PROVIDER BULLETIN. Provider Manual to Be Updated Monthly Instead of Annually. CSHCN Services Program No. 78. IN THIS EDITION General Interest 1

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1 Pub. No CSHCN Services Program No. 78 PROVIDER BULLETIN Children with Special Health Care Needs Services Program May 2011 IN THIS EDITION General Interest 1 Provider Manual to Be Updated Monthly Instead of Annually 1 New Web Page Created for February 2011 National Correct Coding Initiative (NCCI) Guideline Implementation 2 Need Help? 3 Electronic Data Interchange (EDI) Version 5010 Implementation Reminder 3 Initial List of Certified Electronic Health Record (EHR) Products Is Available Online 3 TMHP Deploys New Encryption Software for That Contains Protected Health Information (PHI) 3 Enhancements to Online Fee Lookup (OFL) on the Portal 4 Scheduled System Maintenance 5 Post-Call Customer Service Satisfaction Survey 5 TexMedConnect Claims Status Inquiry (CSI) User s Guide Updated 5 User s Guide Now Available for New Encryption Software 5 Administrative 6 Accreditation Requirement Changes for Sleep Facilities 6 Additional 1 Percent Reimbursement Reduction for February Custom Durable Medical Equipment (DME) Enrollment Policy Change 7 Electronic Health Information Exchange (HIE) Notice Sent to Clients 7 First Quarter HCPCS Updates Now Available 7 CPT and HCPCS Claims Auditing Guidelines Update 8 National Correct Coding Initiative (NCCI) Compliance Guidelines Update 11 Instructions for CMS NCCI and MUE Coding Tools 13 Issue with Global Surgical Period Changes That Were Effective May 1, Providers Must Verify and Update Key Demographic Information in the Online Provider Lookup (OPL) Every Six Months 14 TMHP Provider Relations Representatives 22 Provider Manual to Be Updated Monthly Instead of Annually Effective July 1, 2011, the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual will be updated monthly instead of annually. The updated chapters will be published at the beginning of each month on the TMHP website on the Reference Material web page of the CSHCN Services Program provider section. The updated chapters will contain information that implemented the previous month. The manual will continue to be available as a complete book and as individual chapters in portable document format (PDF) and hypertext markup language (HTML) formats. The current version of the manual will always appear prominently on the CSHCN Services Program Reference Material web page. All previously-published CSHCN Services Program Provider Manuals will be archived, and users will be able to access them through links on the CSHCN Services Program Provider Manual web page. Updating the provider manual monthly eliminates the need for the quarterly CSHCN Services Program Provider Bulletin, which will be discontinued. The May 2011 CSHCN Services Program Provider Bulletin, No. 78, is the final edition that will be published. Previous editions of the bulletin will continue to be available in the archives on the the TMHP website. There will be no change to the way website articles and banner messages are published. Website articles will continue to be published as needed, and banner messages will continue to be included on the providers weekly Remittance and Status (R&S) Reports. continued on next page Copyright Acknowledgements Use of the American Medical Association s (AMA) copyrighted Current Procedural Terminology (CPT) is allowed in this publication with the following disclosure: Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable Federal Acquisition Regula tion System/Defense Federal Acquisition Regulation Supplement (FARS/DFARS) apply. The American Dental Association requires the following copyright notice in all publications containing Current Dental Terminology (CDT) codes: Current Dental Terminology (including procedure codes, nomenclature, descriptors, and other data contained therein) is copyright 2010 American Dental Association. All Rights Reserved. Applicable FARS/DFARS apply.

2 General Interest Website Changes Providers will be able to access the CSHCN Services Program Provider Manual in several ways: The most recent edition of the provider manual will be available on the CSHCN Services Program Provider Manual web page. Links at the bottom of the CSHCN Services Program Provider Manual web page will take providers to the following: Release Notes that are arranged by date (newest first) and include the name of the chapter that was updated, the revision date, and comments containing links to relevant website articles, if applicable Change History with changes grouped by chapter An archive of annual provider manuals (editions 2011 and prior) Benefits to Providers Providers will no longer have to wait for an entire year before updates to the provider manual are published. The Release Notes page will describe the nature of the changes, with links to relevant website articles, if applicable. The Change History page will allow providers to see how individual chapters change over time, which will make it easier to research past changes to the manual. New Web Page Created for February 2011 National Correct Coding Initiative (NCCI) Guideline Implementation IN THIS EDITION continued from page 1 Coding and Reimbursement 23 Benefit Changes for Replacement Hearing Aid Batteries 23 Benefit Changes for Expendable Medical Supplies 23 Benefit Criteria Changes for Cranial Molding Orthosis 24 Benefit Criteria Changes for Expendable Medical Supplies 24 Biofeedback Services are a Benefit 25 Correction to Benefit Changes for Some Expendable Medical Supplies 26 Correction to CSHCN Services Program Reimbursement Rates Will Change December 2010 for Some Surgical Services 26 Update to DME Provider Taxonomy Code Changes 27 Oral and Maxillofacial Surgery Procedures Requiring Prior Authorization 27 Updated List of Drugs Requiring National Drug Code (NDC) for Reimbursement 27 Reimbursement Rate Changes for Some Anesthesia Services Procedure Codes 28 Reimbursement Rate Changes for Some Hearing Aid Services Procedure Codes 28 Reimbursement Rate Implemented on January 2011 for Second Quarter 2010 HCPCS Procedure Code C Reimbursement Rate Changes for Some Eye and Ocular Adnexa Surgery Services Procedure Codes 29 Reimbursement Rate Changes for Some Orthotic Procedure Codes 29 Reimbursement Rate Changes for Some Urinary System Surgery Services Procedure Codes 29 Reimbursement Rate Changes for Some Vision Services Procedure Codes 29 Reimbursement Rate Changes for Some Surgical and Radiological Services Procedure Codes 29 Immunization Administration Procedure Code Changes 30 CSHCN Services Program Contact Information 34 Forms 35 Effective February 25, 2010, for dates of service on or after October 1, 2010, providers must comply with CMS NCCI guidelines. TMHP has created the NCCI Compliance web page to provide updates as TMHP systematically implements the new guidelines. A link to the CMS website is also available on the new web page. Providers are encouraged to refer to the TMHP website at regularly for the most up-to-date information. Providers can refer to the article titled Mandatory State Use of NCCI and Compliance with NCCI Guidelines, which was published on the TMHP website on August 13, 2010, for more information about the CMS NCCI mandate. No. 78, May CSHCN Services Program Provider Bulletin

