PHC TAR REQUIREMENTS
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- Bryce Jordan
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1 A. Hospitalization 1. The hospital must notify PHC of any admission within 24 hours of the admission. 2. Authorization for elective admission must be requested by the admitting physician prior to the admission. B. Long Term Care The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or change in payor status within one working day. (Examples include Medicare non-coverage or exhaustion of benefits / hospice election.) C. Outpatient Surgical Procedures see CPTs Requiring TAR list D. Pain Management see CPTs Requiring TAR list E. Outpatient Hemo / Peritoneal Dialysis (Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after submission of Medicare determination.) F. Drugs and Pharmaceuticals A TAR is required for all prescription drugs, over-the-counter drugs and injectable drugs (including drugs compounded for IV infusion therapy) not on the PHC formulary. PLEASE REFER TO PHC FORMULARY G. Diagnostic Studies CT Scans (Except 76497) MRI (Except 76494, 76380, 76506) MRA PET scan Transcranial Doppler Sleep Studies / Polysomnography H. Ancillary / Support Services RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits requested including initial visit. Acupuncturist Speech Therapy Chiropractor Occupational Therapy Faith Healer Home Infusion Therapy (Nursing Component Only) Physical Therapy Home Health Care I. Hospice Care (Inpatient Only) J. Pulmonary Rehabilitation K. Hyperbaric Oxygen Pressurization Page 1 of 8
2 L. Non-Emergency Medical Transportation M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services N. Phototherapy for dermatological condition O. Dental Anesthesia P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from CCS or GHPP office(s). Q. Supplies / Equipment Orthotics Cumulative costs for repair/maintenance or purchase exceeds $250 / item Prosthetics Cumulative costs for repair / maintenance or purchase exceeds $500 / item And any unlisted / miscellaneous code including: - L0999 Addition to spinal orthosis, not otherwise specified - L1499 Spinal orthosis, not otherwise specified - L2999 Lower extremity orthosis, not otherwise specified - L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified - L3999 Upper limb orthosis, not otherwise specified - L5999 Lower extremity prosthesis, not otherwise specified - L7499 Upper extremity prosthesis, not otherwise specified - L8039 Breast prosthesis, not otherwise specified - L8499 Unlisted procedure for miscellaneous prosthetic services - L8699 Prosthetic implant, not otherwise specified ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY- REPORT OR BY-INVOICE) Ostomy Supplies If monthly cumulative cost for all related supplies exceeds $150 Hearing Aid All purchases, rentals or repairs exceeding $50 / item (Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is required) Oxygen and related supplies Diabetic Supplies are to be provided by Pharmacies ONLY Medical Supplies (If dispensed by PHARMACY, please refer to formulary) Any unlisted or miscellaneous code DME (If dispensed by PHARMACY, please refer to formulary) - Repairs or maintenance over $ / item (Out of guarantee repairs are to be guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will NOT be allowed for parts or labor during a guarantee period if due to a defect in material or workmanship) - Purchase items over $ / item (Vendor to guarantee for a MINIMUM of six (6) months from the date of purchase) - Rental items over $50.00 / month / item (Rental rate includes equipment related supplies.) - Any unlisted or miscellaneous code - Purchase of any wheelchairs for Medi-Medi members Page 2 of 8
3 Incontinence Supplies - Incontinence supplies if monthly cumulative cost for all related supplies exceeds $ AND any unlisted or miscellaneous code - Washes and creams for members with incontinence will only be authorized if the physician justifies medical necessity Nutritional Supplements (Submit TAR to Pharmacy) R. Genetic Testing A TAR is required for certain genetic testing as outlined in Attachment A of the Genetic Testing policy MCUP3131. Page 3 of 8
4 CPT Code Outpatient Surgical Procedures - CPTs Requiring TAR Description Acne Surgery Thru Chemical Peel, Facial Et Al Salabrasion Thru Revision Of Lower Or Upper Eyelid Skin And Muscle Repair, Face Skin Peel Therapy Skin Tissue Procedure Mastectomy For Gynecomastia Mastectomy For Gynecomastia Mastopexy Reduction Mammoplasty 19324/25 Breast Augment; W/O Prosthetic Implant Correction Of Inverted Nipples Revise Breast Reconstruction Design Custom Breast Implant Unlisted Procedure, Breast Musculoskeletal Surgery Augmentation Of Facial Bones Spine Surgery Procedure Abdomen Surgery Procedure Thru Correction Of Bunion Thru Osteotomy / Repair / Reconstruction Thru Reconstruct Of Nose Repair Nasal Septum Chest Surgery Procedure Vessel Injection Procedure Ligation And Division Of Long Saphenous Vein At Saphenofemoral Junction, Or Distal Interruptions Ligation, Division, And Stripping, Short Saphenous Vein Ligation, Division, And Stripping, Long (Greater) Saphenous Veins From Saphenofemoral Junction To Knee Or Below Ligation And Division And Complete Stripping Of Long Or Short Saphenous Veins With Radical Excision Of Ulcer And Skin Graft And/or Interruption Of Communicating Veins Of Lower Leg, With Excision Of Deep Fascia Ligation Of Perforator Veins, Subfascial, Radical (Linton Type) Including Skin Graft, When Performed, Open, 1 Leg Ligation Of Perforator Vein(S), Subfascial, Open, Including Ultrasound Guidance, When Performed, 1 Leg Stab Phlebectomy Of Varicose Veins, 1 Extremity; Stab Incisions Page 4 of 8
