texas medicaid - tmhp · texas medicaid national heritage insurance company (nhic) is the insurer...
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Texas Medicaid
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)
2003 Texas Medicaid Provider Procedures Manual The 2003 Texas Medicaid Provider Procedures Manual will be distributed during January 2003. One provider manual will be mailed to each Texas Provider Identifier (TPI) on file with the National Heritage Insurance Company (NHIC).
Refer to the January/February 2003 Texas Medicaid Bulletin, No. 168 for more information.
Have you visited www.eds-nhic.com lately?You can find out when workshops will be held in your area, download forms and manuals, and learn about important updates of the Texas Medicaid Program.
2002 FQHC/RHC Special Bulletin No. 167
Bulletin Contents, No. 167
Federally Qualified Health Center (FQHC) Providers . . . . . . . . . . . . . . . . . . . . . . . 2
Prospective Payment System (PPS) for FQHC Providers ..................................................... 2
Rural Health Clinic (RHC) Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Prospective Payment System (PPS) for RHC Providers ..................................................... 10
No. 167 2 2002 FQHC/RHC Special Bulletin
Federally Qualified Health Center (FQHC) Providers
Prospective Payment System (PPS) for FQHC Providers
Effective January 3, 2003, FQHC providers will be paid an all-inclusive rate per visit for the following services with the implemen-tation of PPS. All other services will be processed as informational. You should continue to bill using the same procedure codes, diagnosis codes, and modifiers. Refer to the 2002 Texas Medicaid Provider Procedures Manual (TMPPM) for additional information on benefits and limitations.
Note: If you bill general medical services without using one of the modifiers in the following table, the service will be automatically denied.
FQHC providers may now bill other mental health services and vision care services. Refer to the appropriate sections in the 2002 Texas Medicaid Provider Procedures Manual for a complete understanding.
Payable Visit Procedures for an FQHC
General Medical Services (2002 TMPPM Reference–Section 20)
Procedure Code Modifier Description
1-Z9813 7D Performed by physician
1-Z9813 AN Performed by physician assistant
1-Z9813 AL Performed by advanced practice nurse or certified nurse-midwife
1-Z9813 7C Performed by visiting nurse
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-1000D Appliance with horizontal projections
W-1001D Appliance with recurved springs
W-1002D Arch wires for cross bite correction for total treatment
W-1003D Banded maxillary expansion appliance
W-1004D Bite plate/bite plane
W-1005D Bionator
W-1006D Bite block
W-1007D Bite plate with push springs
W-1008D Bonded expansion device
W-1009D Brackets
W-1010D Chateau appliance (face mask palatal expander and hawley)
W-1011D Coffin spring appliance
W-1012D Crib
W-1013D Dental obturator, definitive (obturator)
W-1014D Dental obturator, surgical (obturator surgical stayplate immediate temporary obturator)
W-1015D Distalizing appliance with springs
W-1016D Expansion device
W-1017D Face mask (protraction mask)
W-1018D Fixed expansion appliance
W-1019D Fixed lingual arch
W-1020D Fixed mandibular holding arch
W-1021D Fixed rapid palatal expander
W-1022D Frankel appliance
W-1023D Functional appliance for reduction of anterior openbite and crossbite
W-1024D Headgear (face bow)
W-1025D Herbst appliance (fixed or removable)
W-1026D Inter-occlusal cast cap surgical splints
W-1027D Intrusion arch
W-1028D Jasper jumpers
W-1029D Lingual appliance with hooks
W-1030D Mandibular anterior bridge
W-1031D Mandibular bihelix (similar to quad helix for mandibular expansion to attempt non extrac)
W-1032D Mandibular lip bumper
W-1033D Mandibular fixed 2x4 retainer
W-1034D Mandibular fixed 3x3 retainer
W-1035D Mandibular fixed 4x4 retainer
W-1036D Mandibular lingual 6x6 arch wire
W-1037D Mandibular removable expander with bite plane-crozat
W-1038D Mandibular ricketts rest position splint
W-1039D Mandibular splint
W-1040D Maxillary anterior bridge
W-1041D Maxillary bite-opening appliance with anterior springs
W-1042D Maxillary lingual arch with spurs
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
2002 FQHC/RHC Special Bulletin 3 No. 167
W-1043D Maxillary-mandibular distallizing appliance
W-1044D Maxillary quad helix with finger springs
W-1045D Maxillary retainer with pontics
W-1046D Maxillary schwarz
W-1047D Maxillary splint
W-1048D Mobile intraoral arch-MIA
W-1049D Modified quad helix appliance
W-1050D Modified quad helix appliance with appliance
W-1051D Nance appliance
W-1052D Nasal stent
W-1053D Occlusal orthotic device
W-1054D Orthopedic appliance
W-1055D Other mandibular utilities
W-1056D Other maxillary utilities
W-1057D Palatal bar
W-1058D Post surgical retainer
W-1059D Quad helix appliance held with transpalatal arch horizontal projections
W-1060D Quad helix maintainer
W-1061D Rapid palatal expander rpe such as quad helix haas or menne
W-1062D Removable bite plate
W-1063D Removable mandibular retainer
W-1064D Removable maxillary retainer
W-1065D Removable prosthesis
W-1066D Sagittal appliance (2-way)
W-1067D Sagittal appliance (3-way)
W-1068D Stapled palatal expansion appliance
W-1069D Surgical arch wires
W-1070D Surgical splints (surgical stent/wafer)
W-1071D Surgical stabilizing appliance
W-1072D Thumb-sucking appliance
W-1073D Tongue thrust appliance
W-1074D Tooth positioner (full maxillary and mandibular)
W-1075D Tooth positioner with arch
W-1076D Transpalatal arch
W-1077D Two bands with transpalatal arch and horizontal projections forward
W-1078D W appliance
W-8110D Crossbite therapy, removable appliance
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-8120D Crossbite therapy, fixed appliance
W-D0120 Periodic oral evaluation
W-D0140 Limit oral evaluation problem focus
W-D0150 Comprehensve oral evaluation
W-D0160 Extensv oral evaluation problem focus
W-D0170 Re-evaluation, est pt, problem focus
W-D1110 Dental prophylaxis – adult
W-D1120 Dental prophylaxis – child
W-D1201 Topical fluor with prophy – child
W-D1203 Topical fluor without prophy – child
W-D1204 Topical fluor without prophy – adult
W-D1205 Topical fluoride with prophy – adult
W-D1351 Dental sealant per tooth
W-D1510 Space maintainer fxd unilat
W-D1515 Fixed bilat space maintainer
W-D1520 Remove unilat space maintain
W-D1525 Remove bilat space maintainer
W-D1550 Recement space maintainer
W-D2110 Amalgam one surface primary
W-D2120 Amalgam two surfaces primary
W-D2130 Amalgam three surfaces primary
W-D2131 Amalgam four/more surf primary
W-D2140 Amalgam one surface permanent
W-D2150 Amalgam two surfaces permanent
W-D2160 Amalgam three surfaces permanent
W-D2161 Amalgam 4 or greater than surfaces perm
W-D2330 Resin one surface – anterior
W-D2331 Resin two surfaces – anterior
W-D2332 Resin three surfaces – anterior
W-D2335 Resin 4/greater than surf or with incis an
W-D2336 Composite resin crown
W-D2337 Compo resin crown ant-perm
W-D2380 Resin one surf poster primar
W-D2381 Resin two surf poster primar
W-D2382 Resin three/more surf post p
W-D2385 Resin one surf poster perman
W-D2386 Resin two surf poster perman
W-D2387 Resin three/more surf post p
W-D2388 Resin four/more, post perm
W-D2410 Dental gold foil one surface
W-D2420 Dental gold foil two surface
W-D2430 Dental gold foil three surface
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
No. 167 4 2002 FQHC/RHC Special Bulletin
W-D2510 Dental inlay metalic one surface
W-D2520 Dental inlay metallic 2 surf
W-D2530 Dental inlay metl 3/more sur
W-D2933 Prefab stainless steel crown
W-D2960 Laminate labial veneer
W-D2961 Lab labial veneer resin
W-D2962 Lab labial veneer porcelain
W-D4249 Crown lengthen hard tissue
W-D4260 Osseous surgery per quadrant
W-D4266 Guided tiss regen resorble
W-D4267 Guided tiss regen nonresorb
W-D4270 Pedicle soft tissue graft pr
W-D4271 Free soft tissue graft proc
W-D4273 Subepithelial tissue graft
W-D4274 Distal/proximal wedge proc
W-D4320 Provisional splint intracoronal
W-D4321 Provisional splint extracoro
W-D4341 Periodontal scaling and root
W-D4355 Full mouth debridement
W-D4381 Localized chemo delivery
W-D4910 Periodontal maint procedures
W-D4920 Unscheduled dressing change
W-D4999 Unspecified periodontal proc
W-D5110 Dentures complete maxillary
W-D5120 Dentures complete mandible
