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CSHCN Provider BulletinThe Children with Special Health Care Needs Services Program

May 2006

IN THIS EDITION

General InterestSave the Date ..........................................................................1New Medical Home Resources .............................................. 2

AdministrativeAdministrativeAdministrativCSHCN Provider Workshops ................................................ 2New Demographic Update Form on the TMHP Website ..... 3CMS-1500 Claims Submission Reminder .............................CMS-1500 Claims Submission Reminder .............................CMS-1500 Claims Submission Reminder 4Scheduled System Maintenance ............................................. 4Texas Medicaid Provider Enrollment Application Updated ... 4HCFA-1450 (UB-92) Code Requirements Updated ............. 5National Provider Identifi er Update ...................................... 6Transitional Approach to National Provider Identifi er

Implementation ...............................................................72006 Recommended Immunization Schedule ........................7Welcome to YourTexasBenefi ts.com ....................................... 8

Coding and ReimbursementNew Service Benefi ts ............................................................. 8New Procedure Codes Added for the CSHCN Services

Program .......................................................................... 9Benefi t Expansion for Therapeutic Apheresis ...................... 10Radiation Therapy Benefi ts Reprocessing .............................Radiation Therapy Benefi ts Reprocessing .............................Radiation Therapy Benefi ts Reprocessing 11Immune Globulin Benefi ts .................................................. 12Changes to Reimbursement ................................................. 13Benefi ts and Limitations Changes ........................................14Therapy Rate Changes for Independently

Practicing Physicians and Therapists ............................15RSV Prophylaxis Limitation Changed to Six Doses .............16TMHP-CSHCN Authorization/Prior

Authorization Reminder ................................................Authorization Reminder ................................................Authorization Reminder 16Reimbursement Reprocessing for Imaging Interpretation ....17

FormsRecommended Childhood Immunization Schedule ............ 18Electronic Funds Transfer .....................................................Electronic Funds Transfer .....................................................Electronic Funds Transfer 19Provider Information Change Form .....................................21

No. 58

Save the DateTh e Leadership Education in Adolescent Health (LEAH) Transition Conference, which is held annually in Houston, has been scheduled for November 2-3, 2006. Th e conference addresses issues of adolescents transitioning into adult medical care. Th e target audience for the conference includes physicians who work with children who have chronic illnesses and children with special health care needs including pediatricians, psychiatrists, internists, family physicians, physician assistants, nurses, social workers, psychologists, case managers, other health care professionals, and the children and their parents.

Th e LEAH training program is a specialized training program in adolescent health care that focuses on an interdisciplinary team approach to health care. LEAH is affi liated with the Adolescent Medicine and Sports Medicine Section of Baylor College of Medicine and is based at the Texas Children’s Hospital. Th e program stresses excellence in adoles-cent health and fi nding ways to meet the health care needs of adolescents. Th e program is funded by a grant from the Maternal Child Health Bureau (MHCB) under Title V. For more information, visit www.bcm.edu/pediatrics. Click on the Sections and Centers link. Click Adolescent Medicine and Sports Medicine. Th en select Leadership Educa-tion in Adolescent Health (LEAH) from the Educa-tion and Training link. ng link. ng

Watch for more information about the conference in the July issue of the CSHCN Provider Bulletin.

Current Procedural Terminology (CPT) is copyright 2006 American Medical Association (AMA), and the Current Dental Terminology (CDT) is copyright 2006 American Dental Association (ADA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT or CDT. Th e AMA and the ADA assume no liability for the data contained herein. Applicable Federal Acquisition Regulation System/Department of Defense Regulation System (FARS/DFARS) restrictions apply to government use.

Pub. No. E07-12276

New Medical Home Resources

When families and their doctors work together to make comprehensive care in the community a reality, this partnership is called a Medical Home. Th ere are new medical home resources for families and providers.

For FamiliesTexas Medical Home Toolkit. Th e toolkit was created Texas Medical Home Toolkit. Th e toolkit was created Texas Medical Home Toolkitthrough the collaboration of Texas Parent to Parent, the Texas Medical Home Workgroup, and the Texas Department of State Health Services (DSHS)-Chil-dren with Special Health Care Needs (CSHCN) Ser-vices Program. For more information, visit the Texas Parent to Parent website at www.txp2p.org.

For ProvidersSmall Steps, Big Diff erences, Th e Medical Home Part-nership. Developed by New England SERVE with practical tips for physicians, nurses, and offi ce staff . To obtain this brochure, go to www.medicalho-meinfo.org/states/Downloads/MA Info/Provider Brochure.pdf. Brochure.pdf.

CSHCN Provider Workshops

TMHP will be conducting Success with CSHCN work-shops beginning in July 2006. Information about the CSHCN workshops will be available on the TMHP webiste at www.tmhp.com beginning in June 2006.

To register for workshops and check seat availability, follow these steps:

1. Visit the TMHP website at www.tmhp.com.

2. Click the Register for a Workshop link in the“I would “I would “ like to…” menu on the right side of the page. Th e list of workshops currently available for registra-tion appears.

3. Click on the workshop name to see the schedule and available seating for a specifi c workshop series.

4. Enter a workshop registration user ID and password in the appropriate boxes to register for a workshop.

Click Login if this is an existing workshop regis-Login if this is an existing workshop regis-Logintration user ID.

Click Click Register and follow the instructions to Register and follow the instructions to Registercreate a workshop registration user ID if this is a create a workshop registration user ID if this is a new workshop registration user ID.new workshop registration user ID.

Th e next window includes a selection of workshops Th e next window includes a selection of workshops available for registration.available for registration.

5. Select a workshop and click 5. Select a workshop and click Listing.

6. Select the specifi c location.6. Select the specifi c location.

7. Confi rm the seat availability for this workshop on 7. Confi rm the seat availability for this workshop on the right side of the screen. the right side of the screen.

