Medical Nutrition Services

Medical Nutrition Services Chapter.1 Enrollment..................................................................... -2.2 Vitamins and Minerals........................................................... -2.2.1 Enrollment................................................................ -2.2.2 Benefits, Limitations, and Authorization Requirements..................... -2.2.3 Prior Authorization Requirements......................................... -6.2.4 Claims Information........................................................ -7.2.5 Reimbursement........................................................... -8.3 Medical Foods.................................................................. -8.3.1 Enrollment................................................................ -8.3.2 Benefits, Limitations, and Authorization Requirements..................... -8.3.2.1 Prior Authorization Requirements.................................... -9.3.3 Claims Information........................................................ -9.3.4 Reimbursement..........................................................-10.4 Medical Nutritional Counseling Services........................................-10.4.1 Enrollment...............................................................-10.4.2 Benefits, Limitations, and Authorization Requirements....................-10.4.2.1 Prior Authorization Requirements...................................-11.4.3 Claims Information.......................................................-12.4.4 Reimbursement..........................................................-12.5 Medical Nutritional Products...................................................-12.5.1 Enrollment...............................................................-12.5.2 Benefits, Limitations, and Authorization Requirements....................-13.5.2.1 Prior Authorization Requirements...................................-13.5.3 Claims Information.......................................................-35.5.4 Reimbursement..........................................................-35.6 Total Parenteral Nutrition (TPN)................................................-36.6.1 Enrollment...............................................................-36.6.2 Benefits, Limitations, and Authorization Requirements....................-36.6.2.1 Prior Authorization.................................................-37.6.2.2 Authorization Requirements........................................-56.6.3 Claims Information.......................................................-57.6.4 Reimbursement..........................................................-57.7 TMHP-CSHCN Services Program Contact Center.................................-57 CPT only copyright 2011 American Medical Association. All rights reserved.

CSHCN Services Program Provider Manual December 2012.1 Enrollment To enroll in the CSHCN Services Program, providers of medical nutrition services (medical foods, medical nutritional counseling services, medical nutritional products, and total parenteral nutrition) must meet the conditions outlined in the enrollment sections provided in this chapter. Detailed information about CSHCN Services Program provider enrollment procedures for providers of medical foods are in Section.3.1, Enrollment, on page -8. Detailed information about CSHCN Services Program provider enrollment procedures for providers of medical nutritional counseling services are in Section.4.1, Enrollment, on page -10. Detailed information about CSHCN Services Program provider enrollment procedures for providers of medical nutrition products are in Section.5.1, Enrollment, on page -12. Detailed information about CSHCN Services Program provider enrollment procedures for providers of total parenteral nutrition are in Section.6.1, Enrollment, on page -36. Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC 371.1617(6) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures..2 Vitamins and Minerals.2.1 Enrollment Vitamins and minerals may be reimbursed to Durable Medical Equipment (DME) providers, home health providers, and Custom DME providers. Refer to: Section 17.1, Enrollment, on page 17-3 for more detailed information about CSHCN Services Program provider enrollment procedures for DME and Custom DME providers and Section 21.1, Enrollment, on page 21-2 for more detailed information about CSHCN Services Program provider enrollment procedures for home health providers.2.2 Benefits, Limitations, and Authorization Requirements Vitamin and mineral supplements with a prescription are a benefit of the CSHCN Services Program. The client s diagnosis and a prescription for the requested vitamin(s) and mineral(s) is required to determine coverage. 2 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services The following procedure codes for vitamin and mineral products, which will be manually priced, will be a benefit when prior authorized and submitted with the corresponding procedure code and state modifier: Vitamin or Mineral Procedure Code State Modifier Beta-carotene A9152 U1 Vitamin A (retinol) A9152 Biotin A9152 U2 Boric acid A9152 U3 Copper A9152 Iodine A9152 Phosphorous A9152 Zinc A9152 Calcium A9152 U4 Chloride A9152 U5 Iron A9152 U6 Magnesium A9152 U7 Vitamin B1 (thiamin) A9152 U8 Vitamin B2 (riboflavin) A9152 Vitamin B3 (niacin) A9152 Vitamin B5 (panthothenic acid) A9152 Vitamin B6 (pyridoxine, pyridoxal A9152 5-phosphate) Vitamin B9 (folic acid) A9152 Vitamin B12 (cyanocobalamin) A9152 Vitamin C (ascorbic acid) A9152 U9 Vitamin D (ergocalciferol) A9152 UA Vitamin E (tocopherols) A9152 UB Vitamin K (phytonadione) A9152 UC Multi-minerals A9153 U1 Multi-vitamins A9153 U2 Trace elements A9153 U3 Miscellaneous A9152 or A9153 UD Note: Note: Claims for multivitamins with any combination of additives must be submitted with modifier U2. CPT only copyright 2011 American Medical Association. All rights reserved. 3

