January 2006 HCPCS Special Bulletin, No. 193 - TMHP.com

T EXAS MEDICAID BULLETIN
2006 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin
2006 HCPCS SPECIAL BULLETIN NO. 193
2006 HCPCS Implementation
This is a combined, special bulletin for all Medicaid and
Children with Special Health Care Needs (CSHCN)
Services Program providers. This bulletin is intended to
notify providers of program and coding changes related to
the 2006 Healthcare Common Procedure Coding System
(HCPCS) implementation.
On January 13, 2006, the Texas Medicaid & Healthcare
Partnership (TMHP) will apply the annual 2006 HCPCS
additions, changes, and deletions, effective for dates of
service on or after January 1, 2006. The 2006 deleted
procedure codes will no longer be reimbursed after
December 31, 2005. It is recommended that providers
not submit claims for procedure codes that have been
added until after the updates are implemented in the
system. If claims are submitted prior to the updates being
made, they will be denied. Any denials received between
January 1 and January 13, 2006, due to a HCPCS update
must be appealed by the provider.
Providers who have received prior authorizations for a
2006 discontinued code for dates of services that occur
on, after, or encompass January 1, 2006, must contact
the TMHP Prior Authorization Department to update
the HCPCS procedure codes authorized for those services
except for the procedure codes listed below. Please do not
request changes to authorizations prior to January 13, 2006.
Prior authorizations for the list of codes below will be
updated by TMHP and require no action on the part of
the provider.
Procedure Codes
33918 33919 44200 97504 97520
97703 A5119 B4184 E0972 K0618
K0619 K0620 K0630– K0670 L0860
K0649
L8100 L8110 L8120 L8130 L8140
L8150 L8160 L8170 L8180 L8190
L8195 L8200 L8210 L8220 L8230
L8239
For information specific to the CSHCN authorization process
please see page 24 of this bulletin.
All providers are encouraged to review the “All Providers”
section of this bulletin. Policy updates for specific programs and
provider types are discussed in that program or provider type’s
section of the bulletin.
INSIDE
All Providers 1
2006 HCPCS Implementation 1
2006 Clinical Laboratory Fee Schedule 2
Medicaid Program Policy Updates 2
HCPCS Replacement Codes 2
2006 HCPCS Additions 5
2005 Quarterly Additions 17
Discontinued Codes 19
Description Changes 20
Modifiers 21
ASC/HASC Providers 21
ASC/HASC Code Additions 21
Home Health Providers 21
Title XIX Home Health Policy Updates 21
THSteps-CCP Providers 22
Standing Frames 22
CSHCN Providers 22
CSHCN Program Policy Updates 22
CSHCN HCPCS Additions 23
2005 Quarterly Additions 24
Prior Authorization Update 24
Forms 26
Provider Information Change Form 26
Electronic Funds Transfer 28

All Providers
2006 Clinical Laboratory
Fee Schedule
The National Limitation Amount
(NLA) calculation for 2006 remains
at 74 percent of the median of
the local fees for tests for which
NLAs were established before
January 1, 2001. In accordance with
Section 1833(h)(4)(B)(viii) of the
Social Security Act (amended by Section 531 of the Benefits
Improvement and Protection Act [BIPA] of 2000), the NLA
calculation for 2006 is 100 percent of the median of the
local fees for tests for which NLAs are established on or
after January 1, 2001. In accordance with Section 4553 of
the Balanced Budget Act of 1997 (which amended Section
1833[h][4][B] of the Social Security Act), there is no annual
update (economic index) to the local laboratory fees for
2006.
Medicaid Program Policy Updates
The following Medicaid Program policy updates have
been made to support the 2006 HCPCS implementation.
Lipids
Effective for dates of service on or after January 1, 2006,
procedure code 9-B4185 is a benefit of the Texas
Medicaid Program when submitted with documentation
HCPCS Replacement Codes
of medical necessity and prior authorized. Procedure code
9-B4185 is reimbursed on a daily basis, but will be denied
as part of another service if hyperalimentation/total
parenteral nutrition is also prior authorized.
Antihemophilic Factors
Effective for dates of service on or after January 1, 2006,
1-Q0187 and 1-Q2022 are no longer benefits of the Texas
Medicaid Program.
Procedure codes 1-J7188 and 1-J7189 are benefits of Texas
Medicaid. Procedure code 1-J7188 is limited to diagnosis
code 2864, and procedure code 1-J7189 is limited to
diagnosis codes 2860 and 2861.
Nursing Facility Services
Effective for dates of service on or after January 1, 2006,
procedure code 1-99318 is a benefit of the Texas
Medicaid Program and is limited to once per year.
Incidental Services
Effective for dates of service on or after January 1, 2006,
the following procedure codes are benefits of the Texas
Medicaid Program:
Procedure Codes
1-90760 1-90761 1-90765 1-90766 1-90767
1-90768 1-96521 1-96522 1-96523
The above procedure codes will be denied as part of
another service if billed in conjunction with a surgical or
anesthesia procedure.
The following is a list of discontinued procedure codes and the corresponding new replacement HCPCS codes. All
providers are encouraged to review this table and the tables on the following pages in addition to the sections of this
bulletin applicable to their provider type.
Discontinued Replacement TOS /
Procedure Code Procedure Code Allowable
90780 90760 1 = 1.67 RVUs
90780 90765 1 = 2.04 RVUs
90780 90766 1 = 0.68 RVUs
90782 90772 1 = 0.49 RVUs
Medicaid / Managed
Care Comments
CSHCN
Comments
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
Texas Medicaid Bulletin, No. 193 2 2006 HCPCS Special Bulletin

Discontinued Replacement TOS /
Medicaid / Managed CSHCN
Procedure Code Procedure Code Allowable
Care Comments
Comments
90783 90773 1 = $12.00
90784 90774 1 = 1.52 RVUs
96100 96101 1 = $71.69 (SHARS)
96117 96118 1 = 1.88 RVUs
96400 96401 1 = 1.75 RVUs
96400 96402 1 = 0.94 RVUs
96408 96409 1 = 0.93 RVUs
96410 96413 1 = 1.43 RVUs
96412 96415 NC
96520 96521 1 = 0.96 RVUs
96530 96522 1 = 1.13 RVUs
99052 99053 NC
99054 99051 NC
99301-99303;
99311-99313
99304 1 = 1.43 RVUs
99301-99303;
99311-99313
99305 1 = 1.71 RVUs
99301-99303;
99311-99313
99306 1 = 2.32 RVUs
99301-99303;
99311-99313
99307 1 = 0.89 RVUs
99301-99303;
99311-99313
99308 1 = 1.18 RVUs
99301-99303;
99311-99313
99309 1 = 1.60 RVUs
99301-99303;
99311-99313
99310 1 = 1.60 RVUs
99301-99303;
99311-99313
99318 1 = 1.43 RVUs
A5119 A5120 9 = $0.18
A9523 A9543 9 = MR
A9534 A9545 NC
C9129 J9027 1 = $114.75
J1563 J1566 1 = $35.07
J1563 J1567 1 = $41.31
J1750 J1751 1 = $16.02
J1750 J1752 1 = $16.02
K0618 L0491 9** = $621.58 PA A
K0619 L0492 9** = $402.85 PA A
K0630 L0621 9** = $75.19 PA A
K0631 L0622 9** = $194.97 PA A
K0632 L0623 9** = MR PA A
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
3
All Providers
Texas Medicaid Bulletin, No. 193