8. Enter the number of attendees to be registered in the 8. Enter the number of attendees to be registered in the fi eld at the bottom of the screen. Only one partici-fi eld at the bottom of the screen. Only one partici-pant will be registered if the number of attendees is pant will be registered if the number of attendees is not changed.not changed.

9. Click Sign UpSign Up.

Th e next screen confi rms the registration and provides Th e next screen confi rms the registration and provides a direct link to a map of the workshop location. If the a direct link to a map of the workshop location. If the workshop registration user ID profi le contains an email workshop registration user ID profi le contains an email address, a confi rmation email will be sent. address, a confi rmation email will be sent.

For more information or help with the registration For more information or help with the registration process, call the TMHP-CHSCN Contact Center at process, call the TMHP-CHSCN Contact Center at 1-800-568-2413. 1-800-568-2413.

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CSHCN Bulletin, No. 58 2 May 2006CSHCN Bulletin, No. 58 2 May 2006

General Interest/Administrative

New Demographic Update Form Available Online

Important: Th e DU Form can only be accessed through the secure pages of the TMHP website. Providers must create a provider administrator account to access these secure functions. Nonadministrator users must be assigned by the provider administrator. Only providers or their authorized representatives can access the provider administrator accounts to obtain and complete the DU Form. It is the responsibility of each provider to administer the accounts associated with their Texas Provider Identifi ers (TPIs).

DU Form Instructions

To access the DU Form:

1. Log on to the TMHP website at www.tmhp.com.

2. On the homepage, click the My Account link. Enter My Account link. Enter My Accounta user ID and password in the appropriate boxes. Th e Change/Verify Address Information page opens. At the prompt, verify the accuracy of the following address information by clicking on the Yes or Noradio button:

Physical

Mailing

Secondary (this will appear if the information is in the provider’s fi le)

3. If the Yes radio button is clicked, the DU Form does not appear, and the provider can proceed through the website.

4. If the No radio button is clicked, the system proceeds to the DU Form.

5. Th e provider must complete all of the required fi elds on the DU Form before it can be printed.

6. Upon completion of the DU Form, the provider must print the form and send the DU Form and any required documentation to the TMHP address that is listed on the form.

7. Providers should keep a copy of the completed DU Form for their records.

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

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Beginning April 16, 2006, the new Provider Demo-graphic Update (DU) Form will be available on the TMHP website at www.tmhp.com. Providers may use either the DU Form or the current Provider Informa-tion Change (PIC) Form, which is available in the 2006 CSHCN Provider Manual—Part I, to update their address CSHCN Provider Manual—Part I, to update their address CSHCN Provider Manual—Part Iinformation.

Please note the proper usage of each form:

Th e DU Form is only used to make changes to provider addresses on fi le with TMHP.

Th e PIC Form has been revised. Providers should use the PIC Form to update physical or mailing addresses, telephone numbers, names, a tax identifi cation num-ber (TIN), provider status, and other provider infor-mation on fi le with the Texas Medicaid and CSHCN Services Programs. Traditional Medicaid providers who are enrolled with Medicare can change a physical address with the PIC Form and a copy of the Medi-care letter that confi rms the physical address has been updated with Medicare. To change a mailing address, submit a completed W9 form with the PIC Form. Beginning February 1, 2006, providers must use the revised PIC Form that is available on page 21 of this bulletin and on the TMHP website. Click on the title of the form to access it.

Providers must immediately notify TMHP Provider Enrollment, in writing, of changes to their address (physical location or accounting), telephone number, name, ownership status, TIN, and any other informa-tion about the structure of the provider’s organization. Failure to notify TMHP of changes adversely aff ects claims processing and payment.

Providers can use the DU Form on the website at any time. Providers will be prompted to verify their address(es) and make any necessary changes once a year when accessing a secure page on the TMHP website. After the update has been completed, the form can be faxed to 1-512-514-4214, or mailed to the address below for processing.

Texas Medicaid & Healthcare PartnershipProvider Enrollment

PO Box 200795Austin, TX 78720-0795

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May 2006 3 CSHCN Bulletin, No. 58May 2006 3 CSHCN Bulletin, No. 58May

Administrative

trator accounts must be assigned by the TPI adminis-trator. Billing services and clearinghouses are required to obtain access to protected health information through the appropriate administrator of each TPI/provider number for which they are contracted to provide services.

Providers may continue to submit and appeal claims to TMHP electronically through TDHconnect or submit a paper claim. All claims and fi le transmission records must continue to be retained onsite.

TMHP is in the process of developing additional enhancements and functionality to its website. Review upcoming bulletin articles and banner messages for information on these developments.

For more information, visit the TMHP website at www.tmhp.com, or call the TMHP-CSHCN Contact Center at 1-800-568-2413.

CMS-1500 Claims Submission

Scheduled System Maintenance

System maintenance to the TMHP claims processing system is scheduled for:

Sunday, May 28, 2006, 3 p.m., through Monday, May 29, 2006, 6 p.m.

Sunday, June 11, 2006, 6 p.m. to 11:59 p.m.

Sunday, July 9, 2006, 6 p.m. to 11:59 p.m.

Sunday, August 13, 2006, 6 p.m. to 11:59 p.m.

During system maintenance, some of the secure pages of the website will be unavail-able. Specifi c details about the aff ected features are posted on the TMHP website at www.tmhp.com.

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TMHP, in partnership with the Texas Health and Human Services Commis-sion (HHSC), has recently enhanced the TMHP website at www.tmhp.com to allow CMS-1500 claim submissions and appeals. Th is function-

ality allows the submission and appeal of professional Texas Medicaid, Medicaid Managed Care, and CSHCN Services Program claims that do not require attachments and are not in a zero allowed, zero paid, status. Claims are submitted and appealed over secure pages of the TMHP website.

