Section Laboratory and Portable X-Ray Supplier ... · PDF fileRadiological and Physiological...

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39Radiological and Physiological Laboratory and Portable X-Ray Supplier
39.1 Enrollment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-239.1.1 Medicaid Managed Care Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-2

39.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-2

39.3 Benefits and Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-239.3.1 Magnetic Resonance Angiography (MRA) . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-439.3.2 Magnetic Resonance Imaging (MRI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-439.3.3 Positron-Emission Tomography (PET) Scans . . . . . . . . . . . . . . . . . . . . . . . . . 39-5

39.3.3.1 Brain Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-539.3.3.2 Tumor Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-5

39.3.4 Computerized Axial Tomography (CAT) Scan . . . . . . . . . . . . . . . . . . . . . . . . . 39-539.3.5 Prior Authorization for Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-539.3.6 Cardiac Blood Pool Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-739.3.7 Myocardial Perfusion Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-1039.3.8 Ambulatory Electroencephalogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-1039.3.9 Diagnosis Requirements for Other Services . . . . . . . . . . . . . . . . . . . . . . . . 39-1139.3.10 Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-1139.3.11 Stereotactic Radiosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-11

39.3.11.1 Radiation Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-1239.3.11.2 Medical Radiation Physics, Dosimetry, Treatment Devices, Special Services, and Proton Beam Treatment Delivery . . . . . . . . . . . . 39-1239.3.11.3 Clinical Brachytherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-12

39.3.12 Technical Services (Radiation Treatment Delivery/Port Films) . . . . . . . . . . . 39-1239.3.13 Radiation Treatment Centers/Outpatient Facilities . . . . . . . . . . . . . . . . . . 39-12

39.4 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-1339.4.1 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39-14

CPT only copyright 2005 American Medical Association. All rights reserved.

Section 39

39.1 EnrollmentTo enroll in the Texas Medicaid Program, radiological and physiological laboratories and portable X-ray suppliers must be enrolled in Medicare. Both radiological and physi-ological laboratories must be directed by a physician.

All mammography providers, including those providing stereotactic biopsies, must be certified by the Bureau of Radiation Control (BRC). Providers must submit a certif-icate containing their BRC certification number, dates of issue and expiration, type of service, and Medicaid and Children with Special Health Care Needs (CSHCN) Services Program provider identifiers. For more infor-mation, contact TMHP Provider Enrollment:

Texas Medicaid & Healthcare PartnershipProvider Enrollment

PO Box 200795Austin, TX 78720-0795Fax: 1-512-514-4214

Refer to: “Provider Enrollment” on page 1-2 for more information about enrollment procedures.

39.1.1 Medicaid Managed Care EnrollmentRadiological, physiological laboratory, and portable X-ray suppliers may be eligible to enroll in the Medicaid Managed Care programs as primary care providers. Certain providers may be required to enroll with a Medicaid Managed Care health plan to be reimbursed for services provided to Medicaid Managed Care clients. Contact the individual health plan for enrollment information.

Refer to: “Managed Care” on page 7-1

39.2 ReimbursementThe Medicaid rates for radiological and physiological laboratory and portable X-ray supplier providers are calcu-lated in accordance with Title 1 Texas Administrative Code (TAC) §355.8081 and §355.8085. The applicable Medicaid rates are listed in the current physician fee schedule, which is available on the TMHP website. These services are not payable when the client is in an inpatient setting, as they are included in the diagnosis related group (DRG) payment.

Refer to: “Reimbursement” on page 2-2 for more infor-mation about reimbursement.

39.3 Benefits and LimitationsMedicaid pays only up to the amount allowed for the total component for the same procedure, same client, same date of service, and any provider. Providers who perform the technical service and interpretation must bill for the total component. Providers who perform only the technical service must bill for the technical component; those who perform only the interpretation must bill for the interpre-tation component. Claims filed in excess of the amount allowed for the total component for the same procedure,

39–2

same dates of service, same client, and any provider are denied. Claims are paid based on the order in which they are received.

For example, if a claim is received for the total component and TMHP has already made payment for the technical and/or interpretation component for the same procedure, same date of service, same client, and any provider, the claim for the total component will be denied as previously paid to another provider. The same is true if a total component has already been paid and claims are received for the individual components.

The following procedure codes are payable to radiological laboratories, physiological laboratories, and portable X-ray suppliers.

Descriptions of the following procedure codes can be found in the Physician’s Common Procedural Terminology (CPT) Manual:

Procedure Codes

4/I/T-70030 4/I/T-70100 4/I/T-70110

4/I/T-70120 4/I/T-70130 4/I/T-70134

4/I/T-70140 4/I/T-70150 4/I/T-70160

4/I/T-70170 4/I/T-70190 4/I/T-70200

4/I/T-70210 4/I/T-70220 4/I/T-70240

4/I/T-70332 4/I/T-70336 4/I/T-70350

4/I/T-70355 4/I/T-70360 4/I/T-70370

4/I-70371 4/I/T-70373 4/I/T-70380

4/I/T-70390 4/I/T-70450 4/I/T-70480

4/I/T-70486 4/I/T-70490 4/I/T-70496

4/I/T-70498 4/I/T-70540 4/I/T-70542

4/I/T-70543 4/I/T-70544 4/I/T-70545

4/I/T-70546 4/I/T-70547 4/I/T-70548

4/I/T-70549 4/I/T-70551 4/I/T-70552

4/I/T-70553 4/I/T-71010 4/I/T-71015

4/I/T-71020 4/I/T-71021 4/I/T-71022

4/I/T-71023 4/I/T-71030 4/I/T-71034

4/I/T-71035 4/I/T-71100 4/I/T-71101

4/I/T-71110 4/I/T-71111 4/I/T-71120

4/I/T-71130 4/I/T-71250 4/I/T-71275

4/I/T-71550 4/I/T-71551 4/I/T-71552

4/I/T-72010 4/I/T-72020 4/I/T-72040

4/I/T-72050 4/I/T-72052 4/I/T-72069

4/I/T-72070 4/I/T-72072 4/I/T-72074

4/I/T-72080 4/I/T-72090 4/I/T-72100

4/I/T-72110 4/I/T-72114 4/I/T-72120

4/I/T-72125 4/I/T-72128 4/I/T-72131

4/I/T-72141 4/I/T-72146 4/I/T-72148

4/I/T-72156 4/I/T-72157 4/I/T-72158

4/I/T-72170 4/I/T-72190 4/I/T-72191

4/I/T-72192 4/I/T-72195 4/I/T-72196


Radiological and Physiological Laboratory and Portable X-Ray Supplier

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4/I/T-72197 4/I/T-72198 4/I/T-72200