All Providers
Discontinued Replacement TOS /
Medicaid / Managed CSHCN
Procedure Code Procedure Code Allowable
Care Comments
Comments
K0633 L0624 9** = MR PA A
K0634 L0625 9** = $44.59 PA A
K0635 L0626 9** = $63.09 PA A
K0636 L0627 9** = $332.68 PA A
K0637 L0628 9** = $67.89 PA A
K0638 L0629 9** = $170.13 PA A
K0639 L0630 9** = $131.06 PA A
K0640 L0631 9** = $830.85 PA A
K0641 L0632 9** = MR PA A
K0642 L0633 9** = $232.08 PA A
K0643 L0634 9** = MR PA A
K0644 L0635 9** = $800.80 PA A
K0645 L0636 9** = $1,085.59 PA A
K0646 L0637 9** = $844.89 PA A
K0647 L0638 9** = $1,067.44 PA A
K0648 L0639 9** = $648.94 PA A
K0649 L0640 9** = $846.86 PA A
L0860 L0859 9** = $1,138.35 PA A
L8120 A6532 9 = $60.96 PA A
L8130 A6533 9 = $45.10 PA A
L8140 A6534 9 = $49.98 PA A
L8150 A6535 9 = $70.41 PA A
L8160 A6536 9 = $51.66 PA A
L8170 A6537 9 = $74.99 PA A
L8180 A6538 9 = $77.90 PA A
L8190 A6539 9 = $74.60 PA A
L8195 A6540 9 = $75.84 PA A
L8200 A6541 9 = $98.40 PA A
L8210 A6542 9 = $177.94 PA A
L8220 A6543 9 = $45.69 PA A
L8230 A6544 9 = $34.03 PA A
L8239 A6549 9 = MR PA A
Q0136 J0885 1 = $11.44
Q0137 J0881 1 = $4.24
Q2019 J0480 1 = $1,445.31
Q4054 J0882 1 = $4.24
Q4055 J0886 1 = $11.44
S0071 J0133 1 = $0.20
For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Contact Center at
1-800-568-2413.
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
Texas Medicaid Bulletin, No. 193 4 2006 HCPCS Special Bulletin

2006 HCPCS Additions
The following is a list of new HCPCS procedure codes
that do not replace existing codes.
Procedure
Code
TOS /
Allowable
01965 7 = 4 units
01966 7 = 4 units
15040 2 = 3.37 RVUs
8 = NC
F = Group 2
15110 2 = 17.83 RVUs
8 = NC
F = Group 2
15111 2 = 2.90 RVUs
8 = NC
F = Group 1
15115 2 = 18.33 RVUs
8 = NC
F = Group 2
15116 2 = 3.95 RVUs
8 = NC
F = Group 1
15130 2 = 14.21 RVUs
8 = NC
F = Group 2
15131 2 = 2.35 RVUs
8 = NC
F = Group 1
15135 2 = 17.00 RVUs
8 = NC
F = Group 2
15136 2 = 2.37 RVUs
8 = NC
F = Group 1
15150 2 = 14.36 RVUs
8 = NC
F = Group 2
15151 2 = 2.48 RVUs
8 = NC
F = Group 1
15152 2 = 3.91 RVUs
8 = NC
F = Group 1
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
CSHCN
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
Procedure
Code
TOS /
Allowable
15155 2 = 17.03 RVUs
8 = NC
F = Group 2
15156 2 = 4.35 RVUs
8 = NC
F = Group 1
15157 2 = 4.74 RVUs
8 = NC
F = Group 1
15170 2 = 7.92 RVUs
8 = NC
F = Group 2
15171 2 = 2.36 RVUs
8 = NC
F = Group 1
15175 2 = 11.83 RVUs
8 = NC
F = Group 2
15176 2 = 2.48 RVUs
8 = NC
F = Group 1
15300 2 = 6.72 RVUs
8 = NC
F = Group 2
15301 2 = 1.54 RVUs
8 = NC
F = Group 1
15320 2 = 7.82 RVUs
8 = NC
F = Group 2
15321 2 = 2.30 RVUs
8 = NC
F = Group 1
15330 2 = 6.71 RVUs
8 = NC
F = Group 2
15331 2 = 1.54 RVUs
8 = NC
F = Group 1
15335 2 = 7.50 RVUs
8 = NC
F = Group 2
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
5
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
All Providers
CSHCN
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
Texas Medicaid Bulletin, No. 193

All Providers
Procedure
Code
TOS /
Allowable
15336 2 = 2.20 RVUs
8 = NC
F = Group 1
15340 2 = 6.89 RVUs
8 = NC
F = Group 2
15341 2 = 0.76 RVUs
8 = NC
F = Group 1
15360 2 = 7.39 RVUs
8 = NC
F = Group 2
15361 2 = 1.75 RVUs
8 = NC
F = Group 1
15365 2 = 7.81 RVUs
8 = NC
F = Group 2
15366 2 = 2.20 RVUs
8 = NC
F = Group 1
15420 2 = 8.82 RVUs
8 = NC
F = Group 2
15421 2 = 2.33 RVUs
8 = NC
F = Group 1
15430 2 = 13.04 RVUs
8 = NC
F = Group 2
15431 2 = 0.62 RVUs
8 = NC
F = Group 1
22010 2 = 9.87 RVUs
8 = NC
F = Group 3
22015 2 = 9.87 RVUs
8 = NC
F = Group 3
22523 2 = 16.29 RVUs
8 = 2.61 RVUs
F = Group 2
22524 2 = 15.61 RVUs
8 = 2.50 RVUs
F = Group 2
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
CSHCN
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
Procedure
Code
TOS /
Allowable
22525 2 = 7.47 RVUs
8 = 1.20 RVUs
F = Group 2
28890 NC
32503 2 = 46.39 RVUs
8 = 7.42 RVUs
F = NC
32504 2 = 50.60 RVUs
8 = 8.10 RVUs
F = NC
33507 2 = 47.73 RVUs
8 = 7.64 RVUs
F = NC
33548 2 = 62.83
8 = 10.05
F = NC
33768 2 = 11.98 RVUs
8 = 1.92 RVUs
F = NC
33880 2 = 35.27 RVUs
8 = 5.64 RVUs
F = NC
33881 2 = 35.27 RVUs
8 = 5.64 RVUs
F = NC
33883 2 = 19.09 RVUs
8 = 3.05 RVUs
F = NC
33884 2 = 6.07 RVUs
8 = 0.97 RVUs
F = NC
33886 2 = 6.07 RVUs
8 = 0.97 RVUs
F = NC
33889 2 = 23.28 RVUs
8 = 3.72 RVUs
F = NC
33891 2 = 29.70 RVUs
8 = 4.75 RVUs
F = NC
33925 2 = 36.82 RVUs
8 = 5.89 RVUs
F = NC
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
CSHCN
Texas Medicaid Bulletin, No. 193 6 2006 HCPCS Special Bulletin
F = A

Procedure
Code
TOS /
Allowable
33926 2 = 41.82 RVUs
8 = 6.69 RVUs
F = NC
36598 2 = 1.40 RVUs
8 = NC
F = Group 1
37184 2 = 12.57 RVUs
8 = 2.01 RVUs
F = Group 2
37185 2 = 4.60 RVUs
8 = 0.74 RVUs
F = Group 1
37186 2 = 6.90 RVUs
8 = 1.10 RVUs
F = Group 2
37187 2 = 11.69 RVUs
8 = 1.87 RVUs
F = Group 2
37188 2 = 8.45 RVUs
8 = 1.35 RVUs
F = Group 2
37718 2 = 10.97 RVUs
8 = 1.76 RVUs
F = Group 3
37722 2 = 13.07 RVUs
8 = 2.09 RVUs
F = Group 3
43770 NC
43771 NC
43772 NC
43773 NC
43774 NC
43886 NC
43887 NC
43888 NC
44180 2 = 22.52 RVUs
8 = 3.60 RVUs
F = Group 3
44186 2 = 15.84 RVUs
8 = 2.53 RVUs
F = Group 2
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
CSHCN
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
Procedure
Code
TOS /
Allowable
44187 2 = 26.17 RVUs
8 = 4.19 RVUs
F = Group 4
44188 2 = 18.44 RVUs
8 = 2.95 RVUs
F = Group 3
44213 2 = 3.67 RVUs
8 = 0.59 RVUs
F = NC
44227 2 = 40.52 RVUs
8 = 6.48 RVUs
F = Group 4
45395 2 = 47.83 RVUs
8 = 7.65 RVUs
F = NC
45397 2 = 51.98 RVUs
8 = 8.32 RVUs
F = Group 4
45400 2 = 25.25 RVUs
8 = 4.04 RVUs
F = Group 3
45402 2 = 27.72 RVUs
8 = 4.44 RVUs
F = Group 3
45499 2 = MR
8 = MR
F = MR
45990 2 = 1.39 RVUs
8 = NC
F = Group 2
46505 2 = 4.97 RVUs
8 = NC
F = Group 1
46710 2 = 25.15 RVUs
8 = 4.02 RVUs
F = NC
46712 2 = 33.62 RVUs
8 = 5.38 RVUs
F = NC
50250 2 = 30.54 RVUs
8 = 4.89 RVUs
F = Group 3
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
7
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
All Providers
CSHCN
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
Texas Medicaid Bulletin, No. 193