Security RequirementsProviders are required to register at www.tmhp.com and assign an administrator(s) for each TPI (if not already assigned). Users confi gured with administrator rights will automatically have permission to submit claims electronically. Submissions privileges for nonadminis-

Texas Medicaid Provider Enrollment Application Updated

Th e Texas Medicaid Provider Enrollment Application has been revised. Eff ective February 10, 2006, TMHP began returning all applications not submitted on the new enrollment application. Th e revised enroll-ment application is available on the TMHP website at www.tmhp.com.

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

Getting Help

TMHP-CSHCN Contact Center agents are avail-able from 7 a.m. to 7 p.m., Monday through Friday to verify client eligibility, research claims, and provide general program information. Th e TMHP-CSHCN Contact Center telephone number is 1-800-568-2413.

CSHCN Bulletin, No. 58 4 May 2006

Administrative

HCFA-1450 (UB-92) Code Requirements Updated

TMHP and HHSC have updated all of the code requirements that are necessary for claims processing on the HCFA-1450 (UB-92) claim form. Th e codes will become eff ective on May 28, 2006. Th is information updates the HCFA-1450 (UB-92) Instruction Table located on page C-7 of the 2006 CSHCN Provider Manual —Part I. CSHCN Provider Manual —Part I. CSHCN Provider Manual —Part I

Following are the updated codes:

Block No. Description Updated Code Information19 Type of admis-

sion 5 Trauma Center

22 Patient status 9 Admitted as an inpatient to this hospital

40 Expired at home (hospice use only)

41 Expired in a medical facility (hospice use only)

42 Expired—place unknown (hospice use only)

43 Discharged/transferred to a federal hospital

50 Hospice—home

51 Hospice—medical facility

61 Discharged/transferred within this institution to hospital-based Medicare approved swing bed

62 Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital

63 Discharged/transferred to a Medicare-certifi ed long term care hospital (LTCH)

64 Discharged/transferred to a nursing facility certifi ed under Medicaid but not certifi ed under Medicare

65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

66 Discharged/transferred to a critical access hospital (CAH)36 Occurrence

span codes and dates

For inpatient claims, enter code 71 if this hospital admission is a readmission within seven days of a previous stay. Enter the dates of the previous stay.

84 Remarks Request for 110-day rule for third party insurance

Following are the updated occurrence codes:

Occurence Code Description Updated Occurrence Code Information11 Onset of symptoms Indicate the date the patient fi rst became aware of the symptoms or

illness being treated.

Th is code should replace code 52 for onset of renal dialysis.50 Date other insur-

ance paidDiscontinued


Administrative

Occurence Code Description Updated Occurrence Code Information51 Date claim fi led

with other insur-ance

Discontinued

52 Date renal Dialysis Initiated

Discontinued

Occurrence codes 50 through 52 have been discontinued by the National Uniform Billing Committee (NUBC).

Complete Blocks 50 through 55 to indicate a client’s other insurance payment information.

To request the consideration of payment using the 110-day rule, complete the insurance payment information in Blocks 50 through 55, and state the request of the 110-day rule in the Block 84 (Remarks).


National Provider Identifi er UpdateAs reported in the August 2005 CSHCN Provider Bulletin, No. 55, the United States Department of Health and Human Services (HHS) published the fi nal National Provider Identifi er (NPI) rule in January 2004. Th e rule adopts the NPI as the standard unique identifi er for health care providers. All entities meeting the defi nition of health care provider, as described in the 45 Code of Federal Regulations 45 Code of Federal Regulations 45 Code (CFR) §160.103, can apply for an NPI. Covered entities that meet the defi ni-tion for health care providers will be required to obtain and use the NPI in standard transactions by the compli-ance date of May 23, 2007. On this date, the Texas Medicaid and CSHCN Services Programs, other health plans, and health care clearinghouses must begin using NPIs to identify providers on standard electronic trans-actions. Health care providers and plans may also use NPIs on paper transactions. An individual health care provider should not have more than one NPI. Health plans may not require enumerated providers to obtain additional NPIs.

Providers and health care plans may begin transition to the NPI by applying for the identifi er a full two years before the compliance date. However, covered entities that receive their NPI cannot use the NPI to bill Texas Medicaid and the CSHCN Services Programs until directed to do so by the state. If these entities use the NPI before the state’s claims payment system is modifi ed to accept it, their claims may be rejected or denied. If an

entity does not meet the defi nition of a “health care provider,” as described in the 45 CFR §160.103, it can apply for an NPI. However, there is no requirement for noncovered providers to obtain or use the NPI. Health care clearinghouses cannot require noncovered providers to obtain an NPI and must accommodate legacy identi-fi ers. If an entity does not meet the defi nition of “health care provider” under the Health Insurance Portability and Accountability Act (HIPAA), they will not be eligible to receive an NPI.

Until given further direction by the CSHCN Services Program, health care providers and clearinghouses should do the following:

Become informed about the NPI and its implementation

Identify processes and systems that are aff ected by provider identifi ers

Develop implementation plans

Educate staff

Continue to use TPI numbers until notifi ed that an NPI will be accepted on Texas Medicaid claims

For more information, including directions on how to apply for an NPI, visit the CMS website at www.cms.hhs.gov/hipaa/hipaa2.

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Administrative

Transitional Approach to National Provider Identifi er Implementation

TMHP and HHSC are currently implementing a transition strategy to prepare providers for tran-sition to NPI. Th is tran-sition strategy will allow submission of both the legacy provider numbers (i.e., TPI, universal provider identifi er number

[UPIN], and TIN) and the NPI on standard electronic transactions and will allow the state to collect data from providers before the NPI compliance date of May 23, 2007. Th is strategy is transitional and only permissible until the compliance date. Afterward, legacy identi-fi ers other than required federal TINs must be discon-tinued. Eff ective May 23, 2007, in fi elds where the NPI is required, only the NPI may be used to identify a provider.