4/I/T-72202 4/I/T-72220 4/I/T-73000

4/I/T-73010 4/I/T-73020 4/I/T-73030

4/I/T-73050 4/I/T-73060 4/I/T-73070

4/I/T-73080 4/I/T-73090 4/I/T-73092

4/I/T-73100 4/I/T-73110 4/I/T-73120

4/I/T-73130 4/I/T-73140 4/I/T-73200

4/I/T-73206 4/I/T-73218 4/I/T-73219

4/I/T-73220 4/I/T-73221 4/I/T-73222

4/I/T-73223 4/I/T-73225 4/I/T-73500

4/I/T-73510 4/I/T-73520 4/I/T-73530

4/I/T-73540 4/I/T-73542 4/I/T-73550

4/I/T-73560 4/I/T-73562 4/I/T-73564

4/I/T-73565 4/I/T-73590 4/I/T-73592

4/I/T-73600 4/I/T-73610 4/I/T-73620

4/I/T-73630 4/I/T-73650 4/I/T-73660

4/I/T-73700 4/I/T-73706 4/I/T-73718

4/I/T-73719 4/I/T-73720 4/I/T-73721

4/I/T-73722 4/I/T-73723 4/I/T-73725

4/I/T-74000 4/I/T-74010 4/I/T-74020

4/I/T-74022 4/I/T-74150 4/I/T-74175

4/I/T-74181 4/I/T-74182 4/I/T-74183

4/I/T-74185 4/I/T-74190 4/I/T-74210

4/I/T-74220 4/I/T-74230 4/I/T-74240

4/I/T-74241 4/I/T-74245 4/I/T-74250

4/I/T-75635 4-75952 4/I/T-75989

4/I/T-76010 4/I/T-76012 4/I/T-76013

4/I/T-76020 4/I/T-76040 4/I/T-76061

4/I/T-76062 4/I/T-76065 4/I/T-76066

4/I/T-76090 4/I/T-76091 4/I/T-76092

4/I/T-76100 4/I/T-76101 4/I/T-76102

4/I/T-76350 4/I/T-76355 4/I/T-76360

4/I/T-76376 4/I/T-76377 4/I/T-76380

4/I/T-76390 4/I/T-76393 4/I/T-76400

4/I/T-76496 4/I/T-76497 4/I/T-76498

4/I/T-76499 4/I/T-76506 4/I/T-76510

4/I/T-76511 4/I/T-76512 4/I/T-76513

4/I/T-76516 4/I/T-76519 4/I/T-76529

4/I/T-76536 4/I/T-76604 4/I/T-76645

4/I/T-76700 4/I/T-76705 4/I/T-76770

4/I/T-76775 4/I/T-76778 4/I/T-76800

4/I/T-76801 4/I/T-76802 4/I/T-76805

4/I/T-76810 4/I/T-76811 4/I/T-76812

4/I/T-76815 4/I/T-76816 4/I/T-76817

Procedure Codes


3

4/I/T-76818 4/I/T-76819 4/I/T-76820

4/I/T-76821 4/I/T-76825 4/I/T-76826

4/I/T-76827 4/I/T-76828 4/I/T-76830

4/I/T-76831 4/I/T-76856 4/I/T-76857

4/I/T-76870 4/I/T-76872 4/I/T-76873

4/I/T-76880 4/I/T-76940 4/I/T-76950

4/I/T-76965 4/I/T-76970 4/I/T-76975

4/I/T-76977 4/I/T-76991 4/I/T-76999

4/I/T-78070 4/I/T-78199 4/I/T-78299

4/I/T-78350 4/I/T-78473 4/I/T-78478

4/I/T-78480 4/I/T-78483 4/I/T-78499

4/I/T-78599 4/I/T-78999 5/I-91065

1/I/T-92135 1-92285 5/I/T-92542

1/I/T-92543 1/I/T-92544 1/I/T-92545

1/I/T-92546 5/I-92553 5/I-92555

5/I-92556 5/I-92557 5/I-92561

5/I-92562 5/I-92563 I-92564

5/I-92565 5/I-92568 5/I-92569

5/I-92571 5/I-92572 5/I-92573

5/I-92575 5/I-92577 5/I-92584

5-92586 T-93005 5-93012

5-93015 T-93017 I-93018

5-93040 T-93041 5-93224

T-93225 T-93226 5-93230

T-93231 T-93232 5-93235

T-93236 5-93268 5-93270

5-93271 5/I/T-93278 4/I/T-93307

4/I/T-93308 4/I/T-93312 4/I/T-93313

4/I/T-93314 4/I/T-93315 4/I/T-93316

4/I/T-93317 4/I/T-93318 4/I/T-93320

4/I/T-93321 4/I/T-93325 4/I/T-93350

5-93720 T-93721 5/I/T-93724

5/I/T-93731 5/I/T-93732 5/I/T-93733

5/I/T-93734 5/I/T-93735 5/I/T-93736

5/I/T-93799 4/I/T-93875 4/I/T-93880

4/I/T-93882 4/I/T-93886 4/I/T-93888

4/I/T-93890 4/I/T-93892 4/I/T-93893

4/I/T-93922 4/I/T-93923 4/I/T-93924

4/I/T-93925 4/I/T-93926 4/I/T-93930

4/I/T-93931 4/I/T-93965 4/I/T-93970

4/I/T-93971 4/I/T-93975 4/I/T-93976

4/I/T-93978 4/I/T-93979 4/I/T-93980

4/I/T-93981 5/I/T-94010 5-94014

5-94015 5-94016 5/I/T-94060

Procedure Codes

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Section 39

39.3.1 Magnetic Resonance Angiography (MRA) MRA is a technique which allows the noninvasive visual-ization and study of blood vessels through either two-dimensional (2-D) or three-dimensional (3-D) image recon-struction. The advantages of this noninvasive radiologic test include its safety, large field of view, and the ability to demonstrate complicated 3-D relationships without the need for nephrotoxic contrast media.

