.99
08/3
1/03
3G
0640
41E
Den
tal/
Req
uisi
tion
Fees
15
00
.00
- 1
99
9.9
908/3
1/03
3G
0641
41E
Den
tal/
Req
uisi
tion
Fees
2
00
0.0
0 -
24
99
.99
08/3
1/03
3G
0642
41E
Den
tal/
Req
uisi
tion
Fees
2
50
0.0
0 -
29
99
.99
08/3
1/03
3G
0643
41E
Den
tal/
Req
uisi
tion
Fees
3
00
0.0
0 -
34
99
.99
08/3
1/03
3G
0644
41E
Den
tal/
Req
uisi
tion
Fees
3
50
0.0
0 -
39
99
.99
08/3
1/03
3G
0645
41E
Den
tal/
Req
uisi
tion
Fees
40
00
.00
- 4
49
9.9
908/3
1/03
3G
0646
41E
Den
tal/
Req
uisi
tion
Fees
45
00
.00
- 4
99
9.9
908/3
1/03
3G
0647
41E
Den
tal/
Req
uisi
tion
Fees
50
00
.00
- O
VER
08/3
1/03
3G
0239
53A
Tran
sitio
nal S
uppo
rt S
ervi
ces
08/3
1/03
3N
0600
5A
Den
tal S
ervi
ces
08/3
1/03
Ser
vice
Gro
up 3
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
38 November 2003, No. 16LTC Bul let in
Ser
vice
Gro
up
4
Ser
vice
Gro
up
5
Ser
vice
Gro
up 4
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
4F0
100
1IC
F/M
R C
ampu
s/S
tate
- LO
C 1
C
ontr
act
Spe
cific
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
4F0
101
1IC
F/M
R C
ampu
s/S
tate
- LO
C 5
C
ontr
act
Spe
cific
10/3
1/02
4F0
102
1IC
F/M
R C
ampu
s/S
tate
- LO
C 6
C
ontr
act
Spe
cific
10/3
1/02
4F0
103
1IC
F/M
R C
ampu
s/S
tate
- LO
C 8
C
ontr
act
Spe
cific
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
4F0
104
1IC
F/M
R C
ampu
s/S
tate
-LO
C 1
4/3
0/9
6
4F0
105
1IC
F/M
R C
ampu
s/S
tate
-LO
C 5
4/3
0/9
6
4F0
106
1IC
F/M
R C
ampu
s/S
tate
-LO
C 6
4/3
0/9
6
4F0
210
1IC
F/M
R C
ampu
s/S
tate
-LO
N 1
08/3
1/03
4F0
211
1IC
F/M
R C
ampu
s/S
tate
-LO
N 5
08/3
1/03
4F0
212
1IC
F/M
R C
ampu
s/S
tate
-LO
N 6
08/3
1/03
4F0
213
1IC
F/M
R C
ampu
s/S
tate
-LO
N 8
08/3
1/03
4F0
214
1IC
F/M
R C
ampu
s/S
tate
-LO
N 9
08/3
1/03
4Z9
948
1N
onre
coup
able
Adm
inis
trat
ive
Cla
im
- Gro
up 4
ZZLo
cal c
ode
to b
e re
tain
ed.
P
4Z9
949
1R
ecou
pabl
e Ad
min
istr
ativ
e C
laim
- G
roup
4ZZ
Loca
l cod
e to
be
reta
ined
.P
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 5
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
5F0
108
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
8 C
ontr
act
Spe
cific
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
5F0
109
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
1 C
ontr
act
Spe
cific
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
39 LTC Bul le t inNovember 2003, No. 16
Ser
vice
Gro
up
6
5F0
110
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
5 C
ontr
act
Spe
cific
10/3
1/02
5F0
111
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
6 C
ontr
act
Spe
cific
10/3
1/02
5F0
112
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
14/3
0/9
6
5F0
113
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
54/3
0/9
6
5F0
114
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
64/3
0/9
6
5F0
115
1IC
F/M
R S
tate
/Com
mun
ity
Res
iden
tial L
OC
84/3
0/9
6
5F0
215
1IC
F/M
R S
tate
/Com
mun
ity -
LON
108/3
1/03
5F0
216
1IC
F/M
R S
tate
/Com
mun
ity -
LON
508/3
1/03
5F0
217
1IC
F/M
R S
tate
/Com
mun
ity -
LON
608/3
1/03
5F0
218
1IC
F/M
R S
tate
/Com
mun
ity -
LON
808/3
1/03
5F0
219
1IC
F/M
R S
tate
/Com
mun
ity -
LON
908/3
1/03
5Z9
958
1N
onre
coup
able
adm
inis
trat
ive
clai
m
- gro
up 5
ZZLo
cal c
ode
to b
e re
tain
ed.
P
5Z9
959
1R
ecou
pabl
e ad
min
istr
ativ
e cl
aim
- gr
oup
5ZZ
Loca
l cod
e to
be
reta
ined
.P
Ser
vice
Gro
up 6
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
C
ode
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
6F0
200
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
OC
112/3
1/96
6F0
201
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
OC
512/3
1/96
6F0
202
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
OC
612/3
1/96
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 5
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
40 November 2003, No. 16LTC Bul let in
6F0
203
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
OC
6A
12/3
1/96
6F0
204
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
OC
812/3
1/96
6F0
205
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
ON
10
10
0Al
l Inc
lusi
ve R
oom
& B
oard
Plu
s An
cilla
ryI
6F0
206
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
ON
50
10
0Al
l Inc
lusi
ve R
oom
& B
oard
Plu
s An
cilla
ryI
6F0
207
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
ON
60
10
0Al
l Inc
lusi
ve R
oom
& B
oard
Plu
s An
cilla
ryI
6F0
208
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
ON
80
10
0Al
l Inc
lusi
ve R
oom
& B
oard
Plu
s An
cilla
ryI
6F0
209
1IC
F/M
R N
onst
ate
Com
mun
ity
Res
iden
tial L
ON
90
10
0Al
l Inc
lusi
ve R
oom
& B
oard
Plu
s An
cilla
ryI
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E13
99
02
90
Sta
ndin
g B
oard
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
S8
47
00
29
0G
ait
Trai
ners
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E11
30
02
90
Whe
elch
air
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E19
00
02
90
Elec
tron
ic C
omm
unic
atio
n D
evic
eI
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E19
02
02
90
Com
mun
icat
ion
Dev
ice
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E10
35
02
90
Trav
el C
hair
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E01
86
02
90
Air
Flot
atio
n M
attr
ess
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E10
31
02
90
Adap
tive
Str
olle
rI
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E13
40
02
90
Ref
urbi
shed
/Mod
ified
Whe
elch
air
I
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
L39
52
02
90
Pros
thet
ic/O
rtho
ticI
6G
0508
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 5
HC
E02
50
02
90
Hos
pita
l Wat
erbe
dI
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E13
99
02
90
Sta
ndin
g B
oard
I
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
S8
47
00
29
0G
ait
Trai
ners
I
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E10
35
02
90
Trav
el C
hair
I
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E01
86
02
90
Air
Flot
atio
n M
attr
ess
I
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E10
31
02
90
Adap
tive
Str
olle
rI
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E13
40
02
90
Ref
urbi
shed
/Mod
ified
Whe
elch
air
I
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
L39
52
02
90
Pros
thet
ic/O
rtho
ticI
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E11
30
02
90
Whe
elch
air
I
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E19
00
02
90
Elec
tron
ic C
omm
unic
atio
n D
evic
eI
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E19
02
02
90
Com
mun
icat
ion
Dev
ice
I
Ser
vice
Gro
up 6
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
C
ode
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
41 LTC Bul le t inNovember 2003, No. 16
6G
0509
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 6
HC
E02
50
02
90
Hos
pita
l Wat
erbe
dI
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E11
30
02
90
Whe
elch
air
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E19
00
02
90
Elec
tron
ic C
omm
unic
atio
n D
evic
eI
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E19
02
02
90
Com
mun
icat
ion
Dev
ice
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E13
99
02
90
Sta
ndin
g B
oard
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
S8
47
00
29
0G
ait
Trai
ners
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E10
35
02
90
Trav
el C
hair
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E01
86
02
90
Air
Flot
atio
n M
attr
ess
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E10
31
02
90
Adap
tive
Str
olle
rI
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E13
40
02
90
Ref
urbi
shed
/Mod
ified
Whe
elch
air
I
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
L39
52
02
90
Pros
thet
ic/O
rtho
ticI
6G
0510
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 8
HC
E02
50
02
90
Hos
pita
l Wat
erbe
dI
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E13
99
02
90
Sta
ndin
g B
oard
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
S8
47
00
29
0G
ait
Trai
ners
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E10
35
02
90
Trav
el C
hair
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E01
86
02
90
Air
Flot
atio
n M
attr
ess
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E10
31
02
90
Adap
tive
Str
olle
rI
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E13
40
02
90
Ref
urbi
shed
/Mod
ified
Whe
elch
air
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
L39
52
02
90
Pros
thet
ic/O
rtho
ticI
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E11
30
02
90
Whe
elch
air
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E19
00
02
90
Elec
tron
ic C
omm
unic
atio
n D
evic
eI
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E19
02
02
90
Com
mun
icat
ion
Dev
ice
I
6G
0511
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 9
HC
E02
50
02
90
Hos
pita
l Wat
erbe
dI
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E11
30
02
90
Whe
elch
air
I
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E19
00
02
90
Elec
tron
ic C
omm
unic
atio
n D
evic
eI
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E19
02
02
90
Com
mun
icat
ion
Dev
ice
I
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E13
99
02
90
Sta
ndin
g B
oard
I
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
S8
47
00
29
0G
ait
Trai
ners
I
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E10
35
02
90
Trav
el C
hair
I
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E01
86
02
90
Air
Flot
atio
n M
attr
ess
I
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E10
31
02
90
Adap
tive
Str
olle
rI
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E13
40
02
90
Ref
urbi
shed
/Mod
ified
Whe
elch
air
I
Ser
vice
Gro
up 6
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
C
ode
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
42 November 2003, No. 16LTC Bul let in
Ser
vice
Gro
up
7
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
L39
52
02
90
Pros
thet
ic/O
rtho
ticI
6G
0512
15
DM
E/Ad
aptiv
e Ai
ds -
LO
N 1
HC
E02
50
02
90
Hos
pita
l Wat
erbe
dI
6F0
220
1T
Tran
sitio
nal A
ddon
/ N
onst
ate
Ope
rate
d LO
N 1
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
6F0
221
1T
Tran
sitio
nal A
ddon
/ N
onst
ate
Ope
rate
d LO
N 5
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
6F0
222
1T
Tran
sitio
nal A
ddon
/ N
onst
ate
Ope
rate
d LO
N 6
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
6F0
223
1T
Tran
sitio
nal A
ddon
/ N
onst
ate
Ope
rate
d LO
N 8
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
6F0
224
1T
Tran
sitio
nal A
ddon
/ N
onst
ate
Ope
rate
d LO
N 9
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
Ser
vice
Gro
up 7
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
7G
0103
11
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 1
08/3
1/03
7G
0108
11
Res
pite
- Ad
ult
Fost
er C
are
- C
CAD
Lev
el08/3
1/03
7G
0120
11
Res
pite
- Pe
rson
al A
ssis
tanc
e S
ervi
ces
08/3
1/03
7G
0121
11
Res
pite
- Pe
rson
al A
ssis
tanc
e S
ervi
ces
HC
S5
15
0U
nski
lled
resp
ite c
are,
not
hos
pice
; pe
r 15 m
inut
esP
7G
0122
11
Res
pite
- S
itter
Ser
vice
sZZ
Ret
ain
loca
l cod
e un
til fur
ther
cla
rific
atio
n of
ser
vice
is
obta
ined
P
7G
0123
11
Res
pite
- Ad
ult
Day
Car
e08/3
1/03
7G
0124
11
Res
pite
- N
ursi
ng F
acili
ty
08/3
1/03
7G
0125
11
Res
pite
- H
ospi
tal
08/3
1/03
7G
0126
11
Assi
sted
Liv
ing
CC
AD R
C A
part
men
t08/3
1/03
7G
0127
11
Assi
sted
Liv
ing
CC
AD R
C
Non
apar
tmen
t08/3
1/03
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 6
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
C
ode
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
43 LTC Bul le t inNovember 2003, No. 16
7+9
99
99
17
Expe
dite
d Pa
ymen
tZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0701
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 2 -
Prio
rity
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
7G
0702
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 1 -
Non
prio
rity
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
7G
0703
17
FC P
riorit
y Pr
ior
to 0
9/1
99
708/3
1/03
7G
0704
17
FC N
on P
riorit
y Pr
ior
to 0
9/1
99
808/3
1/03
7G
0800
18
Adul
t Fo
ster
Car
e - L
evel
108/3
1/03
7G
0803
18
Adul
t Fo
ster
Car
e - C
CAD
Lev
elH
CS
51
40
Adul
t fo
ster
car
e, p
er d
iem
P
7G
0903
19
Assi
sted
Liv
ing
- Bed
Hol
d08/3
1/03
7G
0904
19
Assi
sted
Liv
ing
- Em
erge
ncy
Car
e08/3
1/03
7G
0906
19
Assi
sted
Liv
ing
- Res
iden
tial C
are
Apar
tmen
t08/3
1/03
7G
0907
19
Assi
sted
Liv
ing
- Res
iden
tial C
are
Non
apar
tmen
t08/3
1/03
7G
1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
60
In
stal
latio
n an
d Te
stin
gP
7G
1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
61
Mon
thly
Ser
vice
Fee
(ex
clud
es in
stal
latio
n an
d te
stin
g)P
7G
1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
62
Purc
hase
Onl
yP
7C
0100
25
Hom
e D
eliv
ered
Mea
lsH
CS
51
70
Per
mea
l, in
clud
es p
repa
ratio
n an
d de
liver
yP
7C
0101
25
Hom
e D
eliv
ered
Mea
ls08/3
1/03
7C
0400
26
IHFS
Cap
ital E
xpen
ditu
res
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7C
0401
26
IHFS
Sub
sidy
Gra
nts
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7C
0402
26
SS
I Clie
nt P
aym
ent
08/3
1/03
7G
0710
27
Sup
port
ed H
ome
Livi
ng -
LON
108/3
1/03
7G
0720
27
Con
sum
er M
anag
ed P
erso
nal
Atte
ndan
t S
ervi
ces
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7G
0721
27
Clie
nt M
anag
ed A
tten
dant
Ser
vice
s -
Vouc
her
08/3
1/03
7C
0300
28
SS
PD -
Day
Car
eH
CS
51
01
Day
Car
e S
ervi
ces,
Adu
lt, p
er h
alf da
yP
7C
0301
28
SS
PD -
24
hou
r At
tend
ant
Car
e09/3
0/03
7C
0301
28
SS
PD -
24
hou
r At
tend
ant
Car
e09/3
0/03
7C
0302
28
SS
PD -
Oth
er09/3
0/03
7N
0201
28
SS
PD -
24
hou
r At
tend
ant
Car
e(T
ile 2
01
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
Ser
vice
Gro
up 7
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
44 November 2003, No. 16LTC Bul let in
7N
0202
28
SS
PD -
24
hou
r At
tend
ant
Car
e (T
ile 2
02
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0203
28
SS
PD -
24
hou
r At
tend
ant
Car
e (T
ile 2
03
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0204
28
SS
PD -
24
hou
r At
tend
ant
Car
e(T
ile 2
04
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0205
28
SS
PD -
24
hou
r At
tend
ant
Car
e (T
ile 2
05
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0206
28
SS
PD -
24
hou
r At
tend
ant
Car
e(T
ile 2
06
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0207
28
SS
PD -
24
hou
r At
tend
ant
Car
e(T
ile 2
07
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0208
28
SS
PD -
24
hou
r At
tend
ant
Car
e (T
ile 2
08
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0209
28
SS
PD -
24
hou
r At
tend
ant
Car
e(T
ile 2
09
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0210
28
SS
PD -
24
hou
r At
tend
ant
Car
e(T
ile 2
10
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0211
28
SS
PD -
24
hou
r At
tend
ant
Car
e (T
ile 2
11
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0212
28
SS
PD -
24
hou
r At
tend
ant
Car
e (T
ile 2
12
)H
CS
51
26
Atte
ndan
t C
are,
per
die
mP
7N
0500
28
Vent
ilato
r - F
ull
08/3
1/03
7N
0501
28
Vent
ilato
r - P
artia
l08/3
1/03
7N
1201
28
Res
pite
NF
- Tile
20
1H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1202
28
Res
pite
NF
- Tile
20
2H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1203
28
Res
pite
NF
- Tile
20
3H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1204
28
Res
pite
NF
- Tile
20
4H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1205
28
Res
pite
NF
- Tile
20
5H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1206
28
Res
pite
NF
- Tile
20
6H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1207
28
Res
pite
NF
- Tile
20
7H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1208
28
Res
pite
NF
- Tile
20
8H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1209
28
Res
pite
NF
- Tile
20
9H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1210
28
Res
pite
NF
- Tile
21
0H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1211
28
Res
pite
NF
- Tile
21
1H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7N
1212
28
Res
pite
NF
- Tile
21
2H
CS
51
51
Uns
kille
d R
espi
te C
are,
not
Hos
pice
, pe
r di
emP
7C
0200
29
Day
Act
ivity
/Hea
lth S
ervi
ces
(DAH
S)
HC
S5
10
1D
ay C
are
Ser
vice
s, A
dult,
per
hal
f da
yP
Ser
vice
Gro
up 7
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
45 LTC Bul le t inNovember 2003, No. 16
7C
0201
29
Day
Act
ivity
/Hea
lth S
ervi
ces
- D
AHS
Titl
e XX
Neg
otia
ted
Rat
e08/3
1/03
7G
0129
11A
Res
pite
- Ad
ult
Day
Car
e ZZ
Ret
ain
loca
l cod
e un
til fur
ther
cla
rific
atio
n of
ser
vice
is
obta
ined
or
new
pla
ce o
f se
rvic
e fo
r ad
ult
day
care
is
appr
oved
by
CM
S.