W-D5130 Dentures immediat maxillary
W-D5140 Dentures Immediat mandible
W-D5211 Dentures maxill part resin
W-D5212 Dentures mand part resin
W-D5213 Dentures maxill part metal
W-D5214 Dentures mandibl part metal
W-D5281 Removable partial denture
W-D5410 Dentures adjust cmplt maxil
W-D5411 Dentures adjust cmplt mand
W-D5421 Dentures adjust part maxill
W-D5422 Dentures adjust part mandbl
W-D5510 Dentur repr broken compl bas
W-D5520 Replace denture teeth complt
W-D5610 Dentures repair resin base
W-D5620 Rep part denture cast frame
W-D5630 Rep partial denture clasp
W-D5640 Replace part denture teeth
W-D5650 Add tooth to partial denture
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-D5660 Add clasp to partial denture
W-D5710 Dentures rebase cmplt maxil
W-D5711 Dentures rebase cmplt mand
W-D5720 Dentures rebase part maxill
W-D5721 Dentures rebase part mandbl
W-D5730 Denture reln cmplt maxil chr
W-D5731 Denture reln cmplt mand chr
W-D5740 Denture reln part maxil chr
W-D5741 Denture reln part mand chr
W-D5750 Denture reln cmplt max lab
W-D5751 Denture reln cmplt mand lab
W-D5760 Denture reln part maxil lab
W-D5761 Denture reln part mand lab
W-D5810 Denture interm cmplt maxill
W-D5811 Denture interm cmplt mandbl
W-D5820 Denture interm part maxill
W-D5821 Denture interm part mandbl
W-D5850 Denture tiss conditn maxill
W-D5851 Denture tiss condtin mandbl
W-D5860 Overdenture complete
W-D5861 Overdenture partial
W-D5862 Precision attachment
W-D5899 Removable prosthodontic proc
W-D5911 Facial moulage sectional
W-D5912 Facial moulage complete
W-D5913 Nasal prosthesis
W-D5914 Auricular prosthesis
W-D5915 Orbital prosthesis
W-D5916 Ocular prosthesis
W-D5919 Facial prosthesis
W-D5922 Nasal septal prosthesis
W-D5923 Ocular prosthesis interim
W-D5924 Cranial prosthesis
W-D5925 Facial augmentation implant
W-D5926 Replacement nasal prosthesis
W-D5927 Auricular replacement
W-D5928 Orbital replacement
W-D5929 Facial replacement
W-D5931 Surgical obturator
W-D5932 Postsurgical obturator
W-D5933 Refitting of obturator
W-D5934 Mandibular flange prosthesis
W-D5935 Mandibular denture prosthesis
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
2002 FQHC/RHC Special Bulletin 5 No. 167
W-D5937 Trismus appliance
W-D5951 Feeding aid
W-D5952 Pediatric speech aid
W-D5953 Adult speech aid
W-D5954 Superimposed prosthesis
W-D5955 Palatal lift prosthesis
W-D5958 Intraoral con def inter plt
W-D5959 Intraoral con def mod palat
W-D5960 Modify speech aid prosthesis
W-D5982 Surgical stent
W-D5983 Radiation applicator
W-D5984 Radiation shield
W-D5985 Radiation cone locator
W-D5986 Fluoride applicator
W-D5987 Commissure splint
W-D5988 Surgical splint
W-D5999 Maxillofacial prosthesis
W-D6010 Odontics endosteal implant
W-D6020 Odontics abutment placement
W-D6040 Odontics eposteal implant
W-D6050 Odontics transosteal implant
W-D6055 Implant connecting bar
W-D6080 Implant maintenance
W-D6090 Repair implant
W-D6095 Odontics repr abutment
W-D6100 Removal of implant
W-D6199 Implant procedure
W-D6210 Prosthodont high noble metal
W-D6211 Bridge base metal cast
W-D6212 Bridge noble metal cast
W-D6240 Bridge porcelain high noble
W-D6241 Bridge porcelain base metal
W-D6242 Bridge porcelain nobel metal
W-D6245 Bridge porcelain/ceramic
W-D6250 Bridge resin with high noble
W-D6251 Bridge resin base metal
W-D6252 Bridge resin with noble metal
WD-6519 Inlay/onlay porce/ceramic
W-D6520 Dental retainer two surfaces
W-D6530 Retainer metallic 3+ surface
W-D6543 Dental retainr onlay 3 surf
W-D6544 Dental retainr onlay 4/more
W-D6545 Dental retainr cast metl
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-D6548 Porcelain/ceramic retainer
W-D6720 Retain crown resin with hi nble
W-D6721 Crown resin with base metal
W-D6722 Crown resin with noble metal
W-D6740 Crown porcelain/ceramic
W-D6750 Crown porcelain high noble
W-D6751 Crown porcelain base metal
W-D6752 Crown porcelain noble metal
W-D6780 Crown 3/4 high noble metal
W-D6781 Crown 3/4 cast based metal
W-D6782 Crown 3/4 cast noble metal
W-D6783 Crown 3/4 porcelain/ceramic
W-D6790 Crown full high noble metal
W-D6791 Crown full base metal cast
W-D6792 Crown full noble metal cast
W-D6920 Dental connector bar
W-D6930 Dental recement bridge
W-D6940 Stress breaker
W-D6950 Precision attachment
W-D6970 Post and core plus retainer
W-D6971 Cast post bridge retainer
W-D6972 Prefab post and core plus reta
W-D6973 Core build up for retainer
W-D6975 Coping metal
W-D6976 Each additional cast post
W-D6977 Each additional prefab post
W-D6980 Bridge repair
W-D6999 Fixed prosthodontic proc
W-D7110 Oral surgery single tooth
W-D7120 Each add tooth extraction
W-D7130 Tooth root removal
W-D7210 Rem imp tooth with mucoper flp
W-D7220 Impact tooth remov soft tiss
W-D7230 Impact tooth remov part bony
W-D7240 Impact tooth remov comp bony
W-D7241 Impact tooth rem bony with comp
W-D7250 Tooth root removal
W-D7260 Oral antral fistula closure
W-D7270 Tooth reimplantation
W-D7272 Tooth transplantation
W-D7280 Exposure impact tooth orthod
W-D7281 Exposure tooth aid eruption
W-D7285 Biopsy of oral tissue hard
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
No. 167 6 2002 FQHC/RHC Special Bulletin
W-D7286 Biopsy of oral tissue soft
W-D7290 Repositioning of teeth
W-D7291 Transseptal fiberotomy
W-D7310 Alveoplasty with extraction
W-D7320 Alveoplasty without extraction
W-D7340 Vestibuloplasty ridge extens
W-D7350 Vestibuloplasty exten graft
W-D7410 Rad exc lesion up to 1.25 cm
W-D7420 Lesion greater than 1.25 cm
W-D7430 Exc benign tumor to 1.25 cm
W-D7431 Benign tumor exc greater than1.25 cm
W-D7440 Malig tumor exc to 1.25 cm
W-D7441 Malig tumor greater than 1.25 cm
W-D7450 Rem odontogen cyst to 1.25 cm
W-D7451 Rem odontogen cyst greater than 1.25 cm
W-D7460 Rem nonodonto cyst to 1.25 cm
W-D7461 Rem nonodonto cyst greater than 1.25 cm
W-D7465 Lesion destruction
W-D7480 Partial ostectomy
W-D7510 I&D absc intraoral soft tiss
W-D7520 I&D abscess extraoral
W-D7530 Removal fb skin/areolar tiss
W-D7540 Removal of fb reaction
W-D7550 Removal of sloughed off bone
W-D7560 Maxillary sinusotomy
W-D7670 Closd rductn splint alveolus
W-D7820 Closed tmp manipulation
W-D7880 Occlusal orthotic appliance
W-D7899 TMJ unspecified therapy
W-D7910 Dent sutur recent wnd to 5 cm
W-D7911 Dental suture wound to 5 cm
W-D7912 Suture complicate wnd greater than5 cm
W-D7955 Repair maxillofacial defects
W-D7960 Frenulectomy/frenulotomy
W-D7970 Excision hyperplastic tissue
W-D7971 Excision pericoronal gingiva
W-D7980 Sialolithotomy
W-D7983 Closure of salivary fistula
W-D7993 Implant-facisl bones (homologous, heterologous or allopastic) (CCP)
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-D7993 Implant-facisl bones (homologous, heterologous or allopastic)
W-D7997 Appliance removal
W-D7999 Oral surgery procedure
W-D8999 Orthodontic procedure
W-D9110 Tx dental pain minor proc
W-D9210 Dent anesthesia without surgery
W-D9211 Regional block anesthesia
W-D9212 Trigeminal block anesthesia
W-D9215 Local anesthesia
W-D9220 General anesthesia
W-D9221 General anesthesia ea ad 15 m
W-D9230 Analgesia
W-D9248 Sedation (non-IV)
W-D924X Intravenous sedation
W-D9310 Dental consultation
W-D9410 Dental house call
W-D9420 Hospital call
W-D9430 Office visit during hours
W-D9440 Office visit after hours
W-D9610 Dent therapeutic drug inject
W-D9630 Other drugs/medicaments
W-D9910 Dent appl desensitizing med
W-D9920 Behavior management
W-D9930 Treatment of complications
W-D9940 Dental occlusal guard
W-D9950 Occlusion analysis
W-D9951 Limited occlusal adjustment
W-D9952 Complete occlusal adjustment
W-D9974 Intrnl bleaching per tooth
W-D9999 Adjunctive procedure
W-D9999 Unspecified adjunctive procedure, by report
W-Z2008 Initial orthodontic visit
W-Z2009 Diagnostic work up - approved
W-Z2011 Orthodontic appliance, upper
W-Z2012 Orthodontic appliance, lower
W-Z2013 Orthodontic adjustments, per month
W-Z2014 Orthodontic retainer, upper
W-Z2015 Orthodontic retainer, lower
W-Z2016 Premature appliance removal (per arch)
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
2002 FQHC/RHC Special Bulletin 7 No. 167
For THSteps medical claims, always record the following on the HCFA-1450 (UB-92) Claim Form or electronic equivalent to receive reimbursement for a medical checkup:
• The diagnosis code on the HCFA-1450 (UB-92) (Block 67 or appropriate electronic field) will always be V202.
• Type of service on the HCFA-1450(UB-92) (Block 44 or appropriate electronic field) will always be “S.”