CSHCN Services Program Provider Manual December 2012 Vitamin and mineral products may be indicated for, but are not limited to, treatment of the following conditions: Vitamin or Mineral Condition Beta-carotene Vitamin A deficiency Cystic fibrosis Disorders of porphyrin metabolism Intestinal malabsorption Biotin Biotin deficiency Biotinidase deficiency Carnitine deficiency Cystic fibrosis Boric acid Recalcitrant vulvovaginitis Calcium Calcium deficiency Disorders of calcium metabolism Chronic renal disease Pituitary dwarfism, isolated growth hormone deficiency Cystic fibrosis Intestinal disaccharidase deficiencies and disaccharide malabsorption Allergic gastroenteritis and colitis Chloride Hypochloremia Hypercapnia with mixed acid-base disorder Copper Disorders of copper metabolism Iodine Iodine deficiency Simple and unspecified goiter and nontoxic nodular goiter Cystic fibrosis Iron Disorders of iron metabolism Iron deficiency anemia Cystic fibrosis Magnesium Magnesium deficiency Hypoparathyroidism Cystic fibrosis Phosphorous Disorders of phosphorous metabolism Vitamin A (retinol) Vitamin A deficiency Intestinal malabsorption Disorders of the biliary tract Cystic fibrosis Vitamin B1 (thiamin) Vitamin B1 deficiency Disturbances of branched-chain amino-acid metabolism (e.g. maple syrup urine disease) Disorders of mitochondrial metabolism Wernicke-Korsakoff syndrome Cystic fibrosis 4 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services Vitamin or Mineral Vitamin B2 (riboflavin) Vitamin B2 deficiency Disorders of fatty acid oxidation Riboflavin deficiency, ariboflavinosis Disorders of mitochondrial metabolism Cystic fibrosis Vitamin B3 (niacin) Vitamin B3 deficiency Disorders of lipid metabolism (e.g. pure hypercholesterolemia) Cystic fibrosis Vitamin B5 (pantothenic acid) Vitamin B5 deficiency Vitamin B6 (pyridoxine, pyridoxal 5 phosphate) Condition Vitamin B6 deficiency Sideroblastic anemia Cystic fibrosis Vitamin B9 (folic acid) Vitamin B9 deficiency Folate-deficiency anemia Combined B12 and folate-deficiency anemia Disorders of mitochondrial metabolism Sickle-cell disease Pernicious anemia Cystic fibrosis Vitamin B12 (cyanocobalamin) Vitamin B12 deficiency Disturbances of sulphur-bearing amino-acid metabolism (e.g., homocystinuria and disturbances of metabolism of methionine) Pernicious anemia Combined B12 and folate-deficiency anemia Cystic fibrosis Vitamin C (asorbic acid) Vitamin C deficiency Anemia due to disorders of glutathione metabolism Disorders of mitochondrial metabolism Cystic fibrosis Vitamin D (ergocalciferol) Vitamin D deficiency Galactosemia Glycogenosis Disorders of magnesium metabolism Intestinal malabsorption Chronic renal disease Cystic fibrosis Disorders of phosphorous metabolism Hypocalcemia Disorders of the biliary tract Hypoparathyroidism Intestinal disaccharidase deficiencies and disaccharide malabsorption Allergic gastroenteritis and colitis CPT only copyright 2011 American Medical Association. All rights reserved. 5

CSHCN Services Program Provider Manual December 2012 Vitamin or Mineral Condition Vitamin E (tocopherols) Vitamin E deficiency Inflammatory bowel disease (e.g. Crohn s disease and ulcerative colitis) Disorders of mitochondrial metabolism Chronic liver disease Intestinal malabsorption Disorders of the biliary tract Cystic fibrosis Vitamin K (phytonadione) Vitamin K deficiency Congenital deficiency of other clotting factors Intestinal malabsorption Acquired coagulation factor deficiency Cystic fibrosis Disorders of the biliary tract Chronic liver disease Zinc Zinc deficiency Wilson s disease Acrodermatitis enteropathica Cystic fibrosis Multimineral Other and unspecified protein-calorie malnutrition Multivitamins Cystic fibrosis Other and unspecified protein-calorie malnutrition Trace elements Mineral deficiency.2.3 Prior Authorization Requirements Prior authorization for vitamin and mineral products must be requested using the CSHCN Services Program Authorization and Prior Authorization Request form and be submitted on or before the date that the products are dispensed. Vitamin and mineral products that are dispensed before the date that the prior authorization request is received, or before the date of the physician s order, will not be approved. A physician s prescription with the name of the vitamin or mineral product, dosage, frequency, duration, and route of administration. The manufacturer s suggested retail price (MSRP) or average wholesale price (AWP) (whichever is applicable) with the calculated price per dose or the providers documented invoice price. Prior authorization of vitamin and mineral products may be considered for up to 6 months and for a quantity up to a 30-day supply. Requests for additional vitamin and mineral products must be submitted before the current authorized period expires, but no more than 30 days before the expiration. If a client s eligibility expires, all prior authorizations for the client become invalid and benefits may be denied. If eligibility is renewed, a new prior authorization request must be submitted. The following sample tables taken from the CSHCN Services Program Authorization and Prior Authorization Request form, are examples of the information that is required to submit a request for vitamin and mineral products: 6 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services Example 1: Vitamin D Requested Procedure or Service Information Type of Request: Authorization X Prior Authorization Procedure requested: A9152 UA (per CPT code) Other: $40.00/bottle $0.20/dose Service requested: Vitamin D (ergocalciferol) 10 ml bottle (8000 units/ml) Diagnosis: Additional information: (Refer to the appropriate manual section for specific authorization requirements): Dose: 400 units (0.05 ml), Route: PO, Frequency: QD Example 2: Multivitamin Tables Requested Procedure or Service Information Type of Request: Authorization X Prior Authorization Procedure requested: A9153 U2 (per CPT code) Other: $8.99/bottle $0.11/dose Service requested: Centrum Kids (80 tablets/bottle) Diagnosis: Additional information: (Refer to the appropriate manual section for specific authorization requirements): Dose: 1 tablet, Route: PO, Frequency: QD Example 3: Poly-Vi-Sol Drops with Iron Requested Procedure or Service Information Type of Request: Authorization X Prior Authorization Procedure requested: A9153 U1 (per CPT code) Other: $10.05/bottle $0.20/dose Service requested: Poly-Vi-Sol with Iron (50 ml bottle) Diagnosis: Additional information: (Refer to the appropriate manual section for specific authorization requirements): Dose: 1 ml, Route: PO, Frequency: QD Example 4: Fer-In-Sol Iron Supplement Requested Procedure or Service Information Type of Request: Authorization X Prior Authorization Procedure requested: A9153 U1 (per CPT code) Other: $10.75/bottle $0.43/dose Service requested: Fer-In-Sol (50 ml bottle) 30 mg BID Diagnosis: Additional information: (Refer to the appropriate manual section for specific authorization requirements): Dose: 2 ml (15 mg/ml), Route: PO, Frequency: BID Note: Vitamin and mineral supplements are not diagnosis restricted..2.4 Claims Information Claims for vitamin and mineral products must be submitted with procedure code A9152 or A9153, the appropriate modifier, and the corresponding National Drug Code (NDC). Units must be based on the quantity dispensed for up to a 30-day supply. CPT only copyright 2011 American Medical Association. All rights reserved. 7

CSHCN Services Program Provider Manual December 2012.2.5 Reimbursement The CSHCN Services Program reimburses vitamin and mineral products at the lesser of: The provider s billed charges. The published fee determined by the Texas Health and Human Services Commission (HHSC). Manual price as determined by HHSC, which is based on one of the following: MSRP less 18 percent or AWP less 10.5 percent with the calculated price per dose, whichever is applicable. The provider s documented invoice cost. A maximum of $100.00 per 30 days may be reimbursed for all vitamin and mineral products..3 Medical Foods.3.1 Enrollment To enroll in the CSHCN Services Program, providers of medical foods are not required to be actively enrolled in Texas Medicaid. However, they must have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. The Provider Agreement is part of the paper CSHCN Services Program enrollment application. If enrolling in the CSHCN Services Program online, the Provider Agreement must be printed and mailed in separately. The mailing address is available in Section 2.1, Provider Enrollment, on page 2-2. Out-of-state medical food providers may enroll and must meet all these conditions. The 50-mile within the Texas state border limitation does not apply to providers of medical foods. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures and the mailing address for the Provider Agreement if enrolling online..3.2 Benefits, Limitations, and Authorization Requirements Medical foods are a benefit of the CSHCN Services Program for clients with inborn errors of metabolism that prohibit them from eating a regular diet. Medical foods are defined as: Lacking in the compounds which cause complications of the metabolic disorder. Not generally available in grocery stores, health food stores, or pharmacies. Not used as food by the general population. Not foods covered under the Food Stamps program. Approved products listed in enrolled provider s catalogs. The CSHCN Services Program only pays for foods with nutritional value. Providers must use procedure codes S9434 or S9435 when submitting claims for medical foods. Procedure codes S9434 and S9435 will not require authorization or prior authorization for diagnosis code 36350. Foods with minimal nutritional value, including, but not limited to the following, are not a benefit of the CSHCN Services Program: Foods with Minimal Nutritional Value Cakes Cake mixes Candy Candy covered Chips items Chocolate Chocolate Cookies Cookie dough Dessert items covered items Gum Onion rings Pies 8 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services Foods described as gluten-free are not a benefit of the CSHCN Services Program..3.2.1 Prior Authorization Requirements Authorization or prior authorization is not required if the client has one of the diagnoses listed below and the request is for covered items. Covered items are foods with nutritional value. 2700 Disturbance of amino-acid transport 2701 Phenylketonuria (PKU) 2702 Other disturbances of aromatic amino-acid metabolism 2703 Disturbances of branched-chain amino acid metabolism 2704 Disturbances of sulphur-bearing amino-acid metabolism 2706 Disorder of urea cycle metabolism 2707 Other disturbances of straight-chain amino-acid metabolism 36350 Hereditary choroidal dystrophy or atrophy, unspecified Prior authorization and documentation of medical necessity is required for all other diagnoses, new products, or products not listed as approved. Prior authorization requests for products, conditions, quantities, or dollar amounts beyond the limits described in this workbook will be considered with medical necessity on a case-by-case basis after review by the DSHS-CSHCN Medical Director or a designee. Note: Prior authorization requests that were approved before August 1, 2012, will remain valid until the authorized period expires; services