P
7G
0130
11A
Res
pite
- H
ospi
tal
06
60
Res
pite
Car
e, g
ener
al (
Not
e: T
o cr
ossw
alk
back
to
the
loca
l cod
e, p
lace
of se
rvic
e m
ust
be a
ccur
ate.
)I
7G
0131
11B
Res
pite
- Ad
ult
Fost
er C
are
-C
CAD
Lev
el0
66
0I
7G
0141
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (C
CAD
)H
CS
51
51
U2
U1
Uns
kille
d R
espi
te C
are,
per
die
mP
7G
0148
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (C
CAD
)H
CS
51
51
U2
U2
Uns
kille
d R
espi
te C
are,
per
die
mP
7G
0155
11F
Res
pite
- N
ursi
ng F
acili
ty
06
60
Res
pite
Car
e, g
ener
al (
Not
e: T
o cr
ossw
alk
back
to
the
loca
l cod
e, p
lace
of se
rvic
e m
ust
be a
ccur
ate.
)I
7G
0740
17C
PAS
Fam
ily C
are
- Lev
el 2
(Prio
rity)
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
7G
0741
17C
PAS
Fam
ily C
are
- Lev
el 1
(N
onpr
iorit
y)H
CS
51
25
Atte
ndan
t C
are
Ser
vice
s, p
er 1
5 m
inut
esP
7G
0745
17C
VPA
S F
amily
Car
e - C
DS
-Par
ticip
ant
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7G
0746
17C
VPA
S F
amily
Car
e Le
vel 1
(Non
prio
rity)
C
DS
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7G
0747
17C
VPA
S F
amily
Car
e - C
DS
- Ag
ency
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7G
0742
17D
PAS
Com
mun
ity A
tten
dant
Ser
vice
s (1
92
9B
) - L
evel
2 (
Prio
rity)
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
7G
0743
17D
PAS
Com
mun
ity A
tten
dant
Ser
vice
s (1
92
9B
) - L
evel
1 (
Non
prio
rity)
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
7G
0748
17D
VPA
S C
omm
unity
Att
enda
nt S
ervi
ces
Leve
l 1 (
Non
prio
rity)
CD
SZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0749
17D
VPA
S C
omm
unity
Att
enda
nt S
ervi
ces
Leve
l 2 (
prio
rity)
CD
SZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0750
17D
VPA
S C
omm
unity
Att
enda
nt S
ervi
ces
- C
DS
- Ag
ency
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7G
0717
17V
CD
S-P
AS-P
artic
ipan
tZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0718
17V
PAS
Lev
el 1
(N
onpr
iorit
y) C
DS
ZZLo
cal c
ode
to b
e re
tain
ed.
P
7G
0719
17V
CD
S-P
AS-A
genc
yZZ
Loca
l cod
e w
ill r
emai
n fo
r bi
lling
of th
e ag
ency
fee
for
VFI
.P
7G
0920
19A
Assi
sted
Liv
ing
- Res
iden
tial C
are
Apar
tmen
t08/3
1/03
7G
0927
19B
Assi
sted
Liv
ing
- Res
iden
tial C
are
Non
apar
tmen
t08/3
1/03
Ser
vice
Gro
up 7
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
46 November 2003, No. 16LTC Bul let in
7G
0936
19D
Assi
sted
Liv
ing
- Em
erge
ncy
Car
e08/3
1/03
7G
0934
19H
Assi
sted
Liv
ing
- Bed
Hol
d -
Apar
tmen
t08/3
1/03
7G
0943
19I
Res
iden
tial C
are
Bed
Hol
d -
Non
apar
tmen
t - T
itle
XXZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0944
19J
Res
iden
tial C
are
- Bed
Hol
d -
Apar
tmen
t - T
itle
XXZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0944
19J
Res
iden
tial C
are
- Bed
Hol
d -
Apar
tmen
t - T
itle
XXZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0944
19J
Res
iden
tial C
are
- Bed
Hol
d -
Apar
tmen
t - T
itle
XXZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0944
19J
Res
iden
tial C
are
- Bed
Hol
d -
Apar
tmen
t - T
itle
XXZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0945
19K
Res
iden
tial C
are
- Apa
rtm
ent
- Ti
tle X
XH
CT1
02
0U
2U
1Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
7G
0946
19L
Res
iden
tial C
are
- Non
apar
tmen
t -
Title
XX
HC
T10
20
U2
U2
Pers
onal
car
e se
rvic
es, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
7G
0947
19M
Res
iden
tial E
mer
genc
y C
are
- Titl
e XX
- A
part
men
tH
CT1
02
0Pe
rson
al c
are
serv
ices
; pe
r di
emP
7G
0948
19N
Res
iden
tial C
are
- Roo
m &
Boa
rd -
Non
apar
tmen
tZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0949
19O
Res
iden
tial C
are
- Roo
m &
Boa
rd -
Apar
tmen
tZZ
Loca
l cod
e to
be
reta
ined
.P
7G
0722
27A
CM
PAS
- C
lient
Dire
cted
Ser
vice
sZZ
Loca
l cod
e to
be
reta
ined
.P
7C
0303
28A
SS
PD -
Cas
e M
anag
emen
tH
CT1
01
6C
ase
Man
agem
ent,
eac
h 15 m
inut
esP
7C
0202
29A
Day
Act
ivity
/Hea
lth S
ervi
ces
(DAH
S)
- Titl
e 2
0H
CS
51
01
Day
Car
e S
ervi
ces,
Adu
lt, p
er h
alf da
yP
Ser
vice
Gro
up 7
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
47 LTC Bul le t inNovember 2003, No. 16
Ser
vice
Gro
up
8
Ser
vice
Gro
up 8
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
8T0
100
1R
outin
e in
Hom
e C
are
HC
T20
42
06
51
Hos
pice
Rou
tine
Hom
e C
are;
per
die
mI
8T0
200
1C
ontin
uous
Hom
e C
are
HC
T20
43
06
52
Hos
pice
Con
tinuo
us H
ome
Car
e; p
er h
our
I
8T0
300
1In
patie
nt R
espi
te C
are
HC
T20
44
06
55
Hos
pice
Inpa
tient
Res
pite
Car
eI
8T0
301
1G
ener
al In
patie
nt C
are
HC
T20
45
06
56
Hos
pice
Gen
eral
Inpa
tient
Car
e (n
onre
spite
)I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C3
64
89
06
57
Plac
emen
t ce
ntra
l ven
ous
cath
eter
; pe
rcut
ansi
ous,
ove
r ag
e tw
oI
8T0
302
30
Phys
icia
n D
irect
Car
eH
C3
65
33
06
57
inse
rtio
n of
impl
anta
ble
veno
us a
cces
s po
rt w
ith o
r with
out
subc
utan
eous
res
ervo
irI
8T0
302
30
Phys
icia
n D
irect
Car
eH
C4
90
80
06
57
Perit
oneo
cent
esis
, ab
dom
inal
par
acen
tesi
s or
per
itone
al
lava
ge (di
agno
stic
or
ther
apeu
tic) in
itial
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C7
10
10
06
57
Rad
iolo
gic
exam
inat
ion;
che
st; si
ngle
vie
w fro
ntal
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C7
40
00
06
57
Rad
iolo
gic
exam
inat
ion;
abd
omen
; si
ngle
ant
erop
oste
rior
view
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C7
40
20
06
57
Rad
iolo
gic
exam
inat
ion;
abd
omen
; co
mpl
ete,
incl
udin
g de
cubi
tus
and/
or e
rect
vie
ws
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C8
50
23
06
57
Blo
od c
ount
; he
mog
ram
and
pla
tele
t co
unt,
aut
o, a
nd
man
ual d
iffer
entia
l WB
C c
ount
(C
BC
)I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
01
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
new
pat
ient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
02
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
new
pat
ient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
03
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
new
pat
ient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
04
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
new
pat
ient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
05
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
new
pat
ient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
11
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
n es
tabl
ishe
d pa
tient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
12
06
57
Offic
e or
oth
er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
n es
tabl
ishe
d pa
tient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
13
06
57
Offic
e or
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er o
utpa
tient
vis
it fo
r th
e ev
alua
tion
and
man
agem
ent
of a
n es
tabl
ishe
d pa
tient
I
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
92
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ME/
Adap
tive
Aids
, D
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l, an
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Ser
vice
s.
48 November 2003, No. 16LTC Bul let in
8T0
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30
Phys
icia
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Car
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C9
92
21
06
57
Initi
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Phys
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Phys
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Car
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C9
92
38
06
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Hos
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char
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8T0
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Phys
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Car
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C9
92
39
06
57
Hos
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8T0
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Phys
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C9
92
51
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Initi
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Phys
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C9
92
52
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Initi
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Phys
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C9
92
53
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Initi
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8T0
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Phys
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Car
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C9
92
54
06
57
Initi
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8T0
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Phys
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Car
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C9
92
55
06
57
Initi
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8T0
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Phys
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C9
92
61
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Follo
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Phys
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62
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Follo
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Phys
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C9
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Follo
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8T0
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Phys
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Car
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C9
93
01
06
57
Eval
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ew o
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8T0
302
30
Phys
icia
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Car
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C9
93
02
06
57
Eval
uatio
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d m
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Ser
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Gro
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Tabl
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Loc
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laim
Typ
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837I;
P=837P
;D
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Not
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Exce
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: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
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ce P
hysi
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Ser
vice
s.
49 LTC Bul le t inNovember 2003, No. 16
8T0
302
30
Phys
icia
n D
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Car
eH
C9
93
03
06
57
Eval
uatio
n an
d m
anag
emen
t of n
ew o
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ablis
hed
patie
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invo
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with
thr
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s
I
8T0
302
30
Phys
icia
n D
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Car
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C9
93
11
06
57
Sub
sequ
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cilit
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or th
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alua
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and
man
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8T0
302
30
Phys
icia
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Car
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C9
93
12
06
57
Sub
sequ
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or th
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man
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8T0
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Phys
icia
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Car
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C9
93
13
06
57
Sub
sequ
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8T0
302
30
Phys
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Car
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C9
93
21
06
57
Dom
icili
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or r
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for
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eval
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8T0
302
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Phys
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Car
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C9
93
22
06
57
Dom
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or r
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a n
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8T0
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Phys
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Car
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C9
93
23
06
57
Dom
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or r
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sit
for
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8T0
302
30
Phys
icia
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Car
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C9
93
31
06
57
Dom
icili
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or r
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hom
e vi
sit
for
the
eval
uatio
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d m
anag
emen
t of
an
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8T0
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Phys
icia
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Car
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C9
93
32
06
57
Dom
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8T0
302
30
Phys
icia
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Car
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C9
93
33
06
57
Dom
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I
8T0
302
30
Phys
icia
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Car
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C9
93
41
06
57
Hom
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8T0
302
30
Phys
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Car
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C9
93
42
06
57
Hom
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I
8T0
302
30
Phys
icia
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Car
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C9
93
43
06
57
Hom
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I
8T0
302
30
Phys
icia
n D
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Car
eH
C9
93
45
06
57
Hom
e vi
sit
esta
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hed
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nt, th
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com
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nt; 75
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with
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and
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8T0
302
30
Phys
icia
n D
irect
Car
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C9
93
47
06
57
Hom
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sit
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key
com
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min
utes
with
pat
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and
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ilyI
8T0
302
30
Phys
icia
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Car
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C9
93
48
06
57
Hom
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sit
esta
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hed
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com
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nt; 25
min
utes
with
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and
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ilyI
8T0
302
30
Phys
icia
n D
irect
Car
eH
C9
93
49
06
57
Hom
e vi
sit
esta
blis
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patie
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key
com
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min
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with
pat
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and
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ilyI
Ser
vice
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up 8
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Tabl
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Loc
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laim
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837I;
P=837P
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Exce
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ME/
Adap
tive
Aids
, D
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d H
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Ser
vice
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50 November 2003, No. 16LTC Bul let in
8T0
302
30
Phys
icia
n D
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Car
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C9
93
50
06
57
Hom
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sit
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key
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fam
ilyI
8T0
302
30
Phys
icia
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Car
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C9
93
52
06
57
Hom
e vi
sit
for
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eval
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d m
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com
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8T0
302
30
Phys
icia
n D
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Car
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C9
93
54
06
57
Prol
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in t
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ttin
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8T0
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Phys
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Car
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C9
93
55
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57
Prol
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8T0
302
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Phys
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Car
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C9
93
56
06
57
Prol
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8T0
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Phys
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57
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Prol
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41
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42
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44
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44
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Hom
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Car
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C9
92
45
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8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
103
31
ICF/
MR
Cam
pus/
Sta
te -
LOC
8
Con
trac
t S
peci
ficH
CT2
04
60
65
9H
ospi
ce L
TC R
oom
& B
oard
I
8F0
108
31
ICF/
MR
Sta
te/C
omm
unity
R
esid
entia
l LO
C 8
Con
trac
t S
peci
ficH
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
108
31
ICF/
MR
Sta
te/C
omm
unity
R
esid
entia
l LO
C 8
Con
trac
t S
peci
ficH
CT2
04
60
65
9H
ospi
ce L
TC R
oom
& B
oard
I
Ser
vice
Gro
up 8
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
51 LTC Bul le t inNovember 2003, No. 16
8F0
109
31
ICF/
MR
Sta
te/C
omm
unity
R
esid
entia
l LO
C 1
Con
trac
t S
peci
ficH
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
109
31
ICF/
MR
Sta
te/C
omm
unity
R
esid
entia
l LO
C 1
Con
trac
t S
peci
ficH
CT2
04
60
65
9H
ospi
ce L
TC R
oom
& B
oard
I
8F0
110
31
ICF-
MR
Sta
te C
omm
unity
Res
iden
tial
LOC
5 C
ontr
act
Spe
cific
10/3
1/0
2
8F0
111
31
ICF-
MR
Sta
te C
omm
unity
Res
iden
tial
LOC
6 C
ontr
act
Spe
cific
10/3
1/0
2
8F0
113
31
ICF-
MR
Sta
te C
omm
unity
R
esid
entia
l (LO
C 5
)04/3
0/9
6
8F0
114
31
ICF-
MR
Sta
te C
omm
unity
Res
iden
tial
(LO
C 6
)04/3
0/96
8F0
205
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 1
)H
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
205
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 1
)H
CT2
04
60
65
9O
ther
(H
ospi
ce L
TC R
oom
& B
oard
)I
8F0
206
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 5
)H
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
206
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 5
)H
CT2
04
60
65
9O
ther
(H
ospi
ce L
TC R
oom
& B
oard
)I
8F0
207
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 6
)H
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
207
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 6
)H
CT2
04
60
65
9O
ther
(H
ospi
ce L
TC R
oom
& B
oard
)I
8F0
208
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 8
)H
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
208
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 8
)H
CT2
04
60
65
9O
ther
(H
ospi
ce L
TC R
oom
& B
oard
)I
8F0
209
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 9
)H
CT2
04
60
65
8H
ospi
ce L
TC R
oom
& B
oard
I
8F0
209
31
ICF-
MR
Non
-Sta
te C
omm
unity
R
esid
entia
l (LO
N 9
)H
CT2
04
60
65
9O
ther
(H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0201
31
Nur
sing
Fac
ility
, Ti
le 2
01
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0201
31
Nur
sing
Fac
ility
, Ti
le 2
01
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0202
31
Nur
sing
Fac
ility
, Ti
le 2
02
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0202
31
Nur
sing
Fac
ility
, Ti
le 2
02
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0203
31
Nur
sing
Fac
ility
, Ti
le 2
03
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0203
31
Nur
sing
Fac
ility
, Ti
le 2
03
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0204
31
Nur
sing
Fac
ility
, Ti
le 2
04
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
Ser
vice
Gro
up 8
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
52 November 2003, No. 16LTC Bul let in
8N
0204
31
Nur
sing
Fac
ility
, Ti
le 2
04
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0205
31
Nur
sing
Fac
ility
, Ti
le 2
05
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0205
31
Nur
sing
Fac
ility
, Ti
le 2
05
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0206
31
Nur
sing
Fac
ility
, Ti
le 2
06
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0206
31
Nur
sing
Fac
ility
, Ti
le 2
06
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0207
31
Nur
sing
Fac
ility
, Ti
le 2
07
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0207
31
Nur
sing
Fac
ility
, Ti
le 2
07
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0208
31
Nur
sing
Fac
ility
, Ti
le 2
08
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0208
31
Nur
sing
Fac
ility
, Ti
le 2
08
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0209
31
Nur
sing
Fac
ility
, Ti
le 2
09
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0209
31
Nur
sing
Fac
ility
, Ti
le 2
09
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0210
31
Nur
sing
Fac
ility
, Ti
le 2
10
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0210
31
Nur
sing
Fac
ility
, Ti
le 2
10
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0211
31
Nur
sing
Fac
ility
, Ti
le 2
11
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0211
31
Nur
sing
Fac
ility
, Ti
le 2
11
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8N
0212
31
Nur
sing
Fac
ility
, Ti
le 2
12
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8N
0212
31
Nur
sing
Fac
ility
, Ti
le 2
12
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
201
31
VA D
aily
Car
e - T
ile 2
01
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
201
31
VA D
aily
Car
e - T
ile 2
01
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
202
31
VA D
aily
Car
e - T
ile 2
02
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
202
31
VA D
aily
Car
e - T
ile 2
02
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
203
31
VA D
aily
Car
e - T
ile 2
03
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
203
31
VA D
aily
Car
e - T
ile 2
03
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
204
31
VA D
aily
Car
e - T
ile 2
04
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
204
31
VA D
aily
Car
e - T
ile 2
04
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
205
31
VA D
aily
Car
e - T
ile 2
05
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
205
31
VA D
aily
Car
e - T
ile 2
05
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
206
31
VA D
aily
Car
e - T
ile 2
06
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
206
31
VA D
aily
Car
e - T
ile 2
06
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
207
31
VA D
aily
Car
e - T
ile 2
07
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
207
31
VA D
aily
Car
e - T
ile 2
07
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
208
31
VA D
aily
Car
e - T
ile 2
08
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
Ser
vice
Gro
up 8
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
53 LTC Bul le t inNovember 2003, No. 16
Ser
vice
Gro
up
9
8V0
208
31
VA D
aily
Car
e - T
ile 2
08
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
209
31
VA D
aily
Car
e - T
ile 2
09
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
209
31
VA D
aily
Car
e - T
ile 2
09
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
210
31
VA D
aily
Car
e - T
ile 2
10
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
210
31
VA D
aily
Car
e - T
ile 2
10
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
211
31
VA D
aily
Car
e - T
ile 2
11
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
211
31
VA D
aily
Car
e - T
ile 2
11
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8V0
212
31
VA D
aily
Car
e - T
ile 2
12
HC
T20
46
06
58
Hos
pice
LTC
Roo
m &
Boa
rdI
8V0
212
31
VA D
aily
Car
e - T
ile 2
12
HC
T20
46
06
59
Oth
er (H
ospi
ce L
TC R
oom
& B
oard
)I
8T0
400
32
Med
icar
e Ph
arm
acy
Coi
nsur
ance
ZZLo
cal c
ode
to b
e re
tain
ed.
