Expendable Medical Supplies Chapter.1 Enrollment..................................................................... -2.2 Benefits, s, and Authorization Requirements........................... -2.2.1 Examples of Covered Supplies............................................. -5.2.2 Diapers, Briefs, Pull-ups, and Liners........................................ -5.2.2.1 Gastrostomy Devices...............................................-12.3 Claims Information.............................................................-12.4 Reimbursement................................................................-13.5 TMHP-CSHCN Services Program Contact Center.................................-13 CPT only copyright 2012 American Medical Association. All rights reserved.
CSHCN Services Program Provider Manual March 2013.1 Enrollment To enroll in the CSHCN Services Program, providers of expendable medical supplies 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 applicable state laws and requirements. Out-of-state expendable medical supplies providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border. Providers located more than 50 miles from the Texas border will be considered for approval by the Department of State Health Services (DSHS). 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 (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 2-2for more detailed information about CSHCN Services Program provider enrollment procedures..2 Benefits, s, and Authorization Requirements The CSHCN Services Program provides benefits for expendable medical supplies for eligible clients. An expendable medical supply is defined as an item necessary to carry out a medical procedure or to maintain the client s health at home. Expendable is defined as being intended for single or short-term use before being discarded. Most supplies are not reusable and will be discarded after use. Some supplies, including, but not limited to, straight catheters, may be cleaned and reused. Supplies are a benefit only for those clients residing at home. Expendable medical supplies are limited to a quantity used by the typical client. Prior authorization is required with documentation of medical necessity that supports additional quantities greater than maximum limitations listed in the tables below for a client with exceptional needs. The following tables provide listings of these supplies and limitation amounts. Refer to: Section 4.3, Prior Authorizations, on page 4-5 for detailed information about authorization requirements. Incontinence Supplies A4310 2 per month A4311 2 per month A4312 2 per month A4313 2 per month A4314 2 per month A4315 2 per month A4316 2 per month A4320 2 per month A4322 4 per month *Any combination of diapers, pull-ups, briefs, or liners limited to a maximum of 240 per month without requiring prior authorization. 2 CPT only copyright 2012 American Medical Association. All rights reserved.
Expendable Medical Supplies A4326 40 per month A4327 4 per month A4328 4 per month A4330 As needed A4335 2 per month A4338 2 per month A4340 2 per month A4344 2 per month A4346 2 per month A4349 40 per month A4351 150 per month A4352 150 per month A4353 150 per month A4354 2 per month A4355 2 per month A4356 2 per month A4357 2 per month A4358 2 per month A4361 As needed A4362 As needed A4363 As needed A4364 As needed A4365 1 per month A4367 As needed A4368 As needed A4369 As needed A4371 As needed A4372 As needed A4373 As needed A4375 As needed A4376 As needed A4377 As needed A4378 As needed A4379 As needed A4380 As needed A4381 As needed A4382 As needed A4383 As needed A4384 As needed A4385 As needed A4387 As needed A4388 As needed A4389 As needed A4390 As needed A4391 As needed A4392 As needed A4393 As needed A4394 As needed A4395 