4400, User’s Guide to Fee Schedules

Revision 23-1; Effective Jan. 5, 2023

4410 Fee Schedules

Revision 23-1; Effective Jan. 5, 2023

All Texas Medicaid Fee Schedules are available at www.tmhp.com.

The Texas Medicaid Fee Schedule is categorized by field descriptions. Type of Service (TOS) codes are listed in the first field. The TOS identifies the specific field or specialty of services provided. The TOS descriptions are listed below. The most current information can be found in the Texas Medicaid Providers Procedures Manual, Section 6, Claims Filing.

Type of Service (TOS) Table TOS

Procedure Code. The third field lists the current procedure codes. The Texas Medicaid physician, advanced practice nurse (APN), and certified registered nurse anesthetists (CRNA) fee schedules each contain a list of payment rates for Current Procedural Terminology (CPT) codes, including the TOS 7 American Society of Anesthesiologists (ASA) procedure codes. The five-character alphanumeric procedure codes follow the numeric procedure codes.

Modifier. The modifier is placed after the five-digit procedure code, if applicable. A modifier describes and qualifies services that are provided. However, not all procedures require a modifier. Modifiers may affect the CIHCP payment amount. A list of frequently used modifiers is located in the Texas Medicaid Providers Procedures Manual in Section 6, Claims Filing.

Child Age. The sixth and seventh fields list the age range for pricing determination.

Resource-Based Units. Texas Medicaid Reimbursement Methodology (TMRM). The eighth field lists the payable amount for the TOS and procedure code.

Total RVUs. The ninth field lists the relative value units (RVUs) for the procedure code.

Conv Factor. The tenth field lists the conversion factor used in the calculation formula for anesthesia services in determining the TMRM payable amount.

PPS Fee. The eleventh field lists the prospective payment system (PPS) fee. Not applicable for CIHCP.

Access-Based or Max Fee. The twelfth field lists the access-based fee amount or maximum fee.

Effective Date. The thirteenth field lists the effective date for total RVUs for Resource-Based Fees (RBFs). For fees other than RBFs, the effective date for the PPS, access-based, or max fee.

Note Code. The fourteenth field lists the note code indicator. For CIHCP, a payment amount may be negotiated with the provider when the Note Code is 5.

TOS. The CPT codes are divided into sections based on the type of service codes. The one-digit TOS code identifies the specific field or specialty of services provided. TOS 0 and TOS 9 are not basic health care services.

See 4420, Type of Services – Definition and Payment Information, below.

4420 Type of Services – Definition and Payment Information

Revision 23-1; Effective Jan. 5, 2023

1 Medical Services – Includes office, inpatient hospital and emergency room visits; allergy treatment; chemotherapy; injections; physical therapy; dialysis; psychotherapy; ophthalmology; dermatology; ventilation; etc. Excludes anesthesia, radiological interpretations and laboratory interpretations.

2 Surgery – Includes invasive diagnostic procedures.

• Single Surgical Procedure. Unless the description for a surgical procedure clearly states otherwise, a single surgical procedure code represents the full scope of activities performed to complete the surgical procedure.
• Multiple Surgical Procedures. Some surgical services involve multiple surgical procedures that may be payable as separate procedures but only if they are not a component of a more comprehensive procedure. Determine if the multiple surgical procedure codes are:
  • components of one comprehensive procedure; or
  • a primary procedure and secondary procedure(s).

If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full HHSC physician payment standard for the primary procedure and half of the HHSC physician payment standard for the other procedure(s).

3 Consultations – Used when the attending physician consults with another physician concerning some non-surgical aspect of the patient’s treatment.

4 Radiology (total component, i.e., technical and interpretation) – Includes radiological exams (X-rays), computerized axial tomography (CAT) scans, magnetic resonance imaging (MRI), mammography, echography (ultrasound), and other types of internal organ and vascular X-rays. Procedure codes with a type of service (TOS) 4 include radiology services that are both the technical component and the interpretation (professional) component of X-ray services.

• Use the following information for processing bills for TOS 4 (Radiology), TOS T (Technical), and TOS I (Interpretation).
• Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 4).
• Providers who perform only the technical service may be paid only for the technical component (TOS T).
• Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
• TOS 4 = Total Component (Technical + Interpretation)
• TOS 4 = TOS T + TOS I

In summary:

• If a TOS 4 is paid first, then the total component has been met.
• If a TOS T is paid first, then a TOS I may be payable.
• If a TOS I is paid first, then a TOS T may be payable.