P
8T0
401
33
Med
icar
e R
espi
te C
oins
uran
ceZZ
Loca
l cod
e to
be
reta
ined
.P
Ser
vice
Gro
up 9
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
9N
0500
4Ve
ntila
tor
- Ful
l08/3
1/03
9N
0501
4Ve
ntila
tor
- Par
tial
08/3
1/03
9N
0700
6N
urse
’s A
id T
rain
ing
- Tra
inin
g C
ours
e08/3
1/03
9N
0701
6N
urse
’s A
id T
rain
ing
- Ski
lls T
est
- Pa
ssed
08/3
1/03
9N
0702
6N
urse
’s A
id T
rain
ing
- Ski
lls T
est
- Fa
iled
08/3
1/03
9N
0703
6N
urse
’s A
id T
rain
ing
- Writ
ten
Test
- Pa
ssed
08/3
1/03
9N
0704
6N
urse
’s A
id T
rain
ing
- Writ
ten
Test
- Fa
iled
08/3
1/03
9N
0705
6N
urse
’s A
id T
rain
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t -
Pass
ed08/3
1/03
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 8
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
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1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
54 November 2003, No. 16LTC Bul let in
9N
0706
6N
urse
’s A
id T
rain
ing-
Ora
l Tes
t -
Faile
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1/03
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0707
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urse
’s A
id T
rain
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- Tra
inin
g M
ater
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08/3
1/03
9N
0708
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’s A
id T
rain
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Trai
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Cou
rse
08/3
1/03
9G
0452
7O
T R
ehab
HC
97
03
90
43
1U
nlis
ted
mod
ality
I
9G
0452
7O
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HC
97
03
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OU
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P
9G
0453
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sess
men
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ilita
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97
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97
00
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hera
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0458
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T H
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men
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1/03
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abH
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70
39
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Unl
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odal
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9G
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70
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ssm
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08/3
1/03
9G
0456
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T-R
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Ser
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HC
92
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44
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com
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icat
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an
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44
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Spe
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P
Ser
vice
Gro
up 9
- Lo
ng T
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Car
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ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
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onP
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dure
C
ode
Qua
lifie
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HC
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S
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even
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2M
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itio
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End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
55 LTC Bul le t inNovember 2003, No. 16
Ser
vice
Gro
up
10
9G
0463
8A
PT-S
peci
aliz
ed S
ervi
ceH
C9
70
39
04
21
Unl
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d m
odal
ityI
9G
0463
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70
39
GP
Unl
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odal
ityP
9G
0464
8A
PT A
sses
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t-Spe
cial
ized
Ser
vice
HC
97
00
10
42
4Ph
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hera
py E
valu
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9G
0464
8A
PT A
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vice
HC
97
00
1G
PPh
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hera
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valu
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9G
0465
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Spe
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92
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70
44
1Tr
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0465
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Spe
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vice
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92
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ice,
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mun
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an
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, in
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dual
P
9G
0466
9A
ST
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ssm
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aliz
ed S
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C9
25
06
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44
Eval
uatio
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spe
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lang
uage
, vo
ice,
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icat
ion,
au
dito
ry p
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ssin
g, a
nd/o
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ral r
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tion
stat
usI
9G
0466
9A
ST
Asse
ssm
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peci
aliz
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36
40
44
4D
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0466
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ssm
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aliz
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25
06
Eval
uatio
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spe
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lang
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, vo
ice,
com
mun
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au
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End
Dat
eC
laim
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e to
File
: I=
837I;
P=837P
;D
=837D
10
N0201
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F - T
ile 2
01
01
00
All I
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I
10
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1N
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02
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All I
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lus
Anci
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I
10
N0203
1N
F - T
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03
01
00
All I
nclu
sive
Roo
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lus
Anci
llary
I
10
N0204
1N
F - T
ile 2
04
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
10
N0205
1N
F - T
ile 2
05
01
00
All I
nclu
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Roo
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rd P
lus
Anci
llary
I
10
N0206
1N
F - T
ile 2
06
01
00
All I
nclu
sive
Roo
m &
Boa
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lus
Anci
llary
I
10
N0207
1N
F - T
ile 2
07
01
00
All I
nclu
sive
Roo
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Boa
rd P
lus
Anci
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I
10
N0208
1N
F - T
ile 2
08
01
00
All I
nclu
sive
Roo
m &
Boa
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lus
Anci
llary
I
10
N0209
1N
F - T
ile 2
09
01
00
All I
nclu
sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
10
N0210
1N
F - T
ile 2
10
01
00
All I
nclu
sive
Roo
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Boa
rd P
lus
Anci
llary
I
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 9
- Lo
ng T
erm
Car
e B
ill C
ode
Cro
ssw
alk
Tabl
eTe
xas
LTC
Loc
al C
odes
Nat
iona
l Cod
es
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
56 November 2003, No. 16LTC Bul let in
Ser
vice
Gro
up
11
Ser
vice
Gro
up
16
10
N0211
1N
F - T
ile 2
11
01
00
All I
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sive
Roo
m &
Boa
rd P
lus
Anci
llary
I
10
N0212
1N
F - T
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12
01
00
All I
nclu
sive
Roo
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Boa
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lus
Anci
llary
I
Ser
vice
Gro
up 1
1 -
Long
Ter
m C
are
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e C
ross
wal
k Ta
ble
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s LT
C L
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atio
nal C
odes
Ser
vice
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roup
Bill
C
ode
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vice
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ode
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e D
escr
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onP
roce
dure
C
ode
Qua
lifie
r
HC
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S
Cod
eC
PT
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eR
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2M
odifi
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3M
odifi
er
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itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
11
G2000
39
PAC
E (D
ual E
ligib
le)
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to b
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tain
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Onl
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be
reta
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.P
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he Z
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alifi
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for
serv
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3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 1
6 -
Long
Ter
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s LT
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roup
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vice
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onP
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lifie
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2M
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eC
laim
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: I=
837I;
P=837P
;D
=837D
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G0400
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GO
Ser
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GP
Ser
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GN
Spe
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16
S0101
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16
G0100
11
Res
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vice
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16
G0101
11
Res
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-Hom
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16
G0102
11
Res
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ut-o
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1/03
Not
e: T
he Z
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alifi
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ust
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for
serv
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ren
dere
d fo
r 1
0/1
6/0
3.
Exce
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: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 1
0 -
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are
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ble
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vice
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roup
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vice
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onP
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lifie
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Dat
eC
laim
Typ
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: I=
837I;
P=837P
;D
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Not
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Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
57 LTC Bul le t inNovember 2003, No. 16
16
G0171
11
In-H
ome
Res
pite
CD
S -
Agen
cyZZ
Loca
l cod
e to
be
reta
ined
.P
16
G0200
12
Cas
e M
anag
emen
tH
CT1
01
6C
ase
Man
agem
ent,
eac
h 15 m
inut
esP
16
G0300
13
Nur
sing
- R
NH
CS
91
23
TDN
ursi
ng C
are
in t
he H
ome,
by
RN
P
16
G0300
13
Nur
sing
- R
NH
CT1
00
1TD
Nur
sing
ass
essm
ent/
eval
uatio
nP
16
G0300
13
Nur
sing
- R
NH
CT1
00
2TD
RN
ser
vice
s up
to
15 m
inut
esP
16
G0301
13
Nur
sing
- LV
NH
CS
91
24
TEN
ursi
ng C
are
in t
he H
ome,
by
LVN
P
16
G0301
13
Nur
sing
- LV
NH
CT1
00
3TE
LPN
/LVN
ser
vice
s up
to
15 m
inut
esP
16
G0500
15
Adap
tive
Aids
ADD
99
99
Uns
peci
fied
Adju
nctiv
e Pr
oced
ure,
by
Rep
ort
D
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
03
9Ve
hicl
e M
odifi
catio
ns, w
aive
r; p
er s
ervi
ceP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE0
63
6M
ultip
ositi
onal
pat
ient
sup
port
sys
tem
, with
inte
grat
ed li
ft,
patie
ntP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
03
1R
olla
bout
Cha
ir, a
ny a
nd a
ll ty
pes
with
cas
tors
5 in
ches
or
grea
ter
P
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
13
0S
tand
ard
Whe
elch
air,
fixe
d fu
ll le
ngth
arm
s, fi
xed
or s
win
g aw
ay d
etac
habl
eP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
39
9D
urab
le M
edic
al E
quip
men
t, M
isce
llane
ous
P
16
G0500
15
DM
E/Ad
aptiv
e Ai
ds09/2
8/03
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
0S
ynth
esiz
ed S
peec
h Au
gmen
tativ
e C
omm
unic
atio
n D
evic
e w
ith D
ynam
ic D
ispl
ayP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
2C
omm
unic
atio
n B
oard
, N
on-e
lect
roni
c Au
gmen
tativ
e or
Al
tern
ativ
e C
omm
unic
atio
nP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CS
51
99
Pers
onal
Car
e Ite
m, N
OS
, ea
chP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
9S
peci
aliz
ed m
edic
al e
quip
men
t, n
ot o
ther
wis
e sp
ecifi
ed,
wai
ver
P
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
8S
peci
aliz
ed S
uppl
y, N
ot o
ther
wis
e sp
ecifi
ed, w
aive
rP
16
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
00
3N
onem
erge
ncy
tran
spor
tatio
n; e
ncou
nter
/trip
P
16
G0608
16
Hom
e M
odifi
catio
nsH
CS
51
65
Hom
e M
odifi
catio
ns; pe
r se
rvic
eP
16
G0730
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Res
iden
tial
HC
T20
16
Hab
ilita
tion,
res
iden
tial,
wai
ver;
per
15 m
inut
es.
P
16
G0731
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Cho
re08/3
1/03
16
G0900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 6
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
16
G0908
19
Assi
sted
Liv
ing
(Les
s th
an 2
4 h
ours
)08/3
1/03
16
G0909
19
AL R
esid
entia
l Car
e - H
abili
tatio
n (2
4
hour
s)08/3
1/03
16
G1100
21
Pres
crip
tions
- di
scon
tinue
d08/3
1/03
Ser
vice
Gro
up 1
6 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
58 November 2003, No. 16LTC Bul let in
16
G0720
27
Con
sum
er M
anag
ed P
erso
nal
Atte
ndan
t S
ervi
ces
ZZLo
cal c
ode
to b
e re
tain
ed.
P
16
G0721
27
Clie
nt M
anag
ed A
tten
dant
Ser
vice
s -
Vouc
her
08/3
1/03
16
U0210
34
DIE
TAR
Y S
ERVI
CES
HC
S9
46
5D
iabe
tic m
anag
emen
t, d
ietic
ian
visi
tP
16
U0210
34
DIE
TAR
Y S
ERVI
CES
HC
S9
47
0N
utrit
iona
l cou
nsel
ing,
die
ticia
n vi
sit
P
16
U0210
34
DIE
TAR
Y S
ERVI
CES
HC
97
80
2M
edic
al n
utrit
ion
ther
apy,
initi
al a
sses
smen
t an
d in
terv
entio
n, e
ach
15 m
inut
esP
16
G0202
40
Prea
sses
smen
t08/3
1/03
16
G0230
43
Beh
avio
r C
omm
unic
atio
n S
peci
alis
tZZ
Loca
l cod
e to
be
reta
ined
.P
16
G0231
44
Orie
ntat
ion
and
mob
ility
HC
97
53
7C
omm
unity
/wor
k re
inte
grat
ion
trai
ning
(th
at is
, sh
oppi
ng,
tran
spor
tatio
n, m
oney
man
agem
ent,
avo
catio
nal a
ctiv
ities
an
d/or
wor
k en
viro
nmen
t/m
odifi
catio
n an
alys
is, w
ork
task
an
alys
is), d
irect
one
on
one
cont
act
by p
rovi
der,
eac
h 15
min
utes
P
16
G0231
44
Orie
ntat
ion
and
mob
ility
HC
97
53
5S
elf c
are/
hom
e m
anag
emen
t tra
inin
g (t
hat i
s, a
ctiv
ities
of
daily
livi
ng a
nd c
ompe
nsat
ory
trai
ning
, m
eal p
repa
ratio
n,
safe
ty p
roce
dure
s, a
nd in
stru
ctio
n in
use
of ad
aptiv
e eq
uipm
ent)
dire
ct o
ne o
n on
e co
ntac
t by
prov
ider
, eac
h 15
min
utes
P
16
G0232
45
Inte
rven
orH
C9
75
35
Sel
f car
e/ho
me
man
agem
ent t
rain
ing
(tha
t is,
act
iviti
es o
f da
ily li
ving
and
com
pens
ator
y tr
aini
ng, m
eal p
repa
ratio
n,
safe
ty p
roce
dure
s, a
nd in
stru
ctio
n in
use
of ad
aptiv
e eq
uipm
ent)
dire
ct o
ne o
n on
e co
ntac
t by
prov
ider
, eac
h 15
min
utes
P
16
G0236
45
Inte
rven
or C
DS
- Ag
ency
ZZLo
cal c
ode
to b
e re
tain
ed.
P
16
G0238
53
Tran
sitio
nal S
ervi
ces
08/3
1/03
16
G0119
11A
Res
pite
- O
ut-o
f-Hom
e - C
DS
08/3
1/03
16
G0128
11A
Res
pite
- O
ut-o
f-Hom
eH
CS
51
51
Uns
kille
d R
espi
te C
are,
per
die
mP
16
G0170
11A
Out
-of-H
ome
Res
pite
CD
SZZ
Loca
l cod
e to
be
reta
ined
.P
16
G0216
12A
Targ
eted
Cas
e M
anag
emen
t08/3
1/03
16
S9800
13C
Nur
sing
Ser
vice
s by
Hig
hly
Tech
nica
l R
N,
per
hour
HC
S9
80
0TG
Hom
e Th
erap
y; p
rovi
sion
of in
fusi
on, sp
ecia
lty d
rug
adm
inis
trat
ion,
and
/or
asso
ciat
ed n
ursi
ng s
ervi
ces
and
proc
edur
es, by
hig
hly
tech
nica
l R.N
., p
er h
our
P
16
T1003
13D
Nur
sing
Ser
vice
s LV
NH
CT1
00
3TG
LPN
/LVN
ser
vice
s, u
p to
15 m
inut
esP
16
G0744
17E
PAS
Cho
reH
CS
51
20
Cho
re S
ervi
ces,
per
15 m
inut
esP
16
G0717
17V
CD
S-P
AS-P
artic
ipan
tZZ
Loca
l cod
e to
be
reta
ined
.P
16
G0718
17V
PAS
Lev
el 1
(N
onpr
iorit
y) C
DS
ZZLo
cal c
ode
to b
e re
tain
ed.