Th e strategy for the dual use of NPI and legacy iden-tifi ers was originally proposed by the Workgroup for Electronic Data Interchange (WEDI) in a white paper entitled “Dual Use of NPI and Legacy Identifi ers.entitled “Dual Use of NPI and Legacy Identifi ers.entitled “ ” Th e white paper, dated May 31, 2005, is available online at www.wedi.org/cmsUploads/pdfUpload/WhitePaper/pub/WEDISNIPNPIDualIdentifi ers_FINAL.pdf.

Texas Medicaid and CSHCN providers will be permitted to submit NPIs and taxonomy codes through

the following mechanisms:

HIPAA-compliant Claim Transactions (837 Institu-tional, 837 Professional, and 837 Dental) Providers will be able to submit their NPIs with taxonomy codes and their TPIs on all electronic claim transactions. Providers should verify with their soft-ware vendors the availability of fi elds for the NPI and taxonomy codes. TDHconnect will only be upgraded to accept the NPI for Long Term Care (LTC) providers.

HIPAA-compliant Eligibility Transactions (270) Providers will be able to submit both their NPI and TPI on all electronic eligibility transactions. Providers should verify the availability of fi elds for the NPI with their software vendors. TDHconnect will only be upgraded to accept the NPI for LTC providers.

During the dual-use transition period, providers will not receive an electronic rejection if the taxonomy code does not match the provider type or specialty that is on fi le for the provider’s TPI.

During the dual-use transition period, paper billers must continue to use the TPI in appropriate fi elds on paper claim forms. Paper claims with NPIs will be denied. Further information regarding paper claim submissions and the NPI as it relates to the May 23, 2007, imple-mentation of NPI will be published in the future.


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2006 Recommended Immunization Schedule

Th e Centers for Disease Control and Prevention (CDC) Recommended Childhood and Adolescent Immu-nization Schedule indicates the recommended age for the routine administration of currently licensed child-hood vaccines. Th e new schedule is approved by the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). Some combination vaccines are available and may be used when any component of the combination is indicated, and its other components are not contraindicated. Providers should consult the manufacturer’s package insert for detailed recommendations. See the 2006 schedule on page 18 of this bulletin. Th e new schedule can also be downloaded from the CDC website at www.cdc.gov/nip/recs/childschedule. pdf.


Administrative

Welcome to YourTexasBenefi ts.com

HHSC has launched a website at www.yourtexas-benefi ts.com, available in English and Spanish, to provide easy and secure online access to HHSC benefi ts including Medicaid, Food Stamps, Temporary Assistance for Needy Families (TANF), Children’s Health Insurance, nursing home care, and services for people who are elderly or have disabilities.

Please note that screening and applications for the CSHCN Services Program are not available through YourTexasBenefi ts.com, but the website provides access to benefi ts and other services anytime, anywhere. Use the website to:

Screen whether a person may qualify to receive benefi ts

Apply for benefi ts

Check the status of an application

Review current benefi ts

Get answers to frequently asked questions

Find a nearby HHSC benefi ts offi ce

Get referrals to other programs that provide assistance, such as child care, transporta-tion, child support, help with utilities or rent, fi nding work, etc.

For additional help, call the health and human services information line at 2-1-1 between 8 a.m. and 8 p.m., Central Time, Monday through Friday, excluding state holidays. (Ellos hablan español.)

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New Service Benefi ts

Transthoracic and Transesophageal Echocardiograph Eff ective for dates of services on or after December 1, 2005, procedure code 93325 is considered for reim-bursement separately from transthoracic and trans-esophageal echocardiograph procedure codes 93312 and 93350 when billed on the same date of service by the same provider.

New Benefi ts for EchoencephalographyEff ective for dates of services on or after December 1,2005, procedure code 76506 is a benefi t of the CSHCN Services Program when billed with diagnosis codes 78420 (Swelling, mass, or lump in head and neck) and 95901 (Injury, other, head, face, and neck).

Hepatitis Vaccination Eff ective for dates of services on or after December 1, 2005, hepatitis vaccination procedure codes 90632 and 90636 are a benefi t of the CSHCN Services Program.

DME Supplies ReimbursedProviders may be reimbursed for durable medical equipment (DME) supplies related to the rental of an insulin pump. DME supplies should be listed individ-ually on the claim for reimbursement consideration.

If a patient requires more than the amounts listed in the following table, the provider should submit docu-mentation of medical necessity with the appeal:

Procedure Code Limitation9-A4250 2 boxes per month9-A4253 4 boxes per month9-A4254 2 per year9-A4256 2 per year9-A4258 2 per year9-A4259 2 boxes per month9-A9150 1 per 6 months

Insulin Pump SuppliesEff ective for dates of service on or after December 1, 2005, the following insulin pump supply proce-dure codes are now benefi ts of the CSHCN Services


Administrative\Coding and Reimbursement

Program and may be reimbursed separately when billed with an insulin pump.

Th e insulin pump supply procedure codes are limited to the following amounts:

Procedure Code LimitationA4230 10 per monthA4231 15 per monthA4232 10 per monthA4632 1 per month

Proton Beam Therapy Eff ective for dates of service on or after March 1, 2006, proton beam therapy procedure codes 77520 through 77525 are now considered for reimbursement when submitted with diagnosis code 1943 (Malignant neoplasm of other endocrine glands and related struc-tures, pituitary gland, and craniopharyngeal duct) for the CSHCN Services Program.

Th ese procedure codes require prior authorization with documentation of medical necessity.