3 General Interest Electronic Data Interchange (EDI) Version 5010 Implementation Reminder The Texas Health and Human Services Commission (HHSC) and the Texas Medicaid & Healthcare Partnership (TMHP) will soon initiate the implementation of EDI Version 5010 in accordance with the federal Health Insurance Portability and Accountability Act (HIPAA) rules for all EDI transactions. HIPAA rules mandate that the implementation of EDI Version 5010 will begin January 1, This change will not directly affect users of TexMed- Connect or other services provided through the TMHP website. From July 1, 2011, through December 31, 2011, TMHP will support a dual-strategy approach to the implementation of EDI Version Trading partners will be able to submit version 4010 transactions through December 31, 2011; however, trading partners that have passed the EDI Version 5010 testing and certification requirements may send version 5010 transactions beginning July 1, Trading partner outreach began in March of 2011, and trading partner testing is scheduled to begin July 1, 2011, through December 31, EDI Companion Guide updates will be available on the TMHP website on the EDI Companion Guides web page at the end of the first quarter of Additional information about specific changes that will be made with the implementation of EDI Version 5010 will be communicated through future provider notifications. Providers should direct all questions and support requests to the EDI Version 5010 Implementation address at EDI5010Support@tmhp.com. Need Help? Call the THMP-CSHCN Services Program Contact Center at for more information about any article in this bulletin. The contact center is available Monday thru Friday from 7 a.m. to 7 p.m., Central Time. Also see the map on page 22 for information about the Provider Relations Representatives serving your area. Initial List of Certified Electronic Health Record (EHR) Products Is Available Online The Office of the National Coordinator for Health Information Technology (ONC) has released the initial list of certified EHR products that comply with meaningful use eligibility requirements for the EHR Incentive Payment program. The Certified Health IT Product List includes products that have been tested and certified to meet Centers for Medicare & Medicaid Services (CMS) meaningful use criteria. The list will help providers explore their options for EHR software as they take the first steps in becoming compliant with meaningful use standards. The ONC will update the certified product list often. Providers should refer to the ONC webpage for the most up-to-date information. Details, including links to the product list, the ONC webpage, and additional resources, are available on the Health IT page on the TMHP website at For more information, Health IT at HealthIT@tmhp.com or call the TMHP Contact Center at TMHP Deploys New Encryption Software for That Contains Protected Health Information (PHI) Effective January 29, 2011, TMHP deployed new software to encrypt that contains client and provider PHI. Providers can receive, view, reply to, and forward that is encrypted and sent by TMHP. Encrypted contains instructions for retrieving passwords and decrypting the to access the protected information. Providers may contact the sender of the with questions or issues that may arise. CSHCN Services Program Provider Bulletin 3 No. 78, May 2011

4 General Interest Enhancements to Online Fee Lookup (OFL) on the Portal On March 25, 2011, enhancements were made to the OFL on the TMHP website at The OFL may be used to interactively search for fee information on specific procedure codes and to retrieve fee information for the current date or for a specific date of service (DOS). The enhancements allow users to retrieve up to 24 months of DOS-specific information, including any retroactive changes. Users are able to retrieve 24 months of history only if the date of service searched displays the current date. Specific DOS searches retrieve only pricing for that specific DOS. This new functionality applies to the OFL Fee and Batch Searches. Static Fee schedules will continue to be generated on a quarterly basis. Note: Batch search results that exceed 65,000 rows will generate additional worksheets in the Excel workbook. A maximum of five worksheets can be generated per workbook. Providers can use these new OFL features by following these steps: 1. Go to the TMHP website at 2. Click Providers at the top of the web page. 3. Click Fee Schedules on the left side of the web page. 4. Click Fee Search. 5. Select one of the search type options: Single procedure code List of procedure codes (up to ten procedure codes) Range of procedure codes All applicable procedure codes 6. Enter the search criteria: procedure codes, provider type, provider specialty, program, date of service (leave defaulted for today s date), and claim type. 7. Submit the request. The search results data will be displayed. Below is an example of what the interactive search results will return: No. 78, May CSHCN Services Program Provider Bulletin

5 General Interest Post-Call Customer Service Satisfaction Survey Providers that call TMHP provider and prior authorization telephone numbers are given the opportunity to respond to a short customer satisfaction survey after the call is completed. When providers call one of the affected telephone numbers, providers will hear a recorded message about the survey that directs them to ask the agent to transfer them to the survey upon completion of the call. Providers will answer the fivequestion survey by using the buttons on the telephone. Survey results will be reported to the appropriate state agency on a quarterly basis. TexMedConnect Claims Status Inquiry (CSI) User s Guide Updated Effective February 25, 2011, the TexMedConnect Claims Status Inquiry (CSI) User s Guide was updated to include information about a new feature for the NCCI and sourced edits. The updated guide is available on the TMHP website at on the Reference Materials web page for each program. For more information, providers may refer to the articles titled CPT and HCPCS Claims Auditing Guidelines Update and National Correct Coding Initiative (NCCI) Compliance Guidelines, that were published on the TMHP website on January 7, User s Guide Now Available for New Encryption Software On January 29, 2011, TMHP deployed new software to encrypt that contains PHI for clients or providers. The Encryption Basics/Help Guide is now available on the TMHP website at on the Reference Materials web page for each program. For more information, providers may refer to the article titled TMHP to Employ New Encryption Software for That Contains Protected Health Information (PHI), which was published on the TMHP website on January 14, Scheduled System Maintenance System maintenance for the TMHP claims processing system is scheduled as follows: Sunday, May 15, 2011, 4:00 a.m. to 11:59 p.m. Sunday, June 12, 2011, 4:00 p.m. to 11:59 p.m. Sunday, July 10, 2011, 4:00 p.m. to 11:59 p.m. During system maintenance, some applications related to the claims engine will be unavailable. Specific details about the affected applications are posted on the TMHP website at Extended System Maintenance Outage Scheduled for June 5, 2011 TMHP will perform scheduled maintenance to the Claims Engine and LTC systems on Sunday, June 5, This will be a 27-hour maintenance window starting at midnight and will end at 3:00 a.m. Monday, June 6, During the system maintenance window, some applications will be unavailable for both Acute Care and LTC systems. During extended system outage, some applications related to the claims engine will be unavailable. Details about the affected applications are available on the TMHP website at CSHCN Services Program Provider Bulletin 5 No. 78, May 2011