P
16
G0719
17V
CD
S-P
AS-A
genc
yZZ
Loca
l cod
e w
ill r
emai
n fo
r bi
lling
of th
e ag
ency
fee
for
VFI
.P
Ser
vice
Gro
up 1
6 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
59 LTC Bul le t inNovember 2003, No. 16
16
G0937
19E
Assi
sted
Liv
ing
- Hab
ilita
tion
24
hou
rH
CT2
03
3U
1R
esid
entia
l car
e, n
ot o
ther
wis
e sp
ecifi
ed (N
OS
), w
aive
r;
per
diem
P
16
G0938
19F
Assi
sted
Liv
ing
- Hab
ilita
tion
Less
Th
an 2
4 h
our
HC
T10
20
Pers
onal
car
e se
rvic
es, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
16
G0938
19F
Assi
sted
Liv
ing
- Hab
ilita
tion
Less
Th
an 2
4 h
our
02
40
A fla
t ra
te c
harg
e in
curr
ed o
n ei
ther
a d
aily
bas
is o
r to
tal
stay
bas
is for
anc
illar
y se
rvic
es o
nly
I
16
G0722
27A
CM
PAS
- C
lient
Dire
cted
Ser
vice
sZZ
Loca
l cod
e to
be
reta
ined
.P
16
G0207
40A
Prea
sses
smen
tH
CT2
02
4S
ervi
ce a
sses
smen
t/pl
an o
f ca
re d
evel
opm
ent,
wai
ver
P
16
G0637
41E
Den
tal/
Req
uisi
tion
Fees
0 -
49
9.9
908/3
1/03
16
G0638
41E
Den
tal/
Req
uisi
tion
Fees
5
00
.00
- 9
99
.99
08/3
1/03
16
G0639
41E
Den
tal/
Req
uisi
tion
Fees
1
00
0.0
0 -
14
99
.99
08/3
1/03
16
G0640
41E
Den
tal/
Req
uisi
tion
Fees
1
50
0.0
0 -
19
99
.99
08/3
1/03
16
G0641
41E
Den
tal/
Req
uisi
tion
Fees
2
00
0.0
0 -
24
99
.99
08/3
1/03
16
G0642
41E
Den
tal/
Req
uisi
tion
Fees
2
50
0.0
0 -
29
99
.99
08/3
1/03
16
G0643
41E
Den
tal/
Req
uisi
tion
Fees
30
00
.00
- 3
49
9.9
908/3
1/03
16
G0644
41E
Den
tal/
Req
uisi
tion
Fees
3
50
0.0
0 -
39
99
.99
08/3
1/03
16
G0645
41E
Den
tal/
Req
uisi
tion
Fees
40
00
.00
- 4
49
9.9
908/3
1/03
16
G0646
41E
Den
tal/
Req
uisi
tion
Fees
4
50
0.0
0 -
49
99
.99
08/3
1/03
16
G0647
41E
Den
tal/
Req
uisi
tion
Fees
5
00
0.0
0 -
OVE
R08/3
1/03
16
G0239
53A
Tran
sitio
nal S
uppo
rt S
ervi
ces
08/3
1/03
16
N0600
5A
Den
tal S
ervi
ces
08/3
1/03
Ser
vice
Gro
up 1
6 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
60 November 2003, No. 16LTC Bul let in
Ser
vice
Gro
up
17
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
17
G0400
7O
ccup
atio
nal T
hera
pyH
CG
01
52
GO
Ser
vice
s of
an
occu
patio
nal t
hera
pist
in a
hom
e he
alth
se
ttin
g; p
er 1
5 m
inut
esP
17
G0401
8Ph
ysic
al T
hera
pyH
CG
01
51
GP
Ser
vice
s of
a p
hysi
cal t
hera
pist
in a
hom
e he
alth
set
ting;
pe
r 1
5 m
inut
esP
17
G0402
9S
peec
h Th
erap
yH
CG
01
53
GN
Spe
ech
or la
ngua
ge p
atho
logi
st in
hom
e he
alth
set
ting;
per
1
5 m
inut
esP
17
S0101
10
Hab
ilita
tion
- AD
LsH
CT2
02
1U
5D
ay h
abili
tatio
n, w
aive
r; p
er 1
5 m
inut
es.
P
17
G0101
11
Res
pite
- In
-Hom
e ZZ
Loca
l cod
e to
be
reta
ined
. (V
FI P
aym
ent)
P
17
G0301
13
Nur
sing
- LV
NH
CS
91
24
TEN
ursi
ng C
are
in t
he H
ome,
by
LVN
P
17
G0301
13
Nur
sing
- LV
NH
CT1
00
3TE
LPN
/LVN
ser
vice
s up
to
15 m
inut
esP
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
01
Psyc
hiat
ric d
iagn
ostic
inte
rvie
w e
xam
inat
ion
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
10
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r, o
r oth
er
mec
hani
sms
of n
onve
rbal
com
mun
icat
ion,
in a
n of
fice
or
outp
atie
nt fac
ility
, ap
prox
imat
ely
20 -
30 m
inut
es fac
e-to
-fa
ce w
ith t
he p
atie
nt
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
12
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r, o
r oth
er
mec
hani
sms
of n
onve
rbal
com
mun
icat
ion,
in a
n of
fice
or
outp
atie
nt fac
ility
, ap
prox
imat
ely
45 -
50 m
inut
es fac
e-to
-fa
ce w
ith t
he p
atie
nt
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
14
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r, o
r oth
er
mec
hani
sms
of n
onve
rbal
com
mun
icat
ion,
in a
n of
fice
or
outp
atie
nt fac
ility
, ap
prox
imat
ely
75 -
80 m
inut
es fac
e-to
-fa
ce w
ith t
he p
atie
nt
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
16
Indi
vidu
al p
sych
othe
rapy
, in
sigh
t or
ient
ed, be
havi
or
mod
ifyin
g an
d/or
sup
port
ive,
in a
n in
patie
nt h
ospi
tal,
part
ial h
ospi
tal,
or r
esid
entia
l car
e se
ttin
g, a
ppro
xim
atel
y 2
0 -
30
min
utes
fac
e-to
-face
with
pat
ient
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
18
Indi
vidu
al p
sych
othe
rapy
, in
sigh
t or
ient
ed, be
havi
or
mod
ifyin
g an
d/or
sup
port
ive,
in a
n in
patie
nt h
ospi
tal,
part
ial h
ospi
tal,
or r
esid
entia
l car
e se
ttin
g, a
ppro
xim
atel
y 4
5 -
50
min
utes
fac
e-to
-face
with
pat
ient
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
21
Indi
vidu
al p
sych
othe
rapy
, in
sigh
t or
ient
ed, be
havi
or
mod
ifyin
g an
d/or
sup
port
ive,
in a
n in
patie
nt h
ospi
tal,
part
ial h
ospi
tal,
or r
esid
entia
l car
e se
ttin
g, a
ppro
xim
atel
y 7
5 -
80
min
utes
fac
e-to
-face
with
pat
ient
P
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
61 LTC Bul le t inNovember 2003, No. 16
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
23
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r, o
r oth
er
mec
hani
sms
of n
onve
rbal
com
mun
icat
ion,
in a
n in
patie
nt
hosp
ital,
part
ial h
ospi
tal o
r re
side
ntia
l car
e se
ttin
g,
appr
oxim
atel
y 2
0 -
30 m
inut
es fa
ce-to
-face
with
the
patie
nt
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
26
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r, o
r oth
er
mec
hani
sms
of n
onve
rbal
com
mun
icat
ion,
in a
n in
patie
nt
hosp
ital,
part
ial h
ospi
tal o
r re
side
ntia
l car
e se
ttin
g,
appr
oxim
atel
y 45 -
50 m
inut
es fa
ce-to
-face
with
the
patie
nt
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
28
Indi
vidu
al p
sych
othe
rapy
, in
tera
ctiv
e, u
sing
pla
y eq
uipm
ent,
phy
sica
l dev
ices
, lan
guag
e in
terp
rete
r, o
r oth
er
mec
hani
sms
of n
onve
rbal
com
mun
icat
ion,
in a
n in
patie
nt
hosp
ital,
part
ial h
ospi
tal o
r re
side
ntia
l car
e se
ttin
g,
appr
oxim
atel
y 75 -
80 m
inut
es fa
ce-to
-face
with
the
patie
nt
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
45
Psyc
hoan
alys
isP
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
47
Fam
ily p
sych
othe
rapy
(co
njoi
nt c
ouns
elin
g) w
ith p
atie
nt
pres
ent
P
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
08
62
Phar
mac
olog
ical
man
agem
ent,
incl
udin
g pr
escr
iptio
n/us
e/re
view
of m
edic
atio
nP
17
G0403
14
Psyc
holo
gica
l Ser
vice
sH
C9
61
00
Psyc
holo
gica
l tes
ting
P
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
03
9Ve
hicl
e M
odifi
catio
ns, w
aive
r; p
er s
ervi
ceP
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE0
63
6M
ultip
ositi
onal
pat
ient
sup
port
sys
tem
, with
inte
grat
ed li
ft,
patie
ntP
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
03
1R
olla
bout
Cha
ir, a
ny a
nd a
ll ty
pes
with
cas
tors
5 in
ches
or
grea
ter
P
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
13
0S
tand
ard
Whe
elch
air,
fixe
d fu
ll le
ngth
arm
s, fi
xed
or s
win
g aw
ay d
etac
habl
eP
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
39
9D
urab
le M
edic
al E
quip
men
t, M
isce
llane
ous
P
17
G0500
15
DM
E/Ad
aptiv
e Ai
ds09/2
8/03
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
0S
ynth
esiz
ed S
peec
h Au
gmen
tativ
e C
omm
unic
atio
n D
evic
e w
ith D
ynam
ic D
ispl
ayP
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
2C
omm
unic
atio
n B
oard
, N
on-e
lect
roni
c Au
gmen
tativ
e or
Al
tern
ativ
e C
omm
unic
atio
nP
17
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
9S
peci
aliz
ed m
edic
al e
quip
men
t, n
ot o
ther
wis
e sp
ecifi
ed,
wai
ver
P
17
G0608
16
Hom
e M
odifi
catio
nsH
CS
51
65
Hom
e M
odifi
catio
ns; pe
r se
rvic
eP
17
G0701
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 2 -
Prio
rity
HC
S5
12
5At
tend
ant
Car
e S
ervi
ces,
per
15 m
inut
esP
17
G0800
18
Adul
t Fo
ster
Car
e - L
evel
1H
CS
51
40
31
05
U3
Adul
t fo
ster
car
e, p
er d
iem
I
17
G0801
18
Adul
t Fo
ster
Car
e - L
evel
2H
CS
51
40
31
05
U4
Adul
t fo
ster
car
e, p
er d
iem
I
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
62 November 2003, No. 16LTC Bul let in
17
G0802
18
Adul
t Fo
ster
Car
e - L
evel
3H
CS
51
40
31
05
U5
Adul
t fo
ster
car
e, p
er d
iem
I
17
G0900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 6
)H
CT2
03
1U
1U
1As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
17
G1900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 5
)08/3
1/03
17
G2900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 4
)08/3
1/03
17
G3900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 3
)08/3
1/03
17
G4900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 2
)08/3
1/03
17
G5900
19
Assi
sted
Liv
ing
- Apa
rtm
ent
(Lev
el 1
)08/3
1/03
17
G1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
60
In
stal
latio
n an
d Te
stin
gP
17
G1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
61
Mon
thly
Ser
vice
Fee
(ex
clud
es in
stal
latio
n an
d te
stin
g)P
17
G1000
20
Emer
genc
y R
espo
nse
Ser
vice
sH
CS
51
62
Purc
hase
Onl
yP
17
G1200
22
Med
ical
Sup
plie
s H
CS
51
99
Pers
onal
Car
e Ite
m, N
OS
, ea
chP
17
G1200
22
Med
ical
Sup
plie
s H
CT2
02
8S
peci
aliz
ed S
uppl
y, N
ot o
ther
wis
e sp
ecifi
ed, w
aive
rP
17
C0100
25
Hom
e D
eliv
ered
Mea
ls08/3
1/03
17
C0101
25
Wai
ver
Mea
lsH
CS
51
70
Per
mea
l, in
clud
es p
repa
ratio
n an
d de
liver
yP
17
U0210
34
Die
tary
Ser
vice
sH
CS
94
65
Dia
betic
man
agem
ent,
die
ticia
n vi
sit
P
17
U0210
34
Die
tary
Ser
vice
sH
CS
94
70
Nut
ritio
nal c
ouns
elin
g, d
ietic
ian
visi
tP
17
U0210
34
Die
tary
Ser
vice
sH
C9
78
02
Med
ical
nut
ritio
n th
erap
y, in
itial
ass
essm
ent
and
inte
rven
tion,
eac
h 15 m
inut
esP
17
U0300
35
Audi
olog
y/AU
H
CV5
00
8H
earin
g S
cree
ning
P
17
U0300
35
Audi
olog
y/AU
H
CV5
01
0H
earin
g Ai
d As
sess
men
tP
17
U0300
35
Audi
olog
y/AU
H
CV5
01
1Fi
ttin
g/O
rient
atio
n of
Hea
ring
Aid
P
17
U0300
35
Audi
olog
y/AU
H
CV5
02
0C
onfo
rmity
Eva
luat
ion
P
17
U0400
36
Soc
ial W
ork/
SW
HC
G0
15
5S
ervi
ces
of a
clin
ical
soc
ial w
orke
r in
the
hom
e he
alth
se
ttin
g, e
ach
15
min
utes
P
17
U0505
37
Sup
port
ed E
mpl
oym
ent/
SE
HC
T20
19
Hab
ilita
tion,
sup
port
ed e
mpl
oym
ent,
wai
ver;
per
15
min
utes
P
17
G0205
40
Annu
al A
sses
smen
t08/3
1/03
17
G0515
41
ADP
Aide
s/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0516
41
ADP
Aide
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0517
41
ADP
Aide
s/R
equi
sitio
n Fe
es
1
00
0.0
0 -
14
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0518
41
ADP
Aide
s/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
63 LTC Bul le t inNovember 2003, No. 16
17
G0519
41
ADP
Aide
s/R
equi
sitio
n Fe
es
2
00
0.0
0 -
24
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0520
41
ADP
Aide
s/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0521
41
ADP
Aide
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0522
41
ADP
Aide
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0523
41
ADP
Aide
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0524
41
ADP
Aide
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0525
41
ADP
Aide
s/R
equi
sitio
n Fe
es
50
00
.00
- O
VER
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0230
43
Beh
avio
r C
omm
unic
atio
n S
peci
alis
tZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0231
44
Orie
ntat
ion
and
Mob
ility
HC
97
53
7C
omm
unity
/wor
k re
inte
grat
ion
trai
ning
(th
at is
, sh
oppi
ng,
tran
spor
tatio
n, m
oney
man
agem
ent,
avo
catio
nal
activ
ities
, and
/or w
ork
envi
ronm
ent/
mod
ifica
tion
anal
ysis
, w
ork
task
ana
lysi
s), d
irect
one
on
one
cont
act b
y pr
ovid
er,
each
15
min
utes
P
17
G0231
44
Orie
ntat
ion
and
Mob
ility
HC
97
53
5S
elf c
are/
hom
e m
anag
emen
t tra
inin
g (t
hat i
s, a
ctiv
ities
of
daily
livi
ng a
nd c
ompe
nsat
ory
trai
ning
, m
eal p
repa
ratio
n,
safe
ty p
roce
dure
s, a
nd in
stru
ctio
n in
use
of ad
aptiv
e eq
uipm
ent)
dire
ct o
ne o
n on
e co
ntac
t by
prov
ider
, eac
h 15
min
utes
P
17
G0232
45
Inte
rven
orH
C9
75
35
Sel
f car
e/ho
me
man
agem
ent t
rain
ing
(tha
t is,
act
iviti
es o
f da
ily li
ving
and
com
pens
ator
y tr
aini
ng, m
eal p
repa
ratio
n,
safe
ty p
roce
dure
s, a
nd in
stru
ctio
n in
use
of ad
aptiv
e eq
uipm
ent)
dire
ct o
ne o
n on
e co
ntac
t by
prov
ider
, eac
h 15
min
utes
P
17
G0233
48
Tran
spor
tatio
nH
CA0
10
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Tax
iP
17
G0233
48
Tran
spor
tatio
nH
CA0
11
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Bus
P
17
G0233
48
Tran
spor
tatio
nH
CA0
12
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Min
i-Bus
, ot
her
nonp
rofit
tr
ansp
ort
syst
ems
P
17
G0233
48
Tran
spor
tatio
nH
CA0
13
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Whe
elch
air
Van
P
17
G0233
48
Tran
spor
tatio
nH
CA0
16
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Cas
ewor
ker
or S
ocia
l W
orke
rP
17
G0233
48
Tran
spor
tatio
nH
CA0
17
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Anc
illar
y; P
arki
ng F
ees,
To
lls, O
ther
P
17
G0233
48
Tran
spor
tatio
nH
CA0
21
0N
on-e
mer
genc
y Tr
ansp
orta
tion;
Anc
illar
y; M
eals
- Es
cort
P
17
G0233
48
Tran
spor
tatio
nH
CT2
00
1N
on-e
mer
genc
y tr
ansp
orta
tion;
pat
ient
att
enda
nt/e
scor
tP
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
64 November 2003, No. 16LTC Bul let in
17
G0233
48
Tran
spor
tatio
nH
CT2
00
3N
on-e
mer
genc
y tr
ansp
orta
tion;
enc
ount
er/t
ripP
17
G0233
48
Tran
spor
tatio
nH
CT2
00
4N
on-e
mer
genc
y tr
ansp
ort;
com
mer
cial
car
rier,
mul
ti-pa
ssP
17
G0233
48
Tran
spor
tatio
nH
CT2
00
5
Non
-em
erge
ncy
tran
spor
tatio
n; N
on-a
mbu
lato
ry s
tret
cher
va
nP
17
G0234
49
Chi
ld S
uppo
rt S
ervi
ces
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0235
51
Inde
pend
ent
Advo
cacy
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0238
