Clinics and Other Outpatient Facility Services Handbook - TMHP

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TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 2 - JANUARY 2013 Copayments CP001 CP002 CP003 CP004 CP005 CP006 CP007 CP008 Refer to: Subsection 6.3.5, “Modifiers” in Section 6, “Claims Filing” (Vol. 1, General Information) for a definition of modifiers. Section 4, “Texas Health Steps (THSteps) Dental,” and Section 5, “THSteps Medical,” in the Children’s Services Handbook (Vol. 2, Provider Handbooks). Section 3, “Texas Women’s Health Program,” and Section 4, “Department of State Health Services (DSHS) Family Planning Program Services,” in the Gynecological and Reproductive Health and Family Planning Services Handbook (Vol. 2, Provider Handbooks). Section 4, “Vision Care Professionals,” in the Vision and Hearing Services Handbook (Vol. 2, Provider Handbooks). Section 4, “Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), and Licensed Professional Counselor (LPC),” in the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks). Subsection 8.2.60.1.2, “Preventive Care Visits” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks). Section 6, “Physician, Psychologist, and Licensed Psychological Associate (LPA) Providers,” in the Behavioral Health, Rehabilitation, and Case Management Services Handbook (Vol. 2, Provider Handbooks). Subsection 6.12.2.2, “Health Maintenance Organization (HMO) Copayments” in Section 6, “Claims Filing” (Vol. 1, General Information). Medicaid coverage is limited to FQHC services that are covered by Texas Medicaid and are reasonable and medically necessary. When furnished to a client of the FQHC, medically necessary services include the following: • CNM services • Clinical psychologist services • Clinical social worker services; other mental health services • Dental services • NP services • Other ambulatory services included in Medicaid such as family planning, THSteps, and maternity service clinic (MSC) • PA services • Physician services • Services and supplies necessary for services that would be covered otherwise, if furnished by a physician or a physician service • Vision care services • Visiting nurse services to a homebound individual, in the case of those FQHCs located in areas with a shortage of home health agencies Types of FQHC visits are defined in 1 TAC §355.8261. A visit is a face-to-face encounter between an FQHC client and a physician, PA, NP, CNM, visiting nurse, qualified clinical psychologist, clinical social worker, other health-care professional for mental health services, dentist, dental hygienist, or optome- OP-14 CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
CLINICS AND OTHER OUTPATIENT FACILITY SERVICES HANDBOOK trist. Encounters that take place on the same day at a single location with more than one health-care professional or multiple encounters with the same health-care professional constitute a single visit, except where one of the following conditions exists: • After the first encounter, the client suffers illness or injury requiring additional diagnosis or treatment. • The FQHC client has a medical visit and an other health visit such as a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a THSteps medical checkup. All services provided that are incidental to the encounter, including developmental screening, must be included in the total charge for the encounter. They are not billable as a separate encounter. Registered nurses may not be the sole provider of a medical checkup in an FQHC. If immunizations are given outside of a THSteps medical checkup, procedure codes given in the THSteps section of this manual should be used. These procedure codes are informational only, and are not payable. To be reimbursed for Case Management for Children and Pregnant Women, an FQHC must be approved as a case management services provider by the DSHS Case Management Branch. An annual family planning examination is allowed once per state fiscal year (September 1 through August 31), per client, per provider. An FQHC may be reimbursed for up to three family planning encounters per client, per year, regardless of the reason for the encounter. The three encounters may include any combination of general family planning encounters, an annual family planning examination, or intrauterine devices. Family planning services must be submitted with the most appropriate evaluation and management (E/M) procedure code and one of the following family planning diagnosis codes: Family Planning Diagnosis Codes V2501 V2502 V2504 V2509 V2511 V2512 V2513 V252 V2540 V2541 V2542 V2543 V2549 V255 V258 V259 V2651 V2652* *Not covered by the Women’s Health Plan Procedure code 58300 must be submitted on the same claim as J7300 and J7302. Procedure code 58300 will process as informational only. Only the annual family planning examination requires modifier FP. All other family planning visits do not require the FP modifier. Claims filed incorrectly may be denied. FQHC providers may receive DSHS Family Planning Program reimbursement for Texas Women’s Health Program (TWHP) wrap-around services that are rendered during a visit where the primary purpose of the visit is not related to contraception and is not reimbursed by the TWHP. FQHC providers may receive DSHS Family Planning Program reimbursement for the following services that are rendered to TWHP clients when the primary diagnosis is not related to contraception: • Follow-up Pap tests. To receive DSHS Family Planning Program reimbursement, DSHS contractors must file a separate DSHS Family Planning Program claim with diagnosis code 6229. DSHS contractors may be reimbursed for the Pap test, an appropriate counseling code, and the appropriate visit code. • Follow-up visits for sexually transmitted disease/infection (STD/STI) testing. To receive DSHS Family Planning Program reimbursement for a visit that is strictly for the purposes of STD/STI testing for a TWHP client, DSHS contractors must file a separate DSHS Family Planning Program claim with a diagnosis code of V016. DSHS contractors may be reimbursed for STD/STI tests and STD/STIrelated services. OP-15 CPT ONLY - COPYRIGHT 2012 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED.
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