Benefits to Change for Diagnostic and Surgical/Reconstructive Breast Therapies and Corrective Procedures January 1, 2016

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1 Benefits t Change fr Diagnstic and Surgical/Recnstructive Breast Therapies and Crrective Prcedures January 1, 2016 Infrmatin psted Nvember 13, 2015 Effective fr dates f service n r after January 1, 2016, benefit criteria will change fr diagnstic and surgical/recnstructive breast therapies and crrective prcedures fr the Children with Special HealthCare Needs (CSHCN) Services Prgram. The fllwing prcedures will becme benefits f the CSHCN Services Prgram: Breast therapies Diagnstic Surgical Recnstructive Treatment f cmplicatins f breast recnstructin External breast prstheses Crrective prcedures Surgical, recnstructive, and crrective prcedures must be medically necessary. Only new, unused durable medical equipment will be purchased fr CSHCN clients. Breast Therapies Diagnstic Breast Prcedures Diagnstic breast prcedures will be a benefit f CSHCN Services Prgram fr a diagnsis f a cnditin r malignancy f the breast. Diagnstic prcedures may include: Puncture aspiratin Masttmy Injectin prcedure fr ductgram r galactgram Percutaneus bipsy, with r withut imaging guidance Incisinal bipsy Nipple explratin Excisin f the fllwing: Lactiferus duct fistula Benign r malignant breast lesin Chest wall tumr

2 Surgical Breast Prcedures Mastectmy Mastectmy and partial mastectmy (e.g., lumpectmy, tylectmy, quadrantectmy, r segmentectmy) will be benefits f CSHCN Services Prgram when it is medically necessary t remve a breast r prtin f a breast fr cnditins including, but nt limited t: Develpmental abnrmality Cngenital defect Trauma r injury t chest wall Primary r secndary malignancy f the breast Carcinma in situ f the breast Prphylactic Mastectmy Prphylactic mastectmy will be a benefit f CSHCN Services Prgram and is limited t clients wh are at mderate r high-risk fr the develpment f breast cancer and have ne r mre f the fllwing cnditins: Persnal histry Current r previus histry f breast cancer Lbular carcinma in situ (LCIS) Radiatin therapy t the chest befre the age f 30 Family histry f breast r varian cancer in mther, sister, r daughter Presence f any f the fllwing genetic mutatins: Breast cancer gene 1 (BRCA1) Breast cancer gene 2 (BRCA2) Tumr prtein 53 ( TP 53) Phsphatase and tensin hmlg (PTEN) Nte: The abve risk factrs are identified by the Natinal Cancer Institute and the Natinal Cmprehensive Cancer Netwrk. Mastectmy fr Gynecmastia Surgery t crrect gynecmastia will be a benefit f the CSHCN Services Prgram fr males 20 years f age r yunger, when the criteria are met. Breast Recnstructin Breast recnstructin will be a benefit f CSHCN Services Prgram when perfrmed t crrect r repair abnrmal structures f the breast caused by ne r mre f the fllwing:

3 Mastectmy r a histry f cmplicatins f mastectmy Tumr r disease (e.g., fllwing a primary mastectmy prcedure in rder t establish symmetry with a cntralateral breast r fllwing bilateral mastectmy) Cngenital defect Develpmental abnrmality Infectin Trauma r injury t the chest wall Breast recnstructin will be perfrmed using ne f the fllwing: Implants (saline r silicne) Tissue transfers, including but nt limited t: Latissimus drsi flap Transverse rectus abdminis mycutaneus (TRAM) flap Deep inferir epigastric perfratr (DIEP) flap Superficial inferir epigastric artery (SIEA) flap Nipple r arela recnstructin Reductin mammaplasty Mastpexy Tatting t crrect clr defects f the skin Treatment fr cmplicatins f breast recnstructin Breast recnstructin will be perfrmed as single r multiple staged prcedure (e.g., tissue expansin fllwed by implants, nipple r arela recnstructin). Nipple-arela pigmentatin, cmmnly knwn as medical tatting, is the final stage f breast recnstructin surgery. All f the fllwing criteria must be met fr breast recnstructin fllwing a medically necessary mastectmy: The client is eligible fr the CSHCN Services Prgram at the time f the breast recnstructin, and The client has a dcumented histry f a mastectmy, and The client meets age and gender criteria fr the requested prcedure as utlined in the Prcedure Cdes with Eligible Gender and Age Categries table fund in this article. External Breast Prstheses External breast prstheses must be prvided by a durable medical equipment (DME) prvider t a female client with a histry f a medically necessary mastectmy prcedure.