53
Tran
sitio
nal S
ervi
ces
08/3
1/03
17
S0106
10B
Hab
ilita
tion
- Sup
port
ive
Empl
oy
Empl
oym
ent
08/3
1/03
17
S0107
10B
Hab
ilita
tion
- Pre
voca
tiona
lH
CT2
01
5U
4H
abili
tatio
n pr
evoc
atio
nal,
wai
ver,
per
hou
rP
17
S0125
10B
Hab
ilita
tion
- Pre
voca
tiona
l LO
N 1
In
term
itten
t08/3
1/03
17
S0126
10B
Hab
ilita
tion
- Pre
voca
tiona
l LO
N 5
Li
mite
d08/3
1/03
17
S0127
10B
Hab
ilita
tion
- Pre
voca
tiona
l LO
N 6
Pe
rvas
ive
08/3
1/03
17
S0128
10B
Hab
ilita
tion
- Pre
voca
tiona
l LO
N 8
Ex
tens
ive
08/3
1/03
17
S0108
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
HC
97
53
5S
elf c
are/
hom
e m
anag
emen
t tra
inin
g (t
hat i
s, a
ctiv
ities
of
daily
livi
ng a
nd c
ompe
nsat
ory
trai
ning
, m
eal p
repa
ratio
n,
safe
ty p
roce
dure
s, a
nd in
stru
ctio
n in
use
of ad
aptiv
e eq
uipm
ent)
dire
ct o
ne o
n on
e co
ntac
t by
prov
ider
, eac
h 15
min
utes
P
17
S0108
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
09
42
Educ
atio
n/Tr
aini
ngI
17
S0108
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
HC
97
53
7C
omm
unity
/wor
k re
inte
grat
ion
trai
ning
(th
at is
, sh
oppi
ng,
tran
spor
tatio
n, m
oney
man
agem
ent,
avo
catio
nal a
ctiv
ities
an
d/or
wor
k en
viro
nmen
t/m
odifi
catio
n an
alys
is, w
ork
task
an
alys
is), d
irect
one
on
one
cont
act
by p
rovi
der,
eac
h 15
min
utes
P
17
S0129
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
LON
1
Inte
rmitt
ent
08/3
1/03
17
S0130
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
LON
5
Lim
ited
08/3
1/03
17
S0131
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
LON
6
Perv
asiv
e08/3
1/03
17
S0132
10C
Hab
ilita
tion
- Day
Hab
ilita
tion
LON
8
Exte
nsiv
e08/3
1/03
17
G0119
11A
Res
pite
-RE-
LON
808/3
1/03
17
G0128
11A
Res
pite
- O
ut-o
f-Hom
eH
CS
51
51
Uns
kille
d R
espi
te C
are,
per
die
mP
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
65 LTC Bul le t inNovember 2003, No. 16
17
G0132
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 1
HC
S5
15
10
66
0U
3U
nski
lled
Res
pite
Car
e, p
er d
iem
I
17
G0132
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 1
HC
S5
15
1U
3U
nski
lled
Res
pite
Car
e, p
er d
iem
P
17
G0133
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 2
HC
S5
15
10
66
0U
4U
nski
lled
Res
pite
Car
e, p
er d
iem
I
17
G0133
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 2
HC
S5
15
1U
4U
nski
lled
Res
pite
Car
e, p
er d
iem
P
17
G0134
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 3
HC
S5
15
10
66
0U
5U
nski
lled
Res
pite
Car
e, p
er d
iem
I
17
G0134
11B
Res
pite
- Ad
ult
Fost
er C
are
- Lev
el 3
HC
S5
15
1U
5U
nski
lled
Res
pite
Car
e, p
er d
iem
P
17
G0135
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
6)
HC
S5
15
10
66
0U
1U
1I
17
G0135
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
6)
HC
S5
15
1U
1U
1P
17
G0136
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
5)
08/3
1/03
17
G0137
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
4)
08/3
1/03
17
G0138
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
3)
08/3
1/03
17
G0139
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
2)
08/3
1/03
17
G0140
11C
Res
pite
- As
sist
ed L
ivin
g - A
part
men
t (L
evel
1)
08/3
1/03
17
G0142
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
HC
S5
15
10
66
0U
2U
1I
17
G0142
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
6)
HC
S5
15
1U
2U
1P
17
G0143
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
5)
08/3
1/03
17
G0144
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
4)
08/3
1/03
17
G0145
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
3)
08/3
1/03
17
G0146
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
2)
08/3
1/03
17
G0147
11D
Res
pite
- R
esid
entia
l Car
e -
Apar
tmen
t (L
evel
1)
08/3
1/03
17
G0149
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
6)
HC
S5
15
10
66
0U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
I
17
G0149
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
6)
HC
S5
15
1U
2U
2U
nski
lled
Res
pite
Car
e, p
er d
iem
P
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
66 November 2003, No. 16LTC Bul let in
17
G0150
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
5)
08/3
1/03
17
G0151
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
4)
08/3
1/03
17
G0152
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
3)
08/3
1/03
17
G0153
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
2)
08/3
1/03
17
G0154
11E
Res
pite
- R
esid
entia
l Car
e -
Non
apar
tmen
t (L
evel
1)
08/3
1/03
17
N1201
11F
Res
pite
NF
- Tile
20
10
66
3D
aily
Res
pite
Cha
rge
I
17
N1202
11F
Res
pite
NF
- Tile
20
20
66
3D
aily
Res
pite
Cha
rge
I
17
N1203
11F
Res
pite
NF
- Tile
20
30
66
3D
aily
Res
pite
Cha
rge
I
17
N1204
11F
Res
pite
NF
- Tile
20
40
66
3D
aily
Res
pite
Cha
rge
I
17
N1205
11F
Res
pite
NF
- Tile
20
50
66
3D
aily
Res
pite
Cha
rge
I
17
N1206
11F
Res
pite
NF
- Tile
20
60
66
3D
aily
Res
pite
Cha
rge
I
17
N1207
11F
Res
pite
NF
- Tile
20
70
66
3D
aily
Res
pite
Cha
rge
I
17
N1208
11F
Res
pite
NF
- Tile
20
80
66
3D
aily
Res
pite
Cha
rge
I
17
N1209
11F
Res
pite
NF
- Tile
20
90
66
3D
aily
Res
pite
Cha
rge
I
17
N1210
11F
Res
pite
NF
- Tile
21
00
66
3D
aily
Res
pite
Cha
rge
I
17
N1211
11F
Res
pite
NF
- Tile
21
10
66
3D
aily
Res
pite
Cha
rge
I
17
N1212
11F
Res
pite
NF
- Tile
21
20
66
3D
aily
Res
pite
Cha
rge
I
17
G0156
11G
Res
pite
- C
amp
HC
T20
37
06
63
Res
pite
Car
e, T
hera
peut
ic C
ampi
ng, D
ay, ea
ch s
essi
onI
17
G0157
11H
Res
pite
- D
ay C
are/
Lice
nsed
Chi
ld
Car
e Fa
cilit
yH
CT2
02
60
66
3R
espi
te C
are,
Spe
cial
ized
Chi
ldca
re, pe
r da
yI
17
G0159
11K
Res
pite
- IC
F/M
R0
66
0R
espi
te C
are,
gen
eral
(N
ote:
To
cros
swal
k ba
ck t
o th
e lo
cal c
ode,
pla
ce o
f se
rvic
e m
ust
be a
ccur
ate.
)I
17
G0160
11L
Res
pite
- H
ospi
tal
06
60
Res
pite
Car
e, g
ener
al (
Not
e: T
o cr
ossw
alk
back
to
the
loca
l cod
e, p
lace
of se
rvic
e m
ust
be a
ccur
ate.
)I
17
G0162
11N
Res
pite
- LV
N08/3
1/03
17
G0216
12A
Targ
eted
Cas
e M
anag
emen
t08/3
1/03
17
G0302
13A
Nur
sing
Ser
vice
s - L
VNH
CS
91
24
Nur
sing
Car
e in
the
Hom
e, b
y LV
NP
17
G0302
13A
Nur
sing
Ser
vice
s - L
VNH
CT1
00
3LP
N/L
VN s
ervi
ces
up t
o 15 m
inut
esP
17
G0303
13B
Nur
sing
Ser
vice
s - R
NH
CS
91
23
Nur
sing
Car
e in
the
Hom
e, b
y R
NP
17
G0303
13B
Nur
sing
Ser
vice
s - R
NH
CT1
00
1N
ursi
ng a
sses
smen
t/ev
alua
tion
P
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
67 LTC Bul le t inNovember 2003, No. 16
17
G0303
13B
Nur
sing
Ser
vice
s - R
NH
CT1
00
2R
N s
ervi
ces
up t
o 15 m
inut
esP
17
G0705
17A
PAS
Del
egat
ed (
For
Futu
re U
se)
08/3
1/03
17
G0706
17B
PAS
Pro
tect
ive
Sup
ervi
sion
(Fo
r Fu
ture
Use
)08/3
1/03
17
G0744
17E
PAS
Cho
re08/3
1/03
17
G0921
19A
AL R
esid
entia
l Car
e - A
part
men
t
(L
evel
6)
HC
T20
31
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mP
17
G0921
19A
AL R
esid
entia
l Car
e - A
part
men
t
(L
evel
6)
HC
T20
31
02
40
U2
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mI
17
G0922
19A
Assi
sted
Liv
ing
Res
iden
tial C
are
Apar
tmen
t (L
evel
5)
08/3
1/03
17
G0923
19A
Assi
sted
Liv
ing
Res
iden
tial C
are
Apar
tmen
t (L
evel
4)
08/3
1/03
17
G0924
19A
Assi
sted
Liv
ing
Res
iden
tial C
are
Apar
tmen
t (L
evel
3)
08/3
1/03
17
G0925
19A
Assi
sted
Liv
ing
Res
iden
tial C
are
Apar
tmen
t (L
evel
2)
08/3
1/03
17
G0926
19A
Assi
sted
Liv
ing
Res
iden
tial C
are
Apar
tmen
t (L
evel
1)
08/3
1/03
17
G0928
19B
AL R
esid
entia
l Car
e - N
onap
artm
ent
(Lev
el 6
)H
CT2
03
1U
2U
2As
sist
ed li
ving
, w
aive
r; p
er d
iem
P
17
G0929
19B
Assi
sted
Liv
ing
Res
iden
tial C
are
Non
apar
tmen
t (L
evel
5)
08/3
1/03
17
G0930
19B
Assi
sted
Liv
ing
Res
iden
tial C
are
Non
apar
tmen
t (L
evel
4)
08/3
1/03
17
G0931
19B
Assi
sted
Liv
ing
Res
iden
tial C
are
Non
apar
tmen
t (L
evel
3)
08/3
1/03
17
G0932
19B
Assi
sted
Liv
ing
Res
iden
tial C
are
Non
apar
tmen
t (L
evel
2)
08/3
1/03
17
G0933
19B
Assi
sted
Liv
ing
Res
iden
tial C
are
Non
apar
tmen
t (L
evel
1)
08/3
1/03
17
G0935
19C
Assi
sted
Liv
ing
- Per
sona
l Car
e 3
HC
T20
31
U1
Assi
sted
livi
ng,
wai
ver;
per
die
mP
17
G0910
19E
Res
iden
tial S
uppo
rt L
OC
1H
CT1
02
00
24
0U
3U
2U
2A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0910
19E
Res
iden
tial S
uppo
rt L
OC
1H
CT1
02
0U
3Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
68 November 2003, No. 16LTC Bul let in
17
G0911
19E
Res
iden
tial S
uppo
rt L
ON
5H
CT1
02
00
24
0U
7U
2U
2A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0911
19E
Res
iden
tial S
uppo
rt L
ON
5H
CT1
02
0U
7Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
17
G0912
19E
Res
iden
tial S
uppo
rt L
ON
6H
CT1
02
00
24
0U
8U
2U
2A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0912
19E
Res
iden
tial S
uppo
rt L
ON
6H
CT1
02
0U
8Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
17
G0913
19E
Res
iden
tial S
uppo
rt L
ON
8H
CT1
02
00
24
0U
AU
2U
2A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly.
I
17
G0913
19E
Res
iden
tial S
uppo
rt L
ON
8H
CT1
02
0U
APe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
17
G0937
19E
Assi
sted
Liv
ing
- Hab
ilita
tion
24
hou
rH
CT2
03
3U
1R
esid
entia
l car
e, n
ot o
ther
wis
e sp
ecifi
ed (N
OS
), w
aive
r;
per
diem
P
17
G0939
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
1H
CT1
02
00
24
0U
3A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0939
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
1H
CT1
02
0U
3Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
17
G0940
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
5H
CT1
02
00
24
0U
7A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0940
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
5H
CT1
02
0U
7Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
17
G0941
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
8H
CT1
02
00
24
0U
AA
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0941
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
8H
CT1
02
0U
APe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
69 LTC Bul le t inNovember 2003, No. 16
17
G0942
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
6H
CT1
02
00
24
0U
8A
flat
rate
cha
rge
incu
rred
on
eith
er a
dai
ly b
asis
or
tota
l st
ay b
asis
for
anc
illar
y se
rvic
es o
nly
I
17
G0942
19G
Assi
sted
Liv
ing
- Fam
ily S
urro
gate
S
ervi
ces
LON
6H
CT1
02
0U
8Pe
rson
al c
are
serv
ices
, pe
r di
em, no
t fo
r an
inpa
tient
or
resi
dent
of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F/M
R o
r IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent
(Cod
e m
ay n
ot b
e us
ed to
iden
tify
serv
ices
pro
vide
d by
a h
ome
heal
th a
ide
or
cert
ified
nur
se a
ssis
tant
.)
P
17
G0207
40A
Prea
sses
smen
tH
CT2
02
4S
ervi
ce a
sses
smen
t/pl
an o
f ca
re d
evel
opm
ent,
wai
ver
P
17
G1212
41A
Med
ical
S/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1213
41A
Med
ical
S/R
equi
sitio
n Fe
es
50
0.0
0 -
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1214
41A
Med
ical
S/R
equi
sitio
n Fe
es
10
00
.00
- 1
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1215
41A
Med
ical
S/R
equi
sitio
n Fe
es
15
00
.00
- 1
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1216
41A
Med
ical
S/R
equi
sitio
n Fe
es
20
00
.00
- 2
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1217
41A
Med
ical
S/R
equi
sitio
n Fe
es
25
00
.00
- 2
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1218
41A
Med
ical
S/R
equi
sitio
n Fe
es
3
00
0.0
0 -
34
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G1219
41A
Med
ical
S/R
equi
sitio
n Fe
es
35
00
.00
- 3
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1220
41A
Med
ical
S/R
equi
sitio
n Fe
es
40
00
.00
- 4
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1221
41A
Med
ical
S/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G1222
41A
Med
ical
S/R
equi
sitio
n Fe
es
50
00
.00
- O
VER
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0623
41B
MH
Mod
s/R
equi
sitio
n Fe
es
0 -
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0624
41B
MH
Mod
s/R
equi
sitio
n Fe
es
5
00
.00
- 9
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0625
41B
MH
Mod
s/R
equi
sitio
n Fe
es
10
00
.00
- 1
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0626
41B
MH
Mod
s/R
equi
sitio
n Fe
es
1
50
0.0
0 -
19
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0627
41B
MH
Mod
s/R
equi
sitio
n Fe
es
20
00
.00
- 2
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
70 November 2003, No. 16LTC Bul let in
17
G0628
41B
MH
Mod
s/R
equi
sitio
n Fe
es
2
50
0.0
0 -
29
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0629
41B
MH
Mod
s/R
equi
sitio
n Fe
es
30
00
.00
- 3
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0630
41B
MH
Mod
s/R
equi
sitio
n Fe
es
3
50
0.0
0 -
39
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0631
41B
MH
Mod
s/R
equi
sitio
n Fe
es
4
00
0.0
0 -
44
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0632
41B
MH
Mod
s/R
equi
sitio
n Fe
es
45
00
.00
- 4
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0633
41B
MH
Mod
s/R
equi
sitio
n Fe
es
50
00
.00
- 5
49
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0634
41B
MH
Mod
s/R
equi
sitio
n Fe
es
55
00
.00
- 5
99
9.9
9ZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0635
41B
MH
Mod
s/R
equi
sitio
n Fe
es
6
00
0.0
0 -
64
99
.99
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0636
41B
MH
Mod
s/R
equi
sitio
n Fe
es
6
50
0.0
0 -
Ove
rZZ
Loca
l cod
e to
be
reta
ined
.P
17
G0607
41C
Spe
cific
atio
ns A
dapt
ive
Aids
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0604
41D
Spe
cific
atio
ns H
M M
ods
ZZLo
cal c
ode
to b
e re
tain
ed.