must be billed as authorized. Providers must complete the form CSHCN Services Program Prior Authorization Request for Medical Foods located in Appendix B, on page B-55, for medical foods prior authorization requests. Refer to: Section 4.3, Prior Authorizations, on page 4-5 for detailed information about prior authorization requirements..3.3 Claims Information For purposes of billing, one unit is equal to one dose. The total billable units are equal to the total doses requested on the prior authorization. Services by providers of medical foods must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements. The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the Centers for Medicare & Medicaid Services (CMS) NCCI web page at www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails. Refer to: Chapter 39, TMHP Electronic Data Interchange (EDI), on page 39-1 for information about electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. CPT only copyright 2011 American Medical Association. All rights reserved. 9

CSHCN Services Program Provider Manual December 2012 Section 5.7.2.4, CMS-1500 Paper Claim Form Instructions, on page 5-27 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank. The Texas Health and Human Services Commission Texas Medicaid/CHIP Vendor Drug Program website at www.txvendordrug.com for information about the VDP..3.4 Reimbursement Providers must dispense the most cost-effective product in accordance with a prescription from a licensed physician. Organic products will not be reimbursed unless medical documentation is provided to substantiate the need for that formulation. The CSHCN Services Program implemented rate reductions for certain services. The Online Fee Lookup (OFL) includes a column titled Adjusted Fee to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx. Note: Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column..4 Medical Nutritional Counseling Services.4.1 Enrollment To enroll in the CSHCN Services Program, providers of nutritional counseling services must be dieticians licensed by the Texas State Board of Examiners of Dieticians, actively enrolled in Texas Medicaid, and must be enrolled as licensed dietitians, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state medical nutritional counseling services providers must meet all of these conditions, and be located in the United States within 50 miles of the Texas state border. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures..4.2 Benefits, Limitations, and Authorization Requirements The CSHCN Services Program provides coverage for nutritional assessment and counseling to prevent, treat, or minimize the effects of illness, injury, or other impairments. Medical nutritional counseling services are a benefit of the CSHCN Services Program when all of the following criteria are met: Prescribed by a physician Considered medically necessary or medically appropriate, as supported by documentation Completed by a CSHCN Services Program-enrolled dietitian licensed by the Texas State Board of Examiners of Dietitians Provided in the home, office, or in the outpatient hospital setting Medical nutrition therapy (procedure codes 97802 and 97803) and medical nutritional counseling services, dietician visit (procedure code S9470) may be beneficial for disease states in which dietary adjustment has a therapeutic role. These include, but are not limited to, the following conditions: Abnormal weight gain Cardiovascular disease Diabetes or alterations in blood glucose Eating disorders Gastrointestinal disorders 10 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services Hypertension Inherited metabolic disorders Kidney disease Lack of normal weight gain Nutritional deficiencies Nutrition intervention for chronic fatigue syndrome, attention-deficit hyperactivity disorder, idiopathic environmental intolerances, and multiple food and chemical sensitivities is considered experimental and investigational and is not a benefit of the CSHCN Services Program. Medical nutritional counseling service for the diagnosis of obesity without a comorbid condition is not a benefit of the CSHCN Services Program. Nutrition counseling, dietitian visit (procedure code S9470) is a less comprehensive service and does not include an assessment or reassessment. This is limited to four nutritional counseling visits (procedure code S9470) per rolling year. Procedure codes 97802, 97803, and S9470 are not restricted to clients 20 years of age or younger; they may be submitted for clients of any age. Services may be provided in the home, office, or outpatient hospital settings. The CSHCN Services Program reimburses procedure codes 97802, 97803, and S9470. If procedure codes 97802 or 97803 are billed for the same date of service as S9470, procedure code 97802 or 97803 is paid and procedure code S9470 is denied..4.2.1 Prior Authorization Requirements Authorization or prior authorization is not required for the following nutritional counseling services: One hour (four units) for nutrition assessment, and intervention for procedure code 97802 per rolling year and three hours (12 units) per rolling year for nutrition reassessment and intervention for procedure code 97803 Four nutritional counseling visits (procedure code S9470) per rolling year Providers are responsible for maintaining documentation to support medical necessity of nutritional counseling services in the clinical record. Prior authorization is required for additional visits. Requests for additional visits require medical review and must be submitted in writing on the CSHCN Services Program Prior Authorization Request for Medical Nutritional Services form with documentation to support medical necessity or appropriateness. An example of the form is available in Appendix B, on page B-58. This form, and its instructions, has been updated for dates of service on or after August 1, 2011, as follows: The Dietician Information and Required Signature section has been moved above the "Nutritional Products" section and renamed to Dietician Information and Required Signature for Additional Medical Nutritional Counseling. A new Dispensing Provider Information section has been added. Providers must use the updated form to request medical nutrition services with dates of service on or after August 1, 2011. To request medical nutritional services with dates of service on or before July 31, 2011, providers must use the current form. Use procedure codes 97802, 97803, or S9470 when requesting prior authorization or submitting claims. Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission. Refer to: Section 4.3, Prior Authorizations, on page 4-5 for detailed information about prior authorization requirements. CPT only copyright 2011 American Medical Association. All rights reserved. 11

CSHCN Services Program Provider Manual December 2012.4.3 Claims Information Medical nutritional counseling services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements. The HCPCS/CPT codes included in policy are subject to NCCI relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the CMS NCCI web page at www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI MUE guidance, medical policy prevails. Refer to: Chapter 39, TMHP Electronic Data Interchange (EDI), on page 39-1 for information about electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. Section 5.7.2.4, CMS-1500 Paper Claim Form Instructions, on page 5-27 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank..4.4 Reimbursement Nutritional assessment and counseling services may be reimbursed the lower of either the billed amount or the amount allowed by Texas Medicaid. Providers must use the following codes when requesting prior authorization or submitting claims: Procedure Code 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 Medical nutrition therapy; reassessment and intervention, individual, face-to-face with the patient, each 15 minutes S9470 Nutritional counseling, dietitian visit If either procedure code 97802 or 97803 is billed with procedure code S9470 for the same date of service, then either procedure code 97802 or 97803 is paid, and procedure code S9470 is denied. Procedure code 97803 is denied as part of another service when billed for the same date of service as procedure code 97802 by any provider. The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled Adjusted Fee to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx. Note: Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column..5 Medical Nutritional Products.5.1 Enrollment To enroll in the CSHCN Services Program, providers of medical nutritional products must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all 12 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services applicable state laws and requirements. Out-of-state medical nutritional products providers may enroll and must meet all these conditions, and be approved by DSHS. The 50-mile within the Texas state border limitation does not apply to providers of medical nutritional products. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures..5.2 Benefits, Limitations, and Authorization Requirements Medical nutritional products including enteral formulas, food thickeners, and nutritional supplements are a benefit of the CSHCN Services Program when the client has a specialized nutritional requirement. Medical nutritional products are those nutritional products that serve as a therapeutic agent for life and health and are part of a treatment regimen. The CSHCN Services Program does not cover nutritional products for individuals who can be sustained on an age-appropriate diet. The CSHCN Services Program does not cover the following: Nutritional products that are traditionally used for infant feeding Pudding products Nutritional bars Oral electrolyte solutions are reimbursed through VDP and will not be approved or reimbursed by the CSHCN Services Program. Electrolyte solutions (e.g., Pedialyte) that are not covered under VDP may be considered with prior authorization. The procedure codes in the following table may be reimbursed in the home setting to the following provider types: Procedure Code Provider Type B4100, B4150, B4152, Medical supply company providers B4153, B4154, B4155, B4157, B4162, and B9998 B4158, B4159, B4160, and B4161 T1999 Home health durable medical equipment (DME) and medical supply company providers Home health DME, DME suppliers, medical supply company, and custom DME providers.5.2.1 Prior Authorization Requirements Prior authorization is required for medical nutritional products. Prior authorization is required every six months for medical nutritional products when submitted with any of the diagnosis codes in the table below or diagnosis codes in the table in Section.6.2 of this chapter. Appropriate limitations for miscellaneous procedure code B9998 and T1999 are determined on a case-by-case basis through prior authorization. 042 Human immunodeficiency virus (HIV) 1400 Malignant neoplasm of upper lip, vermilion border 1401 Malignant neoplasm of lower lip, vermilion border 1403 Malignant neoplasm of upper lip, inner aspect 1404 Malignant neoplasm of lower lip, inner aspect 1405 Malignant neoplasm of lip, unspecified, inner aspect 1406 Malignant neoplasm of commissure of lip 1408 Malignant neoplasm of other sites of lip 1409 Malignant neoplasm of lip, unspecified vermilion border 1410 Malignant neoplasm of base of tongue CPT only copyright 2011 American Medical Association. All rights reserved. 13