All Providers
Procedure
Code
TOS /
Allowable
50382 2 = 7.71 RVUs
8 = NC
F = Group 1
50384 2 = 7.02 RVUs
8 = NC
F = Group 1
50387 2 = 2.79 RVUs
8 = NC
F = Group 1
50389 2 = 1.54 RVUs
8 = NC
F = Group 1
50592 2 = 10.17 RVUs
8 = NC
F = Group 2
51999 2 = MR
8 = MR
F = MR
57295 2 = 12.80 RVUs
8 = 2.05 RVUs
F = Group 2
58110 2 = 1.17 RVUs
8 = NC
F = Group 1
61630 NC
61635 NC
61640 NC
61641 NC
61642 NC
64650 2 = 1.06 RVUs
8 = NC
F = Group 1
64653 2 = 1.34 RVUs
8 = NC
F = Group 1
75956 NC
75957 NC
75958 NC
75959 NC
76376 4 = 3.8 RUVs
I = 0.29 RVUs
T = 3.51 RVUs
Medicaid /
Managed Care
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
PA (Managed
Care Only)
CSHCN
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
F = A
Procedure
Code
TOS /
Allowable
76377 4 = 4.01 RVUs
I = 0.24 RVUs
T = 3.77 RVUs
77421 4 = 4.00 RVUs
I = 0.54 RVUs
T = 3.46 RVUs
77422 6 = NC
I = NC
T = 1.89 RVUs
77423 6 = NC
I = NC
T = 1.89 RVUs
80195 5 = $18.97
82271 5 = $4.49
82272 5 = $4.49
83037 5 = $27.42
83631 5 = $27.42
83695 5 = $18.09
83700 5 = $15.56
83701 5 = $34.30
83704 5 = $34.30
83900 5 = $14.07
83907 5 = $14.07
83908 5 = $14.07
83909 5 = $14.07
83914 5 = $14.07
86200 5 = $16.70
86355 5 = $52.13
86357 5 = $52.13
86367 5 = $52.13
86480 5 = $52.13
I = NC
T = NC
86923 5 = $13.39
I = NC
T = NC
86960 5 = $16.73
I = NC
T = NC
87209 5 = $12.09
Medicaid /
Managed Care
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
CSHCN
Texas Medicaid Bulletin, No. 193 8 2006 HCPCS Special Bulletin

Procedure
Code
TOS /
Allowable
87900 5 = $182.11
88333 NC
88334 NC
88384 5 = $31.44
88385 5 = 2.21 RVUs
I = NC
T = NC
88386 5 = 2.78 RVUs
I = NC
T = NC
89049 5 = 5.02 RVUs
I = NC
T = NC
90649 NC
90714 1 = Informational
Only
90736 NC
90761 1 = 0.53 RVUs
90767 1 = 1.12 RVUs
90768 1 = 0.65 RVUs
90775 1 = 0.71 RVUs
90779 1 = MR
91022 NC
92626 1 = 0.61 RVUs
92627 1 = 0.15 RVUs
92630 1 = 3.01 RVUs
92633 1 = 3.01 RVUs
95251 NC
95865 5 = 3.13 RVUs
I = 2.42 RVUs
T = 0.71 RVUs
95866 5 = 2.11 RVUs
I = 1.88 RVUs
T = 0.23 RVUs
95873 1 = 0.77 RVUs
95874 1 = 0.78 RVUs
96101 5 = 1.88 RVUs
I = NC
T = NC
96102 NC
Medicaid /
Managed Care
CSHCN
Procedure
Code
TOS /
Allowable
Medicaid /
Managed Care
96103 NC
96116 NC
96118 1 = 1.88 RVUs
96119 NC
96120 NC
96411 1 = 0.93 RVUs
96416 NC
96417 NC
96523 1 = 0.74 RVUs
97760 1 = $35.00 A
97761 1 = $35.00
C = NC
A
97762 1 = $35.00 A
98960 NC
98961 NC
98962 NC
99060 1 = $12.69
99143 NC
99144 NC
99145 NC
99148 NC
99149 NC
99150 NC
99300 1 = 3.58 RVUs
99324 1 = 1.16 RVUs
99325 1 = 1.67 RVUs
99326 1 = 2.20 RVUs
99327 1 = 2.20 RVUs
99328 1 = 2.20 RVUs
99334 1 = 1.20 RVUs
99335 1 = 1.83 RVUs
99336 1 = 2.68 RVUs
99337 1 = 2.68 RVUs
99339 NC
99340 NC
0089T NC
0090T NC
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
9
All Providers
CSHCN
Texas Medicaid Bulletin, No. 193

All Providers
Procedure
Code
TOS /
Allowable
0091T NC
0092T NC
0093T NC
0094T NC
0095T NC
0096T NC
0097T NC
0098T NC
0099T NC
0100T NC
0101T NC
0102T NC
0103T NC
0104T NC
0105T NC
0106T NC
0107T NC
0108T NC
0109T NC
0110T NC
0111T NC
0115T NC
0116T NC
0117T NC
0120T NC
0123T NC
0124T NC
0126T NC
0130T NC
0133T NC
0135T NC
0137T NC
0140T NC
0141T NC
0142T NC
0143T NC
0144T NC
Medicaid /
Managed Care
CSHCN
Procedure
Code
TOS /
Allowable
Medicaid /
Managed Care
0145T NC
0146T NC
0147T NC
0148T NC
0149T NC
0150T NC
0151T NC
0152T NC
0153T NC
0154T NC
1003F NC
1004F NC
1005F NC
1006F NC
1007F NC
1008F NC
2001F NC
2002F NC
2003F NC
2004F NC
3000F NC
3002F NC
4003F NC
4012F NC
4014F NC
4015F NC
4016F NC
4017F NC
4018F NC
A0998 NC
A4218 NC, Bill
Vendor Drug
Program
A4233 9 = $6.55 A
A4234 9 = $6.55 A
A4235 9 = $6.55 A
A4236 9 = $6.55 A
A4363 9 = $1.58
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
CSHCN
Texas Medicaid Bulletin, No. 193 10 2006 HCPCS Special Bulletin

Procedure
Code
TOS /
Allowable
Medicaid /
Managed Care
A4411 9 = $3.72
A4412 9 = $5.50
A4604 NC
A5512 NC
A5513 NC
A6457 9 = $1.14 PA A
A6513 9 = MR PA A
A6530 9 = $36.35 PA A
A6531 9 = $43.27 PA A
A6550 9 = $51.97 PA
A9275 9 = $30.74 PA
A9281 NC
A9282 NC
A9535 NC
A9536 NC
A9537 NC
A9538 NC
A9539 NC
A9540 NC
A9541 NC
A9542 NC
A9544 NC
A9546 NC
A9547 NC
A9548 NC
A9549 NC
A9550 NC
A9551 NC
A9552 NC
A9553 NC
A9554 NC
A9555 NC
A9556 NC
A9557 NC
A9558 NC
A9559 NC
A9560 NC
CSHCN
Procedure
Code
TOS /
Allowable
Medicaid /
Managed Care
A9561 NC
A9562 NC
A9563 9 = $69.39
A9564 9 = $155.47
A9565 NC
A9566 NC
A9567 NC
A9698 NC
B4185 9 = $87.60 PA A
E0170 NC
E0171 NC
E0172 NC
E0485 NC
E0486 NC
E0641 9 = NC
J = $853.57
L = NC
PA A
E0642 9 = NC
J** = MR
L = NC
PA A
E0705 9 = NC
J = $37.91
L = NC
PA A
E0762 NC
E0764 NC
E0911 9 = NC
J = $211.64
L = $18.13
PA A
E0912 9 = NC
J = $311.72
L = $28.40
PA A
E1392 NC
E1812 9 = NC
J** = $1,935.20
L = NC
PA
E2207 9 = NC
J = $43.35
L = $4.34
PA A
E2208 9 = NC
J = $118.78
L = $11.87
PA A
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
11
All Providers
CSHCN
Texas Medicaid Bulletin, No. 193