As needed A4396 1 per day A4397 As needed A4398 As needed A4399 1 per day A4400 As needed A4402 4 per month A4404 As needed A4405 As needed A4406 As needed A4407 As needed A4408 As needed A4409 As needed A4410 As needed A4411 As needed A4412 As needed A4413 As needed A4414 As needed A4415 As needed A4421 As needed A4422 As needed A4554 120 per month A4927 1 per month A5051 As needed A5052 As needed A5053 As needed A5054 As needed A5055 As needed A5056 As needed A5057 As needed A5061 As needed A5062 As needed A5063 As needed A5071 As needed A5072 As needed A5073 As needed A5081 As needed A5082 As needed A5083 As needed A5093 As needed A5102 2 per month A5105 4 per year A5112 2 per month A5113 2 per month A5114 2 per month A5120 50 per month A5121 As needed A5122 As needed A5126 As needed A5131 1 per month A5200 2 per month T4521 T4522 T4523 T4524 T4527 T4525 T4528 T4526 T4529 *Any combination of diapers, pull-ups, briefs, or liners limited to a maximum of 240 per month without requiring prior authorization. CPT only copyright 2012 American Medical Association. All rights reserved. 3
CSHCN Services Program Provider Manual March 2013 T4530 T4533 Wound Care Supplies T4531 T4534 T4532 T4535 T4537 As needed T4540 As needed T4541 120 per month T4542 120 per month T4543 *Any combination of diapers, pull-ups, briefs, or liners limited to a maximum of 240 per month without requiring prior authorization. A4213 As needed A4216 As needed A4217 As needed A4244 1 per month A4246 1 per month A4247 1 per month A4248 As needed A4305 As needed A4306 As needed A4331 50 per month A4332 2 per month A4333 2 per month A4334 2 per month A4366 As needed A4416 As needed A4417 As needed A4419 As needed A4423 As needed A4424 As needed A4425 As needed A4426 As needed A4427 As needed A4429 As needed A4430 As needed A4431 As needed A4432 As needed A4433 As needed A4434 As needed A4435 As needed A4452 20 per month A4455 4 per month A6010 As needed A6011 As needed A6021 As needed A6022 As needed A6023 As needed A6024 As needed A6025 As needed A6154 As needed A6197 As needed A6197 As needed A6198 As needed A6199 As needed A6200 As needed A6201 As needed A6202 As needed A6203 As needed A6204 As needed A6205 As needed A6210 As needed A6211 As needed A6214 As needed A6215 As needed A6217 As needed A62 As needed A6220 As needed A6221 As needed A6228 As needed A6229 As needed A6230 As needed A6234 As needed A6235 As needed A6236 As needed A6238 As needed A6239 As needed A6240 As needed A6241 As needed A6242 As needed A6248 As needed A6250 2 per month A6251 As needed A6252 As needed A6253 As needed A6254 As needed A6255 As needed A6256 As needed A6258 As needed A6259 As needed A6260 As needed A6261 As needed A6262 As needed A6403 As needed A6404 As needed A6407 As needed A6410 As needed A6411 As needed A6412 As needed A6441 As needed A6442 As needed A6443 As needed A6444 As needed A6445 As needed A6446 As needed A6447 As needed A6448 As needed A6449 As needed A6450 As needed A6451 As needed A6452 As needed 4 CPT only copyright 2012 American Medical Association. All rights reserved.
Expendable Medical Supplies A6453 As needed A6454 As needed A6455 As needed A6456 As needed A6550 15 per month A9273 1 per 3 years.2.1 Examples of Covered Supplies The following categories of medical supplies are a benefit of the CSHCN Services Program. This list is not all-inclusive: Incontinence supplies, including, but not limited to, diapers, briefs, pull-ups, liners, urinary catheters, gloves, lubricants, skin disinfectants, ostomy and catheterization supplies, pouches, wafers, cleaning solutions, catheters, and syringes. Feeding supplies, including, but not limited to, feeding bags for pumps, tubing, nasogastric tubes, syringes, nonobturated gastrostomy tubes, and