4 Recnstructive and Crrective Prcedures (Nt Related t Breast Therapies) Recnstructive and crrective prcedures are perfrmed n structures f the bdy fr any f the fllwing purpses: Imprving r restring bdily functins Crrecting significant defrmity resulting frm Disease Trauma Previus surgical prcedure Cngenital r develpmental anmalies Excisin r destructin f a benign lesin, cyst, r lipma will be a benefit nly when the lesin is: Inflamed Infected Irritated Bleeding Increasing in size Obstructing visin Interfering with ral functin Lcated in an area that culd affect mtin r functin Excisin r destructin f a lesin will be a benefit when there is suspicin f malignancy. Diagnstic and surgical/recnstructive breast therapies and crrective prcedures will include: Diagnstic prcedures fr the breast Mastectmy fr the treatment f breast cancer Prphylactic mastectmy Mastectmy fr gynecmastia Recnstructive prcedures Treatment f cmplicatins f breast recnstructin External breast prstheses Crrective prcedures The fllwing prvider types, services and settings will apply:

5 Diagnstic and surgical/recnstructive breast therapies prvided by physicians, physician assistants, and advanced practice registered nurses, in the ffice, utpatient and inpatient hspital settings. Crrective prcedures prvided by physicians, dentists, pdiatrists, physician assistants, and advanced practice registered nurses, in ffice, inpatient and utpatient hspital settings. Breast prstheses which are cnsidered and are prvided by DME prviders in the hme setting. Prir Authrizatin and Authrizatin Requirements All prir authrizatin and authrizatin requests must be submitted with dcumentatin f medical necessity. Prir authrizatin requests must be submitted using a CSHCN Services Prgram Authrizatin and Prir Authrizatin Request frm. Prir authrizatin requests that d nt cntain required infrmatin are cnsidered incmplete and will be denied. The requesting prvider may be asked fr additinal infrmatin t clarify r supprt the authrizatin request. Prir authrizatin requests fr external breast prstheses must be submitted using the CSHCN Services Prgram Prir Authrizatin and Authrizatin Request fr Durable Medical Equipment (DME) Frm and Instructins. Requests must include the physician s riginal signature and the date signed. Stamped r cmputerized signatures and dates will nt be accepted. Requests will be cnsidered incmplete withut this infrmatin. Requests fr DME quantities exceeding limitatins must be prir authrized by the CSHCN medical directr and must be submitted with dcumentatin f medical necessity. Prcedure cde requires prir authrizatin. All requests must be reviewed by the CSHCN Services Prgram Medical Directr r designee. Prir Authrizatin Requirements fr Mastectmy, Breast Recnstructin, and External Prstheses Prir authrizatin is nt required when: The client is 18 years f age r lder, meets gender criteria and the prcedure is a mastectmy r breast recnstructin, r The client is 18 years f age r lder, meets gender criteria, and the request is fr ne f the fllwing external breast prsthesis prcedure cdes: Prcedure Cdes L8000 L8001 L8002 L8010 L8015 L8020 L8030 Nte: The prcedure cdes listed in this table must be within the limitatins fr external breast prstheses.

6 Partial mastectmy, prcedure cdes and are exceptins. Prcedure cdes and are eligible fr reimbursement regardless f the client s age, and therefre they d nt require prir authrizatin. Prir authrizatin is required fr the fllwing: Mastectmy r breast recnstructin when the client des nt meet criteria Mastectmy fr pubertal gynecmastia Unlisted breast prcedure cde Tatting fr clients withut an established histry f breast recnstructin during eligibility fr the CSHCN Services Prgram External breast prsthesis prcedure cdes L8035 and L8039 Mastectmy and Breast Recnstructin Prir authrizatin fr mastectmy, prphylactic mastectmy, r breast recnstructin is required fr ne r mre f the fllwing: The client is 17 years f age r yunger, r The client des nt meet the gender criteria fr the requested prcedure, as required by the CSHCN Services Prgram, r The client des nt have an established histry f related services while eligible fr the CSHCN Services Prgram. Mastectmy Dcumentatin must be submitted fr cnditins, including but nt limited t: Develpmental abnrmality Cngenital defect Trauma r injury t chest wall Primary r secndary malignancy f the breast Carcinma in situ f the breast Prphylactic Mastectmy Dcumentatin must be submitted in rder t identify ne r mre f the fllwing: Persnal histry Current r previus histry f breast cancer Lbular carcinma in situ (LCIS) Radiatin therapy t the client s chest befre the age f 30 Family histry f breast r varian cancer in mther, sister, r daughter Presence f any f the fllwing genetic mutatins: Breast cancer gene 1 (BRCA1)