6 Administrative Accreditation Requirement Changes for Sleep Facilities Effective January 1, 2011, CMS requires that sleep facilities that perform services for CSHCN Services Program clients be accredited by the American Academy of Sleep Medicine (AASM) or the Joint Commission of Accreditation of Healthcare Organizations (JCAHO). Sleep facilities that perform services for CSHCN Services Program clients must also follow current AASM practice parameters and clinical guidelines. Physicians who provide supervision in sleep facilities must be board-certified or board-eligible, as outlined in the AASM guidelines. Sleep facility technicians, technologists, and trainees must demonstrate that they have the skills, competencies, education, and experience that are set forth by their certifying agencies and AASM as necessary for advancement in the profession. The sleep facility must have at least one supervising physician who is responsible for the direct and ongoing oversight of the quality of the testing performed, the proper operation and calibration of the equipment used to perform tests, and the qualifications of the nonphysician staff who use the equipment. Sleep facilities must maintain documentation with proof that the facility is accredited and follows AASM practice and clinical guidelines and that the physicians are board-certified or board-eligible per AASM guidelines for a sleep facility. Documentation is subject to retrospective review. Polysomnography Polysomnographic technologists, technicians, and trainees must meet the following supervision requirements: A polysomnographic trainee provides basic polysomnographic testing and associated interventions under the direct supervision of a polysomnographic technician, polysomnographic technologist, or physician. Note: Direct supervision means that the supervising licensed/ certified professional must be present in the office suite or building and immediately available to furnish assistance and direction throughout the performance of the service. It does not mean that the supervising professional must be present in the room while the service is being provided. A polysomnographic technologist provides comprehensive evaluation and treatment of sleep disorders under the general supervision of the clinical director (M.D. or D.O.). A polysomnographic technician provides comprehensive polysomnographic testing and analysis and associated interventions under the general supervision of a polysomnographic technologist or clinical director (M.D. or D.O.). Note: The supervising physician must be readily available to the performing technologist throughout the duration of the study but is not required to be in the building. Providers may refer to the AASM website at for AASM facility certification requirements or to the Joint Commission website at for Joint Commission facility accreditation information. Additional 1 Percent Reimbursement Reduction for February 2011 Effective for dates of service on or after February 1, 2011, the CSHCN Services Program instituted an additional 1 percent reduction in the final payment amounts for professional and outpatient facility services. The additional 1 percent reduction in addition to the 1 percent reduction that was effective for dates of service on or after September 1, The resulting 2 percent total reduction applies to the CSHCN Services Program rate for affected services that are rendered on or after February 1, Services Affected by the Additional 1 Percent Reimbursement Reduction The 2 percent total reduction (including both the 1 percent from September 1, 2010, and the 1 percent for February 1, 2011) applies to the following services: Services rendered to CSHCN Services Program clients (except for exclusions noted below) Services Not Affected by the Additional 1 Percent Reimbursement Reduction The following are not affected by the 2 percent total reduction (including both the 1 percent from September 1, 2010, and the 1 percent for February 1, 2011): School Health and Related Services (SHARS) Tax Equity and Fiscal Responsibility Act (TEFRA)- reimbursed inpatient hospitals (children s and state teaching hospitals) State hospital freestanding psychiatric facilities Department of Assistive and Rehabilitative Services (DARS) Early Childhood Intervention (ECI) Case Management and Developmental Rehabilitation Program Federally qualified health clinics (FQHCs) that are rendering Medicaid fee-for-service Rural health clinics (RHCs) No. 78, May CSHCN Services Program Provider Bulletin

7 Administrative Department of State Health Services (DSHS) clinical labs Birthing centers Indian Health Services Medicare crossover claims Case Management and Rehabilitative Services Blind Children s Vocational Discovery and Development Program (BCVDDP) Case Management and Rehabilitative Services ECI Case Management and Rehabilitative Services Intellectual Disabilities Outpatient Behavioral Health Chemical Dependency Treatment Facility (CDTF) Medicaid Title XIX personal care services (PCS) (1 percent reduction from September 1, 2010 applied) Exception: PCS continues to receive the 1 percent reduction that was effective for dates of service on or after September 1, PCS services do not receive the additional 1 percent reduction for dates of service on or after February 1, Custom Durable Medical Equipment (DME) Enrollment Policy Change Effective January 1, 2011, the enrollment requirements for custom DME providers changed for the CSHCN Services Program. Providers who want to enroll as custom DME providers in the CSHCN Services Program must provide proof of current certification from the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) as an Assistive Technology Practitioner. Providers no longer have the option of providing three letters of recommendation from practicing occupational or physical therapists who serve a pediatric population. A current RESNA Assistive Technology Supplies license is no longer accepted since RESNA no longer offers the certification. Electronic Health Information Exchange (HIE) Notice Sent to Clients On November 15, 2010, CSHCN Services Program clients were mailed a notice about the benefits of electronic HIE. The notice informed clients of the benefits of HIE and how to opt out if they chose not to participate. New CSHCN Services Program clients will get the information in subsequent mailings. Clients are offered a toll-free number ( ) to call on or after December 1, 2010, for more information or to opt out. The HIE information and opt-out form is available from the client pages of the TMHP website at Providers are being notified about the mailing because it may prompt questions from their patients about HIE and what it means to them. Their questions may offer an opportunity to discuss the benefits of HIE and having a complete health record that can be shared among providers quickly and efficiently over a secure online network. Providers may refer to the following resources to get help and learn more about the Health IT Initiative: Sign up for updates about the Health IT initiative. Visit the Health IT webpage for more information, upcoming webinars, events, and answers to questions. For more information, send an to Health IT at HealthIT@tmhp.com or call the TMHP Contact Center at First Quarter HCPCS Updates Now Available On April 1, 2011, TMHP implemented first quarter 2011 Healthcare Common Procedure Coding System (HCPCS) additions, changes, and deletions that were effective for dates of service on or after April 1, Deleted procedure codes are no longer benefits of CSHCN Services Program. Details of these changes are available on the Code Updates- HCPCS web page. Providers should reference the Required Information for Customized Durable Medical Equipment Providers (CSHCN) page on the CSHCN Services Program webpage for additional information. Providers who use Provider Enrollment on the Portal (PEP) may see a different version of this page during the enrollment process. This page will be revised at a later date. CSHCN Services Program Provider Bulletin 7 No. 78, May 2011

8 Administrative CPT and HCPCS Claims Auditing Guidelines Update Effective February 25, 2011, providers may see claim denials in accordance with Current Procedural Terminology (CPT) and HCPCS guidelines as defined in the American Medical Association (AMA) and CMS coding manuals. Clams that are submitted with dates of service from October 1, 2010, through February 24, 2011, will not be reprocessed in accordance with the CPT and HCPCS guidelines. However, any claims with dates of service on or after October 1, 2010, that are appealed or reprocessed on or after February 25, 2011, for reasons other than CPT and HCPCS auditing will be subject to CPT and HCPCS auditing guidelines. The claims auditing guidelines may be applied to the following claims: Professional and outpatient facility claims that are submitted on the CMS-1500 professional claim form or electronic equivalent Outpatient facility claims that are submitted on the CMS-1450 institutional claim form or electronic equivalent Family planning Titles V and XX claims that are submitted on the CMS-1500 claim form or the Family Planning 2017 Claim Form or electronic equivalent (family planning Titles V and XX claims do not apply for the CSHCN Services Program) If a rendered service does not comply with a guideline as defined by CPT or HCPCS, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement. Note: Medical necessity documentation does not guarantee payment for the service. Claims Auditing Processing Categories The following coding rule categories apply for claims that are submitted with dates of service on or after February 25, 2011: Coding Rule Category Add-on Codes Deleted HCPCS Codes Diagnosis Validity Diagnosis-Age Description Certain services are commonly carried out in addition to the rendering of the primary procedure and are associated with the primary procedures. These additional or supplemental procedures are referred to as add-on procedures. Add-on codes are identified in the CPT manual with a plus mark ( + ) symbol and are also listed in Appendix D of the CPT manual. Add-on codes are always performed in addition to a primary procedure, and should never be reported as a stand-alone service. When an add-on code is submitted and the primary procedure has not been identified on either the same or different claim, then the add-on code will be denied as an inappropriately-coded procedure. If the primary procedure is denied for any reason, then the add-on code will be denied also. Procedure codes undergo revision by the AMA and CMS on a regular basis. Revisions typically include adding new procedure codes, deleting procedure codes, and redefining the description of existing procedure codes. These revisions are normally made on an annual basis by the governing entities with occasional quarterly updates. Claims that are received with deleted procedure codes will be validated against the date of service. If the procedure code is valid for the date of service, the claim will continue processing. If the procedure code is invalid for the date of service, the invalid procedure code will be denied. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes undergo revision by the Centers for Disease Control and Prevention (CDC) and CMS on a regular basis. Revisions typically include adding new diagnosis codes, deleting diagnosis codes, and redefining the description of existing diagnosis codes. These revisions are normally made on an annual basis. Claims that are received with invalid diagnosis codes will be validated against the date of service. If the diagnosis code is valid for the date of service, the claim will continue processing. If the diagnosis code is invalid for the date of service, the procedure that is referenced to the invalid diagnosis code will be denied. Certain diagnosis codes are age-specific. If a diagnosis code that is billed does not match the age of the client on that date of service, all services associated with that diagnosis code will be denied. For example, a newborn diagnosis must be associated with a client who is 29 days of age or younger. No. 78, May CSHCN Services Program Provider Bulletin