MRA of the head and neck may be considered for reimbursement when indicated and utilized for the visual-ization and ruling out of cerebrovascular disease, subarachnoid and intracerebral hemorrhage, and occlusion and stenosis of intracranial vessels. Procedure codes 4/I/T-70544, 4/I/T-70545, 4/I/T-70546, 4/I/T-70547, 4/I/T-70548, and 4/I/T-70549 will be denied for all other diagnoses.

The following procedure codes are a benefit of the Texas Medicaid Program:

MRA of the chest (procedure code 4/I/T-71555) may be indicated and considered for reimbursement for the evalu-ation of coronary artery disease or anomalous arterio-

5/I/T-94070 5/I/T-94150 5/I/T-94200

5/I/T-94240 5/I/T-94250 5/I/T-94260

5/I/T-94350 5/I/T-94360 5/I/T-94370

5/I/T-94375 5/I/T-94400 5/I/T-94450

5/I/T-94620 5/I/T-94621 5/I/T-94680

5/I/T-94681 5/I/T-94690 5/I/T-94720

5/I/T-94725 5/I/T-94750 5/I/T-94772

5/I/T-94799 5/I/T-95805 5/I/T-95808

5/I/T-95810 5/I/T-95811 5/I/T-95812

5/I/T-95813 5/I/T-95816 5/I/T-95819

5/I/T-95822 5/I/T-95824 5/I/T-95827

5/I/T-95860 5/I/T-95861 5/I/T-95863

5/I/T-95864 5/I/T-95865 5/I/T-95866

5/I/T-95867 5/I/T-95868 5/I/T-95870

5/I/T-95872 5/I/T-95900 5/I/T-95903

5/I/T-95904 5/I/T-95925 5/I/T-95926

5/I/T-95927 5/I/T-95933 5/I/T-95934

5/I/T-95936 5/I/T-95937 5/I/T-95950

5/I/T-95951 5/I/T-95953 5/I/T-95956

5/I/T-95958

Procedure Codes

4/I/T-70544 4/I/T-70545 4/I/T-70546

4/I/T-70547 4/I/T-70548 4/I/T-70549

4/I/T-71555 4/I/T-72159 4/I/T-72198

4/I/T-73225 4/I/T-74185

Procedure Codes

39–4

pulmonary systems. It may be utilized to identify thoracic aneurysms or pulmonary emboli in cases where contrast material is contraindicated. MRAs are also indicated to evaluate the coronary vessels in coronary artery disease, vasculitis, or vessel patency postoperatively.

MRA of the abdomen (procedure code 4/I/T-74185) may be considered for reimbursement when indicated to assess the main renal arteries, for the evaluation of renal artery stenosis, abdominal aortic aneurysm or dissection, and/or associated veno-occlusive disease.

MRA of the pelvis (procedure code 4/I/T-72198) may be considered for reimbursement for evaluation of pelvic arteries for stenosis and the detection, grading, and differ-entiation of renovascular disease.

MRA of the lower extremities (procedure code (procedure code 4/I/T-73725) may be considered for reimbursement when indicated for the evaluation of peripheral vascular disease related to the lower extremities, such as heman-gioma, atherosclerosis, arterial embolism and thrombosis, and arterial anomalies.

39.3.2 Magnetic Resonance Imaging (MRI)MRI is a noninvasive nuclear procedure for imaging tissues of high fat and water content, which are poorly seen with other radiologic techniques. MRI is a covered benefit of the Medicaid Program when medically indicated.

When a computerized axial tomography (CAT) scan and an MRI of the same body area are performed on the same day, the CAT scan will be paid and the MRI will be denied as part of an overlapping diagnostic procedure. Additional MRIs or CAT scans of entirely different body areas performed on the same day will be paid with documen-tation of medical necessity.

MRI procedures that specify “with contrast” include payment for paramagnetic contrast, therefore, low osmolar contrast material is not reimbursed separately.

MRI of the breast (procedure codes 4/I/T-76093 and 4/I/T-76094) will be reimbursed by the Texas Medicaid program, when billed for the following diagnosis codes:

Procedure codes 4/I/T-76093 and 4/I/T-76094 will be denied for all other diagnoses.

A freestanding MRI facility may bill type of service (TOS) T for the technical portion only. The radiologist or neurol-ogist who then reads the MRI may bill using TOS I for

Diagnosis Code Description

99654 Mechanical complication of breast prosthesis

99669 Infection and inflammatory reaction due to other internal prosthetic device, implant, and graft

99679 Other complications due to other internal prosthetic device, implant, and graft



9

interpretation only. Additionally, when the client is in the inpatient or outpatient setting, the radiologist or neurol-ogist may bill using TOS I for interpretation.

Refer to: “Hospital (Medical/Surgical Acute Care Facility)” on page 25-1. “Physician” on page 36-1 for more information on MRI and contrast material.

39.3.3 Positron-Emission Tomography (PET) ScansA PET scan is a noninvasive nuclear medicine procedure that images the chemical activity of body organs and tissues. The PET scan uses electronic detection of short-lived positron-emitting radiopharmaceuticals to measure metabolic, biochemical, and functional activity in tissue. A scanner then measures radioactivity as it is dispersed throughout the body, creating three-dimensional pictures of tissue function.

The following procedure codes are a benefit of the Texas Medicaid Program. Prior authorization is required with documentation of medical necessity.

39.3.3.1 Brain Imaging Brain imaging PET scans are a benefit when either of the following is true:

• “When used as part of a pre-surgical evaluation to localize a focus of refractory seizure activity with documentation of a history of seizures that are not controlled through medications”

• “When differentiating recurrent brain tumors from scar tissue with documentation of a history of a primary brain tumor and a plan of treatment”

39.3.3.2 Tumor Imaging Tumor-imaging PET scans are a benefit and are limited to staging and restaging of recurrent tumors in which the PET scan may assist in determining the optimal clinical management of the client.

Procedure codes 78459, 78491, and 78492 are not a benefit of the Texas Medicaid Program.