7 Breast cancer gene 2 (BRCA2) Tumr prtein 53 (TP 53) Phsphatase and tensin hmlg (PTEN) Breast Recnstructin Dcumentatin must be submitted which identifies ne r mre f the fllwing: Mastectmy r a histry f cmplicatins f mastectmy Tumr r disease (e.g., fllwing a primary mastectmy prcedure in rder t establish symmetry with a cntralateral breast r fllwing bilateral mastectmy) Cngenital defect Develpmental abnrmality Infectin Trauma r injury t the chest wall Mastectmy fr Gynecmastia Prir authrizatin is required fr prcedure cde 19300, which indicates mastectmy fr gynecmastia. The fllwing dcumentatin must be submitted with all prir authrizatin requests: Gynecmastia is classified as Grade II, III r IV per the American Sciety f Plastic Surgens classificatin. Puberty is at r near cmpletin, as evidenced by dcumentatin f the fllwing: 95 percent f adult height based n bne age, and Tanner stage V. Glandular breast tissue cnfirming true gynecmastia is dcumented n physical examinatin r mammgraphy. Hrmnal causes, including hyperthyridism, estrgen excess, prlactinmas and hypgnadism, have been excluded by apprpriate labratry testing. If present, hrmnal causes must have been treated fr at least ne year and are reslved, as supprted by apprpriate labratry test results. Medical dcumentatin must be submitted with a prir authrizatin request fr a client that has used gynecmastia inducing drugs r ther substances, when identified as the cause f gynecmastia. The dcumentatin must indicate that the client has been ff the drugs r ther substances fr a minimum f ne year and must include the dates that the client has been ff such substances. Psychlgical and psych-scial effects which were identified in the pre-surgical histry and physical. Identificatin f left breast, right breast r bth breasts, which require mastectmy. Reductin Mammaplasty

8 Prir authrizatin is required fr prcedure cde 19318, which indicates reductin mammaplasty. When requesting prir authrizatin fr prcedure cde 19318, the fllwing dcumentatin must be submitted with all prir authrizatin requests: Surgens are required t include the fllwing infrmatin dcumenting medical necessity when requesting prir authrizatin: Client s name and CSHCN Services Prgram client number, Cmplete histry and physical, including height, weight, and breast size, Descriptin f functinal debility caused by the cnditin, Preperative phtgraphs (bth frnt and side views), Descriptin f past treatments and utcmes, Number f grams f tissue t be remved frm each side, Requesting surgen s prvider identifier, and Name and address f facility where services are t be perfrmed and CSHCN Services Prgram prvider identifier. Unlisted Prcedure Prir authrizatin is required fr prcedure cde 19499, which indicates an unlisted breast prcedure. When requesting a prir authrizatin fr prcedure cde 19499, the fllwing dcumentatin must be submitted t determine cverage: A clear, cncise descriptin f the prcedure t be perfrmed, Reasn fr recmmending this particular prcedure, A CPT r HCPCS prcedure cde, which is cmparable t the prcedure being requested, Dcumentatin this prcedure is nt investigatinal r experimental, Place f service the prcedure is t be perfrmed, and The prvider s intended fee fr this prcedure. Prir authrizatin requests must be submitted using a CSHCN Services Prgram Authrizatin and Prir Authrizatin Request frm. Prir authrizatin requests that d nt cntain the required infrmatin are cnsidered incmplete and will be denied. Breast Prstheses Prir authrizatin requests fr external breast prstheses must be submitted using the CSHCN Services Prgram Prir Authrizatin and Authrizatin Request fr Durable Medical Equipment (DME) Frm and Instructins. External breast prstheses f the same type will be cnsidered fr cverage at any time, thrugh the prir authrizatin prcess, if it is lst, stlen, r irreparably damaged.