Behavioral Health Services Diagnosis CodesEff ective for dates of service on or after April 1, 2005, the following diagnosis codes are payable for outpa-tient behavioral health procedure codes 90801, 90802, 90804 through 90815, 90845, 90847, 90853, 90857, 90862, and 90865:

Diagnosis Codes290–29390 294–29490 295–29990300–30290 3039–30503 3052–305833059–30593 308–31010 311–314909955–99559 9958–99585 V11–V1190V17–V1700 V40–V4090 V6121V6281–V6289 V7101–V7102 V7109V79–V7990

Magnetic Resonance Angiography of the Pelvis Eff ective for dates of service on or after November 1, 2005, magnetic resonance angiography (MRA) proce-

dure code 72198 is now a benefi t of the CSHCN Services Program.

Additionally, diagnosis restrictions have been removed from MRA head and neck procedure codes 70544 through 70549.

Diagnosis restrictions have also been removed from MRA of the chest, procedure code 71555; MRA of the abdomen, procedure code 74185; and MRA of the lower extremities, procedure code 73725.

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

New Procedure Codes Added for the CSHCN Services Program

Eff ective for dates of service on or after November 16, 2005, the following procedure codes are benefi ts of the CSHCN Services Program.

Procedure Code AllowableC9224 1 = $1,621.74 C9225 1 = $19,600.50 Q4080 1 = $31.52 S2075 F = Group 4S2075 2 = 18.19 RVUS2076 F = Group 9S2076 2 = 10.89 RVUS2077 F = Group 7S2077 2 = 7.19 RVUS2114 F = Group 3S2114 2 = 27.96 RVUS2117 F = Group 4S2117 2 = 21.68 RVURVU = Relative value unit



Coding and Reimbursement

Benefi t Expansion for Therapeutic Apheresis

Eff ective for dates of service on or after March 1, 2006, the following diagnosis codes are payable for therapeutic apheresis procedure codes 36511, 36512, 36513, and 36514:

Diagnosis Code Description20310–20381 Other immunoproliferative neoplasms20400–20401 Acute lymphoid leukemia20410–20411 Chronic lymphoid leukemia20420–20421 Subacute lymphoid leukemia20480–20481 Other lymphoid leukemia20490–20491 Unspecifi ed lymphoid leukemia20500–20501 Acute myeloid leukemia20510–20511 Chronic myeloid leukemia20520–20521 Subacute myeloid leukemia20530–20531 Myeloid sarcoma20580–20581 Other myeloid leukemia20590–20591 Unspecifi ed myeloid leukemia20600–20691 Monocytic leukemia20700–20781 Other specifi ed leukemia20800–20891 Leukemia of unspecifi ed cell type2384 Polycythmia vera, primary2387 Idiopathic thrombocythemia2720 Familial homozygous hypercholesterolemia2730, 2731, and 2733 Disorders of plasma protein metabolism28262 Sickle cell crisis2828 Other specifi ed hereditary hemolytic anemias2830 Autoimmune hemolytic anemias2848 Pure red cell aplasia2863 Factor XIII antibodies defi ciency2870–2879 Purpura and other hemorrhagic conditions2890 Secondary polycythemia28951 Chronic congestive splenomegaly28952 Splenic sequestration2896 Familial polycythemia2897 Methemoglobinemia28981 Primary hypercoagulable state28989 Other specifi ed diseases of the blood and blood forming organs2899 Unspecifi ed diseases of blood and blood-forming organs35640 Chronic relapsing polyneuropathy (CIDP)3570–3578 Infl ammatory and toxic neuropathy390 Rheumatic fever without heart involvement3918 Rheumatoid vasculitis



Diagnosis Code Description44620 Hypersensitivity angiitis, unspecifi ed44629 Other specifi ed hypersensitivity angiitis4466 Th rombotic thrombocytopenia purpura570 Acute and subacute necrosis of liver5718 Other chronic nonalcoholic liver5724 Hepatorenal syndrome5731 Hepatitis in viral diseases classifi ed elsewhere5732 Hepatitis in other infectious diseases classifi ed elsewhere5733 Hepatitis unspecifi ed57431 Calculus of bile duct with acute cholecystitis with obstruction57441 Calculus of bile duct with other cholecystitis with obstruction5800 Acute glomerulonephritis with lesion of proliferative glomerulonephritis5804 Acute glomerulonephritis with lesion of rapidly progressive glomerulonephritis5810–5819 Nephrotic syndrome5820–5824 Chronic glomerulonephritis5830–5839 Nephritis and nephropathy, not specifi ed as acute or chronic701 Circumscribed scleroderma7101 Systemic sclerosis7103 Dermatomyositis7104 Polymyositis71430–71439 Juvenile rheumatoid arthritis7141 Felty’s syndrome 7142 Other rheumatoid arthritis with visceral or systemic involvement


Radiation Therapy Benefi ts Reprocessing

Eff ective for dates of service on or after April 1, 2001, the following procedure codes became a benefi t of the CSHCN Services Program when performed by physicians, radiation treatment centers, hospitals, radiological labs, and physiology labs in an inpatient or outpatient hospital setting: 6-77300 allowable fee (relative value unit [RVU] 2.42), 6-77305 allowable fee (RVU 3.10), 6-77310 allowable fee (RVU 4.14), 6-77315 allowable fee (RVU 5.33), 6-77326 allowable fee (RVU 4.01), 6-77327 allowable fee (RVU 5.93), 6-77328 allowable fee (RVU 8.61), 6-77332 allowable fee (RVU 2.31), 6-77333 allowable fee (RVU 3.35), 6-77334 allowable fee (RVU 5.43), and 6-77399 allowable fee ($5.01).

Procedure codes 6-77520, 6-77522, 6-77523, and 6-77525 are manually reviewed to determine pricing.

Claims submitted for dates of service on or after April 1, 2003, through April 14, 2006, that include these procedure codes are being reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary. For more information, call the TMHP -CSHCN Contact Center at 1-800-568-2413.