low profile nonobturated gastrostomy devices (also known as gastrostomy button). Nonobturated gastrostomy tubes and nonobturated low profile gastrostomy devices are limited to two per year. (Enteral feeding pumps are considered durable medical equipment [DME].) Wound care supplies, including, but not limited to, dressings, tape, bandages, masks, eye patches, and ace wraps. Diabetic care, such as testing supplies and lancets. (Glucose monitors are considered DME.) Miscellaneous supplies used in the treatment of a medical condition. Refer to: Chapter 15, Diabetic Equipment and Supplies, on page 15-1 for more detailed information. Chapter 17, Durable Medical Equipment (DME), on page 17-1 for more detailed information. Chapter 35, Respiratory Equipment and Supplies, on page 35-1 for more detailed information. Articles of daily living are not a benefit of the CSHCN Services Program..2.2 Diapers, Briefs, Pull-ups, and Liners Authorization is not required for diapers, pull-ups, briefs, and liners in any combination up to 300 items per month and may be covered if the client s diagnosis is included in the table below. Clients must be 4 years of age or older and be incontinent as a direct complication of a medical condition. Prior authorization must be obtained for clients with diagnoses not listed in the following table or for supplies over the 300 limitation. Fax transmittal confirmations are not accepted as proof of timely prior authorization submissions. Refer to: Section 4.3, Prior Authorizations, on page 4-5 for detailed information about prior authorization requirements. Appendix B, CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners on page B-23. Diagnosis Description 042 Human immunodeficiency virus (HIV) 138 Late effects of acute poliomyelitis 80 Malignant neoplasm of trigone of urinary bladder 81 Malignant neoplasm of dome of urinary bladder 82 Malignant neoplasm of lateral wall of urinary bladder 83 Malignant neoplasm of anterior wall of urinary bladder 84 Malignant neoplasm of posterior wall of urinary bladder CPT only copyright 2012 American Medical Association. All rights reserved. 5
CSHCN Services Program Provider Manual March 2013 Diagnosis Description 85 Malignant neoplasm of bladder neck 86 Malignant neoplasm of ureteric orifice 87 Malignant neoplasm of urachus 88 Malignant neoplasm of other specified sites of bladder 89 Malignant neoplasm of bladder, part unspecified 90 Malignant neoplasm of kidney, except pelvis 91 Malignant neoplasm of renal pelvis 92 Malignant neoplasm of ureter 93 Malignant neoplasm of urethra 94 Malignant neoplasm of paraurethral glands 98 Malignant neoplasm of other specified sites of urinary organs 99 Malignant neoplasm of urinary organ, site unspecified 1910 Malignant neoplasm of cerebrum, except lobes and ventricles 1911 Malignant neoplasm of frontal lobe of brain 1912 Malignant neoplasm of temporal lobe of brain 1913 Malignant neoplasm of parietal lobe of brain 1914 Malignant neoplasm of occipital lobe of brain 1915 Malignant neoplasm of ventricles of brain 1916 Malignant neoplasm of cerebellum NOS 1917 Malignant neoplasm of brain stem 19 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 20917 Malignant carcinoid tumor of the rectum 2250 Benign neoplasm of brain 2251 Benign neoplasm of cranial nerves 2252 Benign neoplasm of cerebral meninges 2253 Benign neoplasm of spinal cord 2254 Benign neoplasm of spinal meninges 2258 Benign neoplasm of other specified sites of nervous system 2259 Benign neoplasm of nervous system, part unspecified 23770 Neurofibromatosis, unspecified 2552 Adrenogenital disorders 3313 Communicating hydrocephalus 3314 Obstructive hydrocephalus 3332 Myoclonus 6 CPT only copyright 2012 American Medical Association. All rights reserved.