• Place of service on the HCFA-1450 (UB-92) (Block 4 or appropriate electronic field) is autoplugged based on the type of bill indicated on the claim.
• Appropriate THSteps medical checkup code (for example, medical screen, exception to periodicity, follow-up visit) (all ages).
• TB skin test code (age 1 year to age 21 years).
• Immunization code(s) (all ages).
• Second newborn hereditary/metabolic testing code (age one week to 52 weeks).
Case Management (2002 TMPPM Reference–Section 12)
Procedure Code Description
1-4001X Face-to-face case management, pregnant adolescent or woman
1-4002X Face-to-face case management, infant
1-4003X Telephone case management, pregnant adolescent or woman
1-4004X Telephone case management, infant
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Description
S-8000Y THSteps medical screen – normal
S-8004Y THSteps exception to periodicity – normal
S-8100Y THSteps medical screen – abnormal, treatment not necessary
S-8104Y THSteps exception to periodicity – abnormal, treatment not necessary
S-8200Y THSteps medical screen – abnormal, treatment initiated
S-8204Y THSteps exception to periodicity – abnormal, treatment initiated
S-8300Y THSteps medical screen – abnormal, referred to primary care physician
S-8304Y THSteps exception to periodicity – abnormal, referred to primary care physician
S-8400Y THSteps medical screen – abnormal, referred to specialist
S-8404Y THSteps exception to periodicity – abnormal, referred to specialist
S-8500Y THSteps medical screen – abnormal, referred to other health agency
S-8504Y THSteps exception to periodicity – abnormal, referred to other health agency
S-8600Y THSteps medical screen – abnormal, condition under treatment
S-8604Y THSteps exception to periodicity – abnormal, condition under treatment
S-8700Y THSteps medical screen – referred to Family Planning
S-8704Y THSteps exception to periodicity – referred to Family Planning
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Description
1-Z9008 Family Planning annual visit-comp H&P, per provider
2-9000X Provide and insert implantable contraceptive capsules
2-X4562 Furnish and insert progestasert IUD (including cost of device)
2-X4563 Furnish and insert copper T 380-A IUD (including cost of device)
2-X4572 Furnish and insert copper T 380-A IUD (including cost of device)
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Description
No. 167 8 2002 FQHC/RHC Special Bulletin
Mental Health Services (Other)
Procedure Code Description 2002 TMPPM Reference
1-1050X Individual counseling services provided by LMSW-ACP or LPC Section 28: Licensed Master Social Worker-Advanced Clinical Practitioner (LMSW-ACP)Section 29: Licensed Professional Counselors (LPCs)
1-1051X Group counseling services provided by LMSW-ACP or LPC
1-1052X Family counseling services provided by LMSW-ACP or LPC
1-1150X Individual counseling services provided by LMFT Section 27: Licensed Marriage and Family Therapist (LMFT)1-1151X Group counseling services provided by LMFT
1-1152X Family counseling services provided by LMFT
1-90801 Psychiatric diagnostic interview examination Section 35: PsychologistSection 34.4.34: Physician Psychiatric Services
1-90802 Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication
1-90804/1-90805*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient
1-90806/1-90807*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient
1-90808/1-90809*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient
1-90810/1-90811*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient
1-90812/1-90813*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient
1-90814/1-90815*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient
1-90816/1-90817*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient
1-90818/1-90819*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient
1-90821/1-90822*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient
1-90823/1-90824*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with patient
1-90826/1-90827*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with patient
1-90828/1-90829*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with patient
1-90845 Psychoanalysis
*These procedure codes should be billed by a psychiatrist and include medical evaluation and management services.
2002 FQHC/RHC Special Bulletin 9 No. 167
1-90847 Family psychotherapy (conjoint psychotherapy) (with patient present) Section 35: Psychologist
1-90853 Group psychotherapy (other than of a multiple-family group)
1-90857 Interactive group psychotherapy
1-90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes (sodium amobarbital interview)
5-96100 Psychological testing
5-96117 Neuropsychological testing battery
Vision Care Services (2002 TMPPM Reference–Section 42)
Diagnosis Code Procedure Code Description
3670 1-Z9513 Hypermetropia, far-sightedness (Hyperopia)
3671 1-Z9513 Myopia, near-sightedness
36720 1-Z9513 Astigmatism, unspecified
36721 1-Z9513 Regular astigmatism
36722 1-Z9513 Irregular astigmatism
36731 1-Z9513 Anisometropia
3674 1-Z9513 Presbyopia
36751 1-Z9513 Paresis of accommodation (Cycloplegia)
36752 1-Z9513 Total or complete internal ophthalmoplegia
36753 1-Z9513 Spasm of accommodation
36781 1-Z9513 Transient refractive change
36789 1-Z9513 Other, drug-induced, toxic disorders of refraction and accommodation
3679 1-Z9513 Unspecified disorder of refraction and accommodation
37182 1-Z9513 Corneal disorder due to contact lens
V720 1-Z9513 Eye examination (exam normal, no prescription required)
Appropriate Diagnosis
1-92002 New patient, intermediate eye exam
1-92004 New patient, comprehensive eye exam, one or more visits
1-92012 Established patient, intermediate eye exam
1-92014 Established patient, comprehensive eye exam, one or more visits
1-92015 Determination of refractive state
1-92020 Gonioscopy
1-92060 Sensorimotor exam with mult measurements of ocular deviation with interp and report
1-92065 Orthoptic and/or pleoptics training, with continuing medical direction and evaluation
1-92081 Visual field examination with medical diagnostic evaluation, tangent screen, autoplot or equivalent
1-92082 Quantitative perimetry (e.g., several isopters on Goldmann perimeter or equivalent)
1-92083 Static and kinetic perimetry, or equivalent quantitative perimetry (e.g., several isopters or Goldmann perimeter, or equivalent)
1-92100 Serial tonometry with mult measure intaocular press ext per e/int
1-92120 Tonography with interpretation and report, recording indention tonometer method or perilimbal suction method
Mental Health Services (Other)
Procedure Code Description 2002 TMPPM Reference
*These procedure codes should be billed by a psychiatrist and include medical evaluation and management services.
No. 167 10 2002 FQHC/RHC Special Bulletin
Rural Health Clinic (RHC) Providers
Prospective Payment System (PPS) for RHC Providers
Effective January 3, 2003, RHC providers, including County Indigent Health Care Program (CIHCP) RHC providers, will be paid an all-inclusive rate per visit for the following services with the implementation of PPS. All other services will be processed as informational.
Note: If you bill general medical services without using one of the modifiers in the table, the service will be automatically denied. The six core lab services are not a payable benefit for hospital-based or freestanding RHCs.
Refer to: The 2002 Texas Medicaid Provider Procedures Manual for additional information on benefits and limitations.
Payable Visit Procedures for an RHC (General Medical Services)
Appropriate Diagnosis
1-92140 Provocative tests for glaucoma with interpretation and report, without tonography
1-92225 Ophthalmoscopy, extended, with retinal drawing (for example, for retinal detachment, melanoma), with interpretation and report; initial
1-92226 Ophthalmoscopy, extended, with retinal drawing (for example, for retinal detachment, melanoma), with interpretation and report; subsequent
1-92230 Fluorescein angioscopy, with interpretation and report
1-92235 Fluorescein angiography (includes multiframe imaging), with interpretation and report
1-92240 Indocyamine green angiography
1-92250 Fundus photography with interpretation and report
1-92260 Ophthalmodynamometry
1-92265 Oculoelectromyography, one or more extraocular muscles, one or both eyes, with medical diagnostic evaluation
1-92270 Electro-oculography, with medical diagnostic evaluation
1-92275 Electroretinography, with medical diagnostic evaluation
1-92285 External ocular photography with interpretation and report, for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography)
1-92286 Special anterior segment photography with interpretation and report; with special endothelial microscopy and cell count
1-92287 With fluorescein angiography
1-95060 Opthamalmic mucous membrane tests
5/I/T--95930 Visually evoked potential (VEP) testing, central nervous system, checkerboard, or flash
5/I/T-95933 Visual evoked potential test
1-9248X Computer assisted corneal topography (unilateral), optometrist only
Hospital-based Rural Health Clinics (2002 TMPPM Reference–Section 38)
Procedure Code Modifier Description
1-9203Z 7D Performed by physician
1-9203Z AN Performed by physician assistant
1-9203Z AL Performed by advanced practice nurse or certifiednurse-midwife
1-9203Z AJ Performed by social worker
1-9203Z 7C Performed by visiting nurse
Vision Care Services (2002 TMPPM Reference–Section 42)
Diagnosis Code Procedure Code Description
2002 FQHC/RHC Special Bulletin 11 No. 167
For THSteps Medical claims, always record the following on the HCFA-1450 (UB-92) Claim Form or electronic equivalent to receive reimbursement for a medical checkup:
• The diagnosis code on the HCFA-1450 (UB-92) (Block 67 or appropriate electronic field) will always be V202.
• Type of service on the HCFA-1450 (UB-92) (Block 44 or appropriate electronic field) will always be “S.”
• Place of service on the HCFA-1450 (UB-92) (Block 4 or appropriate electronic field) is autoplugged based on the type of bill indicated on the claim.
• Appropriate THSteps medical checkup code (for example, medical screen, exception to periodicity, follow-up visit) (all ages).
• TB skin test code (age 1 year to age 21 years).
• Immunization code(s) (all ages).
• Second newborn hereditary/metabolic testing code (age one week to 52 weeks).