CSHCN Services Program Provider Manual December 2012 1411 Malignant neoplasm of dorsal surface of tongue 1412 Malignant neoplasm of tip and lateral border of tongue 1413 Malignant neoplasm of ventral surface of tongue 1414 Malignant neoplasm of anterior two-thirds of tongue, part unspecified 1415 Malignant neoplasm of junctional zone of tongue 1416 Malignant neoplasm of lingual tonsil 1418 Malignant neoplasm of other sites of tongue 1419 Malignant neoplasm of tongue, unspecified 1420 Malignant neoplasm of parotid gland 1421 Malignant neoplasm of submandibular gland 1422 Malignant neoplasm of sublingual gland 1428 Malignant neoplasm of other major salivary glands 1429 Malignant neoplasm of salivary gland, unspecified 1430 Malignant neoplasm of upper gum 1431 Malignant neoplasm of lower gum 1438 Malignant neoplasm of other sites of gum 1439 Malignant neoplasm of gum, unspecified 1440 Malignant neoplasm of anterior portion of floor of mouth 1441 Malignant neoplasm of lateral portion of floor of mouth 1448 Malignant neoplasm of other sites of floor of mouth 1449 Malignant neoplasm of floor of mouth, part unspecified 1450 Malignant neoplasm of cheek mucosa 1451 Malignant neoplasm of vestibule of mouth 1452 Malignant neoplasm of hard palate 1453 Malignant neoplasm of soft palate 1454 Malignant neoplasm of uvula 1455 Malignant neoplasm of palate, unspecified 1456 Malignant neoplasm of retromolar area 1458 Malignant neoplasm of other specified parts of mouth 1459 Malignant neoplasm of mouth, unspecified 1460 Malignant neoplasm of tonsil 1461 Malignant neoplasm of tonsillar fossa 1462 Malignant neoplasm of tonsillar pillars (anterior) (posterior) 1463 Malignant neoplasm of vallecula 1464 Malignant neoplasm of anterior aspect of epiglottis 1465 Malignant neoplasm of junctional region of oropharynx 1466 Malignant neoplasm of lateral wall of oropharynx 1467 Malignant neoplasm of posterior wall of oropharynx 1468 Malignant neoplasm of other specified sites of oropharynx 1469 Malignant neoplasm of oropharynx, unspecified site 1470 Malignant neoplasm of superior wall of nasopharynx 14 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services 1471 Malignant neoplasm of posterior wall of nasopharynx 1472 Malignant neoplasm of lateral wall of nasopharynx 1473 Malignant neoplasm of anterior wall of nasopharynx 1478 Malignant neoplasm of other specified sites of nasopharynx 1479 Malignant neoplasm of nasopharynx, unspecified site 1480 Malignant neoplasm of postcricoid region of hypopharynx 1481 Malignant neoplasm of pyriform sinus 1482 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect 1483 Malignant neoplasm of posterior hypopharyngeal wall 1488 Malignant neoplasm of other specified sites of hypopharynx 1489 Malignant neoplasm of hypopharynx, unspecified site 1490 Malignant neoplasm of pharynx, unspecified 1491 Malignant neoplasm of Waldeyer's ring 1498 Malignant neoplasm of other sites within the lip, and oral cavity 1499 Malignant neoplasm of ill-defined sites within the lip and oral cavity 1500 Malignant neoplasm of cervical esophagus 1501 Malignant neoplasm of thoracic esophagus 1502 Malignant neoplasm of abdominal esophagus 1503 Malignant neoplasm of upper third of esophagus 1504 Malignant neoplasm of middle third of esophagus 1505 Malignant neoplasm of lower third of esophagus 1508 Malignant neoplasm of other specified part of esophagus 1509 Malignant neoplasm of esophagus, unspecified site 1510 Malignant neoplasm of cardia 1511 Malignant neoplasm of pylorus 1512 Malignant neoplasm of pyloric antrum 1513 Malignant neoplasm of fundus of stomach 1514 Malignant neoplasm of body of stomach 1515 Malignant neoplasm of lesser curvature of stomach, unspecified 1516 Malignant neoplasm of greater curvature of stomach, unspecified 1518 Malignant neoplasm of other specified sites of stomach 1519 Malignant neoplasm of stomach, unspecified site 1520 Malignant neoplasm of duodenum 1521 Malignant neoplasm of jejunum 1522 Malignant neoplasm of ileum 1523 Malignant neoplasm of Meckel's diverticulum 1528 Malignant neoplasm of other specified sites of small intestine 1529 Malignant neoplasm of small intestine, unspecified site 1530 Malignant neoplasm of hepatic flexure 1531 Malignant neoplasm of transverse colon 1532 Malignant neoplasm of descending colon CPT only copyright 2011 American Medical Association. All rights reserved. 15

CSHCN Services Program Provider Manual December 2012 1533 Malignant neoplasm of sigmoid colon 1534 Malignant neoplasm of cecum 1535 Malignant neoplasm of appendix 1536 Malignant neoplasm of ascending colon 1537 Malignant neoplasm of splenic flexure 1538 Malignant neoplasm of other specified sites of large intestine 1539 Malignant neoplasm of colon, unspecified site 1540 Malignant neoplasm of rectosigmoid junction 1541 Malignant neoplasm of rectum 1542 Malignant neoplasm of anal canal 1543 Malignant neoplasm of anus, unspecified site 1548 Malignant neoplasm of other sites of rectum, rectosigmoid junction, and anus 1550 Malignant neoplasm of liver, primary 1551 Malignant neoplasm of intrahepatic bile ducts 1552 Malignant neoplasm of liver, not specified as primary or secondary 1560 Malignant neoplasm of gallbladder 1561 Malignant neoplasm of extrahepatic bile ducts 1562 Malignant neoplasm of ampulla of vater 1568 Malignant neoplasm of other specified sites of gallbladder and extrahepatic bile ducts 1569 Malignant neoplasm of biliary tract, part unspecified site 1570 Malignant neoplasm of head of pancreas 1571 Malignant neoplasm of body of pancreas 1572 Malignant neoplasm of tail of pancreas 1573 Malignant neoplasm of pancreatic duct 1574 Malignant neoplasm of Islets of Langerhans 1578 Malignant neoplasm of other specified sites of pancreas 1579 