Expendable Medical Supplies Diagnosis Description 33371 Athetoid cerebral palsy 33379 Other acquired torsion dystonia 3360 Syringomyelia and syringobulbia 3430 Diplegic infantile cerebral palsy 3431 Hemiplegic infantile cerebral palsy 3432 Quadriplegic infantile cerebral palsy 3433 Monoplegic infantile cerebral palsy 3434 Infantile hemiplegia 3438 Other specified infantile cerebral palsy 3439 Unspecified infantile cerebral palsy 3441 Paraplegia 34461 Cauda equina syndrome with neurogenic bladder 34481 Locked-in state 34489 Other specified paralytic syndrome 34500 Generalized nonconvulsive epilepsy without mention of intractable 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 Epileptic petit mal status 3453 Epileptic grand mal status 34540 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial epilepsy, without mention of intractable epilepsy 34541 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial epilepsy, 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 Unspecified epilepsy without mention of intractable epilepsy 34591 Unspecified epilepsy with intractable epilepsy 3590 Congenital hereditary muscular dystrophy 3591 Hereditary progressive muscular dystrophy 436 Acute, but ill-defined, cerebrovascular 43820 Hemiplegia affecting unspecified side due to cerebrovascular 43821 Hemiplegia affecting dominant side due to cerebrovascular 43822 Hemiplegia affecting nondominant side due to cerebrovascular CPT only copyright 2012 American Medical Association. All rights reserved. 7
CSHCN Services Program Provider Manual March 2013 Diagnosis Description 43830 Monoplegia of upper limb affecting unspecified side due to cerebrovascular 43831 Monoplegia of upper limb affecting dominant side due to cerebrovascular 43832 Monoplegia of upper limb affecting nondominant side due to cerebrovascular 43840 Monoplegia of lower limb affecting unspecified side due to cerebrovascular 43841 Monoplegia of lower limb affecting dominant side due to cerebrovascular 43842 Monoplegia of lower limb affecting nondominant side due to cerebrovascular 43850 Other paralytic syndrome affecting unspecified side due to cerebrovascular 43851 Other paralytic syndrome affecting dominant side due to cerebrovascular 43852 Other paralytic syndrome affecting nondominant side due to cerebrovascular 43853 Other paralytic syndrome, bilateral 43881 Apraxia due to cerebrovascular 43882 Dysphagia due to cerebrovascular 43889 Other late effects of cerebrovascular 4389 Unspecified late effects of cerebrovascular due to cerebrovascular 591 Hydronephrosis 59800 Urethral structure due to unspecified infection 59801 Urethral structure due to infective s classified elsewhere 5981 Traumatic urethral stricture 5982 Postoperative urethral stricture 5988 Other specified causes of urethral stricture 5989 Unspecified urethral stricture 5991 Urethral fistula 74100 Spina bifida with hydrocephalus, unspecified region 74101 Spina bifidax with hydrocephalus, cervical region 74102 Spina bifida with hydrocephalus, dorsal (thoracic) region 74103 Spina bifida with hydrocephalus, lumbar region 74190 Spina bifida without mention of hydrocephalus, unspecified region 7420 Encephalocele 7422 Congenital reduction deformities of brain 7423 Congenital hydrocephalus 7424 Other specified congenital anomalies of brain 74251 Diastematomyelia 74253 Hydromyelia 74259 Other specified congenital anomaly of spinal cord 8 CPT only copyright 2012 American Medical Association. All rights reserved.
Expendable Medical Supplies Diagnosis Description 7511 Congenital atresia and stenosis of small intestine 7512 Congenital atresia and stenosis of large intestine, rectum, and anal canal 7513 Hirschsprung s and other congenital functional disorders of colon 7514 Congenital anomalies of intestinal fixation 7515 Other congenital anomalies of intestine 75320 Unspecified obstructive defect of renal pelvis and ureter 75321 Congenital obstruction of ureteropelvic junction 75322 Congenital obstruction of ureterovesical junction 75323 Congenital ureterocele 75329 Other obstructive defect of renal pelvis and ureter 7533 Other specified anomalies of kidney 7534 Other specified anomalies of ureter 7535 Exstrophy of urinary bladder 7536 Congenital atresia and stenosis of urethra and bladder neck 7537 Congenital