Use the following modifiers to identify Family Planning and THSteps medical services performed in a RHC setting:
Freestanding Rural Health Clinics (2002 TMPPM Reference – Section 38)
Procedure Code Modifier Description
1-Z9202 7D Performed by physician
1-Z9202 AN Performed by physician assistant
1-Z9202 AL Performed by advanced practice nurse or certified nurse-midwife
1-Z9202 AJ Performed by social worker
1-Z9202 7C Performed by visiting nurse
Modifier Description
R5 Rural Health Clinic – Physician (MD/DO)
R6 Rural Health Clinic – Physicians Assistant
R7 Rural Health Clinic – Registered Nurse
R8 Rural Health Clinic – Advanced Nurse Practitioner
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Modifier Description
S-8000Y R5–R8 THSteps medical screen – normal
S-8004Y R5–R8 THSteps exception to periodicity – normal
S-8100Y R5–R8 THSteps medical screen – abnormal, treatment not necessary
S-8104Y R5–R8 THSteps exception to periodicity – abnormal treatment not necessary
S-8200Y R5–R8 THSteps medical screen – abnormal, treatment initiated
S-8204Y R5–R8 THSteps exception to periodicity – abnormal, treatment initiated
S-8300Y R5–R8 THSteps medical screen – abnormal, referred to primary care physician
S-8304Y R5–R8 THSteps exception to periodicity – abnormal, referred to primary care physician
S-8400Y R5–R8 THSteps medical screen – abnormal, referred to specialist
S-8404Y R5–R8 THSteps exception to periodicity – abnormal, referred to specialist
S-8500Y R5–R8 THSteps medical screen – abnormal, referred to other health agency
S-8504Y R5–R8 THSteps exception to periodicity – abnormal, referred to other health agency
S-8600Y R5–R8 THSteps medical screen – abnormal, condition under treatment
S-8604Y R5–R8 THSteps exception to periodicity – abnormal, condition under treatment
S-8700Y R5–R8 THSteps medical screen – referred to Family Planning
S-8704Y R5–R8 THSteps exception to periodicity – referred to Family Planning
No. 167 12 2002 FQHC/RHC Special Bulletin
The Family Planning and THSteps medical services that may be performed in an RHC setting are specifically identified in the following two tables and must be identified with one of the following modifiers (R5, R6, R7, or R8).
Informational THSteps Medical Procedures Performed in an RHC
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Modifier Description
1-Z9008 R5–R8 Family Planning annual visit-comp H&P, per provider
2-9000X R5–R8 Provide and insert implantable contraceptive capsules
2-X4562 R5–R8 Furnish and insert progestasert IUD (including cost of device)
2-X4563 R5–R8 Furnish and insert copper T 380-A IUD (including cost of device)
2-X4572 R5–R8 Furnish and insert copper T 380-A IUD (including cost of device)
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Modifier Description
S-32A0Y R5–R8 Administration of DTP #1
S-32B0Y R5–R8 Administration of DTP #2
S-32C0Y R5–R8 Administration of DTP #3
S-32D0Y R5–R8 Administration of DTP #4
S-32E0Y R5–R8 Administration of DTP #5
S-33A0Y R5–R8 Administration of OPV #1
S-33B0Y R5–R8 Administration of OPV #2
S-33C0Y R5–R8 Administration of OPV #3
S-33D0Y R5–R8 Administration of OPV #4 (do not give before age 4)
S-33E0Y R5–R8 Administration of OPV #5 (for children off current sch)
S-34A0Y R5–R8 Administration of DT/Td #1
S-34B0Y R5–R8 Administration of DT/Td #2
S-34C0Y R5–R8 Administration of DT/Td #3
S-34D0Y R5–R8 Administration of DT/Td #4
S-34E0Y R5–R8 Administration of DT/Td #5
S-35A0Y R5–R8 Administration of MMR #1
S-35B0Y R5–R8 Administration of MMR #2
S-36A0Y R5–R8 Administration of HibCV #1
S-36B0Y R5–R8 Administration of HibCV #2
S-36C0Y R5–R8 Administration of HibCV #3
S-36D0Y R5–R8 Administration of HibCV #4
S-37A0Y R5–R8 Administration of Hepatitis A
S-38A0Y R5–R8 Administration of Hepatitis B #1
S-38B0Y R5–R8 Administration of Hepatitis B #2
S-38C0Y R5–R8 Administration of Hepatitis B #3
S-41A0Y R5–R8 Administration of Td #1
S-42A0Y R5–R8 Administration of DTP/Hib #1
S-42B0Y R5–R8 Administration of DTP/Hib #2
S-42C0Y R5–R8 Administration of DTP/Hib #3
S-42D0Y R5–R8 Administration of DTP/Hib #4
S-43A0Y R5–R8 Administration of EIPV #1
S-43B0Y R5–R8 Administration of EIPV #2
S-43C0Y R5–R8 Administration of EIPV #3
S-43D0Y R5–R8 Administration of EIPV #4
2002 FQHC/RHC Special Bulletin 13 No. 167
Informational Family Planning Procedures Performed in an RHC
S-5498X R5–R8 Administration of pnemoncoccal conjugate vaccine, polyvalent
S-5743X R5–R8 Administration of varicella vaccine
S-5745X R5–R8 Administration of DTaP #1
S-5746X R5–R8 Administration of DTaP #2
S-5747X R5–R8 Administration of DTaP #3
S-5748X R5–R8 Administration of DTaP #4
S-5749X R5–R8 Administration of DTaP #5
S-3100Y R5–R8 Immunizations up-to-date
S-3101Y R5–R8 No immunization administered; medically contraindicated
S-3700Y R5–R8 No immunization administered; religious exemptions
S-3701Y R5–R8 No immunization administered; parent refusal or child uncooperative
S-1700Y R5–R8 Second newborn hereditary/metabolic testing – completed elsewhere
S-1701Y R5–R8 Second newborn hereditary/metabolic testing – completed this visit results pending
S-1702Y R5–R8 Second newborn hereditary/metabolic testing – normal
S-1703Y R5–R8 Second newborn hereditary/metabolic testing – abnormal
S-2500Y R5–R8 TB skin test administered this visit – results pending or patient did not return
S-2503Y R5–R8 TB questionnaire administered or TB skin test administered within past 11 months
S-2506Y R5–R8 TB skin test not administered – parent refusal or child uncooperative
S-8005Y R5–R8 THSteps follow-up visit – repeat laboratory work
S-8105Y R5–R8 THSteps follow-up visit – complete immunizations
S-8205Y R5–R8 THSteps follow-up visit – presumptive positive tuberculin skin test reaction
S-8305Y R5–R8 THSteps follow-up visit – other
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Modifier Description
2-11975 R5–R8 Insert only, implant contraceptive without capsule cost
2-11976 R5–R8 Remove only, implantable contraceptive capsules
2-11977 R5–R8 Remove with reinsertion only, implantable contraceptive capsules (not including the cost of the capsules)
1-4600Z R5–R8 Female condom (three individually packaged condoms, bottle of lubricant, and instructions)
2-4836X R5–R8 Furnish and fit diaphragm
2-4837X R5–R8 Furnish and fit cervical cap
2-58300 R5–R8 Insert intrauterine device (IUD) (not including cost of device)
2-58301 R5–R8 Remove intrauterine device (IUD)
1-J1055 R5–R8 Furnish and inject Depo Provera (DMPA, Depot-Medroxyprogesterone Acetate) 150 mg
1-Z0034 R5–R8 Vaginal contraceptive film (quantity 6)
1-Z0035 R5–R8 Spermicidal cream
1-Z0036 R5–R8 Spermicidal jelly
1-Z0037 R5–R8 Contraceptive suppository (each)
1-Z0038 R5–R8 Spermicidal foam
1-Z0039 R5–R8 Other medication for genital infection
1-Z0040 R5–R8 Oral contraceptives (one cycle)
1-Z0041 R5–R8 Cervical cap (supply only)
1-Z0042 R5–R8 Condoms (package of 12)
1-Z0043 R5–R8 Natural family planning supplies (calendar, charts, instruction book, thermometer)
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Modifier Description
No. 167 14 2002 FQHC/RHC Special Bulletin
Contact your NHIC Provider Relations Training Specialist with questions. You can find your specific representative at www.eds-nhic.com\provenrl\imagemap.html. The final rules were published in the Texas Register on October 4, 2002.
1-Z0044 R5–R8 Contraceptive sponge (each)
1-Z0050 R5–R8 Initial client education
1-Z0051 R5–R8 Method-specific education/counseling
1-Z0052 R5–R8 Problem counseling
1-Z0053 R5–R8 Introduction to family planning in hospital setting/auspices
1-Z0054 R5–R8 Instruction in natural family planning methods (per session)
1-Z0055 R5–R8 Antimonilia medication for genital infection
1-Z0056 R5–R8 Diaphragm (supply only)
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Modifier Description
2002 FQHC/RHC Special Bulletin 15 No. 167
NOTES:
ATTENTION: BUSINESS OFFICE
PRSRT STDUS POSTAGE
PAIDAUSTIN TX
PERMIT #156
Visit us online at www.eds-nhic.com for the following:
• Compass21 Frequently Asked Questions (FAQ)
• Medicaid Workshop Schedules and FAQs
• TDH-NHIC 2002 Publications—includes the 2002 Texas Medicaid Provider Procedures Manual, 2002 Texas Medicaid Service Delivery Guide, and Texas Medicaid Bulletins
• Regional Support—lists NHIC Training Specialists
National Heritage Insurance Co.12545 Riata Vista CircleAustin TX 78727-6524
NHICan EDS company
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Texas Medicaid
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)
2003 Texas Medicaid Provider Procedures Manual The 2003 Texas Medicaid Provider Procedures Manual will be distributed during January 2003. One provider manual will be mailed to each Texas Provider Identifier (TPI) on file with the National Heritage Insurance Company (NHIC).