All Providers
Procedure
Code
TOS /
Allowable
E2209 9 = NC
J = $107.16
L = $10.74
E2210 9 = NC
J = $6.55
L = NC
E2211 9 = NC
J = $29.24
L = NC
E2212 9 = NC
J = $5.88
L = NC
E2213 9 = NC
J = $29.24
L = NC
E2214 9 = NC
J = $30.60
L = NC
E2215 9 = NC
J = $9.60
L = NC
E2216 9 = NC
J = $29.24
L = NC
E2217 9 = NC
J = $32.88
L = NC
E2218 9 = NC
J = $29.24
L = NC
E2219 9 = NC
J = $32.88
L = NC
E2220 9 = NC
J = $24.24
L = NC
E2221 9 = NC
J = $25.55
L = NC
E2222 9 = NC
J = $32.88
L = NC
Medicaid /
Managed Care
CSHCN
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
PA A
Procedure
Code
TOS /
Allowable
E2223 9 = NC
J = MR
L = NC
E2224 9 = NC
J = $45.02
L = NC
E2225 9 = NC
J = $32.88
L = NC
E2226 9 = NC
J = $45.88
L = NC
E2371 9 = NC
J = $186.00
L = NC
E2372 NC
G0235 NC
G0332 NC
G0333 NC
G0372 NC
G0375 NC
G0376 NC
G0378 NC
G0379 NC
G8006 NC
G8007 NC
G8008 NC
G8009 NC
G8010 NC
G8011 NC
G8012 NC
G8013 NC
G8014 NC
G8015 NC
G8016 NC
G8017 NC
G8018 NC
G8019 NC
Medicaid /
Managed Care
CSHCN
PA A
PA A
PA A
PA A
PA A
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
Texas Medicaid Bulletin, No. 193 12 2006 HCPCS Special Bulletin

Procedure
Code
TOS /
Allowable
G8020 NC
G8021 NC
G8022 NC
G8023 NC
G8024 NC
G8025 NC
G8026 NC
G8027 NC
G8028 NC
G8029 NC
G8030 NC
G8031 NC
G8032 NC
G8033 NC
G8034 NC
G8035 NC
G8036 NC
G8037 NC
G8038 NC
G8039 NC
G8040 NC
G8041 NC
G8051 NC
G8052 NC
G8053 NC
G8054 NC
G8055 NC
G8056 NC
G8057 NC
G8058 NC
G8059 NC
G8060 NC
G8061 NC
G8062 NC
G8075 NC
G8076 NC
Medicaid /
Managed Care
CSHCN
Procedure
Code
TOS /
Allowable
G8077 NC
G8078 NC
G8079 NC
G8080 NC
G8081 NC
G8082 NC
G8093 NC
G8094 NC
G8099 NC
G8100 NC
G8103 NC
G8104 NC
G8106 NC
G8107 NC
G8108 NC
G8109 NC
G8110 NC
G8111 NC
G8112 NC
G8113 NC
G8114 NC
G8115 NC
G8116 NC
G8117 NC
G8126 NC
G8127 NC
G8128 NC
G8129 NC
G8130 NC
G8131 NC
G8152 NC
G8153 NC
G8154 NC
G8155 NC
G8156 NC
G8157 NC
Medicaid /
Managed Care
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
13
All Providers
CSHCN
Texas Medicaid Bulletin, No. 193

All Providers
Procedure
Code
TOS /
Allowable
G8158 NC
G8159 NC
G8160 NC
G8161 NC
G8162 NC
G8163 NC
G8164 NC
G8165 NC
G8166 NC
G8167 NC
G8170 NC
G8171 NC
G8172 NC
G8182 NC
G8183 NC
G8184 NC
G8185 NC
G8186 NC
G9033 NC
G9041 NC
G9042 NC
G9043 NC
G9044 NC
G9050 NC
G9051 NC
G9052 NC
G9053 NC
G9054 NC
G9055 NC
G9056 NC
G9057 NC
G9058 NC
G9059 NC
G9060 NC
G9061 NC
G9062 NC
G9063 NC
Medicaid /
Managed Care
CSHCN
Procedure
Code
TOS /
Allowable
G9064 NC
G9065 NC
G9066 NC
G9067 NC
G9068 NC
G9069 NC
G9070 NC
G9071 NC
G9072 NC
G9073 NC
G9074 NC
G9075 NC
G9076 NC
G9077 NC
G9078 NC
G9079 NC
G9080 NC
G9081 NC
G9082 NC
G9083 NC
G9084 NC
G9085 NC
G9086 NC
G9087 NC
G9088 NC
G9089 NC
G9090 NC
G9091 NC
G9092 NC
G9093 NC
G9094 NC
G9095 NC
G9096 NC
G9097 NC
G9098 NC
G9099 NC
G9100 NC
Medicaid /
Managed Care
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
CSHCN
Texas Medicaid Bulletin, No. 193 14 2006 HCPCS Special Bulletin

Procedure
Code
TOS /
Allowable
G9101 NC
G9102 NC
G9103 NC
G9104 NC
G9105 NC
G9106 NC
G9107 NC
G9108 NC
G9109 NC
G9110 NC
G9111 NC
G9112 NC
G9113 NC
G9114 NC
G9115 NC
G9116 NC
G9117 NC
G9118 NC
G9119 NC
G9120 NC
G9121 NC
G9122 NC
G9123 NC
G9124 NC
G9125 NC
G9126 NC
G9127 NC
G9128 NC
G9129 NC
G9130 NC
J0132 1 = $1.92
J0278 1 = $1.33
J0365 NC
J0795 1 = $4.39
J1162 1 = $510.00
J1265 1 = $0.58
J1430 1 = $70.98
Medicaid /
Managed Care
CSHCN
Procedure
Code
TOS /
Allowable
J1451 1 = $11.29
J1640 NC
J1675 NC
J1945 1 = $147.29
J2278 1 = $6.21
J2325 1 = $30.03
J2425 1 = $11.22
J2503 1 = $101.49
J2504 1 = $166.60
J2513 1 = $12.98
J2805 NC
J2850 NC
J3285 1 = $58.18
J3355 NC
J3471 1 = $0.13
J3472 1 = $130.00
J7188 1 = $0.85
J7189 1 = $1.26
J7306 NC
J7341 1 = $26.32
J7620 1 = $0.80
J7627 NC
J7640 NC
J8498 NC, Bill
Vendor Drug
Program
J8515 NC, Bill
Vendor Drug
Program
J8540 NC, Bill
Vendor Drug
Program
J8597 NC, Bill
Vendor Drug
Program
J9025 1 = $4.05
J9175 NC
J9225 1 = $5,100.00
J9264 1 = $8.46
Medicaid /
Managed Care
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
15
All Providers
CSHCN
Texas Medicaid Bulletin, No. 193