anomalies of urachus 7538 Other specified congenital anomaly of bladder and urethra 75670 Unspecified congenital anomaly of abdominal wall 75671 Prune belly syndrome 75679 Other congenital anomalies of abdominal wall 7674 Injury to spine and spinal cord, birth trauma 78072 Functional quadriplegia 78899 Other symptoms involving urinary systems 80500 Closed fracture of cervical vertebra, unspecified level without mention of spinal cord 80501 Closed fracture of first cervical vertebra without mention of spinal cord 80502 Closed fracture of second cervical vertebra without mention of spinal cord 80503 Closed fracture of third cervical vertebra without mention of spinal cord 80504 Closed fracture of fourth cervical vertebra without mention of spinal cord 80505 Closed fracture of fifth cervical vertebra without mention of spinal cord 80506 Closed fracture of sixth cervical vertebra without mention of spinal cord 80507 Closed fracture of seventh cervical vertebra without mention of spinal cord 80508 Closed fracture of multiple cervical vertebrae without mention of spinal cord 80510 Open fracture of cervical vertebra, unspecified level without mention of spinal cord 80511 Open fracture of first cervical vertebra without mention of spinal cord 80512 Open fracture of second cervical vertebra without mention of spinal cord 80513 Open fracture of third cervical vertebra without mention of spinal cord 80514 Open fracture of fourth cervical vertebra without mention of spinal cord CPT only copyright 2012 American Medical Association. All rights reserved. 9
CSHCN Services Program Provider Manual March 2013 Diagnosis Description 80515 Open fracture of fifth cervical vertebra without mention of spinal cord 80516 Open fracture of sixth cervical vertebra without mention of spinal cord 80517 Open fracture of seventh cervical vertebra without mention of spinal cord 805 Open fracture of multiple cervical vertebrae without mention of spinal cord 8052 Closed fracture of dorsal (thoracic) vertebra without mention of spinal cord 8053 Open fracture of dorsal (thoracic) vertebra without mention of spinal cord 8054 Closed fracture of lumbar vertebra without mention of spinal cord 8055 Open fracture of lumbar vertebra without mention of spinal cord 8056 Closed fracture of sacrum and coccyx without mention of spinal cord 8057 Open fracture of sacrum and coccyx without mention of spinal cord 8058 Closed fracture of unspecified part of vertebral column without mention of spinal cord 8059 Open fracture of unspecified part of vertebral column without mention of spinal cord 80600 Closed fracture of C1-C4 level with unspecified spinal cord 80601 Closed fracture of C1-C4 level with complete lesion of cord 80602 Closed fracture of C1-C4 level with anterior cord syndrome 80603 Closed fracture of C1-C4 level with central cord syndrome 80604 Closed fracture of C1-C4 level with other specified spinal cord 80605 Closed fracture of C5-C7 level with unspecified spinal cord 80606 Closed fracture of C5-C7 level with complete lesion of cord 80607 Closed fracture of C5-C7 level with anterior cord syndrome 80608 Closed fracture of C5-C7 level with central cord syndrome 80609 Closed fracture of C5-C7 level with other specified spinal cord 80610 Open fracture of C1-C4 level with unspecified spinal cord 80611 Open fracture of C1-C4 level with complete lesion of cord 80612 Open fracture of C1-C4 level with anterior cord syndrome 80613 Open fracture of C1-C4 level with central cord syndrome 80614 Open fracture of C1-C4 level with other specified spinal cord 80615 Open fracture of C5-C7 level with unspecified spinal cord 80616 Open fracture of C5-C7 level with complete lesion of cord 80617 Open fracture of C5-C7 level with anterior cord syndrome 806 Open fracture of C5-C7 level with central cord syndrome 80619 Open fracture of C5-C7 level with other specified spinal cord 80620 Closed fracture of T1-T6 level with unspecified spinal cord 80621 Closed fracture of T1-T6 level with complete lesion of cord 80622 Closed fracture of T1-T6 level with anterior cord syndrome 80623 Closed fracture of T1-T6 level with central cord syndrome 80624 Closed fracture of T1-T6 level with other specified spinal cord 10 CPT only copyright 2012 American Medical Association. All rights reserved.