May 2006 11May 2006 11May CSHCN Bulletin, No. 58


Immune Globulin Benefi ts

Eff ective for dates of service on or after May 1, 2006, procedure codes 90281, 90283, J1460, J1470, J1480, J1490, J1500, J1510, J1520, J1530, J1540, J1550, J1560, J1566, and J1567 will be limited to the following diagnosis codes:

Diagnosis Code Description042 Human immuno virus dis20410 Chronic lymphocytic leukemia2387 Lymphoproliferative disease, NOS27789 Other specifi ed disorders of metabolism27900 Disorders involving the immune mechanism; hypogammaglobulinemia, unspecifi ed27901 Disorders involving the immune mechanism; selective IgA immunodefi ciency27902 Disorders involving the immune mechanism; selective IgM immunodefi ciency27903 Disorders involving the immune mechanism; other selective immunoglobulin defi ciencies27904 Disorders involving the immune mechanism; congenital hypogammaglobulinemia27905 Disorders involving the immune mechanism; immunodefi ciency with increased IgM27906 Disorders involving the immune mechanism; common variable immunodefi ciency27909 Disorders involving the immune mechanism; other27910 Immunodefi ciency with predominant T-cell defect, unspecifi ed27911 DiGeorge’s syndrome27912 Wiskott-Aldrich syndrome27913 Nezelof’s syndrome27919 Other, defi ciency of cell-mediated immunity2792 Combined immunity defi ciency2793 Unspecifi ed immunity defi ciency2794 Autoimmune disease, not elsewhere classifi ed2840 Congenital aplastic anemia28730 Primary thrombocytopenia, unspecifi ed28731 Immune thrombocytopenic purpura28732 Evans’ syndrome28733 Congenital and hereditary thrombocytopenic purpura28739 Other primary thrombocytopenia3348 Spinocerebellar disease nec340 Multiple sclerosis34541 Partial epilepsy, with impairment of consciousness with intractable epilepsy3530 Brachial plexus lesions3570 Acute infective polyneuritis (Guillain-Barre Syndrome)35781 Chronic infl ammatory demyelinating polyneuritis35782 Critical illness polyneuropathy35800 Myasthenia gravis without (acute) exacerbation



Diagnosis Code Description35801 Myasthenia gravis with (acute) exacerbation3929 Rheumatic chorea without mention of heart involvement4461 Acute febrile mucocutaneous lymph node syndrome5855 Chronic kidney disease (CKD), stage V5856 End stage renal disease5859 Chronic kidney disease (CKD), unspecifi ed (chronic renal disease, chronic renal failure

NOS, chronic renal insuffi ciency)586 Renal failure, unspecifi ed7103 Dermatomyositis7140 Rheumatoid arthritis79579 Other and unspecifi ed nonspecifi c immunological fi nding9895 Toxic eff ect venomV0179 Contact or exposure to other viral diseasesV0189 Contact with or exposure to communicable disease; other communicable diseasesV0260 Viral hepatitis, carrierV08 Asymptomatic HIV infection statusV4281 Organ or tissue replaced by transplant; other specifi ed organ or tissue; bone marrowV4282 Organ or tissue replaced by transplant; other specifi ed organ or tissue; peripheral stem cellsV4283 Organ or tissue replaced by transplant; other specifi ed organ or tissue; pancreasV4284 Organ or tissue replaced by transplant; other specifi ed organ or tissue; intestinesV4289 Organ or tissue replaced by transplant; other specifi ed organ or tissue; other

Additionally, procedure codes 90281, 90283, J1566, and J1567 no longer require authorization.


Changes to Reimbursement

Neurostimulator Benefi ts Article CorrectionTh e following is a correction to the article entitled “Change to Neurostimulator Benefi ts,” that was published on page 16 of the February 2006 CSHCN Provider Bulletin, No. 57.

Reimbursement and benefi t changes for neurostimulator procedures and devices were not implemented for dates of service on or after February 1, 2006. HHSC and the CSHCN Services Program will provide additional information about neurostimulator benefi t changes at a future date.

Rate Reduction for ECGsEff ective for dates of service on or after January 20, 2006, procedure code 93272 is now considered a benefi t of the CSHCN Services Program when billed with modifi er 26. Th e reimbursement rate was reduced to 0.73 RVUs. No action on the part of the provider is necessary.



Reimbursement Increase for Procedure Code J2503Eff ective for dates of service on or after January 1, 2006, the CSHCN Services Program fee for procedure code J2503 was increased from $101.49 to $1,014.90.

Claims submitted for dates of service January 1, 2006, through February 3, 2006, that included this proce-dure code were reprocessed. No action on the part of the provider is necessary.

Benefi ts and Limitations Changes

Bacillus Calmette-Guerin (BCG) Vaccine Eff ective for dates of service on or after March 1, 2006, procedure code 1-90586 is no longer a benefi t to outpa-tient hospitals and home health agencies for the CSHCN Services Program.

RSV Globulin Injections Eff ective for dates of service on or after December 16, 2005, procedure code 1-J1565 is no longer a benefi t of the CSHCN Services Program.

Emergency Services Provided in the Offi ce Eff ective for dates of service on or after March 10, 2006, procedure code 99058 is no longer a benefi t of the CSHCN Services Program.

Authorizing Durable Medical EquipmentProviders who request authorization or prior authori-zation for DME that exceeds $1000.00 must provide supporting documentation that indicates a less expensive DME does not exist.

If the DME can be provided at a lower rate, then docu-mentation must be submitted to TMHP-CSHCN clearly stating why the less expensive alternative does not meet the CSHCN client’s needs. Include the required documentation with each DME request for authoriza-tion or prior authorization.

Polysomnography and Multiple Sleep Latency Test Eff ective for dates of service on or after February 1, 2006, the CSHCN Services Program fees have been reduced for the following procedure codes:

Procedure Code Original Fees Reduced FeesI-95808 $5.02 $3.70I-95810 $5.96 $4.87I-95811 $6.36 $5.24

Claims submitted with dates of service on or after February 1, 2006, that include these procedure codes will not be reprocessed. No action on the part of the provider is necessary.