All Providers
Procedure
Code
TOS /
Allowable
Medicaid /
Managed Care
L2034 9** = $625.40 PA A
L2387 9** = $87.90 PA A
L3671 9** = $48.48 PA A
L3672 9** = $580.17 PA A
L3673 9** = $580.17 PA A
L3702 9** = $79.12 PA A
L3763 9** = $79.12 PA A
L3764 9** = $364.35 PA A
L3765 9** = $79.12 PA A
L3766 9** = $833.68 PA A
L3905 9** = $833.68 PA A
L3913 9** = $184.18 PA A
L3919 9** = $184.18 PA A
L3921 9** = $184.18 PA A
L3933 9** = $37.71 PA A
L3935 9** = $37.71 PA A
L3961 9** = $580.17 PA A
L3967 9** = $417.08 PA A
L3971 9** = $959.63 PA A
L3973 9** = $959.63 PA A
L3975 9** = $417.08 PA A
L3976 9** = $580.17 PA A
L3977 9** = $959.63 PA A
L3978 9** = $959.63 PA A
L5703 9** = $1,988.95 PA A
L5858 9** = $1,453.47 PA A
L5971 9** = $667.39 PA A
L6621 9** = $212.21 PA A
L6677 9** = $83.66 PA A
L6883 9** = MR PA A
L6884 9** = MR PA A
L6885 9** = MR PA A
L7400 9** = MR PA A
L7401 9** = MR PA A
L7402 9** = MR PA A
L7403 9** = MR PA A
L7404 9** = MR PA A
CSHCN
Procedure
Code
TOS /
Allowable
Medicaid /
Managed Care
L7405 9** = MR PA A
L7600 9** = MR PA A
L8609 NC
L8623 9** = $52.45 PA A
L8624 9** = $52.45 PA A
L8680 NC
L8681 NC
L8682 NC
L8683 NC
L8684 NC
L8685 NC
L8686 NC
L8687 NC
L8688 NC
L8689 NC
Q0510 NC
Q0511 NC
Q0512 NC
Q0513 NC
Q0514 NC
Q0515 NC, Bill
Vendor Drug
Program
S2068 NC
S2078 NC
S2079 2 = 19.18 RVUs PA (Managed
8 = NC
F = Group 6
Care Only)
S3854 NC
V2788 NC
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
CSHCN
For more information, call the TMHP Contact Center at
1-800-925-9126 or the TMHP-CSHCN Contact Center
at 1-800-568-2413.
Texas Medicaid Bulletin, No. 193 16 2006 HCPCS Special Bulletin

2005 Quarterly Additions
The Centers for Medicare & Medicaid Services (CMS)
updated HCPCS codes on a quarterly basis in 2005. The
following is a complete list of HCPCS codes implemented
throughout 2005. These codes are valid for 2006 (effective
date shown).
Procedure Code TOS / Allowable Effective Date
C1713 NC 8/10/2005
C1714 NC 8/10/2005
C1715 NC 8/10/2005
C1717 NC 8/10/2005
C1721 NC 8/10/2005
C1722 NC 8/10/2005
C1724 NC 8/10/2005
C1725 NC 8/10/2005
C1726 NC 8/10/2005
C1727 NC 8/10/2005
C1728 NC 8/10/2005
C1729 NC 8/10/2005
C1730 NC 8/10/2005
C1731 NC 8/10/2005
C1732 NC 8/10/2005
C1733 NC 8/10/2005
C1750 NC 8/10/2005
C1751 NC 8/10/2005
C1752 NC 8/10/2005
C1753 NC 8/10/2005
C1754 NC 8/10/2005
C1755 NC 8/10/2005
C1756 NC 8/10/2005
C1757 NC 8/10/2005
C1758 NC 8/10/2005
C1759 NC 8/10/2005
C1760 NC 8/10/2005
C1762 NC 8/10/2005
C1763 NC 8/10/2005
C1764 NC 8/10/2005
C1766 NC 8/10/2005
C1767 NC 8/10/2005
C1768 NC 8/10/2005
C1769 NC 8/10/2005
C1770 NC 8/10/2005
Procedure Code TOS / Allowable Effective Date
C1771 NC 8/10/2005
C1772 NC 8/10/2005
C1773 NC 8/10/2005
C1776 NC 8/10/2005
C1777 NC 8/10/2005
C1778 NC 8/10/2005
C1779 NC 8/10/2005
C1780 NC 8/10/2005
C1781 NC 8/10/2005
C1782 NC 8/10/2005
C1784 NC 8/10/2005
C1785 NC 8/10/2005
C1786 NC 8/10/2005
C1787 9 = NC
J = MR
8/10/2005
L = NC
C1788 NC 8/10/2005
C1789 NC 8/10/2005
C1813 NC 8/10/2005
C1815 NC 8/10/2005
C1816 9 = NC
J = MR
8/10/2005
L = NC
C1817 NC 8/10/2005
C1819 NC 8/10/2005
C1874 NC 8/10/2005
C1875 NC 8/10/2005
C1876 NC 8/10/2005
C1877 NC 8/10/2005
C1878 NC 8/10/2005
C1879 NC 8/10/2005
C1880 NC 8/10/2005
C1881 NC 8/10/2005
C1882 NC 8/10/2005
C1883 NC 8/10/2005
C1885 NC 8/10/2005
C1887 NC 8/10/2005
C1891 NC 8/10/2005
C1892 NC 8/10/2005
C1893 NC 8/10/2005
C1894 NC 8/10/2005
C1895 NC 8/10/2005
C1896 NC 8/10/2005
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
17
All Providers
Texas Medicaid Bulletin, No. 193

All Providers
Procedure Code TOS / Allowable Effective Date
C1897 NC 8/10/2005
C1898 NC 8/10/2005
C1899 NC 8/10/2005
C2615 NC 8/10/2005
C2617 NC 8/10/2005
C2619 NC 8/10/2005
C2620 NC 8/10/2005
C2621 NC 8/10/2005
C2622 NC 8/10/2005
C2625 NC 8/10/2005
C2626 NC 8/10/2005
C2627 NC 8/10/2005
C2628 NC 8/10/2005
C2629 NC 8/10/2005
C2630 NC 8/10/2005
C2631 NC 8/10/2005
C2633 NC 8/10/2005
C2634 NC 5/1/2005
C2635 NC 5/1/2005
C2636 NC 5/1/2005
C2637 NC 11/16/2005
C9220 1 = $186.16 5/1/2005
C9221 NC 5/1/2005
C9222 NC 5/1/2005
C9224 NC 11/16/2005
C9225 NC 11/16/2005
C9725 NC 11/16/2005
G0328 NC 8/10/2005
G9034 NC 5/1/2005
G9035 NC 5/1/2005
G9036 NC 5/1/2005
K0730 NC 8/10/2005
Q0480 NC 11/16/2005
Q0481 NC 11/16/2005
Q0482 NC 11/16/2005
Q0483 NC 11/16/2005
Q0484 NC 11/16/2005
Q0485 NC 11/16/2005
Q0486 NC 11/16/2005
Q0487 NC 11/16/2005
Q0488 NC 11/16/2005
Procedure Code TOS / Allowable Effective Date
Q0489 NC 11/16/2005
Q0490 NC 11/16/2005
Q0491 NC 11/16/2005
Q0492 NC 11/16/2005
Q0493 NC 11/16/2005
Q0494 NC 11/16/2005
Q0495 NC 11/16/2005
Q0496 NC 11/16/2005
Q0497 NC 11/16/2005
Q0498 NC 11/16/2005
Q0499 NC 11/16/2005
Q0500 NC 11/16/2005
Q0501 NC 11/16/2005
Q0502 NC 11/16/2005
Q0503 NC 11/16/2005
Q0504 NC 11/16/2005
Q0505 NC 11/16/2005
Q4079 NC 8/10/2005
Q4080 NC 11/16/2005
Q9958 NC 8/10/2005
Q9959 NC 8/10/2005
Q9960 NC 8/10/2005
Q9961 NC 8/10/2005
Q9962 NC 8/10/2005
Q9963 NC 8/10/2005
Q9964 NC 8/10/2005
S0109 NC 5/1/2005
S0133 1 = $5,700.00 8/10/2005
S0145 1 = $343.60 8/10/2005
S0146 1 = $60.24 8/10/2005
S0166 NC 5/1/2005
S0167 NC 5/1/2005
S0168 NC 5/1/2005
S0198 1 = $1,054.70 8/10/2005
S0265 NC 8/10/2005
S0515 NC 5/1/2005
S0613 NC 8/10/2005
S2075 2 = 18.19 RVUs
8 = NC
8/10/2005
F = Group 4
S2076 2 = 10.89 RVUs
8 = NC
F = Group 9
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
8/10/2005
Texas Medicaid Bulletin, No. 193 18 2006 HCPCS Special Bulletin