5 Laboratory (total component, i.e., technical and interpretation) – Includes most types of blood, urine, feces, and sputum tests and tests on other bodily fluids or by-products; tissue studies and analysis; various hearing and speech tests; electrocardiograms (EKGs) and cardiovascular stress tests; respiratory (pulmonary) function tests; electroencephalograms (EEGs) and other brain activity tests. Procedure codes with a TOS 5 include laboratory services that are both the technical component and the interpretation (professional) component of laboratory services.

Use the following information for processing bills for TOS 5 (Laboratory), TOS T (Technical) and TOS I (Interpretation).

• Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 5).
• Providers who perform only the technical service may be paid only for the technical component (TOS T).
• Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
• TOS 5 = Total Component (Technical + Interpretation)
• TOS 5 = TOS T + TOS I

In summary:

• If a TOS 5 is paid first, then the total component has been met.
• If a TOS T is paid first, then a TOS I may be payable.
• If a TOS I is paid first, then a TOS T may be payable.

6 Radiation Therapy (total component, i.e., technical and interpretation) – Includes radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment and radioelement application. Procedure codes with a TOS 6 include radiation therapy services that are both the technical component and the interpretation (professional) component of radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment and radioelement application services.

Use the following information for processing bills for TOS 6 (Radiation Therapy), TOS T (Technical), and TOS I (Interpretation).

• Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 6).
• Providers who perform only the technical service may be paid only for the technical component (TOS T).
• Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
• TOS 6 = Total Component (Technical + Interpretation)
• TOS 6 = TOS T + TOS I

In summary:

• If a TOS 6 is paid first, then the total component has been met.
• If a TOS T is paid first, then a TOS I may be payable.
• If a TOS I is paid first, then a TOS T may be payable.

7 Anesthesia – Usually provided by or under the supervision of a physician in a hospital setting.

8 Assistant Surgery – A surgical procedure that requires the assistance of another surgeon. Procedure codes with a TOS 8 include assistant surgical services and are reimbursed at 16% of the reimbursement rate for TOS 2. In addition, use of a modifier code of 80, 81 and 82 with a surgical procedure code results in TOS 8 being assigned to the procedure.

Although certain surgical procedures require the service of an assistant surgeon, not all surgical procedures require this service.

• Single Surgical Procedure. Unless the description for a surgical procedure clearly states otherwise, a single surgical procedure code represents the full scope of activities performed to complete the surgical procedure.
• Multiple Surgical Procedures. Some surgical services involve multiple surgical procedures that may be payable as separate procedures but only if they are not a component of a more comprehensive procedure. Determine if the multiple surgical procedure codes are:
  • components of one comprehensive procedure; or
  • a primary procedure and secondary procedure(s).

If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full HHSC physician payment standard for the primary procedure and pay half of the HHSC physician payment standard for the other procedure(s).

I Interpretation – Professional component for radiology, laboratory or radiation therapy services. Only one provider is entitled to reimbursement for interpreting a radiology, laboratory or radiation therapy procedure.

• Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 4, 5 or 6).
• Providers who perform only the technical service may be paid only for the technical component (TOS T).
• Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
• TOS 4, 5 or 6 = Total Component (Technical and Interpretation)
• TOS 4, 5 or 6 = TOS T + TOS I

In summary:

• If a TOS 4, 5 or 6 is paid first, then the total component has been met.
• If a TOS T is paid first, then a TOS I may be payable.
• If a TOS I is paid first, then a TOS T may be payable.

T Technical – Technical component for radiology, laboratory or radiation therapy services.

Only one provider is entitled to reimbursement for performing the technical component of a radiology, laboratory or radiation therapy procedure.

• Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 4, 5, or 6).
• Providers who perform only the technical service may be paid only for the technical component (TOS T).
• Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
• TOS 4, 5 or 6 = Total Component (Technical + Interpretation)
• TOS 4, 5, or 6 = TOS T + TOS I

In summary:

• If a TOS 4, 5 or 6 is paid first, then the total component has been met.
• If a TOS T is paid first, then a TOS I may be payable.
• If a TOS I is paid first, then a TOS T may be payable.