Expendable Medical Supplies Diagnosis Description 80625 Closed fracture of T7-T12 level with unspecified spinal cord 80626 Closed fracture of T7-T12 level with complete lesion of cord 80627 Closed fracture of T7-T12 level with anterior cord syndrome 80628 Closed fracture of T7-T12 level with central cord syndrome 80629 Closed fracture of T7-T12 level with other specified spinal cord 80630 Open fracture of T1-T6 level with unspecified spinal cord 80631 Open fracture of T1-T6 level with complete lesion of cord 80632 Open fracture of T1-T6 level with anterior cord syndrome 80633 Open fracture of T1-T6 level with central cord syndrome 80634 Open fracture of T1-T6 level with other specified spinal cord 80635 Open fracture of T7-T12 level with unspecified spinal cord 80636 Open fracture of T7-T12 level with complete lesion of cord 80637 Open fracture of T7-T12 level with anterior cord syndrome 80638 Open fracture of T7-T12 level with central cord syndrome 80639 Open fracture of T7-T12 level with other specified spinal cord 8064 Closed fracture of lumbar spine with spinal cord 8065 Open fracture of lumbar spine with spinal cord 95200 C1-C4 level spinal cord, unspecified 95201 C1-C4 level with complete lesion of spinal cord 95202 C1-C4 level with anterior cord syndrome 95203 C1-C4 level with central cord syndrome 95204 C1-C4 level with other specified spinal cord 95205 C5-C7 level spinal cord, unspecified 95206 C5-C7 level with complete lesion of spinal cord 95207 C5-C7 level with anterior cord syndrome 95208 C5-C7 level with central cord syndrome 95209 C5-C7 level with other specified spinal cord 95210 T1-T6 level spinal cord, unspecified 95211 T1-T6 level with complete lesion of spinal cord 95212 T1-T6 level with anterior cord syndrome 95213 T1-T6 level with central cord syndrome 95214 T1-T6 level with other specified spinal cord 95215 T7-T12 level spinal cord, unspecified 95216 T7-T12 level with complete lesion of spinal cord 95217 T7-T12 level with anterior cord syndrome 952 T7-T12 level with central cord syndrome 95219 T7-T12 level with other specified spinal cord CPT only copyright 2012 American Medical Association. All rights reserved. 11
CSHCN Services Program Provider Manual March 2013.2.2.1 Gastrostomy Devices The CSHCN Services Program may reimburse providers for nonobturated or obturated gastrostomy devices when prescribed by a physician. Authorization Requirements Authorization is required. Documentation supporting medical necessity including, but not limited to, the presence of a gastrostomy (diagnosis code V441) must be submitted on the claim. The following procedure codes must be used to submit claims for gastrostomy devices: s B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 code B4035 is limited to a maximum of 31 per month by any provider. Providers may not bill a quantity greater than the number of days in the month for which they are submitting a claim. Claims with a quantity greater than the number of days in that month may be subject to a recoupment. codes B4087 and B4088 are limited to two per rolling year. Refer to: Section 4.2, Authorizations, on page 4-3 for detailed information about authorization requirements. Appendix B, CSHCN Services Program Prior Authorization Request for Diapers, Pull-ups, Briefs, or Liners on page B-23. Nonobturated Gastrostomy Devices Nonobturated gastrostomy kits may be reimbursed to physicians, pharmacies, medical suppliers, and home health DME providers. Two devices are considered for reimbursement per year, per client. Additional devices may be considered for reimbursement if the documentation submitted with the claim indicates medical necessity (e.g., failure of the device or infection at the gastrostomy site). Obturated Gastrostomy Devices Obturated gastrostomy devices may be reimbursed only to physicians. Two devices may be considered for reimbursement per year, per client. Refer to: Section 31.2.20, Gastrostomy Devices, on page 31-67 for information related to gastrostomy tube devices..3 Claims Information Expendable medical supplies 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. Home health DME providers must use benefit code DM3 on all claims and authorization and prior authorization requests. All other providers must use benefit code CSN on all claims and authorization and prior authorization requests. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. The Healthcare Common 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/nationalcorrectcodi- 12 CPT only copyright 2012 American Medical Association. All rights reserved.
Expendable Medical Supplies nited/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 on 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 Reimbursement Expendable medical supplies may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. Supplies may be reimbursed using the appropriate HCPCS codes. The CSHCN Services Program requires the provider to submit an itemized claim form for supplies for reimbursement. For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. 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 TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community. CPT only copyright 2012 American Medical Association. All rights reserved. 13