When requesting prior authorization for tumor-imaging PET scans, the provider must submit supporting documen-tation which indicates that standard imaging was not conclusive and that the provider's rationale for this procedure supports medical necessity.

39.3.4 Computerized Axial Tomography (CAT) ScanThe Texas Medicaid Program pays for CAT scans for specific diagnoses.

Procedure Codes

4/I/T-78608 4/I/T-78609 4/I/T-78811

4/I/T-78812 4/I/T-78813 4/I/T-78814

4/I/T-78815 4/I/T-78816


3

When a CAT scan and an MRI of the same body area are performed on the same day, the CAT scan will be paid and the MRI will be denied as part of an overlapping diagnostic procedure. Additional MRIs and/or CAT scans of entirely different body areas performed on the same day will be paid with documentation of medical necessity.

Freestanding facilities may bill for CAT scans using TOS T for technical component only. The radiologist or neurol-ogist who then reads the scan bills TOS I for interpretation only.

39.3.5 Prior Authorization for Radiology ServicesTraditional Medicaid and PCCM require prior authorization or retrospective authorization for:

• MRI

• MRA

• Computed Tomography Imaging (CT)

• Computed Tomography Angiography (CTA)

Authorization is not required for emergency department or inpatient hospital MRI, MRA, CT, or CTA.

Prior authorization is required for all outpatient nonemergent CT, CTA, MRI, and MRA studies (e.g., those that are preplanned or scheduled) before services are rendered. Retrospective authorization is required for outpatient emergent studies when the physician deter-mines that a medical emergency that imminently threatens life or limb exists, and the medical emergency requires advanced diagnostic imaging (CT, CTA, MRI, or MRA). Additional studies may be conducted at the time of the test if they are medically indicated by the radiologist. Providers must submit a retrospective authorization request no later than seven calendar days after the study has been completed. A copy should be maintained in the client’s medical record. If radiology services are ordered by a referring physician who is not a Medicaid-enrolled provider in places of service, such as teaching facilities, federally qualified health care centers, and rural health clinics, the Radiology Prior Authorization Request Form must be signed by the referring physician and must include the group or supervising physician's provider identifier.

The addition of post 3-D reconstruction (procedure codes 4/I/T-76376 and 4/I/T-76377) CT and MR studies must be prior authorized. No additional payment will be made without prior authorization.

Providers and facilities are required to use the lowest possible radiation dose that is consistent with acceptable image quality for CT examinations of children. It is recom-mended that providers and facilities utilize national standards for CT imaging, such as those in the Practice Guidelines for Performing and Interpreting Diagnostic CT examinations, which was created by the American College of Radiology.

39–5

Section 39

Nationally-accepted guidelines and radiology protocols that are based on medical literature are utilized in the authorization processes for both emergent and nonemergent studies.

The medical literature includes the works of the: American College of Radiology (specifically, the Appropriateness Criteria), American Academy of Neurology, American Academy of Orthopedic Surgeons, American College of Cardiology, American Heart Association, and National Comprehensive Cancer Care Network.

Prior authorization of nonemergent and emergent retro-spective authorization of CT, CTA, MRI, and MRA studies are considered on an individual basis using standard evidence-based guidelines to evaluate the request. Documentation must support medical necessity for the study.

Providers may request prior or retrospective authorization by calling the TMHP Radiology Services Prior Authorization Line at 1-800-572-2116, by fax to 1-888-693-3210, or by mail to:

Texas Medicaid & Healthcare Partnership730 Cool Springs Blvd, Suite 800

Franklin, TN 37067

Please be prepared to provide the following patient infor-mation for all requests:

• Diagnosis

• Treatment history

• Treatment plan

• Medications

• Previous imaging results

Providers may be requested to provide additional documentation. Requests that are faxed or mailed must be accompanied by a Radiology Prior Authorization Form. The Radiology Prior Authorization Form must be completed, signed, and dated by the ordering physician before submitting the request for authorization of CT, CTA, MRI, or MRA studies, regardless of the method of request for authorization. The physician's signature must be current, unaltered, original, and handwritten. A comput-erized or stamped signature will not be accepted. The physician who ordered the test(s) must keep the completed form with original signature in the client's medical record. In addition, medical record documentation must support the medical necessity of the study. Authori-zation requirements for both nonemergent and emergent studies must be met in order to be considered for reimbursement. In the absence of authorization, both the technical and professional interpretation components will be denied.

Claims for emergency CT, CTA, MRI, and MRA studies provided in the emergency department must be submitted with modifier U6 and must have the appropriate corre-sponding emergency services revenue code.

39–6

If two CTs, CTAs, MRAs, or MRIs are performed in the emergency room or in an out patient setting on the same day without an authorization on file, the second procedure will be denied. Providers may submit additional medical necessity documentation for payment reconsideration.

The following procedure codes require authorization:

Procedure Codes

B-350 B-351 B-352

B-359 B-610 B-611

B-612 B-619 4/I/T-70336

4/I/T-70450 4/I/T-70460 4/I/T-70470

4/I/T-70480 4/I/T-70481 4/I/T-70482

4/I/T-70486 4/I/T-70487 4/I/T-70488

4/I/T-70490 4/I/T-70491 4/I/T-70492

4/I/T-70496 4/I/T-70498 4/I/T-70540

4/I/T-70543 4/I/T-70544 4/I/T-70545

4/I/T-70546 4/I/T-70547 4/I/T-70542

4/I/T-70548 4/I/T-70549 4/I/T-70551

4/I/T-70552 4/I/T-70553 4/I/T-71250

4/I/T-71260 4/I/T-71270 4/I/T-71275

4/I/T-71551 4/I/T-71552 4/I/T-71555

4/I/T-72125 4/I/T-71550 4/I/T-72126

4/I/T-72127 4/I/T-72128 4/I/T-72129

4/I/T-72130 4/I/T-72132 4/I/T-72133

4/I/T-72141 4/I/T-72142 4/I/T-72131

4/I/T-72147 4/I/T-72148 4/I/T-72149

4/I/T-72156 4/I/T-72146 4/I/T-72158

4/I/T-72159 4/I/T-72191 4/I/T-72192

4/I/T-72157 4/I/T-72194 4/I/T-72195

4/I/T-72196 4/I/T-72197 4/I/T-72193

4/I/T-73200 4/I/T-73201 4/I/T-73202

4/I/T-73206 4/I/T-72198 4/I/T-73219

4/I/T-73220 4/I/T-73221 4/I/T-73222

4/I/T-73218 4/I/T-73225 4/I/T-73700

4/I/T-73701 4/I/T-73702 4/I/T-73223

4/I/T-73718 4/I/T-73719 4/I/T-73720

4/I/T-73721 4/I/T-73706 4/I/T-73723

4/I/T-73725 4/I/T-74150 4/I/T-74160

4/I/T-73722 4/I/T-74175 4/I/T-74181

4/I/T-74182 4/I/T-74183 4/I/T-74170

4/I/T-75552 4/I/T-75553 4/I/T-75554

4/I/T-75555 4/I/T-74185 4/I/T-75635

4/I/T-76093 4/I/T-76094 4/I/T-76355

4/I/T-75556 4/I/T-76377 4/I/T-76380

4/I/T-76390 4/I/T-76400 4/I/T-76376



9

39.3.6 Cardiac Blood Pool ImagingCardiac blood pool imaging (procedure codes 4/I/T-78472, 4/I/T-78473, 4/I/T-78481, 4/I/T-78483, 4/I/T-78494, and 4/I/T-78496) is a covered benefit for the following diagnosis codes:


3526 Multiple cranial nerve palsies

3940 Mitral stenosis

3941 Rheumatic mitral insufficiency

3942 Mitral stenosis with insufficiency

3949 Other and unspecified mitral valve diseases

3950 Rheumatic aortic stenosis

3951 Rheumatic aortic insufficiency

3952 Rheumatic aortic stenosis with insufficiency

3959 Other and unspecified rheumatic aortic diseases

3960 Mitral valve stenosis and aortic valve stenosis

3961 Mitral valve stenosis and aortic valve insufficiency

3962 Mitral valve insufficiency and aortic valve stenosis

3963 Mitral valve insufficiency and aortic valve insufficiency

3968 Multiple involvement of mitral and aortic valves

3969 Mitral and aortic valve diseases, unspecified

3970 Diseases of tricuspid valve

3971 Rheumatic diseases of pulmonary valve

3979 Rheumatic diseases of endocardium, valve unspecified

41000 Acute myocardial infarction of anterolateral wall, episode of care unspecified

41001 Acute myocardial infarction of anterolateral wall, initial episode of care

41002 Acute myocardial infarction of anterolateral wall, subsequent episode of care

41010 Acute myocardial infarction of other anterior wall, episode of care unspecified

41011 Acute myocardial infarction of other anterior wall, initial episode of care

41012 Acute myocardial infarction of other anterior wall, subsequent episode of care


3

41020 Acute myocardial infarction of infer-olateral wall, episode of care unspecified

41021 Acute myocardial infarction of infer-olateral wall, initial episode of care

41022 Acute myocardial infarction of infer-olateral wall, subsequent episode of care

41030 Acute myocardial infarction of infer-oposterior wall, episode of care unspecified

41031 Acute myocardial infarction of infer-oposterior wall, initial episode of care

41032 Acute myocardial infarction of infer-oposterior wall, subsequent episode of care

41040 Acute myocardial infarction of other inferior wall, episode of care unspecified

41041 Acute myocardial infarction of other inferior wall, initial episode of care

41042 Acute myocardial infarction of other inferior wall, subsequent episode of care

41050 Acute myocardial infarction of other lateral wall, episode of care unspecified

41051 Acute myocardial infarction of other lateral wall, initial episode of care

41052 Acute myocardial infarction of other lateral wall, subsequent episode of care

41060 True posterior wall infarction, episode of care unspecified

41061 True posterior wall infarction, initial episode of care

41062 True posterior wall infarction, subsequent episode of care

41070 Subendocardial infarction, episode of care unspecified

41071 Subendocardial infarction, initial episode of care

41072 Subendocardial infarction, subse-quent episode of care

41080 Acute myocardial infarction of other specified sites, episode of care unspecified

41081 Acute myocardial infarction of other specified sites, initial episode of care


39–7

Section 39

41082 Acute myocardial infarction of other specified sites, subsequent episode of care

41090 Acute myocardial infarction of unspecified site, episode of care unspecified

41091 Acute myocardial infarction of unspecified site, initial episode of care

41092 Acute myocardial infarction of unspecified site, subsequent episode of care

4110 Postmyocardial infarction syndrome

4111 Intermediate coronary syndrome

41181 Other acute and subacute forms of ischemic heart disease, acute ischemic heart disease without myocardial infarction