9 Administrative Coding Rule Category Diagnosis- Gender Duplicate Claim Evaluation and Management Services Procedure Code Definition Procedure Code Guideline Procedure-Age Procedure- Gender Total, Professional Interpretation, and Technical Services Description Certain diagnosis codes are gender-specific. If the diagnosis code that is billed does not match the gender of the client, all services associated with that diagnosis code will be denied. For example, diagnosis code (benign hypertrophy of prostate) is restricted to male clients. A duplicate claim is defined as a claim or procedure code detail that exactly matches a claim or procedure code detail that has been reimbursed to the same provider for the same client. Duplicate claims or details include the same date of service, procedure code, modifier, and number to units. Duplicate claims or procedure code details will be denied. Note: Modifiers may be used to identify separate services. The AMA defines new and established patients as follows: A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. An established patient is one who has received a professional service from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Only one evaluation and management (E/M) procedure code may be reimbursed for a single date of service by the same provider group and specialty, regardless of place of service. Providers may refer to the 2010 CSHCN Services Program Provider Manual, Section , Evaluation and Management (E/M) Services for additional information about physician E/M services. The CPT Manual assigns each procedure code a specific description or definition to describe the service that is rendered. In order to support correct coding, the procedure code definition rules will deny procedure codes based on the appropriateness of the code selection as directed by the definition and nature of the procedure code. The CPT Manual includes specific reporting guidelines that are located throughout the manual and at the beginning of each section. In order to ensure correct coding, these guidelines provide reporting guidance and must be followed when submitting specific procedure codes. Certain procedure codes, by definition or nature of the procedure, are limited to the treatment of a specific age or age group. For example, code is limited to clients who are 1 through 4 years of age. Certain procedure codes, by definition or nature of the procedure, are limited to the treatment of one gender. For example, hysterectomy procedure code is limited to female clients. Diagnostic tests and radiology services are procedure codes that include two components: professional interpretation and technical. The professional interpretation component describes the physician s interpretation and report services and is billed with modifier 26. The technical component describes the technical portion of a procedure, such as the use of equipment and staff needed to perform the service, and is billed with modifier TC. If the professional interpretation and technical components are rendered by the same provider, the total component may be billed represented by the appropriate procedure code without modifiers 26 and TC. Reimbursement of diagnostic tests and radiology services is limited to no more than the amount for the total component. Providers must refer to the appropriate Texas Medicaid fee schedules to determine payable components for diagnostic and radiology services. Procedure codes that are submitted with an inappropriate modifier will be denied. These guidelines do not be apply to inpatient hospital claims that are submitted on the CMS-1450 claim form or electronic equivalent and to family planning Title X claims (family planning Title X claims do not apply for the CSHCN Services Program). Note: At this time, the coding guidelines do not affect claims for which multiple surgery guidelines apply. CSHCN Services Program Provider Bulletin 9 No. 78, May 2011

10 Administrative Explanation of Benefits (EOB) for Claim Denials One of the following new EOB messages accompanies any necessary claim denials: EOB Code Message All claim diagnosis codes are invalid. Refer to TexMedConnect CSI for details Multiple professional/technical components billed for the same test or procedure. Refer to TexMedConnect CSI for details Claim diagnosis is invalid for client s gender. Refer to TexMedConnect CSI for details Claim diagnosis is invalid for client s age. Refer to TexMedConnect CSI for details Procedure code is invalid for client s age. Refer to TexMedConnect CSI for details Procedure code is invalid for client s age. Refer to TexMedConnect CSI for details Procedure code is invalid for client s gender. Refer to TexMedConnect CSI for details The procedure code is part of another procedure/service previously billed. Refer to TexMedConnect CSI for details Missing or denied primary procedure code for the add-on procedure code billed. Refer to TexMedConnect CSI for details This is a duplicate service that has been paid to different/same provider. Refer to TexMedConnect CSI for details Primary code missing or denied for add-on code billed. Refer to TexMedConnect CSI for details The procedure code is included in global fee for another procedure. Refer to TexMedConnect CSI for details. For claims that are denied with one of the EOB messages in the above table, a link to TexMedConnect has additional information to help providers determine the cause of a denial. If the claim is pending NCCI rule or other review, the following EOB messages may appear on the R&S Report to indicate that the claim may require further review and possible recoupment at a later date: EOB Code Message Unable to validate correct coding compliance. Claim may be adjusted at a later time Unable to validate correct coding compliance. Claim may be adjusted at a later time Unable to validate correct coding compliance. Claim may be adjusted at a later time Unable to validate correct coding compliance. Claim may be adjusted at a later time. Appealing Claims Auditing Denials Claims or procedure codes that have been denied based on CPT and HCPCS claims auditing guidelines may be appealed with an appropriate modifier or documentation of medical necessity. Providers may refer to the CPT and HCPCS procedure coding manuals for guideline exceptions that may be appealed. Currently Published Information The HCPCS and CPT codes included in the Children with Special Health Care Needs (CSHCN) Services Program Provider Manual and the CSHCN Services Program Provider Bulletins are subject to NCCI relationships, which supersede any exceptions to NCCI code relationships that may be noted in the manuals and bulletins. Providers should refer to the CMS NCCI web page at for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy is more restrictive than NCCI Medically Unlikely Edits (MUEs) guidance, CSHCN Services Program medical policy prevails. For additional information about multiple surgery guidelines, providers may refer to the 2010 CSHCN Services Program Provider Manual, Section , Multiple Surgeries. No. 78, May CSHCN Services Program Provider Bulletin