Refer to the January/February 2003 Texas Medicaid Bulletin, No. 168 for more information.
Have you visited www.eds-nhic.com lately?You can find out when workshops will be held in your area, download forms and manuals, and learn about important updates of the Texas Medicaid Program.
2002 FQHC/RHC Special Bulletin No. 167
Bulletin Contents, No. 167
Federally Qualified Health Center (FQHC) Providers . . . . . . . . . . . . . . . . . . . . . . . 2
Prospective Payment System (PPS) for FQHC Providers ..................................................... 2
Rural Health Clinic (RHC) Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Prospective Payment System (PPS) for RHC Providers ..................................................... 10
No. 167 2 2002 FQHC/RHC Special Bulletin
Federally Qualified Health Center (FQHC) Providers
Prospective Payment System (PPS) for FQHC Providers
Effective January 3, 2003, FQHC providers will be paid an all-inclusive rate per visit for the following services with the implemen-tation of PPS. All other services will be processed as informational. You should continue to bill using the same procedure codes, diagnosis codes, and modifiers. Refer to the 2002 Texas Medicaid Provider Procedures Manual (TMPPM) for additional information on benefits and limitations.
Note: If you bill general medical services without using one of the modifiers in the following table, the service will be automatically denied.
FQHC providers may now bill other mental health services and vision care services. Refer to the appropriate sections in the 2002 Texas Medicaid Provider Procedures Manual for a complete understanding.
Payable Visit Procedures for an FQHC
General Medical Services (2002 TMPPM Reference–Section 20)
Procedure Code Modifier Description
1-Z9813 7D Performed by physician
1-Z9813 AN Performed by physician assistant
1-Z9813 AL Performed by advanced practice nurse or certified nurse-midwife
1-Z9813 7C Performed by visiting nurse
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-1000D Appliance with horizontal projections
W-1001D Appliance with recurved springs
W-1002D Arch wires for cross bite correction for total treatment
W-1003D Banded maxillary expansion appliance
W-1004D Bite plate/bite plane
W-1005D Bionator
W-1006D Bite block
W-1007D Bite plate with push springs
W-1008D Bonded expansion device
W-1009D Brackets
W-1010D Chateau appliance (face mask palatal expander and hawley)
W-1011D Coffin spring appliance
W-1012D Crib
W-1013D Dental obturator, definitive (obturator)
W-1014D Dental obturator, surgical (obturator surgical stayplate immediate temporary obturator)
W-1015D Distalizing appliance with springs
W-1016D Expansion device
W-1017D Face mask (protraction mask)
W-1018D Fixed expansion appliance
W-1019D Fixed lingual arch
W-1020D Fixed mandibular holding arch
W-1021D Fixed rapid palatal expander
W-1022D Frankel appliance
W-1023D Functional appliance for reduction of anterior openbite and crossbite
W-1024D Headgear (face bow)
W-1025D Herbst appliance (fixed or removable)
W-1026D Inter-occlusal cast cap surgical splints
W-1027D Intrusion arch
W-1028D Jasper jumpers
W-1029D Lingual appliance with hooks
W-1030D Mandibular anterior bridge
W-1031D Mandibular bihelix (similar to quad helix for mandibular expansion to attempt non extrac)
W-1032D Mandibular lip bumper
W-1033D Mandibular fixed 2x4 retainer
W-1034D Mandibular fixed 3x3 retainer
W-1035D Mandibular fixed 4x4 retainer
W-1036D Mandibular lingual 6x6 arch wire
W-1037D Mandibular removable expander with bite plane-crozat
W-1038D Mandibular ricketts rest position splint
W-1039D Mandibular splint
W-1040D Maxillary anterior bridge
W-1041D Maxillary bite-opening appliance with anterior springs
W-1042D Maxillary lingual arch with spurs
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
2002 FQHC/RHC Special Bulletin 3 No. 167
W-1043D Maxillary-mandibular distallizing appliance
W-1044D Maxillary quad helix with finger springs
W-1045D Maxillary retainer with pontics
W-1046D Maxillary schwarz
W-1047D Maxillary splint
W-1048D Mobile intraoral arch-MIA
W-1049D Modified quad helix appliance
W-1050D Modified quad helix appliance with appliance
W-1051D Nance appliance
W-1052D Nasal stent
W-1053D Occlusal orthotic device
W-1054D Orthopedic appliance
W-1055D Other mandibular utilities
W-1056D Other maxillary utilities
W-1057D Palatal bar
W-1058D Post surgical retainer
W-1059D Quad helix appliance held with transpalatal arch horizontal projections
W-1060D Quad helix maintainer
W-1061D Rapid palatal expander rpe such as quad helix haas or menne
W-1062D Removable bite plate
W-1063D Removable mandibular retainer
W-1064D Removable maxillary retainer
W-1065D Removable prosthesis
W-1066D Sagittal appliance (2-way)
W-1067D Sagittal appliance (3-way)
W-1068D Stapled palatal expansion appliance
W-1069D Surgical arch wires
W-1070D Surgical splints (surgical stent/wafer)
W-1071D Surgical stabilizing appliance
W-1072D Thumb-sucking appliance
W-1073D Tongue thrust appliance
W-1074D Tooth positioner (full maxillary and mandibular)
W-1075D Tooth positioner with arch
W-1076D Transpalatal arch
W-1077D Two bands with transpalatal arch and horizontal projections forward
W-1078D W appliance
W-8110D Crossbite therapy, removable appliance
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-8120D Crossbite therapy, fixed appliance
W-D0120 Periodic oral evaluation
W-D0140 Limit oral evaluation problem focus
W-D0150 Comprehensve oral evaluation
W-D0160 Extensv oral evaluation problem focus
W-D0170 Re-evaluation, est pt, problem focus
W-D1110 Dental prophylaxis – adult
W-D1120 Dental prophylaxis – child
W-D1201 Topical fluor with prophy – child
W-D1203 Topical fluor without prophy – child
W-D1204 Topical fluor without prophy – adult
W-D1205 Topical fluoride with prophy – adult
W-D1351 Dental sealant per tooth
W-D1510 Space maintainer fxd unilat
W-D1515 Fixed bilat space maintainer
W-D1520 Remove unilat space maintain
W-D1525 Remove bilat space maintainer
W-D1550 Recement space maintainer
W-D2110 Amalgam one surface primary
W-D2120 Amalgam two surfaces primary
W-D2130 Amalgam three surfaces primary
W-D2131 Amalgam four/more surf primary
W-D2140 Amalgam one surface permanent
W-D2150 Amalgam two surfaces permanent
W-D2160 Amalgam three surfaces permanent
W-D2161 Amalgam 4 or greater than surfaces perm
W-D2330 Resin one surface – anterior
W-D2331 Resin two surfaces – anterior
W-D2332 Resin three surfaces – anterior
W-D2335 Resin 4/greater than surf or with incis an
W-D2336 Composite resin crown
W-D2337 Compo resin crown ant-perm
W-D2380 Resin one surf poster primar
W-D2381 Resin two surf poster primar
W-D2382 Resin three/more surf post p
W-D2385 Resin one surf poster perman
W-D2386 Resin two surf poster perman
W-D2387 Resin three/more surf post p
W-D2388 Resin four/more, post perm
W-D2410 Dental gold foil one surface
W-D2420 Dental gold foil two surface
W-D2430 Dental gold foil three surface
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
No. 167 4 2002 FQHC/RHC Special Bulletin
W-D2510 Dental inlay metalic one surface
W-D2520 Dental inlay metallic 2 surf
W-D2530 Dental inlay metl 3/more sur
W-D2933 Prefab stainless steel crown
W-D2960 Laminate labial veneer
W-D2961 Lab labial veneer resin
W-D2962 Lab labial veneer porcelain
W-D4249 Crown lengthen hard tissue
W-D4260 Osseous surgery per quadrant
W-D4266 Guided tiss regen resorble
W-D4267 Guided tiss regen nonresorb
W-D4270 Pedicle soft tissue graft pr
W-D4271 Free soft tissue graft proc
W-D4273 Subepithelial tissue graft
W-D4274 Distal/proximal wedge proc
W-D4320 Provisional splint intracoronal
W-D4321 Provisional splint extracoro
W-D4341 Periodontal scaling and root
W-D4355 Full mouth debridement
W-D4381 Localized chemo delivery
W-D4910 Periodontal maint procedures
W-D4920 Unscheduled dressing change
W-D4999 Unspecified periodontal proc
W-D5110 Dentures complete maxillary
W-D5120 Dentures complete mandible
W-D5130 Dentures immediat maxillary
W-D5140 Dentures Immediat mandible
W-D5211 Dentures maxill part resin
W-D5212 Dentures mand part resin
W-D5213 Dentures maxill part metal
W-D5214 Dentures mandibl part metal
W-D5281 Removable partial denture
W-D5410 Dentures adjust cmplt maxil
W-D5411 Dentures adjust cmplt mand
W-D5421 Dentures adjust part maxill