41189 Other acute and subacute forms of ischemic heart disease, other

412 Old myocardial infarction

4130 Angina decubitus

4131 Prinzmetal angina

4139 Other and unspecified angina pectoris

41400 Coronary atherosclerosis of unspecified type of vessel, native or graft

41401 Coronary atherosclerosis of native coronary artery

41402 Coronary atherosclerosis of autol-ogous vein bypass graft

41403 Coronary atherosclerosis of nonau-tologous biological bypass graft

41404 Coronary atherosclerosis of artery bypass graft

41405 Coronary atherosclerosis of unspecified bypass graft

41406 Coronary atherosclerosis of native coronary artery of transplanted hearts

41407 Coronary atherosclerosis, of bypass graft (artery) (vein) of trans-planted heart

41410 Aneurysm of heart (wall)

41411 Aneurysm of coronary vessels

41412 Dissection of coronary artery

41419 Other aneurysm of heart

4148 Other specified forms of chronic ischemic heart disease


39–8

4149 Chronic ischemic heart disease, unspecified

4150 Acute cor pulmonale

41511 Iatrogenic pulmonary embolism and infarction

41519 Other pulmonary embolism and infarction

4160 Primary pulmonary hypertension

4161 Kyphoscoliotic heart disease

4168 Other chronic pulmonary heart diseases

4169 Chronic pulmonary heart disease, unspecified

4170 Arteriovenous fistula of pulmonary vessels

4171 Aneurysm of pulmonary artery

4178 Other specified diseases of pulmonary circulation

4179 Unspecified disease of pulmonary circulation

4200 Acute pericarditis in diseases classified elsewhere

42090 Acute pericarditis, unspecified

42091 Acute idiopathic pericarditis

42099 Other acute pericarditis

4210 Acute and subacute bacterial endocarditis

4211 Acute and subacute infective endocarditis in diseases classified elsewhere

4219 Acute endocarditis, unspecified

4220 Acute myocarditis in diseases classified elsewhere

42290 Acute myocarditis, unspecified

42291 Idiopathic myocarditis

42292 Septic myocarditis

42293 Toxic myocarditis

42299 Other acute myocarditis

4230 Hemopericardium

4231 Adhesive pericarditis

4232 Constrictive pericarditis

4238 Other specified diseases of pericardium

4239 Unspecified disease of pericardium

4240 Mitral valve disorders

4241 Aortic valve disorders

4242 Tricuspid valve disorders, specified as nonrheumatic




9

4243 Pulmonary valve disorders

42490 Endocarditis, valve unspecified, unspecified cause

42491 Endocarditis in diseases classified elsewhere

42499 Other endocarditis, valve unspecified

4250 Endomyocardial fibrosis

4251 Hypertrophic obstructive cardiomyopathy

4252 Obscure cardiomyopathy of africa

4253 Endocardial fibroelastosis

4254 Other primary cardiomyopathies

4255 Alcoholic cardiomyopathy

4257 Nutritional and metabolic cardiomyopathy

4258 Cardiomyopathy in other diseases classified elsewhere

4259 Secondary cardiomyopathy, unspecified

4260 Atrioventricular block, complete

42610 Atrioventricular block, unspecified

42611 First degree atrioventricular block

42612 Mobitz (type) ii atrioventricular block

42613 Other second degree atrioven-tricular block

4262 Left bundle branch hemiblock

4263 Other left bundle branch block

4264 Right bundle branch block

42650 Bundle branch block, unspecified

42651 Right bundle branch block and left posterior fascicular block

42652 Right bundle branch block and left anterior fascicular block

42653 Other bilateral bundle branch block

42654 Trifascicular block

4266 Other heart block

4267 Anomalous atrioventricular excitation

42681 Lown-ganong-levine syndrome

42682 Long QT syndrome

42689 Other specified conduction disorders

4269 Conduction disorder, unspecified

4270 Paroxysmal supraventricular tachycardia

4271 Paroxysmal ventricular tachycardia



3

4272 Paroxysmal tachycardia, unspecified

42731 Atrial fibrillation

42732 Atrial flutter

42741 Ventricular fibrillation

42742 Ventricular flutter

4275 Cardiac arrest

42760 Premature beats, unspecified

42761 Supraventricular premature beats

42769 Other premature beats

42781 Sinoatrial node dysfunction

42789 Other specified cardiac dysrhythmias

4279 Cardiac dysrhythmia, unspecified

4280 Congestive heart failure

4281 Left heart failure

42820 Unspecified systolic heart failure

42821 Acute systolic heart failure

42822 Chronic systolic heart failure

42823 Acute on chronic systolic heart failure

42830 Unspecified diastolic heart failure

42831 Acute diastolic heart failure

42832 Chronic diastolic heart failure

42833 Acute on chronic diastolic heart failure

42840 Unspecified combined systolic and diastolic heart failure

42841 Acute combined systolic and diastolic heart failure

42842 Chronic combined systolic and diastolic heart failure

42843 Acute on chronic combined systolic and diastolic heart failure

4289 Heart failure, unspecified

4290 Myocarditis, unspecified

4291 Myocardial degeneration

4292 Cardiovascular disease, unspecified

4293 Cardiomegaly

4294 Functional disturbances following cardiac surgery

4295 Rupture of chordae tendineae

4296 Rupture of papillary muscle

42971 Certain sequelae of myocardial infarction, not elsewhere classified, acquired cardiac septal defect


39–9

Section 39

39.3.7 Myocardial Perfusion ImagingMyocardial perfusion imaging, which uses radionuclides, is a noninvasive stress test that measures coronary blood flow (perfusion), especially to the left ventricle.

Myocardial perfusion imaging is a covered benefit of the Texas Medicaid Program when it is medically indicated.

Myocardial perfusion imaging studies will be limited to one study per day, including, but not limited to, the following procedure codes: 4/I/T-78460, 4/I/T-78461, 4/I/T-78464, and 4/I/T-78465.

When multiple procedure codes are billed, the most inclusive code will be paid and all other codes will be denied.

Myocardial perfusion imaging may be performed at rest and/or during stress using physical exercise or pharmaco-logicals. The following procedure codes may be used to bill for cardiovascular stress testing: 5-93015, T-93017, and I-93018.

39.3.8 Ambulatory ElectroencephalogramEpilepsy is a clinical diagnosis which, in the overwhelming majority of cases, can be characterized with a standard electroencephalogram, a detailed history, a detailed physical examination that includes a comprehensive neurological examination, and an accurate description of the patient’s epileptic phenomenon (because a positive interictal pattern of the EEG does not confirm the diagnosis beyond doubt).

There are some studies that show an advantage for intensive ambulatory electroencephalographic (A/EEG) monitoring in some cases where it has not been possible to confirm or support a diagnosis of epilepsy or to confirm or support the differential diagnosis of epilepsy from

42979 Certain sequelae of myocardial infarction, not elsewhere classified, other

42981 Other disorders of papillary muscle

42982 Hyperkinetic heart disease

42989 Other ill-defined heart diseases

4299 Heart disease, unspecified

7813 Lack of coordination

78650 Unspecified chest pain

78651 Precordial pain

78652 Painful respiration

78659 Other chest pain

7991 Respiratory arrest

V4321 Organ or tissue replaced by other means, heart assist device

V4581 Postsurgical aortocoronary bypass status


39–10

pseudoconvulsive episodes associated with transient cerebral ischemia from variable causes other than epilepsy.

A/EEG testing is a benefit of the Texas Medicaid Program. A 24-hour A/EEG may be covered for clients in whom:

• A seizure diathesis is suspected but is not defined by history, physical examinations, or resting EEG.