11 Administrative National Correct Coding Initiative (NCCI) Compliance Guidelines Update This is a follow-up to the article titled Mandatory State Use of NCCI and Compliance with NCCI Guidelines that was published on the TMHP website at on August 13, The article stated that the Patient Protection and Affordable Care Act (PPACA) mandates that all claims submitted with dates of service on or after October 1, 2010, must be filed in accordance with the NCCI guidelines. Effective February 25, 2011, providers may see claim denials in accordance with CMS NCCI guidelines. Claims that are submitted with dates of service from October 1, 2010, through February 24, 2011, will not be reprocessed in accordance with the NCCI guidelines. Any claims with dates of service on or after October 1, 2010, that are appealed or reprocessed for reasons other than NCCI auditing on or after February 25, 2011, are subject to NCCI auditing guidelines. The NCCI auditing guidelines may be applied to the following claims: Professional and outpatient facility claims that are submitted on the CMS-1500 professional claim form or electronic equivalent Outpatient facility claims that are submitted on the CMS-1450 institutional claim form or electronic equivalent Family planning Titles V and XX claims that are submitted on the CMS-1500 claim form or the Family Planning 2017 Claim Form or electronic equivalent (family planning Titles V and XX claims do not apply for the CSHCN Services Program) If a rendered service does not comply with a guideline as defined by NCCI, medical necessity documentation may be submitted with the claim for the service to be considered for reimbursement. Note: Medical necessity documentation does not guarantee payment for the service. NCCI Processing Categories The following coding rule categories apply for claims that are submitted with dates of service on or after October 1, 2010: Coding Rule Category Maximum Units Description CMS has assigned all procedure codes maximum numbers of units that may be billed for a client per day, regardless of the provider. The maximum number of units for each procedure code is based on the following criteria: procedure code description, anatomical site, CMS sources, and clinical guidelines. Important: If the maximum number of units has been exceeded on a particular line item, the line item will be denied. The line item will not be cut back to the allowable quantity. The line item may be appealed with the appropriate quantity for consideration of payment. NCCI NCCI is a collection of bundling edits created and sponsored by CMS that are separated into two major categories: Column I and Column II procedure code edits (previously referred to as Comprehensive and Component ), and Mutually Exclusive procedure code edits. NCCI edits are applied to services that are performed by the same provider on the same date of service only and do not apply to services that are performed within the global surgical period. Each NCCI code pair edit is associated with a policy as defined in the National Correct Coding Initiative Policy Manual. Effective dates apply to code pairs in NCCI and represent the date when CMS added the code pair combination to the NCCI edits. Code combinations are processed based on this effective date. Termination dates also apply to code pairs in NCCI. This date represents the date when CMS removed the code pair combination from the NCCI edits. Code combinations are refreshed quarterly. For a list of NCCI and MUEs, providers may refer to the CMS website at: Edits.asp. These guidelines do not apply for inpatient hospital claims that are submitted on the CMS-1450 claim form or electronic equivalent and to family planning Title X claims. Note: At this time, the NCCI guidelines do not affect claims for which multiple surgery guidelines are apply. CSHCN Services Program Provider Bulletin 11 No. 78, May 2011

12 Administrative Explanation of Benefits (EOB) for Claim Denials One of the following new EOB messages accompanies any necessary claim denials: EOB Code Message Procedure code denied per NCCI Column I/ Column II rules. Refer to TexMedConnect CSI for details The maximum number of units allowed has been exceeded. Refer to TexMedConnect CSI for details. For claims that are denied with one of the EOB messages in the above table, a link in TexMedConnect has additional information to help providers determine the cause of a denial. If a claim was paid but could not be audited for NCCI compliance, the following EOB messages may appear on the R&S Report to indicate that the claim may require further review and possible recoupment at a later date: EOB Code Message Unable to validate correct coding compliance. Claim may be adjusted at a later time Unable to validate correct coding compliance. Claim may be adjusted at a later time Unable to validate correct coding compliance. Claim may be adjusted at a later time Unable to validate correct coding compliance. Claim may be adjusted at a later time. Appealing NCCI Denials Claims or procedure codes that have been denied based on NCCI guidelines may be appealed with an appropriate modifier or documentation of medical necessity. If the submitted procedure code is denied because NCCI guidelines indicate the code is included in another procedure, the claim may be appealed with a modifier if applicable. If a modifier does not apply but medical necessity can be proven, the provider must submit documentation of medical necessity that indicates both services were necessary on the same date of service. For guideline exceptions that may be appealed, providers may refer to the CMS website at NCCICoding/03_NCCI%20Appeals.asp. Providers must follow the current standard appeals process when appealing claims to TMHP. Claims Submitted Between October 1, 2010, and February 24, 2011 New day claims that were submitted on or after October 1, 2010, through February 24, 2011, are not being reprocessed to comply with the NCCI guidelines. Claims with dates of service on or after October 1, 2010, that are appealed or reprocessed for other reasons on or after February 25, 2011, are subject to denial in accordance with the CMS NCCI guidelines. Notification of NCCI Updates and Exceptions Providers may refer to the CMS website at MedicaidNCCICoding for the NCCI Policy and Medicare Claims Processing manuals that contain the NCCI rules, relationships, and general information. Providers are encouraged to monitor CMS for updates to the NCCI rules and guidelines. A link to the CMS NCCI website is also available through the TMHP website at on the Code Updates NCCI Compliance web page. When the CSHCN Services Program implements exceptions to the NCCI relationships, providers will be notified in R&S Report banner messages and in web and bulletin articles. Currently Published Information The HCPCS and CPT codes included in the CSHCN Services Program Provider Manual and the CSHCN Services Program Provider Bulletins are subject to NCCI relationships, which supersede any previous exceptions to NCCI code relationships that may be noted in the manuals and bulletins. Providers should refer to the CMS NCCI web page at www. cms.gov/medicaidnccicoding for correct coding guidelines and specific applicable code combinations. In instances when Texas Medicaid or CSHCN Services Program medical policy is more restrictive than NCCI MUE guidance, CSHCN Services Program medical policy prevails. For additional information about multiple surgery guidelines, providers may refer to the 2010 CSHCN Services Program Provider Manual, Section , Multiple Surgeries. No. 78, May CSHCN Services Program Provider Bulletin

13 Administrative Instructions for CMS NCCI and MUE Coding Tools Effective February 25, 2011, for dates of service on or after October 1, 2010, TMHP has adopted the CMS NCCI guidelines. The NCCI guidelines consist of HCPCS or CPT procedure code pairs that must not be reported together and Medically Unlikelyl Edits (MUEs) that determine whether procedure codes are submitted in quantities that are unlikely to be correct. The NCCI and MUE spreadsheets are published and updated by CMS and are available on the CMS Medicaid NCCI Coding web page under NCCI and MUE Edits as follows: NCCI edit spreadsheets. The website contains the Medicaid NCCI edit spreadsheet for hospital services and the Medicaid NCCI edit spreadsheet for practitioner services. The spreadsheets list the procedure code pairs that will not be reimbursed separately if they are billed by the same provider with the same date of service. Column 1 procedure codes may be reimbursed but Column 2 procedure codes are denied. The spreadsheets also contain a column that indicates whether or not a modifier is allowed for services that may be reimbursed separately. MUE edit spreadsheets. The website contains the Medicaid MUE edit spreadsheets for hospital services, practitioner services, and supplier services. The spreadsheets list procedure codes and the number of units that may be reimbursed for each procedure code. Units that are submitted beyond these limitations are denied. Providers may refer to the article titled National Correct Coding Initiative (NCCI) Compliance Guidelines Update on page 10 of this bulletin for information about appealing NCCI denials. Providers may also refer to pages 7-11, 13, and of the instruction document titled How to Use The National Correct Coding Initiative (NCCI) Tools [PDF, 2.94MB], that is available on the CMS website. Issue with Global Surgical Period Changes That Were Effective May 1, 2010 TMHP has identified an issue with the global surgical period changes that were implemented for dates of service on or after May 1, Hospital visits by the surgeon during the same hospitalization as the surgery are usually considered to be related to the surgery and, as a result, not separately billable; however, separate payment for such visits can be allowed if any of the following conditions apply: Immunotherapy management is provided by the transplant surgeon. Immunosuppressant therapy following transplant surgery is covered separately from other postoperative services, so postoperative immunosuppressant therapy is not part of the global fee allowance for the transplant surgery. This coverage applies regardless of the setting. Critical care is provided by the surgeon for a burn or trauma patient. The hospital visit is for a diagnosis that is unrelated to the original surgery. If any of these circumstances occur, the surgeon may bill modifier 24 to indicate that an unrelated evaluation and management service was performed by the same physician during a postoperative period. Providers who submitted claims that qualify for these exceptions may have had their claims denied in error. Affected claims for dates of service on or after May 1, 2010, are being reprocessed, and payments are being adjusted accordingly. No action on the part of the provider is required. Want to know more? You may be eligible for continuing education credits by participating in THSteps Online Provider Education training opportunities. To find out more, visit the THSteps Online Provider Education website at CSHCN Services Program Provider Bulletin 13 No. 78, May 2011