P
17
G0637
41E
Den
tal/
Req
uisi
tion
Fees
0 -
49
9.9
908/3
1/03
17
G0638
41E
Den
tal/
Req
uisi
tion
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5
00
.00
- 9
99
.99
08/3
1/03
17
G0639
41E
Den
tal/
Req
uisi
tion
Fees
1
00
0.0
0 -
14
99
.99
08/3
1/03
17
G0640
41E
Den
tal/
Req
uisi
tion
Fees
1
50
0.0
0 -
19
99
.99
08/3
1/03
17
G0641
41E
Den
tal/
Req
uisi
tion
Fees
2
00
0.0
0 -
24
99
.99
08/3
1/03
17
G0642
41E
Den
tal/
Req
uisi
tion
Fees
2
50
0.0
0 -
29
99
.99
08/3
1/03
17
G0643
41E
Den
tal/
Req
uisi
tion
Fees
3
00
0.0
0 -
34
99
.99
08/3
1/03
17
G0644
41E
Den
tal/
Req
uisi
tion
Fees
3
50
0.0
0 -
39
99
.99
08/3
1/03
17
G0645
41E
Den
tal/
Req
uisi
tion
Fees
4
00
0.0
0 -
44
99
.99
08/3
1/03
17
G0646
41E
Den
tal/
Req
uisi
tion
Fees
4
50
0.0
0 -
49
99
.99
08/3
1/03
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
71 LTC Bul le t inNovember 2003, No. 16
Ser
vice
Gro
up
18
17
G0647
41E
Den
tal/
Req
uisi
tion
Fees
5
00
0.0
0 -
OVE
R08/3
1/03
17
G0239
53A
Tran
sitio
nal S
uppo
rt S
ervi
ces
08/3
1/03
17
N0600
5A
Emer
genc
y D
enta
lAD
D9
99
9U
nspe
cifie
d Ad
junc
tive
Proc
edur
e, b
y R
epor
tD
Ser
vice
Gro
up 1
8 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
18
N0500
4Ve
ntila
tor
- Ful
l08/3
1/03
18
G0121
11
Res
pite
- Pe
rson
al A
ssis
tanc
e S
ervi
ces
HC
S5
15
0U
nski
lled
resp
ite c
are,
not
hos
pice
; pe
r 15 m
inut
esP
18
G0121
11
Res
pite
- Pe
rson
al A
ssis
tanc
e S
ervi
ces
HC
S5
15
00
66
2U
nski
lled
resp
ite c
are,
not
hos
pice
; pe
r 15 m
inut
esI
18
G0122
11
Res
pite
- S
itter
Ser
vice
s08/3
1/03
18
G0171
11
In-H
ome
Res
pite
CD
S -
Agen
cyZZ
Loca
l cod
e to
be
reta
ined
.P
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
03
9Ve
hicl
e M
odifi
catio
ns, w
aive
r; p
er s
ervi
ceP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE0
63
6M
ultip
ositi
onal
pat
ient
sup
port
sys
tem
, with
inte
grat
ed li
ft,
patie
ntP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
03
1R
olla
bout
Cha
ir, a
ny a
nd a
ll ty
pes
with
cas
tors
5 in
ches
or
grea
ter
P
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
13
0S
tand
ard
Whe
elch
air,
fixe
d fu
ll le
ngth
arm
s, fi
xed
or s
win
g aw
ay d
etac
habl
eP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
39
9D
urab
le M
edic
al E
quip
men
t, M
isce
llane
ous
P
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
40
0O
xyge
n C
once
ntra
tor,
man
ufac
ture
r-spe
cifie
d m
axim
um
flow
rat
e do
es n
ot e
xcee
d tw
oP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
0S
ynth
esiz
ed S
peec
h Au
gmen
tativ
e C
omm
unic
atio
n D
evic
e w
ith D
ynam
ic D
ispl
ayP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
2C
omm
unic
atio
n B
oard
, N
on-e
lect
roni
c Au
gmen
tativ
e or
Al
tern
ativ
e C
omm
unic
atio
nP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
9S
peci
aliz
ed m
edic
al e
quip
men
t, n
ot o
ther
wis
e sp
ecifi
ed,
wai
ver
P
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
Ser
vice
Gro
up 1
7 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
72 November 2003, No. 16LTC Bul let in
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
8S
peci
aliz
ed S
uppl
y, N
ot o
ther
wis
e sp
ecifi
ed, w
aive
rP
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
00
29
0S
ynth
esiz
ed S
peec
h Au
gmen
tativ
e C
omm
unic
atio
n D
evic
e w
ith D
ynam
ic D
ispl
ayI
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
90
20
29
0C
omm
unic
atio
n B
oard
, N
on-e
lect
roni
c Au
gmen
tativ
e or
Al
tern
ativ
e C
omm
unic
atio
nI
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
03
90
29
0Ve
hicl
e M
odifi
catio
ns, w
aive
r; p
er s
ervi
ceI
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
90
29
0S
peci
aliz
ed m
edic
al e
quip
men
t, n
ot o
ther
wis
e sp
ecifi
ed,
wai
ver
I
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CT2
02
80
29
0S
peci
aliz
ed S
uppl
y, N
ot o
ther
wis
e sp
ecifi
ed, w
aive
rI
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE0
63
60
29
0M
ultip
ositi
onal
pat
ient
sup
port
sys
tem
, with
inte
grat
ed li
ft,
patie
ntI
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
03
10
29
0R
olla
bout
Cha
ir, a
ny a
nd a
ll ty
pes
with
cas
tors
5 in
ches
or
grea
ter
I
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
13
00
29
0S
tand
ard
Whe
elch
air,
fixe
d fu
ll le
ngth
arm
s, fi
xed
or s
win
g aw
ay d
etac
habl
eI
18
G0500
15
DM
E/Ad
aptiv
e Ai
dsH
CE1
39
90
29
0D
urab
le M
edic
al E
quip
men
t, M
isce
llane
ous
I
18
G0608
16
Hom
e M
odifi
catio
nsH
CS
51
65
Hom
e M
odifi
catio
ns; pe
r se
rvic
eP
18
G0608
16
Hom
e M
odifi
catio
nsH
CS
51
65
31
06
Hom
e M
odifi
catio
ns; pe
r se
rvic
eI
18
G0702
17
Pers
onal
Ass
ista
nce
Ser
vice
s -
Leve
l 1 -
Non
-Prio
rity
08/3
1/03
18
G0238
53
Tran
sitio
nal S
ervi
ces
08/3
1/03
18
N1201
11F
Res
pite
NF
- Tile
20
10
66
3D
aily
Res
pite
Cha
rge
I
18
N1202
11F
Res
pite
NF
- Tile
20
20
66
3D
aily
Res
pite
Cha
rge
I
18
N1203
11F
Res
pite
NF
- Tile
20
30
66
3D
aily
Res
pite
Cha
rge
I
18
N1204
11F
Res
pite
NF
- Tile
20
40
66
3D
aily
Res
pite
Cha
rge
I
18
N1205
11F
Res
pite
NF
- Tile
20
50
66
3D
aily
Res
pite
Cha
rge
I
18
N1206
11F
Res
pite
NF
- Tile
20
60
66
3D
aily
Res
pite
Cha
rge
I
18
N1207
11F
Res
pite
NF
- Tile
20
70
66
3D
aily
Res
pite
Cha
rge
I
18
N1208
11F
Res
pite
NF
- Tile
20
80
66
3D
aily
Res
pite
Cha
rge
I
18
N1209
11F
Res
pite
NF
- Tile
20
90
66
3D
aily
Res
pite
Cha
rge
I
18
N1210
11F
Res
pite
NF
- Tile
21
00
66
3D
aily
Res
pite
Cha
rge
I
18
N1211
11F
Res
pite
NF
- Tile
21
10
66
3D
aily
Res
pite
Cha
rge
I
18
N1212
11F
Res
pite
NF
- Tile
21
20
66
3D
aily
Res
pite
Cha
rge
I
18
G0156
11G
Res
pite
- C
amp
HC
T20
37
06
63
Res
pite
Car
e, T
hera
peut
ic C
ampi
ng, D
ay, ea
ch s
essi
onI
Ser
vice
Gro
up 1
8 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
73 LTC Bul le t inNovember 2003, No. 16
18
G0157
11H
Res
pite
- D
ay C
are/
Lice
nsed
Chi
ld
Car
e Fa
cilit
yH
CT2
02
60
66
3R
espi
te C
are,
Spe
cial
ized
Chi
ldca
re, pe
r da
yI
18
G0158
11J
Res
pite
- Li
cens
ed S
peci
al C
are
Faci
lity
HC
S5
15
00
66
3R
espi
te C
are,
uns
kille
d, p
er 1
5 m
inut
esI
18
G0160
11L
Res
pite
- H
ospi
tal
06
60
Res
pite
Car
e, g
ener
al (
Not
e: T
o cr
ossw
alk
back
to
the
loca
l cod
e, p
lace
of se
rvic
e m
ust
be a
ccur
ate.
)I
18
G0161
11M
Res
pite
- H
CS
S (
RN
/LVN
)H
CS
91
24
06
61
TER
espi
te C
are
by a
n LV
N, pe
r ho
urI
18
G0161
11M
Res
pite
- H
CS
S (
RN
/LVN
)H
CS
91
23
06
61
TDR
espi
te C
are
by a
n R
N, pe
r ho
urI
18
G0162
11N
Res
pite
- LV
NH
CT1
00
30
66
1TE
Res
pite
Car
e by
an
LVN
, pe
r ho
urI
18
G0163
11P
Res
pite
- R
NH
CT1
00
20
66
1TD
Res
pite
Car
e by
an
RN
, pe
r ho
urI
18
G0164
11Q
Res
pite
- PA
S D
eleg
ated
HC
S5
15
00
66
2U
nski
lled
resp
ite c
are,
not
hos
pice
; pe
r 15 m
inut
esI
18
G0165
11R
Adju
nct
- HC
SS
(R
N/L
VN)
HC
S9
12
3N
ursi
ng c
are,
in t
he h
ome;
by
an R
NP
18
G0165
11R
Adju
nct
- HC
SS
(R
N/L
VN)
HC
S9
12
4N
ursi
ng c
are,
in t
he h
ome;
by
an L
VNP
18
G0165
11R
Adju
nct
- HC
SS
(R
N/L
VN)
HC
S9
12
30
55
2N
ursi
ng c
are,
in t
he h
ome;
by
an R
NI
18
G0165
11R
Adju
nct
- HC
SS
(R
N/L
VN)
HC
S9
12
40
55
2N
ursi
ng c
are,
in t
he h
ome;
by
an L
VNI
18
G0181
11R
Adju
nct
HC
SS
(R
N/L
VN)
CD
S -
Agen
cyZZ
Loca
l cod
e to
be
reta
ined
.P
18
G0166
11S
Adju
nct
- LVN
HC
T10
03
Nur
sing
car
e, in
the
hom
e; b
y an
LVN
, pe
r 15 m
inut
esP
18
G0166
11S
Adju
nct
- LVN
HC
T10
03
05
52
Nur
sing
car
e, in
the
hom
e; b
y an
LVN
, pe
r 15 m
inut
esI
18
G0167
11T
Adju
nct
- RN
HC
T10
02
RN
Ser
vice
s, u
p to
15 m
inut
esP
18
G0167
11T
Adju
nct
- RN
HC
T10
02
05
52
RN
Ser
vice
s, u
p to
15 m
inut
esI
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
S5
12
0C
hore
Ser
vice
s, p
er 1
5 m
inut
esP
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
S5
13
0H
omem
aker
ser
vice
, N
OS
, pe
r 15 m
inut
esP
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
S5
13
5C
ompa
nion
car
e, a
dult
(tha
t is,
IAD
L/AD
L), p
er 1
5 m
inut
esP
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
T10
19
Pers
onal
Car
e S
ervi
ces,
per
15 m
inut
es, no
t fo
r an
in
patie
nt o
r res
iden
t of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F-M
R,
or IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent (n
ot t
o be
use
d fo
r se
rvic
es p
rovi
ded
by a
hom
e he
alth
aid
e or
ce
rtifi
ed n
urse
ass
ista
nt)
P
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
T10
19
05
72
Pers
onal
Car
e S
ervi
ces,
per
15 m
inut
es, no
t fo
r an
in
patie
nt o
r res
iden
t of a
hos
pita
l, nu
rsin
g fa
cilit
y, IC
F-M
R,
or IM
D, p
art
of t
he in
divi
dual
ized
pla
n of
tre
atm
ent (n
ot t
o be
use
d fo
r se
rvic
es p
rovi
ded
by a
hom
e he
alth
aid
e or
ce
rtifi
ed n
urse
ass
ista
nt)
I
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
S5
12
00
57
2C
hore
Ser
vice
s, p
er 1
5 m
inut
esI
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
S5
13
00
57
2H
omem
aker
ser
vice
, N
OS
, pe
r 15 m
inut
esI
18
G0168
11U
Adju
nct
- PAS
HC
SS
HC
S5
13
50
57
2C
ompa
nion
car
e, a
dult
(tha
t is,
IAD
L/AD
L), p
er 1
5 m
inut
esI
Ser
vice
Gro
up 1
8 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
74 November 2003, No. 16LTC Bul let in
18
G0169
11V
Adju
nct
- PAS
Del
egat
edH
CS
51
25
Atte
ndan
t C
are
Ser
vice
s, p
er 1
5 m
inut
esP
18
G0169
11V
Adju
nct
- PAS
Del
egat
edH
CS
51
25
05
72
Atte
ndan
t C
are
Ser
vice
s, p
er 1
5 m
inut
esI
18
G0722
27A
CM
PAS
- C
lient
Dire
cted
Ser
vice
sZZ
Loca
l cod
e to
be
reta
ined
.P
18
G0239
53A
Tran
sitio
nal S
uppo
rt S
ervi
ces
08/3
1/03
Ser
vice
Gro
up 1
8 -
Long
Ter
m C
are
Bill
Cod
e C
ross
wal
k Ta
ble
Texa
s LT
C L
ocal
Cod
esN
atio
nal C
odes
Ser
vice
G
roup
Bill
C
ode
Ser
vice
C
ode
Bill
Cod
e D
escr
ipti
onP
roce
dure
C
ode
Qua
lifie
r
HC
PC
S
Cod
eC
PT
Cod
eR
even
ue
Cod
eM
odifi
er
1M
odifi
er
2M
odifi
er
3M
odifi
er
4D
efin
itio
n/C
omm
ents
End
Dat
eC
laim
Typ
e to
File
: I=
837I;
P=837P
;D
=837D
Not
e: T
he Z
Z qu
alifi
er m
ust
be u
sed
for
serv
ices
ren
dere
d fo
r 1
0/1
6/0
3.
Exce
pt for
: D
ME/
Adap
tive
Aids
, D
enta
l, an
d H
ospi
ce P
hysi
cian
Ser
vice
s.
75 LTC Bul le t inNovember 2003, No. 16
Explanation of Benefits Code Table
Note: This is a correction to the Explanation of Benefits (EOB) Code Table that was published in the August 2003 Long Term Care Bulletin, No.15. EOB Code F0060 was listed in the table twice in error with RARC MA58 and MA06. The correct RARC that goes with F0060 is MA58.
HIPAA requires the use of new standard EOB codes, which will appear on the provider’s Claim Status Inquiry (CSI) and Remittance and Status report (R&S). EOB codes are used to report on claim payment/advice transactions. Because the new standard codes – referred to as Remittance Advice Remark Codes (RARC) – do not sufficiently explain the reason for the claim payment/advice, the state elected to provide the old codes in addition to the new codes to assist LTC providers in reviewing the R&S report:
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
F0001 Claim Header Record ID is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0002 Test/Production Flag is missing or invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0003 Program Type is a required field. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0004 Claim Type Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0005 Claim Header Source Identifier must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0006 Claim Header Source Identifier is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0007 Claim header signature indicator is missing or invalid.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0008 Claim Header Endorsement Number is an invalid value.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0009 Detail Count must be present. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0010 Detail Count is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0011 Total Claim Positive Indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0012 Previous claims indicate more than five consecutive days billed.
MA32 Missing/incomplete/invalid number of covered days during the billing period.
F0013 The claim total amount billed is not in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0014 The Provider Number submitted is not in a valid format.
M57 Missing/incomplete/invalid provider identifier.
F0016 Last Name must be present in order to process a claim.
MA36 Missing/incomplete/invalid patient name.
F0018 The Client/Medicaid Number is missing or invalid. MA61 Missing/incomplete/invalid social security number or health insurance claim number.
F0021 Medicaid Patient Days % Positive/Negative Indicator must be present.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0022 Medicaid Patient Days % Positive/Negative Indicator is not a valid entry.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0025 Medicaid Patient Days Percent is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0026 Medicare Patient Days % Positive/Negative Indicator must be present.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0028 Medicare Patient Days % Positive/Negative Indicator is not a valid entry.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
76 November 20003, No. 16LTC Bul let in 76
F0031 The Private Patient Days % entry is invalid. MA33 Missing/incomplete/invalid number of noncovered days during the billing period.
F0032 Medicare Patient Days percent is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0033 Private Patient Days % Positive/Negative Indicator must be present.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0035 Private Patient Days % Positive/Negative Indicator is not a valid entry.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0037 Private Patient Days % is missing. MA33 Missing/incomplete/invalid noncovered days during the billing period.
F0040 Trainee Social Security Number is missing or invalid. MA61 Did not complete or enter correctly the patient's social security number or health
F0041 Service group is missing, invalid, or not currently active.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0042 The payee identification number submitted is invalid.
MA61 Missing/incomplete/invalid social security number or health insurance claim number.
F0044 Payee Identification Number must be submitted on claim.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0045 Claim Header Adjustment Segment Indicator is an invalid value.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0046 Claim Header Special Pay Segment Indicator is an invalid value.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0048 Adjustment claims require an original ICN. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0050 Special Pay segment ID is invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0051 Fund Code is a required field. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0052 PAC Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0053 Special Pay Object Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0054 Special Pay Reason Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0055 Special Pay Type Indicator is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0056 Special Pay Service Code is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0057 Special Pay Agency must be present in order to process a claim.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0058 Special Pay Region/Division Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0059 Special Pay Appropriation Code is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0060 Special Pay Begin Service Date is missing or invalid. MA58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0061 Special Pay End Service Date is missing or invalid. MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0062 Special Pay Expedited Payment Billing Month/Year is missing.
MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0063 Claim Detail Segment ID is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0064 Detail Number must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0065 Claim Detail Adjustment Line Reference Number is an invalid value.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
77 LTC Bul le t inNovember 20003, No. 16
F0067 Detail Number is greater than Detail Count in Header.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0068 Detail Number is an invalid value. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0069 Detail Numbers are not consecutive. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0070 Line item is missing a Service Begin Date. MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0071 Services cannot be before January 1, 1971. MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0072 The Service End Date is missing. MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0073 The Service Begin Date must be on or before the Service End Date.
MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0075 The Service Begin Date is not for the same month and year as the Service End Date.
MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0077 Billing Code not present on claim line item. MA66 Missing/incomplete/invalid principal procedure code or date.
F0078 Claim Detail Training Hours Positive/Negative Indicator must be present.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0080 Training Hours must be in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0081 Applied Income Positive/Negative Indicator must be present
MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0083 Applied Income is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0087 Copayment Amount is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0089 Copayment Percent Positive/Negative Indicator must be present.
MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0091 Copayment Percentage is not in a valid format. MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0092 Units Billed Pos/Neg indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0094 Number of Units Billed is missing. M53 Did not complete or enter the appropriate number (one or more) of days or unit(s) of service.