Procedure Code TOS / Allowable Effective Date
S2077 2 = 7.19 RVUs
8 = NC
F = Group 7
8/10/2005
S2114 2 = 27.96 RVUs
8 = NC
F = Group 3
11/16/2005
S2117 2 = 21.68 RVUs
8 = NC
F = Group 4
11/16/2005
S2900 NC 8/10/2005
S3626 5 = $94.37
I = NC
T = NC
11/16/2005
S3820 G = $1785.00 5/1/2005
S3822 G = $210.00 5/1/2005
S3823 G = $249.00 5/1/2005
S3828 G = $420.00 5/1/2005
S3829 G = $420.00 5/1/2005
S3833 G = $540.00 5/1/2005
S3834 G = $171.00 5/1/2005
S3840 G = $256.80 5/1/2005
S3841 G = $816.00 5/1/2005
S3842 G = $477.00 5/1/2005
S3843 G = $90.00 5/1/2005
S3844 G = $258.00 5/1/2005
S3845 G = $355.25 5/1/2005
S3846 G = $355.25 5/1/2005
S3847 G = $138.00 5/1/2005
S3848 G = $138.00 5/1/2005
S3849 G = $138.00 5/1/2005
S3850 G = $253.75 5/1/2005
S3851 G = $117.00 5/1/2005
S3853 G = $253.75 5/1/2005
S8093 4 = 11.45 RVUs
I = 2.07 RVUs
T = 9.38 RVUs
5/1/2005
S8270 9 = NC
J = MR
L = NC
8/10/2005
S9097 NC 5/1/2005
For more information, call the TMHP Contact Center at
1-800-925-9126 or the TMHP-CSHCN Contact Center at
1-800-568-2413.
Discontinued Codes
The following is a list of procedure codes that have been
discontinued by CMS and have no replacements. For a
list of discontinued codes and their replacements and
allowable amounts, see page 2.
Discontinued Procedure Codes
01964 15342 15343 15350 15351
15810 15811 16010 16015 21493
21494 31585 31586 32520 32522
32525 33918 33919 37720 37730
42325 42326 43638 43639 44200
44201 44239 69410 76375 78160
78162 78170 78172 78455 82273
83715 83716 86064 86379 86585
86587 90781 90788 90799 90871
90939 92330 92335 92390 92391
92392 92393 92395 92396 92510
95858 96115 96408 96414 96545
97020 97504 97520 97703 99141
99142 99261 99262 99263 99271
99272 99273 99274 99275 99321
99322 99323 99331 99332 99333
0023T 0033T 0034T 0035T 0036T
0037T 0038T 0039T 0040T A4254
A4260 A4643 A4644 A4645 A4646
A4647 A4656 A5509 A5511 A6551
A9511 A9513 A9514 A9515 A9519
A9520 A9522 A9525 A9533 B4184
B4186 C1080 C1081 C1082 C1083
C1093 C1775 C9123 C9127 C9128
C9202 C9203 C9205 C9206 C9211
C9212 C9218 C9223 C9400 C9401
C9402 C9403 C9404 C9405 C9410
C9411 C9413 C9414 C9415 C9417
C9418 C9419 C9420 C9421 C9422
C9423 C9424 C9425 C9426 C9427
C9428 C9429 C9430 C9431 C9432
C9433 C9435 C9436 C9437 C9438
C9439 C9440 C9704 C9713 C9718
C9719 C9720 C9721 C9722 E0169
E0590 E0752 E0754 E0756 E0757
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
19
All Providers
Texas Medicaid Bulletin, No. 193

All Providers
Discontinued Procedure Codes
E0758 E0759 E0953 E0954 E0972
E0996 E1000 E1001 E1019 E1021
E1025 E1026 E1027 E1210 E1211
E1212 E1213 G0030 G0031 G0032
G0033 G0034 G0035 G0036 G0037
G0038 G0039 G0040 G0041 G0042
G0043 G0044 G0045 G0046 G0047
G0110 G0111 G0112 G0113 G0114
G0115 G0116 G0125 G0210 G0211
G0212 G0213 G0214 G0215 G0216
G0217 G0218 G0220 G0221 G0222
G0223 G0224 G0225 G0226 G0227
G0228 G0229 G0230 G0231 G0232
G0233 G0234 G0242 G0244 G0253
G0254 G0258 G0263 G0264 G0279
G0280 G0296 G0336 G0338 G0345
G0346 G0347 G0348 G0349 G0350
G0351 G0353 G0354 G0355 G0356
G0357 G0358 G0359 G0360 G0361
G0362 G0363 G0369 G0370 G0371
G0374 G9021 G9022 G9023 G9024
G9025 G9026 G9027 G9028 G9029
G9030 G9031 G9032 J0880 J2324
J7051 J7616 J7617 K0064 K0066
K0067 K0068 K0074 K0075 K0076
K0078 K0102 K0104 K0106 K0415
K0416 K0452 K0600 K0620 K0628
K0629 K0670 K0671 K0731 K0732
L0860 L1750 L2039 L3963 L8100
L8110 L8620 Q0187 Q1001 Q1002
Q2001 Q2002 Q2003 Q2005 Q2006
Q2007 Q2008 Q2011 Q2012 Q2013
Q2014 Q2018 Q2020 Q2021 Q2022
Q3000 Q3002 Q3003 Q3004 Q3005
Q3006 Q3007 Q3008 Q3009 Q3010
Q3011 Q3012 Q4075 Q4076 Q4077
Q9941 Q9942 Q9943 Q9944 S0114
S0118 S0168 S2082 S2090 S2091
S2215 S8434 T2006
For more information, call the TMHP Contact Center at
1-800-925-9126 or the TMHP-CSHCN Contact Center
at 1-800-568-2413.
Description Changes
The following procedure code descriptions have changed.
Please contact the appropriate copyright holder to obtain
procedure code descriptions.
Description Changes
0001F 0005F 0078T 15000
15001 15100 15101 15120
15121 15200 15201 15220
15240 15260 15400 15401
16020 16025 16030 2000F
30130 30140 30801 30930
31520 31525 31526 31530
31531 31535 31536 31540
31541 31560 31561 31570
31571 33502 34833 34834
36415 37209 4011F 43848
44202 44310 44320 45119
45540 45550 50688 52647
52648 57421 61864 64613
67901 67902 75900 76012
77412 82270 83036 83898
83901 84238 86920 86921
86922 87904 88175 90657
90658 90680 90713 90715
90870 90940 91020 92506
92507 92520 92568 92569
95250 96405 96406 96420
96422 96423 97024 97542
97811 97813 97814 99050
99056 99058 99298 A4215
A4216 A4409 A4410 A4414
A4415 A4554 A4630 A4632
A4641 A4642 A6025 A6550
A7032 A7033 A9500 A9502
A9503 A9504 A9505 A9507
A9508 A9510 A9512 A9516
A9517 A9521 A9524 A9526
A9528 A9529 A9530 A9531
A9532 A9600 A9605 A9699
B4100 B4149 C2634 C2635
E0116 E0203 E0637 E0638
E0761 E0935 E0971 E1038
E1039 J7340 J7342 J7343
Texas Medicaid Bulletin, No. 193 20 2006 HCPCS Special Bulletin