14 Administrative Providers Must Verify and Update Key Demographic Information in the Online Provider Lookup (OPL) Every Six Months Effective March 24, 2011, providers with certain provider types must verify and update key demographic information every six months in the Provider Information Management System (PIMS) to ensure that their information is correct in the OPL. If more than six months have elapsed since the required demographic information in the OPL was verified, access to the secure provider portal is blocked until the verification takes place. Upon logging into their accounts, users with administrative rights see a list of National Provider Identifiers (NPIs) that require verification and update. After addressing each NPI listed on the page, administrative providers may proceed to their accounts. If access to the secure portal has been blocked because of needed verification, non-administrative users are not able to perform work functions on NPIs listed on the Review Required page. Non-administrative users are advised to notify users with administrative rights so that they can verify demographic information and remove the block. External Users with Administrative Rights for All NPIs Listed on Review Required Screen Effective March 24, 2011, external users with administrative rights may see changes to the OPL and must ensure that all demographic updates are completed and verified by following these steps: Step 1: The first page that an external user with administrative rights for all NPIs listed sees when logging into My Account is the Review Required Page. If there are any NPIs listed that require review for a six-month demographic information update, including bad address, suggested address change verification, or Women s Health Program (WHP) certification, these NPIs appear on the Review Required page in their respective sections. The Continue button only appears on the Review Required page if the NPIs to be reviewed only require verification of a WHP certification. In this scenario, the Continue button is not available for external users. They are still able to navigate to the My Account main page using the My Account link to manage their provider account, but are redirected to the Review Required page if they click on any Acute Care Online Portal links in My Account. No. 78, May CSHCN Services Program Provider Bulletin

15 Administrative Step 1 continued: If there are NPIs requiring review, the new Review Required page is displayed for the bolded links in the screenshot below when in My Account, even if these links have been bookmarked by the external user on their computer and they do not go through My Account to arrive at the given page: My Account Link View R&S/COF Reports TexMedConnect My Panel Reports View Paid Claim Detail Reports Prior Authorization View Payment Amounts View MET Provider Reports These links are a part of the My Account main screen below: CSHCN Services Program Provider Bulletin 15 No. 78, May 2011

16 Administrative Step 1 continued: If there are NPIs requiring review, the new Review Required page is displayed for the links in the screenshot below for TexMedConnect (TMC) Acute Care functions, even if these links have been bookmarked by the external user on their computer and they do not go through the TMC Acute Care menu to arrive at the given page: TMC Acute Care Link Eligibility Client Group List EV Batch History Claims Entry Individual Template Draft Pending Batch Batch History CSI R&S Appeals ANSI 835 Note: Access to TMC Long Term Care (LTC) links is restricted due to a six-month demographic reminder, bad address reminder, or suggested address change verification reminder. No. 78, May CSHCN Services Program Provider Bulletin

17 Administrative Step 2: Once an external user with administrative rights for all NPIs listed clicks on one of the NPIs on the Review Required page of the My Account or TMC Acute Care screens, the Provider Information Change (PIC) form appears. What were once stand-alone sections of the PIC form, the Address, County, and Office Hours, and Additional Limitations sections have been combined into one section. The external user must enter valid data in each box of this combined section and click the Check to confirm box next to each item in order to successfully save the section and continue. CSHCN Services Program Provider Bulletin 17 No. 78, May 2011

18 Administrative No. 78, May CSHCN Services Program Provider Bulletin

19 Administrative Step 3: When only one NPI remains on the Review Required page, the external user is directed to the last remaining PIC form upon clicking the Continue button on the PIC form of the next to last remaining NPI. Once the external user saves and confirms the information entered on the PIC form of the last remaining NPI, and clicks the Continue button, they are directed to the My Account main page to perform the next desired action. External Users without Administrative Rights For All NPIs Listed on Review Required Screen External users without administrative rights see two possible Review Required pages when attempting to access work products, depending upon whether any demographic item has expired based on the current date: 1. Non-Administrative User Required Review Page - No Expired Items 2. Non-Administrator Review Required - With Expired Items CSHCN Services Program Provider Bulletin 19 No. 78, May 2011

20 Administrative Step 3 continued: When items have expired, the account administrator assigned to the NPIs listed is the only individual who can make changes to demographic information. In these cases, the non-administrator must notify the administrator that updates must be made to the NPIs that require updates. To identify the administrator for certain NPIs, the non-administrative user can either click an NPI on their Review Required page or click on Provider Administrator Lookup from the My Account main page as illustrated below. When the non-administrator clicks on Provider Administrator Lookup they see the following screen, which lists the contact information for the administrator attached to the NPIs to be updated: External Users with Administrative Rights for Some of the NPIs Listed on Review Required Screen In some cases, external users only have administrative rights for some, but not all, of the NPIs listed on the review required page. They must contact the administrator of the remaining NPIs to make any changes to those remaining. In this case, the user sees the following screen upon login to either My Account or TMC Acute Care: No. 78, May CSHCN Services Program Provider Bulletin

21 Administrative Remittance and Status (R&S) Changes in My Account/TMC Acute Care External users visiting the R&S page from either My Account or TMC Acute Care see different screens, depending on whether there are NPIs attached to the user s login information that require attention. If an external user has only LTC items to check on the R&S Report, the notification message in the screenshot above does not appear, and only the LTC items are shown. If an external user has only Acute Care items to check on the R&S Report, the notification message in the screenshot above does appear, but Acute Care items are hidden until necessary actions are performed by an external user with administrative rights to those files. If an external user has both LTC and Acute Care items to check on the R&S Report, the LTC portable document format (.pdf) files are shown, but Acute Care items are hidden until necessary actions are performed by an external user with administrative rights to those files. CSHCN Services Program Provider Bulletin 21 No. 78, May 2011