Malignant neoplasm of pancreas, part unspecified 1580 Malignant neoplasm of retroperitoneum 1588 Malignant neoplasm of specified parts of peritoneum 1589 Malignant neoplasm of peritoneum, unspecified 1590 Malignant neoplasm of intestinal tract, part unspecified 1591 Malignant neoplasm of spleen, not elsewhere classified 1598 Malignant neoplasm of other sites of digestive system and intra-abdominal organs 1599 Malignant neoplasm of ill-defined sites within the digestive organs and peritoneum 1600 Malignant neoplasm of nasal cavities 1601 Malignant neoplasm of auditory tube, middle ear, and mastoid air cells 1602 Malignant neoplasm of maxillary sinus 1603 Malignant neoplasm of ethmoidal sinus 16 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services 1604 Malignant neoplasm of frontal sinus 1605 Malignant neoplasm of sphenoidal sinus 1608 Malignant neoplasm of other sites of nasal cavities, middle ear, and accessory sinuses 1609 Malignant neoplasm of site of nasal cavities, middle ear, and accessory sinus, unspecified site 1610 Malignant neoplasm of glottis 1611 Malignant neoplasm of supraglottis 1612 Malignant neoplasm of subglottis 1613 Malignant neoplasm of laryngeal cartilages 1618 Malignant neoplasm of other specified sites of larynx 1619 Malignant neoplasm of larynx, unspecified site 1620 Malignant neoplasm of trachea 1622 Malignant neoplasm of main bronchus 1623 Malignant neoplasm of upper lobe, bronchus or lung 1624 Malignant neoplasm of middle lobe, bronchus or lung 1625 Malignant neoplasm of lower lobe, bronchus or lung 1628 Malignant neoplasm of other parts of bronchus or lung 1629 Malignant neoplasm of bronchus and lung, unspecified site 1630 Malignant neoplasm of parietal pleura 1631 Malignant neoplasm of visceral pleura 1638 Malignant neoplasm of other specified sites of pleura 1639 Malignant neoplasm of pleura, unspecified site 1640 Malignant neoplasm of thymus 1641 Malignant neoplasm of heart 1642 Malignant neoplasm of anterior mediastinum 1643 Malignant neoplasm of posterior mediastinum 1648 Malignant neoplasm of other parts of mediastinum 1649 Malignant neoplasm of mediastinum, part unspecified 1650 Malignant neoplasm of upper respiratory tract, part unspecified 1658 Malignant neoplasm of other sites within the respiratory system and intrathoracic organs 1659 Malignant neoplasm of ill-defined sites within the respiratory system 1700 Malignant neoplasm of bones of skull and face, except mandible 1701 Malignant neoplasm of mandible 1702 Malignant neoplasm of vertebral column, excluding sacrum and coccyx 1703 Malignant neoplasm of ribs, sternum, and clavicle 1704 Malignant neoplasm of scapula and long bones of upper limb 1705 Malignant neoplasm of short bones of upper limb 1706 Malignant neoplasm of pelvic bones, sacrum, and coccyx 1707 Malignant neoplasm of long bones of lower limb 1708 Malignant neoplasm of short bones of lower limb CPT only copyright 2011 American Medical Association. All rights reserved. 17

CSHCN Services Program Provider Manual December 2012 1709 Malignant neoplasm of bone and articular cartilage, site unspecified 1710 Malignant neoplasm of connective and other soft tissue of head, face, and neck 1712 Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder 1713 Malignant neoplasm of connective and other soft tissue of lower limb, including hip 1714 Malignant neoplasm of connective and other soft tissue of thorax 1715 Malignant neoplasm of connective and other soft tissue of abdomen 1716 Malignant neoplasm of connective and other soft tissue of pelvis 1717 Malignant neoplasm of connective and other soft tissue of trunk, unspecified 1718 Malignant neoplasm of other specified sites of connective and other soft tissue 1719 Malignant neoplasm of connective and other soft tissue, site unspecified 1720 Malignant melanoma of skin of lip 1721 Malignant melanoma of skin of eyelid, including canthus 1722 Malignant melanoma of skin of ear and external auditory canal 1723 Malignant melanoma of skin of other and unspecified parts of face 1724 Malignant melanoma of skin of scalp and neck 1725 Malignant melanoma of skin of trunk, except scrotum 17 Malignant melanoma of skin of upper limb, including shoulder 1727 Malignant melanoma of skin of lower limb, including hip 1728 Malignant melanoma of other specified sites of skin 1729 Malignant melanoma of skin, site unspecified 1740 Malignant neoplasm of nipple and areola of female breast 1741 Malignant neoplasm of central portion of female breast 1742 Malignant neoplasm of upper-inner quadrant of female breast 1743 Malignant neoplasm of lower-inner quadrant of female breast 1744 Malignant neoplasm of upper-outer quadrant of female breast 1745 Malignant neoplasm of lower-outer quadrant of female breast 1746 Malignant neoplasm of axillary tail of female breast 1748 Malignant neoplasm of other specified sites of female breast 1749 Malignant neoplasm of breast (female), unspecified site 1750 Malignant neoplasm of nipple and areola of male breast 1759 Malignant neoplasm of other and unspecified sites of male breast 1760 Kaposi's sarcoma, skin 1761 Kaposi's sarcoma, soft tissue 1762 Kaposi's sarcoma, palate 1763 Kaposi's sarcoma, gastrointestinal sites 1764 Kaposi's sarcoma, lung 1765 Kaposi's sarcoma, lymph nodes 1768 Kaposi's sarcoma, other specified sites 18 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services 1769 Kaposi's sarcoma, unspecified site 179 Malignant neoplasm of uterus, part unspecified 1800 Malignant neoplasm of endocervix 1801 Malignant neoplasm of exocervix 1808 Malignant neoplasm of other specified sites of cervix 1809 Malignant neoplasm of cervix uteri, unspecified site 181 Malignant neoplasm of placenta 1820 Malignant neoplasm of corpus uteri, except isthmus 1821 Malignant