• Syncope or transient ischemic attacks have not been explained by conventional studies.

The monitoring unit is 24 hours. Benefits are limited to two units for each physician for the same patient per six months when it is medically necessary.

A/EEG should be billed using procedure codes 5/I/T-95950, 5/I/T-95951, 5/I/T-95953, or 5/I/T-95956.

Procedure codes 5/I/T-95950, 5/I/T-95951, 5/I/T-95953, and 5/I/T-95956 are related codes. If multiple procedure codes are billed on the same day, the most inclusive code will be paid, and all other codes will be denied.

Procedure codes 4/I/T-95950, 4/I/T-95951, 4/I/T-95953, and 4/I/T-95956 are automatically payable when billed with the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes or their equivalent narrative description listed below.

Request for payment of codes 4/I/T-95950, 4/I/T-95951, 4/I/T-95953, and 4/I/T-95956 in any place of service without the enumerated ICD-9-CM codes or their equivalent narrative description will be denied as an inappropriate service for the diagnosis. Upon appeal to the associate medical director, codes 4/I/T-95950, 4/I/T-95951, 4/I/T-95953, and 4/I/T-95956 may be paid with other related procedure codes when the submitted documentation establishes the medical necessity of the service.


2390 Delirium due to conditions classified elsewhere

2948 Other persistent mental disorders due to conditions classified elsewhere

3332 Myoclonus

34500 Generalized nonconvulsive epilepsy, without mention of intrac-table epilepsy

34501 Generalized nonconvulsive epilepsy, with intractable epilepsy

34510 Generalized convulsive epilepsy, without mention of intractable epilepsy

34511 Generalized convulsive epilepsy, with intractable epilepsy

3452 Petit mal status, epileptic

3453 Grand mal status, epileptic



9

39.3.9 Diagnosis Requirements for Other ServicesA diagnosis is not required with a provider’s request for payment except when providing the following services: ambulatory electroencephalograms (A/EEGs), arterio-grams, cardiac blood pool imaging, chest X-rays, CAT scans, echography, electrocardiograms (EKGs), magnetic resonance angiographies (MRAs), MRIs, mammogra-phies, noninvasive diagnostic studies, polysomnographies, and venographies.

Claims for all services provided to clients eligible for “Emergency Care Only” must have a diagnosis to be considered for reimbursement. As with all procedures billed to the Texas Medicaid Program, most baseline screening or comparison studies are not a benefit.

Refer to: “Physician” on page 36-1 for more information about these services.

34540 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy

34541 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy

34550 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy

34551 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy

34560 Infantile spasms, without mention of intractable epilepsy

34561 Infantile spasms, with intractable epilepsy

34570 Epilepsia partialis continua, without mention of intractable epilepsy

34571 Epilepsia partialis continua, with intractable epilepsy

34580 Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy

34581 Other forms of epilepsy and recurrent seizures, with intractable epilepsy

34590 Epilepsy, unspecified, without mention of intractable epilepsy

34591 Epilepsy, unspecified, with intrac-table epilepsy



3

39.3.10 Radiation Therapy Radiation treatment management will be considered for reimbursement as defined in the paragraphs of the CPT Manual under the heading of “Radiation Treatment Management.” Radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days. Multiple fractions representing two or more treatment sessions furnished on the same day may be counted separately as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days. Procedure code 6-77427 is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment; one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately. The professional services furnished during treatment management typically consists of:

• Review of port films

• Review of dosimetry, dose delivery, and treatment parameters

• Review of patient treatment set-up

• Examination of patient for medical evaluation and management (e.g., assessment of the patient's response to treatment, coordination of care and treatment, review of imaging and/or lab test results)

39.3.11 Stereotactic RadiosurgeryStereotactic radiosurgery is a system used to verify tumor location with precise mapping using live radiographic images throughout the procedure. The linear accelerator attached to a robotic arm delivers multiple, highly focused radiation beams. This high dose radiation can treat multiple sites at one treatment session. A multidisci-plinary team consisting of a neurosurgeon, a radiation oncologist, and a radiation physicist accomplishes treatment with the patient as the central focus. Stereo-tactic radiosurgery is a benefit of the Texas Medicaid Program.

Procedure codes 6/I/T-G0338, T-G0339, and T-G0340 may be considered for reimbursement.

Physicians, radiation treatment centers, and outpatient facilities may bill the technical component only for procedure codes T-G0339 and T-G0340 in either the office (POS 1) or outpatient setting (POS 5) for stereo-tactic radiosurgery therapeutic delivery sessions.

The professional component (TOS I) and the technical component (TOS T) are not reimbursed when billed with the total component (TOS 6). The total component includes the professional and the technical components.

The professional component (TOS I) is payable for services that are rendered in an inpatient hospital (POS 3), a radiation treatment center (POS 5), or an outpa-tient hospital (POS 5). Physicians who bill for client services that are rendered in a facility recognized by

39–11

Section 39

Medicaid as a radiation treatment center (POS 1) or in their offices (POS 1) will be reimbursed for the total component (TOS 6).

Prior authorization requirements for stereotactic radio-surgery may include, but are not limited to, diagnoses that indicate one of the following medical conditions:

• Benign and malignant tumors of the central nervous system

• Vascular malformations

• Soft tissue tumors in the chest, abdomen, and pelvis

• Other diagnoses may be considered after a review of the documentation of medical necessity and a review of current literature that supports the requested use (e.g., trigeminal neuralgia)

The following documentation must be submitted to request prior authorization for stereotactic radiosurgery services:

• A brief history and physical evaluation

• Description of tumor types, sizes, and locations

• Supporting documentation of medical necessity

• ICD-9-CM diagnosis codes

• The physician's provider identifier

• The name and address of the facility where services will be performed

39.3.11.1 Radiation Treatment Planning The following procedure codes are a benefit of the Texas Medicaid Program:

Procedure codes 6-77421, 6-77427, and 6-77499 are payable as the total component (TOS 6) for services performed in POS 1 (office or a facility recognized by Medicaid as a radiation treatment center), POS 3 (inpatient hospital), and POS 5 (outpatient hospital or a radiation treatment center).