Description Changes
J7344 J7350 J7626 K0669
L1832 L1843 L1844 L1845
L1846 L2036 L2037 L2038
L2405 L3170 L3215 L3216
L3217 L3219 L3221 L3222
L3230 L3906 L3923
For more information, call the TMHP Contact Center at
1-800-925-9126 or the TMHP-CSHCN Contact Center
at 1-800-568-2413.
Modifiers
The modifiers QB, QQ, and QU have been discontinued
by CMS.
The following is a complete list of new modifiers:
Modifiers
AQ FB J1 P1 P4 QR
BL GR J2 P2 P5 27
CR GS J3 P3 P6 63
For more information, call the TMHP Contact Center at
1-800-925-9126 or the TMHP-CSHCN Contact Center
at 1-800-568-2413.
ASC/HASC PROVIDERS
ASC/HASC Code Additions
Additions for ambulatory surgical center/hospital
ambulatory surgical center (ASC/HASC) facilities
are effective for dates of service on or after
January 1, 2006, and are listed with appropriate
group payments in the 2006 HCPCS replacement
and additions tables beginning on page 2. For more
information, call the TMHP Contact Center at
1-800-925-9126.
2006 HCPCS Special Bulletin
All Providers / ASC/HASC Providers / Home Health Providers
21
HOME HEALTH PROVIDERS
Title XIX Home Health
Policy Updates
The following policy updates have been made to support
the 2006 HCPCS implementation.
Trapeze Bars
Effective for dates of service on or after January 1, 2006,
procedure codes J/L-E0911 and J/L-E0912 are benefits
of Title XIX Home Health Services when submitted with
documentation of medical necessity and prior authorized.
Purchase is limited to one per five years, and rental is
limited to once per month.
Standing Frames and Wheelchair Accessories
Effective for dates of service on or after January 1, 2006,
the following procedure codes are benefits of Title XIX
Home Health Services when submitted with documentation
of medical necessity and prior authorized.
Procedure Codes
J-E0641 J-E0705 J-E2207 J-E2208
J-E2209 J-E2210 J-E2211 J-E2212
J-E2213 J-E2214 J-E2215 J-E2216
J-E2217 J-E2218 J-E2219 J-E2220
J-E2221 J-E2222 J-E2223 J-E2224
J-E2225 J-E2226 J-E2371 J-E2372
Purchase of the above procedure codes is limited to one
per five years.
Powered Wheelchairs
Effective for dates of service on or after January 1, 2006,
procedure codes J-E1019, J-E1021, J-E1210, J-E1211,
J-E1212, and J-E1213 are no longer benefits of the Texas
Medicaid Program.
Effective for dates of service on or after January 1, 2006,
procedure codes J/L-K0010, J/L-K0011, and J/L-K0012
are benefits of Title XIX Home Health Services with prior
authorization.
The codes in the following table will deny as part of
another service if billed with procedure codes J/L-K0010,
Texas Medicaid Bulletin, No. 193

THSteps-CCP Providers / CSHCN Providers
J/L-K0011, or J/L-K0012, which are considered for reimbursement
only when billed as replacement parts.
Procedure Codes
J-E0970 J-E0971 J-E0973 J-E0981
J-E0982 J-E0990 J-E0994 J-E0995
J-E0996 J-E0997 J-E0998 J-E0999
J-E1000 J-E1001 J-E2210 J-E2366
J-E2368 J-E2369 J-E2370
For more information, call the TMHP Contact Center
at 1-800-925-9126.
THSTEPS-CCP PROVIDERS
Standing Frames
Effective for dates of service on or after January 1, 2006,
procedure code J-E0642 is a benefit of the Texas Health
Steps-Comprehensive Care Program (THSteps-CCP) for
clients under 21 years of age when submitted with documentation
of medical necessity and prior authorized.
For more information, please call the TMHP Contact
Center at 1-800-925-9126.
CSHCN PROVIDERS
CSHCN Program Policy Updates
The following Children with Special Health Care Needs
(CSHCN) Services Program policy changes have been
made to support the 2005 HCPCS implementation.
Powered Wheelchairs
Due to the deletion of HCPCS procedure codes J-E1019,
J-E1210, J-E1211, J-E1212, and J-E1213, effective for
dates of service on or after January 1, 2006, procedure
codes J/L-K0010, J/L-K0011, and J/L-K0012 are
benefits of the CSHCN Services Program with prior
authorization.
The codes in the following table will deny as part of
another service if billed with procedure codes J/L-K0010,
J/L-K0011, or J/L-K0012, which are considered for
reimbursement only when billed as replacement parts.
Procedure Codes
J-E0970 J-E0971 J-E0973 J-E0981
J-E0982 J-E0990 J-E0994 J-E0995
J-E0996 J-E0997 J-E0998 J-E0999
J-E1000 J-E1001 J-E2210 J-E2366
J-E2368 J-E2369 J-E2370
Antihemophilic Factors
Effective for dates of service on or after January 1, 2006,
1-Q0187 and 1-Q2022 are no longer benefits of the
CSHCN Services Program.
Procedure codes 1-J7188 and 1-J7189 are benefits of the
CSHCN Services Program. Procedure code 1-J7188 is
limited to diagnosis code 286.4, and procedure code
1-J7189 is limited to diagnosis codes 286.0 and 286.1.
Lipids
Effective for dates of service on or after January 1, 2006,
procedure code 9-B4185 is a benefit of the CSHCN
Services Program for diagnosis codes 042, 140.0–208.9,
277.0–277.09, or 555.0–555.9. Procedure code 9-B4185
must be authorized if requested for diagnoses other
than 042, 140.0–208.9, 277.0–277.09, or 555.0–555.9.
Procedure code 9-B4185 is reimbursed on a daily basis,
Texas Medicaid Bulletin, No. 193 22 2006 HCPCS Special Bulletin

ut will be denied as part of another service if hyperalimentation/total
parenteral nutrition is billed on the same
date of service.
Trapeze Bars
Effective for dates of service on or after January 1, 2006,
procedure codes J/L-E0911 and J/L-E0912 are benefits
of the CSHCN Services Program when submitted with
documentation of medical necessity and authorized.
Purchase is limited to one per five years and rental is
limited to once per month.
Standing Frames and Wheelchair Accessories
Effective for dates of service on or after January 1, 2006,
the following procedure codes are benefits of the CSHCN
Services Program when submitted with documentation of
medical necessity and authorized.
Procedure Codes
J-E0641 J-E0705 J-E2207 J-E2208
J-E2209 J-E2210 J-E2211 J-E2212
J-E2213 J-E2214 J-E2215 J-E2216
J-E2217 J-E2218 J-E2219 J-E2220
J-E2221 J-E2222 J-E2223 J-E2224
J-E2225 J-E2226 J-E2371 J-E2372
Purchase of the above procedure codes is limited to one
per five years.
Incidental Services
Effective for dates of service on or after January 1, 2006,
the following procedure codes are benefits of the CSHCN
Services Program:
Procedure Codes
1-90760 1-90761 1-90765 1-90766 1-90767
1-90768 1-96521 1-96522 1-96523
The above procedure codes will be denied as part of
another service if billed in conjunction with a surgical or
anesthesia procedure.
For more information, call the TMHP-CSHCN Contact
Center at 1-800-568-2413.
CSHCN HCPCS Additions
New HCPCS codes, applicable rates, and related requirements
for the CSHCN Services Program can be found in
the HCPCS replacement and additions tables beginning
on page 2. CSHCN follows Medicaid covered services
and allowable amounts with the following exceptions:
Procedure Code TOS / Allowable
01965 NC
01966 NC
88333 5 = 2.36 RVUs
I = 1.77 RVUs
T = 0.59 RVUs
88334 5 = 1.23 RVUs
I = 0.87 RVUs
T = 0.36 RVUs
90714 1 = $17.85
96101 NC
96415 1 = 1.03 RVUs
96417 1 = 1.07 RVUs
97761 1 = $35.00
C= NC
99304 NC
99305 NC
99306 NC
99307 NC
99308 NC
99309 NC
99310 NC
99318 NC
99324 NC
99325 NC
99326 NC
99327 NC
99328 NC
99334 NC
99335 NC
99336 NC
99337 NC
99340 NC
J1640 1 = $6.51
J7188 1 = MR
J7189 1 = MR
28890 NC
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
2006 HCPCS Special Bulletin
23
CSHCN Providers
Texas Medicaid Bulletin, No. 193