W-D5422 Dentures adjust part mandbl
W-D5510 Dentur repr broken compl bas
W-D5520 Replace denture teeth complt
W-D5610 Dentures repair resin base
W-D5620 Rep part denture cast frame
W-D5630 Rep partial denture clasp
W-D5640 Replace part denture teeth
W-D5650 Add tooth to partial denture
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-D5660 Add clasp to partial denture
W-D5710 Dentures rebase cmplt maxil
W-D5711 Dentures rebase cmplt mand
W-D5720 Dentures rebase part maxill
W-D5721 Dentures rebase part mandbl
W-D5730 Denture reln cmplt maxil chr
W-D5731 Denture reln cmplt mand chr
W-D5740 Denture reln part maxil chr
W-D5741 Denture reln part mand chr
W-D5750 Denture reln cmplt max lab
W-D5751 Denture reln cmplt mand lab
W-D5760 Denture reln part maxil lab
W-D5761 Denture reln part mand lab
W-D5810 Denture interm cmplt maxill
W-D5811 Denture interm cmplt mandbl
W-D5820 Denture interm part maxill
W-D5821 Denture interm part mandbl
W-D5850 Denture tiss conditn maxill
W-D5851 Denture tiss condtin mandbl
W-D5860 Overdenture complete
W-D5861 Overdenture partial
W-D5862 Precision attachment
W-D5899 Removable prosthodontic proc
W-D5911 Facial moulage sectional
W-D5912 Facial moulage complete
W-D5913 Nasal prosthesis
W-D5914 Auricular prosthesis
W-D5915 Orbital prosthesis
W-D5916 Ocular prosthesis
W-D5919 Facial prosthesis
W-D5922 Nasal septal prosthesis
W-D5923 Ocular prosthesis interim
W-D5924 Cranial prosthesis
W-D5925 Facial augmentation implant
W-D5926 Replacement nasal prosthesis
W-D5927 Auricular replacement
W-D5928 Orbital replacement
W-D5929 Facial replacement
W-D5931 Surgical obturator
W-D5932 Postsurgical obturator
W-D5933 Refitting of obturator
W-D5934 Mandibular flange prosthesis
W-D5935 Mandibular denture prosthesis
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
2002 FQHC/RHC Special Bulletin 5 No. 167
W-D5937 Trismus appliance
W-D5951 Feeding aid
W-D5952 Pediatric speech aid
W-D5953 Adult speech aid
W-D5954 Superimposed prosthesis
W-D5955 Palatal lift prosthesis
W-D5958 Intraoral con def inter plt
W-D5959 Intraoral con def mod palat
W-D5960 Modify speech aid prosthesis
W-D5982 Surgical stent
W-D5983 Radiation applicator
W-D5984 Radiation shield
W-D5985 Radiation cone locator
W-D5986 Fluoride applicator
W-D5987 Commissure splint
W-D5988 Surgical splint
W-D5999 Maxillofacial prosthesis
W-D6010 Odontics endosteal implant
W-D6020 Odontics abutment placement
W-D6040 Odontics eposteal implant
W-D6050 Odontics transosteal implant
W-D6055 Implant connecting bar
W-D6080 Implant maintenance
W-D6090 Repair implant
W-D6095 Odontics repr abutment
W-D6100 Removal of implant
W-D6199 Implant procedure
W-D6210 Prosthodont high noble metal
W-D6211 Bridge base metal cast
W-D6212 Bridge noble metal cast
W-D6240 Bridge porcelain high noble
W-D6241 Bridge porcelain base metal
W-D6242 Bridge porcelain nobel metal
W-D6245 Bridge porcelain/ceramic
W-D6250 Bridge resin with high noble
W-D6251 Bridge resin base metal
W-D6252 Bridge resin with noble metal
WD-6519 Inlay/onlay porce/ceramic
W-D6520 Dental retainer two surfaces
W-D6530 Retainer metallic 3+ surface
W-D6543 Dental retainr onlay 3 surf
W-D6544 Dental retainr onlay 4/more
W-D6545 Dental retainr cast metl
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-D6548 Porcelain/ceramic retainer
W-D6720 Retain crown resin with hi nble
W-D6721 Crown resin with base metal
W-D6722 Crown resin with noble metal
W-D6740 Crown porcelain/ceramic
W-D6750 Crown porcelain high noble
W-D6751 Crown porcelain base metal
W-D6752 Crown porcelain noble metal
W-D6780 Crown 3/4 high noble metal
W-D6781 Crown 3/4 cast based metal
W-D6782 Crown 3/4 cast noble metal
W-D6783 Crown 3/4 porcelain/ceramic
W-D6790 Crown full high noble metal
W-D6791 Crown full base metal cast
W-D6792 Crown full noble metal cast
W-D6920 Dental connector bar
W-D6930 Dental recement bridge
W-D6940 Stress breaker
W-D6950 Precision attachment
W-D6970 Post and core plus retainer
W-D6971 Cast post bridge retainer
W-D6972 Prefab post and core plus reta
W-D6973 Core build up for retainer
W-D6975 Coping metal
W-D6976 Each additional cast post
W-D6977 Each additional prefab post
W-D6980 Bridge repair
W-D6999 Fixed prosthodontic proc
W-D7110 Oral surgery single tooth
W-D7120 Each add tooth extraction
W-D7130 Tooth root removal
W-D7210 Rem imp tooth with mucoper flp
W-D7220 Impact tooth remov soft tiss
W-D7230 Impact tooth remov part bony
W-D7240 Impact tooth remov comp bony
W-D7241 Impact tooth rem bony with comp
W-D7250 Tooth root removal
W-D7260 Oral antral fistula closure
W-D7270 Tooth reimplantation
W-D7272 Tooth transplantation
W-D7280 Exposure impact tooth orthod
W-D7281 Exposure tooth aid eruption
W-D7285 Biopsy of oral tissue hard
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
No. 167 6 2002 FQHC/RHC Special Bulletin
W-D7286 Biopsy of oral tissue soft
W-D7290 Repositioning of teeth
W-D7291 Transseptal fiberotomy
W-D7310 Alveoplasty with extraction
W-D7320 Alveoplasty without extraction
W-D7340 Vestibuloplasty ridge extens
W-D7350 Vestibuloplasty exten graft
W-D7410 Rad exc lesion up to 1.25 cm
W-D7420 Lesion greater than 1.25 cm
W-D7430 Exc benign tumor to 1.25 cm
W-D7431 Benign tumor exc greater than1.25 cm
W-D7440 Malig tumor exc to 1.25 cm
W-D7441 Malig tumor greater than 1.25 cm
W-D7450 Rem odontogen cyst to 1.25 cm
W-D7451 Rem odontogen cyst greater than 1.25 cm
W-D7460 Rem nonodonto cyst to 1.25 cm
W-D7461 Rem nonodonto cyst greater than 1.25 cm
W-D7465 Lesion destruction
W-D7480 Partial ostectomy
W-D7510 I&D absc intraoral soft tiss
W-D7520 I&D abscess extraoral
W-D7530 Removal fb skin/areolar tiss
W-D7540 Removal of fb reaction
W-D7550 Removal of sloughed off bone
W-D7560 Maxillary sinusotomy
W-D7670 Closd rductn splint alveolus
W-D7820 Closed tmp manipulation
W-D7880 Occlusal orthotic appliance
W-D7899 TMJ unspecified therapy
W-D7910 Dent sutur recent wnd to 5 cm
W-D7911 Dental suture wound to 5 cm
W-D7912 Suture complicate wnd greater than5 cm
W-D7955 Repair maxillofacial defects
W-D7960 Frenulectomy/frenulotomy
W-D7970 Excision hyperplastic tissue
W-D7971 Excision pericoronal gingiva
W-D7980 Sialolithotomy
W-D7983 Closure of salivary fistula
W-D7993 Implant-facisl bones (homologous, heterologous or allopastic) (CCP)
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
W-D7993 Implant-facisl bones (homologous, heterologous or allopastic)
W-D7997 Appliance removal
W-D7999 Oral surgery procedure
W-D8999 Orthodontic procedure
W-D9110 Tx dental pain minor proc
W-D9210 Dent anesthesia without surgery
W-D9211 Regional block anesthesia
W-D9212 Trigeminal block anesthesia
W-D9215 Local anesthesia
W-D9220 General anesthesia
W-D9221 General anesthesia ea ad 15 m
W-D9230 Analgesia
W-D9248 Sedation (non-IV)
W-D924X Intravenous sedation
W-D9310 Dental consultation
W-D9410 Dental house call
W-D9420 Hospital call
W-D9430 Office visit during hours
W-D9440 Office visit after hours
W-D9610 Dent therapeutic drug inject
W-D9630 Other drugs/medicaments
W-D9910 Dent appl desensitizing med
W-D9920 Behavior management
W-D9930 Treatment of complications
W-D9940 Dental occlusal guard
W-D9950 Occlusion analysis
W-D9951 Limited occlusal adjustment
W-D9952 Complete occlusal adjustment
W-D9974 Intrnl bleaching per tooth
W-D9999 Adjunctive procedure
W-D9999 Unspecified adjunctive procedure, by report
W-Z2008 Initial orthodontic visit
W-Z2009 Diagnostic work up - approved
W-Z2011 Orthodontic appliance, upper
W-Z2012 Orthodontic appliance, lower
W-Z2013 Orthodontic adjustments, per month
W-Z2014 Orthodontic retainer, upper
W-Z2015 Orthodontic retainer, lower
W-Z2016 Premature appliance removal (per arch)
Texas Health Steps (THSteps) Dental (2002 TMPPM Reference–Section 18)
Procedure Code Description
2002 FQHC/RHC Special Bulletin 7 No. 167
For THSteps medical claims, always record the following on the HCFA-1450 (UB-92) Claim Form or electronic equivalent to receive reimbursement for a medical checkup:
• The diagnosis code on the HCFA-1450 (UB-92) (Block 67 or appropriate electronic field) will always be V202.
• Type of service on the HCFA-1450(UB-92) (Block 44 or appropriate electronic field) will always be “S.”
• Place of service on the HCFA-1450 (UB-92) (Block 4 or appropriate electronic field) is autoplugged based on the type of bill indicated on the claim.
• Appropriate THSteps medical checkup code (for example, medical screen, exception to periodicity, follow-up visit) (all ages).
• TB skin test code (age 1 year to age 21 years).
• Immunization code(s) (all ages).
• Second newborn hereditary/metabolic testing code (age one week to 52 weeks).
Case Management (2002 TMPPM Reference–Section 12)
Procedure Code Description
1-4001X Face-to-face case management, pregnant adolescent or woman
1-4002X Face-to-face case management, infant
1-4003X Telephone case management, pregnant adolescent or woman
1-4004X Telephone case management, infant
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Description
S-8000Y THSteps medical screen – normal
S-8004Y THSteps exception to periodicity – normal
S-8100Y THSteps medical screen – abnormal, treatment not necessary
S-8104Y THSteps exception to periodicity – abnormal, treatment not necessary
S-8200Y THSteps medical screen – abnormal, treatment initiated
S-8204Y THSteps exception to periodicity – abnormal, treatment initiated
S-8300Y THSteps medical screen – abnormal, referred to primary care physician
S-8304Y THSteps exception to periodicity – abnormal, referred to primary care physician
S-8400Y THSteps medical screen – abnormal, referred to specialist
S-8404Y THSteps exception to periodicity – abnormal, referred to specialist
S-8500Y THSteps medical screen – abnormal, referred to other health agency
S-8504Y THSteps exception to periodicity – abnormal, referred to other health agency
S-8600Y THSteps medical screen – abnormal, condition under treatment
S-8604Y THSteps exception to periodicity – abnormal, condition under treatment
S-8700Y THSteps medical screen – referred to Family Planning
S-8704Y THSteps exception to periodicity – referred to Family Planning
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Description
1-Z9008 Family Planning annual visit-comp H&P, per provider
2-9000X Provide and insert implantable contraceptive capsules
2-X4562 Furnish and insert progestasert IUD (including cost of device)
2-X4563 Furnish and insert copper T 380-A IUD (including cost of device)
2-X4572 Furnish and insert copper T 380-A IUD (including cost of device)
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Description
No. 167 8 2002 FQHC/RHC Special Bulletin
Mental Health Services (Other)
Procedure Code Description 2002 TMPPM Reference
1-1050X Individual counseling services provided by LMSW-ACP or LPC Section 28: Licensed Master Social Worker-Advanced Clinical Practitioner (LMSW-ACP)Section 29: Licensed Professional Counselors (LPCs)
1-1051X Group counseling services provided by LMSW-ACP or LPC
1-1052X Family counseling services provided by LMSW-ACP or LPC
1-1150X Individual counseling services provided by LMFT Section 27: Licensed Marriage and Family Therapist (LMFT)1-1151X Group counseling services provided by LMFT
1-1152X Family counseling services provided by LMFT
1-90801 Psychiatric diagnostic interview examination Section 35: PsychologistSection 34.4.34: Physician Psychiatric Services
1-90802 Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication
1-90804/1-90805*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient
1-90806/1-90807*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient
1-90808/1-90809*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient
1-90810/1-90811*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient
1-90812/1-90813*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient
1-90814/1-90815*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient
1-90816/1-90817*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient
1-90818/1-90819*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient
1-90821/1-90822*
Individual psychotherapy, insight-oriented, behavior-modifying and/or supportive, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient
1-90823/1-90824*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with patient
1-90826/1-90827*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with patient
1-90828/1-90829*
Individual psychotherapy, interactive, using play equipment, physical devices, language interpreter, or other mechanisms of nonverbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with patient
1-90845 Psychoanalysis
*These procedure codes should be billed by a psychiatrist and include medical evaluation and management services.
2002 FQHC/RHC Special Bulletin 9 No. 167
1-90847 Family psychotherapy (conjoint psychotherapy) (with patient present) Section 35: Psychologist
1-90853 Group psychotherapy (other than of a multiple-family group)
1-90857 Interactive group psychotherapy
1-90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes (sodium amobarbital interview)
5-96100 Psychological testing
5-96117 Neuropsychological testing battery
Vision Care Services (2002 TMPPM Reference–Section 42)
Diagnosis Code Procedure Code Description
3670 1-Z9513 Hypermetropia, far-sightedness (Hyperopia)
3671 1-Z9513 Myopia, near-sightedness
36720 1-Z9513 Astigmatism, unspecified
36721 1-Z9513 Regular astigmatism
36722 1-Z9513 Irregular astigmatism
36731 1-Z9513 Anisometropia
3674 1-Z9513 Presbyopia
36751 1-Z9513 Paresis of accommodation (Cycloplegia)
36752 1-Z9513 Total or complete internal ophthalmoplegia
36753 1-Z9513 Spasm of accommodation
36781 1-Z9513 Transient refractive change
36789 1-Z9513 Other, drug-induced, toxic disorders of refraction and accommodation
3679 1-Z9513 Unspecified disorder of refraction and accommodation
37182 1-Z9513 Corneal disorder due to contact lens
V720 1-Z9513 Eye examination (exam normal, no prescription required)
Appropriate Diagnosis
1-92002 New patient, intermediate eye exam
1-92004 New patient, comprehensive eye exam, one or more visits
1-92012 Established patient, intermediate eye exam
1-92014 Established patient, comprehensive eye exam, one or more visits
1-92015 Determination of refractive state
1-92020 Gonioscopy
1-92060 Sensorimotor exam with mult measurements of ocular deviation with interp and report
1-92065 Orthoptic and/or pleoptics training, with continuing medical direction and evaluation
1-92081 Visual field examination with medical diagnostic evaluation, tangent screen, autoplot or equivalent
1-92082 Quantitative perimetry (e.g., several isopters on Goldmann perimeter or equivalent)
1-92083 Static and kinetic perimetry, or equivalent quantitative perimetry (e.g., several isopters or Goldmann perimeter, or equivalent)
1-92100 Serial tonometry with mult measure intaocular press ext per e/int
1-92120 Tonography with interpretation and report, recording indention tonometer method or perilimbal suction method
Mental Health Services (Other)
Procedure Code Description 2002 TMPPM Reference
*These procedure codes should be billed by a psychiatrist and include medical evaluation and management services.
No. 167 10 2002 FQHC/RHC Special Bulletin
Rural Health Clinic (RHC) Providers
Prospective Payment System (PPS) for RHC Providers
Effective January 3, 2003, RHC providers, including County Indigent Health Care Program (CIHCP) RHC providers, will be paid an all-inclusive rate per visit for the following services with the implementation of PPS. All other services will be processed as informational.
Note: If you bill general medical services without using one of the modifiers in the table, the service will be automatically denied. The six core lab services are not a payable benefit for hospital-based or freestanding RHCs.
Refer to: The 2002 Texas Medicaid Provider Procedures Manual for additional information on benefits and limitations.
Payable Visit Procedures for an RHC (General Medical Services)
Appropriate Diagnosis
1-92140 Provocative tests for glaucoma with interpretation and report, without tonography
1-92225 Ophthalmoscopy, extended, with retinal drawing (for example, for retinal detachment, melanoma), with interpretation and report; initial
1-92226 Ophthalmoscopy, extended, with retinal drawing (for example, for retinal detachment, melanoma), with interpretation and report; subsequent
1-92230 Fluorescein angioscopy, with interpretation and report
1-92235 Fluorescein angiography (includes multiframe imaging), with interpretation and report
1-92240 Indocyamine green angiography
1-92250 Fundus photography with interpretation and report
1-92260 Ophthalmodynamometry
1-92265 Oculoelectromyography, one or more extraocular muscles, one or both eyes, with medical diagnostic evaluation
1-92270 Electro-oculography, with medical diagnostic evaluation
1-92275 Electroretinography, with medical diagnostic evaluation
1-92285 External ocular photography with interpretation and report, for documentation of medical progress (e.g., close-up photography, slit lamp photography, goniophotography, stereo-photography)
1-92286 Special anterior segment photography with interpretation and report; with special endothelial microscopy and cell count
1-92287 With fluorescein angiography
1-95060 Opthamalmic mucous membrane tests
5/I/T--95930 Visually evoked potential (VEP) testing, central nervous system, checkerboard, or flash
5/I/T-95933 Visual evoked potential test
1-9248X Computer assisted corneal topography (unilateral), optometrist only
Hospital-based Rural Health Clinics (2002 TMPPM Reference–Section 38)
Procedure Code Modifier Description
1-9203Z 7D Performed by physician
1-9203Z AN Performed by physician assistant
1-9203Z AL Performed by advanced practice nurse or certifiednurse-midwife
1-9203Z AJ Performed by social worker
1-9203Z 7C Performed by visiting nurse
Vision Care Services (2002 TMPPM Reference–Section 42)
Diagnosis Code Procedure Code Description
2002 FQHC/RHC Special Bulletin 11 No. 167
For THSteps Medical claims, always record the following on the HCFA-1450 (UB-92) Claim Form or electronic equivalent to receive reimbursement for a medical checkup:
• The diagnosis code on the HCFA-1450 (UB-92) (Block 67 or appropriate electronic field) will always be V202.
• Type of service on the HCFA-1450 (UB-92) (Block 44 or appropriate electronic field) will always be “S.”
• Place of service on the HCFA-1450 (UB-92) (Block 4 or appropriate electronic field) is autoplugged based on the type of bill indicated on the claim.
• Appropriate THSteps medical checkup code (for example, medical screen, exception to periodicity, follow-up visit) (all ages).
• TB skin test code (age 1 year to age 21 years).
• Immunization code(s) (all ages).
• Second newborn hereditary/metabolic testing code (age one week to 52 weeks).