neoplasm of isthmus 1828 Malignant neoplasm of other specified sites of body of uterus 1830 Malignant neoplasm of ovary 1832 Malignant neoplasm of fallopian tube 1833 Malignant neoplasm of broad ligament of uterus 1834 Malignant neoplasm of parametrium 1835 Malignant neoplasm of round ligament of uterus 1838 Malignant neoplasm of other specified sites of uterine adnexa 1839 Malignant neoplasm of uterine adnexa, unspecified site 1840 Malignant neoplasm of vagina 1841 Malignant neoplasm of labia majora 1842 Malignant neoplasm of labia minora 1843 Malignant neoplasm of clitoris 1844 Malignant neoplasm of vulva, unspecified site 1848 Malignant neoplasm of other specified sites of female genital organs 1849 Malignant neoplasm of female genital organ, site unspecified 185 Malignant neoplasm of prostate 1860 Malignant neoplasm of undescended testis 1869 Malignant neoplasm of other and unspecified testis 1871 Malignant neoplasm of prepuce 1872 Malignant neoplasm of glans penis 1873 Malignant neoplasm of body of penis 1874 Malignant neoplasm of penis, part unspecified 1875 Malignant neoplasm of epididymis 1876 Malignant neoplasm of spermatic cord 1877 Malignant neoplasm of scrotum 1878 Malignant neoplasm of other specified sites of male genital organs 1879 Malignant neoplasm of male genital organ, site unspecified 1880 Malignant neoplasm of trigone of urinary bladder 1881 Malignant neoplasm of dome of urinary bladder 1882 Malignant neoplasm of lateral wall of urinary bladder 1883 Malignant neoplasm of anterior wall of urinary bladder 1884 Malignant neoplasm of posterior wall of urinary bladder CPT only copyright 2011 American Medical Association. All rights reserved. 19

CSHCN Services Program Provider Manual December 2012 1885 Malignant neoplasm of bladder neck 1886 Malignant neoplasm of ureteric orifice 1887 Malignant neoplasm of urachus 1888 Malignant neoplasm of other specified sites of bladder 1889 Malignant neoplasm of bladder, part unspecified 1890 Malignant neoplasm of kidney, except pelvis 1891 Malignant neoplasm of renal pelvis 1892 Malignant neoplasm of ureter 1893 Malignant neoplasm of urethra 1894 Malignant neoplasm of paraurethral glands 1898 Malignant neoplasm of other specified sites of urinary organs 1899 Malignant neoplasm of urinary organ, site unspecified 1900 Malignant neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid 1901 Malignant neoplasm of orbit 1902 Malignant neoplasm of lacrimal gland 1903 Malignant neoplasm of conjunctiva 1904 Malignant neoplasm of cornea 1905 Malignant neoplasm of retina 1906 Malignant neoplasm of choroid 1907 Malignant neoplasm of lacrimal duct 1908 Malignant neoplasm of other specified sites of eye 1909 Malignant neoplasm of eye, part unspecified 1910 Malignant neoplasm of cerebrum, except lobes and ventricles 1911 Malignant neoplasm of frontal lobe 1912 Malignant neoplasm of temporal lobe 1913 Malignant neoplasm of parietal lobe 1914 Malignant neoplasm of occipital lobe 1915 Malignant neoplasm of ventricles 1916 Malignant neoplasm of cerebellum NOS 1917 Malignant neoplasm of brain stem 1918 Malignant neoplasm of other parts of brain 1919 Malignant neoplasm of brain, unspecified site 1920 Malignant neoplasm of cranial nerves 1921 Malignant neoplasm of cerebral meninges 1922 Malignant neoplasm of spinal cord 1923 Malignant neoplasm of spinal meninges 1928 Malignant neoplasm of other specified sites of nervous system 1929 Malignant neoplasm of nervous system, part unspecified 193 Malignant neoplasm of thyroid gland 1940 Malignant neoplasm of adrenal gland 1941 Malignant neoplasm of parathyroid gland 20 CPT only copyright 2011 American Medical Association. All rights reserved.

Medical Nutrition Services 1943 Malignant neoplasm of pituitary gland and craniopharyngeal duct 1944 Malignant neoplasm of pineal gland 1945 Malignant neoplasm of carotid body 1946 Malignant neoplasm of aortic body and other paraganglia 1948 Malignant neoplasm of other endocrine glands and related structures 1949 Malignant neoplasm of endocrine gland, site unspecified 1950 Malignant neoplasm of head, face, and neck 1951 Malignant neoplasm of thorax 1952 Malignant neoplasm of abdomen 1953 Malignant neoplasm of pelvis 1954 Malignant neoplasm of upper limb 1955 Malignant neoplasm of lower limb 1958 Malignant neoplasm of other specified sites 1960 Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck 1961 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes 1962 Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes 1963 Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb 1965 Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb 1966 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes 1968 Secondary and unspecified malignant neoplasm of lymph nodes of multiple sites 1969 Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified 1970 Secondary malignant neoplasm of lung 1971 Secondary malignant neoplasm of mediastinum 1972 Secondary malignant neoplasm of pleura 1973 Secondary malignant neoplasm of other respiratory organs 1974 Secondary malignant neoplasm of small intestine including duodenum 1975 Secondary malignant neoplasm of large intestine and rectum 1976 Secondary malignant neoplasm of retroperitoneum and peritoneum 1977 Secondary malignant neoplasm of liver 1978 Secondary malignant neoplasm of other digestive organs and spleen 1980 Secondary malignant neoplasm of kidney 1981 Secondary malignant neoplasm of other urinary organs 1982 Secondary malignant neoplasm of skin 1983 Secondary malignant neoplasm of brain and spinal cord 1984 Secondary malignant neoplasm of other parts of nervous system 1985 Secondary malignant neoplasm of bone and bone marrow CPT only copyright 2011 American Medical Association. All rights reserved. 21