F0095 Units Rate Pos/Neg indicator must be present. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0097 Unit Rate must is missing or invalid. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0098 Claim Detail Line Item Total Positive/Negative Indicator must be present.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0100 Line Item Total Billed must be in a valid format. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0101 Claim Header Adjustment Segment is missing. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0102 A Claim Header Adjustment Segment exists, claim header adjustment indicator is ‘N.’
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0106 Claim Leave Days must be in a valid format. MA33 Missing/incomplete/invalid noncovered days during the billing period.
F0107 The original line item in history is not in an adjustable status.
N36 Claim must meet primary payer's processing requirements before we can consider payment.
F0108 The original line item in history is not in an adjustable status.
N36 Claim must meet primary payer's processing requirements before we can consider payment.
F0110 Matching history detail not found or not in adjustable status.
N36 Claim must meet primary payer's processing requirements before we can consider payment.
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
78 November 20003, No. 16LTC Bul let in 78
F0111 Positive Line Item contains a negative Units Billed. M53 Missing/incomplete/invalid days or units of service.
F0112 Claim Header contains no details. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0113 Number of Details in Claim does not match header count.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0114 Unable to determine Service Code from supplied information, verify Billing Code.
M67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0115 Unable to determine Budget Key from supplied information.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0116 The Units Billed must be greater than zero. M53 Missing/incomplete/invalid days or units of service.
F0117 Unit Rate must be greater than zero. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0118 Incorrect number of billed units for this service. M53 Missing/incomplete/invalid days or units of service.
F0119 Claims for month following submission must be submitted within last week of month before service.
MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0121 Late billing - Claim must be filed 95 days from the end of the month of service.
MA119 Provider level adjustment for late claim filing applies to this claim.
F0123 Original ICN is not on file. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0125 Units billed exceed possible number of Units for Dates of Service.
M53 Missing/incomplete/invalid days or units of service.
F0126 Claim line items cannot span current Fiscal Years. N61 Rebill services on separate claims.
F0128 Provider is not enrolled to provide CMS services, or invalid provider number entered.
M57 Missing/incomplete/invalid provider identifier.
F0131 Provider has been placed on hold. N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0132 Provider is not authorized to perform this service for these Service Dates, verify Billing Code.
N54 Claim information is inconsistent with precertified/authorized services.
F0134 Provider authorized to provide services only to clients residing within Provider Region.
N54 Claim information is inconsistent with precertified/authorized services.
F0136 Provider is not authorized for Expedited Payment. N54 Claim information is inconsistent with precertified/authorized services.
F0138 A valid Service Authorization for this client for this Service on these dates is not available.
N54 Claim information is inconsistent with precertified/authorized services.
F0139 Client/Medicaid Number does not match information on file.
MA61 Missing/incomplete/invalid social security number or health insurance claim number.
F0141 Client ID is a previous reference which is not valid for the service dates.
N30 Client ineligible for this service.
F0142 Client Medicaid Eligibility is not currently active or is on hold for dates of service.
N30 Client ineligible for this service.
F0143 Client last name not on file. MA36 Missing/incomplete/invalid patient name.
F0145 Client last name matched with former name on file. MA36 Missing/incomplete/invalid patient name.
F0147 Client’s LOS Type and Level do not match Service Group and Billing Code Requirements.
N30 Client ineligible for this service.
F0148 Provider not authorized to provide services billed for client.
N54 Claim information is inconsistent with precertified/authorized services.
F0150 Client not living in approved Nursing Facility on Service Dates.
MA134 Missing/Missing/incomplete/invalid provider number of the facility where the patient resides.
F0151 Cannot bill for more than five consecutive days for this service.
M53 Missing/incomplete/invalid days or units of service.
F0152 Records show that client has received this service for more than five consecutive days.
M53 Missing/incomplete/invalid days or units of service.
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
79 LTC Bul le t inNovember 20003, No. 16
F0153 Client is eligible for Medicare enrollment. Bill Medicare first.
N104 This claim/service is not payable under our claims jurisdiction area. You can identify the correct Medicare contractor to process this claim/service through the CMS Web site at www.cms.hhs.gov.
F0155 Unable to determine appropriate Fund Code for Service billed, verify Medicaid Eligibility.
N54 Claim information is inconsistent with precertified/authorized services.
F0163 Item Code billed is not authorized for the Service provided.
N54 Claim information is inconsistent with precertified/authorized services.
F0165 This service has already been paid. Do not file for duplicate services.
M86 Service denied because payment already made for similar procedure within set time frame.
F0167 A claim for this procedure for this tooth has already been paid.
M86 Service denied because payment already made for similar procedure within set time frame.
F0168 Claim denied because Trainee has already completed the full training course.
M86 Service denied because payment already made for similar procedure within set time frame.
F0169 Claim denied because Trainee has not completed the full training course.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0170 Trainee has already passed a Skills Test. M86 Service denied because payment already made for similar procedure within set time frame.
F0171 Trainee has not previously passed a Skills Test. N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0172 Trainee has previously passed a written or oral examination.
M86 Service denied because payment already made for similar procedure within set time frame.
F0173 Trainee has previously passed a written or oral examination.
M86 Service denied because payment already made for similar procedure within set time frame.
F0174 Claim is for a service group that is mutually exclusive with service group for previous claim.
M86 Service denied because payment already made for similar procedure within set time frame.
F0175 Claim is for a service that is mutually exclusive with a service for previous claim with the same Service Dates.
M86 Service denied because payment already made for similar procedure within set time frame.
F0177 The Budget number is not valid for provider. M58 Resubmit the claim with the missing /correct information so that it may be processed.
F0179 Claim can not be paid because client is a Managed Care client.
N54 Claim information is inconsistent with precertified/authorized services.
F0181 Provider has already submitted an expedited payment for the current month.
M86 Service denied because payment already made for similar procedure within set time frame.
F0182 Expedited payment must be for the current month. MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0184 Provider has submitted a claim for the current month of service, for the service code submitted on the claim.
N54 Claim information is inconsistent with precertified/authorized services.
F0185 Claim cannot process due to balance owed by provider to the State.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0187 No units available from client Service Authorization. N54 Claim information is inconsistent with precertified/authorized services.
F0189 Amount of claim exceeds available budget. N131 Total payments under multiple contracts cannot exceed the allowance for this service.
F0191 Units billed exceeds allowable units for this client. N54 Claim information is inconsistent with precertified/authorized services.
F0193 All positive line items must be referenced to a negative line item.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0194 Adjustment request received past the filing deadline.
MA119 Provider level adjustment for late claim filing applies to this claim.
F0195 Header Adjustment: total paid amount submitted does not match paid amount on history.
M54 Missing/incomplete/invalid total charges.
F0196 The sum of the Medicaid Patient Days % and/or Medicare Patient Days % and/or Private Patient Days % does not equal 100.
M54 Missing/incomplete/invalid total charges.
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
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F0198 Cannot bill for future Service Dates or current date. MA06 Missing/incomplete/invalid beginning and/or ending date(s).
F0200 Procedure code is missing. MA66 Missing/incomplete/invalid principal procedure code or date.
F0201 An Item Code is required for this service. M58 Resubmit the claim with the missing /correct information so that it may be processed.
F0202 This Service requires a Tooth ID. N37 Missing/incomplete/invalid tooth number/letter.
F0203 The client's eligibility requires a Budget Number to be submitted.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0204 The Budget Number is invalid. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0205 Medicaid Patient Days % is greater than 100.0. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0206 Medicare Patient Days % is greater than 100.0. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0207 Private Patient Days % is greater than 100.0. M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0208 Leave Days may not exceed the Units Billed. MA32 Missing/incomplete/invalid number of covered days during the billing period.
F0209 Expedited claim has suspended, and will be processed beginning on the State-authorized submission date for this month.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0211 Expedited claim submitted after the State-authorized submission date for this month.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0214 Provider number is missing or invalid. M57 Missing/incomplete/invalid provider identifier.
F0215 Unable to determine Rate Key for detail or contract, verify Billing Code, if correct contact NHIC Helpdesk.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0216 The payee identification number on the claim is not associated with the Client/Medicaid Number.
MA61 Missing/incomplete/invalid social security number or health insurance claim number.
F0218 Expedited ceiling has not been calculated for contract for month of claim - unable to process expedited claims.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0220 Client/Medicaid Number is missing. MA61 Missing/incomplete/invalid social security number or health insurance claim number.
F0222 Copayment amount exceeds claim line item amount.
MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0223 Amount reduced, billed amount is greater than maximum allowed.
M54 Missing/incomplete/invalid total charges.
F0224 Applied Income amount exceeds claim line item amount.
MA34 Missing/incomplete/invalid number of coinsurance days during the billing period.
F0225 Units billed exceeds allowable units for this client. N54 Claim information is inconsistent with precertified/authorized services.
F0226 Payable amount is the expedited payment ceiling amount.
N45 Payment based on authorized amount.
F0228 Units on claim exceeds available budget. M53 Missing/incomplete/invalid days or units of service.
F0229 Rate not found. N54 Claim information is inconsistent with precertified/authorized services.
F0230 County rate not found. N54 Claim information is inconsistent with precertified/authorized services.
F0231 Procedure rate not found. N54 Claim information is inconsistent with precertified/authorized services.
F0232 Amount changed due to difference in copayment. N45 Payment based on authorized amount.
F0233 Claim has more than 28 details. N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0234 Service is duplicate of another line item on same claim for same or overlapping service dates.
M86 Service denied because payment already made for similar procedure within set time frame.
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
81 LTC Bul le t inNovember 20003, No. 16
F0235 Positive Line Item contains a negative units billed. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0236 Unable to determine appropriate state accounting codes for this claim. NHIC is researching this problem.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0237 Authorizing agency has changed or is not consistent for dates of service.
N54 Payment based on authorized amount.
F0238 This line item is approved to pay. N14 Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.
F0239 Claim line item paid amount differs from claim line item billed amount.
N45 Payment based on authorized amount.
F0240 Provider has an outstanding Sanction. N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0241 Applied Income or Copay must exist for the dates of service.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0242 A change to the client’s service authorization has generated a recoupment for services, dates, or units no longer allowed.
MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0243 A change in the rate for this service has generated repayment for this line item.
MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0244 A change to the providers contract has generated a recoupment for services, or dates no longer allowed.
MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0245 A change to the clients applied income or copayment has generated a recoupment for services previously billed.
MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0246 A change to the units authorized for this client has been submitted by a state auditor.
MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0247 The billed tooth ID has been previously billed. M86 Service denied because payment already made for similar procedure within set time frame.
F0248 A repayment for this line item was created to adjust a previous payment due to new updates to claim reference data.
MA67 Missing/incomplete/invalid other procedure code(s) and/or date(s).
F0249 Unable to determine region/division code for client. N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0250 Late billing - Claim must be filed 180 days from the end of the month of service or 180 days from the end of the eligibility add date.
MA119 Provider level adjustment for late claim filing applies to this claim.
F0251 NAT claims may only contain one detail line item. M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0252 Incorrect number of training hours for this training course billing code.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0253 A completed NAT training course has been billed for earlier dates.
M86 Service denied because payment already made for similar procedure within set time frame.
F0254 Only one incomplete training course per trainee is allowed for NAT.
M86 Service denied because payment already made for similar procedure within set time frame.
F0255 Failed skills test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame.
F0256 This NAT service has been paid the maximum number of times.
M86 Service denied because payment already made for similar procedure within set time frame.
F0257 An incomplete NAT training course has been billed for later dates.
M86 Service denied because payment already made for similar procedure within set time frame.
F0258 Amount of claim exceeds available budget. N131 Total payments under multiple contracts cannot exceed the allowance for this service.
F0259 Failed oral test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame.
F0260 Failed written test previously paid for this trainee. M86 Service denied because payment already made for similar procedure within set time frame.
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
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F0261 Incorrect number of training hours for this training course billing code.
M49 Missing/incomplete/invalid value code(s) and/or amount(s).
F0263 Records show that client has received this service for more than 14 consecutive days.
M53 Missing/incomplete/invalid days or units of service.
F0264 Claim is for a Billing Code that is mutually exclusive with Billing Code for previous Claim.
M86 Service denied because payment already made for similar procedure within set time frame.
F0265 This claim is approved to pay. N14 Payment based on a contractual amount or agreement, fee schedule, or maximum allowable amount.
F0266 Unable to determine appropriate state accounting codes for this claim. NHIC is researching this problem.
N36 Claim must meet primary payer's processing requirements before we can consider payment.
F0267 Unable to determine Budget Number from supplied information.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0268 A valid service authorization for client for these service dates not available or claim dates cannot overlap more than one service authorization.
N54 Payment based on authorized amount.
F0269 Claim Detail is an Exact Duplicate of History Claim Detail.
M86 Service denied because payment already made for similar procedure within set time frame.
F0270 Cannot bill a positive line item for a separated alias client ID.
MA61 Missing/incomplete/invalid social security number or health insurance claim number.
F0271 Client has received this service for more than 5 units per billing code per month.
M53 Missing/incomplete/invalid days or units of service.
F0272 The Billed Unit Rate exceeds the current maximum. M49 Missing/incomplete/invalid value code(s) and / or amount(s).
F0273 The Billed Units Count exceeds the current maximum.
M49 Missing/incomplete/invalid value code(s) and / or amount(s).
F0274 The Billed Applied Income/ Billed Copay Amount value has more than two decimal places.
M49 Missing/incomplete/invalid value code(s) and / or amount(s).
F0275 Claim must be filed via a HIPAA-compliant transaction set.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0276 Procedure Qualifier is missing, invalid or not payable under the CMS LTC Program.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0277 National Code is missing, invalid, not billable with Procedure Code Qualifier submitted or not payable under the CMS LTC program.
N36 Claim must meet primary payer’s processing requirements before we can consider payment.
F0278 Claim must be filed with the appropriate HCPCS/CPT or Revenue Code.
M58 Missing/incomplete/invalid claim information. Resubmit claim after corrections.
F0999 Corresponding Negative Line Item or Header Denied.
N142 The original claim was denied. Resubmit a new claim, not a replacement claim. �
Explanation of Benefits (EOB) Code Table
EOB Description RARC Description
83 LTC Bul le t inNovember 20003, No. 16
Helpful HintsKeep in mind the following helpful hints:
• The NHIC LTC Helpdesk operates Monday through Friday, 8 a.m. to 5 p.m. CST (excluding holidays). Call 800-626-4117 or 512-335-4729. Select from the following menu options:
• When contacting the LTC Helpdesk, have your nine-digit provider number ready.
• Claim form 1290 paper submitters: When submitting claims, be sure to correctly enter your nine-digit provider number in box 1 of claim form 1290.
• Send paper claims to the following address:National Heritage Insurance CompanyAttention: Long Term CarePO Box 200105Austin TX 78720-0105
Note: Delivery to NHIC could take three to five business days. Allow seven business days for the claim to appear in the system. Always have your provider number ready when calling the Helpdesk.
• Send overnight mail to:National Heritage Insurance CompanyAttention: Long Term Care12545 Riata Vista CircleAustin TX 78727-6524
Note: To avoid processing delays when sending overnight mail, make sure to include “Attention: Long Term Care.” Delivery to NHIC could take an additional day, depending on the time of day mailed. Allow three to five days for the claim to appear in the system. When calling to check the status, have your tracking number ready for the Helpdesk. ■
Option Description
1 Information about LTC claims
2Information about technical issues regarding TDHconnect
3Hear LTC banner messages if you are a paper submitter
LTC Bul let in 84
LTC Web SiteLTC has a page on the NHIC Web site at www.eds-nhic.com/LTC/default.htm. Refer to this site for helpful information on the LTC Program. ■
RemindersDo not forget to:
• Download your electronic R&S report weekly. R&S reports are available for 30 days only. Use dates from Friday to the following Monday.
• Make sure you create a financial summary when you create an R&S report.
• Download banner pages weekly from the LTCBNPG library on the TexMedNet File Libraries page at www.texmednet.com/library. The banners contain important, helpful information. Telephone the NHIC Helpdesk at 800-626-4117 if you have questions.
• Pull a MESAV request before contacting the NHIC LTC Helpdesk and requesting client information if your claim rejects. ■
84 November 2003, No. 16
Resources for Long Term Care QuestionsGeneral Table – All Providers
TDMHMR/ICF–MR
For questions about TDMHMR/ICF-MR, refer to the resources in the following table:
If you have questions about... Then contact...
HIPAA [email protected]
Cost Reports information (days paid, services paid) Information can be obtained by doing a Claim Status Inquiry (CSI) using TDHconnect.