39.3.11.2 Medical Radiation Physics, Dosimetry, Treatment Devices, Special Services, and Proton Beam Treatment Delivery The following procedure codes are a benefit of the Texas Medicaid Program:

Procedure Codes

6/I-77261 6/I-77262 6/I-77263

6/I-77280 6/I-77285 6/I-77290

6/I-77295 6/I-77299 6/I/T-77301

Procedure Codes

6/I-77300 6/I-77305 6/I-77310

6/I-77315 6/I-77326 6/I-77327

6/I-77328 6/I-77332 6/I-77333

6/I-77334 6/I-77399 6-77520

6-77522 6-77523 6-77525

39–12

39.3.11.3 Clinical Brachytherapy Brachytherapy (short distance or close treatment) is used to describe the use of radioactive isotopes in the treatment of cancer and benign diseases. Brachytherapy involves placement of radioactive sources, such as “seeds” or wires either in tumors (interstitial implants) or near tumors (intracavitary therapy and mold therapy).

The following procedure codes are a benefit of the Texas Medicaid Program:

39.3.12 Technical Services (Radiation Treatment Delivery/Port Films)Only the technical component (TOS T) is payable to physi-cians for the following services when they are rendered in a facility recognized by Medicaid as a radiation treatment center (POS 1) or in the physician's office (POS 1).

39.3.13 Radiation Treatment Centers/Outpatient Facilities Radiation treatment centers and outpatient hospitals will be reimbursed only for the technical component (TOS T) for services rendered in POS 5 for the following services:

Procedure Codes

2/F-57155 2/F-58346 6/I-77750

6/I-77761 6/I-77762 6/I-77763

6/I-77776 6/I-77777 6/I-77778

6/I-77781 6/I-77782 6/I-77783

6/I-77784 6/I-77789 6/I-77799

Procedure Codes

T-77401 T-77402 T-77403

T-77404 T-77406 T-77407

T-77408 T-77409 T-77411

T-77412 T-77413 T-77414

T-77416 T-77417 T-77418

T-77421 T-77422 T-77423

Procedure Codes

Radiation Treatment Planning

T-77280 T-77285 T-77290

T-77295 T-77299

Medical Radiation Physics, Dosimetry, Treatment Devices and Special Services

T-77300 T-77305 T-77310

T-77315 T-77326 T-77327

T-77328 T-77332 T-77333

T-77334 T-77399

Radiation Treatment Delivery/Port Films

T-77401 T-77402 T-77403

T-77404 T-77406 T-77407



9

The following clinical brachytherapy services procedure codes include admission to the hospital and daily care. Initial and subsequent hospital care will be denied on the same day that clinical brachytherapy services are billed.

The following services will be allowed once per day, unless an appeal is submitted with documentation that supports the need for the service to be provided more than once:

• Therapeutic radiation treatment planning

• Therapeutic radiology simulation-aided field setting

• Teletherapy

• Brachytherapy isodose calculation

• Treatment devices

• Proton beam delivery/treatment

• Intracavity radiation source application

• Interstitial radiation source application

• Remote afterloading high intensity brachytherapy

• Radiation treatment delivery

• Localization

• Radioisotope therapy

A consultation on the same day as clinical treatment planning and clinical brachytherapy is included in the therapeutic radiology procedure.

Laboratory and diagnostic radiologic services provided in an office (POS 1) will be reimbursed to physicians as a total component. Radiation treatment centers will also be reimbursed for the total component for these services in POS 5. Injectable medications given during the course of therapy in any setting will be reimbursed separately.

Normal follow-up care by the same physician on the day of any therapeutic radiology service will be denied. Medical services within program limitations may be paid on appeal when documentation supports the medical necessity of the visit due to services unrelated to the radiation treatment or radiation treatment complication.

Procedure code 2/8-19298 is a benefit of the Texas Medicaid Program.

T-77408 T-77409 T-77411

T-77412 T-77413 T-77414

T-77416 T-77417 T-77421

T-77422 T-77423

Clinical Brachytherapy

2/F-57155 2/F-58346 T-77781

T-77782 T-77783 T-77784

T-77789 T-77799

Procedure Codes

6/I-77750 6/I-77761 6/I-77762

6/I-77763 6/I-77776 6/I-77777

6/I/T-77781 6/I/T-77782 6/I/T-77783

6/I/T-77784 6/I/T-77789 6/I/T-77799

Procedure Codes


3

No separate payment will be made for any of the following procedure codes provided on the same day as radiation therapy by the same provider:

No separate payment will be made for established office or outpatient visits within 90 days after radiation treatment by the same provider.

High energy neutron beam radiation therapy (procedure codes 6/I/T-77422 and 6/I/T-77423) are only payable for the following diagnosis codes:

39.4 Claims InformationSubmit radiological and physiological laboratory services and portable X-ray supplier services to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply them. Providers must identify the referring/ordering provider by full name and address or nine-digit TPI in Block 17 and 17a of the CMS-1500 claim form.

Important: Electronic billers must submit the referring/ordering TPI within the electronic claim format. Consult your software vendor for location of the field for your software.

Procedure Codes

2-16000 2-16020 2-16025

2/F-16030 2-36425 1-99050

1-99211 1-99212 1-99213

1-99214 1-99215 1-99241

1-99242 1-99243 1-99244

1-99245 1-99183 1-99281

1-99282 1-99283 1-99284

1-99285

Procedure Codes

1-99211 1-99212 1-99213

1-99214 1-99215 1-99281

1-99282 1-99283 1-99284

1-99285


1420 Malignant neoplasm of parotid gland

1421 Malignant neoplasm of subman-dibular gland

1422 Malignant neoplasm of sublingual gland

1428 Malignant neoplasm of other major salivary glands

1429 Malignant neoplasm of salivary gland, unspecified

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Section 39

39.4.1 Claim Filing ResourcesRefer to the following sections and/or forms when filing claims:

Resource Page Number

Automated Inquiry System (AIS) xiii

TMHP Electronic Data Interchange (EDI)

3-1

CMS-1500 Claim Filing Instructions 5-24

TMHP Electronic Claims Submission 5-10

Communication Guide A-1

Radiological/Physiological Laboratory and Portable X-Ray Supplier Claim Example

D-29

Acronym Dictionary F-1

39–14

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