Radiopharmaceutical Pricing ChangesEff ective for dates of service on or after March 1, 2006, the CSHCN Services Program allowable fees have changed for the following radiopharmaceuticals proce-dure codes:

Procedure Code Allowable A9500 $108.89A9502 $112.46A9503 $37.40A9504 $380.38A9505 $29.73A9507 $2518.99A9600 $862.01A9605 $1214.91

Infusion Pump Procedure Codes Incorrectly ReducedEff ective December 1, 2003, through October 21, 2005, procedure codes B9000 and B9002 were incorrectly reduced by 2.5 percent for claims with eff ective dates of service on or after December 1, 2003.

Claims submitted between December 1, 2003, and October 21, 2005, that included these procedure codes were reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.



Therapy Rate Changes for Independently Practicing Physicians and Therapists

Eff ective for dates of service on or after January 1, 2006, the allowable fee for physical, occupational, and speech therapy changed for independently practicing physicians and therapists enrolled with the CSHCN Services Program.

Th e new allowable fees are:

Procedure Code Allowable92506 $210.00 per evaluation92507 $70.00 per 30 minutes92508 $35.00 per 30 minutes92526 $35.00 per 15 minutes92610 $210.00 per evaluation97001 $140.00 per evaluation97002 $140.00 per evaluation97003 $140.00 per evaluation97004 $140.00 per evaluation97012 $35.00 per 15 minutes97014 $35.00 per 15 minutes97016 $35.00 per 15 minutes97018 $35.00 per 15 minutes97022 $35.00 per 15 minutes97024 $35.00 per 15 minutes97026 $35.00 per 15 minutes97028 $35.00 per 15 minutes97032 $35.00 per 15 minutes97033 $35.00 per 15 minutes97034 $35.00 per 15 minutes97035 $35.00 per 15 minutes97036 $35.00 per 15 minutes97039 $35.00 per 15 minutes97110 $35.00 per 15 minutes97112 $35.00 per 15 minutes97113 $35.00 per 15 minutes97116 $35.00 per 15 minutes97124 $35.00 per 15 minutes*Procedure codes added as part of the 2006 Healthcare Common Procedure Coding System (HCPCS) annual update.

Procedure Code Allowable97139 $35.00 per 15 minutes97140 $35.00 per 15 minutes97150 $17.50 per 15 minutes97530 $35.00 per 15 minutes97535 $35.00 per 15 minutes97537 $35.00 per 15 minutes97542 $35.00 per 15 minutes97750 $35.00 per 15 minutes97760* $35.00 per 15 minutes97761* $35.00 per 15 minutes97762* $35.00 per 15 minutes97799 $35.00 per 15 minutes*Procedure codes added as part of the 2006 Healthcare Common Procedure Coding System (HCPCS) annual update.

On January 13, 2006, TMHP implemented the 2006 HCPCS additions, changes, and deletions that became eff ective for dates of service on or after January 1, 2006. Claims submitted for these new procedure codes for dates of service on or after January 1, 2006, through January 12, 2006, may have been denied. Providers can appeal these claims.

Eff ective for dates of service on or after January 1, 2006, procedure codes 97020, 97504, 97520, and 97703 were deleted as a result of the 2006 HCPCS annual update. Procedure code 97020 is now included as part of proce-dure code 97024.




TMHP-CSHCN Authorization/Prior Authorization Reminder

Authorization is a condi-tion for reimbursement. It is not a guarantee of payment. Each provider must be enrolled, eligible, and must verify client eligibility. Any services provided while the client is not eligible, or services provided beyond the

limitation of the CSHCN Services Program are not reimbursed.

TMHP sends a notifi cation letter to clients when an authorization approval, denial, or reduction in a requested services letter is sent to their provider. Refer to the specifi c provider sections of the 2006 CSHCN Provider Manual—Part I for more details on the Provider Manual—Part I for more details on the Provider Manual—Part Iservices that require authorization or prior authoriza-tion. A fax transmittal of confi rmations and registered mail receipts are not accepted as proof of a timely authorization submission.

An authorization is a request that is submitted to the program to provide a service that the program may consider for reimbursement. Th e request must be submitted on a program-approved form and must contain all of the information that is necessary for the program to make a determination of coverage. Th e request may be submitted before the service is provided, but it must not be received by the program more than 90 days after the date that the service was provided. If the service has already been provided, the authorization form may be attached to the claim, provided that it is received within the 90-day deadline. Only complete authorization requests will be accepted by the program. No extensions beyond the 90-day initial deadline will be given to providers to correct incomplete authorization requests. Th e 90-day dead-line applies to all of the services that require authoriza-tion (not prior authorization, including extensions and emergency situations).

RSV Prophylaxis Limitation Changed to Six Doses

Eff ective for dates of service on or after October 1, 2005, Respiratory Syncytial Virus (RSV) prophylaxis injections were covered without prior authorization for up to six doses within the RSV season. Th is is a policy change that aff ects procedure code 90378 for both the Texas Medicaid and the CSHCN Services Programs.

RSV prophylaxis injections must be prior authorized under certain circumstances (e.g., for certain diagnoses, for dates of service outside the months of October through March, for more than six doses in a season).

Claims submitted for dates of service on or after October 1, 2005, through March 1, 2006, that were denied for the sixth dose of RSV prophy-laxis must be resubmitted to be considered for payment.

Providers are reminded that prophylaxis against RSV is only medically indicated when there is widespread RSV activity in a region or commu-nity. Th e latest statewide Texas RSV surveil-lance data indicates that in most, if not all, regions of the state, the season of widespread RSV activity likely ended by mid to late March 2006. Th erefore, providers should not provide RSV prophylaxis beyond the end of March, unless there is evidence of continued wide-spread RSV activity in their region or commu-nity. Th e Texas Department of State Health Services maintains a summary of the statewide data on the website at www.dshs.state.tx.us. Providers can also contact their local labora-tories for data on the status of RSV activity in their region or community.