CSHCN Providers
Procedure Code TOS / Allowable
43770 NC
43771 NC
43772 NC
43773 NC
43774 NC
E0170 9 = NC
J = MR
L = NC
E0171 9 = NC
J = MR
L = NC
E0172 9 = NC
J = MR
L = NC
S3626 NC
For more inforamtion, call the TMHP-CSHCN Contact
Center at 1-800-568-2413.
2005 Quarterly Additions
The Centers for Medicare & Medicaid Services (CMS)
updated HCPCS codes on a quarterly basis in 2005. A
complete list of HCPCS codes implemented throughout
2005 can be found in the “2005 Quarterly Additions”
table on page 17. The following exceptions to the codes
found in that table exist for the CSHCN Services
Program:
Procedure Code TOS / Allowable Effective Date
C9224 1 = $1,621.74 11/16/2005
C9225 1 = $19,600.50 11/16/2005
Q4080 1 = $31.52 11/16/2005
S3625 NC 5/1/2005
S3626 NC 11/16/2005
S3820 NC 5/1/2005
S3822 NC 5/1/2005
S3823 NC 5/1/2005
S3828 NC 5/1/2005
S3829 NC 5/1/2005
S3833 NC 5/1/2005
S3834 NC 5/1/2005
S3840 NC 5/1/2005
S3841 NC 5/1/2005
Procedure Code TOS / Allowable Effective Date
S3842 NC 5/1/2005
S3843 NC 5/1/2005
S3844 NC 5/1/2005
S3845 NC 5/1/2005
S3846 NC 5/1/2005
S3847 NC 5/1/2005
S3848 NC 5/1/2005
S3849 NC 5/1/2005
S3850 NC 5/1/2005
S3851 NC 5/1/2005
S3853 NC 5/1/2005
For more information, call the TMHP-CSHCN Contact
Center at 1-800-568-2413.
Prior Authorization Update
Effective January 1, 2006, the 2006 HCPCS deleted
procedure codes are no longer reimbursed by the
CSHCN Services Program. Providers who have received
authorizations for dates of service that occur on or after
January 1, 2006, will need to submit a written request on
the appropriate, completed CSHCN authorization request
form in order to update the HCPCS procedure code(s)
authorized for those services, except for the procedure
codes listed below. Authorizations for the codes below will
be updated by TMHP and require no action on the part
of the provider.
Procedure Codes
33918 33919 44200 97504
97520 97703 A5119 K0618
K0619 K0620 K0630 - K0649 L0860
L8100 L8110 L8120 L8130
L8140 L8150 L8160 L8170
L8180 L8190 L8195 L8200
L8210 L8220 L8230 L8239
Important: Please do not request changes to authorizations
prior to January 13, 2006 (see “2006 HCPCS
Implementation” on page 1).
Background
Authorization is a condition for reimbursement. It is not
a guarantee of payment. Each provider must be enrolled
A = Authorization Required; MR = Manually Reviewed; NC = Non-Covered Service; PA = Prior Authorization Required;
RVU = Relative Value Unit; ** = CSHCN and Comprehensive Care Program (CCP) Only
Texas Medicaid Bulletin, No. 193 24 2006 HCPCS Special Bulletin

and 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 notification to the client when an authorization
approval, denial, or reduction in requested services
letter is sent to his or her provider. Refer to the specific
provider sections of the 2006 CSHCN Provider Manual—
Part I for more details on the services that require authorization
or prior authorization. Fax transmittal confirmations
and postal registered mail receipts are not accepted
as proof of timely authorization submission.
An authorization is a request submitted to the program
to provide a service the program may consider for
reimbursement. The request must be submitted on a
program-approved form and must contain all information
necessary for the program to make a determination
regarding coverage. The request may be submitted before
the service is provided, but must not be received by the
program more than 90 days following the date the service
was provided. If the service was already provided, the
authorization form may be attached to the claim, as long
as it is received within the authorization (90-day) deadline.
Only complete authorization requests may be accepted
by the program. No extensions beyond the 90-day initial
deadline are given for providers to correct incomplete
authorization requests. This 90-day deadline applies to all
services requiring authorization (not prior authorization,
including extensions and emergency situations).
Incomplete authorization requests, or claims for services
requiring authorization but submitted without an attached
authorization form or all required documentation, are
denied and are reconsidered only when resubmitted and
received by the program within the initial 90-day authorization
deadline. Requests to extend the deadline beyond
90-days from the date of service are not considered.
A prior authorization is a request submitted to the
program to provide a service the program may consider
for reimbursement. The request must be submitted on a
program-approved form and must contain all information
necessary for the program to make a determination
regarding 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
2006 HCPCS Special Bulletin
25
CSHCN Providers
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. The
program does not grant extensions to these deadlines to
allow providers to correct and resubmit incomplete prior
authorization requests.
Incomplete prior authorization requests are denied and
are reconsidered only when completed and received by the
program before the service is provided. The prior authorization
requirement may be waived if the clients eligibility
had not been determined when the request was received
by TMHP. Claims for these services must be received
within 95 days of the eligibility add date.
All inpatient admission/stays or inpatient rehabilitation
admissions, including extensions of any previously
authorized inpatient stays, must be prior authorized. The
request may be submitted by the hospital, provided that
all required information indicating inpatient admission is
on the request form. Both the facility and the physician/
supplier must be enrolled in the CSHCN Services
Program for either inpatient or outpatient claims to be
considered for reimbursement.
Providers must mail or fax written authorization requests,
along with all other applicable documentation, to the
following address:
Texas Medicaid & Healthcare Partnership
ATTN: CSHCN Authorizations, MC-A11
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4222
Providers must mail or fax written prior authorization
requests, along with all other applicable documentation,
to the following address:
Texas Medicaid & Healthcare Partnership
ATTN: CSHCN Authorizations, MC-1938
12357-B Riata Trace Parkway
Austin, TX 78727
Fax: 1-512-514-4222
For more information call the TMHP-CSHCN Contact
Center at 1-800-568-2413.
Texas Medicaid Bulletin, No. 193

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:
( )
Fax: Fax: Fax:
Phone:
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.
Texas Medicaid Bulletin, No. 193 26 2006 HCPCS Special Bulletin

Instructions for Completing the
Provider Information Change Form
Signatures:
The provider’s signature is required on the Provider Information Change Form for any and all
changes requested for individual provider numbers.
A signature by the authorized representative of a group or facility is acceptable for requested
changes to group or facility provider numbers.
Address:
Performing providers (physicians performing services within a group) may not change
accounting information.
For Traditional Medicaid, changes to the accounting or mailing address require a copy of the
W9 form.
For Traditional Medicaid, a change in ZIP code requires copy of the Medicare letter.
Tax Identification Number (TIN):
TIN changes for individual practitioner provider numbers can only be made by the individual to
whom the number is assigned.
Performing providers cannot change the TIN.
General:
Forms will be returned unprocessed if the nine-digit provider number is not indicated on the
Provider Information Change Form.
The W-9 form is required for all name and TIN changes.
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
2006 HCPCS Special Bulletin
27
Forms
Texas Medicaid Bulletin, No. 193

Forms
Electronic Funds Transfer (EFT) Information
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.
Contact TMHP Customer Service at 1–800–925–9126 if you need assistance.
Page 1 of 2 EFTAG11.17.2003_v1.0
Texas Medicaid Bulletin, No. 193 28 2006 HCPCS Special Bulletin

Electronic Funds Transfer (EFT) Authorization Agreement
Enter ONE Texas Provider Identifier (TPI) per Form
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
Street Address or PO Box City State Zip
Bank Name ABA/Transit Number
Bank Phone Number Account Number
Bank Address Type Account (check one)
Street Address or PO Box City State Zip
2006 HCPCS Special Bulletin
Page 2 of 2 EFTAG11.17.2003_v1.0
29
ext.
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
DO NOT WRITE IN THIS AREA — For Office Use
Return this form to:
Texas Medicaid & Healthcare Partnership
ATTN: Provider Enrollment
PO Box 200795
Austin TX 78720–0795
Input By: Input Date:
Forms
Texas Medicaid Bulletin, No. 193

Notes
Texas Medicaid Bulletin, No. 193 30 2006 HCPCS Special Bulletin

2006 HCPCS Special Bulletin
31
Notes
Texas Medicaid Bulletin, No. 193

Current Procedural Terminology (CPT) is copyright 2006 American Medical Association (AMA), and 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. The 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.
PLACE POSTAGE
HERE
ATTENTION: BUSINESS OFFICE
No. 193
Texas Medicaid
2006 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin