ALL TEXAS MEDICAID FEE SCHEDULES ARE AVAILABLE AT THE FOLLOWING LINK:
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1 User s Guide to SECTION FOUR Page 25 ALL TEXAS MEDICAID FEE SCHEDULES ARE AVAILABLE AT THE FOLLOWING LINK: The Texas Medicaid Fee Schedule is categorized by field descriptions. () codes are listed in the first field. The identifies the specific field or specialty of services provided. The descriptions are listed below: 0 Blood Products 5 Laboratory 9 DME Other 1 Medical Services 6 Radiation Therapy E Eyeglasses 2 Surgery 7 Anesthesia I Interpretation 3 Consultation 8 Assistant Surgery T Technical 4 Radiology F ASC / HASC Procedure Code. The third field lists the current procedure codes. The Texas Medicaid Physician, APN, and CRNA each contain a list of payment rates for Current Procedural Terminology (CPT) codes, including the ( 7) American Society of Anesthesiologists (ASA) procedure codes. The five-character alphanumeric procedure codes follow the numeric procedure codes. Modifier. It is placed after the five-digit procedure code, if applicable. A modifier describes and qualifies services that are provided however not all procedures require a modifier. Modifiers may affect the CIHCP payment amount. A list of frequently used modifiers is located in the Texas Medicaid Providers Procedures Manual in Section 6 Claims Filing at _Texas_Medicaid_Provider_Procedures_Manual.pdf Child Age. The sixth and seventh fields list the age range for pricing determination. Resource-Based Units. Texas Medicaid Reimbursement Methodology. The eighth field lists the payable amount for the and procedure code. Total RVUs. The ninth field lists the relative value units for the procedure code. Conv Factor. The tenth field lists the conversion factor used in the calculation formula for anesthesia services in determining the TMRM payable amount. PPS Fee. The eleventh field lists the prospective payment system (PPS) fee. Not applicable for CIHCP.
2 User s Guide to SECTION FOUR Page 26 Access-Based or Max Fee. The twelfth field lists the access-based fee amount or maximum fee. Effective Date. The thirteenth field lists the effective date for total RVUs for RBFs. For fees other than RBFs, the effective date for the PPS, access-based, or max fee. Note Code. The fourteenth field lists the note code indicator. For CIHCP, a payment amount may be negotiated with the provider when the Note Code is 5.. The CPT codes are divided into sections based on the type of service () codes. The 1-digit code identifies the specific field or specialty of services provided. 0 and 9 are not basic health care services. Use the following definitions and payment information. 1 Medical Services includes office, inpatient hospital, and emergency room visits; allergy treatment; chemotherapy; injections; physical therapy; dialysis; psychotherapy; ophthalmology; dermatology; ventilation; etc. Excludes anesthesia, radiological interpretations, and laboratory interpretations.
3 User s Guide to SECTION FOUR Page 27 2 Surgery includes invasive diagnostic procedures. Single Surgical Procedure. Unless the description for a surgical procedure clearly states otherwise, a single surgical procedure code represents the full scope of activities performed to complete the surgical procedure. Multiple Surgical Procedures. Some surgical services involve multiple surgical procedures that may be payable as separate procedures but only if they are not a component of a more comprehensive procedure. Determine if the multiple surgical procedure codes are: components of one comprehensive procedure, or a primary procedure and secondary procedure(s). If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full TDSHS physician payment standard for the primary procedure and half of the TDSHS physician payment standard for the other procedure(s). 3 Consultations used when the attending physician consults with another physician concerning some non-surgical aspect of the patient s treatment.
4 Page 28 4 Radiology (total component, i. e., technical and interpretation) includes radiological exams (x-rays), computerized axial tomography (CAT scans), magnetic resonance imaging (MRI), mammography, echography (ultrasound), and other types of internal organ and vascular x-rays. Procedure codes with a 4 include radiology services that are both the technical component and the interpretation (professional) component of x-ray services. Use the following information for processing bills for 4 (Radiology), T (Technical), and I (Interpretation). service may be paid for the total component ( 4). for the technical component ( T). only for the interpretation component ( I). 4 = total component (Technical + Interpretation) 4 = T + I If a 4 is paid first, then the total component has been met. If a T is paid first, then a I may be payable. If a I is paid first, then a T may be payable.