9 An external breast prsthesis that is a replacement r a different type will be cnsidered fr cverage at any time, thrugh the prir authrizatin prcess, if the prsthesis is needed due t a change in the client's medical cnditin. Prir authrizatin is required fr prcedure cdes L8035 and L8039 when the request is fr new r replacement external breast prsthesis. The fllwing dcumentatin f medical necessity must be submitted with the prir authrizatin request: The client's diagnsis, Prir treatment fr this diagnsis, and Medical necessity f the requested prsthesis. When requesting a prir authrizatin fr L8039, the fllwing additinal infrmatin must als be submitted in rder t determine cverage: A clear, cncise descriptin f the prsthesis which is requested, Reasn fr recmmending this particular prsthesis, A CPT r HCPCS prcedure cde, which is cmparable t the prsthesis requested, Dcumentatin that this prsthesis is nt investigatinal r experimental, Prvider s place f service, and The prvider s intended fee fr this prsthesis. Prir Authrizatin and Authrizatin fr Crrective Prcedures Oral Prcedures Prcedures that are perfrmed as part f cleft-cranifacial surgery require prir authrizatin. Dermatlgical and Blepharplasty Prcedures Acne surgeries, dermabrasin, and chemical peel, and blepharplasty prcedures (prcedure cdes 10040, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15820, 15821, 15822, and 15823) require prir authrizatin, and must meet ne f the fllwing criteria: Crrectin r repair f severe disfigurement due t disease r accidental injury (phtgraphic dcumentatin is required), r Restratin f physical functin resulting frm disease r accidental injury (specific functin must be detailed in prir authrizatin request). Panniculectmy and Abdminplasty Prir authrizatin is required fr panniculectmy and abdminplasty (prcedure cdes and 15847). The fllwing dcumentatin supprting medical necessity must be submitted with all prir authrizatin requests: Phtgraphic dcumentatin that the panniculus hangs belw the level f the pubis,

10 The panniculus is the result f weight lss f at least 75 punds that has been sustained fr ver ne year, and Dcumentatin f ne r mre f the fllwing cnditins which directly impairs physical functin: Interference with ambulatin, urinatin r ther activities f daily living, r Recurring persistent fungal and bacterial panniculitis that is refractry t gd persnal hygiene and dcumented ptimal medical management including tpical anti-infectives, and at least three systemic medicatin treatments. Reimbursement/Billing Guidelines Prviders must use the apprpriate prcedure cde(s) and mdifier(s) t submit claims. The fllwing prcedure cdes may be reimbursed fr diagnstic and surgical/recnstructive breast therapies and crrective prcedures. Prcedure Cdes Diagnstic 19000, 19001, 19020, 19030, 19081, 19082, 19083,19084, 19085, 19086, 19100, 19101, 19110, 19112, 19120, 19125, 19126, 19260, 19271, 19272, 19281, 19282, 19283, 19284, 19285, 19286, 19287, Mastectmy 19301, 19302, 19303, 19304, 19305, 19306, Mastectmy fr Gynecmastia 19300** Reductin Mammaplasty 19318* Breast Recnstructin 11970, 11971, 19316*, 19324*,19325*, 19340*, 19342*, 19350, 19355, 19357*, 19361, 19364, 19366, 19367, 19368, 19369, 19396*, S2068 Tatting 11920, 11921, Treatment f Cmplicatins f Breast recnstructin 19328*, 19330*, 19370*, 19371*, Unlisted Prcedure, Breast Breast Prstheses L8000*, L8001*,L8002*, L8010*, L8015*, L8020*, L8030*, L8031*, L8032*, L8035*, L8039* Sft Tissue Reinfrcement 15777