22 Administrative TMHP Provider Relations Representatives TMHP Provider Relations representatives offer a variety of services that inform and educate the provider community about the CSHCN Services Program s policies and claims filing procedures. Technical support and training are also provided for TexMedConnect. Provider Relations representatives assist providers through telephone contact, onsite visits, and scheduled workshops. The map at right and the table below indicate the TMHP Provider Relations representatives and the areas they serve. Additional information, including a regional listing by county and workshop information, is available on the TMHP website at (Click on the Provider Support Services link, then click on the Provider Relations Reps link, and then choose your region.) Territory Regional Area Representative Telephone Number 1 Amarillo, Childress, and Lubbock Stephanie Hill Midland, Odessa, and San Angelo Mindy Wiggins Alpine, El Paso, and Van Horn Alma Gonzales Del Rio, Eagle Pass, and Laredo Christina Salinas Brownsville, Harlingen, and McAllen Cynthia Gonzales Abilene, Brownwood, and Wichita Falls Cynthia Rowlett Brady, North Austin,* Round Rock, and Waco Rhonda Williams South Austin,* Bastrop, Buda, Guadalupe, and San Marcos Kimberly Gauquier Kerrville and San Antonio* Kathe Barrett Corpus Christi, San Antonio,* and Victoria Alan Brown Cleburne, Denton, and Fort Worth Vacant at time of printing Corsicana, Dallas,* and Groesbeck Sandra Peterson Dallas,* Paris, and Whitesboro Justin Raymond Texarkana and Tyler Trilby Foster Beaumont and Lufkin Gene Allred Bryan/College Station, Conroe, and Houston* Linda Wood Houston,* Ft. Bend Stephen Hirschfelder Chambers, Galveston, Brazoria, Houston,* Wharton, and Matagorda Michael Duffee Out of State Provider Representative Joann Kunde *Austin, Dallas, Houston, and San Antonio territories are shared by two or more provider representatives. These territories are divided by ZIP Codes. Refer to the TMHP website at for the assigned representative to contact in each ZIP Code. For more information, contact the TMHP CSHCN Contact Center at No. 78, May CSHCN Services Program Provider Bulletin

23 Coding and Reimbursement Benefit Changes for Expendable Medical Supplies This is a update to an article titled April 2011 Benefit Changes for CSHCN Services Program Expendable Medical Supplies, which was published on February 11, 2011, on the TMHP website at This article replaced an article titled February 2011 Benefit changes to CSHCN Services Program Expendable Medical Supplies, which was published on December 17, The December article contained several errors, and providers should ignore the article. Effective for dates of service on or after April 1, 2011, some provider type and place-of-service (POS) limitations changed for some CSHCN Services Program expendable medical supplies procedure codes: The following table shows the affected procedure codes: Procedure Code Changes A4411, A4412, A5120 Services in the home setting are a benefit when rendered by home health DME providers. B4034, B4081 Services rendered in the office setting are no longer a benefit. Services in the home setting are no longer a benefit when rendered by medical supply company providers. B4082, B4083, B4036 Services rendered in the office setting are no longer a benefit. A6000 Services in the home setting are no longer a benefit when rendered by home health agency and medical supply company providers. Is no longer a benefit. Effective for dates of service on or after April 1, 2011, the procedure codes in the following table are a benefit of the CSHCN Services Program as indicated: Procedure Code Changes A4248, A4306 Services in the home setting are a benefit when rendered by home health DME, DME medical supplier, and CSHCN Services Program custom DME providers. A4305 A4332 Services in the home setting are a benefit when rendered by home health DME, DME medical supplier, and CSHCN Services Program custom DME providers. Services in the home setting are a benefit when rendered by home health DME, DME medical supplier, and CSHCN Services Program custom DME providers. A total of 50 services may be reimbursed per calendar month when billed by any provider. A4331, A4333, A4334 Services in the home setting are a benefit when rendered by home health DME, DME medical supplier, and CSHCN Services Program custom DME providers. A4366, A4416, A4417, A4419, A4423, A4424, A4425, A4426, A4427, A4429, A4430, A4431, A4432, A4433, A4434 A total of two services may be reimbursed per calendar month when billed by any provider. Services in the home setting are a benefit when rendered by home health DME, DME medical supplier, and CSHCN Services Program custom DME providers. Benefit Changes for Replacement Hearing Aid Batteries Effective November 17, 2010 for dates of service on or after September 1, 2009, procedure code V5266 may be reimbursed to hearing aid fitter and dispenser providers for services rendered in the office, home, or other location setting. CSHCN Services Program Provider Bulletin 23 No. 78, May 2011

24 Coding and Reimbursement Benefit Criteria Changes for Cranial Molding Orthosis Effective for dates of service on or after February 1, 2011, the benefit criteria for cranial molding orthosis changed for the CSHCN Services Program. A cranial molding orthosis (procedure code S1040) is a benefit of the CSHCN Services Program for clients who are 3 through 12 months of age if it is prior authorized and the cranial molding orthosis is part of a treatment plan for shaping the skull in cases of postoperative synostotic plagiocephaly or positional plagiocephaly with an associated functional impairment. Documentation that the use of the cranial molding orthosis will modify or prevent the development of such impairment is required. The effective use of cranial molding orthosis for the treatment of brachycephaly, or a high cephalic index without cranial asymmetry, has not been clearly documented; therefore, a cranial molding orthosis is not medically necessary and is not a benefit of the CSHCN Services Program. A cranial molding orthosis for nonsynostotic plagiocephaly must be prior authorized for reimbursement through the CSHCN Services Program. The prior authorization request must be submitted with documentation of all of the following: The plan of treatment or follow-up schedule The assessment and recommendations of the appropriate primary care physician, pediatric subspecialist, craniofacial team, or pediatric neurosurgeon A full description of the physical findings, precise diagnosis, age of onset, and the etiology of the deformity Reports of any radiological procedures that were used to make the diagnosis The client is at least 3 months of age but not greater than 12 months of age Anthropometric measurements that document a cranial asymmetry that is greater than 10-mm Aggressive repositioning interventions were attempted, with or without physical therapy, for a duration of at least three months without improvement in cranial asymmetry. Repositioning interventions may include: Repositioning the client s head to the opposite side of the preferred position when the client is either lying down, reclined, or sitting. Gently turning and stretching the client s neck at each diaper change. Repositioning the client s bed to encourage the client to look away from the flattened side to view other objects of interest. The trial of repositioning intervention has failed to improve the deformity and is judged to be unlikely to do so. Note: Repositioning may not be indicated for children over 6 months of age. Repositioning therapy for this age group may be waived with documentation of medical necessity. Prior authorization requests for clients with a comorbid diagnosis that prohibits repositioning will be evaluated on an individual basis. For clients who have had prior cranial molding orthoses, providers must submit documentation of medical necessity that includes new anthropometric measurements when requesting subsequent cranial molding orthoses. Muscular torticollis (wry neck), which is characterized by tight or shortened neck muscles that result in a head tilt or turn, is often associated with the secondary development of positional plagiocephaly; therefore, clients with muscular torticollis and positional plagiocephaly must have documentation of early, aggressive treatment (stretching, positioning, and physiotherapy) before consideration of prior authorization for cranial orthosis. Cranial molding orthoses are reimbursed the lower of the billed amount, the amount allowed by CMS (when available), or Texas Medicaid. Benefit Criteria Changes for Expendable Medical Supplies Effective for dates of service on or after April 1, 2011, benefit criteria for expendable medical supplies changed for the CSHCN Services Program. The limitation for disposable underpads (procedure codes A4554, T4541, and T4542) decreased from 150 per month to 120 per month. The limitation for the following incontinence supply procedure codes decreased from 300 per month to 240 per month: Procedure Codes T4521 T4522 T4523 T4524 T4525 T4526 T4527 T4528 T4529 T4530 T4531 T4532 T4533 T4534 T4535 T4543 For quantities greater than the limitations indicated, prior authorization is required with documentation of medical necessity. No. 78, May CSHCN Services Program Provider Bulletin