5 Outpatient Surgical Procedures - CPTs Requiring TAR (Continued) CPT Code Description More Than 20 Incisions Ligation And Division Of Short Saphenous Vein At Saphenopopliteal Junction (Separate Procedure) Ligation, Division, And/or Excision Of Varicose Vein Cluster(S) 1 Leg 38206, Stem Cell Harvesting Bone Marrow Harvesting Therapeutic Apheresis Of WBC s Therapeutic Apheresis Of RBCs Unrelated Harvesting Of Cells Stem Cell Harvesting From Siblings Stem Cell Storage Gum Surgery Procedure Laparoscopy, Surgical, Gastric Restrictive Procedure Laparoscopy, Surgical, Revision Of Adjust Gastric Band Laparoscopy, Surgical, Removal Of Adjustable Gastric Band Laparoscopy, Surgical, Removal & Placement Of Adj Gastric Band Laparoscopy, Surgical, Removal Of Adjustable Gastric Band Lap Sleeve Gastrectomy Gastroplasty, Vertical Banded, For Morbid Obesity Gastroplasty, Other Than Vertical-Banded, For Morbid Obesity Gastroplasty Gastric Bypass For Obesity Gastric Restrictive Procedure With Gastric Bypass Revision Of Gastric Restrictive Gastric Restrictive Procedure Gastric Restrictive Procedure, Removal Of Subcutaneous Port Component Gastric Restrictive Proc, Removal & Replacement Of Subcutaneous Port Abdomen Surgery Procedure Circumcision TAR not required if patient < 4 months of age (See policy MCUP3121 Neonatal Circumcision Penis Plastic Surgery Thru Penile Prosthesis / Plastic Procedure For Penis 55175/80 Revision Of Scrotum Incision Of Sperm Duct Repair Of Vagina Thru 58294, Hysterectomy Reopen Fallopian Tube Thru Laparoscopy, Surgical; With Vaginal Hysterectomy With Or Without Removal Of Tube(S), With Or Without Removal Of Ovary(S) (Laparoscopic Assisted Vaginal Hysterectomy) 58578/79 Unlisted Procedure, Uterus Page 5 of 8
6 Outpatient Surgical Procedures - CPTs Requiring TAR (Continued) CPT Code Description Thru Tubal Repair Thru Insertion, Revision Or Removal Of Cranial Neurostimulator thru Discography, Lumbar (62290) and Cervical/Thoracic (62291) Thru Insertion, Revision Or Removal Of Spinal Neurostimulator Thru Repair Brow, Ptosis, Blepharoptosis, Lid Thru-66 Revision Of Eyelid Reconstruction Of Eyelid Unlisted Eyelid Procedure Revise External Ear Outer Ear Surgery Procedure Cervical and Thoracic Discography Lumbar discography Page 6 of 8
7 CPT CODE Pain Management CPTs Requiring TAR DESCRIPTION Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid 0027T 0062T 0063T thru Endoscopic lysis of epidural adhesions with direct visualization using mechanical means (e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline) including radiologic localization and epidurography Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels Percutaneous vertebroplasty and percutaneous vertebral augmentation Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumber (e.g. manual or automated percutaneous discectomy, percutaneous laser discectomy) Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day thru thru Implantable or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir Insertion, revision or removal of spinal neurostimulator Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level Cervical or thoracic, each additional level Lumbar or sacral, single level Lumbar or sacral, each additional level Injection(s), diagnostic or therapeutic agent, Paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), cervical or thoracic; single level Second level (List separately in addition to code for primary procedure) Page 7 of 8
8 Pain Management CPTs Requiring TAR (Continued) Third level (List separately in addition to code for primary procedure Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT, lumbar or sacral; single level) Second level (List separately in addition to code for primary procedure) Third level (List separately in addition to code for primary procedure) Destruction by neurolytic agent, paravertebral facet joint nerve. cervical or thoracic, single level Cervical or thoracic, each additional level Destruction by neurolytic agent, paravertebral facet joint nerve. single level lumbar or sacral Lumbar or sacral, each additional level *J0585 (If billed with & 64613) Botulinum A Toxin 1 unit extraocular *J0587 (If billed with & 64613) Botulinum B Toxin 10 units facial * TARs generated by the Pharmacy Department Page 8 of 8
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