11 Crrective Prcedures 10040, 11200, 11201, 11300, 11301, 11302, 11303, 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 11400, 11401, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11760, 11762, 11960, 11970, 11971, 15780, 15781,15782,15783,15786, 15787, 15822, 15823,15792, 15793, 17000, 17003, 17004, 17106, 17107, 17108, 17110, 17111, 17311,17312, 17313, 17314, 17315, 21555, 21740, 21742, 21743, 21930, 21931, 22900, 22901, 22902, 22903, 23071, 23073, 23075, 23076, 23077, 23078, 24071, 24073, 24075, 24076, 24077, 24079, 25075, 26115, 27043, 27045, 27047, 27048, 27049, 27327, 27328, 27337, 27339, 27618, 27619, 27634, 28039, 28041, 28043, 28045, 28313, 40818, Panniculectmy and abdminplasty 15830, *This prcedure cde may be reimbursed fr females nly. **This prcedure cde may be reimbursed fr males nly. Nte: All ther prcedure cdes in the table abve may be reimbursed fr bth male and female CSHCN Services Prgram clients. Prcedure cde is an add-n cde and must be used with the apprpriate prcedure cdes. Claims denied fr breast recnstructin may be appealed with supprting dcumentatin including the date f mastectmy. Tatting may be reimbursed if the client has a dcumented histry f breast recnstructin perfrmed while the client was eligible fr the CSHCN Services Prgram. Denied claims fr tatting may be appealed with supprting dcumentatin stating the date f breast recnstructin. External breast prstheses may be reimbursed if the client has a dcumented histry f breast surgery in the past. Regardless f the client s eligibility at the time f the riginal breast recnstructin, the treatment f cmplicatins is cnsidered fr reimbursement when medical criteria are met. The fllwing table prvides an verview f the payable age and gender categries fr diagnstic and surgical/recnstructive breast therapies prcedures: Prcedure Cdes with Eligible Gender and Age Prcedure Cde Gender Age Diagnstic Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages

12 Prcedure Cdes with Eligible Gender and Age Prcedure Cde Gender Age Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Mastectmy Male Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Breast Recnstructin Bth All ages Bth All ages Female All ages Female All ages

13 Prcedure Cdes with Eligible Gender and Age Prcedure Cde Gender Age Female All ages Female All ages Female All ages Bth All ages Bth All ages Female All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Bth All ages Female All ages S2068 Bth All ages Sft Tissue Reinfrcement Bth All ages Tatting Bth All ages Bth All ages Bth All ages Reductin Mammaplasty Female All ages Treatment f Cmplicatins Female All ages Female All ages Female All ages Female All ages Bth All ages Chest Wall Bth All ages Bth All ages Bth All ages External Breast Prstheses L8000 Female All ages

14 Prcedure Cdes with Eligible Gender and Age Prcedure Cde Gender Age L8001 Female All ages L8002 Female All ages L8010 Female All ages L8015 Female All ages L8020 Female All ages L8030 Female All ages L8031 Female All ages L8032 Female All ages L8035 Female All ages L8039 Female All ages Excisin and/r destructin f multiple lesins, cysts, r lipmas are reimbursed accrding t the multiple surgery payment guidelines. Initial r fllw-up visits billed in additin t a lesin excisin and/r destructin fr the same diagnsis are subject t glbal surgery payment criteria. Nte: Fr additinal infrmatin abut glbal surgery and multiple surgery fees, refer t the Physician chapter in the CSHCN Services Prgram Prvider Manual. Glbal surgery guidelines will be applied t prcedures in this plicy. T be cnsidered fr reimbursement, a LT r RT mdifier must be apprpriately appended t the prcedure cdes submitted fr diagnstic and surgical/recnstructive breast therapies, external breast prstheses, r crrective prcedures. The fllwing quantity limitatins apply t reimbursement f prcedure cdes as listed in the table belw: Prcedure Cdes 19300**, 19303, 19304, 19305, 19306, **, 19303, 19304, 19305, 19306, Limitatin One left breast per lifetime One right breast per lifetime 19272, 15830, One prcedure per lifetime 11920, 11921, 11922, Tw per lifetime L8000* 4 per rlling year L8001* 4 per rlling year, per mdifier L8002* 4 per rlling year L8010* 8 per rlling year L8015* 2 per rlling year L8020* 1 per 6 rlling mnths L8030* 1 per 2 rlling years L8031* 1 per 2 rlling years