25 Coding and Reimbursement Biofeedback Services are a Benefit Effective for dates of service on or after April, 1, 2011, biofeedback services are a benefit of the CSHCN Services Program. Biofeedback is a form of therapy in which physiologic activity is monitored, amplified, and conveyed by visual or acoustic signals. The CSHCN Services Program will reimburse biofeedback services for clients who are 4 years of age and older for the following conditions: Urinary incontinence Fecal incontinence Biofeedback services may be reimbursed using procedure codes and to physicians in the office or outpatient setting. Procedure codes and are limited to a maximum of 18 sessions rendered by any provider for the lifetime of each client for each condition. The physician must provide correct and complete information, including documentation establishing medical necessity of the service requested, which must remain in the client s medical record. Documentation may be subject to retrospective review. Biofeedback Certification A staff member who is certified by Biofeedback Certification International Alliance (BCIA) must perform biofeedback services. The certification types that may be accepted for performing urinary and fecal incontinence biofeedback are the following: General biofeedback certification (BCB) Pelvic muscle dysfunction biofeedback certification (BCB-PMD) The prescribing physician must maintain in the office a record of the current certification of the staff member(s) who perform biofeedback. Prior Authorization Requirements Prior authorization is required for biofeedback services. The initial request for services may be considered for up to 12 visits for a period not to exceed a total duration of 12 weeks. Documentation of the following must be submitted for consideration of prior authorization: Failure of pharmacotherapy and behavioral training Evidence of dyssynergic or nonrelaxing detrusor/ voluntary sphincter activity based on urodynamic evaluation to include urinary flow testing and complex cystometry Agreement by the client actively to participate in the biofeedback sessions Diagnosis of fecal, stress, urge, overflow, or a mix of stress and urge incontinence Medical records that indicate that the physician has excluded any underlying medical conditions that could be causing the problem For clients who are 21 years of age and older with a diagnosis of stress, urge, overflow, or a mix of stress and urge incontinence, the medical records must indicate failed pelvic muscle exercise (PME) service. Note: A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of PME exercises. After the client completes the initial biofeedback treatment course, prior authorization may be considered for a total of six follow-up sessions not to exceed three sessions per week and total duration not to exceed eight weeks. Prior authorization documentation submitted must be for the same condition as the original request and must include each original symptom, and how the symptom has objectively improved. Documentation of the following may include, but is not limited to, the following: For urinary incontinence, the biofeedback therapy should result in improvement of continence scores. There should be a decrease in high-grade stress incontinence, nocturnal enuresis, and loss of urine during activity. For clients who are 21 years of age and older, the pelvic floor muscle contraction strength should improve with the ability to hold the contractions longer and to increase repetitions. For fecal incontinence, the biofeedback therapy should result in improvement of continence scores. Squeeze and anal pressures, squeeze duration, and for clients who are 21 years of age and older, pelvic floor muscle contraction strength should show improvement. Prior authorization requests for biofeedback services must be submitted on the CSHCN Services Program Request for Authorization and Prior Authorization Request Form. This form may be submitted by fax to or by mail to the following address: TMHP-CSHCN Services Program Authorization Department B Riata Trace Parkway Austin, TX CSHCN Services Program Provider Bulletin 25 No. 78, May 2011

26 Coding and Reimbursement Reimbursement Limitations Procedure codes and are limited to one service per day, for each date of service, by any provider, to include all modalities of the services performed during a specific session regardless of the number of modalities performed. Any device used during a biofeedback session is considered part of the procedure and will not be reimbursed separately. Procedure code will be denied if a claim is submitted for the same date of service, by the same provider as procedure code Noncovered Services Neurofeedback, such as, but not limited to, electroencephalography (EEG) biofeedback, is not a benefit of the CSHCN Services Program. Correction to Benefit Changes for Some Expendable Medical Supplies This is a correction to an article titled Benefit Changes for Some Expendable Medical Supplies, which was published in the February 2011 CSHCN Services Program Provider Bulletin, No. 77, and which was originally published on the TMHP website at on August 27, The article incorrectly stated that benefit changes would be effective for dates of service on or after October 1, The correct effective date for benefit changes was November 1, Notice of the corrected effective date was posted on the TMHP website on October 1, Correction to CSHCN Services Program Reimbursement Rates Will Change December 2010 for Some Surgical Services This is a correction to an article titled CSHCN Services Program Reimbursement Rates Will Change December 2010 for Some Surgical Services, which was published on October 8, 2010, on the TMHP website at The article listed incorrect fees for procedure codes 37183, 37184, 37186, 37187, 37188, and The corrected fees appear in the following table: Current and Corrected Fees TOS Procedure Code Age Range Current RVU Current CF Current Fee Corrected RVU Corrected CF Corrected Fee All ages $27.28 $ $28.64 $ years of age and older Fee Difference $ $27.28 $ All ages $27.28 $ $28.64 $ years of age and older $ $27.28 $ All ages 6.90 $27.28 $ $28.64 $ years of age and older $ $27.28 $ All ages $27.28 $ $28.64 $ years of age and older $ $27.28 $ (TOS) Type of service. (RVU) Relative value unit. (CF) Conversion factor. (Corrected Fee) The fee that will be effective for dates of service on or after December 1, (Fee Difference) The difference between the current fee and the fee that will be effective for dates of service on or after December 1, No. 78, May CSHCN Services Program Provider Bulletin

27 Coding and Reimbursement TOS Procedure Code Age Range Current RVU Current CF Current Fee Corrected RVU Corrected CF Corrected Fee Fee Difference All ages 8.45 $27.28 $ $28.64 $ years of age and older $ $27.28 $ All ages 9.80 $27.28 $ $28.64 $ years of age and older $ $27.28 $ (TOS) Type of service. (RVU) Relative value unit. (CF) Conversion factor. (Corrected Fee) The fee that will be effective for dates of service on or after December 1, (Fee Difference) The difference between the current fee and the fee that will be effective for dates of service on or after December 1, Update to DME Provider Taxonomy Code Changes This is a follow-up to the article titled DME Provider Taxonomy Code Changes, which was published on February 11, 2011, on the TMHP website. DME providers that will render custom wheeled mobility systems and services to Texas Medicaid clients must reattest the NPI numbers that are associated with their Texas Medicaid provider identifiers. NPI numbers that are associated with CSHCN Services Program provider identifiers do not need to be reattested. Taxonomy code 332BC3200X will not be replaced for CSHCN Services Program providers. Providers can refer to the original article for more information. Oral and Maxillofacial Surgery Procedures Requiring Prior Authorization Prior authorization is required for most oral and maxillofacial surgery, including, but not limited to, invasive procedures for clients who have a cleft lip, cleft palate, or craniofacial anomaly. Prior authorization is required for procedure codes D7261, D7411, D7413, D7414, and D7472. Updated List of Drugs Requiring National Drug Code (NDC) for Reimbursement Effective for dates of service on or after March 21, 2011, claims for the following injection procedure codes must be submitted with an 11-digit NDC: J0885, J0886, J0894, J2469, J2820, J9025, and J9263. The NDC to use is on the package or container from which the medication was administered. Claims that are submitted to the CSHCN Services Program without the correct NDC information will be denied, even if the procedures are prior authorized. CSHCN Services Program Provider Bulletin 27 No. 78, May 2011