Use the following modifiers to identify Family Planning and THSteps medical services performed in a RHC setting:
Freestanding Rural Health Clinics (2002 TMPPM Reference – Section 38)
Procedure Code Modifier Description
1-Z9202 7D Performed by physician
1-Z9202 AN Performed by physician assistant
1-Z9202 AL Performed by advanced practice nurse or certified nurse-midwife
1-Z9202 AJ Performed by social worker
1-Z9202 7C Performed by visiting nurse
Modifier Description
R5 Rural Health Clinic – Physician (MD/DO)
R6 Rural Health Clinic – Physicians Assistant
R7 Rural Health Clinic – Registered Nurse
R8 Rural Health Clinic – Advanced Nurse Practitioner
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Modifier Description
S-8000Y R5–R8 THSteps medical screen – normal
S-8004Y R5–R8 THSteps exception to periodicity – normal
S-8100Y R5–R8 THSteps medical screen – abnormal, treatment not necessary
S-8104Y R5–R8 THSteps exception to periodicity – abnormal treatment not necessary
S-8200Y R5–R8 THSteps medical screen – abnormal, treatment initiated
S-8204Y R5–R8 THSteps exception to periodicity – abnormal, treatment initiated
S-8300Y R5–R8 THSteps medical screen – abnormal, referred to primary care physician
S-8304Y R5–R8 THSteps exception to periodicity – abnormal, referred to primary care physician
S-8400Y R5–R8 THSteps medical screen – abnormal, referred to specialist
S-8404Y R5–R8 THSteps exception to periodicity – abnormal, referred to specialist
S-8500Y R5–R8 THSteps medical screen – abnormal, referred to other health agency
S-8504Y R5–R8 THSteps exception to periodicity – abnormal, referred to other health agency
S-8600Y R5–R8 THSteps medical screen – abnormal, condition under treatment
S-8604Y R5–R8 THSteps exception to periodicity – abnormal, condition under treatment
S-8700Y R5–R8 THSteps medical screen – referred to Family Planning
S-8704Y R5–R8 THSteps exception to periodicity – referred to Family Planning
No. 167 12 2002 FQHC/RHC Special Bulletin
The Family Planning and THSteps medical services that may be performed in an RHC setting are specifically identified in the following two tables and must be identified with one of the following modifiers (R5, R6, R7, or R8).
Informational THSteps Medical Procedures Performed in an RHC
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Modifier Description
1-Z9008 R5–R8 Family Planning annual visit-comp H&P, per provider
2-9000X R5–R8 Provide and insert implantable contraceptive capsules
2-X4562 R5–R8 Furnish and insert progestasert IUD (including cost of device)
2-X4563 R5–R8 Furnish and insert copper T 380-A IUD (including cost of device)
2-X4572 R5–R8 Furnish and insert copper T 380-A IUD (including cost of device)
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Modifier Description
S-32A0Y R5–R8 Administration of DTP #1
S-32B0Y R5–R8 Administration of DTP #2
S-32C0Y R5–R8 Administration of DTP #3
S-32D0Y R5–R8 Administration of DTP #4
S-32E0Y R5–R8 Administration of DTP #5
S-33A0Y R5–R8 Administration of OPV #1
S-33B0Y R5–R8 Administration of OPV #2
S-33C0Y R5–R8 Administration of OPV #3
S-33D0Y R5–R8 Administration of OPV #4 (do not give before age 4)
S-33E0Y R5–R8 Administration of OPV #5 (for children off current sch)
S-34A0Y R5–R8 Administration of DT/Td #1
S-34B0Y R5–R8 Administration of DT/Td #2
S-34C0Y R5–R8 Administration of DT/Td #3
S-34D0Y R5–R8 Administration of DT/Td #4
S-34E0Y R5–R8 Administration of DT/Td #5
S-35A0Y R5–R8 Administration of MMR #1
S-35B0Y R5–R8 Administration of MMR #2
S-36A0Y R5–R8 Administration of HibCV #1
S-36B0Y R5–R8 Administration of HibCV #2
S-36C0Y R5–R8 Administration of HibCV #3
S-36D0Y R5–R8 Administration of HibCV #4
S-37A0Y R5–R8 Administration of Hepatitis A
S-38A0Y R5–R8 Administration of Hepatitis B #1
S-38B0Y R5–R8 Administration of Hepatitis B #2
S-38C0Y R5–R8 Administration of Hepatitis B #3
S-41A0Y R5–R8 Administration of Td #1
S-42A0Y R5–R8 Administration of DTP/Hib #1
S-42B0Y R5–R8 Administration of DTP/Hib #2
S-42C0Y R5–R8 Administration of DTP/Hib #3
S-42D0Y R5–R8 Administration of DTP/Hib #4
S-43A0Y R5–R8 Administration of EIPV #1
S-43B0Y R5–R8 Administration of EIPV #2
S-43C0Y R5–R8 Administration of EIPV #3
S-43D0Y R5–R8 Administration of EIPV #4
2002 FQHC/RHC Special Bulletin 13 No. 167
Informational Family Planning Procedures Performed in an RHC
S-5498X R5–R8 Administration of pnemoncoccal conjugate vaccine, polyvalent
S-5743X R5–R8 Administration of varicella vaccine
S-5745X R5–R8 Administration of DTaP #1
S-5746X R5–R8 Administration of DTaP #2
S-5747X R5–R8 Administration of DTaP #3
S-5748X R5–R8 Administration of DTaP #4
S-5749X R5–R8 Administration of DTaP #5
S-3100Y R5–R8 Immunizations up-to-date
S-3101Y R5–R8 No immunization administered; medically contraindicated
S-3700Y R5–R8 No immunization administered; religious exemptions
S-3701Y R5–R8 No immunization administered; parent refusal or child uncooperative
S-1700Y R5–R8 Second newborn hereditary/metabolic testing – completed elsewhere
S-1701Y R5–R8 Second newborn hereditary/metabolic testing – completed this visit results pending
S-1702Y R5–R8 Second newborn hereditary/metabolic testing – normal
S-1703Y R5–R8 Second newborn hereditary/metabolic testing – abnormal
S-2500Y R5–R8 TB skin test administered this visit – results pending or patient did not return
S-2503Y R5–R8 TB questionnaire administered or TB skin test administered within past 11 months
S-2506Y R5–R8 TB skin test not administered – parent refusal or child uncooperative
S-8005Y R5–R8 THSteps follow-up visit – repeat laboratory work
S-8105Y R5–R8 THSteps follow-up visit – complete immunizations
S-8205Y R5–R8 THSteps follow-up visit – presumptive positive tuberculin skin test reaction
S-8305Y R5–R8 THSteps follow-up visit – other
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Modifier Description
2-11975 R5–R8 Insert only, implant contraceptive without capsule cost
2-11976 R5–R8 Remove only, implantable contraceptive capsules
2-11977 R5–R8 Remove with reinsertion only, implantable contraceptive capsules (not including the cost of the capsules)
1-4600Z R5–R8 Female condom (three individually packaged condoms, bottle of lubricant, and instructions)
2-4836X R5–R8 Furnish and fit diaphragm
2-4837X R5–R8 Furnish and fit cervical cap
2-58300 R5–R8 Insert intrauterine device (IUD) (not including cost of device)
2-58301 R5–R8 Remove intrauterine device (IUD)
1-J1055 R5–R8 Furnish and inject Depo Provera (DMPA, Depot-Medroxyprogesterone Acetate) 150 mg
1-Z0034 R5–R8 Vaginal contraceptive film (quantity 6)
1-Z0035 R5–R8 Spermicidal cream
1-Z0036 R5–R8 Spermicidal jelly
1-Z0037 R5–R8 Contraceptive suppository (each)
1-Z0038 R5–R8 Spermicidal foam
1-Z0039 R5–R8 Other medication for genital infection
1-Z0040 R5–R8 Oral contraceptives (one cycle)
1-Z0041 R5–R8 Cervical cap (supply only)
1-Z0042 R5–R8 Condoms (package of 12)
1-Z0043 R5–R8 Natural family planning supplies (calendar, charts, instruction book, thermometer)
Texas Health Steps (THSteps) Medical (2002 TMPPM Reference–Section 40)
Procedure Code Modifier Description
No. 167 14 2002 FQHC/RHC Special Bulletin
Contact your NHIC Provider Relations Training Specialist with questions. You can find your specific representative at www.eds-nhic.com\provenrl\imagemap.html. The final rules were published in the Texas Register on October 4, 2002.
1-Z0044 R5–R8 Contraceptive sponge (each)
1-Z0050 R5–R8 Initial client education
1-Z0051 R5–R8 Method-specific education/counseling
1-Z0052 R5–R8 Problem counseling
1-Z0053 R5–R8 Introduction to family planning in hospital setting/auspices
1-Z0054 R5–R8 Instruction in natural family planning methods (per session)
1-Z0055 R5–R8 Antimonilia medication for genital infection
1-Z0056 R5–R8 Diaphragm (supply only)
Family Planning (2002 TMPPM Reference–Section 19)
Procedure Code Modifier Description
2002 FQHC/RHC Special Bulletin 15 No. 167
NOTES:
ATTENTION: BUSINESS OFFICE
PRSRT STDUS POSTAGE
PAIDAUSTIN TX
PERMIT #156
Visit us online at www.eds-nhic.com for the following:
• Compass21 Frequently Asked Questions (FAQ)
• Medicaid Workshop Schedules and FAQs
• TDH-NHIC 2002 Publications—includes the 2002 Texas Medicaid Provider Procedures Manual, 2002 Texas Medicaid Service Delivery Guide, and Texas Medicaid Bulletins
• Regional Support—lists NHIC Training Specialists
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