15 Prcedure Cdes Limitatin L8032* 8 per rlling year L8035* Requires prir authrizatin L8039* Requires prir authrizatin *Female client nly (All ages) **Male client nly (0-20 years f age) Nte: The prcedure cdes listed abve are fr bth male and female clients f all ages except fr the prcedure cdes listed with asterisk (s). Nte: Prir authrizatin must be btained fr quantities exceeding the abve limitatins fr DME prcedure cdes: L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, and L8032. Dcumentatin Requirements In additin t dcumentatin requirements utlined in the Prir Authrizatin and Authrizatin Requirements, in this article, the fllwing requirements apply: All services are subject t retrspective review t ensure that the dcumentatin in the client s medical recrd supprts the medical necessity f the service(s) prvided, and Services nt supprted by dcumentatin are subject t recupment. Prphylactic Mastectmy Dcumentatin supprting medical necessity fr prphylactic mastectmy must be maintained in the client s medical recrd, and must include the fllwing: Dcumentatin that the client is mderate- t high-risk (refer t the criteria abve), Dcumentatin that, as a candidate fr prphylactic mastectmy, the client has undergne cunseling frm a health prfessinal ther than the perating surgen, and Cunseling must include assessment f all f the fllwing: The client's ability t understand the risks and lng-term implicatins f the surgical prcedure, and The client's infrmed chice t prceed with the surgical prcedure. Breast Recnstructin The client must have a dcumented histry f mastectmy r a histry f cmplicatins f mastectmy perfrmed while eligible fr the CSHCN Services Prgram. Crrective Prcedures Dcumentatin supprting medical necessity fr treatment f a benign lesin, cyst, r lipma must be maintained in the client s medical recrd and identify that the lesin requiring treatment is ne r mre f the fllwing:

16 Inflamed Infected Irritated Bleeding Increasing in size Obstructing visin Interfering with ral functin Lcated in an area that culd affect mtin r functin When a lesin is suspicius fr malignancy, dcumentatin supprting medical necessity fr excisin r destructin f the lesin must be maintained in the client s medical recrd. Fr blepharplasty prcedures (prcedure cdes 15820, 15821, and 15823) additinal dcumentatin f medical necessity must be submitted with bth f the fllwing: Phtgraphs f the eyelid prblem, and Visual field measurements. Exclusins The fllwing services are nt benefits f the CSHCN Services Prgram: Alteratin f a natural, undamaged, r unimpaired bdy part, except as specifically utlined in this plicy. The fllwing csmetic prcedures are nt a benefit f the CSHCN Services Prgram: Rhytidectmies (prcedure cdes 15824, 15825, 15826, and 15829) Excisins f excessive skin and subcutaneus tissue (includes lipectmy) (prcedure cdes 15832, 15833, 15834, 15835, 15836, 15837, and 15839) Suctin assisted lipectmies (prcedure cdes 15877, 15878, and 15879) Crytherapy fr acne (prcedure cde 17340) Chemical exfliatin (prcedure cde 17360) Electrlysis epilatin (prcedure cde 17380) New Benefits The fllwing prcedure cdes will be made a benefit f the CSHCN Services Prgram: Prcedure Cde Restrictins

17 Prcedure Cde Restrictins 19300* The surgical cmpnent may be reimbursed t physicians fr services rendered in an inpatient and utpatient hspital setting. The ambulatry surgical cmpnent may be reimbursed t ambulatry surgical centers fr services rendered in an utpatient hspital setting , The ambulatry surgical cmpnent may be reimbursed t ambulatry surgical centers fr services rendered in an utpatient hspital setting The ambulatry surgical cmpnent may be reimbursed t ambulatry surgical centers fr services rendered in an utpatient hspital setting The surgical cmpnent may be reimbursed t physicians fr services rendered in an inpatient and utpatient hspital setting. The ambulatry surgical cmpnent may be reimbursed t ambulatry surgical centers fr services rendered in an utpatient hspital setting The surgical cmpnent may be reimbursed t physicians fr services rendered in an inpatient and utpatient hspital setting. The ambulatry surgical cmpnent may be reimbursed t ambulatry surgical centers fr services rendered in an utpatient hspital setting The assistant surgical cmpnent may be reimbursed t physicians and physician assistants fr services rendered in an inpatient r utpatient hspital setting ,19304,19307 The assistant surgical cmpnent may be reimbursed t physicians, physician assistants, and nurse practitiners, clinical nurse specialists fr services rendered in an inpatient r utpatient hspital setting , The assistant surgical cmpnent may be reimbursed t physicians and physician assistants fr services rendered in an inpatient hspital setting ,15847, The assistant surgical cmpnent may be reimbursed t physicians, physician assistants, and nurse practitiners, clinical nurse specialists fr services rendered in an inpatient r utpatient hspital setting. Nte: Prcedure cdes 19300, and require prir authrizatin. Prvider Type and Place f Service Changes