5 Page 29 5 Laboratory (total component, i. e., technical and interpretation) includes most types of blood, urine, feces, and sputum tests and tests on other bodily fluids or by-products; tissue studies and analysis; various hearing and speech tests; electrocardiograms (EKGs) and cardiovascular stress tests; respiratory (pulmonary) function tests; electroencephalograms (EEGs) and other brain activity tests. Procedure codes with a 5 include laboratory services that are both the technical component and the interpretation (professional) component of laboratory services. Use the following information for processing bills for 5 (Laboratory), T (Technical), and I (Interpretation). service may be paid for the total component ( 5). for the technical component ( T). only for the interpretation component ( I). 5 = total component (Technical + Interpretation) 5 = T + I If a 5 is paid first, then the total component has been met. If a T is paid first, then a I may be payable. If a I is paid first, then a T may be payable.
6 Page 30 6 Radiation Therapy (total component, i. e., technical and interpretation) includes radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment, and radioelement application. Procedure codes with a 6 include radiation therapy services that are both the technical component and the interpretation (professional) component of radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment, and radioelement application services. Use the following information for processing bills for 6 (Radiation Therapy), T (Technical), and I (Interpretation). service may be paid for the total component ( 6). for the technical component ( T). only for the interpretation component ( I). 6 = total component (Technical + Interpretation) 6 = T + I If a 6 is paid first, then the total component has been met. If a T is paid first, then a I may be payable. If a I is paid first, then a T may be payable. 7 Anesthesia usually provided by or under the supervision of a physician in a hospital setting.
7 Page 31 8 Assistant Surgery a surgical procedure that requires the assistance of another surgeon. Procedure codes with a 8 include assistant surgical services. In addition, use of a modifier code of 80, 81, and 82 with a surgical procedure code results in 8 being assigned to the procedure. Although certain surgical procedures require the service of an assistant surgeon, not all surgical procedures require this service. Single Surgical Procedure. Unless the description for a surgical procedure clearly states otherwise, a single surgical procedure code represents the full scope of activities performed to complete the surgical procedure. Multiple Surgical Procedures. Some surgical services involve multiple surgical procedures that may be payable as separate procedures but only if they are not a component of a more comprehensive procedure. Determine if the multiple surgical procedure codes are: components of one comprehensive procedure, or a primary procedure and secondary procedure(s). If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full TDSHS physician payment standard for the primary procedure and pay half of the TDSHS physician payment standard for the other procedure(s). September 2012
8 SERVICE SELIVERY Page 32 I Interpretation professional component for radiology, laboratory, or radiation therapy services. Only one provider is entitled to reimbursement for interpreting a radiology, laboratory or radiation therapy procedure. service may be paid for the total component ( 4, 5, or 6). for the technical component ( T). only for the interpretation component ( I). 4, 5, or 6 = total component (Technical and Interpretation) 4, 5, or 6 = T + I If a 4, 5, or 6 is paid first, then the total component has been met. If a T is paid first, then a I may be payable. If a I is paid first, then a T may be payable.
9 PAGE 33 T Technical technical component for radiology, laboratory, or radiation therapy services. Only one provider is entitled to reimbursement for performing the technical component of a radiology, laboratory, or radiation therapy procedure. service may be paid for the total component ( 4, 5, or 6). for the technical component ( T). only for the interpretation component ( I). 4, 5, or 6 = total component (Technical + Interpretation) 4, 5, or 6 = T + I If a 4, 5, or 6 is paid first, then the total component has been met. If a T is paid first, then a I may be payable. If a I is paid first, then a T may be payable.
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