Services Program for an inpatient prior authorization to be considered.

Providers must mail or fax written authorization requests, along with all other applicable documentation, to:

Texas Medicaid & Healthcare PartnershipATTN: CSHCN Authorizations, MC-A11

12357-B Riata Trace ParkwayAustin, TX 78727

Fax: 1-512-514-4222

Providers must mail or fax written prior authorization requests, along with all other applicable documentation, to:

Texas Medicaid & Healthcare PartnershipATTN: CSHCN Authorizations, MC-1938

12357-B Riata Trace ParkwayAustin, TX 78727

Fax: 1-512-514-4222

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

Incomplete authorization requests or claims for services that require authorization, but that are submitted without an attached authorization form or all of the required documentation, are denied. Th ey are only reconsidered when resubmitted and received by the program and by the 90-day authorization deadline. Requests to extend the deadline beyond 90-days from the date of service will not be considered.

A prior authorization is a request that is submitted to the program to provide a service the program may consider for reimbursement. Th e request must be submitted on a program-approved form and must contain all of the information that is necessary for the program to make a determination of coverage. Prior authorization must be obtained before the delivery of the service; however, when the service is provided after hours or on a TMHP-recognized holiday or weekend, services may be prior authorized when authorization is requested on the next working day. A complete form must be received according to these deadlines for prior authorization to be considered. Th e program does not

extend these deadlines to allow providers to correct and resubmit incom-plete prior authorization requests.

Incomplete prior authori-zation requests are denied and are reconsidered only when completed and received by the program before the service is provided. Th e prior

authorization requirement may be waived if the client’s eligibility has not been determined before the request is received by TMHP. Claims for these services must be received within 95 days of the eligibility add date.

All inpatient admission/stays or inpatient rehabilita-tion admissions, including extensions of any previously authorized inpatient stays, must be prior authorized. Th e request may be submitted by the hospital, provided that all of the required information indicating inpa-tient admission is on the request form. Both the facility and the physician must be enrolled in the CSHCN

Reimbursement Reprocessing for Imaging Interpretation

Eff ective for dates of service on or after July 1, 2004, procedure code I-78804 with an allowable fee relative value unit (RVU) of 1.38 became a benefi t of the CSHCN Services Program when performed by physicians, radiological labs, and physiology labs in an offi ce or outpatient hospital setting.

Claims submitted for dates of service on or after July 1, 2004, through April 14, 2006, that include this procedure are being reprocessed and payments adjusted accordingly. No action on the part of the provider is necessary.





Forms

Electronic Funds Transfer (EFT) Information

— A STATE MEDICAID CONTRACTOR 23

Electronic Funds Transfer (EFT) is a payment method to deposit funds for claims approved for payment directly into a provider’s bank account. These funds can be credited to either checking or savings accounts, provided the bank selected accepts Automated Clearinghouse (ACH) transactions. EFT also avoids the risks associated with mailing and handling paper checks, ensuring funds are directly deposited into a specified account.

The following items are specific to EFT:

• Applications are processed within five workdays of receipt. • Pre–notification to your bank takes place on the cycle following the application

processing.• Future deposits are received electronically after pre–notification. • The Remittance and Status (R&S) report furnishes the details of individual credits

made to the provider’s account during the weekly cycle. • Specific deposits and associated R&S reports are cross–referenced by both Texas

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

the same manner and time frame as currently received.

TMHP must provide the following notification according to ACH guidelines:

Most receiving depository financial institutions receive credit entries on the day before the effective date, and these funds are routinely made available to their depositors as of the opening of business on the effective date. Please contact your financial institution regarding posting time if funds are not available on the release date.

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

In all cases, credits received should be posted to the customer’s account on the effective date and thus be made available to cover checks or debits that are presented for payment on the effective date.

To enroll in the EFT program, complete the attached Electronic Funds Transfer Authorization Agreement. You must return a voided check or deposit slip with the agreement to the TMHP address indicated on the form.

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


Forms

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

— A STATE MEDICAID CONTRACTOR 23

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

Type of Authorization: NEW CHANGE

Provider Name Nine–Character Billing TPI

Provider Accounting Address Provider Phone Number ( ) ext.

Bank Name ABA/Transit Number

Bank Phone Number Account Number

Bank Address Type Account (check one) Checking Savings

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

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

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

Authorized Signature Date

Title Email Address (if applicable)

Contact Name Phone

Return this form to: Texas Medicaid & Healthcare Partnership

ATTN: Provider Enrollment PO Box 200795

Austin TX 78720–0795

DO NOT WRITE IN THIS AREA — For Office Use

Input By: Input Date:


Forms

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

Check the box to indicate a PCCM Provider � Date:

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

List any additional TPIs that use the same provider information:

TPI:______________________ TPI:______________________ TPI:______________________

TPI:______________________ TPI:______________________ TPI:______________________

Physical Address* Accounting/Mailing Address** Secondary Address

City: City: City:

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

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

Email: Email: Email:

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

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

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

Comments:

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

Tax ID Number: Effective Date:

Exact name reported to the IRS for this Tax ID:

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

Provider Signature: Date:

Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP) Provider Enrollment MC-B05 PO Box 200795 Austin, TX 78720-0795

Fax: 1-512-514-4214

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

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


Forms


Notes

PLACE POSTAGE HERE

CSHCN Provider BulletinThe Children with Special Health Care Needs Services Program

May 2006 No. 58

ATTENTION: BUSINESS OFFICE

Pub. No. E 07-12276

the children with special health care needs services program · 2008-06-18 · cshcn provider...

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