18 The fllwing prvider types and place f service changes will be effective January 1, 2016: Type f Service Prcedure Cdes Prvider Type and Additinal Infrmatin Surgery 11303, 11308, 11313, 11403, 11404, 11406, 11423, 11424, 11426, 11443, 11444, 11446, 11760, 17106, 17107, 17108, 17311, 17312, 17313, 17314, 19001, 19020, 19030, 19100, 21930, 23075, 26115, 27047, 27327, 27618, 28043, 28045, Surgery 11200, 11201, 11300,11301, 11302, 11303, 11305,11306, 11307, 11308, 11310,11311, 11312, 11313, 11400,11401, 11402, 11403, 11404,11406, 11420, 11421, 11422,11423, 11424, 11440, 11441,11442, 11443, 11444, 11446,11760, 15782, 15783,15786, 15787, 15792, 15793, 17110, 17111, 19328, 19330, 10040, Will n lnger be a benefit f the CSHCN Services Prgram fr physician assistants (PA), Advanced practice nurse (APRN [nurse practitiners (NP), r certified nurse specialists (CNS) in an ffice setting. Will n lnger be a benefit f the CSHCN Services Prgram fr physician assistants (PA), Advanced practice nurse (APRN [nurse practitiners (NP), r certified nurse specialists (CNS) in an utpatient hspital setting. Surgery 10040, 11200, 11201, 54660, Will n lnger be a benefit f the CSHCN Services Prgram fr physician assistants (PA), Advanced practice nurse (APRN [nurse practitiners (NP), r certified nurse specialists (CNS) in an inpatient hspital setting. Surgery Will becme a benefit f the CSHCN Services Prgram fr pdiatrists r pdiatry grups in an ffice, inpatient, and utpatient hspital setting. Surgery 11300, 11301, 11302, 11303, 11440, 11441, 11442, 11443, 11444, 11446, 15782, 15783, 15792, 15793, 17000, 17003, 17004, 17106, 17107, 17108, 17110, 17111, 19328, Will n lnger be a benefit f the CSHCN Services Prgram fr pdiatrists r pdiatry grups in an inpatient, and utpatient hspital setting.

19 Type f Service Prcedure Cdes Prvider Type and Additinal Infrmatin Surgery 11300, 11301, 11302, 11303, 11440, 11441, 11442, 11443, 11444, 11446, 15782, 15783, 15792, 15793, 17000, 17003, 17004, 17106, 17107, 17108, 17110, Will n lnger be a benefit f the CSHCN Services Prgram fr pdiatrists r pdiatry grups in an ffice setting. Surgery 19305, Will n lnger be a benefit f the CSHCN Services Prgram in an utpatient hspital setting. Surgery 15782, 15783, 17000, 17003, 17004, 17106, 17107, 17108, 17110, Will becme a benefit f the CSHCN Services Prgram fr dentists (D.D.S., D.M.D.) and dentist grups in an ffice, inpatient, and utpatient hspital setting. Surgery Will becme a benefit f the CSHCN Services Prgram fr dentists (D.D.S., D.M.D.) and dentist grups in an ffice setting. Surgery Will becme a benefit f the CSHCN Services Prgram fr physicians, physician grups, dentists (D.D.S., D.M.D.), and dentist grups in an inpatient hspital setting. Surgery 19020, 19120, Will n lnger be a benefit f the CSHCN Services Prgram in an ffice setting. Assistant Surgery Surgery and Assistant Surgery Assistant Surgery Assistant Surgery Will n lnger be a benefit f the CSHCN Services Prgram in an ffice setting , 19364, 19367, S2068 Will n lnger be a benefit f the CSHCN Services Prgram in an utpatient hspital setting Will n lnger be a benefit f the CSHCN Services Prgram in an utpatient hspital setting , Will n lnger be a benefit f the CSHCN Services Prgram fr a certified nurse midwife, registered nurse, r licensed midwife in an inpatient and utpatient hspital setting.

20 Type f Service Prcedure Cdes Prvider Type and Additinal Infrmatin Assistant Surgery Durable Medical Equipment (DME) Other Durable Medical Equipment (DME) Other 11960, 11970, 19340, Will n lnger be a benefit f the CSHCN Services Prgram. L8000, L8010, L8015, L8020, L8030, L8035, L8039 L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8035, L8039 Will n lnger be a benefit f the CSHCN Services Prgram in an utpatient hspital setting. Will n lnger be a benefit f the CSHCN Services Prgram fr prsthetist and rthtist in a hme setting. Fr mre infrmatin, call the TMHP-CSHCN Services Prgram Cntact Center at

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