How to prepare a Cost Report (forms, instructions) www.hhsc.state.tx.us/medicaid/programs/rad/index.html or call 512-338-6468 ■
If you have questions about… Then contact…
CARE Helpdesk 512-438-4720
Provider Warrants 512-206-5377
Applied Income Medicaid Eligibility (ME) worker for client
TPR Issues 512-490-4635
Health and Human Services Commission Network (HHSCN) 512-438-4720
ICF/MR Helpdesk Issues
Medicaid Administration Enrollment/Deductions• Provider vendor holds• Provider eligibility• Provider systems access forms
Medicaid Administration Billing
• Claims Management System billing claim form request• Service authorization• Client movement 3618• Durable medical equipment (DME)
Medicaid Administration UR/UC
• MR/RC assessment 3650• LOC claim form• Level of Service, LON, LOC• User documentation
512-206-5577 ■
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DHS – Provider Claims Services
For questions about Nursing Facilities, Hospice, Swing Beds, and Rehabilitation Specialized Services, refer to the resources in the following table:
If you have questions about… Then contact…
Client Service Authorization• Service dates• Units of service approved• Service group service code
DHS512-490-4666 telephone512-490-4668 fax
ausmis31.dhs.state.tx.us/cmsmail
Level of Service
• TILE changes• Medical necessity
DHS512-490-4666 telephone512-490-4668 fax
ausmis31.dhs.state.tx.us/cmsmail
Provider Authorization System (PAS)• Provider enrollment• Deductions• Monetary penalties• Program enrollment staff issues• Provider on hold questions
DHS512-490-4666 telephone512-490-4668 fax
ausmis31.dhs.state.tx.us/cmsmail
Policy Questions/SAVERR/Client Eligibility• Applied income changes• Client financial eligibility issues• Client name changes
DHS512-490-4666 telephone512-490-4668 fax
ausmis31.dhs.state.tx.us/cmsmail
Regional Staff Issues• Contract manager issues• ME, CCAD, or CBA worker issues not resolved at
local/regional level• Administrative, clerical, technical staff issues• Caseworker/regional nurse issues
DHS512-490-4666 telephone512-490-4668 fax
ausmis31.dhs.state.tx.us/cmsmail
Hospice Issues DHS512-490-4666 telephone512-490-4668 fax
ausmis31.dhs.state.tx.us/cmsmail
TPR Issues and/or Audits 512-490-4635 telephone �
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DHS LTC
For questions about Community Care - CBA - CLASS - Deaf and Blind - Consolidated Waiver - MDCP, refer to the resources in the following table:
If you have questions about… Then contact…
Client Service Authorization• Client not registered• Missing/wrong service dates• 2060 scores, priority levels• Service group/code• Wrong copayment amount• Missing/wrong client information
Caseworker/Case Manager
Claim Form 3652• Medical necessity• TILE• Diagnoses
Caseworker/Case Manager
PAS and DAHS (SG7-SC 17 and SC29)
• Prior approval questions• Physician orders
Regional Prior Approval Nurse (PAN)
Policy Questions/SAVERR/Client Eligibility
• Applied income changes• Client financial eligibility issues• Client name changes
DHS512-490-4666 telephone512-490-4668 faxausmis31.dhs.state.tx.us/cmsmail
Client-Specific Policies/Procedures
• Financial/functional eligibility criteria• How to read/understand form 2101 or form 3671
Caseworker/Case Manager
Provider Policies/Procedures• Program rules• Rates• Enrollment procedures
Contract Manager
Provider Agencies’ Contract• Contract not registered• Clients not registered to contract• Missing/wrong budget/rates• Contract numbers• Missing/wrong service contract information• Provider on hold questions
Contract Managerausmis31.dhs.state.tx.us/cmsmail
Regional Staff Issues• Contract manager issues• ME, CCAD, or CBA worker issues not resolved at
local/regional level• Administrative, clerical, technical staff issues• Caseworker/regional nurse issues
DHS512-490-4666 telephone512-490-4668 faxausmis31.dhs.state.tx.us/cmsmail
Obtaining a copy of LTC claim form 1290 Contract Manager
The CLASS Program 877-438-5658
The Consolidated Waiver Program 512-438-3443 or 512-438-3444
The Deaf and Blind Program 512-438-2622
The Medically Dependent Children’s Program (MDCP) 877-438-5658
Status of claim after it has been transmitted to Fiscal by NHIC (When calling Fiscal, provide the DLN number assigned by NHIC.)
The Comptroller’s Web site: www.window.state.tx.us or TDHS Fiscal Office 512-438-3996 telephone or Contract Manager �
87 LTC Bul le t inNovember 2003, No. 16
NHIC
For questions about NHIC, refer to the resources in the following table:
If you have questions about… Then contact…
Using TDHconnect or claim form 1290• Claim form 1290 completion• Claim form 1290 required fields• Claim adjustment questions• Claim status inquiries• Claim history questions• Claim rejection and denials• Understanding R&S• Research batch tracking
Long Term Care Helpdesk800-626-4117 (outside Austin)512-335-4729 (Austin)Option 1
TDHconnect Technical Issues• Obtain TDHconnect access• Modem and telecommunication issues• ANSI ASC X12 specification issues• ANSI ASC X12 testing and transmission• Obtain User ID and passwords• Process provider agreements• Verify system screens are functioning• Assist software developers with Electronic Data Interchange
(EDI) and connectivity
EDI Technical Helpdesk800-626-4117 (outside Austin)512-335-4729 (Austin)Option 2
Banner Messages in Audio
• Updated monthly• Paper submitters
800-626-4117 (outside Austin)512-335-4729 (Austin)Option 3
Medical Necessity/Client Appeal
• Additional information for claim form 3652• Client appeal request• Appeal/denial process and guidelines
Nursing Facility Division800-727-5436 Option 1 (Nurses)
General Inquiry • General policy about claim forms 3652, 3618, 3619• Denied Purpose Code E• Status of claim form 3652• TILE level• Effective dates of forms
Nursing Facility Division800-727-5436Option 2 (Customer Service)
Electronic transmission of claim forms 3652, 3618, and 3619• Weekly status reports• CARE Claim Form Software (CFS) installation• Problems with transmitting forms
Nursing Facility Division800-727-5436 (electronic claims submission)Option 3
MDS submission or reports
• General MDS guidelines• Interpreting Quality Indicator (QI) reports
Nursing Facility Division800-727-5436 (electronic claims submission)Option 3 �
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Your NHIC Training Specialists by TerritoryThe NHIC has a team of training specialists to serve the Texas Medicaid Program provider community. These training specialists conduct educational workshops such as Success with Medicaid and TDHconnect. Feel free to contact the training specialist assigned to your territory to schedule a visit. You can find more information at www.eds-nhic.com/provenrl/imagemap.html.
Territory Regional Area Training SpecialistTelephone Number E-mail Address
1 Amarillo, Lubbock Toni Emmons 512-514-3267 [email protected]
2 Abilene, Odessa Christy Mangum 512-514-3215 [email protected]
3 El Paso TBD 512-514-3253 TBD
4 San Angelo Bob Perez 512-514-3605 [email protected]
5 San Marcos, Victoria JoAnn Kunde 512-514-3238 [email protected]
6 Austin, Georgetown Ginny Mahoney 512-514-3275 [email protected]
7 San Antonio, Eagle Pass Jill Ray 512-514-3606 [email protected]
8 Laredo, Harlingen Cynthia Gonzales 512-514-3221 [email protected]
9 San Antonio, Corpus Christi Jill Ray 512-514-3606 [email protected]
10 Bastrop, Bryan/College Station TBD 512-514-3608 TBD
11 Fort Worth, Wichita Falls Rita Martinez 512-514-3231 [email protected]
12 Dallas TBD 512-514-3270 TBD
13 Dallas, Arlington Elaine Watson 512-514-3216 [email protected]
14 Dallas, Tyler Dawn Pearce 512-514-3203 [email protected]
15 Beaumont, Nacogdoches John Miller 512-514-3249 [email protected]
16 Houston Jennifer Vandiver 512-514-3285 [email protected]
17 Houston, Galveston TBD 512-514-3241 TBD
18 Houston Linda Wood 512-514-3278 [email protected]
19 Waco Paul Spock 512-514-3254 [email protected]
20 Austin TBD 512-514-3607 TBD �
89 LTC Bul le t inNovember 2003, No. 16
Glossary of TermsThe table below is a collection of the terms and definitions used in this bulletin:
Term Definition
270 Health Care Eligibility Benefit Inquiry
271 Health Care Eligibility Benefit Response
276 Health Care Claims Status Request
277 Health Care Claims Status Response
278 Health Care Services Request for Review and Response (Prior Authorization)
835 Health Care Claims Payment/Advice
837 Health Care Claim
837D Dental Health Care Claim
837I Institutional Health Care Claim
837P Professional Health Care Claim
Accepted Terminology referring to paper-, electronic-, and system-generated claims that are accepted into the EDS-CMS system for processing
ADA American Dental Association (develops codes for dental procedures)
Adjustment Request Provider generated request to make a change on a previously submitted claim
AFC Adult Foster Care
ANSI American National Standards Institute, an organization that accredits various standards setting committees and monitors their compliance
Applied Income The portion of a client’s income to be applied towards the cost of his/her long term care services per Medicaid rules
Atypical Services that are deemed nonmedical in nature or those services determined by DHS/TDMHMR to not have an appropriate National Procedure/Revenue Code
Batch Scheduled processing of one or more logical documents grouped together as a file; a group of transactions for one provider within a transmission
Batch Number The number assigned to an individual batch within a transmission to ECMS
BBS Bulletin Board System
Bill Code Code depicting a service performed by the provider
Bill Code Crosswalk Table A reference table that translates or maps the information used in filing a claim now to information necessary to complete the claim after HIPAA implementation; see “Long Term Care Bill Code Crosswalk Table” on page 17.
Billing Cycle The period of time from the point of submitting a request for payment to the point of receipt of payment
Budget Number The budget a claim will bill against; the second modifier field will be used to denote which budget is being used.
CBA Community-based Alternatives Waiver Program
CCAD Community Care for the Aged and Disabled Program
Claim An original/initial request for payment of services for a single client that consists of one or more line item; a claim can be submitted on paper or electronically.
Claim Filing Indicator Code Code identifying the type of claim or expected adjudication process; found on the 835 and 837 transactions
Claim Frequency Code Code specifying the frequency of the claim; found on the 835 and 837 transactions
Claim History A record of all accepted claims submitted to CMS
Claim Status Codes A national administrative code set that identifies the status of health care claims; this code set is used in the X12 277 Claim Status Notification transaction.
Claim Status Inquiry (CSI) A transaction (276) requesting information on the status of a claim previously submitted to CMS for processing
Claim Type A code that identifies the category a claim falls within
90 November 2003, No. 16LTC Bul let in 90
Claims Management System Integrated, generic term for the computer platforms and applications that work together to support long term care programs for Texas
CLASS Community Living Assistance and Support Services Program
Client CMS term for the health care consumer eligible for long term care services through DHS or TDMHMR
Client Control Number (Patient Account Number)
User-defined number submitted on a claim to identify the health care consumer
Client Number The number assigned to an individual by DHS; the client becomes Medicaid eligible, the client number becomes their Medicaid number.
CMS Acronym for the DHS/TDMHMR claims management system
Code Set Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.
Compliance Date Under HIPAA, this is the date which a covered entity must comply with a standard, an implementation specification, or a modification. For EDI, it is October 16, 2003.
Covered Entity Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.
Consumer Managed Personal Attendant Services (CMPAS)
Financial intermediary services provided to eligible clients who supervise or have some who can supervise their attendant or have clients who are responsible for interviewing, selecting, training, supervising, and releasing their attendants
Copayment The assessed amount or percentage of the cost of services that the client or coinsurance is responsible for paying
CPT-4 Physician Current Procedural Terminology (for most acute care medical services)
CWP Consolidated Waiver Program
DAHS Day Activity and Health Services
Data Content Under HIPAA, this is all of the data elements and code sets inherent to a transaction.
DBMD Deaf-Blind with Multiple Disabilities Program
Deny Terminology referring to paper-, electronic-, and system-generated claims that are accepted into the EDS-CMS system for processing but are subsequently denied for claims payment
DHS Texas Department of Human Services
Diagnosis Code An ICD-9-CM diagnosis code identifying a diagnosed medical condition
DLN Document Locator Number
DME Durable Medical Equipment
Document Locator Number (DLN) Number assigned to identify each warrant request
EBX EDS Clearinghouse for Electronic Transmissions
EDI Acronym for Electronic Data Interchange
Edits Checkpoints for claim validity and long term care business rules in claims processing; four types of edits are acceptance, local, LTC policy, and validity.
EDS Electronic Data Systems
Electronic Data Interchange Electronic exchange of formatted data
Emergency Dental Services Program that provides dental care to residents in nursing facilities
Emergency Response Systems Services provided through electronic monitoring systems used to convey signals for assistance
EOB Explanation of Benefits
ERS Emergency Response Systems
ESI Eligibility Services Incorporated
Expedited Claims Claims submitted for rapid payment for services.
Explanation of Benefits Explanation of the disposition of a provider claim
Term Definition
91 LTC Bul le t inNovember 2003, No. 16
Explanation of Benefits An explanation of the payment or denial of a provider claim
Finalized Claim A claim that has completed processing through CMS resulting in payment or denial of payment
Fund Code Code that identifies the source of funds to be paid to a provider for a particular service
Graphical User Interface (GUI) A graphical vs purely textual user interface of a computer; it provides a “picture-oriented” way to interact with technology.
HCPCS Health Care Common Procedural Coding System is a medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes.
Health Care Claim (837) Claim submitted by a provider requesting payment for services provided to the health care consumer
Health Care Clearinghouse Under HIPAA, an entity that processes or translates claims received from another entity in nonstandard format into HIPAA-compliant format
HIPAA Health Insurance Portability and Accountability Act of 1996
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
HIPAA is a federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers, and employers; and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. (Public Law 104-191)
ICN Internal Control Number
Interactive Real time processing of a transaction taking place while the submitter remains directly or indirectly connected to the processing computer
Interactive Submission Submission of a single transaction to the Tandem MMIS
Interface The point at which two systems connect to pass data
Internal Control Number A number assigned by EDS-CMS to uniquely identify a claim
Item Code Defines the item authorized for purchase or the service authorized for payment; the item code will not be used for services or purchases made on or after October 16, 2003.
Line Item A claim line item consists of services performed for a client within a specified period of time.
Line Item Control Number Identifier assigned by the submitter to the respective line item
Local Code A generic term for code values that are defined for a state or other political subdivision, or for a specific payer; this term is most commonly used to describe HCPCS Level III Codes but also applies to other code sets as well.
LTC Long Term Care
MDCP Medically Dependent Children’s Program
Medicaid Federally funded program, administered by the states, to pay for health care for eligible individuals
Medical Record Number (Trace Sequence Number)
A unique number assigned to the client by the provider to assist in the retrieval of medical records
MESAV Medicaid Eligibility and Service Authorization Verification application
MHMR (TDMHMR) Texas Department of Mental Health and Mental Retardation
Modifier A two-digit code with a specific meaning used to further define the procedure code to assist in claims adjudication
NAT Nurse Aide Training
National Procedure Codes HCPCS, CPT, and dental codes representing services provided to the health care consumer
National Provider ID A system for uniquely identifying all providers of health care services, supplies, and equipment
NHIC National Heritage Insurance Company
Nonatypical Nonatypical services are those services that are considered medical/health related.
Term Definition
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PACE Program of All Inclusive Care for the Elderly
PAS Personal Assistance Services
Patient Account Number (Client Control Number)
This is a unique identification number assigned by the provider to the claim patient to facilitate posting of payment information and identification of the billed claim; it is found on the 837 transactions.
Pended Claim Suspended claim
Per Authorized Unit Type Units approved to equal the cost of the authorized service
POS Place of Service is the location where services were obtained.
Principal Procedure Code Code identifying the principal procedure, product, or service; it is found on the 837I.
Procedure Code A standard national code used to uniquely identify a procedure, product, or service delivered to the client
Procedure Code Qualifier Code identifying the source of the procedure code
Provider Person, group, or agency who is contracted to perform a service for health care consumers
Provider Number (Provider ID) This is the contract number assigned to the Long Term Care provider/provider agency by the state of Texas; it was formerly known as Vendor Number. On ANSI provider systems, this will be the “Secondary Provider ID.”
Provider Taxonomy Code An administrative code set for identifying the provider type and area of specialization for all health care providers
R&S Remittance and Status Report
RC Respite Care
Reject Terminology referring to electronic- or system-generated claims that are not accepted into the EDS-CMS system for processing
Release of Information Code Code indicating whether the provider has on file, a signed statement permitting the release of medical data to other organizations
Remittance and Status Report An electronic or paper report that informs a provider on pending, paid, denied, or adjusted claims
Rendering Provider The name of the provider who performed the service
Response An electronic message returned to the submitter of an electronic transmission that contains information about a claim or query
Retroactive Adjustments Adjustments initiated by the state to a claim after it has been finalized
Revenue Code A three-(four) digit standard national code depicting the “revenue” center for the specific services being billed; revenue codes are used to classify types of services (that is, accommodations, ancillary services) and in some cases, must be used in tandem with HCPCS codes. (UB-92)
Service Authorization Approval by DHS/TDMHMR for a client to receive a service in a specified period of time from a contract provider
Service Code A code used to denote a specific service or category of service
Service From Date The date the service referenced in the claim or service line was initiated
Service Group The long term care program for which the client is eligible
SSPD Special Services to Persons with Disabilities
Standard Transaction Under HIPAA, this is a transaction that complies with the applicable HIPAA standard.
Suspended Claim A claim that has failed a program edit and is pending edit resolution before continued processing
TDHconnect A Windows-based application for personal computers to support provider electronic claims submissions, Medicaid eligibility/service verification authorization inquiries, claim status inquiries, electronic remittance and status, and adjustment request submissions for Long Term Care services
Template A TDHconnect window that shows all of the data fields needed to submit a claim or MESAV request; templates allow information to be saved for future use.
Term Definition
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Texas Index of Level of Effort (TILE) The level of effort required by providers to provide the appropriate service(s) to a client based on an assessment of the client's medical need; a TILE is used in the calculation of the payment rate for certain services to a client. There are 11 different TILEs (values 201 through 211).
TILE Acronym for Texas index for level of effort
Trace Sequence Number (Medical Record Number)
Provider submitted number allowing the provider to associate a particular response to a claim that is sent as feedback by CMS to the original claim input
Transaction Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care.
Unit The authorized amount of service
Unit Rate The dollar amount applied to each unit being billed
VA Veteran’s Affairs
Warrants Checks or direct deposits from the Comptroller for payment to providers and vendors for services rendered to LTC clients �
Term Definition
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Notes:
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